Impact of necrotizing enterocolitis on length of stay and hospital charges in very low birth weight infants

Detection of an intestinal cell DNA methylation signature in blood samples from neonates with necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is an often fatal intestinal injury that primarily affects preterm infants for which screening tools are lacking. We performed a pilot analysis of DNA methylation in peripheral blood samples from preterm infants with and without NEC to identify potential NEC biomarkers.

METHODS

Peripheral blood samples were collected from infants at NEC diagnosis (n = 15) or from preterm controls (n = 13). Targeted genome-wide analysis was performed to identify DNA methylation differences between cases and controls.

RESULTS

Broad differences between NEC cases and controls were identified in distinct genomic elements. Differences between surgical NEC cases and controls were frequently associated with inflammation. Deconvolution analysis to identify cell type-specific DNA signatures revealed increases in ileal, vascular endothelial, and cardiomyocyte cell type proportions and decreases in colonic and neuronal cell type proportions in blood from NEC cases relative to controls.

CONCLUSIONS

We identified marked differences in DNA methylation of peripheral blood samples from preterm infants with and without NEC. Increased ileal cell-specific methylation signatures in the blood of infants with NEC relative to controls, with a marked increase seen in surgical cases, provides rationale for further analysis of intestinal DNA methylation signatures as biomarkers of NEC.

Effectiveness and Risks of Probiotics in Preterm Infants

OBJECTIVE

To evaluate the effectiveness and risks of probiotics among infants born before 34 weeks' gestation and with a birth weight less than 1000 g.

METHODS

A population-based retrospective cohort study of infants born before 34 weeks' gestation and admitted to 33 Canadian Neonatal Network (CNN) units between January 1, 2016, and December 31, 2022. We excluded infants who were moribund on admission, died within the first 2 days, were admitted to CNN sites more than 2 days after birth, had major congenital anomalies, or never received enteral feeds. Logistic regression, propensity score-matched, and inverse probability of treatment weighting analyses were applied.

RESULTS

Among 32 667 eligible infants born before 34 weeks' gestation, 18 793 (57.5%) (median [IQR] gestational age, 29 [27-31] weeks) received probiotics, and 13 874 (42.5%) (median [IQR] gestational age, 31 [29-33] weeks) did not receive probiotics. In these infants, probiotics were associated with decreased mortality rates (adjusted odds ratio [aOR], 0.62; 98.3% CI, 0.53-0.73) but not decreased rates of necrotizing enterocolitis (NEC) (aOR, 0.92; 98.3% CI, 0.78-1.09) or late-onset sepsis (aOR, 0.90; 98.3% CI, 0.80-1.01). In 7401 infants with a birth weight less than 1000 g, probiotics were associated with decreased mortality rates (aOR, 0.58; 98.3% CI, 0.47-0.71) but not decreased NEC (aOR, 0.90; 98.3% CI. 0.71-1.13) or late-onset sepsis rates (aOR, 1.01; 98.3% CI, 0.86-1.18). Probiotic sepsis occurred in 27 (1.4/1000) infants born before 34 weeks' gestation and 20 (4/1000) infants with a birth weight less than 1000 g. Three infants with probiotic sepsis died, with probiotic sepsis deemed a possible cause in 2 cases.

CONCLUSION

Probiotics used in Canadian neonatal units were associated with decreased mortality in infants born before 34 weeks' gestation and with a birth weight less than 1000 g with limited effects on NEC and late-onset sepsis. Probiotic sepsis was rare.

Characteristics, progression, management, and outcomes of NEC: a retrospective cohort study

BACKGROUND

Necrotising enterocolitis (NEC) in preterm infants is associated with high morbidity and mortality. In most neonates, it is a progressive disease from medical NEC (mNEC) to surgical NEC (sNEC); however, in some, it presents as sNEC from onset.

OBJECTIVE

To evaluate the rate, the timing of progression, different surgical approaches, and outcomes of mNEC and sNEC in preterm neonates.

DESIGN

A retrospective cohort study of preterm infants with diagnosis of NEC between 2010 and 2020 was conducted. Data on clinical presentation, NEC progression, treatment received, different surgical approaches, resource utilization, and outcomes were abstracted. Infants were classified into 3 groups: mNEC, mNEC that progressed to sNEC, and sNEC at presentation.

RESULTS

Among 208 included infants with NEC, 109 (52%) were mNEC, 66 (32%) progressed from mNEC to sNEC, and 33 (16%) presented with sNEC. Gestational age, birth weight, and postnatal age at NEC were inversely associated with the development of sNEC. mNEC progressed to sNEC occurred after a median of 2.5 (IQR 1-4.25) days. Ninety (91%) of sNEC patients underwent interventions: peritoneal drain only in 19 (21%), laparotomy in 59 (66%), or both in 12 (13%). In comparison with mNEC, those with sNEC infants had longer duration on antibiotics, inotropes, respiratory support, length of stay, and time to reaching full enteral feeds; and were more likely to have recurrent NEC episodes, BPD, and mortality.

CONCLUSION

There is a high burden of illness for sNEC cases. Insight into the expected clinical course of sNEC patients can facilitate anticipatory management and provide a window of opportunity for timely interventions that may ameliorate the course of sNEC.

Cannabidiol decreases histological intestinal injury in a neonatal experimental model of necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is a severe inflammatory bowel disease in neonates. Our group has developed an experimental model of NEC, with an effectiveness of 73%. Cannabidiol (CBD) is an innovative treatment for neonatal cerebral hypoxic-ischemic pathologies due to its neuroprotective effect, as a potent anti-inflammatory and reducing oxidative stress substance. Our aim was to evaluate the effect of CBD on intestinal lesions in an experimental model of NEC.

RESULTS

Mortality and intestinal histological damage was significantly lower in the CBD group compared to the rest (p<0.05), establishing CBD as a protective factor against the development of NEC (OR=0.0255; 95% CI=0.0015-0.4460). At IHQ level (TUNEL technique), a lower cell death rate was also observed in the CBD group compared to the VEH group (p<0.05).

CONCLUSIONS

In our experimental model, intraperitoneal CBD acts as a protective factor against NEC, resulting in less histological damage and a lower rate of intestinal cell death.

Impact of fetal inflammatory response on the severity of necrotizing enterocolitis in preterm infants

OBJECTIVE

Neonates born with fetal inflammatory response (FIR) are at increased risk for adverse neonatal outcomes. Our objective was to determine whether FIR and its severity is associated with severity of necrotizing enterocolitis (NEC) in preterm infants.

METHODS

A case-control retrospective study of infants <33 weeks gestational age or <1500 g birthweight, including 260 with stage I-III NEC and 520 controls matched for gestational age. Placental pathology was evaluated, and FIR progression and its severity were defined according to Amsterdam classification.

RESULTS

In this study, mild FIR (i.e., stage 1 FIR) was present in 52 controls (10.0%) and 22 infants with stage I-III NEC (8.5%), while moderate to severe FIR (i.e., ≥stage 2 FIR) was present in 16 controls (3.1%) and 47 infants with stage I-III NEC (18.1%). Both stage and grade of FIR were associated with stage of NEC (P < 0.001). On multinomial logistic regression, stage III NEC was associated with stage of FIR (P < 0.001).

CONCLUSION

This is the first report demonstrating the association between progression and increasing severity of FIR and stage of NEC.

IMPACT

Fetal Inflammatory Response (FIR) and its progression and severity are associated with the stages of necrotizing enterocolitis (NEC). This is the first study demonstrating the impact of progression and severity of FIR on stage III NEC. These observations provide additional insight into understanding the impact of intrauterine exposure to inflammation on the severity of NEC in preterm infants.

A budget impact analysis of exclusive human milk diet in very low birth weight infants in United Arab Emirates

INTRODUCTION

Very low birth weight (VLBW) infants have the highest rate of neonatal intensive care unit (NICU) admissions owing to the higher comorbidities associated with premature birth and long hospital stays. VLBW infants fed a bovine (BOV)-based diet have higher mortality rates, necrotizing enterocolitis (NEC), late-onset sepsis (LOS), and other comorbidities than those fed 100% human milk-based products. This study aims to evaluate the budgetary impact of adopting an exclusive human milk diet (EHMD) instead of a BOV-based diet in VLBW infants from Al-Ain Hospital, Sheikh Shakhbout Medical City, and Dubai Health Authority (DHA) in the United Arab Emirates (UAE).

