Single Nucleotide Polymorphisms in Neonatal Necrotizing Enterocolitis

The etiopathogenesis of necrotizing enterocolitis (NEC) remains unclear, but increasing information suggests that the risk and severity of NEC may be influenced by single nucleotide polymorphisms in many genes. In this article, we have reviewed gene variations that have either been specifically identified in NEC or have been noted in other inflammatory bowel disorders with similar histopathological abnormalities. We present evidence from our own peer-reviewed laboratory studies and data from an extensive literature search in the databases PubMed, EMBASE, and Scopus. To avoid bias in the identification of existing studies, search keywords were short-listed both from our own studies and from PubMed's Medical Subject Heading (MeSH) thesaurus.

Correlation of systemic immune-inflammation Index with surgical necrotizing enterocolitis

BACKGROUND

Systemic Immune-Inflammation Index (SII), known as an easy, economical and useful marker, correlates with the severity of inflammatory response. However, the usefulness of SII in necrotizing enterocolitis (NEC) remains unclear. Therefore, we evaluated the correlation of SII at NEC diagnosis and subsequent surgery.

METHODS

Retrospective review of 131 neonates with NEC in a tertiary-level pediatric referral hospital was conducted with assessments of demographic data, general blood examination results at NEC diagnosis, treatment strategies and clinical outcomes. The receiver operating characteristic (ROC) curve determined the optimal cut-off values of SII, platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio. Univariate/multivariate logistic regression analysis and ROC curve were conducted to evaluate the predictive significance of SII in identifying the patients who eventually received surgery. Additionally, NEC-related deaths were assessed.

RESULTS

Overall, 49 (37.4%) cases received surgical intervention and mortality was 12.3% (14/131). The area under ROC curve of SII at NEC diagnosis to predict subsequent surgery was 0.833 (optimal cut-off value: 235.85). The SII value in surgical intervention group was significantly higher than that in medical treatment group (332.92 ± 158.52 vs. 158.84 ± 106.82, P < 0.001). Independent influencing factors for surgical NEC were SII (95% confidence interval [CI]: 4.568∼36.449, odds ratio [OR]:12.904, P < 0.001) and PLR (95% CI: 1.071∼7.356, OR:2.807, P = 0.036). SII ≤ 235.85 could identify patients at high risk for surgery, with 87.76% sensitivity, 73.17% specificity, outperformed PLR. Furthermore, mortality was significantly higher in patients with SII ≤ 235.85 than those with SII > 235.85 (20.0% vs. 1.5%, P < 0.001).

CONCLUSION

SII and PLR at NEC diagnosis were independent influencing factors for subsequent surgery. SII ≤ 235.85 may be a useful predictive marker for the identification of surgical NEC and mortality.

Prediction of necrotizing enterocolitis in very low birth weight infants by superior mesenteric artery ultrasound of postnatal day 1: A nested prospective study

BACKGROUND

Necrotizing enterocolitis (NEC) is a devastating intestinal complication that occurs mainly in very-low-birth-weight infants (VLBWI). The study's aim was to investigate the possibility of early prediction of NEC on postnatal day 1 based on superior mesenteric artery (SMA) doppler ultrasonograpy.

METHODS

A prospective, observational, nested case control study (ChiCTR1900026197) was conducted to enroll VLBWIs (birth weight <1,500 grams) between October 2019 and September 2021. Doppler ultrasound measurement was done during the first 12 h of life and before first feeding. Infants developing NEC (stage II or III) subsequently were included in NEC group and infants spare of NEC were included in control group.

RESULTS

370 VLBWIs were enrolled (30 NEC cases). Among the ultrasound parameters, S/D was significantly higher in the NEC group (OR: 2.081, 95% CI: 1.411-3.069, P = 0.000). The area under the receiver operating curve (AUROC) following the Logistic regression was 0.704 (95% CI: 0.566-0.842, P = 0.001). The sensitivity of S/D for predicting NEC was 52.2% and the specificity was 92.7%. The critical value of S/D was 6.944 and Youden index was 0.449. Preplanned subgroup analysis confirmed that NEC infants of different stages were characterized by different SMA bloodstream. Small for gestational age (SGA) might be a confounding factor affecting intestinal bloodflow. And infants with delayed initiation or slow advancement of feeding exhibited characteristic intestinal perfusion.

CONCLUSIONS

In VLBWI, early SMA ultrasound shows the potential to predict NEC. It is reasonable to speculate that SMA bloodstream is related to intestinal structural and functional integrity.

Premature Infants have no Higher Risk of Atopy and Respiratory Functions Compared to Control at 4-6 Years of Age

AIMS

This study aimed to evaluate the respiratory functions and atopy conditions of preterm infants treated with aminophylline or caffeine for apnea in NICU in early childhood.

MATERIALS AND METHODS

This is a retrospective cohort study. In this study, 27 patients aged 4 to 6 years hospitalized in NICU for prematurity and 26 healthy children were included. The subjects were evaluated for fx5, phadiatope, total IgE levels, skin tests, and respiratory function tests.

RESULTS

There was no statistically significant difference among groups in terms of fx5, phadiatope, total IgE levels, and skin test results. Moreover, no statistically significant difference was found among the groups in terms of FVC, FEV₁, FEV₁/ FVC, PEF, MEF₇₅, MEF₅₀, MEF₂₅, and MEF_25-75 values in respiratory function tests. Preterm neonates with bronchopulmonary dysplasia (BPD) had higher FEV₁ values compared to ones without BPD (p=0.02).

CONCLUSION

Preterm infants treated with aminophylline or caffeine did not have a higher risk of atopy and had similar respiratory function tests compared to healthy infants at 4-6 years old. However, FEV₁ values were higher in infants with BPD. These results suggested that respiratory functions could be affected in the long-term follow-up of premature infants with BPD.

Analysis of Factors Influencing Outcomes in Preterm Infants With Necrotizing Enterocolitis

BACKGROUND

To explore the surgical outcomes between patients with perforated and non-perforated neonatal necrotizing enterocolitis (NEC) and identify indications for surgical intervention.

METHODS

The surgical outcomes of 271 children with NEC admitted to the Seventh Medical Center of Chinese PLA General Hospital between August 2009 and August 2020 were retrospectively analyzed. The patients were divided into the non-perforated and perforated groups. The preoperative factors, including gestational age, birth weight, intrauterine infection, cholestasis, platelet change, white blood cell count, and C-reactive protein level were compared between the two groups, along with postoperative factors including infection status, complications, enteral and parenteral nutrition time, ICU time, ventilator use time, and intestinal necrosis length. Bell staging was performed for the two groups and the mortality of different Bell stages was explored. The risk of death and predisposing factors of patients with NEC were analyzed.

RESULTS

In total, 271 children undergoing surgery were included in this study. A total of 188 children were observed without perforation, including 57 deaths (30.3%), and 83 children with perforation, including 24 deaths (28.9%). Preoperative cholestasis and time from NEC diagnosis to surgery were significantly different between the two groups (P < 0.05). Postoperative factors, including parenteral nutrition time (32 [3-94] days vs. 23 [1-53] days), enteral nutrition time (27 [0-86] days vs. 18 [0-81] days), NICU time (44 [5-125] days vs. 29 [1-92] days), and length of intestinal necrosis (15 [0-92] cm vs. 10 [2-70] cm), were significant. The mortality rate of patients with Bell stage IIIA was higher than that of patients with Bell stage IIIB. A total of 81 patients had 30-day postoperative mortality (57 non-perforated cases). Multivariate Cox regression analysis showed that non-perforation was a poor prognostic factor for survival outcome (hazard ratio 2.288, 95% confidence interval [1.329-3.940], P = 0.003).

CONCLUSIONS

Preterm infants in the non-perforated group had more serious complications and had a longer recovery time after surgery. Bell staging is not accurate in diagnosing severe NEC that needs surgical intervention.

Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective

Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.

Abnormalities in microbial composition and function in infants with necrotizing enterocolitis: A single-center observational study

OBJECTIVE

To investigate the features and functions of the intestinal microbiota in neonates with necrotizing enterocolitis (NEC) in a single center in China.

METHODS

We collected clinical information and stool samples from 19 participants in our center, including 9 infants with necrotizing enterocolitis and 10 control infants. DNA was extracted from the samples, and 16S rRNA gene sequencing was used to analyse the participants' gut microbiota. Functional prediction was achieved using PICRUSt2.

