Diminished vagal tone is a predictive biomarker of necrotizing enterocolitis-risk in preterm infants

Preoperative autonomic failure in neonates with critical congenital heart disease

BACKGROUND

Neonates with critical congenital heart disease (cCHD) undergo a complicated transition to ex-utero life. However, continuous monitoring of autonomic tone using heart rate variability is currently lacking.

MATERIALS AND METHODS

We retrieved continuous electrocardiograms from the time of admission or from 10 days prior to surgery for neonates with dextro-transposition of the great arteries (d-TGA) and hypoplastic left heart syndrome (HLHS). Beat-to-beat intervals (RRi) were calculated and divided into 10-min epochs. Spectral metrics, including low-frequency (LF) and high-frequency (HF) powers, as well as detrended fluctuation analysis metrics (αS, αL, RMSS, and RMSL), were computed for RRi within each epoch and averaged over 24 h. The relationship between RRi metrics and time to surgery was analyzed using linear mixed-effects models, adjusting for prenatal and postnatal factors.

RESULTS

The study included 10 neonates with HLHS and 23 with d-TGA. RRi metrics were available for 110 days. In the unadjusted models, LF power (Estimate: -4.4×10-3, P = 0.02), HF power (-4.1 x 10-2, 5 x 10-5), RMSS(-3.7 x 10-4, 8.7 x 10-3), and RMSL(-1.4× 10-3, 0.02) were all negatively associated with time to surgery, with HF power showing the strongest association. After adjusting for covariates, HF power retained its significant negative association with time (-0.04, P = 0.03). The cCHD diagnosis did not significantly influence RRi metrics.

CONCLUSIONS

In neonates with cCHD, there is a progressive decline in autonomic function leading up to surgery. RRi metrics may serve as valuable indicators of deteriorating physiology in these patients.

Noninvasive Tools to Predict Necrotizing Enterocolitis in Infants with Congenital Heart Diseases: A Narrative Review

BACKGROUND

Necrotizing enterocolitis (NEC) is the most frightening gastrointestinal emergency in newborns. Despite being primarily a disease of premature infants, neonates with congenital heart disease (CHD) are at increased risk of development. Acute and chronic hemodynamic changes in this population may lead to mesenteric circulatory insufficiency.

OBJECTIVES

In this narrative review, we describe monitoring tools, alone or in multimodal use, that may help in the early recognition of patients with CHD at major risk of NEC development.

METHODS

We focused on vital parameters, echocardiography, Doppler flowmetry, abdominal near-infrared spectroscopy (aNIRS), and abdominal ultrasound (aUS).

RESULTS

The number of studies on this topic is small and includes a wide range of patients' ages and types of CHD. Peripheral oxygen saturation (SpO2) and certain echocardiographic indices (antegrade and retrograde velocity time integral, cardiac output, etc.) do not seem to differentiate infants with further onset of NEC from those not developing it. Hypotensive events, persistent diastolic flow reversal in the descending aorta, and low mesenteric oxygen saturation (rsSO2) measured by aNIRS appear to occur more frequently in infants who later develop NEC. aUS may be helpful in the diagnosis of cardiac NEC, potentially showing air contrast tracked to the right atrium in the presence of pneumatosis.

CONCLUSIONS

This narrative review describes the current knowledge on bedside tools for the early prediction of cardiac NEC. Future research needs to further explore the use of easy-to-learn, reproducible instruments to assist patient status and monitor patient trends.

Understanding necrotizing enterocolitis endotypes and acquired intestinal injury phenotypes from a historical and artificial intelligence perspective

Necrotizing enterocolitis (NEC) remains a devastating disease in preterm and term neonates. Despite significant progress made in understanding NEC pathogenesis over the last 50 years, the inability of current definitions to discriminate the various pathophysiological processes underlying NEC has led to an umbrella term that limits clinical and research progress. In this mini review, we provide a historical perspective on how NEC definitions and pathogenesis have evolved to our current understanding of NEC endotypes. We also discuss how artificial intelligence-based approaches are influencing our knowledge of risk-factors, classification and prognosis of NEC and other neonatal intestinal injury phenotypes.

Heart Rate Variability as a Prognostic Tool for Gastroschisis Infants in the Neonatal Intensive Critical Unit

OBJECTIVE

 Gastroschisis is the most common congenital abdominal wall defect, with an increasing incidence. It results in extrusion of abdominal contents with associated delayed intestinal motility. Abnormal heart rate characteristics (HRCs) such as decreased variability occur due to the inflammatory response to sepsis in preterm infants. This study aimed to test the hypothesis that infants with gastroschisis have decreased heart rate variability (HRV) after birth and that this physiomarker may predict outcomes.

STUDY DESIGN

 We analyzed heart rate data from and clinical variables for all infants admitted with gastroschisis from 2009 to 2020.

RESULTS

 Forty-seven infants were admitted during the study period and had available data. Complex gastroschisis infants had reduced HRV after birth. For those with sepsis and necrotizing enterocolitis, abnormal HRCs occurred early in the course of illness.

CONCLUSION

 Decreased HRV was associated with complex gastroschisis. Infants in this group experienced complications that prolonged time to full enteral feeding and time on total parenteral nutrition.

KEY POINTS

· Infants with gastroschisis can be classified into two subcategories, simple and complex disease.. · Those with complex disease often require prolonged stays in the neonatal intensive care unit and costly hospitalizations. We hypothesized that infants with complex gastroschisis are more likely to have abnormal HRC due to intestinal inflammation.. · In this study, we identified associations between abnormal HRV, heart rate characteristicHRC, and the development of gastroschisis complications. Additionally, we described differences in clinical characteristics between infants with complex versus simple gastroschisis..

Prediction of outcome of hypoxic-ischemic encephalopathy in newborns undergoing therapeutic hypothermia using heart rate variability

OBJECTIVE

To assess the use of continuous heart rate variability (HRV) as a predictor of brain injury severity in newborns with moderate to severe HIE that undergo therapeutic hypothermia.

STUDY DESIGN

Two cohorts of newborns (n1 = 55, n2 = 41) with moderate to severe hypoxic-ischemic encephalopathy previously treated with therapeutic hypothermia. HRV was characterized by root mean square in the short time scales (RMSS) during therapeutic hypothermia and through completion of rewarming. A logistic regression and Naïve Bayes models were developed to predict the MRI outcome of the infants using RMSS. The encephalopathy grade and gender were used as control variables.

RESULTS

For both cohorts, the predicted outcomes were compared with the observed outcomes. Our algorithms were able to predict the outcomes with an area under the receiver operating characteristic curve of about 0.8.

CONCLUSIONS

HRV assessed by RMSS can predict severity of brain injury in newborns with HIE.

Transforming neonatal care with artificial intelligence: challenges, ethical consideration, and opportunities

Artificial intelligence (AI) offers tremendous potential to transform neonatology through improved diagnostics, personalized treatments, and earlier prevention of complications. However, there are many challenges to address before AI is ready for clinical practice. This review defines key AI concepts and discusses ethical considerations and implicit biases associated with AI. Next we will review literature examples of AI already being explored in neonatology research and we will suggest future potentials for AI work. Examples discussed in this article include predicting outcomes such as sepsis, optimizing oxygen therapy, and image analysis to detect brain injury and retinopathy of prematurity. Realizing AI's potential necessitates collaboration between diverse stakeholders across the entire process of incorporating AI tools in the NICU to address testability, usability, bias, and transparency. With multi-center and multi-disciplinary collaboration, AI holds tremendous potential to transform the future of neonatology.

State of the art review on machine learning and artificial intelligence in the study of neonatal necrotizing enterocolitis

Necrotizing Enterocolitis (NEC) is one of the leading causes of gastrointestinal emergency in preterm infants. Although NEC was formally described in the 1960's, there is still difficulty in diagnosis and ultimately treatment for NEC due in part to the multifactorial nature of the disease. Artificial intelligence (AI) and machine learning (ML) techniques have been applied by healthcare researchers over the past 30 years to better understand various diseases. Specifically, NEC researchers have used AI and ML to predict NEC diagnosis, NEC prognosis, discover biomarkers, and evaluate treatment strategies. In this review, we discuss AI and ML techniques, the current literature that has applied AI and ML to NEC, and some of the limitations in the field.

Predicting clinical outcomes using artificial intelligence and machine learning in neonatal intensive care units: a systematic review

BACKGROUND

Advances in technology, data availability, and analytics have helped improve quality of care in the neonatal intensive care unit.

OBJECTIVE

To provide an in-depth review of artificial intelligence (AI) and machine learning techniques being utilized to predict neonatal outcomes.

METHODS

The PRISMA protocol was followed that considered articles from established digital repositories. Included articles were categorized based on predictions of: (a) major neonatal morbidities such as sepsis, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and retinopathy of prematurity; (b) mortality; and (c) length of stay.

