Risk Factors for Necrotizing Enterocolitis: A Prospective Multicenter Case-Control Study

Clinical characteristics of postoperative necrotizing enterocolitis in patients with congenital jejunoileal atresia and its risk factors

Objective

To review postoperative necrotizing enterocolitis (NEC) in patients with jejunoileal atresia (JIA) and to explore the potential risk factors related to the concurrence of NEC.

Methods

Patients diagnosed with JIA who received surgical treatment from January 2016 to June 2021 were enrolled. Demographics, viral infection of the fetus, transfusion within 48 hours before NEC, sepsis before JIA repair, pathological and anatomical classification of JIA, combined malformation, occurrence time of NEC after the operation, treatment, and prognosis of patients were analyzed. Patients were divided into NEC group and non-NEC group, and all patients were followed up for 3-6 months to observe for complications.

Results

A total of 180 patients with JIA were included, of whom 12 were diagnosed with NEC after surgery and 1 patient with NEC died during follow-up. The average age, birth weight, gestational age, proportion of premature infants, proportion of preoperative infections, and pathological classification of JIA did not significantly differ between the two groups. The probability of patients with proximal jejunal atresia (PJA) in the NEC group (58.3%) was higher than that in the non-NEC group (22.6%) (p=0.011), and patients with PJA had longer parenteral nutrition time than patients without PJA (26.64±9.21 days vs 15.11±6.58 days, p<0.001).

Conclusion

PJA was more likely to be associated with concurrent NEC after surgery, which is a highly NEC-related risk factor inherent in JIA.

Risk factor analysis and nomogram prediction model construction for NEC complicated by intestinal perforation

OBJECTIVE

To investigate the clinical characteristics of neonatal necrotizing enterocolitis (NEC) complicated by intestinal perforation and predict the incidence of intestinal perforation in NEC.

METHODS

Neonates diagnosed with NEC at the Affiliated Hospital of Zunyi Medical University from January 2012 to May 2022 were enrolled, and the clinical data were collected and analyzed retrospectively. The patients were divided into two groups based on intestinal perforation occurrence or not. Mann-Whitney U tests, t-tests, chi-square tests, and fisher's exact tests were performed between-group comparisons. Logistic and lasso regressions were applied to screen independent risk factors for concomitant bowel perforation, and R software (RMS package) was used to formulate the nomogram prediction model. In addition, the receiver operating curve (ROC) and the calibration curve were drawn to verify the predictive power, while decision curve analysis (DCA) was constructed to evaluate the clinical applicability of the nomogram model.

RESULTS

One hundred eighty neonates with NEC were included, of which 48 had intestinal perforations, and 132 did not; the overall incidence of intestinal perforation was 26.67% (48/180). Bloody stool (OR = 5.60), APTT ≥ 50 s (OR = 3.22), thrombocytopenia (OR = 4.74), and hypoalbuminemia (OR = 5.56) were identified as independent risk variables for NEC intestinal perforation (P < 0.05) through multivariate logistic regression analysis. These factors were then applied to develop a nomogram prediction model (C-index = 0.838) by using the R software. The area under the curve (AUC) for the nomogram in the training and validation cohorts were 0.838 (95% Cl: 0.768, 0.908) and 0.802 (95% CI: 0.659, 0.944), respectively. The calibration curve shown that the nomogram has a good predictive ability for predicting the risk of intestinal perforation occurrence. And the decision curve and clinical impact curve analyses demonstrated good clinical utility of the nomogram model.

CONCLUSION

We found that Bloody stool, APTT ≥ 50 s, Thrombocytopenia, and hypoalbuminemia could be used as independent risk factors for predicting intestinal perforation in neonates with NEC. The nomogram model based on these variables had high predictive values to identify NEC patients with intestinal perforation.

Risk factors of necrotizing enterocolitis among neonates admitted to the neonatal intensive care unit at the selected public hospitals in southern Ethiopia, 2023

Introduction

Necrotizing enterocolitis (NEC) is a serious intestinal condition characterized by ischemic necrosis of the intestinal mucosa, inflammation, and invasion by gas-forming organisms, posing a significant threat to neonatal health. Necrotizing enterocolitis remains a significant cause of neonatal morbidity and mortality, particularly in developing countries. Due to limited research conducted in Ethiopia and the study area, there is a lack of information regarding the risk factors associated with necrotizing enterocolitis. Therefore, the goal of this study is to fill the aforementioned gap.

Objective

This study aims to identify the risk factors of necrotizing enterocolitis among neonates admitted to the neonatal intensive care unit (NICU) at selected general and referral hospitals in southern Ethiopia in the year 2023.

Methods and materials

A facility-based unmatched case-control study was conducted. All neonates admitted to the NICU and diagnosed with necrotizing enterocolitis by the attending physician during the data collection period were considered as cases, whereas neonates admitted to the NICU but not diagnosed with necrotizing enterocolitis during the data collection period were considered as controls. Data were collected through face-to-face interviews and record reviews using the Kobo toolbox platform. The binary logistic regression method was used to determine the relationship between a dependent variable and independent variables. Finally, a p-value of < 0.05 was considered statistically significant.

Results

This study included 111 cases and 332 controls. Normal BMI [AOR = 0.11, 95% CI: (0.02, 0.58)], history of khat chewing [AOR = 4.21, 95% CI: (1.96, 9.06)], term gestation [AOR = 0.06, 95% CI: (0.01, 0.18)], history of cigarette smoking [AOR = 2.86, 95% CI: (1.14, 7.14)], length of hospital stay [AOR = 3.3, 95% CI: (1.43, 7.67)], and premature rupture of membrane [AOR = 3.51, 95% CI: (1.77, 6.98)] were significantly associated with NEC.

Conclusion

The study identified several risk factors for necrotizing enterocolitis, including body mass index, history of khat chewing, gestational age, history of cigarette smoking, length of hospital stays, and premature rupture of membrane. Therefore, healthcare providers should be aware of these risk factors to identify newborns at high risk and implement preventive measures.

Clostridium butyricum and Clostridium tyrobutyricum: angel or devil for necrotizing enterocolitis?

IMPORTANCE

This study sheds light on that treatment with Clostridium tyrobutyricum but not Clostridium butyricum is entitled to protect against necrotizing enterocolitis (NEC) development potentially. The mechanisms behind the opposite effect on NEC may result in different modulation on the level of Akkermansia muciniphila, which is deeply associated with intestinal homoeostasis. Briefly, through improving the abundance of A. muciniphila to alleviate intestinal inflammation and enhance intestinal barrier integrity, C. tyrobutyricum supplement may become a promising therapy for NEC.

Hepatoblastoma with neonatal necrotizing enterocolitis: Two case reports

We report two children with hepatoblastoma (HB) with a history of neonatal necrotizing enterocolitis (NEC). Case 1 was diagnosed with HB at 5 months of age. Liver enlargement was found during the NEC operation at 3 months of age and then was clinically diagnosed by imaging. After six chemotherapy courses, a partial hepatectomy was performed. Three months after ceasing the chemotherapy, a chest computed tomography scan suggested that distant metastasis of the tumor should be considered, and the lesion was removed. However, 9 months after the operation, alpha-fetoprotein concentrations were increased, and abdominal imaging showed a recurrence of the tumor in situ, resulting in a hepatectomy. Case 2 was diagnosed with NEC shortly after birth and underwent an intestinal resection and anastomosis 1 month later. He was diagnosed with HB at 3 years of age. Hepatectomy was performed after five courses of chemotherapy. Chemotherapy was stopped after 10 courses, and alpha-fetoprotein concentrations were normal. At present, both children have survived and are in a healthy condition. Physicians should be aware of the possibility of HB and a history of NEC in children. Premature birth and low birth weight are common factors leading to the pathogenesis of HB and NEC. The association between these two diseases requires further study.

Novel scoring system for early diagnosis of necrotizing enterocolitis: integrating clinical and laboratory data with urinary caveolin-1 levels

Introduction

Necrotizing enterocolitis (NEC) poses a significant threat to preterm infants, with nonspecific early manifestations complicating timely diagnosis. Therefore, this study aimed to develop a novel scoring system for early diagnosis of NEC, incorporating clinical and laboratory data with urinary caveolin-1 levels.

Material and methods

A single-center prospective cohort study was conducted at a tertiary hospital in East Java, Indonesia. NEC diagnosis was established by Bell's criteria and proven gut dysbiosis. Urinary levels of claudin-2, caveolin-1, and epidermal growth factor (EGF) were assessed as potential indicators of tight junction disruption. The selected urine biomarker cutoff value was determined using symbolic classification analysis and combined with clinical and laboratory parameters from Bell's criteria to create an NEC scoring system, validated with the Aiken index. Sensitivity and specificity analyses were performed.

