Advanced necrotizing enterocolitis part 1: mortality

Clinical applications of stem cell-derived exosomes

Although stem cell-based therapy has demonstrated considerable potential to manage certain diseases more successfully than conventional surgery, it nevertheless comes with inescapable drawbacks that might limit its clinical translation. Compared to stem cells, stem cell-derived exosomes possess numerous advantages, such as non-immunogenicity, non-infusion toxicity, easy access, effortless preservation, and freedom from tumorigenic potential and ethical issues. Exosomes can inherit similar therapeutic effects from their parental cells such as embryonic stem cells and adult stem cells through vertical delivery of their pluripotency or multipotency. After a thorough search and meticulous dissection of relevant literature from the last five years, we present this comprehensive, up-to-date, specialty-specific and disease-oriented review to highlight the surgical application and potential of stem cell-derived exosomes. Exosomes derived from stem cells (e.g., embryonic, induced pluripotent, hematopoietic, mesenchymal, neural, and endothelial stem cells) are capable of treating numerous diseases encountered in orthopedic surgery, neurosurgery, plastic surgery, general surgery, cardiothoracic surgery, urology, head and neck surgery, ophthalmology, and obstetrics and gynecology. The diverse therapeutic effects of stem cells-derived exosomes are a hierarchical translation through tissue-specific responses, and cell-specific molecular signaling pathways. In this review, we highlight stem cell-derived exosomes as a viable and potent alternative to stem cell-based therapy in managing various surgical conditions. We recommend that future research combines wisdoms from surgeons, nanomedicine practitioners, and stem cell researchers in this relevant and intriguing research area.

Clostridium scindens exacerbates experimental necrotizing enterocolitis via upregulation of the apical sodium-dependent bile acid transporter

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in premature infants. Evidence indicates that bile acid homeostasis is disrupted during NEC: ileal bile acid levels are elevated in animals with experimental NEC, as is expression of the apical sodium-dependent bile acid transporter (Asbt). In addition, bile acids, which are synthesized in the liver, are extensively modified by the gut microbiome, including via the conversion of primary bile acids to more cytotoxic secondary forms. We hypothesized that the addition of bile acid-modifying bacteria would increase susceptibility to NEC in a neonatal rat model of the disease. The secondary bile acid-producing species Clostridium scindens exacerbated both incidence and severity of NEC. C. scindens upregulated the bile acid transporter Asbt and increased levels of intraenterocyte bile acids. Treatment with C. scindens also altered bile acid profiles and increased hydrophobicity of the ileal intracellular bile acid pool. The ability of C. scindens to enhance NEC requires bile acids, as pharmacological sequestration of ileal bile acids protects animals from developing disease. These findings indicate that bile acid-modifying bacteria can contribute to NEC pathology and provide additional evidence for the role of bile acids in the pathophysiology of experimental NEC.NEW & NOTEWORTHY Necrotizing enterocolitis (NEC), a life-threatening gastrointestinal emergency in premature infants, is characterized by dysregulation of bile acid homeostasis. We demonstrate that administering the secondary bile acid-producing bacterium Clostridium scindens enhances NEC in a neonatal rat model of the disease. C. scindens-enhanced NEC is dependent on bile acids and driven by upregulation of the ileal bile acid transporter Asbt. This is the first report of bile acid-modifying bacteria exacerbating experimental NEC pathology.

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.

Association of anemia and platelet activation with necrotizing enterocolitis with or without sepsis among low birth weight neonates: a case-control study

Background

This study aims to evaluate the value of the proportion of large platelets (PLCR) and platelet crit (PCT) in predicting necrotizing enterocolitis (NEC) in low birth weight (LBW) neonates.

Methods

A total of 155 LBW (<2,500 g) neonates with NEC, who were admitted to the neonatal intensive care unit (NICU) of the hospital from January 1, 2017, to November 30, 2019, were included in the case group. According to the 1:3 case-control study design, a total of 465 LBW neonates without NEC (three for each LBW neonate with NEC), who were admitted to the NICU and born ≤24 h before or after the birth of the subjects, were included in the control group.

Results

During the study period, a total of 6,946 LBW neonates were born, of which 155 had NEC, including 92 who also had sepsis. Neonatal sepsis was the most important risk factor and confounding factor for NEC in LBW neonates. Further stratified analysis showed that in LBW neonates without sepsis, anemia [P = 0.001, odds ratio (OR) = 4.367, 95% confidence interval (CI): 1.853-10.291], high PLCR (P < 0.001, OR = 2.222, 95% CI: 1.633-3.023), and high PCT (P = 0.024, OR = 1.368, 95% CI: 1.042-1.795) increased the risk of NEC and the receiver operating characteristic curve area of PLCR, sensitivity, specificity, and cutoff value were 0.739, 0.770, 0.610, and 33.55, respectively.

Conclusions

The results showed that 2/100 LBW neonates were at risk for NEC, and the stratified analysis of the confounding factors of sepsis identified the risk factors of NEC in LBW neonates. This study first reported the significance of PLCR in the early prediction of NEC occurrence in LBW neonates without sepsis.

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.

A Nomogram for Predicting Surgical Timing in Neonates with Necrotizing Enterocolitis

OBJECTIVE

To explore the surgical risk variables in patients with necrotizing enterocolitis (NEC) and develop a nomogram model for predicting the surgical intervention timing of NEC.

METHODS

Infants diagnosed with NEC were enrolled in our study. We gathered information from clinical data, laboratory examinations, and radiological manifestations. Using LASSO (least absolute shrinkage and selection operator) regression analysis and multivariate logistic regression analysis, a clinical prediction model based on the logistic nomogram was developed. The performance of the nomogram model was evaluated using the receiver operating characteristic (ROC) curve, calibration curves, and decision curve analysis (DCA).

RESULTS

A surgical intervention risk nomogram based on hypothermia, absent bowel sounds, WBC > 20 × 10⁹/L or < 5 × 10⁹/L, CRP > 50 mg/L, pneumatosis intestinalis, and ascites was practical, had a moderate predictive value (AUC > 0.8), improved calibration, and enhanced clinical benefit.

CONCLUSIONS

This simple and reliable clinical prediction nomogram model can help physicians evaluate children with NEC in a fast and effective manner, enabling the early identification and diagnosis of children at risk for surgery. It offers clinical revolutionary value for the development of medical or surgical treatment plans for children with NEC.

Neural stem/progenitor cell-derived extracellular vesicles: A novel therapy for neurological diseases and beyond

As bilayer lipid membrane vesicles secreted by neural stem/progenitor cells (NSCs), NSC-derived extracellular vesicles (NSC-EVs) have attracted growing attention for their promising potential to serve as novel therapeutic agents in treatment of neurological diseases due to their unique physicochemical characteristics and biological functions. NSC-EVs exhibit advantages such as stable physical and chemical properties, low immunogenicity, and high penetration capacity to cross blood-brain barrier to avoid predicaments of the clinical applications of NSCs that include autoimmune responses, ethical/religious concerns, and the problematic logistics of acquiring fetal tissues. More importantly, NSC-EVs inherit excellent neuroprotective and neuroregenerative potential and immunomodulatory capabilities from parent cells, and display outstanding therapeutic effects on mitigating behavioral alterations and pathological phenotypes of patients or animals with neurological diseases. In this review, we first comprehensively summarize the progress in functional research and application of NSC-EVs in different neurological diseases, including neurodegenerative diseases, acute neurological diseases, dementia/cognitive dysfunction, and peripheral diseases. Next, we provide our thoughts on current limitations/concerns as well as tremendous potential of NSC-EVs in clinical applications. Last, we discuss future directions of further investigations on NSC-EVs and their probable applications in both basic and clinical research.

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.

Fingolimod protects against experimental necrotizing enterocolitis by regulating intestinal T cell differentiation

BACKGROUND

Necrotizing enterocolitis (NEC)-the leading cause of neonatal death-has been shown to be associated with an excessive inflammatory response of the intestines. Fingolimod has shown efficacy in treating many inflammatory diseases. In this study, we aimed to explore the protective effects of fingolimod on a mouse model of NEC.

