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Lee CC, Chiu CH. Link between gut microbiota and neonatal sepsis. J Formos Med Assoc 2024; 123:638-646. [PMID: 37821302 DOI: 10.1016/j.jfma.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/15/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023] Open
Abstract
In neonates, the gastrointestinal tract is rapidly colonized by bacteria after birth. Gut microbiota development is critical during the first few years of life. However, disruption of gut microbiota development in neonates can lead to gut dysbiosis, characterized by overcolonization by pathogenic bacteria and delayed or failed maturation toward increasing microbial diversity and Fermicutes dominance. Gut dysbiosis can predispose infants to sepsis. Pathogenic bacteria can colonize the gut prior to sepsis and cause sepsis through translocation. This review explores gut microbiota development in neonates, the evidence linking gut dysbiosis to neonatal sepsis, and the potential role of probiotics in gut microbiota modulation and sepsis prevention.
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Affiliation(s)
- Chien-Chung Lee
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Cheng-Hsun Chiu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan; Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
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2
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Wang Y, Florez ID, Morgan RL, Foroutan F, Chang Y, Crandon HN, Zeraatkar D, Bala MM, Mao RQ, Tao B, Shahid S, Wang X, Beyene J, Offringa M, Sherman PM, El Gouhary E, Guyatt GH, Sadeghirad B. Probiotics, Prebiotics, Lactoferrin, and Combination Products for Prevention of Mortality and Morbidity in Preterm Infants: A Systematic Review and Network Meta-Analysis. JAMA Pediatr 2023; 177:1158-1167. [PMID: 37782505 PMCID: PMC10546299 DOI: 10.1001/jamapediatrics.2023.3849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/01/2023] [Indexed: 10/03/2023]
Abstract
Importance Modulation of intestinal microbiome by administering probiotics, prebiotics, or both may prevent morbidity and mortality in premature infants. Objective To assess the comparative effectiveness of alternative prophylactic strategies through a network meta-analysis (NMA) of randomized clinical trials. Data Sources MEDLINE, EMBASE, Science Citation Index Expanded, CINAHL, Scopus, Cochrane CENTRAL, and Google Scholar from inception until May 10, 2023. Study Selection Eligible trials tested probiotics, prebiotics, lactoferrin, and combination products for prevention of morbidity or mortality in preterm infants. Data Extraction and Synthesis A frequentist random-effects model was used for the NMA, and the certainty of evidence and inferences regarding relative effectiveness were assessed using the GRADE approach. Main Outcomes and Measures All-cause mortality, severe necrotizing enterocolitis, culture-proven sepsis, feeding intolerance, time to reach full enteral feeding, and duration of hospitalization. Results A total of 106 trials involving 25 840 preterm infants were included. Only multiple-strain probiotics were associated with reduced all-cause mortality compared with placebo (risk ratio [RR], 0.69; 95% CI, 0.56 to 0.86; risk difference [RD], -1.7%; 95% CI, -2.4% to -0.8%). Multiple-strain probiotics alone (vs placebo: RR, 0.38; 95% CI, 0.30 to 0.50; RD, -3.7%; 95% CI, -4.1% to -2.9%) or in combination with oligosaccharides (vs placebo: RR, 0.13; 95% CI, 0.05 to 0.37; RD, -5.1%; 95% CI, -5.6% to -3.7%) were among the most effective interventions reducing severe necrotizing enterocolitis. Single-strain probiotics in combination with lactoferrin (vs placebo RR, 0.33; 95% CI, 0.14 to 0.78; RD, -10.7%; 95% CI, -13.7% to -3.5%) were the most effective intervention for reducing sepsis. Multiple-strain probiotics alone (RR, 0.61; 95% CI, 0.46 to 0.80; RD, -10.0%; 95% CI, -13.9% to -5.1%) or in combination with oligosaccharides (RR, 0.45; 95% CI, 0.29 to 0.67; RD, -14.1%; 95% CI, -18.3% to -8.5%) and single-strain probiotics (RR, 0.61; 95% CI, 0.51 to 0.72; RD, -10.0%; 95% CI, -12.6% to -7.2%) proved of best effectiveness in reduction of feeding intolerance vs placebo. Single-strain probiotics (MD, -1.94 days; 95% CI, -2.96 to -0.92) and multistrain probiotics (MD, -2.03 days; 95% CI, -3.04 to -1.02) proved the most effective in reducing the time to reach full enteral feeding compared with placebo. Only single-strain and multistrain probiotics were associated with greater effectiveness compared with placebo in reducing duration of hospitalization (MD, -3.31 days; 95% CI, -5.05 to -1.58; and MD, -2.20 days; 95% CI, -4.08 to -0.31, respectively). Conclusions and Relevance In this systematic review and NMA, moderate- to high-certainty evidence demonstrated an association between multistrain probiotics and reduction in all-cause mortality; these interventions were also associated with the best effectiveness for other key outcomes. Combination products, including single- and multiple-strain probiotics combined with prebiotics or lactoferrin, were associated with the largest reduction in morbidity and mortality.
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Affiliation(s)
- Yuting Wang
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Ivan D. Florez
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, University of Antioquia, Medellin, Colombia
- Pediatric Intensive Care Unit, Clínica Las Americas-AUNA, Medellin, Colombia
| | - Rebecca L. Morgan
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Farid Foroutan
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Holly N. Crandon
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Malgorzata M. Bala
- Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Randi Q. Mao
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Brendan Tao
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shaneela Shahid
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Xiaoqin Wang
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Joseph Beyene
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Philip M. Sherman
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Enas El Gouhary
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
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Darbandi A, Banar M, Koupaei M, Afifirad R, Asadollahi P, Bafandeh E, Rasooli I, Emamie A, Navidifar T, Owlia P. Clinical efficacy of probiotics in prevention of infectious diseases among hospitalized patients in ICU and non-ICU wards in clinical randomized trials: A systematic review. Health Sci Rep 2023; 6:e1469. [PMID: 37547361 PMCID: PMC10400784 DOI: 10.1002/hsr2.1469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 07/13/2023] [Accepted: 07/18/2023] [Indexed: 08/08/2023] Open
Abstract
Background and Aims The present study aimed to review probiotics' clinical efficacy in preventing infectious diseases among hospitalized patients in ICU and non-ICU wards. Methods A search of Medline, EMBASE, The Cochrane Library, Science Direct, Open Grey, and Google Scholar was conducted for eligible publications from 2002 to 2020 following the requirements outlined in the PRISMA guideline. The search strategy was based on the combination of the following terms: "probiotics," "prebiotics," "synbiotics," and "cross-infection." The logical operators "AND" (or the equivalent operator for the databases) and "OR" (e.g., probiotics OR prebiotics OR synbiotics) were used. Results The results indicated that the probiotic consumption caused a significant reduction in antibiotic-associated diarrhea (AAD) and Clostridioides difficile infection (CDI) in 2/8 randomized clinical trials (RCTs) investigating AAD/CDI. Also, 5/12 clinical trials highlighted the considerable effects of probiotics on the reduction or prevention of ventilator associated pneumoniae (VAP), so the mean prevalence of VAP was lower in the probiotic group than in the placebo group. The total rate of nosocomial infections among preterm infants was nonsignificantly higher in the probiotic group compared to the control group. Conclusion This systematic review shows that the administration of probiotics has moderate preventive or mitigating effects on the occurrence of VAP in ICU patients, CDI, AAD, and nosocomial infections among children. Consequently, applying antibiotics along with the proper probiotic species can be advantageous.
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Affiliation(s)
- Atieh Darbandi
- Molecular Microbiology Research CenterShahed UniversityTehranIran
| | - Maryam Banar
- Department of PathobiologySchool of Public Health, Tehran University of Medical SciencesTehranIran
| | - Maryam Koupaei
- Department of Microbiology and ImmunologySchool of Medicine, Kashan University of Medical SciencesKashanIran
| | - Roghayeh Afifirad
- Department of MicrobiologySchool of Medicine, Tehran University of Medical SciencesTehranIran
| | - Parisa Asadollahi
- Department of MicrobiologyFaculty of Medicine, Ilam University of Medical SciencesIlamIran
| | - Elnaz Bafandeh
- Department of Medical BiotechnologyFaculty of Medicine, Lorestan University of Medical SciencesKhorramabadIran
| | - Iraj Rasooli
- Molecular Microbiology Research Center, Faculty of SciencesShahed UniversityTehranIran
| | - Amir Emamie
- Department of PathobiologySchool of Public Health, Tehran University of Medical SciencesTehranIran
| | | | - Parviz Owlia
- Molecular Microbiology Research CenterShahed UniversityTehranIran
- Molecular Microbiology Research Center, Faculty of SciencesShahed UniversityTehranIran
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Wang K, Duan F, Sun T, Zhang Y, Lu L. Galactooligosaccharides: Synthesis, metabolism, bioactivities and food applications. Crit Rev Food Sci Nutr 2023:1-17. [PMID: 36632761 DOI: 10.1080/10408398.2022.2164244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Prebiotics are non-digestible ingredients that exert significant health-promoting effects on hosts. Galactooligosaccharides (GOS) have remarkable prebiotic effects and structural similarity to human milk oligosaccharides. They generally comprise two to eight sugar units, including galactose and glucose, which are synthesized from substrate lactose by microbial β-galactosidase. Enzyme sources from probiotics have received particular interest because of their safety and potential to synthesize specific structures that are particularly metabolized by intestinal probiotics. Owing to advancements in modern analytical techniques, many GOS structures have been identified, which vary in degree of polymerization, glycosidic linkage, and branch location. After intake, GOS adjust gut microbiota which produce short chain fatty acids, and exhibit excellent biological activities. They selectively stimulate the proliferation of probiotics, inhibit the growth and adhesion of pathogenic bacteria, alleviate gastrointestinal, neurological, metabolic and allergic diseases, modulate metabolites production, and adjust ion storage and absorption. Additionally, GOS are safe and stable, with high solubility and clean taste, and thus are widely used as food additives. GOS can improve the appearance, flavor, taste, texture, viscosity, rheological properties, shelf life, and health benefits of food products. This review systemically covers GOS synthesis, structure identifications, metabolism mechanisms, prebiotic bioactivities and wide applications, focusing on recent advances.
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Affiliation(s)
- Ke Wang
- School of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feiyu Duan
- School of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tong Sun
- School of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Zhang
- School of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lili Lu
- School of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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DeVeaux A, Ryou J, Dantas G, Warner BB, Tarr PI. Microbiome-targeting therapies in the neonatal intensive care unit: safety and efficacy. Gut Microbes 2023; 15:2221758. [PMID: 37358104 PMCID: PMC10294772 DOI: 10.1080/19490976.2023.2221758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/25/2023] [Indexed: 06/27/2023] Open
Abstract
Microbiome-targeting therapies have received great attention as approaches to prevent disease in infants born preterm, but their safety and efficacy remain uncertain. Here we summarize the existing literature, focusing on recent meta-analyses and systematic reviews that evaluate the performance of probiotics, prebiotics, and/or synbiotics in clinical trials and studies, emphasizing interventions for which the primary or secondary outcomes were prevention of necrotizing enterocolitis, late-onset sepsis, feeding intolerance, and/or reduction in hospitalization length or all-cause mortality. Current evidence suggests that probiotics and prebiotics are largely safe but conclusions regarding their effectiveness in the neonatal intensive care unit have been mixed. To address this ambiguity, we evaluated publications that collectively support benefits of probiotics with moderate to high certainty evidence in a recent comprehensive network meta-analysis, highlighting limitations in these trials that make it difficult to support with confidence the routine, universal administration of probiotics to preterm infants.
