http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, Early Online: 1–8 ! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2015.1017463

REVIEW ARTICLE

Lactoferrin and neonatology – role in neonatal sepsis and necrotizing enterocolitis: present, past and future Deepak Sharma1 and Sweta Shastri2 J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 04/11/15 For personal use only.

1

Department of Neonatology, Fernandez Hospital, Hyderabad, India, 2Department of Pediatrics, ACPM Medical College, Dhule, Maharashtra, India

Abstract

Keywords

Neonatal sepsis and necrotizing enterocolitis (NEC) are two most important neonatal problems in nursery which constitute the bulk of neonatal mortality and morbidity. Inflammatory mediators secondary to sepsis and NEC increases morbidity, by affecting various system of body like lung, brain and eye, thus causing long term implications. Lactoferrin (LF) is a component of breast milk and multiple actions that includes antimicrobial, antiviral, anti-fungal and anti-cancer and various other actions. Few studies have been completed and a number of them are in progress for evaluation of efficacy and safety of LF in the prevention of neonatal sepsis and NEC in field of neonatology. In future, LF prophylaxis and therapy may have a significant impact in improving clinical outcomes of vulnerable preterm neonates. This review analyse the role of lactoferrin in prevention of neonatal sepsis and NEC, with emphasis on mechanism of action, recent studies and current studies going on around the globe.

Lactoferrin, necrotizing enterocolitis, neonatal sepsis

Introduction Neonatal sepsis and necrotizing enterocolitis (NEC) is a night mare for the neonatologist and they are major contributor to morbidity and mortality of the very low birth weight (VLBW) and extremely low birth weight (ELBW) in all neonatal intensive care units, all over the world with reported incidences that are dramatically inspite of the improvements in the level of care and strict aseptic adherence in all nursery [1]. This might be because we are now saving more and more premature neonates in the nursery. Antimicrobial resistance is now emerging as a global and regional threat to public health [2–4]. In a recent study published in Lancet showed that prematurity and neonatal sepsis is a major contributor to infant and under-five mortality [5–7]. Neonatal sepsis means the presence of bacteria in the body fluids which are sterile and it includes blood, urine, cerebrospinal, peritoneal, pleural infections and are classified based on the onset of infection [8,9]. Early onset infection (EOS) occurs within 72 h of life and late-onset sepsis (LOS) occurs after 72 h [10]. Prevention of EOS depends mainly on maternal–perinatal policies [11], but prevention of LOS depends on the health giver as the clinical features of LOS are non-specific, inadequate sensitivity of diagnostic tests and late recognition. The various strategies which has been proven

Address for correspondence: Dr Deepak Sharma, Department of Neonatology, Fernandez Hospital, Hyderabad, India. E-mail: [email protected]

History Received 12 December 2014 Accepted 6 February 2015 Published online 17 March 2015

effective in reducing the incidence of LOS [12] and neonatal sepsis includes hand hygiene practices and prevention of catheter-related bloodstream infections (CRBSI) [12–14]. The other things which has been tried for prevention of sepsis includes lactoferrin prophylaxis [15], the use of heparin for the prevention of CRBSIs, the judicious use of antibiotics and chemoprophylaxis, antibiotic stewardship, restrictive use of cephalosporin [16], fluconazole prophylaxis for prevention of invasive fungal infections [17], the use of specific antistaphylococcal immunoglobulins, selenium [18], early curtailment of antibiotics after sterile cultures, breast milk [19,20] and earlier initiation of colostrum in high risk preterm infants. Some of these studies met with variable success [21]. Necrotizing enterocolitis (NEC) is a devastating gastrointestinal (GI) disease that occurs primarily among prematurely delivered infants [22,23], with an incidence inversely proportionate to gestational age at birth, though few cases of term NEC are also seen though very rarely in nursery [24]. NEC is associated with high morbidity and mortality with mortality rate ranging between 20 and 30%, and neonates who require surgical intervention are at particularly high risk of neonatal death secondary to various complications [25]. Usually, NEC has three types of clinical presentation, i.e. silent, saltatory and catastrophic. The classical triad of NEC includes abdominal distension, pre-feed altered aspirate and blood in stool. The metabolic triad consists of metabolic acidosis, hyponatremia and thrombocytopenia. Classical NEC in preterm neonates presents in a fulminant/catastrophic manner with few antecedent signs and progress rapidly to