METHODS

Experimental NEC was induced in 5-day-old C57BL/6 neonatal mice. Many methods include Hematoxylin and eosin (H&E), immunofluorescence staining, polymerase chain reaction (PCR) and western blot were used to evaluate the degreed of inflammation of NEC. A model of T-cell co-culture system in vitro was used to explain the way Fingolimod acted on T cell. We also detected the NEC associated brain injury by immunofluorescence staining.

RESULTS

Fingolimod treatment ameliorated NEC-induced intestinal injury, reduced inflammatory T cell infiltration, and regulated the balance between T helper 17 (Th17) and regulatory T cells in intestinal tissues. In addition, fingolimod treatment was found to blunt the pro-inflammatory phenotype of activated macrophages and decrease interleukin-17 (IL-17) secretion. Fingolimod treatment also ameliorated NEC-induced neuroinflammation.

CONCLUSIONS

Fingolimod can protect neonatal mice from NEC-related death by ameliorating intestinal injury and attenuating excessive inflammatory responses. These effects may be mediated through an improved Th17/Treg balance, which may result from direct and indirect effects of fingolimod on T cell infiltration and macrophage differentiation.

Melatonin Alleviates Neonatal Necrotizing Enterocolitis by Repressing the Activation of the NLRP3 Inflammasome

Objective

Necrotizing enterocolitis (NEC) is one of the commonest gastrointestinal critical diseases in newborns. Several researches have proven the efficacy of melatonin (MEL) on NEC, but the latent mechanisms were ambiguous. We designed the current research to evaluate the function and mechanism of MEL on NEC in a neonatal mouse model.

Methods

The newborn mice were subjected to formula milk containing LPS and hypoxia to establish a NEC model and also intraperitoneally injected with MEL. During the experiment, all mice were closely monitored and weighed. The effect of MEL on the histopathological injury of the terminal ileum tissues, inflammation, and oxidative stress of serum in NEC mice was examined by hematoxylin-eosin (H&E) staining and ELISA. The effect of MEL on the NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome was assessed via quantitative real-time PCR and Western blot.

Results

MEL intensified the survival rate and body weight in NEC mice. The H&E staining illustrated that MEL improved the histopathological injury in NEC mice. Moreover, MEL repressed the IL-1β, TNF-α, and MDA levels of serum and enhanced the SOD and GSH-Px levels of serum in NEC mice. We also discovered that MEL attenuated the mRNA and protein levels of NLRP3, Toll-like Receptor 4 (TLR4), NF-κB, and caspase-1 of the terminal ileum tissues in NEC mice.

Conclusion

Our research illuminated that MEL attenuated the severity of NEC via weakening the activation of the NLRP3 inflammasome.

Analysis of Factors Influencing Outcomes in Preterm Infants With Necrotizing Enterocolitis

BACKGROUND

To explore the surgical outcomes between patients with perforated and non-perforated neonatal necrotizing enterocolitis (NEC) and identify indications for surgical intervention.

METHODS

The surgical outcomes of 271 children with NEC admitted to the Seventh Medical Center of Chinese PLA General Hospital between August 2009 and August 2020 were retrospectively analyzed. The patients were divided into the non-perforated and perforated groups. The preoperative factors, including gestational age, birth weight, intrauterine infection, cholestasis, platelet change, white blood cell count, and C-reactive protein level were compared between the two groups, along with postoperative factors including infection status, complications, enteral and parenteral nutrition time, ICU time, ventilator use time, and intestinal necrosis length. Bell staging was performed for the two groups and the mortality of different Bell stages was explored. The risk of death and predisposing factors of patients with NEC were analyzed.

RESULTS

In total, 271 children undergoing surgery were included in this study. A total of 188 children were observed without perforation, including 57 deaths (30.3%), and 83 children with perforation, including 24 deaths (28.9%). Preoperative cholestasis and time from NEC diagnosis to surgery were significantly different between the two groups (P < 0.05). Postoperative factors, including parenteral nutrition time (32 [3-94] days vs. 23 [1-53] days), enteral nutrition time (27 [0-86] days vs. 18 [0-81] days), NICU time (44 [5-125] days vs. 29 [1-92] days), and length of intestinal necrosis (15 [0-92] cm vs. 10 [2-70] cm), were significant. The mortality rate of patients with Bell stage IIIA was higher than that of patients with Bell stage IIIB. A total of 81 patients had 30-day postoperative mortality (57 non-perforated cases). Multivariate Cox regression analysis showed that non-perforation was a poor prognostic factor for survival outcome (hazard ratio 2.288, 95% confidence interval [1.329-3.940], P = 0.003).

CONCLUSIONS

Preterm infants in the non-perforated group had more serious complications and had a longer recovery time after surgery. Bell staging is not accurate in diagnosing severe NEC that needs surgical intervention.

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.

Amniotic fluid stem cell administration can prevent epithelial injury from necrotizing enterocolitis

BACKGROUND

Stem cell therapy has been proven to rescue intestinal injury and stimulate intestinal regeneration in necrotizing enterocolitis (NEC). Specifically, stem cells derived from amniotic fluid (AFSCs) and mesenchymal stem cells (MSCs) derived from bone marrow have shown promising results in the treatment of experimental NEC. This study aims to examine the effects of AFSCs and MSCs on the prevention of intestinal injury during experimental NEC.

METHODS

Supernatants from AFSC and MSC cultures were collected to perform proteomic analysis. Prior to NEC induction, mice received intraperitoneal injections of phosphate-buffered saline (PBS), 2 × 10⁶ AFSCs, or 2 × 10⁶ MSCs.

RESULTS

We found that AFSCs grew faster than MSCs. Proteomic analysis indicated that AFSCs are primarily involved in cell development and growth, while MSCs are involved in immune regulation. Administering AFSCs before NEC induction decreased NEC severity and mucosal inflammation. Intestinal proliferation and endogenous stem cell activation were increased after AFSC administration. However, administering MSCs before NEC induction had no beneficial effects.

CONCLUSIONS

This study demonstrated that AFSCs and MSCs have different protein release profiles. AFSCs can potentially be used as a preventative strategy for neonates at risk of NEC, while MSCs cannot be used.

IMPACT

AFSCs and MSCs have distinct protein secretory profiles, and AFSCs are primarily involved in cell development and growth, while MSCs are involved in immune regulation. AFSCs are unique in transiently enhancing healthy intestinal epithelial cell growth, which offers protection against the development of experimental NEC. The prevention of NEC via the administration of AFSCs should be evaluated in infants at great risk of developing NEC or in infants with early signs of NEC.

Current therapy option for necrotizing enterocolitis: Practicalities and challenge

Necrotizing enterocolitis (NEC) is one of the most prevalent neonatal gastrointestinal disorders. Despite ongoing breakthroughs in its treatment and prevention, the incidence and mortality associated with NEC remain high. New therapeutic approaches, such as breast milk composition administration, stem cell therapy, immunotherapy, and fecal microbiota transplantation (FMT) have recently evolved the prevention and the treatment of NEC. This study investigated the most recent advances in NEC therapeutic approaches and discussed their applicability to bring new insight to NEC treatment.

Near-Infrared Spectroscopy: A Tool for Diagnosing Necrotizing Enterocolitis at Onset of Symptoms in Preterm Neonates with Acute Gastrointestinal Symptoms?

OBJECTIVE

In premature neonates, bloody stools and/or abdominal distension with feeding intolerance may be inaugural signs of necrotizing enterocolitis (NEC). We assessed the ability of near-infrared spectroscopy (NIRS) to distinguish those neonates with NEC soon after the occurrence of these symptoms.

