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Sampath V, Martinez M, Caplan M, Underwood MA, Cuna A. Necrotizing enterocolitis in premature infants-A defect in the brakes? Evidence from clinical and animal studies. Mucosal Immunol 2023; 16:208-220. [PMID: 36804483 DOI: 10.1016/j.mucimm.2023.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023]
Abstract
A key aspect of postnatal intestinal adaptation is the establishment of symbiotic relationships with co-evolved gut microbiota. Necrotizing enterocolitis (NEC) is the most severe disease arising from failure in postnatal gut adaptation in premature infants. Although pathological activation of intestinal Toll-like receptors (TLRs) is believed to underpin NEC pathogenesis, the mechanisms are incompletely understood. We postulate that unregulated aberrant TLR activation in NEC arises from a failure in intestinal-specific mechanisms that tamponade TLR signaling (the brakes). In this review, we discussed the human and animal studies that elucidate the developmental mechanisms inhibiting TLR signaling in the postnatal intestine (establishing the brakes). We then evaluate evidence from preclinical models and human studies that point to a defect in the inhibition of TLR signaling underlying NEC. Finally, we provided a framework for the assessment of NEC risk by screening for signatures of TLR signaling and for NEC prevention by TLR-targeted therapy in premature infants.
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Affiliation(s)
- Venkatesh Sampath
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA; School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA.
| | - Maribel Martinez
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA; School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Michael Caplan
- Department of Pediatrics, North Shore University Health System, Evanston, Illinois, USA
| | - Mark A Underwood
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | - Alain Cuna
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA; School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
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2
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Chen W, Yang C, Xue H, Huang Q. The protective effect and mechanism of epidermal growth factor on necrotizing enterocolitis in a neonatal rat model. Transl Pediatr 2021; 10:900-913. [PMID: 34012839 PMCID: PMC8107864 DOI: 10.21037/tp-21-81] [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] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is the most common acquired gastrointestinal emergency in premature infants. This study aimed to investigate the protective effect and mechanism of epidermal growth factor (EGF) on NEC in a neonatal rat model. METHODS We randomly divided 50 newborn SD rats into a control group, NEC group, NEC + 50 ng/mL EGF group, NEC + 500 ng/mL EGF group, and NEC + 1,000 ng/mL EGF group, with 10 cases in each group. The appearance of intestinal tissue, physiological status score, inflammatory factor level, HE staining, and pathological score were used to evaluate the protective effect. A one cm tissue sample from the proximal ileum of the ileocecal area of five rats from the NEC group and the group that showed a significant protective effect were extracted for transcriptome sequencing. RESULTS The levels of IL-1β and IL-6 in the intestinal mucosa in the NEC + 500 ng/mL EGF group were significantly lower than those in the NEC + 1,000 ng/mL EGF group (P<0.05). Transcriptome sequencing suggested that EGF effects the intestinal barrier, apoptosis, and inflammation of the NEC intestine. CONCLUSIONS We conclude that the oral administration of 500 ng/mL EGF effectively inhibits intestinal inflammation in NEC neonatal rat models, thereby affecting the barrier function of the intestinal tract.
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Affiliation(s)
- Wenqian Chen
- Department of Neonatology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Changyi Yang
- Department of Neonatology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Heng Xue
- Department of Laboratory Medicine, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qi Huang
- Department of Neonatology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
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3
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Turner JM, George P, Lansing M, Slim G, Wizzard PR, Nation P, Brubaker PL, Wales PW. In the Short-term, Milk Fat Globule Epidermal Growth Factor-8 Causes Site-specific Intestinal Growth in Resected Piglets. J Pediatr Gastroenterol Nutr 2020; 71:543-549. [PMID: 32910624 DOI: 10.1097/mpg.0000000000002818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Short bowel syndrome (SBS) remains the leading cause of neonatal intestinal failure. Milk fat globule epidermal growth factor-8 (MFG-E8), present in human milk, has homology with epidermal growth factor (EGF), known to enhance adaptation in SBS. In this pilot study, the role of oral MFG-E8 treatment in SBS was explored in neonatal piglets. METHODS Neonatal piglets underwent 75% intestinal resection, either distal (jejunal-colonic [JC] anastomosis) or mid-intestinal (jejunal-ileal [JI] anastomosis). Piglets were randomized to intragastric treatment with MFG-E8 (5 mg/kg per day) or saline and were maintained on parenteral nutrition and enteral nutrition for 7 days. Adaptation was assessed by intestinal length and weight, histopathology, fecal fat analysis and RT-qPCR analysis of mucosal transcripts, including growth factors. RESULTS JI piglets demonstrated intestinal lengthening (P < 0.001), 2-fold greater in ileum than jejunum (P = 0.02), where lengthening was increased by MFG-E8 treatment (P = 0.02). JC piglets did not exhibit jejunal lengthening, regardless of treatment. Fat absorption was greater for JI piglets (P = 0.02), unaffected by treatment. In JI piglets, expression of Egf was increased in the ileum (P < 0.01) and MFG-E8 treatment increased Egfr (receptor) expression (P = 0.02). CONCLUSIONS MF-EG8 demonstrated site-specific trophic effects, only with JI anatomy. This may limit the utility of this treatment for SBS, except for rare patients with retained ileum. The mechanisms of these site-specific effects, however, and the role of MFG-E8 in neonatal gut growth and in diseases, such as necrotizing enterocolitis that commonly target ileum, warrant further exploration.
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Affiliation(s)
| | | | | | | | | | - Patrick Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta
| | | | - Paul W Wales
- Department of Pediatrics.,Department of Surgery, University of Toronto.,Group for the Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, Toronto, Ontario, Canada
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Amphiregulin Regulates Phagocytosis-Induced Cell Death in Monocytes via EGFR and the Bcl-2 Protein Family. Mediators Inflamm 2019; 2019:1603131. [PMID: 32082070 PMCID: PMC7012211 DOI: 10.1155/2019/1603131] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 08/08/2019] [Accepted: 08/26/2019] [Indexed: 01/24/2023] Open
Abstract
Neonates are extremely susceptible to bacterial infections, and evidences suggest that phagocytosis-induced cell death (PICD) is less frequently triggered in neonatal monocytes than in monocytes from adult donors. An insufficient termination of the inflammatory response, leading to a prolonged survival of neonatal monocytes with ongoing proinflammatory cytokine release, could be associated with the progression of various inflammatory diseases in neonates. Our previous data indicate that amphiregulin (AREG) is increasingly expressed on the cell surface of neonatal monocytes, resulting in remarkably higher soluble AREG levels after proteolytic shedding. In this study, we found that E. coli-infected neonatal monocytes show an increased phosphorylation of ERK, increased expression of Bcl-2 and Bcl-XL, and reduced levels of cleaved caspase-3 and caspase-9 compared to adult monocytes. In both cell types, additional stimulation with soluble AREG further increased ERK activation and expression of Bcl-2 and Bcl-XL and reduced levels of cleaved caspase-3 and caspase-9 in an EGFR-dependent manner. These data suggest that reduced PICD of neonatal monocytes could be due to reduced intrinsic apoptosis and that AREG can promote protection against PICD. This reduction of the intrinsic apoptosis pathway in neonatal monocytes could be relevant for severely prolonged inflammatory responses of neonates.
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5
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Necrotizing Enterocolitis: Using Regulatory Science and Drug Development to Improve Outcomes. J Pediatr 2019; 212:208-215.e1. [PMID: 31235383 DOI: 10.1016/j.jpeds.2019.05.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/02/2019] [Accepted: 05/13/2019] [Indexed: 01/24/2023]
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6
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Ahmed HM, Kamel NM. The relation between serum levels of epidermal growth factor and necrotizing enterocolitis in preterm neonates. KOREAN JOURNAL OF PEDIATRICS 2019; 62:307-311. [PMID: 30999731 PMCID: PMC6702115 DOI: 10.3345/kjp.2018.07108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 03/14/2019] [Indexed: 11/27/2022]
Abstract
Purpose Necrotizing enterocolitis (NEC) is one of the most serious complications of prematurity. Many risk factors can contribute to the development of NEC. The epidermal growth factor (EGF) plays a major role in intestinal barrier function, increases intestinal enzyme activity, and improves nutrient transport. The aim of this study was to assess the role of epidermal growth factor in the development of NEC in preterm neonates. Methods In this study, 130 preterm neonates were included and divided into 3 groups, as follows: group 1, 40 preterm neonates with NEC; group 2, 50 preterm neonates with sepsis; and group 3, 40 healthy preterm neonates as controls. The NEC group was then subdivided into medical and surgical NEC subgroups. The serum EGF level was measured using enzyme-linked immunosorbent assay. Results Serum EGF levels (pg/dL) were significantly lower in the NEC group (median [interquartile range, IQR], 9.6 [2–14]) than in the sepsis (10.1 [8–14]) and control groups (11.2 [8–14], P<0.001), with no significant difference between the sepsis and control groups, and were positively correlated with gestational age (r=0.7, P<0.001). A binary logistic regression test revealed that low EGF levels and gestational ages could significantly predict the development of NEC. The receiver-operating characteristic curve for EGF showed an optimal cutoff value of 8 pg/mL, with 73.3% sensitivity, 98% specificity, and an area under the curve of 0.92. Conclusion The patients with NEC in this study had significantly lower serum EGF levels (P<0.001), which indicated that EGF could be a reliable marker of NEC in preterm neonates.
