The gut microbiota and SES in preterm infants in the Chicago area - - PowerPoint PPT Presentation

Erika C. Claud, MD Professor Departments of Pediatrics Section of Neonatology Director of Neonatology Research The University of Chicago

The gut microbiota and SES in preterm infants in the Chicago area

Prematurity

• What is full term?
• What is prematurity?
• What is the limit of viability?

37-40 weeks gestation < 37 weeks gestation 22-23 weeks gestation

Prematurity

Full Term, 40 weeks Premature, 23 weeks

Smallest Survivor

Birth weight 8.6 oz 12 oz.

450 450 -

• 500

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900 901- 901- 1000 1000

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Su Surv rviv ival al vs vs Birth Birth Weigh Weight for for EL ELBW W Infants Infants

Birth Birth Weigh Weight (g) (g) Su Surv rviv ival al (% (%)

William Meadow, MD PhD

• Dept. of Pediatrics and MacLean Center for Clinical Medical Ethics

The University of Chicago

1 2 3 4 5 7 10 14 21 10 20 30 40

Day Day of

• f Deat

Death for for EL ELBW BW No Non- n-Survi urvivo vors rs

Day of Death Non-Survivors (%)

William Meadow, MD PhD

• Dept. of Pediatrics and MacLean Center for Clinical Medical Ethics

The University of Chicago

<500 <500 gms gms 5 0 1 - 6 2 5 5 0 1 - 6 2 5 626-750 626-750 7 5 1 - 8 7 5 7 5 1 - 8 7 5 8 7 6 - 1 0 0 0 8 7 6 - 1 0 0 0 20 20 40 40 60 60 80 80 100 100

Su Survival rvival as as a a function function of

• f birt

birthweigh weight for for all all patients patients alive alive on

• n Da

Day y 4 4 (n (n = = 249) 249)

Birthwe Birthweight ight (gms (gms) % % Su Surv rviv ival al

William Meadow, MD PhD

• Dept. of Pediatrics and MacLean Center for Clinical Medical Ethics

The University of Chicago

Born too soon… The Preterm Infant

Disproportionately account for: 40% of children who have cerebral palsy (CP) 25% of children with hearing impairment 35% of those with vision impairment.

• 12% of births

NICU Delayed Feeding Antibiotics Breast Milk vs. Formula Instrumentation Opioids H2 Blockers

The NICU

Like the canary in the coal mine—or asthmatics in air pollution studies—children born preterm may serve as a sentinel population owing to increased susceptibility to the sometimes modest effects of common toxicants, improving study power and decreasing necessary sample size.

Necrotizing Enterocolitis (NEC)-

Inflammatory bowel necrosis that primarily afflicts premature infants after the initiation of enteral feeding.

Risk Factors

• Prematurity
• Bacterial Colonization
• Enteral Feeding
• Hypoxia/Altered intestinal blood flow

NEC and Neurologic Outcome

Neurodevelopmental and Growth Outcomes of Extremely Low Birth Weight Infants after NEC Hintz, et al Pediatrics 2005

Multicenter, retrospective analysis 1995-1998 Infants in NICHD Neonatal Network <1000gm 5553 ELBW entered into registry 2948 infants evaluated at 18 and 22 months 124 – surgically managed NEC 121 – Medically managed NEC

Hintz, S. R. et al. Pediatrics 2005;115:696-703

Neurodevelopmental Outcome associated with NEC

SurgNEC PVL 14% vs. 7% BPD 57% vs. 43% CP 24% vs 15% Decreased growth all parameters

Hypothesis:

Enteral feeding results in colonization of the uniquely susceptible premature intestine with pathogenic bacteria, resulting in an exaggerated inflammatory response.

FASEB 2001; 15: 1398-1403

Question:

• Can microbiome analysis be used to identify the

pathogenic bacteria associated with NEC?

Methods:

• 20 patients – 10 with NEC 10 control
• 4 sets of twins
• Analysis of fecal samples prior to onset of NEC by

16S rRNA sequencing

Bacterial Diversity and NEC

Wang et al ISME 3(8):944-54, 2009.