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disseminated intravascular coagulation (DIC), multiorgan failure and neonatal death within hours or days of clinical presentation [26–28]. NEC also leads to various long term complications, including short bowel syndrome, systemic infection, parenteral nutrition-associated cholestasis, nutritional deficiency and poor physical growth. It has also been postulated to have long-term neurodevelopmental impairments [29,30]. Many interventions has been tried to prevent NEC which includes probiotics, prebiotics, postbiotics [31], lactoferrin [32], Minimal enteral nutrition (MEN), slow increment in enteral feeds, prolonged fasting in VLBW and ELBW neonates, preventing use of formula feeds and promoting breast milk usage in VLBW and ELBW neonates [33]. Many of these interventions have met with success for prevention of NEC. Lactoferrin (LF), also known lacto-transferrin, is an ironbinding protein, is a normal component of human colostrum, milk, tears and saliva can enhance host defense and may be effective in the prevention of sepsis and necrotizing enterocolitis (NEC) in preterm neonates [34]. LF was identified as a whey protein in 1939 [35], and was isolated and purified from human milk in 1960 [36]. LF is produced mainly from the neutrophils but other cells also contribute to its levels in breast milk. LF is composed of 703 amino acid sequence [37] and action of pepsin on LF in the stomach released a potent microbicide called lactoferricin (LFcin), which is responsible all the properties of lactoferrin [38]. LF is an important component of the human innate immune system and help in the response to infection [39–41]. LF have very high concentration in human milk with human colostrum contains approximate 6 mg/ml and mature breast milk contains around 1 mg/ml, which accounts to approximate 7% of total breast milk protein [42,43]. The other secretion which contains LF includes tears, saliva, cerebrospinal fluid and other secretions like vaginal mucus [44]. LF has broad microbicidal activity which includes antibacterial property against Escherichia coli [45], Staphylococcus aureus [46], Klebsiella pneumoniae, Streptococcus mutans, Pseudomonas aeruginosa [47], Haemophilus influenzae [48], Helicobacter pylori [49], Clostridium difficile [50], Shigella flexnieria [51], antifungal property against Candida albicans [52], anti-cancer properties against head and neck squamous cell carcinoma [53], breast cancer [54], anti-viral properties against HCV [55], HIV [56], antioxidant, regulation of cell growth and differentiation (especially in intestine, bone and hematopoietic tissues), and enzymatic, signal transduction and immunomodulatory properties (Table 1 and Figure 1) [57]. Development of resistance to LF will require multiple simultaneous mutations in structure of LF making it less prone to develop resistant with it [58]. Various mechanism of LF antimicrobial and anti-cancer action has been proposed, out of them few includes cell membrane disruption, iron sequestration, disruption of cell surface expressed virulence proteins, cell membrane damage, prevention of microbial adhesion to host cells and inhibition of formation of biofilm (Table 2) [59]. Bovine lactoferrin (BLF), which has been used in majority of preclinical and clinical trials, shares a high homology with human lactoferrin (HLF) to the tune of 77% when amino-acid

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Table 1. Spectrum of various effects of lactoferrin. Anti-microbial A. Antibacterial 1. Pseudomonas aeruginosa 2. Haemophilus influenzae 3. E. coli 4. Helicobacter pylori 5. Clostridium difficile 6. Shigella flexnieria 7. Staphylococcus aureus 8. Streptococcus mutans 9. Streptococcus pneumoniae 10. Aggregatibacter actinomycetemcomitans 11. Yersinia enterocolitica 12. Listeria monocytogenes

