Intestinal muscularis propria increases in thickness with corrected gestational age and is focally attenuated in patients with isolated intestinal perforations

Wide use of broad-spectrum antibiotics in very low birth weight infants with spontaneous focal intestinal perforation-is it really justified?

PURPOSE

Very low birth weight (VLBW) infants are at a risk of spontaneous focal intestinal perforation (FIP). Treatment includes supportive care, antibiotics, and drainage with/without surgery. Broad-spectrum antibiotic agents like carbapenems are applied frequently, although their use is not well-supported by the limited evidence of causal pathogens. We hypothesize that the use of carbapenems may not be necessary in VLBW infants with FIP. Our primary objective was to evaluate the antimicrobial use in VLBW infants with FIP in a cohort of the German Neonatal Network (GNN). The secondary objective was to characterize a subset in detail as a benchmark for future targets of stewardship.

METHODS

Data on VLBW infants with FIP was collected prospectively within the GNN, a collaboration of 68 neonatal intensive care units (NICU). With regards to the primary objective, patient characteristics and antimicrobial treatment were extracted from the predefined GNN database. To address our secondary objective, an additional on-site assessment of laboratory and microbiological culture results were performed.

RESULTS

In the GNN cohort, 613/21,646 enrolled infants (2.8%) developed FIP requiring surgery. They were frequently treated with carbapenems (500/613 (81.6%)) and vancomycin (497/613 (81.1%)). In a subset of 124 VLBW infants, 77 (72.6%) had proof of gram-positive bacteria in the abdominal cavity, coagulase-negative staphylococci (CoNS) predominantly. Despite the low prevalence of gram-negative bacteria (n = 6 (4.8%)), the combination of meropenem and vancomycin was prescribed most frequently (n = 96 (78.0%)).

CONCLUSION

The use of carbapenems as broad-spectrum antimicrobials agents might not be justified in most VLBW infants with FIP. Knowledge on the development of the neonatal gut microbiota, local resistance patterns and individual microbiological findings should be taken into consideration when implementing antimicrobial stewardship programs (ASPs).

Gastrointestinal perforation in extremely low birth weight infants: A single center retrospective study in China

BACKGROUND

Gastrointestinal perforation in extremely low birth weight infants, characterized by its rapid onset, multiple complications, and critical condition, poses a significant risk of infant mortality. The aim of this study was to investigate the clinical characteristics of pneumoperitoneum in extremely low birth weight infants (ELBWI) and explore the risk factors associated with gastrointestinal perforation in very low birth weight preterm infants. Additionally, we shared our surgical experiences in managing gastrointestinal perforation among extremely low birth weight infants.

METHODS

The Department of Neonatology at Chengdu Women and Children's Central Hospital conducted a retrospective study on gastrointestinal perforation in extremely low birth weight infants (birth weight <1000 g) who were admitted between 2014 and 2021. After baseline analysis and comparing it with the control group, we identified the risk factors associated with gastrointestinal perforation in ELBWI by multiple logistic regression analysis. The Kaplan-Meier analysis was performed to assess the adverse effect of gastrointestinal perforation for survival in ELBW infants. Cox multivariate regression analysis was used to evaluate hazard level of different variables for ELBW infants survival.

RESULTS

Hemodynamically significant patent ductus arteriosus (hsPDA)(p = 0.043, OR = 2.779) and sepsis (p = 0.014, OR = 2.265) were significant risk factors for gastrointestinal perforation in extremely low birth weight infants. The Cox proportional hazard model revealed that intraventricular hemorrhage (HR = 2.854, p＜0.001) Sepsis (HR = 1.645, p = 0.015) and gastrointestinal perforation (HR = 1.876, p = 0.008) had detrimental effects on the survival of extremely low birth weight infants; conversely, ibuprofen (HR = 0.304, p＜0.001) and blood transfusion (HR = 0.372, p＜0.001) are beneficial factors for their survival. The preoperative indicators of infection in infants with spontaneous intestinal perforation (SIP) were significantly better than those in the necrotizing enterocolitis (NEC) group (p < 0.05).

CONCLUSIONS

Gastrointestinal perforation poses a significant threat the survival of extremely low birth weight (ELBW) infants, with hsPDA and sepsis serving as predisposing factors for gastrointestinal perforation. The gastrointestinal perforation caused by various diseases exhibits distinct clinical characteristics, necessitating tailored surgical approaches based on operative conditions.

Prophylactic indomethacin, antenatal betamethasone, and the risk of intestinal perforation in infants <28 weeks' gestation

OBJECTIVE

To determine if intestinal perforations before 14 days (either spontaneous (SIP) or necrotizing enterocolitis-induced) are increased when infants who received antenatal betamethasone shortly before birth are treated with prophylactic indomethacin (PINDO).

