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Zhou J, Yang M, Wang F, Liu S, Hei M, Jiang M. Assessment of food supplements for the prevention of necrotizing enterocolitis in preterm neonates: A systematic review and network meta-analysis. Comput Biol Med 2023; 167:107601. [PMID: 37924642 DOI: 10.1016/j.compbiomed.2023.107601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/14/2023] [Accepted: 10/17/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The network meta-analysis (NMA) investigated the efficacy of six food supplements, namely glutamine, arginine, lactoferrin, prebiotics, synbiotics, and probiotics, in preventing necrotizing enterocolitis in premature infants. METHODS MEDLINE, Embase, and Cochrane Library were searched. Randomized controlled trials comparing different food supplements for premature infants were included. RESULTS Probiotics (OR, 0.47; 95% CrI, 0.33-0.63), arginine (OR, 0.38; 95% CrI, 0.14-0.98), glutamine (OR, 0.30; 95% CrI, 0.079-0.90), and synbiotics (OR, 0.13; 95% CrI, 0.037-0.37). were associated with a decreased incidence of NEC. Only probiotics (OR, 0.81; 95% CrI, 0.69-0.95) and lactoferrin (OR, 0.74; 95% CrI, 0.54-0.92) achieved lower risk of sepsis. Probiotics (OR, 0.58; 95% CrI, 0.40-0.79), prebiotics (OR, 0.23; 95% CrI, 0.043-0.86), and synbiotics (OR, 0.15; 95% CrI, 0.035-0.50) were associated with lower odds of mortality. Probiotics (MD, -2.3; 95% CrI: -3.7- -0.63) appeared to have earlier age of attainment of full feeding. CONCLUSIONS Based on this NMA, probiotics and synbiotics had the potential to be the top two preferable food supplements.
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Affiliation(s)
- Jingjing Zhou
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 56 Nanlishi Road, Xicheng District, Beijing, China
| | - Mengyang Yang
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 56 Nanlishi Road, Xicheng District, Beijing, China
| | - Fuming Wang
- Department of Neonatology, Kaifeng Children's Hospital, 87 Middle Section of Freedom Road, Kaifeng City, Henan Province, China
| | - Shiqi Liu
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 56 Nanlishi Road, Xicheng District, Beijing, China
| | - Mingyan Hei
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 56 Nanlishi Road, Xicheng District, Beijing, China
| | - Min Jiang
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 56 Nanlishi Road, Xicheng District, Beijing, China.
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Deshmukh M, Patole S. Current Status of Probiotics for Preterm Infants. Indian J Pediatr 2021; 88:703-708. [PMID: 33877563 DOI: 10.1007/s12098-021-03736-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Abstract
Probiotics have been shown to reduce the risk of all-cause mortality, necrotizing enterocolitis (NEC ≥ stage II), late onset sepsis (LOS), and feeding intolerance in preterm infants. Considering the substantial health burden imposed by these conditions, the importance of probiotics in preterm infants cannot be overemphasized. Based on the data from experimental studies, and systematic reviews of randomized controlled trials (RCTs) and non-RCTs, the uptake of this intervention in neonatal medicine has been increasing over the last few years. However, many are still hesitating to adopt this intervention for various reasons, including concerns about probiotic sepsis, product quality, and lack of clarity on optimal strain/s or their combinations. Some question the validity of meta-analyses of studies involving different probiotic strains or their combinations because probiotics effects are considered to be strain-specific. Some of the early concerns about probiotics in preterm infants have been shown to be unjustified. However, the resistance to probiotics continues in many neonatal units around the world. The future of probiotics for preterm infants depends on continued efforts to develop high-quality probiotic products using stringent quality control, improving access to such products, and robust head-to-head comparisons to know the optimal strains or their combinations. Monitoring for adverse effects such as probiotic sepsis and development of antibiotic resistance is crucial. The authors review the current status of probiotics in preterm infants and discuss the scope for further research in this field.
