Neonatal liver disease

Antenatally detected liver and biliary pathology

Liver and biliary pathology in the neonate are rare and include a broad range of structural, neoplastic, infectious, genetic, and metabolic diseases. While most conditions present postnatally, antenatal detection is increasing given recent advances in antenatal imaging capabilities. In certain structural or obstructive liver diseases, antenatal detection now proves essential to help guide treatment and prevent morbidity. We review the epidemiology, pathophysiology, common antenatal diagnostic findings, and recommendations for surgical liver and biliary pathology in the neonate.

Successful Outcome and Biliary Drainage in an Infant with Concurrent Alpha-1-Antitrypsin Deficiency and Biliary Atresia

We describe the rare instance of concomitant biliary atresia and alpha-1-antitrypsin deficiency and the first documented successful portoenterostomy in this scenario. The potential for dual pathology must be recognized and underscores that prompt diagnosis of biliary atresia, despite concomitant alpha-1-antitrypsin deficiency, is essential to afford potential longstanding native liver function.

Cholestasis in Infancy

Jaundice is a key manifestation of hepatobiliary disease in all age groups. Jaundice is a common finding in the first 2 weeks after birth, occurring in 2.4% to 15% of newborns. The neonatal liver is at increased susceptibility to cholestasis, with an incidence ranging from 1 in 2,500 to 1 in 5,000 live births. Etiologies vary, but the most common is biliary atresia. In 2004, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition published guidelines for the evaluation of cholestasis that clearly stated any infant with jaundice persisting beyond age 2 weeks (3 weeks in breast-fed infants with an otherwise normal history and physical examination) should be evaluated with a fractionated serum bilirubin level. Prompt evaluation, diagnosis, and intervention are vital to optimize timely intervention and improve clinical outcomes. This article discusses the etiology, diagnosis and evaluation of cholestatis in infants. [Pediatr Ann. 2016;45(12):e414-e419.].

Incidence and Risk Factors of Parenteral Nutrition-Associated Cholestasis in Omani Neonates: Single centre experience

OBJECTIVES

Parenteral nutrition-associated cholestasis (PNAC) is one of the most challenging complications of prolonged parenteral nutrition (PN) in neonates. There is a lack of research investigating its incidence in newborn infants in Oman and the Arab region. Therefore, this study aimed to assess the incidence of PNAC and its risk factors in Omani neonates.

METHODS

This retrospective study took place between January and April 2014. All neonates who received PN for ≥14 days during a four-year period (June 2009 to May 2013) at the neonatal intensive care unit (NICU) in Sultan Qaboos University Hospital, Muscat, Oman, were enrolled.

RESULTS

A total of 1,857 neonates were admitted to the NICU over the study period and 135 neonates (7.3%) received PN for ≥14 days. Determining the incidence of PNAC was only possible in 97 neonates; of these, 38 (39%) had PNAC. The main risk factors associated with PNAC were duration of PN, duration of enteral starvation, gastrointestinal surgeries, blood transfusions and sepsis. Neonates with PNAC had a slightly higher incidence of necrotising enterocolitis in comparison to those without PNAC.

CONCLUSION

This study found a PNAC incidence of 39% in Omani neonates. There were several significant risk factors for PNAC in Omani neonates; however, after logistic regression analysis, only total PN duration remained statistically significant. Preventive strategies should be implemented in NICUs so as to avoid future chronic liver disease in this population.

Multidrug-resistant Acinetobacter baumannii infection among neonates in a neonatal intensive care unit at a medical center in central Taiwan

BACKGROUND

Few studies have focused on multidrug-resistant Acinetobacter baumannii (MDRAB) infection in neonates. The aim of this study was to investigate risk factors for mortality in neonates with MDRAB infection.

METHODS

This retrospective case-series study was conducted at the Children's Hospital of China Medical University, Taichung, Taiwan. All patients hospitalized between January 2010 and December 2013 in the neonatal intensive care unit (NICU) with MDRAB infections were reviewed.

RESULTS

A total of 67 isolates from 59 neonatal patients were positive for MDRAB. Of the 67 isolates, 38 were from blood (56.72%), 16 from sputum (23.88%), seven from pus (10.45%), three from ascites (4.48%), two from cerebrospinal fluid (2.99%), and one from pleural fluid (1.49%). There were five episodes of MDRAB clusters consisting of 28 cases during the study period. The mortality rate due to MDRAB sepsis was 20.34% (12/59). The statistically significant risk factors for mortality due to MDRAB infection were being infected with MDRAB within 7 days of admission to the NICU, use of umbilical vein catheters, absolute neutrophil count < 1500/mm(3), platelet count < 100,000/mm(3), and a delay in initiating adequate antibiotic treatment.

