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Yuu EY, Bührer C, Eckmanns T, Fulde M, Herz M, Kurzai O, Lindstedt C, Panagiotou G, Piro VC, Radonic A, Renard BY, Reuss A, Siliceo SL, Thielemann N, Thürmer A, Vorst KV, Wieler LH, Haller S. The gut microbiome, resistome, and mycobiome in preterm newborn infants and mouse pups: lack of lasting effects by antimicrobial therapy or probiotic prophylaxis. Gut Pathog 2024; 16:27. [PMID: 38735967 PMCID: PMC11089716 DOI: 10.1186/s13099-024-00616-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 04/13/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Enhancing our understanding of the underlying influences of medical interventions on the microbiome, resistome and mycobiome of preterm born infants holds significant potential for advancing infection prevention and treatment strategies. We conducted a prospective quasi-intervention study to better understand how antibiotics, and probiotics, and other medical factors influence the gut development of preterm infants. A controlled neonatal mice model was conducted in parallel, designed to closely reflect and predict exposures. Preterm infants and neonatal mice were stratified into four groups: antibiotics only, probiotics only, antibiotics followed by probiotics, and none of these interventions. Stool samples from both preterm infants and neonatal mice were collected at varying time points and analyzed by 16 S rRNA amplicon sequencing, ITS amplicon sequencing and whole genome shotgun sequencing. RESULTS The human infant microbiomes showed an unexpectedly high degree of heterogeneity. Little impact from medical exposure (antibiotics/probiotics) was observed on the strain patterns, however, Bifidobacterium bifidum was found more abundant after exposure to probiotics, regardless of prior antibiotic administration. Twenty-seven antibiotic resistant genes were identified in the resistome. High intra-variability was evident within the different treatment groups. Lastly, we found significant effects of antibiotics and probiotics on the mycobiome but not on the microbiome and resistome of preterm infants. CONCLUSIONS Although our analyses showed transient effects, these results provide positive motivation to continue the research on the effects of medical interventions on the microbiome, resistome and mycobiome of preterm infants.
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Affiliation(s)
- Elizabeth Y Yuu
- Data Analytics & Computational Statistics, Hasso Plattner Institute, University of Potsdam, Prof.-Dr.-Helmert-Straße 2-3, 14482 , Potsdam, Germany
| | | | | | - Marcus Fulde
- Department of Mathematics and Computer Science, Freie Universität Berlin, 14195, Berlin, Germany
| | - Michaela Herz
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Oliver Kurzai
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
- Department of Microbiome Dynamics, Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Beutenbergstraße 11A, 07745 , Jena, Germany
| | | | - Gianni Panagiotou
- Department of Microbiome Dynamics, Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Beutenbergstraße 11A, 07745 , Jena, Germany
- Faculty of Biological Sciences, Friedrich Schiller University, 07745, Jena, Germany
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Vitor C Piro
- Data Analytics & Computational Statistics, Hasso Plattner Institute, University of Potsdam, Prof.-Dr.-Helmert-Straße 2-3, 14482 , Potsdam, Germany
- Department of Mathematics and Computer Science, Freie Universität Berlin, 14195, Berlin, Germany
| | | | - Bernhard Y Renard
- Data Analytics & Computational Statistics, Hasso Plattner Institute, University of Potsdam, Prof.-Dr.-Helmert-Straße 2-3, 14482 , Potsdam, Germany
| | - Annicka Reuss
- Robert Koch Institute, Berlin, Germany
- Ministry of Justice and Health, Schleswig-Holstein, Kiel , Germany
| | - Sara Leal Siliceo
- Department of Microbiome Dynamics, Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Beutenbergstraße 11A, 07745 , Jena, Germany
| | - Nadja Thielemann
- Institute for Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | | | - Kira van Vorst
- Department of Mathematics and Computer Science, Freie Universität Berlin, 14195, Berlin, Germany
| | - Lothar H Wieler
- Data Analytics & Computational Statistics, Hasso Plattner Institute, University of Potsdam, Prof.-Dr.-Helmert-Straße 2-3, 14482 , Potsdam, Germany
- Robert Koch Institute, Berlin, Germany
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Blanchetière A, Dolladille C, Goyer I, Join-Lambert O, Fazilleau L. State of the Art of Probiotic Use in Neonatal Intensive Care Units in French-Speaking European Countries. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1889. [PMID: 38136091 PMCID: PMC10742297 DOI: 10.3390/children10121889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023]
Abstract
The effectiveness of probiotics in reducing the incidence of necrotizing enterocolitis has been supported by a very large number of studies. However, the utilization of probiotics in preterm infants remains a topic of debate. This study aims to assess the rate of probiotic use in European neonatal intensive care units (NICUs), compare administration protocols, and identify barriers and concerns associated with probiotic use. An online questionnaire was distributed via email to European NICUs between October 2020 and June 2021. Different questions related to the frequency of probiotic use were proposed. Data on probiotic administration protocols and reasons for non-utilization were collected. The majority of responses were from France and Switzerland, with response rates of 85% and 89%, respectively. A total of 21% of French NICUs and 100% of Swiss NICUs reported routine probiotic use. There was significant heterogeneity in probiotic administration protocols, including variations in probiotic strains, administration, and treatment duration. The main obstacles to routine probiotic use were the absence of recommendations, lack of consensus on strain selection, insufficient scientific evidence, and concerns regarding potential adverse effects. The rate of routine probiotic administration remains low in European NICUs, with heterogeneity among protocols. Further trials are necessary to elucidate optimal treatment modalities and ensure safety of administration.
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Affiliation(s)
| | - Charles Dolladille
- Pharmaco-Epidemiology Unit, Department of Cardiology, University Hospital of Caen, 14000 Caen, France
| | - Isabelle Goyer
- Department of Pharmacy, University Hospital of Caen, 14000 Caen, France
| | | | - Laura Fazilleau
- Department of Neonatology, University Hospital of Caen, 14000 Caen, France
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de la Fuente-Nunez C, Cesaro A, Hancock REW. Antibiotic failure: Beyond antimicrobial resistance. Drug Resist Updat 2023; 71:101012. [PMID: 37924726 DOI: 10.1016/j.drup.2023.101012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023]
Abstract
Despite significant progress in antibiotic discovery, millions of lives are lost annually to infections. Surprisingly, the failure of antimicrobial treatments to effectively eliminate pathogens frequently cannot be attributed to genetically-encoded antibiotic resistance. This review aims to shed light on the fundamental mechanisms contributing to clinical scenarios where antimicrobial therapies are ineffective (i.e., antibiotic failure), emphasizing critical factors impacting this under-recognized issue. Explored aspects include biofilm formation and sepsis, as well as the underlying microbiome. Therapeutic strategies beyond antibiotics, are examined to address the dimensions and resolution of antibiotic failure, actively contributing to this persistent but escalating crisis. We discuss the clinical relevance of antibiotic failure beyond resistance, limited availability of therapies, potential of new antibiotics to be ineffective, and the urgent need for novel anti-infectives or host-directed therapies directly addressing antibiotic failure. Particularly noteworthy is multidrug adaptive resistance in biofilms that represent 65 % of infections, due to the lack of approved therapies. Sepsis, responsible for 19.7 % of all deaths (as well as severe COVID-19 deaths), is a further manifestation of this issue, since antibiotics are the primary frontline therapy, and yet 23 % of patients succumb to this condition.
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Affiliation(s)
- Cesar de la Fuente-Nunez
- Machine Biology Group, Departments of Psychiatry and Microbiology, Institute for Biomedical Informatics, Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Departments of Bioengineering and Chemical and Biomolecular Engineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, USA; Penn Institute for Computational Science, University of Pennsylvania, Philadelphia, PA, USA.
| | - Angela Cesaro
- Machine Biology Group, Departments of Psychiatry and Microbiology, Institute for Biomedical Informatics, Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Departments of Bioengineering and Chemical and Biomolecular Engineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA, USA; Penn Institute for Computational Science, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E W Hancock
- Centre for Microbial Diseases and Immunity Research, University of British Columbia, Vancouver, Canada.
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Xiang Q, Yan X, Shi W, Li H, Zhou K. Early gut microbiota intervention in premature infants: Application perspectives. J Adv Res 2023; 51:59-72. [PMID: 36372205 PMCID: PMC10491976 DOI: 10.1016/j.jare.2022.11.004] [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: 08/08/2022] [Revised: 10/30/2022] [Accepted: 11/05/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Preterm birth is the leading cause of death in children under the age of five. One of the major factors contributing to the high risk of diseases and deaths in premature infants is the incomplete development of the intestinal immune system. The gut microbiota has been widely recognized as a critical factor in promoting the development and function of the intestinal immune system after birth. However, the gut microbiota of premature infants is at high risk of dysbiosis, which is highly associated with adverse effects on the development and education of the early life immune system. Early intervention can modulate the colonization and development of gut microbiota and has a long-term influence on the development of the intestinal immune system. AIM OF REVIEW This review aims to summarize the characterization, interconnection, and underlying mechanism of gut microbiota and intestinal innate immunity in premature infants, and to discuss the status, applicability, safety, and prospects of different intervention strategies in premature infants, thus providing an overview and outlook of the current applications and remaining gaps of early intervention strategies in premature infants. KEY SCIENTIFIC CONCEPTS OF REVIEW This review is focused on three key concepts. Firstly, the gut microbiota of premature infants is at high risk of dysbiosis, resulting in dysfunctional intestinal immune system processes. Secondly, contributing roles of early intervention have been observed in improving the intestinal environment and promoting gut microbiota colonization, which is significant in the development and function of gut immunity in premature infants. Thirdly, different strategies of early intervention, such as probiotics, fecal microbiota transplantation, and nutrients, show different safety, applicability, and outcome in premature infants, and the underlying mechanism is complex and poorly understood.