RESULTS

A total of 366 studies were considered; 68 studies were eligible for inclusion in the review. The current set of predictor models are primarily built on supervised learning and mostly used regression models built on retrospective data.

CONCLUSION

With the availability of EMR data and data-sharing of NICU outcomes across neonatal research networks, machine learning algorithms have shown breakthrough performance in predicting neonatal disease.

Autonomic measures identify stress, pain, and instability associated with retinopathy of prematurity ophthalmologic examinations

BACKGROUND

Retinopathy of prematurity (ROP) ophthalmologic examinations cause stress and pain. Infants' stress and pain can be measured non-invasively using skin conductance (SC) and high frequency heart rate variability (HF-HRV), reflecting sympathetic-mediated sweating and parasympathetic activity, respectively.

OBJECTIVES

To test the utility of SC to detect sympathetic activation during ROP examination, and the contribution of HF-HRV to predict stability post-examination.

METHODS

In this prospective, single center study, we measured SC continuously pre-, during, and post-examination, and HRV at 24 h pre-ROP examination. Clinical data included stability [apneas, bradycardias, and desaturations (A/B/Ds)], and interventions post-examination.

RESULTS

SC increased 56% above baseline during ROP examination (p = 0.001) and remained elevated post-examination (p = 0.02). Post-hoc analysis showed higher illness acuity, represented by need for respiratory support, was associated with lower HF-HRV at 24 h pre-ROP examination (p = 0.001). Linear regression indicated lower HF-HRV at 24 h pre-examination contributed to the need for higher intervention (i.e., stimulation to breathe, oxygen support) particularly among infants with higher illness acuity [F(1, 15) = 5.05, p = 0.04; β = -1.33, p = 0.04].

CONCLUSION

ROP examination induced a 2-fold increase in sympathetic activation which remained above baseline in recovery. Also, we propose that the low parasympathetic tone associated with autonomic imbalance contributes to instability and need for higher intervention to assure stabilization with A/B/D events. Our findings provide insight into the underestimation of adverse events associated with ROP examination and identification of infants who may be more vulnerable to potential sequelae following ROP examinations.

Correlation between diminished vagal tone and somatic dysfunction severity in very and extremely low birth weight preterm infants assessed with frequency spectrum heart rate variability and salivary cortisol

Osteopathic manipulative treatment (OMT) is evolving in the neonatal intensive care unit (NICU) setting. Studies showed its efficacy in length of stay and hospitalization costs reduction. Moreover, it was suggested that OMT has a modulatory effect on the preterm infants' autonomic nervous system (ANS), influencing saturation and heart rate. Even if OMT is based on the palpatory examination of the somatic dysfunctions (SD), there are controversies about its identification and clinical relevance. The objective of this study was to evaluate the inter-rater reliability, clinical characteristics, and functional correlation of the SD Grade score with the heart rate variability (HRV) and the salivary cortisol (sCor) using a multivariate linear model approach. To evaluate those features, we implemented an ad hoc SD examination for preterm infants that was performed by 2 trained osteopaths. It was based on the new variability model of SD that includes an SD Grade assessment procedure. The ANS features were assessed by frequency parameters of HRV studying high frequency (HF), low frequency (LF), and HF/LF, whereas sCor was tested with a radioimmunoassay. The ANS assessment was standardized and performed before SD testing. Sixty-nine premature infants were eligible. SD Grade showed excellent concordance between the blinded raters. Using SD Grade as a grouping variable, the infants presented differences in GA, Apgar, pathological findings, length of stay, and ventilatory assistance. In our multivariate model, HF, LF, and LF/HF resulted linearly correlated with SD Grade. Instead, sCor presented a linear correlation with 5' Apgar and respiratory distress syndrome but not with SD Grade. SD Grade was in line with the natural history of the underdevelopment due to prematurity. Our models indicate that the cardiac vagal tone is linearly related with SD Grade. This finding may improve the multidisciplinary decision making inside NICU and the management of modifiable factors, like SD, for cardiac vagal tone regulation.

Splanchnic oxygen saturation during reoxygenation with 21% or 100% O2 in newborn piglets

BACKGROUND

Increasing evidence recognizes the harm of excess oxygen to lungs, eyes, and brain of preterm infants, but not yet to the intestine. We assessed changes in splanchnic oxygenation during reoxygenation with 21% compared to 100% O₂ in a newborn piglet model of perinatal asphyxia.

METHODS

We randomized 25 piglets to control or intervention. Intervention groups underwent global hypoxia until acidosis and hypotension occurred. Piglets were reoxygenated for 30 min with 21% or 100% O₂ and observed for 9 h. We continuously measured regional splanchnic oxygen saturation (r_sSO₂) using near-infrared spectroscopy (NIRS). We calculated mean r_sSO₂ and r_sCoVar (as SD/mean). We measured PaO₂ and SaO₂, sampled from the right carotid artery.

RESULTS

Reoxygenation after global hypoxia restored r_sSO₂. Reoxygenation with 100% O₂ increased r_sSO₂ to values significantly higher than baseline. In intervention groups, r_sCoVar decreased during observation compared to baseline. We found a correlation between r_sSO₂ and PaO₂ (r = 0.420, P < 0.001) and between r_sSO₂ and SaO₂ (r = 0.648, P < 0.001) in pooled data from the entire experiment.

CONCLUSION

Reoxygenation after global hypoxia improves splanchnic oxygenation, but is associated with reduced variability of r_sSO₂. Reoxygenation with 100% O₂ exposes the intestine to hyperoxia. Splanchnic NIRS is able to detect intestinal hypoxia and hyperoxia.

IMPACT

Splanchnic oxygenation improves during reoxygenation after global hypoxia, though reoxygenation with 100% O₂ exposes the intestine to hyperoxia. Decreased variability of splanchnic oxygenation several hours after hypoxia and reoxygenation seems to be independent of the resuscitation strategy, and may indicate intestinal injury. Splanchnic NIRS monitoring was able to detect intestinal hypoxia and exposure to hyperoxia, as evidenced by a strong correlation between splanchnic oxygenation and arterial oxygen content.

In infants with congenital heart disease autonomic dysfunction is associated with pre-operative brain injury

BACKGROUND

Brain injury is a serious and common complication of critical congenital heart disease (CHD). Impaired autonomic development (assessed by heart rate variability (HRV)) is associated with brain injury in other high-risk neonatal populations.

OBJECTIVE

To determine whether impaired early neonatal HRV is associated with pre-operative brain injury in CHD.

METHODS

In infants with critical CHD, we evaluated HRV during the first 24 h of cardiac ICU (CICU) admission using time-domain (RMS 1, RMS 2, and alpha 1) and frequency-domain metrics (LF, nLF, HF, nHF). Pre-operative brain magnetic resonance imaging (MRI) was scored for injury using an established system. Spearman's correlation coefficient was used to determine the association between HRV and pre-operative brain injury.

RESULTS

We enrolled 34 infants with median birth gestational age of 38.8 weeks (IQR 38.1-39.1). Median postnatal age at pre-operative brain MRI was 2 days (IQR 1-3 days). Thirteen infants had MRI evidence of brain injury. RMS 1 and RMS 2 were inversely correlated with pre-operative brain injury.

CONCLUSIONS

Time-domain metrics of autonomic function measured within the first 24 h of admission to the CICU are associated with pre-operative brain injury, and may perform better than frequency-domain metrics under non-stationary conditions such as critical illness.

IMPACT

Autonomic dysfunction, measured by heart rate variability (HRV), in early transition is associated with pre-operative brain injury in neonates with critical congenital heart disease. These data extend our earlier findings by providing further evidence for (i) autonomic dysfunction in infants with CHD, and (ii) an association between autonomic dysfunction and brain injury in critically ill neonates. These data support the notion that further investigation of HRV as a biomarker for brain injury risk is warranted in infants with critical CHD.

Structural and functional connections between the autonomic nervous system, hypothalamic-pituitary-adrenal axis, and the immune system: a context and time dependent stress response network

The autonomic nervous system (ANS), hypothalamic-pituitary-adrenal (HPA) axis, and immune system are connected anatomically and functionally. These three systems coordinate the central and peripheral response to perceived and systemic stress signals. Both the parasympathetic and sympathetic components of the autonomic nervous system rapidly respond to stress signals, while the hypothalamic-pituitary-adrenal axis and immune system have delayed but prolonged actions. In vitro, animal, and human studies have demonstrated consistent anti-inflammatory effects of parasympathetic activity. In contrast, sympathetic activity exerts context-dependent effects on immune signaling and has been associated with both increased and decreased inflammation. The location of sympathetic action, adrenergic receptor subtype, and timing of activity in relation to disease progression all influence the ultimate impact on immune signaling. This article reviews the brain circuitry, peripheral connections, and chemical messengers that enable communication between the ANS, HPA axis, and immune system. We describe findings of in vitro and animal studies that challenge the immune system with lipopolysaccharide. Next, neuroimmune connections in animal models of chronic inflammatory disease are reviewed. Finally, we discuss how a greater understanding of the ANS-HPA-immune network may lead to the development of novel therapeutic strategies that are focused on modulation of the sympathetic and parasympathetic nervous system.