Results

Thirty-four neonates, comprising NEC, preterm non-NEC, and term infants, were included. qPCR analysis highlighted elevated Klebsiella, Lactobacillus, Clostridium, and Bacteroides levels in NEC patients, indicating a gut dysbiosis trend. Among 3 biomarkers, caveolin-1 ≥ 17.81 ng/dl on day 3 demonstrated 72.86% negative predictive value and 87.50% positive predictive value. The combined scoring system which comprised abdominal cellulitis, distension, radiology, advanced resuscitation at birth, prematurity or low birthweight, platelet count, sepsis, orogastric retention, metabolic acidosis and caveolin-1 findings exhibited an AUC of 0.922 (95% CI: 0.81-1.00, p < 0.001), with ≥ 1.81 as the cutoff, offering 93% sensitivity and 94% specificity.

Conclusions

Urine caveolin-1 on day 3 signifies enterocyte tight junction damage and the acute phase of NEC in premature infants. The proposed scoring system demonstrates good performance in predicting NEC incidence in preterm infants.

A prediction model for neonatal necrotizing enterocolitis in preterm and very low birth weight infants

Objectives

Neonatal necrotizing enterocolitis (NEC) is a severe gastrointestinal disease that primarily affects preterm and very low birth weight infants, with high morbidity and mortality. We aim to build a reliable prediction model to predict the risk of NEC in preterm and very low birth weight infants.

Methods

We conducted a retrospective analysis of medical data from infants (gestational age <32 weeks, birth weight <1,500 g) admitted to Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region. We collected clinical data, randomly dividing it into an 8:2 ratio for training and testing. Multivariate logistic regression was employed to identify significant predictors for NEC. Principal component analysis was used for dimensionality reduction of numerical variables. The prediction model was constructed through logistic regression, incorporating all relevant variables. Subsequently, we calculated performance evaluation metrics, including Receiver Operating Characteristic (ROC) curves and confusion matrices. Additionally, we conducted model performance comparisons with common machine learning models to establish its superiority.

Results

A total of 292 infants were included, with 20% (n = 58) randomly selected for external validation. Multivariate logistic regression revealed the significance of four predictors for NEC in preterm and very low birth weight infants: temperature (P = 0.003), Apgar score at 5 min (P = 0.004), formula feeding (P = 0.007), and gestational diabetes mellitus (GDM, P = 0.033). The model achieved an accuracy of 82.46% in the test set with an F1 score of 0.90, outperforming other machine learning models (support vector machine, random forest).

Conclusions

Our logistic regression model effectively predicts NEC risk in preterm and very low birth weight infants, as confirmed by external validation. Key predictors include temperature, Apgar score at 5 min, formula feeding, and GDM. This study provides a vital tool for NEC risk assessment in this population, potentially improving early interventions and child survival. However, clinical validation and further research are necessary for practical application.

Risk factors associated with necrotizing enterocolitis in preterm infants: A case-control study

BACKGROUND

Necrotizing enterocolitis (NEC) is the most common life-threatening gastrointestinal emergency in prematurity. The pathophysiology is multifactorial and remains incompletely understood. Early diagnosis and treatment could reduce the risk of mortality and morbidity. We aimed to identify factors associated with NEC in preterm newborns.

METHOD

This case-control study included all preterm newborns presenting with NEC and managed between January 1, 2009 and December 31, 2018 in the neonatal intensive care unit of Nancy. For each case, two controls were matched according to three criteria: gestational age (WG), date of birth, and mode of delivery. Antenatal, peripartum, and postnatal risk factors prior to NEC were analyzed.

RESULTS

A total of 292 infants were involved in the study, 113 of whom had NEC. Mean gestational age for newborns with NEC was 29 WG, and mean birth weight, 1340 g. Only early-onset infection was identified as a significant risk factor for NEC (15% vs. 6.6% for infection p<0.04, and 28.3% vs. 16.4% p<0.02 for infection and sepsis, NEC vs. controls, respectively). Late-onset feeding and initial continuous enteral feeding were significantly associated with the occurrence of more severe NEC (p<0.02 and p = 0.03, respectively).

CONCLUSION

The results of this study are consistent with intestinal dysbiosis being a risk factor for NEC. Early-onset infection was found to be a significant risk factor. Enteral feeding practice may also be associated with NEC.

Time to first passage of meconium and defecation frequency preceding necrotizing enterocolitis in preterm infants: a case-control study

Necrotizing enterocolitis (NEC) is associated with significant morbidity and mortality in preterm infants. Early recognition and treatment of NEC are critical to improving outcomes. Enteric nervous system (ENS) immaturity has been proposed as a key factor in NEC pathophysiology. Gastrointestinal dysmotility is associated with ENS immaturity and may serve as a predictive factor for the development of NEC. In this case-control study, preterm infants (gestational age (GA) < 30 weeks) were included in two level-IV neonatal intensive care units. Infants with NEC in the first month of life were 1:3 matched to controls based on GA (± 3 days). Odds ratios for NEC development were analyzed by logistic regression for time to first passage of meconium (TFPM), duration of meconial stool, and mean daily defecation frequency over the 72 h preceding clinical NEC onset (DF < T0). A total of 39 NEC cases and 117 matched controls (median GA 27 + 4 weeks) were included. Median TFPM was comparable in cases and controls (36 h [IQR 13-65] vs. 30 h [IQR 9-66], p = 0.83). In 21% of both cases and controls, TFPM was ≥ 72 h (p = 0.87). Duration of meconial stool and DF < T0 were comparable in the NEC and control group (median 4 and 3, resp. in both groups). Odds of NEC were not significantly associated with TFPM, duration of meconial stools, and DF < T0 (adjusted odds ratio [95% confidence interval]: 1.00 [0.99-1.03], 1.16 [0.86-1.55] and 0.97 [0.72-1.31], resp.).

CONCLUSION

In this cohort, no association was found between TFPM, duration of meconium stool, and DF < T0 and the development of NEC.

WHAT IS KNOWN

• Necrotizing enterocolitis (NEC) is a life-threatening acute intestinal inflammatory disease of the young preterm infant. Early clinical risk factors for NEC have been investigated in order to facilitate early diagnosis and treatment. • Signs of disrupted gastrointestinal mobility, such as gastric retention and paralytic ileus, have been established to support the diagnosis of NEC. Nevertheless, defecation patterns have insufficiently been studied in relation to the disease.

WHAT IS NEW

• Defecation patterns in the three days preceding NEC did not differ from gestational age-matched controls of corresponding postnatal age. Additionally, the first passage of meconium and the duration of meconium passage were comparable between cases and controls. Currently, defecation patterns are not useful as early warning signs for NEC. It remains to be elucidated whether these parameters are different based on the location of intestinal necrosis.

Age of onset of necrotising enterocolitis (NEC) and focal intestinal perforation (FIP) in very preterm and low birthweight infants: a systematic review

OBJECTIVE

Review of age of onset of necrotising enterocolitis (NEC) and focal intestinal perforation (FIP) in very preterm (≤32 weeks) and/or very low birthweight (VLBW, ≤1500 g) infants.

DESIGN

Preregistered review undertaken according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses in July 2021 and updated October 2021.

DATA SOURCES

MEDLINE/ PubMed, Embase, CINAHL and Cochrane Central Register of Controlled Trials.

ELIGIBILITY

Eligible studies reported age of onset of NEC and/or FIP in randomised controlled trials of >200 or observational studies of >500 infants.

DATA EXTRACTION AND SYNTHESIS

Titles/abstracts were screened; eligible articles underwent data extraction. Age of onset as day of life (DOL) and/or corrected gestational age (CGA) were extracted alongside study information, such as NEC definition, included population, intervention, location and dates studied. Weighted means were used to compare onset by birth gestation, study type, NEC definition, trial intervention, location and dates studied. Comparison was done by Mann-Whitney U test or one-way analysis of variance.

RESULTS

Of the 747 screened studies 188 were eligible. Removal of duplicates, studies without onset data and ineligible populations left 10 RCTs and 14 observational studies contributing 51 NEC cohorts; 49 reported onset DOL and 14 CGA. 2984 cases of NEC had average DOL onset of 16.7 (15.5 in RCTs, 16.9 in observational studies), and CGA onset of 30.1 weeks. Gestation did not impact DOL onset. No other demographic feature impacted NEC onset. Few studies included data on FIP.

CONCLUSIONS

Average onset of NEC in exclusively very preterm/very low birthweight infants is in the third week of life and unlike in cohorts including more mature or heavier infants is not impacted by birth gestation.

Less is more: Antibiotics at the beginning of life

Antibiotic exposure at the beginning of life can lead to increased antimicrobial resistance and perturbations of the developing microbiome. Early-life microbiome disruption increases the risks of developing chronic diseases later in life. Fear of missing evolving neonatal sepsis is the key driver for antibiotic overtreatment early in life. Bias (a systemic deviation towards overtreatment) and noise (a random scatter) affect the decision-making process. In this perspective, we advocate for a factual approach quantifying the burden of treatment in relation to the burden of disease balancing antimicrobial stewardship and effective sepsis management.

