Hospital transfers and patterns of mortality in very low birth weight neonates with surgical necrotizing enterocolitis

Contemporary Outcomes for Infants with Necrotizing Enterocolitis-A Systematic Review

OBJECTIVE

To develop an accurate understanding of outcomes for necrotizing enterocolitis (NEC) to inform parental counseling, clinical care, and research agendas.

STUDY DESIGN

A systematic review of recent (January 2010-January 2018) large cohort studies reporting outcomes of infants who developed NEC. Only studies reporting national, regional, or multicenter outcomes of NEC in high income countries were included. Outcomes assessed were mortality, neurodevelopmental outcome, and intestinal failure. Meta-analyses were used to generate summary statistics for these outcomes.

RESULTS

Of 1375 abstracts, 38 articles were included. Overall mortality was 23.5% in all neonates with confirmed NEC (Bell stage 2a+) (95% CI 18.5%-28.8%), 34.5% (30.1%-39.2%) for neonates that underwent surgery for NEC, 40.5% (37.2%-43.8%) for extremely low birthweight infants (<1000 g), and 50.9% (38.1%-63.5%) for extremely low birthweight infants with surgical NEC. Studies examining causes of neonatal mortality showed NEC is responsible for around 1 in 10 of all neonatal deaths. Neurodevelopmental disability was reported in 4 studies at between 24.8% and 61.1% (1209 total NEC cases). Three studies reported intestinal failure with an incidence of 15.2%-35.0% (n = 1370). The main limitation of this review is the lack of an agreed definition for diagnosing NEC and the differences in the way that outcomes are reported.

CONCLUSIONS

Mortality following NEC remains high. These contemporary data inform clinical care and justify ongoing research efforts. All infants with NEC should have long-term neurodevelopmental assessment. Data on the long-term risk of intestinal failure are limited.

TRIAL REGISTRATION

CRD42018094791.

Vermont Oxford Network: a worldwide learning community

A health care learning community engages providers and families in a collaborative environment to improve outcomes. Vermont Oxford Network (VON), a voluntary organization dedicated to improving the quality, safety and value of care through a coordinated program of data-driven quality improvement, education, and research, is a worldwide learning community in newborn medicine. Through collection of pragmatic structured data items and benchmarking reports, quality improvement collaboratives, pragmatic trials, and observational research, VON facilitates quality improvement by multidisciplinary teams and families in neonatal intensive care units (NICU) in low, middle, and high resource countries. By bringing health professionals and families together across disciplines and geographies to enable shared learning and knowledge dissemination, VON empowers individuals, organizations, and systems to meet the shared vision that every infant around the world can and should achieve their full potential.

Health outcomes and the healthcare and societal cost of optimizing pediatric surgical care in the United States

BACKGROUND

There is a movement to ensure that pediatric patients are treated in appropriately resourced hospitals through the ACS Children's Surgery Verification (CSV) program. The objective of this study was to assess the potential difference in care provision, health outcomes and healthcare and societal costs after implementation of the CSV program.

METHODS

All 2011 inpatient admissions for selected complex pediatric patients warranting treatment at a hospital with Level I resources were evaluated across 6 states. Multivariate regressions were used to analyze differences in healthcare outcomes (postoperative complications including death, length of stay, readmissions and ED visits within 30 days) and costs by CSV level. Recycled predictions were used to estimate differences between the base case scenario, where children actually received care, and the optimized scenario, where all children were theoretically treated at Level I centers.

RESULTS

8,006 children (mean age 3.06 years, SD 4.49) met inclusion criteria, with 45% treated at Level I hospitals, 30% at Level II and 25% at Level III. No statistically significant differences were observed in healthcare outcomes. Readmissions within 30 days were higher at Level II compared to Level I centers (adjusted IRR 1.61; 95% CI 1.11, 2.34), with an estimated 24 avoidable readmissions per 1000 children if treatment were shifted from Level II to Level I centers. Overall, costs per child were not significantly different between the base case and the optimized scenario.

CONCLUSION

Many complex surgical procedures are being performed at Level II/III centers. This study found no statistically significant increase in healthcare or societal costs if these were performed instead at Level I centers under the optimized scenario. Ongoing evaluation of efforts to match institutional resources with individual patient needs is needed to optimize children's surgical care in the United States.

LEVEL OF EVIDENCE

II.

Enteric dysbiosis and fecal calprotectin expression in premature infants

BACKGROUND

Premature infants often develop enteric dysbiosis with a preponderance of Gammaproteobacteria, which has been related to adverse clinical outcomes. We investigated the relationship between increasing fecal Gammaproteobacteria and mucosal inflammation, measured by fecal calprotectin (FC).

METHODS

Stool samples were collected from very-low-birth weight (VLBW) infants at ≤2, 3, and 4 weeks' postnatal age. Fecal microbiome was surveyed using polymerase chain reaction amplification of the V4 region of 16S ribosomal RNA, and FC was measured by enzyme immunoassay.

