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Use of Probiotics in the NICU - Part 2

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Use of Probiotics in the NICU - Part 2

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Use of Probiotics in the NICU - Part 2

  1. 1. Use of Probiotics in the NICU <ul><li>Part 2 </li></ul>
  2. 2. Immunonutrition
  3. 3. <ul><li>Probiotics for prevention of NEC </li></ul><ul><ul><li>The primary objective </li></ul></ul><ul><ul><ul><li>To compare the effectiveness and safety of prophylactic enteral probiotics administration versus placebo or no treatment in the prevention of severe (stage II or more) NEC and/or sepsis in preterm infants </li></ul></ul></ul><ul><ul><li>The secondary objective </li></ul></ul><ul><ul><ul><li>To conduct a subgroup analysis to investigate the effect of probiotics in extreme low birth weight infants (infants with birth weight <1000 g) </li></ul></ul></ul>Immunonutrition
  4. 4. <ul><li>The Available Literature </li></ul><ul><ul><li>191 potentially relevant citations </li></ul></ul><ul><ul><li>179 citations excluded because irrelevant </li></ul></ul><ul><ul><li>12 RCTs were identified as potentially relevant </li></ul></ul><ul><ul><li>10 studies comparing probiotics to control </li></ul></ul><ul><ul><li>9 RCTs included in the meta-analysis </li></ul></ul><ul><ul><li>2 RCTs were excluded since no clinical outcomes were reported </li></ul></ul><ul><ul><li>1 RCT was deferred till further assessment </li></ul></ul>Immunonutrition
  5. 5. <ul><li>Prebiotics - Clinical Evidence </li></ul><ul><ul><li>1425 infants were randomized </li></ul></ul><ul><ul><li>Highly variable with regard to </li></ul></ul><ul><ul><ul><li>Enrollment criteria </li></ul></ul></ul><ul><ul><ul><li>Baseline risk of NEC in the control groups </li></ul></ul></ul><ul><ul><ul><li>Timing </li></ul></ul></ul><ul><ul><ul><li>Dose </li></ul></ul></ul><ul><ul><ul><li>Formulation of the probiotics </li></ul></ul></ul><ul><ul><ul><li>Feeding regimens </li></ul></ul></ul>Immunonutrition
  6. 6. Immunonutritio n <ul><li>Probiotics – NEC Prevention </li></ul>
  7. 7. Immunonutrition <ul><li>Probiotics – Mortality </li></ul>
  8. 8. Immunonutrition <ul><li>Probiotics – Days to Full Feeds </li></ul>
  9. 9. <ul><li>Probiotics – Safety Profile </li></ul><ul><ul><li>Risk of translocation </li></ul></ul><ul><ul><ul><li>Several reported cases with Lactobacillis </li></ul></ul></ul><ul><ul><ul><li>No reported cases with Bifidbacterum </li></ul></ul></ul><ul><ul><li>Several reports of probiotic species sepsis have been reported in the literature </li></ul></ul><ul><ul><ul><li>Mostly in immunocompromised hosts </li></ul></ul></ul><ul><ul><ul><li>None of the included studies reported sepsis caused by probiotics organism </li></ul></ul></ul><ul><ul><li>Several cases of sepsis in short gut patients </li></ul></ul>Immunonutrition
  10. 10. Immunonutrition <ul><li>Questions and Probiotics in the NICU </li></ul><ul><ul><li>Have we also looked at ↓ antibiotic usage? </li></ul></ul><ul><ul><li>Can we initiate practices that facilitate infant colonization with maternal flora? </li></ul></ul><ul><ul><ul><li>C/S without ROM </li></ul></ul></ul><ul><ul><ul><li>Early skin-to-skin opportunities </li></ul></ul></ul><ul><ul><li>When using probiotics in the NICU? </li></ul></ul><ul><ul><ul><li>Is there evidence of best preparations? </li></ul></ul></ul><ul><ul><ul><li>Which preparation is best for neonatal population? </li></ul></ul></ul><ul><ul><ul><li>Are the probiotics of human origin? </li></ul></ul></ul><ul><ul><ul><li>Where did we get them? </li></ul></ul></ul><ul><ul><ul><li>How do we determine dosage? </li></ul></ul></ul>
  11. 11. Immunonutrition <ul><li>Dosing Prebiotics </li></ul><ul><ul><li>Considered supplements </li></ul></ul><ul><ul><li>Not regulated by the FDA </li></ul></ul><ul><ul><li>Unclear, non-standardized </li></ul></ul><ul><ul><li>3.5 X 10 7 to 3.5 X 10 9 CFU </li></ul></ul><ul><ul><li>Duh! </li></ul></ul>
  12. 12. <ul><li>Prebiotics </li></ul><ul><ul><li>Non-digestible food ingredients </li></ul></ul><ul><ul><li>Fructo-oligosaccharides (FOS) </li></ul></ul><ul><ul><li>Galacto-oligosaccharides (GOS) </li></ul></ul><ul><li>Positively affect the endogenous flora </li></ul><ul><li>Stimulate the growth of one or a limited number of bacterial species </li></ul><ul><ul><li>FOS - Bifidobacteria </li></ul></ul><ul><ul><li>Lactulose - Lactobacilli </li></ul></ul>Immunonutrition
  13. 13. <ul><li>Synbiotics </li></ul><ul><ul><li>A probiotic organism + its prebiotic food </li></ul></ul><ul><ul><li>Providing both the organism and substrate at the time of ingestion may offer improved chance of the prebiotics survival in GI tract </li></ul></ul><ul><li>Risk of adding prebiotics </li></ul><ul><ul><li>Recent reports of thickening agents being linked to NEC </li></ul></ul><ul><ul><li>There are similar substances in these agents and prebiotics </li></ul></ul>Immunonutrition

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