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Kum VTL, Chung PHY, Wong KKY. Quality of Life in Long-Term Survivors of Surgical Necrotizing Enterocolitis. J Pediatr Surg 2024; 59:553-556. [PMID: 38158259 DOI: 10.1016/j.jpedsurg.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE This study evaluated the quality of life (QoL) in patients who have recovered from surgical necrotizing enterocolitis (NEC). METHODS This is a cross-sectional study conducted in a tertiary centre and patients who have received surgery for NEC between 2000 and 2014 were invited to participate. The Pediatric Quality of Life Inventory Generic (PedsQL™) Core Scale Version 4.0 was used as the assessment tool. Values were reported as median (interquartile rage) and compared with age-matched controls. RESULTS During the study period, 90 patients were eligible for the study and 29 patients have completed the survey. There was no gender difference and the median age was 10 years (9-13 years). Nine patients have suffered from short bowel syndrome (SBS) as a result of the surgery. For the QoL assessment, 17 participants have completed both parent proxy and child-rated survey; 11 completed the parent-rated survey and 1 completed child-rated survey only. The scores for parent-rated survey were - overall: 86.4 (70.7-92.7); physical: 95.3 (83.6-100) and psychosocial: 82.5 (66.3-90.4). The scores for child-rated survey were - overall: 82.1 (73.4-96.2); physical: 96.9 (90.6-99.2) and psychosocial: 81.7 (64.2-95.8). Regarding the impact of previous SBS on the QoL, there were no significant difference in the overall score for both parent proxy and child-rated survey (SBS-ve vs + ve) (parent-rated: 87.5 vs 85.3, p = 0.849; child-rated: 81.0 vs 88.0, p = 0.503). There were also no differences in physical and psychosocial assessments (parent-rated: [physical] 95.3 vs 95.3, p = 0.267; [psychosocial] 84.2 vs 80.0, p = 0.274; child-rated: [physical] 95.3 vs 96.9, p = 0.395; [psychosocial] 79.2 vs 87.5, p = 0.611). CONCLUSION The QoL in long-term survivors of surgical NEC without major medical illnesses is comparable to normal population. However, they may have a lower psychosocial well-being that should be addressed. Previous history of SBS does not have a significant impact on the future QoL. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Venus Tsz Ling Kum
- Division of Paediatric Surgery, Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, HKSAR
| | - Patrick Ho Yu Chung
- Division of Paediatric Surgery, Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, HKSAR.
| | - Kenneth Kak Yuen Wong
- Division of Paediatric Surgery, Department of Surgery, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, HKSAR
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Magnusson A, Swolin-Eide D, Elfvin A. Body composition and bone mass among 5-year-old survivors of necrotizing enterocolitis. Pediatr Res 2023; 93:924-931. [PMID: 35974161 PMCID: PMC10033411 DOI: 10.1038/s41390-022-02236-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/09/2022] [Accepted: 07/19/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) affects the intestine of preterm infants. Preterm infants risk inadequate bone mineralization. This risk may increase if the intestinal uptake of minerals is affected after NEC. METHODS This is a study of growth, bone mineral density (BMD), bone mineral content (BMC), and body composition at 5 years of age among Swedish children born before gestational week 37 + 0 with a history of NEC, minimum stage IIA, compared to matched controls. Fifty children, 25 NEC cases and 25 controls, were examined with dual energy X-ray absorptiometry (DXA) and DXA with laser. RESULTS The NEC cases had lower weight, -1.3 SDS vs -0.7 SDS, a lower fat mass and fat percent, 23.4 vs 29.1%, compared to the controls. NEC cases had lower BMC total body head excluded, 355.6 g vs 416.7 g. BMD Z-scores were lower among NEC cases in total body head excluded, -0.7 vs -0.1, and in lumbar spine. CONCLUSIONS Preterm NEC survivors at 5 years of age had reduced growth, an altered body composition, and indications of a lower bone mass compared to matched controls. The study suggests that preterm infants diagnosed with NEC need special attention during childhood regarding growth and bone health. IMPACT A follow-up longitudinal study of growth, bone health, and body composition at 5 years of age among children born preterm with a history of NEC compared to matched controls. The NEC cases had lower weight than controls. NEC cases had an altered body composition with lower fat mass compared to controls. The DXA results showed that the NEC cases had lower bone mineral content and a tendency to lower bone mineral density. The study suggests that preterm infants diagnosed with NEC need special attention at follow-up regarding growth and bone health compared to preterm infants without NEC.
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Affiliation(s)
- Amanda Magnusson
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Diana Swolin-Eide
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Garg PM, Denton MX, Talluri R, Ansari MAY, Riddick R, Ostrander MM, McDonald AG, Premkumar MH, Hillegass WB, Garg PP. Clinical determinants of intestinal failure and death in preterm infants with surgical necrotizing enterocolitis. J Neonatal Perinatal Med 2023; 16:589-596. [PMID: 38007677 PMCID: PMC10841979 DOI: 10.3233/npm-230157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
OBJECTIVE We sought to investigate the clinical determinants of intestinal failure and death in preterm infants with surgical NEC. METHODS Retrospective comparison of clinical information between Group A = intestinal failure (Parenteral nutrition (PN) >90 days) and death and Group B = survivors and with PN dependence < 90 days in preterm infants with surgical NEC. RESULTS Group A (n = 99/143) had a lower mean gestational age (26.4 weeks [SD3.5] vs. 29.4 [SD 3.5]; p = 0.013), lower birth weight (873 gm [SD 427g] vs. 1425 gm [894g]; p = <0.001), later age of NEC onset (22 days [SD20] vs. 16 days [SD 17]; p = 0.128), received surgery later (276 hours [SD 544] vs. 117 hours [SD 267]; p = 0.032), had cholestasis, received dopamine (80.6% vs. 58.5%; p = 0.010) more frequently and had longer postoperative ileus time (19.8 days [SD 15.4] vs. 11.8 days [SD 6.5]; p = <0.001) and reached full feeds later (93 days [SD 45] vs. 44 [SD 22]; p = <0.001) than Group B.On multivariate logistic regression, higher birth weight was associated with lower risk (OR 0.35, 95% CI 0.15-0.82; p = 0.016) of TPN > 90 days or death. Longer length of bowel resected (OR 1.76, 95% CI 1.02-3.02; p = 0.039) and longer postoperative ileus (OR 2.87, 95% CI 1.26-6.53; p = 0.011) were also independently associated with TPN >90days or death adjusted for gestational age and antenatal steroid treatment. CONCLUSION In preterm infants with surgical NEC, clinical factors such as lower birth weight, longer bowel loss, and postoperative ileus days were significantly and independently associated with TPN >90 days or death.
