Surgical decision making in necrotizing enterocolitis and focal intestinal perforation: predictive value of radiologic findings

Decision-making in surgical neonatal necrotizing enterocolitis

AIM

To know whether laboratory or clinical parameters can predict disease progression, need for laparotomy in patients managed with peritoneal drain and mortality in surgical neonatal necrotizing enterocolitis patients.

MATERIALS AND METHODS

The study was retrospectively carried out on 27 neonates over a period of one and a half year. All neonates who had surgical neonatal necrotizing enterocolitis in the form of bowel perforation, positive paracentesis, abdominal wall erythema and abdominal lump were included. Patients with Bell's stage I and those developing enterocolitis after surgery were excluded. The patients were evaluated with parameters, namely, clinical, laboratory and radiological. These included age and stage at presentation, primary symptom/sign at presentation with laboratory parameters of blood counts, pH, base deficit, platelet counts, electrolytes and random blood sugar levels. A comparison was done between survivors and nonsurvivors, patients with primary peritoneal drainage versus those requiring laparotomy after drain, Bell' stage II versus III patients and operated versus nonoperated patients. Statistical significance was observed in the above mentioned comparisons.

RESULTS

There were 22 male and 5 females patients with mean birth weight of 1.85 kg. Age at presentation ranged from 2 to 19 days, mean 9.25 days. Mortality was 37% (10/27). Majority of the stage II patients presented with feed intolerance and abdominal distension. The neonates with severe disease had abdominal distension with wall erythema. Sixty percent of the patients had shock at the time of admission. In the comparison of peritoneal drain only and patients with peritoneal drain followed by laparotomy patients, it was observed that neonates who were acidotic and had higher base deficit had more chances of requirement of laparotomy. They also had progressive fall in platelets counts. There was no difference in the birth weight, gestational age, total counts, serum electrolytes, blood sugar and other measured parameters; thus, these carry negligible predictive value to judge deteriorating neonate. In the remaining of the comparison, patients not presenting with shock were more likely to survive.

CONCLUSION

In the present study, neonate with persistently low pH, higher base deficit and presentation with shock predicted need for laparotomy in drain managed patients as well as chances of survival.

Radiographic predictors of disease severity in neonates and infants with necrotizing enterocolitis

OBJECTIVE

The objective of our study was to validate a radiographic scale, the Duke abdominal assessment scale (DAAS), as a tool for predicting the severity of disease in neonates and infants with suspected necrotizing enterocolitis (NEC).

MATERIALS AND METHODS

Study group patients (n = 43) underwent at least two two-view abdominal radiographic series within 48 hours of surgical intervention for suspected NEC complications. Control group patients (n = 86) were patients with suspected NEC who did not undergo surgery for suspected NEC complications. DAAS scores were assigned by two pediatric radiologists with 20 and 6 years' experience.

RESULTS

The initial radiographs of 26 of 43 (60.5%) patients in the study group showed fixed bowel loops (10/43, 23.3%), highly probable or definite pneumatosis (9/43, 20.9%), or portal venous gas (7/43, 16.3%). These findings had progressed to pneumoperitoneum on the follow-up series in 20 (46.5%) study group patients. Among the control group, three patients (3.5%) had highly probable or definite pneumatosis, and none had fixed bowel loops, portal venous gas, or pneumoperitoneum. Patients with higher DAAS scores were more likely to undergo surgical intervention than patients with lower scores (odds ratio, 1.69; 95% CI, 1.40-2.03). A receiver operating characteristic curve analysis showed good overall performance (c statistic = 0.83) for predicting eventual surgical intervention in the study group with higher DAAS scores.

CONCLUSION

The DAAS provides a standardized 10-point radiographic scale that increases with disease severity when using need for surgical intervention as a surrogate for severe NEC. For every 1-point increase in the DAAS score, patients were statistically significantly more likely to have severe disease as measured by need for surgical intervention.

