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Hirsch TI, Wang SZ, Fligor SC, Quigley M, Gura KM, Puder M, Tsikis ST. Fat malabsorption in short bowel syndrome: A review of pathophysiology and management. Nutr Clin Pract 2024; 39 Suppl 1:S17-S28. [PMID: 38429962 PMCID: PMC10914324 DOI: 10.1002/ncp.11119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/13/2023] [Accepted: 12/28/2023] [Indexed: 03/03/2024] Open
Abstract
Fat malabsorption is central to the pathophysiology of short bowel syndrome (SBS). It occurs in patients with insufficient intestinal surface area and/or function to maintain metabolic and growth demands. Rapid intestinal transit and impaired bile acid recycling further contribute to fat malabsorption. A significant portion of patients require parenteral nutrition (PN) for their survival but may develop sepsis and liver dysfunction as a result. Despite advancements in the treatment of SBS, fat malabsorption remains a chronic issue for this vulnerable patient population. Peer-reviewed literature was assessed on the topic of fat malabsorption in SBS. Current management of patients with SBS involves dietary considerations, PN management, antidiarrheals, glucagon-like peptide 2 agonists, and multidisciplinary teams. Clinical trials have focused on improving intestinal fat absorption by facilitating fat digestion with pancreatic enzymes. Targeting fat malabsorption in SBS is a potential pathway to improving lifestyle and reducing morbidity and mortality in this rare disease.
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Affiliation(s)
- Thomas I. Hirsch
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Z. Wang
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott C. Fligor
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Mikayla Quigley
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathleen M. Gura
- Department of Pharmacy and the Division of Gastroenterology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark Puder
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Savas T. Tsikis
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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Frazer LC, Yamaguchi Y, Singh DK, Akopyants NS, Good M. DNA methylation in necrotizing enterocolitis. Expert Rev Mol Med 2024; 26:e16. [PMID: 38557638 PMCID: PMC11140546 DOI: 10.1017/erm.2024.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 03/05/2024] [Accepted: 03/26/2024] [Indexed: 04/04/2024]
Abstract
Epigenetic modifications, such as DNA methylation, are enzymatically regulated processes that directly impact gene expression patterns. In early life, they are central to developmental programming and have also been implicated in regulating inflammatory responses. Research into the role of epigenetics in neonatal health is limited, but there is a growing body of literature related to the role of DNA methylation patterns and diseases of prematurity, such as the intestinal disease necrotizing enterocolitis (NEC). NEC is a severe intestinal inflammatory disease, but the key factors that precede disease development remain to be determined. This knowledge gap has led to a failure to design effective targeted therapies and identify specific biomarkers of disease. Recent literature has identified altered DNA methylation patterns in the stool and intestinal tissue of neonates with NEC. These findings provide the foundation for a new avenue in NEC research. In this review, we will provide a general overview of DNA methylation and then specifically discuss the recent literature related to methylation patterns in neonates with NEC. We will also discuss how DNA methylation is used as a biomarker for other disease states and how, with further research, methylation patterns may serve as potential biomarkers for NEC.
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Affiliation(s)
- Lauren C. Frazer
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yukihiro Yamaguchi
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dhirendra K. Singh
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Natalia S. Akopyants
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Misty Good
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Pugliesi RA, Dasyam AK, Borhani AA. Intestinal and Multivisceral Transplantation: Indications and Surgical Techniques. Radiol Clin North Am 2023; 61:861-870. [PMID: 37495293 DOI: 10.1016/j.rcl.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Intestinal transplantation and multivisceral transplantation are technically challenging and complex procedures mainly performed on patients with irreversible and non-medically manageable end-stage intestinal failure. Increasingly, other organs besides small intestines are included in the allograft for which the terms "composite intestinal transplantation" and "multivisceral transplantation" are used. Commonly, complex vascular reconstructions are used for these procedures. Knowledge of surgical anatomy hence is essential for accurate interpretation of postoperative imaging in these patients. This article reviews the indications and most common surgical techniques for intestinal and multivisceral transplantations.
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Affiliation(s)
- Rosa Alba Pugliesi
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 North St. Claire Street, Suite 800, Chicago, IL 60611, USA
| | - Anil K Dasyam
- Department of Radiology, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Amir A Borhani
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 North St. Claire Street, Suite 800, Chicago, IL 60611, USA.
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Chiba M, Masumoto K, Kaji T, Matsuura T, Morii M, Fagbemi A, Hill S, Pakarinen MP, Protheroe S, Urs A, Chen ST, Sakui S, Udagawa E, Wada M. Efficacy and Safety of Teduglutide in Infants and Children With Short Bowel Syndrome Dependent on Parenteral Support. J Pediatr Gastroenterol Nutr 2023; 77:339-346. [PMID: 37364133 PMCID: PMC10412081 DOI: 10.1097/mpg.0000000000003867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 06/08/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES Our objective was to evaluate the short- and long-term safety and efficacy of teduglutide treatment in infants and children with short bowel syndrome with intestinal failure (SBS-IF). METHODS Two open-label phase 3 studies and 1 extension study investigated the short- and long-term safety and efficacy of teduglutide (0.05 mg/kg/day) in infants and children with SBS-IF: NCT03571516, 24-week study of infants who were randomized to receive teduglutide or standard of care (SoC); NCT02980666, 24-week study of infants and children who all received teduglutide; and NCT03268811, 24-week extension study of patients who completed NCT02980666 (patients could receive up to 48 weeks of total treatment). RESULTS Twelve infants and 8 children enrolled in the core studies, and 2 infants and 7 children in the extension study. After 24 weeks of treatment, parenteral support (PS) requirements reduced by ≥20% from baseline for 4 infants (57.1%) and 4 children (66.7%) receiving teduglutide and for 2 infants receiving SoC (50.0%). One infant (50.0%) and 4 children (80.0%) receiving teduglutide maintained the ≥20% reduction in PS at 48 weeks of treatment. Two children receiving teduglutide achieved enteral autonomy, after 12 weeks and 28 weeks of treatment, respectively. All adverse events (AEs) were in line with known impacts of SBS-IF and adverse reactions to teduglutide. Only one serious AE (abdominal pain) was considered related to teduglutide. CONCLUSIONS Short- and long-term treatment with teduglutide resulted in clinically meaningful reductions in PS requirements for infants and children with SBS-IF. Teduglutide was well tolerated, and efficacy improved with longer-term treatment.
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Affiliation(s)
- Masahiro Chiba
- From the Division of Pediatric Surgery, Department of Surgery, Showa University, Tokyo, Japan
| | - Kouji Masumoto
- the Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tatsuru Kaji
- the Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Toshiharu Matsuura
- the Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mayako Morii
- the Department of Pediatric Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Andrew Fagbemi
- the Department of Paediatric Gastroenterology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Susan Hill
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, NHS Foundation Trust and UCL Institute of Child Health, London, UK
| | - Mikko P. Pakarinen
- the Pediatric Research Center, Children’s Hospital, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Susan Protheroe
- the Department of Gastroenterology and Nutrition, Birmingham Women and Children’s Hospital, Birmingham, UK
| | - Arun Urs
- the Department of Paediatric Gastroenterology, Sheffield Children’s Hospital, Sheffield, UK
| | - Szu-Ta Chen
- Takeda Development Center Americas, Inc., Boston, MA, USA
| | - Sho Sakui
- Statistical and Quantitative Sciences, Data Sciences Institute, Takeda Pharmaceutical Company Limited, Osaka, Japan
| | - Eri Udagawa
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Motoshi Wada
- the Department of Pediatric Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- the Division of Pediatric Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Japan
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Caporilli C, Giannì G, Grassi F, Esposito S. An Overview of Short-Bowel Syndrome in Pediatric Patients: Focus on Clinical Management and Prevention of Complications. Nutrients 2023; 15:nu15102341. [PMID: 37242224 DOI: 10.3390/nu15102341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/26/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Short-bowel syndrome (SBS) in pediatric age is defined as a malabsorptive state, resulting from congenital malformations, significant small intestine surgical resection or disease-associated loss of absorption. SBS is the leading cause of intestinal failure in children and the underlying cause in 50% of patients on home parental nutrition. It is a life-altering and life-threatening disease due to the inability of the residual intestinal function to maintain nutritional homeostasis of protein, fluid, electrolyte or micronutrient without parenteral or enteral supplementation. The use of parenteral nutrition (PN) has improved medical care in SBS, decreasing mortality and improving the overall prognosis. However, the long-term use of PN is associated with the incidence of many complications, including liver disease and catheter-associated malfunction and bloodstream infections (CRBSIs). This manuscript is a narrative review of the current available evidence on the management of SBS in the pediatric population, focusing on prognostic factors and outcome. The literature review showed that in recent years, the standardization of management has demonstrated to improve the quality of life in these complex patients. Moreover, the development of knowledge in clinical practice has led to a reduction in mortality and morbidity. Diagnostic and therapeutic decisions should be made by a multidisciplinary team that includes neonatologists, pediatric surgeons, gastroenterologists, pediatricians, nutritionists and nurses. A significant improvement in prognosis can occur through the careful monitoring of nutritional status, avoiding dependence on PN and favoring an early introduction of enteral nutrition, and through the prevention, diagnosis and aggressive treatment of CRSBIs and SIBO. Multicenter initiatives, such as research consortium or data registries, are mandatory in order to personalize the management of these patients, improve their quality of life and reduce the cost of care.
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Affiliation(s)
- Chiara Caporilli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Giuliana Giannì
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Federica Grassi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
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Oshima K, Hinoki A, Uchida H, Tanaka Y, Okuno Y, Go Y, Shirota C, Tainaka T, Sumida W, Yokota K, Makita S, Takimoto A, Kano Y, Sawa S. Single-cell RNA sequencing of intestinal immune cells in neonatal necrotizing enterocolitis. Pediatr Surg Int 2023; 39:179. [PMID: 37041419 DOI: 10.1007/s00383-023-05461-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 04/13/2023]
Abstract
PURPOSE Necrotizing enterocolitis (NEC) causes fatal intestinal necrosis in neonates, but its etiology is unknown. We analyzed the intestinal immune response to NEC. METHODS Using single-cell RNA sequencing (scRNA-seq), we analyzed the gene expression profiles of intestinal immune cells from four neonates with intestinal perforation (two with NEC and two without NEC). Target mononuclear cells were extracted from the lamina propria of the resected intestines. RESULTS In all four cases, major immune cells, such as T cells (15.1-47.7%), B cells (3.1-19.0%), monocytes (16.5-31.2%), macrophages (1.6-17.4%), dendritic cells (2.4-12.2%), and natural killer cells (7.5-12.8%), were present in similar proportions to those in the neonatal cord blood. Gene set enrichment analysis showed that the MTOR, TNF-α, and MYC signaling pathways were enriched in T cells of the NEC patients, suggesting upregulated immune responses related to inflammation and cell proliferation. In addition, all four cases exhibited a bias toward cell-mediated inflammation, based on the predominance of T helper 1 cells. CONCLUSION Intestinal immunity in NEC subjects exhibited stronger inflammatory responses compared to non-NEC subjects. Further scRNA-seq and cellular analysis may improve our understanding of the pathogenesis of NEC.