Bacterial Colonization and NEC

Wang et al ISME 3(8):944-54, 2009.

Wang et al ISME 3(8):944-54, 2009.

Bacterial Colonization and NEC

Shift in Microbiome

Claud et al. Microbiome, 2013

Temporal progression of the preterm infant microbiota

Claud et al. Microbiome, 2013

Modification of the early microbiome and NEC

0.02 0.04 0.06 0.08 0.1 0.12 0.14 0.16 0.18 control probiotics prolonged abx <5 days abx control any breast milk

Absolute risk difference .02 NNT - 48 Absolute risk difference .03 NNT - 32 Absolute risk difference .04 NNT – 25 (death or NEC)

Risk of NEC

AlFaleh K and Anabrees J The Cochrane Collaboration 2014; Cotten et al Pediatrics 2009 January; 123: 58-66; Meinzen-Derr et al J Perinatol 2009 January; 29 (1): 57-62

Prematurity

Full Term, 40 weeks Premature, 23 weeks

Host development coincides with microbiome development

Pediatrics 2006

500 1000 1500 2000 2500 3000 2 4 6 8 10 Weight in grams Week of life

MPI-L MPI-H MPI-H MPI-L

Preterm Infant Microbiota (MPI)

Transfer of infant microbiome to germ free mice

Germ free pregnant dam C57/Bl6 Daily weight

Fecal lysate from infant

Litter Wean

2 4 6 8 10 10 20 30 Weight in grams Day of life

500 1000 1500 2000 2500 3000 2 4 6 8 10 Weight in grams Week of life

MPI_L MPI_H

Inflammatory Response Related Networks

MPI-L MPI-H

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LTA TNFa VCAM1 TLR9 TLR5 FOXP3 MCP-1 IFNg CXCL2 CXCL10 TLR4 IL6 IL1b PPARg ICAM1 Relative mRNA expression levels in MPI-L and MPI-H ileum

PCR validation of Microarray Intestine

Cytokine Expression

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IL-1b IL-4 IL-6 IL-10 TNFa IL-18 GM-CSF IFN-g VEGF Cytokine unit/ 0.1ml serum Ileum lysates

Serum

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IL-1b IL-4 IL-6 IL-10 TNFa IL-18 GM-CSF IFN-g VEGF

MPI-L MPI-H GF – GermFree SPF

pNFkB p65 GF MPI-L MPI-H SPF

Labeling index for pNFkB p65 nuclear translocation

20 40 60 MPI-L MPI-H SPF GF

NF-κB Activation

GF

Magnification 40x

VCAM-1 MCP-1 MPI-L MPI-H SPF

NF-κB Dependent Cytokines

Inflammation and Prematurity

BPD ROP NEC PVL

Neurodevelopmental Outcome in Preterm infants

Morbidities

• 1. Bronchopulmonary

dysplasia

• 2. Necrotizing Enterocolitis
• 3. Intraventricular

Hemorrhage

• 4. Periventricular

Leukomalacia

• 5. Retinopathy of

Prematurity

• 6. Sepsis

Neurodevelopmental Impairment at Age 2

GAPDH NeuN

Regulation of cortex neuronal development by gut microbiota.

A. DAPI NeuN B.

11/16/17

SPF GF

1 2 1 2 1 2 1 2 3 3 3 3

MPI-L MPI-H SPF GF MPI-L MPI-H

DAPI MBP SP F GF

1 2 1 2 1 2 1 2

GAPDH MBP

Regulation of cortex myelination by gut microbiota.

A. B.

11/16/17

3 3 3 3

SPF GF MPI-L MPI-H MPI-L MPI-H

IGF1

• We have established that certain microbiota colonization

normalized the growth in GF mice (M2).

• Mutation(s) in the igf-1 gene or in the igf1r gene are found to

be associated with severe body growth failure, microcephaly, and developmental delay.

• In rodents, igf-1 gene disruption results in reduced brain size,

CNS hypomyelination and loss of hippocampal granules and striatal parvalbumin-containing neurons.

