Arnaud Legrand

Oral supplementation with probiotics in very-low-birth-weight preterm infants: a randomized, double-blind, placebo-controlled trial

BACKGROUND Although recent reports suggest that supplementation with probiotics may enhance intestinal function in premature infants, the mechanisms are unclear, and questions remain regarding the safety and efficacy of probiotics in extremely low-birth-weight infants. OBJECTIVE The objective was to evaluate the efficacy of probiotics on the digestive tolerance to enteral feeding in preterm infants born with a very low or extremely low birth weight. DESIGN In a bicentric, double-blind, randomized controlled clinical trial that was stratified for center and birth weight, 45 infants received enteral probiotics (Bifidobacterium longum BB536 and Lactobacillus rhamnosus GG; BB536-LGG) and 49 received placebo. The primary endpoint was the percentage of infants receiving >50% of their nutritional needs via enteral feeding on the 14th day of life. A triangular test was used to perform sequential analysis. RESULTS The trial was discontinued after the fourth sequential analysis concluded a lack of effect. The primary endpoint was not significantly different between the probiotic (57.8%) and placebo (57.1%) groups (P = 0.95). However, in infants who weighed >1000 g, probiotic supplementation was associated with a shortening in the time to reach full enteral feeding (P = 0.04). Other than colonization by the probiotic strains, no alteration in the composition of intestinal microbiota or changes in the fecal excretion of calprotectin was observed. No colonization by probiotic strains was detected in infants who weighed < or =1000 g, presumably because of more frequent suspensions of enteral feeding, more courses of antibiotic treatment, or both. CONCLUSIONS Supplementation with BB536-LGG may not improve the gastrointestinal tolerance to enteral feeding in very-low-birth-weight infants but may improve gastrointestinal tolerance in infants weighing >1000 g. This trial was registered at clinicaltrials.gov as NCT 00290576.

Investigation of the intestinal microbiota in preterm infants using different methods.

Modifications in microbial colonization of the human gut are believed to affect intestinal homeostasis and increase the risk of gastrointestinal diseases. The present study examined different methods for investigating the dynamic characterization of the intestinal microbiota in preterm infants. Fecal samples were collected weekly from ten preterm infants during their stay in a neonatal intensive care unit. The infants had a mean gestational age of 29 weeks (range: 28-32 weeks) and a mean birth weight of 1233g (range: 935-1450g). Bacterial colonization was assessed using conventional culture techniques and molecular biological methods. More specifically, the recently developed denaturing high performance liquid chromatography (dHPLC) technique was compared to established methods such as temporal temperature gradient gel electrophoresis (TTGE) and rRNA gene library sequencing. Our results indicate that the gastrointestinal tract of preterm infants, born at a gestational age of less than 33 weeks, has a low biodiversity of mainly, culturable bacteria. Finally, dHPLC was evaluated in terms of speed, labor and sensitivity for its use as a tool to analyze microbial colonization in preterm infants. We found that this technique provided major improvements over gel-based fingerprinting methods, such as TTGE, that are commonly used for studying microbial ecology. As such, it may become a common analytical tool for this purpose.

Fecal Calprotectin Excretion in Preterm Infants during the Neonatal Period

Background Fecal calprotectin has been proposed as a non-invasive marker of intestinal inflammation in inflammatory bowel disease in adults and children. Fecal calprotectin levels have been reported to be much higher in both healthy full-term and preterm infants than in children and adults. Objective To determine the time course of fecal calprotectin (f-calprotectin) excretion in preterm infants from birth until hospital discharge and to identify factors influencing f-calprotectin levels in the first weeks of life, including bacterial establishment in the gut. Methodology F-calprotectin was determined using an ELISA assay in 147 samples obtained prospectively from 47 preterm infants (gestational age, and birth-weight interquartiles 27–29 weeks, and 880–1320 g, respectively) at birth, and at 2-week intervals until hospital discharge. Principal Findings Although median f-calprotectin excretion was 138 µg/g, a wide range of inter- and intra-individual variation in f-calprotectin values (from day 3 to day 78) was observed (86% and 67%, respectively). In multivariate regression analysis, f-calprotectin correlated negatively with ante and per natal antibiotic treatment (p = 0.001), and correlated positively with the volume of enteral feeding (mL/kg/d) (p = 0.009), the need to interrupt enteral feeding (p = 0.001), and prominent gastrointestinal colonization by Clostridium sp (p = 0.019) and Staphylococcus sp (p = 0.047). Conclusion During the first weeks of life, the high f-calprotectin values observed in preterm infants could be linked to the gut bacterial establishment.