B. Anti-fungal 1. Candida albicans 2. Yeast

C. Antiviral D. Anti-cancer 1. Human Immunodeficiency 1. Head and neck squamous Virus (HIV) cell carcinoma 2. Cytomegalovirus (CMV) 2. Breast cancer 3. Herpes simplex virus (HSV) 3. Colon carcinoma 4. Hepatitis C virus (HCV) 4. Malignant melanoma 5. Rotavirus 5. bronchogenic carcinoma 6. Poliovirus (PV) 7. Respiratory syncytial virus (RSV) 8. Hepatitis B virus (HBV) 9. Parainfluenza virus (PIV) 10. Alphavirus 11. Hantavirus 12. Human papillomavirus (HPV) 13. Feline calicivirus (FCV) 14. Adenovirus 15. Enterovirus 71 (EV71) 16. Echovirus 6 17. Influenza A virus 18. Japanese encephalitis virus 19. Tomato yellow leaf curl virus (TYLCV)

An-cancer

An-bacterial

Immunomodulaon

Lactoferrin An-Viral

Immature gut growth

Bone growth property

An-fungal

Figure 1. The spectrum of lactoferrin.

are compared, and also have the same N-terminal peptide, called lactoferricin, that is responsible for the anti-microbial property [37]. Both these are resist proteolysis by the neonatal digestive tract, bind to specific receptors on enterocytes and may be found intact in stools that are poorly absorbed in the gut and recently fecal LF has been used as a biomarker for

DOI: 10.3109/14767058.2015.1017463

Table 2. Mechanism of action of lactoferrin.

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1. Microbicidal actions of lactoferrin A. Disruption of cell membrane B. Iron sequestration C. Prevention of biofilm formation D. Proteolysis of virulence factors E. Blocks bacterial adhesion to host cells by binding to glycosaminoglycans F. Initiates ‘‘anoikis’’ in which cells containing viable bacteria undergo apoptosis G. Enhances the growth of the normal commensal bifidogenic microflora in the gut. 2. Anti-cancer action A. Cell cycle arrest B. Promotes apoptosis C. Anti-angiogenesis D. Anti-metastasis E. Immune modulation F. Promotes necrosis

severe Clostridium difficile Infection in Hospitalized Patients of geriatric age group [60].

Lactoferrin and NEC Pre-clinical trials done for evaluating the role of lactoferrin in NEC showed that feeding human recombinant LF to neonatal rats before an artificial intestinal infection with Escherichia coli, showed significant reduction in translocation, bacteremia and death [61]. This finding was confirmed in another preclinical trial in which feeding recombinant human LF and Lactobacillus rhamnosus GG (LGG) had more beneficial effect than feeding LGG alone in reducing gut-related translocation after an enteral infection with E. coli and human LF enhanced intestinal colonization with LGG [62]. The first clinical trial was done by Manzoni et al. in 2009 [63]. Since then field of neonatology has seen many trials with positive results of LF in the prevention of neonatal sepsis and NEC. In the first prospective, multicenter, double-blind, placebo controlled randomized trial conducted by Manzoni et al. which was done to see effect of LF on neonatal sepsis as primary outcome, reported that though oral LF alone did not reduced the incidence of NEC (1.9 versus 6%, p ¼ 0.09, but a significant reduction in NEC was noted when LF was given in combination with LGG (n ¼ 0/151 versus n ¼ 10/168, p ¼ 0.002) [63]. In the other study conducted by Ocha et al. which included 190 low birth weight neonates compared Bovine LF with maltodextrin as placebo and reported that for VLBW neonates, the occurrence of NEC was reduced to 50% though the difference was not statistically significant (20% in the BLF group [8/40] versus 40% in the control group [16/40]) [64]. In a recently published well-conducted largest randomized clinical trial in 13 nurseries of Italy and New Zealand, Manzoni et al. evaluated bovine LF supplementation for prevention of NEC in 743 VLBW neonates and they were observed till discharge for any sign and symptom of NEC. The neonates were randomly allotted to three arms which received orally either Bovine LF (BLF; 100 mg/day) alone (group LF; n ¼ 247) or with LGG (at 6  109 CFU/day; group BLF + LGG; n ¼ 238), or placebo arm (Control group; n ¼ 258) after birth until day 30 of life (45 for neonates51000 g at birth). The primary outcome was stage 2