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Affiliation(s)
- Quanhang Xiang
- Shenzhen Institute of Respiratory Diseases, the Second Clinical Medical College, Jinan University (Shenzhen People's Hospital), Shenzhen, China
| | - Xudong Yan
- Department of Neonatal Intensive Care Unit, the Second Clinical Medical College, Jinan University (Shenzhen People's Hospital), Shenzhen, China
| | - Wei Shi
- Department of Obstetrics and Gynecology, the Second Clinical Medical College, Jinan University (Shenzhen People's Hospital), Shenzhen, China
| | - Huiping Li
- Department of Respiratory and Critical Care Medicine, the first affiliated hospital of Southern University of Science and Technology of China, Shenzhen People's Hospital, Shenzhen, China; The First Affiliated Hospital (Shenzhen People's Hospital), Southern University of Science and Technology, Shenzhen, China
| | - Kai Zhou
- Shenzhen Institute of Respiratory Diseases, the Second Clinical Medical College, Jinan University (Shenzhen People's Hospital), Shenzhen, China; The First Affiliated Hospital (Shenzhen People's Hospital), Southern University of Science and Technology, Shenzhen, China.
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5
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Sharif S, Meader N, Oddie SJ, Rojas-Reyes MX, McGuire W. Probiotics to prevent necrotising enterocolitis in very preterm or very low birth weight infants. Cochrane Database Syst Rev 2023; 7:CD005496. [PMID: 37493095 PMCID: PMC10370900 DOI: 10.1002/14651858.cd005496.pub6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND Intestinal dysbiosis may contribute to the pathogenesis of necrotising enterocolitis (NEC) in very preterm or very low birth weight (VLBW) infants. Dietary supplementation with probiotics to modulate the intestinal microbiome has been proposed as a strategy to reduce the risk of NEC and associated mortality and morbidity in very preterm or VLBW infants. OBJECTIVES To determine the effect of supplemental probiotics on the risk of NEC and associated mortality and morbidity in very preterm or very low birth weight infants. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, the Maternity and Infant Care database, and CINAHL from inception to July 2022. We searched clinical trials databases and conference proceedings, and examined the reference lists of retrieved articles. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing probiotics with placebo or no probiotics in very preterm infants (born before 32 weeks' gestation) and VLBW infants (weighing less than 1500 g at birth). DATA COLLECTION AND ANALYSIS Two review authors independently evaluated risk of bias of the trials, extracted data, and synthesised effect estimates using risk ratios (RRs), risk differences (RDs), and mean differences (MDs), with associated 95% confidence intervals (CIs). The primary outcomes were NEC and all-cause mortality; secondary outcome measures were late-onset invasive infection (more than 48 hours after birth), duration of hospitalisation from birth, and neurodevelopmental impairment. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 60 trials with 11,156 infants. Most trials were small (median sample size 145 infants). The main potential sources of bias were unclear reporting of methods for concealing allocation and masking caregivers or investigators in about half of the trials. The formulation of the probiotics varied across trials. The most common preparations contained Bifidobacterium spp., Lactobacillus spp., Saccharomyces spp., andStreptococcus spp., alone or in combination. Very preterm or very low birth weight infants Probiotics may reduce the risk of NEC (RR 0.54, 95% CI 0.46 to 0.65; I² = 17%; 57 trials, 10,918 infants; low certainty). The number needed to treat for an additional beneficial outcome (NNTB) was 33 (95% CI 25 to 50). Probiotics probably reduce mortality slightly (RR 0.77, 95% CI 0.66 to 0.90; I² = 0%; 54 trials, 10,484 infants; moderate certainty); the NNTB was 50 (95% CI 50 to 100). Probiotics probably have little or no effect on the risk of late-onset invasive infection (RR 0.89, 95% CI 0.82 to 0.97; I² = 22%; 49 trials, 9876 infants; moderate certainty). Probiotics may have little or no effect on neurodevelopmental impairment (RR 1.03, 95% CI 0.84 to 1.26; I² = 0%; 5 trials, 1518 infants; low certainty). Extremely preterm or extremely low birth weight infants Few data were available for extremely preterm or extremely low birth weight (ELBW) infants. In this population, probiotics may have little or no effect on NEC (RR 0.92, 95% CI 0.69 to 1.22, I² = 0%; 10 trials, 1836 infants; low certainty), all-cause mortality (RR 0.92, 95% CI 0.72 to 1.18; I² = 0%; 7 trials, 1723 infants; low certainty), or late-onset invasive infection (RR 0.93, 95% CI 0.78 to 1.09; I² = 0%; 7 trials, 1533 infants; low certainty). No trials provided data for measures of neurodevelopmental impairment in extremely preterm or ELBW infants. AUTHORS' CONCLUSIONS Given the low to moderate certainty of evidence for the effects of probiotic supplements on the risk of NEC and associated morbidity and mortality for very preterm or VLBW infants, and particularly for extremely preterm or ELBW infants, there is a need for further large, high-quality trials to provide evidence of sufficient validity and applicability to inform policy and practice.
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Affiliation(s)
- Sahar Sharif
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Nicholas Meader
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Sam J Oddie
- Centre for Reviews and Dissemination, University of York, York, UK
- Bradford Neonatology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Maria X Rojas-Reyes
- Institut d'Recerca Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Evaluation Unit of the Canary Islands Health Service (SESCS), Tenerife, Spain
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
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Wala SJ, Ragan MV, Sajankila N, Volpe SG, Purayil N, Dumbauld Z, Besner GE. Probiotics and novel probiotic delivery systems. Semin Pediatr Surg 2023; 32:151307. [PMID: 37295299 DOI: 10.1016/j.sempedsurg.2023.151307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Necrotizing enterocolitis (NEC) is an infectious and inflammatory intestinal disease that is the most common surgical emergency in the premature patient population. Although the etiology of the disease is multifactorial, intestinal dysbiosis is a hallmark of this disease. Based on this, probiotics may play a therapeutic role in NEC by introducing beneficial bacteria with immunomodulating, antimicrobial, and anti-inflammatory functions into the gastrointestinal tract. Currently, there is no Food and Drug Administration (FDA)-approved probiotic for the prevention and treatment of NEC. All probiotic clinical studies to date have administered the bacteria in their planktonic (free-living) state. This review will discuss established probiotic delivery systems including planktonic probiotics, prebiotics, and synbiotics, as well as novel probiotic delivery systems such as biofilm-based and designer probiotics. We will also shed light on whether or not probiotic efficacy is influenced by administration with breast milk. Finally, we will consider the challenges associated with developing an FDA-approved probiotic for NEC.
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Affiliation(s)
- Samantha J Wala
- Center for Perinatal Research, Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Mecklin V Ragan
- Center for Perinatal Research, Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Nitin Sajankila
- Center for Perinatal Research, Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Samuel G Volpe
- Center for Perinatal Research, Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Nanditha Purayil
- Center for Perinatal Research, Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Zachary Dumbauld
- Center for Perinatal Research, Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Gail E Besner
- Center for Perinatal Research, Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
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Barbian ME, Patel RM. Probiotics for prevention of necrotizing enterocolitis: Where do we stand? Semin Perinatol 2023; 47:151689. [PMID: 36621416 PMCID: PMC10201375 DOI: 10.1016/j.semperi.2022.151689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In this review, we provide a historical perspective on probiotic use in preterm infants. We review recent data on the treatment effects of probiotics on necrotizing enterocolitis, sepsis, and mortality. We highlight guidance statements from professional societies and organizations, discussing key points within the context of the currently available evidence from both randomized trials and cohort studies. Finally, we summarize experiences from several North American centers that have reported on the routine use of probiotics, including our center. Our goal is to highlight some of the considerations and complexities surrounding routine probiotics use in preterm infants.
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Affiliation(s)
- Maria Estefania Barbian
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Dr. NE, Atlanta, GA 30322, United States
| | - Ravi Mangal Patel
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Dr. NE, Atlanta, GA 30322, United States.