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Affiliation(s)
- P M Garg
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, NC, USA
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - M X Denton
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - R Talluri
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
| | - M A Y Ansari
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
| | - R Riddick
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - M M Ostrander
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - A G McDonald
- Department of Pathology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - M H Premkumar
- Department of Pediatrics/Neonatology, Texas Children Hospital, Baylor College of Medicine, Houston, TX, USA
| | - W B Hillegass
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - P P Garg
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
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CCL3 aggravates intestinal damage in NEC by promoting macrophage chemotaxis and M1 macrophage polarization. Pediatr Res 2022:10.1038/s41390-022-02409-w. [PMID: 36550354 DOI: 10.1038/s41390-022-02409-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 11/04/2022] [Accepted: 11/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND NEC is a life-threatening gastrointestinal disease in neonates, the pathogenesis of which remains poorly understood. METHODS CCL3 levels in intestinal tissue of mice were measured and analyzed. HE staining was used to assess pathological changes in intestinal tissue. FCM was used to detect the proportion and phenotype of macrophages. RNA-seq and RT-PCR were used to evaluate the effect of CCL3 on macrophages. RESULTS CCL3 was highly expressed in the intestinal tissues of mice with NEC and induced macrophage infiltration. Transcriptome data showed that CCL3 strongly induced a transition in the phenotype of macrophages into a proinflammatory one. Mechanistically, in vivo experiments confirmed that CCL3 induced M1 macrophage polarization in NEC intestinal tissue, thereby aggravating inflammatory injury of intestinal tissue, which was alleviated by anti-CCL3 treatment. In addition, in vitro experiments showed that CCL3 significantly enhances the expression of M1-related genes in both PMφ and BMDM while inhibiting the expression of M2-related genes, which was also alleviated by anti-CCl3 treatment. CONCLUSIONS Our data elucidated the involvement of CCL3 in the pathogenesis of NEC, in which upregulated CCL3 expression exacerbated inflammatory intestinal damage by regulating macrophage chemotaxis and M1 phenotype polarization, suggesting that blocking CCL3 may be a potential strategy for effective intervention in NEC. IMPACT Our study represents an important conceptual advancement that CCL3 may be one of the key culprits of intestinal tissue damage in patients with NEC. CCL3 aggravates inflammatory intestinal injury and intestinal mucosal barrier imbalance by regulating the chemotaxis, polarization, and function of macrophages. Blocking CCL3 significantly reduced NEC-mediated intestinal injury, suggesting a new potential therapeutic strategy.
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Jeziorczak PM, Frenette RS, Aprahamian CJ. Lack of Enteral Feeding Associated with Mortality in Prematurity and Necrotizing Enterocolitis. J Surg Res 2021; 270:266-270. [PMID: 34715538 DOI: 10.1016/j.jss.2021.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 08/24/2021] [Accepted: 09/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Necrotizing Enterocolitis (NEC) remains a significant cause of morbidity and mortality. Recently, there has been an increased recognition of the importance of intestinal immunity and the associations with antibiotics and enteral feeds in the pathophysiology of NEC. The primary purpose of this study is to examine the association of enteral feeds on the survival of premature neonates with NEC. MATERIAL AND METHODS A retrospective review using the Vermont Oxford Network for a Level IV NICU from January 1, 2013 through December 31, 2019 was performed. All neonates had a gestational age between 22 to 29 weeks, weighed at least 300 grams (n = 653), had a reported enteral feed status and were treated for NEC (n = 43). Data analysis utilized two-tailed t-tests for NEC and infection rates then Fisher's exact tests for survival status. RESULTS The incidence of NEC in the population was 6.6% (43/653). Of the 43 neonates treated for NEC, 27 were enterally fed, while the other 16 were not. All 27 neonates with NEC that were able to achieve enteral feeds survived and had an infection rate of 22.2%. Meanwhile, all 16 neonates with NEC that were unable to achieve enteral feeds died and had an infection rate of 62.5%. CONCLUSIONS There is a significant association between enteral feeds and NEC, survival, and infection rates in premature neonates. These findings support the importance of intestinal immunity and the microbiota in NEC. Given the limitations of the retrospective review, the profound survival advantage with enteral feeds reinforces the need for further study.
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Affiliation(s)
- Paul M Jeziorczak
- OSF Healthcare- Children's Hospital of Illinois, Peoria, IL; University of Illinois College of Medicine at Peoria, Peoria, IL
| | - Riley S Frenette
- OSF Healthcare- Children's Hospital of Illinois, Peoria, IL; A.T. Still University-Kirksville College of Osteopathic Medicine, Kirksville, MO.
| | - Charles J Aprahamian
- OSF Healthcare- Children's Hospital of Illinois, Peoria, IL; University of Illinois College of Medicine at Peoria, Peoria, IL
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Long-term digestive hospitalizations of premature infants (besides necrotizing enterocolitis): is there a critical threshold? Arch Gynecol Obstet 2021; 304:455-463. [PMID: 33885970 DOI: 10.1007/s00404-021-06068-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 04/09/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND In this study we sought to ascertain a critical threshold of the degree of prematurity and long-term digestive morbidity of the offspring. METHODS A population-based cohort analysis was conducted, comparing long-term incidence of digestive morbidity in infants born preterm. Cases were divided into four groups according to the extremity of prematurity. Digestive morbidity included hospitalizations involving a predefined set of ICD9 codes. A Kaplan-Meier survival curve was constructed to compare cumulative incidence of digestive morbidity. A Cox proportional hazards model was used to control for confounders. RESULTS During the study period 220,563 patients met the inclusion criteria. Offspring born preterm had significantly more hospitalizations due to digestive morbidity compared to term offspring. The Kaplan-Meier survival curve demonstrated significant higher cumulative incidence of long-term digestive morbidity of the offspring with decreasing gestational age (Log rank p < 0.001). The risk was highest at 28 weeks gestation. Using a Cox proportional hazards model, being born at very and moderate to late preterm birth was independently associated with long-term digestive morbidity. CONCLUSION Preterm delivery is an independent risk factor for long-term digestive morbidity of the offspring. In our population, 28 weeks gestation is the critical cut-off for pronounced digestive morbidity.
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Zhang H, Guo L, Ling K, Hu X, Li W, Li L. Specific imaging features of intestinal perforation on supine abdominal X-ray evaluation in infants with necrotizing enterocolitis. WORLD JOURNAL OF PEDIATRIC SURGERY 2021; 4:e000255. [DOI: 10.1136/wjps-2020-000255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/20/2021] [Accepted: 03/23/2021] [Indexed: 11/04/2022] Open
Abstract
BackgroundNecrotizing enterocolitis (NEC) is associated with high mortality and morbidity in neonates. For infants with NEC, intestinal perforation is the most serious complication, and confirming perforation and performing radical surgical treatment as early as possible may reduce mortality and sequelae. The aim of this study was to identify the specific imaging characteristics of intestinal perforation after NEC on supine abdominal X-ray for the early diagnosis of intestinal perforation.MethodsA retrospective study was conducted at the Children’s Hospital of Chongqing Medical University. Infants admitted to the hospital from 2013 to 2020 with NEC (Bell’s stage ≥Ⅱ) were divided into perforation and non-perforation groups. All infants were examined by abdominal X-ray in the erect and supine positions. The sensitivity and specificity of specific X-ray signs were analyzed.ResultsA total of 598 infants were included, 113 of whom suffered from perforation. On the supine abdominal films, lucency over the liver shadow, the liver falciform ligament sign, the football sign, the Rigler sign, the triangle sign and more than any one of the above signs had sensitivities of 64.60%, 45.13%, 37.17%, 30.97%, 15.93% and 86.73%, respectively. None of these signs were found on erect or supine abdominal films in the non-perforation group. The total of accuracy of prediction was 46.76%, and the specificity of all the signs was 100%.ConclusionSpecific signs on supine abdominal X-ray could be used to confirm perforation in neonates with NEC with 86.73% sensitivity and 100% specificity.
