Necrotizing Enterocolitis In Preterm Neonates Research Articles

Comparing two different Protocols in Withholding Feeds around time of Packed Red Cell Transfusion and Occurrence of TANEC (Transfusion Associated Necrotizing Enterocolitis) in Preterm Neonates

Background: Necrotizing enterocolitis (NEC) is a gastrointestinal disease characterized by pneumatosis intestinalis, pneumoperitoneum, or intestinal necrosis accompanied by signs or symptoms of shock. Our study aims to determine incidence of occurrence of NEC in preterm neonates after red blood cell transfusion with different feeding protocols and to assess the value of withholding feeds around the pRBCs transfusion in decreasing the incidence of transfusion associated necrotizing enterocolitis (TANEC). Methods: The study was done on 90 preterms who received packed red blood cells (pRBCs) during their admission in the neonatal intensive care unit (NICU). Theywere divided in two groups according to different feeding protocols; Group (A): 45 preterms where only one feed was withheld during pRBCs transfusion and Group (B): 45 preterms where feeds were withheld 4 hours before till 4 hours after pRBCs transfusion. Results: The incidence of transfusion related NEC (positive TANEC) in preterm neonates and other complications of prematurity such as (intracranial hemorrhage (ICH), bronchopulmonary dysplasia (BPD), patent ductus arteriosus (PDA), retinopathy of prematurity (ROP) and pneumothorax in group (A) were relatively higher than those of group (B). Conclusion: The modulation of feeding protocol and necessity of keeping nothing per oral (NPO) before, during and after blood transfusion. Significant risk factors for NEC occurrence are feeding preterm before and after pRBCS transfusion, low birth weight, low gestational age, low APGAR score.

Comparison of probiotics and placebo in preventing necrotizing enterocolitis in preterm babies.

Objective: To compare the probiotics with placebo in preventing the necrotizing enterocolitis (NEC) in preterm newborns. Study Design: Randomized Controlled Trial. Setting: Department of Pediatrics Unit-1, Bahawal Victoria Hospital, Bahawalpur, Pakistan. Period: May 2022 to April 2023. Material & Methods: A total of 92 pre-term neonates with gestational age between 28-32 weeks gestation were included. Patients were randomly assigned to either probiotics or placebo groups (46 in each group). In probiotics group, probiotics named Bifidobacteria (hiflora/gutcare one sachet daily) were given for 5 days while in placebo group, neonates were given placebo for 5 days. All neonates were observed for feeding intolerance, abdominal distension, grossly bloody stools (naked eye blood in stool) and change in colour of skin of abdomen (erythema). Patients having three or more of these features in first 7 days of life were labeled as having NEC. Results: In a total of 92 newborns, maternal age ranged between 18 to 40 years with mean age of 29.30±5.27 years. The mean gestational age was 30.88±2.08 weeks while the mean weight was 2.06±0.71 kg. The NEC was found in 3 (6.52%) neonates in probiotics groups versus 11 (23.9%) in placebo group (p=0.020). In the probiotics group, NEC was found to have significant association with gestational age between 31-32 weeks (p=0.012), spontaneous vaginal delivery (p=0.028) and maternal educational status as educated (p=0.006). In the placebo group, NEC had significant association with birth weight between 1-1.5 kg (p=0.007). Conclusion: This study concluded that probiotics are better in preventing NEC in preterm neonates than placebo.

Remote ischemic conditioning in necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a devastating intestinal inflammatory disorder, most prevalent in premature infants, and associated with a high mortality rate that has remained unchanged in the past two decades. NEC is characterized by inflammation, ischemia, and impaired microcirculation in the intestine. Preclinical studies by our group have led to the discovery of remote ischemic conditioning (RIC) as a promising non-invasive intervention in protecting the intestine against ischemia-induced damage during early-stage NEC. RIC involves the administration of brief reversible cycles of ischemia and reperfusion in a limb (similar to taking standard blood pressure measurement) which activate endogenous protective signaling pathways that are conveyed to distant organs such as the intestine. RIC targets the intestinal microcirculation and by improving blood flow to the intestine, reduces the intestinal damage of experimental NEC and prolongs survival. A recent Phase I safety study by our group demonstrated that RIC was safe in preterm infants with NEC. A phase II feasibility randomized controlled trial involving 12 centers in 6 countries is currently underway, to investigate the feasibility of RIC as a treatment for early-stage NEC in preterm neonates. This review provides a brief background on RIC as a therapeutic strategy and summarizes the progression of RIC as a treatment for NEC from preclinical investigation to clinical evaluation.

Platelet Indices: Universally Available Clinical Adjunct for Diagnosing Necrotizing Enterocolitis.