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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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Sajankila N, Wala SJ, Ragan MV, Volpe SG, Dumbauld Z, Purayil N, Mihi B, Besner GE. Current and future methods of probiotic therapy for necrotizing enterocolitis. Front Pediatr 2023; 11:1120459. [PMID: 36937955 PMCID: PMC10017871 DOI: 10.3389/fped.2023.1120459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 01/31/2023] [Indexed: 03/06/2023] Open
Abstract
Necrotizing enterocolitis (NEC) is a complex intestinal disease that primarily affects premature neonates. Given its significant mortality and morbidity, there is an urgent need to develop improved prophylactic measures against the disease. One potential preventative strategy for NEC is the use of probiotics. Although there has been significant interest for decades in probiotics in neonatal care, no clear guidelines exist regarding which probiotic to use or for which patients, and no FDA-approved products exist on the market for NEC. In addition, there is lack of agreement regarding the benefits of probiotics in neonates, as well as some concerns about the safety and efficacy of available products. We discuss currently available probiotics as well as next-generation probiotics and novel delivery strategies which may offer an avenue to capitalize on the benefits of probiotics, while minimizing the risks. Thus, probiotics may still prove to be an effective prevention strategy for NEC, although further product development and research is needed to support use in the preterm population.
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Mills DA, German JB, Lebrilla CB, Underwood MA. Translating neonatal microbiome science into commercial innovation: metabolism of human milk oligosaccharides as a basis for probiotic efficacy in breast-fed infants. Gut Microbes 2023; 15:2192458. [PMID: 37013357 PMCID: PMC10075334 DOI: 10.1080/19490976.2023.2192458] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 03/13/2023] [Indexed: 04/05/2023] Open
Abstract
For over a century, physicians have witnessed a common enrichment of bifidobacteria in the feces of breast-fed infants that was readily associated with infant health status. Recent advances in bacterial genomics, metagenomics, and glycomics have helped explain the nature of this unique enrichment and enabled the tailored use of probiotic supplementation to restore missing bifidobacterial functions in at-risk infants. This review documents a 20-year span of discoveries that set the stage for the current use of human milk oligosaccharide-consuming bifidobacteria to beneficially colonize, modulate, and protect the intestines of at-risk, human milk-fed, neonates. This review also presents a model for probiotic applications wherein bifidobacterial functions, in the form of colonization and HMO-related catabolic activity in situ, represent measurable metabolic outcomes by which probiotic efficacy can be scored toward improving infant health.
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Affiliation(s)
- David A. Mills
- Department of Food Science and Technology, University of California-Davis, Davis, CA, United States
- Department of Viticulture and Enology, University of California-Davis, Davis, CA, United States
- Foods for Health Institute, University of California-Davis, Davis, CA, United States
| | - J. Bruce German
- Department of Food Science and Technology, University of California-Davis, Davis, CA, United States
- Foods for Health Institute, University of California-Davis, Davis, CA, United States
| | - Carlito B. Lebrilla
- Foods for Health Institute, University of California-Davis, Davis, CA, United States
- Department of Chemistry, University of California-Davis, Davis, CA, United States
- Department of Biochemistry and Molecular Medicine, University of California-Davis, Davis, CA, United States
| | - Mark A. Underwood
- Foods for Health Institute, University of California-Davis, Davis, CA, United States
- Division of Neonatology, Department of Pediatrics, University of California-Davis, Sacramento, CA, United States
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Rückle X, Rühle J, Judd L, Hebel J, Dietz S, Poets CF, Gille C, Köstlin-Gille N. Different probiotic strains alter human cord blood monocyte responses. Pediatr Res 2022:10.1038/s41390-022-02400-5. [PMID: 36476746 DOI: 10.1038/s41390-022-02400-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Probiotics have a protective effect on various diseases. In neonatology, they are predominantly used to prevent necrotising enterocolitis (NEC), a severe inflammatory disease of the neonatal intestine. The mechanisms by which probiotics act are diverse; little is known about their direct effect on neonatal immune cells. METHODS In this study, we investigated the effect of probiotics on the functions of neonatal monocytes in an in vitro model using three different strains (Lactobacillus rhamnosus (LR), Lactobacillus acidophilus (LA) and Bifidobacterium bifidum (BB)) and mononuclear cells isolated from cord blood. RESULTS We show that stimulation with LR induces proinflammatory effects in neonatal monocytes, such as increased expression of surface molecules involved in monocyte activation, increased production of pro-inflammatory and regulatory cytokines and increased production of reactive oxygen species (ROS). Similar effects were observed when monocytes were stimulated simultaneously with LPS. Stimulation with LA and BB alone or in combination also induced cytokine production in monocytes, with BB showing the least effects. CONCLUSIONS Our results suggest that probiotics increase the defence functions of neonatal monocytes and thus possibly favourably influence the newborn's ability to fight infections. IMPACT Probiotics induce a proinflammatory response in neonatal monocytes in vitro. This is a previously unknown mechanism of how probiotics modulate the immune response of newborns. Probiotic application to neonates may increase their ability to fight off infections.
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Affiliation(s)
- Xenia Rückle
- Department of Neonatology, Tübingen University Children's Hospital, Tübingen, Germany
| | - Jessica Rühle
- Department of Neonatology, Tübingen University Children's Hospital, Tübingen, Germany
| | - Leonie Judd
- Department of Neonatology, Tübingen University Children's Hospital, Tübingen, Germany
| | - Janine Hebel
- Department of Neonatology, Tübingen University Children's Hospital, Tübingen, Germany
| | - Stefanie Dietz
- Department of Neonatology, Tübingen University Children's Hospital, Tübingen, Germany.,Department of Neonatology, Heidelberg University Children's Hospital, Heidelberg, Germany
| | - Christian F Poets
- Department of Neonatology, Tübingen University Children's Hospital, Tübingen, Germany
| | - Christian Gille
- Department of Neonatology, Heidelberg University Children's Hospital, Heidelberg, Germany
| | - Natascha Köstlin-Gille
- Department of Neonatology, Tübingen University Children's Hospital, Tübingen, Germany. .,Department of Neonatology, Heidelberg University Children's Hospital, Heidelberg, Germany.
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12
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Granger C, Dermyshi E, Roberts E, Beck LC, Embleton N, Berrington J. Necrotising enterocolitis, late-onset sepsis and mortality after routine probiotic introduction in the UK. Arch Dis Child Fetal Neonatal Ed 2022; 107:352-358. [PMID: 34433587 DOI: 10.1136/archdischild-2021-322252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/04/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare necrotising enterocolitis (NEC), late-onset sepsis (LOS), focal intestinal perforation (FIP) and mortality in infants from a single neonatal unit before and after probiotic introduction. DESIGN Retrospective review of infants <32 weeks admitted January 2009-December 2012 (no probiotic) and January 2013-December 2017 (routine probiotics). Infants included were admitted before day 3, and not transferred out before day 3. NEC, LOS and FIP were defined with standard definitions. PATIENTS 1061 infants were included, 509 preprobiotic and 552 postprobiotic. Median gestation, birth weight and antenatal steroid use did not differ, and proportions of extremely low birthweight infants were similar (37% and 41%). RESULTS Overall unadjusted risk of NEC (9.2% (95% CI 7.1 to 12.1) vs 10.6% (95% CI 8.2 to 13.4), p=0.48), LOS (16.3% (95% CI 13.2 to 19.6) vs 14.1% (95% CI 11.5 to 17.4), p=0.37) and mortality (9.2% (95% CI 7.1 to 12.1) vs 9.7% (95% CI 7.6 to 12.6), p=0.76) did not differ, nor proportion of surgical NEC. In multiple logistic regression, accounting for gestation, birth weight, antenatal steroid, maternal milk, chorioamnionitis and sex, probiotic receipt was not significantly associated with NEC (adjusted OR (aOR) 1.08 (95% CI 0.71 to 1.68), p=0.73), LOS or mortality. In subgroup (645 infants) >28 weeks, aOR for NEC in the probiotic cohort was 0.42 (95% CI 0.2 to 0.99, p=0.047). FIP was more common in the probiotic cohort (OR 2.3 (95% CI 1.0 to 5.4), p=0.04), not significant in regression analysis (2.11 (95% CI 0.97 to 4.95), p=0.05). CONCLUSIONS Probiotic use in this centre did not reduce overall mortality or rates of NEC, LOS or FIP but subgroup analysis identified NEC risk reduction in infants >28 weeks, and LOS reduction <28 weeks.