Biomarkers of gut injury in neonates - where are we in predicting necrotising enterocolitis?

Despite advances in neonatal care Necrotising Enterocolitis (NEC) continues to have a significant mortality and morbidity rate, and with increasing survival of those more immature infants the population at risk of NEC is increasing. Ischaemia, reperfusion, and inflammation underpin diseases affecting intestinal blood flow causing gut injury including Necrotising Enterocolitis. There is increasing interest in tissue biomarkers of gut injury in neonates, particularly those representing changes in intestinal wall barrier and permeability, to determine whether these could be useful biomarkers of gut injury. This article reviews current and newly proposed markers of gut injury, the available literature evidence, recent advances and considers how effective they are in clinical practice. We discuss each biomarker in terms of its effectiveness in predicting NEC onset and diagnosis or predicting NEC severity and then those that will aid in surveillance and identifying those infants are greatest risk of developing NEC.

Enteric Nervous System in Neonatal Necrotizing Enterocolitis

BACKGROUND

The pathophysiology of necrotizing enterocolitis (NEC) is not clear, but increasing information suggests that the risk and severity of NEC may be influenced by abnormalities in the enteric nervous system (ENS).

OBJECTIVE

The purpose of this review was to scope and examine the research related to ENS-associated abnormalities that have either been identified in NEC or have been noted in other inflammatory bowel disorders (IBDs) with histopathological abnormalities similar to NEC. The aim was to summarize the research findings, identify research gaps in existing literature, and disseminate them to key knowledge end-users to collaborate and address the same in future studies.

METHODS

Articles that met the objectives of the study were identified through an extensive literature search in the databases PubMed, EMBASE, and Scopus.

RESULTS

The sources identified through the literature search revealed that: (1) ENS may be involved in NEC development and post-NEC complications, (2) NEC development is associated with changes in the ENS, and (3) NEC-associated changes could be modulated by the ENS.

CONCLUSION

The findings from this review identify the enteric nervous as a target in the development and progression of NEC. Thus, factors that can protect the ENS can potentially prevent and treat NEC and post-NEC complications. This review serves to summarize the existing literature and highlights a need for further research on the involvement of ENS in NEC.

Vital signs as physiomarkers of neonatal sepsis

Neonatal sepsis accounts for significant morbidity and mortality, particularly among premature infants in the Neonatal Intensive Care Unit. Abnormal vital sign patterns serve as physiomarkers of sepsis and provide early warning of illness before overt clinical decompensation. The systemic inflammatory response to pathogens signals the autonomic nervous system, leading to changes in temperature, respiratory rate, heart rate, and blood pressure. In infants with comorbidities of prematurity, vital sign abnormalities often occur in the absence of infection, which confounds sepsis diagnosis. This review will cover the mechanisms of vital sign changes in neonatal sepsis, including the cholinergic anti-inflammatory pathway mediated by the vagus nerve, which is critical to the host response to infectious and inflammatory insults. We will also review the clinical implications of vital sign changes in neonatal sepsis, including their use in early warning scores and systems to direct clinicians to the bedside of infants with physiologic changes that might be due to sepsis. IMPACT: This manuscript summarizes and reviews the relevant literature on the physiological manifestations of neonatal sepsis and how we monitor and analyze these through vital signs and advanced analytics.

Neonatal heart rate variability: a contemporary scoping review of analysis methods and clinical applications

BACKGROUND

Neonatal heart rate variability (HRV) is widely used as a research tool. However, HRV calculation methods are highly variable making it difficult for comparisons between studies.

OBJECTIVES

To describe the different types of investigations where neonatal HRV was used, study characteristics, and types of analyses performed.

ELIGIBILITY CRITERIA

Human neonates ≤1 month of corrected age.

SOURCES OF EVIDENCE

A protocol and search strategy of the literature was developed in collaboration with the McGill University Health Center's librarians and articles were obtained from searches in the Biosis, Cochrane, Embase, Medline and Web of Science databases published between 1 January 2000 and 1 July 2020.

CHARTING METHODS

A single reviewer screened for eligibility and data were extracted from the included articles. Information collected included the study characteristics and population, type of HRV analysis used (time domain, frequency domain, non-linear, heart rate characteristics (HRC) parameters) and clinical applications (physiological and pathological conditions, responses to various stimuli and outcome prediction).

RESULTS

Of the 286 articles included, 171 (60%) were small single centre studies (sample size <50) performed on term infants (n=136). There were 138 different types of investigations reported: physiological investigations (n=162), responses to various stimuli (n=136), pathological conditions (n=109) and outcome predictor (n=30). Frequency domain analyses were used in 210 articles (73%), followed by time domain (n=139), non-linear methods (n=74) or HRC analyses (n=25). Additionally, over 60 different measures of HRV were reported; in the frequency domain analyses alone there were 29 different ranges used for the low frequency band and 46 for the high frequency band.

CONCLUSIONS

Neonatal HRV has been used in diverse types of investigations with significant lack of consistency in analysis methods applied. Specific guidelines for HRV analyses in neonates are needed to allow for comparisons between studies.

Vagal Tone and Proinflammatory Cytokines Predict Feeding Intolerance and Necrotizing Enterocolitis Risk

BACKGROUND

Necrotizing enterocolitis (NEC) is the leading cause of death due to gastrointestinal disease in preterm neonates; yet, clinicians lack reliable and noninvasive predictive tools.

PURPOSE

We aimed to test that diminished high-frequency heart rate variability (HF-HRV) and elevated levels of proinflammatory cytokines would have utility in NEC prediction.

METHODS

In this multisite prospective study, we enrolled 250 preterm (26-34 weeks' postmenstrual age [PMA]) neonates with physiological stability at 72 hours of life. HRV was measured noninvasively using electrocardiograhic data from standardized cardiorespiratory monitors at postnatal week 1 of life and weekly thereafter until 35 weeks' PMA or discharge; blood was collected for cytokines at postnatal weeks 1 and 3. NEC was diagnosed via Modified Bell's Staging Criteria.

RESULTS

HF-HRV was decreased at weeks 1 and 2 in neonates (47% females) who developed feeding intolerance or stage 2+ NEC. In addition, these neonates displayed elevated levels of IL-8 at week 1 and increased levels of IL-1β, IL-6, TNF-α, and IL-8 at week 3 of life. Low HF-HRV was associated with elevated IL-6 or IL-8 levels at weeks 1 and 3 of life. Logistic regression indicated that only HF-HRV was a significant predictor of feeding intolerance or NEC development.

IMPLICATIONS FOR PRACTICE AND RESEARCH

HRV is a promising noninvasive modality for NEC risk detection. The association of low HF-HRV with elevated proinflammatory cytokines provides evidence for a putative role of the vagal cholinergic pathway in NEC pathogenesis. Future studies should focus on application of these techniques to test clinical therapeutics.Video Abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=54.

Necrotizing Enterocolitis in Neonates With Hyperinsulinemic Hypoglycemia Treated With Diazoxide

The most common cause of persistent hypoglycemia in the neonatal period is hyperinsulinism. Severe, refractory hypoglycemia resulting from hyperinsulinism can lead to significant brain injury and permanent cognitive disability. Diazoxide is the first-line and only US Food and Drug Administration-approved, pharmacologic treatment for refractory hyperinsulinism. In recent years, the use of diazoxide in neonates with persistent hyperinsulinemic hypoglycemia has increased in the United States. Known adverse effects of diazoxide include fluid retention, hypertrichosis, neutropenia, thrombocytopenia, and more recently, pulmonary hypertension. It is currently unknown if diazoxide exposure is associated with an increased risk of necrotizing enterocolitis (NEC) in neonates. We reviewed the cases of 24 patients in a level IV NICU at Massachusetts General Hospital who received diazoxide over 12 years (April 2006-April 2018). All 24 patients received enteral diazoxide for refractory hyperinsulinemic hypoglycemia. A total of 5 patients developed NEC after initiation of diazoxide based on clinical and radiographic findings, corresponding to 20% of infants exposed to diazoxide. This is above our baseline incidence of NEC (1% for all inborn infants and 6% for all inborn very low birth weight infants). More research and monitoring are necessary to characterize the potential risk of NEC associated with the use of diazoxide in the neonatal period.

