Abstract
Abstract Title: Probiotic prophylaxis in the prevention of necrotizing enterocolitis in preterm infants Background: Necrotizing enterocolitis (NEC) is one of the most serious gastrointestinal emergencies and a leading cause of death amongst premature infants. Early detection is difficult, prevention is essential. Probiotics have been proposed as a measure to prevent NEC and prophylactic use has been routine in Norwegian neonatal intensive care units (NICUs) since 2014. However, recent publications have raised questions regarding the efficacy and safety of probiotics, especially in extremely premature infants (ELBW). Updated reviews and guidelines express concerns and the newest edition of UpToDate now advises against routine prophylactic use. Objective: The thesis’ objective is to address the following questions: Does prophylactic administration of probiotics reduce the incidence of NEC in premature born infants, including ELBW infants1? And does the evidence for efficacy and safety support routine administration in NICUs? Material and methods: A systematic literature search was performed in PubMed. Additional literature was identified through Norwegian NICUs’ method books, UpToDate and articles provided by my project thesis supervisor. Results: Of 21 included studies, 18 (86%) found a significant reduction in incidence of NEC in premature infants. Of these 18 studies, 12 had pooled data across the entire premature population. Seven out of 21 studies separated the ELBW infants, only one (14%) of which found a significant reduction in NEC in this subgroup. Five additional studies reported insufficient data on ELBW infants. Two studies performed separate analysis of efficacy adjusted for study location; one found the reduction in NEC to be greatest in Asian populations and the other found significant reductions only in Asian countries and Australia. Nine of the 18 studies that found a significant reduction in NEC recommended routine implementation of probiotics as a preventive measure. Conclusion: Probiotics seem to be efficacious in the prevention of NEC in premature infants, but only in VLBW and higher weight groups. Conversely, the evidence is very limited for ELBW infants, and studies suggest there might not be an effect at all in this weight group. Product safety remains a concern as long as probiotics classify as dietary supplements and thereby avoid the stringent quality controls of pharmaceuticals. Scandinavian based studies are needed to apply the current knowledge onto Scandinavian children, and a change in current practice in Norwegian NICUs could be warranted.
Abstract Title: Probiotic prophylaxis in the prevention of necrotizing enterocolitis in preterm infants Background: Necrotizing enterocolitis (NEC) is one of the most serious gastrointestinal emergencies and a leading cause of death amongst premature infants. Early detection is difficult, prevention is essential. Probiotics have been proposed as a measure to prevent NEC and prophylactic use has been routine in Norwegian neonatal intensive care units (NICUs) since 2014. However, recent publications have raised questions regarding the efficacy and safety of probiotics, especially in extremely premature infants (ELBW). Updated reviews and guidelines express concerns and the newest edition of UpToDate now advises against routine prophylactic use. Objective: The thesis’ objective is to address the following questions: Does prophylactic administration of probiotics reduce the incidence of NEC in premature born infants, including ELBW infants1? And does the evidence for efficacy and safety support routine administration in NICUs? Material and methods: A systematic literature search was performed in PubMed. Additional literature was identified through Norwegian NICUs’ method books, UpToDate and articles provided by my project thesis supervisor. Results: Of 21 included studies, 18 (86%) found a significant reduction in incidence of NEC in premature infants. Of these 18 studies, 12 had pooled data across the entire premature population. Seven out of 21 studies separated the ELBW infants, only one (14%) of which found a significant reduction in NEC in this subgroup. Five additional studies reported insufficient data on ELBW infants. Two studies performed separate analysis of efficacy adjusted for study location; one found the reduction in NEC to be greatest in Asian populations and the other found significant reductions only in Asian countries and Australia. Nine of the 18 studies that found a significant reduction in NEC recommended routine implementation of probiotics as a preventive measure. Conclusion: Probiotics seem to be efficacious in the prevention of NEC in premature infants, but only in VLBW and higher weight groups. Conversely, the evidence is very limited for ELBW infants, and studies suggest there might not be an effect at all in this weight group. Product safety remains a concern as long as probiotics classify as dietary supplements and thereby avoid the stringent quality controls of pharmaceuticals. Scandinavian based studies are needed to apply the current knowledge onto Scandinavian children, and a change in current practice in Norwegian NICUs could be warranted.