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Affiliation(s)
- Claire Granger
- Newcastle Neonatal Service, Ward 35 Neonatal Unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Elda Dermyshi
- Newcastle Neonatal Service, Ward 35 Neonatal Unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Eve Roberts
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lauren C Beck
- Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Nicholas Embleton
- Newcastle Neonatal Service, Ward 35 Neonatal Unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Janet Berrington
- Newcastle Neonatal Service, Ward 35 Neonatal Unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK .,Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
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13
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Ragan MV, Wala SJ, Goodman SD, Bailey MT, Besner GE. Next-Generation Probiotic Therapy to Protect the Intestines From Injury. Front Cell Infect Microbiol 2022; 12:863949. [PMID: 35837474 PMCID: PMC9273849 DOI: 10.3389/fcimb.2022.863949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/25/2022] [Indexed: 12/20/2022] Open
Abstract
Probiotics are live microorganisms that, when administered in adequate amounts, provide health benefits to the host. Some strains of the probiotic Lactobacillus reuteri (L. reuteri) have both antimicrobial and anti-inflammatory properties that may be exploited for the treatment and prevention of different gastrointestinal diseases, including necrotizing enterocolitis (NEC) and Clostridioides difficile (C. difficile) infection. Our laboratory has developed a new delivery system for L. reuteri in which the probiotic is incubated with biocompatible, semipermeable, porous dextranomer microspheres (DM) that can be loaded with beneficial and diffusible cargo. L. reuteri can be induced to form a biofilm by incubating the bacteria on the surface of these microspheres, which enhances the efficacy of the probiotic. Loading the DM with sucrose or maltose induces L. reuteri to produce more biofilm, further increasing the efficacy of the probiotic. Using a rat model of NEC, L. reuteri administered in its biofilm state significantly increases animal survival, reduces the incidence of NEC, preserves gut barrier function, and decreases intestinal inflammation. In a murine model of Clostridiodes difficile infection, L. reuteri administered in its biofilm state decreases colitis when administered either before or after C. difficile induction, demonstrating both prophylactic and therapeutic efficacy. There are currently no FDA-approved probiotic preparations for human use. An FDA-approved phase I clinical trial of L. reuteri in its biofilm state in healthy adults is currently underway. The results of this trial will be used to support a phase 1 clinical trial in neonates, with the goal of utilizing L. reuteri in its biofilm state to prevent NEC in premature neonates in the future.
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Affiliation(s)
- Mecklin V. Ragan
- Center for Perinatal Research, Department of Pediatric Surgery, Columbus, OH, United States
| | - Samantha J. Wala
- Center for Perinatal Research, Department of Pediatric Surgery, Columbus, OH, United States
| | - Steven D. Goodman
- Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, United States
| | - Michael T. Bailey
- Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, United States
| | - Gail E. Besner
- Center for Perinatal Research, Department of Pediatric Surgery, Columbus, OH, United States
- *Correspondence: Gail E. Besner,
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14
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Stricker S, Hain T, Chao CM, Rudloff S. Respiratory and Intestinal Microbiota in Pediatric Lung Diseases-Current Evidence of the Gut-Lung Axis. Int J Mol Sci 2022; 23:ijms23126791. [PMID: 35743234 PMCID: PMC9224356 DOI: 10.3390/ijms23126791] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 02/07/2023] Open
Abstract
The intestinal microbiota is known to influence local immune homeostasis in the gut and to shape the developing immune system towards elimination of pathogens and tolerance towards self-antigens. Even though the lung was considered sterile for a long time, recent evidence using next-generation sequencing techniques confirmed that the lower airways possess their own local microbiota. Since then, there has been growing evidence that the local respiratory and intestinal microbiota play a role in acute and chronic pediatric lung diseases. The concept of the so-called gut–lung axis describing the mutual influence of local microbiota on distal immune mechanisms was established. The mechanisms by which the intestinal microbiota modulates the systemic immune response include the production of short-chain fatty acids (SCFA) and signaling through pattern recognition receptors (PRR) and segmented filamentous bacteria. Those factors influence the secretion of pro- and anti-inflammatory cytokines by immune cells and further modulate differentiation and recruitment of T cells to the lung. This article does not only aim at reviewing recent mechanistic evidence from animal studies regarding the gut–lung axis, but also summarizes current knowledge from observational studies and human trials investigating the role of the respiratory and intestinal microbiota and their modulation by pre-, pro-, and synbiotics in pediatric lung diseases.
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Affiliation(s)
- Sebastian Stricker
- Department of Pediatrics, Justus Liebig University Giessen, 35392 Giessen, Germany;
- Correspondence: ; Tel.: +49-641-985-56617
| | - Torsten Hain
- Institute of Medical Microbiology, Justus Liebig University Giessen, 35392 Giessen, Germany;
- German Center for Infection Research (DZIF), Partner Site Giessen-Marburg-Langen, Justus Liebig University Giessen, 35392 Giessen, Germany
| | - Cho-Ming Chao
- Department of Pediatrics, University Medical Center Rostock, 18057 Rostock, Germany;
| | - Silvia Rudloff
- Department of Pediatrics, Justus Liebig University Giessen, 35392 Giessen, Germany;
- Department of Nutritional Science, Justus Liebig University Giessen, 35392 Giessen, Germany
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15
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Zhang W, Wang S, Xing Y, Wang H, Fu B, Long M, Cao J. Clinical efficacy of probiotics on feeding intolerance in preterm infants: a systematic review and meta-analysis. Transl Pediatr 2022; 11:229-238. [PMID: 35282030 PMCID: PMC8905106 DOI: 10.21037/tp-21-624] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/20/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The physiological organ system of premature infants is still very immature, so it is easy to result feeding intolerance. Therefore, effective probiotic supplementation plays a very important role and clinical research significance in promoting the growth and development of preterm infants, improving the quality of life and improving the occurrence of feeding intolerance. To explore the clinical effect of probiotics on feeding intolerance (FI) in preterm infants by meta-analysis. METHODS The PubMed, Web of Science, EMBASE and MEDLINE literature databases were searched for relevant literature. The literature related to the clinical effect of probiotics on FI in preterm infants was published from January 2002 to January 2021. RevMan 5.3 was used to calculate the reinforcement mean difference (MD) and evaluate the publication bias. RESULTS Nine articles were included, involving a total of 1,244 preterm infants with FI. Through the sensitivity analysis of each excluded study, the results showed no significant differences. Compared with patients in the control group, the probiotics group had significant improvements (P<0.1) in the total intestinal feeding time (MD =-2.54, 95% CI: -3.57, -1.52, P<0.00001), weight gain (MD =23.81, 95% CI: 19.75, 27.81, P<0.00001), maximum enteral feeding (MD =6.41, 95% CI: 1.94, 10.88, P=0.005), hospital stay (MD =-5.18, 95% CI: -5.63, -4.74, P<0.00001), incidence of FI [odds rate (OR) =0.38, 95% CI: 0.27, 0.55, P<0.00001] and improvement in the gastrointestinal tract (OR =2.34, 95% CI: 1.07, 5.14, P=0.03). DISCUSSION Our study shows that the use of probiotics can promote the early growth of preterm infants and effectively improve the occurrence of FI in preterm infants.
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Affiliation(s)
- Wei Zhang
- Department of Neonatology, Hainan Women and Children's Medical Center, Haikou, China
| | - Shiqun Wang
- Department of Pediatrics, Qionghai Hospital of Traditional Chinese Medicine, Qionghai, China
| | - Yu Xing
- Department of Pediatrics, Hainan Modern Women and Children's Hospital, Haikou, China
| | - Hongyi Wang
- Department of Pediatrics, Hainan Modern Women and Children's Hospital, Haikou, China
| | - Binsha Fu
- Department of Pediatrics, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Haikou, China
| | - Mingjia Long
- Department of Pediatrics, Qionghai Hospital of Traditional Chinese Medicine, Qionghai, China
| | - Juan Cao
- Department of Pediatrics, Hainan Modern Women and Children's Hospital, Haikou, China
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16
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Murphy K, Ross RP, Ryan CA, Dempsey EM, Stanton C. Probiotics, Prebiotics, and Synbiotics for the Prevention of Necrotizing Enterocolitis. Front Nutr 2021; 8:667188. [PMID: 34557508 PMCID: PMC8453148 DOI: 10.3389/fnut.2021.667188] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 08/09/2021] [Indexed: 02/02/2023] Open
Abstract
Necrotizing enterocolitis (NEC) is a major cause of morbidity and mortality in preterm infants. The exact mechanism by which NEC develops is poorly understood however there is growing evidence to suggest that perturbations in the early-life gut microbiota composition increase the risk for NEC. Modulation of the gut microbiota with probiotics, prebiotics, or in combination (synbiotics) is an area which has attracted intense interest in recent years. In this narrative review, we present an overview of the role of the gut microbiota in the pathogenesis of NEC. We also examine the evidence currently available from randomized controlled trials, observational studies, systematic reviews, and meta-analysis examining the role of probiotics, prebiotics, and synbiotics in reducing the risk of or preventing NEC. Current clinical practice guidelines with recommendations on the routine administration of probiotics to preterm infants for NEC are also explored.