Necrotizing enterocolitis--bench to bedside: novel and emerging strategies

Necrotizing enterocolitis (NEC) is a devastating illness that predominantly affects premature neonates. The mortality associated with this disease has changed very little during the last two decades. Neonates with NEC fall into two categories: those who respond to medical management alone and those who require surgical treatment. The disease distribution may be focal, multifocal, or panintestinal. Surgical treatment should therefore be based on disease presentation. Recent studies have added significant insight into our understanding of the pathogenesis of NEC. Several groups have shown that upregulation of nitric oxide plays an integral role in the development of epithelial injury in NEC. As a result, some treatment strategies have been aimed at abrogating the toxic effects of nitric oxide. In addition, several investigators have reported the cytoprotective effect of epidermal growth factor, which is found in high levels in breast milk, on the intestinal epithelium. Thus, fortification of infant formula with specific growth factors could soon become a preferred strategy to accelerate intestinal maturation in the premature neonate to prevent the development of NEC. One of the most devastating complications of NEC is the development of short bowel syndrome (SBS). The current treatment of SBS involves intestinal lengthening procedures or bowel transplantation. A novel emerging method for treating SBS involves the use of tissue-engineered intestine. In laboratory animals, tissue-engineered small intestine has been shown to be successful in treating intestinal failure. This article examines recent data regarding surgical treatment options for NEC as well as emerging treatment modalities.

Evidence vs experience in the surgical management of necrotizing enterocolitis and focal intestinal perforation

INTRODUCTION

Necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) are neonatal intestinal emergencies that affect premature infants. Although most cases of early NEC can be successfully managed with medical therapy, prompt surgical intervention is often required for advanced or perforated NEC and FIP.

METHODS

The surgical management and treatment of FIP and NEC are discussed on the basis of literature review and our personal experience.

RESULTS

Surgical options are diverse, and include peritoneal drainage, laparotomy with diverting ostomy alone, laparotomy with intestinal resection and primary anastomosis or stoma creation, with or without second-look procedures.

CONCLUSIONS

The optimal surgical therapy for FIP and NEC begins with prompt diagnosis and adequate fluid resuscitation. It appears that there is no significant difference in patient outcome based on surgical management alone. However, the infant's weight, comorbidities, surgeon preference and timing of intervention should be taken into account before operative intervention.

A case of necrotizing enterocolitis associated with adenovirus infection in a term infant with 22q11 deletion syndrome

Infections with adenoviruses are a common problem in the pediatric population. Normally asymptomatic to mild, those infections tend to take a more severe course in immunocompromised patients. 22q11 deletion syndrome (22q11DS) represents a common genetic disorder causing immunodeficiency from thymic hypoplasia or aplasia, heart defects, a characteristic facial appearance, and velopharyngeal dysfunction. Necrotizing enterocolitis (NEC) is a frequent gastrointestinal emergency observed in neonatal intensive care units. The occurrence of NEC is more prevalent in preterm infants. However, there are cases in term infants, but usually, they are associated with predisposing disorders. In this case report, a child is presented with 22q11DS that postnatally developed NEC associated with an adenoviral infection. Although other viruses such as toroviruses or cytomegaloviruses have been implicated in the pathogenesis of NEC in preterm infants, we could not find any report in the recent medical literature describing an association between adenoviral infections, NEC, and 22q11DS in a term infant.

Emerging trends in acquired neonatal intestinal disease: is it time to abandon Bell's criteria?

In the last decade, it has become increasingly clear that necrotizing enterocolitis (NEC) is neither a uniform nor a well-defined disease entity. There are many factors that are forcing this unwelcome realization upon the neonatal and pediatric surgery communities. In the course of this manuscript we will review the history and the physical findings of the disparate etiologies of acquired neonatal intestinal diseases (ANIDs), some which do lead to the common final pathology of NEC and some which do not. New guidelines for distinguishing between ANIDs will also be suggested.

T-tube ileostomy for intestinal perforation in extremely low birth weight neonates

To evaluate the results of use of T-tube ileostomy in selected cases of intestinal perforation in extremely low birth weight (ELBW) neonates. The records of 288 ELBW neonates treated at author's institution, from 1998 to 2003 were retrospectively reviewed to identify neonates operated for intestinal perforation with T-tube placement. T-tube was inserted into the bowel through the site of perforation or proximally to the perforated gut via separate stab incision. T-tubes were used in five ELBW neonates (BW 600-900 g, gestational age 25-27 weeks) with intestinal perforation, in four of them at the time of primary surgery and in one neonate 8 days after primary anastomosis. All patients survived and there were no serious complications related to the T-tube insertion. Median duration of T-tube placement was 4 weeks (range 3-8 weeks), full enteral feeding after T-tube insertion was achieved in 4 weeks (range 1-6 weeks). All sites of T-tube insertion closed spontaneously. T-tube ileostomy is an effective and safe technique for treatment of selected cases of intestinal perforation in ELBW neonates. With respect to the hypoperistalsis of immature bowel, we recommend the use of T-tube in all cases of isolated intestinal perforation in ELWB neonates.