STUDY DESIGN

Observational study of 475 infants <28 week's gestation assigned to either a PINDO-protocol (n = 231) or expectant management protocol (n = 244) during consecutive protocol epochs.

RESULTS

Intestinal perforations before 14 days occurred in 33/475 (7%). In unadjusted and adjusted models, we found no associations between PINDO-protocol and intestinal perforations. PINDO-protocol did not increase intestinal perforations or SIP-alone even when given to infants who received betamethasone <7 or <2 days before delivery. 213/231 (92%) PINDO-protocol infants actually received indomethacin. The results were unchanged when examined just in those who received indomethacin.

CONCLUSION

In our study, early intestinal perforations and SIP-alone were not increased when PINDO was used by protocol in infants who received antenatal betamethasone shortly before birth.

Ability of Lactobacillus brevis 47f to Alleviate the Toxic Effects of Imidacloprid Low Concentration on the Histological Parameters and Cytokine Profile of Zebrafish (Danio rerio)

In the present article, the possible mitigation of the toxic effect of imidacloprid low-concentration chronic exposure on Danio rerio by the probiotic strain Lactobacillus brevis 47f (1 × 108 CFU/g) was examined. It was found that even sublethal concentration (2500 µg/L) could lead to the death of some fish during the 60-day chronic experiment. However, the use of Lactobacillus brevis 47f partially reduced the toxic effects, resulting in an increased survival rate and a significant reduction of morphohistological lesions in the intestines and kidneys of Danio rerio. The kidneys were found to be the most susceptible organ to toxic exposure, showing significant disturbances. Calculation of the histopathological index, measurement of morphometric parameters, and analysis of principal components revealed the most significant parameters affected by the combined action of imidacloprid and Lactobacillus brevis 47f. This effect of imidacloprid and the probiotic strain had a multidirectional influence on various pro/anti-inflammatory cytokines (IL-1β, TNF-α, IL-6, IL-8). Therefore, the results suggest the possibility of further studying the probiotic strain Lactobacillus brevis 47f as a strain that reduces the toxic effects of xenobiotics. Additionally, the study established the possibility of using imidacloprid as a model toxicant to assess the detoxification ability of probiotics on the kidney and gastrointestinal tract of fish.

Feeding Strategies in Preterm Very Low Birth-Weight Infants: State-of-the-Science Review

BACKGROUND

Providing enteral feeds to preterm very low birth-weight (VLBW) infants is critical to optimize nutrition, enhance growth, and reduce complications. Protocols guiding feeding practices can improve outcomes, but significant variation exists between institutions, which may limit their utility. To be most effective, protocols should be based on the best available evidence.

PURPOSE

To examine the state of the science on several key components of feeding protocols for VLBW infants.

SEARCH STRATEGY

The authors searched PubMed, CINAHL, and EMBASE databases for terms related to feeding VLBW infants less than 32 weeks' gestational age, including initiation of feedings, rate of feeding advancement, timing of human milk (HM) fortification, and feeding during blood transfusions, when diagnosed with a patent ductus arteriosus (PDA) and during medical treatment of PDA closure.

RESULTS

Initiation of feeds within the first 3 days of life and advancement by 30 mL/kg/d may decrease time to attain full feeds without increasing complications. Insufficient evidence guides optimal timing of HM fortification, as well as feeding infants undergoing blood transfusions, infants diagnosed with a PDA, and infants receiving medical treatment of PDA closure.

IMPLICATIONS FOR PRACTICE

Integration of existing research regarding feeding initiation and advancement into feeding protocols may improve outcomes. Infants at highest risk of feeding-related complications may benefit from a personalized feeding approach.

IMPLICATIONS FOR RESEARCH

Additional research is needed to provide evidence concerning the optimal timing of HM fortification and feeding strategies for infants undergoing blood transfusions and those diagnosed with a PDA or receiving medical treatment of PDA closure to incorporate into evidence-based feeding protocols.

A role for neonatal bacteremia in deaths due to intestinal perforation: spontaneous intestinal perforation compared with perforated necrotizing enterocolitis

OBJECTIVE

To examine the relationship between intestinal perforations (caused by either spontaneous perforation (SIP) or necrotizing enterocolitis (NEC)) and the outcome "death due to intestinal perforation".

METHODS

Multivariable logistic regression analyses were used to compare infants <28 weeks' gestation with SIP (n = 32) and perforated-NEC (n = 45) for the outcome perforation-related death.