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Affiliation(s)
- Heba Mostafa Ahmed
- Department of Pediatrics, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Nsreen Mostafa Kamel
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
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7
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Shelby RD, Cromeens B, Rager TM, Besner GE. Influence of Growth Factors on the Development of Necrotizing Enterocolitis. Clin Perinatol 2019; 46:51-64. [PMID: 30771819 PMCID: PMC6380490 DOI: 10.1016/j.clp.2018.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Growth factors have important roles in gastrointestinal tract development, maintenance, and response to injury. Various experiments have been used to demonstrate growth factor influence in multiple disease processes. These studies demonstrated enhancement of mucosal proliferation, intestinal motility, immune modulation, and many other beneficial effects. Select growth factors, including epidermal growth factor and heparin-binding epidermal growth factor like growth factor, demonstrate some beneficial effects in experimental and clinical intestinal injury demonstrated in necrotizing enterocolitis. The roles of glucagon-like peptide 2, insulin-like growth factor 1, erythropoietin, growth hormone, and hepatocyte growth factor in necrotizing enterocolitis are summarized in this article.
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Affiliation(s)
- Rita D. Shelby
- Surgical Research Fellow, Department of Pediatric Surgery, Nationwide Children’s Hospital, Center for Perinatal Research, the Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Barrett Cromeens
- Surgical Research Fellow, Department of Pediatric Surgery, Nationwide Children’s Hospital, Center for Perinatal Research, the Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Terrance M Rager
- Surgical Research Fellow, Department of Pediatric Surgery, Nationwide Children’s Hospital, Center for Perinatal Research, the Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Gail E. Besner
- Chief, Department of Pediatric Surgery, H. William Clatworthy, Jr. Professor of Surgery, Department of Pediatric Surgery, Nationwide Children’s Hospital, Center for Perinatal Research, the Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
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8
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Abstract
Necrotizing enterocolitis (NEC) is a devastating disease of prematurity, with no current method for early diagnosis. Diagnosis is particularly challenging, frequently occurring after the disease has progressed to the point of significant and often irreversible intestinal damage. Biomarker research has tremendous potential to advance clinical management of NEC and our understanding of its pathogenesis. This review discusses the need for novel biomarkers in NEC management, evaluates studies investigating such biomarkers, and explains the difficulties associated with translating biomarker discovery into clinical use.
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Affiliation(s)
- Gregory P Goldstein
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94304
| | - Karl G Sylvester
- Department of Surgery, Division of Pediatric Surgery, 300 Pasteur Drive, Alway Building M116, MC 5733, Stanford, CA 94305.
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9
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Teresa C, Antonella D, de Ville de Goyet Jean. New Nutritional and Therapeutical Strategies of NEC. Curr Pediatr Rev 2019; 15:92-105. [PMID: 30868956 DOI: 10.2174/1573396315666190313164753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/09/2018] [Accepted: 03/06/2019] [Indexed: 11/22/2022]
Abstract
Necrotizing enterocolitis (NEC) is an acquired severe disease of the digestive system affecting mostly premature babies, possibly fatal and frequently associated to systemic complications. Because of the severity of this condition and the possible long-term consequences on the child's development, many studies have aimed at preventing the occurrence of the primary events at the level of the bowel wall (ischemia and necrosis followed by sepsis) by modifying or manipulating the diet (breast milk versus formula) and/or the feeding pattern (time for initiation after birth, continuous versus bolus feeding, modulation of intake according clinical events). Feeding have been investigated so far in order to prevent NEC. However, currently well-established and shared clinical nutritional practices are not available in preventing NEC. Nutritional and surgical treatments of NEC are instead well defined. In selected cases surgery is a therapeutic option of NEC, requiring sometimes partial intestinal resection responsible for short bowel syndrome. In this paper we will investigate the available options for treating NEC according to the Walsh and Kliegman classification, focusing on feeding practices in managing short bowel syndrome that can complicate NEC. We will also analyze the proposed ways of preventing NEC.
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Affiliation(s)
- Capriati Teresa
- Artificial Nutrition in Pediatric Children's Hospital, Bambino Gesu, Rome, Italy
| | - Diamanti Antonella
- Artificial Nutrition in Pediatric Children's Hospital, Bambino Gesu, Rome, Italy
| | - de Ville de Goyet Jean
- Pediatric Department for the Treatment and Study of abdominal Disease and Abdominal Transplants, ISMETT-UPMC, Palermo, Italy
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10
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Garg BD, Sharma D, Bansal A. Biomarkers of necrotizing enterocolitis: a review of literature. J Matern Fetal Neonatal Med 2017; 31:3051-3064. [PMID: 28756708 DOI: 10.1080/14767058.2017.1361925] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Necrotizing enterocolitis (NEC) is among the most serious gastrointestinal emergency in very low birth weight (VLBW), extremely low birth weight (ELBW) and extremely low gestational age neonates (ELGAN), affecting 7-14% of these neonates. Despite extensive research, the underlying aetiology of NEC still remains blurred. Due to high mortality, morbidity and its delayed presentation, early detection of NEC is considered to be lifesaving. A number of biomarkers have been studied for early detection and prediction of severity of NEC but till date, no ideal marker has been discovered. Molecular techniques like proteomic and metabolomic have recently emerged in the field for the development of biomarkers for early detection and understanding the pathophysiology of NEC. We did literature search for identifying all biomarkers that have been used for the detection of NEC and, in this review article, we discuss these biomarkers along with the available current evidence.
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Affiliation(s)
- Bhawan Deep Garg
- a Department of Neonatology , Surya Children's Medicare Pvt. Ltd , Mumbai , India
| | - Deepak Sharma
- b Department of Neonatology , National Institute of Medical Sciences , Jaipur , India
| | - Anju Bansal
- c Department of Surgery , Aadrash Hospital , Sri Ganganagar , India
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11
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Ferretti E, Tremblay E, Thibault MP, Grynspan D, Burghardt KM, Bettolli M, Babakissa C, Levy E, Beaulieu JF. The nitric oxide synthase 2 pathway is targeted by both pro- and anti-inflammatory treatments in the immature human intestine. Nitric Oxide 2017; 66:53-61. [PMID: 28315470 DOI: 10.1016/j.niox.2017.03.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/16/2017] [Accepted: 03/13/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM NO synthase 2 (NOS2) was recently identified as one the most overexpressed genes in intestinal samples of premature infants with necrotizing enterocolitis (NEC). NOS2 is widely implicated in the processes of epithelial cell injury/apoptosis and host immune defense but its specific role in inflammation of the immature human intestinal mucosa remains unclear. Interestingly, factors that prevent NEC such as epidermal growth factor (EGF) attenuate the inflammatory response in the mid-gestation human small intestine using serum-free organ culture while drugs that are associated with NEC occurrence such as the non-steroidal anti-inflammatory drug, indomethacin (INDO), exert multiple detrimental effects on the immature human intestine. In this study we investigate the potential role of NOS2 in modulating the gut inflammatory response under protective and stressful conditions by determining the expression profile of NOS2 and its downstream pathways in the immature intestine. METHODS Gene expression profiles of cultured mid-gestation human intestinal explants were investigated in the absence or presence of a physiological concentration of EGF (50 ng/ml) or 1 μM INDO for 48 h using Illumina whole genome microarrays, Ingenuity Pathway Analysis software and quantitative PCR to investigate the expression of NOS2 and NOS2-pathway related genes. RESULTS In the immature intestine, NOS2 expression was found to be increased by EGF and repressed by INDO. Bioinformatic analysis identified differentially regulated pathways where NOS2 is known to play an important role including citrulline/arginine metabolism, epithelial cell junctions and oxidative stress. At the individual gene level, we identified many differentially expressed genes of the citrulline/arginine metabolism pathway such as ARG1, ARG2, GLS, OAT and OTC in response to EGF and INDO. Gene expression of tight junction components such as CLDN1, CLDN2, CLDN7 and OCN and of antioxidant markers such as DUOX2, GPX2, SOD2 were also found to be differentially modulated by EGF and INDO. CONCLUSION These results suggest that the protective effect of EGF and the deleterious influence of INDO on the immature intestine could be mediated via regulation of NOS2. Pathways downstream of NOS2 involved with these effects include metabolism linked to NO production, epithelial barrier permeability and antioxidant expression. These results suggest that NOS2 is a likely regulator of the inflammatory response in the immature human gut and may provide a mechanistic basis for the protective effect of EGF and the deleterious effects of INDO.
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Affiliation(s)
- Emanuela Ferretti
- Research Consortium on Child Intestinal Inflammation, Division of Neonatology, Department of Pediatrics, University of Ottawa, Ottawa, Canada
| | - Eric Tremblay
- Research Consortium on Child Intestinal Inflammation, Department of Anatomy and Cell Biology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Marie-Pier Thibault
- Research Consortium on Child Intestinal Inflammation, Department of Anatomy and Cell Biology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - David Grynspan
- Research Consortium on Child Intestinal Inflammation, Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Canada
| | - Karolina M Burghardt
- Research Consortium on Child Intestinal Inflammation, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Marcos Bettolli
- Research Consortium on Child Intestinal Inflammation, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Corentin Babakissa
- Research Consortium on Child Intestinal Inflammation, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Emile Levy
- Research Consortium on Child Intestinal Inflammation, Department of Nutrition, CHU Sainte-Justine, Université de Montréal, Montréal, Canada
| | - Jean-François Beaulieu
- Research Consortium on Child Intestinal Inflammation, Department of Anatomy and Cell Biology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada.
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Abstract
Necrotizing enterocolitis (NEC) is a devastating disease in premature infants with high case fatality and significant morbidity among survivors. Immaturity of intestinal host defenses predisposes the premature infant gut to injury. An abnormal bacterial colonization pattern with a deficiency of commensal bacteria may lead to a further breakdown of these host defense mechanisms, predisposing the infant to NEC. Here, we review the role of the innate and adaptive immune system in the pathophysiology of NEC.