Fecal calprotectin in very low birth weight infants

OBJECTIVES

To measure concentrations of fecal calprotectin (f-calprotectin) in infants with very low birth weight (VLBW; <1500 g) longitudinally and to describe changes in f-calprotectin in infants who develop severe abdominal disease.

PATIENTS AND METHODS

The study included 59 VLBW infants. Seven patients (disease group) developed severe abdominal disease defined as necrotizing enterocolitis (NEC) or a condition leading to laparotomy. The remainder (n = 52) were considered reference infants and had a mean (+/-SD) gestational age of 27.2 +/- 2.6 weeks and a birth weight of 939 +/- 273 g. F-calprotectin was analyzed in meconium and weekly during postnatal weeks 1 to 8. In disease cases, more frequent samples were analyzed around the time of abdominal disease diagnosis.

RESULTS

In reference infants the median (range) f-calprotectin level in meconium was 332 (12-9386) microg/g and correlated negatively to Apgar score. F-calprotectin in postmeconium samples was 253 (9-1867) microg/g and correlated positively to delivery by cesarean section, postnatal age, and volume of enteral feeds, and negatively to treatment with antibiotics and corticosteroids. In reference infants no postmeconium sample had f-calprotectin levels >2000 microg/g. In disease cases f-calprotectin was increased to >2000 microg/g in 3 cases of NEC and 1 case of covered perforation with microscopic bowel inflammation. In 1 case of NEC without microscopic bowel inflammation and 2 cases of focal intestinal perforation, f-calprotectin levels never exceeded 2000 microg/g.

CONCLUSIONS

F-calprotectin concentrations in VLBW infants are similar to previously reported levels in healthy term and moderately preterm infants. An f-calprotectin level >2000 microg/g is a useful but not an early marker of NEC and other severe intestinal inflammatory conditions in VLBW infants.

To drain or not to drain: a single institution experience with neonatal intestinal perforation

AIMS

The optimal surgical treatment for extremely-low-birth-weight (ELBW) neonates with pneumoperitoneum is controversial. This study aimed to identify clinical factors associated with two known causes of pneumoperitoneum-necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP), and assesses the treatment outcome with primary peritoneal drainage (PPD) vs. laparotomy.

METHODS

We reviewed and analyzed clinical characteristics and outcome from records of neonates with pneumoperitoneum treated at our institution from January 1999 to January 2003.

RESULTS

Forty-six neonates (31 NEC, 15 SIP) were treated with either PPD (20 with NEC, 13 with SIP) or laparotomy (11 with NEC, 2 with SIP). In neonates who underwent PPD, those with NEC (vs. SIP) were less likely to have a patent ductus arteriosus, but were more likely to have been fed, have drains placed later in life, have a subsequent laparotomy, a longer total parental nutrition course, a higher 30-day mortality, and to take more days to begin enteral feeds.

CONCLUSION

The etiology of pneumoperitoneum (NEC vs. SIP) in ELBW neonates can usually be determined preoperatively. Neonates with SIP should have a drain placed while those with NEC should undergo laparotomy.

Primary peritoneal drainage in necrotising enterocolitis: an 18-year experience

Primary peritoneal drainage (PPD) was initially introduced as a method for the pre-operative resuscitation of critically ill infants with complicated necrotising enterocolitis (NEC). Some have recommended it as definitive strategy for a select group of extremely low birth weight babies. The role of laparotomy in neonates who do not respond to initial PPD has also been challenged. With this background, we analysed our experience with the use of PPD in babies with NEC over an 18-year period. We retrospectively reviewed all patients with NEC who had PPD as their initial surgical management over an 18-year period. A total of 122 babies with NEC were treated surgically, of whom 42 had PPD as the initial procedure. There were 28 survivors (67%) in the PPD group, of whom 7 recovered without laparotomy. Twenty-nine infants (69%) had a good clinical response to PPD with 80% (23/29) survival, compared to a 27% survival (3/11) in those who did not respond to drainage. Six patients underwent rescue laparotomy after a poor response to PPD and three of these survived. Six of the 28 pts who underwent laparotomy had isolated intestinal perforation and their clinical characteristics were no different from those with typical NEC. PPD is a useful option in the management of complicated NEC. It is difficult to recognise with certainty those infants who will not require a subsequent laparotomy and therefore we do not support the concept of PPD solely as a definitive strategy. The response to PPD is a good prognostic indicator for ultimate survival. Despite a low salvage rate of 27% in non-responders compared to 80% in responders, there is a role for early laparotomy for those infants who do not respond to PPD.

