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Cheddadi R, Khandekar NN, Yeramilli V, Martin C. The impact of maternal stress on the development of necrotizing enterocolitis: A comprehensive review. Semin Pediatr Surg 2023:151324. [PMID: 37316382 DOI: 10.1016/j.sempedsurg.2023.151324] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Necrotizing Enterocolitis (NEC) is a devastating intestinal inflammatory disease with significant morbidity and mortality. Numerous predictors have been implicated in the development of NEC, with a relatively less emphasis on maternal factors. Pregnancy drives women into a new stage of life that increases their susceptibility to biological and psychological stress. Additionally, maternal stress during pregnancy has been linked to various complications that can negatively impact both the mother and the developing fetus. These detrimental effects are facilitated by various systemic modifications. Similarly, there is evidence from animal studies that suggest a relationship between maternal stress and the occurrence of NEC due to the alterations observed in neonates. In this review, we will (1) discuss the physiological and psychological burden of maternal stress and how it can be linked to NEC, (2) summarize various predictors and risk factors of NEC, and (3) discuss the most widely utilized animal models for assessing the effects of prenatal stress on offspring.
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Affiliation(s)
- Riadh Cheddadi
- Department of Surgery, Division of Pediatric Surgery, Children's of Alabama, University of Alabama at Birmingham, 1600 7th Ave. S., Lowder Building Suite 300, Birmingham, AL 35233, United States
| | | | - Venkata Yeramilli
- Department of Surgery, Division of Pediatric Surgery, Children's of Alabama, University of Alabama at Birmingham, 1600 7th Ave. S., Lowder Building Suite 300, Birmingham, AL 35233, United States
| | - Colin Martin
- Department of Surgery, Division of Pediatric Surgery, Children's of Alabama, University of Alabama at Birmingham, 1600 7th Ave. S., Lowder Building Suite 300, Birmingham, AL 35233, United States.
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Sowden M, van Weissenbruch MM, Bulabula ANH, van Wyk L, Twisk J, van Niekerk E. Effect of a Multi-Strain Probiotic on the Incidence and Severity of Necrotizing Enterocolitis and Feeding Intolerances in Preterm Neonates. Nutrients 2022; 14:nu14163305. [PMID: 36014810 PMCID: PMC9415863 DOI: 10.3390/nu14163305] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Necrotizing enterocolitis (NEC) is a multifactorial disease, causing inflammation of the bowel. The exact root of NEC is still unknown, but a low weight and gestational age at birth are known causes. Furthermore, antibiotic use and abnormal bacterial colonization of the premature gut are possible causes. Premature neonates often experience feeding intolerances that disrupts the nutritional intake, leading to poor growth and neurodevelopmental impairment. Methods: We conducted a double-blind, placebo-controlled, randomized clinical trial to investigate the effect of a multi-strain probiotic formulation (LabinicTM) on the incidence and severity of NEC and feeding intolerances in preterm neonates. Results: There were five neonates in the placebo group who developed NEC (Stage 1A−3B), compared to no neonates in the probiotic group. Further, the use of probiotics showed a statistically significant reduction in the development of feeding intolerances, p < 0.001. Conclusion: A multi-strain probiotic is a safe and cost-effective way of preventing NEC and feeding intolerances in premature neonates.