Effect of sex and gestational age on neonatal body composition

To determine the effects of length of gestation and sex on infant body composition, air displacement plethysmography was performed in forty-six full-term neonates at 3 d of life and during the week prior to hospital discharge in 180 preterm neonates. Fat mass, as a percentage of body weight, was higher in preterm than in term infants (13.4 (SD 4.2) v. 10.1 (sd 3.7) %, respectively; P= 0.001). The absolute amount of fat mass did not differ between preterm and full-term newborns (323 (SD 126) v. 335 (SD 138) g; P= 0.58), whereas lean body mass was lower in preterm than in term infants (2055 (SD 280) v. 2937 (SD 259) g, respectively; P< 0.001). Among full-term infants, fat mass was higher in females than in males (11.1 (SD 3.7) v. 9.0 (SD 3.3) %, respectively; P= 0.047), whereas we did not observe any sex difference in preterm infants (13.5 (SD 4.1) v. 13.4 (SD 4.3) %; P= 0.89). Our data suggest that by the time they are discharged from hospital: (1) preterm infants have a higher percentage of body fat than term neonates and (2) this is presumably due to a lesser accretion in lean body mass in the first few weeks of extra-uterine life, particularly in boys.

Silent hypersensitivity to Escherichia coli asparaginase in children with acute lymphoblastic leukemia

This prospective study aimed to assess the incidence of silent hypersensitivity to Escherichia coli asparaginase in the treatment of acute lymphoblastic leukemia (ALL). Thirty-three children with newly diagnosed ALL were included in the study and treated according to the FRALLE 2000 protocol. The ‘A group’ (n = 18) differed from the ‘B-T group’ (n = 15) by a less intensive chemotherapy, the absence of concurrent prednisone therapy, and different asparaginase administration modalities during the second intensification. Asparagine, asparaginase activity, and anti-asparaginase antibodies were measured in each phase before the next injection of asparaginase. Eighteen percent of children presented a silent hypersensitivity. Most of them were in the ‘B-T group’ (p = 0.07), and maintained low antibody titers throughout the treatment. Clinical hypersensitivity was statistically more frequent in group A (p = 0.002), and allergy occurred mainly during the second intensification when antibody concentrations were significantly increased. We did not find any significant difference between asparaginase activity or asparagine depletion between the silent hypersensitivity and clinical allergy groups. In all, the results of this study suggest that chemotherapy and corticosteroid therapy associated with asparaginase treatment can lower antibody production and contribute to maintaining a silent hypersensitivity state.

Recovery of Exfoliated Cells From the Gastrointestinal Tract of Premature Infants: A New Tool to Perform “Noninvasive Biopsies?”

To gain insight into specific gene expression in the gastrointestinal (GI) tract of preterm infants, we adapted a method to isolate exfoliated epithelial cells. Gastric residual fluid aspirates (n = 89) or stool samples (n = 10) were collected from 96 neonates (gestational age, 24–36 wk). Cells were characterized by microscopic observation, cytokeratin-18 immunodetection, and expression of transcripts. The human origin of cellular DNA was confirmed by amplification of specific X and Y chromosome sequences. Isolation yielded 100–500 cells per sample for gastric aspirates (n = 8) and 10–20 cells for fecal samples (n = 5). Epithelial origin was confirmed by immunodetection of cytokeratin 18. Analyses of reverse transcribed products, using two independent methods, from 15 gastric fluid and two stool samples showed that 18S-rRNA and transcripts of beta-actin, glyceraldehyde-3-phosphate dehydrogenase (gapdh), and period1 were in quantities corresponding to at least 10 cells. On 59 aspirates, we found beta-actin transcripts (all but one), cytokeratin 18 (eight positive of eight samples), SLC26-A7-1 (13 positive of 19 samples), period2 (17 positive of 17 samples), and clock (25 positive of 26 samples). Exfoliated cells can be recovered from gastric aspirates and fecal samples and serve as a tool to investigate the impact of therapeutic and nutritional regimens on the maturation of GI functions.