Laparotomy versus peritoneal drainage for necrotizing enterocolitis or isolated intestinal perforation in extremely low birth weight infants: outcomes through 18 months adjusted age

OBJECTIVE

Extremely low birth weight (ELBW; < or =1000 g) infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP) are treated surgically with either initial laparotomy or peritoneal drain placement. The only published data comparing these therapies are from small, retrospective, single-center studies that do not address outcomes beyond nursery discharge. The objective of this study was to conduct a prospective, multicenter, observational study to (1) develop a hypothesis about the relative effect of these 2 therapies on risk-adjusted outcomes through 18 to 22 months in ELBW infants and (2) to obtain data that would be useful in designing and conducting a successful trial of this hypothesis.

METHODS

A prospective, cohort study was conducted at 16 clinical centers within the National Institute of Child Health and Human Development Neonatal Research Network. To assist in risk adjustment, the attending pediatric surgeon recorded the preoperative diagnosis and intraoperative diagnosis and identified infants who were considered to be too ill for laparotomy. Predefined measures of short- and longer-term outcome included (1) either predischarge death or prolonged parenteral nutrition (>85 days) after enrollment and (2) either death or neurodevelopmental impairment on a standardized examination at 18 to 22 months' adjusted age.

RESULTS

Severe NEC or IP occurred in 156 (5.2%) of 2987 ELBW infants; 80 were treated with initial drainage, and 76 were treated with initial laparotomy. By 18 to 22 months, 78 (50%) had died; 112 (72%) had died or were shown to be impaired. Outcome was worse in the subgroup with NEC. Laparotomy was never performed in 76% (28 of 36) of drain-treated survivors.

CONCLUSIONS

Drainage was commonly used, and outcome was poor. Our findings, particularly the risk-adjusted odds ratio favoring laparotomy for death or impairment, indicate the need for a large, multicenter clinical trial to assess the effect of the initial surgical therapy on outcome at > or =18 months.

Surgical therapy for necrotizing enterocolitis: bringing evidence to the bedside

Necrotizing enterocolitis is the most common surgical emergency in the neonatal intensive care unit. Despite decades of research that have led to a growing knowledge base about this disease, NEC continues to challenge the pediatric surgeon. In this review, we will examine the development of surgical therapy for NEC in the context of the supportive evidence, or lack thereof, for treatment approaches. We will discuss issues of indications for surgical intervention, primary peritoneal drainage versus laparotomy, enterostomy versus primary anastamosis and issues surrounding NEC totalis.

Treatment of intestinal perforation in extremely low-birthweight infants

BACKGROUND

The mortality of intestinal perforation in extremely low-birthweight infants (ELBWI) is high. It still remains to be determined whether peritoneal drainage is a definitive treatment instead of laparotomy. The authors used bedside peritoneal drainage (BSPD) as the diagnostic procedure, and exchange transfusion (ET) as the preparatory procedure for invasive stress of laparotomy. The treatment protocol is composed primarily of laparotomy combined with BSPD and ET.

METHODS

ELBWI who developed intestinal perforation during hospitalization between 1993 and 2000 were treated according to the aforementioned protocol. Their medical records were examined retrospectively.

RESULTS

Eight ELBWI were identified. The subjects' birthweights ranged from 553 to 892 g and the gestational age ranged from 23 to 26 weeks. The subjects consisted of five cases with idiopathic intestinal perforation, two cases with necrotizing enterocolitis, and one case with meconium plug syndrome. Laparotomy was performed in all cases, and BSPD was performed in seven cases. Intestinal perforation was definitively diagnosed by X-ray only in three cases, while by stool-like drainage in BSPD in the other five cases. Seven (87.5%) cases survived.

CONCLUSION

In this limited experience, the treatment mainly composed of laparotomy combined with BSPD and ET appeared beneficial.