• GF mice have lower circulating IGF-1 comparing to SPF mice.
• IGF1 crosses the blood brain barrier

Hypothesis

• Microbial colonization can modulate brain

development through regulation of IGF1.

G F M P I

• L

M P I

• H

1 0 0 2 0 0 3 0 0 4 0 0 5 0 0

S e ru m IG F -1 2 w e e k s

IG F -1 (n g /m L )

G F M P I-L M P I-H 1 0 0 2 0 0 3 0 0 4 0 0 5 0 0

S e ru m IG F -1 4 w e e k s

IG F -1 (n g /m L )

A B

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Microbiome influences serum IGF-1

G F M P I-L M P I-H 2 0 4 0 6 0 8 0

B ra in IG F -1 2 w e e k s

IG F -1 (n g /m l)

G F M P I-L M P I-H 2 0 4 0 6 0 8 0

B ra in IG F -1 4 w e e k s

IG F -1 (n g /m l)

A B

G F M P I-L M P I-H 0 .0 0 0 0 .0 0 1 0 .0 0 2 0 .0 0 3 0 .0 0 4 0 .0 0 5

Ig f1 tra n s c rip ts 2 w e e k s

Igf1 m R N A re la tiv e to G a pdh

G F M P I-L M P I-H 0 .0 0 0 0 .0 0 1 0 .0 0 2 0 .0 0 3 0 .0 0 4 0 .0 0 5

Ig f1 tra n s c rip ts 4 w e e k s

Igf1 m R N A re la tiv e to G a pdh

C D

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Alterations in brain IGF-1

G F M P I-L M P I-H 0 .0 0 0 0 .0 0 2 0 .0 0 4 0 .0 0 6 0 .0 0 8

Ig f1 r tra n s c rip ts 2 w e e k s

Ig fr1 m R N A re la tiv e to G a pdh

G F M P I-L M P I-H 0 .0 0 0 0 .0 0 2 0 .0 0 4 0 .0 0 6 0 .0 0 8

Ig f1 r tra n s c rip ts 4 w e e k s

Ig fr1 m R N A re la tiv e to G a pdh

G F M P I-L M P I-H 0 .0 0 0 .0 1 0 .0 2 0 .0 3 0 .0 4

Ig fb p 3 tra n s c rip ts 2 w e e k s

Igfbp3 m R N A re la tiv e to G a pdh

G F M P I-L M P I-H 0 .0 0 0 .0 1 0 .0 2 0 .0 3 0 .0 4

4 w k s ig fb p 3 tra n s c rip ts

Igfbp3 m R N A re la tiv e to G a pdh

E F G H

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Alterations in brain IGF1r and IGFBP3

Effect of socioeconomic status on Neurodevelopment

Microbiome?

Patrianakos-Hoobler et al Dev Med Child Neurol. 2010 Apr;52(4):379-85

The microbiome as a potential mediator of socio-economic disparities in preterm infant neurodevelopmental trajectories from NICU discharge to school age The means by which poverty alters neurodevelopment are unknown. The microbiome is influenced by environment and in turn influences brain development. We hypothesize that the microbiome is a biologic effector of the influence of SES and environment on neurodevelopment.

Broaden Scope

Impact The Microbiome is Modifiable

Acknowledgments

Lei Lu, MD Jing Lu, PhD Ellen Yu, MS Jeanette Hoenig, MD Paula Osterhout, MD Nicole Grady, MD Lauren Astrug, MD Christina Kim, MD Elizabeth Humphrey, MD candidate DDRCC Eugene B. Chang, MD Dionysios Antonopoulos, PhD Funding: NIH, March of Dimes, and The Comer Children’s Hospital Women’s Board Bree Andrews, MD MPH Chase Corbin, MS Jack Gilbert, PhD Robert Goerge, PhD James Heckman, PhD Michael Msall, MD Sam Volchenboum, MD, PhD, MS Leidy Guttierez, MSc Sarah Holtschlag, MSW, LSW

The ECHO Team