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Affiliation(s)
- Kazuo Oshima
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Pediatric Surgery, Saitama Medical University, Saitama, Japan
| | - Akinari Hinoki
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yujiro Tanaka
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Pediatric Surgery, Saitama Medical University, Saitama, Japan
| | - Yusuke Okuno
- Department of Virology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yasuhiro Go
- Cognitive Genomics Research Group, Exploratory Research Center on Life and Living Systems (ExCELLS), National Institutes of Natural Sciences, Okazaki, Japan
- Department of System Neuroscience, National Institute for Physiological Science, Okazaki, Japan
- Department of Physiological Science, School of Life Science, SOKENDAI (The Graduate University for Advanced Studies), Okazaki, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahisa Tainaka
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuki Yokota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Aitaro Takimoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoko Kano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinichiro Sawa
- Division of Mucosal Immunology, Research Center for Systems Immunology, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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Lee ES, Kim EK, Shin SH, Jung YH, Song IG, Kim YJ, Kim HY, Choi YH, Moon KC, Kim B. Efficacy and safety of mucous fistula refeeding in preterm infants: an exploratory randomized controlled trial. BMC Pediatr 2023; 23:137. [PMID: 36991415 PMCID: PMC10053085 DOI: 10.1186/s12887-023-03950-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 03/09/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND This study aimed to evaluate whether mucous fistula refeeding (MFR) is safe and beneficial for the growth and intestinal adaptation of preterm infants with enterostomies. METHODS This exploratory randomized controlled trial enrolled infants born before 35 weeks' gestation with enterostomy. If the stomal output was ≥ 40 mL/kg/day, infants were assigned to the high-output MFR group and received MFR. If the stoma output was < 40 mL/kg/day, infants were randomized to the normal-output MFR group or the control group. Growth, serum citrulline levels, and bowel diameter in loopograms were compared. The safety of MFR was evaluated. RESULTS Twenty infants were included. The growth rate increased considerably, and the colon diameter was significantly larger after MFR. However, the citrulline levels did not significantly differ between the normal-output MFR and the control group. One case of bowel perforation occurred during the manual reduction for stoma prolapse. Although the association with MFR was unclear, two cases of culture-proven sepsis during MFR were noted. CONCLUSIONS MFR benefits the growth and intestinal adaptation of preterm infants with enterostomy and can be safely implemented with a standardized protocol. However, infectious complications need to be investigated further. TRIAL REGISTRATION clinicaltrials.gov NCT02812095, retrospectively registered on June 6, 2016.
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Affiliation(s)
- Eun Sun Lee
- Department of Pediatrics, Seoul National University Children's Hospital, 101, Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
- Department of Pediatrics, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University Children's Hospital, 101, Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea.
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University Children's Hospital, 101, Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Hwa Jung
- Department of Pediatrics, Seoul National University Children's Hospital, 101, Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - In-Gyu Song
- Department of Pediatrics, Seoul National University Children's Hospital, 101, Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
- Department of Pediatrics, Korea University Medical Centre, Guro Hospital, Seoul, Republic of Korea
| | - Yoo-Jin Kim
- Department of Pediatrics, Seoul National University Children's Hospital, 101, Daehak-Ro, Jongno-Gu, Seoul, 03080, South Korea
- Department of Pediatrics, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Hyun Young Kim
- Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Young-Hun Choi
- Department of Radiology, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Kyung Chul Moon
- Department of Pathology, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Bohyun Kim
- Department of Pathology, Seoul National University Children's Hospital, Seoul, Republic of Korea
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Chaaban H, Hunter C. Introduction. Semin Perinatol 2023; 47:151697. [PMID: 36599762 DOI: 10.1016/j.semperi.2022.151697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Hala Chaaban
- Department of Pediatrics, The University of Oklahoma Health Science Center.
| | - Catherine Hunter
- Division of Pediatric Surgery, The University of Oklahoma Health Sciences Center (OUHSC)
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Roggero P, Liotto N, Piemontese P, Menis C, Perrone M, Tabasso C, Amato O, Orsi A, Pesenti N, Leva E, Mosca F. Neonatal intestinal failure: Growth pattern and nutrition intakes in accordance with weaning from parenteral nutrition. JPEN J Parenter Enteral Nutr 2023; 47:236-244. [PMID: 36398420 DOI: 10.1002/jpen.2465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/08/2022] [Accepted: 11/13/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Short bowel syndrome is the most common cause of intestinal failure (IF) in infants. We aimed to evaluate growth, nutrition intakes, and predictors of weaning from parenteral nutrition (PN) of infants with IF. METHODS Clinical parameters, nutrition intakes, body weight and length z-scores were compared monthly from the 1st to 12th and at 18 and 24 months among infants receiving PN and those weaned. Logistic regression analysis was conducted to explore the predictors of weaning. RESULTS We included 23 infants (10/23 weaned). Median [range: minimum; maximum] birth weight and gestational age were 1620 [590; 3490] g and 31 [24; 39] weeks, respectively. All infants showed growth retardation with similar median delta weight z-score from birth to discharge: -1.48 [-1.92; -0.94] in not-weaned and -1.18 [-2.70; 0.31] in weaned infants (P = 0.833) and a subsequent regain after the discharge: 0.20 [-3.47; 3.25] and 0.84 [-0.03; 2.58], respectively (P = 0.518). No differences in length z-score were found. After the sixth month, infants weaned from PN received lower PN energy and protein intakes compared with those not-weaned. Infants weaned from PN showed lower PN dependency index (PNDI%) from 5 months onward (45% for weaned and 113% for not-weaned infants at 5 months: P < 0.001). The Belza score, a predictor of enteral autonomy computed at 6 months, is associated with being weaned from PN within 24 months (odds ratio: 1.906; P = 0.039). CONCLUSION Infants weaned and not-weaned showed similar growth patterns. Our findings support the clinical relevance of Belza score and PNDI% as predictors of weaning from PN.
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Affiliation(s)
- Paola Roggero
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Nadia Liotto
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Pasqua Piemontese
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Camilla Menis
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Michela Perrone
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Chiara Tabasso
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Orsola Amato
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Anna Orsi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Nicola Pesenti
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Fabio Mosca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Milan, Italy
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CCL3 aggravates intestinal damage in NEC by promoting macrophage chemotaxis and M1 macrophage polarization. Pediatr Res 2022:10.1038/s41390-022-02409-w. [PMID: 36550354 DOI: 10.1038/s41390-022-02409-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 11/04/2022] [Accepted: 11/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND NEC is a life-threatening gastrointestinal disease in neonates, the pathogenesis of which remains poorly understood. METHODS CCL3 levels in intestinal tissue of mice were measured and analyzed. HE staining was used to assess pathological changes in intestinal tissue. FCM was used to detect the proportion and phenotype of macrophages. RNA-seq and RT-PCR were used to evaluate the effect of CCL3 on macrophages. RESULTS CCL3 was highly expressed in the intestinal tissues of mice with NEC and induced macrophage infiltration. Transcriptome data showed that CCL3 strongly induced a transition in the phenotype of macrophages into a proinflammatory one. Mechanistically, in vivo experiments confirmed that CCL3 induced M1 macrophage polarization in NEC intestinal tissue, thereby aggravating inflammatory injury of intestinal tissue, which was alleviated by anti-CCL3 treatment. In addition, in vitro experiments showed that CCL3 significantly enhances the expression of M1-related genes in both PMφ and BMDM while inhibiting the expression of M2-related genes, which was also alleviated by anti-CCl3 treatment. CONCLUSIONS Our data elucidated the involvement of CCL3 in the pathogenesis of NEC, in which upregulated CCL3 expression exacerbated inflammatory intestinal damage by regulating macrophage chemotaxis and M1 phenotype polarization, suggesting that blocking CCL3 may be a potential strategy for effective intervention in NEC. IMPACT Our study represents an important conceptual advancement that CCL3 may be one of the key culprits of intestinal tissue damage in patients with NEC. CCL3 aggravates inflammatory intestinal injury and intestinal mucosal barrier imbalance by regulating the chemotaxis, polarization, and function of macrophages. Blocking CCL3 significantly reduced NEC-mediated intestinal injury, suggesting a new potential therapeutic strategy.
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11
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Garg PM, Paschal JL, Ansari MAY, Block D, Inagaki K, Weitkamp JH. Clinical impact of NEC-associated sepsis on outcomes in preterm infants. Pediatr Res 2022; 92:1705-1715. [PMID: 35352003 DOI: 10.1038/s41390-022-02034-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 03/07/2022] [Accepted: 03/11/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To determine risk factors and outcomes of necrotizing enterocolitis (NEC)-associated sepsis in infants with NEC. METHODS A retrospective review comparing demographic and clinical information in infants with and without NEC-associated sepsis (defined as positive blood culture at the time of NEC onset). RESULTS A total of 209 infants with medical (n = 98) and surgical NEC (n = 111) had a median gestational age of 27 weeks (IQR 25; 30.5) and a median birth weight of 910 g [IQR 655; 1138]. Fifty of 209 (23.9%) infants had NEC-associated sepsis. Infants with NEC-associated sepsis had lower median GA (26.4 vs. 27.4 weeks; p = 0.01), lower birth weight (745 vs. 930 g; p = 0.009), were more likely mechanically ventilated [p < 0.001], received dopamine [p < 0.001], had more evidence of acute kidney injury [60% vs. 38.4%, p = 0.01], longer postoperative ileus (16 [13.0; 22.0] vs. 12 [8; 16] days; p = 0.006), higher levels of C-reactive protein, lower platelet counts, longer hospitalization compared to infants without NEC-associated sepsis. On multivariate regression, cholestasis was an independent risk factor for NEC-associated sepsis (OR 2.94; 95% CI 1.1-8.8, p = 0.038). CONCLUSION NEC-associated sepsis was associated with greater hemodynamic support, acute kidney injury, longer postoperative ileus, and hospitalization on bivariate analysis, and cholestasis was associated with higher odds of sepsis on multi regression analysis. IMPACT NEC-associated sepsis was present in 24% of infants with NEC. Gram-positive bacteria, Gram-negative bacteria, and Candida were found in 15.3%, 10.5%, and 2.8% of cases, respectively. Infants with NEC-associated sepsis had a greater inflammatory response (CRP levels), received more blood transfusion before NEC onset, frequently needed assisted ventilation ionotropic support, and had acute kidney injury after NEC onset. NEC infants with Gram-negative sepsis had higher portal venous gas, received more platelet transfusions before NEC onset, and had higher CRP levels and lower median lymphocyte counts at 24 h after NEC onset than those with Gram-positive sepsis.
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA.
| | - Jaslyn L Paschal
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Md Abu Yusuf Ansari
- Department of Data Science, University of Mississippi Medical Center, Jackson, MS, USA
| | - Danielle Block
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kengo Inagaki
- Department of Pediatrics/Infectious Disease, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jörn-Hendrik Weitkamp
- Department of Pediatrics/Neonatology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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12
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Saayman BD, Millar AJW, van Niekerk E. Nutritional interventions and outcomes of children with short bowel syndrome in a tertiary hospital setting in South Africa. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2022. [DOI: 10.1080/16070658.2022.2114404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- BD Saayman
- Department of Dietetics, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - AJW Millar
- Department of Pediatric Surgery, University of Cape Town and Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - E van Niekerk
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
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13
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Okeke R, Saliba C, Phocas A, Schmidt EM, Keranalli P, Hallcox T, Wycoff M, Lin J, Kurashima M, Wunker C, Miyata S, Blewett C. Transluminal stenting: An intraoperative adjunct for preserving bowel length in the surgical management of necrotizing enterocolitis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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14
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Vinit N, Talbotec C, De Tristan MA, Salomon LJ, Giuseppi A, Rousseau V, Beaudoin S, Lambe C, Ville Y, Sarnacki S, Goulet O, Chardot C, Lapillonne A, Khen-Dunlop N. Predicting Factors of Protracted Intestinal Failure in Children with Gastroschisis. J Pediatr 2022; 243:122-129.e2. [PMID: 34748742 DOI: 10.1016/j.jpeds.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To identify prenatal and neonatal predictors of short bowel syndrome-related intestinal failure (SBS-IF) in gastroschisis. STUDY DESIGN This retrospective study included all patients with gastroschisis born between 2000 and 2017 who were enrolled in our home parenteral nutrition program, and all patients with gastroschisis born in our institution who survived 2 weeks, during the same time period. Prenatal ultrasound features, neonatal status, anatomic features, oral feeding, and parenteral nutrition dependency were analyzed. RESULTS Among 180 patients, 35 required long-term parenteral nutrition (SBS-IF group) and 145 acquired full oral feeding within 6 months (oral feeding group). The mean follow-up was 7.9 years (IQR, 1.6-17.5 years) and 5.0 years (IQR, 0.1-18.2 years), respectively. Both bowel matting (OR, 14.23; 1.07-16.7; P = .039) and secondarily diagnosed atresia or stenosis (OR, 17.78; 3.13-100.98; P = .001) were independent postnatal predictors of SBS-IF. Eighteen children (51% of the SBS-IF group) were still dependent on artificial nutrition at the last follow-up. patients with SBS-IF who achieved full oral feeding had a median residual small-bowel length of 74 cm (IQR, 51-160 cm) vs 44 cm (IQR, 10-105 cm) for those still dependent on artificial nutrition (P = .02). An initial residual small bowel length of more than 50 cm was the best predictive cut-off for nutritional autonomy, with a sensitivity of 67% and a specificity of 100%. CONCLUSIONS Bowel matting, complex gastroschisis, and secondary intestinal obstruction were associated with SBS-IF in gastroschisis. For patients with SBS-IF, a small bowel length of more than 50 cm was predictive of secondary nutritional autonomy.