RESULTS

Alpha diversity analysis found that similar levels of bacterial richness and diversity were found in the gut microbiota of infants with NEC and control infants (P = 0.1800), whereas beta diversity analysis suggested that the overall structures of the gut microbiota were significantly different (P = 0.0020). The Mann-Whitney U test of bacterial composition and abundance analysis revealed that the abundance levels of Proteobacteria (P = 0.03049) and Firmicutes (P = 0.01011) significantly differed between the two groups at the phylum level. Proteobacteria was the most abundant phylum in the NEC group. At the genus level, the abundance levels of Enterococcus (P = 0.0003), Streptococcaceae (P = 0.0109) and Lactobacillales (P = 0.0171) were significantly decreased in infants with NEC. Furthermore, the linear discriminant analysis effect size (LEfSe) method showed 12 bacterial taxa with significant differences in relative abundances in the two groups. Interestingly, members of Proteobacteria were enriched in NEC samples. In addition, functional prediction suggested that the microbial changes observed in infants with NEC resulted in a decline in galactose metabolism, the pentose phosphate pathway, fructose and mannose metabolism, amino sugar and nucleotide sugar metabolism, glycolysis/gluconeogenesis, starch and sucrose metabolism, and phosphotransferase system (PTS) pathways (P < 0.05).

CONCLUSIONS

Our study shows the compositional and functional alterations of the intestinal microbiota in NEC, which will help demonstrate the relationship between the gut microbiota and NEC pathogenesis.

The Outcome of Late versus Early Ileostomy Closure at Low Body Weight (<1500 g) in Babies with Necrotizing Enterocolitis

AIM

The aim of this study is to determine the surgical outcome of ileostomy closure at low body weight (<1500 g) and to find any differences in complications and growth of infants whose ileostomy was reversed early (4-6 weeks) versus late (8-10 weeks).

METHODS

A prospective comparative study was conducted on patients who underwent ileostomy reversal created for necrotizing enterocolitis from January 2017 to December 2019. The patients were divided into two groups: group 1 (early ileostomy closure) between 4 and 6 weeks and Group 2 (late closure) between 8 and 10 weeks. The primary outcome was expressed as the presence of anastomotic leak, obstruction, perforation, wound infection, sepsis, and death.

RESULTS

A cohort of 31 patients with 16 patients in Group 1 and 15 in Group 2 were studied. The mean duration between ostomy creation and reversal was 5.1 ± 0.63 weeks in Group 1 and 8.9 ± 0.66 weeks in Group 2. The mean weight at reversal was 1435.5 ± 163.8 g for patients in Group 1 and 1405 ± 99.93 g for patients in Group 2. Weight gain at 90 days in Group 1 was 895 ± 85.2 g and in Group 2 was 455 ± 34.6 g, which was statistically significant (P < 0.00001). Parenteral nutrition, ability to reach full enteral nutrition, and total ventilator days, mortality rate, and complications were not statistically different between the groups. The overall survival rate was 87.27%.

CONCLUSIONS

Ileostomy reversal at a lower weight and within 6 weeks was not associated with an increased risk of complications. Early stoma reversal may help in weight gain.

Association between glial fibrillary acidic protein, glial-derived neurotrophic factor, and fatty acid-binding protein-2 at birth in the incidence of necrotizing enterocolitis in preterm infants

BACKGROUND

This study aimed to analyze the relationship between glial fibrillary acidic protein (GFAP), glial-derived neurotrophic factor (GDNF), and fatty acid-binding protein-2 (FABP-2) in preterm infants on the incidence of NEC.

METHODS

Preterm infants with a birth weight <1,500 g and gestational age <34 weeks were included in this study. Biomarker examination was performed using the umbilical vein blood at birth (first sample). Biomarker examination was repeated if the infant developed symptoms of NEC using peripheral vein blood (second sample). Infants were observed for 14 days. If NEC did not exist, a biomarker examination was performed at 14 days.

RESULTS

This study included 30 preterm infants, nine infants experienced NEC. The values of GFAP, GDNF, and FABP-2 (median and range) in the group with NEC were higher than those in the group without NEC in both the first samples {GFAP [1.40 (0.20-6.50) vs. 0.30 (0.10-1.30) P = 0.014], GDNF [2.84 (1.05-14.11) vs. 1.56 (1.07-3.48) P = 0.050], and FABP-2 [621.70 (278.40-2,207.00) vs. 294.20 (211.40-597.50) P = 0.002]} and second samples {GFAP [2.40 (0.30-3.10) vs. 0.30 (0.10-0.60) P = 0.003], GDNF [2.99 (0.56-10.30) vs. 1.46 (0.85-2.24) P = 0.019], and FABP-2 [646.8 (179.20-1,571.00) vs. 314.90 (184.70-521.60) P = 0.040]}. In infants with NEC, the median values of GFAP [2.40 (0.30-3.10) vs. 1.40 (0.20-6.50) P = 0.767], GDNF [2.99 (0.56-10.30) vs. 2.84 (1.05-14.11) P = 0.859], and FABP-2 [646.80 (179.20-1,571.00) vs. 621.70 (278.40-2,207.00) P = 0.953] in the second sample were higher than those in the first sample. Logistic regression demonstrated that GFAP at birth (Odds Ratio [OR] = 15.629, 95% Confidence Interval [CI] = 1.697-143.906, P = 0.015) and FABP-2 levels at birth (OR = 1.008, 95% CI = 1.001-1.015, P = 0.033) were significantly associated with an increased risk of NEC.

CONCLUSION

Increased GFAP, GDNF, and FABP-2 at birth are associated with NEC occurrence within two weeks of birth. These findings suggest that early-onset NEC is associated with intestinal injury that occurs during the perinatal or even prenatal period.

Prolonged antibiotic therapy increased necrotizing enterocolitis in very low birth weight infants without culture-proven sepsis

OBJECTIVES

We aimed to identify the factors associated with necrotizing enterocolitis (NEC) and to assess the associations of the initial empirical antibiotic therapy (IEAT) duration and antibiotic therapy duration/hospital stay ratio (A/H ratio) before NEC with subsequent NEC in very low birth weight (VLBW) infants with gestational age less than 32 weeks without proven sepsis.

METHODS

A retrospective study was conducted at the NICU of the First Affiliated Hospital of Medical University of Anhui province from June 2015 to May 2022, and 567 VLBW infants with gestational age less than 32 weeks were included in the study. We divided the VLBW infants into those with and without NEC according to modified Bell's criteria. We then used descriptive statistics to identify the factors associated with NEC and multivariate analyses to evaluate the associations of IEAT duration and A/H ratio with the occurrence of NEC.

RESULTS

Of the 567 VLBW neonates admitted to our center, 547 survived and reached the normal discharge criteria. Fifty-one infants (8.99%) were diagnosed as showing NEC. Infants with NEC had a longer total parenteral nutrition time, total enteral nutrition time, and IEAT duration, as well as a higher A/H ratio than those without NEC. In multivariate analyses adjusted for the other factors, IEAT duration was associated with an increased odds of NEC [odds ratio (OR) = 1.267; 95% confidence interval (CI), 1.128-1.423], and the A/H ratio was also associated with increased odds of NEC (OR = 8.718; 95% CI, 2.450-31.030). For the A/H ratio, the area under the curve (AUC) was 0.767 and the ideal cutoff was 0.357, and the sensitivity and specificity were 0.843 and 0.645, respectively.

CONCLUSION

Prolonged antibiotic therapy may increase the risk of NEC in VLBW infants with a gestational age of fewer than 32 weeks and should be used with caution.

NEC in Infancy Is NEC for Life

Necrotizing enterocolitis (NEC) in the NICU does not stay in the NICU. Infants are often discharged with little concern long term, yet that is not true. Meet Linseigh, a former NICU patient who was full-term at birth and was ultimately diagnosed with NEC. In this article, we talk to Linseigh about what it was like growing up with the residual effects of NEC and even how it affects her today. This is a must-read for every NICU nurse so that families can better understand the long-term effects and know what resources to turn to for assistance.

