1
|
Deshmukh M, Patole S. Prophylactic Probiotic Supplementation for Preterm Neonates-A Systematic Review and Meta-Analysis of Nonrandomized Studies. Adv Nutr 2021; 12:1411-1423. [PMID: 33460432 PMCID: PMC8321836 DOI: 10.1093/advances/nmaa164] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/05/2020] [Accepted: 11/20/2020] [Indexed: 12/18/2022] Open
Abstract
Systematic review and meta-analyses of randomized controlled trials (RCTs) show that probiotics reduce the risk of necrotizing enterocolitis (NEC ≥ Stage II), late onset sepsis (LOS), all-cause mortality, and feeding intolerance in preterm neonates. Data from observational studies is important to confirm probiotic effects in clinical practice. We aimed to compare outcomes before and after implementing routine probiotic supplementation (RPS) in preterm neonates (<37 weeks of gestation) by performing a systematic review of non-RCTs using Cochrane methodology. Databases including PubMed, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Central library, and Google Scholar were searched in May 2020. A meta-analysis was performed using a random effects model. Categorical measure of effect size was expressed as OR and 95% CI. Statistical heterogeneity was assessed by the chi-squared test, I2 statistic. The level of evidence (LOE) was summarized using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) guidelines. Primary outcomes were NEC ≥ Stage II, LOS, and all-cause mortality. Secondary outcomes included probiotic sepsis. Thirty good-quality non-RCTs (n = 77,018) from 18 countries were included. The meta-analysis showed RPS was associated with significantly reduced: 1) NEC ≥ Stage II (30 studies, n = 77,018; OR: 0.60; 95% CI: 0.50, 0.73; P <0.00001, I2: 65%; LOE: Moderate), 2) LOS: (21 studies, n = 65,858; OR: 0.85; 95% CI: 0.74, 0.97; P = 0.02, I2: 74%; LOE: Low), and 3) all-cause mortality (27 non-RCTs, n = 70,977; OR: 0.77; 95% CI: 0.68, 0.88; P = 0.0001, I2: 49%; LOE: Low). Subgroups: 1) extremely low birth weight (ELBW: birth weight <1000 g) neonates: RPS was associated with significantly reduced NEC ≥ Stage II (4.5% compared with 7.9%). However, there was no difference in LOS and mortality. 2) Multistrain RPS was more effective than single strain. One study reported 3 nonfatal cases of probiotic sepsis. In summary, moderate- to low-quality evidence indicates that RPS was associated with significantly reduced NEC ≥ Stage II, LOS, and all-cause mortality in neonates <37 weeks of gestation and NEC ≥ Stage II in ELBW neonates.
Collapse
|
2
|
Underwood MA, Umberger E, Patel RM. Safety and efficacy of probiotic administration to preterm infants: ten common questions. Pediatr Res 2020; 88:48-55. [PMID: 32855513 PMCID: PMC8210852 DOI: 10.1038/s41390-020-1080-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In spite of a large number of randomized placebo-controlled clinical trials and observational cohort studies including >50,000 preterm infants from 29 countries that have demonstrated a decrease in the risk of necrotizing enterocolitis, death, and sepsis, routine prophylactic probiotic administration to preterm infants remains uncommon in much of the world. This manuscript reflects talks given at NEC Society Symposium in 2019 and is not intended to be a state-of-the-art review or systematic review, but a summary of the probiotic-specific aspects of the symposium with limited additions including a recent strain-specific network analysis and position statement from the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN). We address ten common questions related to the intestinal microbiome and probiotic administration to the preterm infant.
Collapse
Affiliation(s)
- Mark A Underwood
- Division of Neonatology, Department of Pediatrics, University of California Davis School of Medicine, Sacramento, CA, USA.
| | - Erin Umberger
- Necrotizing Enterocolitis (NEC) Society, Davis, CA, USA
| | - Ravi M Patel
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| |
Collapse
|
3
|
Navarro-Tapia E, Sebastiani G, Sailer S, Toledano LA, Serra-Delgado M, García-Algar Ó, Andreu-Fernández V. Probiotic Supplementation During the Perinatal and Infant Period: Effects on Gut Dysbiosis and Disease. Nutrients 2020; 12:E2243. [PMID: 32727119 PMCID: PMC7468726 DOI: 10.3390/nu12082243] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/15/2020] [Accepted: 07/22/2020] [Indexed: 02/07/2023] Open
Abstract
The perinatal period is crucial to the establishment of lifelong gut microbiota. The abundance and composition of microbiota can be altered by several factors such as preterm delivery, formula feeding, infections, antibiotic treatment, and lifestyle during pregnancy. Gut dysbiosis affects the development of innate and adaptive immune responses and resistance to pathogens, promoting atopic diseases, food sensitization, and infections such as necrotizing enterocolitis (NEC). Recent studies have indicated that the gut microbiota imbalance can be restored after a single or multi-strain probiotic supplementation, especially mixtures of Lactobacillus and Bifidobacterium strains. Following the systematic search methodology, the current review addresses the importance of probiotics as a preventive or therapeutic tool for dysbiosis produced during the perinatal and infant period. We also discuss the safety of the use of probiotics in pregnant women, preterm neonates, or infants for the treatment of atopic diseases and infections.
Collapse
Affiliation(s)
- Elisabet Navarro-Tapia
- Grup de Recerca Infancia i Entorn (GRIE), Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Valencian International University (VIU), 46002 Valencia, Spain
| | - Giorgia Sebastiani
- Department of Neonatology, Hospital Clínic-Maternitat, ICGON, BCNatal, 08028 Barcelona, Spain
| | - Sebastian Sailer
- Department of Neonatology, Hospital Clínic-Maternitat, ICGON, BCNatal, 08028 Barcelona, Spain
| | - Laura Almeida Toledano
- Institut de Recerca Sant Joan de Déu, 08950 Esplugues de Llobregat, Spain
- BCNatal, Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, 08950 Barcelona, Spain
| | - Mariona Serra-Delgado
- Institut de Recerca Sant Joan de Déu, 08950 Esplugues de Llobregat, Spain
- BCNatal, Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), University of Barcelona, 08950 Barcelona, Spain
| | - Óscar García-Algar
- Grup de Recerca Infancia i Entorn (GRIE), Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Department of Neonatology, Hospital Clínic-Maternitat, ICGON, BCNatal, 08028 Barcelona, Spain
| | - Vicente Andreu-Fernández
- Grup de Recerca Infancia i Entorn (GRIE), Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Valencian International University (VIU), 46002 Valencia, Spain
- Department of Neonatology, Hospital Clínic-Maternitat, ICGON, BCNatal, 08028 Barcelona, Spain
| |
Collapse
|
4
|
Probiotics and Preterm Infants: A Position Paper by the European Society for Paediatric Gastroenterology Hepatology and Nutrition Committee on Nutrition and the European Society for Paediatric Gastroenterology Hepatology and Nutrition Working Group for Probiotics and Prebiotics. J Pediatr Gastroenterol Nutr 2020; 70:664-680. [PMID: 32332478 DOI: 10.1097/mpg.0000000000002655] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
More than 10,000 preterm infants have participated in randomised controlled trials on probiotics worldwide, suggesting that probiotics in general could reduce rates of necrotising enterocolitis (NEC), sepsis, and mortality. Answers to relevant clinical questions as to which strain to use, at what dosage, and how long to supplement are, however, not available. On the other hand, an increasing number of commercial products containing probiotics are available from sometimes suboptimal quality. Also, a large number of units around the world are routinely offering probiotic supplementation as the standard of care despite lacking solid evidence. Our recent network meta-analysis identified probiotic strains with greatest efficacy regarding relevant clinical outcomes for preterm neonates. Efficacy in reducing mortality and morbidity was found for only a minority of the studied strains or combinations. In the present position paper, we aim to provide advice, which specific strains might potentially be used and which strains should not be used. In addition, we aim to address safety issues of probiotic supplementation to preterm infants, who have reduced immunological capacities and occasional indwelling catheters. For example, quality reassurance of the probiotic product is essential, probiotic strains should be devoid of transferable antibiotic resistance genes, and local microbiologists should be able to routinely detect probiotic sepsis. Provided all safety issues are met, there is currently a conditional recommendation (with low certainty of evidence) to provide either Lactobacillus rhamnosus GG ATCC53103 or the combination of Bifidobacterium infantis Bb-02, Bifidobacterium lactis Bb-12, and Streptococcus thermophilus TH-4 in order to reduce NEC rates.