Platelet function parameters can be predictive of several adult diseases and their severity. However, few studies report on the association between platelet indices and neonatal diseases, specifically necrotizing enterocolitis (NEC). The objective of this study is to investigate whether platelet indices are associated with NEC diagnosis and NEC-related mortality. We retrospectively examined records from infants admitted to the neonatal intensive care unit with a diagnosis of NEC, verified by the presence of pneumatosis on X-ray or pathology at surgery. We compared them with an age-matched group of prematures without NEC. We investigated platelet count, mean platelet volume (MPV), platelet distribution width and red cell distribution width to platelet ratio (RPR) and delta platelets from birth to the time of NEC diagnosis or day of life 14 in the control group. Sixty-nine infants with NEC and 78 control infants were studied. Basic sociodemographic data were similar in both groups. All platelet parameters measured-except for MPV-were significantly associated with NEC diagnosis. Although MPV was not associated with the diagnosis of NEC (p = 0.800), it was significantly associated with NEC-related mortality (p < 0.001). Only total platelet count and RPR were significantly associated with both NEC diagnosis (p < 0.0001) and mortality (p = 0.04 and 0.01, respectively). On multivariable analysis only the change in platelet count from birth to time of diagnosis remained significant. While not definitive, this study demonstrates that these routinely available, inexpensive, and easily calculated platelet indices can provide a clinical adjunct in the often-elusive attempts to definitively diagnose NEC in preterm neonates. · Platelet indices were associated with NEC diagnosis.. · MPV was predictive of NEC-related mortality.. · Delta platelet count from birth was significantly related to NEC diagnosis..

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

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

Association Between Platelet-to-Lymphocyte Ratio and Preterm Necrotizing Enterocolitis.

Introduction: Necrotizing enterocolitis (NEC) is a fatal condition for very-low-birth-weight infants. Necrotizing enterocolitis is a multi-factor phenomenon that results in intestinal mucosal damage and leads to intestinal necrosis. However, sensitive laboratory indicators for NEC are lacking, making early diagnosis difficult. This study aimed to explore the relationship between the platelet-to-lymphocyte ratio (PLR) and NEC in preterm neonates to enable an earlier diagnosis of the condition.Methods: This was a retrospective case–control study of preterm neonates diagnosed with NEC between January 2018 and December 2019 in the West China Second University Hospital. Controls were selected from preterm neonatal intensive care unit (NICU) graduates, and they were matched for gestation and year of birth to the preterms diagnosed without NEC. In total, 93 and 107 infants were included in the NEC and control groups, respectively. Empowerstats analysis was used to identify the association between PLR and preterm NEC.Results: The NEC group had significantly higher PLR levels than the control group. PLR > 100 within 1 week before NEC diagnosis was a risk factor for NEC. There was a positive connection between PLR and preterm NEC. A PLR of >100 was determined as the optimal cutoff for predicting preterm NEC, with patients with PLR >100 having a higher risk of NEC [odds ratio (OR): 18.82 (95% confidence interval (CI): 2.93–120.98), p = 0.002].Conclusions: A PLR of >100 within 1 week after clinical abnormalities is associated with a high risk of NEC in preterm neonates.

Fecal High-Mobility Group Box 1 as a Marker of Early Stage of Necrotizing Enterocolitis in Preterm Neonates.

Introduction: An early diagnosis of necrotizing enterocolitis (NEC), a major gastrointestinal emergency in preterm newborns, is crucial to improve diagnostic approach and prognosis. We evaluated whether fecal high-mobility group box protein 1 (HMGB1) may early identify preterms at risk of developing NEC.Materials and Methods: A case-control study including neonates admitted at the Neonatal Intensive Care Unit (NICU) of the Sapienza University Hospital “Umberto I” in Rome, from July 2015 to December 2016. Stool samples obtained from cases (preterm newborns with NEC) and controls (newborns without NEC) were collected at the enrolment (T0) and within 7–14 days after the first sample collection (T1). HMGB1, extracted and measured with western blot, was reported as densitometry units (DUS).Results: HMGB1 levels in 30 cases (n = 28—Bell stage 1, n = 2 Bell stage 2) were higher [T0: 21,462 DUS (95% CI, 16,370–26,553 DUS)—T1: 17,533 DUS (95% CI, 13,052–22,014 DUS)] than in 30 preterm controls [T0: 9,446 DUS (95% CI, 6,147–12,746 DUS)—T1: 9,261 DUS (95% CI, 5,126–13,396 DUS), p < 0.001). Preterm newborns showed significant higher levels of HMGB1 (15,690 DUS (95% CI, 11,929–19,451 DUS)] in comparison with 30 full-term neonates with birth weight >2,500 g [6,599 DUS (95% CI, 3,141–10,058 DUS), p = 0.003]. Multivariate analysis showed that the risk of NEC was significantly (p = 0.012) related to the HMGB1 fecal levels at T0.Conclusions: We suggest fecal HMGB1 as a reliable marker of early NEC in preterm neonates. This study supports further investigation on the role of fecal HMGB1 assessment in managing preterm newborns at risk of NEC. Further studies are advocated to evaluate diagnostic accuracy of this marker in more severe forms of the disease.

