Doppler ultrasound assessment of splanchnic perfusion and heart rate for the detection of necrotizing enterocolitis

Hydrocortisone in very preterm neonates for BPD prevention: meta-analysis and effect size modifiers

OBJECTIVES

To clarify if systemic hydrocortisone, in protocols allowing to start it before the 15th day of life, prevents bronchopulmonary dysplasia (BPD) or other adverse outcomes in very preterm neonates, and to identify any possible effect size modifiers.

STUDY DESIGN

Systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Additional analyses included meta-regressions and review of biological plausibility.

RESULTS

Seven trials were included, they were of general good quality and accounted for a total of 2193 infants. Hydrocortisone treatment did not reduce BPD (risk ratio (RR) 0.84 (95% CI 0.64 to 1.04)), but heterogeneity was evident (I2=51.6%). The effect size for BPD is greatest for 10-12 days duration of treatment (β=0.032 (0.01), p=0.007) and tended to be greater in patients with chorioamnionitis (β=-1.5 (0.841), p=0.07). Hydrocortisone treatment may significantly reduce mortality (RR 0.75 (95% CI 0.59 to 0.91)), there is no heterogeneity (I2=0) and the reduction tended to be greater in males (β=-0.06 (0.03), p=0.07). Hydrocortisone may significantly reduce necrotising enterocolitis (NEC; RR 0.72 (95% CI 0.53 to 0.92)); there is neither heterogeneity (I2=0%) nor any effect size modifiers. Hydrocortisone did not affect other adverse outcomes of prematurity.

CONCLUSIONS

Systemic hydrocortisone may be considered, on a case-by-case evaluation, to reduce mortality and NEC, while it does not affect BPD. There are some potential effect size modifiers for mortality and BPD which should be addressed in future explanatory trials.

PROSPERO REGISTRATION NUMBER

CRD42023400520.

Gastrointestinal effects of caffeine in preterm infants: a systematic review and Bayesian meta-analysis

OBJECTIVE

Caffeine is widely used in preterm infants to prevent or treat apnoea of prematurity. Adverse gastrointestinal effects of caffeine have not been thoroughly researched in preterm infants. With this systematic review and meta-analysis, we aim to summarise the results of trials on the gastrointestinal effects of caffeine in preterm infants.

DESIGN

We searched MEDLINE, Web of Science, Scopus and ClinicalTrials.gov up to 21 April 2023. We included randomised controlled trials assessing caffeine versus placebo in preterm neonates and reporting gastrointestinal side effects. Risk of bias was assessed using the Cochrane Risk of Bias tool. A Bayesian meta-analysis was performed to estimate the pooled OR of gastrointestinal side effects.

RESULTS

Nine trials involving 2746 preterm infants were analysed. Seven trials assessing necrotising enterocolitis and four trials assessing feeding intolerance in our meta-analysis found no differences between caffeine and placebo (OR=1.007 (95% credible interval 0.021, 5.462), I2=97.4%, and OR=1.266 (95% credible interval 0.064, 28.326), I2=84.8%, respectively). Four trials assessed the outcomes spontaneous intestinal perforation, constipation, gastrointestinal disorder (composite outcome: gastro-oesophageal regurgitation or dilated bowel loops), age at oral feeding and cholestasis syndrome and found no differences between groups. One trial assessed the outcomes gastro-oesophageal symptoms and duration of tube feeding and found that caffeine was associated with a reduced burden of gastro-oesophageal reflux symptoms at 2 weeks (p<0.05), but not at term.

CONCLUSIONS

According to this systematic review and meta-analysis, the use of caffeine at usual doses in preterm infants does not seem to be associated with significant gastrointestinal adverse effects.

A Nomogram for Predicting Surgical Timing in Neonates with Necrotizing Enterocolitis

OBJECTIVE

To explore the surgical risk variables in patients with necrotizing enterocolitis (NEC) and develop a nomogram model for predicting the surgical intervention timing of NEC.

METHODS

Infants diagnosed with NEC were enrolled in our study. We gathered information from clinical data, laboratory examinations, and radiological manifestations. Using LASSO (least absolute shrinkage and selection operator) regression analysis and multivariate logistic regression analysis, a clinical prediction model based on the logistic nomogram was developed. The performance of the nomogram model was evaluated using the receiver operating characteristic (ROC) curve, calibration curves, and decision curve analysis (DCA).

RESULTS

A surgical intervention risk nomogram based on hypothermia, absent bowel sounds, WBC > 20 × 10⁹/L or < 5 × 10⁹/L, CRP > 50 mg/L, pneumatosis intestinalis, and ascites was practical, had a moderate predictive value (AUC > 0.8), improved calibration, and enhanced clinical benefit.

CONCLUSIONS

This simple and reliable clinical prediction nomogram model can help physicians evaluate children with NEC in a fast and effective manner, enabling the early identification and diagnosis of children at risk for surgery. It offers clinical revolutionary value for the development of medical or surgical treatment plans for children with NEC.

Prediction of necrotizing enterocolitis in very low birth weight infants by superior mesenteric artery ultrasound of postnatal day 1: A nested prospective study

BACKGROUND

Necrotizing enterocolitis (NEC) is a devastating intestinal complication that occurs mainly in very-low-birth-weight infants (VLBWI). The study's aim was to investigate the possibility of early prediction of NEC on postnatal day 1 based on superior mesenteric artery (SMA) doppler ultrasonograpy.

METHODS

A prospective, observational, nested case control study (ChiCTR1900026197) was conducted to enroll VLBWIs (birth weight <1,500 grams) between October 2019 and September 2021. Doppler ultrasound measurement was done during the first 12 h of life and before first feeding. Infants developing NEC (stage II or III) subsequently were included in NEC group and infants spare of NEC were included in control group.

RESULTS

370 VLBWIs were enrolled (30 NEC cases). Among the ultrasound parameters, S/D was significantly higher in the NEC group (OR: 2.081, 95% CI: 1.411-3.069, P = 0.000). The area under the receiver operating curve (AUROC) following the Logistic regression was 0.704 (95% CI: 0.566-0.842, P = 0.001). The sensitivity of S/D for predicting NEC was 52.2% and the specificity was 92.7%. The critical value of S/D was 6.944 and Youden index was 0.449. Preplanned subgroup analysis confirmed that NEC infants of different stages were characterized by different SMA bloodstream. Small for gestational age (SGA) might be a confounding factor affecting intestinal bloodflow. And infants with delayed initiation or slow advancement of feeding exhibited characteristic intestinal perfusion.

CONCLUSIONS

In VLBWI, early SMA ultrasound shows the potential to predict NEC. It is reasonable to speculate that SMA bloodstream is related to intestinal structural and functional integrity.