STUDY DESIGN

We prospectively collected NIRS measurements of abdominal and cerebral regional tissue oxygen saturation (r-SO₂), with values masked by an opaque cover. Two physicians, blinded to the NIRS data, determined whether the gastrointestinal symptoms were related to NEC 10 days after symptom onset.

RESULTS

Forty-five neonates with mean (standard deviation [SD]) gestational, birth weight and postnatal ages of 31 (3.9) weeks, 1,486 (794) g, and 18 (14) days were enrolled over 30 months. Gastrointestinal symptoms were related to NEC in 23 patients and associated with other causes in 22. Analysis of the 48 hours of monitoring revealed comparable abdominal r-SO₂ and splanchnic-cerebral oxygenation ratio (SCOR) in patients with and without NEC (r-SO2: 47.3 [20.4] vs. 50.4 [17.8], p = 0.59, SCOR: 0.64 [0.26] vs. 0.69 [0.24], p = 0.51). Results were unchanged after NIRS analysis in 6-hour periods, and restriction of the analysis to severe NEC (i.e., grade 2 and 3, 57% of the NEC cases).

CONCLUSION

In this study, NIRS monitoring was unable to individualize NEC in premature infants with acute gastrointestinal symptoms.

Blood group AB increases risk for surgical necrotizing enterocolitis and focal intestinal perforation in preterm infants with very low birth weight

Necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) are two of the most common emergencies of the gastrointestinal tract in preterm infants with very low birth weight (VLBW, birth weight < 1500 g). Identification of risk factors among these children is crucial for earlier diagnosis and prompt intervention. In this study, we investigated a relationship between ABO blood groups and the risk for surgical NEC/FIP. We genotyped the ABO locus (rs8176746 and rs8176719) in VLBW infants enrolled in a prospective, population-based cohort study of the German Neonatal Network (GNN). Of the 10,257 VLBW infants, 441 (4.3%) had surgical NEC/FIP. In univariate analyses, the blood group AB was more prevalent in VLBW infants with surgical NEC/FIP compared to non-AB blood groups (OR 1.51, 95% CI 1.07–2.13, p = 0.017; absolute risk difference 2.01%, 95% CI 0.06–3.96%). The association between blood group AB and surgical NEC/FIP was observed in a multivariable logistic regression model (OR of 1.58, 95% CI 1.10–2.26, p = 0.013) as well. In summary, our study suggests that the risk of surgical NEC and FIP is higher in patients with blood group AB and lower in those having non-AB blood groups.

Specific imaging features of intestinal perforation on supine abdominal X-ray evaluation in infants with necrotizing enterocolitis

Background

Necrotizing enterocolitis (NEC) is associated with high mortality and morbidity in neonates. For infants with NEC, intestinal perforation is the most serious complication, and confirming perforation and performing radical surgical treatment as early as possible may reduce mortality and sequelae. The aim of this study was to identify the specific imaging characteristics of intestinal perforation after NEC on supine abdominal X-ray for the early diagnosis of intestinal perforation.

Methods

A retrospective study was conducted at the Children’s Hospital of Chongqing Medical University. Infants admitted to the hospital from 2013 to 2020 with NEC (Bell’s stage ≥Ⅱ) were divided into perforation and non-perforation groups. All infants were examined by abdominal X-ray in the erect and supine positions. The sensitivity and specificity of specific X-ray signs were analyzed.

Results

A total of 598 infants were included, 113 of whom suffered from perforation. On the supine abdominal films, lucency over the liver shadow, the liver falciform ligament sign, the football sign, the Rigler sign, the triangle sign and more than any one of the above signs had sensitivities of 64.60%, 45.13%, 37.17%, 30.97%, 15.93% and 86.73%, respectively. None of these signs were found on erect or supine abdominal films in the non-perforation group. The total of accuracy of prediction was 46.76%, and the specificity of all the signs was 100%.

Conclusion

Specific signs on supine abdominal X-ray could be used to confirm perforation in neonates with NEC with 86.73% sensitivity and 100% specificity.

Lactobacillus reuteri in its biofilm state promotes neurodevelopment after experimental necrotizing enterocolitis in rats

Necrotizing enterocolitis (NEC) is a devastating disease affecting premature newborns with no known cure. Up to half of survivors subsequently exhibit cognitive impairment and neurodevelopmental defects. We created a novel probiotics delivery system in which the probiotic Lactobacillus reuteri (Lr) was induced to form a biofilm [Lr (biofilm)] by incubation with dextranomer microspheres loaded with maltose (Lr-DM-maltose). We have previously demonstrated that a single dose of the probiotic Lr administered in its biofilm state significantly reduces the incidence of NEC and decreases inflammatory cytokine production in an animal model of the disease. The aim of our current study was to determine whether a single dose of the probiotic Lr administered in its biofilm state protects the brain after experimental NEC. We found that rat pups exposed to NEC reached developmental milestones significantly slower than breast fed pups, with mild improvement with Lr (biofilm) treatment. Exposure to NEC had a negative effect on cognitive behavior, which was prevented by Lr (biofilm) treatment. Lr administration also reduced anxiety-like behavior in NEC-exposed rats. The behavioral effects of NEC were associated with increased numbers of activated microglia, decreased myelin basic protein (MBP), and decreased neurotrophic gene expression, which were prevented by administration of Lr (biofilm). Our data indicate early enteral treatment with Lr in its biofilm state prevented the deleterious effects of NEC on developmental impairments.

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Early treatment with Lr in its biofilm state improves cognitive function in pups that survive experimental NEC.

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Lr in its biofilm state reduces microglia activation and MBP loss, and maintains memory and learning-related gene expression.

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Administration of Lr in its biofilm state protects the brain, as well as intestines, during experimental NEC.

Necrotising enterocolitis-A 15-year outcome report from a UK specialist centre

AIMS

Necrotising enterocolitis (NEC) is a disease associated with high mortality and morbidity, low birthweight and prematurity are risk factors. This study reports outcomes of babies having emergency laparotomy for NEC, examining institutional trends and exploring impact of multiple variables on mortality at 30 days and 1 year post-operatively.

METHODS

Case records of babies with ICD coding for NEC were examined from 2000 to 2015. After exclusions, 243 cases were identified-confirmed by operative findings and histology. Cohort demographics and trends in mortality were investigated, and the relationship of common variables to mortality was modelled with univariate and multivariate logistic regression to generate a mortality prediction tool.

RESULTS

Mean gestational age was 28 + 4 weeks. A 30-day mortality was 18.9%. Gestation, birthweight and area of bowel affected were significant of outcome (mortality), and the presence of pre-operative pneumoperitoneum was strongly correlated. Year of surgery and congenital cardiac pathology requiring intervention were not significant. Using multivariate regression modelling, a mortality outcome prediction tool has been developed.

CONCLUSION

Good survival following operation for NEC (>70%) is feasible, even in those babies born extremely premature (<28 weeks) and post-operatively re-located to tertiary NICUs. With increasing gestational age (>32 weeks), mortality is uncommon.

Outcomes and Prognostic Factors for Survival of Neonates With Necrotizing Enterocolitis

Background: Due to the survival of preterm neonates being continually improved, the modifiable prognostic factors of necrotizing enterocolitis (NEC) are essential to be investigated and considered in making a suitable treatment to decrease the prevalence and effect of NEC. Many prognostic factors have been associated with the survival of neonates with NEC; however, the studies show conflicting results. Moreover, the study from developing countries regarding NEC outcomes is minimal. Here, we aimed to determine the survival of neonates with NEC and associate it with the prognostic factors. Methods: A retrospective study was conducted using medical records of neonates with NEC at our institution from January 2014 to December 2019. Results: Fifty-two neonates with NEC were involved with the overall survival of 44.2%. Log-rank analysis showed that NEC staging and birth weight were significantly associated with the survival of neonates with NEC with a p-value of 0.010 and 0.002, respectively, while sex, APGAR score, platelet count, and type of treatment were not (p = 0.068, 0.752, 0.087, and 0.343, respectively). Multivariate analysis revealed that sex and NEC staging were strongly associated with the survival of neonates with NEC with a p-value of 0.018 [HR = 3.10 (95% CI = 1.21-7.93)] and 0.019 [HR = 0.44 (0.22-0.87)], respectively. Conclusions: Our study shows that sex and NEC staging might affect the survival of neonates with NEC. It implies that NEC staging should be closely monitored and intervened as early as necessary to prevent further morbidity and mortality.

