Evidence-Based Practices Reduce Necrotizing Enterocolitis and Improve Nutrition Outcomes in Very Low-Birth-Weight Infants

Nursing practice of routine gastric aspiration in preterm infants and its link to necrotizing enterocolitis: is the practice still clinically relevant?

The practice of routine gastric residual aspiration in preterm infants remains controversial, with conflicting evidence regarding its impact on necrotizing enterocolitis (NEC). As front-line caregivers, nurses play a vital role in gastric aspiration procedures and must be informed by evidence. This quasi-experimental nursing study aimed to assess whether gastric aspiration is clinically relevant in reducing the risk of NEC in preterm infants.A total of 250 preterm infants from two NICUs in Egypt were allocated to the gastric aspiration (n = 125) and non-aspiration (n = 125) groups. Feeding practices, gastric residuals, and incidence/severity of NEC were compared between groups according to modified Bell's criteria. Risk factors were analyzed using multivariate regression. There were no significant baseline differences between the groups. The gastric residual attributes and feeding outcomes did not differ substantially from aspiration. The overall incidence of NEC was 14-15%, with no significant differences in the odds of onset or progression of NEC by stage between the groups. Lower gestational age and birth weight emerged as stronger predictors of NEC. Routine gastric aspiration does not appear to directly prevent or reduce the severity of NEC in this population. Although gastric residuals retain clinical importance, study findings question assumptions that aspiration protects against NEC and informs nursing practice. Evidence-based feeding protocols must continually evolve through ongoing research on modifiable risk factors for this devastating intestinal disease in preterm infants.

Influence of an Early Human Milk Diet on the Duration of Parenteral Nutrition and Incidence of Late-Onset Sepsis in Very Low Birthweight (VLBW) Infants: A Systematic Review

Introduction: Human milk is the preferred source of enteral nutrition for very low birthweight (VLBW) infants, and it possibly decreases dependence on parenteral nutrition (PN) and reduces incidence of late-onset sepsis (LOS). No systematic review to date has specifically addressed the value of early versus late introduction of human milk diet (HMD) on duration of PN and incidence of LOS among VLBW infants. Objective: To review the evidence for an early versus late introduction of HMD on duration of PN and incidence of LOS in VLBW infants. Method: Preferred reporting items for systematic reviews and meta-analysis-guided search of EMBASE and PubMed/Medline databases was conducted for this systematic review using phrases addressing population, intervention, comparator, and outcome framework to identify articles published over the past two decades without language restrictions. Full-text articles (both observational and randomized) that studied an early versus late initiation of HMD were included. Mean difference (MD) and relative risk (RR) with 95% confidence intervals (CIs) were calculated for PN and LOS. Quality of evidence was analyzed using UK National Service Framework and the risk-of-bias was assessed using Robvis®. Results: One randomized controlled trial (RCT) and two observational studies (two English and one Chinese) recruited 474 VLBW infants (455 analyzed). Among an intrauterine growth-restricted cohort enrolled in the RCT (n = 72), early HMD resulted in statistically significant reduction in PN dependence. However, no statistically significant difference was found in LOS. Two observational studies found similar reductions in PN duration and LOS incidence among the early HMD cohort. One observational study reported significant PN reduction; however, the incidence of LOS did not reach statistical significance in either case. Conclusion: An early HMD may reduce the duration of PN for a growth-restricted VLBW cohort. Observational studies suggesting reduced PN and LOS from early HMD endorse the need for bioactivity-focused human milk research. Variations in feeding guidelines among VLBW infants have the potential to influence neonatal outcomes significantly.

Implementing an exclusive human milk diet for preterm infants: real-world experience in diverse NICUs

BACKGROUND

Human milk-based human milk fortifier (HMB-HMF) makes it possible to provide an exclusive human milk diet (EHMD) to very low birth weight (VLBW) infants in neonatal intensive care units (NICUs). Before the introduction of HMB-HMF in 2006, NICUs relied on bovine milk-based human milk fortifiers (BMB-HMFs) when mother's own milk (MOM) or pasteurized donor human milk (PDHM) could not provide adequate nutrition. Despite evidence supporting the clinical benefits of an EHMD (such as reducing the frequency of morbidities), barriers prevent its widespread adoption, including limited health economics and outcomes data, cost concerns, and lack of standardized feeding guidelines.