Lactoferrin neonatal sepsis and necrotizing enterocolitis

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NEC; death-and/or stage 2 NEC prior to discharge. They found out significantly reduction in incidence of NEC in both the groups of BLF and BLF + LGG [5/247 (2.0%) and 0/238 (0%), respectively] against the control arm [14/258 (5.4%)] (RR ¼ 0.37; 95% CI: 0.136–1.005; p ¼ 0.055 for BLF versus control; RR ¼ 0.00; p50.001 for BLF + LGG vs. control). The incidence of death-and/or NEC was significantly lower in both treatment groups (4.0 and 3.8% in BLF and BLF + LGG versus 10.1% in control; RR ¼ 0.39; 95% CI: 0.19–0.80; p ¼ 0.008. RR ¼ 0.37; 95% CI: 0.18–0.77; p ¼ 0.006, respectively). This study concluded that when compared with placebo, BLF supplementation alone or in combination with LGG reduced the incidence of stage 2 NEC and of deathand/or  stage 2 NEC in VLBW neonates, hence favoring the use of BLF to prevent NEC [65]. These results are promising and give hope for prevention of NEC but we need to wait for many trials which are going around the globe (Table 3).

Lactoferrin and neonatal sepsis Late-onset sepsis (LOS) is an increasing concern in nursery all over the world, be it either developed countries or developing countries, and is associated with high morbidity and mortality. The LOS is also responsible to cause severe late neuro-developmental impairment [66,67]. In the first study conducted by Manzoni et al. for evaluating the role of BLF in prevention of LOS in VLBW, enrolled 472 VLBW neonates, which were divided randomly in three arms, to receive orally either BLF (100 mg/d) alone (n ¼ 153), or BLF plus LGG (6  109 colony-forming units/d; n ¼ 151), or placebo (n ¼ 168) from birth until day 30 of life (day 45 for neonates51000 g at birth). They reported the incidence of LOS occurred less frequently in the BLF and BLF plus LGG group than in the control group (RR 0.34, 95% CI: 0.17–0.70, p ¼ 0.002 for BLF versus control; RR 0.27, 95% CI: 0.12–0.60, p ¼ 0.001 for BLF plus LGG versus control). LOS was significantly decreased in ELBW neonates (RR 0.31, 95% CI: 0.14–0.70; p ¼ 0.002 for BLF versus control and RR ¼ 0.30, 95% CI: 0.13–0.69; p ¼ 0.002 for BLF plus LGG versus control), whereas no significant difference was seen in neonates weighing 1001–1500 g. Neonatal death secondary to neonatal sepsis was significantly lower in VLBW neonates when supplemented with BLF [63]. In the secondary analysis of this study done to see effect of BLF on fungal sepsis, though Manzoni et al. reported similar fungal colonization rates in both treatment and control groups but invasive fungal infection occurred less in both intervention groups (p ¼ 0.004 in BLF and p ¼ 0.07 in BLF plus LGG) [68]. In the first study conducted form our country and from developing countries, Kaur et al. randomized 121 low birth weight neonates with birth weight less than 2000 g within first 12 h of life to either BLF or placebo group. BLF was supplemented until day 28 of life. The reported significant reduction in the incidence of LOS in the BLF group when compared with placebo group [n ¼ 2/59 versus n ¼ 9/62, p ¼ 0.033). They also reported a trend towards lower neonatal mortality secondary to neonatal sepsis in the intervention group (n ¼ 0/59 versus 5/62, p ¼ 0.058). They also reported decreasing trend in incidence of fungal sepsis in BLF group in comparison to control group [69]. The Peruvian study