Collapse
|
5
|
Meyer MP, Chow SSW, Alsweiler J, Bourchier D, Broadbent R, Knight D, Lynn AM, Patel H. Probiotics for Prevention of Severe Necrotizing Enterocolitis: Experience of New Zealand Neonatal Intensive Care Units. Front Pediatr 2020; 8:119. [PMID: 32318522 PMCID: PMC7154127 DOI: 10.3389/fped.2020.00119] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 03/06/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Necrotizing enterocolitis (NEC) affects mainly preterm infants, has a multifactorial etiology and is associated with intestinal dysbiosis and disordered immunity. Use of probiotics for prophylaxis is beneficial with studies indicating reduction in NEC ≥ stage 2, late onset sepsis (LOS) and mortality. However, not all studies have shown a reduction, there are questions regarding which probiotic to use, whether infants <1,000 g benefit and the risk of probiotic sepsis. All neonatal intensive care units in New Zealand (NZ) use probiotics and contribute to an international database (Australian and New Zealand Neonatal Network or ANZNN). Objective: To use ANZNN data to investigate the experience of NZ neonatal units with probiotics for NEC prevention in a setting where the baseline incidence of severe NEC was low, to compare results of 2 commonly used probiotic regimes and report on the extremely low birth weight subgroup. Method: Outcomes before (Pre group 2007-2010) and after (Probiotic group 2013-2015) starting routine probiotics for preterm infants <1,500 g or <32 weeks were compared. Clinicians reviewed cases to ensure they met database criteria. Five units used Infloran (Bifidobacterium bifidum and Lactobacillus acidophilus) and 1 unit used Lactobacillus GG (LGG) and bovine lactoferrin (bLF). Results: Four thousand five hundred and twenty nine infants were included and Pre and Probiotic groups were well-balanced with regard to gestation, birth weight and gender. The incidence of NEC in the Probiotic group was 1.6 and 2.7% in the pre group (corrected OR 0.62 CI 0.41-0.94). There was one case of probiotic sepsis. There was no significant difference between the Infloran and LGG/bLF combinations in regard to observed NEC rates. Late onset sepsis rates were significantly lower in the Probiotic group (p < 0.01). Conclusions: Introduction of probiotics for preterm infants in NZ has been associated with significant reductions in NEC and late onset sepsis.
Collapse
Affiliation(s)
- Michael P Meyer
- Neonatal Unit, KidzFirst, Middlemore Hospital, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Sharon S W Chow
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Jane Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.,Neonatal Unit, Auckland City Hospital, Auckland, New Zealand
| | | | | | - David Knight
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.,Neonatal Unit, Auckland City Hospital, Auckland, New Zealand
| | - Adrienne M Lynn
- Neonatal Unit, Christchurch Women's Hospital, Christchurch, New Zealand
| | - Harshad Patel
- Neonatal Unit, Wellington Hospital, Wellington, New Zealand
| |
Collapse
|
6
|
Modi N, Ashby D, Battersby C, Brocklehurst P, Chivers Z, Costeloe K, Draper ES, Foster V, Kemp J, Majeed A, Murray J, Petrou S, Rogers K, Santhakumaran S, Saxena S, Statnikov Y, Wong H, Young A. Developing routinely recorded clinical data from electronic patient records as a national resource to improve neonatal health care: the Medicines for Neonates research programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2019. [DOI: 10.3310/pgfar07060] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background
Clinical data offer the potential to advance patient care. Neonatal specialised care is a high-cost NHS service received by approximately 80,000 newborn infants each year.
Objectives
(1) To develop the use of routinely recorded operational clinical data from electronic patient records (EPRs), secure national coverage, evaluate and improve the quality of clinical data, and develop their use as a national resource to improve neonatal health care and outcomes. To test the hypotheses that (2) clinical and research data are of comparable quality, (3) routine NHS clinical assessment at the age of 2 years reliably identifies children with neurodevelopmental impairment and (4) trial-based economic evaluations of neonatal interventions can be reliably conducted using clinical data. (5) To test methods to link NHS data sets and (6) to evaluate parent views of personal data in research.
Design
Six inter-related workstreams; quarterly extractions of predefined data from neonatal EPRs; and approvals from the National Research Ethics Service, Health Research Authority Confidentiality Advisory Group, Caldicott Guardians and lead neonatal clinicians of participating NHS trusts.
Setting
NHS neonatal units.
Participants
Neonatal clinical teams; parents of babies admitted to NHS neonatal units.
Interventions
In workstream 3, we employed the Bayley-III scales to evaluate neurodevelopmental status and the Quantitative Checklist of Autism in Toddlers (Q-CHAT) to evaluate social communication skills. In workstream 6, we recruited parents with previous experience of a child in neonatal care to assist in the design of a questionnaire directed at the parents of infants admitted to neonatal units.
Data sources
Data were extracted from the EPR of admissions to NHS neonatal units.
Main outcome measures
We created a National Neonatal Research Database (NNRD) containing a defined extract from real-time, point-of-care, clinician-entered EPRs from all NHS neonatal units in England, Wales and Scotland (n = 200), established a UK Neonatal Collaborative of all NHS trusts providing neonatal specialised care, and created a new NHS information standard: the Neonatal Data Set (ISB 1595) (see http://webarchive.nationalarchives.gov.uk/±/http://www.isb.nhs.uk/documents/isb-1595/amd-32–2012/index_html; accessed 25 June 2018).
