Progress in the field of necrotising enterocolitis – year 2012

Lack of Enteral Feeding Associated with Mortality in Prematurity and Necrotizing Enterocolitis

BACKGROUND

Necrotizing Enterocolitis (NEC) remains a significant cause of morbidity and mortality. Recently, there has been an increased recognition of the importance of intestinal immunity and the associations with antibiotics and enteral feeds in the pathophysiology of NEC. The primary purpose of this study is to examine the association of enteral feeds on the survival of premature neonates with NEC.

MATERIAL AND METHODS

A retrospective review using the Vermont Oxford Network for a Level IV NICU from January 1, 2013 through December 31, 2019 was performed. All neonates had a gestational age between 22 to 29 weeks, weighed at least 300 grams (n = 653), had a reported enteral feed status and were treated for NEC (n = 43). Data analysis utilized two-tailed t-tests for NEC and infection rates then Fisher's exact tests for survival status.

RESULTS

The incidence of NEC in the population was 6.6% (43/653). Of the 43 neonates treated for NEC, 27 were enterally fed, while the other 16 were not. All 27 neonates with NEC that were able to achieve enteral feeds survived and had an infection rate of 22.2%. Meanwhile, all 16 neonates with NEC that were unable to achieve enteral feeds died and had an infection rate of 62.5%.

CONCLUSIONS

There is a significant association between enteral feeds and NEC, survival, and infection rates in premature neonates. These findings support the importance of intestinal immunity and the microbiota in NEC. Given the limitations of the retrospective review, the profound survival advantage with enteral feeds reinforces the need for further study.

Admission hypothermia, neonatal morbidity, and mortality: evaluation of a multicenter cohort of very low birth weight preterm infants according to relative performance of the center

This prospective cohort study aimed to assess the association of admission hypothermia (AH) with death and/or major neonatal morbidities among very low birth weight (VLBW) preterm infants based on the relative performance of 20 centers of the Brazilian Network of Neonatal Research. This is a retrospective analysis of prospectively collected data using the database registry of the Brazilian Network on Neonatal Research. Center performance was defined by the relative mortality rate using conditional inference trees. A total of 4356 inborn singleton VLBW preterm infants born between January 2013 and December 2016 without malformations were included in this study. The centers were divided into two groups: G1 (with lower mortality rate) and G2 (with higher mortality rate). Crude and adjusted relative risks (RR) and 95% confidence intervals (95%CI) were estimated by simple and multiple log-binomial regression models. An AH rate of 53.7% (19.8-93.3%) was significantly associated with early neonatal death in G1 (adjusted RR 1.41, 95% CI 1.09-1.84) and G2 (adjusted RR 1.29, 95%CI 1.01-1.65) and with in-hospital death in G1 (adjusted RR 1.29, 95%CI 1.07-1.58). AH was significantly associated with a lower frequency of necrotizing enterocolitis (adjusted RR 0.58, 95%CI 38-0.88) in G2.Conclusion: AH significantly associated with early neonatal death regardless of the hospital performance. In G2, an unexpected protective association between AH and necrotizing enterocolitis was found, whereas the other morbidities assessed were not significantly associated with AH. What is Known: • Admission hypothermia is associated with early neonatal death. • The association of admission hypothermia with major neonatal morbidities has not been fully established. What is New: • Admission hypothermia was significantly associated with early neonatal and in-hospital death in centers with the lowest relative mortality rates. • Admission hypothermia was not associated with major neonatal morbidities and with in-hospital death but was found to be a protective factor against necrotizing colitis in centers with the highest relative mortality rates.

Time to reintroduction of feeding in infants with nonsurgical necrotizing enterocolitis

BACKGROUND

For infants with necrotizing enterocolitis (NEC) treated nonoperatively, no consensus exists on the optimal fasting period prior to reintroducing feeds after NEC. We report our experience with early (<7days) and late (≥7days) refeeding in this population.

METHODS

A chart review of infants with NEC born between 2006 and 2016 was performed. Data elements include demographics, comorbidities, day of diagnosis, Bell's stage, recurrence, strictures, length of stay and mortality, and were grouped into early and late refeeding. T-tests were used for means and chi-squared tests for distribution of proportions. Linear and logistic regressions were used to further evaluate the association of length of stay, stricture, recurrence, and death with time to refeeding.

RESULTS

Of 228 NEC patients, 149(65%) were treated nonoperatively (Bell Stages I, IIA, IIB, IIIA). Eleven patients were excluded owing to never restarting feeds, largely secondary to early death. The early (n=40) and late refeeding (n=98) groups were not significantly different with regard to mean gestational age at birth, race, birth weight, day of life at NEC diagnosis, or cardiac disease. NEC Stage was significantly different (p<0.001). The late group had significantly more Stage IIB patients (p=.02), and the early group had more stage I patients (p=<0.01). After adjusting for Bell's stage, the odds of NEC recurrence, death, and the composite outcome of recurrence or stricture or death were not significantly different between early and late groups.