Oral lactoferrin supplementation for prevention of sepsis in preterm neonate; NCT01821989

Trial of lactoferrin for prevention of infections in very premature babies (LACUNA); ISRCTN66482337

Lactoferrin Infant Feeding Trial (LIFT) to prevent sepsis and death in preterm infants; ACTRN12611000247976

2

3

4

Study

Enteral LactoFerrin In Neonates (ELFIN); ISRCTN88261002

1

Serial no

Primary outcome 1. Evaluate the effectiveness of oral LF in preventing cultureproven neonatal sepsis Secondary outcome 1. Complete blood count with differential leucocytic count. 2. Compare two dose regimen of LF supplementation 3. Study effect of LF supplementation on serum iron stones Primary outcome 1. Death or at least one Health-care associated infections before discharge home. 2. Tolerance of LF Secondary outcome 1. Infections per 1000 patient day 2. NEC 3. Surgical intervention for NEC 4. Death ascribe to acute effects of sepsis Primary outcome 1. Incidence of sepsis or brain injury or chronic lung disease or NEC or severe retinopathy Secondary outcome 1. Death related to culture-proven sepsis

Placebo in form of distilled water

Milk without LF

Breast milk or formula without BLF until 34 weeks corrected age or discharge

Two arms: LF 100 mg/ kg daily OR LF 150 mg/kg twice daily. Unspecified duration

Bovine LF 100 mg/day, 2 doses per day until 36 weeks gestational age or discharge

Bovine LF 200 mg/kg/ day until 34 weeks corrected age or discharge

Neonates with birth weight between 500 and 2500 g and less than 36 weeks of gestational age and admitted to the NICU in the first 48 h of age (n ¼ 180) Neonates with a gestational age of 23–30.6 weeks admitted to the NICU in the first 48 h of age (n ¼ 79)

Neonates with a birth weight less than 1500 g and gestational age of 22–28 weeks in the first 7 days of age (n ¼ 1100)

Outcome Primary outcome 1. Culture-proven or clinically suspected LOS from trial entry until discharge. Secondary outcome 1. All-cause mortality prior to hospital discharge 2. NEC: Bell’s stage II or III 3. Severe retinopathy of prematurity treated medically or surgically 4. Bronchopulmonary dysplasia 5. A composite of invasive infection, major morbidity and mortality. 6. Total number of days of administration of antibiotics per infant from 72 h until death or discharge from hospital 7. Total number of days of administration of antifungal agents per infant 8. Total length of stay until discharge home 9. A range of health economic outcomes

Control group Milk with placebo

Intervention group Bovine LF 150 mg/kg/ day (maximum: 300 mg) until discharge

Population Neonates with gestational age less than 32 weeks in the first 72 h of age (n ¼ 2200)

Table 3. Table showing various lactoferrin studies which are in progress across the world (registered trials).

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Supplementation with lactoferrin in preterm newborns (lactoprenew); NCT01172236

Effect of prebiotic or lactoferrin supplementation in formula on the gut flora of preterm infants ISRCTN71737811

Lactoferrin for prevention of sepsis in infants (NEOLACTO); NCT01525316

Lactoferrin prophylaxis in VLBW; NCT01287507

Pilot study: lactoferrin for prevention of neonatal sepsis (NEOLACTO); NCT01264536

6

7

8

9

10

Primary outcome 1. Reduction in incidence of culture-proven and CRP elevated LOS Secondary outcome 1. NEC 2. Length of stay 3. Mortality during hospitalization Primary outcome 1. Evaluate the antioxidant effect of LF and its ability to reduce free radicals related diseases in the newborn (neurodevelopment follow-up 12 months). Secondary outcome 1. Identify the panel of markers for assessing oxidative stress Primary Outcome 1. Composition of gut flora 2. Incidence of infections 3. Oxidative stress and iron status Secondary outcome 1. Growth (head circumference, length, weight) at 6 months 2. Psychomotor development at 12 months Primary outcome 1. First-episode of LOS or sepsis- associated death Secondary outcome 1. Neurodevelopment at 24 month of corrected age