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Weis VG, Deal AC, Mekkey G, Clouse C, Gaffley M, Whitaker E, Peeler CB, Weis JA, Schwartz MZ, Atala A. Human placental-derived stem cell therapy ameliorates experimental necrotizing enterocolitis. Am J Physiol Gastrointest Liver Physiol 2021; 320:G658-G674. [PMID: 33566727 PMCID: PMC8238163 DOI: 10.1152/ajpgi.00369.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 02/06/2023]
Abstract
Necrotizing enterocolitis (NEC), a life-threatening intestinal disease, is becoming a larger proportionate cause of morbidity and mortality in premature infants. To date, therapeutic options remain elusive. Based on recent cell therapy studies, we investigated the effect of a human placental-derived stem cell (hPSC) therapy on intestinal damage in an experimental NEC rat pup model. NEC was induced in newborn Sprague-Dawley rat pups for 4 days via formula feeding, hypoxia, and LPS. NEC pups received intraperitoneal (ip) injections of either saline or hPSC (NEC-hPSC) at 32 and 56 h into NEC induction. At 4 days, intestinal macroscopic and histological damage, epithelial cell composition, and inflammatory marker expression of the ileum were assessed. Breastfed (BF) littermates were used as controls. NEC pups developed significant bowel dilation and fragility in the ileum. Further, NEC induced loss of normal villi-crypt morphology, disruption of epithelial proliferation and apoptosis, and loss of critical progenitor/stem cell and Paneth cell populations in the crypt. hPSC treatment improved macroscopic intestinal health with reduced ileal dilation and fragility. Histologically, hPSC administration had a significant reparative effect on the villi-crypt morphology and epithelium. In addition to a trend of decreased inflammatory marker expression, hPSC-NEC pups had increased epithelial proliferation and decreased apoptosis when compared with NEC littermates. Further, the intestinal stem cell and crypt niche that include Paneth cells, SOX9+ cells, and LGR5+ stem cells were restored with hPSC therapy. Together, these data demonstrate hPSC can promote epithelial healing of NEC intestinal damage.NEW & NOTEWORTHY These studies demonstrate a human placental-derived stem cell (hPSC) therapeutic strategy for necrotizing enterocolitis (NEC). In an experimental model of NEC, hPSC administration improved macroscopic intestinal health, ameliorated epithelial morphology, and supported the intestinal stem cell niche. Our data suggest that hPSC are a potential therapeutic approach to attenuate established intestinal NEC damage. Further, we show hPSC are a novel research tool that can be utilized to elucidate critical neonatal repair mechanisms to overcome NEC.
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Affiliation(s)
- Victoria G Weis
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, North Carolina
| | - Anna C Deal
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, North Carolina
| | - Gehad Mekkey
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, North Carolina
- Faculty of Science, Zagazig University, Zagazig, Egypt
| | - Cara Clouse
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, North Carolina
| | - Michaela Gaffley
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, North Carolina
- General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Emily Whitaker
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, North Carolina
| | - Cole B Peeler
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, North Carolina
- School of Biomedical Engineering and Sciences, Virginia Tech-Wake Forest University, Blacksburg, Virginia
| | - Jared A Weis
- School of Biomedical Engineering and Sciences, Virginia Tech-Wake Forest University, Blacksburg, Virginia
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Comprehensive Cancer Center, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Marshall Z Schwartz
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, North Carolina
| | - Anthony Atala
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, North Carolina
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A role for neonatal bacteremia in deaths due to intestinal perforation: spontaneous intestinal perforation compared with perforated necrotizing enterocolitis. J Perinatol 2020; 40:1662-1670. [PMID: 32433511 PMCID: PMC7578088 DOI: 10.1038/s41372-020-0691-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/20/2020] [Accepted: 05/07/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the relationship between intestinal perforations (caused by either spontaneous perforation (SIP) or necrotizing enterocolitis (NEC)) and the outcome "death due to intestinal perforation". METHODS Multivariable logistic regression analyses were used to compare infants <28 weeks' gestation with SIP (n = 32) and perforated-NEC (n = 45) for the outcome perforation-related death. RESULTS In univariate analyses the incidence of death due to perforation was higher among infants with perforated-NEC (36%) than infants with SIP (13%). However, infants with perforated-NEC were more likely to be older than 10 days and have bacteremia/fungemia with non-coagulase-negative staphylococci (non-CONS) organisms than infants with SIP. After adjusting for confounding the only variable that was significantly associated with mortality due to perforation was the presence of non-CONS bacteremia/fungemia at the onset of perforation. CONCLUSIONS The apparent association between death and perforated-NEC could be explained by the higher incidence of non-CONS bacteremia/fungemia among infants with perforated-NEC.
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Pillai A, Tan J, Paquette V, Panczuk J. Does probiotic bacteremia in premature infants impact clinically relevant outcomes? A case report and updated review of literature. Clin Nutr ESPEN 2020; 39:255-259. [PMID: 32859326 DOI: 10.1016/j.clnesp.2020.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 05/13/2020] [Accepted: 05/17/2020] [Indexed: 01/26/2023]
Abstract
Prophylactic use of probiotics decreases the incidence of necrotizing enterocolitis (NEC) in premature infants. However, there are ongoing concerns related to the routine use of probiotics including inconsistent literature regarding optimal dose and strain, lack of regulatory standards in production and reports regarding potential side effects. There is limited data regarding the incidence of probiotic bacteremia and its impact on relevant clinical outcomes in the premature population. We report the first case of Bifidobacterium longum bacteremia in our center since the routine introduction of probiotics. The neonate had NEC with perforation on day of life 7, which likely led to translocation of the probiotic strain to the blood stream. The neonate did not have any hemodynamic instability and the repeat blood culture was negative after starting antibiotic therapy. We also conducted a literature review and found 13 other cases of probiotic bacteremia in premature or very low birth weight neonates. Although the incidence of probiotic bacteremia is low, it can impact several clinical outcomes including prolonged exposure to antibiotics, removal of central lines and additional laboratory testing such as lumbar puncture. There has been no mortality attributable to probiotic bacteremia and there is no data regarding long term neurodevelopmental outcomes.