Beyond the Syndrome: Extensive Congenital Abnormalities in an Infant With Trisomy 21

Herein we discuss the clinical course and subsequent autopsy of a female infant with trisomy 21 with balanced Rastelli Type "C" complete atrioventricular septal defect (AVSD), tetralogy of Fallot and right aortic arch with mirror image branching pattern who underwent a palliative right modified Blalock-Taussig-Thomas shunt (mBTTS) for hypoxemia from progressive right ventricular outflow tract obstruction. The baby was found to have multiple concomitant pathologic findings not typically seen with this constellation of cardiac anatomy. Autopsy revealed significant abdominal adhesions with near-complete stenosis of the transverse colon. In addition, the infant was found to have significantly elongated villi within the small and large bowel and a relatively large collagenous polyp in the small bowel. The decedent also had an abnormal tracheal bronchus, characterized by an additional superior right-sided bronchus, which is an extremely rare abnormality. Her clinical course was complicated by severe pulmonary hypertensive arteriolar changes out of proportion to what would be typical for her age, trisomy 21 status, and degree of left to right intracardiac shunting. Furthermore, she had refractory anasarca and recurrent chylous pleural effusions without gross lymphatic abnormalities that may have been secondary to systemic capillary leak syndrome (SCLS) versus severe pulmonary hypertension. Due to the aforementioned findings, the family elected for comfort care and the baby expired shortly after extubation. Overall, the infant had multiple, rare coexisting congenital abnormalities that likely represents an extreme phenotype of trisomy 21 that has not been described in the literature to date.

Necrotizing enterocolitis: Bench to bedside approaches and advancing our understanding of disease pathogenesis

Necrotizing enterocolitis (NEC) is a devastating, multifactorial disease mainly affecting the intestine of premature infants. Recent discoveries have significantly enhanced our understanding of risk factors, as well as, cellular and genetic mechanisms of this complex disease. Despite these advancements, no essential, single risk factor, nor the mechanism by which each risk factor affects NEC has been elucidated. Nonetheless, recent research indicates that maternal factors, antibiotic exposure, feeding, hypoxia, and altered gut microbiota pose a threat to the underdeveloped immunity of preterm infants. Here we review predisposing factors, status of unwarranted immune responses, and microbial pathogenesis in NEC based on currently available scientific evidence. We additionally discuss novel techniques and models used to study NEC and how this research translates from the bench to the bedside into potential treatment strategies.

Fecal HBD-2 and Claudin-3 may be potential biomarkers to predict the deterioration of necrotizing enterocolitis: A prospective study

BACKGROUND AND PURPOSE

Necrotizing enterocolitis (NEC) is a critical gastrointestinal disease. We aim to explore the value of fecal human β-defensin 2 (HBD-2), Claudin-3, high-mobility group box-1 protein (HMGB-1), and resistin-like molecule β (Relmβ) as well as some laboratory metrics to predict the deterioration of NEC.

METHODS

Infants diagnosed with NEC at Stage II were enrolled in our study. Those who progressed to Stage III were included in the Stage III group and the rest were included in the Stage II group. Clinical data and laboratory metrics of the infants were collected. Fecal samples of HBD2, HMGB-1, Claudin-3, and Relmβ collected during their enrollment were determined by using enzyme-linked immunosorbent assay (ELISA) kits. Student's t-test, the Mann-Whitney U test, the chi-square test, receiver operating characteristic (ROC), and logistic regression analysis were performed.

RESULTS

Sixty infants diagnosed with NEC at Stage II were enrolled in our study, with 27 in the Stage III group (n = 27) and 33 in the Stage II group (n = 33). Although many of these NEC cases were late preterm and term infants, the infants in the Stage III group had a lower gestational age (P < 0.05). The incidence of gestational diabetes mellitus, peritonitis, intestinal adhesion, and sepsis was higher and more infants in the Stage III group underwent surgeries (P < 0.05). The levels of HBD-2 and Claudin-3 were higher and neutrophil count was lower in the Stage III group than in the Stage II Group, and the area under the curve (AUC) was 0.754, 0,755, and 0.666, respectively (P < 0.05). HBD-2 ≥ 1649.02 ng/g and Claudin-3 ≥ 2488.71 pg/g were included in the multivariate stepwise logistic regression analysis (P < 0.05), and the AUC of the model was 0.805 (95% CI: 0.688-0.922).

CONCLUSION

Fecal HBD-2 and Claudin-3 may be potential biomarkers to predict the deterioration of NEC from Stage II to Stage III.

The safety and effectiveness of Santulli enterostomy in neonatal intestinal conditions

BACKGROUND

As an end stoma, Santulli enterostomy provides early restoration of intestinal continuity without formal laparotomy. Short amputation of the common limb enables closure on a side to restore anatomic continuity without sacrificing valuable intestine; additionally, the procedure is simple and safe. Most newborns who require enterostomy might benefit from Santulli enterostomy; however, several pediatric surgeons lack information regarding this procedure. Therefore, we have reviewed our experience about Santulli enterostomy and explore the advantages and indications in neonatal intestinal conditions.

METHODS

The clinical data of 76 neonates who underwent enterostomywere obtained. The patients were divided into two groups: the Santulli group with 33 cases who underwent Santulli enterostomy, and the control group with 43 cases who underwent double- or single-lumen ostomy. The general data of the two groups were analyzed, and the perioperative/postoperative complications, clinical data and the long-term outcomes were compared.

RESULTS

There was no difference in the demographic informations, the level of enterostomy, the rate of high-sight stoma, the operative time and bleeding of enterostomy between the two groups. Compared to the control group, the operative time of ostomy closure was less in the Santulli group (53.00 vs. 152.47, P < 0.001). The duration of parenteral nutrition (27.45 vs. 44.56, P = 0.010), the mean interval of initial enterostomy to stomal closure (131.21 vs. 216.42, P < 0.001), and length of stay (46.00 vs. 67.60, P = 0.007) were shorter, while the incidence of postoperative complications and hospitalization costs (11.21 vs. 15.49, P = 0.006) were lower. The Santulli procedure can reduce the morbidity of high output ostomy (2 vs. 10, P = 0.042) and short bowel syndrome (3 vs. 132, P = 0.025), shorten the discrepancy of diameter between the proximal and distal segments, maximize the available intestine, and monitor the movement of the distal bowel. The length of incision was shorter, and the catch-up growth was significantly faster in the Santulli group.

CONCLUSION

Santulli enterostomy is a superior procedure in the treatment of neonatal intestinal conditions, in terms of fewer complications, faster catch-up growth, shorter hospitalization time and treatment duration. It should be the procedure of choice in several newborns with intestinal conditions that require ostomy.

A Systematic Review of the Literature

Necrotizing enterocolitis (NEC) is a serious condition related to prematurity and the initiation of enteral feeding. In this article, we review the evidence published in recent years on necrotizing enterocolitis risk factors (prematurity, feeding with low-weight formula, existence of intestinal dysbiosis) and protective factors (human milk or donated milk supply, supplementation of human milk with oligosaccharides, probiotics administration, and the determination of disease predictive biomarkers). A systematic review was conducted of preventive, risk and predictive factors for necrotizing enterocolitis in neonates prior to 37 weeks' gestational age, based on a literature search for clinical trials, meta-analyses, randomized controlled trials and systematic reviews published between January 2018 and October 2021. For this purpose, the PubMed, MEDLINE, and Cochrane Library databases were consulted. The literature search obtained 113 articles, of which 19 were selected for further analysis after applying the inclusion and exclusion criteria. The conclusions drawn from this analysis were that adequate knowledge of risk factors that can be prevented or modified (such as alteration of the intestinal microbiota, oxidative stress, metabolic dysfunction at birth, or alteration of the immunity modulation) can reduce the incidence of NEC in premature infants. These factors include the supplementation of enteral nutrition with human milk oligosaccharides (with prebiotic and immunomodulatory effects), the combined administration of probiotics (especially the Lactobacillus spp and Bifidobacterium spp combination, which inhibits bacterial adhesion effects, improves the intestinal mucosa barrier function, strengthens the innate and adaptive immune system and increases the secretion of bioactive metabolites), the supplementation of human milk with lactoferrin and the use of donated milk fortified in accordance with the characteristics of the premature newborn. The determination of factors that can predict the existence of NEC, such as fecal calprotectin, increased TLR4 activity, and IL6 receptor, can lead to an early diagnosis of NEC. Although further studies should be conducted to determine the values of predictive biomarkers of NEC, and/or the recommended doses and strains of probiotics, lactoferrin or oligosaccharides, the knowledge acquired in recent years is encouraging.

Identification and Validation of Autophagy-Related Genes in Necrotizing Enterocolitis

BACKGROUND

Autophagy plays an essential role in the occurrence and progression of necrotizing enterocolitis (NEC). We intend to carry out the identification and validation of the probable autophagy-related genes of NEC via bioinformatics methods and experiment trials.