METHODS

We use a decision-tree model to estimate the budget impact of adopting EHMD versus the current local practice (BOV) over 5 years. Patients enter the tree model and have a probability of transitioning to one of the following mutually exclusive health states: NEC, which may be treated medically or surgically; LOS, NEC, and LOS; or neither NEC nor LOS. Depending on the feeding strategy, infants in the aforementioned health states are likely to develop any of the following complications: retinopathy of prematurity, bronchopulmonary dysplasia, or short bowel syndrome. The model accounts for the costs associated with diet, management of health states and complications, and the follow-up period.

RESULTS

Al-Ain Hospital saved United Arab Emirates Dirham (AED) 3.3 million ($1.4million) in the first year of the EHMD feeding arm and AED 16.6 million ($7.1million) over the course of 5 years. In comparison to Sheikh Shabout Medical City and DHA, AED 36.7 million ($15.8million) and AED 24 million ($10.3million) were saved over 5 years, respectively, with AED 7.3 million ($3.1million) and 4.8 million ($2million) saved in the first year. The estimated pooled results across the three institutions were AED 5.1 million ($2.2million) and AED 25.7 million ($11million) savings in the first year and over 5 years, respectively.

CONCLUSION

Implementing the EHMD feeding scheme in VLBWs that has significant clinical benefits has resulted in substantial budget savings from the payer's perspective in the UAE owing to fewer comorbidities associated with premature birth and shorter hospital stays. It is highly recommended for the Emirati health care settings to evaluate the real-world neonatal complication rates.

The incidence and modifiable risk factors for necrotizing enterocolitis in preterm infants: a retrospective cohort study

OBJECTIVES

To evaluate the incidence and modifiable risk factors for Necrotizing enterocolitis (NEC) in preterm infants born at ≤32 weeks of gestation weighing <1500 grams, at a private tertiary care hospital in Kenya.

MATERIALS AND METHODS

This retrospective cohort study was conducted at the Aga Khan University Hospital Neonatal Intensive Care Unit (NICU). Preterm infants born at ≤ 32 weeks' gestation and weighing <1500 grams admitted to NICU between 2009 and 2019, were recruited into the study. The primary outcome was NEC Bell Stage IIa-IIIb based on Modified Bell's criteria. Maternal and neonatal characteristics were evaluated. The association between variables of interest and NEC was determined using logistic regression analysis and the incidence of NEC for the study period was calculated.

RESULTS

A total of 261 charts of infants born at ≤ 32 weeks' gestation, weighing <1500 were reviewed, and 200 charts met the inclusion criteria. Fifteen preterm infants developed the primary outcome of interest: NEC Stage ≥2a within the first 30 days of admission. The overall incidence of NEC for the study period was 7.5%. Three risk factors were identified as significantly associated with NEC on multivariate logistic regression analysis: antenatal exposure to steroids (OR = 0.056 CI = 0.003-0.964 p = 0.047), cumulative duration of exposure to invasive mechanical ventilation (OR = 2.172 CI = 1.242-3.799 p = 0.007) and cumulative duration of exposure to umbilical vein catheter (OR = 1.344 CI = 1.08-1.672 p = 0.008).

CONCLUSIONS

The overall incidence for the study period of NEC Stage ≥ II a was 7.5%. Exposure to antenatal steroids, duration of mechanical ventilation, and duration of umbilical vein catheterization were three independent modifiable risk factors for NEC Stage II a-Stage III b.

A Quality Improvement Initiative to Reduce Necrotizing Enterocolitis in Very Preterm Infants

OBJECTIVE

To reduce the incidence of necrotizing enterocolitis (NEC) among very preterm infants in the Calgary Health Region to ≤2% within 2 years.

METHODS

A multidisciplinary team developed key drivers for NEC. Targeted interventions included strategies to increase mothers' own milk (MOM), improve compliance with feeding regimens, standardize management of feeding intolerance, prevent intestinal microbial aberrations, and feed conservatively during blood transfusion and the treatment of patent ductus arteriosus. The outcome measure was NEC (≥ stage 2). Changes in NEC rates were examined among racial and ethnic groups. Process measures included MOM feeding at discharge, the difference between actual and expected time to reach full feeds, lowest hemoglobin, and the duration of empirical antibiotics. Growth, the rate of blood transfusion, and the duration of parenteral nutrition were balancing measures. The preintervention, intervention, and sustainment periods were January 2013 to June 2016, July 2016 to December 2018, and December 2018 to December 2021, respectively.

RESULTS

We included 2787 infants born at ≤326/7 weeks' gestation (1105 preintervention, 763 during intervention, and 919 in sustainment). NEC decreased from 5.6% to 1.9%. Process measures indicated increased MOM feeding at discharge, improved compliance with feeding regimens, increased lowest hemoglobin levels, and shorter durations of empirical antibiotics. Balancing measures revealed improved weight Z-scores, shorter durations on parenteral nutrition, and increased rates of blood transfusion.

CONCLUSIONS

Quality improvement initiatives to increase MOM, improve compliance with feeding regimens, feed conservatively during blood transfusion and treatment of patent ductus arteriosus, and prevent intestinal microbial aberrations were associated with reduced NEC.

Can Enterococcus faecium prevent NEC in preterm infants?: A systematic review and meta-analysis

OBJECTIVE

Previous some systematic reviews reported that probiotics may benefit the prevention of NEC in preterm infants. But dissimilar bacterial strains and taxa used in included studies possibly result in bias. There is not a rounded systematic review which has estimated the benefit and safety of Enterococcus faecium to prevent NEC in preterm infants to date before we conducted.

METHODS

This systematic review of randomized controlled trials and retrospective studies analyzing the benefit of Enterococcus faecium to prevent NEC in preterm infants was performed using PubMed, Web of Science, Cochrane Library, EMBASE, Wanfang data and China National Knowledge Infrastructure databases from inception to April 14, 2023. The search terms were "preterm" AND "necrotizing enterocolitis" AND "Enterococcus faecium OR probiotics." Studies reporting NEC involving preterm infants who were given Enterococcus faecium were included in this systematic review. A sensitivity analysis was conducted to assess the stability of results. A funnel plot was generated to identify publication bias. Two authors appraised studies quality and extracted data independently. This work has been reported according with preferred reporting items for systematic reviews and meta-analyses and assessing the methodological quality of systematic reviews. Statistical analysis was conducted using Review Manager 5.3 software. Risk ratio (RR) with 95% confidence intervals (CI) was calculated and analyzed.

RESULTS

Seven studies (N = 1487 participants) were included in this systematic review, and 6 randomized, controlled trials (N = 1237 participants) were included in the meta-analysis. Comparing with the control groups, the Enterococcus faecium groups had a significant decline in the incidence of NEC Bell stage II or higher (RR: 0.3138, 95% CI: 0.1983-0.4965; P < .00001; 6 studies, n = 1237) and infection (RR: 0.4818, 95% CI: 0.2950-0.7869; P = .004; 3 studies, n = 710).

CONCLUSIONS

Enterococcus faecium is effective and safe in preventing NEC (Bell stage II or higher) in preterm infants. But all studies included came from China. The dosages and durations of taking Enterococcus faecium were various.