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Affiliation(s)
- Anna DeVeaux
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jian Ryou
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gautam Dantas
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Barbara B. Warner
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Phillip I. Tarr
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
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Schneider R, Sant'Anna A. Using probiotics in paediatric populations. Paediatr Child Health 2022; 27:482-502. [PMID: 36583073 PMCID: PMC9792287 DOI: 10.1093/pch/pxac087] [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: 03/01/2021] [Accepted: 04/25/2022] [Indexed: 12/28/2022] Open
Abstract
This statement defines probiotics and reviews the most recent literature on their use in paediatrics. Many studies have examined the potential benefit of probiotics, but significant variation in the strains and doses of probiotics used, the patient populations studied, and in study design, have led to heterogeneous results. Present evidence suggests that probiotics can decrease mortality and lower incidence of necrotizing enterocolitis in preterm and low birth weight neonates. Probiotics may also be beneficial in reducing feeding intolerance. In infants, probiotics may be considered to reduce symptoms of colic. In older children, probiotics can be considered to prevent antibiotic-associated diarrhea and Clostridium difficile -associated diarrhea. Probiotic supplements used in conjunction with standard therapy can help with Helicobacter pylori eradication and decrease the side effects of treatment. Lactobacillus species can be considered to treat irritable bowel syndrome. Probiotics can also be considered to help prevent atopic dermatitis and eczema. To optimize paediatric policy and practice, large, quality studies are needed to determine what types and combinations of probiotics are most efficacious.
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Affiliation(s)
- Rilla Schneider
- Canadian Paediatric Society, Nutrition and Gastroenterology Committee, Ottawa, Ontario, Canada
| | - Ana Sant'Anna
- Canadian Paediatric Society, Nutrition and Gastroenterology Committee, Ottawa, Ontario, Canada
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Schneider R, Sant'Anna A. L’utilisation des probiotiques dans la population pédiatrique. Paediatr Child Health 2022; 27:482-502. [PMID: 36583070 PMCID: PMC9792288 DOI: 10.1093/pch/pxac086] [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: 03/01/2021] [Accepted: 04/25/2022] [Indexed: 12/28/2022] Open
Abstract
Le présent document de principes définit les probiotiques et fournit une analyse des publications scientifiques les plus récentes sur leur utilisation en pédiatrie. De nombreuses études ont évalué les avantages potentiels des probiotiques, mais en raison des variations importantes dans les souches et les doses utilisées, des populations de patients étudiées et des méthodologies privilégiées, les résultats sont hétérogènes. Selon les données probantes à jour, les probiotiques peuvent réduire le taux de mortalité et l’incidence d’entérocolite nécrosante chez les nouveau-nés prématurés et de petit poids à la naissance. Ils peuvent également être bénéfiques pour réduire l’intolérance alimentaire. Chez les nourrissons, on peut envisager de les utiliser pour limiter les symptômes de coliques, et chez les enfants plus âgés, pour prévenir la diarrhée associée aux antibiotiques ou au Clostridium difficile . Les suppléments de probiotiques utilisés conjointement avec un traitement standard peuvent contribuer à éradiquer l’Helicobacter pylori et à atténuer les effets secondaires du traitement. On peut envisager d’utiliser des espèces de Lactobacillus pour traiter le syndrome du côlon irritable ou de recourir à des probiotiques pour contribuer à prévenir la dermatite atopique et l’eczéma. Afin d’optimiser les politiques et les pratiques en pédiatrie, de vastes études de qualité devront être réalisées pour déterminer les types et les combinaisons de probiotiques les plus efficaces.
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Affiliation(s)
- Rilla Schneider
- Société canadienne de pédiatrie, comité de nutrition et de gastroentérologie, Ottawa (Ontario)Canada
| | - Ana Sant'Anna
- Société canadienne de pédiatrie, comité de nutrition et de gastroentérologie, Ottawa (Ontario)Canada
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Guitor AK, Yousuf EI, Raphenya AR, Hutton EK, Morrison KM, McArthur AG, Wright GD, Stearns JC. Capturing the antibiotic resistome of preterm infants reveals new benefits of probiotic supplementation. MICROBIOME 2022; 10:136. [PMID: 36008821 PMCID: PMC9414150 DOI: 10.1186/s40168-022-01327-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/14/2022] [Indexed: 05/28/2023]
Abstract
BACKGROUND Probiotic use in preterm infants can mitigate the impact of antibiotic exposure and reduce rates of certain illnesses; however, the benefit on the gut resistome, the collection of antibiotic resistance genes, requires further investigation. We hypothesized that probiotic supplementation of early preterm infants (born < 32-week gestation) while in hospital reduces the prevalence of antibiotic resistance genes associated with pathogenic bacteria in the gut. We used a targeted capture approach to compare the resistome from stool samples collected at the term corrected age of 40 weeks for two groups of preterm infants (those that routinely received a multi-strain probiotic during hospitalization and those that did not) with samples from full-term infants at 10 days of age to identify if preterm birth or probiotic supplementation impacted the resistome. We also compared the two groups of preterm infants up to 5 months of age to identify persistent antibiotic resistance genes. RESULTS At the term corrected age, or 10 days of age for the full-term infants, we found over 80 antibiotic resistance genes in the preterm infants that did not receive probiotics that were not identified in either the full-term or probiotic-supplemented preterm infants. More genes associated with antibiotic inactivation mechanisms were identified in preterm infants unexposed to probiotics at this collection time-point compared to the other infants. We further linked these genes to mobile genetic elements and Enterobacteriaceae, which were also abundant in their gut microbiomes. Various genes associated with aminoglycoside and beta-lactam resistance, commonly found in pathogenic bacteria, were retained for up to 5 months in the preterm infants that did not receive probiotics. CONCLUSIONS This pilot survey of preterm infants shows that probiotics administered after preterm birth during hospitalization reduced the diversity and prevented persistence of antibiotic resistance genes in the gut microbiome. The benefits of probiotic use on the microbiome and the resistome should be further explored in larger groups of infants. Due to its high sensitivity and lower sequencing cost, our targeted capture approach can facilitate these surveys to further address the implications of resistance genes persisting into infancy without the need for large-scale metagenomic sequencing. Video Abstract.
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Affiliation(s)
- Allison K Guitor
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
- Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Canada
- David Braley Centre for Antibiotic Discovery, McMaster University, Hamilton, Canada
| | - Efrah I Yousuf
- Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Amogelang R Raphenya
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
- Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Canada
- David Braley Centre for Antibiotic Discovery, McMaster University, Hamilton, Canada
| | - Eileen K Hutton
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, Canada
- The Baby & Mi and the Baby & Pre-Mi Cohort Studies, Hamilton, Canada
| | - Katherine M Morrison
- Department of Pediatrics, McMaster University, Hamilton, Canada
- The Baby & Mi and the Baby & Pre-Mi Cohort Studies, Hamilton, Canada
| | - Andrew G McArthur
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
- Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Canada
- David Braley Centre for Antibiotic Discovery, McMaster University, Hamilton, Canada
| | - Gerard D Wright
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
- Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Canada
- David Braley Centre for Antibiotic Discovery, McMaster University, Hamilton, Canada
| | - Jennifer C Stearns
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada.
- The Baby & Mi and the Baby & Pre-Mi Cohort Studies, Hamilton, Canada.
- Department of Medicine, McMaster University, Hamilton, Canada.
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada.
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Sowden M, van Weissenbruch MM, Bulabula ANH, van Wyk L, Twisk J, van Niekerk E. Effect of a Multi-Strain Probiotic on the Incidence and Severity of Necrotizing Enterocolitis and Feeding Intolerances in Preterm Neonates. Nutrients 2022; 14:nu14163305. [PMID: 36014810 PMCID: PMC9415863 DOI: 10.3390/nu14163305] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Necrotizing enterocolitis (NEC) is a multifactorial disease, causing inflammation of the bowel. The exact root of NEC is still unknown, but a low weight and gestational age at birth are known causes. Furthermore, antibiotic use and abnormal bacterial colonization of the premature gut are possible causes. Premature neonates often experience feeding intolerances that disrupts the nutritional intake, leading to poor growth and neurodevelopmental impairment. Methods: We conducted a double-blind, placebo-controlled, randomized clinical trial to investigate the effect of a multi-strain probiotic formulation (LabinicTM) on the incidence and severity of NEC and feeding intolerances in preterm neonates. Results: There were five neonates in the placebo group who developed NEC (Stage 1A−3B), compared to no neonates in the probiotic group. Further, the use of probiotics showed a statistically significant reduction in the development of feeding intolerances, p < 0.001. Conclusion: A multi-strain probiotic is a safe and cost-effective way of preventing NEC and feeding intolerances in premature neonates.
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Affiliation(s)
- Marwyn Sowden
- Department of Global Health, Division of Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
- Correspondence: ; Tel.: +27-21-938-9474
| | - Mirjam Maria van Weissenbruch
- Amsterdam UMC, Department of Pediatrics-Neonatology, VU University Medical Center, 1081 HV Amsterdam, The Netherlands
| | | | - Lizelle van Wyk
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town 7505, South Africa
| | - Jos Twisk
- Department of Epidemiology and Data Science, Amsterdam UMC, 1081 HV Amsterdam, The Netherlands
| | - Evette van Niekerk
- Department of Global Health, Division of Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
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Park HW. The Use of Probiotics in Preterm Infants. NEONATAL MEDICINE 2022. [DOI: 10.5385/nm.2022.29.2.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Probiotics are live microorganisms that positively affect host health by altering the composition of the host microbiota. Gastrointestinal dysbiosis refers to adverse alterations of the intestinal flora and is associated with several diseases, including necrotizing enterocolitis, late-onset sepsis in preterm infants as well as atopic disease, colic, diabetes, and diarrhea in term infants. The risk factors for gastrointestinal dysbiosis are preterm birth, cesarean section delivery, and formula feeding, in contrast to term birth infants, vaginal delivery and breast milk feeding. Probiotics have been used to restore synbiosis in infants with gastrointestinal dysbiosis. Probiotics inhibit colonization of pathogenic bacteria in the gastrointestinal tract, thereby improving the barrier function of the gastrointestinal tract, and the immune function. In preterm infants, probiotics reduce mortality as well as rates of necrotizing enterocolitis and late-onset sepsis. The combined use of probiotics such as <i>Lactobacillus</i> and <i>Bifidobacterium</i> and the combination of probiotics with prebiotics yield better outcomes in the prevention of necrotizing enterocolitis than those achieved with a single pro- or prebiotic strain. However, the routine use of probiotics has been hindered by the lack of pharmaceutical-quality products, and a definite effect has yet to be demonstrated in preterm infants with a birth weight <1,000 g. Therefore, to reduce the risk of necrotizing enterocolitis in preterm infants, probiotics should be provided along with breast milk and other strategies aimed at preventing gastrointestinal dysbiosis.
