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Talavera-Barber MM, Sánchez PJ, Conces M, Kaptsan I, Everhart K, Leber A, Malleske DT, Moallem M, Panesso-Gómez S, Shimamura M. Molecular testing for gastrointestinal pathogens in intestinal tissue of infants with necrotizing enterocolitis or spontaneous intestinal perforation. J Perinatol 2024:10.1038/s41372-024-01999-z. [PMID: 38849546 DOI: 10.1038/s41372-024-01999-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 04/26/2024] [Accepted: 05/02/2024] [Indexed: 06/09/2024]
Abstract
OBJECTIVE The objective of this study was to determine the frequency of common gastrointestinal bacterial, parasitic, and viral pathogen detection in necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP) -associated intestinal tissue. STUDY DESIGN Retrospective cohort study examined formalin fixed, paraffin embedded (FFPE) surgical or autopsy intestinal tissue from NEC or SIP specimens. DNA and RNA were extracted and analyzed by multiplex PCR panel (GIFA Biofire). DNA or RNA from stool samples containing each pathogen were extracted for positive controls. RESULTS The total number of intestinal tissue samples were 193 from 310 infants (156 NEC, 37 SIP). Six (3%) infants with stage III NEC tested positive for a target pathogen; 2, C. difficile; 3, Enteroaggregtive E. coli; and 1, Giardia. No gastrointestinal viral pathogens were detected. CONCLUSION Molecular testing yielded few GI pathogens suggesting that these organisms are likely not major causes or facilitators of NEC or SIP.
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Affiliation(s)
- Maria M Talavera-Barber
- Department of Pediatrics, Avera Research Institute and University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA.
| | - Pablo J Sánchez
- Department of Pediatrics, Division of Neonatology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Perinatal Research, Ohio Perinatal Research Network, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Miriam Conces
- Department of Pathology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Irina Kaptsan
- Center for Vaccines and Immunity, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Kathy Everhart
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Amy Leber
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Daniel T Malleske
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mohannad Moallem
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Santiago Panesso-Gómez
- Department of Gynecology Oncology, Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Masako Shimamura
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Vaccines and Immunity, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
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Pijpers AGH, Gorter RR, Eeftinck Schattenkerk LD, van Schuppen J, van den Akker CHP, Vanhamel S, van Heurn ELW, Musters GD, Derikx JPM. Identifying Preoperative Clinical Characteristics of Unexpected Gastrointestinal Perforation in Infants-A Retrospective Cohort Study. CHILDREN (BASEL, SWITZERLAND) 2024; 11:505. [PMID: 38790500 PMCID: PMC11119732 DOI: 10.3390/children11050505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/08/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Infants presenting with unexpected pneumoperitoneum upon abdominal X-ray, indicating a gastrointestinal perforation (GIP), have a surgical emergency with potential morbidity and mortality. Preoperative determination of the location of perforation is challenging but will aid the surgeon in optimizing the surgical strategy, as colon perforations are more challenging than small bowel perforations. Therefore, the aim of this study is to provide an overview of preoperative patient characteristics, determine the differences between the small bowel and colon, and determine underlying causes in a cohort of infants with unexpected GIP. METHODS All infants (age ≤ 6 months) who presented at our center with unexpected pneumoperitoneum (no signs of pneumatosis before) undergoing surgery between 1996 and 2024 were retrospectively included. The differences between the location of perforation were analyzed using chi-squared and t-tests. Bonferroni correction was used to adjust for multiple tests. RESULTS In total, 51 infants presented with unexpected pneumoperitoneum at our center, predominantly male (N = 36/51) and premature (N = 40/51). Among them, twenty-six had small bowel, twenty-two colon, and three stomach perforations. Prematurity (p = 0.001), birthweight < 1000 g (p = 0.001), respiratory support (p = 0.001), and lower median arterial pH levels (p = 0.001) were more present in patients with small bowel perforation compared with colon perforations. Pneumatosis intestinalis was more present in patients with colon perforation (p = 0.004). All patients with Hirschsprung disease and cystic fibrosis had colon perforation. The final diagnoses were mainly focal intestinal perforations (N = 27/51) and necrotizing enterocolitis (N = 9/51). CONCLUSIONS Infants with unexpected GIP, birthweight < 1000 g, and prematurity have more risk for small bowel perforation. In case of colon perforation, additional screening (for Hirschsprung and cystic fibrosis) should be considered.