Response of the Glutathione (GSH) Antioxidant Defense System to Oxidative Injury in Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a neonatal intestinal disease associated with oxidative stress. The targets of peroxidation and the role of the innate intestinal epithelial antioxidant defense system are ill-defined. We hypothesized that oxidative stress in NEC correlates with oxidized GSH redox potentials, lipid peroxidation, and a dysfunctional antioxidant system. Methods: Intestinal samples from infants +/- NEC were generated into enteroids and incubated with lipopolysaccharide (LPS) and hypoxia to induce experimental NEC. HPLC assayed GSH redox potentials. Lipid peroxidation was measured by flow cytometry. Immunoblotting measured glutathione peroxidase 4 (Gpx4) expression. Results: GSH redox potentials were more oxidized in NEC intestinal tissue and enteroids as compared to controls. Lipid radicals in NEC-induced enteroids were significantly increased. Human intestinal tissue with active NEC and treated enteroid cultures revealed decreased levels of Gpx4. Conclusions: The ability of neonatal intestine to mitigate radical accumulation plays a role in its capacity to overcome oxidative stress. Accumulation of lipid radicals is confirmed after treatment of enteroids with NEC-triggering stimuli. Decreased Gpx4 diminishes a cell's ability to effectively neutralize lipid radicals. When lipid peroxidation overwhelms antioxidant machinery, cellular death ensues. Identification of the mechanisms behind GSH-dependent enzyme dysfunction in NEC may provide insights into strategies for reversing radical damage.

Necrotizing enterocolitis: recent advances in treatment with translational potential

Necrotizing enterocolitis (NEC) is one of the most prevalent and devastating gastrointestinal disorders in neonates. Despite advances in neonatal care, the incidence and mortality due to NEC remain high, highlighting the need to devise novel treatments for this disease. There have been a number of recent advancements in therapeutic approaches for the treatment of NEC; these involve remote ischemic conditioning (RIC), stem cell therapy, breast milk components (human milk oligosaccharides, exosomes, lactoferrin), fecal microbiota transplantation, and immunotherapy. This review summarizes the most recent advances in NEC treatment currently underway as well as their applicability and associated challenges and limitations, with the aim to provide new insight into the paradigm of care for NEC worldwide.

Enteral Feeding and Antibiotic Treatment Do Not Influence Increased Coefficient of Variation of Total Fecal Bile Acids in Necrotizing Enterocolitis

Introduction

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in preterm infants. In animal models, the accumulation of ileal bile acids (BAs) is a crucial component of NEC pathophysiology. Recently, we showed that the coefficient of variation of total fecal BAs (CV-TBA) was elevated in infants who develop NEC compared to matched controls. However, neither the type of enteral nutrition nor antibiotic treatments-parameters that could potentially influence BA levels-were used to match pairs. Thus, we assessed the relationships between exposure to enteral feeding types and antibiotic treatments with NEC status and CV-TBA.

Materials and methods

Serial fecal samples were collected from 79 infants born with birth weight (BW) ≤1800 gm and estimated gestational age (EGA) ≤32 weeks; eighteen of these infants developed NEC. Total fecal BA levels (TBA) were determined using a commercially available enzyme cycling kit. Relationships between CV-TBA and dichotomous variables (NEC status, demographics, early exposure variables) were assessed by independent samples t-tests. Fisher's exact tests were used to assess relationships between NEC status and categorical variables.

Results

High values for CV-TBA levels perfectly predicted NEC status among infants in this study. However, feeding type and antibiotic usage did not drive this relationship.

Conclusions

As in previous studies, high values for the CV-TBA levels in the first weeks of life perfectly predicted NEC status among infants. Importantly, feeding type and antibiotic usage-previously identified risk factors for NEC-did not drive this relationship.

Enteral long-chain polyunsaturated fatty acids and necrotizing enterocolitis: A systematic review and meta-analysis

BACKGROUND

Preterm infants are at risk of long-chain polyunsaturated fatty acid (LCPUFA) deficiency. Recent studies on high-dose DHA; n-3 LCPUFA in preterm infants suggested potential positive effects on cognitive outcomes but raised concerns about some increased neonatal morbidities. These studies and recent recommendations for DHA supplementation generated controversy owing to the lack of balance between DHA and arachidonic acid (ARA; n-6 LCPUFA).

OBJECTIVES

To identify the effect of enteral supplementation of DHA, with and without ARA, on necrotizing enterocolitis (NEC) in very preterm infants.

METHODS

A systematic review of randomized and controlled trials compared enteral LCPUFAs with placebo or no supplementation in very preterm infants. We searched PubMed, Ovid-MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINHAL databases from inception to July 2022. Data were extracted in duplicate using a structured proforma. A meta-analysis and metaregression with random-effects models were used. The interventions evaluated were DHA alone vs. that combined with ARA, source of DHA, dose, and supplement delivery methods. Methodological qualities and risk of bias were assessed using the Cochrane risk-of-bias tool.

RESULTS

Fifteen randomized clinical trials (RCTs) included 3963 very preterm infants with 217 cases of NEC. Supplementation with DHA alone increased NEC (2620 infants; RR: 1.56; 95% CI: 1.02, 2.39) with no evidence of heterogeneity (I² = 0.0%, P = 0.46). Multiple metaregression revealed significant reduction in NEC when ARA was supplemented with DHA (aRR 0.42; 95% CI: 0.21, 0.88). The source of DHA, dose, and feeding type revealed no associations with NEC. Two RCTs supplemented high-dose DHA to lactating mothers. There was a significant increase in risk of NEC with this approach (1148 infants; RR: 1.92; 95% CI: 1.02, 3.61) with no evidence of heterogeneity (I² = 0.0, P = 0.81).

CONCLUSIONS

Supplementation with DHA alone may increase risk of NEC. Concurrent supplementation with ARA needs to be considered when adding DHA to preterm infants' diet.

The Role of the Interleukin-1 Family in Complications of Prematurity

Preterm birth is a major contributor to neonatal morbidity and mortality. Complications of prematurity such as bronchopulmonary dysplasia (BPD, affecting the lung), pulmonary hypertension associated with BPD (BPD-PH, heart), white matter injury (WMI, brain), retinopathy of prematurity (ROP, eyes), necrotizing enterocolitis (NEC, gut) and sepsis are among the major causes of long-term morbidity in infants born prematurely. Though the origins are multifactorial, inflammation and in particular the imbalance of pro- and anti-inflammatory mediators is now recognized as a key driver of the pathophysiology underlying these illnesses. Here, we review the involvement of the interleukin (IL)-1 family in perinatal inflammation and its clinical implications, with a focus on the potential of these cytokines as therapeutic targets for the development of safe and effective treatments for early life inflammatory diseases.

Impact of a Standardized Nutrition Bundle Including Donor Human Milk on Hospital Outcomes in Very Low Birth-Weight (VLBW) Infants in a Safety-Net Hospital

BACKGROUND

Standardized protocols have been shown to reduce clinical practice variation and improve patient outcomes.

PURPOSE

To measure the impact of a standardized nutrition bundle inclusive of donor human milk (DHM) on hospital outcomes of very low birth-weight (VLBW) infants in a safety-net hospital.

METHODS

The study used the Model for Improvement methodology to drive improvement in practice. Outcome measures consisted of necrotizing enterocolitis (NEC), mortality, growth at 36 weeks' postmenstrual age and discharge, as well as volume and type of milk consumption during hospitalization.

FINDINGS

NEC rate decreased from 16.67% in the control group to 6.78% in the standardized nutrition bundle group (P = .07). Similarly, there was significant reduction in mortality with the bundled intervention (15.6% in the control group vs 1.6% in the nutrition bundle group; P = .006). Time to first (15 vs 27.5 hours of life; P < .001) and full-volume enteral feeding (8.5 vs 10 days; P = .086) were reduced in the standardized nutrition bundle group compared with the control group. The human milk volume almost doubled with the intervention.

IMPLICATIONS FOR PRACTICE

Our standardized nutrition bundle protocol inclusive of DHM resulted in lower NEC rates and reduced mortality. The implementation of the DHM program proved to be cost-effective and saved lives. Our findings may help guide development of a structured approach to nutrition protocols inclusive of DHM that can be adapted by other units located in safety-net hospitals.

IMPLICATIONS FOR RESEARCH

Future research on ethnic and racial barriers to access and affordability of DHM is warranted and much needed.