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Hascoët JM, Chevallier M, Gire C, Brat R, Rozé JC, Norbert K, Chen Y, Hartweg M, Billeaud C. Use of a Liquid Supplement Containing 2 Human Milk Oligosaccharides: The First Double-Blind, Randomized, Controlled Trial in Pre-term Infants. Front Pediatr 2022; 10:858380. [PMID: 35601412 PMCID: PMC9119431 DOI: 10.3389/fped.2022.858380] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/17/2022] [Indexed: 11/29/2022] Open
Abstract
There is growing evidence supporting the benefit of human milk oligosaccharides (HMOs) on reducing risk of illnesses and improving immune function in newborn infants, but evidence in pre-term infants is lacking. This randomized, double-blind, placebo-controlled trial (NCT03607942) of pre-term infants evaluated the effects of HMO supplementation on feeding tolerance, growth, and safety in 7 neonatal units in France. Pre-term infants (27-33 weeks' gestation, birth weight <1,700 g) were randomized early after birth to receive HMO supplement (n = 43) [2'-fucosyllactose (2'FL) and lacto-N-neotetraose (LNnT) in a 10:1 ratio (0.374 g/kg body weight/day)] or an isocaloric placebo (n = 43) consisting of only glucose (0.140 g/kg/day) until discharge from the neonatal unit. Anthropometric z-scores were calculated using Fenton growth standards. Primary outcome was feeding tolerance, measured by non-inferiority (NI) in days to reach full enteral feeding (FEF) from birth in HMO vs. placebo group (NI margin = 4+ days). Mean number of days on intervention prior to FEF was 8.9 and 10.3 days in HMO and placebo, respectively. Non-inferiority in time to reach FEF in HMO (vs. placebo) was achieved [LS mean difference (95% CI) = -2.16 (-5.33, 1.00); upper bound of 95% CI < NI margin] in full analysis set and similar for per protocol. Adjusted mean time to reach FEF from birth was 2 days shorter in HMO (12.2) vs. placebo (14.3), although not statistically significant (p = 0.177). There was no difference in weight-for-age z-scores between groups throughout the FEF period until discharge. Length-for-age z-scores were higher in HMO at FEF day 14 [0.29 (0.02, 0.56), p = 0.037] and 21 [0.31 (0.02, 0.61), p = 0.037]. Head circumference-for-age z-score was higher in HMO vs. placebo at discharge [0.42 (0.12, 0.71), p = 0.007]. Occurrence of adverse events (AEs) was similar in both groups and relatively common in this population, whereas 2.3 and 14.3%, respectively, experienced investigator-confirmed, related AEs. HMO supplementation is safe and well-tolerated in pre-term infants. After 9 days of supplementation, the HMO group reached FEF 2 days earlier vs. placebo, although the difference was not statistically significant. In addition, HMO supplementation supports early postnatal growth, which may have a positive impact on long-term growth and developmental outcomes.
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Affiliation(s)
| | | | | | | | - Jean-Christophe Rozé
- Hôpital Femme Enfant Adolescent Néonatologie et Réanimation Pédiatrique, Nantes, France
| | | | - Yipu Chen
- Nestlé Product Technology Center-Nutrition, Vevey, Switzerland
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12
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Clinical Presentation and Multifactorial Pathogenesis of Necrotizing Enterocolitis in the Preterm Infant. Adv Neonatal Care 2021; 21:349-355. [PMID: 33958518 DOI: 10.1097/anc.0000000000000880] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a serious infection of the bowel wall induced by multiple pathological factors, which include inflammation and tissue invasion with bacteria known to cause severe infections. NEC is now understood to be several disease processes under one umbrella. The most common form occurs in premature infants and can exert significant impacts to preterm morbidity and mortality. PURPOSE This narrative review describes current knowledge of the clinical presentation and pathophysiology of NEC in premature infants. METHODS/SEARCH STRATEGY A review of literature was conducted using key words in PubMed and CINAHL with preference for years 2015 to 2020. FINDINGS/RESULTS Several converging and interrelated factors including characteristics of the premature intestinal mucosa, gut ischemia, dysregulation of the microbiome, enteral feeding, and genetics create an environment where NEC is more likely to occur. IMPLICATIONS FOR PRACTICE To recognize and diagnose NEC in preterm infants, an understanding of underlying factors that create an optimal environment for disease acquisition in premature infants is essential. IMPLICATIONS FOR RESEARCH Prevention of NEC remains the most important strategy for decreasing morbidity and mortality. Multiple areas of potential study exist for NEC pathophysiology including those that consider how the factors discussed in this review are interrelated and how each particular pathway can be optimized to prevent the onset of NEC.
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13
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Abstract
This review highlights clinical outcomes of human milk from infancy through adulthood. Human milk outcomes of both preterm and term infants, including critically ill term infants (such as infants with congenital heart disease and those requiring therapeutic hypothermia) are summarized. Several human milk diets are identified to reduce the risk of specific diseases. Emerging research of newly discovered components of human milk are also reviewed. Human milk has significant effects on the gut microbiome, somatic growth, and neurocognitive outcomes. Continued research promises to improve donor human milk and donor milk derived products to achieve better outcomes for infants who do not receive their own mother's milk. The promotion of human milk is well-founded on evidence from the previous half century.
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Affiliation(s)
- Katherine E Chetta
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, Shawn Jenkins Children's Hospital, 10 McClennan Banks Drive, MSC 915, Charleston, SC 29425, United States.
| | - Elizabeth V Schulz
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Uniformed Services University, United States
| | - Carol L Wagner
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, Shawn Jenkins Children's Hospital, 10 McClennan Banks Drive, MSC 915, Charleston, SC 29425, United States
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14
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Perrone S, Cremonini I, Marinelli F, Monaco S, Nicoletti L, Giordano M, Esposito S. New Strategies for Necrotizing Enterocolitis Diagnosis and Prevention in Newborns. Curr Pediatr Rev 2021; 17:191-200. [PMID: 33902422 DOI: 10.2174/1573396317666210426102610] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/27/2020] [Accepted: 02/23/2021] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Serafina Perrone
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | | | - Sara Monaco
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Laura Nicoletti
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maurizio Giordano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Susanna Esposito
- Department of Medicine and Surgery, University of Parma, Parma, Italy
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15
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Nolan LS, Rimer JM, Good M. The Role of Human Milk Oligosaccharides and Probiotics on the Neonatal Microbiome and Risk of Necrotizing Enterocolitis: A Narrative Review. Nutrients 2020; 12:nu12103052. [PMID: 33036184 PMCID: PMC7600747 DOI: 10.3390/nu12103052] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 12/19/2022] Open
Abstract
Preterm infants are a vulnerable population at risk of intestinal dysbiosis. The newborn microbiome is dominated by Bifidobacterium species, though abnormal microbial colonization can occur by exogenous factors such as mode of delivery, formula feeding, and exposure to antibiotics. Therefore, preterm infants are predisposed to sepsis and necrotizing enterocolitis (NEC), a fatal gastrointestinal disorder, due to an impaired intestinal barrier, immature immunity, and a dysbiotic gut microbiome. Properties of human milk serve as protection in the prevention of NEC. Human milk oligosaccharides (HMOs) and the microbiome of breast milk are immunomodulatory components that provide intestinal homeostasis through regulation of the microbiome and protection of the intestinal barrier. Enteral probiotic supplements have been trialed to evaluate their impact on establishing intestinal homeostasis. Here, we review the protective role of HMOs, probiotics, and synbiotic combinations in protecting a vulnerable population from the pathogenic features associated with necrotizing enterocolitis.
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16
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Probiotics for Preterm Infants in India - Systematic Review and Meta-Analysis of Randomized Controlled Trials. Indian J Pediatr 2020; 87:817-825. [PMID: 32185693 DOI: 10.1007/s12098-020-03223-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/29/2020] [Indexed: 10/24/2022]
Abstract
The objective of the present study is to review current evidence from randomized controlled trials (RCTs) of probiotics for preterm infants in India. A systematic review of RCTs of probiotics for preterm infants in India was conducted using Cochrane methodology and PRISMA guidelines. Fixed effects model was used for meta-analysis. Nine RCTs (n = 1514) were included. Meta-analysis showed reduced risk of necrotizing enterocolitis (NEC) ≥ Stage II {Risk ratio (RR): 0.36 [95% confidence interval (CI): 0.20, 0.66], p = 0.0009, (9 RCTs)}, late onset sepsis [RR: 0.56 (95% CI: 0.45, 0.71), p < 0.00001, (7 RCTs)] and mortality [RR: 0.62 (95% CI: 0.41, 0.95, p = 0.03 (8 RCTs)] in the probiotic group. Probiotics also reduced the time to full feeds [Mean difference (MD): -4.09 d (95% CI: -4.52, -3.65), p < 0.00001, 5 RCTs] and duration of hospital stay [Fixed effects model (FEM): MD: -2.00 d (95% CI: -2.46, -1.53), p < 0.00001, 6 RCTs]. Current evidence from RCTs supports probiotic supplementation for optimizing outcomes of preterm infants in India.
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17
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Yousuf EI, Carvalho M, Dizzell SE, Kim S, Gunn E, Twiss J, Giglia L, Stuart C, Hutton EK, Morrison KM, Stearns JC. Persistence of Suspected Probiotic Organisms in Preterm Infant Gut Microbiota Weeks After Probiotic Supplementation in the NICU. Front Microbiol 2020; 11:574137. [PMID: 33117319 PMCID: PMC7552907 DOI: 10.3389/fmicb.2020.574137] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/26/2020] [Indexed: 12/12/2022] Open
Abstract
Probiotics are becoming a prevalent supplement to prevent necrotizing enterocolitis in infants born preterm. However, little is known about the ability of these live bacterial supplements to colonize the gut or how they affect endogenous bacterial strains and the overall gut community. We capitalized on a natural experiment resulting from a policy change that introduced the use of probiotics to preterm infants in a single Neonatal Intensive Care Unit. We used amplicon sequence variants (ASVs) derived from the v3 region of the 16S rRNA gene to compare the prevalence and abundance of Bifidobacterium and Lactobacillus in the gut of preterm infants who were and were not exposed to a probiotic supplement in-hospital. Infants were followed to 5 months corrected age. In the probiotic-exposed infants, ASVs belonging to species of Bifidobacterium appeared at high relative abundance during probiotic supplementation and persisted for up to 5 months. In regression models that controlled for the confounding effects of age and antibiotic exposure, probiotic-exposed infants had a higher abundance of the suspected probiotic bifidobacteria than unexposed infants. Conversely, the relative abundance of Lactobacillus was similar between preterm groups over time. Lactobacillus abundance was inversely related to antibiotic exposure. Furthermore, the overall gut microbial community of the probiotic-exposed preterm infants at term corrected age clustered more closely to samples collected from 10-day old full-term infants than to samples from unexposed preterm infants at term age. In conclusion, routine in-hospital administration of probiotics to preterm infants resulted in the potential for colonization of the gut with probiotic organisms post-discharge and effects on the gut microbiome as a whole. Further research is needed to fully discriminate probiotic bacterial strains from endogenous strains and to explore their functional role in the gut microbiome and in infant health.
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Affiliation(s)
- Efrah I Yousuf
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.,Centre for Metabolism, Obesity and Diabetes Research, McMaster University, Hamilton, ON, Canada
| | - Marilia Carvalho
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada
| | - Sara E Dizzell
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada
| | - Stephanie Kim
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.,Centre for Metabolism, Obesity and Diabetes Research, McMaster University, Hamilton, ON, Canada
| | - Elizabeth Gunn
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.,Centre for Metabolism, Obesity and Diabetes Research, McMaster University, Hamilton, ON, Canada
| | - Jennifer Twiss
- Department of Pediatrics, Division of Neonatology, McMaster University, Hamilton, ON, Canada
| | - Lucy Giglia
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Connie Stuart
- Neonatal Follow Up Clinic, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Eileen K Hutton
- Centre for Metabolism, Obesity and Diabetes Research, McMaster University, Hamilton, ON, Canada.,Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada
| | - Katherine M Morrison
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.,Centre for Metabolism, Obesity and Diabetes Research, McMaster University, Hamilton, ON, Canada
| | - Jennifer C Stearns
- Centre for Metabolism, Obesity and Diabetes Research, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
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18
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Abstract
Intestinal dysbiosis precedes and is a likely causative factor in necrotizing enterocolitis (NEC) and many cases of late-onset sepsis. Randomized controlled trials and observational cohort studies demonstrate decreased risk of NEC, sepsis, and death with the administration of probiotic microbes and decreased risk of NEC and sepsis with feeding of human milk. Animal studies suggest promising mechanisms by which probiotic microbes and human milk oligosaccharides alter the composition of the intestinal microbiota and may prevent disease in premature infants. Inclusion of parents in discussions of the risks and benefits of human milk and probiotics for premature infants is essential.