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Affiliation(s)
- Kiera Murphy
- Food Biosciences Department, Teagasc Food Research Centre, Cork, Ireland.,APC Microbiome Ireland, University College Cork, Cork, Ireland
| | - R Paul Ross
- APC Microbiome Ireland, University College Cork, Cork, Ireland
| | - C Anthony Ryan
- APC Microbiome Ireland, University College Cork, Cork, Ireland.,Neonatal Intensive Care Unit, Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- APC Microbiome Ireland, University College Cork, Cork, Ireland.,Neonatal Intensive Care Unit, Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Catherine Stanton
- Food Biosciences Department, Teagasc Food Research Centre, Cork, Ireland.,APC Microbiome Ireland, University College Cork, Cork, Ireland
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17
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Deshmukh M, Patole S. Prophylactic Probiotic Supplementation for Preterm Neonates-A Systematic Review and Meta-Analysis of Nonrandomized Studies. Adv Nutr 2021; 12:1411-1423. [PMID: 33460432 PMCID: PMC8321836 DOI: 10.1093/advances/nmaa164] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/05/2020] [Accepted: 11/20/2020] [Indexed: 12/18/2022] Open
Abstract
Systematic review and meta-analyses of randomized controlled trials (RCTs) show that probiotics reduce the risk of necrotizing enterocolitis (NEC ≥ Stage II), late onset sepsis (LOS), all-cause mortality, and feeding intolerance in preterm neonates. Data from observational studies is important to confirm probiotic effects in clinical practice. We aimed to compare outcomes before and after implementing routine probiotic supplementation (RPS) in preterm neonates (<37 weeks of gestation) by performing a systematic review of non-RCTs using Cochrane methodology. Databases including PubMed, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Central library, and Google Scholar were searched in May 2020. A meta-analysis was performed using a random effects model. Categorical measure of effect size was expressed as OR and 95% CI. Statistical heterogeneity was assessed by the chi-squared test, I2 statistic. The level of evidence (LOE) was summarized using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) guidelines. Primary outcomes were NEC ≥ Stage II, LOS, and all-cause mortality. Secondary outcomes included probiotic sepsis. Thirty good-quality non-RCTs (n = 77,018) from 18 countries were included. The meta-analysis showed RPS was associated with significantly reduced: 1) NEC ≥ Stage II (30 studies, n = 77,018; OR: 0.60; 95% CI: 0.50, 0.73; P <0.00001, I2: 65%; LOE: Moderate), 2) LOS: (21 studies, n = 65,858; OR: 0.85; 95% CI: 0.74, 0.97; P = 0.02, I2: 74%; LOE: Low), and 3) all-cause mortality (27 non-RCTs, n = 70,977; OR: 0.77; 95% CI: 0.68, 0.88; P = 0.0001, I2: 49%; LOE: Low). Subgroups: 1) extremely low birth weight (ELBW: birth weight <1000 g) neonates: RPS was associated with significantly reduced NEC ≥ Stage II (4.5% compared with 7.9%). However, there was no difference in LOS and mortality. 2) Multistrain RPS was more effective than single strain. One study reported 3 nonfatal cases of probiotic sepsis. In summary, moderate- to low-quality evidence indicates that RPS was associated with significantly reduced NEC ≥ Stage II, LOS, and all-cause mortality in neonates <37 weeks of gestation and NEC ≥ Stage II in ELBW neonates.
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18
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van Best N, Trepels-Kottek S, Savelkoul P, Orlikowsky T, Hornef MW, Penders J. Influence of probiotic supplementation on the developing microbiota in human preterm neonates. Gut Microbes 2020; 12:1-16. [PMID: 33095113 PMCID: PMC7588225 DOI: 10.1080/19490976.2020.1826747] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Oral administration of probiotic bacteria to preterm neonates has been recommended to prevent the development of necrotizing enterocolitis (NEC). The influence of probiotics on the endogenous microbiome, however, has remained incompletely understood. STUDY DESIGN & METHODS Here, we performed an observational study including 80 preterm neonates born at a gestational age <32-weeks to characterize the persistence of probiotic bacteria after no treatment or oral administration of two different probiotic formula and their influence on the microbial ecosystem during and after the intervention and their association with the development of NEC. Weekly fecal samples were profiled by 16S rRNA sequencing and monitored for the presence of the probiotic bacteria by quantitative PCR. RESULTS Microbiota profiles differed significantly between the control group and both probiotic groups. Probiotic supplementation was associated with lower temporal variation as well as higher relative abundance of Bifidobacterium and Enterobacter combined with reduced abundance of Escherichia, Enterococcus, and Klebsiella. Colonization by probiotic bifidobacteria was observed in approximately 50% of infants although it remained transient in the majority of cases. A significantly reduced monthly incidence of NEC was observed in neonates supplemented with probiotics. CONCLUSION Our results demonstrate successful transient colonization by probiotic bacteria and a significant influence on the endogenous microbiota with a reduced abundance of bacterial taxa associated with the development of NEC. These results emphasize that probiotic supplementation may allow targeted manipulation of the enteric microbiota and confer a clinical benefit. (Clinical Trial Registry accession number: DRKS/GCTR 00021034).
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Affiliation(s)
- Niels van Best
- Institute of Medical Microbiology, RWTH University Hospital Aachen, RWTH University Aachen, Aachen, Germany,Department of Medical Microbiology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | | | - Paul Savelkoul
- Department of Medical Microbiology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | | | - Mathias W. Hornef
- Institute of Medical Microbiology, RWTH University Hospital Aachen, RWTH University Aachen, Aachen, Germany
| | - John Penders
- Department of Medical Microbiology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands,School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands,CONTACT John Penders Department of Medical Microbiology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, HX6229, Maastricht, The Netherlands; Mathias Hornef Institute for Medical Microbiology; RWTH University Hospital; Pauwelsstr. 30, Aachen D-52074, Germany; Thorsten Orlikoswsky, Section of Neonatology, University Children’s Hospital, Pauwelsstr. 30, Aachen 52074, Germany
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19
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Sharif S, Meader N, Oddie SJ, Rojas-Reyes MX, McGuire W. Probiotics to prevent necrotising enterocolitis in very preterm or very low birth weight infants. Cochrane Database Syst Rev 2020; 10:CD005496. [PMID: 33058137 PMCID: PMC8094746 DOI: 10.1002/14651858.cd005496.pub5] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intestinal dysbiosis may contribute to the pathogenesis of necrotising enterocolitis (NEC) in very preterm or very low birth weight infants. Dietary supplementation with probiotics to modulate the intestinal microbiome has been proposed as a strategy to reduce the risk of NEC and associated mortality and morbidity. OBJECTIVES: To determine the effect of supplemental probiotics on the risk of NEC and mortality and morbidity in very preterm or very low birth weight infants. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 2) in the Cochrane Library; MEDLINE Ovid (1946 to 17 Feb 2020), Embase Ovid (1974 to 17 Feb 2020), Maternity & Infant Care Database Ovid (1971 to 17 Feb 2020), the Cumulative Index to Nursing and Allied Health Literature (1982 to 18 Feb 2020). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included RCTs and quasi-RCTs comparing probiotic supplementation with placebo or no probiotics in very preterm or very low birth weight infants. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane Neonatal. Two review authors separately evaluated trial quality, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of evidence for effects on NEC, all-cause mortality, late-onset infection, and severe neurodevelopmental impairment. MAIN RESULTS We included 56 trials in which 10,812 infants participated. Most trials were small (median sample size 149). Lack of clarity on methods to conceal allocation and mask caregivers or investigators were the main potential sources of bias in about half of the trials. Trials varied by the formulation of the probiotics. The most commonly used preparations contained Bifidobacterium spp., Lactobacillus spp., Saccharomyces spp., and Streptococcus spp. alone or in combinations. Meta-analysis showed that probiotics may reduce the risk of NEC: RR 0.54, 95% CI 0.45 to 0.65 (54 trials, 10,604 infants; I² = 17%); RD -0.03, 95% CI -0.04 to -0.02; number needed to treat for an additional beneficial outcome (NNTB) 33, 95% CI 25 to 50. Evidence was assessed as low certainty because of the limitations in trials design, and the presence of funnel plot asymmetry consistent with publication bias. Sensitivity meta-analysis of trials at low risk of bias showed a reduced risk of NEC: RR 0.70, 95% CI 0.55 to 0.89 (16 trials, 4597 infants; I² = 25%); RD -0.02, 95% CI -0.03 to -0.01; NNTB 50, 95% CI 33 to 100. Meta-analyses showed that probiotics probably reduce mortality (RR 0.76, 95% CI 0.65 to 0.89; (51 trials, 10,170 infants; I² = 0%); RD -0.02, 95% CI -0.02 to -0.01; NNTB 50, 95% CI 50 to 100), and late-onset invasive infection (RR 0.89, 95% CI 0.82 to 0.97; (47 trials, 9762 infants; I² = 19%); RD -0.02, 95% CI -0.03 to -0.01; NNTB 50, 95% CI 33 to 100). Evidence was assessed as moderate certainty for both these outcomes because of the limitations in trials design. Sensitivity meta-analyses of 16 trials (4597 infants) at low risk of bias did not show an effect on mortality or infection. Meta-analysis showed that probiotics may have little or no effect on severe neurodevelopmental impairment (RR 1.03, 95% CI 0.84 to 1.26 (five trials, 1518 infants; I² = 0%). The certainty on this evidence is low because of limitations in trials design and serious imprecision of effect estimate. Few data (from seven of the trials) were available for extremely preterm or extremely low birth weight infants. Meta-analyses did not show effects on NEC, death, or infection (low-certainty evidence). AUTHORS' CONCLUSIONS Given the low to moderate level of certainty about the effects of probiotic supplements on the risk of NEC and associated morbidity and mortality for very preterm or very low birth weight infants, and particularly for extremely preterm or extremely low birth weight infants, further, large, high-quality trials are needed to provide evidence of sufficient quality and applicability to inform policy and practice.