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Affiliation(s)
- Adinda G. H. Pijpers
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, 1105 AZ Amsterdam, The Netherlands
| | - Ramon R. Gorter
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Laurens D. Eeftinck Schattenkerk
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Joost van Schuppen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Chris H. P. van den Akker
- Amsterdam Reproduction & Development Research Institute, 1105 AZ Amsterdam, The Netherlands
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Sylvie Vanhamel
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Ernest L. W. van Heurn
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Gijsbert D. Musters
- Department of Surgery, Zaans Medisch Centrum, Koningin Julianaplein 58, 1502 DV Zaandam, The Netherlands
| | - Joep P. M. Derikx
- Department of Pediatric Surgery, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Mantle A, Yang MJ, Judkins A, Chanthavong I, Yoder BA, Chan B. Association of Intrapartum Drugs with Spontaneous Intestinal Perforation: A Single-Center Retrospective Review. Am J Perinatol 2024; 41:174-179. [PMID: 34666387 PMCID: PMC10435317 DOI: 10.1055/a-1673-0183] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Spontaneous intestinal perforation (SIP) occurs commonly in extremely low gestational age newborns (ELGANs; <30 weeks' GA). Early, concurrent neonatal use of indomethacin (Neo_IN) and hydrocortisone (Neo_HC) is a known risk for SIP. Mothers in premature labor often receive indomethacin (Mat_IN) for tocolysis and steroids (Mat_S) for fetal maturation. Coincidentally, ELGANs may receive Neo_IN or Neo_HC within the first week of life. There are limited data on the effect of combined exposures to maternal and neonatal medications. We hypothesized that proximity exposure to these medications may increase the risk of SIP. STUDY DESIGN We reviewed the medical records of ELGANs from June 2014 to December 2019 at a single level III neonatal intensive care unit. We compared antenatal and postnatal indomethacin and steroid use between neonates with and without SIP. For analysis, chi-square, Student's t-test, Fisher's exact test, and Mann-Whitney U tests were used. RESULTS Among 417 ELGANs, SIP was diagnosed in 23, predominantly in neonates < 26 weeks' GA (n = 21/126, 16.7%). Risk factors analysis focused on this GA cohort in which SIP was most prevalent. Mat_IN administration within 2 days of delivery increased SIP risk (odds ratio: 3; 95% confidence interval: 1.25-7.94; p = 0.036). Neo_HC was not independently associated with SIP (p = 0.38). A higher proportion of SIP group had close temporal exposure of Mat_IN and Neo_HC compared with the non-SIP group, though not statistically significant (14 vs. 7%, p = 0.24). CONCLUSION Peripartum Mat_IN was associated with increased risk for SIP in this small study sample. Larger studies are needed to further delineate SIP risk from the interaction of peripartum maternal medication with early postnatal therapies and disease pathophysiology. KEY POINTS · Perinatal indomethacin is associated with SIP in preterm infants born at less than 26 weeks.. · Temporal proximity of prenatal/postnatal medication exposure matters.. · Indomethacin and Hydrocortisone the risks, benefits, and timing related to SIP..
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Affiliation(s)
- Ashley Mantle
- College of Nursing, University of Utah Health, Salt Lake City, Utah
| | - Michelle J Yang
- Division of Neonatology, University of Utah Health, Salt Lake City, Utah
| | - Allison Judkins
- Division of Neonatology, University of Utah Health, Salt Lake City, Utah
| | - Iwa Chanthavong
- Decision Support, University of Utah Health, Salt Lake City, Utah
| | - Bradley A Yoder
- Division of Neonatology, University of Utah Health, Salt Lake City, Utah
| | - Belinda Chan
- Division of Neonatology, University of Utah Health, Salt Lake City, Utah
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Peila C, Spada E, Riboldi L, Capitanio M, Pellegrino F, Coscia A. Twinning as a risk factor for neonatal acute intestinal diseases: a case-control study. Front Pediatr 2023; 11:1308538. [PMID: 38161432 PMCID: PMC10755860 DOI: 10.3389/fped.2023.1308538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/01/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Acute intestinal diseases (AID), including necrotizing enterocolitis and spontaneous intestinal perforation, are a group of conditions that typically present in preterm infants, and are associated with an elevated mortality and morbidity rate. The risk factors for these diseases remain largely unknown. The aim of the study is to identify the correlation between twinning and the development of AID. Methods A single-center retrospective case-control study was conducted. We recruited all infants with a diagnosis of AID, confirmed by anatomopathology, recovered in NICU between 2010 and 2020. Considering the rarity of the outcome, 4 matched controls for each subject were randomly chosen from the overall population of newborns. Odds Ratio (OR) and 95% Confidence Interval (CI) were calculated using a conditional logistic regression model and a multivariate model by the creation of a Directed Acyclic Graph (www.dagitty.net). Results The study population resulted in 65 cases and 260 controls. The two groups present similar median gestational age and mean birthweight in grams. The cases have a higher frequency of neonatal pathology (defined as at least one of patent ductus arteriosus, early or late sepsis, severe respiratory distress) (84.6% vs. 51.9%), medically assisted procreation (33.8% vs. 18.8%) and periventricular leukomalacia (10.8% vs. 2.7%), and a lower frequency of steroids prophylaxis (67.7% vs. 86.9%). About 50% of cases needed surgery. The OR for the direct effect were difference from one using logistic regression booth without and with repeated measures statements: from 1.14 to 4.21 (p = .019) and from 1.16 to 4.29 (p = .016), respectively. Conclusions Our study suggests that twinning may be a risk factor for the development of AID. Due to the small number of cases observed, further studies on larger populations are needed.