CONCLUSION

MDRAB infection is responsible for a high mortality rate among neonates in the NICU, especially in those who have neutropenia or thrombocytopenia. Infection control and appropriateness of the initial antimicrobial agent with colistin play an important role in reducing mortality.

Common misdiagnoses of biliary atresia

OBJECTIVES

Discrimination of biliary atresia (BA) from other causes of neonatal cholestasis (NC) is challenging. We aimed to analyze the clinicopathological findings in cholestatic infants who were provisionally diagnosed with BA and then excluded by intraoperative cholangiography compared with those with a definitive diagnosis of BA and to shed light on common misdiagnoses of BA.

METHODS

We retrospectively analyzed the data of infants diagnosed preoperatively with BA and referred to surgery between the years 2009 and 2013. On the basis of intraoperative cholangiography results, infants were divided into those with a definitive diagnosis of BA and those misdiagnosed with BA.

RESULTS

Out of 147 infants, there was a misdiagnosis of BA in 10 (6.8%) infants. Alanine transaminase was significantly higher in the non-BA group, whereas other clinical and laboratory findings were comparable in both groups. Hepatomegaly and abnormal gallbladder in ultrasound, and ductular proliferation and advanced grades of portal fibrosis in liver biopsy were significantly higher in infants with BA. However, giant cells were more common in the non-BA infants. Nonetheless, the frequency of clay stool, hepatomegaly, abnormal gallbladder, ductular proliferation, and advanced portal fibrosis was remarkable (100, 70, 40, 70, and 50%, respectively) in the misdiagnosed infants. The misdiagnoses were idiopathic neonatal hepatitis, progressive familial intrahepatic cholestasis type 3, cytomegalovirus hepatitis, Alagille syndrome, and a cholangitic form of congenital hepatic fibrosis.

CONCLUSION

A meticulous preoperative workup should be performed to exclude other causes of NC even if signs of BA are present, especially if features such as giant cells in histopathology are present. This involves completing the NC workup in parallel involving all common causes of NC rather than performing them in series to avoid loss of valuable time and efforts.

Impact of standardized feeding guidelines on enteral nutrition administration, growth outcomes, metabolic bone disease, and cholestasis in the NICU

OBJECTIVES

The objectives of this study were to determine whether the implementation of standardized feeding guidelines (SFGs) in a neonatal intensive care unit had an impact on the administration of enteral nutrition, growth, and bone and liver health.

METHODS

This was a retrospective chart review of infants ≤ 32 weeks' gestation and ≤ 1500 g at birth who received enteral nutrition either via traditional care (TC) or via SFGs. The outcomes of the study were to determine the day of life the first enteral feedings were started, the day of life full, fortified enteral feedings were established, the day of life the infant returned to birth weight, the change in weight z score from birth to day of life 30, and the presence of metabolic bone disease and cholestasis.

RESULTS

There were 128 infants in the TC group and 125 infants in the SFG group. Based on the Cox regression, no significant differences were found between the 2 groups in the length of time to the first feed (P=0.110; CI 1.03-1.70), in the length of time to full, fortified enteral feedings (P=0.334; CI 0.87-1.44), in the length of time to return to birth weight (P=0.545; CI 0.77-1.28), incidence of metabolic bone disease (P=0.990), or incidence of cholestasis (P=0.926).

CONCLUSIONS

This study provides preliminary evidence that SFGs have an effect on enteral nutrition administration, growth, and morbidity for preterm infants. Although the findings were not statistically significant, they are clinically relevant.

Case-control analysis of endemic Acinetobacter baumannii bacteremia in the neonatal intensive care unit

BACKGROUND

We aimed to characterize the clinical manifestations and outcomes of patients with Acinetobacter baumannii bacteremia in the neonatal intensive care unit (NICU).

METHODS

All patients with A baumannii bacteremia in our NICU from 2004 to 2010 were reviewed. A matched case-control study was performed by comparing each case of A baumannii to 2 uninfected controls and all cases of Escherichia coli and Klebsiella bacteremia, respectively.

RESULTS

Thirty-seven cases with A baumannii bacteremia were identified. Multidrug-resistant isolate was noted in only 2 cases (5.4%), and the overall mortality rate was 8.1%. Compared with matched, uninfected controls, infants with A baumannii were more likely to have had a central vascular catheter (CVC) (P = .009), use of total parenteral nutrition (TPN) (P = .021), longer duration of ventilator use (P = .002), and hospitalization (P = .010). Compared with E coli or Klebsiella bacteremia, infants with A baumannii bacteremia had lower birth weight (median of 1,090 g vs 1,300 g, P = .044) and a higher rate of CVC and TPN use (both P < .001) at the time of infection.