Effect of Probiotics on Enteral Milk Tolerance and Prevention of Necrotizing Enterocolitis in Preterm Neonates

Background: There is a dearth of studies in Iran on the efficacy of probiotics in reducing necrotizing enterocolitis (NEC), yielding contradictory results. Therefore, the present study aimed to assess the effect of probiotics on milk tolerance and the prevention of NEC in preterm neonates. Methods: This randomized triple-blind clinical trial study was conducted on all preterm neonates between 30 and 36 weeks gestation and birth weight >1250 g hospitalized in the neonatal intensive care unit (NICU) at Bentolhoda Hospital in Bojnurd, Iran. Thereafter, 76 eligible neonates were randomly assigned to two groups of oral placebo (n=38) and BB care probiotic (n=38). Subsequently, the following information was extracted based on the hospital checklist: early or late NEC (after 7 days of birth), types of NEC (grade I, II, and III), length of hospitalization, time to reach complete oral nutrition, weight at discharge, and milk tolerance. Results: In the current study, 52.6% and 47.4% of newborns in control and intervention groups were male, and no significant difference was observed between the two groups (P= 0.646). The incidence of NEC was significantly reduced among the intervention group. The feeding onset in the placebo group was significantly later, as compared to that in the intervention group. A significant difference was detected between the two groups in the length of hospital stay and weight gain during hospitalization. Conclusion: As evidenced by the obtained results, the administration of probiotics in preterm neonates might prevent NEC. Moreover, it can shorten the onset time of feeding and hospitalization duration.

Human Milk Oligosaccharides Activate Epidermal Growth Factor Receptor and Protect Against Hypoxia-Induced Injuries in the Mouse Intestinal Epithelium and Caco2 Cells

Hypoxia-induced intestinal barrier injuries lead to necrotizing enterocolitis (NEC). Although NEC in preterm neonates is preventable by human milk oligosaccharides (HMOs), the underlying mechanism remains unknown. To reveal the role and mechanism of HMOs in protecting against hypoxia-induced injuries in intestinal epithelium of neonatal mice and cultured Caco2 cells. NEC was induced by hypoxia and cold stress. Seventy C57BL/C pups (7-d-old) were divided into 5 groups and fed maternal breast milk (BM), formula alone (FF), or the formula added with HMOs at 5 (LHMO), 10 (MHMO), or 20mg/mL (HHMO) for 3 d. Ileal hypoxia inducible factor 1α (HIF1α) and cleaved Caspase 3 were determined, along with staining for Ki-67 protein to labeled proliferative cells. In vitro, adherent Caco2 cells (undifferentiated, passage 14) were treated with HMOs, galacto-oligosaccharides, fructo-oligosaccharides, or mixed oligosaccharides at 10mg/mL for 1 d exposed to 1% O2. Cell proliferation and apoptosis, along with phosphorylated epidermal growth factor receptor (P-EGFR) and 38KD MAPK (P-P38), were assayed in differentiated or undifferentiated Caco2 cells. Compared with the FF-fed mice, those fed MHMO and HHMO had 52% lower (P <0.05) NEC scores, 60-80% greater (P <0.05) KI67-positive cell numbers, and 56-71% decreases (P <0.05) in ileal HIF1α and cleaved Caspase 3 (56-71%). Compared with those untreated, the HMO-treated Caco2 cells displayed 60% greater (P <0.05) proliferative activity and 19% lower (P <0.05) apoptotic cells after the hypoxia exposure. The HMO treatment led to 58% or 10-fold increases (P <0.05) of P-EGFR and 48-89% decreases (P <0.05) of P-P38 in either differentiated or undifferentiated Caco2 cells compared with the controls. Supplementing HMOs at 10-20mg/mL into the formula for neonatal mice or media for Caco2 cells conferred protection against the hypoxia-induced injuries. The protection in the Caco2 cells was associated with an activation of EGFR.

Enteral lactoferrin supplementation for prevention of sepsis and necrotizing enterocolitis in preterm infants.