RESULTS

In univariate analyses the incidence of death due to perforation was higher among infants with perforated-NEC (36%) than infants with SIP (13%). However, infants with perforated-NEC were more likely to be older than 10 days and have bacteremia/fungemia with non-coagulase-negative staphylococci (non-CONS) organisms than infants with SIP. After adjusting for confounding the only variable that was significantly associated with mortality due to perforation was the presence of non-CONS bacteremia/fungemia at the onset of perforation.

CONCLUSIONS

The apparent association between death and perforated-NEC could be explained by the higher incidence of non-CONS bacteremia/fungemia among infants with perforated-NEC.

Histological and ultrastructural changes of the colon in dextran sodium sulfate-induced mouse colitis

Ulcerative colitis (UC) is a complex disease that results from a dysregulated immune response in the gastrointestinal tract. A mouse model orally administered with dextran sodium sulfate (DSS) is the most widely used experimental animal model of UC. However, the ultrastructure of the colon in mouse colitis is poorly understood. In the present study, colonic specimens from DSS-induced UC mice underwent hematoxylin and eosin staining, Masson's trichrome staining and Verhoeff's elastic staining. In addition, the ultrastructure of samples was examined by transmission electron microscopy. UC was successfully induced by 7 consecutive days of DSS oral administration. The goblet cell architecture of the UC tissue was damaged in the mucosa. Additionally, a significant number of inflammatory cells infiltrated into the stroma and the structure of the intestinal gland was destroyed. The tissue in the submucosa showed significant edema. Hyperplasia was also identified in the submucosa, promoting a disorganized microstructure within the colon wall. Numerous collagen fibers in the muscular layer were disrupted, and the fiber bundles were thinner compared with those in the normal control group. Furthermore, in the DSS-induced UC group, the smooth muscle cell showed edema, the cell membrane structure was unclear and the shape of the nucleus was irregular. In conclusion, the present study revealed important histological and ultrastructural changes in the colon of DSS-induced UC mice. These features may contribute to improved understanding of the pathogenesis and mechanism of UC.

Gut Injury and the Microbiome in Neonates

The causes of neonatal gut injury are multifactorial and include ischemia, tissue hypoxia due to anemia, excessive inflammation, deficiency of growth factors, and food protein sensitivity. The developing intestinal microbiome plays a role in some of these forms of intestinal injury but knowledge of its relative role in each remains poorly understood. Commensal bacteria are required for normal immune development and immune tolerance. Dysbiosis in the neonatal gut that alters the patterns of commensal and pathogenic bacteria may accentuate gut injury.

Necrotizing enterocolitis comes in different forms: Historical perspectives and defining the disease

The specific cause of what is commonly referred to as necrotizing enterocolitis (NEC) disease has been elusive largely because it is becoming clear that this entity represents more than one disease with multifactorial pathogenic mechanisms. Furthermore, finding clear and consistent diagnostic biomarkers will be difficult until the different subsets of what we are calling this disease are better delineated. In this introductory chapter, we discuss different disease entities that are frequently termed "NEC" in the newborn infant. We hope this will set the stage for more focused research and development of preventative measures for at least the most common forms of this disease.

Intestinal perforation in the premature infant

OBJECTIVE

To compare demographic data, prenatal and postnatal characteristics, laboratory data, and outcomes in a cohort of premature infants with spontaneous ileal perforation (SIP), surgical necrotizing enterocolitis (sNEC) and matched controls.

METHODS

A retrospective case-control study of infants with intestinal perforation with a birth weight (BW) less than 2,000 grams and gestational age (GA) less than 34 weeks and infants without perforation matched for BW (±150 grams) and GA (±1week).

RESULTS

130 premature infants were included, 30 infants with SIP, 35 infants with sNEC and 65 control infants. The median age of onset was 5 days postnatal age in SIP versus 25 days in sNEC (p < 0.001) and the peak onset was at 26 weeks corrected GA for SIP and 30 weeks corrected GA for sNEC. Infants with perforation had significantly higher rates of mortality (p < 0.001) and common morbidities associated with prematurity. Administration of corticosteroids and indomethacin did not differ among groups. SIP was more common among infants born to young mothers (p = 0.04) and less common in infants receiving caffeine (p = 0.02). sNEC was less common among infants receiving early red cell transfusion (p = 0.01). Perforation and sNEC trended towards less common in infants receiving inhaled nitric oxide.

CONCLUSION

SIP and sNEC are distinct clinical entities. Potential protective effects of caffeine, inhaled nitric oxide, and early transfusion should be further studied.

Blood Level of Inter-Alpha Inhibitor Proteins Distinguishes Necrotizing Enterocolitis From Spontaneous Intestinal Perforation

OBJECTIVE

To examine circulating levels of inter-alpha inhibitor protein (IaIp) in infants with necrotizing enterocolitis (NEC), spontaneous intestinal perforation (SIP), and matched controls to assess the diagnostic accuracy of IaIp to differentiate NEC from SIP and to compare receiver operating characteristics of IaIp for NEC with C-reactive protein (CRP).