Results
We found low discordance between clinical (NNRD) and research data for most important infant and maternal characteristics, and higher prevalence of clinical outcomes. Compared with research assessments, NHS clinical assessment at the age of 2 years has lower sensitivity but higher specificity for identifying children with neurodevelopmental impairment. Completeness and quality are higher for clinical than for administrative NHS data; linkage is feasible and substantially enhances data quality and scope. The majority of hospital resource inputs for economic evaluations of neonatal interventions can be extracted reliably from the NNRD. In general, there is strong parent support for sharing routine clinical data for research purposes.
Limitations
We were only able to include data from all English neonatal units from 2012 onwards and conduct only limited cross validation of NNRD data directly against data in paper case notes. We were unable to conduct qualitative analyses of parent perspectives. We were also only able to assess the utility of trial-based economic evaluations of neonatal interventions using a single trial. We suggest that results should be validated against other trials.
Conclusions
We show that it is possible to obtain research-standard data from neonatal EPRs, and achieve complete population coverage, but we highlight the importance of implementing systematic examination of NHS data quality and completeness and testing methods to improve these measures. Currently available EPR data do not enable ascertainment of neurodevelopmental outcomes reliably in very preterm infants. Measures to maintain high quality and completeness of clinical and administrative data are important health service goals. As parent support for sharing clinical data for research is underpinned by strong altruistic motivation, improving wider public understanding of benefits may enhance informed decision-making.
Future work
We aim to implement a new paradigm for newborn health care in which continuous incremental improvement is achieved efficiently and cost-effectively by close integration of evidence generation with clinical care through the use of high-quality EPR data. In future work, we aim to automate completeness and quality checks and make recording processes more ‘user friendly’ and constructed in ways that minimise the likelihood of missing or erroneous entries. The development of criteria that provide assurance that data conform to prespecified completeness and quality criteria would be an important development. The benefits of EPR data might be extended by testing their use in large pragmatic clinical trials. It would also be of value to develop methods to quality assure EPR data including involving parents, and link the NNRD to other health, social care and educational data sets to facilitate the acquisition of lifelong outcomes across multiple domains.
Study registration
This study is registered as PROSPERO CRD42015017439 (workstream 1) and PROSPERO CRD42012002168 (workstream 3).
Funding
The National Institute for Health Research Programme Grants for Applied Research programme (£1,641,471). Unrestricted donations were supplied by Abbott Laboratories (Maidenhead, UK: £35,000), Nutricia Research Foundation (Schiphol, the Netherlands: £15,000), GE Healthcare (Amersham, UK: £1000). A grant to support the use of routinely collected, standardised, electronic clinical data for audit, management and multidisciplinary feedback in neonatal medicine was received from the Department of Health and Social Care (£135,494).
Collapse
Affiliation(s)
- Neena Modi
- Department of Medicine, Imperial College London, London, UK
| | - Deborah Ashby
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | | | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Kate Costeloe
- Centre for Genomics and Child Health, Queen Mary University of London, London, UK
| | | | - Victoria Foster
- Department of Social Sciences, Edge Hill University, Ormskirk, UK
| | - Jacquie Kemp
- National Programme of Care, NHS England, London, UK
| | - Azeem Majeed
- School of Public Health, Imperial College London, London, UK
| | | | - Stavros Petrou
- Division of Health Sciences, University of Warwick, Coventry, UK
| | - Katherine Rogers
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Sonia Saxena
- School of Public Health, Imperial College London, London, UK
| | | | - Hilary Wong
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Alys Young
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| |
Collapse
|
7
|
Jarrett P, Meczner A, Costeloe K, Fleming P. Historical aspects of probiotic use to prevent necrotising enterocolitis in preterm babies. Early Hum Dev 2019; 135:51-57. [PMID: 31153726 DOI: 10.1016/j.earlhumdev.2019.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Over the last few decades, numerous studies have evaluated probiotic use for the prevention of necrotising enterocolitis in preterm babies. Early 'proof of concept' studies evaluating whether probiotics are capable of colonising the preterm gut have translated into multiple observational studies, small and large randomised controlled trials. Some show evidence of benefit while others have produced disappointing results. In this paper, we review the history of probiotic use in preterm babies for NEC prevention in an attempt to explain why uncertainty exists and why this intervention has not been universally adopted into routine neonatal practice.
Collapse
Affiliation(s)
- Prudence Jarrett
- Homerton University Hospital, NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland.
| | - Andras Meczner
- Homerton University Hospital, NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Kate Costeloe
- Barts and the London School of Medicine and Dentistry, London, United Kingdom of Great Britain and Northern Ireland
| | - Paul Fleming
- Homerton University Hospital, NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland; Barts and the London School of Medicine and Dentistry, London, United Kingdom of Great Britain and Northern Ireland
| |
Collapse
|
8
|
Types, Frequency, Duration, and Dosage of Probiotics to Prevent Necrotizing Enterocolitis in Preterm Infants Among Countries. Adv Neonatal Care 2019; 19:188-197. [PMID: 31140979 DOI: 10.1097/anc.0000000000000605] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Probiotic use in the neonatal intensive care unit (NICU) has been linked to reduced rates of necrotizing enterocolitis in preterm infants. Currently, in the United States, probiotic use within the NICU is limited despite being commonly used in other countries. PURPOSE To provide an overview of the current practices of using probiotics in preterm infants for the prevention of NEC in the NICU in preselected countries. METHODS A comprehensive literature search was conducted on PubMed and clinicaltrials.gov. Also, studies from 2 recent meta-analyses on the topic were reviewed for inclusion. Selection criteria were as follows: studies involving preterm infants using probiotics in the NICU, reporting on the impact of probiotic use on the incidence of necrotizing enterocolitis, published within the last 10 years and in the English language, and originating from the United States, Canada, or any European country. RESULTS Twenty-three studies were selected. The most common types of probiotics used were Bifidobacterium infantis and Lactobacillus rhamnosus. The most common frequency of administration was daily or twice day. Duration ranged from 10 days to the entire NICU stay. The dosage was commonly 1 billion colony-forming units daily but ranged from 12 million daily to 12 billion per kilogram daily. IMPLICATIONS FOR PRACTICE Examining the current practices of probiotic use in the NICU provides useful information as this adjunctive therapy rises in popularity. IMPLICATIONS FOR RESEARCH Refining methods of probiotic research for necrotizing enterocolitis prevention will improve safety and effectiveness and provide a framework for future clinical trials.
