Kaltirkawi

A recently published meta-analysis* assessed the overall risk-benefit profile of probiotic use in the preterm infants. The analysis included 77 articles (40 RCTs, 23 cohorts, and 14 case reports), and the pooled estimates of incidence were calculated using random-effects models. Results indicated that: • Among the 20,323 infants exposed to probiotics, there were 8 cases (<0.04%) of "probiotic sepsis”, mainly in ELBW infants and those at risk for bacterial translocation. • Risk-benefit modeling revealed that for each case of probiotic-associated sepsis, an estimated 92 additional cases of clinical sepsis, 62 additional cases of NEC, and 42 additional deaths would be expected in the population NOT receiving probiotics. Given the overwhelming benefit-to-risk ratio, this study supports the use of probiotics in preterm infants. Risk stratification may be appropriate to exclude the most vulnerable subgroups, particularly those at highest risk for bacterial translocation or with severely compromised gut integrity. As diagnostic tools and monitoring capabilities improve, the already rare incidence of probiotic-associated sepsis could be reduced even further. Perhaps it is time to reframe the discussion and move beyond the clinical hesitancy around the probiotic use. After all, is it justifiable to risk 92 additional cases of sepsis, 62 cases of NEC, and 42 deaths to prevent a single case of probiotic-associated sepsis? The data speak clearly…now it's your turn to decide. * Feldman K, Noel-MacDonnell JR, Pappas LB, Romald JH, Olson SL, Oschman A, Cuna AC, Sampath V. Incidence of probiotic sepsis and morbidity risk in premature infants: a meta-analysis. Pediatr Res. 2025 May 13. doi: 10.1038/s41390-025-04072-3. Epub ahead of print. PMID: 40360772. PubMedIncidence of probiotic sepsis and morbidity risk in prema...This study quantifies the risk of probiotic sepsis in preterm infants utilizing a meta-analysis. In over 20,000 exposed infants across 40 randomized trials and 23 observational studies, 8 cases of...

The best approach for managing infants born at 22 weeks' gestation is always a loaded subject. However, some compelling evidence suggests that proactive approach may be the way to go. A cohort study (https://www.nature.com/articles/s41372-018-0248-y) enrolled infants born at 22 weeks' gestation between 2006 and 2015 in two institutions with different care approaches: proactive vs. selective. The proactive center (Uppsala, Sweden; UUCH) provided comprehensive care to all infants (including antenatal corticosteroids, neonatal resuscitation, and intensive care), while the selective center (Nationwide Children’s Hospital, USA; NCH) initiated or withheld treatment based on physician and family preferences. The results were revealing: infants treated at UUCH had significantly higher in-hospital survival rates than those at NCH (53% vs. 8%; P < 0.01). Among the infants receiving proactive care, survival was higher at UUCH compared to NCH (53% vs. 19%; P < 0.05). The conclusion is clear: even when infants were proactively managed at NCH, their survival was lower than those provided proactive care at UUCH. A second study (https://doi.org/10.1016/j.jpeds.2019.08.028) enrolled infants born at 22-25 weeks' gestation between 2006 and 2015, reported about the neurodevelopmental outcomes at 18-22 months of corrected age. The results echoed the Japanese experience: survival to hospital discharge was 78% at 22-23 weeks and 89% at 24-25 weeks. Of the survivors born at 22-23 weeks, 64% had no or mild neurodevelopmental impairments (NDIs), and 76% of those born at 24-25 weeks had no or mild NDIs. Clearly, a proactive approach has improved both survival-to-discharge rates and intact survival.

Thank you for the great work! Here are the links: Nature https://www.nature.com/articles/d41586-023-03974-8 Science https://www.science.org/content/article/what-massive-database-retracted-papers-reveals-about-science-publishing-s-death-penalty Khalid Altirkawi, MD

Integrity matters.pdf

In conditions when reducing feeding volumes and total fluid intakes are deemed necessary, MCT oil may provide some help; they are after all rich in calories. However, NO significant differences in short-term growth markers have been reported for infants fed low versus high MCT formulas. (https://pubmed.ncbi.nlm.nih.gov/33620090/) Moreover, the glucose oxidation in infants fed formulas with high MCT content was reported to be significantly decreased, suggesting that a larger portion of carbohydrate was used in the nonoxidative pathway ( lipogenesis), i. e., it is utilized to generate further fat, not muscle mass or new cells in various tissues. Another concern is that providing large quantities of MCT in the diet, may predispose infants to the deficiency of unsaturated fatty acids and some fat-soluble vitamins. Notably, the caloric value of the MCTs, compared to long-chain triglycerides, is lower. Finally, formulas with MCT have a igher osmolality, therefore, MCT is not recommended as an additive to standard formulas for healthy infants, and its use should be restricted to clearly indicated conditions, such as short bowel syndrome. Intrestingly, formulas designed specifically for preterm infants contain 25% to 50% of total fatty acids as MCT. Whereas, in human milk, MCT constitutes about 8% to 10% of the total fatty acids. All being said, adding more MCT to the diet of a preterm infant, who is already on a formula rich in this type of fat, seems unjustified.