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Affiliation(s)
- Sahar Sharif
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Nicholas Meader
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Sam J Oddie
- Centre for Reviews and Dissemination, University of York, York, UK
- Bradford Neonatology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Maria Ximena Rojas-Reyes
- Department of Clinical Epidemiology and Public Health, Institut de Recerca Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
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20
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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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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: 16] [Impact Index Per Article: 4.0] [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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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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23
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Gray KD, Messina JA, Cortina C, Owens T, Fowler M, Foster M, Gbadegesin S, Clark RH, Benjamin DK, Zimmerman KO, Greenberg RG. Probiotic Use and Safety in the Neonatal Intensive Care Unit: A Matched Cohort Study. J Pediatr 2020; 222:59-64.e1. [PMID: 32418818 PMCID: PMC7321859 DOI: 10.1016/j.jpeds.2020.03.051] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the prevalence of probiotic administration in infants born preterm over time, as well as the association between probiotic administration and select adverse outcomes. STUDY DESIGN We performed a multicenter cohort study of infants 23-29 weeks of gestational age admitted to 289 neonatal intensive care units from 1997 to 2016. We evaluated the type of probiotics given and prevalence of exposure to probiotics over time and by site. We matched infants exposed to probiotics by several factors to unexposed infants receiving enteral feeds on the same postnatal day. We performed conditional logistic regression to evaluate the association between probiotics exposure and adverse outcomes, including necrotizing enterocolitis (NEC), bloodstream infections, meningitis, and death. RESULTS Of 78 076 infants, 3626 (4.6%) received probiotics. Probiotic use increased over the study period and varied among neonatal intensive care units. We matched 2178 infants exposed to probiotics to 33 807 without exposure. Probiotic administration was associated with a decrease in NEC (OR 0.62, 95% CI 0.48-0.80) and death (OR 0.52, 95% CI 0.39-0.70), an increase in Candida infection (OR 2.23, 95% CI 1.29-3.85), but no increase in bloodstream infection (OR 0.86, 95% CI 0.70-1.05) or meningitis (OR 1.18, 95% CI 0.40-3.46). CONCLUSIONS Probiotic use increased over time and was associated with decreased odds of NEC and death. Prospective, randomized-controlled studies of specific probiotic products are needed to further investigate the safety and efficacy of probiotics in preterm infants.
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Affiliation(s)
- Keyaria D Gray
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | | | | | | | | | | | | | | | | | | | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC; and.
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24
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Vermeulen MJ, Luijendijk A, Toledo L, Kaam AH, Reiss IKM. Quality of probiotic products for preterm infants: Contamination and missing strains. Acta Paediatr 2020; 109:276-279. [PMID: 31423636 DOI: 10.1111/apa.14976] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/18/2019] [Accepted: 08/16/2019] [Indexed: 12/11/2022]
Abstract
Probiotics are effective in reducing necrotising enterocolitis in preterm infants, but routine use is not generally adopted. We describe a safety issue concerning contamination by pathogenic bacteria and missing of labelled strains in a probiotic product widely used in neonatal care. We recommend all centres using probiotics in the care of vulnerable patients to consider product safety checks in addition to the quality reports of manufacturers. Meanwhile, clinicians and manufacturers should collaborate to define quality standards for probiotic products in clinical settings as long as specific international regulations are lacking.
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Affiliation(s)
- Marijn J. Vermeulen
- Division of Neonatology, Department of Paediatrics Erasmus MC Sophia Children's Hospital Rotterdam The Netherlands
| | - Ad Luijendijk
- Department of Medical Microbiology and Infectious Diseases Erasmus MC Rotterdam The Netherlands
| | - Letty Toledo
- Department of Neonatology, Emma Children's Hospital Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Anton H. Kaam
- Department of Neonatology, Emma Children's Hospital Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Irwin K. M. Reiss
- Division of Neonatology, Department of Paediatrics Erasmus MC Sophia Children's Hospital Rotterdam The Netherlands
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25
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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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26
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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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27
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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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28
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Recent Advances in Prevention and Therapies for Clinical or Experimental Necrotizing Enterocolitis. Dig Dis Sci 2019; 64:3078-3085. [PMID: 30989465 DOI: 10.1007/s10620-019-05618-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 04/08/2019] [Indexed: 01/09/2023]
Abstract
Necrotizing enterocolitis (NEC) is one of the most severe diseases of preterm neonates and has a high mortality rate. With the development of inspection techniques and new biomarkers, the diagnostic accuracy of NEC is constantly improving. The most recognized potential risk factors include prematurity, formula-feeding, infection, and microbial dysbiosis. With further understanding of the pathogenesis, more effective prevention and therapies will be applied to clinical or experimental NEC. At present, such new potential prevention and therapies for NEC are mainly focused on the Toll-like receptor 4 inflammatory signaling pathway, the repair of intestinal barrier function, probiotics, antioxidative stress, breast-feeding, and immunomodulatory agents. Many new studies have changed our understanding of the pathogenesis of NEC and improve our approaches for preventing and treating of NEC each year. This review provides an overview of the recent researches focused on clinical or experimental NEC and highlights the advances made within the past 5 years toward the development of new potential preventive approaches and therapies for this disease.
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29
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Wang J, Kortsalioudaki C, Heath PT, Buttery J, Clarke P, Gkentzi D, Anthony M, Tan K. Epidemiology and healthcare factors associated with neonatal enterococcal infections. Arch Dis Child Fetal Neonatal Ed 2019; 104:F480-F485. [PMID: 30425112 DOI: 10.1136/archdischild-2018-315387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 09/28/2018] [Accepted: 10/09/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the epidemiology and healthcare factors associated with late-onset neonatal enterococcal infections. DESIGN Multicentre, multinational retrospective cohort study using prospectively collected infection data from a neonatal infection surveillance network between 2004 and 2016; this was supplemented with healthcare data from a questionnaire distributed to participating neonatal units. SETTING Sixty neonatal units across Europe (UK, Greece, Estonia) and Australia. PATIENTS Infants admitted to participating neonatal units who had a positive culture of blood, cerebrospinal fluid or urine after 48 hours of life. RESULTS In total, 414 episodes of invasive Enterococcus spp infection were reported in 388 infants (10.1% of a total 4083 episodes in 3602 infants). Enterococcus spp were the second most common cause of late-onset infection after coagulase-negative Staphylococcus spp and were strongly associated with necrotising enterocolitis (NEC) (adjusted OR 1.44, 95% CI 1.02 to 2.03, p=0.038), total parenteral nutrition (TPN) (adjusted OR 1.34, 95% CI 1.06 to 1.70, p=0.016), increasing postnatal age (per 1-week increase: adjusted OR 1.04, 95% CI 1.02 to 1.06, p<0.001) and decreasing birth weight (per 1 kg increase: adjusted OR 0.85, 95% CI 0.74 to 0.97, p=0.017). There was no evidence that inadequate nurse to patient staffing ratios in high-dependency units were associated with a higher risk of enterococcal infections. CONCLUSIONS Enterococcus spp were the second most frequent cause of late-onset infections. The association between enterococcal infections, NEC and TPN may inform empiric antimicrobial regimens in these contexts and provide insights into reducing these infections.
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Affiliation(s)
- Joanna Wang
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Christina Kortsalioudaki
- Paediatric Infectious Diseases Research Group, Infection and Immunity, St George's University of London, London, UK
| | - Paul T Heath
- Paediatric Infectious Diseases Research Group, Infection and Immunity, St George's University of London, London, UK
| | - Jim Buttery
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia.,Monash Children's Hospital, Melbourne, Victoria, Australia.,Monash Centre for Health Research and Implementation, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Paul Clarke
- Neonatal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Despoina Gkentzi
- Department of Paediatrics, University General Hospital of Patras, Patras, Greece
| | - Mark Anthony
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kenneth Tan
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia.,Monash Children's Hospital, Melbourne, Victoria, Australia
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30
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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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32
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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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33
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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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34
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Duffield SD, Clarke P. Current use of probiotics to prevent necrotising enterocolitis. Arch Dis Child Fetal Neonatal Ed 2019; 104:F228. [PMID: 30464004 DOI: 10.1136/archdischild-2018-316199] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Samuel David Duffield
- Neonatal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, 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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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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36
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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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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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38
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Denning NL, Prince JM. Neonatal intestinal dysbiosis in necrotizing enterocolitis. Mol Med 2018; 24:4. [PMID: 30134786 PMCID: PMC6016883 DOI: 10.1186/s10020-018-0002-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 02/13/2018] [Indexed: 12/11/2022] Open
Abstract
Necrotizing Enterocolitis (NEC) is one of the most devastating gastrointestinal diseases in neonates, particularly among preterm infants in whom surgical NEC is the leading cause of morbidity. NEC pathophysiology occurs in the hyper-reactive milieu of the premature gut after bacterial colonization. The resultant activation of the TLR4 pathway appears to be a strongly contributing factor. Advancements in metagenomics may yield new clarity to the relationship between the neonatal intestinal microbiome and the development of NEC. After a century without effective directed treatments, microbiome manipulation offers a promising therapeutic target for the prevention and treatment of this devastating disease.