Lactoferrin, a normal component of human colostrum and milk, can enhance host defenses and may be effective for prevention of sepsis and necrotizing enterocolitis (NEC) in preterm neonates. To assess the safety and effectiveness of lactoferrin supplementation to enteral feeds for prevention of sepsis and NEC in preterm neonates. Secondarily, we assessed the effects of lactoferrin supplementation to enteral feeds on the duration of positive-pressure ventilation, development of chronic lung disease (CLD) or periventricular leukomalacia (PVL), length of hospital stay to discharge among survivors, and adverse neurological outcomes at two years of age or later. We used the standard search strategy of Cochrane Neonatal to update our search. We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 9), MEDLINE via PubMed (1966 to 20 January 2020), PREMEDLINE (1996 to 20 January 2020), Embase (1980 to 20 January 2020), and CINAHL (1982 to 20 January 2020). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. In our search, we included randomized controlled trials (RCTs) evaluating enteral lactoferrin supplementation at any dose or duration to prevent sepsis or NEC in preterm neonates. We used the standard methods of Cochrane Neonatal and the GRADE approach to assess the certainty of evidence. Meta-analysis of data from twelve randomized controlled trials showed that lactoferrin supplementation to enteral feeds decreased late-onset sepsis (typical RR 0.82, 95% CI 0.74 to 0.91; typical RD -0.04, 95% CI, -0.06, -0.02; NNTB 25, 95% CI 17 to 50; 12 studies, 5425 participants, low-certainty evidence) and decreased length of hospital stay (MD -2.38, 95% CI, -4.67, -0.09; 3 studies, 1079 participants, low-certainty evidence). Sensitivity analysis including only good methodological certainty studies suggested a decrease in late-onset sepsis with enteral lactoferrin supplementation (typical RR 0.87, 95% CI, 0.78, 0.97; typical RD -0.03, 95% CI, -0.05, -0.0; 9 studies, 4702 participants, low-certainty evidence). There were no differences in NEC stage II or III (typical RR 1.10, 95% CI, 0.86, 1.41; typical RD -0.00, 95% CI, -0.02, 0.01; 7 studies, 4874 participants; low-certainty evidence) or 'all-cause mortality' (typical RR 0.90, 95% CI 0.69, 1.17; typical RD -0.00, 95% CI, -0.01, 0.01; 11 studies, 5510 participants; moderate-certainty evidence). One study reported no differences in neurodevelopmental testing by Mullen's or Bayley III at 24 months of age after enteral lactoferrin supplementation (one study, 292 participants, low-certainty evidence). Lactoferrin supplementation to enteral feeds with probiotics decreased late-onset sepsis (RR 0.25, 95% CI 0.14 to 0.46; RD -0.13, 95% CI -0.18 to -0.08; NNTB 8, 95% CI 6 to 13; 3 studies, 564 participants; low-certainty evidence) and NEC stage II or III (RR 0.04, 95% CI 0.00 to 0.62; RD -0.05, 95% CI -0.08 to -0.03; NNTB 20, 95% CI 12.5 to 33.3; 1 study, 496 participants; very low-certainty evidence), but not 'all-cause mortality' (very low-certainty evidence). Lactoferrin supplementation to enteral feeds with or without probiotics had no effect on CLD, duration of mechanical ventilation or threshold retinopathy of prematurity (low-certainty evidence). Investigators reported no adverse effects in the included studies. We found low-certainty evidence from studies of good methodological quality that lactoferrin supplementation of enteral feeds decreases late-onset sepsis but not NEC ≥ stage II or 'all cause mortality' or neurodevelopmental outcomes at 24 months of age in preterm infants without adverse effects. Low- to very low-certainty evidence suggests that lactoferrin supplementation of enteral feeds in combination with probiotics decreases late-onset sepsis and NEC ≥ stage II in preterm infants without adverse effects, however, there were few included studies of poor methodological quality. The presence of publication bias and small studies of poor methodology that may inflate the effect size make recommendations for clinical practice difficult.

The relation between serum levels of epidermal growth factor and necrotizing enterocolitis in preterm neonates.

PurposeNecrotizing enterocolitis (NEC) is one of the most serious complications of prematurity. Many risk factors can contribute to the development of NEC. The epidermal growth factor (EGF) plays a major role in intestinal barrier function, increases intestinal enzyme activity, and improves nutrient transport. The aim of this study was to assess the role of epidermal growth factor in the development of NEC in preterm neonates.MethodsIn this study, 130 preterm neonates were included and divided into 3 groups, as follows: group 1, 40 preterm neonates with NEC; group 2, 50 preterm neonates with sepsis; and group 3, 40 healthy preterm neonates as controls. The NEC group was then subdivided into medical and surgical NEC subgroups. The serum EGF level was measured using enzyme-linked immunosorbent assay.ResultsSerum EGF levels (pg/dL) were significantly lower in the NEC group (median [interquartile range, IQR], 9.6 [2–14]) than in the sepsis (10.1 [8–14]) and control groups (11.2 [8–14], P<0.001), with no significant difference between the sepsis and control groups, and were positively correlated with gestational age (r=0.7, P<0.001). A binary logistic regression test revealed that low EGF levels and gestational ages could significantly predict the development of NEC. The receiver-operating characteristic curve for EGF showed an optimal cutoff value of 8 pg/mL, with 73.3% sensitivity, 98% specificity, and an area under the curve of 0.92.ConclusionThe patients with NEC in this study had significantly lower serum EGF levels (P<0.001), which indicated that EGF could be a reliable marker of NEC in preterm neonates.