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Affiliation(s)
- Mangesh Deshmukh
- Department of Neonatology, Fiona Stanley Hospital, Perth, Western Australia.,Department of Neonatology, St. John of God Subiaco Hospital, Perth, Western Australia
| | - Sanjay Patole
- Neonatal Directorate, King Edward Memorial Hospital for Women, 374 Bagot Road, Subiaco, Western Australia, 6008. .,School of Medicine, University of Western Australia, Perth, Western Australia.
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Chi C, Li C, Buys N, Wang W, Yin C, Sun J. Effects of Probiotics in Preterm Infants: A Network Meta-analysis. Pediatrics 2021; 147:peds.2020-0706. [PMID: 33323491 DOI: 10.1542/peds.2020-0706] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Probiotics have proven to be effective in promoting premature infants' health, but the optimal usage is unknown. OBJECTIVE To compare probiotic supplements for premature infants. DATA SOURCES We searched PubMed, Embase, Cochrane, and ProQuest from inception of these databases to June 1, 2020. STUDY SELECTION Randomized trials of probiotic supplement intervention for preterm infants were screened by 2 reviewers independently. The primary outcomes were mortality and the morbidity of necrotizing enterocolitis (NEC). Secondary outcomes were morbidity of sepsis, time to achieve full enteral feeding, and length of hospital stay. DATA EXTRACTION The data of primary and secondary outcomes were extracted by 2 reviewers and pooled with a random-effects model. RESULTS The meta-analysis included 45 trials with 12 320 participants. Bifidobacterium plus Lactobacillus was associated with lower rates of mortality (risk ratio 0.56; 95% credible interval 0.34-0.84) and NEC morbidity (0.47; 0.27-0.79) in comparison to the placebo; Lactobacillus plus prebiotic was associated with lower rates of NEC morbidity (0.06; 0.01-0.41) in comparison to the placebo; Bifidobacterium plus prebiotic had the highest probability of having the lowest rate of mortality (surface under the cumulative ranking curve 83.94%); and Lactobacillus plus prebiotic had the highest probability of having the lowest rate of NEC (surface under the cumulative ranking curve 95.62%). LIMITATIONS In few studies did authors report the data of infants with a lower birth weight or gestational age. CONCLUSIONS The efficacy of single probiotic supplements is limited, compared to combined use of probiotics. To achieve optimal effect on premature infant health, combined use of prebiotic and probiotic, especially Lactobacillus or Bifidobacterium, is recommended.
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Affiliation(s)
- Cheng Chi
- School of Nursing, Jining Medical University, Jining, China.,Department of Internal Medicine, Beijing Obstetrics and Gynecology Hospital and Capital Medical University, Beijing, China; and.,School of Medicine and
| | - Cheng Li
- School of Nursing, Jining Medical University, Jining, China; .,Department of Internal Medicine, Beijing Obstetrics and Gynecology Hospital and Capital Medical University, Beijing, China; and
| | - Nicholas Buys
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Wenjun Wang
- School of Nursing, Jining Medical University, Jining, China
| | - Chenghong Yin
- Department of Internal Medicine, Beijing Obstetrics and Gynecology Hospital and Capital Medical University, Beijing, China; and
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4
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Pratt M, Wieland S, Ahmadzai N, Butler C, Wolfe D, Pussagoda K, Skidmore B, Veroniki A, Rios P, Tricco AC, Hutton B. A scoping review of network meta-analyses assessing the efficacy and safety of complementary and alternative medicine interventions. Syst Rev 2020; 9:97. [PMID: 32354348 PMCID: PMC7191816 DOI: 10.1186/s13643-020-01328-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 03/10/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Network meta-analysis (NMA) has rapidly grown in use during the past decade for the comparison of healthcare interventions. While its general use in the comparison of conventional medicines has been studied previously, to our awareness, its use to assess complementary and alternative medicines (CAM) has not been studied. A scoping review of the literature was performed to identify systematic reviews incorporating NMAs involving one or more CAM interventions. METHODS An information specialist executed a multi-database search (e.g., MEDLINE, Embase, Cochrane), and two reviewers performed study selection