Implementation of a Nurse-Driven Sedation Protocol in a PICU Decreases Daily Doses of Midazolam

Objectives: To evaluate the impact of a nurse-driven sedation protocol on the length of mechanical ventilation, total daily doses of sedatives, and complications of sedation. Design: A single-center prospective before and after study was conducted from October 2010 to December 2013. Setting: Twelve-bed surgical and medical PICU of the university-affiliated hospital in Nantes, France. Patients: A total of 235 patients, between 28 days and 18 years old, requiring mechanical ventilation for at least 24 hours were included in the study; data from 194 patients were analyzed. Interventions: During the first study phase, no protocol was used. During the second phase, patients were sedated according to a nurse-driven protocol. Measurements and Main Results: In the whole population, the length of mechanical ventilation did not differ between protocol and control groups (protocol, 4 [3–8] vs control, 5 [3–7.5]; p = 0.44). Analyzing age subgroups, the length of mechanical ventilation was significantly shorter in the protocol group than in the control group in children older than 12 months (4 [3–8] vs 5 [2.75–11.25] d; p = 0.04). Daily dose of midazolam decreased during the protocol phase compared with the control phase (1 [0.56–1.8] and 1.2 [0.85–2.4] mg/kg/d, respectively; p = 0.02). No differences were shown regarding other daily dose of drugs. In the control group, 68% of children had more than 20% of COMFORT-behavior scale assessment under the target (oversedation) versus 59% in the protocol group (p = 0.139). Conclusions: Implementation of a nurse-driven sedation protocol in a PICU is feasible and safe, allowed a decrease in daily dose of benzodiazepines, and decreased the duration of mechanical ventilation in older patients.

Breast Milk Lipidome Is Associated with Early Growth Trajectory in Preterm Infants

Human milk is recommended for feeding preterm infants. The current pilot study aims to determine whether breast-milk lipidome had any impact on the early growth-pattern of preterm infants fed their own mother’s milk. A prospective-monocentric-observational birth-cohort was established, enrolling 138 preterm infants, who received their own mother’s breast-milk throughout hospital stay. All infants were ranked according to the change in weight Z-score between birth and hospital discharge. Then, we selected infants who experienced “slower” (n = 15, −1.54 ± 0.42 Z-score) or “faster” (n = 11, −0.48 ± 0.19 Z-score) growth; as expected, although groups did not differ regarding gestational age, birth weight Z-score was lower in the “faster-growth” group (0.56 ± 0.72 vs. −1.59 ± 0.96). Liquid chromatography–mass spectrometry lipidomic signatures combined with multivariate analyses made it possible to identify breast-milk lipid species that allowed clear-cut discrimination between groups. Validation of the selected biomarkers was performed using multidimensional statistical, false-discovery-rate and ROC (Receiver Operating Characteristic) tools. Breast-milk associated with faster growth contained more medium-chain saturated fatty acid and sphingomyelin, dihomo-γ-linolenic acid (DGLA)-containing phosphethanolamine, and less oleic acid-containing triglyceride and DGLA-oxylipin. The ability of such biomarkers to predict early-growth was validated in presence of confounding clinical factors but remains to be ascertained in larger cohort studies.