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MESH Headings
- Adaptive Immunity
- Enterocolitis, Necrotizing/immunology
- Enterocolitis, Necrotizing/microbiology
- Enterocolitis, Necrotizing/physiopathology
- Evidence-Based Medicine
- Humans
- Immunity, Innate
- Infant, Premature
- Infant, Premature, Diseases/immunology
- Infant, Premature, Diseases/microbiology
- Infant, Premature, Diseases/physiopathology
- Intestinal Mucosa/immunology
- Intestinal Mucosa/microbiology
- Intestinal Mucosa/physiopathology
- Intestines/blood supply
- Intestines/immunology
- Intestines/physiopathology
- Milk, Human/immunology
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Affiliation(s)
- Timothy L Denning
- Institute for Biomedical Sciences, Georgia State University, Atlanta, GA
| | - Amina M Bhatia
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Andrea F Kane
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Ravi M Patel
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Patricia W Denning
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.
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13
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Yamakawa T, Itabashi K, Kusuda S. Mortality and morbidity risks vary with birth weight standard deviation score in growth restricted extremely preterm infants. Early Hum Dev 2016; 92:7-11. [PMID: 26615548 DOI: 10.1016/j.earlhumdev.2015.10.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 10/20/2015] [Accepted: 10/27/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess whether the mortality and morbidity risks vary with birth weight standard deviation score (BWSDS) in growth restricted extremely preterm infants. STUDY DESIGN This was a multicenter retrospective cohort study using the database of the Neonatal Research Network of Japan and including 9149 infants born between 2003 and 2010 at <28 weeks gestation. According to the BWSDSs, the infants were classified as: <-2.0, -2.0 to -1.5, -1.5 to -1.0, -1.0 to -0.5, and ≥-0.5. Infants with BWSDS≥-0.5 were defined as non-growth restricted group. RESULTS After adjusting for covariates, the risks of mortality and some morbidities were different among the BWSDS groups. Compared with non-growth restricted group, the adjusted odds ratio (aOR) for mortality [aOR, 1.69; 95% confidence interval (CI), 1.35-2.12] and chronic lung disease (CLD) (aOR, 1.28; 95% CI, 1.07-1.54) were higher among the infants with BWSDS -1.5 to <-1.0. The aOR for severe retinopathy of prematurity (ROP) (aOR, 1.36; 95% CI, 1.09-1.71) and sepsis (aOR, 1.72; 95% CI, 1.32-2.24) were higher among the infants with BWSDS -2.0 to <-1.5. The aOR for necrotizing enterocolitis (NEC) (aOR, 2.41; 95% CI, 1.64-3.55) was increased at a BWSDS<-2.0. CONCLUSION Being growth restricted extremely preterm infants confer additional risks for mortality and morbidities such as CLD, ROP, sepsis and NEC, and these risks may vary with BWSDS.
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Affiliation(s)
- Takuji Yamakawa
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Kazuo Itabashi
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan.
| | - Satoshi Kusuda
- Department of Neonatology, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
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14
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Wilcock A, Begley P, Stevens A, Whatmore A, Victor S. The metabolomics of necrotising enterocolitis in preterm babies: an exploratory study. J Matern Fetal Neonatal Med 2015; 29:758-62. [PMID: 25786474 DOI: 10.3109/14767058.2015.1017462] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE No single diagnostic investigation is currently available for necrotising enterocolitis (NEC). We implemented a novel, untargeted, exploratory study to determine whether metabolomics can reveal early biomarker(s) of NEC. The effect of gestational age on the metabolome was also investigated. METHODS Two serum samples were obtained from 12 preterm babies (born <30 weeks gestation) and eight term controls: sample "A" at ≤1 week of age and sample "B" once fully fed. Samples were subjected to gas chromatography-mass spectrometry. Metabolomic data was analysed by principal component analysis (PCA), univariate and network analysis. RESULTS Sixteen metabolite features significantly differed when B samples were compared between preterm babies who subsequently developed NEC and preterm/term controls (p value <0.05). Of these seven metabolites were linked to up-regulation of IL-1β. Significant differences in 54 metabolite features (p value <0.05) were observed between preterm and term metabolomes. Of these, 12 metabolite features were linked to one network involved in carbohydrate/lipid metabolism (p = 1 × 10(-30)). CONCLUSIONS Metabolomic differences were observed in preterm babies at risk of NEC. However, sample sizes were insufficient to confidently identify a biomarker. Network modelling of preterm and term metabolomes suggest possible nutritional deficiency and altered pro-insulin action in preterm babies.
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Affiliation(s)
- Amy Wilcock
- a Faculty of Medical and Human Sciences , University of Manchester , Manchester , UK
| | - Paul Begley
- b Faculty of Medical and Human Sciences , Centre for Endocrinology and Diabetes, Institute of Human Development, The University of Manchester , Manchester , UK .,c Centre for Advanced Discovery and Experimental Therapeutics (CADET), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre , Manchester , UK
| | - Adam Stevens
- d Faculty of Medical and Human Sciences , Centre for Paediatrics and Child Health, Institute of Human Development, University of Manchester , Manchester , UK .,e Manchester Academic Health Sciences Centre (MAHSC), Central Manchester University Hospitals NHS Foundation Trust , Manchester , UK , and
| | - Andrew Whatmore
- d Faculty of Medical and Human Sciences , Centre for Paediatrics and Child Health, Institute of Human Development, University of Manchester , Manchester , UK .,e Manchester Academic Health Sciences Centre (MAHSC), Central Manchester University Hospitals NHS Foundation Trust , Manchester , UK , and
| | - Suresh Victor
- d Faculty of Medical and Human Sciences , Centre for Paediatrics and Child Health, Institute of Human Development, University of Manchester , Manchester , UK .,e Manchester Academic Health Sciences Centre (MAHSC), Central Manchester University Hospitals NHS Foundation Trust , Manchester , UK , and.,f Neonatology Center of Excellence, Sidra Medical and Research Center , Doha , Qatar
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15
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Sylvester KG, Ling XB, Liu GYG, Kastenberg ZJ, Ji J, Hu Z, Wu S, Peng S, Abdullah F, Brandt ML, Ehrenkranz RA, Harris MC, Lee TC, Simpson BJ, Bowers C, Moss RL. Urine protein biomarkers for the diagnosis and prognosis of necrotizing enterocolitis in infants. J Pediatr 2014; 164:607-12.e1-7. [PMID: 24433829 PMCID: PMC4161235 DOI: 10.1016/j.jpeds.2013.10.091] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Revised: 08/21/2013] [Accepted: 10/14/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To test the hypothesis that an exploratory proteomics analysis of urine proteins with subsequent development of validated urine biomarker panels would produce molecular classifiers for both the diagnosis and prognosis of infants with necrotizing enterocolitis (NEC). STUDY DESIGN Urine samples were collected from 119 premature infants (85 NEC, 17 sepsis, 17 control) at the time of initial clinical concern for disease. The urine from 59 infants was used for candidate biomarker discovery by liquid chromatography/mass spectrometry. The remaining 60 samples were subject to enzyme-linked immunosorbent assay for quantitative biomarker validation. RESULTS A panel of 7 biomarkers (alpha-2-macroglobulin-like protein 1, cluster of differentiation protein 14, cystatin 3, fibrinogen alpha chain, pigment epithelium-derived factor, retinol binding protein 4, and vasolin) was identified by liquid chromatography/mass spectrometry and subsequently validated by enzyme-linked immunosorbent assay. These proteins were consistently found to be either up- or down-regulated depending on the presence, absence, or severity of disease. Biomarker panel validation resulted in a receiver-operator characteristic area under the curve of 98.2% for NEC vs sepsis and an area under the curve of 98.4% for medical NEC vs surgical NEC. CONCLUSIONS We identified 7 urine proteins capable of providing highly accurate diagnostic and prognostic information for infants with suspected NEC. This work represents a novel approach to improving the efficiency with which we diagnose early NEC and identify those at risk for developing severe, or surgical, disease.
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Affiliation(s)
- Karl G. Sylvester
- Division of Pediatric Surgery, Lucile Packard Children’s Hospital, Palo Alto, CA,Department of Surgery, Stanford University School of Medicine, Baltimore, MD
| | - Xuefeng B. Ling
- Department of Surgery, Stanford University School of Medicine, Baltimore, MD
| | - Gigi Yuen-Gee Liu
- Department of Surgery, Stanford University School of Medicine, Baltimore, MD,Pediatric Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Zachary J. Kastenberg
- Division of Pediatric Surgery, Lucile Packard Children’s Hospital, Palo Alto, CA,Department of Surgery, Stanford University School of Medicine, Baltimore, MD
| | - Jun Ji
- Department of Surgery, Stanford University School of Medicine, Baltimore, MD
| | - Zhongkai Hu
- Department of Surgery, Stanford University School of Medicine, Baltimore, MD
| | - Shuaibin Wu
- Department of Surgery, Stanford University School of Medicine, Baltimore, MD
| | - Sihua Peng
- Department of Surgery, Stanford University School of Medicine, Baltimore, MD
| | - Fizan Abdullah
- Pediatric Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Mary L. Brandt
- Pediatric Surgery, Department of Surgery, Texas Children’s Hospital, Houston, TX
| | - Richard A. Ehrenkranz
- Department of Pediatrics, Division of Neonatology, Yale University School of Medicine, New Haven, CT
| | - Mary Catherine Harris
- Department of Pediatrics, Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Timothy C. Lee
- Pediatric Surgery, Department of Surgery, Texas Children’s Hospital, Houston, TX
| | - B. Joyce Simpson
- Department of Pediatrics, Division of Neonatology, Yale University School of Medicine, New Haven, CT
| | - Corinna Bowers
- Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
| | - R. Lawrence Moss
- Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, Columbus, OH
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16
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ErbB receptors and their growth factor ligands in pediatric intestinal inflammation. Pediatr Res 2014; 75:127-32. [PMID: 24402051 PMCID: PMC4005598 DOI: 10.1038/pr.2013.210] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 06/24/2013] [Indexed: 12/13/2022]
Abstract
The ErbB tyrosine kinases (epidermal growth factor receptor (EGFR), ErbB2/HER2, ErbB3, and ErbB4) are cell surface growth factor receptors widely expressed in many developing mammalian tissues, including in the intestinal tract. Signaling elicited by these receptors promotes epithelial cell growth and survival, and ErbB ligands have been proposed as therapeutic agents for intestinal diseases of pediatric populations, including inflammatory bowel disease (IBD), necrotizing enterocolitis (NEC), and inflammation associated with total parenteral nutrition (TPN). Furthermore, emerging evidence points to reduced ErbB ligand expression and thus reduced ErbB activity in IBD, NEC, and TPN models. This review will discuss the current understanding of the role of ErbB receptors in the pathogenesis and potential treatment of pediatric intestinal inflammation, with focus on the altered signaling in disease and the molecular mechanisms by which exogenous ligands are protective.