Bolus versus continuous feedings following treatment for medical necrotizing enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is a serious, often fatal, disease of neonates. Minimal data exists regarding the optimal method for reintroducing feeds after successful treatment. This study aims to compare outcomes in patients reintroduced to bolus or continuous feeds after treatment for medical NEC.

METHODS

A retrospective review of infants treated for medical NEC in the neonatal intensive care unit (NICU) from 2011-2018 was performed. Demographics, information about initial feeds, clinical diagnosis data, and information about reintroduction of feeds were recorded. Patients with significant congenital heart disease or those who required procedures for treatment were excluded.

RESULTS

Sixty-one patients were analyzed; 45 were reintroduced to bolus feeds and 16 to continuous feeds. There were no differences between the two groups. Bolus-fed patients reached goal feeds quicker (p = 0.007), required fewer days of parenteral nutrition (p = 0.002), had shorter hospital stays (p = 0.013) and were discharged faster from diagnosis to discharge (p = 0.002). Differences were confirmed with multivariate regression.

CONCLUSION

Infants given bolus feeds reached goal feeds faster, required less time on PN, and were discharged quicker than those fed continuously. This suggests that, compared to continuous feeding, bolus feeding is associated with superior clinical outcomes among patients treated for medical NEC.

Low serum albumin concentration predicts the need for surgical intervention in neonates with necrotizing enterocolitis

PURPOSE

To investigate whether serum albumin (SA) concentration can predict the need for surgical intervention in neonates with necrotizing enterocolitis (NEC).

METHODS

Retrospective review of all cases with NEC Bell's stage 2 and 3 that were treated in a single center between 2009 and 2015. Data on patient demographics, clinical parameters, laboratory findings and surgical status were recorded. Receiver operating characteristics analysis was used to evaluate optimal cutoffs and predictive values.

RESULTS

Overall, 151 neonates with NEC were identified. Of these, 132 (87.4%) had confirmed NEC Bell's stage 2. The median gestational age was 28.4 (range, 23.1-39.0) weeks and 69 (52.3%) had a birth weight of ≤1000 g. Sixty-eight (51.5%) underwent surgery, showing a sustained reduction in SA over time with significantly lower median SA levels compared to 64 (48.5%) cases that responded well to medical treatment (18.3 ± 3.7 g/L vs. 26.0 ± 2.0 g/L; P < 0.001). SA concentration of ≤20 g/L on day 2 of NEC diagnosis was a significant predictor for surgery (OR 3.41; P = 0.019) with a positive predictive value of 71.4%.

CONCLUSIONS

An SA concentration of ≤20 g/L on day 2 of the NEC disease process is associated with a higher likelihood for surgical intervention in neonates with NEC Bell's stage 2. SA, in combination with other clinical parameters and serological markers, may be a useful predictive tool for surgery in NEC.

LEVEL OF EVIDENCE

II.

Expressions of Fib, IL-12 in Serum of Neonatal Necrotizing Enterocolitis and Their Correlation with Clinicopathological Features

Background:

To investigate the expressions of fibrinogen (Fib) and Interleukin-12 (IL-12) in serum of neonatal necrotizing enterocolitis (NEC), and to analyze the correlation between the two and their relationship with clinicopathological features.

Methods:

Forty two children with NEC treated in Xuzhou Children’s Hospital, Xuzhou Medical University Xuzhou, China from 2016–2019 were selected as an observation group and 40 children who underwent physical examination at the same period as a control group. The expression levels of Fib and IL-12 in the serum of two groups were detected by ELISA. The correlation between Fib and IL-12 in the observation group and the correlation among the expressions of Fib, IL-12, the clinicopathological features and common examination indexes of the children with NEC were investigated by Pearson correlation analysis.

Results:

The levels of Fib and IL-12 in the serum of the children in observation group were significantly higher than those in the control group were (P<0.05). There was a significant positive correlation between the levels of Fib and IL-12 in the serum of the children in observation group (P<0.05). The expression levels of Fib, IL-12 were not significantly correlated with sex and age of NEC children, but correlated with vomiting, diarrhea, bloody stool and bradycardia in NEC children (P<0.05). Fib and IL-12 were positively correlated with erythrocyte level (P<0.05) and negatively correlated with platelet level.

Conclusion:

The expressions of Fib and IL-12 in the serum of NEC children can objectively predict the severity of NEC.

Postoperative outcomes based on crystalloid administration in pediatric patients with necrotizing enterocolitis undergoing laparotomy

Intravenous fluid prescription is an essential part of postoperative care and may play a causal role in postoperative complications. The objective of the present study was to evaluate the relationship between intraoperative fluid administration and postoperative outcomes in a large cohort of pediatric patients.This analysis included a retrospective review of 172 patients who underwent gastroenterological surgery from January 2012 to September 2018 at an academic tertiary care hospital. Patients were evaluated based on the median amount of corrected crystalloids and subsequently dichotomized as low (<25.89 mL/kg h) versus high (>25.89 mL/kg h). The primary outcome measure was the postoperative length of hospital stay (pLOS). Secondary outcome measures included the postoperative time to restore gastroenterological functions and postoperative complications.Patients who received larger amounts of crystalloids were more likely to have a lower intraoperative level of hemoglobin (P = .78) and an intraoperative blood transfusion (P = .27). There were trends toward lower incidence rates of hyperchloremic acidosis (P = .375) and metabolic acidosis (P = .54) in the high crystalloid administration cohort. The incidence of postoperative complications increased as the amount of administered fluid decreased (P = .046). The total length of hospital stay was shorter in patients who received high volumes of crystalloid fluid (19.5 [15.75-32.25] days) than in patients who received low volumes (22 [16-29.5] days, P = .283).Significant and multifaceted variability in crystalloid administration was noted among pediatric patients undergoing major surgery. High fluid administration was associated with favorable postoperative outcomes; these findings could be applied to improve patient safety and facilitate better quality of care.

Activation of Wnt signaling by amniotic fluid stem cell-derived extracellular vesicles attenuates intestinal injury in experimental necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a devastating intestinal disease primarily affecting preterm neonates and causing high morbidity, high mortality, and huge costs for the family and society. The treatment and the outcome of the disease have not changed in recent decades. Emerging evidence has shown that stimulating the Wnt/β-catenin pathway and enhancing intestinal regeneration are beneficial in experimental NEC, and that they could potentially be used as a novel treatment. Amniotic fluid stem cells (AFSC) and AFSC-derived extracellular vesicles (EV) can be used to improve intestinal injury in experimental NEC. However, the mechanisms by which they affect the Wnt/β-catenin pathway and intestinal regeneration are unknown. In our current study, we demonstrated that AFSC and EV attenuate NEC intestinal injury by activating the Wnt signaling pathway. AFSC and EV stimulate intestinal recovery from NEC by increasing cellular proliferation, reducing inflammation and ultimately regenerating a normal intestinal epithelium. EV administration has a rescuing effect on intestinal injury when given during NEC induction; however, it failed to prevent injury when given prior to NEC induction. AFSC-derived EV administration is thus a potential emergent novel treatment strategy for NEC.

Prophylactic efficacy of enteral antifungal administration of miconazole for intestinal perforation, especially for necrotizing enterocolitis: a historical cohort study at a single institution

PURPOSE

Despite improvements in neonatal intensive care, the outcomes of extremely-low-birth-weight infants (ELBWIs) with surgical diseases remain to be improved. We started administering enteral miconazole (MCZ) to ELBWIs from 2002 to prevent fungal infection. Since then, the incidence of intestinal perforation has significantly decreased. We investigated this prophylactic effect of MCZ against necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) and explored a new prophylactic concept against intestinal perforation.