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Affiliation(s)
- Anish Pillai
- Division of Neonatology, Surya Mother and Child Super Specialty Hospital, Mumbai, Maharashtra, India.
| | - Jason Tan
- Department of Pharmacy, British Columbia Women's and Children's Hospital, Vancouver, BC, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.
| | - Vanessa Paquette
- Department of Pharmacy, British Columbia Women's and Children's Hospital, Vancouver, BC, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.
| | - Julia Panczuk
- Neonatal-Perinatal Medicine, Department of Pediatrics, British Columbia Women's Hospital and Health Centre, University of British Columbia, Vancouver, BC Canada.
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Matei A, Montalva L, Goodbaum A, Lauriti G, Zani A. Neurodevelopmental impairment in necrotising enterocolitis survivors: systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2020; 105:432-439. [PMID: 31801792 DOI: 10.1136/archdischild-2019-317830] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 11/08/2019] [Accepted: 11/12/2019] [Indexed: 02/06/2023]
Abstract
AIM To determine (1) the incidence of neurodevelopmental impairment (NDI) in necrotising enterocolitis (NEC), (2) the impact of NEC severity on NDI in these babies and (3) the cerebral lesions found in babies with NEC. METHODS Systematic review: three independent investigators searched for studies reporting infants with NDI and a history of NEC (PubMed, Medline, Cochrane Collaboration, Scopus). Meta-analysis: using RevMan V.5.3, we compared NDI incidence and type of cerebral lesions between NEC infants versus preterm infants and infants with medical vs surgical NEC. RESULTS Of 10 674 abstracts screened, 203 full-text articles were examined. In 31 studies (n=2403 infants with NEC), NDI incidence was 40% (IQR 28%-64%) and was higher in infants with surgically treated NEC (43%) compared with medically managed NEC (27%, p<0.00001). The most common NDI in NEC was cerebral palsy (18%). Cerebral lesions: intraventricular haemorrhage (IVH) was more common in NEC babies (26%) compared with preterm infants (18%; p<0.0001). There was no difference in IVH incidence between infants with surgical NEC (25%) and those treated medically (20%; p=0.4). The incidence of periventricular leukomalacia (PVL) was significantly increased in infants with NEC (11%) compared with preterm infants (5%; p<0.00001). CONCLUSIONS This study shows that a large proportion of NEC survivors has NDI. NEC babies are at higher risk of developing IVH and/or PVL than babies with prematurity alone. The degree of NDI seems to correlate to the severity of gut damage, with a worse status in infants with surgical NEC compared with those with medical NEC. TRIAL REGISTRATION NUMBER CRD42019120522.
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Affiliation(s)
- Andreea Matei
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Louise Montalva
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alexa Goodbaum
- Division of General and Thoracic Surgery, Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Giuseppe Lauriti
- Department of Pediatric Surgery, Spirito Santo Hospital, Pescara, Italy.,G. d'Annunzio University, Chieti-Pescara, Italy
| | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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Intestinal Oxygenation and Survival After Surgery for Necrotizing Enterocolitis: An Observational Cohort Study. Ann Surg 2020; 275:e503-e510. [PMID: 32324690 DOI: 10.1097/sla.0000000000003913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess whether regional intestinal oxygen saturation (rintSO2) and regional cerebral oxygen saturation (rcSO2) measurements aid in estimating survival of preterm infants after surgery for NEC. SUMMARY OF BACKGROUND DATA Predicting survival after surgery for NEC is difficult yet of the utmost importance for counseling parents. METHODS We retrospectively studied prospectively collected data of preterm infants with surgical NEC who had available rintSO2 and rcSO2 values measured via near-infrared spectroscopy 0-24 hours preoperatively. We calculated mean rintSO2 and rcSO2 for 60-120 minutes for each infant. We analyzed whether preoperative rintSO2 and rcSO2 differed between survivors and non-survivors, determined cut-off points, and assessed the added value to clinical variables. RESULTS We included 22 infants, median gestational age 26.9 weeks [interquartile range (IQR): 26.3-28.4], median birth weight 1088 g [IQR: 730-1178]. Eleven infants died postoperatively. Preoperative rintSO2, but not rcSO2, was higher in survivors than in non-survivors [median: 63% (IQR: 42-68) vs 29% (IQR: 21-43), P < 0.01), with odds ratio for survival 4.1 (95% confidence interval, 1.2-13.9, P = 0.02) per 10% higher rintSO2. All infants with rintSO2 values of >53% survived, whereas all infants with rintSO2 <35% died. Median C-reactive protein [138 mg/L (IQR: 83-179) vs 73 mg/L (IQR: 12-98), P < 0.01), lactate [1.1 mmol/L (IQR: 1.0-1.6) vs 4.6 mmol/L (IQR: 2.8-8.0), P < 0.01], and fraction of inspired oxygen [25% (IQR: 21-31) vs 42% (IQR: 30-80), P < 0.01] differed between survivors and non-survivors. Only rintSO2 remained significant in the multiple regression model. CONCLUSIONS Measuring rintSO2, but not rcSO2, seems of added value to clinical variables in estimating survival of preterm infants after surgery for NEC. This may help clinicians in deciding whether surgery is feasible and to better counsel parents about their infants' chances of survival.
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13
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Shi C, Jin T, Guo D, Zhang W, Yang B, Su D, Xia X. Citral Attenuated Intestinal Inflammation Induced by Cronobacter sakazakii in Newborn Mice. Foodborne Pathog Dis 2020; 17:243-252. [DOI: 10.1089/fpd.2019.2729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Chao Shi
- College of Food Science and Engineering, Northwest A&F University, Yangling, China
| | - Tong Jin
- College of Food Science and Engineering, Northwest A&F University, Yangling, China
| | - Du Guo
- College of Food Science and Engineering, Northwest A&F University, Yangling, China
| | - Wenting Zhang
- College of Food Science and Engineering, Northwest A&F University, Yangling, China
| | - Baowei Yang
- College of Food Science and Engineering, Northwest A&F University, Yangling, China
| | - Dongfang Su
- Department of Clinical Nutrition, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiaodong Xia
- College of Food Science and Engineering, Northwest A&F University, Yangling, China
- National Engineering Research Center of Seafood, Dalian Polytechnic University, Dalian, China
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14
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Meister AL, Doheny KK, Travagli RA. Necrotizing enterocolitis: It's not all in the gut. Exp Biol Med (Maywood) 2019; 245:85-95. [PMID: 31810384 DOI: 10.1177/1535370219891971] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Necrotizing enterocolitis is the leading cause of death due to gastrointestinal disease in preterm neonates, affecting 5–12% of neonates born at a very-low birth weight. Necrotizing enterocolitis can present with a slow and insidious onset, with some neonates displaying early symptoms such as feeding intolerance. Treatment during the early stages includes bowel rest and careful use of antibiotics, but surgery is required if pneumoperitoneum and intestinal perforation occur. Mortality rates among neonates requiring surgery are estimated to be 20–30%, mandating the development of non-invasive and reliable biomarkers to predict necrotizing enterocolitis before the onset of clinical signs. Such biomarkers would allow at-risk neonates to receive maximal preventative therapies such as careful nutritional consideration, probiotics, and increased skin-to-skin care.Impact statementNecrotizing enterocolitis (NEC) is a devastating gastrointestinal disease; its high mortality rate mandates the development of non-invasive biomarkers to predict NEC before its onset. This review summarizes the pathogenesis, prevention, unresolved issues, and long-term outcomes of NEC.