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17
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Erythropoietin protects epithelial cells from excessive autophagy and apoptosis in experimental neonatal necrotizing enterocolitis. PLoS One 2013; 8:e69620. [PMID: 23936061 PMCID: PMC3723879 DOI: 10.1371/journal.pone.0069620] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 06/12/2013] [Indexed: 12/17/2022] Open
Abstract
Neonatal necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease of preterm infants. Increased intestinal epithelium permeability is an early event in NEC pathogenesis. Autophagy and apoptosis are induced by multiple stress pathways which may impact the intestinal barrier, and they have been associated with pathogenesis of diverse gastrointestinal diseases including inflammatory bowel disease. Using both in vitro and in vivo models, this study investigates autophagy and apoptosis under experimental NEC stresses. Furthermore this study evaluates the effect of erythropoietin (Epo), a component of breast milk previously shown to decrease the incidence of NEC and to preserve intestinal barrier function, on intestinal autophagy and apoptosis. It was found that autophagy and apoptosis are both rapidly up regulated in NEC in vivo as indicated by increased expression of the autophagy markers Beclin 1 and LC3II, and by evidence of apoptosis by TUNEL and cleaved caspase-3 staining. In the rat NEC experimental model, autophagy preceded the onset of apoptosis in intestine. In vitro studies suggested that Epo supplementation significantly decreased both autophagy and apoptosis via the Akt/mTOR signaling pathway and the MAPK/ERK pathway respectively. These results suggest that Epo protects intestinal epithelium from excessive autophagy and apoptosis in experimental NEC.
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18
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Prevention of necrotizing enterocolitis in preterm very low birth weight infants: is it feasible? J Formos Med Assoc 2013; 113:490-7. [PMID: 23701837 DOI: 10.1016/j.jfma.2013.03.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 03/08/2013] [Accepted: 03/29/2013] [Indexed: 01/11/2023] Open
Abstract
Necrotizing enterocolitis (NEC) is still one of the most catastrophic intestinal emergencies in preterm very low-birth weight infants. Primary prevention of NEC should be the priority, since NEC frequently progresses from nonspecific signs, to extensive necrosis within a matter of hours with medical or surgical treatment, making successful treatment and secondary prevention difficult to achieve. Currently available strategies for primary prevention of NEC include antenatal glucocorticosteroids, breast milk feeding, cautious feeding strategy, fluid restriction and probiotics. Nonetheless, based on current research evidence, mixed flora probiotics, and/or breast milk feeding, would appear to be the most effective feasible methods in the prevention of NEC at present.
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19
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Rowland KJ, Choi PM, Warner BW. The role of growth factors in intestinal regeneration and repair in necrotizing enterocolitis. Semin Pediatr Surg 2013; 22:101-11. [PMID: 23611614 PMCID: PMC3635039 DOI: 10.1053/j.sempedsurg.2013.01.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Necrotizing enterocolitis (NEC) is a devastating intestinal disease resulting in major neonatal morbidity and mortality. The pathology is poorly understood, and the means of preventing and treating NEC are limited. Several endogenous growth factors have been identified as having important roles in intestinal growth as well as aiding intestinal repair from injury or inflammation. In this review, we will discuss several growth factors as mediators of intestinal regeneration and repair as well as potential therapeutic agents for NEC.
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Affiliation(s)
| | | | - Brad W. Warner
- Correspondence: Brad W. Warner, M.D. St. Louis Children's Hospital One Children's Place; Suite 5S40 St. Louis MO 63110 (314) 454-6022 - Phone (314) 454-2442 – Fax
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20
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Kubota A, Mochizuki N, Shiraishi J, Nakayama M, Kawahara H, Yoneda A, Tazuke Y, Goda T, Nakahata K, Sano H, Hirano S, Kitajima H. Parenteral-nutrition-associated liver disease after intestinal perforation in extremely low-birthweight infants: consequent lethal portal hypertension. Pediatr Int 2013; 55:39-43. [PMID: 23240986 DOI: 10.1111/ped.12026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 09/12/2012] [Accepted: 09/21/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Parenteral nutrition (PN)-associated liver dysfunction (PNALD) in term infants usually manifests as intrahepatic cholestasis, which recovers with enteral nutrition (EN) in most cases; however, as the number of extremely low-birthweight infants (ELBWI) has been increasing, and consequently intestinal diseases associated with ELBWI have been increasing, more intractable PNALD has been encountered after surgical treatment in ELBWI, which does not resolve or rather worsens with EN. METHODS Three cases of ELBWI with intestinal perforation, which developed PNALD and eventually died of hepatic failure with intractable portal hypertension, were reviewed. Their gestational age and birthweight ranged from 23 to 26 weeks, and from 434 to 968 g, respectively. The intestinal diseases included necrotizing enteritis in two and meconium-related ileus with focal intestinal perforation in one. RESULTS The duration of total PN without EN in the three cases was 17, 24 and 24 days, respectively. The interval between the introduction of PN and the onset of PNALD was 14, 4 and 18 days, respectively. A marked elevation of serum endotoxin level was detected in both cases of necrotizing enteritis. Histopathological study of the liver revealed marked cholestasis, significant hepatic necrosis with fibrosis, and proliferation of ductules in all these cases, which was responsible for portal hypertension. CONCLUSIONS PN after gastrointestinal disorders in ELBWI may cause refractory PNALD, which does not resolve, or rather worsens with the resumption of EN. Portal hypertension secondary to hepatic necrosis may be responsible for the exacerbation with the resumption of EN.
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Affiliation(s)
- Akio Kubota
- Department of Pediatric Surgery, Osaka, Japan.
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21
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Luedtke SA, Yang JT, Wild HE. Probiotics and necrotizing enterocolitis: finding the missing pieces of the probiotic puzzle. J Pediatr Pharmacol Ther 2012; 17:308-28. [PMID: 23412969 PMCID: PMC3567885 DOI: 10.5863/1551-6776-17.4.308] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Necrotizing enterocolitis (NEC) is one of the leading causes of death in the neonatal intensive care unit. Morbidity and mortality rates significantly increase with decreases in gestational age and birth weight. Strong evidence suggests probiotic prophylaxis may significantly decrease the incidence of NEC and should therefore be incorporated into the standard of care for preterm infants. However, debate still remains because of limitations of completed studies. The purpose of this review was to provide an overview of the controversies regarding probiotic use in preterm infants and to shed light on the practical considerations for implementation of probiotic supplementation.
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Affiliation(s)
- Sherry A. Luedtke
- Texas Tech University Health Sciences Center School of Pharmacy, Amarillo, Texas
| | - Jacob T. Yang
- Texas Tech University Health Sciences Center School of Pharmacy, Amarillo, Texas
| | - Heather E. Wild
- Texas Tech University Health Sciences Center School of Pharmacy, Amarillo, Texas
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22
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McElroy SJ, Hobbs S, Kallen M, Tejera N, Rosen MJ, Grishin A, Matta P, Schneider C, Upperman J, Ford H, Polk DB, Weitkamp JH. Transactivation of EGFR by LPS induces COX-2 expression in enterocytes. PLoS One 2012; 7:e38373. [PMID: 22675459 PMCID: PMC3364993 DOI: 10.1371/journal.pone.0038373] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 05/04/2012] [Indexed: 12/21/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is the leading cause of gastrointestinal morbidity and mortality in preterm infants. NEC is characterized by an exaggerated inflammatory response to bacterial flora leading to bowel necrosis. Bacterial lipopolysaccharide (LPS) mediates inflammation through TLR4 activation and is a key molecule in the pathogenesis of NEC. However, LPS also induces cyclooxygenase-2 (COX-2), which promotes intestinal barrier restitution through stimulation of intestinal cell survival, proliferation, and migration. Epidermal growth factor receptor (EGFR) activation prevents experimental NEC and may play a critical role in LPS-stimulated COX-2 production. We hypothesized that EGFR is required for LPS induction of COX-2 expression. Our data show that inhibiting EGFR kinase activity blocks LPS-induced COX-2 expression in small intestinal epithelial cells. LPS induction of COX-2 requires Src-family kinase signaling while LPS transactivation of EGFR requires matrix metalloprotease (MMP) activity. EGFR tyrosine kinase inhibitors block LPS stimulation of mitogen-activated protein kinase ERK, suggesting an important role of the MAPK/ERK pathway in EGFR-mediated COX-2 expression. LPS stimulates proliferation of IEC-6 cells, but this stimulation is inhibited with either the EGFR kinase inhibitor AG1478, or the selective COX-2 inhibitor Celecoxib. Taken together, these data show that EGFR plays an important role in LPS-induction of COX-2 expression in enterocytes, which may be one mechanism for EGF in inhibition of NEC.