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Affiliation(s)
- Mark A Underwood
- Department of Pediatrics, University of California Davis, Sacramento, CA
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19
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Prevention, diagnosis and treatment of necrosing enterocolitis in newborns less than 32 weeks at birth in Spain. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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20
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Camacho JH, Rusinky Pinilla L, Salazar Peña D, Sanabria Dueñas S, Rojas Carvajal D, Burbano Castillo N, Ruiz Peña R, Palacino Saenz I, Martínez Quesada S, García Salazar A, Abdala Galvis N. Microbiota intestinal en pediatría. REPERTORIO DE MEDICINA Y CIRUGÍA 2020. [DOI: 10.31260/repertmedcir.01217372.1100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
La microbiota intestinal es el conjunto de millones de microrganismos vivos ubicados en el tracto gastrointestinal. Es indispensable en múltiples funciones del organismo, regulación de la inmunidad, en aspectos nutricionales y procesos de inflamación sistémica entre otros. La disbiosis es la alteración del equilibrio de la microbiota normal, debido a cambios en la composición, funcionamiento, orden o su distribución; esto puede predisponer al individuo a la adquisición de enfermedades gastrointestinales, alérgicas y metabólicas, entre otras. El objetivo del presente artículo es realizar una revisión narrativa de la literatura sobre los conceptos claves de la microbiota intestinal, sus asociaciones fisiopatológicas con desórdenes gastrointestinales, alérgicos y metabólicos en pediatría.
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21
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Underwood MA, Umberger E, Patel RM. Safety and efficacy of probiotic administration to preterm infants: ten common questions. Pediatr Res 2020; 88:48-55. [PMID: 32855513 PMCID: PMC8210852 DOI: 10.1038/s41390-020-1080-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In spite of a large number of randomized placebo-controlled clinical trials and observational cohort studies including >50,000 preterm infants from 29 countries that have demonstrated a decrease in the risk of necrotizing enterocolitis, death, and sepsis, routine prophylactic probiotic administration to preterm infants remains uncommon in much of the world. This manuscript reflects talks given at NEC Society Symposium in 2019 and is not intended to be a state-of-the-art review or systematic review, but a summary of the probiotic-specific aspects of the symposium with limited additions including a recent strain-specific network analysis and position statement from the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN). We address ten common questions related to the intestinal microbiome and probiotic administration to the preterm infant.
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Affiliation(s)
- Mark A Underwood
- Division of Neonatology, Department of Pediatrics, University of California Davis School of Medicine, Sacramento, CA, USA.
| | - Erin Umberger
- Necrotizing Enterocolitis (NEC) Society, Davis, CA, USA
| | - Ravi M Patel
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
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22
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Indole-3-lactic acid, a metabolite of tryptophan, secreted by Bifidobacterium longum subspecies infantis is anti-inflammatory in the immature intestine. Pediatr Res 2020; 88:209-217. [PMID: 31945773 PMCID: PMC7363505 DOI: 10.1038/s41390-019-0740-x] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC), a necrotic inflammation of the intestine, represents a major health problem in the very premature infant. Although prevention is difficult, the combination of ingestion of maternal-expressed breastmilk in conjunction with a probiotic provides the best protection. In this study, we establish a mechanism for breastmilk/probiotic protection. METHODS Ultra-high-performance liquid chromatography-tandem mass spectrometry of Bifidobacterium longum subsp. infantis (B. infantis) secretions was used to identify an anti-inflammatory molecule. Indole-3-lactic acid (ILA) was then tested in an established human immature small intestinal cell line, necrotizing colitis enterocytes, and other immature human enteroids for anti-inflammatory effects and to establish developmental function. ILA was also examined in immature and mature enterocytes. RESULTS We have identified ILA, a metabolite of breastmilk tryptophan, as the anti-inflammatory molecule. This molecule is developmentally functional in immature but not mature intestinal enterocytes; ILA reduces the interleukin-8 (IL-8) response after IL-1β stimulus. It interacts with the transcription factor aryl hydrocarbon receptor (AHR) and prevents transcription of the inflammatory cytokine IL-8. CONCLUSIONS This molecule produced by B. infantis (ATCC No. 15697) interaction with ingested breastmilk functions in a complementary manner and could become useful in the treatment of all at-risk premature infants for NEC if safety and clinical studies are performed.
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Abstract
Although risk for necrotizing enterocolitis (NEC) is often presented from the perspective of a premature infant's vulnerability to nonmodifiable risk factors, in this paper we describe the evidence and present recommendations to manage modifiable risks that are amenable to clinical actions. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, we present recommendations in the context of their supporting evidence in a way that balances risks (e.g. potential harm, cost) and benefits. Across the prenatal, intrapartum, early and late clinical course, strategies to limit NEC risk in premature infants are presented. Our goal is to summarize modifiable NEC risk factors, grade the evidence to offer quality improvement (QI) targets for healthcare teams and offer a patient-family advocate's perspective on how to engage parents to recognize and reduce NEC risk.
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Robertson C, Savva GM, Clapuci R, Jones J, Maimouni H, Brown E, Minocha A, Hall LJ, Clarke P. Incidence of necrotising enterocolitis before and after introducing routine prophylactic Lactobacillus and Bifidobacterium probiotics. Arch Dis Child Fetal Neonatal Ed 2020; 105:380-386. [PMID: 31666311 PMCID: PMC7363787 DOI: 10.1136/archdischild-2019-317346] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/03/2019] [Accepted: 09/24/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To compare rates of necrotising enterocolitis (NEC), late-onset sepsis, and mortality in 5-year epochs before and after implementation of routine daily multistrain probiotics administration in high-risk neonates. DESIGN Single-centre retrospective observational study over the 10-year period from 1 January 2008 to 31 December 2017. SETTING Level 3 neonatal intensive care unit (NICU) of the Norfolk and Norwich University Hospital, UK. PATIENTS Preterm neonates at high risk of NEC: admitted to NICU within 3 days of birth at <32 weeks' gestation or at 32-36 weeks' gestation and of birth weight <1500 g. INTERVENTION Prior to 1 January 2013 probiotics were not used. Thereafter, dual-species Lactobacillus acidophilus and Bifidobacterium bifidum combination probiotics were routinely administered daily to high-risk neonates; from April 2016 triple-species probiotics (L. acidophilus, B. bifidum, and B. longum subspecies infantis) were used. MAIN OUTCOME MEASURES Incidence of NEC (modified Bell's stage 2a or greater), late-onset sepsis, and mortality. RESULTS Rates of NEC fell from 7.5% (35/469 neonates) in the pre-implementation epoch to 3.1% (16/513 neonates) in the routine probiotics epoch (adjusted sub-hazard ratio=0.44, 95% CI 0.23 to 0.85, p=0.014). The more than halving of NEC rates after probiotics introduction was independent of any measured covariates, including breast milk feeding rates. Cases of late-onset sepsis fell from 106/469 (22.6%) to 59/513 (11.5%) (p<0.0001), and there was no episode of sepsis due to Lactobacillus or Bifidobacterium. All-cause mortality also fell in the routine probiotics epoch, from 67/469 (14.3%) to 47/513 (9.2%), although this was not statistically significant after multivariable adjustment (adjusted sub-hazard ratio=0.74, 95% CI 0.49 to 1.12, p=0.155). CONCLUSIONS Administration of multispecies Lactobacillus and Bifidobacterium probiotics has been associated with a significantly decreased risk of NEC and late-onset sepsis in our neonatal unit, and no safety issues. Our data are consistent with routine use of Lactobacillus and Bifidobacterium combination probiotics having a beneficial effect on NEC prevention in very preterm neonates.
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Affiliation(s)
- Claire Robertson
- Neonatal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Gut Microbes and Health, Quadram Institute Bioscience, Norwich, UK
| | - George M Savva
- Core Science Resources, Quadram Institute Bioscience, Norwich, UK
| | - Raducu Clapuci
- Neonatal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Jacqueline Jones
- Neonatal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Hassan Maimouni
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Eleanor Brown
- Neonatal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Ashish Minocha
- Paediatric and Neonatal Surgery, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Lindsay J Hall
- Gut Microbes and Health, Quadram Institute Bioscience, Norwich, UK
| | - Paul Clarke
- Neonatal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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25
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Pammi M, De Plaen IG, Maheshwari A. Recent Advances in Necrotizing Enterocolitis Research: Strategies for Implementation in Clinical Practice. Clin Perinatol 2020; 47:383-397. [PMID: 32439118 PMCID: PMC7245582 DOI: 10.1016/j.clp.2020.02.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Necrotizing enterocolitis (NEC) is a complex inflammatory necrosis of the neonatal intestine, which is likely to require a multipronged approach for prevention and treatment. Despite identifying and defining NEC as a disease entity several decades back, no major progress has been made toward its early identification, treatment, or prevention. This article reviews the latest research strategies that are currently ongoing for early diagnosis and monitoring and prevention of the disease.
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Affiliation(s)
- Mohan Pammi
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Isabelle G. De Plaen
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Akhil Maheshwari
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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26
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E-SCOPE: A Strategic Approach to Identify and Accelerate Implementation of Evidence-based Best Practices. Med Care 2020; 57 Suppl 10 Suppl 3:S239-S245. [PMID: 31517794 PMCID: PMC6750149 DOI: 10.1097/mlr.0000000000001191] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
More than 50,000 randomized controlled trials and 8000 systematic reviews are anticipated to be published annually in the coming years. This huge volume of published findings makes it challenging for health care delivery systems to review new evidence, prioritize health care practices that warrant implementation, and implement best practices.
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27
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Lactobacillus Acidophilus/Bifidobacterium Infantis Probiotics Are Beneficial to Extremely Low Gestational Age Infants Fed Human Milk. Nutrients 2020; 12:nu12030850. [PMID: 32235769 PMCID: PMC7146289 DOI: 10.3390/nu12030850] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 11/17/2022] Open
Abstract
Objective: To evaluate the nutrition-related effects of prophylactic Lactobacillus acidophilus/Bifidobacterium infantis probiotics on the outcomes of preterm infants <29 weeks of gestation that receive human milk and/or formula nutrition. We hypothesize that human-milk-fed infants benefit from probiotics in terms of sepsis prevention and growth. Methods: We performed an observational study of the German Neonatal Network (GNN) over a period of six years, between 1 January, 2013 and 31 December, 2018. Prophylactic probiotic use of L. acidophilus/B. infantis was evaluated in preterm infants <29 weeks of gestation (n = 7516) in subgroups stratified to feeding type: (I) Exclusively human milk (HM) of own mother and/or donors (HM group, n = 1568), (II) HM of own mother and/or donor and formula (Mix group, n = 5221), and (III) exclusive exposure to formula (F group, n = 727). The effect of probiotics on general outcomes and growth was tested in univariate models and adjusted in linear/logistic regression models. Results: 5954 (76.5%) infants received L. acidophilus/B. infantis prophylactically for the prevention of necrotizing enterocolitis (NEC). Probiotic use was associated with improved growth measures in the HM group (e.g., weight gain velocity in g/day: effect size B = 0.224; 95% CI: 2.82–4.35; p < 0.001) but not in the F group (effect size B = −0.06; 95% CI: −3.05–0.28; p = 0.103). The HM group had the lowest incidence of clinical sepsis (34.0%) as compared to the Mix group (35.5%) and the F group (40.0%). Only in the Mix group, probiotic supplementation proved to be protective against clinical sepsis (OR 0.69; 95% CI: 0.59–0.79; p < 0.001). Conclusion: Our observational data indicate that the exposure to L. acidophilus/B. infantis probiotics may promote growth in exclusively HM-fed infants as compared to formula-fed infants. To exert a sepsis-preventive effect, probiotics seem to require human milk.