New Strategies for Necrotizing Enterocolitis Diagnosis and Prevention in Newborns

Necrotizing enterocolitis is one of the most frequent and severe gastrointestinal diseases that affect preterm newborns in Neonatal Intensive Care Units. It was firstly described in 1960s, but this clinical entity was not widely recognized until the advent of modern neonatal intensive care. The disease is characterized by submucosal edema, infiltration of intestinal wall by immune cells, specifically neutrophils and, in severe forms, wall necrosis that leads to intestinal perforation. Its incidence is inversely associated to birth weight and gestational age. Necrotizing enterocolitis has been responsible for high rates of morbidity and mortality (15-30%), despite improvements made in neonatal care in the last decades. The challenge is to optimize strategies for early diagnosis, define the best medical and surgical treatments and standardize preventive measures. Several biomarkers have been proposed for the early prediction of necrotizing enterocolitis onset in preterm newborns and can be useful not only for diagnostic purposes but also for prediction of disease progression and severity. The purpose of this paper is to illustrate the most recent evidence regarding the diagnosis and prevention of necrotizing enterocolitis. This manuscript contributes to clinical decision-making in preterm neonates at high risk of developing necrotizing enterocolitis.

Gut transit time, using radiological contrast imaging, to predict early signs of necrotizing enterocolitis

BACKGROUND

Immature gut motility in preterm neonates may be a risk factor for necrotizing enterocolitis (NEC). Using preterm pigs as a model for infants, we hypothesized that intestinal dysmotility precedes NEC development.

METHODS

Eighty-five preterm pigs were fed increasing amounts of milk diets to induce NEC lesions, as detected at autopsy on day 5. Gut transit time was determined on day 4 by x-ray imaging after oral intake of contrast solution.

RESULTS

No clinical or radiological signs of NEC were detected on day 4, but macroscopic NEC lesions were recorded in 59% of pigs (n = 50) on day 5. Relative to pigs without NEC (noNEC, n = 35), pigs with small intestinal lesions (siNEC, n = 18) showed delayed stomach emptying time (StEmpty) and time for contrast to reach cecum (ToCecum) already on day 4. Pigs with lesions only in colon (coNEC, n = 20) showed more diarrhea, shorter ToCecum time, but longer small intestinal emptying time (SiEmpty). ToCecum time predicted siNEC and coNEC lesions with a receiver-operator characteristic area under the curve of 78-81%.

CONCLUSIONS

Region-dependent changes in gut transit time is associated with early NEC development in preterm pigs. How gut dysmotility is related to NEC in preterm infants requires further investigations.

IMPACT

Using preterm pigs as a model for preterm infants, we show that gut transit time, using serial x-ray contrast imaging, was changed in individuals with NEC-like lesions before they showed the typical radiological signs of NEC. Thus prolonged transit time across the entire gut was recorded when NEC lesions appeared in the small intestine but not when lesions were detected only in the colon. Until now, recordings of food transit have mainly investigated changes in the upper gut. Using serial x-rays, this study describes food transit across the entire gut and documents a region-dependent effect of NEC lesions on gut transit changes in preterm individuals. The findings provide proof of concept for use of x-ray contrast imaging as a tool to monitor gut transit in preterm pigs as models for infants. Delayed passage across the entire gut may be an early sign of small intestinal NEC, at least in pigs. More studies are needed to confirm relations in infants. In the future, it might be possible to use x-ray contrast imaging in preterm infants to better understand gut motility in relation to early NEC progression and need for medical NEC treatment.

Heart rate variability and inflammatory bowel disease in humans: A systematic review and meta-analysis

The autonomic nervous system (ANS) maintains homeostasis in the gastrointestinal tract, including immunity, inflammation and motility, through the brain-gut axis. To date, the associations between ANS function and inflammatory bowel disease (IBD) have been controversial and inconclusive in human studies. PubMed, Cochrane Library, and Embase were searched through February 2020 for articles reporting these association between heart rate variability (HRV), an indirect measure of ANS activity, and IBD. The standardized mean differences and 95% confidence intervals (CIs) were calculated. Ten eligible studies involving 273 ulcerative colitis patients, 167 Crohn's disease patients and 208 healthy controls were included. The values of the total power (SMD = -0.83, 95% CI = -1.44, -0.21), high frequency (SMD = -0.79, 95% CI = -1.20, -0.38), RR interval (SMD = -0.66, 95% CI = -1.04, -0.27), standard deviation of the RR intervals (SMD = -1.00, 95% CI = -1.73, -0.27), percentage of RR intervals with a greater than 50-millisecond variation (SMD = -0.82, 95% CI = -1.33, -0.30) and the square root of the mean squared differences in successive RR intervals (SMD = -0.71, 95% CI = -1.15, -0.26) of the IBD patients were lower than those of the healthy controls, and moderate to large effect sizes were observed in all HRV indices, except for low frequency (SMD = -0.41, 95% CI = 0.95, 0.13). IBD was strongly associated with an overall decrease in HRV, indicating substantially decreased ANS activity. Furthermore, the parasympathetic nerve displayed a stronger inverse association with ANS activity than the sympathetic nerve, indicating ANS dysfunction in patients with IBD.

Heart Rate Variability in the Perinatal Period: A Critical and Conceptual Review

Neonatal intensive care units (NICUs) greatly expand the use of technology. There is a need to accurately diagnose discomfort, pain, and complications, such as sepsis, mainly before they occur. While specific treatments are possible, they are often time-consuming, invasive, or painful, with detrimental effects for the development of the infant. In the last 40 years, heart rate variability (HRV) has emerged as a non-invasive measurement to monitor newborns and infants, but it still is underused. Hence, the present paper aims to review the utility of HRV in neonatology and the instruments available to assess it, showing how HRV could be an innovative tool in the years to come. When continuously monitored, HRV could help assess the baby’s overall wellbeing and neurological development to detect stress-/pain-related behaviors or pathological conditions, such as respiratory distress syndrome and hyperbilirubinemia, to address when to perform procedures to reduce the baby’s stress/pain and interventions, such as therapeutic hypothermia, and to avoid severe complications, such as sepsis and necrotizing enterocolitis, thus reducing mortality. Based on literature and previous experiences, the first step to efficiently introduce HRV in the NICUs could consist in a monitoring system that uses photoplethysmography, which is low-cost and non-invasive, and displays one or a few metrics with good clinical utility. However, to fully harness HRV clinical potential and to greatly improve neonatal care, the monitoring systems will have to rely on modern bioinformatics (machine learning and artificial intelligence algorithms), which could easily integrate infant’s HRV metrics, vital signs, and especially past history, thus elaborating models capable to efficiently monitor and predict the infant’s clinical conditions. For this reason, hospitals and institutions will have to establish tight collaborations between the obstetric, neonatal, and pediatric departments: this way, healthcare would truly improve in every stage of the perinatal period (from conception to the first years of life), since information about patients’ health would flow freely among different professionals, and high-quality research could be performed integrating the data recorded in those departments.

Mechanisms of bradycardia in premature infants: Aerodigestive-cardiac regulatory-rhythm interactions

OBJECTIVE

Eating difficulties coupled with cardiorespiratory spells delay acquisition of feeding milestones in convalescing neonates, and the mechanisms are unclear. Aims were to examine and compare the pharyngoesophageal-cardiorespiratory (PECR) response characteristics: (a) in control neonates and those with recurrent bradycardia spells; and (b) during pharyngeal stimulation when bradycardia occurs versus when no bradycardia occurs.

METHODS

Preterm infants (N = 40, 27 ± 3 weeks gestation), underwent concurrent pharyngoesophageal manometry, electrocardiography, respiratory inductance plethysmography, and nasal airflow thermistor to evaluate pharyngoesophageal motility, heart rate (HR), and respiration during graded abrupt pharyngeal sterile water stimuli. Infants with recurrent bradycardia (N = 28) and controls (N = 12) were evaluated at 38 (38-40) and 39 (38-40) weeks postmenstrual age, respectively. Comparisons were performed (a) between study and control groups; and (b) among HR responses of <80 BPM, 80-100 BPM, and >100 BPM.

RESULTS

Overall, characteristics of PECR responses in infants with a history of recurrent bradycardia (vs. controls) did not differ (p > .05). However, when pharyngeal stimulus induced severe bradycardia (<80 BPM): prolonged respiratory rhythm change, increased pharyngeal activity, increased esophageal dysmotility (as evidenced by prolonged esophageal inhibition and motor activity), and prolonged lower esophageal sphincter relaxation were noted (all p < .05).

CONCLUSIONS

In control infants and those with recurrent bradycardia, pharyngeal stimulation results in similar PECR response characteristics. However, when severe bradycardia occurs, PECR response characteristics are distinct. The mechanisms of severe bradycardia spells are related to abnormal prolongation of vagal inhibitory effects on cardiorespiratory rhythms in conjunction with prolonged esophageal inhibition and delays with terminal swallow.