State of the Science on the Benefits of Human Milk for Hospitalized, Vulnerable Neonates

Research on human milk has increased dramatically in recent years. The purpose of this review is to describe the literature on the health benefits of human milk for hospitalized, vulnerable neonates. PubMed, CINAHL, and Embase were searched for research articles reporting the health outcomes of hospitalized neonates who were exposed to human milk. Human milk, particularly a mother's own milk, has the potential to reduce the risk of death and the risk and severity of necrotizing enterocolitis, infection, retinopathy of prematurity, bronchopulmonary dysplasia, intraventricular hemorrhage, kidney disease, and liver disease. Dose and timing of human milk is important, with more human milk and earlier introduction having a greater impact on health. When a mother's own milk is not available, donor human milk provides benefits over infant formula.

Early antibiotics and risk for necrotizing enterocolitis in premature infants: A narrative review

While prompt initiation of antibiotics at birth due to concerns for early onset sepsis is common, it often leads to many preterm infants being exposed to treatment despite negative blood cultures. Such exposure to early antibiotics can impact the developing gut microbiome putting infants at increased risk of several diseases. Necrotizing enterocolitis (NEC), a devastating inflammatory bowel disease that affects preterm infants, is among the most widely studied neonatal disease that has been linked to early antibiotics. While some studies have demonstrated an increased risk of NEC, other studies have demonstrated seemingly contrary findings of decreased NEC with early antibiotics. Studies using animal models have also yielded differing findings of benefit vs. harm of early antibiotic exposure on subsequent NEC susceptibility. We thus sought to conduct this narrative review to help clarify the relationship between early antibiotics exposure and future risk of NEC in preterm infants. Our objectives are to: (1) summarize findings from human and animal studies that investigated the relationship between early antibiotics and NEC, (2) highlight important limitations of these studies, (3) explore potential mechanisms that can explain why early antibiotics may increase or decrease NEC risk, and (4) identify future directions for research.

Early Empirical Antibiotics and Adverse Clinical Outcomes in Infants Born Very Preterm: A Population-Based Cohort

OBJECTIVE

The objective of this study was to evaluate the association between empirical antibiotic therapy in the first postnatal week in uninfected infants born very preterm and the risk of adverse outcomes until discharge.

STUDY DESIGN

Population-based, nationwide registry study in Norway including all live-born infants with a gestational age <32 weeks surviving first postnatal week without sepsis, intestinal perforation, or necrotizing enterocolitis (NEC) between 2009 and 2018. Primary outcomes were severe NEC, death after the first postnatal week, and/or a composite outcome of severe morbidity (severe NEC, severe bronchopulmonary dysplasia [BPD], severe retinopathy of prematurity, late-onset sepsis, or cystic periventricular leukomalacia). The association between empirical antibiotics and adverse outcomes was assessed using multivariable logistic regression models, adjusting for known confounders.

RESULTS

Of 5296 live-born infants born very preterm, 4932 (93%) were included. Antibiotics were started in first postnatal week in 3790 of 4932 (77%) infants and were associated with higher aOR of death (aOR 9.33; 95% CI: 1.10-79.5, P = .041), severe morbidity (aOR 1.88; 95% CI: 1.16-3.05, P = .01), and severe BPD (aOR 2.17; 95% CI: 1.18-3.98; P = .012), compared with those not exposed. Antibiotics ≥ 5 days were associated with higher odds of severe NEC (aOR 2.27; 95% CI: 1.02-5.06; P = .045). Each additional day of antibiotics was associated with 14% higher aOR of death or severe morbidity and severe BPD.

CONCLUSIONS

Early and prolonged antibiotic exposure within the first postnatal week was associated with severe NEC, severe BPD, and death after the first postnatal week.

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

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

Noninvasive Fecal Cytokine and Microbiota Profiles Predict Commencement of Necrotizing Enterocolitis in a Proof-of-Concept Study

Background and Aims

Necrotizing enterocolitis (NEC) is a life-threatening disease and the most common gastrointestinal emergency in premature infants. Accurate early diagnosis is challenging. Modified Bell's staging is routinely used to guide diagnosis, but early diagnostic signs are nonspecific, potentially leading to unobserved disease progression, which is problematic given the often rapid deterioration observed. We investigated fecal cytokine levels, coupled with gut microbiota profiles, as a noninvasive method to discover specific NEC-associated signatures that can be applied as potential diagnostic markers.

Methods

Premature babies born below 32 weeks of gestation were admitted to the 2-site neonatal intensive care unit (NICU) of Imperial College hospitals (St. Mary's or Queen Charlotte's & Chelsea) between January 2011 and December 2012. During the NICU stay, expert neonatologists grouped individuals by modified Bell's staging (healthy, NEC1, NEC2/3) and fecal samples from diapers were collected consecutively. Microbiota profiles were assessed by 16S rRNA gene amplicon sequencing and cytokine concentrations were measured by V-Plex multiplex assays.

Results

Early evaluation of microbiota profiles revealed only minor differences. However, at later time points, significant changes in microbiota composition were observed for Bacillota (adj. P = .0396), with Enterococcus being the least abundant in Bell stage 2/3 NEC. Evaluation of fecal cytokine levels revealed significantly higher concentrations of IL-1α (P = .045), IL-5 (P = .0074), and IL-10 (P = .032) in Bell stage 1 NEC compared to healthy individuals.

Conclusion

Differences in certain fecal cytokine profiles in patients with NEC indicate their potential use as diagnostic biomarkers to facilitate earlier diagnosis. Additionally, associations between microbial and cytokine profiles contribute to improving knowledge about NEC pathogenesis.

Artificial rearing alters intestinal microbiota and induces inflammatory response in piglets

With the ongoing genetic selection for high prolificacy in sow lines and the improvements in environment and farm management, litter size has increased in recent years. Artificial rearing is becoming widely used to raise the surplus piglets in pig industry. This study aimed to investigate the changes that happened in the morphology, microbiota, mucosal barrier function, and transcriptome caused by artificial rearing in piglet colon. Two hundred and forty newborn piglets were randomly assigned into three treatments, sow rearing until weaning (CON group), artificial rearing from day 21 (AR21 group), and artificial rearing from day 7 (AR7 group). On day 35, the piglets were euthanized to collect colon samples. The results showed that the artificially reared-piglets displayed increased pre-weaning diarrhea incidence and reduced growth performance. Artificial rearing changed the diversity and structure of colonic microbiota and increased relative abundance of harmful bacteria, such as Escherichia-Shigella. In addition, the morphological disruption was observed in AR7 group, which was coincided with decreased tight junction proteins and goblet cell numbers. Moreover, the expression of TNFSF11, TNF-α, IL-1β, TLR2, TLR4, MyD88, NF-κB, COX-2, PTGEs, iNOS, IL-2, IL-6, IL-17A, and IFN-γ was upregulated in the colon of the artificially reared-piglets, while the expression of IL-1Ra and IκBα was downregulated, indicating that artificial rearing induced inflammatory response through the activation of NF-κB pathway. Furthermore, artificial rearing regulated SLC family members, which affected solute transport and destroyed intestinal homeostasis. In conclusion, artificial rearing caused microbiota alteration, morphology disruption, the destruction of mucosal barrier function, and inflammatory response, and thus, led to subsequent increased diarrhea incidence and reduced growth performance.

Proteomics Profiling of Stool Samples from Preterm Neonates with SWATH/DIA Mass Spectrometry for Predicting Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a life-threatening condition for premature infants in neonatal intensive care units. Finding indicators that can predict NEC development before symptoms appear would provide more time to apply targeted interventions. In this study, stools from 132 very-low-birth-weight (VLBW) infants were collected daily in the context of a multi-center prospective study aimed at investigating the potential of fecal biomarkers for NEC prediction using proteomics technology. Eight of the VLBW infants received a stage-3 NEC diagnosis. Stools collected from the NEC infants up to 10 days before their diagnosis were available for seven of them. Their samples were matched with those from seven pairs of non-NEC controls. The samples were processed for liquid chromatography-tandem mass spectrometry analysis using SWATH/DIA acquisition and cross-compatible proteomic software to perform label-free quantification. ROC curve and principal component analyses were used to explore discriminating information and to evaluate candidate protein markers. A series of 36 proteins showed the most efficient capacity with a signature that predicted all seven NEC infants at least a week in advance. Overall, our study demonstrates that multiplexed proteomic signature detection constitutes a promising approach for the early detection of NEC development in premature infants.