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Affiliation(s)
- Naomi-Liza Denning
- Division of Pediatric Surgery, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, 269-01 76th Avenue, CH 158, New Hyde Park, New York, NY, 11040, USA. .,Feinstein Institute for Medical Research, Manhasset, NY, 11030, USA.
| | - Jose M Prince
- Division of Pediatric Surgery, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, 269-01 76th Avenue, CH 158, New Hyde Park, New York, NY, 11040, USA.,Feinstein Institute for Medical Research, Manhasset, NY, 11030, USA.,Trauma Institute, Northwell Health System, Manhasset, NY, 11030, USA
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Esaiassen E, Hjerde E, Cavanagh JP, Pedersen T, Andresen JH, Rettedal SI, Støen R, Nakstad B, Willassen NP, Klingenberg C. Effects of Probiotic Supplementation on the Gut Microbiota and Antibiotic Resistome Development in Preterm Infants. Front Pediatr 2018; 6:347. [PMID: 30505830 PMCID: PMC6250747 DOI: 10.3389/fped.2018.00347] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/26/2018] [Indexed: 12/15/2022] Open
Abstract
Objectives: In 2014 probiotic supplementation (Lactobacillus acidophilus and Bifidobacterium longum subspecies infantis; InfloranⓇ) was introduced as standard of care to prevent necrotizing enterocolitis (NEC) in extremely preterm infants in Norway. We aimed to evaluate the influence of probiotics and antibiotic therapy on the developing gut microbiota and antibiotic resistome in extremely preterm infants, and to compare with very preterm infants and term infants not given probiotics. Study design: A prospective, observational multicenter study in six tertiary-care neonatal units. We enrolled 76 infants; 31 probiotic-supplemented extremely preterm infants <28 weeks gestation, 35 very preterm infants 28-31 weeks gestation not given probiotics and 10 healthy full-term control infants. Taxonomic composition and collection of antibiotic resistance genes (resistome) in fecal samples, collected at 7 and 28 days and 4 months age, were analyzed using shotgun-metagenome sequencing. Results: Median (IQR) birth weight was 835 (680-945) g and 1,290 (1,150-1,445) g in preterm infants exposed and not exposed to probiotics, respectively. Two extremely preterm infants receiving probiotic developed NEC requiring surgery. At 7 days of age we found higher median relative abundance of Bifidobacterium in probiotic supplemented infants (64.7%) compared to non-supplemented preterm infants (0.0%) and term control infants (43.9%). Lactobacillus was only detected in small amounts in all groups, but the relative abundance increased up to 4 months. Extremely preterm infants receiving probiotics had also much higher antibiotic exposure, still overall microbial diversity and resistome was not different than in more mature infants at 4 weeks and 4 months. Conclusion: Probiotic supplementation may induce colonization resistance and alleviate harmful effects of antibiotics on the gut microbiota and antibiotic resistome. Clinical Trial Registration: Clinicaltrials.gov: NCT02197468. https://clinicaltrials.gov/ct2/show/NCT02197468.
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Affiliation(s)
- Eirin Esaiassen
- Paediatric Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway
| | - Erik Hjerde
- Department of Chemistry, Norstruct, UiT The Arctic University of Norway, Tromsø, Norway
| | - Jorunn Pauline Cavanagh
- Paediatric Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway
| | - Tanja Pedersen
- Department of Paediatrics, Haukeland University Hospital, Bergen, Norway
| | - Jannicke H Andresen
- Department of Neonatal Intensive Care, Oslo University Hospital, Oslo, Norway
| | - Siren I Rettedal
- Department of Paediatrics, Stavanger University Hospital, Stavanger, Norway
| | - Ragnhild Støen
- Department of Paediatrics, St. Olavs University Hospital, Trondheim, Norway.,Department of Laboratory Medicine, Children's and Women's Health, University of Science and Technology, Trondheim, Norway
| | - Britt Nakstad
- Department of Paediatric and Adolescents Medicine, Akershus University Hospital, Nordbyhagen, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nils P Willassen
- Department of Chemistry, Norstruct, UiT The Arctic University of Norway, Tromsø, Norway
| | - Claus Klingenberg
- Paediatric Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway
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Athalye-Jape G, Rao S, Simmer K, Patole S. Bifidobacterium breve M-16V as a Probiotic for Preterm Infants: A Strain-Specific Systematic Review. JPEN J Parenter Enteral Nutr 2017; 42:677-688. [PMID: 28796951 DOI: 10.1177/0148607117722749] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 06/30/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Bifidobacterium breve M-16V has been used as a probiotic in preterm infants. Probiotic strain-specific data are essential to guide clinical practice. OBJECTIVE To assess effects of B breve M-16V in preterm neonates. DESIGN A systematic review of randomized controlled trials (RCTs) and non-RCTs of B breve M-16V in preterm infants was conducted. Multiple databases, proceedings of Pediatric Academy Society, and other relevant conferences were searched in September 2016 and on January 5, 2017. RESULTS Five RCTs (n = 482) and 4 non-RCTs (n = 2496) were included. Of the 5 RCTs, 4 carried high/unclear risk of bias in many domains. Meta-analysis (fixed effects model) of RCTs showed no significant benefits on stage ≥2 necrotizing enterocolitis, late-onset sepsis, mortality, and postnatal age at full feeds. Meta-analysis of non-RCTs showed significant benefits on (1) late-onset sepsis-3 studies (n = 2452), odds ratio = 0.56 (95% CI, 0.45-0.71), P < .0001; (2) mortality-2 studies (n = 2319), odds ratio = 0.61 (95% CI, 0.44-0.84), P = .002; and (3) postnatal age at full feeds (days)-2 studies (n = 361), mean difference, -2.42 (95% CI, -2.55 to -2.3), P < .00001. There were no adverse effects from B breve M-16V. On Grading of Recommendations, Assessment, Development, and Evaluation analysis, the overall quality of evidence was deemed very low. CONCLUSIONS Current evidence is limited regarding the potential of B breve M-16V in preterm neonates. Adequately powered, preferably cluster RCTs are needed to confirm these findings.
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Affiliation(s)
- Gayatri Athalye-Jape
- Department of Neonatal Paediatrics, King Edward Memorial Hospital, Perth, Australia.,Department of Neonatal Paediatrics, Princess Margaret Hospital for Children, Perth, Australia.,Centre for Neonatal Research and Education, School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - Shripada Rao
- Department of Neonatal Paediatrics, King Edward Memorial Hospital, Perth, Australia.,Department of Neonatal Paediatrics, Princess Margaret Hospital for Children, Perth, Australia.,Centre for Neonatal Research and Education, School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - Karen Simmer
- Department of Neonatal Paediatrics, King Edward Memorial Hospital, Perth, Australia.,Centre for Neonatal Research and Education, School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - Sanjay Patole
- Department of Neonatal Paediatrics, King Edward Memorial Hospital, Perth, Australia.,Centre for Neonatal Research and Education, School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
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41
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Affiliation(s)
- Sanjay Patole
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia.
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42
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Denkel LA, Schwab F, Garten L, Geffers C, Gastmeier P, Piening B. Dual-strain probiotics reduce NEC, mortality and neonatal bloodstream infections among extremely low birthweight infants. Arch Dis Child Fetal Neonatal Ed 2017; 102:F559-F560. [PMID: 28923984 DOI: 10.1136/archdischild-2017-313897] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2017] [Indexed: 11/03/2022]
Affiliation(s)
- Luisa Anna Denkel
- Institute of Hygiene and Environmental Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Schwab
- Institute of Hygiene and Environmental Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Lars Garten
- Department of Neonatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christine Geffers
- Institute of Hygiene and Environmental Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Brar Piening
- Institute of Hygiene and Environmental Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
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43
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Strunk T, Hibbert J, Doherty D, Granland C, Trend S, Simmer K, Burgner D, Patole S, Currie A. Probiotics and antimicrobial protein and peptide levels in preterm infants. Acta Paediatr 2017; 106:1747-1753. [PMID: 28294428 DOI: 10.1111/apa.13826] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/22/2017] [Accepted: 03/07/2017] [Indexed: 12/26/2022]
Abstract
AIM To characterise the secreted and inducible antimicrobial protein and peptide (APP) levels in a prospective cohort of preterm infants (<30 weeks gestational age) with or without Bifidobacterium breve M16V supplementation during the first month of life. METHODS We analysed serial biosamples of infants who did (n = 13) or did not receive (n = 62) B. breve (3 × 109 cfu/day). Peripheral blood was obtained on days 1, 14 and 28, and infant stool prior to commencement of probiotic supplementation and on day 21. Levels of APP (bactericidal/permeability inducing protein (BPI), beta defensins 1 and 2, lactoferrin, human cathelicidin, secretory phospholipase A2) in plasma and stool were determined. Further, we characterised induced APP levels in whole blood cultured with live S. epidermidis or with agonists of Toll-like receptors 2/6 and 4. RESULTS Stool, plasma and stimulated blood APP levels changed significantly during the first month of life. Supplementation with B. breve did not affect basal or stimulated APP levels except for a transient increase in inducible BPI. CONCLUSION Supplementation with B. breve does not appear to act via modulation of systemic or enteric APP expression in preterm infants although small effects cannot be excluded. Further work with other probiotic preparations is warranted.