Effect of EKG Sampling Rate on Heart Rate Variability Analysis

We studied the effect of EKG sampling rate on heart rate variability (HRV) analysis. We acquired EKG from four term hypoxic-ischemic encephalopathic infants undergoing therapeutic hypothermia. The EKG signal was acquired continuously for 4 days from the cardiorespiratory monitor through the analog port. The following HRV metrics were calculated: normalized low-frequency (nLF), normalized high-frequency (nHF), low-frequency (LF), high-frequency (HF), short-term detrended fluctuation analysis (DFA) exponent (α_s), long-term DFA exponent (α_L), root mean square (RMS) short (RMSS), and RMS long (RMSL). In addition, heart rate was used. These metrics were calculated for EKG acquired at 1 KHz (served as reference, EKGref) as well as from EKGs downsampled at 500 Hz (EKG₅₀₀), 250 Hz (EKG₂₅₀), and 125 Hz (EKG₁₂₅). The bedside monitors were simultaneously sending the EKG to a data warehouse, storing the EKG (EKG_DWH) at 250 Hz. All HRV metrics were also calculated for the EKG_DWH. The comparison between HRV metrics calculated from EKG_ref and downsampled EKG (EKG₅₀₀, EKG₂₅₀, EKG₁₂₅) was made with intraclass correlation coefficient (r). The comparisons of HRV metrics between EKG₂₅₀ and EKG_DWH were also made with ICC. Our results show that HRV calculated with EKG_ref and from downsampled EKG were highly correlated (r>0.8 for all comparisons, P<; 0.001). HRV metrics from EKG₂₅₀ and EKG_DWH were also significantly correlated (r=0.7, P<; 0.001) for all metrics except for HF (r=0.276). These data show that HF power is compromised in the EKG_DWH signal and caution must be exercised in interpreting the HF power calculated from this EKG.

Continuous vital sign analysis for predicting and preventing neonatal diseases in the twenty-first century: big data to the forefront

In the neonatal intensive care unit (NICU), heart rate, respiratory rate, and oxygen saturation are vital signs (VS) that are continuously monitored in infants, while blood pressure is often monitored continuously immediately after birth, or during critical illness. Although changes in VS can reflect infant physiology or circadian rhythms, persistent deviations in absolute values or complex changes in variability can indicate acute or chronic pathology. Recent studies demonstrate that analysis of continuous VS trends can predict sepsis, necrotizing enterocolitis, brain injury, bronchopulmonary dysplasia, cardiorespiratory decompensation, and mortality. Subtle changes in continuous VS patterns may not be discerned even by experienced clinicians reviewing spot VS data or VS trends captured in the monitor. In contrast, objective analysis of continuous VS data can improve neonatal outcomes by allowing heightened vigilance or preemptive interventions. In this review, we provide an overview of the studies that have used continuous analysis of single or multiple VS, their interactions, and combined VS and clinical analytic tools, to predict or detect neonatal pathophysiology. We make the case that big-data analytics are promising, and with continued improvements, can become a powerful tool to mitigate neonatal diseases in the twenty-first century.

Necrotizing enterocolitis: It's not all in the gut

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 statement

Necrotizing 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.

Ghrelin ameliorates the phenotype of newborn rats induced with mild necrotizing enterocolitis

BACKGROUND

We have shown previously that an attenuated rodent model of mild necrotizing enterocolitis (NEC) increases intestinal histopathological severity grade, prevents typical developmental increases in the high-frequency spectrum of heart rate variability (HF-HRV), alters the nitrergic myenteric phenotype, and increases IL-6 and IL-1β when combined with anterior subdiaphragmatic vagotomy. The aims of the present study were to test the hypotheses that in mild NEC-induced pups, administration of the orexigenic hormone ghrelin (a) reduces the histopathological score, (b) increases the HF-HRV power, (c) improves the altered myenteric phenotype, and (d) subdiaphragmatic vagotomy prevents the effects of ghrelin.

METHODS

Newborn Sprague Dawley rats were subjected to seven days of brief periods of cold stress and hypoxia to induce mild NEC with or without anterior subdiaphragmatic vagotomy. HRV was measured at postnatal days one, five, and ten; intraperitoneal ghrelin (0.05 mg kg^-1 ) was administered postnatal days five through ten b.i.d. Pups were sacrificed at day 12, and whole brains, gastrointestinal tissues, and blood were collected for immunohistochemical, corticosterone, and cytokine analysis.

KEY RESULTS

Ghrelin treatment reduced the intestinal histopathological score, increased the HF-HRV power, improved the altered intestinal myenteric phenotype, and subdiaphragmatic vagotomy prevented the effects of ghrelin. There were no differences in serum cytokines or corticosterone between groups.

CONCLUSIONS AND INFERENCES

Our data suggest that ghrelin administration is able to recover the mild NEC-induced changes to the histology, HF-HRV, and myenteric phenotype in a vagally dependent manner.

Heart Rate Variability during Periods of Low Blood Pressure as a Predictor of Short-Term Outcome in Preterms

Efficient management of low blood pressure (BP) in preterm neonates remains challenging with a considerable variability in clinical practice. The ability to assess preterm wellbeing during episodes of low BP will help to decide when and whether hypotension treatment should be initiated. This work aims to investigate the relationship between heart rate variability (HRV), BP and the short-term neurological outcome in preterm infants less than 32 weeks gestational age (GA). The predictive power of common HRV features with respect to the outcome is assessed and shown to improve when HRV is observed during episodes of low mean arterial pressure (MAP) - with a single best feature leading to an AUC of 0.87. Combining multiple features with a boosted decision tree classifier achieves an AUC of 0.97. The work presents a promising step towards the use of multimodal data in building an objective decision support tool for clinical prediction of short-term outcome in preterms who suffer episodes of low BP.

Identifying an optimal epoch length for spectral analysis of heart rate of critically-ill infants

BACKGROUND AND OBJECTIVE

To identify the optimal epoch length for power spectral analysis of cardiac beat-to-beat intervals (BBi) in critically ill newborns.

MATERIALS AND METHOD

BBi of 49 term newborns undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy with well-defined outcomes (good outcome (n = 28): no or mild brain injury and adverse outcome (n = 21): moderate or severe brain injury or death) served as test population. A power spectrum of BBi was calculated with an autoregressive model in three different epoch lengths: 2 min, 5 min, and 10 min. Spectral power was quantified in three different frequency bands: very low-frequency (0.016-0.04 Hz), low-frequency (0.05-0.25 Hz), and high-frequency (0.3-1 Hz). In each frequency band, the absolute power and the normalized power were calculated. Furthermore, standard deviation (SDNN) of BBi was calculated. These metrics were compared between the outcome groups with a receiver operator characteristic (ROC) analysis in 3-h windows. The ROC curve area >0.7 was regarded as a significant separation.

RESULTS

The absolute spectral powers in all three epoch lengths in all three frequency bands and SDNN distinguished the two outcome groups consistently for most time points. The spectral metrics calculated with a 2-min epoch length performed as well as the five- and 10-min epoch lengths (paired t-test P < 0.05).

CONCLUSION

Spectral analysis of BBi in 2-min epoch shows a similar discriminatory power as longer epoch lengths. A shorter epoch also has clinical advantages for translation into a continuous real-time bedside monitor of heart rate variability in the intensive care unit.

Prediction of short-term health outcomes in preterm neonates from heart-rate variability and blood pressure using boosted decision trees

BACKGROUND AND OBJECTIVE

Efficient management of low blood pressure (BP) in preterm neonates remains challenging with considerable variability in clinical practice. There is currently no clear consensus on what constitutes a limit for low BP that is a risk to the preterm brain. It is argued that a personalised approach rather than a population based threshold is more appropriate. This work aims to assist healthcare professionals in assessing preterm wellbeing during episodes of low BP in order to decide when and whether hypotension treatment should be initiated. In particular, the study investigates the relationship between heart rate variability (HRV) and BP in preterm infants and its relevance to a short-term health outcome.

METHODS

The study is performed on a large clinically collected dataset of 831 h from 23 preterm infants of less than 32 weeks gestational age. The statistical predictive power of common HRV features is first assessed with respect to the outcome. A decision support system, based on boosted decision trees (XGboost), was developed to continuously estimate the probability of neonatal morbidity based on the feature vector of HRV characteristics and the mean arterial blood pressure.

RESULTS

It is shown that the predictive power of the extracted features improves when observed during episodes of hypotension. A single best HRV feature achieves an AUC of 0.87. Combining multiple HRV features extracted during hypotensive episodes with the classifier achieves an AUC of 0.97, using a leave-one-patient-out performance assessment. Finally it is shown that good performance can even be achieved using continuous HRV recordings, rather than only focusing on hypotensive events - this had the benefit of not requiring invasive BP monitoring.