Primary outcome 1. Effect of oral LF in culture-proven sepsis 2. Effect of oral LF in NEC Secondary outcome 1. Safety of LF in VLBW infants: effect on feeding tolerance, abdominal distension, vomiting and gastric residuals 2. Duration of hospitalization Primary outcome 1. Number of confirmed episodes of LOS Secondary outcome 1. Incidence of Gram-positive and Gram-negative bacterial and fungal bouts of sepsis, pneumonia, diarrhea and mortality in first month of life

Placebo (not mentioned)

Standard therapy

Standard preterm formula without addition of prebiotics or LF for 6 weeks after start of full enteral feeds Maltodextrin 200 mg/ kg/day, three times per day for 8 weeks

Oral saline daily till discharge

Maltodextrin 200 mg/ kg/day, three times per day for 4 weeks

Talactoferrin alfa (recombinant human LF) (enteral) 300 mg/ kg/day, twice per day, from birth to 29 days of life Bovine LF 100 mg/day and standard therapy. Unspecified duration

Standard preterm formula with addition of GOS OR Standard preterm formula with LF 1 mg/100 ml/day, for 6 weeks after start of full enteral feeds Bovine LF 200 mg/kg/ day, three times per day for 8 weeks

Bovine lactoferrin 200 mg/day till discharge

Bovine LF 200 mg/kg/ day, three times per day for 4 weeks

Neonates with a birth weight between 750 and 1500 g in the first 24 h of age (n ¼ 120)

Neonates with a birth weight below 1500 g or gestational age between 23 and 32 weeks (n ¼ 1300) Neonates of gestational age between 26 and 35.6 weeks admitted to the NICU or High Care Unit of the hospital (n ¼ 80) Neonates with a birth weight between 500 and 2000 g admitted to the NICU in the first 72 h of age (n ¼ 414) Neonates with birth weight less than 1500 g and less than 32 weeks of gestational age (n ¼ 50)

Neonates with a birth weight between 500 and 2500 g admitted to the NICU in the first 72 h of age (n ¼ 190)

CRP, C-reactive protein; GOS, galacto-oligosaccharides; LF, lactoferrin; LOS, late-onset-sepsis; NEC, necrotizing enterocolitis; NICU, Neonatal Intensive Care Unit; VLBW, very-low birth weight.

Study of talactoferrin oral Solution for nosocomial infection in preterm infants; NCT00854633

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Lactoferrin neonatal sepsis and necrotizing enterocolitis 5

Lactoferrin for prevention of sepsis in Peruvian neonates [64]

Bovine lactoferrin supplementation for prevention of necrotizing enterocolitis in very-lowbirth-weight neonates: a randomized clinical trial [65]

A pilot study of Biotene OralBalanceÕ gel for oral care in mechanically ventilated preterm neonates [71]

Oral lactoferrin to prevent nosocomial sepsis and NEC of premature neonates and effect on T-regulatory cells [70].

3

4

5.

6

Timed oral care with Biotene OralBalanceÕ gel

200 mg LF daily till discharge

41 neonates born before 28 weeks of gestation and mechanically ventilated between 7 and 10 postnatal days. 50 neonates either VLBW or born before 32 weeks

Neonates received orally administered Bovine Lactoferrin (BLF; 100 mg/d) alone (n ¼ 247), BLF plus Lactobacillus rhamnosus GG (LGG) (6  109 colony forming units/d) (n ¼ 238), or placebo (n ¼ 258) from birth until day 30 of life (day 45 for neonates 51000 g at birth).

743 VLBW neonates

Control group received placebo. Third group healthy neonates [16]

Timed oral care with sterile water

Control group received placebo

Significant reduction in sepsis episodes in intervention group.

No significant differences in mortality or short-term outcomes. Significant shorter length of hospital stay and lower rate of VAP.