METHODS

We designed a historical cohort study to evaluate the effect of MCZ for intestinal perforation in ELBWIs who underwent treatment in our neonatal intensive-care unit between January 1998 and December 2005. We divided these cases into two groups: the Pre-MCZ group and the Post-MCZ group. We compared the morbidity, clinical outcomes and pathological features of NEC and FIP.

RESULTS

The rate of intestinal perforation with NEC was significantly reduced after the introduction of MCZ (p = 0.007, odds ratio; 3.782, 95% confidence interval; 1.368-12.08). The pathological findings of NEC specimens showed that the accumulation of inflammatory cells was significantly reduced in the Post-MCZ group when compared with the Pre-MCZ group (p < 0.05).

CONCLUSIONS

The efficacy of the enteral administration of MCZ on intestinal perforation with NEC highlights a new prophylactic concept in the clinical management of ELBWIs.

Low Splanchnic Oxygenation and Risk for Necrotizing Enterocolitis in Extremely Preterm Newborns

OBJECTIVE

The aim of the study was to investigate whether splanchnic oxygenation (SrSO2), measured with near-infrared spectroscopy (NIRS), during the first week of life is associated with the risk of developing necrotizing enterocolitis (NEC) in extremely preterm infants.

METHODS

This was a prospective observational cohort study including extremely preterm infants (<28 weeks of gestation) born at Karolinska University Hospital from September 2014 to December 2016. Using 1-hour NIRS monitoring during enteral feeding, mainly continuous enteral feeding, in the first week of life we measured both cerebral and splanchnic oxygenation. Primary outcome was risk of developing NEC (Bell stage ≥ II). Secondary outcome was the association between low mean SrSO2 during the first week of life and postnatal age at full enteral nutrition.

RESULTS

We enrolled 52 extremely preterm newborns, but only 45 infants had complete NIRS data. One infant developed NEC within 1 day of NIRS monitoring and was excluded from the study. Median gestational age was 25.6 weeks (range 23.0-27.9) and median birth weight 698 g (range 485-1353). Eight infants developed NEC at the median postnatal age of 15 days (range 6-35). Median postnatal age at full enteral nutrition was 10 days (range 6-23). Infants with mean SrSO2 <30% had a higher risk for developing NEC compared with those with SrSO2 >30% (crude risk ratio 5.25; 95% CI [1.19-23.01]). Small for gestational age, gestational age, birth weight, postnatal age did not affect the results. We found no association between SrSO2 and age at full enteral nutrition.

CONCLUSIONS

Low mean SrSO2 (<30%) during the first week of life is associated with an increased risk for developing NEC in extremely preterm infants on mainly continuous enteral nutrition.

Fecal Volatile Organic Compound Profiles are Not Influenced by Gestational Age and Mode of Delivery: A Longitudinal Multicenter Cohort Study

Fecal volatile organic compounds (VOC) reflect human and gut microbiota metabolic pathways and their interaction. VOC behold potential as non-invasive preclinical diagnostic biomarkers in various diseases, e.g., necrotizing enterocolitis and late onset sepsis. There is a need for standardization and assessment of the influence of clinical and environmental factors on the VOC outcome before this technique can be applied in clinical practice. The aim of this study was to investigate the influence of gestational age (GA) and mode of delivery on the fecal VOC pattern in preterm infants born below 30 weeks of gestation. Longitudinal fecal samples, collected on days 7, 14, and 21 postnatally, were analyzed by an electronic nose device (Cyranose 320^®). In total, 58 preterm infants were included (29 infants born at GA 24–26 weeks vs. 29 at 27–29 completed weeks, 24 vaginally born vs. 34 via C-section). No differences were identified at any predefined time point in terms of GA and delivery mode (p > 0.05). We, therefore, concluded that correction for these factors in this population is not warranted when performing fecal VOC analysis in the first three weeks of life.

Contemporary Outcomes for Infants with Necrotizing Enterocolitis-A Systematic Review

OBJECTIVE

To develop an accurate understanding of outcomes for necrotizing enterocolitis (NEC) to inform parental counseling, clinical care, and research agendas.

STUDY DESIGN

A systematic review of recent (January 2010-January 2018) large cohort studies reporting outcomes of infants who developed NEC. Only studies reporting national, regional, or multicenter outcomes of NEC in high income countries were included. Outcomes assessed were mortality, neurodevelopmental outcome, and intestinal failure. Meta-analyses were used to generate summary statistics for these outcomes.

RESULTS

Of 1375 abstracts, 38 articles were included. Overall mortality was 23.5% in all neonates with confirmed NEC (Bell stage 2a+) (95% CI 18.5%-28.8%), 34.5% (30.1%-39.2%) for neonates that underwent surgery for NEC, 40.5% (37.2%-43.8%) for extremely low birthweight infants (<1000 g), and 50.9% (38.1%-63.5%) for extremely low birthweight infants with surgical NEC. Studies examining causes of neonatal mortality showed NEC is responsible for around 1 in 10 of all neonatal deaths. Neurodevelopmental disability was reported in 4 studies at between 24.8% and 61.1% (1209 total NEC cases). Three studies reported intestinal failure with an incidence of 15.2%-35.0% (n = 1370). The main limitation of this review is the lack of an agreed definition for diagnosing NEC and the differences in the way that outcomes are reported.

CONCLUSIONS

Mortality following NEC remains high. These contemporary data inform clinical care and justify ongoing research efforts. All infants with NEC should have long-term neurodevelopmental assessment. Data on the long-term risk of intestinal failure are limited.

TRIAL REGISTRATION

CRD42018094791.

Elevated Coefficient of Variation in Total Fecal Bile Acids Precedes Diagnosis of Necrotizing Enterocolitis

Accumulation of bile acids (BAs) may mediate development of necrotizing enterocolitis (NEC). Serial fecal samples were collected from premature infants with birth weight (BW) ≤ 1800 g, estimated gestational age (EGA) ≤ 32 weeks, and <30 days old prior to initiation of enteral feeding. Nine infants that developed Bell’s Stage ≥ II NEC were matched with control infants based on BW, EGA, day of life (DOL) enteral feeding was initiated and DOL of the first sample. From each subject, five samples matched by DOL collected were analyzed for BA levels and composition. Fifteen individual BA species were measured via LC-MS/MS and total BA levels were measured using the Diazyme Total Bile Acid Assay kit. No statistically significant differences in composition were observed between control and NEC at the level of individual species (p = 0.1133) or grouped BAs (p = 0.0742). However, there was a statistically significant difference (p = 0.000012) in the mean coefficient of variation (CV) between the two groups with infants developing NEC having more than four-fold higher mean CV than controls. Importantly, these variations occurred prior to NEC diagnosis. These data suggest fluctuations in total fecal BA levels could provide the basis for the first predictive clinical test for NEC.

Impaired Wnt/β-catenin pathway leads to dysfunction of intestinal regeneration during necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a devastating neonatal disease characterized by acute intestinal injury. Intestinal stem cell (ISC) renewal is required for gut regeneration in response to acute injury. The Wnt/β-catenin pathway is essential for intestinal renewal and ISC maintenance. We found that ISC expression, Wnt activity and intestinal regeneration were all decreased in both mice with experimental NEC and in infants with acute active NEC. Moreover, intestinal organoids derived from NEC-injured intestine of both mice and humans failed to maintain proliferation and presented more differentiation. Administration of Wnt7b reversed these changes and promoted growth of intestinal organoids. Additionally, administration of exogenous Wnt7b rescued intestinal injury, restored ISC, and reestablished intestinal epithelial homeostasis in mice with NEC. Our findings demonstrate that during NEC, Wnt/β-catenin signaling is decreased, ISC activity is impaired, and intestinal regeneration is defective. Administration of Wnt resulted in the maintenance of intestinal epithelial homeostasis and avoidance of NEC intestinal injury.