CONCLUSIONS

The work presents a promising step towards the use of multimodal data in providing objective decision support for the prediction of short-term outcome in preterm infants with hypotensive episodes.

Evaluation of the autonomic nervous system by analysis of heart rate variability in the preterm infants

BACKGROUND

Premature infants may present with damage to the autonomic nervous system (ANS), which may be related to poorer neurological development. Among the techniques used to evaluate the ANS, heart rate variability (HRV) emerged as a simple, non-invasive, and easy to apply tool. The aim of the present study was to analyze and compare HRV in preterm infants at different times of hospitalization in order to verify the possible environmental relationships or clinical evolution with HRV.

METHODS

A longitudinal, prospective, and descriptive study with non-probabilistic sampling composed of 25 collections of preterm infants of HRV at two moments: moment I (within 15 days of birth) and moment II (after 45 days post-birth). The Polar V800 heart rate monitor was used with the Polar H10 cardiac transducer to collect HRV, which was collected in the supine position for 15 min. The HRV data were analyzed by the linear method in frequency domain and time domain and by the nonlinear method using Kubios HRV analysis software, version 3.0.2.

RESULTS

There was an increase in HRV values at moment II, these being statistically significant in the SD1, ApEn, and SampEn. Data related to increased sympathetic nervous system activity, parasympathetic nervous system activity, and increased index complexity.

CONCLUSIONS

The data demonstrate an increase in HRV values in premature infants at moment II, demonstrating a possible development in the maturation of the ANS during hospitalization.

TRIAL REGISTRATION

RBR-3x7gz8 retrospectively registered.

Correlation between the motility of the proximal antrum and the high-frequency power of heart rate variability in freely moving rats

BACKGROUND

Cardiac vagal tone can be monitored non-invasively via electrocardiogram measurements of the high-frequency power spectrum of heart rate variability (HF-HRV). Vagal inputs to the upper GI tract are cumbersome to measure non-invasively. Although cardiac and GI vagal outputs arise from distinct brainstem nuclei, the nucleus ambiguus, and the dorsal motor nucleus of the vagus, respectively, we aim to test the hypotheses that in freely moving rats HF-HRV power is correlated to proximal antral motility and can be altered by high levels of circulating estrogen and vagal-selective treatments known to affect antral motility.

METHODS

Male and female Sprague-Dawley rats were implanted with a miniaturized strain gauge on the proximal gastric antrum and ECG electrodes to collect simultaneous antral motility and electrocardiogram. After recovery, male rats underwent baseline recordings before and after administration of saline (N = 8), cholecystokinin (CCK; N = 7), ghrelin (N = 6), or food (N = 6). Female rats (N = 6) underwent twice-daily recordings to determine baseline correlations during estrous cycle stages.

KEY RESULTS

There was a significant positive correlation between HF-HRV and proximal antral motility at baseline in males and females with low, but not high, estrogen levels. In male rats, the significant positive correlation was maintained following CCK, but not ghrelin or food administration.

CONCLUSIONS AND INFERENCES

Our data suggest that in rodents, HF-HRV positively correlates to proximal antral motility at baseline conditions in males and low-estrogen females or following interventions, such as CCK, known to affect vagal tone. This correlation is not observed when antral motility is influenced by more complex events.

Common Genetic Variants Link the Abnormalities in the Gut-Brain Axis in Prematurity and Autism

This review considers a link between prematurity and autism by comparing symptoms, physiological abnormalities, and behavior. It focuses on the bidirectional signaling between the microbiota and the brain, here defined as the microbiota-gut-vagus-heart-brain (MGVHB) axis and its systemic disruption accompanying altered neurodevelopment. Data derived from clinical and animal studies document increased prevalence of gastrointestinal, cardiovascular, cognitive, and behavioral symptoms in both premature and autistic children and suggest an incomplete maturation of the gut-blood barrier resulting in a “leaky gut,” dysbiosis, abnormalities in vagal regulation of the heart, altered development of specific brain regions, and behavior. Furthermore, this review posits the hypothesis that common genetic variants link the abnormalities in the MGVHB axis in premature and autistic pathologies. This hypothesis is based on the recently identified common genetic variants: early B cell factor 1 (EBF1), selenocysteine tRNA-specific eukaryotic elongation factor (EEFSEC), and angiotensin II receptor type 2 (AGTR2), in the maternal and infant DNA samples, associated with risk of preterm birth and independently implicated in a risk of autism. We predict that the AGTR2 variants involved in the brain maturation and oxytocin-arginine-vasopressin (OXT-AVP) pathways, related to social behavior, will contribute to our understanding of the link between prematurity and autism paving a way to new therapies.

Heart rate variability is depressed in the early transitional period for newborns with complex congenital heart disease

PURPOSE

To compare early changes in autonomic nervous system (ANS) tone between newborns with complex congenital heart disease (CHD) and newborns without CHD.

METHODS

We performed a case-control study of heart rate variability (HRV) in newborns with complex CHD [transposition of the great arteries (TGA) or hypoplastic left heart syndrome (HLHS)] and low-risk control newborns without CHD. Cases with CHD were admitted following birth to a pediatric cardiac intensive care unit and had archived continuous ECG data. Control infants were prospectively enrolled at birth. ECG data in cases and controls were analyzed for HRV in the time and frequency domains at 24 h of age. We analyzed the following HRV metrics: alpha short (α_s), alpha long (α_L), root mean square short and long (RMS_s and RMS_L), low-frequency (LF) power, normalized LF (nLF), high-frequency (HF) power, and normalized HF (nHF). We used ANOVA to compare HRV metrics between groups and to control for medication exposures.

RESULTS

HRV data from 57 infants with CHD (TGA, n = 33 and HLHS, n = 24) and from 29 controls were analyzed. The HRV metrics α_S, RMS_L, LF, and nLF were significantly lower in infants with CHD than in the controls. Due to the effect of normalization, nHF was higher in CHD infants (P < 0.0001), although absolute HF was lower (P = 0.0461). After adjusting for medications, α_S and nLF remained lower and nHF higher in newborns with CHD (P  < 0.0005).

CONCLUSIONS

Infants with complex CHD have depressed autonomic balance in the early postnatal period, which may complicate the fetal-neonatal transition.

Recent Potential Noninvasive Biomarkers in Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a rare but devastating gastrointestinal disease that predominately affects preterm neonates. Numerous studies have revealed that NEC is strongly associated with very low birth weight, degree of prematurity, formula feeding, infection, hypoxic/ischemic injury, and enteric dysbiosis. Given these clinical associations, the search for a deeper understanding of disease pathogenesis has led to an intense interest in the discovery and development of noninvasive biomarkers of NEC from stool, urine, and serum. Biomarkers for NEC may serve at least two general purposes of urgent unmet need: to improve diagnostic accuracy and disease prediction and to reveal the mechanism of the disease. This review will provide an overview of recent research focused on clinical NEC and highlight the advances that were made within the past five years towards the development of noninvasive diagnostic biomarkers.

Necrotizing enterocolitis attenuates developmental heart rate variability increases in newborn rats

BACKGROUND

We have shown previously that a decreased high-frequency spectrum of heart rate variability (HF-HRV), indicative of reduced vagal tone, shows promise in predicting neonates likely to develop necrotizing enterocolitis (NEC) before its clinical onset. We hypothesized that NEC induction in rat pups decreases HF-HRV power; subdiaphragmatic vagotomy worsens the severity of the NEC phenotype, increases levels of pro-inflammatory cytokines, and alters the myenteric phenotype.

METHODS

Newborn Sprague-Dawley rats, representative of preterm human neonates, were subjected to 7-8 days of brief periods of cold stress and hypoxia to induce NEC with or without unilateral subdiaphragmatic vagotomy. HRV was measured at postnatal days one and five, pups were sacrificed at day 8/9, and gastrointestinal tissues and blood were collected for immunohistochemical, corticosterone, and cytokine analysis.

KEY RESULTS

Compared to control, NEC-induced rats showed the following: (a) typical histological signs of grade 2 NEC, which were more severe in rats that underwent vagotomy; (b) reduced developmental increases in time (RMSSD) and frequency (HF) HRV spectra when combined with the stress of laparotomy/vagotomy; (c) increases in nitric oxide synthase-immunoreactivity in the myenteric plexus of jejunum and ileum; furthermore, compared to mild NEC and controls, vagotomized NEC rats had increased plasma values of pro-inflammatory cytokines IL-1β and IL-6.