and data collection. Information on publication characteristics, diseases studied, interventions compared, reporting transparency, outcomes assessed, and other parameters were extracted from each review. RESULTS A total of 89 SR/NMAs were included. The largest number of NMAs was conducted in China (39.3%), followed by the United Kingdom (12.4%) and the United States (9.0%). Reviews were published between 2010 and 2018, with the majority published between 2015 and 2018. More than 90 different CAM therapies appeared at least once, and the median number per NMA was 2 (IQR 1-4); 20.2% of reviews consisted of only CAM therapies. Dietary supplements (51.1%) and vitamins and minerals (42.2%) were the most commonly studied therapies, followed by electrical stimulation (31.1%), herbal medicines (24.4%), and acupuncture and related treatments (22.2%). A diverse set of conditions was identified, the most common being various forms of cancer (11.1%), osteoarthritis of the hip/knee (7.8%), and depression (5.9%). Most reviews adequately addressed a majority of the PRISMA NMA extension items; however, there were limitations in indication of an existing review protocol, exploration of network geometry, and exploration of risk of bias across studies, such as publication bias. CONCLUSION The use of NMA to assess the effectiveness of CAM interventions is growing rapidly. Efforts to identify priority topics for future CAM-related NMAs and to enhance methods for CAM comparisons with conventional medicine are needed. SYSTEMATIC REVIEW REGISTRATION: https://ruor.uottawa.ca/handle/10393/35658.
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Affiliation(s)
- Misty Pratt
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201, Ottawa, Ontario K1H 8 L6 Canada
| | - Susan Wieland
- University of Maryland School of Medicine, Baltimore, MD USA
| | - Nadera Ahmadzai
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201, Ottawa, Ontario K1H 8 L6 Canada
| | - Claire Butler
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201, Ottawa, Ontario K1H 8 L6 Canada
| | - Dianna Wolfe
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201, Ottawa, Ontario K1H 8 L6 Canada
| | - Kusala Pussagoda
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201, Ottawa, Ontario K1H 8 L6 Canada
| | - Becky Skidmore
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201, Ottawa, Ontario K1H 8 L6 Canada
| | - Argie Veroniki
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Canada
- Institute of Reproductive and Developmental Biology, Department of Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Patricia Rios
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Canada
| | - Andrea C. Tricco
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Canada
- Epidemiology Division, Dalla Lana School of Public Health and Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 201, Ottawa, Ontario K1H 8 L6 Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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5
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Liu Y, Tran DQ, Rhoads JM. Probiotics in Disease Prevention and Treatment. J Clin Pharmacol 2019; 58 Suppl 10:S164-S179. [PMID: 30248200 DOI: 10.1002/jcph.1121] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/17/2018] [Indexed: 12/17/2022]
Abstract
Few treatments for human diseases have received as much investigation in the past 20 years as probiotics. In 2017, English-language meta-analyses totaling 52 studies determined the effect of probiotics on conditions ranging from necrotizing enterocolitis and colic in infants to constipation, irritable bowel syndrome, and hepatic encephalopathy in adults. The strongest evidence in favor of probiotics lies in the prevention or treatment of 5 disorders: necrotizing enterocolitis, acute infectious diarrhea, acute respiratory tract infections, antibiotic-associated diarrhea, and infant colic. Probiotic mechanisms of action include the inhibition of bacterial adhesion; enhanced mucosal barrier function; modulation of the innate and adaptive immune systems (including induction of tolerogenic dendritic cells and regulatory T cells); secretion of bioactive metabolites; and regulation of the enteric and central nervous systems. Future research is needed to identify the optimal probiotic and dose for specific diseases, to address whether the addition of prebiotics (to form synbiotics) would enhance activity, and to determine if defined microbial communities would provide benefit exceeding that of single-species probiotics.