Lactoferrin: An Effective Weapon in the Battle Against Bacterial Infections

The emergence of multidrug-resistant bacterial strains with respect to commercially available antimicrobial drugs has marked a watershed in treatment therapies to fight pathogens and has stimulated research on alternative remedies. Proteins of the innate immune system of mammals have been highlighted as potentially yielding possible treatment options for infections. Lactoferrin (Lf) is one of these proteins; interestingly, no resistance to it has been found. Lf is a conserved cationic nonheme glycoprotein that is abundant in milk and is also present in low quantities in mucosal secretions. Moreover, Lf is produced and secreted by the secondary granules of neutrophils at infection sites. Lf is a molecule of approximately 80 kDa that displays multiple functions, such as antimicrobial, anti-viral, anti-inflammatory, and anticancer actions. Lf can synergize with antibiotics, increasing its potency against bacteria. Lactoferricins (Lfcins) are peptides resulting from the N-terminal end of Lf by proteolytic cleavage with pepsin. They exhibit several anti-bacterial effects similar to those of the parental glycoprotein. Synthetic analog peptides exhibiting potent antimicrobial properties have been designed. The aim of this review is to update understanding of the structure and effects of Lf and Lfcins as anti-bacterial compounds, focusing on the mechanisms of action in bacteria and the use of Lf in treatment of infections in patients, including those studies where no significant differences were found. Lf could be an excellent option for prevention and treatment of bacterial diseases, mainly in combined therapies with antibiotics or other antimicrobials.

Association Between Pulsatility Index and the Development of Necrotizing Enterocolitis in Infants with Congenital Heart Disease

Infants with congenital heart disease are known to have higher rates of necrotizing enterocolitis (NEC) which is associated with poorer outcomes. Although the etiology is recognized as distinct from the premature neonatal population, there is not a universal consensus regarding etiology or specific risk factors. In this retrospective single-institution case-control study, we assessed whether aortic pulsatility index (PI) as detected via ultrasound might be associated with NEC in neonates undergoing cardiac surgical repair within the first month of life. The study identified 30 participants who developed NEC and 50 matched controls. Baseline demographic and surgical characteristics were similar between groups. Patients who developed NEC had higher mortality (26% vs 4%, p < 0.01). Standard PI and the modified pulsatility values were calculated manually and underwent logistic regression. The median log PI of the NEC cohort was higher compared to the lowest control PI (0.68 vs 0.48, p = 0.03); the median log PI of the NEC cohort was significantly lower than the highest PI of the control cohort (0.61 vs 0.98, p = 0.05). The modified pulsatility index demonstrated similar trends with the median log MODPI of the NEC cohort being significantly greater than that of the control cohort (3.9 vs. 3.1, p = 0.01). Infants with congenital heart disease who develop NEC have a higher PI and MODPI when compared to the lowest control PI. This suggests that infants with a higher baseline PI may be at increased risk for developing NEC.

Selective hypermethylation is evident in small intestine samples from infants with necrotizing enterocolitis

OBJECTIVE

Necrotizing enterocolitis (NEC) is the most common and lethal gastrointestinal disease affecting preterm infants. NEC develops suddenly and is characterized by gut barrier destruction, an inflammatory response, intestinal necrosis and multi-system organ failure. There is currently no method for early NEC detection, and the pathogenesis of NEC remains unclear.

DESIGN

To further understand the molecular mechanisms that support NEC, we used solution phase hybridization and next-generation DNA sequencing of bisulfite converted DNA to perform targeted genome-wide analysis of DNA methylation at high read depth.

RESULTS

We found that ileal samples from surgical NEC infants (n = 5) exist in a broadly hypermethylated state relative to their non-NEC counterparts (n = 9). These trends were not uniform, with hypermethylation being most consistently observed outside CpG islands and promoters. We further identified several biologically interesting gene promoters that displayed differential methylation in NEC and a number of biological pathways that appear dysregulated in NEC. We also found that DNA methylation patterns identified in ileal NEC tissue were correlated with those found and published previously in stool samples from NEC-affected infants.

CONCLUSION

We confirmed that surgical NEC is associated with broad DNA hypermethylation in the ileum, and this may be detectable in stool samples of affected individuals. Thus, an epigenomic liquid biopsy of stool may have significant potential as a biomarker with respect to the diagnostic/predictive detection of NEC. Our findings, along with recent similar observations in colon, suggest that epigenomic dysregulation is a significant feature of surgical NEC. These findings motivate future studies which will involve the longitudinal screening of samples obtained prior to the onset of NEC. Our long-term goal is the development of novel screening, diagnostic and phenotyping methods for NEC.

The Mean Platelet Volume Combined with Procalcitonin as an Early Accessible Marker Helps to Predict the Severity of Necrotizing Enterocolitis in Preterm Infants

Purpose

Methods

Results

Conclusion

Electromagnetic Waves Can Help Improve the Rate of Increase of Milk Feeds Per Day in Premature Infants With Necrotizing Enterocolitis: A Pilot Trial

Objective

To evaluate the effects of electromagnetic waves generated by a commercial medical electromagnetic instrument (trade name, TDP, the Chinese phonetic abbreviation of "Te-ding Dian-ci-bo Pu") as an adjuvant to improve the rate of increase of milk feeds per day by premature infants with necrotizing enterocolitis (NEC).

Methods

This study was a prospective randomized clinical trial. A total of 103 premature infants were diagnosed with NEC II, but there was no need for surgery. The infants were randomly divided into the TDP intervention group and the control group by a randomized method using SPSS 24.0. The patients in the TDP intervention group were treated with TDP irradiation and routine interventions; those in the control group were treated with routine interventions. The rate of increase of milk feeds per day, the time to achieve total gastrointestinal nutrition, the velocity of weight gain, and the complication incidence rate were recorded and compared.

Results

The rate of increase of milk feeds per day in the TDP intervention group was significantly greater than that in the control group [14.51 (11.58~22.11) ml/kg/d vs. 10.15 (6.15~15.87) ml/kg/d, P = 0.002]. Compared to the control group, the time to achieve total gastrointestinal nutrition (21.45 ± 1.87 d vs. 36.43 ± 2.585 d, P = 0.000) and the velocity of weight gain (19.65 ± 15.27% vs. 13.68 ± 7.15%, P = 0.013) in the TDP intervention group were substantially better than those in the control group. The complication incidence rate was not significantly different between the two groups (P > 0.05).

Conclusion

Treatment with TDP-generated electromagnetic waves improved the volume of milk consumed per day in premature infants with NEC II and were conducive to improving their clinical outcomes.

The Current State of Donor Human Milk Use and Practice

Human milk contains nutrients and immune factors that promote health and growth of an infant. Donor human milk is recommended as the best alternative for infants whose mothers' breast milk is unavailable. This article describes the current status of donor human milk practice and suggests the areas of educational and research needs. Articles published in the last 10 years were reviewed, and findings were summarized under 4 themes: (1) women's knowledge and concerns about donor human milk use, (2) hospital practices, (3) cost-effectiveness, and (4) access and affordability of donor human milk. Women were concerned about donor human milk contamination, disease transmission, cost, and access to bank donor human milk, due to lack of knowledge and awareness of donor human milk benefits and its processing procedures. The absence of health care providers' support for donor human milk adds to the confusion. There is a rising trend of donor human milk use in hospitals for both healthy and vulnerable newborns and infants with varying policies on screening for donor human milk use, cost coverage, or consent procedure. However, a shortage of safe and affordable donor human milk is a barrier to its adoption. A standardized guideline is needed for hospitals regarding donor human milk implementation and cost coverage. Education programs for health care providers are needed to improve knowledge and understanding of donor human milk benefits and safety to provide guidance to parents. It is crucial to develop legislation expanding insurance coverage to achieve donor human milk equity and optimizing long-term human milk diet outcomes.

Enteral Feeding Interventions in the Prevention of Necrotizing Enterocolitis: A Systematic Review of Experimental and Clinical Studies

Necrotizing enterocolitis (NEC), which is characterized by severe intestinal inflammation and in advanced stages necrosis, is a gastrointestinal emergency in the neonate with high mortality and morbidity. Despite advancing medical care, effective prevention strategies remain sparse. Factors contributing to the complex pathogenesis of NEC include immaturity of the intestinal immune defense, barrier function, motility and local circulatory regulation and abnormal microbial colonization. Interestingly, enteral feeding is regarded as an important modifiable factor influencing NEC pathogenesis. Moreover, breast milk, which forms the currently most effective prevention strategy, contains many bioactive components that are known to support neonatal immune development and promote healthy gut colonization. This systematic review describes the effect of different enteral feeding interventions on the prevention of NEC incidence and severity and the effect on pathophysiological mechanisms of NEC, in both experimental NEC models and clinical NEC. Besides, pathophysiological mechanisms involved in human NEC development are briefly described to give context for the findings of altered pathophysiological mechanisms of NEC by enteral feeding interventions.