METHODS

The autophagy-related differentially expressed genes (arDEGs) of NEC were identified by analyzing the RNA sequencing data of the experiment neonatal mouse model and dataset GSE46619. Protein-protein interactions (PPIs), Gene Ontology (GO) enrichment analysis, and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis were used for the arDEGs. Then, co-expressed autophagy-related genes in two datasets were identified by Venn analysis and verified by qRT-PCR in experimental NEC.

RESULTS

Autophagy increased in experimental NEC and 47 arDEGs were identified in experimental NEC by RNA-sequencing. The PPI results proclaimed those genes interplayed with each other. The GO and KEGG enrichment results of arDEGs reported certain enriched pathways related to autophagy and macroautophagy. Furthermore, 22 arDEGs were identified in human NEC from dataset GSE46619. The GO and KEGG enrichment analysis of these genes showed similar enriched terms with the results of experimental NEC. Finally, HIF-1a, VEGFA, ITGA3, ITGA6, ITGB4, and NAMPT were identified as co-expressed autophagy-related genes by Venn analysis in human NEC from dataset GSE46619 and experimental NEC. The result of quantified real-time PCR (qRT-PCR) revealed that the expression levels of HIF-1a and ITGA3 were upregulated, while VEGFA and ITGB4 were downregulated in experimental NEC.

CONCLUSION

We identified 47 arDEGs in experimental NEC and 22 arDEGs in human NEC via bioinformatics analysis. HIF-1a, ITGA3, VEGFA, and ITGB4 may have effects on the progression of NEC through modulating autophagy.

Predictive factors for rapid progression in preterm neonates with necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal emergency with significant mortality and morbidity rates. A subset of patients progressed rapidly and underwent surgical intervention within a short period. This study aimed to establish a model to predict the rapid progression of NEC in preterm neonates.

METHODS

A retrospective study was conducted to review neonates with NEC between December 2015 and April 2019 at the Guangzhou Women and Children's Medical Center. Rapidly progressive NEC was defined as the need for surgical intervention or death within 48 h of NEC onset. Patients were divided into two groups: rapidly progressive NEC (RP-NEC) and non-rapidly progressive NEC (nRP-NEC). Data on demographics, perinatal characteristics, examination variables, and radiographic findings at onset were collected.

RESULTS

A total of 216 preterm neonates with NEC were included in the study, of which 64 had RP-NEC and 152 had nRP-NEC. The mortality rates of patients with RP-NEC and nRP-NEC were 32.8% and 3.28%, respectively. Male sex (p-value, adjusted odds ratio [95% confidence interval]: 0.002, 3.43 [1.57, 7.53]), portal venous gas (0.000, 8.82 [3.73, 20.89]), neutrophils <2.0 × 10⁹/L (0.005, 4.44 [1.59, 12.43]), pH <7.3 (7.2 ≤ pH < 7.3) (0.041, 2.95 [1.05, 8.31]), and pH <7.2 (0.000, 11.95 [2.97, 48.12]) at NEC onset were identified as independent risk factors for RP-NEC. An established model that included the four risk factors presented an area under the curve of 0.801 with 83% specificity and 66% sensitivity.

CONCLUSION

Among preterm neonates with NEC, a significantly higher mortality rate was observed in those with rapid progression. It is recommended that close surveillance be performed in these patients, and we are confident that our established model can efficiently predict this rapid progression course.

Imaging manifestations of neonatal necrotizing enterocolitis to predict timing of surgery

BACKGROUND

To find the predictor of optimal surgical timing for neonatal necrotizing enterocolitis (NEC) patients by analyzing the risk factors of conservative treatment and surgical therapy.

METHODS

Data were collected from 184 NEC patients (Surgery, n=41; conservative treatment, n=143) between the years 2015 and 2019. Data were analyzed by univariate analysis, and multivariate binary logistic regression analysis.

RESULTS

Univariate analysis showed that statistically significant differences between the surgery and conservative treatment groups. The results of multivariate Logistic regression analysis indicated intestinal wall thickening by B-ultrasound and gestational age were independent factors to predict early surgical indications of NEC (p < 0.05). The true positive rate, false positive rate, true negative rate and false negative rate in the diagnosis of necrotic bowel perforation guided by DAAS (Duke abdominal X-ray score) ≥7 and MD7 (seven clinical metrics of metabolic derangement) ≥3 were 12.8%, 0.0%, 100.0% and 87.2%, respectively.

CONCLUSIONS

In summary, the ultrasound examination in NEC children showing thickening intestinal wall and poor intestinal peristalsis indicated for early operation.

Current therapy option for necrotizing enterocolitis: Practicalities and challenge

Necrotizing enterocolitis (NEC) is one of the most prevalent neonatal gastrointestinal disorders. Despite ongoing breakthroughs in its treatment and prevention, the incidence and mortality associated with NEC remain high. New therapeutic approaches, such as breast milk composition administration, stem cell therapy, immunotherapy, and fecal microbiota transplantation (FMT) have recently evolved the prevention and the treatment of NEC. This study investigated the most recent advances in NEC therapeutic approaches and discussed their applicability to bring new insight to NEC treatment.

Association between pulmonary vein stenosis and necrotizing enterocolitis or gastrointestinal pathology: A case-control study

Objective

Pulmonary vein stenosis (PVS) is an emerging cause of pulmonary hypertension in preterm infants. It is an often lethal condition with poor long.term prognosis and high mortality. Previous work suggests an association between necrotizing enterocolitis (NEC) and PVS, supporting a possible role for inflammatory processes due to gastrointestinal (GI) pathology as an associated risk factor for PVS.

Study Description

We performed a matched case-control study where infants with PVS were matched for gestational age with infants without PVS. Hospital records were reviewed for prior history of NEC or other gut pathology.

Results

Twenty-four PVS patients were matched with 68 controls; 63% of patients (15/24) had prior GI pathology as opposed to 19% (13/68) of controls. The GI pathology group had a significantly higher growth restriction and C-reactive protein. The mean gradient across the pulmonary veins was higher in the gut pathology group versus controls, as was mortality (29% vs. 9%).

Conclusions

The previously described association between PVS and intestinal pathology was further strengthened by this study. The presence of GI pathology should lead to early surveillance and intervention for PVS.

The Impact of MicroRNAs in Neonatal Necrotizing Enterocolitis and other Inflammatory Conditions of Intestine: A Review

The understanding of necrotizing enterocolitis (NEC) etiopathogenesis is incomplete, contributing to the lack of early biomarkers and therapeutic options. Micro RNAs (miRNAs) are a class of RNAs that can alter gene expression and modulate various physiological and pathological processes. Several studies have been performed to evaluate the role of miRNA in the pathogenesis of NEC. In this article, we review the information on miRNAs that have been specifically identified in NEC or have been noted in other inflammatory bowel disorders that share some of the histopathological abnormalities seen frequently in NEC. This review highlights miRNAs that could be useful as early biomarkers of NEC and suggests possible approaches for future translational studies focused on these analytes. It is a novel field with potential for immense translational and clinical relevance in preventing, detecting, or treating NEC in very premature infants. Impact • Current information categorizes necrotizing enterocolitis (NEC) as a multifactorial disease, but microRNAs (miRNAs) may influence the risk of occurrence of NEC. • MiRNAs may alter the severity of the intestinal injury and the clinical outcome of NEC. • The literature on intestinal diseases of adults suggests additional miRNAs that have not been studied in NEC yet but share some features and deserve further exploration in human NEC, especially if affecting gut dysbiosis, intestinal perfusion, and coagulation disorders.

Electromagnetic Waves Can Help Improve the Rate of Increase of Milk Feeds Per Day in Premature Infants With Necrotizing Enterocolitis: A Pilot Trial

OBJECTIVE

To evaluate the effects of electromagnetic waves generated by a commercial medical electromagnetic instrument (trade name, TDP, the Chinese phonetic abbreviation of "Te-ding Dian-ci-bo Pu") as an adjuvant to improve the rate of increase of milk feeds per day by premature infants with necrotizing enterocolitis (NEC).

METHODS

This study was a prospective randomized clinical trial. A total of 103 premature infants were diagnosed with NEC II, but there was no need for surgery. The infants were randomly divided into the TDP intervention group and the control group by a randomized method using SPSS 24.0. The patients in the TDP intervention group were treated with TDP irradiation and routine interventions; those in the control group were treated with routine interventions. The rate of increase of milk feeds per day, the time to achieve total gastrointestinal nutrition, the velocity of weight gain, and the complication incidence rate were recorded and compared.