NEC incidence was significantly reduced in BLF and BLF + LGG groups. Incidence of death-and/or NEC was significantly lower in both treatment groups.

Reduction in incidence of neonatal sepsis and NEC in intervention group. Control group received placebo (maltodextrin) enterally at 200 mg/d into three divided doses over the first four weeks of life

BLF was given enterally at 200 mg/d into three divided doses over the first four weeks of life.

190 low birth weight (LBW) neonates

Incidence of first episode of culture proven LOS significantly lower in the BLF group.

Control group (n ¼ 62) received placebo daily from first to 28th day of life.

Bovine Lactoferrin [BLF] (n ¼ 59) was supplemented daily from first to 28th day of life.

121 low birth weight (52000 g) neonates

Outcome Significant reduction of incidence of LOS in both the intervention group in compare to control group. Both fungal and bacterial sepsis decreased.

Control group Control group received placebo (2 mL of a 5% glucose solution)

Intervention group Neonates received orally administered Bovine lactoferrin (BLF; 100 mg/d) alone (n ¼ 153), BLF plus Lactobacillus rhamnosus GG (LGG) (6  109 colony forming units/d) (n ¼ 151), or placebo (n ¼ 168) from birth until day 30 of life (day 45 for neonates 51000 g at birth).

Population 472 very low birth weight (VLBW) neonates

D. Sharma et al.

LOS, Late onset sepsis; LBW, low birth weight; NEC, necrotizing enterocolitis; VLBW, Very low birth weight.

Efficacy of bovine lactoferrin supplementation in preventing late onset sepsis in low birth weight neonates: randomized placebo controlled clinical trial [69].

2

Title

Bovine lactoferrin Supplementation for prevention of late onset sepsis in very low birth-weight neonates: a randomized trial [63].

1

Serial number

Table 4. Table showing various lactoferrin studies completed in neonatology.

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conducted by Ocha et al. also reported reduction in the cumulative incidence of sepsis in the BLF group as compared with placebo group [64], hence raising our hope for control of neonatal sepsis. In a recently published randomized control trial, Akin et al. evaluated the use of oral LF for prevention of nosocomial sepsis in premature neonates and to see the effect on Tregulatory cells. They enrolled total 50 neonates either VLBW or born before 32 weeks, 25 in either group with control received placebo and control received 200 mg BLF daily throughout hospitalization. The primary outcome was episodes of culture proven nosocomial sepsis and NEC. There were reduction in episodes of sepsis in intervention arm (4.4 versus 17.3/1000 patient days, p ¼ 0.007), though not significant statistically. Hence the authors concluded that LF prophylaxis reduced nosocomial sepsis episodes [70]. In a pilot study conducted by Stefanescu et al. evaluated the feasibility of Biotene gel for oral care in mechanically ventilated preterm neonates. Biotene gel contains lactoferrin as a component. Forty-one neonates who were born before 28 weeks of gestation, and were mechanically ventilated between 7 and 10 postnatal days, were randomized to receive timed oral care with Biotene OralBalanceÕ gel or sterile water. Neonates of either of the group were treated with a standard bundle of procedures to reduce the risk of ventilator associated pneumonia (VAP). They reported lower rate of VAP in the intervention group, although the difference was not statistically significant [71]. All the studies have been summarized in Table 4. The other uses of lactoferrin in field of perinatology includes its role in retinopathy of prematurity, bronchopulmonary dysplasia [59], prevention of preterm delivery [72–74] and in treatment of iron deficiency anemia of pregnancy [75].

Conclusion LF has multiple effects on various antimicrobials and can be very helpful for the field of neonatology. LF prophylaxis can supplement the breast milk in the conditions where either breast milk cannot be fed to neonate or is not available. All the evidences till now show that LF enhances immunity in neonates. A review published by Cochrane advised for further studies for evaluating the effect of LF on NEC and sepsis [76,77]. All the above-mentioned trials and trials which are going on throughout the world give us a hope that LF can be very helpful in the field of perinatology. Only future hold the key about LF in neonatology.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

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