CONCLUSIONS

No standardized guidelines exist for restarting enteral nutrition following medical NEC. In patients managed nonoperatively, early reintroduction of feeding was not significantly associated with increased NEC recurrence, mortality, or stricture.

LEVEL OF EVIDENCE

Treatment Study - Level III.

Role of lactoferrin in neonatal care: a systematic review

BACKGROUND

Lactoferrin (LF) is present in breast milk and have numerous properties including antimicrobial, antiviral, antifungal, and anticancer. Recent studies have emphasized the role of LF in neonatal care Aims and objective: To evaluate the various roles of LF in neonatal care in preterm infants.

SEARCH METHODS

The literature search was done for this systematic review by searching the electronic database namely Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, Web of Science, Scopus, Index Copernicus, African Index Medicus (AIM), Thomson Reuters (ESCI), Chemical Abstracts Service (CAS), SCIWIN (Scientific World Index), Google Scholar, Latin American and Caribbean Health Sciences Information System (LILACS), Index Medicus for the Eastern Mediterranean Region (IMEMR), Index Medicus for the South-East Asian Region (IMSEAR), Western Pacific Region Index Medicus (WPRIM), various sites for ongoing trials namely clinical trial registry ( www.clinicaltrials.gov , www.controlled-trials.com , Australian and New Zealand Clinical Trials Registry ( http://www.anzctr.org.au ), Indian Clinical Trials Registry ( http://ctri.nic.in/Clinicaltrials ), and the World Health Organization (WHO) International Clinical Trials Registry, and Platform ( http://www.who.int/ictrp/search/en/ ) and abstracts of conferences namely proceedings of Pediatric Academic Societies (American Pediatric Society, Society for Pediatric Research, and European Society for Pediatric Research).

RESULTS

Nine eligible studies were analyzed that fulfilled the inclusion criteria of the systematic review. Six duplicate publications were excluded from review. Four studies were excluded due to nonfulfillment of inclusion criteria. All of the studies had more than one outcome of interest. Four studies showed reduction in late onset sepsis (LOS), one showed reduction in invasive fungal infection (IFI), three showed significant decrease in incidence of necrotizing enterocolitis (NEC), one showed reduction in NEC scares, and two showed decrease in mortality, and one showed decrease in combined death and/or NEC. Only one study evaluated role of LF for ventilator-associated pneumonia (VAP) reduction and showed lower rate of VAP. Still the role of LF in Bronchopulmonary dysplasia (BPD) and Retinopathy of prematurity (ROP) is unclear.

CONCLUSION

LF has shown to be promising agent for reduction of LOS and NEC. The role of LF in prevention of neonatal mortality, BPD, and ROP needs further studies. The trials that are going on around the world may be able to give reply of this question in future.

Standardized Slow Enteral Feeding Protocol and the Incidence of Necrotizing Enterocolitis in Extremely Low Birth Weight Infants

BACKGROUND

Compared with early enteral feeds, the delayed introduction and slow advancement of enteral feedings to reduce the incidence of necrotizing enterocolitis (NEC) are not well studied in extremely low birth weight (ELBW) infants.

OBJECTIVE

To study the effects of a standardized slow enteral feeding (SSEF) protocol in ELBW infants.

METHODS

ELBW infants who followed an SSEF protocol (September 2009 to December 2012) were compared with a similar group of historical controls (January 2003 to July 2009). Short-term outcomes between the 2 groups were compared by propensity score (PS) analysis.

RESULTS

One hundred twenty-five infants in the SSEF group were compared with 294 historical controls. Compared with the controls, feeding initiation day, full enteral feeding day, parenteral nutrition (PN) days, and total central line days were longer in the SSEF group. There was no significant difference in overall NEC (5.6% vs 11.2%, respectively; P = .10) or surgical NEC (1.6% vs 4.8%, respectively; P = .17) between the SSEF group and controls. However, in infants with birth weight <750 g, NEC (2.1% vs 16.2%, respectively; P < .01) or combined NEC/death (12.8% vs 29.5%, respectively; P = .03) was significantly less in the SSEF group compared with controls. In infants who survived to discharge, there was no significant difference in the discharge weight or length of stay in PS-adjusted analysis.

CONCLUSIONS

An SSEF protocol significantly reduces the incidence of NEC and combined NEC/death in infants with birth weight <750 g. Despite taking longer to achieve full enteral feeding on this protocol, surviving ELBW infants demonstrated comparable weight gain at discharge without prolonging their hospital stay.