Collapse
|
9
|
Schönherr-Hellec S, Aires J. Clostridia and necrotizing enterocolitis in preterm neonates. Anaerobe 2019; 58:6-12. [PMID: 30980889 DOI: 10.1016/j.anaerobe.2019.04.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 03/26/2019] [Accepted: 04/09/2019] [Indexed: 02/08/2023]
Abstract
Necrotizing enterocolitis (NEC) is the most severe life threatening gastrointestinal disease among preterm neonates. NEC continues to account for substantial morbidity and mortality in neonatal intensive care units worldwide. Although its pathogenesis remains incompletely elucidated, NEC is recognized as a multifactorial disease involving intestinal unbalanced inflammatory response, feeding strategies, and bacterial colonization. Epidemiological studies, clinical signs, and animal models support the participation of anaerobic bacteria, particularly clostridia species, in NEC development. Colonization by clostridia seems particularly deleterious. The present review is the opportunity to propose an update on the role of clostridia and NEC.
Collapse
Affiliation(s)
| | - J Aires
- EA 4065, Faculty of Pharmacy, Paris Descartes University, Paris, France.
| |
Collapse
|
10
|
Costeloe K, Bowler U, Brocklehurst P, Hardy P, Heal P, Juszczak E, King A, Panton N, Stacey F, Whiley A, Wilks M, Millar MR. A randomised controlled trial of the probiotic Bifidobacterium breve BBG-001 in preterm babies to prevent sepsis, necrotising enterocolitis and death: the Probiotics in Preterm infantS (PiPS) trial. Health Technol Assess 2018; 20:1-194. [PMID: 27594381 DOI: 10.3310/hta20660] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Necrotising enterocolitis (NEC) and late-onset sepsis remain important causes of death and morbidity in preterm babies. Probiotic administration might strengthen intestinal barrier function and provide protection; this is supported by published meta-analyses, but there is a lack of large well-designed trials. OBJECTIVE To test the use of the probiotic Bifidobacterium breve strain BBG-001 to prevent NEC, late-onset sepsis and death in preterm babies while monitoring probiotic colonisation of participants. DESIGN Double-blind, randomised, placebo-controlled trial. SETTING Recruitment was carried out in 24 hospitals, and the randomisation programme used a minimisation algorithm. Parents, clinicians and outcome assessors were blinded to the allocation. PARTICIPANTS Babies born between 23 and 30 weeks' gestation and randomised within 48 hours of birth. Exclusions included life-threatening or any gastrointestinal malformation detected within 48 hours of birth and no realistic chance of survival. INTERVENTIONS Active intervention: 1 ml of B. breve BBG-001 in one-eighth-strength infant formula Neocate(®) (Nutricia Ltd, Trowbridge, UK), (6.7 × 10(7) to 6.7 × 10(9) colony-forming units) per dose administered enterally. Placebo: 1 ml of one-eighth-strength infant formula Neocate. Started as soon as practicable and continued daily until 36 weeks' postmenstrual age. MAIN OUTCOME MEASURES Primary outcomes were an episode of bloodstream infection, with any organism other than a skin commensal, in any baby between 72 hours and 46 weeks' postmenstrual age; an episode of NEC Bell stage ≥ 2 in any baby; and death before discharge from hospital. Secondary outcomes included stool colonisation with B. breve. RESULTS In total, 654 babies were allocated to receive probiotic and 661 to receive placebo over 37 months from July 2010. Five babies were withdrawn; 650 babies from the probiotic group and 660 from the placebo group were included in the primary analysis. Baseline characteristics were well balanced. There was no evidence of benefit for the primary outcomes {sepsis: 11.2% vs. 11.7% [adjusted relative risk (RR) 0.97, 95% confidence interval (CI) 0.73 to 1.29]; NEC Bell stage ≥ 2: 9.4% vs. 10.0% [adjusted RR 0.93, 95% CI 0.68 to 1.27]; and death: 8.3% vs. 8.5% [adjusted RR 0.93, 95% CI 0.67 to 1.30]}. B. breve colonisation status was available for 1186 (94%) survivors at 2 weeks' postnatal age, of whom 724 (61%) were positive: 85% of the probiotic group and 37% of the placebo group. There were no differences for subgroup analyses by minimisation criteria and by stool colonisation with B. breve at 2 weeks. No harms associated with the interventions were reported. LIMITATIONS Cross-colonisation of the placebo arm could have reduced statistical power and confounded results; analyses suggest that this did not happen. CONCLUSIONS This is the largest trial to date of a probiotic intervention. It shows no evidence of benefit and does not support routine use of probiotics for preterm infants. FUTURE WORK RECOMMENDATIONS The increasing understanding of the pathogenesis of NEC and sepsis will inform the choice of probiotics for testing and better define the target population. Future Phase III trials should incorporate monitoring of the quality and viability of the intervention and colonisation rates of participants; cluster design should be considered. TRIAL REGISTRATION Current Controlled Trials ISRCTN05511098 and EudraCT 2006-003445-17. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 66. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Kate Costeloe
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Homerton University Hospital NHS Foundation Trust, London, UK
| | - Ursula Bowler
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Peter Brocklehurst
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK.,Institute for Women's Health, University College London, London, UK
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Paul Heal
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Andy King
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Nicola Panton
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Fiona Stacey
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Homerton University Hospital NHS Foundation Trust, London, UK
| | - Angela Whiley
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark Wilks
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Barts Health NHS Trust, London, UK
| | - Michael R Millar
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Barts Health NHS Trust, London, UK
| |
Collapse
|
11
|
Abstract
In this review, we summarize existing knowledge regarding the effects of probiotics on necrotizing enterocolitis (NEC). We review the role of the microbiome in NEC and pre-clinical data on mechanisms of probiotic action. Next, we summarize existing randomized controlled trials and observational studies of probiotics to prevent NEC. We also summarize findings from several recent meta-analyses and report a new cumulative meta-analysis of probiotic trials. Finally, we review data from cohorts routinely using commercially available probiotics. Our goal is to inform clinicians about the risks and benefits of probiotics, which may be helpful for those considering use in preterm infants to prevent NEC, death, or sepsis.
Collapse
Affiliation(s)
- Ravi Mangal Patel
- Department of Pediatrics, Division of Neonatology, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Dr. NE, 3rd Floor, Atlanta, Georgia 30322.
| | - Mark A. Underwood
- Professor, Department of Pediatrics, Division of Neonatology, University of California Davis School of Medicine, Sacramento, CA
| |
Collapse
|
12
|
Meyer MP, Alexander T. Reduction in necrotizing enterocolitis and improved outcomes in preterm infants following routine supplementation with Lactobacillus GG in combination with bovine lactoferrin. J Neonatal Perinatal Med 2018; 10:249-255. [PMID: 28854514 DOI: 10.3233/npm-16130] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Preterm infants remain at high risk of adverse outcomes following necrotizing enterocolitis (NEC) and late onset sepsis (LOS). Meta-analysis of randomized trials has indicated a reduction in severe NEC following use of probiotics and bovine lactoferrin (LF). Overall, however, uncertainty remains over which probiotic, or combination to use. The aim of this study was to compare the incidence of severe NEC and LOS before and after routine supplementation with Lactobacillus GG (LGG) and LF. METHODS In this retrospective cohort study, infants <32 weeks or <1500 g routinely received LGG and 100 mg lactoferrin daily from 2011 -2015 were compared with similar infants born from 2004-2008. Cases of NEC were Bell stage 2 or greater and LOS was blood or spinal fluid culture positive after 48 hrs of age. RESULTS We noted a marked decline in the incidence of NEC from 3% to 1% with a RR of 0.29 (CI 0.1-0.9) and a number needed to benefit of 50. The cost of preventing one case of NEC was estimated to be NZ $2800, considerably lower than the cost of treatment. LOS rates were not significantly different. There was a decrease in retinopathy treatment rates. During the period there was one case of LGG sepsis in a 23 week gestation infant with abdominal pathology and one infant developed NEC after stopping prophylaxis. CONCLUSION The rates of severe NEC was markedly reduced following prophylaxis. The case of LGG sepsis indicates caution is required in extremely preterm infants.