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Affiliation(s)
- Alissa L Meister
- Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Kim K Doheny
- Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, PA, USA.,Neonatal-Perinatal Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - R Alberto Travagli
- Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, PA, USA
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15
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Fredriksson F, Engstrand Lilja H. Survival rates for surgically treated necrotising enterocolitis have improved over the last four decades. Acta Paediatr 2019; 108:1603-1608. [PMID: 30825252 PMCID: PMC6767135 DOI: 10.1111/apa.14770] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 02/03/2019] [Accepted: 02/27/2019] [Indexed: 12/12/2022]
Abstract
Aim Improved survival rates for premature infants have also increased the population at risk of necrotising enterocolitis (NEC). This study evaluated the outcomes of surgically treated NEC and identified risk factors for mortality, intestinal failure (IF) and IF associated liver disease (IFALD). Methods This was a retrospective observational study of 131 infants with surgically treated NEC from 1976 to 2016 in a Swedish tertiary referral centre: 20 in 1976–1996, 33 in 1997–2006 and 78 in 2007–2016. Data were extracted from medical records, and the Cox regression model was used to identify risk factors. Results When the first and last periods were compared, they showed decreases in both gestational age, from 30 to 26 weeks, and mortality rates, from 45% to 29%. IF was found in 67 patients (56%), IFALD in 41 patients (34%) and short bowel syndrome (SBS) in 13 (19%). The incidence of IF was high, even in infants without SBS. Low gestational age was an independent risk factor for mortality. No risk factors were identified for IF or IFALD. Conclusion Survival rates for NEC improved from 1976–2016, despite a decrease in gestational age. Clinicians should be particularly aware of the risk of infants without SBS developing IF.
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Affiliation(s)
- F Fredriksson
- Department of Women's and Children's Health Section of Pediatric Surgery Uppsala University Uppsala Sweden
| | - H Engstrand Lilja
- Department of Women's and Children's Health Section of Pediatric Surgery Uppsala University Uppsala Sweden
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16
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Magnusson A, Ahle M, Andersson RE, Swolin-Eide D, Elfvin A. Increased risk of rickets but not fractures during childhood and adolescence following necrotizing enterocolitis among children born preterm in Sweden. Pediatr Res 2019; 86:100-106. [PMID: 30970375 DOI: 10.1038/s41390-019-0390-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/24/2019] [Accepted: 03/26/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim was to clarify whether children born preterm with a history of necrotizing enterocolitis (NEC) had an increased risk of rickets, fractures, and/or vitamin D deficiency during childhood and adolescence compared to controls without NEC, matched for gestational age. METHODS All infants born in Sweden between 1987 and 2009 with a gestational age <32 + 0 weeks and a diagnosis of NEC were identified. Totally, 465 children with a history of NEC and 2127 controls were included. International Classification of Diseases codes for all categories of fractures, rickets, vitamin D deficiency, and malnutrition were analyzed. RESULTS In total, 94 of the 465 children with NEC died within 28 days. Of the 2127 controls, 288 died within 28 days. Among the remaining 371 NEC cases, 39 fracture occasions were identified. The 1839 controls had 204 fracture occasions. There was no significant difference in fractures. Rickets was diagnosed in 11 (3%) of the children with a history of NEC compared to 21 (1%) of the controls (odds ratio 2.65, 95% CI 1.26-5.53, p = 0.007). CONCLUSIONS This study showed an increased risk of rickets but not fractures during childhood and adolescence in children born preterm and with a history of NEC, compared to matched controls.
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Affiliation(s)
- Amanda Magnusson
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Margareta Ahle
- Department of Medical and Health Sciences, Division of Radiology, Faculty of Health Sciences, Linköping University, Linköping, Sweden.,Department of Radiology in Linköping, County Council of Östergötland, Linköping, Sweden
| | - Roland E Andersson
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Jönköping, Sweden.,Department of Surgery, County Hospital Ryhov, Jönköping, Sweden
| | - Diana Swolin-Eide
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Pediatrics, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Department of Pediatrics, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden.
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17
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Hau EM, Meyer SC, Berger S, Goutaki M, Kordasz M, Kessler U. Gastrointestinal sequelae after surgery for necrotising enterocolitis: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2019; 104:F265-F273. [PMID: 29945925 DOI: 10.1136/archdischild-2017-314435] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 05/26/2018] [Accepted: 05/28/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To document what types of gastrointestinal sequelae were described after surgery for necrotising enterocolitis (NEC) and to analyse their frequency. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, EMBASE and the Cochrane library (CENTRAL) from 1990 to October 2016. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included studies, which provided original data on the occurrence of gastrointestinal sequelae in patients surviving surgery for NEC. Meta-analysis and metaregression to assess heterogeneity were performed for studies including 10 or more patients with gastrointestinal strictures, recurrence of NEC, intestinal failure (IF) and adhesion ileus. RESULTS Altogether 58 studies, including 4260 patients, met the inclusion criteria. Strictures were reported to occur in 24% (95% CI 17% to 31%) of surviving patients, recurrence of NEC in 8% (95% CI 3% to 15%), IF in 13% (95% CI 7% to 19%) and adhesion ileus in 6% (95% CI 4% to 9%). Strictures were more common following enterostomy (30%; 95% CI 23% to 37%) than after primary anastomosis (8%; 95% CI 0% to 23%) and occurred more often after enterostomy without bowel resection than with bowel resection. We found considerable heterogeneity in the weighted average frequency of all sequelae (I2 range: 38%-90%). Intestinal outcomes were poorly defined, there were important differences in study populations and designs, and the reported findings bear a substantial risk of bias. CONCLUSIONS Gastrointestinal sequelae in neonates surviving surgery for NEC are frequent. Long-term follow-up assessing defined gastrointestinal outcomes is warranted.