Gastrointestinal sequelae and growth impairment at school age following necrotising enterocolitis in the newborn period

AIM

To evaluate gastrointestinal sequelae and growth impairment at school age in children who suffered from necrotising enterocolitis (NEC).

METHODS

This historic cohort study compared all surviving children born in Denmark between 1 January 2002 and 31 December 2011 with NEC in the newborn period, to surviving children without NEC, but same gestational age, birthweight and year of birth. Outcomes were investigated through a parental questionnaire, including gastrointestinal and growth-related outcomes. We performed exploratory ad hoc analysis, by adjusting for possible confounding and by dividing NEC children into surgical and medical.

RESULTS

In total, 163 children with NEC (50%) and 237 (36%) without NEC completed the parental questionnaire. Episodes of diarrhoea were more often reported in the NEC group (p = 0.0002). The increased risk seemed to be limited to those who underwent surgery for NEC. The absence from school (1.67 versus 1.31 days), rate of low height for age (17.9 versus 12.1%) and weight (29.9 versus 31.6 kg) did not differ significantly between children with NEC and children without NEC.

CONCLUSION

Our findings suggest that long-term gastrointestinal complications following NEC appeared to be of little clinical importance at the population level and therefore do not encourage specific routine follow-up.

Survival rates for surgically treated necrotising enterocolitis have improved over the last four decades

Aim

Improved survival rates for premature infants have also increased the population at risk of necrotising enterocolitis (NEC). This study evaluated the outcomes of surgically treated NEC and identified risk factors for mortality, intestinal failure (IF) and IF associated liver disease (IFALD).

Methods

This was a retrospective observational study of 131 infants with surgically treated NEC from 1976 to 2016 in a Swedish tertiary referral centre: 20 in 1976–1996, 33 in 1997–2006 and 78 in 2007–2016. Data were extracted from medical records, and the Cox regression model was used to identify risk factors.

Results

When the first and last periods were compared, they showed decreases in both gestational age, from 30 to 26 weeks, and mortality rates, from 45% to 29%. IF was found in 67 patients (56%), IFALD in 41 patients (34%) and short bowel syndrome (SBS) in 13 (19%). The incidence of IF was high, even in infants without SBS. Low gestational age was an independent risk factor for mortality. No risk factors were identified for IF or IFALD.

Conclusion

Survival rates for NEC improved from 1976–2016, despite a decrease in gestational age. Clinicians should be particularly aware of the risk of infants without SBS developing IF.

Historical aspects of probiotic use to prevent necrotising enterocolitis in preterm babies

Over the last few decades, numerous studies have evaluated probiotic use for the prevention of necrotising enterocolitis in preterm babies. Early 'proof of concept' studies evaluating whether probiotics are capable of colonising the preterm gut have translated into multiple observational studies, small and large randomised controlled trials. Some show evidence of benefit while others have produced disappointing results. In this paper, we review the history of probiotic use in preterm babies for NEC prevention in an attempt to explain why uncertainty exists and why this intervention has not been universally adopted into routine neonatal practice.

Behavioural and neurodevelopmental impairment at school age following necrotising enterocolitis in the newborn period

AIM

The aim of this study was to evaluate long-term behavioural and neurodevelopmental complications of neonatal necrotizing enterocolitis at school age.

METHOD

This was a historic cohort study comparing all surviving children born in Denmark between 1st of January 2002 and 31st of December 2011 with a diagnosis of necrotizing enterocolitis to a group of children without necrotizing enterocolitis, but same gestational age, birth weight and year of birth. Outcomes were investigated through a parental questionnaire. The primary outcome was the Strength and Difficulties Questionnaire score and secondary outcomes were cerebral palsy and impaired head growth.

RESULTS

Response rates were 50% (163 of 328) and 36% (237 of 652) among children with and without necrotizing enterocolitis, respectively. There was a higher rate of abnormal Strength and Difficulties score (23.9 versus 17.8%), moderate/severe cerebral palsy (3.1 versus 0.9%) and small head circumference for age (11.7 versus 7.2%) among children with necrotizing enterocolitis. However, these differences were all statistically insignificant and did not change significantly by adjustment for potential confounders.

CONCLUSION

To our knowledge, this study includes the largest cohort of necrotizing enterocolitis children evaluated for possible long-term complications at school age. The increased risks of behavioural- and neurodevelopmental impairments were statistically insignificant, moderate in magnitude and may be of little clinical importance for management in the neonatal period or when planning follow-up.

Prevention of necrotizing enterocolitis in premature infants – an updated review

Necrotizing enterocolitis (NEC) is among the most common and devastating diseases encountered in premature infants, yet the true etiology continues to be poorly understood despite decades of research. Recently, gut bacterial dysbiosis has been proposed as a risk factor for the development of NEC. Based on this theory, several best clinical practices designed to reduce the risk of NEC have been proposed and/or implemented. This review summarizes the results of recent clinical trials and meta-analyses that support some of the existing clinical practices for reducing the risk of NEC in premature infants. It is evident that human milk feeding can reduce the incidence of NEC. While most of the studies demonstrated that probiotic supplementation can significantly reduce the incidence of NEC in premature infants, there are still some concerns regarding the quality, safety, optimal dosage, and treatment duration of probiotic preparations. Antibiotic prophylaxis does not reduce the incidence of NEC, and prolonged initial empirical use of antibiotics might in fact increase the risk of NEC for high-risk premature infants. Lastly, standardized feeding protocols are strongly recommended, both for prevention of postnatal growth restriction and NEC.

A pilot case-control study of urine metabolomics in preterm neonates with necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a leading cause of gastrointestinal morbidity and mortality in preterm neonates. The aim of this pilot study was to explore using metabolomics alternations in the urine metabolites related to NEC that could possibly serve as diagnostic biomarkers of the disease. Urine samples were prospectively collected at the day of initial evaluation for NEC from 15 diseased preterm neonates (five Bell's stage I and ten stage II/III) and an equal number of matched controls. Urine metabolic profiles were assessed using non-targeted nuclear magnetic resonance spectroscopy and targeted liquid chromatography-tandem mass spectrometry monitoring 108 metabolites. Multivariate statistical models with data from either analytical approach showed clear separation between the metabolic profiles of neonates with NEC and controls. Twenty-five discriminant metabolites were identified belonging to amino and organic acids, sugars and vitamins. A number of metabolite combinations were found to have an excellent diagnostic performance in detecting neonates developing NEC. Our results show that the metabolic profile of neonates with NEC differs significantly from that of controls, making possible their separation using urine metabolomic analysis. Nevertheless, whether the small set of significant metabolites detected in this investigation could be used as early diagnostic biomarkers of NEC should be validated in larger studies.

Comparative Effectiveness of Prophylactic Therapies for Necrotizing Enterocolitis in Preterm Infants: Protocol for a Network Meta-analysis of Randomized Trials

Necrotizing enterocolitis (NEC) is a common and devastating disease with high morbidity and mortality in premature infants. Current literature on the prevention of NEC has limitations including lack of direct and indirect comparisons of available therapies. We will search MEDLINE, EMBASE, Science Citation Index Expanded, Social Sciences Citation Index, CINAHL, Scopus, ProQuest Dissertations and Theses database, and grey literature sources to identify eligible trials evaluating NEC preventive therapies. Eligible studies will (1) enroll preterm (gestational age <37 weeks) and/or low birth weight (birth weight <2500 g) infants, (2) randomize infants to any preventive intervention or a placebo, or alternative active or nonactive intervention. Our outcomes of interest are severe NEC (stage II or more, based on Bell's criteria), all-cause mortality, NEC-related mortality, late-onset sepsis, duration of hospitalization, weight gain, time to establish full enteral feeds, and treatment-related adverse events. Two reviewers will independently screen trials for eligibility, assess risk of bias, and extract data. All discrepancies will be resolved by discussion. We will specify a priori explanations for heterogeneity between studies. For available comparisons between treatment and no treatment, and direct comparisons of treatments, we will conduct conventional meta-analysis using a random effects model. We will conduct a network meta-analysis using a random effects model within the Bayesian framework using Markov chain Monte Carlo methods to assess relative effects of eligible interventions. We will assess the certainty in direct, indirect, and network estimates using the Grading of Recommendations Assessment, Development and Evaluation approach.