Collapse
Affiliation(s)
- Michael P Meyer
- Neonatal Unit Kidz First Paediatrics, Middlemore Hospital, Otahuhu, Auckland, New Zealand.,Department of Paediatrics, University of Auckland, Grafton Auckland, New Zealand
| | - Tanith Alexander
- Dietetics, Allied Health, Middlemore Hospital, Otahuhu, Auckland, New Zealand
| |
Collapse
|
13
|
Abstract
Colonization of the extremely preterm infant's gastrointestinal tract and skin begins in utero and is influenced by a variety of factors, the most important including gestational age and environmental exposures. The composition of the intestinal and skin microbiota influences the developing innate and adaptive immune responses with short-term and long-term consequences including altered risks for developing necrotizing enterocolitis, sepsis, and a wide variety of microbe-related diseases of children and adults. Alteration of the composition of the microbiota to decrease disease risk is particularly appealing for this ultra-high-risk cohort that is brand new from an evolutionary standpoint.
Collapse
|
14
|
Statnikov Y, Ibrahim B, Modi N. A systematic review of administrative and clinical databases of infants admitted to neonatal units. Arch Dis Child Fetal Neonatal Ed 2017; 102:F270-F276. [PMID: 28087722 DOI: 10.1136/archdischild-2016-312010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 12/14/2016] [Accepted: 12/17/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVES High quality information, increasingly captured in clinical databases, is a useful resource for evaluating and improving newborn care. We conducted a systematic review to identify neonatal databases, and define their characteristics. METHODS We followed a preregistered protocol using MesH terms to search MEDLINE, EMBASE, CINAHL, Web of Science and OVID Maternity and Infant Care Databases for articles identifying patient level databases covering more than one neonatal unit. Full-text articles were reviewed and information extracted on geographical coverage, criteria for inclusion, data source, and maternal and infant characteristics. RESULTS We identified 82 databases from 2037 publications. Of the country-specific databases there were 39 regional and 39 national. Sixty databases restricted entries to neonatal unit admissions by birth characteristic or insurance cover; 22 had no restrictions. Data were captured specifically for 53 databases; 21 administrative sources; 8 clinical sources. Two clinical databases hold the largest range of data on patient characteristics, USA's Pediatrix BabySteps Clinical Data Warehouse and UK's National Neonatal Research Database. CONCLUSIONS A number of neonatal databases exist that have potential to contribute to evaluating neonatal care. The majority is created by entering data specifically for the database, duplicating information likely already captured in other administrative and clinical patient records. This repetitive data entry represents an unnecessary burden in an environment where electronic patient records are increasingly used. Standardisation of data items is necessary to facilitate linkage within and between countries.
Collapse
Affiliation(s)
- Yevgeniy Statnikov
- Neonatal Data Analysis Unit, Section of Neonatal Medicine, Department of Medicine, Imperial College London, Chelsea & Westminster Hospital campus, London, UK
| | - Buthaina Ibrahim
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, Chelsea & Westminster Hospital campus, London, UK
| | - Neena Modi
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, Chelsea & Westminster Hospital campus, London, UK
| |
Collapse
|
15
|
Dermyshi E, Wang Y, Yan C, Hong W, Qiu G, Gong X, Zhang T. The "Golden Age" of Probiotics: A Systematic Review and Meta-Analysis of Randomized and Observational Studies in Preterm Infants. Neonatology 2017; 112:9-23. [PMID: 28196365 DOI: 10.1159/000454668] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 11/21/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Over the last few years, probiotics have been one of the most studied interventions in neonatal medicine. OBJECTIVES The aim of this work was to analyse all studies (randomized controlled trials, RCTs, and observational studies) assessing the use of probiotics in very low birth weight (VLBW) preterm infants. SEARCH METHODS A systematic literature search was conducted using PubMed, Embase, Cochrane Library, and Web of Science. The data from RCTs and observational studies were pooled and analysed separately. SELECTION CRITERIA RCTs and observational studies that enrolled VLBW infants with enteral administration of probiotics were considered. Extracted study data included probiotic characteristics and at least 1 clinical outcome (necrotizing enterocolitis [NEC], late-onset sepsis or all-cause mortality). DATA COLLECTION AND ANALYSIS Forty-four studies were eligible for our review: 30 RCTs and 14 observational studies. Severe NEC rates (stage II or more) and all-cause mortality were reduced among the probiotic groups in both the RCTs (RR 0.57, 95% CI 0.47-0.70, and RR 0.77, 95% CI 0.65-0.92, respectively) and the observational studies (RR 0.51, 95% CI 0.37-0.70, and RR 0.71, 95% CI 0.62-0.81, respectively). Furthermore, there was a 12% reduction in the risk of sepsis in RCTs and a 19% reduction in observational studies. The meta-analysis of observational studies showed a reduction in the risk of NEC in extremely low birth weight infants. However, this was not statistically significant. CONCLUSIONS This meta-analysis of RCT and observational studies found that the use of probiotics was beneficial for the prevention of severe NEC, late-onset sepsis, and all-cause mortality in VLBW infants.
Collapse
Affiliation(s)
- Elda Dermyshi
- Department of Gastroenterology, Hepatology, and Nutrition, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, PR China
| | | | | | | | | | | | | |
Collapse
|
16
|
Anderson S. Probiotics for Preterm Infants: A Premature or Overdue Necrotizing Enterocolitis Prevention Strategy? Neonatal Netw 2016; 34:83-101. [PMID: 26803090 DOI: 10.1891/0730-0832.34.2.83] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Common among preterm, very low birth weight (VLBW) and extremely low birth weight (ELBW) infants, necrotizing enterocolitis (NEC) is a gastrointestinal, infectious disease that remains a leading cause of morbidity and mortality among this high-risk population. To combat this devastating condition, research efforts have been redirected from treatment toward prevention strategies. Although there are several proposed risk-reduction strategies, one intervention gaining support is the administration of prophylactic enteral probiotics. Regardless of growing evidentiary support and a benign safety profile, neonatal providers have yet to embrace this therapy. This article provides an overview of the proposed benefits of probiotics, focusing on their role as a NEC prevention strategy. A review of several sentinel research studies targeting preterm, VLBW, and ELBW infants is provided. Considerations for ongoing research are reviewed. Finally, two evidence-based NEC prevention probiotics protocols are presented.