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Zozaya C, Avila-Alvarez A, Somoza Argibay I, García-Muñoz Rodrigo F, Oikonomopoulou N, Encinas JL, Saenz de Pipaón M, Couce ML. [Prevention, diagnosis and treatment of necrotising enterocolitis in newborns less than 32 weeks at birth in Spain]. An Pediatr (Barc) 2020; 93:161-169. [PMID: 32111552 DOI: 10.1016/j.anpedi.2019.12.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/15/2019] [Accepted: 12/18/2019] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To describe preventive, diagnostic and therapeutic strategies regarding necrotising enterocolitis in Spain and to identify the strengths, areas of further improvement, and future research lines. METHODS Two questionnaires on the management of preterm infants less than 32 weeks, at risk of, or with diagnosed necrotising enterocolitis, were distributed among selected representatives of the surgeons and neonatologists of the Spanish Neonatal Network (SEN1500) participant hospitals with a Paediatric Surgery Department. RESULTS Percentage of response was 77.1% of contacted surgeons and 88.6% of neonatologists. There is a written protocol on the diagnosis and medical management of necrotising enterocolitis in 52% of the hospitals, and as regards surgical treatment in 33%. There is wide access to donor bank milk and to staff dedicated to breastfeeding promotion (87%). On the contrary, only 52% of the centres perform delayed cord clamping, and probiotics are used in just 23%. The use of abdominal ultrasound is increasing. There are no large differences as regards duration of antibiotic use and bowel rest, whereas there was as regards antibiotic selection, surgical indication, and type of intervention. CONCLUSIONS As regards prevention, delayed cord clamping and extended access to donor milk are two possible aspects of further improvement. The observed discrepancies noted in diagnostic and therapeutic aspects are common in precisely the areas where evidence in the literature is weakest.
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Affiliation(s)
- Carlos Zozaya
- División de Neonatología, The Hospital for Sick Children, Toronto, Ontario, Canadá.
| | - Alejandro Avila-Alvarez
- Unidad de Neonatología, Servicio de Pediatría, Complexo Hospitalario Universitario A Coruña, A Coruña, España
| | - Iván Somoza Argibay
- Servicio de Cirugía Pediátrica, Complexo Hospitalario Universitario A Coruña, A Coruña, España
| | - Fermín García-Muñoz Rodrigo
- Servicio de Neonatología, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, España
| | - Niki Oikonomopoulou
- División de Neonatología, The Hospital for Sick Children, Toronto, Ontario, Canadá
| | - José Luis Encinas
- Departamento de Cirugía Pediátrica, Hospital Universitario La Paz, Madrid, España
| | | | - María Luz Couce
- Servicio de Neonatología, Hospital Clínico Universitario de Santiago de Compostela. Universidad de Santiago, IDIS; CIBERER, Santiago de Compostela, A Coruña, España
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Underwood MA, Mukhopadhyay S, Lakshminrusimha S, Bevins CL. Neonatal intestinal dysbiosis. J Perinatol 2020; 40:1597-1608. [PMID: 32968220 PMCID: PMC7509828 DOI: 10.1038/s41372-020-00829-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/17/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022]
Abstract
The initial colonization of the neonatal intestinal tract is influenced by delivery mode, feeding, the maternal microbiota, and a host of environmental factors. After birth, the composition of the infant's microbiota undergoes a series of significant changes particularly in the first weeks and months of life ultimately developing into a more stable and diverse adult-like population in childhood. Intestinal dysbiosis is an alteration in the intestinal microbiota associated with disease and appears to be common in neonates. The consequences of intestinal dysbiosis are uncertain, but strong circumstantial evidence and limited confirmations of causality suggest that dysbiosis early in life can influence the health of the infant acutely, as well as contribute to disease susceptibility later in life.
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Affiliation(s)
- Mark A. Underwood
- grid.27860.3b0000 0004 1936 9684Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA USA
| | - Sagori Mukhopadhyay
- grid.25879.310000 0004 1936 8972Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Satyan Lakshminrusimha
- grid.27860.3b0000 0004 1936 9684Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA USA
| | - Charles L. Bevins
- grid.27860.3b0000 0004 1936 9684Department of Medical Microbiology and Immunology, UC Davis School of Medicine, Davis, CA USA
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Bührer C, Fischer HS, Wellmann S. Nutritional interventions to reduce rates of infection, necrotizing enterocolitis and mortality in very preterm infants. Pediatr Res 2020; 87:371-377. [PMID: 31645057 DOI: 10.1038/s41390-019-0630-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 10/03/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
Observational studies demonstrating reduced rates of infections, necrotizing enterocolitis (NEC), and mortality in preterm infants fed their own mother's milk, as opposed to formula, have prompted endeavors to achieve similar effects with the right choice of food and food additives. In a systematic review of meta-analyses and randomized controlled trials (RCTs), we considered nutritional interventions aimed at reducing the rates of infections, NEC, or mortality in very preterm infants. The overall effects of particular interventions were presented as risk ratios with 95% confidence intervals. In RCTs, pasteurized human donor milk, as opposed to formula, reduced NEC but not infections or mortality. No differences emerged between infants receiving human or bovine milk-based fortifiers. Pooled data of small trials and a recent large RCT suggested that bovine lactoferrin reduced rates of fungal sepsis without impact on other infections, NEC, or mortality. Pooled data of RCTs assessing the use of prebiotic oligosaccharides found reduced infection but not mortality. Enteral L-glutamine (six RCTs) lowered infection rates, and enteral L-arginine (three RCTs) reduced NEC. A meta-analysis sensitivity approach found multiple-strain (but not single-strain) probiotics to be highly effective in reducing NEC and mortality. Thus, selected food components may help to improve outcomes in preterm infants.
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Affiliation(s)
- Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Hendrik S Fischer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sven Wellmann
- Division of Neonatology, University Children's Hospital Regensburg (KUNO), University of Regensburg, Regensburg, Germany
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Meyer MP, Chow SSW, Alsweiler J, Bourchier D, Broadbent R, Knight D, Lynn AM, Patel H. Probiotics for Prevention of Severe Necrotizing Enterocolitis: Experience of New Zealand Neonatal Intensive Care Units. Front Pediatr 2020; 8:119. [PMID: 32318522 PMCID: PMC7154127 DOI: 10.3389/fped.2020.00119] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 03/06/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Necrotizing enterocolitis (NEC) affects mainly preterm infants, has a multifactorial etiology and is associated with intestinal dysbiosis and disordered immunity. Use of probiotics for prophylaxis is beneficial with studies indicating reduction in NEC ≥ stage 2, late onset sepsis (LOS) and mortality. However, not all studies have shown a reduction, there are questions regarding which probiotic to use, whether infants <1,000 g benefit and the risk of probiotic sepsis. All neonatal intensive care units in New Zealand (NZ) use probiotics and contribute to an international database (Australian and New Zealand Neonatal Network or ANZNN). Objective: To use ANZNN data to investigate the experience of NZ neonatal units with probiotics for NEC prevention in a setting where the baseline incidence of severe NEC was low, to compare results of 2 commonly used probiotic regimes and report on the extremely low birth weight subgroup. Method: Outcomes before (Pre group 2007-2010) and after (Probiotic group 2013-2015) starting routine probiotics for preterm infants <1,500 g or <32 weeks were compared. Clinicians reviewed cases to ensure they met database criteria. Five units used Infloran (Bifidobacterium bifidum and Lactobacillus acidophilus) and 1 unit used Lactobacillus GG (LGG) and bovine lactoferrin (bLF). Results: Four thousand five hundred and twenty nine infants were included and Pre and Probiotic groups were well-balanced with regard to gestation, birth weight and gender. The incidence of NEC in the Probiotic group was 1.6 and 2.7% in the pre group (corrected OR 0.62 CI 0.41-0.94). There was one case of probiotic sepsis. There was no significant difference between the Infloran and LGG/bLF combinations in regard to observed NEC rates. Late onset sepsis rates were significantly lower in the Probiotic group (p < 0.01). Conclusions: Introduction of probiotics for preterm infants in NZ has been associated with significant reductions in NEC and late onset sepsis.
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Affiliation(s)
- Michael P Meyer
- Neonatal Unit, KidzFirst, Middlemore Hospital, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Sharon S W Chow
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Jane Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.,Neonatal Unit, Auckland City Hospital, Auckland, New Zealand
| | | | | | - David Knight
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.,Neonatal Unit, Auckland City Hospital, Auckland, New Zealand
| | - Adrienne M Lynn
- Neonatal Unit, Christchurch Women's Hospital, Christchurch, New Zealand
| | - Harshad Patel
- Neonatal Unit, Wellington Hospital, Wellington, New Zealand
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Hogan S, Lui K, Kent AL. Perceptions of Australian and New Zealand clinicians caring for neonates born at the borderline of viability have changed since the 2005 consensus guideline. J Paediatr Child Health 2019; 55:1429-1436. [PMID: 30920065 DOI: 10.1111/jpc.14434] [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: 09/26/2018] [Revised: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 11/29/2022]
Abstract
AIM To determine whether clinician and consumer considerations have changed regarding the resuscitation and support of neonates born at the borderlines of viability since the 2005 New South Wales (NSW) and Australian Capital Territory (ACT) consensus guidelines were developed. METHODS A prospective survey based on the hypotheses and scenarios developed in the original NSW and ACT consensus workshop on perinatal care at the borderlines of viability was sent to neonatologists, fetal medicine specialists, clinical midwife and clinical neonatal consultants and consumer representatives in Australia and New Zealand. Four scenarios and 16 questions were used to explore the respondent's views towards different aspects of the management of neonates born at the borderlines of viability. Australian and New Zealand Neonatal Network data from 2013 or NSW/ACT Neonatal Intensive Care Units (NICUS) data from 1998 to 2004 were used to provide outcome data for each scenario. RESULTS A total of 87% or more of respondents advocated for resuscitation of neonates at 24 and 25 weeks' gestation in 2015. Only 29% (49/169) would agree to parental request not to resuscitate at 25 weeks and only 10% (17/170) at 260-6 weeks. The number of perinatal clinical care providers considering resuscitation at 235 weeks' gestation increased from 23% in 2005 to more than 50% in 2015. CONCLUSION These findings support the development of updated guidelines for the management of neonates in Australia and New Zealand born at the borderlines of viability to reflect the changes in clinical perceptions and management.