CONCLUSION

A baumannii bacteremia occurs endemically or sporadically in the NICU, primarily in low-birth-weight infants on TPN use and with CVC in situ. Although A baumannii does not often cause mortality, and multidrug-resistant A baumannii is uncommon, it contributes significantly to longer hospitalization.

Value of hepatic subcapsular flow by color Doppler ultrasonography in the diagnosis of biliary atresia

BACKGROUND AND AIM

Diagnosis of biliary atresia (BA), particularly distinguishing it from other causes of neonatal cholestasis (NC), is challenging. Ultrasonography is a helpful investigation when evaluating NC. The aim was to determine the value of color Doppler ultrasound, particularly hepatic subcapsular flow, as a possible tool in early discrimination of BA from other causes of NC.

METHODS

Ultrasonographic and color Doppler findings of 27 BA patients were compared with that in 27 non-BA cholestasis patients and a control group of 22 non-hepatic neonates.

RESULTS

Hepatic artery diameter was significantly higher in BA (2.48 ± 0.55 mm) than that in non-BA group (1.91 ± 0.63 mm) (P = 0.001) and the control group (1.6 ± 0.47 mm) (P < 0.0001), while there were no statistically significant difference between BA and non-BA groups as regards portal vein diameter and flow, hepatic vein flow, and hepatic artery resistance index. The frequency of hepatic subcapsular flow was significantly higher in BA than that in non-BA group (96.3% vs 3.7%; P < 0.0001), while it was not detected in any of the non-hepatic control group. The presence of hepatic subcapsular flow had 96.3% sensitivity and specificity in predicting BA.

CONCLUSIONS

Color Doppler ultrasound findings could help significantly in discriminating BA from other causes of NC, among which hepatic subcapsular flow had the best performance. Considering the young age of BA patients (61.8 ± 15.1 days), hepatic subcapsular flow can help in early diagnosis of BA and prevent the delay in surgical correction.

Early detection of minor neurodevelopmental dysfunctions at age 6 months in prematurely born neonates

OBJECTIVE

To investigate the 6-month neurodevelopmental outcomes of prematurely born neonates and find the determining neonatal factors of minor neurological dysfunctions (MNDs).

STUDY DESIGN

We examined data collected prospectively on 151 infants born before 37th week of gestation in 2009-2010 who were assessed at 6 months corrected age with the Bayley Scales of Infant Development-2nd Edition (BSID-II) and the Denver Developmental Screening Test (DDST).

RESULTS

Of 151 neonates born before 37 weeks, 20 (13.2%) had MNDs at 6 months corrected age. These proportions were 21.6%, 13.2%, and 8.2% for neonates born before 28 weeks, 29 weeks to 32 weeks, and 33 weeks to 36 weeks, respectively. Half of neonates with MNDs have a birth body weight of less than 1000g. BSID-II and DDST are highly correlated in assessing the MNDs of premature neonates at 6 months corrected age. MND was independently associated with postnatal corticosteroid use (odds ratio [OR], 11.2; 95% confidence interval [CI], 1.9-66.0, P=0.008) and cholestasis (OR, 6.2; 95% CI, 1.16-33.1, P=0.033).

CONCLUSIONS

Premature neonates, even those born at 33 to 36 weeks, are found to have MNDs as early as 6 months corrected age by BSID-II and DDST, with risk increasing as gestation decreases.

Biliary atresia: 50 years after the first kasai

Biliary atresia is a rare neonatal disease of unknown etiology, where obstruction of the biliary tree causes severe cholestasis, leading to biliary cirrhosis and death in the first years of life, if the condition is left untreated. Biliary atresia is the most frequent surgical cause of cholestatic jaundice in neonates and should be evoked whenever this clinical sign is associated with pale stools and hepatomegaly. The treatment of biliary atresia is surgical and currently recommended as a sequence of, eventually, two interventions. During the first months of life a hepatoportoenterostomy (a "Kasai," modifications of which are discussed in this paper) should be performed, in order to restore the biliary flow to the intestine and lessen further damage to the liver. If this fails and/or the disease progresses towards biliary cirrhosis and life-threatening complications, then liver transplantation is indicated, for which biliary atresia represents the most frequent pediatric indication. Of importance, the earlier the Kasai is performed, the later a liver transplantation is usually needed. This warrants a great degree of awareness of biliary atresia, and the implementation of systematic screening for this life-threatening pathology.

