England have been dealt another forward injury blow after No 8 Alex Matthews was ruled out of the final two matches of the Women's Six Nations.
The double World Cup winner is to undergo surgery this week on the shoulder damage sustained in the 33-12 victory over Ireland in round one, preventing her from facing Italy on Saturday or France in the likely title decider a week later.
Lilli Ives Campion and Sadia Kabeya are continuing their rehab in camp in the hope of being available for the visit to Bordeaux on May 17, while Hannah Botterman and Morwenna Talling are also in the treatment room.
Furthermore, Zoe Stratford, Abbie Ward, Lark Atkin-Davies and Rosie Galligan are missing due to pregnancy.
The absences have not halted England's charge through the tournament with their 62-24 victory over Wales in round three a 36th successive win.
Ellie Kildunne returns to the left wing against Italy in Parma with Emma Sing restored at full-back and Mia Venner appearing on the right wing for her fourth cap. Zoe Harrison replaces Holly Aitchison at fly-half.
Australian-born Haidee Head is set to make her debut after being named on the bench as back row cover, while rookie Bristol duo Delaney Burns and Demelza Short continue in the back row.
"We've built momentum throughout this tournament by stacking strong moments together and that will be crucial again this weekend," head coach John Mitchell said.
"Italy will be full of confidence after their result against Scotland (winning 41-14) and they'll challenge us in different ways.
"For us, it's about staying locked in on our key actions - applying pressure and intentionally attacking the space with speed.
"Ultimately, it always comes down to showing courage in the moments that matter."
England: E Sing (Gloucester-Hartpury); M Venner (Gloucester-Hartpury), M Jones (Trailfinders Women, capt), H Rowland (Loughborough Lightning), E Kildunne (Harlequins); Z Harrison (Saracens), L Packer (Harlequins); K Clifford (Saracens), A Cokayne (Sale Sharks), M Muir (Gloucester-Hartpury), A Burton (Trailfinders Women), D Burns (Bristol Bears), D Short (Bristol Bears), M Packer (Saracens), M Feaunati (Exeter Chiefs).
Replacements: C Powell (Harlequins), M Carson (Gloucester-Hartpury), S Bern (Bristol Bears), H Lutui (Loughborough Lightning), H Head (Trailfinders Women), F Robinson (Exeter Chiefs), H Aitchison (Sale Sharks), C Moloney-MacDonald (Exeter Chiefs).