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Affiliation(s)
- C. Peila
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - E. Spada
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
- Laboratorio Della Conoscenza Carlo Corchia—APS, Florence, Italy
| | - L. Riboldi
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - M. Capitanio
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - F. Pellegrino
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - A. Coscia
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
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Association between Abnormal Antenatal Doppler Characteristics and Gastrointestinal Outcomes in Preterm Infants. Nutrients 2022; 14:nu14235121. [PMID: 36501150 PMCID: PMC9738995 DOI: 10.3390/nu14235121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/18/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
Antenatal Doppler disturbances are associated with fetal hypoxia and may induce a brain-sparing vascular redistribution at the expense of splanchnic circulation, possibly predisposing to gut complications. We aimed to compare several gastrointestinal outcomes among very-low-birthweight (VLBW) preterm infants with different antenatal Doppler features. VLBW infants born between 2010-2022 were retrospectively included and stratified into the following clusters based on antenatal Doppler characteristics: normal Doppler (controls); absent or reversed end-diastolic flow in the umbilical artery (UA-AREDF) alone or also in the ductus venosus (UA+DV-AREDF); and abnormal Doppler with or without brain-sparing redistribution. The following outcomes were evaluated: time to reach full enteral feeds (FEF), feeding intolerance (FI), necrotizing enterocolitis (NEC), and spontaneous intestinal perforation (SIP). Overall, 570 infants were included. Infants born following UA+DV-AREDF had significantly higher FI, NEC, and SIP rates and achieved FEF later compared to controls. Increased FI prevalence and a longer time to FEF compared to controls were also observed among UA-AREDF infants and in the presence of brain-sparing redistribution, which also increased NEC rates. Antenatal Doppler abnormalities exacerbate the gastrointestinal risks of preterm infants. Detailed knowledge of Doppler features can aid in identifying those at highest risk of intestinal complications who may benefit from tailored enteral feeding management.
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Patent ductus arteriosus and spontaneous intestinal perforation in a cohort of preterm infants. J Perinatol 2022; 42:1649-1653. [PMID: 35589970 DOI: 10.1038/s41372-022-01403-8] [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: 10/04/2021] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess whether either duration and magnitude of ductal shunt or medical treatment for patent ductus arteriosus (PDA) are related to spontaneous intestinal perforation (SIP). STUDY DESIGN Clinical charts of infants <29 weeks' gestation born from 2006 to 2018 were reviewed. Echocardiographic examinations were evaluated according to McNamara and Sehgal's staging system. RESULTS A higher percentage of patients with SIP had a hemodynamically significant PDA (HSPDA) and was treated with either NSAIDs or paracetamol (79% vs 53% and 81% vs 54%, respectively). Among non-treated patients, we found a 1.32 increase in the odds of SIP per day of persistence of HSPDA. In the cohort of patients treated despite the absence of HSPDA, we found a 2.35 increase in the odds of SIP per dose of drug administered. CONCLUSION Both treating a non-HSPDA and leaving a HSPDA to its natural history seem to be associated with SIP.
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Ang JL, Rath CP, Tan H, Patole S, Rao SC. Mortality and neurodevelopmental outcomes of infants with spontaneous intestinal perforation: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022; 108:256-266. [PMID: 36328412 DOI: 10.1136/archdischild-2022-324157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is limited information about the mortality and neurodevelopmental outcomes of very preterm infants (<32 weeks) with spontaneous intestinal perforation (SIP). OBJECTIVE To explore the association between SIP and neurodevelopmental outcomes and mortality in very preterm infants. DATA SOURCES Medline, EMBASE, Cochrane Library, EMCARE and MedNar. STUDY SELECTION Databases were searched until September 2021. Studies comparing outcomes of 'SIP' versus 'no SIP or necrotising enterocolitis (NEC)' were included. DATA EXTRACTION Neurodevelopmental outcomes at ≥1 year corrected age were extracted as the main outcome measure. Data were pooled separately for adjusted and unadjusted ORs using the random-effects model. The evidence level was assessed using the GRADE (Grading of Recommendations, Assessments, Development and Evaluations) framework. RESULTS Eighteen cohort studies (13 606 infants) were included. Meta-analysis of unadjusted ORs showed that SIP was significantly associated with increased odds of mortality, cerebral palsy, composite outcome of death or disability, visual impairment and hearing impairment. However, pooling of adjusted ORs (aOR) found significant associations only for mortality (aOR (95% CI) 2.27 (2.07 to 2.49); I2: 0%; four studies (n=10 695)), severe disability (aOR (95% CI) 2.06 (1.38 to 3.08); I2: 0%; two studies (n=321)) and composite outcome of 'death or disability' (aOR (95% CI) 2.18 (1.55 to 3.06); I2: 0%; two studies (n=321)). The level of evidence was 'low' or 'very low'. LIMITATIONS Lack of information on aORs from many studies. CONCLUSIONS SIP in very preterm infants is associated with higher odds of mortality, severe disability, and death or disability.