Deletion of clock gene Per2 exacerbates cholestatic liver injury and fibrosis in mice

The Period 2 (Per2) gene is an important component of the circadian system and is thought to modulate many physiological and pathological processes in mammals. In the previous study, we have disclosed the protective role of Per2 against carbon tetrachloride induced liver injury and fibrosis. Here we further assess the effect of Per2 deficiency on cholestatic hepatic injury and fibrosis. Cholestasis was induced by bile duct ligation (BDL) for 10 days in wild-type (WT) and Per2(-/-) mice. Masson trichrome staining and analysis of α-SMA immunohistochemistry were performed to show the collagen accumulation and the HSC activation, respectively. The mRNA levels of fibrosis-related genes were monitored by quantitative real-time PCR. Following BDL, livers from Per2(-/-) mice exhibited markedly increased extent of bile infarct and extracellular matrix (ECM) deposition compared with WT mice. Furthermore, the expressions of fibrosis-related genes like TNF-α, TGF-β1, Col1α1 and TIMP-1 were dramatically elevated in Per2(-/-) cholestatic liver. Our observations indicated that clock gene Per2 plays a protective role in mediating liver injury and fibrosis during cholestasis.

Short-term use of parenteral nutrition with a lipid emulsion containing a mixture of soybean oil, olive oil, medium-chain triglycerides, and fish oil: a randomized double-blind study in preterm infants

BACKGROUND

For premature neonates needing parenteral nutrition (PN), a balanced lipid supply is crucial. The authors hypothesized that a lipid emulsion containing medium-chain triglycerides (MCTs) and soybean, olive, and fish oils would be as safe and well tolerated as a soybean emulsion while beneficially influencing the fatty acid profile.

METHODS

Double-blind, controlled study in 53 neonates (<34 weeks' gestation) randomized to receive at least 7 days of PN containing either an emulsion of MCTs and soybean, olive, and fish oils or a soybean oil emulsion. Target lipid dosage was 1.0 g fat/kg body weight [BW]/d on days 1-3, 2 g/kg BW/d on day 4, 3 g/kg BW/d on day 5, and 3.5 g/kg BW/d on days 6-14.

RESULTS

Test emulsion vs control, mean ± SD: baseline triglyceride concentrations were 0.52 ± 0.16 vs 0.54 ± 0.19 mmol/L and increased similarly in both groups to 0.69 ± 0.38 vs 0.67 ± 0.36 on day 8 of treatment (P = .781 for change). A significantly higher decrease in total and direct bilirubin vs baseline was seen in the test group compared with the control group P < .05 between groups). In plasma and red blood cell phospholipids, eicosapentaenoic acid and docosahexaenoic acid were higher, and the n-6/n-3 fatty acid ratio was lower in the test group (P < .05 vs control).

CONCLUSIONS

The lipid emulsion, based on a mixture of MCTs and soybean, olive, and fish oils, was safe and well tolerated by preterm infants while beneficially modulating the fatty acid profile.

Paediatric cholestatic liver disease: Diagnosis, assessment of disease progression and mechanisms of fibrogenesis

Cholestatic liver disease causes significant morbidity and mortality in children. The diagnosis and management of these diseases can be complicated by an inability to detect early stages of fibrosis and a lack of adequate interventional therapy. There is no single gold standard test that accurately reflects the presence of liver disease, or that can be used to monitor fibrosis progression, particularly in conditions such as cystic fibrosis. This has lead to controversy over how suspected liver disease in children is detected and diagnosed. This review discusses the challenges in using commonly available methods to diagnose hepatic fibrosis and monitor disease progression in children with cholestatic liver disease. In addition, the review examines the mechanisms hypothesised to be involved in the development of hepatic fibrogenesis in paediatric cholestatic liver injury which may ultimately aid in identifying new modalities to assist in both disease detection and therapeutic intervention.

Biliary atresia: color doppler US findings in neonates and infants

PURPOSE

To describe color Doppler ultrasonographic (US) findings in livers of neonates with biliary atresia (BA) and to compare them with US findings in livers of neonates with non-BA and control subjects.