Necrotizing enterocolitis as a prognostic factor for the neurodevelopmental outcome of preterm infants - match control study after 2years

PURPOSE

Necrotizing enterocolitis (NEC) in very low birth weight infants is a risk factor for developmental delay. To our knowledge, there are no studies published investigating the neurodevelopmental outcome of patients with NEC comparing surgically treated and conservatively treated patients versus match paired controls. The aim of this retrospective case control study was to measure the neurodevelopmental outcome of patients with NEC who were treated surgically or conservatively METHODS: All patients were identified, who have been diagnosed with NEC (ICD-10 code, P77) born between 2006 and 2013. Patients with NEC received antibiotic therapy, nasogastric decompression and fasting. Surgical treatment was indicated for patients with Bell stages IIIb. We excluded patients suffering from other relevant diseases with a possible impact on their neurodevelopmental outcome (e.g., intraventricular hemorrhage, associated malformations, asphyxia, focal intestinal perforation, short bowel syndrome). Patients were tested at the corrected gestational age of 24months according to the Bayley Scales of Infant Development II. Each participant was compared to a child of the same sex, gestational age at birth (+/-two days), birth weight (+/-10%), and age at neurodevelopmental testing (IRB approval, No. 14/2014). The outcome measures were the psychomotor index (PDI) and the mental developmental index (MDI).

RESULTS

We included 13 conservatively and 24 surgically treated patients. The patients in group A (without surgery) achieved a mean PDI of 106, and those in group B (with surgery) a mean PDI of 90. These values were significantly higher in the conservative group A. The mean MDIs were 99 in the patient group A and 85 in patient group B. This difference was also significant.

CONCLUSION

We found significantly lower MDIs and PDIs in children with surgical treatment of NEC. Further systematic prospective research on the prevention of NEC and systematic follow-ups at later stages in the patients' development are necessary in order to implement early intervention.

TYPE OF STUDY

case control study.

LEVEL OF EVIDENCE

III.

Human and Bovine Colostrum for Prevention of Necrotizing Enterocolitis: A Meta-analysis

CONTEXT

Human and bovine colostrum (HBC) administration has been linked to beneficial effects on morbidity and mortality associated with necrotizing enterocolitis (NEC).

OBJECTIVES

To determine the effectiveness and safety of HBC for reducing NEC, mortality, sepsis, time to full-feed and feeding intolerance in preterm infants.

DATA SOURCES

We conducted searches through Medline, Embase, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and gray literature.

STUDY SELECTION

Randomized controlled trials comparing human or bovine colostrum to placebo.

DATA EXTRACTION

Two reviewers independently did screening, review, and extraction.

RESULTS

Eight studies (385 infants) proved eligible. In comparison with placebo, HBC revealed no effect on the incidence of severe NEC (relative risk [RR]: 0.99; 95% confidence interval [CI] 0.48 to 2.02, I² = 2.2%; moderate certainty of evidence), all-cause mortality (RR: 0.88; 95% CI 0.39 to 1.82, I² = 0%; moderate certainty), culture-proven sepsis (RR: 0.78; 95% CI 0.53 to 1.14, I² = 0%; moderate certainty), and feed intolerance (RR: 0.97; 95% CI 0.37 to 2.56, I² = 55%; low certainty). HBC revealed a significant effect on reducing the mean days to reach full enteral feed (mean difference: -3.55; 95% CI 0.33 to 6.77, I² = 41.1%; moderate certainty). The indirect comparison of bovine versus human colostrum revealed no difference in any outcome.

LIMITATIONS

The number of patients was modest, whereas the number of NEC-related events was low.

CONCLUSIONS

Bovine or human colostrum has no effect on severe NEC, mortality, culture-proven sepsis, feed intolerance, or length of stay. Additional research focused on the impact on enteral feeding may be needed to confirm the findings on this outcome.

Treatment of experimental necrotizing enterocolitis with stem cell-derived exosomes

PURPOSE

Necrotizing enterocolitis (NEC) remains a devastating disease in premature infants. We previously showed that four stem cell (SC) types equivalently improve experimental NEC. Exosomes are intercellular nanovesicles containing RNA, miRNA, DNA, and protein. Because SC therapy faces challenges, our aim was to determine if the beneficial effects of SC are achievable with cell-free exosomes.

METHODS

Exosomes from four SC types were compared: (1) amniotic fluid-derived mesenchymal SC (AF-MSC); (2) bone marrow-derived MSC (BM-MSC); (3) amniotic fluid-derived neural SC (AF-NSC); and (4) neonatal enteric NSC (E-NSC). Rat pups exposed to NEC received a varying concentration of a single type of exosome with control pups receiving PBS only. Intestinal damage was graded histologically.

RESULTS

The incidence of NEC was 0% in unstressed pups and 60.7% in control pups subjected to NEC. Exosomes (4.0×10⁸) reduced NEC incidence to: AF-MSC 25.0%; BM-MSC 23.1%; AF-NSC 11.1%; E-NSC 27.3%. When administered at a concentration of at least 4.0×10⁸, all groups demonstrated a significant reduction in NEC compared to untreated pups. At this minimum concentration, there was no difference in treatment efficacy between exosomes and the SC from which they were derived.

CONCLUSION

Stem cell-derived exosomes reduce the incidence and severity of experimental NEC as effectively as the stem cells from which they are derived, supporting the potential for novel cell-free exosome therapy for NEC.

TYPE OF STUDY

Basic science.

Development of the necrotizing enterocolitis society registry and biorepository

Necrotizing enterocolitis (NEC) is a devastating disease affecting premature infants. New advances in diagnostic and treatment options are desperately needed. Accordingly, the NEC Society initiated a research collaborative with a group of investigators dedicated to advancing the state of NEC-associated knowledge. Recent advances in high-content molecular interrogation and bio-computation (e.g., genomics, transcriptomics, proteomics, and metabolomics) can provide new insights from afflicted infants with NEC, however, individual centers do not have sufficient cases to conduct these studies independently. The development of a NEC Society Biorepository (NSB) has emerged to advance collaboration among institutions through the shared use of biologic samples in the dedicated pursuit of molecular indicators of disease and to gain greater pathophysiologic insights through research. The NSB will provide key infrastructure across several centers to harness the potential for new discoveries, while ensuring specimens are processed consistently, appropriate clinical data is collected, and privacy is maintained. The NSB will provide a comprehensive framework for sharing biological samples and clinical data through a robust and secure system that supports the investigation of research studies on NEC.

Effects of probiotics on experimental necrotizing enterocolitis: a systematic review and meta-analysis

BackgroundMeta-analyses of randomized controlled trials (RCTs) suggest that probiotics decrease the risk of necrotizing enterocolitis (NEC) in preterm infants. Many animal RCTs have evaluated probiotics for preventing NEC. We systematically reviewed the literature on this topic.MethodsThe protocol for systematic review of animal intervention studies (SYRCLE) was followed. Medline, Embase, ISI Web of Science, e-abstracts from the Pediatric Academic Society meetings, and other neonatal conferences were searched in December 2015 and August 2016. RCTs comparing probiotics vs. placebo/no probiotic were included.ResultsA total of 29 RCTs were included (Rats: 16, Mice: 7, Piglets: 3, Quail: 2, Rabbit: 1; N~2,310), with 21 reporting on histopathologically confirmed NEC; remaining 8 assessed only pathways of probiotic benefits. Twenty of the 21 RCTs showed that probiotics significantly reduced NEC. Pooling of data was possible for 16/21 RCTs. Meta-analysis using random-effects model showed that probiotics significantly decreased the risk of NEC (203/641 (31.7%) vs. 344/571 (60.2%); relative risk: 0.51; 95% confidence interval (CI): 0.42-0.62; P<0.00001; I2=44%; number needed to treat: 4; 95% CI: 2.9, 4.3).ConclusionProbiotics significantly reduced NEC via beneficial effects on immunity, inflammation, tissue injury, gut barrier, and intestinal dysbiosis.