CONCLUSIONS AND INFERENCES

Our data suggest that in rodents, similar to neonatal observations, NEC induction attenuated developmental HF-HRV increases, furthermore, subdiaphragmatic vagotomy worsened the histological severity, increased pro-inflammatory cytokines, and altered the nitrergic myenteric phenotype, suggesting a role of the vagus in the development of NEC pathology.

Early Pulse Oximetry Data Improves Prediction of Death and Adverse Outcomes in a Two-Center Cohort of Very Low Birth Weight Infants

BACKGROUND

We previously showed, in a single-center study, that early heart rate (HR) characteristics predicted later adverse outcomes in very low birth weight (VLBW) infants. We sought to improve predictive models by adding oxygenation data and testing in a second neonatal intensive care unit (NICU).

METHODS

HR and oxygen saturation (SpO2) from the first 12 hours and first 7 days after birth were analyzed for 778 VLBW infants at two NICUs. Using multivariate logistic regression, clinical predictive scores were developed for death, severe intraventricular hemorrhage (sIVH), bronchopulmonary dysplasia (BPD), treated retinopathy of prematurity (tROP), late-onset septicemia (LOS), and necrotizing enterocolitis (NEC). Ten HR-SpO2 measures were analyzed, with first 12 hours data used for predicting death or sIVH and first 7 days for the other outcomes. HR-SpO2 models were combined with clinical models to develop a pulse oximetry predictive score (POPS). Net reclassification improvement (NRI) compared performance of POPS with the clinical predictive score.

RESULTS

Models using clinical or pulse oximetry variables alone performed well for each outcome. POPS performed better than clinical variables for predicting death, sIVH, and BPD (NRI > 0.5, p < 0.01), but not tROP, LOS, or NEC.

CONCLUSION

Analysis of early HR-SpO2 characteristics adds to clinical risk factors to predict later adverse outcomes in VLBW infants.

Heart rate variability changes and its association with the development of severe retinopathy of prematurity

PURPOSE

To evaluate differences in autonomic nervous system (ANS) activity associated with the development of retinopathy of prematurity.

METHODS

Heart rate variability (HRV) as an indicator of ANS activity was calculated in two groups of premature infants: (1) a treatment group of infants who developed type 1 ROP and underwent treatment and (2) a control group of infants who did not develop ROP more severe than stage 1 and who were matched to the treatment group in terms of age, weight, and similar risk factors, including similar frequency of intraventricular hemorrhage, bronchopulmonary dysplasia, and sepsis. HRV was analyzed during the first 5 days of life, within 5 days of initial ROP examination, and within 5 days of ROP treatment for the treatment group or, for controls, on the day of last electrocardiogram data prior to discharge. Calculations were performed for the high frequency, low frequency, and low frequency-high frequency values of the HRV components for all infants.

RESULTS

Between the initial ophthalmologic evaluation and the final evaluation, there was a tendency for reduction in both the low- and high-frequency components of the HRV indices in the treatment group, whereas there was a tendency for an increase in both components of the HRV indices in the control group. The difference in the rate of change of the high frequency between groups was statistically significant (P = 0.021).

CONCLUSIONS

Disruption in ANS activity may play an important role in the development and severity of ROP.

Preterm Stress Behaviors, Autonomic Indices, and Maternal Perceptions of Infant Colic

BACKGROUND

While biological and behavioral stress response systems are intact in early gestation, preterm infants' behaviors are often more subtle and difficult to interpret compared with full-term infants. They are also more vulnerable for regulatory issues (ie, colic) that are known to impact caregiver-infant interactions. Biobehavioral measures such as behavioral responsivity and heart rate variability (HRV), particularly cardiac vagal tone, may help elucidate preterm infants' stress/regulatory systems.

PURPOSE

To test the hypotheses that preterm infants' consoling behaviors and high-frequency (HF) HRV in the first week of life are significantly associated and they are inverse correlates of future colic risk.

METHODS/SEARCH STRATEGY

Thirty preterm (mean ± SE = 32.7 ± 0.3 weeks postmenstrual age [PMA]) infants underwent direct NIDCAP (Newborn Individualized Development and Assessment Program) observation during routine care and had HRV measurements during their first week postbirth. Sixty-three percent of mothers completed the Infant Colic Scale at 6 to 8 weeks adjusted postnatal age. Nonparametric tests were used to determine associations among behaviors, HRV, and maternal perceptions of infant colic.

FINDINGS/RESULTS

Self-consoling behaviors were positively associated with HF-HRV (vagal tone). In addition, stress behaviors were positively associated with low-frequency/high-frequency HRV (sympathetic dominance). Infants who displayed more stress behaviors also demonstrated more self-consoling behaviors. No significant associations were found with colic.

IMPLICATIONS FOR PRACTICE

HF-HRV provides information on the infant's capacity to modulate stress and is a useful, noninvasive measure when behaviors are more difficult to discern.

IMPLICATIONS FOR RESEARCH

Further study in a larger sample is needed to determine whether behavioral stress measures and HF-HRV may be useful to determine colic risk.

Biomarkers of necrotizing enterocolitis: a review of literature

Necrotizing enterocolitis (NEC) is among the most serious gastrointestinal emergency in very low birth weight (VLBW), extremely low birth weight (ELBW) and extremely low gestational age neonates (ELGAN), affecting 7-14% of these neonates. Despite extensive research, the underlying aetiology of NEC still remains blurred. Due to high mortality, morbidity and its delayed presentation, early detection of NEC is considered to be lifesaving. A number of biomarkers have been studied for early detection and prediction of severity of NEC but till date, no ideal marker has been discovered. Molecular techniques like proteomic and metabolomic have recently emerged in the field for the development of biomarkers for early detection and understanding the pathophysiology of NEC. We did literature search for identifying all biomarkers that have been used for the detection of NEC and, in this review article, we discuss these biomarkers along with the available current evidence.

Biomarkers for the diagnosis of neonatal sepsis and necrotizing enterocolitis: Clinical practice guidelines

Sepsis and necrotizing enterocolitis are major contributors to morbidity and mortality in neonates, especially in those born preterm. While therapeutic interventions are available for both (for e.g. antibiotics), a major dilemma is early diagnosis so that these interventions can be done in a timely manner. As clinical evaluation alone is unreliable in identifying infants in the early stages of neonatal sepsis or necrotizing enterocolitis, there is a need to find specific biomarkers associated with these conditions to improve diagnostic capabilities. Optimal use of biomarkers in the identification and management of affected neonates requires an understanding of the properties of each marker within the timeline of the inflammatory response. We propose that early- and mid-phase markers such as neutrophil CD64 and procalcitonin should be combined with the late-phase biomarker C-reactive protein for maximal diagnostic benefit. Appropriately powered trials evaluating the serial measurements of these markers in decisions related to antibiotic stewardship in the neonatal population are indicated, in addition to more studies investigating other potentially useful biomarkers.

Electrical Grounding Improves Vagal Tone in Preterm Infants

BACKGROUND

Low vagal tone (VT) is a marker of vulnerability to stress and the risk of developing necrotizing enterocolitis in preterm infants. Electric fields produced by equipment in the neonatal intensive care unit (NICU) induce an electric potential measurable on the skin in reference to ground. An electrical connection to ground reduces the skin potential and improves VT in adults.

OBJECTIVES

We aimed to measure the electric field strengths in the NICU environment and to determine if connecting an infant to electrical ground would reduce the skin potential and improve VT. We also wished to determine if the skin potential correlated with VT.

METHODS

Environmental magnetic flux density (MFD) was measured in and around incubators. Electrical grounding (EG) was achieved with a patch electrode and wire that extended to a ground outlet. We measured the skin potential in 26 infants and heart rate variability in 20 infants before, during, and after grounding. VT was represented by the high-frequency power of heart rate variability.

RESULTS

The background MFD in the NICU was below 0.5 mG, but it ranged between 1.5 and 12.7 mG in the closed incubator. A 60-Hz oscillating potential was recorded on the skin of all infants. With EG, the skin voltage dropped by about 95%. Pre-grounding VT was inversely correlated with the skin potential. VT increased by 67% with EG. After grounding, the VT fell to the pre-grounding level.

CONCLUSION

The electrical environment affects autonomic balance. EG improves VT and may improve resilience to stress and lower the risk of neonatal morbidity in preterm infants.

Vagal neurocircuitry and its influence on gastric motility

A large body of research has been dedicated to the effects of gastrointestinal peptides on vagal afferent fibres, yet multiple lines of evidence indicate that gastrointestinal peptides also modulate brainstem vagal neurocircuitry, and that this modulation has a fundamental role in the physiology and pathophysiology of the upper gastrointestinal tract. In fact, brainstem vagovagal neurocircuits comprise highly plastic neurons and synapses connecting afferent vagal fibres, second order neurons of the nucleus tractus solitarius (NTS), and efferent fibres originating in the dorsal motor nucleus of the vagus (DMV). Neuronal communication between the NTS and DMV is regulated by the presence of a variety of inputs, both from within the brainstem itself as well as from higher centres, which utilize an array of neurotransmitters and neuromodulators. Because of the circumventricular nature of these brainstem areas, circulating hormones can also modulate the vagal output to the upper gastrointestinal tract. This Review summarizes the organization and function of vagovagal reflex control of the upper gastrointestinal tract, presents data on the plasticity within these neurocircuits after stress, and discusses the gastrointestinal dysfunctions observed in Parkinson disease as examples of physiological adjustment and maladaptation of these reflexes.