MATERIALS AND METHODS

Institutional review board approval was obtained; acquisition of informed consent was exempted. US and color Doppler US findings were retrospectively reviewed in 64 patients with neonatal cholestasis and 19 control subjects. BA and non-BA were confirmed in 29 and 35 patients, respectively. Three pediatric radiologists assessed US and color Doppler US images, independently documented their findings, and resolved discrepancies by consensus. Triangular cord (TC) sign, gallbladder length, and hepatic artery and portal vein diameters were evaluated on US images. The presence of hepatic subcapsular flow was evaluated on color Doppler US images. Diagnostic value of TC sign and hepatic subcapsular flow in the diagnosis of BA were evaluated. Significance of hepatic artery and portal vein diameters in each group was assessed.

RESULTS

In the diagnosis of BA, sensitivity and specificity of the TC sign on US images were 62% and 100%, respectively. On color Doppler US images, hepatic subcapsular flow was detected in all patients with BA and in five patients with non-BA. At the first review, there was a discrepancy between radiologists in interpretation of hepatic subcapsular flow in patients with non-BA. However, consensus was reached at the second review. There was no hepatic subcapsular flow in control subjects. Sensitivity and specificity of hepatic subcapsular flow on color Doppler US images were 100% and 80%-86%, respectively, on the basis of individual interpretations of reviewers. Sensitivity and specificity of hepatic subcapsular flow on color Doppler US images were 100% and 86%, respectively, on the basis of consensus reading. Mean diameter of the hepatic artery in patients with BA (2.1 mm +/- 0.7 [standard deviation]) was significantly larger than that in patients with non-BA (1.5 mm +/- 0.4, P < .001) and control subjects (1.5 mm +/- 0.4, P = .001).

CONCLUSION

The presence of hepatic subcapsular flow is useful for differentiating between BA and other causes of neonatal jaundice.

TRAIL mediates liver injury by the innate immune system in the bile duct-ligated mouse

The contribution of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), a death ligand expressed by cells of the innate immune system, to cholestatic liver injury has not been explored. Our aim was to ascertain if TRAIL contributes to liver injury in the bile duct-ligated (BDL) mouse. C57/BL6 wild-type (wt), TRAIL heterozygote (TRAIL(+/-)), and TRAIL knockout (TRAIL(-/-)) mice were used for these studies. Liver injury and fibrosis were examined 7 and 14 days after BDL, respectively. Hepatic TRAIL messenger RNA (mRNA) was 6-fold greater in BDL animals versus sham-operated wt animals (P < 0.01). The increased hepatic TRAIL expression was accompanied by an increase in liver accumulation of natural killer 1.1 (NK 1.1)-positive NK and natural killer T (NKT) cells, the predominant cell types expressing TRAIL. Depletion of NK 1.1-positive cells reduced hepatic TRAIL mRNA expression and serum alanine aminotransferase (ALT) values. Consistent with a role for NK/NKT cells in this model of liver injury, stress ligands necessary for their recognition of target cells were also up-regulated in hepatocytes following BDL. Compared to sham-operated wt mice, BDL mice displayed a 13-fold increase in terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) and an 11-fold increase in caspase 3/7-positive hepatocytes (P < 0.01). The number of TUNEL and caspase 3/7-positive cells was reduced by >80% in BDL TRAIL knockout animals (P < 0.05). Likewise, liver histology, number of bile infarcts, serum ALT values, hepatic fibrosis, and animal survival were also improved in BDL TRAIL(-/-) animals as compared to wt animals.

CONCLUSION

These observations support a pivotal role for TRAIL in cholestatic liver injury mediated by NK 1.1-positive NK/NKT cells.

Alpha-1 antitrypsin deficiency: pathogenesis, clinical presentation, diagnosis, and treatment

Alpha-1 antitrypsin deficiency is an inherited disease affecting the lung and liver. The typical pulmonary manifestation is chronic obstructive pulmonary disease and emphysema. Severe chronic obstructive pulmonary disease may occur in young adulthood, and terminal respiratory insufficiency causes premature death in many patients. In the liver, alpha-1 antitrypsin deficiency may manifest as benign neonatal hepatitis syndrome; a small percentage of adults develop liver fibrosis, with progression to cirrhosis and hepatocellular carcinoma. The alpha-1 antitrypsin molecule is a serine protease inhibitor that is predominantly produced in the liver. Its most important physiologic functions are the protection of pulmonary tissue from aggressive proteolytic enzymes and regulation of pulmonary immune processes. Diagnosis of alpha-1 antitrypsin deficiency can be established by measurement of the serum alpha-1 antitrypsin concentration or by genetic analysis. Treatment is similar to the usual treatment for patients with chronic obstructive pulmonary disease. A further option is substitution therapy with human alpha-1 antitrypsin. The targets of treatment are the prevention of the accelerated decline of pulmonary function, reduction of lung infections, and improvements in exercise capacity.