Surgical findings during exploratory laparotomy are closely related to mortality in premature infants with necrotising enterocolitis

AIM

This study investigated whether a correlation existed between surgical findings during the first laparotomy for necrotising enterocolitis (NEC) and death and, or, disease progression.

METHODS

We included infants admitted within one day of birth to our tertiary neonatal department at Rigshospitalet, Denmark, from 2006 to 2015, who underwent a laparotomy for acute NEC. They were classified according to the locality and extent of intestinal necrosis by a paediatric surgeon, based on the surgical findings. We correlated the surgical findings with postoperative outcomes, namely death and, or, progression of NEC.

RESULTS

The first laparotomy showed that 48 infants had NEC, including 21 who demonstrated postoperative progression. Of these, six died before undergoing another laparotomy and 14 of the 15 infants who underwent relaparotomy also died. There was a significant association between surgical findings and NEC-related mortality (p = 0.03). The association between surgical findings and the progression of NEC was also significant (p < 0.0001).

CONCLUSION

Surgical findings during laparotomy for NEC were strongly correlated with mortality, which was close to 100% after relaparotomy. Considering the discouraging outcome, further studies should focus on alternative surgical approaches, such as proximal diverting jejunostomy and the clip and drop technique for the treatment of severe NEC.

Differences in the Clinical Characteristics of Early- and Late-Onset Necrotizing Enterocolitis in Full-Term Infants: A Retrospective Case-Control Study

Information regarding the influence of age at onset on prognosis in full-term infants with necrotizing enterocolitis (NEC) is limited, and identifying differences between the clinical characteristics of early-onset NEC (EO-NEC) and late-onset NEC (LO-NEC) may be helpful in the determination of effective management strategies. In the present study, the medical records of 253 full-term infants with NEC were reviewed, and the clinical characteristics of the EO-NEC group (n = 150) and the LO-NEC group (n = 103) were compared. Infants in the EO-NEC group were characterized by increased gestational age and higher rates of stage III NEC and peritonitis when compared with LO-NEC infants (P  < 0.05). Mortality was significantly associated with stage III NEC, peritonitis, sepsis, respiratory failure and shock in univariate analysis (P < 0.05). In logistic regression analysis, peritonitis and renal failure were identified as independent risk factors for mortality in infants with EO-NEC, and peritonitis and respiratory failure were significant predictors of mortality in neonates with LO-NEC. Our finding indicated that the characteristics of the severe medical conditions identified in infants with EO-NEC were distinct from those observed in infants with LO-NEC. Peritonitis and kidney failure and peritonitis and respiratory failure were identified as risk factors for mortality in EO-NEC and LO-NEC infants, respectively.

Necrotizing enterocolitis symposium: Epidemiology and early diagnosis

Despite decades of research on necrotizing enterocolitis (NEC), the outlook for infants afflicted by this devastating disease is all too often bleak. The aim of this symposium at the BAPS conference in Amsterdam was to highlight recent advances in the knowledge of the epidemiology and diagnosis of NEC. There were important contributions on the disease in the United Kingdom, both from a neonatal and from a surgical point of view, whereas colleagues from the Netherlands and elsewhere in Europe shared their insights into novel diagnostic tools, both biofluid and imaging based.

LEVEL OF EVIDENCE

Level V.

Current Research on the Epidemiology, Pathogenesis, and Management of Necrotizing Enterocolitis

Despite decades of research on necrotizing enterocolitis, we still do not fully understand the pathogenesis of the disease, or how to prevent or how to treat it. However, as a result of recent significant advances in the microbiology, molecular biology, and cell biology of the intestine of preterm infants and infants with necrotizing enterocolitis, there is some hope that research into this devastating disease will yield some important translation into effective prevention, more rapid diagnosis, and novel therapies.

[Analysis of population characteristics of infants affected by necrotizing enterocolitis in a tertiary centre in the last 12 years]

BACKGROUND

Necrotizing enterocolitis is the most lethal gastrointestinal emergency in the neonatal period. Incidence and mortality have remained stable in recent years despite advances in neonatal intensive care. The aim of this study is to show the general characteristics of patients diagnosed with necrotizing enterocolitis at Teresa Herrera's Hospital (La Coruna, Spain) in the last 12years.

MATERIAL AND METHODS

This study makes a retrospective and prospective descriptive analysis, evaluating the medical records and collecting radiological demographic variables, gestational data, perinatal history, clinical, analytical and perinatal therapeutic management and events in patients diagnosed with and treated for necrotizing enterocolitis between 2003 and 2015.

RESULTS

A total of 124 patients met the criteria for inclusion in the study. The mean gestational age of our patients was 33 weeks and remained stable compared with other studies. The average weight of our patients was 1,873g. In our series of cases there was a progressive and significant increase in maternal age and the rate of artificial pregnancies and multiple births. In our series 38.7% of our patients required surgical treatment and the fatality rate was 11.4%.

DISCUSSION

Despite advances in pre- and perinatal care necrotizing enterocolitis represents the leading cause of premature mortality. Incidence has remained unchanged in recent decades. More studies are required to identify both, risk and protective factors to reduce the morbidity and mortality of this entity.

Necrotizing enterocolitis: new insights into pathogenesis and mechanisms

Necrotizing enterocolitis (NEC) is the most frequent and lethal disease of the gastrointestinal tract of preterm infants. At present, NEC is thought to develop in the premature host in the setting of bacterial colonization, often after administration of non-breast milk feeds, and disease onset is thought to be due in part to a baseline increased reactivity of the premature intestinal mucosa to microbial ligands as compared with the full-term intestinal mucosa. The increased reactivity leads to mucosal destruction and impaired mesenteric perfusion and partly reflects an increased expression of the bacterial receptor Toll-like receptor 4 (TLR4) in the premature gut, as well as other factors that predispose the intestine to a hyper-reactive state in response to colonizing microorganisms. The increased expression of TLR4 in the premature gut reflects a surprising role for this molecule in the regulation of normal intestinal development through its effects on the Notch signalling pathway. This Review will examine the current approach to the diagnosis and treatment of NEC, provide an overview of our current knowledge regarding its molecular underpinnings and highlight advances made within the past decade towards the development of specific preventive and treatment strategies for this devastating disease.

Prophylactic efficacy of enteral miconazole administration for neonatal intestinal perforation and its potential mechanism

PURPOSE

Intestinal perforation (IP) is a fatal complication in extremely low birth weight infants (ELBWI). We started administrating enteral miconazole (MCZ) to ELBWI in 2002. Since then, the incidence of IP has significantly decreased. The aim of this study was to elucidate the prophylactic effect of MCZ for the treatment of neonatal IP, and to establish a new prophylactic concept for this disease.

METHODS

In in vivo experiments, the effects of MCZ were examined histopathologically using a mouse model of intestinal ischemia. In in vitro experiments, the cytoprotective effect of MCZ against hypoxia was evaluated using Caco-2 intestinal cells, and its anti-inflammatory potential using a co-culture model of Caco-2 and HL60 cells.

RESULTS

MCZ showed a tissue protective effect against intestinal ischemia. MCZ reduced high mobility group-box 1 (HMGB1) release in Caco-2 cells under hypoxic stress and attenuated the potential to activate co-cultured HL60 leukocytes with Caco-2 cells by suppressing interleukin-8 (IL-8).

CONCLUSION

MCZ may have preventive roles in the clinical management of IP in ELBWI by the suppression of IL-8 and HMGB-1.