RESULTS

The rate of increase of milk feeds per day in the TDP intervention group was significantly greater than that in the control group [14.51 (11.58~22.11) ml/kg/d vs. 10.15 (6.15~15.87) ml/kg/d, P = 0.002]. Compared to the control group, the time to achieve total gastrointestinal nutrition (21.45 ± 1.87 d vs. 36.43 ± 2.585 d, P = 0.000) and the velocity of weight gain (19.65 ± 15.27% vs. 13.68 ± 7.15%, P = 0.013) in the TDP intervention group were substantially better than those in the control group. The complication incidence rate was not significantly different between the two groups (P > 0.05).

CONCLUSION

Treatment with TDP-generated electromagnetic waves improved the volume of milk consumed per day in premature infants with NEC II and were conducive to improving their clinical outcomes.

Amniotic Fluid: A Perspective on Promising Advances in the Prevention and Treatment of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a common and potentially fatal disease that typically affects preterm (PIs) and very low birth weight infants (VLBWIs). Although NEC has been extensively studied, the current therapeutic approaches are unsatisfactory. Due to the similarities in the composition between human amniotic fluid (AF) and human breast milk (BM), which plays a protective role in the development of NEC in PIs and VLBWIs, it has been postulated that AF has similar effects on the outcome of NEC and potential therapeutic implications. AF has been long used for its diagnostic purposes and is often discarded after birth as "biological waste". However, researchers have started to elucidate its therapeutic potential. Experimental studies in animal models have shown that diseases of various organ systems can possibly benefit from AF-based therapy. Hence, we have identified three approaches which show promising results for future clinical application in the prevention and/or treatment of NEC: (1) administration of processed AF (PAF) isolated from donor mothers, (2) administration of AF stem cells (AFSCs), and (3) administration of simulated AF (SAF) formulated to mimic the composition of physiological AF. We have highlighted the most important aspects that should be taken into account to guide further research on the clinical application of AF-based therapy. We hope that this review can provide a framework to identify the challenges of AF-based therapy and help to design future studies to better evaluate AF-based approaches for the treatment and/or prevention of NEC in PIs and VLBWIs.

Risk factors for necrotizing enterocolitis in neonates: A meta-analysis

OBJECTIVE

The objective is to identify the risk factors for necrotizing enterocolitis (NEC) in neonates by a meta-analysis, and to provide a reference for the prevention of NEC.

METHODS

The databases, including Chinese Biomedical Literature Datebase, China National Knowledge Infrastructure, Wanfang database, and Weipu Periodical database, PubMed, Web of Science, Embase, Cochrane Library, were searched for studies on the risk factors for NEC in neonates. The meta-analysis was carried out with the aid of Stata software.

RESULTS

A total of 52 studies were included, with 48 case-control studies and 4 cohort studies. There were 166,580 neonates in total, with 33,522 neonates in the case group and 133,058 neonates in the control group. The meta-analysis showed that gestational diabetes (OR = 3.62, 95% CI:1.77-7.41), premature rupture of membranes (OR = 3.81, 95% CI:1.16-12.52), low birth weight (OR = 3.00, 95% CI:2.26-3.97), small for gestational age (OR = 1.85, 95% CI:1.15-2.97), septicemia (OR = 4.34, 95% CI:3.06-6.15), blood transfusion (OR = 3.08, 95% CI:2.16-4.38), congenital heart disease (OR = 2.73, 95% CI:1.10-6.78), respiratory distress syndrome (OR = 2.12, 95% CI:1.24-3.63), premature birth (OR = 5.63, 95% CI:2.91-10.92), pneumonia (OR = 4.07, 95% CI:2.84-5.82) were risk factors for NEC in neonates. Breastfeeding (OR = 0.37, 95% CI:0.23-0.59), take probiotics (OR = 0.30, 95% CI:0.22-0.40), prenatal use of glucocorticoids (OR = 0.39, 95% CI:0.30-0.50), Hyperbilirubinemia (OR = 0.28, 95% CI:0.09-0.86) were protective factors for NEC in neonates.

CONCLUSIONS

Gestational diabetes, premature rupture of membranes, low birth weight, small for gestational age, septicemia, blood transfusion, congenital heart disease, respiratory distress syndrome, premature birth, and pneumonia may increase the risk of NEC in neonates. Breastfeeding, taking probiotics, prenatal use of glucocorticoids, and Hyperbilirubinemia may reduce the risk of NEC in neonates.

The Role of Dietary Fats in the Development and Prevention of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a significant cause of mortality and morbidity in preterm infants. The pathogenesis of NEC is not completely understood; however, intestinal immaturity and excessive immunoreactivity of intestinal mucosa to intraluminal microbes and nutrients appear to have critical roles. Dietary fats are not only the main source of energy for preterm infants, but also exert potent effects on intestinal development, intestinal microbial colonization, immune function, and inflammatory response. Preterm infants have a relatively low capacity to digest and absorb triglyceride fat. Fat may thereby accumulate in the ileum and contribute to the development of NEC by inducing oxidative stress and inflammation. Some fat components, such as long-chain polyunsaturated fatty acids (LC-PUFAs), also exert immunomodulatory roles during the early postnatal period when the immune system is rapidly developing. LC-PUFAs may have the ability to modulate the inflammatory process of NEC, particularly when the balance between n3 and n6 LC-PUFAs derivatives is maintained. Supplementation with n3 LC-PUFAs alone may have limited effect on NEC prevention. In this review, we describe how various fatty acids play different roles in the pathogenesis of NEC in preterm infants.

Intussusception in preterm neonates: A systematic review of a rare condition

Background

While necrotizing enterocolitis (NEC) is a prevalent condition in preterm neonates admitted to neonatal intensive care unit (NICU), intussusception is exceedingly uncommon and often overlooked. This is due to the fact that they share many clinical characteristics. The initial misdiagnosis of intussusception in preterm neonates (IPN) especially has led to a delay in their management, which increases the risk of developing compromised bowel. Additionally, it is difficult to reach a diagnosis as neonatal intussusception does not have any classical radiological signs even when contrast enema is used. This systematic review is based on the published literature including case reports and case series to review the clinical features of IPN and how to differentiate it from NEC in order to shed the light on this rare disease and how having a high index of suspicion would help practitioners to make an early and accurate diagnosis

Methods

A systematic literature search to report all cases of relevant articles that reported IPN till date. All cases that were born before 37 weeks gestational age, presented within the neonatal period and having well established documentation were included in the study. Any case that did not have these criteria was excluded from our study.

Results

Only 52 cases met these criteria during the period from 1963 till date. An average of 10 days had elapsed before the cases were confirmed to have IPN either clinically or intraoperatively. The most frequent manifestations were abdominal distension and bilious gastric residuals, occurring in 85% and 77% of the cases respectively, followed by bloody stools in 43% of cases. However, this triad was present only in approximately one-third of the cases. Only 13 cases were diagnosed as having intussusception preoperatively. About two thirds of the intussusception were located in the ileum. Pathological lead point was present in 7 cases only; 4 of them were due to Meckel’s diverticulum. Nine cases only out of the 52 cases with IPN died.

Conclusion

It is crucial to detect the clues for diagnosis of intussusception because in contrast to NEC, it is unresponsive to conservative management, affects the viability of the bowel and surgery is essential.

Structure-Function Relationships of Human Milk Oligosaccharides on the Intestinal Epithelial Transcriptome in Caco-2 Cells and a Murine Model of Necrotizing Enterocolitis

SCOPE

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal emergency affecting preterm infants. Breastmilk protects against NEC, partly due to human milk oligosaccharides (HMOs). HMO compositions are highly diverse, and it is unclear if anti-NEC properties are specific to carbohydrate motifs. Here, this study compares intestinal epithelial transcriptomes of five synthetic HMOs (sHMOs) and examines structure-function relationships of HMOs on intestinal signaling.

METHODS AND RESULTS

This study interrogates the transcriptome of Caco-2Bbe1 cells in response to five synthetic HMOs (sHMOs) using RNA sequencing: 2'-fucosyllactose (2'-FL), 3-fucosyllactose (3FL), 6'-siallyllactose (6'-SL), lacto-N-tetraose (LNT), lacto-N-neotetraose (LNnT). Protection against intestinal barrier dysfunction and inflammation occurred in an HMO-dependent manner. Each sHMO exerts a unique set of host transcriptome changes and modulated unique signaling pathways. There is clustering between HMOs bearing similar side chains, with little overlap in gene regulation which is shared by all sHMOs. Interestingly, most sHMOs protect pups against NEC, exerting divergent mechanisms on intestinal cell morphology and inflammation.