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Affiliation(s)
- Ju Li Ang
- Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Neonatology, King Edward memorial hospital For Women, Subiaco, Western Australia, Australia
| | - Chandra Prakash Rath
- Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia .,Neonatology, King Edward memorial hospital For Women, Subiaco, Western Australia, Australia
| | - Herr Tan
- Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Neonatology, King Edward memorial hospital For Women, Subiaco, Western Australia, Australia
| | - Sanjay Patole
- Neonatology, King Edward memorial hospital For Women, Subiaco, Western Australia, Australia.,Paediatrics, The University of Western Australia School of Medicine, Nedlands, Western Australia, Australia
| | - Shripada C Rao
- Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Paediatrics, The University of Western Australia School of Medicine, Nedlands, Western Australia, Australia
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Development of artificial neural networks for early prediction of intestinal perforation in preterm infants. Sci Rep 2022; 12:12112. [PMID: 35840701 PMCID: PMC9287325 DOI: 10.1038/s41598-022-16273-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 07/07/2022] [Indexed: 11/09/2022] Open
Abstract
Intestinal perforation (IP) in preterm infants is a life-threatening condition that may result in serious complications and increased mortality. Early Prediction of IP in infants is important, but challenging due to its multifactorial and complex nature of the disease. Thus, there are no reliable tools to predict IP in infants. In this study, we developed new machine learning (ML) models for predicting IP in very low birth weight (VLBW) infants and compared their performance to that of classic ML methods. We developed artificial neural networks (ANNs) using VLBW infant data from a nationwide cohort and prospective web-based registry. The new ANN models, which outperformed all other classic ML methods, showed an area under the receiver operating characteristic curve (AUROC) of 0.8832 for predicting IP associated with necrotizing enterocolitis (NEC-IP) and 0.8797 for spontaneous IP (SIP). We tested these algorithms using patient data from our institution, which were not included in the training dataset, and obtained an AUROC of 1.0000 for NEC-IP and 0.9364 for SIP. NEC-IP and SIP in VLBW infants can be predicted at an excellent performance level with these newly developed ML models. https://github.com/kdhRick2222/Early-Prediction-of-Intestinal-Perforation-in-Preterm-Infants.
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Morowitz MJ, Katheria AC, Polin RA, Pace E, Huang DT, Chang CCH, Yabes JG. The NICU Antibiotics and Outcomes (NANO) trial: a randomized multicenter clinical trial assessing empiric antibiotics and clinical outcomes in newborn preterm infants. Trials 2022; 23:428. [PMID: 35606829 PMCID: PMC9125935 DOI: 10.1186/s13063-022-06352-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 04/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Early-onset sepsis is an important cause of neonatal morbidity and mortality in the preterm population. Infants perceived to be at increased risk for early-onset sepsis are often treated empirically with broad-spectrum antibiotics while awaiting confirmatory blood cultures, despite an overall incidence of early-onset sepsis of 2–3% among extremely-low-birthweight (ELBW) infants. Recent observational studies associate perinatal antibiotic use with an increased incidence of necrotizing enterocolitis, late-onset sepsis, and mortality among ELBW infants. Given currently available data and variability in clinical practice, we designed a prospective multi-institutional randomized controlled trial to determine the safety of early antibiotic use in ELBW infants. Methods The NICU Antibiotics and Outcomes (NANO) trial is a multicenter, double-blinded, randomized controlled trial. A sample of 802 ELBW preterm infants will undergo web-based stratified block randomization to receive empiric antibiotics (EA; ampicillin and gentamicin) or placebo during routine evaluation for early-onset sepsis. Participating sites will use preexisting institutional protocols for antibiotic dosage and duration. Infants born at participating sites with a gestational age of 29 weeks or less are eligible for enrollment. Exclusion criteria include maternal intrauterine infection, hemodynamic or respiratory instability, delivery by caesarean section for maternal indications without labor or prolonged rupture of membranes, and prior administration of antibiotics. The primary outcome is the composite incidence of necrotizing enterocolitis, late-onset sepsis, or death during participants’ index hospitalization. Maternal and infant samples will be collected longitudinally and assessed for differences in microbiome composition and diversity. Discussion The NANO trial is designed to compare the rate of adverse outcomes of EA use at birth versus placebo in ELBW preterm infants. If EA at birth worsens clinical outcomes, then the results of the trial may help providers decrease antibiotic utilization in the NICU and subsequently decrease the incidence of complications associated with early antibiotic use in ELBW infants. If we instead find that EA improve outcomes, then the trial will validate a longstanding clinical practice that has not previously been supported by high-quality data. Future studies will assess long-term clinical and microbial outcomes in infants who received empiric antibiotics following delivery. Trial registration Trial registration data: June 25, 2019 NCT03997266. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06352-3.