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Affiliation(s)
- Marwyn Sowden
- Department of Global Health, Division of Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
- Correspondence: ; Tel.: +27-21-938-9474
| | - Mirjam Maria van Weissenbruch
- Amsterdam UMC, Department of Pediatrics-Neonatology, VU University Medical Center, 1081 HV Amsterdam, The Netherlands
| | | | - Lizelle van Wyk
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town 7505, South Africa
| | - Jos Twisk
- Department of Epidemiology and Data Science, Amsterdam UMC, 1081 HV Amsterdam, The Netherlands
| | - Evette van Niekerk
- Department of Global Health, Division of Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
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Short-term outcomes of HIV-exposed and HIV-unexposed preterm, very low birthweight neonates: a longitudinal, hospital-based study. J Perinatol 2020; 40:445-455. [PMID: 31673041 DOI: 10.1038/s41372-019-0541-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 10/08/2019] [Accepted: 10/20/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare short-term outcomes of very low birthweight (VBLW, <1500 g) neonates by maternal HIV status. DESIGN Retrospective hospital-based cohort in Cape Town, South Africa. RESULTS Of 1579 mothers, 316 (20%) were HIV-positive; 183/316 (58%) received ≥8 weeks of antenatal antiretrovirals. HIV-exposed neonates (HIVE, vs HIV-unexposed, HIVU) had increased risk of necrotising enterocolitis (NEC; OR 1.93, 95% CI 1.27-2.92) and invasive ventilation (OR 1.35, 95% CI 1.01-1.79). Extremely low birthweight (ELBW, <1000 g) modified the HIV-exposure-mortality relationship: among ELBW neonates, HIVE vs HIVU mortality OR 1.75 (95% CI 1.13-2.69); among non-ELBW, OR 0.89 (95% CI 0.54-1.49). Antiretrovirals (≥8 vs <8 weeks/none) reduced NEC (OR 0.46, 95% CI 0.22-0.97) and invasive ventilation risks (OR 0.57, 95% CI 0.32-0.99). HIV-PCR results were available for 228/316 (72%) HIVE neonates; 11/228 (5%) tested positive. CONCLUSIONS Among VLBW neonates, HIV-exposure was associated with increased risk of adverse short-term outcomes; antenatal antiretrovirals were protective.
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Grønborg HL, Jespersen S, Hønge BL, Jensen-Fangel S, Wejse C. Review of cytomegalovirus coinfection in HIV-infected individuals in Africa. Rev Med Virol 2016; 27. [PMID: 27714898 DOI: 10.1002/rmv.1907] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/25/2016] [Accepted: 08/26/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection among HIV-infected individuals may cause end-organ disease, which is an AIDS-defining condition. Evidence from high-income countries suggests that CMV may alter the outcome of HIV infection, other than causing end-organ diseases. We reviewed literature on HIV and CMV coinfection in Africa. METHODS Systematic review of published studies on HIV and CMV coinfection in Africa using the PubMed database. RESULTS High CMV seroprevalence was found throughout Africa, exceeding 90% in most populations. Retinitis, pneumonia, and colitis were the most commonly reported CMV manifestations in HIV-infected individuals. Among patients with pulmonary symptoms, the prevalence of CMV pneumonitis varied from 20% to over 60%, whereas CMV was found in 0% to 14% of patients with gastrointestinal manifestations. Cytomegalovirus retinitis was found in 0% to 2.6% of examined HIV-infected individuals. The diagnostics of CMV end-organ diseases were found complex and difficult to interpret in African settings. Cytomegalovirus viremia was correlated with significantly lower CD4 cell count and increase in activated and apoptosis vulnerable T-lymphocytes. Also, CMV coinfection was found to be associated with increased transmission and progression of HIV infection. Moreover, detectable CMV DNA was an independent predictor of HIV transmission and mortality among HIV-infected individuals. CONCLUSIONS Cytomegalovirus is highly prevalent in Africa and a common cause of disease manifestations in HIV-infected individuals among all age groups. Cytomegalovirus coinfection in HIV-infected individuals in Africa is associated with increased transmission and mortality of HIV, but it is a neglected area of research.
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Affiliation(s)
- Helene Ladefoged Grønborg
- GloHAU, Department of Public Health, Global Health, Aarhus University, Aarhus N, Denmark.,Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark.,Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
| | - Sanne Jespersen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark.,Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
| | - Bo Langhoff Hønge
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark.,Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Department of Clinical Immunology, Aarhus University Hospital, Aarhus N, Denmark
| | - Søren Jensen-Fangel
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark
| | - Christian Wejse
- GloHAU, Department of Public Health, Global Health, Aarhus University, Aarhus N, Denmark.,Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark.,Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
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Van Niekerk E, Nel DG, Blaauw R, Kirsten GF. Probiotics Reduce Necrotizing Enterocolitis Severity in HIV-exposed Premature Infants. J Trop Pediatr 2015; 61:155-64. [PMID: 25724213 DOI: 10.1093/tropej/fmv004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To assess the effect of probiotics on the incidence of necrotizing enterocolitis (NEC) in premature infants born to human immunodeficiency virus (HIV)-positive and HIV-negative women. PATIENTS AND METHODS HIV-exposed and HIV-unexposed premature infants were randomized to either the probiotic or the placebo group. The probiotic consisted of 1 × 10(9) colony-forming units, Lactobacillus rhamnosus GG and Bifidobacterium infantis per day. RESULTS In total, 74 HIV-exposed and 110 HIV-unexposed infants were enrolled and randomized. The incidence of death [4 (5.4%) vs. 7 (6%); p = 0.79] and NEC [4 (5%) vs. 5 (5%); p = 0.76] did not differ significantly between the HIV-exposed and HIV-unexposed groups. A significant difference was found for total NEC incidence between the study and control groups [3 (3%) vs. 6 (6%); p = 0.029]. The incidence of NEC in the HIV-exposed group differed significantly [Bells I 2 (5%) vs. Bells III 2 (5%); p = 0.045). CONCLUSION Probiotic supplementation reduced the incidence of NEC in the premature very low birth weight infants; however, results failed to show a lower incidence of NEC in HIV-exposed premature infants. A reduction in the severity of disease was found in the HIV-exposed study group.