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Affiliation(s)
- Steven J. McElroy
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Stuart Hobbs
- Department of Cell and Developmental Biology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Michael Kallen
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Noemi Tejera
- Department of Pharmacology and Vanderbilt Institute of Chemical Biology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Michael J. Rosen
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Anatoly Grishin
- Division of Pediatric Surgery, Saban Research Institute, Children's Hospital Los Angeles, Los Angeles, California, United States of America
| | - Poojitha Matta
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Claus Schneider
- Department of Pharmacology and Vanderbilt Institute of Chemical Biology, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Jeffrey Upperman
- Division of Pediatric Surgery, Saban Research Institute, Children's Hospital Los Angeles, Los Angeles, California, United States of America
| | - Henri Ford
- Division of Pediatric Surgery, Saban Research Institute, Children's Hospital Los Angeles, Los Angeles, California, United States of America
| | - D. Brent Polk
- Departments of Pediatrics and Biochemistry and Molecular Biology, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California, United States of America
| | - Jörn-Hendrik Weitkamp
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
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23
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Abstract
PURPOSE OF REVIEW This review will summarize the clinical and experimental studies evaluating the role of epidermal growth factor (EGF) in prophylaxis and treatment of necrotizing enterocolitis (NEC). RECENT FINDINGS Clinical studies have suggested the importance of EGF in protection of the intestine against NEC, as well as its safety for infants suffering from NEC. The recent experimental studies identified the molecular mechanisms EGF uses for intestinal protection, which involves regulation of intestinal epithelial homeostasis and barrier function. Further studies are necessary to identify the optimal dose, timing, and route of administration of EGF to NEC patients. No clinical studies are currently underway. SUMMARY NEC is a devastating problem for preterm neonates, but the exact disease pathogenesis remains unclear. Growing clinical evidence supports the use of EGF as a predictive marker of NEC and its use for prevention and treatment of NEC. In addition, experimental data indicate potential mechanisms of EGF prevention against NEC. These include reduction of inflammation, improvement of barrier function, and regulation of epithelial apoptosis and autophagy.
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25
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Xiao C, Puddicombe SM, Field S, Haywood J, Broughton-Head V, Puxeddu I, Haitchi HM, Vernon-Wilson E, Sammut D, Bedke N, Cremin C, Sones J, Djukanović R, Howarth PH, Collins JE, Holgate ST, Monk P, Davies DE. Defective epithelial barrier function in asthma. J Allergy Clin Immunol 2011; 128:549-56.e1-12. [PMID: 21752437 DOI: 10.1016/j.jaci.2011.05.038] [Citation(s) in RCA: 433] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 05/23/2011] [Accepted: 05/27/2011] [Indexed: 12/24/2022]
Abstract
BACKGROUND Asthma is a complex disease involving gene and environment interactions. Although atopy is a strong predisposing risk factor for asthma, local tissue susceptibilities are required for disease expression. The bronchial epithelium forms the interface with the external environment and is pivotally involved in controlling tissue homeostasis through provision of a physical barrier controlled by tight junction (TJ) complexes. OBJECTIVES To explain the link between environment exposures and airway vulnerability, we hypothesized that epithelial TJs are abnormal in asthma, leading to increased susceptibility to environmental agents. METHODS Localization of TJs in bronchial biopsies and differentiated epithelial cultures was assessed by electron microscopy or immunostaining. Baseline permeability and the effect of cigarette smoke and growth factor were assessed by measurement of transepithelial electrical resistance and passage of fluorescently labeled dextrans. RESULTS By using immunostaining, we found that bronchial biopsies from asthmatic subjects displayed patchy disruption of TJs. In differentiated bronchial epithelial cultures, TJ formation and transepithelial electrical resistance were significantly lower (P < .05) in cultures from asthmatic donors (n = 43) than from normal controls (n = 40) and inversely correlated with macromolecular permeability. Cultures from asthmatic donors were also more sensitive to disruption by cigarette smoke extract. Epidermal growth factor enhanced basal TJ formation in cultures from asthmatic subjects (P < .01) and protected against cigarette smoke-induced barrier disruption (P < .01). CONCLUSIONS Our results show that the bronchial epithelial barrier in asthma is compromised. This defect may facilitate the passage of allergens and other agents into the airway tissue, leading to immune activation and may thus contribute to the end organ expression of asthma.
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Affiliation(s)
- Chang Xiao
- Synairgen Research Ltd, Southampton General Hospital, Southampton, United Kingdom
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26
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Gourlay DM. The good and the bad of the innate immune response in necrotizing enterocolitis. J Surg Res 2011; 175:51-3. [PMID: 21920553 DOI: 10.1016/j.jss.2011.07.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 06/28/2011] [Accepted: 07/11/2011] [Indexed: 10/17/2022]
Affiliation(s)
- David M Gourlay
- Division of Pediatric Surgery, Children's Hospital of Wisconsin, 999 N 92nd Ave, Suite 320, Milwaukee, WI 53226, USA.
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27
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Siggers RH, Siggers J, Thymann T, Boye M, Sangild PT. Nutritional modulation of the gut microbiota and immune system in preterm neonates susceptible to necrotizing enterocolitis. J Nutr Biochem 2010; 22:511-21. [PMID: 21193301 DOI: 10.1016/j.jnutbio.2010.08.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Accepted: 08/23/2010] [Indexed: 02/07/2023]
Abstract
The gastrointestinal inflammatory disorder, necrotizing enterocolitis (NEC), is among the most serious diseases for preterm neonates. Nutritional, microbiological and immunological dysfunctions all play a role in disease progression but the relationship among these determinants is not understood. The preterm gut is very sensitive to enteral feeding which may either promote gut adaptation and health, or induce gut dysfunction, bacterial overgrowth and inflammation. Uncontrolled inflammatory reactions may be initiated by maldigestion and impaired mucosal protection, leading to bacterial overgrowth and excessive nutrient fermentation. Tumor necrosis factor alpha, toll-like receptors and heat-shock proteins are identified among the immunological components of the early mucosal dysfunction. It remains difficult, however, to distinguish the early initiators of NEC from the later consequences of the disease pathology. To elucidate the mechanisms and identify clinical interventions, animal models showing spontaneous NEC development after preterm birth coupled with different forms of feeding may help. In this review, we summarize the literature and some recent results from studies on preterm pigs on the nutritional, microbial and immunological interactions during the early feeding-induced mucosal dysfunction and later NEC development. We show that introduction of suboptimal enteral formula diets, coupled with parenteral nutrition, predispose to disease, while advancing amounts of mother's milk from birth (particularly colostrum) protects against disease. Hence, the transition from parenteral to enteral nutrition shortly after birth plays a pivotal role to secure gut growth, digestive maturation and an appropriate response to bacterial colonization in the sensitive gut of preterm neonates.
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MESH Headings
- Animals
- Animals, Newborn
- Enterocolitis, Necrotizing/etiology
- Enterocolitis, Necrotizing/immunology
- Enterocolitis, Necrotizing/microbiology
- Gastrointestinal Tract/growth & development
- Gastrointestinal Tract/immunology
- Gastrointestinal Tract/microbiology
- Heat-Shock Proteins/metabolism
- Humans
- Immune System/immunology
- Infant Nutritional Physiological Phenomena
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/etiology
- Infant, Premature, Diseases/immunology
- Infant, Premature, Diseases/microbiology
- Intestinal Mucosa/immunology
- Intestinal Mucosa/microbiology
- Intestine, Small/metabolism
- Metagenome/physiology
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Affiliation(s)
- Richard H Siggers
- Department of Human Nutrition, Faculty of Life Sciences, University of Copenhagen, 30 Rolighedsvej, DK-1958 Frederiksberg C, Denmark
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28
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Abstract
Maternal milk is a complex fluid, with multifunctional roles within the developing gastrointestinal tract. Epidermal growth factor (EGF) and heparin-binding EGF-like growth factor (HB-EGF) are members of the family of EGF-related peptides. Biological actions of these growth factors are mediated via interaction with the EGF-receptor (EGF-R). In the early postnatal period, breast milk is the major source of EGF for the developing intestinal mucosa. HB-EGF is also detected in breast milk, but in concentrations 2 to 3 times lower than EGF. With normal physiological conditions, the intestinal epithelium undergoes a continuing process of cell proliferation, differentiation, and maturation. EGF plays an important role in these processes. In pathophysiologic situations, EGF contributes to epithelial protection from injury and post-injury mucosal repair. Necrotizing enterocolitis (NEC) is a devastating disease affecting infants born prematurely. The pathogenesis of NEC is not known, and there is no effective treatment for this disease. In an experimental NEC model, oral administration of a physiological dose of EGF significantly reduces the incidence and severity of NEC. HB-EGF provides similar protection against NEC, but only when pharmacological doses are used. Further studies are necessary before EGF can be introduced as an efficient therapeutic approach of intestinal injury.
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Affiliation(s)
- Bohuslav Dvorak
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA.
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29
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Abstract
Necrotizing enterocolitis (NEC) remains a major cause of neonatal morbidity and death. The pathophysiology is poorly understood. Prevailing evidence suggests that NEC is due to an inappropriate inflammatory response of the immature gut to some undefined insult. The mortality rate (15%-25%) for affected infants has not changed appreciably in 30 years. Many infants with NEC recover uneventfully with medical therapy and have long-term outcomes similar to unaffected infants of matched gestational age. Infants with progressive disease requiring surgical intervention suffer almost all of the mortality and morbidity. Of these, approximately 30%-40% will die of their disease and most of the remainder will develop long-term neurodevelopmental and gastrointestinal morbidity. Recent randomized trials suggest that the choice of operation does not influence patient outcome. Current work is focusing on developing a better understanding of the pathogenesis and improving means to identify which infants are at greatest risk of disease progression.