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Affiliation(s)
- Tobias Strunk
- Centre for Neonatal Research and Education; School of Paediatrics and Child Health; University of Western Australia; Perth WA Australia
- Neonatal Clinical Care Unit; King Edward Memorial Hospital; Perth WA Australia
| | - Julie Hibbert
- Centre for Neonatal Research and Education; School of Paediatrics and Child Health; University of Western Australia; Perth WA Australia
| | - Dorota Doherty
- School of Women's and Infant's Health; University of Western Australia; Perth WA Australia
| | - Caitlyn Granland
- Centre for Neonatal Research and Education; School of Paediatrics and Child Health; University of Western Australia; Perth WA Australia
| | - Stephanie Trend
- Centre for Neonatal Research and Education; School of Paediatrics and Child Health; University of Western Australia; Perth WA Australia
| | - Karen Simmer
- Centre for Neonatal Research and Education; School of Paediatrics and Child Health; University of Western Australia; Perth WA Australia
- Neonatal Clinical Care Unit; King Edward Memorial Hospital; Perth WA Australia
| | - David Burgner
- Murdoch Childrens Research Institute; Royal Children's Hospital; Parkville VIC Australia
- Department of Paediatrics; University of Melbourne; Melbourne VIC Australia
| | - Sanjay Patole
- Centre for Neonatal Research and Education; School of Paediatrics and Child Health; University of Western Australia; Perth WA Australia
- Neonatal Clinical Care Unit; King Edward Memorial Hospital; Perth WA Australia
| | - Andrew Currie
- Centre for Neonatal Research and Education; School of Paediatrics and Child Health; University of Western Australia; Perth WA Australia
- School of Veterinary and Life Sciences; Murdoch University; Perth WA Australia
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Abstract
Necrotizing enterocolitis (NEC) is a multifactorial disease that occurs when multiple risk factors and/or stressors overlap, leading to profound inflammation and intestinal injury. Due to its multifactorial nature, there has been much uncertainty in identifying clear strategies for prevention of NEC. Despite these obstacles, the incidence of NEC has gradually been decreasing over the past 10 years, in part due to quality improvement (QI) initiatives to prevent NEC. Current QI strategies primarily target the various predisposing conditions. This article reviews the evidence on which QI interventions to prevent NEC have been based and provides examples of successful QI interventions.
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45
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Torow N, Hornef MW. The Neonatal Window of Opportunity: Setting the Stage for Life-Long Host-Microbial Interaction and Immune Homeostasis. THE JOURNAL OF IMMUNOLOGY 2017; 198:557-563. [PMID: 28069750 DOI: 10.4049/jimmunol.1601253] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/17/2016] [Indexed: 02/06/2023]
Abstract
The existence of a neonatal window was first highlighted by epidemiological studies that revealed the particular importance of this early time in life for the susceptibility to immune-mediated diseases in humans. Recently, the first animal studies emerged that present examples of early-life exposure-triggered persisting immune events, allowing a detailed analysis of the factors that define this particular time period. The enteric microbiota and the innate and adaptive immune system represent prime candidates that impact on the pathogenesis of immune-mediated diseases and are known to reach a lasting homeostatic equilibrium following a dynamic priming period after birth. In this review, we outline the postnatal establishment of the microbiota and maturation of the innate and adaptive immune system and discuss examples of early-life exposure-triggered immune-mediated diseases that start to shed light on the critical importance of the early postnatal period for life-long immune homeostasis.
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Affiliation(s)
- Natalia Torow
- Institute of Medical Microbiology, RWTH Aachen University Hospital, 52074 Aachen, Germany
| | - Mathias W Hornef
- Institute of Medical Microbiology, RWTH Aachen University Hospital, 52074 Aachen, Germany
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Härtel C, Pagel J, Spiegler J, Buma J, Henneke P, Zemlin M, Viemann D, Gille C, Gehring S, Frommhold D, Rupp J, Herting E, Göpel W. Lactobacillus acidophilus/Bifidobacterium infantis probiotics are associated with increased growth of VLBWI among those exposed to antibiotics. Sci Rep 2017; 7:5633. [PMID: 28717131 PMCID: PMC5514087 DOI: 10.1038/s41598-017-06161-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 06/08/2017] [Indexed: 12/15/2022] Open
Abstract
We performed an observational study with very-low-birth weight infants (VLBWI) ≤33 weeks of gestation born in centers of the German Neonatal Network (GNN; (total n = 8534, n = 6229 received probiotics). The primary objectives of our study were (a) to assess the effect of Lactobacillus acidophilus/Bifidobacterium infantis probiotics on growth in VLBWI during primary stay in hospital and (b) to determine whether this effect is modified by antibiotic exposure. In linear regression models the administration of probiotics was independently associated with improved weight gain [g/d; effect size B = 0.62 (95% CI: 0.37-0.87), p < 0.001], and higher growth rates for body length [(mm/d; B = 0.06 (95% CI: 0.04-0.08), p < 0.001] and head circumference [mm/d; B = 0.03, 95% CI: 0.02-0.04, p < 0.001]. This effect was pronounced in infants with postnatal exposure to antibiotics; i.e. weight gain [g/d; B = 0.66 (95% CI: 0.32-1), p < 0.001], growth rate body length [(mm/d; B = 0.09 (95% CI: 0.06-0.12), p < 0.001] and head circumference [mm/d; B = 0.04, 95% CI: 0.02-0.06, p < 0.001]. In the small subgroup that was available for analysis at 5-year-follow-up (with probiotics: n = 120 vs. without probiotics: n = 54) we noted a sustained effect of probiotics in infants who received postnatal antibiotics. Probiotics may improve growth in antibiotic-treated infants which needs to be confirmed in randomized-controlled trials.
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Affiliation(s)
- Christoph Härtel
- Department of Pediatrics, University of Lübeck, Lubeck, Germany.
| | - Julia Pagel
- Department of Pediatrics, University of Lübeck, Lubeck, Germany
| | | | - Janne Buma
- Department of Pediatrics, University of Lübeck, Lubeck, Germany
| | - Philipp Henneke
- Center for Pediatrics and Adolescent Medicine and Center for Chronic, Immunodeficiency, University Medical Center, Freiburg, Germany
| | - Michael Zemlin
- Department of Pediatrics, University of Marburg, Marburg, Germany
| | - Dorothee Viemann
- Department of Neonatology, Hanover Medical School, Hanover, Germany
| | - Christian Gille
- Department of Neonatology, University of Tübingen, Tubingen, Germany
| | - Stephan Gehring
- Department of Infectious Diseases, Gastroenterology and Pediatric Intensive Care, University of Mainz, Mainz, MD, Germany
| | - David Frommhold
- Department of Neonatology, University of Heidelberg, Heidelberg, Germany
| | - Jan Rupp
- Department of Infectious Diseases and Microbiology, University of Lübeck, Lubeck, Germany
| | - Egbert Herting
- Department of Pediatrics, University of Lübeck, Lubeck, Germany
| | - Wolfgang Göpel
- Department of Pediatrics, University of Lübeck, Lubeck, Germany
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47
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Dermyshi E, Wang Y, Yan C, Hong W, Qiu G, Gong X, Zhang T. The "Golden Age" of Probiotics: A Systematic Review and Meta-Analysis of Randomized and Observational Studies in Preterm Infants. Neonatology 2017; 112:9-23. [PMID: 28196365 DOI: 10.1159/000454668] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 11/21/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Over the last few years, probiotics have been one of the most studied interventions in neonatal medicine. OBJECTIVES The aim of this work was to analyse all studies (randomized controlled trials, RCTs, and observational studies) assessing the use of probiotics in very low birth weight (VLBW) preterm infants. SEARCH METHODS A systematic literature search was conducted using PubMed, Embase, Cochrane Library, and Web of Science. The data from RCTs and observational studies were pooled and analysed separately. SELECTION CRITERIA RCTs and observational studies that enrolled VLBW infants with enteral administration of probiotics were considered. Extracted study data included probiotic characteristics and at least 1 clinical outcome (necrotizing enterocolitis [NEC], late-onset sepsis or all-cause mortality). DATA COLLECTION AND ANALYSIS Forty-four studies were eligible for our review: 30 RCTs and 14 observational studies. Severe NEC rates (stage II or more) and all-cause mortality were reduced among the probiotic groups in both the RCTs (RR 0.57, 95% CI 0.47-0.70, and RR 0.77, 95% CI 0.65-0.92, respectively) and the observational studies (RR 0.51, 95% CI 0.37-0.70, and RR 0.71, 95% CI 0.62-0.81, respectively). Furthermore, there was a 12% reduction in the risk of sepsis in RCTs and a 19% reduction in observational studies. The meta-analysis of observational studies showed a reduction in the risk of NEC in extremely low birth weight infants. However, this was not statistically significant. CONCLUSIONS This meta-analysis of RCT and observational studies found that the use of probiotics was beneficial for the prevention of severe NEC, late-onset sepsis, and all-cause mortality in VLBW infants.
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Affiliation(s)
- Elda Dermyshi
- Department of Gastroenterology, Hepatology, and Nutrition, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, PR China
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