Postoperative outcomes of extremely low birth-weight infants with necrotizing enterocolitis or isolated intestinal perforation: a prospective cohort study by the NICHD Neonatal Research Network

OBJECTIVE

Purposes of this study were: 1) to compare mortality and postoperative morbidities (intra-abdominal abscess, wound dehiscence, and intestinal stricture) in extremely low birth weight (ELBW) infants who underwent initial laparotomy or drainage for necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP); 2) to determine the ability to distinguish NEC from IP preoperatively and the importance of this distinction on outcome measures; and 3) to evaluate the association between extent of intestinal disease determined at operation and outcome measures.

BACKGROUND

ELBW infants who undergo operation for NEC or IP have a postoperative, in-hospital mortality rate of approximately 50%. Whether to perform laparotomy or drainage initially is controversial. Also unknown is the importance of distinguishing NEC from IP and the current ability to make this distinction based on objective data available prior to operation.

METHODS

A prospective, multicenter cohort study of 156 ELBW infants at 16 neonatal intensive care units (NICU) within the NICHD Neonatal Research Network.

RESULTS

Among the 156 enrolled infants, 80 underwent initial peritoneal drainage and 76 initial laparotomy. Mortality rate was 49% (76 of 156). Ninety-six patients had a preoperative diagnosis of NEC and 60 had presumed IP. There was a high level of agreement between the presumed preoperative diagnosis and intraoperative diagnosis in patients undergoing initial laparotomy (kappa = 0.85). The relative risk for death with a preoperative diagnosis of NEC (versus IP) was 1.4 (95% confidence interval, 0.99-2.1, P = 0.052). The overall incidence of postoperative intestinal stricture was 10.3%, wound dehiscence 4.4%, and intra-abdominal abscess 5.8%, and did not significantly differ between groups undergoing initial laparotomy versus initial drainage.

CONCLUSIONS

Survival to hospital discharge after operation for NEC or IP in ELBW neonates remains poor (51%). Patients with a preoperative diagnosis of NEC have a relative risk for death of 1.4 compared with those with a preoperative diagnosis of IP. A distinction can be made preoperatively between NEC and IP based on abdominal radiographic findings and the patient's age at operation. Future randomized trials that compare laparotomy versus drainage would likely benefit from stratification of treatment assignment based on preoperative diagnosis.

Surgical strategies for necrotising enterocolitis: a survey of practice in the United Kingdom

BACKGROUND

Strategies for the surgical management of necrotising enterocolitis are various and controversial.

OBJECTIVE

To characterise variation in surgical management of this disease across the United Kingdom.

METHODS

Postal survey of 104 consultant paediatric surgeons with a 77% response rate.

RESULTS

Duration of antibiotic treatment (median 10 days, range 6-14), time until the start of enteral feeding (median 10 days, range 4-21), and absolute indications for surgery all vary between surgeons. Peritoneal drainage is used by 95% of surgeons. Forty two percent use it in neonates of all weights, whereas 36% restrict its use to those <1000 g. Peritoneal drainage is used for stabilisation by 95% and as definitive treatment by 58%. At laparotomy, operative procedures include diverting jejunostomy, resection and stoma, resection with primary anastomosis, and "clip and drop". All procedures are used in infants of all weights except resection and primary anastomosis, which is used predominantly in larger infants (55% in <1000 g; 77% in >1000g; p=0.005). Infants may be considered too unwell for peritoneal drainage by 11% of surgeons compared with 90% for laparotomy (p<0.0001).

CONCLUSIONS

There is considerable variation in surgical strategies for necrotising enterocolitis. Peritoneal drainage is used by most surgeons, with controversial indications and expectations. The use of resection and primary anastomosis is influenced by the weight of the neonate.

Portal venous gas and surgical outcome of neonatal necrotizing enterocolitis

PURPOSE

The prognostic significance of portal venous gas (PVG) in neonatal necrotizing enterocolitis (NEC) for operative intervention (OP), neonatal complications, and mortality remains uncertain. The authors designed a long-term prospective study to describe the natural history of PVG related to these outcomes and to test the hypothesis that PVG does not mandate OP.

METHODS

All infants admitted to a single center between October 1991 and February 2003 were evaluated weekly to identify all cases of NEC (defined as Bell stage II or higher). Demographic, radiological, surgical, and outcome data were abstracted prospectively. Radiographic studies were performed at the onset of illness and at subsequent 6- to 8-hour intervals or as clinically indicated. A single pediatric radiologist reviewed all radiographs. Values are expressed as mean +/- SD. Odds ratios and relative risk ratios are reported with 95% CIs. The level of significance was P < or = .05.