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Affiliation(s)
- Eva-Maria Hau
- Department of Pediatric Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sarah C Meyer
- Department of Pediatric Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Steffen Berger
- Department of Pediatric Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Myrofora Goutaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marcin Kordasz
- Department of Pediatric Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ulf Kessler
- Department of Pediatric Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Center of Visceral Surgery, Klinik Beau-Site, Hirslanden, Bern, Switzerland
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Abstract
PURPOSE OF REVIEW Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality among premature neonates. Although randomized trials have shown that probiotics may be efficacious in the prevention of NEC, their use has not been universally adopted in the neonatal intensive care unit (NICU). Caveats regarding routine probiotic supplementation for the prevention of NEC are summarized in this review. RECENT FINDINGS Accumulating evidence indicates that prophylactic probiotic supplementation in preterm infants can reduce the incidence of NEC. However, substantial knowledge gaps, regulatory issues, and implementation challenges should be addressed before probiotics are introduced as standard of care for all preterm neonates. Limitations of published trial data have made it challenging to define regimens that optimize efficacy and safety in specific patient subgroups. Moreover, the current probiotic market lacks rigorous regulatory oversight, which could raise concerns about the quality and safety of probiotic products. Finally, implementation pitfalls include risks of cross-colonization and resource requirements to monitor and mitigate potential adverse events. SUMMARY Probiotics have shown promise in the prevention of NEC. However, there is insufficient evidence to guide the selection of optimal regimens. Furthermore, issues related to regulatory and institutional oversight should be addressed before supplementation is routinely implemented in NICUs.
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19
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Karila K, Anttila A, Iber T, Pakarinen M, Koivusalo A. Intestinal failure associated cholestasis in surgical necrotizing enterocolitis and spontaneous intestinal perforation. J Pediatr Surg 2019; 54:460-464. [PMID: 30413273 DOI: 10.1016/j.jpedsurg.2018.10.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 09/07/2018] [Accepted: 10/07/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgery for necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) is often complicated by intestinal failure (IF) and intestinal failure associated cholestasis (IFAC). OBJECTIVE Assessment of incidence, predictors, and mortality associated with IFAC in surgically treated NEC and SIP. METHODS A retrospective observational study based on hospital records during 1986-2014 in the two largest Finnish neonatal intensive care units was performed. IFAC was defined as conjugated bilirubin >34 μmol/l (2.0 mg/dl) for ≥ two postoperative weeks while receiving parenteral nutrition (PN). RESULTS In total 225 patients underwent surgery for NEC (n = 142; 63%) or SIP (n = 83; 37%). Included were 57 survivors with ≥two weeks PN. Sixty-five (42%) patients developed IFAC. Two-year survival with IFAC was 80% and without IFAC 89% (p = 0.13). Of the 65 patients with IFAC, all eight with unresolved IFAC died in comparison to six of 57 (11%) whose IFAC resolved (p < 0.0001), while IFAC resolved in all survivors. Survival among patients with resolved IFAC was 89% and with unresolved IFAC (n = 8) 0%, (p < 0.0001). IFAC lasted for median 83 (IQR 45-120) days and correlated with the duration of PN (R2 = 0.16, p = 0.03), delay of starting enteral feeds (R2 = 0.12, p = 0.05) and PN lipid emulsion (RR = 1.0 (95% CI = 1.0-1.1) (p = 0.02). In multivariate logistic regression analysis, IFAC development associated with septicemias and reoperations. CONCLUSIONS 42% of prematures who underwent surgery for NEC or SIP developed IFAC. Reoperations and septicemias increased the risk of IFAC. None of the patients with unresolved IFAC survived, but IFAC did not increase overall mortality. TYPE OF STUDY Retrospective prognosis study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
| | | | - Tarja Iber
- Children's Hospital, University of Tampere, Finland.
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20
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Bazacliu C, Neu J. Necrotizing Enterocolitis: Long Term Complications. Curr Pediatr Rev 2019; 15:115-124. [PMID: 30864508 DOI: 10.2174/1573396315666190312093119] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 02/27/2019] [Accepted: 03/04/2019] [Indexed: 12/21/2022]
Abstract
Necrotizing enterocolitis (NEC) remains the most threatening gastrointestinal complication of prematurity leading to high mortality, morbidity and cost. Common complications of NEC include neurodevelopmental delay, failure to thrive, gastrointestinal problems including strictures and adhesions, cholestasis, short bowel syndrome with or without intestinal failure that can be difficult to manage. Infants who develop NEC benefit from close follow-up for early diagnosis and treatment of complications. Those who present with severe complications such as intestinal failure benefit from a multidisciplinary approach involving careful assessment and treatment. Studies done so far are limited in providing a long-term prognosis. Here we review some of these complications. More studies with a longer follow-up period are needed to better understand the later comorbidities that develop in babies with NEC.
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Affiliation(s)
- Catalina Bazacliu
- Department of Pediatrics, Division of Neonatology, University of Florida, Florida, United States
| | - Josef Neu
- Department of Pediatrics, Division of Neonatology, University of Florida, Florida, United States
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21
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Trivić I, Mlakar AS, Hojsak I. The Role of Probiotics in the Prevention of Necrotizing Enterocolitis. Curr Pediatr Rev 2019; 15:88-91. [PMID: 30582482 DOI: 10.2174/1573396315666181224123223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 10/10/2018] [Accepted: 12/14/2018] [Indexed: 01/18/2023]
Abstract
Necrotizing enterocolitis (NEC) is a frequent and severe life-threatening disease affecting the gastrointestinal tract of preterm infants. Given that NEC occurs in a well-defined population of patients, there might be a considerable benefit in identifying specific pharmacological and nutritional preventive strategies, that could reduce the incidence of NEC. Amongst nutritional strategies emphasis has been put on the use of probiotics. Therefore, the aim of this review is to summarize currently available evidence on the role of probiotics in general, as well as the role of specific probiotic strains or their combinations, in the prevention of NEC.
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Affiliation(s)
| | - Ana Savić Mlakar
- Center for Research and Knowledge Transfer in Biotechnology, University of Zagreb, Zagreb, Croatia
| | - Iva Hojsak
- Children's Hospital Zagreb, Zagreb, Croatia.,University of Zagreb, School of Medicine, Zagreb, Croatia.,University J.J. Strossmayer, School of Medicine Osijek, Osijek, Croatia
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22
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Karila K, Anttila A, Iber T, Pakarinen M, Koivusalo A. Outcomes of surgery for necrotizing enterocolitis and spontaneous intestinal perforation in Finland during 1986-2014. J Pediatr Surg 2018; 53:1928-1932. [PMID: 30122449 DOI: 10.1016/j.jpedsurg.2018.07.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 06/12/2018] [Accepted: 07/31/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are the most common abdominal surgical conditions in preemies. Associated mortality remains high and long periods of parenteral nutrition (PN) may be required. We assessed the developments in the outcomes of surgically treated NEC and SIP in the two largest Finnish neonatal intensive care units (NICU). METHODS Retrospective observational study based on hospital records during 1986-2014. Main outcome measures were three-month survival during 1986-2000 compared with 2001-2014 and predictors of mortality. RESULTS Included were 225 patients (NICU A 131 and NICU B 94) with NEC in 142 (63%) and SIP 83 (37%). The median birth weight (BW) (870 vs 900 g) and gestation age (GA) (27 vs 27 weeks, p = 0.96) were similar in NEC and SIP. Small intestine was affected in 85% of NEC and 76% of SIP patients (p = 0.12). In 5% of patients NEC was panintestinal. Median small intestinal loss was 25% in NEC and 4.0% in SIP (p < 0.001). Ileocecal valve was resected in 29% of NEC and 14% of SIP patients (p = 0.01). Enterostomy was performed in 78% of patients and primary anastomosis in 18%; 4% died of extensive NEC without definitive surgery. Overall survival was 74% (NEC 73%, SIP 77%, p = 0.48; NICU A 82%, NICU B 65%, p = 0.003). From 1986-2000 to 2001-2014 overall survival increased from 69 to 81% (p = 0.04). Treating NICU was the strongest predictor of survival, RR = 2.8 (95% CI = 1.4-5.1), p = 0.003. CONCLUSIONS Overall survival improved significantly from the early (1986-2000) to the late (2001-2014) study period. Strongest predictor of mortality was the treating neonatal intensive care unit. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | - Tarja Iber
- Children's Hospital, University of Tampere, Finland.