The Metabolome and the Gut Microbiota for the Prediction of Necrotizing Enterocolitis and Spontaneous Intestinal Perforation: A Systematic Review

Necrotizing enterocolitis (NEC) is the most devastating gastrointestinal emergency in preterm neonates. Research on early predictive biomarkers is fundamental. This is a systematic review of studies applying untargeted metabolomics and gut microbiota analysis to evaluate the differences between neonates affected by NEC (Bell’s stage II or III), and/or by spontaneous intestinal perforation (SIP) versus healthy controls. Five studies applying metabolomics (43 cases, 95 preterm controls) and 20 applying gut microbiota analysis (254 cases, 651 preterm controls, 22 term controls) were selected. Metabolomic studies utilized NMR spectroscopy or mass spectrometry. An early urinary alanine/histidine ratio >4 showed good sensitivity and predictive value for NEC in one study. Samples collected in proximity to NEC diagnosis demonstrated variable pathways potentially related to NEC. In studies applying untargeted gut microbiota analysis, the sequencing of the V3−V4 or V3 to V5 regions of the 16S rRNA was the most used technique. At phylum level, NEC specimens were characterized by increased relative abundance of Proteobacteria compared to controls. At genus level, pre-NEC samples were characterized by a lack or decreased abundance of Bifidobacterium. Finally, at the species level Bacteroides dorei, Clostridium perfringens and perfringens-like strains dominated early NEC specimens, whereas Clostridium butyricum, neonatale and Propionibacterium acnei those at disease diagnosis. Six studies found a lower Shannon diversity index in cases than controls. A clear separation of cases from controls emerged based on UniFrac metrics in five out of seven studies. Importantly, no studies compared NEC versus SIP. Untargeted metabolomics and gut microbiota analysis are interrelated strategies to investigate NEC pathophysiology and identify potential biomarkers. Expression of quantitative measurements, data sharing via biorepositories and validation studies are fundamental to guarantee consistent comparison of results.

Understanding the development and function of the gut microbiota in health and inflammation

The gut microbiota is known to play an important role in maintaining gut health through a symbiotic relationship with the host. Altered gut microbiota is a common feature of several diseases of the gastrointestinal tract; however, the causal relationship between microbiota and disease pathogenesis is poorly understood. Necrotising enterocolitis (NEC) and inflammatory bowel disease (IBD) are both severe inflammatory diseases affecting the gastrointestinal tract. Although they affect very different patient populations, with NEC primarily being a disease of prematurity and IBD predominantly affecting adults although children can be affected, they both demonstrate common features of gut microbial dysbiosis and a dysregulated host immune response. By comparing and contrasting the changes in gut microbiota, host immune response and function, we aim to highlight common features in diseases that may seem clinically unrelated. Key areas of interest are the role of pattern recognition receptors in altered recognition and responses to the gut microbiota by the host immune system and the associated dysfunctional gut epithelial barrier. The challenge of identifying causal relationships between microbiota and disease is ever-present; however, considering a disease-agnostic approach may help to identify mechanistic pathways shared across several clinical diseases.

Infection prevention for extremely low birth weight infants in the NICU

Extremely preterm infants are particularly vulnerable to systemic infections secondary to their immature immune defenses, prolonged hospitalizations, delays in enteral feeding, early antibiotic exposure, and need for life-sustaining invasive interventions. There have been several evidence-based practices for infection prevention in this population, such as human milk feedings, utilization of "bundle checklists" and decolonization of pathogenic organisms. Other practices, such as the use of probiotics, human milk-derived fortifiers, and antifungal prophylaxis are more controversial and require further investigation regarding the risks and benefits of such interventions. This chapter examines the susceptibility of the preterm newborn infant to invasive infections and describes several strategies for infection prevention, along with the associated limitations of such practices. It also addresses the various gaps in our understanding of preventing infections in this population, and the need for additional large multi-center randomized controlled trials. Additionally, the role of the SARs-CoV-2 global pandemic and associated strategies for infection prevention in the NICU are discussed.

The role of ultrasound in necrotizing enterocolitis

Ultrasound has proved to be a useful modality for enhancing the diagnostic accuracy of necrotizing enterocolitis and associated complications. The standard imaging algorithm for evaluating necrotizing enterocolitis includes radiographs and clinical symptoms, the combination of which constitutes the Bell criteria. Major limitations of using the Bell criteria for diagnosing and clinically managing necrotizing enterocolitis include low diagnostic accuracy of radiographs and nonspecific symptomatology of preterm infants. In this regard, US can offer additional insights into bowel health by helping to characterize bowel motility, echogenicity, thickness, pneumatosis and perfusion. Extramural findings such as portal venous gas, nature and extent of ascites, and pneumoperitoneum can also be assessed. Recently, contrast-enhanced US was explored in a case series of preterm bowel disease and its diagnostic utility warrants further investigation. This article reviews the US features of necrotizing enterocolitis and highlights the role of US as a complement to radiographs, as well as the emerging use of contrast-enhanced US in necrotizing enterocolitis.

Early versus late-onset necrotizing enterocolitis in very low birth infants in the neonatal intensive care unit

BACKGROUND

Necrotizing enterocolitis (NEC), one of the most severe emergencies in neonates, is a multifactorial disease with diverse risk factors.

OBJECTIVES

To compare between the clinical and laboratory characteristics of premature infants diagnosed with early-onset NEC (EO-NEC) and those with late-onset NEC (LO-NEC).

PATIENTS AND METHODS

Enrolled infants were identified from prospective local data collected for the Israel National very low birth weight (VLBW, < 1500 g) infant database and from the local electronic patient files data base for the period 1996-2017.

RESULTS

Overall, 95 VLBW infants (61, 64.21% EO-NEC and 34, 35.87% LO-NEC) were enrolled. EO-NEC infants had higher rate of IVH grade 3 and 4 (26.2% vs 2.9%, p = 0.005) and were more likely to undergo surgery (49.2% vs 26.5%, p = 0.031). LO-NEC infants had a higher incidence of previous bloodstream infections (35.3% vs 8.2%, p = 0.002) compared to EO-NEC. In multivariable analysis models, surgical intervention was associated with EO-NEC (OR: 4.627, p = 0.013) as well as PDA and positive blood culture prior to the NEC episode.

CONCLUSIONS

Our data support the hypothesis that EO-NEC has significant different clinical and microbiological attributes compared to LO-NEC.

Necrotizing Enterocolitis in a Dutch Cohort of Very Preterm Infants: Prevalence, Mortality, and Long-Term Outcomes

INTRODUCTION

 To improve counseling of parents and to guide care strategies, we studied the disease course and outcomes of necrotizing enterocolitis (NEC) up to 2 years of corrected age (CA) from a multidisciplinary perspective.

MATERIALS AND METHODS

 This was a retrospective cohort study in preterm infants (birth weight < 1,500 g, gestational age < 32 weeks), diagnosed with NEC (Bell's stage ≥ II) from 2008 through 2020. Data on prevalence, mortality, surgery, intestinal failure (IF), growth, and neurodevelopment at 2-year follow-up were separately analyzed for medically and surgically treated children.

RESULTS

 Of 3,456 preterm infants, 200 (6%) were diagnosed with NEC, of whom 135 developed an indication for surgery within 7 days after the diagnosis; 28/135 died before surgery, and 37/107 died after an open-and-close procedure. An enterostomy was constructed in 62 patients and an end-to-end anastomosis in 15. The postoperative course was described for 77 patients, of whom 23 developed surgical complications (12/23 incisional hernias, 9/23 anastomotic strictures), 13/77 a short bowel, and 25/77 IF. Sixty-day survival after birth for medical NEC patients was 88% (hazard ratio [HR]: 0.698; p = 0.318), and for surgically treated NEC patients was 40% (HR: 3.729; p < 0.001). At 2-year follow-up, one patient received parenteral nutrition. Severe delay in weight for age, motor, and cognitive development was seen in 3, 6, and 2%, respectively.

CONCLUSION

 In this cohort, the mortality rate was high, especially in surgically treated NEC patients. The surgical complication rate is comparable to previous studies, but in surviving patients, persisting IF and severe delay in growth and neurodevelopment at 2 years CA were relatively rare.

Risk factors for necrotizing enterocolitis and establishment of prediction model of necrotizing enterocolitis in preterm infants

OBJECTIVES

To investigate the risk factors for necrotizing enterocolitis (NEC) in preterm infants, and to establish a scoring model that can predict the development and guide the prevention of NEC.

METHODS

A retrospective analysis was performed on the medical data of preterm infants who were admitted to the Department of Neonatology,Bethune First Hospital of Jilin University, from January 2011 to December 2020. These infants were divided into two groups: NEC (298 infants with Bell II stage or above) and non-NEC (300 infants). Univariate and multivariate analyses were performed to identify the factors influencing the development of NEC. A nomogram for predicting the risk of NEC was established based on the factors. The receiver operator characteristic (ROC) curve and the index of concordance (C-index) were used to evaluate the predictive performance of the nomogram.