METHODS

Nine experts from seven institutions gathered for a virtual roundtable discussion in October 2020 to discuss the benefits and challenges to implementing an EHMD program in the NICU environment. Each center provided a review of the process of starting their program and also presented data on various neonatal and financial metrics associated with the program. Data gathered were either from their own Vermont Oxford Network outcomes or an institutional clinical database. As each center utilizes their EHMD program in slightly different populations and over different time periods, data presented was center-specific. After all presentations, the experts discussed issues within the field of neonatology that need to be addressed with regards to the utilization of an EHMD in the NICU population.

RESULTS

Implementation of an EHMD program faces many barriers, no matter the NICU size, patient population or geographic location. Successful implementation requires a team approach (including finance and IT support) with a NICU champion. Having pre-specified target populations as well as data tracking is also helpful. Real-world experiences of NICUs with established EHMD programs show reductions in comorbidities, regardless of the institution's size or level of care. EHMD programs also proved to be cost effective. For the NICUs that had necrotizing enterocolitis (NEC) data available, EHMD programs resulted in either a decrease or change in total (medical + surgical) NEC rate and reductions in surgical NEC. Institutions that provided cost and complications data all reported a substantial cost avoidance after EHMD implementation, ranging between $515,113 and $3,369,515 annually per institution.

CONCLUSIONS

The data provided support the initiation of EHMD programs in NICUs for very preterm infants, but there are still methodologic issues to be addressed so that guidelines can be created and all NICUs, regardless of size, can provide standardized care that benefits VLBW infants.

Necrotizing Enterocolitis: The Role of Hypoxia, Gut Microbiome, and Microbial Metabolites

Necrotizing enterocolitis (NEC) is a life-threatening disease that predominantly affects very low birth weight preterm infants. Development of NEC in preterm infants is accompanied by high mortality. Surgical treatment of NEC can be complicated by short bowel syndrome, intestinal failure, parenteral nutrition-associated liver disease, and neurodevelopmental delay. Issues surrounding pathogenesis, prevention, and treatment of NEC remain unclear. This review summarizes data on prenatal risk factors for NEC, the role of pre-eclampsia, and intrauterine growth retardation in the pathogenesis of NEC. The role of hypoxia in NEC is discussed. Recent data on the role of the intestinal microbiome in the development of NEC, and features of the metabolome that can serve as potential biomarkers, are presented. The Pseudomonadota phylum is known to be associated with NEC in preterm neonates, and the role of other bacteria and their metabolites in NEC pathogenesis is also discussed. The most promising approaches for preventing and treating NEC are summarized.

Pneumatosis coli in preterm neonates: Can they be managed more conservatively to maintain the intestinal milieu?

Necrotising enterocolitis (NEC) is a severe gastrointestinal disease mostly in premature infants due to intestinal necrosis. The aetiology of NEC is multifactorial and includes gut immaturity, intestinal dysbiosis and exaggerated intestinal mucosal reactivity to microbial ligands. Radiographic evidence of pneumatosis intestinalis has been a critical feature for diagnosing NEC Bell stage ≥IIA and recommended treatment includes prolonged antibiotics (7-14 days) while off enteral feeds. Pneumatosis coli (Pcoli), a mild or benign form of NEC, is characterised by pneumatosis limited to the colon in an infant having haematochezia, negative septic screening and no systemic signs. We report two healthy preterm infants with haematochezia and colonic pneumatosis while on breast milk feeds. The sepsis screen was negative. A brief period of antibiotics and gut rest led to the spontaneous resolution of haematochezia and colonic pneumatosis, facilitating early enteral feeds. This case report emphasises the need to differentiate NEC from benign Pcoli.

Safety and efficacy of low-dose diazoxide in small-for-gestational-age infants with hyperinsulinaemic hypoglycaemia

OBJECTIVES

Diazoxide (DZX) is the drug of choice for treating hyperinsulinaemic hypoglycaemia (HH), and it has potentially serious adverse effects. We studied the safety and efficacy of low-dose DZX in small-for-gestational-age (SGA) infants with HH.

DESIGN

An observational cohort study from 1 September 2014 to 31 September 2020.

SETTING

A tertiary Women's and Children's Hospital in Singapore.