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Affiliation(s)
- Michael J Morowitz
- Division of Pediatric General and Thoracic Surgery, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Rangos Research Center 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
| | - Anup C Katheria
- Division of Pediatrics, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, 92123, USA
| | - Richard A Polin
- Department of Pediatrics, Columbia University, New York, NY, 10032, USA
| | - Elizabeth Pace
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - David T Huang
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Chung-Chou H Chang
- Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Johathan G Yabes
- Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, USA
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Fundora JB, Zhu J, Yanek LR, Go M, Shakeel F, Brooks SS, Yang J, Hackam DJ, Everett AD, Shores DR. Galectin-4 as a Novel Biomarker of Neonatal Intestinal Injury. Dig Dis Sci 2022; 67:863-871. [PMID: 33738671 PMCID: PMC8939249 DOI: 10.1007/s10620-021-06929-z] [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: 09/15/2020] [Accepted: 02/26/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Neonates are at risk of gastrointestinal emergencies including necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP). Identifying biomarkers to aid in diagnosis is imperative. We hypothesized that circulating intestinal-specific protein concentrations would distinguish infants with intestinal injury from controls. AIMS To identify serum concentrations of intestinal-specific protein(s) in infants with intestinal injury and controls. METHODS We used an in silico approach to identify intestinal-specific proteins. We collected serum from control infants and infants with NEC or SIP and measured protein concentrations using ELISA. If baseline concentrations were near the detection limit in initial control assays, we proceeded to assess concentrations in a larger cohort of controls and infants with injury. Control infants were frequency matched to infants with injury and compared with nonparametric and mixed-effects models analysis. RESULTS We evaluated four proteins with high intestinal expression: Galectin-4 (Gal-4), S100G, Trefoil Factor-3, and alanyl aminopeptidase. Only Gal-4 demonstrated consistent results near the lower limit of quantification in controls and was studied in the larger cohorts. Gal-4 concentration was low in 111 control infants (median 0.012 ng/ml). By contrast, Gal-4 was significantly increased at diagnosis in infants with surgical NEC and SIP (n = 14, p ≤ 0.001 and n = 8, p = 0.031) compared to matched controls, but not in infants with medical NEC (n = 32, p = 0.10). CONCLUSIONS Of the intestinal-specific proteins evaluated, circulating Gal-4 concentrations were at the assay detection limit in control infants. Gal-4 concentrations were significantly elevated in infants with surgical NEC or SIP, suggesting that Gal-4 may serve as a biomarker for neonatal intestinal injury.
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Affiliation(s)
- Jennifer B Fundora
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, 1800 Orleans St, Suite 8534, Baltimore, MD, 21287, USA.