RESULTS

The multivariate logistic regression analysis showed that grade ≥2 intracranial hemorrhage, peripherally inserted central catheterization, breast milk fortifier, transfusion of red cell suspension, hematocrit >49.65%, mean corpuscular volume >114.35 fL, and mean platelet volume >10.95 fL were independent risk factors for NEC (P<0.05), while the use of pulmonary surfactant, the use of probiotics, and the platelet distribution width >11.8 fL were protective factors against NEC (P<0.05). The nomogram showed good accuracy in predicting the risk of NEC, with a bootstrap-corrected C-index of 0.844. The nomogram had an optimal cutoff value of 171.02 in predicting the presence or absence of NEC, with a sensitivity of 74.7% and a specificity of 80.5%.

CONCLUSIONS

The prediction nomogram for the risk of NEC has a certain clinical value in early prediction, targeted prevention, and early intervention of NEC.

Development and Validation of a Nomogram for Predicting the Risk of Bell's Stage II/III Necrotizing Enterocolitis in Neonates Compared to Bell's Stage I

BACKGROUND

Patients with Bell's Stage II/III necrotizing enterocolitis (NEC) may have more severe presentations, higher rates of death, and more long-term complications than those with Bell's Stage I NEC, so the purpose of this article was to construct a nomogram model to distinguish Bell's stage II/III NEC early from Bell's Stage I NEC, which is critical in the clinical management of NEC.

PATIENTS AND METHODS

A total of 730 NEC newborns diagnosed from January 2015 to January 2021 were retrospectively studied. They were randomly divided into training and validation groups at the ratio of 7:3. A nomogram model for predicting NEC was developed based on all the independent risk factors by multivariate regression analysis. The model's performance was mainly evaluated through three aspects: the area under the curve (AUC) to verify discrimination, the Hosmer-Lemeshow test and calibration curve to validate the consistency, and decision curve analysis (DCA) to determine the clinical effectiveness.

RESULTS

Predictors included in the prediction model were gestational age (GA), birth weight (BW), asphyxia, septicemia, hypoglycemia, and patent ductus arteriosus (PDA). This nomogram model containing the above-mentioned six risk factors had good discrimination ability in both groups, and the AUCs were 0.853 (95% CI, 0.82-0.89) and 0.846 (95% CI, 0.79-0.90), respectively. The calibration curve and DCA confirmed that the nomogram had good consistency and clinical usefulness.

CONCLUSIONS

This individual prediction nomogram based on GA, BW, asphyxia, septicemia, hypoglycemia, and PDA served as a useful tool to risk-stratify patients with NEC, and can help neonatologists early distinguish Bell's stage II/III NEC early from Bell's Stage I NEC.

Lipocalin-2 and calprotectin as stool biomarkers for predicting necrotizing enterocolitis in premature neonates

BACKGROUND

Necrotizing enterocolitis (NEC) is a major challenge for premature infants in neonatal intensive care units and efforts toward the search for indicators that could be used to predict the development of the disease have given limited results until now.

METHODS

In this study, stools from 132 very low birth weight infants were collected daily in the context of a multi-center prospective study aimed at investigating the potential of fecal biomarkers for NEC prediction. Eight infants (~6%) received a stage 3 NEC diagnosis. Their stools collected up to 10 days before diagnosis were included and matched with 14 non-NEC controls and tested by ELISA for the quantitation of eight biomarkers.

RESULTS

Biomarkers were evaluated in all available stool samples leading to the identification of lipocalin-2 and calprotectin as the two most reliable predicting markers over the 10-day period prior to NEC development. Pooling the data for each infant confirmed the significance of lipocalin-2 and calprotectin, individually and in combination 1 week in advance of the NEC clinical diagnosis.

CONCLUSIONS

The lipocalin-2 and calprotectin tandem represents a significant biomarker signature for predicting NEC development. Although not yet fulfilling the "perfect biomarker" criteria, it represents a first step toward it.

IMPACT

Stool biomarkers can be used to predict NEC development in very low birth weight infants more than a week before the diagnosis. LCN2 was identified as a new robust biomarker for predicting NEC development, which used in conjunction with CALPRO, allows the identification of more than half of the cases that will develop NEC in very low birth weight infants. Combining more stool markers with the LCN2/CALPRO tandem such as PGE2 can further improve the algorithm for the prediction of NEC development.

Association between duration of early empiric antibiotics and necrotizing enterocolitis and late-onset sepsis in preterm infants: a multicenter cohort study

The threshold to initiate empiric antibiotics for suspicion of early-onset sepsis (EOS) is low in preterm infants. Antibiotics' effects on short-term outcomes have recently been debated. We aimed at exploring the extent of early empiric antibiotic exposure (EEAE) in preterm infants and the association between the duration of EEAE with necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) within different EEAE groups. EEAE practice for suspicion of EOS was evaluated in all included infants (gestational age < 30 weeks) born in 9 centers in the Netherlands and Belgium between Oct. 2014 and Jan. 2019. EEAE association with NEC and LOS development was analyzed by multivariate regression. After excluding 56 EOS cases, 1259 infants were included. A total of 1122 infants (89.1%) were exposed to empirical antibiotics for the suspicion of EOS of whom 802 (63.7%) had short (≤ 72 h) and 320 (25.4%) prolonged EEAE (> 72 h). Infants with EEAE ≤ 72 h had a lower incidence of NEC compared to both infants without EEAE (adjusted odds ratio (aOR) 0.39; 95% confidence interval (CI) [0.19-0.80]; p = 0.01) and with prolonged EEAE (> 72 h) (aOR [95%CI]: 0.58 [0.35-0.96]; p = 0.03). With every additional day of EEAE, LOS incidence decreased (aOR [95%CI]: 0.90 [0.85-0.97]; p = 0.003).

CONCLUSION

Almost 90% of preterm infants who have negative blood culture results in the first 72 h of life are exposed to EEAE under suspicion of EOS. One-fourth has prolonged EEAE. Duration of EEAE was differently associated with NEC and LOS incidence. The effects of antibiotics, and potentially induced microbial dysbiosis related to development of NEC and LOS, should further be explored.

WHAT IS KNOWN

• Preterm infants often receive antibiotics empirically directly after birth for suspicion of early-onset sepsis. • The effects of the duration of early empirical antibiotic exposure on the risk for necrotizing enterocolitis and late-onset sepsis are debated.

WHAT IS NEW

• Almost 90% of preterm infants with a gestational age below 30 weeks are exposed to antibiotics empirically after birth despite negative culture results. In a quarter of these culture-negative infants, empirical antibiotics are prolonged. • A short course of empirical antibiotics (≤72h) is associated with decreased odds for necrotizing enterocolitis compared to both prolonged (>72h) or no empirical antibiotics after birth. Furthermore, every additional day of empirical antibiotic exposure is associated with decreased risk for late-onset sepsis in the first month of life.

Newborns with Bloody Stools-At the Crossroad between Efficient Management of Necrotizing Enterocolitis and Antibiotic Stewardship

The onset of bloody stools in neonates often results in antibiotic treatment for suspected necrotizing enterocolitis (NEC). Food protein-induced allergic proctocolitis (FPIAP) is an often-neglected differential diagnosis. We performed a retrospective analysis of antibiotic exposure at our tertiary center from 2011 to 2020 that included three time periods of differing antimicrobial stewardship goals. We compared these data with the conventional treatment guidelines (modified Bell's criteria). In our cohort of 102 neonates with bloody stools, the length of antibiotic exposure was significantly reduced from a median of 4 to 2 days. The proportion of treated neonates decreased from 100% to 55% without an increase in negative outcomes. There were 434 antibiotic days. Following a management strategy according to modified Bell's criteria would have led to at least 780 antibiotic days. The delayed initiation of antibiotic treatment was observed in 7 of 102 cases (6.9%). No proven NEC case was missed. Mortality was 3.9%. In conclusion, with FPIAP as a differential diagnosis of NEC, an observational management strategy in neonates with bloody stools that present in a good clinical condition seems to be justified. This may lead to a significant reduction of antibiotic exposure. Further prospective, randomized trials are needed to prove the safety of this observational approach.

Effect of Postpartum Depo Medroxyprogesterone Acetate on Lactation in Mothers of Very Low-Birth-Weight Infants

Objective: This study examined the effect of postpartum administration of depo medroxyprogesterone acetate (DMPA) on milk production, time to onset of secretory activation, lactation duration, and infant consumption of mother's own milk (MOM) in mothers of preterm very low-birth-weight (VLBW) infants. Materials and Methods: We conducted a secondary analysis of data from mothers who delivered infants weighing ≤1,500 g and at ≤32 weeks' gestation. The volume of milk produced was measured on days 1-7, 14, and 21 by weighing all expressed milk on an electronic scale. Time to secretory activation was determined through self-report of a feeling of breast fullness. Information on lactation duration and the percent of feeds consisting of MOM consumed by infants was obtained from the medical records. Results: Mothers who received postpartum DMPA were more likely to be African American (72.4% versus 31.4%; p = 0.0006), unemployed (65.5% versus 44.5%; p = 0.027), and Medicaid eligible (89.7% versus 67.2%; p = 0.019). There were no differences in daily milk production between mothers who received DMPA before hospital discharge (n = 29) compared with those who did not (n = 141). When mothers who reached secretory activation before receiving DMPA were removed from analysis, receiving DMPA was associated with a later onset of secretory activation (103.7 versus 88.6 hours; p = 0.028). There were no statistically significant differences between the study groups in lactation duration or infant MOM consumption. Conclusions: DMPA, when administered postpartum to mothers of preterm VLBW infants, delayed secretory activation, but had no detrimental effect on milk production or lactation duration. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT01892085.

