الفهرس 
Aim of the WorkOnly 14 pages are availabe for public view
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Abstract
N
ecrotizing enterocolitis (NEC) is a critical intestinal emergency condition, which mainly occurs in preterm low birth weight infants.
Necrotizing enterocolitis (NEC) is the most devastating gastrointestinal disease in neonates. The pathogenesis of NEC is not well defined but evidence strongly suggests that it is multifactorial. Prematurity and enteral feeding are major risk factors for NEC. An excessive inflammatory response by the immature intestine to external stimuli, impaired intestinal barrier integrity and/or abnormal bacterial colonization are key factors implicated in pathophysiology of NEC.
In Egypt, the incidence of feeding intolerance 2.6%, incidence of NEC is 9.6% with a mortality rate 20-30%.
One of the key inflammatory mediators associated with NEC is Platelet activating factor (PAF). Platelet activating factor receptor (PAFR) blockade or enhanced intestinal PAF degradation via PAF acetylhydrolase (PAF-AH) supplementation reduces the incidence of NEC. We hypothesized that the protective effect of PUFA on NEC may be due to the ability of PUFA to suppress platelet-activating factor receptor (PAFR) gene expression.
Premature infants are at increased risk of NEC because Long chain poly unsaturated fatty acids (LCPUFA) accretion occurs primarily during the last trimester of pregnancy, when maternal levels are high and growth and brain development are rapid. The lack of exposure of premature infant’s gut to PUFA is associated with their microbiota and risk for NEC.
DHA supplementation may have beneficial effects on epithelial cell integrity by reducing bacterial or endotoxin translocation and/or reducing mucosal PAF synthesis and receptor activation.
Docosahexanoic acid (DHA) serve as mediator to promote oral tolerance and also modulate developing immune response allowing infants to respond effectively and appropriately to self and pathogenic environmental stimuli. DHA support the colonization of beneficial bacteria and protect against growth of pathogenic bacteria. also significantly reduced PAF receptor and TLR gene expression in intestinal epithelial cells, both play a significant rule in the initiation of NEC.
The purpose of this study is to determine whether DHA is effective in the prevention or reducing severity of necrotizing enterocolitis in preterm/low birth weight neonates.
With this study we are presenting evidence that administration of DHA to preterm infants with NEC may provide a benefit when administered by orogastric pathway in the acute phase. This study demonstrates the feasibility, tolerability and efficacy of daily enteral DHA supplementation for premature infants. Our results should aid in the development of larger multicenter studies aimed at improving both short- and long-term outcomes in premature infants through optimization of daily enteral DHA provision.
We conducted an interventional two armed double blinded randomized control trial during the period from September 2017 to August 2020 in our tertiary level NICU. Our study recruited 80 neonates, they were divided blindly in to two groups (40 each) where; one group was labelled by yellow card and the other by red card. One color was assigned to receive DHA and the other receive the placebo; where their information were kept hidden and unknown till results of lab was received. The nurses were not informed by the type of the medication they give to patients.
Both groups were age and gender matched. Baseline characteristics were compared between the two studied groups. Infants randomized to receive DHA were significantly smaller than infants randomized to the placebo group. The patients were recruited from newly admitted neonates (age at admission were 1.1 and 1.2 days in group A and B respectively.
The neonates were further evaluated clinically by measuring anthropometric measurements at baseline & after 10 days follow-up evaluation.
Our results showed a significant increase in the length of the neonates received DHA than those who received placebo (P=0.000). Additionally, although all other arthropometric measurements have been significantly increased in neonates of DHA at the follow-up evaluation, it was of no significant value when compared with the neonates of the opposite group.
As regards the incidence of feeding intolerance, our results demonstrated a significant statistical improvement among neonates of DHA group; regarding abdominal girth, intestinal sound, gastric residual, passage of stool and modified NEC BELL’S criteria (P < 0.05).
As regard the bleeding profile, it was evaluated for both groups where, it was increased from 1.1 to 1.3 while decreased from 1.3 to 1.2 among neonates of group B and A respectively. The study had significant difference between both groups (P<0.001).
It was of most important to monitor the effect of DHA On sepsis and clinical laboratory including CBC. SNAP score for evaluation of sepsis was evaluated initially and 10 days later for both groups where, it increased from 9.6 to 19.2 among patients of group B and decreased from 14.4 to 8.3 among neonates of group A (P<0.001 and 0.001) respectively. This reflects the improvement of group A. Furthermore, the platelet count also decreased in group B from 199.3 to 123.1 while; it increased from 93.7 to 192.8 among neonates of group A, yielding a high significant difference at further evaluation and demonstrates the improvement occurred in the neonates taking DHA. These findings signify the possible role of DHA during sepsis in preterm infants.
It is worth mentioning that one of the secondary outcome finding in our study was the high statistical difference regarding the length of hospital stay being higher in group B(25.1days) than in group A(22 days) (p=0.02). It was noticed that the length of hospital stay of group A who received DHA was much less than those receiving the placebo.
PAF was measured initially in both group and then after 10 days. It was found that there was a significant decrease in PAF at follow-up evaluation among neonates of group A (decreased from 5611.9 to 3237.6) (P < 0.01), while in group B it was increased from 5048.7 to 5600.3 (P=0.016) indicating the role of DHA in decreasing the severity of NEC in preterm neonates.