Near-Infrared Spectroscopy: Clinical Use in High-Risk Neonates

In this review, we describe the near-infrared spectroscopy (NIRS) technology and its clinical use in high-risk neonates in critical care settings. We searched databases (e.g., PubMed, Google Scholar, EBSCOhost) to find studies describing the use of NIRS on critically ill and high-risk neonates. Near-infrared spectroscopy provides continuous noninvasive monitoring of venous oxygen saturation. It uses technology similar to pulse oximetry to measure the oxygen saturation of hemoglobin in a tissue bed to describe the relative delivery and extraction of oxygen. Near-infrared spectroscopy can be a valuable bedside tool to provide clinicians indirect evidence of perfusion. It may prompt early interventions that promote oxygen delivery, which can improve high-risk neonatal outcomes.

Prophylactic Probiotic Supplementation for Preterm Neonates-A Systematic Review and Meta-Analysis of Nonrandomized Studies

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.

Early Postnatal Comprehensive Biomarkers Cannot Identify Extremely Preterm Infants at Risk of Developing Necrotizing Enterocolitis

Background: Necrotizing enterocolitis (NEC) is a fatal disease where current diagnostic tools are insufficient for preventing NEC. Early predictive biomarkers could be beneficial in identifying infants at high risk of developing NEC. Objective: To explore early biomarkers for predicting NEC in extremely preterm infants (EPIs). Methods: Blood samples were collected on day 2 (median 1.7; range 1.5-2.0) from 40 EPI (median 25 gestational weeks; range 22-27): 11 developed NEC and 29 did not (controls). In each infant, 189 inflammatory, oncological, and vascular proteomic biomarkers were quantified through Proximity Extension Assay. Biomarker expression and clinical data were compared between the NEC group and Controls. Based on biomarker differences, controls were sorted automatically into three subgroups (1, 2, and 3) by a two-dimensional hierarchical clustering analysis. Results: None of the biomarkers differed in expression between all controls and the NEC group. Two biomarkers were higher in Control 1, and 16 biomarkers were lower in Control group 2 compared with the NEC group. No biomarker distinguished Control 3 from the NEC group. Perinatal data were similar in the whole population. Conclusions: Early postnatal comprehensive biomarkers do not identify EPIs at risk of developing NEC in our study. Future studies of predictors of NEC should include sequential analysis of comprehensive proteomic markers in large cohorts.

Early full enteral feeding for preterm or low birth weight infants

BACKGROUND

The introduction and advancement of enteral feeds for preterm or low birth weight infants is often delayed because of concerns that early full enteral feeding will not be well tolerated or may increase the risk of necrotising enterocolitis. Early full enteral feeding, however, might increase nutrient intake and growth rates; accelerate intestinal physiological, metabolic, and microbiomic postnatal transition; and reduce the risk of complications associated with intravascular devices for fluid administration.  OBJECTIVES: To determine how early full enteral feeding, compared with delayed or progressive introduction of enteral feeds, affects growth and adverse events such as necrotising enterocolitis, in preterm or low birth weight infants.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search Cochrane Central Register of Controlled Trials; MEDLINE Ovid, Embase Ovid, Maternity & Infant Care Database Ovid, the Cumulative Index to Nursing and Allied Health Literature, and clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials to October 2020.

SELECTION CRITERIA

Randomised controlled trials that compared early full enteral feeding with delayed or progressive introduction of enteral feeds in preterm or low birth weight infants.

DATA COLLECTION AND ANALYSIS

We used the standard methods of Cochrane Neonatal. Two review authors separately assessed trial eligibility, evaluated trial quality, extracted data, and synthesised effect estimates using risk ratios (RR), risk differences, and mean differences (MD) with 95% confidence intervals (CI). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included six trials. All were undertaken in the 2010s in neonatal care facilities in India. In total, 526 infants participated. Most were very preterm infants of birth weight between 1000 g and 1500 g. Trials were of good methodological quality, but a potential source of bias was that parents, clinicians, and investigators were not masked. The trials compared early full feeding (60 mL/kg to 80 mL/kg on day one after birth) with minimal enteral feeding (typically 20 mL/kg on day one) supplemented with intravenous fluids. Feed volumes were advanced daily as tolerated by 20 mL/kg to 30 mL/kg body weight to a target steady-state volume of 150 mL/kg to 180 mL/kg/day. All participating infants were fed preferentially with maternal expressed breast milk, with two trials supplementing insufficient volumes with donor breast milk and four supplementing with preterm formula.  Few data were available to assess growth parameters. One trial (64 participants) reported a slower rate of weight gain (median difference -3.0 g/kg/day), and another (180 participants) reported a faster rate of weight gain in the early full enteral feeding group (MD 1.2 g/kg/day). We did not meta-analyse these data (very low-certainty evidence). None of the trials reported rate of head circumference growth. One trial reported that the mean z-score for weight at hospital discharge was higher in the early full enteral feeding group (MD 0.24, 95% CI 0.06 to 0.42; low-certainty evidence). Meta-analyses showed no evidence of an effect on necrotising enterocolitis (RR 0.98, 95% CI 0.38 to 2.54; 6 trials, 522 participants; I² = 51%; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Trials provided insufficient data to determine with any certainty how early full enteral feeding, compared with delayed or progressive introduction of enteral feeds, affects growth in preterm or low birth weight infants. We are uncertain whether early full enteral feeding affects the risk of necrotising enterocolitis because of the risk of bias in the trials (due to lack of masking), inconsistency, and imprecision.

Hospitalization charges for extremely preterm infants: a ten-year analysis in Shanghai, China

OBJECTIVES

Extreme prematurity exerts a substantial economic burden on families and societies worldwide, especially in developing countries with limited healthcare resources. This study aimed to estimate initial hospitalization charges after extremely preterm birth in China over the previous decade.

METHODS

A retrospective study was conducted in the largest tertiary neonatal intensive care unit in Shanghai, China, including 441 extremely preterm infants (gestational age <28 weeks) discharged between 2010 and 2019. Hospitalization data and medical charges were obtained from electronic inpatient medical records. Subgroup analysis was conducted to examine how the charges and length of stay varied by gestational age, discharge year, survival status, and major morbidities.

RESULTS

The median total hospitalization charge was $20,770.70 with a median length of stay of 70.0 days. Total and daily charges declined as gestational age increased. A rising trend was found over time for overall and daily medical charges. Compared with decedents, survivors had a longer length of stay and higher total hospitalization charges, but their charge per day was lower. Total hospitalization charges were significantly higher in infants with necrotizing enterocolitis (Stage II-III), bronchopulmonary dysplasia, and sepsis when compared with neonates of the same gestational age without these co-morbidities. Charges for treatments accounted for the highest proportion (31.3%).

LIMITATIONS

Local statistics collected retrospectively might limit generalizability to other regions. Long-term medical charges were not reported.

CONCLUSION

Economic burden of the initial hospitalization for extremely preterm infants was substantial in China. Such economic factors should be fully taken into account for perinatal consultations, medical insurance policy-making, and clinical decisions.

Cost-effectiveness Analysis of Feeding Guidelines for Infants Following Intestinal Surgery

OBJECTIVE

The aim of the study was to determine the cost-effectiveness of postoperative feeding guidelines to reduce complications in infants with intestinal surgery compared to standard feeding practices.

METHODS

Using outcomes from a cohort study, Markov models from health care and societal perspectives simulated costs per hospitalization among infants fed via guidelines versus standard practice. Short-term outcomes included intestinal failure-associated liver disease, necrotizing enterocolitis after feeding, sepsis, and mortality. Effectiveness was measured as length of stay. The incremental cost-effectiveness ratios (ICER) compared cost over length of stay. Univariate and multivariate probabilistic sensitivity analyses with 10,000 Monte Carlo Simulations were performed. A second decision tree model captured the cost per quality-adjusted life years (QALYs) using utilities associated with long-term outcomes (liver cirrhosis and transplantation).