Antibiotic Stewardship for the Neonatologist and Perinatologist

Antibiotic use is common in the neonatal intensive care unit. The density and heterogeneity of antibiotic prescribing suggests inappropriate and overuse of these agents. Potential antibiotic stewardship targets include sepsis, necrotizing enterocolitis, and perioperative prophylaxis. Diagnostic stewardship principles, including appropriately obtained cultures, may be leveraged to decrease unnecessary antibiotic prescribing. Strategies including guideline development, prospective audit and feedback, and formulary restriction have been successfully deployed in the neonatal intensive care unit to improve the quality of antibiotic prescribing. Implementation of antibiotic stewardship in the neonatal intensive care unit requires multidisciplinary collaboration between neonatologists, surgeons, infectious diseases specialists, pharmacists, and nurses.

The Prevalence of Necrotizing Enterocolitis and Associated Factors Among Enteral Fed Preterm and Low Birth Weight Neonates Admitted in Selected Public Hospitals in Addis Ababa, Ethiopia: A Cross-sectional Study

Necrotizing enterocolitis (NEC) remains to be the most critical and frequent gastrointestinal disorder understood in neonatal intensive care units (NICU). The presented study was intended to assess the prevalence of NEC and associated factors among enteral Fed preterm and low birth weight neonates. Institution based retrospective cross-sectional study was conducted on 350 enteral Fed preterm and low birth weight neonates who were admitted at selected public hospitals of Addis Ababa from March 25/2020 to May 10/2020. The data were collected through neonates' medical record chart review. A total of 350 participants were enrolled in to the study with the response rate of 99.43%. One hundred eighty-four (52.6%) of them were male. The majority 123 (35.1%) of them were (32 + 1 to 34) weeks gestational age. The prevalence of NEC was (25.4%) (n = 89, [95% CI; 21.1, 30.0]). Being ≤28 weeks gestational age (AOR = 3.94, 95% CI [2.67, 9.97]), being (28 + 1 to 32 weeks) gestational age (AOR = 3.65, 95% CI [2.21, 8.31]), birth weight of 1000 to 1499 g (AOR = 2.29, 95% CI [1.22, 4.33]), APGAR score ≤3 (AOR = 2.34, 95% CI [1.32, 4.16]), prolonged labor (AOR = 2.21, 95% CI [1.35, 6.38]), maternal chronic disease particularly hypertension (AOR = 3.2, 95% CI [1.70, 5.90]), chorioamnionitis (AOR = 4.8, 95% CI [3.9, 13]), failure to breath/resuscitated (AOR = 2.1, 95% CI [1.7, 4.4]), CPAP ventilation (AOR = 3.7, 95% CI [1.50, 12.70]), mixed milk (AOR = 3.58, 95% CI [2.16, 9.32]) were factors significantly associated with NEC. Finally, the prevalence of NEC in the study area was high. So that, initiating the programs that could minimize this problem is required to avoid the substantial morbidity and mortality associated with NEC.

Measures of Lactation Outcomes in Women Delivering Preterm Infants

BACKGROUND

Mother's own milk (MOM) is well known to decrease prematurity-related morbidities, yet mothers delivering preterm infants often produce insufficient quantities of milk to provide these benefits. Although a critical need exists for research to support lactation success in this vulnerable population, development and investigation of interventions to increase available MOM for infant consumption requires consistent, valid, and reliable measures of lactation outcomes.

OBJECTIVES

The aim of this study was to compare and contrast methods of measuring lactation outcomes in mothers of preterm infants and evaluate their advantages and disadvantages.

METHODS

Measures of lactation outcomes were reviewed and synthesized. Insights on best practices and future research directions are provided.

RESULTS

Volume of MOM produced, lactation duration, and time to onset of secretory activation are important measures of lactation success. The most valid and reliable measure of milk production is likely weighing each vial of expressed milk combined with test weighing when infants breastfeed. Measures of lactation duration should include actual days mothers lactated rather than limiting to infant consumption of MOM as a proxy for duration and include not only whether mothers are lactating at infant discharge but whether they are also lactating at other health-relevant time points during hospitalization. Although time to onset of secretory activation is an important lactation outcome, information regarding valid and reliable indicators of onset in women delivering preterm infants is limited, and investigation of such indicators is a research priority. Variables that may affect lactation outcomes, including time to initiation of expression following delivery, duration of expression sessions, expression method, time spent in skin-to-skin care, maternal demographics and comorbidities, as well as maternal intent to lactate, must be considered when researchers investigate lactation outcomes in mothers of very low birth weight infants.

DISCUSSION

Consistent and valid measures of lactation outcomes are required to produce reliable results from which evidence-based practice recommendations can be developed in order to improve lactation success in this vulnerable population.

Estimating Neonatal Necrotizing Enterocolitis Based on Feeding Practices

(1) Background: The relationship between enteral nutrition and neonatal necrotizing enterocolitis (NEC) among premature neonates is still unclear. The present work was designed to assess the relationship between NEC and feeding strategies compared to control infants. (2) Methods: A retrospective case-control study of premature infants (<35 weeks' gestation) with or without NEC that examined feeding practices and clinical characteristics at birth and 3, 7, and 14-day hospitalization, with a longitudinal and cross-sectional analysis. (3) Results: A total of 100 newborns with NEC diagnosis and 92 neonates without the disease with similar demographic and clinical characteristics were included. The median day of NEC diagnosis was 15 days (Interquartile Range (IQR) 5-25 days). A significantly higher number of neonates that were fasting on days 7 and 14 developed NEC (p < 0.05). In the longitudinal analysis, generalized linear and mixed models were fit to evaluate NEC association with feeding strategies and showed that exclusive mother's own milk (MM) and fortified human milk (FHM) across time were significantly less likely associated with NEC (p < 0.001) and that enteral fasting was positively related with NEC. In the cross-sectional analysis, a binary logistic regression model was fit and predicted 80.7% of NEC cases. MM was also found to correlate with a reduced risk for NEC (OR 0.148, 95% CI 0.044-0.05, p = 0.02), and in particular, on day 14, several factors were related to a decreased odd for NEC, including birth weight, antenatal steroids, and the use of FHM (p < 0.001). (4) Conclusions: MM and FHM were associated with less NEC compared to fasting on days 7 and 14. Feeding practices in Neonatal Intensive Care Units (NICUs) should promote exclusive MM across the two-week critical period as a potential guideline to improve NEC outcome.

Pathogenesis of necrotising enterocolitis: The impact of the altered gut microbiota and antibiotic exposure in preterm infants

Necrotising enterocolitis (NEC) is a devastating condition with high morbidity and mortality seen predominately in preterm infants. Multiple factors are associated with the pathogenesis of NEC. The widespread use of antibiotics in the neonatal intensive care unit might play a role in the pathogenesis of NEC in preterm infants. This review provides a summary on the intestinal microbiota in preterm infants with a focus on how antibiotic exposure may reduce the biodiversity of the intestinal microbiota and may predispose preterm infants to NEC. CONCLUSION: Prolonged antibiotic therapy has been suggested as a risk factor for the development of NEC in preterm infants.

Outcomes of Neonates Requiring Neonatal Intensive Care Admission for Necrotizing Enterocolitis in a Resource-Restricted Hospital in Cape Town, South Africa

AIM

The aim of this study is to describe the 30-day mortality, neurodevelopmental outcome and composite outcome (mortality or abnormal neurodevelopmental outcome) of neonates with necrotizing enterocolitis (NEC), requiring neonatal intensive care (NICU) admission, in a resource-restricted environment.

METHODS

All neonates admitted to Tygerberg Hospital, NICU, with a presumptive diagnosis of NEC Bell stage IIB or more, over a 5-year period, were included.

RESULTS

One hundred and thirty-five neonates were included with a mean gestational age of 29 ± 2.7 weeks and mean birth weight of 1185 g ± 446 g. The 30-day mortality was 52%, neurodevelopment abnormalities occurred in 35% of survivors and adverse composite outcome in 63%. The 30-day mortality and adverse composite outcome risk were increased by small for gestational age, shock, metabolic acidosis, inotrope requirement and first feed >9 days after surgery.

CONCLUSION

In resource-restricted environments, mortality and abnormal neurodevelopmental outcome of neonates with NEC, remain high. However, outcomes are comparable with international literature. Neonates with NEC, requiring NICU admission and surgery, require neurodevelopmental follow-up.