Use of serum citrulline concentrations from routine newborn screen as a biomarker for necrotizing enterocolitis.

Necrotizing enterocolitis (NEC), a leading cause of mortality and morbidity in preterm neonates, lacks a reliable biomarker. Citrulline is primarily produced by enterocytes and correlates with intestinal function. Serum citrulline concentration (CIT) is routinely measured in routine newborn screening (NBS). The purpose of the study is to test if CIT from NBS may predict the occurrence of NEC and whether it correlates with the time to full feeds (TTFF) and length of stay (LOS), serving as a biomarker of NEC and intestinal health. In a retrospective case control study conducted on neonates with gestational age of 26-32weeks, we compared CIT levels between cases (neonates with NEC) and controls (next-born neonate). NBS was collected within first 24h, at day5 and when the neonates achieved full feeds and were compared using non-parametric tests. There was no difference in CIT between the controls and cases on day1 [11.42 (7.42-14.84 vs. 11.93 (6.85-18.8)µmol/L, p = 0.55], on day5 [11.99 (7.99-16.55) vs. 13.70 (7.42-26.83)µmol/L, p = 0.05], or at full feeds [14.86 (6.85-25.69) vs. 15.7 (7.42-26.26)µmol/L, p = 0.87]. CIT on day1 did not correlate with TTFF (r = 0.08, p = 0.53) or LOS (r = 0.23, p = 0.06), respectively). CIT from routine NBS does not serve as a biomarker to predict NEC in preterm neonates.

Oral lactoferrin for the prevention of sepsis and necrotizing enterocolitis in preterm infants.

Lactoferrin, a normal component of human colostrum and milk, can enhance host defense and may be effective in the prevention of sepsis and necrotizing enterocolitis (NEC) in preterm neonates. Primary objective To assess the safety and effectiveness of oral lactoferrin in the prevention of sepsis and NEC in preterm neonates. Secondary objectives1. To determine the effects of oral lactoferrin used to prevent neonatal sepsis and/or NEC on duration of positive-pressure ventilation, development of chronic lung disease (CLD) or periventricular leukomalacia (PVL), length of hospital stay to discharge among survivors, and adverse neurological outcomes at two years of age or later.2. To determine the adverse effects of oral lactoferrin in the prophylaxis of neonatal sepsis and/or NEC.When data were available, we analyzed the following subgroups.1. Gestational age < 32 weeks and 32 to 36 weeks.2. Birth weight < 1000 g (extremely low birth weight (ELBW) infants) and birth weight < 1500 g (very low birth weight (VLBW) infants).3. Type of feeding: breast milk versus formula milk. We used the search strategy of the Cochrane Neonatal Review Group (CNRG) and updated our search in July 2014. We searched the databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PREMEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), as well as trials registries and conference proceedings. Randomized controlled trials (RCTs) evaluating oral lactoferrin at any dose or duration to prevent sepsis or NEC in preterm neonates. Review authors used standard methods of the CNRG. Four RCTs are included in this review. Oral lactoferrin supplementation decreased late-onset sepsis (typical risk ratio (RR) 0.49, 95% confidence interval (CI) 0.32 to 0.73; typical risk difference (RD) -0.09, 95% CI -0.14 to -0.04; number needed to treat for an additional beneficial outcome (NNTB) 11, 95% CI 7 to 25; four trials, 678 participants, moderate-quality evidence), NEC stage II or greater (typical RR 0.30, 95% CI 0.12 to 0.76; typical RD -0.05, 95% CI -0.08 to -0.01; NNTB 20, 95% CI 12.5 to 100; two studies, 505 participants, low-quality evidence), and "all-cause mortality" (typical RR 0.30, 95% CI 0.12 to 0.75; typical RD -0.05, 95% CI -0.08 to -0.01; NNTB 20, 95% CI 12.5 to 100; two studies, 505 participants, low-quality evidence).Oral lactoferrin supplementation with a probiotic decreased late-onset sepsis (RR 0.27, 95% CI 0.12 to 0.60; RD -0.13, 95% CI -0.19 to -0.06; NNTB 8, 95% CI 5 to 17; one study, 321 participants, low-quality evidence) and NEC stage II or greater (RR 0.04, 95% CI 0.00 to 0.62; RD -0.05, 95% CI -0.08 to -0.03; NNTB 20, 95% CI 12.5 to 33.3; one study, 496 participants, low-quality evidence), but not "all-cause mortality."Oral lactoferrin with or without probiotics decreased fungal sepsis but not chronic lung disease or length of hospital stay (from one study, low-quality evidence). No adverse effects were reported. Long-term neurological outcomes or periventricular leukomalacia was not evaluated. Evidence of moderate to low quality suggests that oral lactoferrin prophylaxis with or without probiotics decreases late-onset sepsis and NEC stage II or greater in preterm infants without adverse effects. Completion of ongoing trials will provide evidence from more than 6000 preterm neonates and may enhance the quality of the evidence. Clarifications regarding optimum dosing regimens, type of lactoferrin (human or bovine), and long-term outcomes are still needed.