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Affiliation(s)
- Yuying Liu
- Department of Pediatrics, Division of Gastroenterology, and the Pediatric Research Center, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Dat Q Tran
- Department of Pediatrics, Division of Gastroenterology, and the Pediatric Research Center, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - J Marc Rhoads
- Department of Pediatrics, Division of Gastroenterology, and the Pediatric Research Center, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
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6
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A Quality Improvement Intervention to Reduce Necrotizing Enterocolitis in premature infants with Probiotic Supplementation. Pediatr Qual Saf 2019; 4:e201. [PMID: 31745505 PMCID: PMC6805101 DOI: 10.1097/pq9.0000000000000201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/04/2019] [Indexed: 01/22/2023] Open
Abstract
Supplemental Digital Content is available in the text. Necrotizing Enterocolitis (NEC) is a severe intestinal inflammatory disease due to multifactorial causes that present in preterm infants. Compared with similar neonatal intensive care units, our NEC rate was increasing and prompted reduction by a quality improvement (QI) intervention.
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7
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Schwingshackl L, Schwarzer G, Rücker G, Meerpohl JJ. Perspective: Network Meta-analysis Reaches Nutrition Research: Current Status, Scientific Concepts, and Future Directions. Adv Nutr 2019; 10:739-754. [PMID: 31075165 PMCID: PMC6743830 DOI: 10.1093/advances/nmz036] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/15/2019] [Accepted: 03/18/2019] [Indexed: 12/17/2022] Open
Abstract
Traditional pairwise meta-analysis (PMA) is a very useful method that pools evidence from one study design type if appropriate; its widespread use in nutrition research is an important phenomenon. Recently, a promising method for more advanced evidence-synthesis, called network meta-analysis (NMA), was introduced. NMA is an extension of PMA that enables simultaneous comparison of multiple interventions. NMA combines direct evidence (i.e., trials comparing 2 interventions directly) and indirect evidence (i.e., from a connected route via ≥1 comparators, e.g. placebo) in a network of studies. NMAs have the potential to advance knowledge in the field of nutrition as they provide insights that cannot be obtained by individual 2-arm randomized controlled trials or PMA. Thus, in this perspective paper, we aim to summarize the current (methodologic) status of published NMAs in nutrition research and emphasize advances and strengths in comparison with traditional PMA through specific examples, and highlight potential pitfalls and limitations. NMA is an emerging methodology in the field of nutrition research. A PubMed search identified only 23 nutrition research-related NMAs published since the inception of journals up to January 8, 2019 (61% of them published since 2017), compared with >5000 published PMAs. Moreover, we aim to highlight the scientific concepts and standards through the use of the following NMA example: "Which type of oils/solid fats offers the greatest impact on blood lipids?" In this regard, we discuss intervention definitions, transitivity/similarity, statistical methods, description and visualization of results, inconsistency, ranking, dissemination bias, assessing the certainty of evidence by Grading of Recommendations Assessment, Development and Evaluation, and reporting guidelines. We expect that rigorously conducted NMAs based on high-quality systematic reviews will become the new evidence synthesis benchmark in nutrition research. However, caution is warranted because abuse and misinterpretations of PMA and NMA findings could hamper the scientific field and possibly decision-making regarding public policy.
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Affiliation(s)
| | - Guido Schwarzer
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Gerta Rücker
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
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8
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Jarrett P, Meczner A, Costeloe K, Fleming P. Historical aspects of probiotic use to prevent necrotising enterocolitis in preterm babies. Early Hum Dev 2019; 135:51-57. [PMID: 31153726 DOI: 10.1016/j.earlhumdev.2019.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Over the last few decades, numerous studies have evaluated probiotic use for the prevention of necrotising enterocolitis in preterm babies. Early 'proof of concept' studies evaluating whether probiotics are capable of colonising the preterm gut have translated into multiple observational studies, small and large randomised controlled trials. Some show evidence of benefit while others have produced disappointing results. In this paper, we review the history of probiotic use in preterm babies for NEC prevention in an attempt to explain why uncertainty exists and why this intervention has not been universally adopted into routine neonatal practice.