| | - Jie Zhu
- Department of Pediatrics, Division of Pediatric Cardiology, Johns Hopkins University School of Medicine, 720 Rutland Ave. Ross Building 1129, Baltimore, MD, 21205, USA
| | - Lisa R Yanek
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 E Monument St 1830 Building Suite 8024, Baltimore, MD, 21287, USA
| | - Mitzi Go
- Division of Neonatology, Maternal, Fetal and Neonatal Institute, Johns Hopkins All Children's Hospital, 501 6th Ave S, St. Petersburg, FL, 33701, USA
| | - Fauzia Shakeel
- Division of Neonatology, Maternal, Fetal and Neonatal Institute, Johns Hopkins All Children's Hospital, 501 6th Ave S, St. Petersburg, FL, 33701, USA
| | - Sandra S Brooks
- Division of Neonatology, Maternal, Fetal and Neonatal Institute, Johns Hopkins All Children's Hospital, 501 6th Ave S, St. Petersburg, FL, 33701, USA
| | - Jun Yang
- Department of Pediatrics, Division of Pediatric Cardiology, Johns Hopkins University School of Medicine, 720 Rutland Ave. Ross Building 1129, Baltimore, MD, 21205, USA
| | - David J Hackam
- Department of Surgery, Division of Pediatric Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Suite 7310, Baltimore, MD, 21287, USA
| | - Allen D Everett
- Department of Pediatrics, Division of Pediatric Cardiology, Johns Hopkins University School of Medicine, 720 Rutland Ave. Ross Building 1129, Baltimore, MD, 21205, USA
| | - Darla R Shores
- Department of Pediatrics, Division of Pediatric Gastroenterology, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
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Juul N, Willacy O, Maagaard M, Olsen T, Ek J, Ifaoui I, Fossum M. Simultaneous debut of spontaneous intestinal perforation in a pair of preterm monozygotic twins assessed by whole genome sequencing. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2021.102123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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12
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Martos Rodríguez M, Guillén G, López-Fernández S, Martín Gimenez M, Ruiz CW, Ribes C, López M, Molino JA. Anastomosis near to the ileocecal valve in neonates with focal intestinal perforation, is it safe. J Matern Fetal Neonatal Med 2021; 35:7011-7014. [PMID: 34096446 DOI: 10.1080/14767058.2021.1934444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Anastomosis near the ileocecal valve (ICV) are controversial due to the increased pressure on the suture; in this situation, the valve could be removed at a first stage or at the moment of stoma closure. However, preservation of the ICV has proved important benefits in the long term. The aim of this study is to evaluate its feasibility in neonates with focal intestinal perforation (FIP). METHODS Retrospective study (2010-2019) of neonates with FIP who underwent intestinal resection and primary anastomosis. Patients were divided into group A (anastomosis less than 5 cm from ICV) and group B (more than 5 cm). RESULTS Forty patients were treated. Patients ostomized or with resection of ICV were excluded. Finally, 24 patients (birth weight 1043 ± 594 g (520-3000), age 8.8 ± 7.8 days (2-39)) were included for analysis. Patent ductus arteriosus was present in 75%. There were 6 patients in group A (25%) and 18 in group B (75%). Groups were comparable in terms of gestational age, birth weight, and age at the time of surgery (p > .05). There were no cases of dehiscence nor stenosis of the anastomosis. There were no differences in reoperation rate, infectious complications, time to enteral feeding, days of parenteral nutrition, hospital stay nor survival (p > .05). CONCLUSION Ileo-ileal anastomosis closer to the ileocecal junction, in neonates with focal intestinal perforation, is an effective and safe option which also allows the preservation of the ICV avoiding the complications derived from its absence in a group of patients with high morbidity.
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Affiliation(s)
| | - Gabriela Guillén
- Neonatal Surgery Unit, Pediatric Surgery Division, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Sergio López-Fernández
- Neonatal Surgery Unit, Pediatric Surgery Division, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - César W Ruiz
- Neonatology Division, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Cármen Ribes
- Neonatology Division, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Manuel López
- Pediatric Surgery Division, Vall d'Hebron University Hospital, Barcelona, Spain
| | - José Andrés Molino
- Neonatal Surgery Unit, Pediatric Surgery Division, Vall d'Hebron University Hospital, Barcelona, Spain
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13
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Reisner A, Smith AD, Wrubel DM, Buster BE, Sawvel MS, Blackwell LS, Laxpati NG, Brahma B, Chern JJ. Utility of ventriculogallbladder shunts in complex cases of hydrocephalus related to extreme prematurity. J Neurosurg Pediatr 2021; 27:511-517. [PMID: 33636696 DOI: 10.3171/2020.9.peds20522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 09/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The management of hydrocephalus resulting from intraventricular hemorrhage related to extreme prematurity remains demanding. Given the complexities of controlling hydrocephalus in this population, less commonly used procedures may be required. The authors examined the utility of ventriculogallbladder (VGB) shunts in a series of such children. METHODS The authors retrospectively reviewed the medical records of all children who underwent surgery for hydrocephalus in the period from 2011 through 2019 at Children's Healthcare of Atlanta. Six patients who underwent VGB shunt placement were identified among a larger cohort of 609 patients who had either a new shunt or a newly changed distal terminus site. The authors present an analysis of this series, including a case of laparoscopy-assisted distal VGB shunt revision. RESULTS The mean age at initial shunt placement was 5.1 months (range 3.0-9.4 months), with patients undergoing a mean of 11.8 shunt procedures (range 5-17) prior to the initial VGB shunt placement at a mean age of 5.3 years (range 7.9 months-12.8 years). All 6 patients with VGB shunt placement had hydrocephalus related to extreme prematurity (gestational age < 28 weeks). At the time of VGB shunt placement, all had complex medical and surgical histories, including poor venous access due to congenital or iatrogenic thrombosis or thrombophlebitis and a peritoneum hostile to distal shunt placement related to severe necrotizing enterocolitis. VGB complications included 1 case of shunt infection, identified at postoperative day 6, and 2 cases of distal shunt failure due to retraction of the distal end of the VGB shunt. In all, there were 3 conversions back to ventriculoperitoneal or ventriculoatrial shunts due to the 2 previously mentioned complications, plus 1 patient who outgrew their initial VGB shunt. Three of 6 patients remain with a VGB shunt, including 1 who underwent laparoscopy-assisted distal shunt revision 110.5 months after initial VGB shunt insertion. CONCLUSIONS Placement of VGB shunts should be considered in the armamentarium of procedures that may be used in the particularly difficult cohort of children with hydrocephalus related to extreme prematurity. VGB shunts show utility as both a definitive treatment and as a "bridge" procedure until the patient is larger and comorbid abdominal and/or vascular issues have resolved sufficiently to allow conversion back to ventriculoperitoneal or ventriculoatrial shunts, if needed.