CONCLUSIONS

These results demonstrate that while structurally distinct HMOs impact intestinal physiology, their mechanisms of action differ. This finding establishes the first structure-function relationship of HMOs in the context of intestinal cell signaling responses and offers a functional framework by which to screen and design HMO-like compounds.

Potential Role of Serum Intestinal Fatty Acid-Binding Protein as a Marker for Early Prediction and Diagnosis of Necrotizing Enterocolitis in Preterm Neonates

Introduction:

Intestinal fatty acid-binding protein (I-FABP) is located in the apex of mature enterocytes and released into circulation; once the injury of enterocyte happens, its circulating levels are considered an early and sensitive marker of intestinal ischemia as in necrotizing enterocolitis (NEC); because of its small molecular weight, it can be detected in urine.

Aims:

The aim was to study the usefulness of both serum and urine I-FABP in early diagnosis of NEC and to correlate the serum and urinary levels.

Settings and Design:

This study was case–control design.

Methods:

Simultaneous serum and urine samples obtained at the onset of symptoms, in 40 preterms with suspected NEC, with gestational age ± 27.70 weeks and birth weight ± 1.11 kg, i.e., 20 preterms diagnosed at Stage I, 12 preterms at Stage II, and 8 preterms at Stage III, were compared with age- and weight-matched preterms with no NEC.

Statistical Analysis:

The collected data were tabulated, coded, and then analyzed using the computer program Statistical Package for the Social Science (SPSS version 22).

Results:

Serum levels of I-FABP in NEC cases were significantly higher than the control group, with a mean of 6005.77 ± 6384.77 and 1480.79 ± 1276.48 pg/ml, respectively (P < 0.001). Urine levels of I-FABP in NEC cases were significantly higher than the control group, with a mean of 5009.22 ± 3941.64 and 2677.62 ± 2257.29 pg/ml, respectively (P = 0.04). Both serum and urine I-FABP levels not only in Stage II are significantly higher than Stage I but also in Stage III are significantly higher than Stage I and II (P < 0.001, P = 0.03, respectively), which showed significant positive correlation with stages of NEC (r = 0.618; P < 0.001; r = 0.306; P = 0.049, respectively). Both serum and urine I-FABP levels had a highly significant positive correlation with each other (r = 0.406 P < 0.0001). Receiving operating characteristic curve showed an area under the curve of 0.92 and 0.81 for serum and urine I-FABP, respectively.

Conclusions:

Whether serum or urinary I-FABP is valuable in the diagnosis and prediction of NEC and strongly correlated with the disease severity and with each other.

Histopathology of intestinal villi in neonatal and paediatric age: main features with clinical correlation - Part I

The neonatal and paediatric spectrum of small bowel disorders encompass a wide variety of conditions, ranging from food allergies to life-threatening surgical emergencies or life-long medical conditions and, as such, it comes with a whole set of diagnostic challenges for the non-paediatric pathologist. Histologic examination is a cornerstone of diagnosis in a large number of diseases and may still provide important diagnostic clues in the appropriate clinical context. In this review, divided in two sections, we aim to provide a comprehensive histopathological summary of paediatric small bowel alteration and their differential diagnoses with a reference to the main clinical aspects required for appropriate interpretation. Specifically, in this first part, we describe congenital and metabolic disorders, intestinal lymphangiectasia, immunodeficiencies, GVHD, and necrotising enterocolitis.

Neutrophil extracellular trap inhibition increases inflammation, bacteraemia and mortality in murine necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease affecting primarily premature infants. The disease is characterized by intestinal inflammation and leucocyte infiltration, often progressing to necrosis, perforation, systemic inflammatory response and death. Neutrophil extracellular traps (NETs), denoting nuclear DNA, histone and antimicrobial protein release, have been suggested to play a role in NEC. This study aimed to determine the role of NETs in NEC and explore the effect of chloramidine, a NET inhibitor, on a murine NEC-like intestinal injury model. Blood and intestinal tissues were collected from infants diagnosed with ≥ Stage II NEC, and levels of nucleosomes and NETs, respectively, were compared with those of case-matched controls. In mice, NEC was induced with dithizone/Klebsiella, and mice in the treatment group received 40 mg/kg chloramidine. Bacterial load, intestinal histology, plasma myeloperoxidase and cytokine levels, and immunofluorescent staining were compared with controls. Nucleosomes were significantly elevated in both human and mouse NEC plasma, whereas NET staining was only present in NEC tissue in both species. Chloramidine treatment increased systemic inflammation, bacterial load, organ injury and mortality in murine NEC. Taken together, our findings suggest that NETs are critical in the innate immune defence during NEC in preventing systemic bacteraemia.

Cytotoxic Lactalbumin-Oleic Acid Complexes in the Human Milk Diet of Preterm Infants

Frozen storage is necessary to preserve expressed human milk for critically ill and very preterm infants. Milk pasteurization is essential for donor milk given to this special population. Due to these storage and processing conditions, subtle changes occur in milk nutrients. These changes may have clinical implications. Potentially, bioactive complexes of unknown significance could be found in human milk given to preterm infants. One such complex, a cytotoxic α-lactalbumin-oleic acid complex named "HAMLET," (Human Alpha-Lactalbumin Made Lethal to Tumor cells) is a folding variant of alpha-lactalbumin that is bound to oleic acid. This complex, isolated from human milk casein, has specific toxicity to both carcinogenic cell lines and immature non-transformed cells. Both HAMLET and free oleic acid trigger similar apoptotic mechanisms in tissue and stimulate inflammation via the NF-κB and MAPK p38 signaling pathways. This protein-lipid complex could potentially trigger various inflammatory pathways with unknown consequences, especially in immature intestinal tissues. The very preterm population is dependent on human milk as a medicinal and broadly bioactive nutriment. Therefore, HAMLET's possible presence and bioactive role in milk should be addressed in neonatal research. Through a pediatric lens, HAMLET's discovery, formation and bioactive benefits will be reviewed.

Newborns with Bloody Stools-At the Crossroad between Efficient Management of Necrotizing Enterocolitis and Antibiotic Stewardship

The onset of bloody stools in neonates often results in antibiotic treatment for suspected necrotizing enterocolitis (NEC). Food protein-induced allergic proctocolitis (FPIAP) is an often-neglected differential diagnosis. We performed a retrospective analysis of antibiotic exposure at our tertiary center from 2011 to 2020 that included three time periods of differing antimicrobial stewardship goals. We compared these data with the conventional treatment guidelines (modified Bell's criteria). In our cohort of 102 neonates with bloody stools, the length of antibiotic exposure was significantly reduced from a median of 4 to 2 days. The proportion of treated neonates decreased from 100% to 55% without an increase in negative outcomes. There were 434 antibiotic days. Following a management strategy according to modified Bell's criteria would have led to at least 780 antibiotic days. The delayed initiation of antibiotic treatment was observed in 7 of 102 cases (6.9%). No proven NEC case was missed. Mortality was 3.9%. In conclusion, with FPIAP as a differential diagnosis of NEC, an observational management strategy in neonates with bloody stools that present in a good clinical condition seems to be justified. This may lead to a significant reduction of antibiotic exposure. Further prospective, randomized trials are needed to prove the safety of this observational approach.

A case of transfusion-associated necrotizing enterocolitis in neonates

A male infant, whose weight was 1 120 g at 28+2 weeks of gestational age, was admitted to Neonatal Intensive Care Unit of West China Second Hospital of Sichuan University at 20 min after preterm birth. Blood transfusion was performed for anemia (hemoglobin 81 g/L) on day 30 of hospitalization, and feeding was continued during the transfusion. Eight hours after blood transfusion, the patient's manifestations included abdominal distension and stiff to palpation, bowel sound weakening, currant jelly stool, poor responsiveness, and apnea. The clinical diagnosis was necrotizing enterocolitis. Abdominal X-ray showed that the abdominal bowel was significantly dilated and inflated. The patient was immediately treated with fasting, gastrointestinal decompression, enema, and anti-infection treatment. After 40 days in hospital, the patient recovered and was discharged.

Biochemical Parameters in Extremely Preterm Infants Receiving Mixed Lipid Emulsions

OBJECTIVE

A mixture of soybean, medium-chain triglycerides, olive, and fish oils (SMOF) contains higher α-tocopherol and n-3 polyunsaturated fatty acids and lower phytosterol content compared with conventional soybean oil lipid emulsions (SOLE). We sought to characterize plasma total fatty acid profiles (FAPs) and assess the tolerability of long-term SMOF therapy in extremely preterm infants.