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23
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Sjoberg Bexelius T, Ahle M, Elfvin A, Björling O, Ludvigsson JF, Andersson RE. Intestinal failure after necrotising enterocolitis: incidence and risk factors in a Swedish population-based longitudinal study. BMJ Paediatr Open 2018; 2:e000316. [PMID: 30613802 PMCID: PMC6307589 DOI: 10.1136/bmjpo-2018-000316] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 10/10/2018] [Accepted: 10/15/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Paediatric intestinal failure (IF) is a disease entity characterised by gut insufficiency often related to short bowel syndrome. It is commonly caused by surgical removal of a large section of the small intestine in association with necrotising enterocolitis (NEC), which usually affects premature infants. This study investigated the incidence and risk of IF in preterm infants with or without NEC. DESIGN A matched cohort study to investigate the incidence and risk factors for IF in a population-based setting in Sweden from 1987 to 2009 using the Swedish Patient Register. PARTICIPANTS Infants with a diagnosis of NEC (n=720) were matched for gestational age and year of birth with reference individuals without NEC (n=3656). The study cohort was censored at death, IF or at end of follow-up (2 years of age). We calculated HRs with 95%CIs for IF using Cox regression, adjusting for pertinent perinatal factors. RESULTS IF was 15 times more common in the infants with NEC compared with the reference infants (HR=7.2, with 95% CI 3.7 to 14.0). Other risk factors for IF were small for gestational age, extreme preterm birth and abdominal surgery. Neonatal mortality in infants with NEC decreased from 20.6% in 1987-1993 to 10.4% in 2007-2009. CONCLUSION IF was more common in the infants with NEC but was also linked to extreme preterm birth, a history of abdominal surgery and small for gestational age. IF was more common at the end of the study period, indicating that it increases when more preterm infants with NEC survive the neonatal period.
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Affiliation(s)
- Tomas Sjoberg Bexelius
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Astrid Lindgren's Children Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Margareta Ahle
- Division of Radiology, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,Department of Radiology in Linköping, Region of Östergötland, Linköping, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Oscar Björling
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden.,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK.,Department of Medicine, Columbia University College of Physicians and Surgeons, New York City, New York, USA
| | - Roland E Andersson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Surgery, County Hospital Ryhov, Jönköping, Sweden
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24
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Mϋller MJ, Paul T, Seeliger S. Necrotizing enterocolitis in premature infants and newborns. J Neonatal Perinatal Med 2017; 9:233-42. [PMID: 27589549 DOI: 10.3233/npm-16915130] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Necrotizing enterocolitis (NEC) is the most common acquired disease of the gastrointestinal tract (GIT) in premature infants and newborns. It is defined as an ulcerative inflammation of the intestinal wall. The clinical signs of incipient NEC are often very discrete, and range from localized intestinal symptoms to generalized signs of sepsis. NEC is classified depending on its severity into disease states according to the modified Bell's Classification. Treatment of NEC ranges, depending on its severity, from a conservative therapeutic approach to surgery with resection of the affected parts of the intestine. Mortality is considerably high in extremely small preterm infants reaching up to 42% of the affected children. Measures such as breastfeeding or alternatively nutrition with pasteurized human donor milk from a milk bank, administration of probiotics, avoidance of histamine type II receptor antagonists, and restrictive antibiotic treatment should be considered early on for prevention of NEC.
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Affiliation(s)
- M J Mϋller
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical Center Georg August University Göttingen, Germany
| | - T Paul
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical Center Georg August University Göttingen, Germany
| | - S Seeliger
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical Center Georg August University Göttingen, Germany.,St. Elisabeth Children's Hospital, Neuburg/Donau, Germany
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25
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Magnusson A, Ahle M, Swolin-Eide D, Elfvin A, Andersson RE. Population-based study showed that necrotising enterocolitis occurred in space-time clusters with a decreasing secular trend in Sweden. Acta Paediatr 2017; 106:1097-1102. [PMID: 28349558 PMCID: PMC7159790 DOI: 10.1111/apa.13851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 01/03/2017] [Accepted: 03/24/2017] [Indexed: 12/14/2022]
Abstract
Aim This study investigated space–time clustering of neonatal necrotising enterocolitis over three decades. Methods Space–time clustering analyses objects that are grouped by a specific place and time. The Knox test and Kulldorff's scan statistic were used to analyse space–time clusters in 808 children diagnosed with necrotising enterocolitis in a national cohort of 2 389 681 children born between 1987 and 2009 in Sweden. The municipality the mother lived in and the delivery hospital defined closeness in space and the time between when the cases were born – seven, 14 and 21 days – defined closeness in time. Results The Knox test showed no indication of space–time clustering at the residential level, but clear indications at the hospital level in all the time windows: seven days (p = 0.026), 14 days (p = 0.010) and 21 days (p = 0.004). Significant clustering at the hospital level was found during 1987–1997, but not during 1998–2009. Kulldorff's scan statistic found seven significant clusters at the hospital level. Conclusion Space–time clustering was found at the hospital but not residential level, suggesting a contagious environmental effect after delivery, but not in the prenatal period. The decrease in clustering over time may reflect improved routines to minimise the risk of contagion between patients receiving neonatal care.