Impact of Early Empiric Antibiotic Regimens on the Gut Microbiota in Very Low Birth Weight Preterm Infants: An Observational Study

Frequent use of antibiotics in preterm infants disturbs their gut microbial balance. In this preliminary observational study, we investigated the effect of different antibiotic regimens, administered during the first week of life, on microbial composition and diversity in very low birth weight (VLBW) preterm infants. We performed fecal sampling of breastfed VLBW infants on days 7, 14, and 30. After excluding stool samples from infants who received probiotics or who were administered antibiotics beyond the age of 7 days, we compared gut microbiota profiles between infants receiving a combination of ampicillin and gentamicin for 3 days (AG group, n = 10) and those receiving a combination of ampicillin and cefotaxime for 7 days (AC group, n = 14) using 16S ribosomal DNA community profiling. We also assessed the changes over time in each group. Compared to the AG group, Enterococcus species were significantly more abundant in the AC group (P = 0.002), especially in 7-day samples (12.3 vs. 0.6%, respectively, P = 0.032). No difference was observed at phylum and genus level over time within each group. Species richness in the AC group decreased significantly in the 14-day (P = 0.038) and 30-day (P = 0.03) samples compared to that in the 7-day sample. The same was observed for microbial evenness; in contrast, no significant difference in Shannon index and beta-diversity was detected between the two groups. Controlling for relevant confounding variables did not change the results. In conclusion, different antibiotic regimens affect the early development of gut microbiota in VLBW preterm infants. Prolonged use of ampicillin and cefotaxime might result in overabundance of Enterococcus. However, given that no significant differences were observed in 1-month samples, bacterial genera appear to continue colonizing the gastrointestinal tract despite previous exposure to antibiotics. The clinical relevance of these findings should be elucidated by further studies.

The association between clinical and biochemical characteristics of late-onset sepsis and bronchopulmonary dysplasia in preterm infants

Studies in preterm infants have shown an association between late-onset sepsis (LOS) and the development of bronchopulmonary dysplasia (BPD). It is unknown whether clinical or biochemical characteristics during sepsis modulate the risk for BPD. This single-center retrospective cohort study included all patients with a gestational age < 30 weeks, born between 2009 and 2015, in whom empiric antimicrobial treatment was initiated > 72 h after birth and continued for at least 5 days, independent on microbiological results. The association between clinical and biochemical characteristics of LOS and the development of BPD in survivors were assessed with multivariate logistic regression analysis adjusted for early-onset sepsis, small for gestational age, and gestational age. Of the 756 admitted infants, 256 infants (mean GA: 27.0 weeks; birthweight: 924 grams) had at least one LOS episode, of whom 79 (30.9%) developed BPD. Analyses showed that only the need for and duration of mechanical ventilation during LOS were independently associated with an increased risk for BPD (adjusted OR 2.62, 95% CI 1.38, 4.96, p value 0.003, and OR 1.004, 95% CI 1.00, 1.007, p value 0.045, respectively).Conclusion: During a LOS, the need for and duration of mechanical ventilation are independently associated with the risk of developing BPD in preterm infants. What is Known: • Premature infants diagnosed with a late-onset sepsis are at higher risk of developing bronchopulmonary dysplasia • This association is mainly shown in infants with a positive blood culture What is New: • This study investigates the clinical and biochemical characteristics of late-onset sepsis and the development of bronchopulmonary dysplasia • The need for mechanical ventilation and duration of mechanical ventilation during late-onset sepsis are associated with an increased risk of developing bronchopulmonary dysplasia.

Routine Administration of a Multispecies Probiotic Containing Bifidobacterium and Lactobacillus to Very Low Birth Weight Infants Had No Significant Impact on the Incidence of Necrotizing Enterocolitis

Background: Necrotizing enterocolitis (NEC) is the leading cause of gastrointestinal morbidity in preterm infants, and prevention and treatment strategies have remained largely unchanged over the past several decades. As understanding of the microbiome has increased, probiotics have been hypothesized as a possible strategy for decreasing rates of NEC, and several studies have noted significant decreases in rates of NEC after initiation of probiotics in preterm infants. However, a recent AAP report cited caution on the use of probiotic use in part because studies of probiotic use in ELBW infants are lacking. As our unit began routine use of probiotics for all infants <33 weeks in 2015 and we are a leading institution for intact survival of ELBW infants, we attempted to answer if probiotic use can impact the rate of NEC in VLBW and ELBW infants. Methods: We conducted a single-center retrospective chart review of infants with modified Bell's stage ≥2a NEC for the 4 years prior to and 5 years after initiation of a protocol involving routine supplementation of a multispecies probiotic to premature infants at the University of Iowa, Stead Family Children's Hospital. The primary outcome measures were rates of modified Bell's stage ≥2a NEC and all-cause pre-discharge mortality at our institution before and after initiation of routine probiotic supplementation in 2015. Results: In our institution, neither the rates of modified Bell's stage ≥2a NEC, nor the rates of all-cause mortality were significantly altered in very low birth weight (VLBW) infants by the initiation of routine probiotic use (NEC rates pre-probiotic 2.1% vs. post-probiotic 1.5%; all-cause mortality rates pre-probiotic 8.4% vs. post-probiotic 7.4%). Characteristics of our two cohorts were overall similar except for a significantly lower 5-minute APGAR score in infants in the post-probiotic epoch (pre-probiotic 8 vs. post-probiotic 6 p = 0.0316), and significantly more infants in the post-probiotic epoch received probiotics (pre-probiotics 0% vs. post-probiotics 65%; p < 0.0001). Similarly, probiotic use had no impact on the incidence of NEC when we restricted our data to only extremely low birth weight (ELBW) infants (pre-probiotics 1.6% vs post-probiotics 4.1%). When we restricted our analysis to only inborn infants, probiotics still had no impact on NEC rates in VLBW infants (1.5% pre- and 1.1% post-probiotic, p = 0.61) or ELBW infants (2% pre- and 2.1% post-probiotic, p = 0.99) Conclusions: Contrary to other studies, we found no significant difference in rates of modified Bell's stage ≥2a NEC or all-cause pre-discharge mortality in VLBW infants following routine administration of a multispecies probiotic supplement.

Early Use of Antibiotics Is Associated with a Lower Incidence of Necrotizing Enterocolitis in Preterm, Very Low Birth Weight Infants: The NEOMUNE-NeoNutriNet Cohort Study

OBJECTIVE

To determine whether commencement of antibiotics within 3 postnatal days in preterm, very low birth weight (VLBW; ≤1500 g) infants is associated with the development of necrotizing enterocolitis (NEC).

STUDY DESIGN

Preplanned statistical analyses were done to study the association between early antibiotic treatment and later NEC development, using the NEOMUNE-NeoNutriNet cohort of VLBW infants from 13 neonatal intensive care units (NICUs) in 5 continents (n = 2831). NEC incidence was compared between infants who received early antibiotics and those who did not, with statistical adjustments for NICU, gestational age, birth weight, sex, delivery mode, antenatal steroid use, Apgar score, and type and initiation of enteral nutrition.

RESULTS

The incidence of NEC was 9.0% in the group of infants who did not receive early antibiotics (n = 269), compared with 3.9% in those who did receive early antibiotics (n = 2562). The incidence remained lower in the early antibiotic group after stepwise statistical adjustments for NICU (OR, 0.57; 95% CI, 0.35-0.94, P < .05) and other potential confounders (OR, 0.25; 95% CI, 0.12-0.47; P < .0001).

CONCLUSIONS

In this large international cohort of preterm VLBW infants, a small proportion of infants did not receive antibiotics just after birth, and these infants had a higher incidence of NEC. It is important to better understand the role of such variables as time, type, and duration of antibiotic treatment on NEC incidence, immune development, gut colonization, and antibiotic resistance in the NICU.

Timing of milk expression following delivery in mothers delivering preterm very low birth weight infants: a randomized trial

OBJECTIVE

To determine the effect of timing of expression initiation on mother's own milk production and time to secretory activation in mothers of preterm infants.

STUDY DESIGN

180 mothers delivering infants ≤1500 grams and ≤32 weeks gestation were randomized to begin expression within 60 (early), 61-180 (intermediate) or 181-360 (late) minutes following delivery. Milk volume was measured on days 1-7 and weekly for 6 weeks. Time to secretory activation was determined through self-report.

RESULTS

The late group produced more milk than the early group in the first 3 days (p = 0.015-0.031) and over 6 weeks (p = 0.045). The late group had more expressions on day 1 (early: p = 0.049; intermediate; p = 0.048).

CONCLUSION

Initiation of expression at 181-360 min following delivery was associated with increased milk production for 6 weeks following delivery. Further research is needed to determine the effect of expression frequency on milk production in the first days following birth.

