Infloran as probiotics fed enterally with breast milk reduces the incidence and severity of NEC in VLBW infants.

Probiotics, in the form of Bifidobacterium and Lactobacillus, fed enterally to very low birth weight preterm infants for 6 weeks reduced the incidence of death or necrotizing enterocolitis.

This pilot study indicated that early postnatal intratracheal instillation of budesonide using surfactant as vehicle significantly improved the combined outcome of death or chronic lung disease in small premature infants without causing immediate adverse effects. The results are encouraging, and a large sample multicenter trial is warranted.

Helicobacter pylori activates the transcription factor NF-B, leading to proinflammatory cytokine production by gastric epithelial cells. However, the receptors for the initial bacterial interaction with host cells which activate downstream signaling events have not been completely defined. Recently, it has been shown that microbial components activate Toll-like receptors (TLRs), thereby leading to AP-1-and NF-B-dependent transcription and resulting in the production of proinflammatory cytokines. Helicobacter pylori is a gram-negative bacterium that plays an etiologic role in the development of gastritis, peptic ulceration, and gastric adenocarcinoma (2). Several bacterial factors are proposed to play a role in disease pathogenesis. Type I H. pylori strains contain a pathogenicity island, which carries a number of virulence factors, including cagA and cagE (7), and is associated with more severe gastroduodenal disease (2). Studies using isogenic mutants demonstrate that certain genes carried on the cag pathogenicity island, including cagE but not cagA, are responsible for nuclear factor-B (NF-B) activation resulting in the transcription of a number of proinflammatory genes such as interleukin-8 (IL-8), IL-1␤, gamma interferon, and tumor necrosis factor alpha (20,29). However, the eukaryotic receptors involved in H. pylori activation of the innate immune response have not been clearly defined.Toll-like receptors (TLRs) play a crucial role in host innate and adaptive immune responses to microbial pathogens and their products (1). TLRs have leucine-rich motifs in their extracellular domains similar to those of other pattern-recognition proteins that promote ligand binding (1). TLR proteins also contain a cytoplasmic tail that is homologous to the IL-1 and IL-18 receptor and hence can trigger intracellular signaling pathways (23). To date, 10 TLRs have been described (31), with TLR2 and TLR4 the two best characterized. TLR2 responds to peptidoglycan, lipoteichoic acid (24), and bacterial lipoproteins (19). TLR4 is activated by the lipopolysaccharide (LPS) of gram-negative bacteria (3). Recently, it has been demonstrated that TLR2 and TLR4 are expressed on human intestinal epithelial cell lines (4, 5) and that Escherichia coli (O26:B6)-derived LPS induces TLR4 trafficking in epithelial cells (3). Maeda et al. (20) showed that TLR4 mRNA is also expressed on gastric epithelial MKN45 cells. In contrast to macrophages, TLR4 is not involved in H. pylori-induced NF-B activation in gastric epithelia (21). Therefore, the precise function(s) of TLR4 in gastric epithelial cells is still not known. MATERIALS AND METHODSReagents. H. pylori-derived LPS was kindly provided by Mario Monteiro (Institute for Biological Sciences, National Research Council, Ottawa, Ontario, Canada). Polyclonal anti-TLR4 and anti-actin were purchased from Santa Cruz Biotechnology (Santa Cruz, Calif.), and monoclonal anti-TLR4 (HTA125) antibody was purchased from eBioscience (San Diego, Calif.). Polyclonal H. pylori immune serum was purchased from DAKO (...

Extrauterine growth restriction is common in very preterm infants. The incidence in very-low-birth-weight infants ranges between 43% and 97% in various centers, with a wide variability due to the use of different reference growth charts and nonstandard nutritional strategies. Extrauterine growth restriction is associated with an increased risk of poor neurodevelopmental outcome. Inadequate postnatal nutrition is an important factor contributing to growth failure, as most very preterm infants experience major protein and energy deficits during neonatal intensive care unit hospitalization. First-week protein and energy intake are associated with 18-month developmental outcomes in very preterm infants. Early aggressive nutrition, including parenteral and enteral, is well tolerated in the very preterm infant and is effective in improving growth. Continued provision of appropriate nutrition (fortified human milk or premature formula) is important throughout the growing care during the hospitalization. After discharge, exclusively breast-fed infants require additional supplementation. If formula-fed, nutrient-enriched postdischarge formula should be continued for approximately 9 months corrected age. Supplementation of the preterm formulas with protein would increase the protein/energy ratio (3 g/100 kcal), leading to increased lean mass with relatively decreased fat deposition. Further research is required to optimize the nutritional needs of preterm infants and to evaluate the effects of nutritional interventions on long-term growth, neurodevelopment, and other health outcomes.

Aims-To identify the patent ductus arteriosus (PDA) shunt flow pattern using Doppler echocardiography; and to assess whether it could be used to predict the development of clinically significant PDA. Methods-Premature infants weighing under 1500 g, who required mechanical ventilation, and in whom daily echocardiography could be performed from day 1 until the ductus closed, and on day 7 to confirm closure, were studied. The PDA shunt flow was identified from four Doppler patterns, and the closed pattern of a closed duct was also presented. Clinically significant PDA was diagnosed when there was colour Doppler echocardiographic evidence of left to right ductal shunt associated with at least two of the following clinical signs: heart murmur (systolic or continuous); persistent tachycardia (heart rate>160/min); hyperactive precordial pulsation; bounding pulses; and radiographic evidence of cardiomegaly or pulmonary congestion. Results-Of 68 infants enrolled into this study, clincally significant PDA developed in 31. The most recordable sequence of transition change of shunt flow pattern for clinically significant PDA was: pulmonary hypertension pattern, to growing pattern, to pulsatile pattern, to closing pattern, to closed pattern. And that for non-clinically significant PDA was: pulmonary hypertension pattern, to closing pattern, to closed pattern. The growing and the pulsatile patterns were mostly documented in infants with clinically significant PDA. The first documented growing pattern to predict clinically significant PDA gave a sensitivity of 64.5% and a specificity of 81.1%; the first documented pulsatile pattern gave a sensitivity of 93.5% and a specificity of 100%. Conclusion-Doppler echocardiographic assessment of PDA shunt flow pattern during the first 4 days of life is useful for predicting the development of clinically significant PDA in premature infants. At that stage, the closing or closed Doppler pattern indicates that infants are not at risk of developing clinically significant PDA; the growing or pulsatile Doppler pattern indicates a continuing risk of developing clinically significant PDA. (Arch Dis Child 1997;77:F36-F40)

Chorioamnionitis is a common cause of preterm birth and may cause adverse neonatal outcomes, including neurodevelopmental sequelae. Chorioamnionitis has been marked to a heterogeneous setting of conditions characterized by infection or inflammation or both, followed by a great variety in clinical practice for mothers and their newborns. Recently, a descriptive term: "intrauterine inflammation or infection or both" abbreviated as "Triple I" has been proposed by a National Institute of Child Health and Human Development expert panel to replace the term chorioamnionitis. It is particularly important to recognize that an isolated maternal fever does not automatically equate to chorioamnionitis. This article will review the current literature on chorioamnionitis, and introduce the concept of Triple I, as well as recommendations for assessment and management of pregnant women and their newborns with a diagnosis of Triple I.

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