RESULTS

In the hospital perspective, standard feeding had a cost of $31,258,902 and 8296 hospital days, and the feeding guidelines had a cost of $29,295,553 and 8096 hospital days. The ICER was $-9832 per hospital stay with guideline use. More than 90% of the ICERs were in the dominant quadrant. Results were similar for the societal perspective. Long-term costs and utilities in the guideline group were $2830 and 0.91, respectively, versus $4030 and 0.90, resulting in an ICER of $-91,756/QALY.

CONCLUSION

In our models, feeding guideline use resulted in cost savings and reduction in hospital stay in the short-term and cost savings and an increase in QALYs in the long-term. Using a systematic approach to feed surgical infants appears to reduce costly complications, but further data from a larger cohort are needed.

Early full enteral feeding for preterm or low birth weight infants

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

We aim to assess the benefits and harms of early full enteral nutrition versus progressive introduction of enteral feeds in preterm or low birth weight (LBW) infants.

Where data are available, we will undertake subgroup analyses of very preterm or very low birth weight (VLBW) infants (versus infants born after a longer gestation or with higher birth weight), infants who are 'small for gestational age' at birth (versus those deemed 'appropriate for gestation'), infants fed with human milk only (versus formula‐fed infants), and trials set in low‐ or middle‐income countries (versus high‐income countries).

Necrotizing Enterocolitis and Associated Mortality in Neonates With Congenital Heart Disease: A Multi-Institutional Study

OBJECTIVE

There are scarce data about the prevalence and mortality of necrotizing enterocolitis in neonates with congenital heart disease. The purpose of this study is to provide a multi-institutional description and comparison of the overall prevalence and mortality of necrotizing enterocolitis in neonates with congenital heart disease.

DESIGN

Retrospective multi-institutional study.

SETTING

The Pediatric Health Information System database.

PATIENTS

Neonates with congenital heart disease between 2004 and 2014.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary study measure is the prevalence of necrotizing enterocolitis. Secondary measures include in-hospital mortality, hospital charges, ICU length of stay, hospital length of stay, and 30-day readmission. The prevalence of necrotizing enterocolitis was 3.7% (1,448/38,770) and varied significantly among different congenital heart disease diagnoses. The lowest prevalence of necrotizing enterocolitis was in transposition of the great arteries (n = 104, 2.1%). Compared with transposition of the great arteries, necrotizing enterocolitis occurred more frequently in neonates with hypoplastic left heart syndrome (odds ratio, 2.7; 95% CI, 2.1-3.3), truncus arteriosus (odds ratio, 2.6; 95% CI, 1.9-3.5), common ventricle (odds ratio, 2.1; 95% CI, 1.5-2.8), and aortic arch obstruction (odds ratio, 1.4; 95% CI, 1.1-1.7). Prematurity is a significant risk factor for necrotizing enterocolitis and for mortality in neonates with necrotizing enterocolitis, conferring varying risk by cardiac diagnosis. Unadjusted mortality associated with necrotizing enterocolitis was 24.4% (vs 11.8% in neonates without necrotizing enterocolitis; p < 0.001), and necrotizing enterocolitis increased the adjusted mortality in neonates with transposition of the great arteries (odds ratio, 2.5; 95% CI, 1.5-4.4), aortic arch obstruction (odds ratio, 1.8; 95% CI, 1.3-2.6), and tetralogy of Fallot (odds ratio, 1.6; 95% CI, 1.1-2.4). Necrotizing enterocolitis was associated with increased hospital charges (p < 0.0001), ICU length of stay (p = 0.001), and length of stay (p = 0.001).

CONCLUSIONS

The prevalence of necrotizing enterocolitis among neonates with congenital heart disease is 3.7% and is associated with increased in-hospital mortality, length of stay, and hospital charges. The prevalence and associated mortality of necrotizing enterocolitis in congenital heart disease vary among different heart defects.

Safety and efficacy of Lactobacillus for preventing necrotizing enterocolitis in preterm infants

AIM

To evaluate the safety and efficacy of Lactobacillus for preventing necrotizing enterocolitis (NEC) in preterm infants.

METHODS

We searched the Cochrane Library, PubMed, EMBASE, and Web of Science databases from inception to September 2019. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated to compare outcomes. We also performed a subgroup analysis of the incidence of NEC. Moreover, a sensitivity analysis was performed to examine the stability of the results. A Begg funnel plot was generated to detect publication bias. Two reviewers assessed trial quality and extracted data independently. This work has been reported in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement and the Assessing the Methodological Quality of Systematic Reviews guidelines. Statistical analysis was performed using standard procedures in Review Manager 5.2 software.

RESULTS

Twenty-three randomized, placebo-controlled studies (N = 4686 participants) were included in this analysis. Comparing the Lactobacillus and control groups, a significant reduction was found in the incidence of NEC (RR 0.34, 95% CI 0.25-0.46; P < 0.00001) and death (RR 0.48, 95% CI 0.36-0.64; P < 0.00001). No significant difference in the incidence of sepsis was found between the Lactobacillus and placebo groups (RR 0.90, 95% CI 0.72-1.12; P = 0.34).

CONCLUSIONS

Lactobacillus is safe and can prevent necrotizing enterocolitis in preterm infants.

Probiotics for Prevention of Severe Necrotizing Enterocolitis: Experience of New Zealand Neonatal Intensive Care Units

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.

Necrotizing enterocolitis: It's not all in the gut

Necrotizing enterocolitis is the leading cause of death due to gastrointestinal disease in preterm neonates, affecting 5–12% of neonates born at a very-low birth weight. Necrotizing enterocolitis can present with a slow and insidious onset, with some neonates displaying early symptoms such as feeding intolerance. Treatment during the early stages includes bowel rest and careful use of antibiotics, but surgery is required if pneumoperitoneum and intestinal perforation occur. Mortality rates among neonates requiring surgery are estimated to be 20–30%, mandating the development of non-invasive and reliable biomarkers to predict necrotizing enterocolitis before the onset of clinical signs. Such biomarkers would allow at-risk neonates to receive maximal preventative therapies such as careful nutritional consideration, probiotics, and increased skin-to-skin care.

Impact statement

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease; its high mortality rate mandates the development of non-invasive biomarkers to predict NEC before its onset. This review summarizes the pathogenesis, prevention, unresolved issues, and long-term outcomes of NEC.

What Is the Impact of NICU-Dedicated Lactation Consultants? An Evidence-Based Practice Brief

BACKGROUND

Benefits of exclusive human milk diets for preterm and low birth-weight infants are well established. Despite known benefits, supporting mothers in the provision of mother's own milk for high-risk infants is challenging. Lactation support in the neonatal intensive care unit (NICU) is highly variable. Lactations consultants (LCs) are often shared between postpartum units and the NICU, potentially increasing LC workload with less time spent with high-risk mothers. Furthermore, less than half of NICUs in the United States staff an international board-certified lactation consultant. Limited understanding exists regarding impacts of NICU-specific lactation support on breastfeeding outcomes.

PURPOSE

The purpose of this evidence-based practice brief is to synthesize the literature on the impact of NICU-specific lactation support, LCs who work exclusively in the NICU, and provide guidance about how NICU staffing with LCs solely focused on supporting mothers of high-risk infants impacts breastfeeding outcomes for low birth-weight infants.

SEARCH STRATEGY

CINAHL PLUS, PubMed, Cochrane Library, and OVID databases were searched using key words and restricted to English language.

FINDINGS

During hospitalization, NICUs staffed with dedicated board-certified LCs have increased potential to yield improved breastfeeding rates through hospital discharge, increased proportion of infants who receive mother's own milk, and increased duration of breastfeeding or human milk expression through hospital discharge.

IMPLICATIONS FOR PRACTICE

Human milk nutrition is related to improved outcomes for high-risk infants. Neonatal intensive care unit-specific lactation support can potentially optimize maternal breastfeeding practices and improve outcomes for high-risk infants.