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Affiliation(s)
- Prudence Jarrett
- Homerton University Hospital, NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland.
| | - Andras Meczner
- Homerton University Hospital, NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Kate Costeloe
- Barts and the London School of Medicine and Dentistry, London, United Kingdom of Great Britain and Northern Ireland
| | - Paul Fleming
- Homerton University Hospital, NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland; Barts and the London School of Medicine and Dentistry, London, United Kingdom of Great Britain and Northern Ireland
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9
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Sadeghirad B, Florez ID, Chang Y, Forutan F, Zeraatkar D, Morgan RL, Shahid S, Bala MM, Beyene J, Offringa M, Adams-Webber T, Sherman PM, El-Gouhary E, Guyatt GH, Johnston BC. Comparative Effectiveness of Prophylactic Therapies for Necrotizing Enterocolitis in Preterm Infants: Protocol for a Network Meta-analysis of Randomized Trials. Int J Prev Med 2018; 9:83. [PMID: 30283615 PMCID: PMC6151977 DOI: 10.4103/ijpvm.ijpvm_328_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 08/17/2017] [Indexed: 01/08/2023] Open
Abstract
Necrotizing enterocolitis (NEC) is a common and devastating disease with high morbidity and mortality in premature infants. Current literature on the prevention of NEC has limitations including lack of direct and indirect comparisons of available therapies. We will search MEDLINE, EMBASE, Science Citation Index Expanded, Social Sciences Citation Index, CINAHL, Scopus, ProQuest Dissertations and Theses database, and grey literature sources to identify eligible trials evaluating NEC preventive therapies. Eligible studies will (1) enroll preterm (gestational age <37 weeks) and/or low birth weight (birth weight <2500 g) infants, (2) randomize infants to any preventive intervention or a placebo, or alternative active or nonactive intervention. Our outcomes of interest are severe NEC (stage II or more, based on Bell's criteria), all-cause mortality, NEC-related mortality, late-onset sepsis, duration of hospitalization, weight gain, time to establish full enteral feeds, and treatment-related adverse events. Two reviewers will independently screen trials for eligibility, assess risk of bias, and extract data. All discrepancies will be resolved by discussion. We will specify a priori explanations for heterogeneity between studies. For available comparisons between treatment and no treatment, and direct comparisons of treatments, we will conduct conventional meta-analysis using a random effects model. We will conduct a network meta-analysis using a random effects model within the Bayesian framework using Markov chain Monte Carlo methods to assess relative effects of eligible interventions. We will assess the certainty in direct, indirect, and network estimates using the Grading of Recommendations Assessment, Development and Evaluation approach.
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Affiliation(s)
- Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.,HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Ivan D Florez
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Department of Pediatrics, University of Antioquia, Medellin, Colombia
| | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Farid Forutan
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Shaneela Shahid
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Malgorzata M Bala
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Joseph Beyene
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Martin Offringa
- Hospital Library, The Hospital for Sick Children, Toronto, ON, Canada
| | - Thomasin Adams-Webber
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Philip M Sherman
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Enas El-Gouhary
- Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Bradley C Johnston
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada.,Systematic Overviews through advancing Research Technology (SORT), Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
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Probiotics for Preterm Infants: A Strain-Specific Systematic Review and Network Meta-analysis. J Pediatr Gastroenterol Nutr 2018; 67:103-122. [PMID: 29384838 DOI: 10.1097/mpg.0000000000001897] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Several randomized controlled trials (RCTs) on the use of probiotics to reduce morbidity and mortality in preterm infants have provided inconsistent results. Although meta-analyses that group all of the used strains together are suggesting efficacy, it is not possible to determine the most effective strain that is more relevant to the clinician. We therefore used a network meta-analysis (NMA) approach to identify strains with greatest efficacy. METHODS A PubMed search identified placebo-controlled or head-to-head RCTs investigating probiotics in preterm infants. From trials that recorded mortality, necrotizing enterocolitis, late-onset sepsis, or time until full enteral feeding as outcomes, data were extracted and Bayesian hierarchical random-effects models were run to construct a NMA. RESULTS Fifty-one RCTs involving 11,231 preterm infants were included. Most strains or combinations of strains were only studied in one or a few RCTs. Only 3 of 25 studied probiotic treatment combinations showed significant reduction in mortality rates. Seven treatments reduced necrotizing enterocolitis incidence, 2 reduced late-onset sepsis, and 3 reduced time until full enteral feeding. There was no clear overlap of strains, which were effective on multiple outcome domains. CONCLUSIONS This NMA showed efficacy in reducing mortality and morbidity only in a minority of the studied strains or combinations. This may be due to an inadequate number, or size, of RCTs, or due to a true lack of effect for certain species. Further large and adequately powered RCTs using strains with the greatest apparent efficacy will be needed to more precisely define optimal treatment strategies.