RESULTS

After the exclusion of 24 infants with lethal diseases, major congenital or chromosomal anomalies, or recurrent episodes of NEC, 194 of 5891 infants developed NEC. The overall incidence of NEC was 3.7%. In 194 infants with NEC, the incidence of PVG was 33% (n = 64). Gestational age (30.8 +/- 4 vs 29.3 +/- 4.2 weeks; P = .02) but not birth weight (1609 +/- 761 vs 1434 +/- 810 g; P = NS) was greater in infants with PVG compared with infants without PVG (n = 130). Sixty-six (34%) infants with NEC underwent OP. Operative intervention occurred more frequently in infants with PVG compared with infants without PVG (OR, 2.5; CI, 1.37-4.76; P = .003)--only 48% of infants with PVG underwent OP. Among the variables, gestational age, severe NEC (Bell stage III), severe intramural gas (in all 4 abdominal quadrants), and the presence of PVG, severe NEC was most highly associated with OP (OR, 77.47; CI, 10.36-580.16; P < .0001). Bell stage III NEC was present in 98% of infants who underwent OP compared with 40% of infants without OP ( P < .0001). Of all infants with NEC, 37 (19%) died. Mortality was higher among infants who underwent OP (33% vs 12%; P < .0003). A multivariate regression model identified Bell stage III (OR, 3.74; CI, 1.20-11.62; P = .02), but neither PVG nor OP, to be significantly associated with mortality. Of interest is that survival in infants with PVG was greater (but not significantly so) than in infants without PVG in both OP (74% vs 59%) and non-OP (91% vs 87%) groups. Furthermore, 30 of 64 (47%) infants with PVG survived without OP, and of all 33 infants with PVG who did not undergo OP, 30 (91%) infants survived.

CONCLUSIONS

Decision for OP should be based on the severity of NEC and not on the presence of PVG alone because nearly half of infants with PVG survive without OP. Overall, the presence of PVG does not increase the risk of mortality among infants with NEC. Severe NEC, but not OP, is associated with higher mortality.

Clinical microbiology of bacterial and fungal sepsis in very-low-birth-weight infants

Twenty percent of very-low-birth-weight (<1500 g) preterm infants experience a serious systemic infection, and despite advances in neonatal intensive care and antimicrobials, mortality is as much as threefold higher for these infants who develop sepsis than their counterparts without sepsis during their hospitalization. Outcomes may be improved by preventative strategies, earlier and accurate diagnosis, and adjunct therapies to combat infection and protect the vulnerable preterm infant during an infection. Earlier diagnosis on the basis of factors such as abnormal heart rate characteristics may offer the ability to initiate treatment prior to the onset of clinical symptoms. Molecular and adjunctive diagnostics may also aid in diagnosing invasive infection when clinical symptoms indicate infection but no organisms are isolated in culture. Due to the high morbidity and mortality, preventative and adjunctive therapies are needed. Prophylaxis has been effective in preventing early-onset group B streptococcal sepsis and late-onset Candida sepsis. Future research in prophylaxis using active and passive immunization strategies offers prevention without the risk of resistance to antimicrobials. Identification of the differences in neonatal intensive care units with low and high infection rates and implementation of infection control measures remain paramount in each neonatal intensive care unit caring for preterm infants.

Current issues in the management of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the most common surgical emergency in the neonatal intensive care unit and remains a major cause of death in neonates. Although the pathophysiology of NEC has not been completely elucidated, progress has been made in the characterization of the molecular events which may take place during an episode of ischemia. This possible initiating event is followed by a complex cascade of inflammatory mediators active in NEC: epidermal growth factor, platelet-activating factor, and, nitric oxide. Additionally, unique characteristics of the premature gut are thought to be crucial to the development of NEC. The diagnosis of NEC continues to be based on clinical and radiographic features. Several new laboratory tests are under investigation for the purposes of earlier diagnosis, but none have prevailed at this time. Both exploratory laparotomy, with intestinal resection and peritoneal drainage are widely practiced. Mortality rates remain high and have improved little over the last couple of decades. Therefore, prevention remains crucial in order to decrease the incidence of NEC. Cautious feeding regimens, the use of maternal breast milk, passive immunization, and the use of probiotics have all been suggested but not proven as possible preventive methods. Although many advances have been made, significant opportunity remains to improve our understanding of the disease process and to develop better strategies for prevention and treatment.