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Affiliation(s)
- Evette Van Niekerk
- Division Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Daniel G Nel
- Department of Statistics and Actuarial Science, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Reneé Blaauw
- Division Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Gert F Kirsten
- Division of Neonatology, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
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Abstract
BACKGROUND Several risk factors have been implicated in the development of necrotising enterocolitis (NEC). However, little has been reported on the risk factors for NEC in infants born in a setting where exposure to maternal human immunodeficiency virus (HIV) is prevalent. OBJECTIVES To determine maternal and infant characteristics associated with NEC in a setting with a high prevalence of HIV infection and to compare clinical presentation and mortality of NEC in HIV-exposed and unexposed infants. METHODS This was a retrospective, case-control study. Infants with a confirmed diagnosis of NEC, admitted between January 2005 and December 2008 were identified as cases. Two controls for each case were selected by matching them for birthweight, gestational age and date of birth. Hospital records were reviewed for maternal and infant characteristics. RESULTS One hundred and ten infants with confirmed NEC were identified and 220 were selected as controls. Median birthweight and gestational age were similar between cases and controls, (1370 and 1380 g, P = 0·96, and 31 weeks each, P = 0·62, respectively). Lack of use of antenatal corticosteroids (ANS) (OR 2·77, 95% CI 1·42-5·38, P = 0·003), presence of chorio-amnionitis (OR 7·28, 95% CI 2·16-24·51, P = 0·001) and not mechanically ventilated at birth (OR 3·54, 95% CI 1·29-9·69, P = 0·01) were independently associated with NEC. Maternal HIV status was not associated with NEC. Clinical presentation and mortality from NEC were similar between HIV-exposed and unexposed infants. CONCLUSIONS Infants who develop NEC were less likely to have received mechanical ventilation at birth, suggesting that they were less critically ill when born. Use of ANS should be encouraged as it is protective against NEC. Infants born to HIV-infected mothers were not at increased risk of NEC.
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Necrotizing enterocolitis and the placenta - a key etiological link. J Pediatr Surg 2013; 48:359-62. [PMID: 23414865 DOI: 10.1016/j.jpedsurg.2012.11.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 11/12/2012] [Indexed: 02/07/2023]
Abstract
AIM Necrotizing enterocolitis (NEC) is the most common and severe acquired acute neonatal surgical condition, associated with premature neonates. Antenatal factors (e.g. vascular insufficiency and antenatal infections) may be important factors in "priming" the inflammatory cascade, thus predisposing to the disease. This study explores the role of placental pathology in predisposing to NEC pathogenesis. METHODS 5338 placentas of high risk pregnancies were evaluated for placental insufficiency, infarction, and evidence of antenatal infection. Placentas of 72 premature infants developing surgical NEC (2007-2011) were identified as a separate study group and pathological placental features compared with unaffected infants. RESULTS Placentas of 72 of the 134 infants with surgically treated NEC (>grade 2 Bells) were available for pathologic evaluation (the remainder having been referred from other delivery units). Placentas of surgical NEC cases had significantly more evidence of noteworthy vascular pathology (placental infarcts) than high risk cases [n=38 (54.5%) versus n=1122 (21%); P<0.01]. Evidence of placental infection/chorioamnionitis or villitis plus evidence of foetal inflammatory response was present in surgical NEC infants versus unaffected infants [n=22 (31.8%) versus n=647 (12%); P<0.01], suggesting a possible pathogenic role. CONCLUSION This study suggests that exposure to antenatal placental infection may contribute to pathogenesis of NEC by modifying foetal vascular response and warrants further study.
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