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Affiliation(s)
- Marion C W Henry
- Section of Pediatric Surgery, Yale University School of Medicine, New Haven, Connecticut 06510, USA
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30
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Untalan PB, Keeney SE, Palkowetz KH, Rivera A, Goldman AS. Heat susceptibility of interleukin-10 and other cytokines in donor human milk. Breastfeed Med 2009; 4:137-44. [PMID: 19366315 DOI: 10.1089/bfm.2008.0145] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Holder pasteurization renders donor human milk safe for consumption. Because human milk reduces the risk of necrotizing enterocolitis in preterm infants, we tested whether Holder pasteurization affects certain factors in human milk that protect the intestines: epidermal growth factor (EGF), transforming growth factor (TGF)-beta1, erythropoietin (EPO), and interleukin (IL)-10. Donor human milk from a milk bank was examined. METHODS The aqueous phase of 17 samples of donor term human milk (mean duration of lactation, 8 +/- 3.5 months) was examined before and after Holder pasteurization. In the case of IL-10, lesser degrees of pasteurization were also evaluated. The agents were quantified using enzyme immunoassays. The function of IL-10 was also tested. RESULTS Concentrations of EGF and IL-10 were markedly lower than previously reported values in human milk from earlier phases of lactation. Holder pasteurization significantly reduced the concentrations of EPO and IL-10, whereas lesser degrees of heating increased the detection of IL-10. The immunosuppression of T-cell proliferation by human milk, thought to be attributed to IL-10 alone, persisted after Holder pasteurization. CONCLUSIONS Holder pasteurization greatly decreased concentrations of EPO and IL-10 in human milk. These decreases may impact the ability of human milk to protect against necrotizing enterocolitis. Evidence of possible binding of IL-10 to other proteins in human milk was also found. Experiments to test whether Holder pasteurization affects the function of IL-10 in human milk produced evidence for an agent in human milk other than IL-10 that inhibits T-cell proliferation and resists Holder pasteurization.
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Affiliation(s)
- Peter B Untalan
- Department of Neonatology, St. David's Medical Center, Austin, Texas, USA
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31
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Swindle EJ, Collins JE, Davies DE. Breakdown in epithelial barrier function in patients with asthma: identification of novel therapeutic approaches. J Allergy Clin Immunol 2009; 124:23-34; quiz 35-6. [PMID: 19560576 DOI: 10.1016/j.jaci.2009.05.037] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Revised: 05/26/2009] [Accepted: 05/27/2009] [Indexed: 01/19/2023]
Abstract
The bronchial epithelium is pivotally involved in the provision of chemical, physical, and immunologic barriers to the inhaled environment. These barriers serve to maintain normal homeostasis, but when compromised, the immunologic barrier becomes activated to protect the internal milieu of the lung. We discuss what is currently understood about abnormalities in these barrier functions in patients with asthma and consider novel therapeutic opportunities that target this key structure.
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Affiliation(s)
- Emily J Swindle
- Division of Infection, Inflammation and Immunity, University of Southampton School of Medicine, Southampton General Hospital, Southampton SO16 6YD, United Kingdom
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32
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Abstract
The incidence of necrotising enterocolitis (NEC) has not changed significantly despite the dramatic advances in perinatal-neonatal care. The absolute number of survivors of NEC is expected to rise, as prevention of prematurity, the single most important risk factor for the illness, continues to be difficult. Prevention of NEC has thus become an area of research priority. Given the role of inflammatory mediators in its pathogenesis newer immune modulators are being studied as potential agents for prevention/treatment of NEC. Caution, however, is warranted because the failure of sepsis trials in adults has clearly indicated that the concept of down-regulating the inflammatory response is deceptively simple. Clinical trials of any such promising preventative agent(s) need to be designed carefully and must include long-term neurodevelopmental outcomes as almost an entire population of high-risk preterm neonates will be exposed to their adverse effects. As new frontiers continue to be explored, the proven benefits of simple and safe interventions like antenatal glucocorticoid therapy and the preferential use of breast milk for feeding high-risk neonates must not be forgotten. Given that a single effective agent is unlikely in the near future, utilizing a package of "potentially better practices" seems to be the most appropriate strategy to prevent and minimize NEC.
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Affiliation(s)
- Sanjay Patole
- Department of Neonatal Paediatrics, KEM Hospital for Women, University of Western Australia, Perth, WA, Australia.
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Radulescu A, Zorko NA, Yu X, Besner GE. Preclinical neonatal rat studies of heparin-binding EGF-like growth factor in protection of the intestines from necrotizing enterocolitis. Pediatr Res 2009; 65:437-42. [PMID: 19127210 PMCID: PMC3754802 DOI: 10.1203/pdr.0b013e3181994fa0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
We have previously demonstrated that enterally administered heparin-binding EGF-like growth factor (HB-EGF) produced in Escherichia coli decreases the incidence and severity of intestinal injury in a neonatal rat model of necrotizing enterocolitis (NEC). In preparation for upcoming human clinical trials, large-scale production of HB-EGF according to Good Manufacturing Practice (GMP) has been successfully accomplished using a Pichia pastoris yeast system. The current studies used a neonatal rat model of NEC to elucidate several important preclinical characteristics of HB-EGF therapy. We found that enteral administration of HB-EGF (800 microg/kg/dose) four times a day effectively reduced the incidence and severity of NEC, that Pichia-derived HB-EGF was not significantly different from E. coli-derived HB-EGF in preventing NEC, that EGF was not superior to HB-EGF in preventing NEC, and that prophylactic administration of HB-EGF added to formula starting with the first feed or 12 h later significantly reduced the incidence of NEC, with no change in the incidence of NEC noted if HB-EGF was added to the formula starting 24, 48, or 72 h after birth. Thus, large-scale production of GMP-grade HB-EGF in Pichia pastoris yeast produces a biologically active molecule suitable for human clinical trials.
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Affiliation(s)
- Andrei Radulescu
- Center for Perinatal Research, Nationwide Children's Hospital, Columbus, Ohio 43205, USA
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Guner YS, Chokshi N, Petrosyan M, Upperman JS, Ford HR, Grikscheit TC. Necrotizing enterocolitis--bench to bedside: novel and emerging strategies. Semin Pediatr Surg 2008; 17:255-65. [PMID: 19019294 DOI: 10.1053/j.sempedsurg.2008.07.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Necrotizing enterocolitis (NEC) is a devastating illness that predominantly affects premature neonates. The mortality associated with this disease has changed very little during the last two decades. Neonates with NEC fall into two categories: those who respond to medical management alone and those who require surgical treatment. The disease distribution may be focal, multifocal, or panintestinal. Surgical treatment should therefore be based on disease presentation. Recent studies have added significant insight into our understanding of the pathogenesis of NEC. Several groups have shown that upregulation of nitric oxide plays an integral role in the development of epithelial injury in NEC. As a result, some treatment strategies have been aimed at abrogating the toxic effects of nitric oxide. In addition, several investigators have reported the cytoprotective effect of epidermal growth factor, which is found in high levels in breast milk, on the intestinal epithelium. Thus, fortification of infant formula with specific growth factors could soon become a preferred strategy to accelerate intestinal maturation in the premature neonate to prevent the development of NEC. One of the most devastating complications of NEC is the development of short bowel syndrome (SBS). The current treatment of SBS involves intestinal lengthening procedures or bowel transplantation. A novel emerging method for treating SBS involves the use of tissue-engineered intestine. In laboratory animals, tissue-engineered small intestine has been shown to be successful in treating intestinal failure. This article examines recent data regarding surgical treatment options for NEC as well as emerging treatment modalities.
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Affiliation(s)
- Yigit S Guner
- Department of Surgery, Childrens Hospital Los Angeles, and the Keck School of Medicine, University of Southern California, Los Angeles, California 90027, USA
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Thompson AM, Bizzarro MJ. Necrotizing enterocolitis in newborns: pathogenesis, prevention and management. Drugs 2008; 68:1227-38. [PMID: 18547133 DOI: 10.2165/00003495-200868090-00004] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Necrotizing enterocolitis (NEC) is primarily a disease process of the gastrointestinal (GI) tract of premature neonates that results in inflammation and bacterial invasion of the bowel wall. Despite advances in the care of premature infants, NEC remains one of the leading causes of morbidity and mortality in this population. It occurs in 1-5% of all neonatal intensive care admissions and 5-10% of all very low birthweight (<1500 g) infants. Although research has presented an interesting array of potential contributing factors, the precise aetiology of this multifactorial disease process remains elusive. Historically, it was believed that NEC arose predominantly from ischaemic injury to the immature GI tract, yet alternate plausible hypotheses indicate that many factors are likely to be involved. These may include issues related to the introduction and advancement of enteric feeding, alterations in the normal bacterial colonization of the GI tract, bacterial translocation and activation of the cytokine cascade, decreased epidermal growth factor, increased platelet activating factor, and mucosal damage from free radical production. Clinical manifestations of NEC may be vague, including increased episodes of apnoea, desaturations, bradycardia, lethargy and temperature instability. There may also be GI-specific symptoms such as feeding intolerance, emesis, bloody stools, abdominal distention and tenderness, and abdominal wall discolouration. Laboratory values may be indicative of infection, coagulation abnormalities and fluid retention. Radiographic signs may include ileus, dilated or fixed intestinal loops, air in the intestinal wall or free air in the abdomen. Medical treatment typically consists of bowel rest and decompression, antibacterial therapy, and management of other haematological or electrolyte imbalances. Increased respiratory and cardiovascular support is sometimes needed. In neonates who do not respond adequately to medical management, or if pneumoperitoneum is present, surgical intervention may occur with either use of a peritoneal drain or laparotomy. Advances in antenatal and neonatal care have resulted in increased survival of extremely preterm neonates. As this at-risk population continues to increase, an effective preventative strategy for NEC is needed. One preventative strategy is the use of antenatal corticosteroids to enhance maturation of the fetus if preterm delivery is likely. Recommendation of use of breast milk, early initiation of trophic feeds and judicoius advancement of enteric feeds are current postnatal strategies. Other preventative strategies that have been investigated include the use of oral antibacterials, antioxidants, supplementation of arginine and epidermal growth factor, none of which have changed clinical practice. Recent promising data indicate that prophylactic use of probiotics may play a role in preventing the onset of NEC. However, more large-scale, definitive studies are needed.