Translational Advances in Pediatric Nutrition and Gastroenterology: New Insights from Pig Models

Pigs are increasingly important animals for modeling human pediatric nutrition and gastroenterology and complementing mechanistic studies in rodents. The comparative advantages in size and physiology of the neonatal pig have led to new translational and clinically relevant models of important diseases of the gastrointestinal tract and liver in premature infants. Studies in pigs have established the essential roles of prematurity, microbial colonization, and enteral nutrition in the pathogenesis of necrotizing enterocolitis. Studies in neonatal pigs have demonstrated the intestinal trophic effects of akey gut hormone, glucagon-like peptide 2 (GLP-2), and its role in the intestinal adaptation process and efficacy in the treatment of short bowel syndrome. Further, pigs have been instrumental in elucidating the physiology of parenteral nutrition-associated liver disease and the means by which phytosterols, fibroblast growth factor 19, and a new generation of lipid emulsions may modify disease. The premature pig will continue to be a valuable model in the development of optimal infant diets (donor human milk, colostrum), specific milk bioactives (arginine, growth factors), gut microbiota modifiers (pre-, pro-, and antibiotics), pharmaceutical drugs (GLP-2 analogs, FXR agonists), and novel diagnostic tools (near-infrared spectroscopy) to prevent and treat these pediatric diseases.

The Impact of Human Milk on Necrotizing Enterocolitis: A Systematic Review and Meta-Analysis

Background. Premature infants receiving breastfeed have a lower incidence of NEC than those fed preterm formula. This study aimed: (1) to update a systematic review and meta-analyses to evaluate the relationship between feeding and necrotizing enterocolitis (NEC) in low weight premature infants; (2) to conduct meta-regression analyses by subgroups; (3) to describe geographical distribution of milk banks in the world. Methods. Papers included in the meta-analysis were updated as of June 2019. Relative risks were used as a measure of effect size. Random effect models were used to account for different sources of variation among studies. For milk banks, the data reviewed by the literature were integrated with the information collected from countries’ institutional sites and milk bank networks. Results. Thirty-two papers were included in meta-analysis: six randomized controlled trials (RCTs) and 26 observational studies (OS). The census has found 572 milk banks around in the world. Brazil has the most active milk banks. RCTs meta-analysis indicates a risk reduction of NEC using human milk respect to formula: Relative risk (RR) = 0.62 (0.42–0.93). Seven OS compared quantities lower than human milk or higher than the 50th quantile showing a risk reduction of NEC:RR = 0.51 (0.31–0.85); 3 OS that evaluated human milk versus mixed feeding showing that human milk has a protective role on the development of NEC:RR = 0.74 (0.63–0.91). Results of subgroups analysis show that the risk reduction is statistically significant only for studies in which premature infants are given both their own and donated breastmilk. Conclusions. The possibility of preserving human milk and promoting donations guarantees an improvement in the health of newborns.

Mode of delivery and necrotizing enterocolitis in very preterm very-low-birth-weight infants

Objective: To investigate the association between delivery mode and necrotizing enterocolitis (NEC) in very preterm (24-31 weeks' gestational age (GA)) very-low-birth-weight (VLBW) (≤1500 g) infants.Design: Population-based observational study using univariate and multivariable logistic regression analyses.Setting: The Israel National VLBW infant database 1995-2015.Patients: 20,223 VLBW infants, 11,832 singletons and 8391 multiples.Main outcome measures: The association of NEC occurrence to delivery by cesarean section (CS) in singletons and multiples VLBW very preterm infants.Results: NEC occurred in 7.6% of singletons and 6.4% of multiples. 71.5% were delivered by CS (64.7% of singletons, 80.9% of multiples). CS delivery was not significantly associated with NEC stages 2-3 in singletons; but multiple births CS were associated with significantly higher odds for NEC (OR 1.31, 95% CI 1.01-1.69). Odds for NEC were greater with lower GA, small for GA (SGA) and patent ductus arteriosus (PDA) in both singletons and multiples, and lower in multiples with antenatal corticosteroids.Conclusions: We demonstrated association between deliveries by CS and increased risk for NEC only in multiple pregnancies.

Recent Advances in Prevention and Therapies for Clinical or Experimental Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is one of the most severe diseases of preterm neonates and has a high mortality rate. With the development of inspection techniques and new biomarkers, the diagnostic accuracy of NEC is constantly improving. The most recognized potential risk factors include prematurity, formula-feeding, infection, and microbial dysbiosis. With further understanding of the pathogenesis, more effective prevention and therapies will be applied to clinical or experimental NEC. At present, such new potential prevention and therapies for NEC are mainly focused on the Toll-like receptor 4 inflammatory signaling pathway, the repair of intestinal barrier function, probiotics, antioxidative stress, breast-feeding, and immunomodulatory agents. Many new studies have changed our understanding of the pathogenesis of NEC and improve our approaches for preventing and treating of NEC each year. This review provides an overview of the recent researches focused on clinical or experimental NEC and highlights the advances made within the past 5 years toward the development of new potential preventive approaches and therapies for this disease.

Recent Potential Noninvasive Biomarkers in Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a rare but devastating gastrointestinal disease that predominately affects preterm neonates. Numerous studies have revealed that NEC is strongly associated with very low birth weight, degree of prematurity, formula feeding, infection, hypoxic/ischemic injury, and enteric dysbiosis. Given these clinical associations, the search for a deeper understanding of disease pathogenesis has led to an intense interest in the discovery and development of noninvasive biomarkers of NEC from stool, urine, and serum. Biomarkers for NEC may serve at least two general purposes of urgent unmet need: to improve diagnostic accuracy and disease prediction and to reveal the mechanism of the disease. This review will provide an overview of recent research focused on clinical NEC and highlight the advances that were made within the past five years towards the development of noninvasive diagnostic biomarkers.

Strategies to improve antibiotic use in the neonatal ICU

PURPOSE OF REVIEW

Neonates are at a high risk of infection and may have nonspecific signs of sepsis. Accordingly, they are heavily exposed to antimicrobials. Neonates are also uniquely at risk of both short-term and long-term complications from antibiotic exposure. This review discusses advances in antibiotic stewardship in the neonatal population.

RECENT FINDINGS

Antimicrobial utilization is highly variable among NICUs in excess of case-mix variation. Rates of early-onset sepsis because of Group B Streptococcus have decreased substantially with the introduction of intrapartum antibiotic prophylaxis. Recent epidemiologic studies have created evidence-based tools to more accurately estimate a newborn's risk of early-onset sepsis. Antibiotic selection and duration for late-onset sepsis and necrotizing enterocolitis are variable among centers, with inadequate evidence to guide practice. Novel diagnostic methods and biomarkers are increasingly used to assist with diagnosing infection, but inadequate specificity in many cases may result in excess antibiotic exposure. Published antimicrobial stewardship experiences in the neonatal inpatient setting have largely been successful and well tolerated.

SUMMARY

Recent publications have identified many ways to safely reduce antimicrobial exposure and developed strategies to implement antimicrobial stewardship in the neonatal inpatient setting. However, new approaches are needed to further improve antibiotic use and to implement these interventions more universally in NICUs.

Risk Factors for Late-Onset Sepsis in Preterm Infants: A Multicenter Case-Control Study

BACKGROUND

Late-onset sepsis (LOS) in preterm infants is a leading cause of mortality and morbidity. Timely recognition and initiation of antibiotics are important factors for improved outcomes. Identification of risk factors could allow selection of infants at an increased risk for LOS.

OBJECTIVES

The aim was to identify risk factors for LOS.

METHODS

In this multicenter case-control study, preterm infants born at ≤30 weeks of gestation were included at 9 neonatal intensive care units. Detailed demographical and clinical data were collected daily up to day 28 postnatally. Clinical and demographic risk factors were identified using univariate and multivariate regression analyses in a 1: 1 matched case-control cohort.

RESULTS

In total, 755 infants were included, including 194 LOS cases (41 gram-negative cases, 152 gram-positive cases, and 1 fungus). In the case-control cohort, every additional day of parenteral feeding increased the risk for LOS (adjusted OR = 1.29; 95% CI 1.07-1.55; p = 0.006), whereas antibiotics administration decreased this risk (OR = 0.08; 95% CI 0.01-0.88; p = 0.039). These findings could largely be attributed to specific LOS-causative pathogens, since these predictive factors could be identified for gram-positive, but not for gram-negative, LOS cases. Specifically cephalosporins administration prior to clinical onset was inversely related to coagulase-negative staphylococcus LOS (CoNS-LOS) development. Formula feeding was an independent risk factor for development of CoNS-LOS (OR = 3.779; 95% CI 1.257-11.363; p = 0.018).

CONCLUSION

The length of parenteral feeding was associated with LOS, whereas breastmilk administration was protective against CoNS-LOS. A rapid advancement of enteral feeding, preferably with breastmilk, may proportionally reduce the number of parenteral feeding days and consequently the risk for LOS.