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Affiliation(s)
- Sara Hogan
- College of Health and Medicine, Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Kei Lui
- Department of Neonatology, Royal Women's Hospital, Sydney, New South Wales, Australia
| | - Alison L Kent
- College of Health and Medicine, Australian National University Medical School, Canberra, Australian Capital Territory, Australia.,Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Woden, Australian Capital Territory, Australia
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Marißen J, Haiß A, Meyer C, Van Rossum T, Bünte LM, Frommhold D, Gille C, Goedicke-Fritz S, Göpel W, Hudalla H, Pagel J, Pirr S, Siller B, Viemann D, Vens M, König I, Herting E, Zemlin M, Gehring S, Bork P, Henneke P, Härtel C. Efficacy of Bifidobacterium longum, B. infantis and Lactobacillus acidophilus probiotics to prevent gut dysbiosis in preterm infants of 28+0-32+6 weeks of gestation: a randomised, placebo-controlled, double-blind, multicentre trial: the PRIMAL Clinical Study protocol. BMJ Open 2019; 9:e032617. [PMID: 31753895 PMCID: PMC6886923 DOI: 10.1136/bmjopen-2019-032617] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION The healthy 'eubiosis' microbiome in infancy is regarded as the microbiome derived from term, vaginally delivered, antibiotic free, breastfed infants at 4-6 months. Dysbiosis is regarded as a deviation from a healthy state with reduced microbial diversity and deficient capacity to control drug-resistant organisms. Preterm infants are highly sensitive to early gut dysbiosis. Latter has been associated with sepsis and necrotising enterocolitis, but may also contribute to long-term health problems. Probiotics hold promise to reduce the risk for adverse short-term outcomes but the evidence from clinical trials remains inconclusive and none has directly assessed the effects of probiotics on the microbiome at high resolution. METHODS AND ANALYSIS A randomised, double blind, placebo-controlled study has been designed to assess the safety and efficacy of the probiotic mix of Bifidobacterium longum and infantis and Lactobacillus acidophilus in the prevention of gut dysbiosis in preterm infants between 28+0 and 32+6 weeks of gestation. The study is conducted in 18 German neonatal intensive care units. Between April 2018 and March 2020, 654 preterm infants of 28+0-32+6 weeks of gestation will be randomised in the first 48 hours of life to 28 days of once daily treatment with either probiotics or placebo. The efficacy endpoint is the prevention of gut dysbiosis at day 30 of life. A compound definition of gut dysbosis is used: (1) colonisation with multidrug-resistant organisms or gram-negative bacteria with high epidemic potential or (2) a significant deviation of the gut microbiota composition as compared with healthy term infants. Dysbiosis is determined by (1) conventional microbiological culture and (2) phylogenetic microbiome analysis by high-throughput 16S rRNA and metagenome sequencing. Persistence of dysbiosis will be assessed at 12-month follow-up visits. Side effects and adverse events related to the intervention will be recorded. Key secondary endpoint(s) are putative consequences of dysbiosis. A subgroup of infants will be thoroughly phenotyped for immune parameters using chipcytometry. ETHICS AND DISSEMINATION Ethics approval was obtained in all participating sites. Results of the trial will be published in peer-review journals, at scientific meetings, on the website (www.primal-study.de) and via social media of parent organisations. TRIAL REGISTRATION NUMBER DRKS00013197; Pre-results.
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Affiliation(s)
- Janina Marißen
- Department of Paediatrics, University of Lübeck, Lübeck, Germany
| | - Annette Haiß
- Department of Paediatrics, University of Lübeck, Lübeck, Germany
| | - Claudius Meyer
- Department of Paediatrics, University Medical Centre, Mainz, Germany
| | - Thea Van Rossum
- Structural and Computational Biology Unit, European Molecular Biology Laboratory, Heidelberg, Germany
| | - Lisa Marie Bünte
- Department of Paediatrics, University of Lübeck, Lübeck, Germany
| | | | - Christian Gille
- Department of Neonatology, University of Tübingen, Tübingen, Germany
| | - Sybelle Goedicke-Fritz
- Department of General Paediatrics and Neonatology, Saarland University, Homburg, Germany
| | - Wolfgang Göpel
- Department of Paediatrics, University of Lübeck, Lübeck, Germany
| | - Hannes Hudalla
- Department of Neonatology, University of Heidelberg, Heidelberg, Germany
| | - Julia Pagel
- Department of Paediatrics, University of Lübeck, Lübeck, Germany
| | - Sabine Pirr
- Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Bastian Siller
- Department of Paediatrics, University of Lübeck, Lübeck, Germany
| | - Dorothee Viemann
- Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Maren Vens
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Inke König
- Institute of Medical Biometry and Statistics, University of Lübeck, Lübeck, Germany
| | - Egbert Herting
- Department of Paediatrics, University of Lübeck, Lübeck, Germany
| | - Michael Zemlin
- Department of General Paediatrics and Neonatology, Saarland University, Homburg, Germany
| | - Stephan Gehring
- Department of Paediatrics, University Medical Centre, Mainz, Germany
| | - Peer Bork
- Structural and Computational Biology Unit, European Molecular Biology Laboratory, Heidelberg, Germany
| | - Philipp Henneke
- Insitute for Immunodeficiency (CCI) and Centre for Paediatrics and Adolescent Medicine, Medical Centre and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Härtel
- Department of Paediatrics, University of Lübeck, Lübeck, Germany
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Cui X, Shi Y, Gao S, Xue X, Fu J. Effects of Lactobacillus reuteri DSM 17938 in preterm infants: a double-blinded randomized controlled study. Ital J Pediatr 2019; 45:140. [PMID: 31706331 PMCID: PMC6842458 DOI: 10.1186/s13052-019-0716-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 09/11/2019] [Indexed: 01/02/2023] Open
Abstract
Background Preterm infants have immature gastrointestinal tracts and poor immunity. In this study, the effects of Lactobacillus reuteri DSM 17938 first on early feeding tolerance, growth, and second on infection prevention in preterm infants were evaluated. Methods One hundred fourteen formula-fed preterm infants with a gestational age between 30 weeks and 37 weeks, and a birth weight between 1500 and 2000 g were enrolled; 57 in the intervention and 57 in the control group:the intervention group was given a dose of 1 × 108 colony-forming units (5 drops) of L. reuteri DSM 17938 once daily, beginning with the first feeding until discharge. The control group did not receive probiotics. Early feeding tolerance (as time to full enterla feeding and number of reflux), growth, incidences of sepsis, localized infection, NEC, and adverse effects were recorded for both groups. Results The number of Daily reflux episodes (times/d) was lower (2.18 ± 0.83 vs. 3.77 ± 0.66, P < 0.01) and time to full enteral feedings (120 mL/kg/d) (9.95 ± 2.46 d vs. 13.80 ± 3.47 d, P < 0.05) was shorter in the intervention group. Average daily weight gain (14.55 ± 3.07 g/d vs. 10.12 ± 2.80 g/d), head circumference increas e(0.0760 ± 0.0157 cm/d vs. 0.0681 ± 0.0108 cm/d), and body length increase (0.1878 ± 0.0151 cm/d vs. 0.1756 ± 0.0166 cm/d) of the intervention group were higher (P < 0.01). There were no significant differences in the incidences of sepsis (4.44% vs. 8.33%), localized infection (6.67% vs. 8.33%), or NEC (2.22% vs. 10.42%) between the 2 groups (P > 0.05). The number of daily defecations (times/d) in the intervention group was higher (3.08 ± 0.33 vs. 2.29 ± 0.20, P < 0.01) and the length of hospital stay was shorter than that in the control group (20.60 ± 5.36 d vs. 23.75 ± 8.57 d, P < 0.05). No adverse effects were noted among the infants receiving L. reuteri. Conclusion L. reuteri may be an useful tool in improving early feeding tolerance in preterm infants, promoting growth, increasing the frequency of defecation, and shortening the length of hospital stay. Trial registration ChiCTR, ChiCTR1900025590. Registered 1 February 2019- Retrospectively registered, http://www.chictr.org.cn/listbycreater.aspx.
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Affiliation(s)
- Xuewei Cui
- Department of Neonatology, Shengjing Hospital, China Medical University, Shenyang, China
| | - Yongyan Shi
- Department of Neonatology, Shengjing Hospital, China Medical University, Shenyang, China
| | - Siyang Gao
- Department of Neonatology, Shengjing Hospital, China Medical University, Shenyang, China
| | - Xindong Xue
- Department of Neonatology, Shengjing Hospital, China Medical University, Shenyang, China
| | - Jianhua Fu
- Department of Neonatology, Shengjing Hospital, China Medical University, Shenyang, China.
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Abstract
Late-onset sepsis (LOS) and necrotising enterocolitis (NEC) account for the highest number of deaths in premature infants and often cause severe morbidity in survivors. NEC is an inflammatory mediated condition, but its pathophysiology remains poorly understood. There is increasing evidence that in LOS the causative organism most often translocates from the gut. No causative microorganism has been consistently associated with either LOS or NEC, but an aberrant gut microbiome development could play a pivotal role. A low bacterial diversity and a delay in anaerobic bacteria colonization may predispose preterm infants to disease development. Conversely, a predominance of Bifidobacterium species and breast milk feeding might help to prevent disease onset. With numerous studies reporting conflicting results, further research is needed to better understand the role of microorganisms and type of feeding in the health status of preterm infants.
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Affiliation(s)
- Andrea C Masi
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Neonate Bloodstream Infections in Organization for Economic Cooperation and Development Countries: An Update on Epidemiology and Prevention. J Clin Med 2019; 8:jcm8101750. [PMID: 31640253 PMCID: PMC6832148 DOI: 10.3390/jcm8101750] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/07/2019] [Accepted: 10/18/2019] [Indexed: 02/06/2023] Open
Abstract
The term neonatal sepsis is used to describe a generalized bloodstream infection of bacterial, viral, or fungal origin which is associated with hemodynamic changes and other clinical symptoms and signs, however, there is no unified definition. There are no basic criteria regarding differentiation of early-onset sepsis (EOS) versus late-onset sepsis (LOS). Stratification used in studies on neonatal sepsis also rarely includes the general condition of the newborn according to unambiguous assessment at birth, which hampers the establishment of a clear, uniform epidemiological description of neonatal sepsis. We aim to review the published data about the epidemiology and microbiology of sepsis in Organization for Economic Cooperation and Development (OECD) countries. Data was also collected on sepsis prevention programs that can be implemented in neonatal units. The outcomes of interest were incidence or incidence density of EOS and LOS, microbiology of EOS and LOS, and data on the methodology of the research, in particular the criteria for inclusion and exclusion of newborns from the study. Pubmed, EMBASE, LILACS Embase, Scopus, and Google Scholar were used. For the preselection step, inclusion criteria included: "bloodstream infection" or "neonatal sepsis" (MesH), "very low birth weight", and "country" full-text studies, human, and English language. Exclusion criteria included: studies published in languages other than English and studies available only as an abstracts. For proper selection, inclusion criteria included: information about epidemiology or microbiology bloodstream infection (BSI), study population and case definitions, exclusion criteria, narrative reviews, commentaries, case studies, pilot studies, study protocols, pediatric studies, and only clinical data (without microbiology or epidemiology) or studies with only one etiological factor analysis. The data review indicated the lack of an unequivocal, unified definition and no unambiguous basic criteria with regard to differentiation of EOS versus LOS. Among infants <1500 g, studies reported an EOS rate from 7% to 2%. For studies using other definitions (mostly all inborn babies), the rate of EOS ranged from 1% to 3%. The LOS incidences were much more varied among countries; the highest rates were in the multicenter studies focused on very low birth weight (VLBW) infants. The main pathogens in EOS are GBS and Gram-negative bacteria in LOS. Our review data shows that LOS microbiology is very diverse and that Gram-positive cocci, especially staphylococci, predominate versus Gram-negative rods. Unfortunately, the lack of uniform, international prevention programs results in high newborn morbidity and insufficient postnatal prevention of late-onset infections.
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Abstract
PURPOSE OF REVIEW There is growing evidence encouraging the use of probiotics in many conditions in children. However, given the wide number of probiotics available and contradictory data in the literature, the health-care provider is often faced with uncertainness about whether or not to use probiotics and which one(s) to choose. We here review current hypotheses regarding the efficacy and safety of probiotics and evaluate the available data on the use of probiotics in most common diseases in children. Considering that probiotics have strain-specific effects, we will focus on individual probiotic strains rather than on probiotics in general. RECENT FINDINGS Strain-specific efficacy was clearly demonstrated with Lactobacillus rhamnosus GG and Saccharomyces boulardii I-745 in the treatment of acute infectious diarrhea, Lactobacillus reuteri DSM 17938 in infantile colics, Lactobacillus rhamnosus GG, and VSL#3 in irritable bowel syndrome. In addition, encouraging results are seen for use of probiotics in necrotizing enterocolitis, food allergy, and nonalcoholic fatty liver disease. However, the data available for constipation are to be considered somewhat equivocal. SUMMARY The clinical relevance of these findings indicates that healthcare providers need to take strain-specificity and disease specificity of probiotics into consideration when recommending probiotic for their patients.