Diagnostic utility of fecal calprotectin as a biomarker of gut inflammation in neonates to predict necrotizing enterocolitis: A prospective study

Background: Necrotizing enterocolitis (NEC) is a neonatal emergency that affects preterm newborns during the 1st weeks of life. Diagnosis is made mainly by clinical criteria since no specific diagnostic tests are available. Objective: The objective was to evaluate fecal calprotectin (fCal) as a biomarker of gut inflammation to predict NEC in preterm neonates. Methods: Design: Diagnostic test evaluation. Inclusion criteria: 102 preterm neonates &lt;36 weeks gestation and within 7 days of birth admitted in Level III neonatal intensive care unit (NICU) were recruited from January 2010 to May 2011. Exclusion criteria: Congenital anomalies and overt infection. Paired stool samples at day 3 and 7 were analyzed by lateral quantum blue rapid calprotectin assay. Cut-off values of fCal were determined among 30 term healthy infants. A structured questionnaire which included gestational age, symptoms at admission, and modified Bell’s staging was used to record NEC episodes on day 3 and 7 of admission. Septic screen and radiological tools were done as per NICU protocol. Results: 48% were above 34 weeks gestation; 31.3% were of very low birth weight. As per modified Bell’s staging on day 3 and 7, 22 and 11 neonates had 1a or above stage, respectively. 15 had features of NEC; of these, 12 were managed appropriately and discharged and 3 died. In the receiver-operated curve with fCal &gt;279 ?g/g as cutoff, the area under the curve was 0.652 (95% confidence interval: 0.516-0.789). Day 3 fCal levels were high in 65.7% neonates. Using NEC as outcome, sensitivity of the test was 93.3%; specificity was 39%; positive predictive value was 20.8% and negative predictive value was 97.14%. Conclusion: fCal has high sensitivity for diagnosing NEC in preterm neonates. However, further research is needed to establish its clinical usefulness.

Premature Delivery Reduces Intestinal Cytoskeleton, Metabolism, and Stress Response Proteins in Newborn Formula‐Fed Pigs

Preterm infants often show intolerance to the first enteral feeds, and the structural and functional basis of this intolerance remains unclear. We hypothesized that preterm and term neonates show similar gut trophic responses to feeding but different expression of intestinal functional proteins, thus helping to explain why preterm neonates are more susceptible to feeding-induced disorders such as necrotizing enterocolitis (NEC). Incidence of feeding-induced NEC, intestinal mass, and brush border enzyme activities, and the intestinal proteome in preterm cesarean-delivered pigs were compared with the corresponding values in pigs delivered spontaneously at term. For both preterm and term pigs, mucosal mass and maltase activity increased (50%-100%), whereas lactase decreased (-50%), relative to values at birth. Only preterm pigs were highly NEC sensitive (30% vs 0% in term pigs, P < 0.05). By gel-based proteomics, 36 identified proteins differed in expression, with most proteins showing downregulation in preterm pigs, including proteins related to intestinal structure and actin filaments, stress response, protein processing, and nutrient metabolism. Despite that enteral feeding induces rapid gut tropic response in both term and preterm neonates, the expression level of cellular proteins related to mucosal integrity, metabolism, and stress response differed markedly (including complement 3, prohibitin, ornithine carbamoyltransferase, and arginosuccinate synthetase). These proteins may play a role in the development of functional gut disorders and NEC in preterm neonates.

Postnatal amniotic fluid intake reduces gut inflammatory responses and necrotizing enterocolitis in preterm neonates

Preterm neonates are susceptible to gastrointestinal disorders such as necrotizing enterocolitis (NEC). Maternal milk and colostrum protects against NEC via growth promoting, immunomodulatory, and antimicrobial factors. The fetal enteral diet amniotic fluid (AF), contains similar components, and we hypothesized that postnatal AF administration reduces inflammatory responses and NEC in preterm neonates. Preterm pigs (92% gestation) were delivered by caesarean section and fed parental nutrition (2 days) followed by enteral (2 days) porcine colostrum (COLOS, n = 7), infant formula (FORM, n = 13), or AF supplied before and after introduction of formula (AF, n = 10) in experiment 1, and supplied only during the enteral feeding period in experiment 2 (FORM, n = 16; AF, n = 14). The NEC score was reduced in both AF and COLOS pigs, relative to FORM, when AF was provided prior to full enteral feeding (9.9 and 7.7 compared with 17.3, P < 0.05). There was no effect of AF when provided only during enteral feeding. AF pigs showed decreased bacterial abundance in colon and intestinal inflammation-related genes (e.g., TNF-α, IL-1α, IL-6, NOS) were downregulated, relative to FORM pigs with NEC. Anti-inflammatory properties of AF were supported by delayed maturation and decreased TNF-α production in murine dendritic cells, as well as increased proliferation and migration, and downregulation of IL-6 expression in intestinal cells (IEC-6, IPEC-J2). Like colostrum, AF may reduce NEC development in preterm neonates by suppressing the proinflammatory responses to enteral formula feeding and gut colonization when provided before the onset of NEC.