Early Heart Rate Characteristics Predict Death and Morbidities in Preterm Infants

OBJECTIVES

To determine whether an early heart rate characteristics (HRC) index (HeRO score), measured in the first day and week after birth predicts death and morbidities compared with established illness severity scores.

STUDY DESIGN

For all very low birth weight infants in a single neonatal intensive care unit from 2004-2014, the average first day HRC index was calculated within 24 hours of birth (aHRC-24h) and the average first week HRC index within 7 days of birth (aHRC-7d). The Score for Neonatal Acute Physiology (SNAP-II) and Clinical Risk Indicator for Babies (CRIB-II) were calculated when data were available. The aHRC was compared with the SNAP-II and CRIB-II for predicting death, late-onset septicemia, necrotizing enterocolitis, bronchopulmonary dysplasia, severe intraventricular hemorrhage, or severe retinopathy of prematurity.

RESULTS

All 4 scores were associated with death and severe intraventricular hemorrhage (P < .01). The OR and 95% CI for every 1-point increase in aHRC for predicting mortality, adjusted for gestational age, was 1.59 (1.25-2.00) for aHRC-24h and 2.61 (1.58-4.33) for aHRC-7d. High aHRC-7d, SNAP-II, and CRIB-II were associated with bronchopulmonary dysplasia (P < .001). High aHRC-7d was associated with late-onset septicemia (P < .05). None of the scores predicted necrotizing enterocolitis or severe retinopathy of prematurity.

CONCLUSIONS

HRC assessed in the first day or first week after birth compares favorably to established risk scores to predict death and morbidities in very low birth weight infants.

Vagal tone: effects on sensitivity, motility, and inflammation

The vagus nerve (VN) is a key element of the autonomic nervous system. As a mixed nerve, the VN contributes to the bidirectional interactions between the brain and the gut, i.e., the brain-gut axis. In particular, after integration in the central autonomic network of peripheral sensations such as inflammation and pain via vagal and spinal afferents, an efferent response through modulation of preganglionic parasympathetic neurons of the dorsal motor nucleus of the vagus and/or preganglionic sympathetic neurons of the spinal cord is able to modulate gastrointestinal nociception, motility, and inflammation. A low vagal tone, as assessed by heart rate variability, a marker of the sympatho-vagal balance, is observed in functional digestive disorders and inflammatory bowel diseases. To restore a normal vagal tone appears as a goal in such diseases. Among the therapeutic tools, such as drugs targeting the cholinergic system and/or complementary medicine (hypnosis, meditation…), deep breathing, physical exercise, VN stimulation (VNS), either invasive or non-invasive, appears as innovative. There is new evidence in the current issue of this Journal supporting the role of VNS in the modulation of gastrointestinal functions.

Can Monitoring Fetal Intestinal Inflammation Using Heart Rate Variability Analysis Signal Incipient Necrotizing Enterocolitis of the Neonate?

OBJECTIVE

Necrotizing enterocolitis of the neonate is an acute inflammatory intestinal disease that can cause necrosis and sepsis. Chorioamnionitis is a risk factor of necrotizing enterocolitis. The gut represents the biggest vagus-innervated organ. Vagal activity can be measured via fetal heart rate variability. We hypothesized that fetal heart rate variability can detect fetuses with incipient gut inflammation.

DESIGN

Prospective animal study.

SETTING

University research laboratory.

SUBJECTS

Chronically instrumented near-term fetal sheep (n = 21).

MEASUREMENTS AND MAIN RESULTS

Animals were surgically instrumented with vascular catheters and electrocardiogram to allow manipulation and recording from nonanesthetized animals. In 14 fetal sheep, inflammation was induced with lipopolysaccharide (IV) to mimic chorioamnionitis. Fetal arterial blood samples were drawn at selected time points over 54 hours post lipopolysaccharide for blood gas and cytokines (interleukin-6 and tumor necrosis factor-α enzymelinked immunosorbent assay). Fetal heart rateV was quantified throughout the experiment. The time-matched fetal heart rate variability measures were correlated to the levels of interleukin-6 and tumor necrosis factor-α. Upon necropsy, ionized calcium binding adaptor molecule 1+ (Iba1+), CD11c+ (M1), CD206+ (M2 macrophages), and occludin (leakiness marker) immunofluorescence in the terminal ileum was quantified along with regional Iba1+ signal in the brain (microglia). Interleukin-6 peaked at 3 hours post lipopolysaccharide accompanied by mild cardiovascular signs of sepsis. At 54 hours, we identified an increase in Iba1+ and, specifically, M1 macrophages in the ileum accompanied by increased leakiness, with no change in Iba1 signal in the brain. Preceding this change on tissue level, at 24 hours, a subset of nine fetal heart rate variability measures correlated exclusively to the Iba+ markers of ileal, but not brain, inflammation. An additional fetal heart rate variability measure, mean of the differences of R-R intervals, correlated uniquely to M1 ileum macrophages increasing due to lipopolysaccharide.

CONCLUSIONS

We identified a unique subset of fetal heart rate variability measures reflecting 1.5 days ahead of time the levels of macrophage activation and increased leakiness in terminal ileum. We propose that such subset of fetal heart rate variability measures reflects brain-gut communication via the vagus nerve. Detecting such noninvasively obtainable organ-specific fetal heart rate variability signature of inflammation would alarm neonatologists about neonates at risk of developing necrotizing enterocolitis and sepsis. Clinical validation studies are required.

Physical Activity and Gastric Residuals as Biomarkers for Region-Specific NEC Lesions in Preterm Neonates

BACKGROUND

Necrotizing enterocolitis (NEC) is a serious feeding-related inflammatory gut disease with high mortality. Early clinical markers of NEC are of great importance for optimizing preventive interventions.

OBJECTIVE

Using preterm pigs as models, we hypothesized that an early postnatal onset of NEC can be predicted by decreased physical activity during the first few days after birth.

METHODS

Cesarean-delivered preterm pigs were fed parenteral nutrition and increasing amounts of formula for 5 days after birth (n = 120). Their physical activity was quantified by a continuous camera surveillance system and they were evaluated twice daily for clinical signs of apathy, discoloration, respiratory distress, abdominal distension and diarrhea. The volume of gastric residuals and the presence of macroscopic NEC-like lesions in the stomach, intestine and colon were recorded at euthanasia on day 5.

RESULTS

Half of the pigs (48%) showed clear NEC-like lesions on day 5, and these individuals had more adverse clinical symptoms from day 3 but decreased physical activity already from day 2 relative to the unaffected pigs (both p < 0.05). Only animals with NEC lesions in the small intestine had lower physical activity on days 2 and 3, and the increased volume of gastric residuals was specifically related to colon lesions (both p < 0.05).

CONCLUSIONS

Decreased physical activity precedes the clinical symptoms of NEC in the small intestine of preterm pigs, and increased gastric residuals predict NEC lesions in the colon. Physical activity and gastric residuals may function as clinical biomarkers for region-specific NEC lesions in preterm neonates.

Predictive monitoring for sepsis and necrotizing enterocolitis to prevent shock

Despite vigilant clinical assessment of infants in the neonatal intensive care unit (NICU), diagnosis of sepsis and necrotizing enterocolitis often does not occur until an infant has significant hemodynamic compromise. Predictive monitoring involves analysis of vital signs and other clinical data to identify infants at highest risk and to detect early-stage illness, leading to timelier treatment and improved outcomes. The first vital-sign predictive monitoring device developed for sepsis detection in babies in the NICU is the heart rate characteristics index (HeRO) monitor, which continuously analyzes the electrocardiogram signal for low heart rate variability and transient decelerations. Use of this monitor in very low birth weight infants (<1500 g) was shown in a large multicenter randomized clinical trial to significantly reduce mortality. The purpose of this review is (1) to summarize the physiologic changes in neonatal sepsis and progression to shock, (2) to review efforts toward risk stratification for sepsis shortly after birth based on demographic and physiologic scoring systems, (3) to describe development and implementation of heart rate characteristics monitoring and other important aspects of sepsis early warning systems, and (4) to provide an overview of current research analyzing multiple vital signs and other clinical variables in an attempt to develop even more effective predictive monitoring devices and systems.