STUDY DESIGN

A prospective, nested case-control study of infants with feeding intolerance was carried out. Blood and clinical data were collected from 27 infants diagnosed with NEC or SIP and from 26 matched controls admitted to our unit. Infants with modified Bell criteria stage 2 or greater were included as NEC. Clinical, radiologic, and/or surgical findings were used to identify infants with SIP. Controls were matched for gestational age, postnatal age, sex, and birth weight.

RESULTS

Mean ± SD IaIp blood levels were 147 ± 38 mg/L, 276 ± 67 mg/L, and 330 ± 100 mg/L in infants with NEC, SIP, and matched controls, respectively (P < .004 and P < .01). Receiver operating characteristics analysis to establish the predictive value of NEC demonstrated areas under curve of 0.98 and 0.63 for IaIp and CRP, respectively.

CONCLUSIONS

IaIp levels were significantly decreased in infants with NEC compared with SIP and matched controls. The diagnostic accuracy of IaIp for NEC was superior to that of CRP.

Postoperative Gastric Perforation in a Newborn with Duodenal Atresia

Gastric perforation (GP) in neonates is a rare entity with high mortality. Although the etiology is not completely understood, it mostly occurs in premature neonates on assisted ventilation. Combination of duodenal atresia and gastric perforation is very rare. We present a case duodenal atresia who developed gastric perforation after operetion for duodenal atresia. Analysis of the patient medical record and histology report did not reveal the etiology of the perforation.

Long term outcome of preterm infants with isolated intestinal perforation: A comparison between primary anastomosis and ileostomy

AIM OF THE STUDY

Management of isolated intestinal perforation (IIP) poses a challenge for the pediatric surgeon. Intestinal resection and primary anastomosis is considered to be as good as the classical approach, namely, intestinal diversion by ileostomy. However, few reports compare primary anastomosis and ileostomy as IIP treatment. In our institution we favored primary anastomosis as first line treatment whenever patient's condition permitted. Our purpose is to retrospectively compare the outcomes of preterm infants treated with primary anastomosis or ileostomy during a laparotomy in which an IIP was found.

METHOD

We identified all newborns who had abdominal operations for IIP from 2000 through 2013. Patients with extensive necrotizing entorocolitis and comorbidities were excluded, as well as those who died in the first 24h. Demographics, type of treatment and complications were reviewed. Major complications included the need for an urgent reoperation, development of late NEC and death.

RESULTS

Twenty-three patients with a median gestational age (GA) of 27weeks and median birth weight (BW) of 883g had receive two types of treatment: group I included 9 patients who had intestinal resection of the affected bowel and ileostomy; group PA consisted of 14 patients who had intestinal resection and primary anastomosis. The decision to perform PA or I was based on the surgeon's judgment, in the absence of a specific protocol. There were no significant differences in GA and BW between both groups. Overall mortality was 30.4%. However mortality was restricted to group PA (n=7 cases; 50%) (p=0.019). Most major complications occurred in group PA (71% vs. 11%, p=0.029). There were six cases of late NEC, all in group PA (p=0.048), and four of those patients died. Other than the type of treatment, no differences could be identified between both groups.

CONCLUSION

Preterm newborns with IIP are at a higher risk for developing life-threatening complications if treated with primary anastomosis than with ileostomy.

Intestinal perforation in very preterm neonates: risk factors and outcomes

OBJECTIVE

To compare neonatal outcomes of preterm infants (born at <32 weeks' gestation) with focal/spontaneous intestinal perforation (SIP), necrotizing enterocolitis (NEC)-related perforation, NEC without perforation or no NEC/perforation.

STUDY DESIGN

Retrospective cohort study of 17,426 infants admitted to Canadian neonatal intensive care units during 2010 to 2013. The primary outcome was a composite of mortality or morbidity (bronchopulmonary dysplasia, severe retinopathy, periventricular leukomalacia or nosocomial infection). Association of intestinal perforation with neonatal outcome was evaluated using multivariate logistic regression.

RESULT

SIP was present in 178 (1.0%) infants, NEC-related perforation in 246 (1.4%) and NEC without perforation in 538 (3.1%). Any intestinal perforation was associated with higher odds of the composite outcome (adjusted odds ratio (AOR): 8.21, 95% confidence interval (95% CI) 6.26 to 10.8); however, the odds were significantly lower for focal/SIP compared with NEC-related perforation (AOR: 0.29, 95% CI 0.17 to 0.51).

CONCLUSION

Of the two types of intestinal perforation, NEC-related perforation was associated with the highest risk of an adverse neonatal outcome.