IMPLICATIONS FOR RESEARCH

There is a need for further studies pertaining to NICU-specific lactation consultants and influences on breastfeeding outcomes.

The Role of Melanin to Dissociate Oxygen from Water to Treat Retinopathy of Prematurity

BACKGROUND

Retinopathy of Prematurity (ROP) is a potentially blinding disorder that commonly afflicts premature infants who are born prior to 31weeks of gestation or with a body weight less than 1250 grams (about 2.75 pounds). Another risk factor is excessive oxygen in incubators, which can lead to blindness. A compounding factor is that survival rates for premature infants are rising with concomitantly more cases of ROP. We have reported an unsuspected intrinsic property of melanin to dissociate water. This capability can be considered an alternative treatment option for adult and neonatal diseases. It is known that exogenous surfactant administration suppresses bronchopulmonary dysplasia and consequent death, randomized, controlled trials with various respiratory interventions did not show any significant reductions in morbidity and mortality rates. During a descriptive study about the three leading causes of blindness in the world, the ability of melanin to transform light energy into chemical energy through the dissociation of water molecule was unraveled. Initially, during 2 or 3 years; we tried to link together our findings with the widely accepted metabolic pathways already described in molecular pathway databases, which have been developed to collect and organize the current knowledge on metabolism scattered across a multitude of scientific evidence.

OBSERVATIONS

The current report demonstrates the main problems that afflict premature babies with an emphasis on the growth of abnormal vessels in the retina, the explanation for which is unknown until date. We also reported a case of a baby who suffered digestive and respiratory problems with a brain haemorrhage that was successfully treated by laser photocoagulation. We hypothesise that most likely this effect was due to the melanin level and melanin itself produces oxygen via dissociating with water molecules.

CONCLUSION

We postulate that the intrinsic effect of melanin may easily convert visible and invisible light into chemical energy via a water dissociation reaction similar to the one in plant's chlorophyll, and markedly elevated with diagnosis and treatment of the complications related to premature babies.

Probiotics for preterm infants: A National Retrospective Cohort Study

OBJECTIVE

To evaluate the effect of prophylactic probiotic (PP) administration on rates of necrotizing enterocolitis (NEC), late-onset sepsis (LOS), and mortality in preterm infants.

STUDY DESIGN

We conducted a retrospective cohort study of infants < 29 weeks' gestation, admitted to neonatal intensive care units participating in the Canadian Neonatal Network between 1 January 2014 and 31 December 2015. Infants in the exposure group received PP. A multiple logistic regression model with generalized estimation equation was used.

RESULTS

A total of 3093 infants were included, 652 infants (21%) received PP. The adjusted odds ratios (aOR) of NEC (aOR 0.64, 95% confidence interval [CI] 0.410, 0.996), mortality (aOR 0.41, 95% CI 0.26, 0.63), and a composite of NEC or mortality were significantly lower in the PP group. There was no significant difference in the aOR of LOS.

CONCLUSION

Prophylactic probiotic administration is associated with a reduction in NEC and mortality in preterm infants.

Necrotizing Enterocolitis Pathophysiology: How Microbiome Data Alter Our Understanding

Necrotizing enterocolitis is a major cause of mortality and morbidity in the preterm infant population. The gut microbiome is of particular interest in research surrounding necrotizing enterocolitis, because variations in the intestinal microbiota seem to correlate with the risk of inflammation and disease. Recent advances in non-culture-based genomic sequencing have also allowed for more intricate analyses of the intestinal microbiome. Its evolution seems to be influenced by intrauterine and extrauterine factors, ranging from antenatal antibiotic exposure to type of enteral feeds. Ultimately, these alterations in the gut microbiome have the potential to result in devastating diseases like necrotizing enterocolitis.

Enteral feeding composition and necrotizing enterocolitis

Enteral feeding and composition play a chief role in the prevention and treatment of necrotizing enterocolitis (NEC). In the face of decades of research on this fatal disease, the exact mechanism of disease is still poorly understood. There is established evidence that providing mother's own breast milk and standardization of feeding regimens leads to a decreased risk for NEC. More recent studies have focused on the provision of donor human milk or an exclusive human milk diet in the endeavor to prevent NEC while still maintaining adequate nutrition to the premature infant. There is growing literature on the provision of specific human milk components and its effect on the incidence of NEC.

The cost of necrotizing enterocolitis in premature infants

Necrotizing enterocolitis (NEC), a common morbidity of prematurity, affects 5-10% of premature infants with a birthweight <1500 g. The added cost remains unclear. Multiple studies report the cost of care for an infant with NEC as higher than that of well premature infants, but these studies are fraught with limitations. Surgical intervention and type of surgery appear to impact overall costs. Health care resource utilization extends beyond the birth hospitalization, particularly in those infants requiring surgery, and persists to at least three years of age. This narrative review of the literature reveals a paucity of studies and significant methodological deficiencies in most included studies. Further studies of the cost of NEC need to address the issues of significant confounding in this complex population.

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

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

Bifidobacterium may benefit the prevention of necrotizing enterocolitis in preterm infants: A systematic review and meta-analysis

AIM

A systematic review and meta-analysis was designed to evaluate the efficacy and safety of Bifidobacterium for preventing necrotizing enterocolitis (NEC) in preterm infants.

METHODS

We searched the Cochrane Library, PubMed, EMBASE and Web of Science to December 2017. Risk ratio (RR) with 95% confidence intervals (CIs) were estimated to compare the outcomes of the groups. For the pooled RR estimating the incidence of NEC, we also performed subgroup analysis. Besides, sensitivity analysis was performed to examine the stability of the combined results. Two reviewers assessed trial quality and extracted data independently. The work has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines. All statistical analyses were performed using standard statistical procedures provided in Review Manager 5.2.

RESULTS

Twenty four randomized, placebo-controlled studies (N = 6155 participants) were included in this analysis, of which twenty two studies were used for assessing the efficacy of Bifidobacterium for preventing NEC and seventeen for assessing the safety (sepsis and death). When comparing Bifidobacterium groups with control groups, the relative risk of developing NEC (RR 0.38, 95% CI 0.25-0.58; P < 0.00001) or death (RR 0.74, 95% CI 0.60-0.92; P = 0.006) was significantly lower in the Bifidobacterium groups. No significant difference in the incidence of sepsis was found (RR 0.87, 95% CI 0.73-1.03; P = 0.11). In addition, significant results for NEC were also found in all subgroups we made.

CONCLUSIONS

Bifidobacterium may have a beneficial effect and be safe in preventing necrotizing enterocolitis in preterm infants.

Estimation of Neonatal Intestinal Perforation Associated with Necrotizing Enterocolitis by Machine Learning Reveals New Key Factors

Intestinal perforation (IP) associated with necrotizing enterocolitis (NEC) is one of the leading causes of mortality in premature neonates; with major nutritional and neurodevelopmental sequelae. Since predicting which neonates will develop perforation is still challenging; clinicians might benefit considerably with an early diagnosis tool and the identification of critical factors. The aim of this study was to forecast IP related to NEC and to investigate the predictive quality of variables; based on a machine learning-based technique. The Back-propagation neural network was used to train and test the models with a dataset constructed from medical records of the NICU; with birth and hospitalization maternal and neonatal clinical; feeding and laboratory parameters; as input variables. The outcome of the models was diagnosis: (1) IP associated with NEC; (2) NEC or (3) control (neither IP nor NEC). Models accurately estimated IP with good performances; the regression coefficients between the experimental and predicted data were R² > 0.97. Critical variables for IP prediction were identified: neonatal platelets and neutrophils; orotracheal intubation; birth weight; sex; arterial blood gas parameters (pCO₂ and HCO₃); gestational age; use of fortifier; patent ductus arteriosus; maternal age and maternal morbidity. These models may allow quality improvement in medical practice.

Oropharyngeal colostrum in preventing mortality and morbidity in preterm infants

BACKGROUND

Placing a small volume of colostrum directly onto the buccal mucosa of preterm infants during the early neonatal period may provide immunological and growth factors that stimulate the immune system and enhance intestinal growth. These benefits could potentially reduce the risk of infection and necrotising enterocolitis (NEC) and improve survival and long-term outcome.