Collapse
|
17
|
Barriers to Knowledge Translation Regarding the Use of Probiotics as a Risk-Reduction Strategy for Necrotizing Enterocolitis. Adv Neonatal Care 2016; 16:E3-E14. [PMID: 27391560 DOI: 10.1097/anc.0000000000000270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Increasingly, evidence supports enteral probiotics are an important risk-reduction strategy for necrotizing enterocolitis (NEC) among very low birth-weight and extremely low birth-weight preterm infants. Yet, the majority of providers remain reluctant to implement practice changes. PURPOSE The aim of this study was to better understand the discrepancy between the available evidence and clinical practice regarding the use of probiotics and other NEC prevention strategies in New Jersey. METHODS Using an exploratory descriptive design, a multimodal interprofessional survey was developed and executed to elicit intensive care nursery provider knowledge, views, and current practice. RESULTS Although the sample size was small (N = 29), approximately one-half of respondents familiar with the literature rated the quality of the evidence regarding probiotics as "above average" to "excellent." These respondents were "very likely" to "extremely likely" to recommend probiotics as an NEC prevention strategy; however, none actually prescribed this intervention. The most important reason respondents did not prescribe probiotics was the focus on providing exclusive maternal and donor breast milk feedings. Other confounding factors included provision of oral colostrum care, standardized feeding protocols, and withholding feedings during blood transfusion. IMPLICATIONS FOR PRACTICE Study results suggested that some providers (primarily nurses) were not familiar with probiotic literature, which may contribute to deficits in knowledge translation to practice. IMPLICATIONS FOR RESEARCH Areas for future study include identifying improved mechanisms for knowledge dissemination, recognizing and addressing barriers and facilitators to knowledge translation, and understanding how probiotics fit and/or contrast with other NEC risk-reduction strategies in the research and clinical settings.
Collapse
|
18
|
Vongbhavit K, Underwood MA. Prevention of Necrotizing Enterocolitis Through Manipulation of the Intestinal Microbiota of the Premature Infant. Clin Ther 2016; 38:716-32. [PMID: 26872618 DOI: 10.1016/j.clinthera.2016.01.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 12/30/2015] [Indexed: 12/17/2022]
Abstract
PURPOSE In spite of four decades of research, necrotizing enterocolitis (NEC) remains the most common gastrointestinal complication in premature infants with high mortality and long-term morbidity. The composition of the intestinal microbiota of the premature infant differs dramatically from that of the healthy term infant and appears to be an important risk factor for NEC. METHODS We review the evidence of an association between intestinal dysbiosis and NEC and summarize published English language clinical trials and cohort studies involving attempts to manipulate the intestinal microbiota in premature infants. FINDINGS Promising NEC prevention strategies that alter the intestinal microbiota include probiotics, prebiotics, synbiotics, lacteroferrin, and human milk feeding. IMPLICATIONS Shaping the intestinal microbiota of the premature infant through human milk feeding and dietary supplements decreases the risk of NEC. Further studies to identify the ideal microbial composition and the most effective combination of supplements are indicated.
Collapse
Affiliation(s)
- Kannikar Vongbhavit
- Department of Pediatrics, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakornayok, Thailand; Department of Pediatrics, University of California Davis, Sacramento, California
| | - Mark A Underwood
- Department of Pediatrics, University of California Davis, Sacramento, California.
| |
Collapse
|
19
|
Olsen R, Greisen G, Schrøder M, Brok J. Prophylactic Probiotics for Preterm Infants: A Systematic Review and Meta-Analysis of Observational Studies. Neonatology 2016; 109:105-12. [PMID: 26624488 DOI: 10.1159/000441274] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/24/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a major morbidity and cause of mortality in preterm neonates. Probiotics seem to have a beneficial role in preventing NEC, which is confirmed in meta-analyses of randomized controlled trials (RCTs). We therefore aimed to review and confirm the efficacy of probiotics in preterm neonates obtained in observational studies. OBJECTIVE To assess the effects of prophylactic probiotics in preterm infants. METHODS A meta-analysis was performed searching PubMed, EMBASE, CENTRAL (the Cochrane Library) and www.clinicaltrials.gov. Reference lists of reviews of RCTs were also searched. Included studies were observational studies that enrolled preterm infants <37 weeks of gestational age. Trials were included if they administered any probiotics and measured at least one clinical outcome (e.g. NEC, all-cause mortality, sepsis or long-term development scores). Two authors extracted characteristics and outcomes from included studies. The Newcastle-Ottawa Scale was used for quality assessment. A random-effects meta-analysis model was used, and heterogeneity was assessed by the I2 test. RESULTS We included 12 studies with 10,800 premature neonates (5,144 receiving prophylactic probiotics and 5,656 controls). The meta-analysis showed a significantly decreased incidence of NEC (risk ratio, RR = 0.55, 95% confidence interval, 95% CI, 0.39-0.78; p = 0.0006) and mortality (RR = 0.72, 95% CI, 0.61-0.85; p < 0.0001). Sepsis did not differ significantly between the two groups (RR = 0.86, 95% CI, 0.74-1.00; p = 0.05). CONCLUSIONS Probiotic supplementation reduces the risk of NEC and mortality in preterm infants. The effect sizes are similar to findings in meta-analyses of RCTs. However, the optimal strain, dose and timing need further investigation.
Collapse
Affiliation(s)
- Rie Olsen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | | | | |
Collapse
|
20
|
Feuerstein JD, White N, Berzin TM. Pneumatosis intestinalis with a focus on hyperbaric oxygen therapy. Mayo Clin Proc 2014; 89:697-703. [PMID: 24797647 DOI: 10.1016/j.mayocp.2014.01.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 01/12/2014] [Accepted: 01/14/2014] [Indexed: 12/16/2022]
Abstract
Pneumatosis intestinalis is a rare condition of air in the bowel wall. Pneumatosis intestinalis is most often secondary to another medical condition. The diagnosis is most often made radiologically with a computed tomography scan. The disease severity ranges from benign to life-threatening. Predictors of poor outcomes include pH less than 7.3, bicarbonate level of less than 20 mEq/L, lactate level of more than 2 mmol/L, amylase level of more than 200 U/L, and portal venous gas on imaging. Early recognition of life-threatening signs and symptoms is critical. Treatment options include bowel rest, antibiotics, surgery, and, more recently, the use of hyperbaric oxygen therapy. Hyperbaric oxygen therapy is extremely safe, with no reported complications in the literature when used for pneumatosis intestinalis. When surgery is not emergently needed, symptomatic pneumatosis intestinalis can be safely treated with hyperbaric oxygen with a high likelihood of success without any considerable adverse effects.