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Affiliation(s)
- Nicolas Vinit
- Department of Pediatric Surgery and Transplantation, Necker-Enfants Malades Hospital, APHP, Paris, France.
| | - Cécile Talbotec
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Necker-Enfants Malades Hospital, APHP, Paris, France
| | | | - Laurent J Salomon
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France; Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Agnès Giuseppi
- Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Véronique Rousseau
- Department of Pediatric Surgery and Transplantation, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Sylvie Beaudoin
- Department of Pediatric Surgery and Transplantation, Necker-Enfants Malades Hospital, APHP, Paris, France; Paris Descartes School of Medicine, Paris Center University, Paris, France
| | - Cécile Lambe
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Yves Ville
- Department of Obstetrics, Fetal Medicine and Surgery, Necker-Enfants Malades Hospital, APHP, Paris, France; Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Sabine Sarnacki
- Department of Pediatric Surgery and Transplantation, Necker-Enfants Malades Hospital, APHP, Paris, France; Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Olivier Goulet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Necker-Enfants Malades Hospital, APHP, Paris, France; Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Christophe Chardot
- Department of Pediatric Surgery and Transplantation, Necker-Enfants Malades Hospital, APHP, Paris, France; Paris Descartes School of Medicine, Paris Center University, Paris, France
| | - Alexandre Lapillonne
- Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, APHP, Paris, France; Paris Descartes School of Medicine, Paris Center University, Paris, France
| | - Naziha Khen-Dunlop
- Department of Pediatric Surgery and Transplantation, Necker-Enfants Malades Hospital, APHP, Paris, France; Paris Descartes School of Medicine, Paris Center University, Paris, France
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15
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Garg PM, Paschal JL, Lett K, Middleton C, Varshney N, Maheshwari A. Intestinal Resection is More Likely to be Effective in Necrotizing Enterocolitis Extending to Colon than in Disease Limited to the Small Intestine. NEWBORN 2022; 1:14-26. [PMID: 35846895 PMCID: PMC9282977 DOI: 10.5005/jp-journals-11002-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: The prognosis in surgical necrotizing enterocolitis (NEC) has focused on the total length of the resected bowel; the relative impact of small intestinal vs colonic resection is not well studied. Objective: We hypothesized that intestinal resections may reduce mortality and length of hospital stay (LOS) more likely in infants who have NEC extending into the colon than in those with disease limited to the small intestine. We also investigated the relationship between gestational maturation and NEC-related mortality. Methods: A retrospective study of 153 patients compared demographic, clinical, and histopathological information in infants who had NEC limited to the small intestine vs disease with colonic involvement. Results: Our 153 infants had a mean (±standard deviation) gestational age of 27.4 ± 3.4 weeks and a birth weight of 987 ± 505 g. NEC was limited to the small intestine in 103 (67.3%) infants and extended into the colon in 50 (32.7%). Infants with small intestinal NEC needed shorter bowel resections of 28 ± 31.9 cm than 42.2 ± 40.7 cm in those with colonic involvement (p = 0.02). The LOS was longer in NEC limited to the small intestine than in disease with colonic lesions (96 ± 88.1 vs 69.7 ± 19.1 days; p <0.05). In small intestinal NEC, mortality decreased to <50% beyond a gestational age (GA) >37 weeks. In contrast, infants with NEC that involved the colon had mortality <50% mortality beyond 27.3 weeks’ GA (p = 0.008). Conclusions: Bowel resections may be more likely associated with shorter LOS in surgical NEC that involves both the small bowel and colon, even when longer segments of the gastrointestinal tract are removed, than in disease limited to the small intestine.
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Affiliation(s)
- Parvesh M Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Jaslyn L Paschal
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Katherine Lett
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Charles Middleton
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Neha Varshney
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Akhil Maheshwari
- Global Newborn Society, Clarksville, Maryland, United States of America
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16
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Tazuke Y, Udagawa E, Mizushima T, Nakamura S, Fernandez J, Okuyama H. Real-world etiologies and treatments of pediatric short bowel syndrome in Japan. Pediatr Int 2022; 64:e15258. [PMID: 36163637 PMCID: PMC9828786 DOI: 10.1111/ped.15258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Short bowel syndrome (SBS) is a rare disease that can result in intestinal failure (IF). Short bowel syndrome intestinal failure leads to stunted growth and development and high mortality rates. The primary goal of treatment is to enhance intestinal adaptation and nutrient absorption. Parenteral nutrition (PN) is used to support this process until enteral autonomy can be restored. Some patients experience prolonged partial or complete dependency on PN and face an increased risk of life-threatening catheter-related bloodstream infections and intestinal failure-associated liver disease. This study aimed to provide real-world insights into the patient characteristics and treatment dynamics of PN-dependent children with SBS-IF in Japan. METHODS This retrospective observational study used anonymized information from a large hospital-based medical insurance database to identify pediatric patients who received PN for ≥6 months between April 2008 and January 2020. The primary endpoint was weaning from PN. Secondary endpoints included duration and complications of PN. RESULTS Forty-eight children (mean age, 2.9 years) were eligible for inclusion. The most common causes of SBS-IF were mechanical bowel obstruction, functional bowel disorders, and Hirschsprung's disease. Twenty-two patients (45.8%) were weaned from PN during the study. The mean time to first weaning was 464.2 days and five patients (22.7%) restarted PN. The mean total duration of PN was 692.6 days in weaned patients and 1,170.9 days in unweaned patients. The most frequent complications were sepsis, catheter infections (both 79.2%), and liver dysfunction (64.6%). CONCLUSIONS Pediatric patients with SBS-IF faced difficulties when weaning off PN and rates of life-threatening complications were high.
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Affiliation(s)
- Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Eri Udagawa
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Tsunekazu Mizushima
- Department of Therapeutics for Inflammatory Bowel Diseases, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shiro Nakamura
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Jovelle Fernandez
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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17
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Modi BP, Galloway DP, Gura K, Nucci A, Plogsted S, Tucker A, Wales PW. ASPEN definitions in pediatric intestinal failure. JPEN J Parenter Enteral Nutr 2021; 46:42-59. [PMID: 34287974 DOI: 10.1002/jpen.2232] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 11/09/2022]
Abstract
Pediatric intestinal failure (PIF) is a relatively rare disease entity which requires focused interdisciplinary care and specialized nutrition management. There has long been a lack of consensus in the definition of key terms related to PIF due to its rarity and plethora of small studies rather than large trials. As such, the American Society for Parenteral and Enteral Nutrition (ASPEN) Pediatric Intestinal Failure Section, composed of clinicians from a variety of disciplines caring for children with intestinal failure, is uniquely poised to provide insight into this definition void. This document is the product of an effort by the Section to create evidence-based consensus definitions, with the goal of allowing for appropriate comparisons between clinical studies and measurement of longterm patient outcomes. This manuscript was approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David P Galloway
- Division of Gastroenterology, Hepatology and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kathleen Gura
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anita Nucci
- Department of Nutrition, Georgia State University, Atlanta, Georgia, USA
| | | | - Alyssa Tucker
- Department of Clinical Nutrition, Children's National Medical Center, Washington, District of Columbia, USA
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment, Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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18
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Strobel KM, Romero T, Kramer K, Fernandez E, Rottkamp C, Uy C, Keller R, Moyer L, Poulain F, Kim JH, DeUgarte DA, Calkins KL. Growth Failure Prevalence in Neonates with Gastroschisis : A Statewide Cohort Study. J Pediatr 2021; 233:112-118.e3. [PMID: 33647253 PMCID: PMC8154735 DOI: 10.1016/j.jpeds.2021.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To perform a multicenter study to assess growth failure in hospitalized infants with gastroschisis. STUDY DESIGN This study included neonates with gastroschisis within sites in the University of California Fetal Consortium. The study's primary outcome was growth failure at hospital discharge, defined as a weight or length z score decrease >0.8 from birth. Regression analysis was performed to assess changes in z scores over time. RESULTS Among 125 infants with gastroschisis, the median gestational age was 37 weeks (IQR 35-37). Length of stay was 32 days (23-60); 55% developed weight or length growth failure at discharge (28% had weight growth failure, 42% had length growth failure, and 15% had both weight and length growth failure). Weight and length z scores at 14 days, 30 days, and discharge were less than birth (P < .01 for all). Weight and length z scores declined from birth to 30 days (-0.10 and -0.11 z score units/week, respectively, P < .001). Length growth failure at discharge was associated with weight and length z score changes over time (P < .05 for both). Lower gestational age was associated with weight growth failure (OR 0.70 for each gestational age week, 95% CI 0.55-0.89, P = .004). CONCLUSIONS Growth failure, in particular linear growth failure, is common in infants with gastroschisis. These data suggest the need to improve nutritional management in these infants.
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Affiliation(s)
- Katie M Strobel
- Division of Neonatology and Developmental Biology, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA.