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Jarrett P, Meczner A, Costeloe K, Fleming P. Historical aspects of probiotic use to prevent necrotising enterocolitis in preterm babies. Early Hum Dev 2019; 135:51-57. [PMID: 31153726 DOI: 10.1016/j.earlhumdev.2019.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Over the last few decades, numerous studies have evaluated probiotic use for the prevention of necrotising enterocolitis in preterm babies. Early 'proof of concept' studies evaluating whether probiotics are capable of colonising the preterm gut have translated into multiple observational studies, small and large randomised controlled trials. Some show evidence of benefit while others have produced disappointing results. In this paper, we review the history of probiotic use in preterm babies for NEC prevention in an attempt to explain why uncertainty exists and why this intervention has not been universally adopted into routine neonatal practice.
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Affiliation(s)
- Prudence Jarrett
- Homerton University Hospital, NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland.
| | - Andras Meczner
- Homerton University Hospital, NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Kate Costeloe
- Barts and the London School of Medicine and Dentistry, London, United Kingdom of Great Britain and Northern Ireland
| | - Paul Fleming
- Homerton University Hospital, NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland; Barts and the London School of Medicine and Dentistry, London, United Kingdom of Great Britain and Northern Ireland
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Abstract
Probiotic administration to preterm infants is not universal despite randomised trial data from >10,000 infants, significant observational data and multiple meta-analyses. Advocates point to reductions in necrotising enterocolitis and sepsis, 'sceptics' hold concerns over data quality/interpretation or risks. Issues revolve around different products, primary outcomes, uncertain dosing strategies and individual large 'negative' trials alongside probiotic associated sepsis and quality control concerns. We review concerns and how to move probiotic use forward. Surprisingly little is known about parental perspectives, vital to inform next steps. How to share information and decisions around probiotic use now, and how this impacts on future available strategies is discussed. We address placebo controlled trials and propose alternate designs, including head to head studies, using 'routine' data collection systems, opt out consents and 'learning technologies' embedded in health care systems. We also raise the importance of underpinning mechanistic work to inform future trials.
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Baldassarre ME, Di Mauro A, Capozza M, Rizzo V, Schettini F, Panza R, Laforgia N. Dysbiosis and Prematurity: Is There a Role for Probiotics? Nutrients 2019; 11:E1273. [PMID: 31195600 PMCID: PMC6627287 DOI: 10.3390/nu11061273] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 12/23/2022] Open
Abstract
Healthy microbiota is a critical mediator in maintaining health and it is supposed that dysbiosis could have a role in the pathogenesis of a number of diseases. Evidence supports the hypothesis that maternal dysbiosis could act as a trigger for preterm birth; aberrant colonization of preterm infant gut might have a role in feeding intolerance and pathogenesis of necrotizing enterocolitis. Despite several clinical trials and meta-analyses, it is still not clear if modulation of maternal and neonatal microbiota with probiotic supplementation decreases the risk of preterm birth and its complications.
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Affiliation(s)
- Maria Elisabetta Baldassarre
- Neonatology and Neonatal Intensive Care Unit, Department of Biomedical Science and Human Oncology, "Aldo Moro" University of Bari, P.zza Giulio Cesare 11, 70124 Bari, Italy.
| | - Antonio Di Mauro
- Neonatology and Neonatal Intensive Care Unit, Department of Biomedical Science and Human Oncology, "Aldo Moro" University of Bari, P.zza Giulio Cesare 11, 70124 Bari, Italy.
| | - Manuela Capozza
- Neonatology and Neonatal Intensive Care Unit, Department of Biomedical Science and Human Oncology, "Aldo Moro" University of Bari, P.zza Giulio Cesare 11, 70124 Bari, Italy.
| | - Valentina Rizzo
- Neonatology and Neonatal Intensive Care Unit, Department of Biomedical Science and Human Oncology, "Aldo Moro" University of Bari, P.zza Giulio Cesare 11, 70124 Bari, Italy.
| | - Federico Schettini
- Neonatology and Neonatal Intensive Care Unit, Department of Biomedical Science and Human Oncology, "Aldo Moro" University of Bari, P.zza Giulio Cesare 11, 70124 Bari, Italy.
| | - Raffaella Panza
- Neonatology and Neonatal Intensive Care Unit, Department of Biomedical Science and Human Oncology, "Aldo Moro" University of Bari, P.zza Giulio Cesare 11, 70124 Bari, Italy.
| | - Nicola Laforgia
- Neonatology and Neonatal Intensive Care Unit, Department of Biomedical Science and Human Oncology, "Aldo Moro" University of Bari, P.zza Giulio Cesare 11, 70124 Bari, Italy.
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Suez J, Zmora N, Segal E, Elinav E. The pros, cons, and many unknowns of probiotics. Nat Med 2019; 25:716-729. [DOI: 10.1038/s41591-019-0439-x] [Citation(s) in RCA: 615] [Impact Index Per Article: 123.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 03/28/2019] [Indexed: 02/07/2023]
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Probiotics for preterm infants: A National Retrospective Cohort Study. J Perinatol 2019; 39:533-539. [PMID: 30692619 DOI: 10.1038/s41372-019-0315-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 12/13/2018] [Accepted: 12/23/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the effect of prophylactic probiotic (PP) administration on rates of necrotizing enterocolitis (NEC), late-onset sepsis (LOS), and mortality in preterm infants. STUDY DESIGN We conducted a retrospective cohort study of infants < 29 weeks' gestation, admitted to neonatal intensive care units participating in the Canadian Neonatal Network between 1 January 2014 and 31 December 2015. Infants in the exposure group received PP. A multiple logistic regression model with generalized estimation equation was used. RESULTS A total of 3093 infants were included, 652 infants (21%) received PP. The adjusted odds ratios (aOR) of NEC (aOR 0.64, 95% confidence interval [CI] 0.410, 0.996), mortality (aOR 0.41, 95% CI 0.26, 0.63), and a composite of NEC or mortality were significantly lower in the PP group. There was no significant difference in the aOR of LOS. CONCLUSION Prophylactic probiotic administration is associated with a reduction in NEC and mortality in preterm infants.
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Abstract
PURPOSE OF REVIEW Probiotic administration to premature infants for the purpose of prevention of necrotizing enterocolitis is common in many parts of the world but uncommon in the United States. The present review will emphasize recent findings in support of routine administration of probiotics to this highly vulnerable population. RECENT FINDINGS Additional evidence from animal models describing mechanisms of protection of probiotics in the immature gut and updated meta-analyses of randomized placebo-controlled trials and observational cohorts are presented (now including more than 40 000 premature infants from countries across the globe). SUMMARY The preponderance of evidence suggests that probiotic administration to premature infants is well tolerated and decreases the risk of death, necrotizing enterocolitis, and sepsis. Further comparisons of probiotic administration to placebo are not likely to alter these conclusions. Rather, future work should focus on assurance of high-quality products with demonstrated purity and viability of probiotic microbes, and future clinical trials should focus on comparisons between high-quality products and doses.
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Rao SC, Patole SK. Probiotic research in neonates with congenital gastrointestinal surgical conditions - Now is the time. Microb Biotechnol 2019; 12:254-258. [PMID: 30575294 PMCID: PMC6389852 DOI: 10.1111/1751-7915.13358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 11/29/2018] [Indexed: 12/17/2022] Open
Abstract
Neonates with congenital gastrointestinal surgical conditions (CGISC) receive parenteral nutrition, get exposed to multiple courses of antibiotics, undergo invasive procedures, and are nursed in intensive care units. They do not receive early enteral feeding and have limited opportunities for skin to skin contact with their mothers. Many of these infants receive gastric acid suppression therapies. All these factors increase the risk of gut dysbiosis in these infants. Gut dysbiosis is known to be associated with increased risk of infections and other morbidities in ICU patients. Experimental studies have shown that probiotics inhibit gut colonization with pathogenic bacteria, enhance gut barrier function, facilitate colonization with healthy commensals, protect from enteropathogenic infection through production of acetate, reduce antimicrobial resistance, enhance innate immunity, and increase the maturation of the enteric nervous system and promote gut peristalsis. Through these mechanisms, probiotics have the potential to decrease the risk of sepsis and inflammation, improve feed tolerance and minimise cholestasis in neonates with CGISC. Among preterm non-surgical infants, evidence from more than 35 RCTs and multiple observational studies have shown probiotics to be safe and beneficial. A RCT in neonates (N=24) with gastroschisis found that probiotic supplementation partially attenuated gut dysbiosis. Two ongoing RCTs (total N=168) in neonates with gastrointestinal surgical conditions are expected to provide feasibility data to enable the conduct of large RCTs. Rigorous quality assurance of the probiotic product, ongoing microbial surveillance and clinical vigilance are warranted while conducting such RCTs.
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Affiliation(s)
- Shripada C. Rao
- Neonatal Intensive Care UnitPerth Children's HospitalHospital AvenueNedlandsWA6009Australia
- Centre for Neonatal Research and EducationUniversity of Western AustraliaPerthWAAustralia
| | - Sanjay K. Patole
- Centre for Neonatal Research and EducationUniversity of Western AustraliaPerthWAAustralia
- Neonatal DirectorateKing Edward Memorial Hospital for WomenPerthWAAustralia
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Underwood MA. Probiotics and the prevention of necrotizing enterocolitis. J Pediatr Surg 2019; 54:405-412. [PMID: 30241961 DOI: 10.1016/j.jpedsurg.2018.08.055] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 07/19/2018] [Accepted: 08/16/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Immaturity of the host immune system and alterations in the intestinal microbiome appear to be key factors in the pathogenesis of necrotizing enterocolitis (NEC). The aim of this paper is to weigh the evidence for the use of probiotics to prevent NEC in premature infants. METHODS Animal studies, randomized controlled trials, observational cohort studies and meta-analyses involving administration of probiotic products for the prevention of NEC were reviewed. This review of the evidence summarizes the available preclinical and clinical data. RESULTS In animal models probiotic microbes alter the intestinal microbiome, decrease inflammation and intestinal permeability and decrease the incidence and severity of experimental NEC. In randomized, placebo-controlled trials and cohort studies of premature infants, probiotic microbes decrease the risk of NEC, death and sepsis. CONCLUSION Evidence is strong for the prevention of NEC with the use of combination probiotics in premature infants who receive breast milk. The potential risks and benefits of probiotic administration to premature infants should be carefully reviewed with parents. TYPE OF STUDY Therapeutic. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Mark A Underwood
- Division of Neonatology, University of California Davis, Ticon 2, Suite 253, 2516 Stockton Blvd, Sacramento, CA 95817, USA.
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Athalye‐Jape G, Patole S. Probiotics for preterm infants - time to end all controversies. Microb Biotechnol 2019; 12:249-253. [PMID: 30637944 PMCID: PMC6389843 DOI: 10.1111/1751-7915.13357] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 11/29/2018] [Indexed: 01/13/2023] Open
Abstract
Mortality, necrotising enterocolitis (NEC), late onset sepsis (LOS) and feeding intolerance are significant issues for very preterm (< 32 weeks) and extremely preterm (< 28 weeks) infants. The complications of ≥ Stage II NEC [e.g. Resection of the gangrenous gut, survival with intestinal failure, recurrent infections, prolonged hospital stay, and long-term neurodevelopmental impairment (NDI)] impose a significant health burden. LOS also carries significant burden including long-term NDI due to adverse effects of inflammation on the preterm brain during the critical phase of development. Frequent stopping of feeds due to feeding intolerance is a significant iatrogenic contributor to postnatal growth failure in extremely preterm infants. Over 25 systematic reviews and meta-analyses of RCTs (~12 000 participants) have reported that probiotics significantly reduce the risk of all-cause mortality, NEC ≥ Stage II, LOS and feeding intolerance in preterm infants. Systematic reviews and meta-analysis of non-RCTs have also shown that the benefits after adopting probiotics as a standard prophylaxis for preterm infants are similar to those reported in RCTs. No intervention comes close to probiotics when it comes to significant reduction in death, NEC, LOS and feeding intolerance at a cost of less than a dollar a day irrespective of the setting and baseline incidence of NEC. The common controversies that are preventing the rapid uptake of probiotics for preterm infants are addressed in this paper.