Collapse
Affiliation(s)
- Joseph D Feuerstein
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA.
| | - Nicole White
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - Tyler M Berzin
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| |
Collapse
|
21
|
Wójkowska-Mach J, Różańska A, Borszewska-Kornacka M, Domańska J, Gadzinowski J, Gulczyńska E, Helwich E, Kordek A, Pawlik D, Szczapa J, Heczko PB. Necrotising enterocolitis in preterm infants: epidemiology and antibiotic consumption in the Polish neonatology network neonatal intensive care units in 2009. PLoS One 2014; 9:e92865. [PMID: 24658445 PMCID: PMC3962467 DOI: 10.1371/journal.pone.0092865] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 02/27/2014] [Indexed: 12/19/2022] Open
Abstract
UNLABELLED The aim of this study was to describe the epidemiology of necrotising enterocolitis (NEC), antibiotic consumption and the usefulness of microbiological tests in very low birth weight (VLBW) Polish newborns. METHODS Prospective surveillance was performed in the year 2009 by local infection control teams. The study covered 910 infants hospitalized in six Polish neonatal intensive care units. Two kinds of indicators were used for the description of antibiotic usage: the duration of treatment (days of treatment, DOTs) and the defined daily dose (DDD). RESULTS NEC incidence was 8.7% and fatality rate was 19%. Chorioamnionitis, late gestational age and low birth weight were identified as risk factors for NEC. Catheterization, mechanical ventilation and other selected procedures were used considerably longer in newborns with NEC than in the remaining neonates. Total usage of antibiotics reached 2.9 DDDs or 1.437 days; the average use of drugs per case of NEC amounted to 0.47 DDD or 23.2 DOTs. The level of antibiotic usage was analysed with correlation to microbiological tests performed and it was non-significantly greater in the group of children with NEC in whom the tests were performed. CONCLUSIONS A high risk of developing NEC is closely associated with VLBW and with inflammation of the amnion during labour. We observed no relationship between the consumption of antibiotics in neonates with NEC and positive results of microbiological testing indicating sepsis accompanying NEC or gut colonization with pathogens.
Collapse
MESH Headings
- Anti-Bacterial Agents/therapeutic use
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/drug therapy
- Enterocolitis, Necrotizing/epidemiology
- Enterocolitis, Necrotizing/microbiology
- Female
- Humans
- Incidence
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/epidemiology
- Intensive Care Units, Neonatal
- Male
- Patient Outcome Assessment
- Poland
- Prospective Studies
- Public Health Surveillance
- Risk Factors
Collapse
Affiliation(s)
| | - Anna Różańska
- Chair of Microbiology, Jagiellonian University Medical College, Kraków, Poland
| | | | - Joanna Domańska
- Institute of Theoretical and Applied Informatics of the Polish Academy of Sciences, Gliwice, Poland
| | - Janusz Gadzinowski
- Chair and Department of Neonatology, Poznań University of Medical Sciences, Poznań, Poland
| | - Ewa Gulczyńska
- Clinic of Neonatology, Polish Mother's Memorial Hospital-Research Institute, Łódź, Poland
| | - Ewa Helwich
- Clinic of Neonatology and Intensive Neonatal Care, Institute of Mother and Child, Warsaw, Poland
| | - Agnieszka Kordek
- Department of Neonatal Diseases, Pomeranian Medical University, Szczecin, Poland
| | - Dorota Pawlik
- Clinic of Neonatology, Jagiellonian University Medical College, Kraków, Poland
| | - Jerzy Szczapa
- Chair and Department of Neonatology, Poznań University of Medical Sciences, Poznań, Poland
| | - Piotr B. Heczko
- Chair of Microbiology, Jagiellonian University Medical College, Kraków, Poland
| |
Collapse
|
22
|
Nair V, Soraisham AS. Probiotics and prebiotics: role in prevention of nosocomial sepsis in preterm infants. Int J Pediatr 2013; 2013:874726. [PMID: 23401695 PMCID: PMC3557621 DOI: 10.1155/2013/874726] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 12/27/2012] [Indexed: 02/07/2023] Open
Abstract
Nosocomial sepsis is associated with increased mortality and morbidity including neurodevelopmental impairment and prolonged hospital stay. Prevention of sepsis especially in the preterm infants in the neonatal intensive care unit remains a major challenge. The gastrointestinal tract is an important source of potential pathogens causing nosocomial sepsis as the immature intestinal epithelium can permit translocation of bacteria and yeast. The intestinal tract and its microflora play an important role in the immunity. Altering the gut microflora has been extensively studied for immunomodulation in preterm infants. Probiotics are live microorganisms which when administered in adequate amounts confer a health benefit on the host. Probiotics have been used for prevention and treatment of various medical conditions in children and adults. Studies on probiotics in premature infants have focused on normalizing intestinal flora, improvement in feeding intolerance, prevention of necrotizing enterocolitis and sepsis. In this paper, we discuss the intestinal bacterial colonization pattern; the rational for probiotics and prebiotic therapy with special focus on the prevention of nosocomial sepsis in preterm infants.
Collapse
Affiliation(s)
- Vrinda Nair
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada T1N 1N4
| | - Amuchou S. Soraisham
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada T1N 1N4
- Alberta Children's Hospital Research Institute for Child and Maternal Health, University of Calgary, Calgary, AB, Canada
- Department of Pediatrics, Foothills Medical Centre, Rm C211-1403-29th Street NW, Calgary, AB, Canada T2N 2T9
| |
Collapse
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
Abstract
Probiotics are micro-organisms that confer health benefits on the host. Postulated mechanisms include: increasing resistance of the mucosal barrier to migration of bacteria and their toxins by strengthening intestinal cell junctions, modification of host response to microbial products, augmentation of immunoglobulin A mucosal responses, enhancement of enteral nutrition to inhibit the growth of pathogens; production of antimicrobial proteins; and competitive exclusion of potential pathogens. Published meta-analyses and systematic reviews report the effects of probiotics on important clinical outcomes in neonates. This paper will review the evidence for probiotic supplementation in neonatology, with a focus on preterm infants.