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, Department of Medicine Statistics Core, University of California Los Angeles, Los Angeles, CA
| | - Katelin Kramer
- Division of Neonatology, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Erika Fernandez
- Division of Neonatology, Department of Pediatrics, University of California San Diego, San Diego, CA
| | - Catherine Rottkamp
- Division of Neonatology, Department of Pediatrics, University of California Davis, Davis, CA
| | - Cherry Uy
- Division of Neonatal/Perinatal Medicine, Department of Pediatrics, University of California Irvine, Irvine, CA
| | - Roberta Keller
- Division of Neonatology, Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Laurel Moyer
- Division of Neonatology, Rady Children's Hospital, San Diego, CA
| | - Francis Poulain
- Division of Neonatology, Department of Pediatrics, University of California Davis, Davis, CA
| | - Jae H Kim
- Division of Neonatology, Department of Pediatrics, University of California San Diego, San Diego, CA
| | - Daniel A DeUgarte
- Division of Pediatric Surgery, Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Kara L Calkins
- Division of Neonatology and Developmental Biology, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA
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19
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Sanaksenaho G, Mutanen A, Godbole N, Hukkinen M, Merras-Salmio L, Kivisaari R, Kyrönlahti A, Pihlajoki M, Lohi J, Heikinheimo M, Pakarinen MP. Compromised duodenal mucosal integrity in children with short bowel syndrome after adaptation to enteral autonomy. J Pediatr Surg 2021; 56:966-974. [PMID: 33131778 DOI: 10.1016/j.jpedsurg.2020.09.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/23/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Intestinal adaptation has been extensively studied experimentally, but very limited data is available on human subjects. In this study we assessed intestinal adaption in humans with short bowel syndrome (SBS). METHODS We comparatively evaluated mucosal hyperplasia, inflammation, barrier function and nutrient transport using histology, immunohistochemistry and qPCR for selected 52 key genes in duodenal biopsies obtained from children with SBS after weaning off parenteral nutrition (n = 33), and matched controls without intestinal pathology (n = 12). Small bowel dilatation was assessed from contrast small bowel series. RESULTS Duodenal mucosa of SBS children showed increased histologic inflammation of lamina propria (p = 0.033) and mucosal mRNA expression of tumor necrosis factor (p = 0.027), transforming growth factor (TGF)-β2 (p = 0.006) and caveolin-1 (CAV1; p = 0.001). Villus height, crypt depth, enterocyte proliferation, apoptosis and expression of proliferation and nutrient transport genes remained unchanged. Pathologic small bowel dilatation reduced crypt depth (p = 0.045) and downregulated mRNA expression of interleukin (IL)-6 by three-fold (p = 0.008), while correlating negatively with IL6 (r = -0.609, p = 0.004). Loss of ileocecal valve (ICV) upregulated mRNA expression of toll-like receptor 4 (TLR4), TGF-β1, CAV1, several apoptosis regulating genes, and mRNA expression of zonulin (p < 0.05 for all). CONCLUSIONS Despite successful adaptation to enteral autonomy, duodenal mucosa of SBS children displayed histologic and molecular signs of abnormal inflammation and regulation of epithelial permeability, whereas no structural or molecular signs of adaptive hyperplasia or enhanced nutrient transport were observed. Excessive dilatation of the remaining small bowel paralleled impaired duodenal crypt homeostasis, while absence of ICV modified regulation of mucosal inflammation, regeneration and permeability. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Galina Sanaksenaho
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Annika Mutanen
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nimish Godbole
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maria Hukkinen
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laura Merras-Salmio
- Department of Pediatric Gastroenterology, Pediatric Liver and Gut Research Group, Children's Hospital, Pediatric Research Centre, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Reetta Kivisaari
- HUS Medical Imaging Center, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Antti Kyrönlahti
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marjut Pihlajoki
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jouko Lohi
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markku Heikinheimo
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko P Pakarinen
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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20
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Moschino L, Duci M, Fascetti Leon F, Bonadies L, Priante E, Baraldi E, Verlato G. Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection. Nutrients 2021; 13:nu13020340. [PMID: 33498880 PMCID: PMC7910892 DOI: 10.3390/nu13020340] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 02/07/2023] Open
Abstract
Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20–50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.
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MESH Headings
- Enterocolitis, Necrotizing/complications
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/prevention & control
- Enterocolitis, Necrotizing/surgery
- Failure to Thrive/prevention & control
- Humans
- Infant
- Infant Nutritional Physiological Phenomena
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/prevention & control
- Infant, Premature, Diseases/surgery
- Intestines/surgery
- Short Bowel Syndrome/etiology
- Short Bowel Syndrome/prevention & control
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Affiliation(s)
- Laura Moschino
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Elena Priante
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Giovanna Verlato
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
- Correspondence: ; Tel.: +39-0498211428
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21
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Thänert R, Thänert A, Ou J, Bajinting A, Burnham CAD, Engelstad HJ, Tecos ME, Ndao IM, Hall-Moore C, Rouggly-Nickless C, Carl MA, Rubin DC, Davidson NO, Tarr PI, Warner BB, Dantas G, Warner BW. Antibiotic-driven intestinal dysbiosis in pediatric short bowel syndrome is associated with persistently altered microbiome functions and gut-derived bloodstream infections. Gut Microbes 2021; 13:1940792. [PMID: 34264786 PMCID: PMC8284144 DOI: 10.1080/19490976.2021.1940792] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/27/2021] [Accepted: 06/01/2021] [Indexed: 02/08/2023] Open
Abstract
Surgical removal of the intestine, lifesaving in catastrophic gastrointestinal disorders of infancy, can result in a form of intestinal failure known as short bowel syndrome (SBS). Bloodstream infections (BSIs) are a major challenge in pediatric SBS management. BSIs require frequent antibiotic therapy, with ill-defined consequences for the gut microbiome and childhood health. Here, we combine serial stool collection, shotgun metagenomic sequencing, multivariate statistics and genome-resolved strain-tracking in a cohort of 19 patients with surgically-induced SBS to show that antibiotic-driven intestinal dysbiosis in SBS enriches for persistent intestinal colonization with BSI causative pathogens in SBS. Comparing the gut microbiome composition of SBS patients over the first 4 years of life to 19 age-matched term and 18 preterm controls, we find that SBS gut microbiota diversity and composition was persistently altered compared to controls. Commensals including Ruminococcus, Bifidobacterium, Eubacterium, and Clostridium species were depleted in SBS, while pathobionts (Enterococcus) were enriched. Integrating clinical covariates with gut microbiome composition in pediatric SBS, we identified dietary and antibiotic exposures as the main drivers of these alterations. Moreover, antibiotic resistance genes, specifically broad-spectrum efflux pumps, were at a higher abundance in SBS, while putatively beneficial microbiota functions, including amino acid and vitamin biosynthesis, were depleted. Moreover, using strain-tracking we found that the SBS gut microbiome harbors BSI causing pathogens, which can persist intestinally throughout the first years of life. The association between antibiotic-driven gut dysbiosis and enrichment of intestinal pathobionts isolated from BSI suggests that antibiotic treatment may predispose SBS patients to infection. Persistence of pathobionts and depletion of beneficial microbiota and functionalities in SBS highlights the need for microbiota-targeted interventions to prevent infection and facilitate intestinal adaptation.
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Affiliation(s)
- Robert Thänert
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Anna Thänert
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jocelyn Ou
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Adam Bajinting
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Carey-Ann D. Burnham
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Holly J. Engelstad
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Maria E. Tecos
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - I. Malick Ndao
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Carla Hall-Moore
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Colleen Rouggly-Nickless
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Mike A. Carl
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Deborah C. Rubin
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Nicholas O. Davidson
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Phillip I. Tarr
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Barbara B. Warner
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gautam Dantas
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Brad W. Warner
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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22
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Yang M, Du J, Yang Q, Dou W, Jiang M, Hei M. Influence of Family Integrated Care on the Intestinal Microbiome of Preterm Infants With Necrotizing Enterocolitis and Enterostomy: A Preliminary Study. Front Pediatr 2021; 9:678254. [PMID: 34900854 PMCID: PMC8662560 DOI: 10.3389/fped.2021.678254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 10/28/2021] [Indexed: 11/13/2022] Open
Abstract
The aim of this study was to investigate the influence of family integrated care (FICare) on the intestinal microbiome of preterm infants with necrotizing enterocolitis and enterostomy. This was a prospective pilot study at Beijing Children's Hospital. Premature infants with an enterostomy who met the enrollment criteria were divided into the 2-week FICare and non-FICare groups (non-randomly). We collected their fecal samples and subjected the intestinal microbiomes to 16S rRNA gene sequencing. Operational taxonomic units (OTU) were analyzed to assess the intestinal microbiome richness, and we then carried out α-diversity, β-diversity, and species clustering analyses and a linear discriminant analysis (LDA) effect size (LEfSe) analysis to identify the differences in the microbial communities between the two groups. There were 12 patients enrolled in the study (FICare, n = 7; non-FICare, n = 5). There were no significant between-group differences in demographic characteristics, or in the relative abundances of phyla and genera. The major bacterial phyla were Proteobacteria, Firmicutes, and Actinobacteria, and Serratia, Enterococcus, Cronobacter, and Bifidobacterium dominated at the genus level. The α-diversity analysis indicated that the intestinal flora was more diverse in the non-FICare group than the FICare group (p < 0.05). However, most of the other indicators did not suggest a difference between the two groups. There was a high proportion of shared OTUs between the two groups, and the PCoA and clustering analyses indicated that the two groups were difficult to distinguish, indicating that the intestinal microbiomes were relatively similar between the groups. In summary, short-term FICare had no significant positive effect on the establishment of intestinal flora diversity in premature infants with necrotizing enterocolitis and enterostomy. The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-OPN-17011801).
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Affiliation(s)
- Mengyang Yang
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center of Children's Health, Beijing, China
| | - Juan Du
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center of Children's Health, Beijing, China
| | - Qin Yang
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center of Children's Health, Beijing, China
| | - Wenyan Dou
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center of Children's Health, Beijing, China
| | - Min Jiang
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center of Children's Health, Beijing, China
| | - Mingyan Hei
- Department of Neonatology, Neonatal Center, Beijing Children's Hospital, Capital Medical University, National Center of Children's Health, Beijing, China
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23
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Gastroschisis: A State-of-the-Art Review. CHILDREN-BASEL 2020; 7:children7120302. [PMID: 33348575 PMCID: PMC7765881 DOI: 10.3390/children7120302] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/08/2020] [Accepted: 12/14/2020] [Indexed: 01/17/2023]
Abstract
Gastroschisis, the most common type of abdominal wall defect, has seen a steady increase in its prevalence over the past several decades. It is identified, both prenatally and postnatally, by the location of the defect, most often to the right of a normally-inserted umbilical cord. It disproportionately affects young mothers, and appears to be associated with environmental factors. However, the contribution of genetic factors to the overall risk remains unknown. While approximately 10% of infants with gastroschisis have intestinal atresia, extraintestinal anomalies are rare. Prenatal ultrasound scans are useful for early diagnosis and identification of features that predict a high likelihood of associated bowel atresia. The timing and mode of delivery for mothers with fetuses with gastroschisis have been somewhat controversial, but there is no convincing evidence to support routine preterm delivery or elective cesarean section in the absence of obstetric indications. Postnatal surgical management is dictated by the condition of the bowel and the abdominal domain. The surgical options include either primary reduction and closure or staged reduction with placement of a silo followed by delayed closure. The overall prognosis for infants with gastroschisis, in terms of both survival as well as long-term outcomes, is excellent. However, the management and outcomes of a subset of infants with complex gastroschisis, especially those who develop short bowel syndrome (SBS), remains challenging. Future research should be directed towards identification of epidemiological factors contributing to its rising incidence, improvement in the management of SBS, and obstetric/fetal interventions to minimize intestinal damage.
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24
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Cernat E, Corlett C, Iglesias N, Onyeador N, Steele J, Batra A. Short bowel syndrome in infancy: recent advances and practical management. Frontline Gastroenterol 2020; 12:614-621. [PMID: 34925748 PMCID: PMC8640374 DOI: 10.1136/flgastro-2020-101457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/25/2020] [Accepted: 12/06/2020] [Indexed: 02/04/2023] Open
Abstract
Short bowel syndrome (SBS) is a rare condition characterised by extensive loss of intestinal mass secondary to congenital or acquired disease. The outcomes are determined by dependency on parenteral nutrition (PN), its possible complications and factors that influence intestinal adaptation. In order to achieve the best results, patients should be managed by a specialised multidisciplinary team with the aims of promoting growth and development, stimulating intestinal adaptation and preventing possible complications. This involves timely surgical management aimed at rescuing maximum bowel length and eventually re-establishing intestinal continuity where appropriate. A combination of enteral and parenteral nutrition needs to be targeted towards maintaining a balance between fulfilling the nutritional and metabolic needs of the child while preventing or at least minimising potential complications. Enteral nutrition and establishment of oral feeding play a fundamental role in stimulating bowel adaptation and promoting enteral autonomy. Other measures to promote enteral autonomy include the chyme recycling in patients where bowel is not in continuity, autologous gastrointestinal reconstruction and pharmacological treatments, including promising new therapies like teduglutide. Strategies such as lipid reduction, changing the type of lipid emulsion and cycling PN are associated with a reduction in the rates of intestinal failure-associated liver disease. Even though vast improvements have been made in the surgical and medical management of SBS, there is still lack of consensus in many aspects and collaboration is essential.