Randomised controlled trial shows that co‐bedding twins may reduce birthweight recovery delay, parenteral nutrition weaning time and hospitalisation

INTRODUCTION Multiple pregnancies have been increasing, due to advances in assisted reproductive technology and delayed childbearing (1), and adapting and optimising medical protocols for multiple births have become a priority (2). In utero ultrasound has highlighted remarkable social bonds between twins, including the similarity of heart rates, sleep and wake rhythms and early behavioural interactions (3). The co-bedding technique is in line with the co-regulation and synactive theories, where the goal is to provide developmental and health benefits to twins (4,5). Cobedding essentially prolongs the behavioural bond and in utero interactive development between twins and may significantly reduce postnatal stress due to separation. Although the technique is now widely employed (6), cobedding was traditionally performed late in hospitalisation, which was questionable given its objective to reduce separation stress at a critical clinical stage. We believe that early co-bedding, as soon as possible after birth, may be of critical importance. To date, there has been a lack of consensus among studies and a paucity of compelling data on the potential clinical benefits of co-bedding (7). Lai et al.’s database analysis in 2012 pinpointed discrepancies in the data produced by co-bedding studies, as well as the absence of data and safety and long-term outcomes (8). Heterogeneous practices, clinical judgement criteria and, most importantly, the delayed co-bedding of stable newborn twins several weeks after birth, may have contributed to this lack of clarity (6,9–12). We decided to assess the effects of early co-bedding just after birth on twins ventilated with continuous positive airway pressure. We primarily focused on weight gain, but also considered thermoregulation, cardiorespiratory function, comfort and long-term neurodevelopmental outcomes at two years of age. Neonatology and Cobedding (NEOCOB) was a monocentric prospective study using a randomised unblinded protocol and approved by the Medical Ethics Committee of Nantes, France.Weplanned to co-bedall twins bornbetween 30 and 34 weeks of gestation, who did not have severe congenital pathologies but needed intubation, in the first 24 hours following birth. If intubated ventilated preterm infants were not eligible for practical reasons, due to the organisation of our unit, noninvasive ventilation support such as continuous positive airway pressure was accepted. Because intrauterine growth restriction (IUGR) has a significant impact on neonatal weight gain, the block randomisation was stratified by whether one or both of the twins were IUGR, in accordance with the usual Fenton curves. Parental consent was requested as soon as possible after birth, and initial resuscitation and randomisation were performed immediately by the hospital’s Women’s and Children’s Clinical InvestigationCenter todetermine the treatment arm. Abbreviations ANOVA, ANalysis Of VAriance; IUGR, IntraUterin Growth Restriction; LoS, Length of Stay; NEOCOB, NEOnatology & CO-Bedding; NICU, Neonatal Intensive Care Unit.

SFP CO-71 - PCR automatisée et identification des infections néonatales à Streptococcus agalactiae

Les infections materno-foetales (IMF) a Streptococcus agalactiae (SGB) sont rares mais de pronostic grave. L’hemoculture peripherique est le test diagnostic principal, mais le resultat est peu sensible et tardif (24–48h). Des techniques de biologie moleculaire automatisee, rapides et sensibles ont ete validees sur ecouvillon dans le diagnostic du portage vaginal de SGB per partum. Objectif Etudier les performances diagnostiques de la PCR automatisee pour la detection du SGB dans le sang. Materiels et methodes Analyse par PCR automatisee (GENEXPERT®), comparativement a la culture, de 65 echantillons de sang de cordon inocules avec une quantite croissante de SGB ; puis du sang de cordon de 24 nouveau-nes suspects d’IMF a SGB et 74 temoins non infectes. Resultats principaux Detection par PCR de 10 2 CFU/mL et 10 6 CFU/mL dans 23,8% et 100% des cas respectivement. 4% des NN suspects d’IMF avaient une hemoculture positive a SGB alors que la PCR etait negative (SE et VPP 0, SP 100% (IC95% [99,97-100,02]), VPN 94,4% (IC95% [89,4–99,4]). Conclusions Les performances diagnostiques du GENEXPERT® sont insuffisantes pour mettre en evidence une bacteriemie antenatale a SGB sur sang de cordon. Cette technique doit etre perfectionnee afin de faciliter le diagnostic precoce d’IMF a SGB.