PATIENTS

All SGA infants with HH.

INTERVENTION

Diazoxide, at 3-5 mg/kg/day.

MAIN OUTCOME MEASURES

Short-term outcomes; adverse drug events and fasting studies to determine 'safe to go home' and 'resolution' of HH.

RESULTS

Among 71 836 live births, 11 493 (16%) were SGA. Fifty-six (0.5%) SGA infants with HH were identified, of which 27 (47%) with a mean gestational age of 36.4±2 weeks and birth weight of 1942±356 g required DZX treatment. Diazoxide was initiated at 3 mg/kg/day at a median age of 10 days. The mean effective dose was 4.6±2.2 mg/kg/day, with 24/27 (89%) receiving 3-5 mg/kg/day. Generalised hypertrichosis occurred in 2 (7.4%) and fluid retention in 1 (3.7%) infant. A fasting study was performed before home while on DZX in 26/27 (96%) cases. Diazoxide was discontinued at a median age of 63 days (9-198 days), and resolution of HH was confirmed in 26/27 (96%) infants on passing a fasting study.

CONCLUSION

Our study demonstrates that low-dose DZX effectively treats SGA infants with HH as measured by fasting studies. Although the safety profile was excellent, minimal adverse events were still observed with DZX, even at low doses.

Prevention of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is considered to be one of the most devastating intestinal diseases seen in neonatal intensive care. Measures to treat NEC are often too late, and we need effective preventative measures to alleviate the burden of this disease. The purpose of this review is to summarize currently used measures, and those showing future promise for prevention.

Safety and efficacy of probiotics in the prevention of necrotizing enterocolitis in premature and/or low-birthweight infants: a systematic review and meta-analysis

BACKGROUND

Neonatal necrotizing enterocolitis (NEC) is a serious pediatric gastrointestinal disease and a cause of death in neonates, especially in premature infants. The addition of probiotics to the diet can reduce the incidence and severity of neonatal NEC. This meta-analysis explored the preventive effect of probiotics on NEC.

METHODS

Endnote X9 software was used to search for relevant studies in the Ovid, Embase, PubMed, and Web of Science databases. The search terms were "probiotics" and "necrotizing enterocolitis". After retrieval, screening, and quality evaluation of the studies, Stata 16.0 software was used to analyze the data.

RESULTS

A total of 10 studies, which collectively included 3,227 patients, were selected for analysis. Of them, 5 used a multiple-strain probiotics, and 5 used single-strain probiotic. Meta-analysis showed that treatment with probiotics could reduce the incidence of severe NEC [risk ratio (RR) =0.66; 95% confidence interval (CI): (0.50, 0.87); Z=-2.978; P=0.003], reduce mortality in underweight premature children [RR =0.81; 95% CI: (0.70, 0.94); Z=-2.864; P=0.004], and reduce the incidence of feeding intolerance [RR =0.78; 95% CI: (0.67, 0.90); Z=-3.280; P=0.001].

DISCUSSION

The addition of probiotics to the diet of low-birthweight and premature infants can reduce the incidence of severe NEC and reduce related mortality rates.

Probiotics in the Prevention and Treatment of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a disease with high morbidity and mortality that occurs mainly in premature born infants. The pathophysiologic mechanisms indicate that gastrointestinal dysbiosis is a major risk factor. We searched for relevant articles published in PubMed and Google Scholar in the English language up to October 2020. Articles were extracted using subject headings and keywords of interest to the topic. Interesting references in included articles were also considered. Network meta-analysis suggests the preventive efficacy of Bifidobacterium and Lactobacillus spp., but even more for mixtures of Bifidobacterium, Streptococcus, and Bifidobacterium, and Streptococcus spp. However, studies comparing face-to-face different strains are lacking. Moreover, differences in inclusion criteria, dosage strains, and primary outcomes in most trials are major obstacles to providing evidence-based conclusions. Although adverse effects have not been reported in clinical trials, case series of adverse outcomes, mainly septicemia, have been published. Consequently, systematic administration of probiotic bacteria to prevent NEC is still debated in literature. The risk-benefit ratio depends on the incidence of NEC in a neonatal intensive care unit, and evidence has shown that preventive measures excluding probiotic administration can result in a decrease in NEC.