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Affiliation(s)
- Andrew Reisner
- Departments of1Pediatrics.,2Neurosurgery, and.,Departments of4Neurosurgery and
| | - Alexis D Smith
- 3Surgery, Emory University School of Medicine, Atlanta; and.,Departments of4Neurosurgery and
| | | | | | | | | | | | | | - Joshua J Chern
- Departments of1Pediatrics.,2Neurosurgery, and.,Departments of4Neurosurgery and
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14
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Abstract
One of the many challenges with necrotizing enterocolitis (NEC) remains our inability to make an accurate diagnosis of NEC. The lack of a unifying cause and multiple variations in presentations lead to great uncertainty with NEC. Separating out the needs of the researcher wanting to define NEC from the clinician and patient family's perspectives who want an accurate diagnosis for NEC is important. The need to augment and/or replace the outdated modified Bell staging criteria is crucial to improving NEC management. Emerging literature suggests that genetic susceptibility and stool microbiota signatures may help identify preterm infants at increased risk of the disease. Ongoing studies using single or multi-omic approaches may help to characterize biomarkers that will aid in the prediction or early diagnosis of NEC, as well as differentiate other causes of severe bowel injury. Bowel ultrasound shows promise in improving our diagnostic accuracy for NEC but has been slow in adoption. Patient family perspectives are key in accelerating our efforts to integrate newer diagnostic methods into practice.
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Affiliation(s)
- Jae H Kim
- Division of Neonatology, Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Venkatesh Sampath
- Division of Neonatology, Department of Pediatrics, Children's Mercy Hospital, Children's Mercy Research Institute, Kansas City, MO, USA
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15
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Abstract
Progress in our understanding of the pathophysiology, prevention and treatment of necrotizing enterocolitis (NEC) has been hampered for many reasons. Included among these is the fact that what we are calling "NEC" is likely to represent different disease processes, which need to be delineated before evaluating individual pathogenic mechanisms and attempting to develop predictive and diagnostic biomarkers. Treatment is also likely to be hampered because not all of the different entities called "NEC" will respond to the same regimen. In this review, some of these entities will be discussed in more detail, with suggestions for refining our approach toward improving methods for their diagnosis, prevention and treatment.
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Affiliation(s)
- Josef Neu
- Pediatrics/Neonatology, University of Florida, Gainesville, Florida, USA,
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16
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Barreiros Mota I, Marques C, Faria A, Neto MT, Cordeiro-Ferreira G, Virella D, Pita A, Pereira-da-Silva L, Calhau C. Colonisation of the proximal intestinal remnant in newborn infants with enterostomy: a longitudinal study protocol. BMJ Open 2019; 9:e028916. [PMID: 31767579 PMCID: PMC6886948 DOI: 10.1136/bmjopen-2019-028916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The gut microbiota plays a main role in the maintenance of host's health. Exposure to different conditions in early life contributes to distinct 'pioneer' bacterial communities in the intestine, which shape the newborn infant development. Newborn infants with congenital malformations of the gastrointestinal tract (CMGIT), necrotising enterocolitis (NEC) and spontaneous intestinal perforation (SIP) commonly require abdominal surgery and enterostomy. The knowledge about the colonisation of these newborns' intestine by microorganisms is scarce. This protocol is designed to explore the microbial colonisation over time of the proximal intestinal remnant in newborn infants who underwent surgery for CMGIT, NEC or SIP and require enterostomy. METHODS AND ANALYSIS The literature about microbiota colonisation in newborn infants with enterostomy was reviewed and an observational, longitudinal, prospective study was designed. The infants will be recruited at the Neonatal Intensive Care Unit of the Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central. Samples of the enterostomy effluent will be collected every 3 days, through 21 days after the first collection. The microorganisms colonising the proximal intestinal remnant will be identified using the 16S rRNA sequence analysis and a subset of microorganisms will be quantified using real-time PCR. This protocol may serve as basis for future observational and interventional studies on the modulation of the intestinal microbiota (eg, probiotics) on short and long-term outcomes in this population. ETHICS AND DISSEMINATION This study protocol was approved by the Ethics Committee of Centro Hospitalar Universitário de Lisboa Central (441/2017) and by the Ethics Committee of NOVA Medical School, Universidade Nova de Lisboa (n°50/2018/CEFCM). The results will be spread through peer-reviewed publications and presentations at international scientific meetings. TRIAL REGISTRATION NUMBER NCT03340259.