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Affiliation(s)
- Elena Cernat
- Department of Gastroenterology and Nutrition, Leeds Children’s Hospital, Leeds, UK
| | - Chloe Corlett
- Department of Paediatric Gastroenterology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Natalia Iglesias
- Medicines Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nkem Onyeador
- Department of Paediatric Gastroenterology, St George’s Healthcare NHS Trust, London, UK
| | - Julie Steele
- Dietetic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Akshay Batra
- Department of Paediatric Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
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25
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Tian L, Li W, Su Y, Gao H, Yang Q, Lin P, Wang L, Zeng J, Li Y. Risk Factors for Central Venous Access Device-Related Thrombosis in Hospitalized Children: A Systematic Review and Meta-Analysis. Thromb Haemost 2020; 121:625-640. [PMID: 33186995 DOI: 10.1055/s-0040-1720976] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To identify the potential associations of patient-, treatment-, and central venous access device (CVAD)-related factors with the CVAD-related thrombosis (CRT) risk in hospitalized children. METHODS A systematic search of PubMed, EMBASE, Web of Science, the Cochrane Library, China National Knowledge Infrastructure, Wanfang, and VIP database was conducted. RevMan 5.3 and Stata 12.0 statistical software were employed for data analysis. RESULTS In terms of patient-related factors, the patient history of thrombosis (odds ratio [OR] = 3.88, 95% confidence interval [CI]: 2.57-5.85), gastrointestinal/liver disease (OR = 1.85, 95% CI: 0.99-3.46), hematologic disease (OR = 1.45, 95% CI: 1.06-1.99), and cancer (OR = 1.58, 95% CI: 1.01-2.48) were correlated with an increased risk of CRT. In terms of treatment-related factors, parenteral nutrition (PN)/total PN (OR = 1.70, 95% CI: 1.21-2.39), hemodialysis (OR = 2.17, 95% CI: 1.34-3.51), extracorporeal membrane oxygenation (OR = 1.51, 95% CI: 1.31-1.71), and cardiac catheterization (OR = 3.92, 95% CI: 1.06-14.44) were associated with an increased CRT risk, while antibiotics (OR = 0.46, 95% CI: 0.32-0.68) was associated with a reduced CRT risk. In terms of the CVAD-related factors, CRT risk was more significantly increased by peripherally inserted central catheter than tunneled lines (OR = 1.81, 95% CI: 1.15-2.85) or totally implantable venous access port (OR = 2.81, 95% CI: 1.41-5.60). And subclavian vein catheterization significantly contributed to a lower CRT risk than femoral vein catheterization (OR = 0.36, 95% CI: 0.14-0.88). Besides, multiple catheter lines (OR = 4.06, 95% CI: 3.01-5.47), multiple catheter lumens (OR = 3.71, 95% CI: 1.99-6.92), central line-associated bloodstream infection (OR = 2.66, 95% CI: 1.15-6.16), and catheter malfunction (OR = 1.65, 95% CI: 1.07-2.54) were associated with an increased CRT risk. CONCLUSION The exact identification of the effect of risk factors can boost the development of risk assessment tools with stratifying risks.
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Affiliation(s)
- Lingyun Tian
- Xiangya Nursing School, Central South University, Changsha, China.,School of Nursing, Anhui University of Chinese Medicine, Hefei, China
| | - Wan Li
- Xiangya Nursing School, Central South University, Changsha, China
| | - Yanan Su
- Xiangya Nursing School, Central South University, Changsha, China
| | - Huimin Gao
- Xiangya Nursing School, Central South University, Changsha, China
| | - Qiuhong Yang
- Xiangya Nursing School, Central South University, Changsha, China
| | - Pan Lin
- Xiangya Nursing School, Central South University, Changsha, China
| | - Liqian Wang
- Xiangya Nursing School, Central South University, Changsha, China
| | - Jiaqi Zeng
- Xiangya Nursing School, Central South University, Changsha, China
| | - Yinglan Li
- Xiangya Nursing School, Central South University, Changsha, China.,School of Nursing, Xinjiang Medical University, Urumqi, China
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26
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Yin Y, Wu X, Zou H, Li S, Qin Z, Zhang T, Cao J. Expressions of Fib, IL-12 in Serum of Neonatal Necrotizing Enterocolitis and Their Correlation with Clinicopathological Features. IRANIAN JOURNAL OF PUBLIC HEALTH 2020; 49:1439-1446. [PMID: 33083320 PMCID: PMC7554385 DOI: 10.18502/ijph.v49i8.3874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: To investigate the expressions of fibrinogen (Fib) and Interleukin-12 (IL-12) in serum of neonatal necrotizing enterocolitis (NEC), and to analyze the correlation between the two and their relationship with clinicopathological features. Methods: Forty two children with NEC treated in Xuzhou Children’s Hospital, Xuzhou Medical University Xuzhou, China from 2016–2019 were selected as an observation group and 40 children who underwent physical examination at the same period as a control group. The expression levels of Fib and IL-12 in the serum of two groups were detected by ELISA. The correlation between Fib and IL-12 in the observation group and the correlation among the expressions of Fib, IL-12, the clinicopathological features and common examination indexes of the children with NEC were investigated by Pearson correlation analysis. Results: The levels of Fib and IL-12 in the serum of the children in observation group were significantly higher than those in the control group were (P<0.05). There was a significant positive correlation between the levels of Fib and IL-12 in the serum of the children in observation group (P<0.05). The expression levels of Fib, IL-12 were not significantly correlated with sex and age of NEC children, but correlated with vomiting, diarrhea, bloody stool and bradycardia in NEC children (P<0.05). Fib and IL-12 were positively correlated with erythrocyte level (P<0.05) and negatively correlated with platelet level. Conclusion: The expressions of Fib and IL-12 in the serum of NEC children can objectively predict the severity of NEC.
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Affiliation(s)
- Yiyu Yin
- Department of General Surgery, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou 221006, P.R. China
| | - Xiaole Wu
- Department of Anesthesiology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou 221006, P.R. China
| | - Huaxin Zou
- Department of General Surgery, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou 221006, P.R. China
| | - Shixian Li
- Department of General Surgery, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou 221006, P.R. China
| | - Zhenfang Qin
- Department of General Surgery, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou 221006, P.R. China
| | - Tengfei Zhang
- Department of General Surgery, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou 221006, P.R. China
| | - Junhua Cao
- Department of Emergency Medicine, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou 221006, P.R. China
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27
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Reducing Antacid Use in a Level IV NICU: A QI Project to Reduce Morbidity. Pediatr Qual Saf 2020; 5:e303. [PMID: 32607459 PMCID: PMC7297399 DOI: 10.1097/pq9.0000000000000303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/22/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Gastroesophageal reflux is a physiologic occurrence in infants. Clinicians caring for neonates use histamine-2 receptor antagonists (H2As) or proton pump inhibitors (PPIs) for symptomatic reflux, apnea/bradycardia/desaturations, or irritability. Recent studies have shown that there is an increased incidence of infection, fracture, and mortality in neonates who receive antacids. Methods A multidisciplinary team aimed to decrease nonindicated antacid use in the NICU by 50% by April 2019. Outcome measures include the median number of inappropriate antacid prescriptions and patient-days on acid-suppressants. Interventions include education regarding use and risks of antacids, development of a list of indications deemed "appropriate" for starting an H2A or PPI, mandatory discussion on rounds when considering antacids, documentation of treatment goal, and indication, and an automatic drop-off in the electronic medical record. Results Baseline data (June-December 2017) showed 19 prescriptions of H2As or PPIs. Of those, 10 orders were deemed "inappropriate," according to our indicated uses. There were 407 total patient-days of medication-use (median: 51 patient-days). After the implementation of the interventions (October 2018-May 2019), there were 11 prescriptions of antacid medications, 3 of which were deemed "inappropriate." There were 206 total days of medication-use (median: 18.5 patient-days). Conclusions A multidisciplinary agreement on indications for antacid use in neonates stimulates discussion and creates more purposeful use. Overall, we successfully decreased nonindicated antacid prescriptions in the NICU. For the next steps, we hope to educate physicians on the risks of antacid use and reduce prescriptions in other areas of the hospital and the outpatient setting.
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28
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Ou J, Courtney CM, Steinberger AE, Tecos ME, Warner BW. Nutrition in Necrotizing Enterocolitis and Following Intestinal Resection. Nutrients 2020; 12:nu12020520. [PMID: 32085587 PMCID: PMC7071274 DOI: 10.3390/nu12020520] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 12/25/2022] Open
Abstract
This review aims to discuss the role of nutrition and feeding practices in necrotizing enterocolitis (NEC), NEC prevention, and its complications, including surgical treatment. A thorough PubMed search was performed with a focus on meta-analyses and randomized controlled trials when available. There are several variables in nutrition and the feeding of preterm infants with the intention of preventing necrotizing enterocolitis (NEC). Starting feeds later rather than earlier, advancing feeds slowly and continuous feeds have not been shown to prevent NEC and breast milk remains the only effective prevention strategy. The lack of medical treatment options for NEC often leads to disease progression requiring surgical resection. Following resection, intestinal adaptation occurs, during which villi lengthen and crypts deepen to increase the functional capacity of remaining bowel. The effect of macronutrients on intestinal adaptation has been extensively studied in animal models. Clinically, the length and portion of intestine that is resected may lead to patients requiring parenteral nutrition, which is also reviewed here. There remain significant gaps in knowledge surrounding many of the nutritional aspects of NEC and more research is needed to determine optimal feeding approaches to prevent NEC, particularly in infants younger than 28 weeks and <1000 grams. Additional research is also needed to identify biomarkers reflecting intestinal recovery following NEC diagnosis individualize when feedings should be safely resumed for each patient.
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Affiliation(s)
- Jocelyn Ou
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA;
| | - Cathleen M. Courtney
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Allie E. Steinberger
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Maria E. Tecos
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Brad W. Warner
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
- Correspondence: ; Tel.: 314-454-6022
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29
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Snyder AN, Burjonrappa S. Central line associated blood stream infections in gastroschisis patients: A nationwide database analysis of risks, outcomes, and disparities. J Pediatr Surg 2020; 55:286-291. [PMID: 31708200 DOI: 10.1016/j.jpedsurg.2019.10.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 10/26/2019] [Indexed: 01/27/2023]
Abstract
PURPOSE The aim of this study was to determine the risk of central line associated blood-stream infections (CLABSI) in neonatal gastroschisis patients, risk factors, outcomes, and financial implications. METHODS The 2016 Healthcare Cost and Utilization Project (HCUP)'s kid's inpatient database (KID), a national database of pediatric inpatient admissions across the United States, was used to obtain a large sample of gastroschisis admissions. Incidence of CLABSI in the gastroschisis patient population was compared to the incidence of CLABSI in the database. To further study the factors influencing CLABSI in gastroschisis, demographic and clinical features of patients were analyzed. Categorical variables were analyzed using Fisher's exact test or Pearson's chi-squared test. Odds ratios (OR) with 95% confidence intervals (CI) for variables found to have significance (p < 0.05) were calculated. FINDINGS Incidence of CLABSI in this database for pediatric inpatients was 4449 out of 298,862 central line insertions [1.48%] and was 81 out of 2032 [3.9%] (OR 2.83, 95% CI 2.26-3.54, p < 0.001) in the gastroschisis cohort. African American neonates had a significantly higher risk of CLABSI with gastroschisis. Prematurity and low birth-weight in gastroschisis were protective from CLABSI, along with patients from suburban areas or admitted in the Southern USA. Average costs were greater in gastroschisis patients with CLABSI, increasing from $281,779 to $421,970 (p = 0.008). The average length of stay increased from 31 days to 38 days with a CLABSI (p < 0.001). CONCLUSIONS In gastroschisis patients, CLABSI incidence is high and adds great morbidity and expense. For uncertain reasons, premature and low birth weight babies appear to be protected. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Alana N Snyder
- University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Blvd, Tampa, FL 33612, USA
| | - Sathyaprasad Burjonrappa
- University of South Florida Morsani College of Medicine, Tampa General Hospital, 1 Tampa General Circle, Tampa, FL 33606, USA.