Collapse
Affiliation(s)
- Leah Hickey
- Women's Centre for Infectious Diseases, The Royal Women's Hospital, Melbourne, Victoria, Australia.
| | | | | | | |
Collapse
|
25
|
Mihatsch WA, Braegger CP, Decsi T, Kolacek S, Lanzinger H, Mayer B, Moreno LA, Pohlandt F, Puntis J, Shamir R, Stadtmüller U, Szajewska H, Turck D, van Goudoever JB. Critical systematic review of the level of evidence for routine use of probiotics for reduction of mortality and prevention of necrotizing enterocolitis and sepsis in preterm infants. Clin Nutr 2011; 31:6-15. [PMID: 21996513 DOI: 10.1016/j.clnu.2011.09.004] [Citation(s) in RCA: 134] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 09/06/2011] [Accepted: 09/12/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Probiotics have been suggested to prevent severe necrotizing enterocolitis (NEC) and decrease mortality in preterm infants. The aim of this paper was to systematically analyze the level of evidence (LoE) of published controlled randomized trials (RCTs) on probiotics in preterm infants. METHODS Literature searches were made up to November 2010. LoE of recommendations based on single trials or meta-analyses were scored following the Oxford Center for Evidence based Medicine approach (1a - meta-analyses of 1b LoE studies; 1b - well designed RCT; 2a - meta-analyses which include 2b LoE studies; 2b - lesser quality RCT). RESULTS Fifteen trials were included (Two 1b LoE trials and thirteen 2b LoE trials). Methodological assessment revealed considerable heterogeneity. Some probiotics may be beneficial in relation to reduction of severe NEC (2b LoE) and reduction of mortality (2b LoE). Probiotics do not accelerate feeding advancement (1b and 2b LoE). There was no convincing benefit with regard to prevention of sepsis (1b and 2b LoE). CONCLUSION There is insufficient evidence to recommend routine probiotics. However, there is encouraging data (2b LoE) which justifies the further investigation regarding the efficacy and safety of specific probiotics in circumstances of high local incidence of severe NEC.
Collapse
|
26
|
Genzel-Boroviczeny O. Leitlinie zur nekrotisierenden Enterokolitis (NEK). Monatsschr Kinderheilkd 2011. [DOI: 10.1007/s00112-011-2412-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
27
|
Deshpande GC, Rao SC, Keil AD, Patole SK. Evidence-based guidelines for use of probiotics in preterm neonates. BMC Med 2011; 9:92. [PMID: 21806843 PMCID: PMC3163616 DOI: 10.1186/1741-7015-9-92] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 08/02/2011] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Current evidence indicates that probiotic supplementation significantly reduces all-cause mortality and definite necrotising enterocolitis without significant adverse effects in preterm neonates. As the debate about the pros and cons of routine probiotic supplementation continues, many institutions are satisfied with the current evidence and wish to use probiotics routinely. Because of the lack of detail on many practical aspects of probiotic supplementation, clinician-friendly guidelines are urgently needed to optimise use of probiotics in preterm neonates. AIM To develop evidence-based guidelines for probiotic supplementation in preterm neonates. METHODS To develop core guidelines on use of probiotics, including strain selection, dose and duration of supplementation, we primarily used the data from our recent updated systematic review of randomised controlled trials. For equally important issues including strain identification, monitoring for adverse effects, product format, storage and transport, and regulatory hurdles, a comprehensive literature search, covering the period 1966-2010 without restriction on the study design, was conducted, using the databases PubMed and EMBASE, and the proceedings of scientific conferences; these data were used in our updated systematic review. RESULTS In this review, we present guidelines, including level of evidence, for the practical aspects (for example, strain selection, dose, duration, clinical and laboratory surveillance) of probiotic supplementation, and for dealing with non-clinical but important issues (for example, regulatory requirements, product format). Evidence was inadequate in some areas, and these should be a target for further research. CONCLUSION We hope that these evidence-based guidelines will help to optimise the use of probiotics in preterm neonates. Continued research is essential to provide answers to the current gaps in knowledge about probiotics.
Collapse
Affiliation(s)
- Girish C Deshpande
- Department of Neonatal Paediatrics, Nepean Hospital Sydney, Sydney, Australia
- University of Sydney, Australia Sydney, Australia
| | - Shripada C Rao
- Department of Neonatal Paediatrics, KEM Hospital for Women, Perth, Australia
- Department of Neonatal Paediatrics, Princess Margaret Hospital for Children, Perth, Australia
- University of Western Australia, Perth, Australia
| | - Anthony D Keil
- Department of Neonatal Paediatrics, KEM Hospital for Women, Perth, Australia
- PathWest Laboratory Medicine, WA, USA
| | - Sanjay K Patole
- Department of Neonatal Paediatrics, KEM Hospital for Women, Perth, Australia
- University of Western Australia, Perth, Australia
| |
Collapse
|
28
|
Mihatsch WA. What is the power of evidence recommending routine probiotics for necrotizing enterocolitis prevention in preterm infants? Curr Opin Clin Nutr Metab Care 2011; 14:302-6. [PMID: 21502919 DOI: 10.1097/mco.0b013e3283454e78] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW There is a lively discussion in literature whether routine use of probiotics should be recommended to reduce the incidence of severe necrotizing enterocolitis (NEC) and mortality in preterm infants. The aim of the present review is to analyze the level of evidence of published randomized controlled trials (RCTs) that different probiotic products reduce the incidence of severe NEC and mortality in preterm infants following Oxford Center for Evidence-based Medicine approach. RECENT FINDINGS Application of probiotics is not a homogeneous intervention and meta-analyses across the available trials may be misleading with the risk that generalized conclusions are erroneously extrapolated to other probiotics. Each individual probiotic intervention should be analyzed separately. Currently, there are 16 RCTs studying 12 different probiotic preparations in preterm infants which report data on clinically important outcomes such as NEC, mortality, sepsis, or feeding advancement. Certain probiotics may be beneficial in relation to severe NEC (level of evidence, LoE 2b). SUMMARY In circumstances of high local incidence of severe NEC, there is encouraging data (LoE 2b) for the use of probiotics. However, currently there is no level 1a evidence to recommend that all preterm infants should be fed probiotics routinely. Further, well designed RCTs on specific probiotics are required.
Collapse
Affiliation(s)
- Walter A Mihatsch
- Department of Pediatrics, Diakonieklinikum, Schwäbisch Hall, Germany.
| |
Collapse
|
29
|
Bibliography. Neonatology and perinatology. Current world literature. Curr Opin Pediatr 2011; 23:253-7. [PMID: 21412083 DOI: 10.1097/mop.0b013e3283454167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
30
|
|
31
|
Gareau MG, Sherman PM, Walker WA. Probiotics and the gut microbiota in intestinal health and disease. Nat Rev Gastroenterol Hepatol 2010; 7:503-14. [PMID: 20664519 PMCID: PMC4748966 DOI: 10.1038/nrgastro.2010.117] [Citation(s) in RCA: 577] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The use of probiotics is increasing in popularity for both the prevention and treatment of a variety of diseases. While a growing number of well-conducted, prospective, randomized, controlled, clinical trials are emerging and investigations of underlying mechanisms of action are being undertaken, questions remain with respect to the specific immune and physiological effects of probiotics in health and disease. This Review considers recent advances in clinical trials of probiotics for intestinal disorders in both adult and pediatric populations. An overview of recent in vitro and in vivo research related to potential mechanisms of action of various probiotic formulations is also considered.
Collapse
Affiliation(s)
- Mélanie G Gareau
- Cell Biology Program, Research Institute, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | | | | |
Collapse
|