OBJECTIVES

To determine if early (within the first 48 hours of life) oropharyngeal administration of mother's own fresh or frozen/thawed colostrum can reduce rates of NEC, late-onset invasive infection, and/or mortality in preterm infants compared with controls. To assess trials for evidence of safety and harm (e.g. aspiration pneumonia). To compare effects of early oropharyngeal colostrum (OPC) versus no OPC, placebo, late OPC, and nasogastric colostrum.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 8), MEDLINE via PubMed (1966 to August 2017), Embase (1980 to August 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to August 2017). We also searched clinical trials registries for ongoing and recently completed trials (clinicaltrials.gov; the World Health Organization International Trials Registry (www.whoint/ictrp/search/en/), and the ISRCTN Registry), conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We performed the last search in August 2017. We contacted trial investigators regarding unpublished studies and data.

SELECTION CRITERIA

We searched for published and unpublished randomised controlled trials comparing early administration of oropharyngeal colostrum (OPC) versus sham administration of water, oral formula, or donor breast milk, or versus no intervention. We also searched for studies comparing early OPC versus early nasogastric or nasojejunal administration of colostrum. We considered only trials that included preterm infants at < 37 weeks' gestation. We did not limit the review to any particular region or language.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened retrieved articles for inclusion and independently conducted data extraction, data analysis, and assessments of 'Risk of bias' and quality of evidence. We graded evidence quality using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We contacted study authors for additional information or clarification when necessary.

MAIN RESULTS

We included six studies that compared early oropharyngeal colostrum versus water, saline, placebo, or donor, or versus no intervention, enrolling 335 preterm infants with gestational ages ranging from 25 to 32 weeks' gestation and birth weights of 410 to 2500 grams. Researchers found no significant differences between OPC and control for primary outcomes - incidence of NEC (typical risk ratio (RR) 1.42, 95% confidence interval (CI) 0.50 to 4.02; six studies, 335 infants; P = 0.51; I² = 0%; very low-quality evidence), incidence of late-onset infection (typical RR 0.86, 95% CI 0.56 to 1.33; six studies, 335 infants; P = 0.50; I² = 0%; very low-quality evidence), and death before hospital discharge (typical RR 0.76, 95% CI 0.34 to 1.71; six studies, 335 infants; P = 0.51; I² = 0%; very low-quality evidence). Similarly, meta-analysis showed no difference in length of hospital stay between OPC and control groups (mean difference (MD) 0.81, 95% CI -5.87 to 7.5; four studies, 293 infants; P = 0.65; I² = 49%). Days to full enteral feeds were reduced in the OPC group with MD of -2.58 days (95% CI -4.01 to -1.14; six studies, 335 infants; P = 0.0004; I² = 28%; very low-quality evidence).The effect of OPC was uncertain because of small sample sizes and imprecision in study results (very low-quality evidence).No adverse effects were associated with OPC; however, data on adverse effects were insufficient, and no numerical data were available from the included studies.Overall the quality of included studies was low to very low across all outcomes. We downgraded GRADE outcomes because of concerns about allocation concealment and blinding, reporting bias, small sample sizes with few events, and wide confidence intervals.

AUTHORS' CONCLUSIONS

Large, well-designed trials would be required to evaluate more precisely and reliably the effects of oropharyngeal colostrum on important outcomes for preterm infants.

Combination of plasma white blood cell count, platelet count and C-reactive protein level for identifying surgical necrotizing enterocolitis in preterm infants without pneumoperitoneum

PURPOSE

To evaluate whether plasma white blood cell count (WBC), platelet count (PLT), and C-reactive protein level (CRP) can be used to differentiate surgical necrotizing enterocolitis (NEC) from medical NEC.

METHODS

Preterm infants admitted between January 1, 2011 and July 31, 2015 were stratified by the need of surgery as surgical NEC (n = 41) and medical NEC (n = 43). The values of WBC, PLT and CRP were collected at time before NEC occurred (T₀), at onset of NEC (T₁) and when surgical assessment was required (T₂). Patients admitted between August 1, 2015 and March 1, 2018 (n = 53) were collected for further verification.

RESULTS

Variables identified in logistic regression analysis predicting surgical NEC were WBC and PLT at T₂ (WBC₂ and PLT₂). The predictive probability of surgery (P) could be calculated by the equation [Formula: see text]. The area under curve of P was 0.84 and the ideal cutoff value was 0.55, with sensitivity and specificity of 85 and 81%, respectively. This cutoff value got an sensitivity of 80% and specificity of 79% in the verification group.

CONCLUSION

Combination of WBC and PLT can effectively differentiate surgical NEC from medical NEC infants when surgical assessment was required.

An update on the human and animal enteric pathogen Clostridium perfringens

Clostridium perfringens, a rapid-growing pathogen known to secrete an arsenal of >20 virulent toxins, has been associated with intestinal diseases in both animals and humans throughout the past century. Recent advances in genomic analysis and experimental systems make it timely to re-visit this clinically and veterinary important pathogen. This Review will summarise our understanding of the genomics and virulence-linked factors, including antimicrobial potentials and secreted toxins of this gut pathogen, and then its up-to-date clinical epidemiology and biological role in the pathogenesis of several important human and animal-associated intestinal diseases, including pre-term necrotising enterocolitis. Finally, we highlight some of the important unresolved questions in relation to C. perfringens-mediated infections, and implications for future research directions.

Evolving understanding of neonatal necrotizing enterocolitis

PURPOSE OF REVIEW

Necrotizing enterocolitis (NEC) is a devastating disease that predominately affects premature neonates. The pathogenesis of NEC is multifactorial and poorly understood. Risk factors include low birth weight, formula-feeding, hypoxic/ischemic insults, and microbial dysbiosis. This review focuses on our current understanding of the diagnosis, management, and pathogenesis of NEC.

RECENT FINDINGS

Recent findings identify specific mucosal cell types as potential therapeutic targets in NEC. Despite a broadly accepted view that bacterial colonization plays a key role in NEC, characteristics of bacterial populations associated with this disease remain elusive. The use of probiotics such as lactobacilli and bifidobacteria has been studied in numerous trials, but there is a lack of consensus regarding specific strains and dosing. Although growth factors found in breast milk such as epidermal growth factor and heparin-binding epidermal growth factor may be useful in disease prevention, developing new therapeutic interventions in NEC critically depends on better understanding of its pathogenesis.

SUMMARY

NEC is a leading cause of morbidity and mortality in premature neonates. Recent data confirm that growth factors and certain bacteria may offer protection against NEC. Further studies are needed to better understand the complex pathogenesis of NEC.

Point-of-Care Fecal Calprotectin Monitoring in Preterm Infants at Risk for Necrotizing Enterocolitis

OBJECTIVE

To establish baseline trends in fecal calprotectin, a protein excreted into the stool when there is neutrophilic inflammation in the bowel, in infants at risk for necrotizing enterocolitis (NEC).

STUDY DESIGN

We performed a prospective observational cohort study in infants with a birth weight of <1500 g without existing bowel disease at a level IV neonatal intensive care unit from October 2015 to September 2016. Stools were collected once daily for 30 days or until 32 weeks postmenstrual age and processed using the Fecal Calprotectin High Range Quantitative Quantum Blue assay.

RESULTS

In 64 preterm infants, during the first week after birth, 62% of infants had an initial stool sample with high baseline calprotectin levels (≥200 µg/g). In assessment of maternal and neonatal risk factors, maternal etiology for preterm birth (ie, eclamplsia or preeclampsia) was the only significant factor associated with high baseline calprotectin level. Two patients in the cohort developed NEC. Calprotectin levels for the entire cohort fluctuated during the observed period but generally increased in the third and fourth weeks after birth.

CONCLUSIONS

At-risk infants had highly variable fecal calprotectin levels, with maternal causes for preterm birth associated with higher baseline levels. More longitudinal data in infants with NEC are necessary to determine whether acute rises in fecal calprotectin levels prior to clinical diagnosis can be confirmed as a diagnostic or prognostic biomarker.