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Affiliation(s)
- Alecia M Thompson
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut 06520-8064, USA
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Dvorak B, Khailova L, Clark JA, Hosseini DM, Arganbright KM, Reynolds CA, Halpern MD. Comparison of epidermal growth factor and heparin-binding epidermal growth factor-like growth factor for prevention of experimental necrotizing enterocolitis. J Pediatr Gastroenterol Nutr 2008; 47:11-8. [PMID: 18607263 DOI: 10.1097/mpg.0b013e3181788618] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease of prematurely born infants. Epidermal growth factor (EGF) and heparin-binding EGF-like growth factor (HB-EGF) have protective effects against intestinal injury. The aim of this study was to compare the effect of oral administration of HB-EGF, EGF, or both on the incidence of NEC in a neonatal rat model. MATERIALS AND METHODS Premature rats were fed by hand and exposed to asphyxia and cold stress to develop NEC. Four diets were used: formula (NEC), formula supplemented with 500 ng/mL HB-EGF (HB), 500 ng/mL EGF (EGF), or a combination of both (E+HB). Ileal injury, endogenous HB-EGF production, expression of EGF receptors, goblet cell density, and expression of apoptotic proteins were evaluated. RESULTS Oral administration of either EGF or HB-EGF significantly reduced the incidence of NEC; however, EGF provided better protection in physiologically relevant doses. Simultaneous administration of both growth factors did not result in any synergistic protective effect against NEC. There were no significant differences between treatment groups in ileal gene expression of EGF receptors or HB-EGF. However, the balance of apoptotic proteins in the ileum was shifted in favor of cell survival in EGF-treated rats. This mechanism may be responsible for the higher efficiency of EGF protection against NEC. CONCLUSIONS These data suggest that a physiological dosage of EGF or a pharmacological dosage of HB-EGF could be used for prevention of NEC.
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Affiliation(s)
- Bohuslav Dvorak
- Department of Pediatrics, Steele Children's Research Center, University of Arizona, Tucson, AZ 85724-5073, USA.
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Silva DCBD, Quinello C, Pires DA, Pinto JR, Mattar AC, Krebs VLJ, Ceccon MEJR. Uso de fatores de crescimento epidérmico e estimulador de colônias de granulócitos na prevenção e tratamento da enterocolite necrosante no recém-nascido. REVISTA PAULISTA DE PEDIATRIA 2008. [DOI: 10.1590/s0103-05822008000200013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJETIVO: Revisar os conhecimentos existentes em relação ao uso de fatores de crescimento epidérmico e estimulador de colônias de granulócitos na prevenção e/ou no tratamento da enterocolite necrosante (ECN) durante o período neonatal. FONTES DE DADOS: Revisão da literatura, nas bases de dados Medline, Lilacs, SciELO e PubMed, utilizando os unitermos "recém-nascidos", "enterocolite" e "fatores de crescimento", no período de 2003 a 2007. Nesta busca, 49 artigos foram encontrados, sendo 17 pertinentes ao tema. Também foram utilizados outros artigos, independente do ano de publicação, relacionados a aspectos definidores da ECN no recém-nascido. SÍNTESE DOS DADOS: A ECN continua sendo responsável por uma elevada morbimortalidade neonatal. Os mecanismos fisiopatológicos vêm sendo elucidados e, a partir deles, são discutidas novas terapias, como o uso de fatores de crescimento, destacando-se o fator de crescimento epidérmico e o fator estimulador de colônias de granulócitos. CONCLUSÕES: O uso de fatores de crescimento no tratamento e prevenção da ECN neonatal parece promissor. É necessário maior número de ensaios clínicos para comprovar sua eficácia e segurança. Enquanto isso, a melhor prática médica continua sendo a prevenção da doença.
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Schnabl KL, Aerde JEV, Thomson ABR, Clandinin MT. Necrotizing enterocolitis: A multifactorial disease with no cure. World J Gastroenterol 2008; 14:2142-61. [PMID: 18407587 PMCID: PMC2703838 DOI: 10.3748/wjg.14.2142] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Necrotizing enterocolitis is an inflammatory bowel disease of neonates with significant morbidity and mortality in preterm infants. Due to the multifactorial nature of the disease and limitations in disease models, early diagnosis remains challenging and the pathogenesis elusive. Although preterm birth, hypoxic-ischemic events, formula feeding, and abnormal bacteria colonization are established risk factors, the role of genetics and vasoactive/inflammatory mediators is unclear. Consequently, treatments do not target the specific underlying disease processes and are symptomatic and surgically invasive. Breast-feeding is the most effective preventative measure. Recent advances in the prevention of necrotizing enterocolitis have focused on bioactive nutrients and trophic factors in human milk. Development of new disease models including the aspect of prematurity that consistently predisposes neonates to the disease with multiple risk factors will improve our understanding of the pathogenesis and lead to discovery of innovative therapeutics.
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Frost BL, Jilling T, Caplan MS. The importance of pro-inflammatory signaling in neonatal necrotizing enterocolitis. Semin Perinatol 2008; 32:100-6. [PMID: 18346533 PMCID: PMC2362144 DOI: 10.1053/j.semperi.2008.01.001] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Despite modern medical advances, necrotizing enterocolitis (NEC) remains a significant cause of morbidity and mortality in neonatal intensive care units, affecting 10% of premature neonates born weighing less than 1500 g. Although many advances have been made in the understanding of NEC, the etiology and pathophysiology remain incompletely understood, and treatment is limited to supportive care. In recent years, many studies have evaluated the inflammatory cascade that is central to the disease process, and research is ongoing into strategies to prevent and/or ameliorate neonatal NEC. In this review, we examine the key points in the signaling pathways involved in NEC, and potential strategies for prevention and treatment of this dreaded disease.
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40
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Lin PW, Nasr TR, Stoll BJ. Necrotizing enterocolitis: recent scientific advances in pathophysiology and prevention. Semin Perinatol 2008; 32:70-82. [PMID: 18346530 DOI: 10.1053/j.semperi.2008.01.004] [Citation(s) in RCA: 216] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality among infants in the neonatal intensive care unit. Here we review the epidemiology and pathophysiology of NEC, with an emphasis on the latest research findings and potential areas for future research. NEC continues to be one of the most devastating and unpredictable diseases affecting premature infants. Despite decades of research, the pathogenesis of this disease remains unclear, and prevention and treatment strategies are limited. Hopefully, future studies aimed at understanding premature intestinal defenses, commensal or probiotic bacterial influences, and possible genetic predisposition will lead to the improvement of prevention and treatment strategies.
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Affiliation(s)
- Patricia W Lin
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.
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41
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Nair RR, Warner BB, Warner BW. Role of epidermal growth factor and other growth factors in the prevention of necrotizing enterocolitis. Semin Perinatol 2008; 32:107-13. [PMID: 18346534 DOI: 10.1053/j.semperi.2008.01.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Necrotizing enterocolitis (NEC) presents as the most common gastrointestinal emergency during the neonatal period and results in ulceration and necrosis of the distal small intestine and proximal colon. The etiology of NEC remains unknown. Based on the complexity of gut development, multiple growth factors and cytokines may be needed to synergistically support the developing gut. Epidermal growth factor (EGF) has been shown to play an important role in intestinal cell restitution, proliferation, and maturation. EGF is found in abundant quantities in many fluids, including the gastrointestinal tract, amniotic fluid, breast milk, and saliva. Preliminary clinical trials using EGF in neonates diagnosed with NEC have been shown to promote repair of intestinal epithelium. Additionally, other growth factors are also emerging as potential treatment modalities, including erythropoietin, granulocyte colony stimulating factor, and heparin-binding EGF. The role of EGF and other growth factors in the pathogenesis and prevention of NEC will be reviewed.
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Affiliation(s)
- Rajalakshmi R Nair
- Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO 63110, USA
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42
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Abstract
In necrotizing enterocolitis (NEC) the small (most often distal) and/or large bowel becomes injured, develops intramural air, and may progress to frank necrosis with perforation. Even with early, aggressive treatment, the progression of necrosis, which is highly characteristic of NEC, can lead to sepsis and death. This article reviews the current scientific knowledge related to the etiology and pathogenesis of NEC and discusses some possible preventive measures.
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Grave GD, Nelson SA, Walker WA, Moss RL, Dvorak B, Hamilton FA, Higgins R, Raju TNK. New therapies and preventive approaches for necrotizing enterocolitis: report of a research planning workshop. Pediatr Res 2007; 62:510-4. [PMID: 17667844 DOI: 10.1203/pdr.0b013e318142580a] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The National Institute of Child Health and Human Development and the Digestive Diseases Interagency Coordinating Committee held a workshop, chaired by Dr. W. Allan Walker, on July 10-11, 2006, to identify promising leads in necrotizing enterocolitis (NEC) research. The goals of the workshop were to identify new approaches to the prevention and treatment of NEC, to define basic and translational mechanisms of potential approaches to NEC, and to develop recommendations for clinical studies to reduce the incidence of NEC. Workshop participants implicated prematurity, introduction of enteral feedings, gastrointestinal bacterial colonization, gut motility, proinflammatory cytokines, impaired gut blood flow, and various neonatal complications in the pathogenesis of NEC. They concluded that a unifying hypothesis encompassing these pathogenetic factors is the uncontrolled exuberant inflammatory response to bacterial colonization that characterizes the intestine of premature infants. The inflammatory cascade appears to offer multiple targets for interventions with a variety of anti-inflammatory agents, including human milk and probiotics. Because of the rapidity with which the inflammatory response gets out of control in infants with NEC, workshop participants agreed that searching for ways to prevent NEC will be more rewarding than trying to identify ways to treat the condition once it has become established.
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Affiliation(s)
- Gilman D Grave
- Endocrinology, Nutrition and Growth Branch, National Institute of Child Health and Development/National Institutes of Health, Bethesda, Maryland 20892, USA.