Enteral intestinal alkaline phosphatase administration in newborns decreases iNOS expression in a neonatal necrotizing enterocolitis rat model

PurposeTo determine if intestinal alkaline phosphatase (IAP) decreases intestinal injury resulting from experimentally induced necrotizing enterocolitis (NEC). We hypothesized that IAP administration prevents the initial development of NEC related intestinal inflammation. MethodsPre- and full-term newborn Sprague–Dawley rat pups were sacrificed on day 1 of life. Pre-term pups were exposed to intermittent hypoxia and formula containing LPS to induce NEC. Select NEC pups were given 40, 4 or 0.4units/kg of bovine IAP (NEC+IAP40u, IAP4u or IAP0.4u) enterally, once daily. Ileal sections were evaluated by real-time PCR (qRT-PCR) for IAP, iNOS, IL-1β, IL-6, and TNF-α mRNA and immunofluorescence for 3-nitrotyrosine (3-NT). ResultsExperimentally induced NEC decreased IAP mRNA expression by 66% (p≤0.001). IAP supplementation increased IAP mRNA expression to control. Supplemental enteral IAP decreased nitrosative stress as measured by iNOS mRNA expression and 3-NT staining in the NEC stressed pups (p≤0.01), as well as decreased intestinal TNF-α mRNA expression. In addition, IAP decreased LSP translocation into the serum in the treated pups. ConclusionsWe conclude that enterally administered IAP prevents NEC-related intestinal injury and inflammation. Enteral IAP may prove a useful strategy in the prevention of NEC in preterm neonates.

Exposure to HIV and antiretroviral medication as a potential cause of necrotizing enterocolitis in term neonates

Desfrere et al. [1] recently reported an association between maternal HIV infection and necrotizing enterocolitis (NEC) in neonates, independent of the classic NEC risks such as prematurity, hypoxia/ischaemia, cardiac malformation, anaemia, and formula feeding. The authors hypothesized that altered IL-12 expression and zidovudine-induced mitochondropathy, observed in HIV-exposed infants, may contribute to the development of NEC. Their study was limited to preterm infants, and suggested that HIV exposure could increase the immature infant's risk of NEC. We observed NEC in a term neonate without identifiable risk factors other than than being born to an HIV-positive mother. A male infant was delivered by elective caesarean section at 37 + 4 weeks of gestation to an HIV-positive mother. Maternal CD4 cell counts were normal above 500 cells/μl, and the HIV viral load was 55 800 copies/ml before the initiation of therapy. At 31 + 2 weeks of gestation, antiretroviral treatment was started using nevirapine (400 mg/day), lamivudine (300 mg/day) and zidovudine (600 mg/day). At 35 weeks, the viral load was 64 copies/ml. The mother received 100 mg intravenous zidovudine intrapartum. The postnatal adaptation of the newborn was uneventful, birthweight was 3015 g, scores at 1, 5 and 10 min were 6, 10 and 10, respectively. Postnatal transmission prophylaxis in the neonate was initiated at 6 h according to the Berlin regimen [2] of intravenous zidovudine 1.3 mg/kg body weight four times a day; blood cell counts and IL-6 were within normal ranges (see Table 1). Oral feeding of formula milk was started. On the fifth day of life, the infant developed clinical signs of sepsis, with pale skin, floppyness, and blood-stained stools. Elevated IL-6 of 50 000 ng/nl and granulocytopenia of 1.3/nl confirmed the diagnosis. An abdominal X-ray revealed intestinal pneumatosis. Oral feeding and antiretroviral medication were discontinued. Intravenous fluids and antibiotic treatment, including ampicillin, gentamycin, and metronidazole, were initiated. The next day, an abdominal X-ray showed pneumoperitoneum, and the infant underwent surgical resection of perforated and necrotic bowel. Oral feeding was restarted on the tenth postoperative day. After 3 months, three consecutive HIV-DNA polymerase chain reaction tests showed negative results, therefore the vertical transmission of HIV-1 could be excluded.Table 1: Blood tests and intravenous zidovudine administration in the infant.The study of Desfrere et al. [1] has highlighted the fact that vertical HIV exposure may be associated with an elevated risk of NEC in preterm neonates. We can add to their observation by showing that HIV exposure and its treatment may also be associated with NEC in term newborns. Maternal HIV infection might contribute to the risk of NEC through an alteration of cytokine expression and decreased T-cell function [3–5]. Zidovudine used for transmission prophylaxis may further increase the risk of NEC through its recognized adverse effects, including anaemia, granulocytopenia, and gastrointestinal toxicity [6]. Little is known about the potential effects of other antiretroviral drugs used during pregnancy. In this case, hyperosmolarity or local zidovudine toxicity did not play a role, because zidovudine was administered parenterally, and anaemia or granulocytopenia were not present until the onset of NEC (Table 1). In our centre, 105 infants fullfilled Bell's criteria for NEC (grade IIa and more), 100 of them were born before 37 weeks of gestation. In three of the five term infants with NEC, cardiac malformations were identified. The remaining two were a hypotrophic infant and the HIV-exposed infant presented here. Among the factors predisposing to NEC in term neonates, congenital heart disease, severe intraunterine growth retardation, early feeding, gastroschisis, hypercoagulable states, sepsis, but not HIV exposure have been described [7]. We conclude that exposure to HIV and antiretroviral drugs do not only augment the preterm infant's genuine risk of NEC, but may be an independent risk factor for this disease, possibly by altering the cellular immunity of the neonate.