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Affiliation(s)
- Gayatri Athalye‐Jape
- Neonatal DirectorateKing Edward Memorial Hospital for WomenPerthWAAustralia
- Centre for Neonatal Research and EducationUniversity of Western AustraliaPerthWAAustralia
| | - Sanjay Patole
- Neonatal DirectorateKing Edward Memorial Hospital for WomenPerthWAAustralia
- Centre for Neonatal Research and EducationUniversity of Western AustraliaPerthWAAustralia
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Plaza-Diaz J, Ruiz-Ojeda FJ, Gil-Campos M, Gil A. Mechanisms of Action of Probiotics. Adv Nutr 2019; 10:S49-S66. [PMID: 30721959 PMCID: PMC6363529 DOI: 10.1093/advances/nmy063] [Citation(s) in RCA: 493] [Impact Index Per Article: 98.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 07/27/2018] [Indexed: 12/14/2022] Open
Abstract
Probiotics are living microorganisms that confer health benefits to the host when administered in adequate amounts; however, dead bacteria and their components can also exhibit probiotic properties. Bifidobacterium and strains of lactic acid bacteria are the most widely used bacteria that exhibit probiotic properties and are included in many functional foods and dietary supplements. Probiotics have been shown to prevent and ameliorate the course of digestive disorders such as acute, nosocomial, and antibiotic-associated diarrhea; allergic disorders such as atopic dermatitis (eczema) and allergic rhinitis in infants; and Clostridium difficile-associated diarrhea and some inflammatory bowel disorders in adults. In addition, probiotics may be of interest as coadjuvants in the treatment of metabolic disorders, including obesity, metabolic syndrome, nonalcoholic fatty liver disease, and type 2 diabetes. However, the mechanisms of action of probiotics, which are diverse, heterogeneous, and strain specific, have received little attention. Thus, the aim of the present work was to review the main mechanisms of action of probiotics, including colonization and normalization of perturbed intestinal microbial communities in children and adults; competitive exclusion of pathogens and bacteriocin production; modulation of fecal enzymatic activities associated with the metabolization of biliary salts and inactivation of carcinogens and other xenobiotics; production of short-chain and branched-chain fatty acids, which, in turn, have wide effects not only in the intestine but also in peripheral tissues via interactions with short-chain fatty acid receptors, modulating mainly tissue insulin sensitivity; cell adhesion and mucin production; modulation of the immune system, which results mainly in the differentiation of T-regulatory cells and upregulation of anti-inflammatory cytokines and growth factors, i.e., interleukin-10 and transforming growth factor; and interaction with the brain-gut axis by regulation of endocrine and neurologic functions. Further research to elucidate the precise molecular mechanisms of action of probiotics is warranted.
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Affiliation(s)
- Julio Plaza-Diaz
- Department of Biochemistry and Molecular Biology II, School of Pharmacy, University of Granada, Armilla, Granada, Spain,Institute of Nutrition and Food Technology “José Mataix,” Biomedical Research Center, University of Granada, Armilla, Granada, Spain,Instituto de Investigación Biosanitaria IBS.GRANADA, Complejo Hospitalario Universitario de Granada, Granada, Spain
| | - Francisco Javier Ruiz-Ojeda
- Department of Biochemistry and Molecular Biology II, School of Pharmacy, University of Granada, Armilla, Granada, Spain,Institute of Nutrition and Food Technology “José Mataix,” Biomedical Research Center, University of Granada, Armilla, Granada, Spain,Instituto de Investigación Biosanitaria IBS.GRANADA, Complejo Hospitalario Universitario de Granada, Granada, Spain
| | - Mercedes Gil-Campos
- CIBEROBN (Physiopathology of Obesity and Nutrition CB12/03/30038), Instituto de Salud Carlos III, Madrid, Spain,Pediatric Research and Metabolism Unit, Reina Sofia University Hospital, Maimonides Institute for Biomedical Research, Cordoba, Spain
| | - Angel Gil
- Department of Biochemistry and Molecular Biology II, School of Pharmacy, University of Granada, Armilla, Granada, Spain,Institute of Nutrition and Food Technology “José Mataix,” Biomedical Research Center, University of Granada, Armilla, Granada, Spain,Instituto de Investigación Biosanitaria IBS.GRANADA, Complejo Hospitalario Universitario de Granada, Granada, Spain,CIBEROBN (Physiopathology of Obesity and Nutrition CB12/03/30038), Instituto de Salud Carlos III, Madrid, Spain,Address correspondence to AG (e-mail: )
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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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Andersen AD, Nguyen DN, Langhorn L, Renes IB, van Elburg RM, Hartog A, Tims S, van de Looij Y, Sangild PT, Thymann T. Synbiotics Combined with Glutamine Stimulate Brain Development and the Immune System in Preterm Pigs. J Nutr 2019; 149:36-45. [PMID: 30608604 DOI: 10.1093/jn/nxy243] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 08/31/2018] [Indexed: 02/07/2023] Open
Abstract
Background Preterm infants are born with an immature gut, brain, and immune system, predisposing them to short- and long-term complications. Objective We hypothesized that a milk diet supplemented with pre- and probiotics (i.e. synbiotics) and glutamine would improve gut, brain, and immune maturation in preterm neonates, using preterm pigs as a model. Methods Preterm pigs (Landrace x Yorkshire x Duroc, n = 40, delivered by c-section at 90% of gestation) were reared individually until day 23 after birth under highly standardized conditions. Piglets in the intervention group (PPG, n = 20) were fed increasing volumes of bovine milk supplemented with prebiotics (short-chain galacto- and long chain fructo-oligosaccharides 9:1, 4-12 g/L), probiotics (Bifidobacterium breve M16-V, 3 × 109 CFU/d) and l-glutamine [0.15-0.30 g/(kg · d)], and compared with pigs fed bovine milk with added placebo compounds as control (CON, n = 20). Clinical, gastrointestinal, immunological, cognitive, and neurological endpoints were measured. Results The PPG pigs showed more diarrhea but weight gain, body composition, and gut parameters were similar between the groups. Cognitive performance, assessed in a T-maze, was significantly higher in PPG pigs (P < 0.01), whereas motor function and exploratory interest were similar between the groups. Using ex vivo diffusion imaging, the orientation dispersion index in brain cortical gray matter was 50% higher (P = 0.04), and fractional anisotropy value was 7% lower (P = 0.05) in PPG pigs compared with CON pigs, consistent with increased dendritic branching in PPG. In associative fibers, radial diffusivity was lower and fractional anisotropy was higher in PPG pigs compared with CON pigs (all P < 0.05), while measures in the internal capsule showed a tendency towards reduced radial diffusivity and mean diffusivity (both P = 0.09). On day 23 pigs in the PPG group showed higher blood leukocyte numbers (+43%), neutrophil counts (+100%), and phagocytic rates (+24%), relative to CON, all P < 0.05. Conclusion Preterm pigs supplemented with Bifidobacterium breve, galacto- and fructo-oligosaccharides, and l-glutamine showed enhanced neuronal and immunological development. The findings indicate the potential for targeted nutritional interventions after preterm birth, to support development of important systems such as immunity and brain.
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Affiliation(s)
- Anders D Andersen
- Section of Comparative Pediatrics and Nutrition, University of Copenhagen, Denmark
| | - Duc Ninh Nguyen
- Section of Comparative Pediatrics and Nutrition, University of Copenhagen, Denmark
| | - Louise Langhorn
- Section of Comparative Pediatrics and Nutrition, University of Copenhagen, Denmark
| | - Ingrid B Renes
- Danone Nutricia Research, Utrecht, Netherlands.,Department of Pediatrics, Emma Children's Hospital AMC, Amsterdam, Netherlands
| | - Ruurd M van Elburg
- Danone Nutricia Research, Utrecht, Netherlands.,Department of Pediatrics, Emma Children's Hospital AMC, Amsterdam, Netherlands
| | - Anita Hartog
- Danone Nutricia Research, Utrecht, Netherlands.,Department of Pharmacology & Pathophysiology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, Netherlands
| | | | - Yohan van de Looij
- Division of Child Development & Growth, University Children's Hospital Geneva & Functional and Metabolic Imaging Laboratory, Lausanne, Switzerland
| | - Per T Sangild
- Section of Comparative Pediatrics and Nutrition, University of Copenhagen, Denmark
| | - Thomas Thymann
- Section of Comparative Pediatrics and Nutrition, University of Copenhagen, Denmark
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Athalye-Jape G, Minaee N, Nathan E, Simmer K, Patole S. Outcomes in preterm small versus appropriate for gestation infants after Bifidobacterium breve M-16 V supplementation. J Matern Fetal Neonatal Med 2018; 33:2209-2215. [PMID: 30394171 DOI: 10.1080/14767058.2018.1543657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Fecal bifidobacteria response after Bifidobacterium breve M-16 V supplementation was comparable in preterm small (SGA) versus appropriate for gestational age (AGA) infants.Objectives: To compare clinical outcomes between preterm SGA versus AGA infants after routine probiotic supplementation (RPS) with Bifidobacterium breve M-16V (3 × 109 CFU/day).Design: Retrospective cohort study (June 2012-August 2015) comparing outcomes between preterm (<34 weeks, subgroup: <29 weeks) SGA versus AGA infants after RPS with B. breve M-16 V using multivariable regression analysis. Primary outcome: necrotizing enterocolitis (NEC)≥Stage II/all-cause mortality. Secondary outcomes: NEC ≥ Stage II, all-cause mortality, late onset sepsis (LOS), postnatal age at full feeds (PAFF).Results: Outcomes in inborn 1380/1481 (162 SGA versus 1218 AGA) admissions were analyzed. Primary outcome "NEC ≥ Stage II /all-cause mortality" was higher in SGA versus AGA infants <29 weeks (21 versus 12%; p = .040), and showed trend toward reduction (8 versus 6%; p = .057) in AGA <34 weeks. NEC ≥ Stage II, LOS, and all-cause mortality was comparable in SGA versus AGA infants <34 weeks (3 versus 2, 9 versus 8, 9% versus 6%) and <29 weeks (5 versus 4, 16 versus 9, 18% versus 19%), respectively. Median (IQR) PAFF was significantly higher in SGA versus AGA infants <34 weeks (8 (6-12) versus 7 (5-10) days), and <29 weeks (14 (12-17) versus 11 (8-16) days).Conclusions: NEC, LOS and all-cause mortality rates were similar in preterm SGA versus AGA infants after RPS with Bifidobacterium breve M-16 V, but PAFF was higher in SGA infants.
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Affiliation(s)
- Gayatri Athalye-Jape
- Neonatal Directorate, King Edward Memorial Hospital for Women, Perth, Australia.,School of Paediatrics and Child Health, Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
| | - Novia Minaee
- Department of Biostatistics, Women and Infants Research Foundation, Subiaco, Australia
| | - Elizabeth Nathan
- Department of Biostatistics, Women and Infants Research Foundation, Subiaco, Australia
| | - Karen Simmer
- Neonatal Directorate, King Edward Memorial Hospital for Women, Perth, Australia.,School of Paediatrics and Child Health, Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
| | - Sanjay Patole
- Neonatal Directorate, King Edward Memorial Hospital for Women, Perth, Australia.,School of Paediatrics and Child Health, Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
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