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Affiliation(s)
- Amanda Magnusson
- Department of Pediatrics; Institution of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - Margareta Ahle
- Division of Radiology; Department of Medical and Health Sciences; Faculty of Health Sciences; Linköping University; Linköping Sweden
- Department of Radiology in Linköping; County Council of Östergötland; Linköping Sweden
| | - Diana Swolin-Eide
- Department of Pediatrics; Institution of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - Anders Elfvin
- Department of Pediatrics; Institution of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
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Li QY, An Y, Liu L, Wang XQ, Chen S, Wang ZL, Li LQ. Differences in the Clinical Characteristics of Early- and Late-Onset Necrotizing Enterocolitis in Full-Term Infants: A Retrospective Case-Control Study. Sci Rep 2017; 7:43042. [PMID: 28211488 PMCID: PMC5314368 DOI: 10.1038/srep43042] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 01/17/2017] [Indexed: 11/24/2022] Open
Abstract
Information regarding the influence of age at onset on prognosis in full-term infants with necrotizing enterocolitis (NEC) is limited, and identifying differences between the clinical characteristics of early-onset NEC (EO-NEC) and late-onset NEC (LO-NEC) may be helpful in the determination of effective management strategies. In the present study, the medical records of 253 full-term infants with NEC were reviewed, and the clinical characteristics of the EO-NEC group (n = 150) and the LO-NEC group (n = 103) were compared. Infants in the EO-NEC group were characterized by increased gestational age and higher rates of stage III NEC and peritonitis when compared with LO-NEC infants (P < 0.05). Mortality was significantly associated with stage III NEC, peritonitis, sepsis, respiratory failure and shock in univariate analysis (P < 0.05). In logistic regression analysis, peritonitis and renal failure were identified as independent risk factors for mortality in infants with EO-NEC, and peritonitis and respiratory failure were significant predictors of mortality in neonates with LO-NEC. Our finding indicated that the characteristics of the severe medical conditions identified in infants with EO-NEC were distinct from those observed in infants with LO-NEC. Peritonitis and kidney failure and peritonitis and respiratory failure were identified as risk factors for mortality in EO-NEC and LO-NEC infants, respectively.
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Affiliation(s)
- Qiu-Yu Li
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
| | - Yao An
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
| | - Li Liu
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
| | - Xue-Qiu Wang
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
| | - Shi Chen
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
| | - Zheng-Li Wang
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
| | - Lu-Quan Li
- Neonatal Diagnosis and Treatment Center, Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; China International Science and Technology Cooperation base of Child Development and Critical Disorders; Key Laboratory of Pediatrics in Chongqing. Chongqing, 400014, P.R. China
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27
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Niño DF, Sodhi CP, Hackam DJ. Necrotizing enterocolitis: new insights into pathogenesis and mechanisms. Nat Rev Gastroenterol Hepatol 2016; 13:590-600. [PMID: 27534694 PMCID: PMC5124124 DOI: 10.1038/nrgastro.2016.119] [Citation(s) in RCA: 312] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Necrotizing enterocolitis (NEC) is the most frequent and lethal disease of the gastrointestinal tract of preterm infants. At present, NEC is thought to develop in the premature host in the setting of bacterial colonization, often after administration of non-breast milk feeds, and disease onset is thought to be due in part to a baseline increased reactivity of the premature intestinal mucosa to microbial ligands as compared with the full-term intestinal mucosa. The increased reactivity leads to mucosal destruction and impaired mesenteric perfusion and partly reflects an increased expression of the bacterial receptor Toll-like receptor 4 (TLR4) in the premature gut, as well as other factors that predispose the intestine to a hyper-reactive state in response to colonizing microorganisms. The increased expression of TLR4 in the premature gut reflects a surprising role for this molecule in the regulation of normal intestinal development through its effects on the Notch signalling pathway. This Review will examine the current approach to the diagnosis and treatment of NEC, provide an overview of our current knowledge regarding its molecular underpinnings and highlight advances made within the past decade towards the development of specific preventive and treatment strategies for this devastating disease.
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MESH Headings
- Animals
- Biological Factors/therapeutic use
- Biomarkers/metabolism
- Breast Feeding
- Disease Models, Animal
- Disease Susceptibility
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/etiology
- Enterocolitis, Necrotizing/prevention & control
- Gastrointestinal Microbiome/physiology
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/etiology
- Infant, Premature, Diseases/therapy
- Probiotics/therapeutic use
- Treatment Outcome
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Affiliation(s)
- Diego F Niño
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- The Bloomberg Children's Center, 1800 Orleans Street, Baltimore, Maryland 21287, USA
| | - Chhinder P Sodhi
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- The Bloomberg Children's Center, 1800 Orleans Street, Baltimore, Maryland 21287, USA
| | - David J Hackam
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, Maryland 21287, USA
- The Bloomberg Children's Center, 1800 Orleans Street, Baltimore, Maryland 21287, USA
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Lei G, Zhang J, Wang X, Chen M. Plasma D-lactate Levels in Necrotizing Enterocolitis in Premature Infants. IRANIAN JOURNAL OF PEDIATRICS 2016; 26:e4403. [PMID: 27307969 PMCID: PMC4906561 DOI: 10.5812/ijp.4403] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 12/05/2015] [Accepted: 12/16/2015] [Indexed: 12/22/2022]
Abstract
Background D-Lactate is normally present in the blood of humans at nanomolar concentrations due to methylglyoxal metabolism; millimolar D-lactate concentrations can arise due to excess gastrointestinal microbial production. Objectives To examine the levels of plasma D-lactate in the necrotizing enterocolitis in premature infants. Patients and Methods 128 premature infants were divided into control (group I, n = 69), feeding intolerance (group II, n = 42) and NEC (group III, n = 27) groups. Plasma D-lactate levels were measured at the onset of feeding intolerance or NEC and at weeks 2-3 in control infants (group I) by ELISA. Data were analyzed using descriptive statistics, non-parametric tests and Student’s t-test. Results In groups I, II, III, median birth weights were 1845.7 ± 267.5 g, 1913.1 ± 306.5 g, and 1898.4 ± 285.3 g, median gestational ages were 34.3 ± 1.7 weeks, 33.9 ± 2.2 weeks and 35.1 ± 2.6 weeks, ages of sampling were 12.3 ± 2.9 days, 14.6 ± 3.7 days and 15.1 ± 1.8 days, respectively. The differences of median birth weights, median gestational ages and ages of sampling were not statistically significant (P > 0.05). The plasma D-lactate levels in groups I, II, III were 3.6 ± 1.9 μg/mL, 12.7 ± 8.3 μg/mL, and 35.4 ± 29.1 μg/mL, respectively, group III had higher plasma D-lactate level than groups I, II, and the difference among these groups was significant (x2 = 21.6, P < 0.01). Conclusions Plasma D-lactate significantly increased early in NEC. Plasma D-lactate levels were associated with extensive disease in NEC infants. Therefore, it could be used as a diagnosis indicator in the early stage of NEC.
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Affiliation(s)
- Guofeng Lei
- Department of Neonatal Intensive Care Unit, Sanmenxia Central Hospital, Sanmenxia, China
| | - Junping Zhang
- Department of Neonatal Intensive Care Unit, Sanmenxia Central Hospital, Sanmenxia, China
- Corresponding author: Junping Zhang, Department of Neonatal Intensive Care Unit, Sanmenxia Central Hospital, Sanmenxia, Henan 472000, China. Tel: +86-15036469906, Fax: +86-0398933151, E-mail:
| | - Xiaobing Wang
- Department of Neonatal Intensive Care Unit, Sanmenxia Central Hospital, Sanmenxia, China
| | - Meiling Chen
- Department of Neonatal Intensive Care Unit, Sanmenxia Central Hospital, Sanmenxia, China
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