METHODS

We retrospectively evaluated infants born <28 weeks gestational age who received at least 30 consecutive days of SMOF between July 2016 and June 2019. We evaluated monthly FAPs and biochemical tolerance to SMOF using direct bilirubin (DB) and triglyceride (TG) levels. Growth parameters were evaluated longitudinally until discharge.

RESULTS

Sixteen patients with median gestational age 24 weeks (IQR, 23-25 weeks) received SMOF for median 76 days (IQR, 52-130 days). Fourteen patients had necrotizing enterocolitis (NEC) requiring surgical intervention and 15 patients received SOLE for median 19 days (IQR, 14-26 days) prior to switching to SMOF. Median docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) levels were elevated, whereas the remaining fatty acid levels fell within reported reference ranges. There were no incidents of essential fatty acid deficiency (triene to tetraene ratio >0.2) or hypertriglyceridemia (TG >200 mg/dL) with a general downtrend in DB after the first month on SMOF. All growth Z-scores declined throughout hospital stay.

CONCLUSIONS

Infants who received SMOF had a more pronounced elevation in DHA than EPA, of which the clinical significance remains unknown. Growth Z-scores declined with SMOF but were confounded by a high prevalence of surgically treated NEC.

An Update on the Role of Extracellular Vesicles in the Pathogenesis of Necrotizing Enterocolitis and Inflammatory Bowel Diseases

Some of the most fundamental influences of microorganisms inhabiting the human intestinal tract are exerted during infant development and impact the maturation of intestinal mucosa and gut immune system. The impact of bacteria on the host gut immune system is partially mediated via released extracellular vesicles (EVs). The heterogeneity in EV content, size, and bacterial species origin can have an impact on intestinal cells, resulting in inflammation and an immune response, or facilitate pathogen entry into the gut wall. In mammals, maintaining the integrity of the gut barrier might also be an evolutionary function of maternal milk EVs. Recently, the usage of EVs has been explored as a novel therapeutic approach in several pathological conditions, including necrotizing enterocolitis (NEC) and inflammatory bowel disease (IBD). In this review, we attempt to summarize the current knowledge of EV biology, followed by a discussion of the role that EVs play in gut maturation and the pathogenesis of NEC and IBD.

Impacts of Enriched Human Milk Cells on Fecal Metabolome and Gut Microbiome of Premature Infants with Stage I Necrotizing Enterocolitis: A Pilot Study

SCOPE

Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality in preterm infants, occurring more often in formula-fed infants than in breastfed infants. Recent animal studies have shown that cells in fresh breast milk survive in the newborns' digestive tract. However, no clinical studies have been conducted on the effects of human milk cells, and their biological roles in the infants' intestines remain unexplored.

METHODS AND RESULTS

Twenty premature infants are enrolled. Cells from fresh milk of their own mothers are enriched and fed to infants with Bell's Stage I NEC once a day for 7 days since the onset of NEC. Fecal samples are collected at enrollment and 2 weeks later. Fecal sphingolipids are observed to be enriched in NEC patients and positively correlated with calprotectin levels. After intervention with enriched human milk cells, inflammation-associated sphingolipids and microbiome profiles are altered and resembled those of the controls.

CONCLUSION

These preliminary findings reveal the potential impacts of enriched human milk cells on premature infants with Bell's Stage I NEC and provide insight into the roles of fecal sphingolipid metabolism in the neonates' intestinal inflammation. However, the limited sample size of the study indicates the need for further investigation.

miR-200a-3p improves neonatal necrotizing enterocolitis by regulating RIPK1

BACKGROUND

Necrotizing enterocolitis (NEC) is an acquired disease, which mainly occurs in premature infants or sick newborns. microRNA (miR), as a common non-coding RNA in recent years, is found in many diseases. In this research, miR usefulin NEC is analyzed by GEO.

METHOD

The differentially expressed miRs in NEC were screened by analyzing GSE68054, and miR-200a-3p in IEC-6 cells induced by lipopolysaccharide (LPS) and serum of NEC children were detected by qRT-PCR. The role of miR-200a-3p in LPS-induced IEC-6 cells was tested using CCK-8, PI dyeing, and inflammatory cytokine detection. The direct downstream molecules of miR-200a-3p were identified using TargetScanHuman and verified by luciferase reporter gene assay. The mechanism of action was explored using western blot.

RESULTS

miR-200a-3p in IEC-6 treated with NEC and LPS was significantly decreased. In vitro experiments revealed that miR-200a-3p mimetic could inhibit IL-6 and TNF-α in IEC-6 cells induced by LPS and reduce the positive rate of PI. In addition, it was determined that receptor-interacting protein kinase 1 (RIPK1) was a downstream molecule of miR-200a-3p, and overexpression of RIPK1 could aggravate LPS-induced IEC-6 injury, while miR-200a-3p mimics could alleviate the overexpression of RIPK1. miR-200a-3p mimics inhibited the elevation of necrosis-related molecules and the interaction between RIPK1 and RIPK3 in LPS-induced IEC-6 cells.

CONCLUSION

miR-200a-3p can protect intestinal epithelial cells from LPS injury by inhibiting inflammation and necrosis mediated by RIPK1, which provides a possible target for NEC.

Mesenteric tissue oxygenation status on the development of necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is an important cause of morbidity and mortality in preterm infants. There is limited data about the role of mesenteric oxygenation status during the first enteral feeding. Therefore, the aim of this study was to determine the mesenteric tissue oxygen saturation values before, during and after the first enteral feeding and to evaluate the effect of these values on the development of NEC in preterm infants.

METHODS

A total of 105 preterm babies with ≤ 32 gestational weeks were included in this prospective study. The continuous monitoring of the mesenteric tissue oxygenation status was performed before, during and 3 hours after the first feeding by near-infrared spectroscopy (NIRS).

RESULTS

The mean gestational week and birth weight of the study group were 28.8±2.1 weeks, and 1215±387 g, respectively. The first enteral feeding was started at 2.4±1.4 days with breast milk in 85% of infants. A total of 12 infants (11.4%) developed NEC (66% stage II, 34% stage III). The mean mesenteric tissue oxygen saturation levels of the infants that developed NEC were significantly lower both before and one hour after feeding (56.1±3.4 vs. 34±8.8, and 47.4±3.3 vs 37.8±10.9, respectively) compared with infants that did not develop NEC.

CONCLUSIONS

Lower mesenteric tissue oxygenation values measured before, and one hour after enteral feeding was associated with NEC development. We suggest that lower mesenteric tissue oxygenation during continuous monitoring of first enteral feeding may be used to predict NEC development during follow-up.

Necrotizing enterocolitis and mortality after transfusion of ABO non-identical blood

BACKGROUND

The relationship between ABO non-identical transfusion and the outcomes of necrotizing enterocolitis (NEC), and all-cause mortality in very-low birth weight (VLBW) neonates receiving red blood cell transfusion is unknown.

STUDY DESIGN AND METHODS

A retrospective multicenter cohort study was conducted in VLBW neonates in neonatal intensive care units between 2004 and 2016. VLBW (≤1500 grams) neonates were followed until discharge or in-hospital death. The primary exposure was ABO group. Secondary exposures included platelet count, plasma transfusions, and maternal ABO group. Outcome measures were NEC (defined as Bell stage ≥ 2) and all-cause mortality. Time-dependent Cox regression models with competing risks were used to investigate factors associated with NEC and mortality.

RESULTS

Thousand and sixteen neonates were included with 10.8% developing NEC (n = 110) and 14.1% mortality (n = 143). Platelet count (hazard ratio [HR] = 0.995; 95% confidence interval [CI]: 0.922-0.998) and number of plasma transfusions (HR = 2.908; 95% CI:1.265-6.682) were associated with NEC, while ABO group (non-O vs. O) was not (HR = 0.761; 95% CI: 0.393-1.471). Higher all-cause mortality occurred in neonates without NEC who were non-O compared with O (HR = 17.5; 95% CI: 1.784-171.692), but not in neonates with NEC (HR = 1.112; 95% CI: 0.142-8.841). Plasma transfusion was associated with increased mortality in both groups.

DISCUSSION

ABO non-identical transfusion was not associated with NEC or mortality in neonates with NEC. It was associated with increased mortality in neonates without NEC. As many neonatal intensive care units transfuse only O group blood as routine practice, future trials are needed to investigate the association between this practice and neonatal mortality.