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Affiliation(s)
- Inês Barreiros Mota
- Nutrition and Metabolism, NOVA Medical School | Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
- CINTESIS - Center for Health Technology and Services Research, Porto, Portugal
| | - Cláudia Marques
- Nutrition and Metabolism, NOVA Medical School | Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
- CINTESIS - Center for Health Technology and Services Research, Porto, Portugal
| | - Ana Faria
- Nutrition and Metabolism, NOVA Medical School | Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
- CINTESIS - Center for Health Technology and Services Research, Porto, Portugal
- Comprehensive Health Research Centre, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Maria Teresa Neto
- Neonatal Intensive Care Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- Medicine of Woman, Childhood and Adolescence, NOVA Medical School | Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Gonçalo Cordeiro-Ferreira
- Neonatal Intensive Care Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Daniel Virella
- Neonatal Intensive Care Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- Research Unit, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Ana Pita
- Neonatal Intensive Care Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Luís Pereira-da-Silva
- Neonatal Intensive Care Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- Medicine of Woman, Childhood and Adolescence, NOVA Medical School | Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
- Research Unit, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Conceição Calhau
- Nutrition and Metabolism, NOVA Medical School | Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
- CINTESIS - Center for Health Technology and Services Research, Porto, Portugal
- Unidade Universitária Lifestyle Medicine, José de Mello Saúde by NOVA Medical School, Lisbon, Portugal
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Aviles-Otero N, Kumar R, Khalsa DD, Green G, Carmody JB. Caffeine exposure and acute kidney injury in premature infants with necrotizing enterocolitis and spontaneous intestinal perforation. Pediatr Nephrol 2019; 34:729-736. [PMID: 30415418 DOI: 10.1007/s00467-018-4140-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/06/2018] [Accepted: 11/06/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is common in preterm infants, but specific therapies remain scarce. Recent studies have demonstrated an association between caffeine exposure and less frequent AKI in the first 7-10 days after birth. We hypothesized that patients with necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) would provide a better natural model of AKI to evaluate this association. METHODS We reviewed all premature patients diagnosed with NEC or SIP at our institution from 2008 to 2014. AKI was defined by change in serum creatinine using the neonatal Kidney Disease: Improving Global Outcomes definition. Caffeine was prescribed for apnea of prematurity and caffeine exposure was determined by chart review. RESULTS A total of 146 patients with NEC/SIP were reviewed. Of these, 119 (81.5%) received caffeine, and 91 (62.3%) developed AKI. AKI occurred less frequently in patients who received caffeine than in those who did not (55.5% vs. 92.6%; odds ratio (OR) 0.10; 95% confidence interval (CI) 0.02-0.44). This association persisted in multivariable models after adjustment for potential confounders (adjusted OR 0.08; 95% CI 0.01-0.42; number needed to be exposed to caffeine to prevent one case of AKI = 2.6). Although baseline serum creatinine did not differ by caffeine exposure, patients receiving caffeine had lower peak creatinine (median 1.0 mg/dl vs. 1.5 mg/dl; p = 0.008) and absolute creatinine change (median 0.42 mg/dl vs. 0.68 mg/dl; p = 0.003) than those who did not. CONCLUSIONS Caffeine exposure in preterm infants with NEC/SIP is associated with decreased incidence and severity of AKI.
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Affiliation(s)
- Noelia Aviles-Otero
- Department of Pediatrics, Division of Neonatology, University of Virginia, Charlottesville, VA, USA
| | - Reeti Kumar
- Department of Pediatrics, Division of Nephrology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dev Darshan Khalsa
- Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Glen Green
- Department of Pediatrics, Division of Neonatology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - J Bryan Carmody
- Department of Pediatrics, Division of Nephrology, Eastern Virginia Medical School, 601 Children's Lane, Norfolk, VA, 23507, USA.
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