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30
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Meister AL, Doheny KK, Travagli RA. Necrotizing enterocolitis: It's not all in the gut. Exp Biol Med (Maywood) 2019; 245:85-95. [PMID: 31810384 DOI: 10.1177/1535370219891971] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Necrotizing enterocolitis is the leading cause of death due to gastrointestinal disease in preterm neonates, affecting 5–12% of neonates born at a very-low birth weight. Necrotizing enterocolitis can present with a slow and insidious onset, with some neonates displaying early symptoms such as feeding intolerance. Treatment during the early stages includes bowel rest and careful use of antibiotics, but surgery is required if pneumoperitoneum and intestinal perforation occur. Mortality rates among neonates requiring surgery are estimated to be 20–30%, mandating the development of non-invasive and reliable biomarkers to predict necrotizing enterocolitis before the onset of clinical signs. Such biomarkers would allow at-risk neonates to receive maximal preventative therapies such as careful nutritional consideration, probiotics, and increased skin-to-skin care.Impact statementNecrotizing enterocolitis (NEC) is a devastating gastrointestinal disease; its high mortality rate mandates the development of non-invasive biomarkers to predict NEC before its onset. This review summarizes the pathogenesis, prevention, unresolved issues, and long-term outcomes of NEC.
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Affiliation(s)
- Alissa L Meister
- Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Kim K Doheny
- Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, PA, USA.,Neonatal-Perinatal Medicine, Penn State College of Medicine, Hershey, PA, USA
| | - R Alberto Travagli
- Department of Neural and Behavioral Sciences, Penn State College of Medicine, Hershey, PA, USA
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31
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Suzuki R, Brown GA, Christopher JA, Scully CCG, Congreve M. Recent Developments in Therapeutic Peptides for the Glucagon-like Peptide 1 and 2 Receptors. J Med Chem 2019; 63:905-927. [PMID: 31577440 DOI: 10.1021/acs.jmedchem.9b00835] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Glucagon-like peptide 1 (GLP-1) and glucagon-like peptide 2 (GLP-2) are proglucagon derived peptides that are released from gut endocrine cells in response to nutrient intake. These molecules are rapidly inactivated by the action of dipeptidyl peptidase IV (DPP-4) which limits their use as therapeutic agents. The recent emergence of three-dimensional structures of GPCRs such as GLP-1R and glucagon receptor has helped to drive the rational design of innovative peptide molecules that hold promise as novel peptide therapeutics. One emerging area is the discovery of multifunctional molecules that act at two or more pharmacological systems to enhance therapeutic efficacy. In addition, drug discovery efforts are also focusing on strategies to improve patient convenience through alternative routes of peptide delivery. These novel strategies highlight the broad utility of peptide-based therapeutics in human disease settings where unmet needs still exist.
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Affiliation(s)
- Rie Suzuki
- Sosei Heptares , Steinmetz Building, Granta Park , Cambridge CB21 6DG , U.K
| | - Giles A Brown
- Sosei Heptares , Steinmetz Building, Granta Park , Cambridge CB21 6DG , U.K
| | - John A Christopher
- Sosei Heptares , Steinmetz Building, Granta Park , Cambridge CB21 6DG , U.K
| | - Conor C G Scully
- Sosei Heptares , Steinmetz Building, Granta Park , Cambridge CB21 6DG , U.K
| | - Miles Congreve
- Sosei Heptares , Steinmetz Building, Granta Park , Cambridge CB21 6DG , U.K
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Abstract
Intussusception is the most common cause of intestinal obstruction in infants and toddlers; however, it is a rare entity in neonates. During intussusception, a proximal portion of the bowel pushes inside the adjacent, distal segment of the bowel in a telescoping fashion leading to obstruction, strangulation of the mesentery, ischemia, and necrosis. The etiology of intussusception is often unknown and there are currently no preventive techniques. Intussusception often mimics other common disease processes affecting neonates; this can result in detrimental delays in diagnosis and treatment. Intussusception is considered a surgical emergency and a delay in treatment results in significant morbidity and mortality. With proper education on this rare complication, neonatal nurses play a vital role in early diagnosis. To improve the care of neonates affected, it is imperative that intussusception remain a differential diagnosis for clinicians.
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Malek AJ, Mrdutt MM, Scrushy MG, Mallet LH, Shaver CN, Sanders EC, Stagg HW, Perger L. Long-term growth outcomes in neonates diagnosed with necrotizing enterocolitis: a 20-year analysis. J Pediatr Surg 2019; 54:949-954. [PMID: 30782443 DOI: 10.1016/j.jpedsurg.2019.01.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 01/27/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE Limited data exists for longitudinal growth outcomes in neonates with a history of necrotizing enterocolitis (NEC). We aimed to study 20-year growth outcomes in NEC survivors. METHODS A retrospective matched cohort study included neonates diagnosed with NEC and control subjects matched for birth year, birth weight, and gestational age who had at least one post-discharge follow-up. The primary outcome was growth, measured by length and weight until 20 years. Logistic regression was used to test the change in growth from birth until most recent encounter. RESULTS Five hundred twenty-seven neonates were included: 294 with NEC, and 233 controls. Sixty-eight percent of NEC cases were Bell's stage I, 25% were stage II, and 7% were stage III. Median gestational age was 29 weeks, and median birth weight was 1237 g. Infants with NEC had a longer NICU stay (p < 0.0001) and increased number of comorbidities (p < 0.0001). Compared to overall and sex-matched controls, infants with NEC had a significantly slower growth rate in terms of weight (p < 0.0068) but not length (p = 0.09). Neither group exhibited failure to thrive. CONCLUSIONS These results suggest that non-surgical NEC may have a more profound impact on long-term growth than previously considered. TYPE OF STUDY Retrospective Cohort-Matched Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Adil J Malek
- Department of General Surgery, Baylor Scott and White Health, Texas A&M, Temple, TX
| | - Mary M Mrdutt
- Department of General Surgery, Baylor Scott and White Health, Texas A&M, Temple, TX
| | | | - Lea H Mallet
- Department of Pediatrics, Baylor Scott and White Health, Texas A&M Health Science Center
| | - Courtney N Shaver
- Department of Biostatistics, Baylor Scott and White Research Institute, Temple, TX
| | - Emily C Sanders
- College of Medicine, Texas A&M Health Science Center, Temple, TX
| | - Hayden W Stagg
- Division of Pediatric Surgery, Department of General Surgery, McLane's Children's Medical Center, Texas A&M, Temple, TX
| | - Lena Perger
- Division of Pediatric Surgery, Department of General Surgery, University of New Mexico, Albuquerque, NM.
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LaRusso K, Schaack G, Fung T, McGregor K, Long J, Dumas MP, Attari Z, Yousef Y, Girgis H, Raghunathan R, Sant'Anna A, Emil S. Should you pick the PICC? Prolonged use of peripherally inserted central venous catheters in children with intestinal failure. J Pediatr Surg 2019; 54:999-1004. [PMID: 30795912 DOI: 10.1016/j.jpedsurg.2019.01.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 01/27/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Prolonged central vascular access is a source of significant morbidity in children with intestinal failure (IF). In an effort to decrease morbidity, our multidisciplinary IF team has primarily used peripherally inserted central catheters (PICCs) for these patients. We compared outcomes of PICCs to Broviacs®. METHODS A review of children with IF (2006-2018) at an academic children's hospital was conducted. INCLUSION CRITERIA total parenteral nutrition duration >42 days or small bowel length < 25% of total for gestational age. Complications/1000 catheter days were extracted, and a Poisson model was used to compare complications between PICCs and Broviacs®. RESULTS Thirty-seven patients with IF were included, accounting for 19,452 catheter days. There were 209 PICCs (1.2-4F) and 39 Broviacs® (2.7-7F). The median duration of overall PICC access/patient was 166 days (range: 35 days-8 years). Incidences of central line associated blood stream infection and venous thrombosis were 3.95 and 0.55 per 1000 catheter days, respectively. There were no significant differences in complication rates per line per catheter day between PICCs and Broviacs® on multivariate analysis. Broviacs® showed a trend towards increased of catheter-related hospital admissions when compared to PICCs. CONCLUSIONS PICCs in children with intestinal failure have similar complication rates to Broviacs® but may reduce catheter-related hospital admissions. Use of tunneled PICCs and increasing experience with this vascular access method may allow it to realize its potential advantages. LEVEL OF EVIDENCE Retrospective study, level III.
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Affiliation(s)
- Kathryn LaRusso
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Geraldine Schaack
- Nursing Education, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Tiffany Fung
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Kevin McGregor
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Justin Long
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Marie-Pier Dumas
- Nursing Education, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Zahia Attari
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Hidy Girgis
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Rajam Raghunathan
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Ana Sant'Anna
- Division of Pediatric Gastroenterology and Nutrition, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Sherif Emil
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.
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Pinto F, Fernandes E, Virella D, Abrantes A, Neto M. Born Preterm: A Public Health Issue. PORTUGUESE JOURNAL OF PUBLIC HEALTH 2019. [DOI: 10.1159/000497249] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Narang A, Carlsen V, Long A, Battin M, Upadhyay V, Sadler L, Stone P. Anterior abdominal wall defects managed at a tertiary maternal-fetal medicine service in New Zealand: What counselling advice can we offer parents? Aust N Z J Obstet Gynaecol 2019; 59:805-810. [PMID: 30841012 DOI: 10.1111/ajo.12965] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 01/23/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anterior abdominal wall defects, including gastroschisis and omphalocoele, are common fetal anomalies. The management remains complicated, and their diagnosis may lead to significant parental distress. Effective parental counselling may impact on parental perceptions of the defect and help guide pregnancy management. AIMS Using contemporary data, we aimed to describe clinical outcomes of patients with gastroschisis or omphalocoele in order to provide information for clinicians to assist in parental counselling. MATERIALS AND METHODS We followed a case-series of patients with anterior abdominal wall defects referred to our regional Maternal Fetal Medicine services from 2011 to 2016. Outcomes of interest antenatally included details of diagnosis, associated anomalies and outcomes of pregnancy and postnatally included the nature of surgical repair, hospital stay and secondary complications until initial discharge. RESULTS Eighty babies with gastroschisis were referred antenatally, and 72 were liveborn. Forty-nine babies with omphalocoele were referred antenatally, and 24 were liveborn. One further neonate with omphalocoele was postnatally diagnosed. Seventy-one neonates with gastroschisis progressed to operation, 30 developed complications post-surgery, and 68 survived until initial discharge. Twenty-two neonates with omphalocoele progressed to surgery, only two developed complications, and 21 survived until initial discharge. Eight of the surviving neonates with omphalocoele had associated structural abnormalities. The median hospital stay was 27 and eight days for gastroschisis and omphalocoele, respectively. CONCLUSION Neonates with gastroschisis can have complex postnatal periods. Omphalocoele is associated with high antenatal mortality, especially in the presence of associated abnormalities; however, surviving neonates may have uneventful postnatal periods.