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Pirr S, Richter M, Fehlhaber B, Pagel J, Härtel C, Roth J, Vogl T, Viemann D. High Amounts of S100-Alarmins Confer Antimicrobial Activity on Human Breast Milk Targeting Pathogens Relevant in Neonatal Sepsis. Front Immunol 2017; 8:1822. [PMID: 29326708 PMCID: PMC5733341 DOI: 10.3389/fimmu.2017.01822] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 12/04/2017] [Indexed: 12/15/2022] Open
Abstract
Sepsis is a leading cause of perinatal mortality worldwide. Breast milk (BM) feeding is protective against neonatal sepsis, but the molecular mechanisms remain unexplained. Despite various supplementations with potential bioactive components from BM formula feeding cannot protect from sepsis. S100-alarmins are important immunoregulators in newborns preventing excessive inflammation. At high concentrations, the S100A8/A9 protein complex also has antimicrobial properties due to its metal ion chelation capacity. To assess whether BM contains S100-alarmins that might mediate the sepsis-protective effect of BM 97 human BM samples stratified for gestational age, mode of delivery and sampling after birth were collected and analyzed. S100A8/A9 levels were massively elevated after birth (p < 0.0005). They slowly decreased during the first month of life, then reaching levels comparable to normal values in adult serum. The concentration of S100A8/A9 in BM was significantly higher after term compared with preterm birth (extremely preterm, p < 0.005; moderate preterm, p < 0.05) and after vaginal delivery compared with cesarean section (p < 0.0005). In newborn s100a9−/− mice, enterally supplied S100-alarmins could be retrieved systemically in the plasma. To explore the antimicrobial activity against common causal pathogens of neonatal sepsis, purified S100-alarmins and unmodified as well as S100A8/A9-depleted BM were used in growth inhibition tests. The high amount of S100A8/A9 proved to be an important mediator of the antimicrobial activity of BM, especially inhibiting the growth of manganese (Mn) sensitive bacteria such as Staphylococcus aureus (p < 0.00005) and group B streptococci (p < 0.005). Depletion of S100A8/A9 significantly reduced this effect (p < 0.05, respectively). The growth of Escherichia coli was also inhibited by BM (p < 0.00005) as well as by S100A8/A9 in culture assays (p < 0.05). But its growth in BM remained unaffected by the removal of S100A8/A9 and was neither dependent on Mn suggesting that the antimicrobial effects of S100A8/A9 in BM are primarily mediated by its Mn chelating capacity. In summary, the enteral supply of bioavailable, antimicrobially active amounts of S100-alarmins might be a promising option to protect newborns at high risk from infections and sepsis.
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Affiliation(s)
- Sabine Pirr
- Department of Pediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Manuela Richter
- Department of Pediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany.,Children's Hospital "Auf der Bult", Hannover, Germany
| | - Beate Fehlhaber
- Department of Pediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
| | - Julia Pagel
- Department of Pediatrics, University of Lübeck, Lübeck, Germany
| | | | - Johannes Roth
- Institute of Immunology, University of Münster, Münster, Germany
| | - Thomas Vogl
- Institute of Immunology, University of Münster, Münster, Germany
| | - Dorothee Viemann
- Department of Pediatric Pneumology, Allergy and Neonatology, Hannover Medical School, Hannover, Germany
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