A case report of a low-birth-weight infant with a subcapsular liver hematoma and spontaneous bowel perforation

This case report describes a 27-week, 1040-g infant, whose mother presented with an acute abruption and fetal distress prompting emergency cesarean birth. The birth was further complicated by fetal malposition, manual version, birth trauma, and perinatal depression requiring intubation, ventilation, and chest compressions. On day of life (DOL) 7, the infant suddenly deteriorated with cardiovascular collapse and severe coagulopathy. Coexisting spontaneous bowel perforation (SBP) and ruptured subcapsular liver hematoma (SLH) were confirmed operatively. Although survival with ruptured SLH is rarely reported, with aggressive medical and surgical management, this infant survived and was discharged home at 43 weeks postconceptual age. SBP may occur silently; pneumoperitoneum may be an incidental finding. Conversely, rupture of an SLH typically presents with a sudden clinical deterioration. The common predisposing factor for both conditions is low birth weight (LBW). A review of the known and proposed risk factors, clinical signs and symptoms, pathophysiology, and treatment of both SBP and SLH are provided. A literature review highlighting the potential impact of drug exposures (indomethacin, hydrocortisone, and low molecular weight heparin) is provided, along with a discussion of the implications for clinical practice and research.

Clinical features and treatment outcome of intussusception in premature neonates

BACKGROUND/PURPOSE

Less than 1.3% of all cases of intussusception occur in term neonates. Intussusception in premature neonates (IPN) is exceedingly rare. Its rarity and difficulty to differentiate IPN from common neonatal diseases like necrotizing enterocolitis (NEC) often delays its diagnosis. The authors set out to characterize diagnosis, treatment, and outcome of this rare condition.

METHODS

The authors analyzed 2 new cases of IPN and 33 previously reported cases from the literature.

RESULTS

The 35 patients with IPN had an average gestational age, postconceptual age at diagnosis, and birth weight of 28.4 +/- 0.6 weeks (all data, mean +/- SEM), 31.1 +/- 0.5 weeks, and 1,165 +/- 21 g, respectively. Gastrointestinal symptoms first presented at age 8 +/- 1 days. A preoperative diagnosis of NEC was assumed in 24 patients, delaying diagnosis by 10 +/- 2 days. Intussusception was diagnosed radiographically in 2 patients (1 contrast enema and 1 ultrasound scan) and during surgery or autopsy in the remainder. Resection was reported in 28 patients for bowel that was irreducible, necrotic, or perforated. The overall mortality rate was 20%, mainly owing to sepsis.

CONCLUSIONS

Intussusception in the premature neonate often is misdiagnosed as NEC, delaying operative intervention. Contrast enema has limited diagnostic capability. Early diagnosis may be achieved with use of ultrasound scan. Intussusception can be treated successfully with resection and primary anastomosis, achieving good results.

Disease severity and associated family impact in childhood atopic dermatitis

AIM

To examine the association between childhood atopic dermatitis (AD) severity and family impact at baseline and after an intervention by a physician specialist, using validated measures of both severity and family impact.

METHODS

Cross sectional self administered survey of parent-caregivers of 49 randomly selected children with AD; 35 parents were available for follow up. Family impact was measured using a modified AD Family Impact Scale completed by the parent-caregiver. The child's disease severity was measured using both the investigator's assessment via the Eczema Area and Severity Index (EASI) and the caregiver's assessment via the recently validated Self Assessment Eczema Area and Severity Index (SA-EASI).

RESULTS

The parent-caregiver's assessment of severity of the child was the most significant correlate of the family impact of the child's AD (p = 0.65 at baseline and p = 0.38 at follow up). In multivariate regression models, the parent-caregiver's estimate of severity remained the single strongest predictor of family impact before and after receipt of dermatologist care, as well as the difference in impact between pre and post-dermatologist care.

CONCLUSIONS

There is evidence to support the ability of parent-caregivers of children with AD to accurately determine severity of their child's AD; perceived severity is the driver of the family impact of this condition. Treatment of a child by a physician specialist is associated with reductions in both perceived severity, as well as family impact of this condition.