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Affiliation(s)
- Apoorv Narang
- Faculty of Medical and Health Sciences, Auckland City Hospital, University of Auckland, Auckland, New Zealand
| | - Victoria Carlsen
- Department of Obstetrics and Gynaecology, Waikato Hospital, Hamilton, New Zealand
| | - Audrey Long
- Department of Obstetrics and Gynaecology, National Women's Health, Auckland, New Zealand
| | - Malcolm Battin
- Newborn Services, Auckland City Hospital, Auckland, New Zealand
| | - Vipul Upadhyay
- Department of Paediatric Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Lynn Sadler
- Women's Health, Auckland District Health Board, Auckland, New Zealand
| | - Peter Stone
- Maternal Fetal Medicine, School of Medicine, University of Auckland, Auckland, New Zealand
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Mangalat N. Pediatric Intestinal Failure: A Review of the Scope of Disease and a Regional Model of a Multidisciplinary Care Team. MISSOURI MEDICINE 2019; 116:129-133. [PMID: 31040499 PMCID: PMC6461325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The term "intestinal failure" signifies the inability of the body to meet the digestive, absorptive and nutritive needs of the body. In children, intestinal failure is most often due to short bowel syndrome, often a result of necrotizing enterocolitis, a severe GI ischemic pathology that is generally associated with prematurity. With advances in neonatal care, more preterm infants are surviving, and subsequently we care for more children with SBS than ever before. These children require parenteral nutrition (PN) for survival. Neurodevelopmental outcomes are tied to nutrition in early years; thus these children are the most vulnerable to the sequelae of intestinal failure. As such, the development of multi-disciplinary intestinal rehabilitation programs have emerged as the state of the art in the care of children with intestinal failure.
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Affiliation(s)
- Nisha Mangalat
- Nisha Mangalat, MD, is the Medical Director, Glennon Intestinal Rehabilitation and Feeding Program, Department of Pediatrics, Saint Louis University, St. Louis, Missouri
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Bazacliu C, Neu J. Necrotizing Enterocolitis: Long Term Complications. Curr Pediatr Rev 2019; 15:115-124. [PMID: 30864508 DOI: 10.2174/1573396315666190312093119] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 02/27/2019] [Accepted: 03/04/2019] [Indexed: 12/21/2022]
Abstract
Necrotizing enterocolitis (NEC) remains the most threatening gastrointestinal complication of prematurity leading to high mortality, morbidity and cost. Common complications of NEC include neurodevelopmental delay, failure to thrive, gastrointestinal problems including strictures and adhesions, cholestasis, short bowel syndrome with or without intestinal failure that can be difficult to manage. Infants who develop NEC benefit from close follow-up for early diagnosis and treatment of complications. Those who present with severe complications such as intestinal failure benefit from a multidisciplinary approach involving careful assessment and treatment. Studies done so far are limited in providing a long-term prognosis. Here we review some of these complications. More studies with a longer follow-up period are needed to better understand the later comorbidities that develop in babies with NEC.
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Affiliation(s)
- Catalina Bazacliu
- Department of Pediatrics, Division of Neonatology, University of Florida, Florida, United States
| | - Josef Neu
- Department of Pediatrics, Division of Neonatology, University of Florida, Florida, United States
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Jardine S, Dhingani N, Muise AM. TTC7A: Steward of Intestinal Health. Cell Mol Gastroenterol Hepatol 2019; 7:555-570. [PMID: 30553809 PMCID: PMC6406079 DOI: 10.1016/j.jcmgh.2018.12.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/03/2018] [Accepted: 12/06/2018] [Indexed: 12/15/2022]
Abstract
The increasing incidence of pediatric inflammatory bowel disease, coupled with the efficiency of whole-exome sequencing, has led to the identification of tetratricopeptide repeat domain 7A (TTC7A) as a steward of intestinal health. TTC7A deficiency is an autosomal-recessively inherited disease. In the 5 years since the original description, more than 50 patients with more than 20 distinct disease-causing TTC7A mutations have been identified. Patients show heterogenous intestinal and immunologic disease manifestations, including but not limited to multiple intestinal atresias, very early onset inflammatory bowel disease, loss of intestinal architecture, apoptotic enterocolitis, combined immunodeficiency, and various extraintestinal features related to the skin and/or hair. The focus of this review is to highlight trends in patient phenotypes and to consolidate functional data related to the role of TTC7A in maintaining intestinal homeostasis. TTC7A deficiency is fatal in approximately two thirds of patients, and, as more patients continue to be discovered, elucidating the comprehensive role of TTC7A could show druggable targets that may benefit the growing cohort of individuals suffering from inflammatory bowel disease.
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Affiliation(s)
- Sasha Jardine
- SickKids Inflammatory Bowel Disease Center and Cell Biology Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Institute for Medical Science and Biochemistry, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Neel Dhingani
- SickKids Inflammatory Bowel Disease Center and Cell Biology Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Institute for Medical Science and Biochemistry, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aleixo M Muise
- SickKids Inflammatory Bowel Disease Center and Cell Biology Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Institute for Medical Science and Biochemistry, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada.
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Mucosal homeostasis is altered in the ileum of gnotobiotic mice. J Surg Res 2018; 231:331-337. [DOI: 10.1016/j.jss.2018.05.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/20/2018] [Accepted: 05/24/2018] [Indexed: 02/08/2023]
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Pediatric Intestinal Failure Review. CHILDREN-BASEL 2018; 5:children5070100. [PMID: 30037012 PMCID: PMC6069045 DOI: 10.3390/children5070100] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 01/23/2023]
Abstract
The term, ‘intestinal failure’, signifies the inability of the body to meet the digestive, absorptive and nutritive needs of the body. As such, these individuals require parenteral nutrition (PN) for survival. The subsequent nutritional, medical and surgical facets to the care are complex. Improved care has resulted in decreased need for intestinal transplantation. This review will examine the unique etiologies and management strategies in pediatric patients with intestinal failure.
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Duci M, Fascetti-Leon F, Erculiani M, Priante E, Cavicchiolo ME, Verlato G, Gamba P. Neonatal independent predictors of severe NEC. Pediatr Surg Int 2018; 34:663-669. [PMID: 29644455 DOI: 10.1007/s00383-018-4261-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE Necrotizing enterocolitis (NEC) is a severe neonatal disease. The present study aimed to identify factors predisposing the development of severe forms of NEC. METHODS This retrospective study examined NEC patients in a single centre between 2002 and 2015. Data concerning clinical characteristics, therapeutic management as well as short-term outcomes were collected. We compared the patients receiving successful medical treatment and those requiring surgical intervention. Patients who underwent surgery were distinguished in three subcategories. Bivariate and multivariate analyses were used for the statistical analysis. RESULTS We identified 155 patients in the study period. 102 were treated conservatively and 53 required surgery. 8 received a primary peritoneal drainage, 31 received a drainage and a subsequent laparotomy and 14 received a laparotomy. Multivariate regression analysis identified a lower risk for surgery with a later onset and higher serum pH values, whereas an increased risk with higher C reactive Protein (CRP) levels at the onset. Pneumatosis intestinalis was identified as a protective factor. Overall mortality was 6.4%, with higher percentage in surgical NEC. CONCLUSION This study suggests that a later onset is a protective sign for the progression to surgery, whereas lower pH values and higher CRP levels are prognostic factors associated with the need for surgery. The line of treatment involving explorative laparotomy in case of perforation seems to be rewarded by low morbidity and mortality rate.
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Affiliation(s)
- Miriam Duci
- Division of Paediatric Surgery, Department of 'Salute della Donna e del Bambino', University of Padova, Padova, Italy
| | - Francesco Fascetti-Leon
- Division of Paediatric Surgery, Department of 'Salute della Donna e del Bambino', University of Padova, Padova, Italy.
| | - Marta Erculiani
- Division of Paediatric Surgery, Department of 'Salute della Donna e del Bambino', University of Padova, Padova, Italy
| | - Elena Priante
- Division on Neonatal Intensive Care Unit, Department of 'Salute della Donna e del Bambino', University of Padova, Padova, Italy
| | - Maria Elena Cavicchiolo
- Division on Neonatal Intensive Care Unit, Department of 'Salute della Donna e del Bambino', University of Padova, Padova, Italy
| | - Giovanna Verlato
- Division on Neonatal Intensive Care Unit, Department of 'Salute della Donna e del Bambino', University of Padova, Padova, Italy
| | - Piergiorgio Gamba
- Division of Paediatric Surgery, Department of 'Salute della Donna e del Bambino', University of Padova, Padova, Italy
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Nakayuenyongsuk W, Christofferson M, Stevenson DK, Sylvester K, Lee HC, Park KT. Point-of-Care Fecal Calprotectin Monitoring in Preterm Infants at Risk for Necrotizing Enterocolitis. J Pediatr 2018. [PMID: 29519542 DOI: 10.1016/j.jpeds.2017.12.069] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To establish baseline trends in fecal calprotectin, a protein excreted into the stool when there is neutrophilic inflammation in the bowel, in infants at risk for necrotizing enterocolitis (NEC). STUDY DESIGN We performed a prospective observational cohort study in infants with a birth weight of <1500 g without existing bowel disease at a level IV neonatal intensive care unit from October 2015 to September 2016. Stools were collected once daily for 30 days or until 32 weeks postmenstrual age and processed using the Fecal Calprotectin High Range Quantitative Quantum Blue assay. RESULTS In 64 preterm infants, during the first week after birth, 62% of infants had an initial stool sample with high baseline calprotectin levels (≥200 µg/g). In assessment of maternal and neonatal risk factors, maternal etiology for preterm birth (ie, eclamplsia or preeclampsia) was the only significant factor associated with high baseline calprotectin level. Two patients in the cohort developed NEC. Calprotectin levels for the entire cohort fluctuated during the observed period but generally increased in the third and fourth weeks after birth. CONCLUSIONS At-risk infants had highly variable fecal calprotectin levels, with maternal causes for preterm birth associated with higher baseline levels. More longitudinal data in infants with NEC are necessary to determine whether acute rises in fecal calprotectin levels prior to clinical diagnosis can be confirmed as a diagnostic or prognostic biomarker.
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Affiliation(s)
- Warapan Nakayuenyongsuk
- Department of Pediatrics, Division of Gastroenterology, Stanford University School of Medicine, Palo Alto, CA
| | - Megan Christofferson
- Department of Pediatrics, Division of Gastroenterology, Stanford University School of Medicine, Palo Alto, CA
| | - David K Stevenson
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Karl Sylvester
- Departement of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Henry C Lee
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - K T Park
- Department of Pediatrics, Division of Gastroenterology, Stanford University School of Medicine, Palo Alto, CA.
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Altan S, Koç Y, Alkan F, Sayın Z, Erol M. Impact of bacterial translocation in calves with atresia coli. J Vet Emerg Crit Care (San Antonio) 2018; 28:261-268. [PMID: 29608243 DOI: 10.1111/vec.12709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/29/2017] [Accepted: 08/17/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To identify whether enteric bacteria pass into the mesenteric lymph nodes (MLNs) and peritoneal cavity in calves with atresia coli and to evaluate whether the presence of bacterial translocation (BT) has an impact on the success of surgical treatment. DESIGN Prospective clinical study. ANIMALS Twenty-six client-owned calves. INTERVENTIONS During laparotomy, swab samples were collected from the peritoneal cavity and MLNs using a sterile swab stick and were submitted for microbiological analysis. MEASUREMENTS AND MAIN RESULTS Bacterial cultures of swab samples revealed that 65% (n = 17) of the calves experienced BT. Of these, 14 calves experienced BT to the MLNs, 9 to the peritoneal cavity, and 5 to both regions. Of the bacteria isolated from the MLNs, 72% (n = 10) were Escherichia coli. Of the samples isolated from the peritoneal fluid, 33% (n = 3) contained E. coli and 33% (n = 3) contained E. coli + coagulase-negative Staphylococcus (CNS). In calves with BT that were discharged (n = 13) and without BT that were discharged (n = 7), the median survival was 30 days; these data were found to be similar in the 2 groups. CONCLUSIONS This study revealed that BT is observed in the majority of atresia coli cases. E. coli is more common in BT, and translocation occurs primarily through the lymphatic route. These results suggest that the presence of BT is closely related to the success of the operation for correction of atresia coli.