Maternal Hypertensive Disorders Are an Independent Risk Factor for the Development of Necrotizing Enterocolitis in Very Low Birth Weight Infants

Objective: The purpose of this study was to compare complications and outcome of preterm neonates weighing ≤1,500 g who developed necrotizing enterocolitis (NEC) to neonates without NEC. Study Design: During January, 1995 to December, 1998, 211 live preterm neonates were born with birth weight ≤1,500 g. A cross sectional prospective study was designed and two groups were defined: 17 neonates who developed NEC and 194 without NEC. Multiple logistic regression analysis was performed to determine independent risk factors for the development of NEC. Results: The prevalence of NEC was 8% (17/211). The following complications were found to be significantly higher among mothers of neonates with NEC: mild pre-eclampsia (11.8 vs. 2.6%, p = 0.04); severe pre-eclampsia (35.5 vs. 12.9%, p = 0.01); chronic hypertension (29.4 vs. 5.7%, p < 0.001) and low birth weight (968 ± 233 vs. 1,123 ± 257 g, p = 0.02). In contrast, mean maternal age, mean gestational age at delivery and parity were not significantly different between the groups. A multivariate analysis including the following factors: maternal hypertensive disorders, pregestational diabetes mellitus, birth weight and gestational age at delivery, found only maternal hypertensive disorders to be independent risk factors for NEC (OR = 5.21, 95% CI 1.64–16.58). Conclusions: Maternal hypertension is an independent risk factor for the development of NEC in preterm neonates weighing <1,500 g. Thus, maternal vascular disorders may play an important role in the pathophysiology of NEC.

Interleukin-11 Levels in Healthy and Thrombocytopenic Neonates

Thrombocytopenia is common in sick neonates, and affected neonates have adverse outcomes compared with those without thrombocytopenia. As impaired platelet production underlies many neonatal thrombocytopenias, affected neonates are potential candidates for hemopoietic growth factor therapy. Although recombinant human (rh) thrombopoietin remains under therapeutic development, rhIL-11, which stimulates megakaryocytopoiesis and increases platelet counts after chemotherapy, is already licensed for clinical use. However, nothing is known about IL-11 in neonates. We therefore measured plasma IL-11 by ELISA in healthy term neonates, stable preterm neonates with or without thrombocytopenia, and preterm neonates with sepsis or necrotizing enterocolitis (NEC) with or without thrombocytopenia. At birth IL-11 was undetectable (<10 pg/mL) in healthy term neonates (n = 20) and 27 of 31 (87%) stable preterm neonates. Three stable preterm neonates with detectable IL-11 (mean±SD, 11.3 ± 0.4 pg/mL; median, 11.6 pg/mL) suffered chorioamnionitis, the remaining neonate (IL-11, 14 pg/mL) being one of nine with early onset thrombocytopenia (present by <72 h of age). IL-11 was also measured in 58 preterm neonates with suspected sepsis or NEC. In 25 of 58, sepsis or NEC was unconfirmed and IL-11 was undetectable. By contrast, 14 of 33 with proven sepsis or NEC had elevated IL-11 (median, 14.9 pg/mL; range, 11.2–92.2 pg/mL). Of these 33 neonates, 19 developed thrombocytopenia: nine of 19 (47%) had detectable IL-11 and 10 of 19 (53%) did not (p > 0.05). Although its role in platelet production in neonates remains unclear, these data suggest that IL-11 is involved in the endogenous cytokine response to sepsis or NEC in preterm neonates. Further studies of IL-11 in neonates are warranted to assess its role both in platelet production and in mediation of the endogenous inflammatory response.