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Oslislo A, Czuba Z, Sławska H, Kaźmierczak W, Król W. Decreased human milk concentration of epidermal growth factor after preterm delivery of intrauterine growth-restricted newborns. J Pediatr Gastroenterol Nutr 2007; 44:464-7. [PMID: 17414145 DOI: 10.1097/mpg.0b013e3180331e15] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIM The aim of the study was to compare epidermal growth factor (EGF) concentration in 81 colostrum samples collected from mothers of newborns in the following growth categories: preterm appropriate for gestational age (AGA), preterm small for gestational age (SGA), and full term (FT). RESULTS Significantly higher concentrations of EGF were found in the colostrum of mothers who delivered premature AGA infants at less than 32 weeks of gestation compared with mothers who delivered premature SGA babies at the same gestational age. CONCLUSIONS We concluded that the maternal compensatory mechanism accelerating the development of immature breast-fed infants may be disturbed when gestation is complicated by intrauterine growth retardation.
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Affiliation(s)
- Anna Oslislo
- Department of Perinatology and Gynecology, Medical University of Silesia, Zabrze, Poland.
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45
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Warner BB, Ryan AL, Seeger K, Leonard AC, Erwin CR, Warner BW. Ontogeny of salivary epidermal growth factor and necrotizing enterocolitis. J Pediatr 2007; 150:358-63. [PMID: 17382110 DOI: 10.1016/j.jpeds.2006.11.059] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2006] [Revised: 10/05/2006] [Accepted: 11/21/2006] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To examine the ontogeny of salivary epidermal growth factor (sEGF) in premature infants and to determine the relation of sEGF to the development of necrotizing enterocolitis (NEC). STUDY DESIGN Salivary EGF was prospectively measured in 327 infants with gestational ages from 23 weeks to term. Infants of < or = 32 weeks' gestation (n = 261) were followed with weekly sEGF measurements through 3 weeks of life. Multivariable regression analyses were used to determine variables significantly related to sEGF levels and to identify predictors of NEC. RESULTS Over the first 3 weeks of life, sEGF increased across gestational age and postnatal age categories. In multivariable models, gestational age was a significant predictor of sEGF levels (P < .009). In a cohort of 27 infants who had NEC, gestational age, race, and changes in sEGF levels between weeks of life 1 and 2 were predictive of the development of NEC. These infants had lower sEGF at week 1 and greater increases from week 1 to week 2 compared with infants without NEC. CONCLUSIONS There is a positive relation between sEGF levels and gestational age. Patterns of sEGF levels over the first 2 weeks of life were significantly related to development of NEC in very low birth weight infants.
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Affiliation(s)
- Barbara B Warner
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA.
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46
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47
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Abstract
Neonatal necrotizing enterocolitis is the second most common cause of morbidity in premature infants and requires intensive care over an extended period. Despite advances in medical and surgical techniques, the mortality and long-term morbidity due to necrotizing enterocolitis remain very high. Recent advances have shifted the attention of researchers from the classic triad (ischemia, bacteria, and the introduction of a metabolic substrate into the intestine) of necrotizing enterocolitis, to gut maturation, feeding practices, and inflammation. The focus on inflammation includes proinflammatory cytokines such as tumor necrosis factor-alpha, interleukin (IL)-6, IL-18, and platelet-activating factor. Research related to the etiology of necrotizing enterocolitis has moved quickly from clostridial toxin to bacterial and other infectious agents. More recently, the pattern of bacterial colonization has been given emphasis rather than the particular species or strain of bacteria or their virulence. Gram-negative bacteria that form part of the normal flora are now speculated as important factors in triggering the injury process in a setting where there is a severe paucity of bacterial species and possible lack of protective Gram-positive organisms. Although the incidence of necrotizing enterocolitis has increased because of the survival of low birthweight infants, clinicians are more vigilant in their detection of the early gastrointestinal symptoms of necrotizing enterocolitis; however, radiographic demonstration of pneumatosis intestinalis remains the hallmark of necrotizing enterocolitis. With prompt diagnosis, a large proportion of infants with necrotizing enterocolitis are now able to be managed medically with intravenous fluid and nutrition, nasogastric suction, antibacterials, and close monitoring of physiologic parameters. In the advanced cases that require surgery, clinicians tend to opt for either simple peritoneal drainage (for very small and sick infants) or laparotomy and resection of the affected part. Intestinal transplantation later in life is available as a viable option for those who undergo resection of large segments of the intestine. It is becoming more evident that treatment of this devastating disease is expensive and comes with the toll of significant long-term sequelae. This has resulted in renewed interest in designing alternative strategies to prevent this serious gastrointestinal disease. Simple trophic feeding and the use of L-glutamine and arginine are novel avenues that have been examined. The use of probiotics ('friendly' bacterial flora) has been introduced as a promising tool for establishing healthy bacterial flora in the newborn gut to block the injury process that may ultimately lead to necrotizing enterocolitis.
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Affiliation(s)
- Pinaki Panigrahi
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, USA.
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48
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Clark JA, Doelle SM, Halpern MD, Saunders TA, Holubec H, Dvorak K, Boitano SA, Dvorak B. Intestinal barrier failure during experimental necrotizing enterocolitis: protective effect of EGF treatment. Am J Physiol Gastrointest Liver Physiol 2006; 291:G938-49. [PMID: 16798726 DOI: 10.1152/ajpgi.00090.2006] [Citation(s) in RCA: 208] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Necrotizing enterocolitis (NEC) is the most common intestinal disease of premature infants. Although increased mucosal permeability and altered epithelial structure have been associated with many intestinal disorders, the role of intestinal barrier function in NEC pathogenesis is currently unknown. We investigated the structural and functional changes of the intestinal barrier in a rat model of NEC. In addition, the effect of EGF treatment on intestinal barrier function was evaluated. Premature rats were divided into three groups: dam fed (DF), formula fed (NEC), or fed with formula supplemented with 500 ng/ml EGF (NEC + EGF); all groups were exposed to asphyxia/cold stress to develop NEC. Intestinal permeability, goblet cell density, mucin production, and composition of tight junction (TJ) proteins were evaluated in the terminal ileum, the site of NEC injury, and compared with the proximal jejunum, which was unaffected by NEC. Animals with NEC had significantly increased intestinal paracellular permeability compared with DF pups. Ileal goblet cell morphology, mucin production, and TJ composition were altered in animals with NEC. EGF treatment significantly decreased intestinal paracellular permeability, increased goblet cell density and mucin production, and normalized expression of two major TJ proteins, occludin and claudin-3, in the ileum. In conclusion, experimental NEC is associated with disruption of the intestinal barrier. EGF treatment maintains intestinal integrity at the site of injury by accelerating goblet cell maturation and mucin production and normalizing expression of TJ proteins, leading to improved intestinal barrier function.
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Affiliation(s)
- Jessica A Clark
- Department of Pediatrics, University of Arizona, Tucson, AZ 85724-5073, USA
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49
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Martin CR, Walker WA. Intestinal immune defences and the inflammatory response in necrotising enterocolitis. Semin Fetal Neonatal Med 2006; 11:369-77. [PMID: 16690363 DOI: 10.1016/j.siny.2006.03.002] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Necrotising enterocolitis is a devastating neonatal gastrointestinal emergency predominantly affecting low birth weight, premature infants and is accompanied by significant mortality and morbid sequelae. The pathophysiology remains obscure and the management of infants with necrotising enterocolitis has not changed since the recognition of this disease. Necrotising enterocolitis is most likely the clinical culmination of multiple different risk factors interacting with each other to produce bowel injury through a final, common inflammatory pathway. Here, we review intestinal immunity and the specific inflammatory mediators involved in this disease process.
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MESH Headings
- Enterocolitis, Necrotizing/immunology
- Enterocolitis, Necrotizing/mortality
- Enterocolitis, Necrotizing/pathology
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/immunology
- Infant, Premature, Diseases/mortality
- Infant, Premature, Diseases/pathology
- Intestines/immunology
- Prevalence
- Risk Factors
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Affiliation(s)
- Camilia R Martin
- Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Rose-318, Boston, MA 02215, USA.
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50
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Schmolzer G, Urlesberger B, Haim M, Kutschera J, Pichler G, Ritschl E, Resch B, Reiterer F, Müller W. Multi-modal approach to prophylaxis of necrotizing enterocolitis: clinical report and review of literature. Pediatr Surg Int 2006; 22:573-80. [PMID: 16775708 DOI: 10.1007/s00383-006-1709-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2006] [Indexed: 12/23/2022]
Abstract
For the first time a multimodal approach to NEC prophylaxis is reported, consisting of early trophic feeding with human breast milk, and enteral administration of an antibiotic, an antifungal agent, and probiotics. A retrospective analysis of local protocol of NEC prophylaxis is presented. Included were all VLBWI admitted to the NICU, including transfers within the first 28 days of life. These infants were divided into two groups, an "inborn group" (infants admitted within the first 24 h of life) and an "outborn group" (infants admitted after the onset of their second day of life). Prophylaxis of NEC according to protocol was started at the day of admission, and was continued until discharge. Between 1998 and 2004, 405 VLBWI were admitted, including all transfers within the first 28 days of life. A total of 334 (82%) infants were admitted within the first 24 h of life (inborn group), and 71 (18%) were admitted after 24 h of life (outborn group). Five infants developed clinical features of necrotizing enterocolitis. The inborn group showed a NEC incidence of 0.7% (two infants), whereas the outborn group showed a NEC incidence of 4.5% (three infants), respectively. This difference was significant (P=0.049, Fisher's exact test). A surgical treatment with bowel resection was performed in two infants (both from the outborn group). The present study used a combination of different strategies, all having shown to have some beneficial effect, but not having brought a clinical breakthrough in single administration studies. Combinated were the beneficial effects of human breast milk feeding, oral antiobiotics, oral antifungal agents, and the administration of probiotics. In a homogenous group of preterm infants, using this protocol of multimodal NEC prophylaxis, there was a very low incidence of NEC, when started within the first 24 h of life.
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Affiliation(s)
- G Schmolzer
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Auenbruggerplatz 30, 8036, Graz, Austria.
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