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Affiliation(s)
- Semih Altan
- Faculty of Veterinary Medicine, Department of Surgery, University of Dicle, 21280, Diyarbakır, Turkey (Altan)
| | - Yılmaz Koç
- Faculty of Veterinary Medicine, Department of Surgery (Koç and Alkan)
| | - Fahrettin Alkan
- Faculty of Veterinary Medicine, Department of Surgery (Koç and Alkan)
| | - Zafer Sayın
- Department of Microbiology (Sayın), University of Selçuk, 42075 Konya, Turkey
| | - Muharrem Erol
- Faculty of Veterinary Medicine, Department of Surgery, University of Balıkesir, 10145 Balıkesir, Turkey (Erol)
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Kerui G, Jasmin L. Dual effects of brain sparing opioid in newborn rats: Analgesia and hyperalgesia. NEUROBIOLOGY OF PAIN 2018; 3:1-7. [PMID: 31194154 PMCID: PMC6550121 DOI: 10.1016/j.ynpai.2018.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 01/08/2018] [Accepted: 01/09/2018] [Indexed: 01/16/2023]
Abstract
The peripherally acting opioid loperamide produces sustained antinociception in the newborn rat. Loperamide minimally crosses the blood brain barrier in the newborn rat. Daily systemic administration of loperamide produces opioid induced hyperalgesia in the newborn rat.
Effective pain management in neonates without the unwanted central nervous system (CNS) side effects remains an unmet need. To circumvent these central effects we tested the peripherally acting (brain sparing) opioid agonist loperamide in neonate rats. Our results show that: 1) loperamide (1 mg/kg, s.c.) does not affect the thermal withdrawal latency in the normal hind paw while producing antinociception in all pups with an inflamed hind paw. 2) A dose of loperamide 5 times higher resulted in only 6.9 ng/mL of loperamide in the cerebrospinal fluid (CSF), confirming that loperamide minimally crosses the blood–brain barrier (BBB). 3) Unexpectedly, sustained administration of loperamide for 5 days resulted in a hyperalgesic behavior, as well as increased excitability (sensitization) of dorsal root ganglia (DRGs) and spinal nociceptive neurons. This indicates that opioid induced hyperalgesia (OIH) can be induced through the peripheral nervous system. Unless prevented, OIH could in itself be a limiting factor in the use of brain sparing opioids in the neonate.
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Affiliation(s)
- Gong Kerui
- Department of Oral and Maxillofacial Surgery, University of California San Francisco, San Francisco, CA, United States
| | - Luc Jasmin
- Department of Oral and Maxillofacial Surgery, University of California San Francisco, San Francisco, CA, United States
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Chandra R, Kesavan A. Current treatment paradigms in pediatric short bowel syndrome. Clin J Gastroenterol 2017; 11:103-112. [PMID: 29280097 DOI: 10.1007/s12328-017-0811-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 12/18/2017] [Indexed: 12/23/2022]
Abstract
Pediatric short bowel syndrome (SBS) is a serious condition which occurs in children with congenital or acquired reduction in length of the small intestine. SBS results in excessive fluid loss, nutrient malabsorption, electrolyte abnormalities, increased susceptibility to infections, parenteral nutrition associated complications and affects weight gain and growth. In children, SBS is debilitating and uniformly fatal without treatment. The primary goal of treatment is to restore enteral autonomy and reduce long-term dependence on parenteral support by increasing the absorptive potential of the remnant intestine. In this review, the medical and surgical management of SBS including pharmacologic agents, parenteral nutrition, dietary strategies, surgical lengthening procedures, and small bowel transplant will be discussed.
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Affiliation(s)
- Raghav Chandra
- Doctor of Medicine (MD) Program, Rush Medical College, 600 S. Paulina St, Chicago, IL, 60612, USA
| | - Anil Kesavan
- Section of Pediatric Gastroenterology, Rush University Medical Center, Professional Building, 1725 W. Harrison Street, Suite 710, Chicago, IL, 60612, USA.
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Small Bowel Dilatation Predicts Prolonged Parenteral Nutrition and Decreased Survival in Pediatric Short Bowel Syndrome. Ann Surg 2017; 266:369-375. [PMID: 27433892 DOI: 10.1097/sla.0000000000001893] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To analyze risk factors and prognostic significance of small bowel (SB) dilatation in children with short bowel syndrome (SBS). BACKGROUND In SBS, the remaining SB may dilate as part of intestinal adaptation. The impact of dilatation on parenteral nutrition (PN) dependence and survival has not been studied systematically. METHODS SB diameter of SBS children (n = 61) was measured in contrast SB series (n = 169, median age 0.94, range 0.32-2.7 years) during 2002 to 2015, and expressed as millimeters (SB width) and as ratio to L5 vertebra height (SB diameter ratio). Linear regression was used to examine risk factors for dilatation. PN weaning and survival were analyzed with Cox proportional hazards regression. RESULTS Maximal SB diameter ratio during follow-up was predicted by PN dependence and SB atresia, while maximal absolute SB width by birth weight, age, PN duration, and remaining bowel length. Weaning off PN was 14-fold more likely in patients with maximal SB diameter ratio <2.00 compared with >3.00 (P = 0.005), and 5.4-fold more likely when maximal SB width was <20 mm compared with >30 mm (P = 0.023). After adjustment for age, remaining SB length, and the presence of ileocecal valve, both estimates of maximal SB dilatation remained significant independent predictors for weaning off PN. When all measurements were included, the cumulative survival was worse if SB diameter ratio exceeded 2.00 (P = 0.002-0.042). CONCLUSIONS SB dilatation predicts prolonged PN duration and decreased survival in SBS children. Measurement of maximal SB diameter standardized to L5 vertebra height may be a valuable objective tool for patient follow-up and assessment of prognosis.
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Fowler KL, Wieck MM, Hilton AE, Hou X, Schlieve CR, Grikscheit TC. Marked stem/progenitor cell expansion occurs early after murine ileostomy: a new model. J Surg Res 2017; 220:182-196. [PMID: 29180181 DOI: 10.1016/j.jss.2017.06.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 06/09/2017] [Accepted: 06/28/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Improving treatment for short bowel syndrome requires a better understanding of how intestinal adaptation is affected by factors like mechanoluminal stimulation. We hypothesized that in mice, luminal diversion via an ileostomy would drive adaptive changes similar to those seen in human intestine after diversion while offering the opportunity to study the immediate events after resection that precede intestinal adaptation. MATERIALS AND METHODS With Institutional Animal Care and Use Committee approval, a distal ileostomy with a long distal Hartman's was created in 9- to 14-week-old C57/B6 mice (n = 8). Control mice only had a midline laparotomy without stoma formation (n = 5). A rim of tissue from the proximal stoma was resected as a historical control for the proximal segment. Postoperatively, mice received a high-protein liquid diet and water ad libitum. On day 3, tissue from both the proximal and distal limbs were collected for histologic and RNA analysis. Morphometric measures, immunofluorescent antigen detection, and RNA expression were compared with Student paired t-tests with a P value < 0.05 considered significant. RESULTS At 3 d, survival for mice with an ileostomy was 87% and average weight loss was 12.5% of initial weight compared to 6.05% for control mice. Compared to the distal limb, the proximal limb in mice with an ileostomy demonstrated significantly taller villi with deeper and wider crypts. The proximal limb also had decreased expression of intestinal stem cell markers lgr5, bmi1, sox9, and ascl2. Fewer goblet and enteroendocrine cells per hemivillus were also noted in the proximal limb. In control mice, none of these measures were significant between proximal and distal ileum except for villus height. CONCLUSIONS This new murine ileostomy model allows study of intestinal adaptation without intestinal anastomosis, which can be technically challenging and morbid.
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Affiliation(s)
- Kathryn L Fowler
- Developmental Biology and Regenerative Medicine Program, The Saban Research Institute at Children's Hospital Los Angeles, Los Angeles, California
| | - Minna M Wieck
- Developmental Biology and Regenerative Medicine Program, The Saban Research Institute at Children's Hospital Los Angeles, Los Angeles, California; Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Ashley E Hilton
- Keck Medical School, University of Southern California, Los Angeles, California
| | - Xiaogang Hou
- Developmental Biology and Regenerative Medicine Program, The Saban Research Institute at Children's Hospital Los Angeles, Los Angeles, California
| | - Christopher R Schlieve
- Developmental Biology and Regenerative Medicine Program, The Saban Research Institute at Children's Hospital Los Angeles, Los Angeles, California; Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Tracy C Grikscheit
- Developmental Biology and Regenerative Medicine Program, The Saban Research Institute at Children's Hospital Los Angeles, Los Angeles, California; Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, California; Keck Medical School, University of Southern California, Los Angeles, California.
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Hukkinen M, Kivisaari R, Koivusalo A, Pakarinen MP. Risk factors and outcomes of tapering surgery for small intestinal dilatation in pediatric short bowel syndrome. J Pediatr Surg 2017; 52:1121-1127. [PMID: 28185632 DOI: 10.1016/j.jpedsurg.2017.01.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 11/20/2016] [Accepted: 01/24/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND In remains unclear why in some short bowel syndrome (SBS) patients, the remaining small bowel (SB) dilates excessively leading to requirement of tapering surgery. METHODS Among SBS children, we retrospectively analyzed risk factors for tapering surgery with logistic regression and compared the outcome of operated patients (n=16) to those managed conservatively (n=44) with Cox proportional hazards regression. RESULTS SBS was caused by necrotizing enterocolitis (NEC) (n=31), SB atresia (SBA) (n=13), midgut volvulus (n=12), or gastroschisis (n=4). Patients with spontaneous symptomatic SB dilatation unable to wean parenteral nutrition (PN) underwent tapering surgery at median age of 1.04 (interquartile range 0.70-3.27) years. Missing ICV was related to an 8-fold (p=0.003) increased risk while SBA diagnosis was related to a 13-fold risk of tapering surgery (p<0.001). Increasing SB length and NEC diagnosis were protective of tapering (p=0.027-0.004). Of operated patients, 75% reached enteral autonomy during follow-up and their postoperative adjusted PN weaning rate was similar to nonoperated children (p=0.842). CONCLUSION SBS children with short remaining SB, missing ICV, and SBA etiology are more likely while NEC patients are less likely than others to necessitate tapering surgery. Postoperative PN weaning rates were comparable to patients who initially had more favorable intestinal anatomy and adapted without surgery.
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Affiliation(s)
- Maria Hukkinen
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Reetta Kivisaari
- HUS Medical Imaging Center, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Antti Koivusalo
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Mikko P Pakarinen
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
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Mayer O, Kerner JA. Management of short bowel syndrome in postoperative very low birth weight infants. Semin Fetal Neonatal Med 2017; 22:49-56. [PMID: 27576105 DOI: 10.1016/j.siny.2016.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Short bowel syndrome is a potentially devastating morbidity for the very low birth weight infant and family with a high risk for mortality. Prevention of injury to the intestine is the ideal, but, if and when the problem arises, it is important to have a systematic approach to manage nutrition, use pharmaceutical strategies and tools to maximize the outcome potential. Safely maximizing parenteral nutrition support by providing adequate macronutrients and micronutrients while minimizing its hepatotoxic effects is the initial postoperative strategy. As the infant stabilizes and starts to recover from that initial injury and/or surgery, a slow and closely monitored enteral nutrition approach should be initiated. Enteral feeds can be complemented with medications and supplements emerging as valuable clinical tools. Engaging a multidisciplinary team of neonatologists, gastroenterologists, pharmacists, skilled clinical nutrition support staff including registered dietitians and nutrition support nurses will facilitate optimizing each and every infant's long term result. Promoting intestinal rehabilitation and adaptation through evidence-based practice where it is found, and ongoing pursuit of research in this rare and devastating disease, is paramount in achieving optimal outcomes.
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Affiliation(s)
- Olivia Mayer
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
| | - John A Kerner
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA; Stanford University Medical Center, Stanford, CA, USA
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