Unraveling the Microbiome of Necrotizing Enterocolitis: Insights in Novel Microbial and Metabolomic Biomarkers

Necrotizing enterocolitis (NEC) is among the most relevant gastrointestinal diseases affecting mostly prematurely born infants with low birth weight. While intestinal dysbiosis has been proposed as one of the possible factors involved in NEC pathogenesis, the role of the gut microbiota remains poorly understood. In this study, the gut microbiota of preterm infants was explored to highlight differences in the composition between infants affected by NEC and infants prior to NEC development. A large-scale gut microbiome analysis was performed, including 47 shotgun sequencing data sets generated in the framework of this study, along with 124 retrieved from publicly available repositories. Meta-analysis led to the identification of preterm community state types (PT-CSTs), which recur in healthy controls and NEC infants. Such analyses revealed an overgrowth of a range of opportunistic microbial species accompanying the loss of gut microbial biodiversity in NEC subjects. Moreover, longitudinal insights into preterm infants prior to NEC development indicated Clostridium neonatale and Clostridium perfringens species as potential biomarkers for predictive early diagnosis of this disease. Furthermore, functional investigation of the enzymatic reaction profiles associated with pre-NEC condition suggested DL-lactate as a putative metabolic biomarker for early detection of NEC onset.

IMPORTANCE Necrotizing enterocolitis (NEC) is a severe gastrointestinal disease occurring predominantly in premature infants whose etiology is still not fully understood. In this study, the analysis of infant fecal samples through shotgun metagenomics approaches revealed a marked reduction of the intestinal (bio)diversity and an overgrowth of (opportunistic) pathogens associated with the NEC development. In particular, dissection of the infant’s gut microbiome before NEC diagnosis highlighted the potential involvement of Clostridium genus members in the progression of NEC. Remarkably, our analyses highlighted a gastrointestinal DL-lactate accumulation among NEC patients that might represent a novel potential functional biomarker for the early diagnosis of NEC.

Effects of Probiotics and Lactoferrin on Necrotizing Enterocolitis in Preterm Infants

Background

Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality in neonates. Despite intensive research, the etiology and pathophysiology of NEC is still obscure. Evidence from recent studies and meta-analyses showed a significant role of probiotics as a prophylactic measure in reducing NEC, sepsis, and mortality. However, obstacles against the generalization of the results still remain. The aim of the study was to evaluate the role of prophylactic administration of probiotics and lactoferrin in reducing the rate of NEC in preterm infants.

Methods

In this retrospective cohort study, all medical records of infants born with a birth weight of 1,500 g and less who were born between 2012 and 2017 were reviewed. The enrolled infants were divided into two groups: group 1 included infants born between January 2012 and August 2014, a period before probiotics were started in our unit, and group 2 included infants born between January 2014 and December 2017 after starting probiotics and lactoferrin. Multiple variables were collected including maternal data, neonatal data, and risk factors for NEC.

Results

Medical records of 284 infants who met our inclusion criteria were reviewed. Of the 284 infants, 134 were in group 1 and 150 infants were in group 2. There were no significant statistical differences between group 1 and group 2 in neonatal and maternal demographic data and clinical data. Of 134 infants who received probiotics and lactoferrin, 11 developed NEC, while 26 of the 150 infants in group 2 developed NEC, and the difference was statistically significant (p = 0.023).

Conclusion

Probiotics and lactoferrin given orally to very low birth weight preterm infants were associated with a decreased rate of NEC.

Early Enteral Feeding Improves Tolerance of Parenteral Nutrition in Preterm Newborns

(1) Background: The tolerance of preterm newborns for the high nutritional intakes given by parenteral nutrition (PN) is still debated because of the risk of metabolic complications. Despite enteral nutrition (EN) being the preferred route of nutrition, an exclusive enteral feeding is not always possible, as in preterm newborns, the gut is immature and less tolerant of EN. We aimed to study the impact of a minimal enteral feeding (MEF) on the possible early metabolic complications of PN in a cohort of preterms with gestational age at birth GA ≤ 29 + 6/7 weeks of postmenstrual age. (2) Methods: We divided the study sample in two cohorts: 1) Late-Feeding (cohort 1), newborns who received MEF starting from the 8th day of age, and (2) Early-Feeding (cohort 2), newborns who received MEF, consisting of the administration of at least 4–5 mL/kg/day by the enteral route, in the first 7 days of age. The primary outcome of the study was the rate of at least one metabolic complication, including hyperglycemia, hypertriglyceridemia, or metabolic acidosis. (3) Results: We enrolled 80 newborns (Late-Feeding cohort 51 vs. Early-Feeding cohort 29). The rate of all metabolic complications was statistically higher in the Late-Feeding cohort compared to the Early-Feeding cohort. Binary logistic regression analysis showed that late administration of MEF negatively influenced the rate of all metabolic complications. (4) Conclusions: Early minimal administration of EN is associated with less frequent PN-related metabolic side effects and a higher rate of survival in critically ill newborns.

Human Milk Growth Factors and Their Role in NEC Prevention: A Narrative Review

Growing evidence demonstrates human milk's protective effect against necrotizing enterocolitis (NEC). Human milk derives these properties from biologically active compounds that influence intestinal growth, barrier function, microvascular development, and immunological maturation. Among these protective compounds are growth factors that are secreted into milk with relatively high concentrations during the early postnatal period, when newborns are most susceptible to NEC. This paper reviews the current knowledge on human milk growth factors and their mechanisms of action relevant to NEC prevention. It will also discuss the stability of these growth factors with human milk pasteurization and their potential for use as supplements to infant formulas with the goal of preventing NEC.

Is preterm donor milk better than preterm formula for very-low-birth-weight infants?

Background

Preterm human milk has advantages over preterm formula (PF), but it may compromise some functions after pasteurization.

Objective

To explore the effects of preterm donor milk (DM) on growth, feeding tolerance, and severe morbidity in very-low-birth-weight infants.

Method

This was a single-center, prospective cohort study that included 304 preterm infants weighing <1,500 g or of gestational age <32 weeks. If the mother's own milk was insufficient, the parents decided to use PF (n = 155) or DM (n = 149). The two groups were uniformly managed according to the standard NICU protocol. Growth parameters, feeding tolerance, and severe morbidity such as necrotizing enterocolitis, were compared between the two groups.

Results

The daily weight gain and weekly head growth in the DM group were not different from those in the PF group (P > 0.05). Feeding intolerance in the DM group was significantly lower than that in PF group (P < 0.05), and parenteral nutrition time and hospitalization time were also shorter than that in the PF group (P < 0.05). Moreover, the incidence of necrotizing enterocolitis and sepsis was also significantly lower in the DM group (P < 0.05).

Conclusion

The study indicated that preterm DM does not affect the growth of very-low-birth-weight infants. Further, it significantly reduces feeding intolerance, helps achieve full enteral feeding early, and has protective effects against necrotizing enterocolitis and sepsis. Thus, compared with formula, preterm DM can lower the rate of infection in preterm infants and is worthy of promotion.

Untargeted Metabolomic Analysis of Human Milk from Mothers of Preterm Infants

The application of metabolomics in neonatology offers an approach to investigate the complex relationship between nutrition and infant health. Characterization of the metabolome of human milk enables an investigation into nutrients that affect the neonatal metabolism and identification of dietary interventions for infants at risk of diseases such as necrotizing enterocolitis (NEC). In this study, we aimed to identify differences in the metabolome of breast milk of 48 mothers with preterm infants with NEC and non-NEC healthy controls. A minimum significant difference was observed in the human milk metabolome between the mothers of infants with NEC and mothers of healthy control infants. However, significant differences in the metabolome related to fatty acid metabolism, oligosaccharides, amino sugars, amino acids, vitamins and oxidative stress-related metabolites were observed when comparing milk from mothers with control infants of ≤1.0 kg birth weight and >1.5 kg birth weight. Understanding the functional biological features of mothers’ milk that may modulate infant health is important in the future of tailored nutrition and care of the preterm newborn.

Epigenome - A mediator for host-microbiome crosstalk

The interaction between the gut and its eventual trillions of microbe inhabitants during microbial colonization, represents a critical time period for establishing the overall health and wellbeing of an individual. The gut microbiome represents a diverse community of microbes that are critical for many physiological roles of the host including host metabolism. These processes are controlled by a fine-tuned chemical cross talk between the host and microbiota. Although the exact mechanisms behind this cross talk remains elusive, microbiota induced epigenetic mechanisms like DNA methylation and histone modifications may be key. This review presents our perspective on the epigenome as a mediator for host-microbiota cross talk, as well as methodology to study epigenetics, the role of dysbiosis in disease, and how the gut microbiome-host axis may be used in personal medicine.