RESULTS

We enrolled 45 VLBW infants (gestation 27.9 ± 2.2 weeks, birth weight 1126 ± 208 g) and obtained stool samples at 9.9 ± 3, 20.7 ± 4.1, and 29.4 ± 4.9 days. FC was positively correlated with the genus Klebsiella (r = 0.207, p = 0.034) and its dominant amplicon sequence variant (r = 0.290, p = 0.003), but not with the relative abundance of total Gammaproteobacteria. Klebsiella colonized the gut in two distinct patterns: some infants started with low Klebsiella abundance and gained these bacteria over time, whereas others began with very high Klebsiella abundance.

CONCLUSION

In premature infants, FC correlated with relative abundance of a specific pathobiont, Klebsiella, and not with that of the class Gammaproteobacteria. These findings indicate a need to define dysbiosis at genera or higher levels of resolution.

Impact of disease-specific volume and hospital transfer on outcomes in gastroschisis

BACKGROUND

Gastroschisis, a surgical condition requiring complex interdisciplinary care, may benefit from treatment at higher volume centers. Recent studies on surgical volume and outcomes have conflicting findings.

METHODS

Data were collected prospectively on newborns ≥1500 g with gastroschisis born 2009-2015, admitted to 159 US centers, and separated into terciles based on number of annual gastroschisis repairs. Infants transferred after gastroschisis repair were excluded.

RESULTS

There were 4663 infants included: 307 from 53 low, 1201 from 55 medium, and 3155 from 51 high volume centers. Infants at high volume centers had higher rates of intestinal atresia (P = 0.04) and outborn status (P < 0.0001). Outborn infants (N = 1134) had higher rates of gastrostomy/jejunostomy placement (P < 0.001). Mortality was universally low (2.0% low, 2.4% medium, and 1.7% high; 2.0% outborn and 1.9% inborn). On multivariate analysis, mortality, sepsis rates, and length of stay did not differ by center volume. Outborn status was associated with longer length of stay (P = 0.001), not mortality or sepsis.

CONCLUSION

Infant characteristics and management vary based on gastroschisis surgical volume and transfer status. Center volume and early transfers were not associated with mortality. Further investigation to identify subsets of gastroschisis infants who would benefit from care at higher volume centers is warranted.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level II.

Outcomes of surgery for necrotizing enterocolitis and spontaneous intestinal perforation in Finland during 1986-2014

BACKGROUND

Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are the most common abdominal surgical conditions in preemies. Associated mortality remains high and long periods of parenteral nutrition (PN) may be required. We assessed the developments in the outcomes of surgically treated NEC and SIP in the two largest Finnish neonatal intensive care units (NICU).

METHODS

Retrospective observational study based on hospital records during 1986-2014. Main outcome measures were three-month survival during 1986-2000 compared with 2001-2014 and predictors of mortality.

RESULTS

Included were 225 patients (NICU A 131 and NICU B 94) with NEC in 142 (63%) and SIP 83 (37%). The median birth weight (BW) (870 vs 900 g) and gestation age (GA) (27 vs 27 weeks, p = 0.96) were similar in NEC and SIP. Small intestine was affected in 85% of NEC and 76% of SIP patients (p = 0.12). In 5% of patients NEC was panintestinal. Median small intestinal loss was 25% in NEC and 4.0% in SIP (p < 0.001). Ileocecal valve was resected in 29% of NEC and 14% of SIP patients (p = 0.01). Enterostomy was performed in 78% of patients and primary anastomosis in 18%; 4% died of extensive NEC without definitive surgery. Overall survival was 74% (NEC 73%, SIP 77%, p = 0.48; NICU A 82%, NICU B 65%, p = 0.003). From 1986-2000 to 2001-2014 overall survival increased from 69 to 81% (p = 0.04). Treating NICU was the strongest predictor of survival, RR = 2.8 (95% CI = 1.4-5.1), p = 0.003.

CONCLUSIONS

Overall survival improved significantly from the early (1986-2000) to the late (2001-2014) study period. Strongest predictor of mortality was the treating neonatal intensive care unit.

LEVEL OF EVIDENCE

III.

Perioperative support, not volume, is necessary to optimize outcomes in surgical management of necrotizing enterocolitis

BACKGROUND

This study examines the relationship between hospital volume of surgical cases for necrotizing enterocolitis (NEC) and patient outcomes.

METHODS

A retrospective cross-sectional review was performed using the HCUP SID for California from 2007 to 2011. Patients with NEC who underwent surgery were identified using ICD-9CM codes. Risk-adjusted models were constructed with mixed-effects logistic regression using patient and demographic covariates.

RESULTS

23 hospitals with 618 patients undergoing NEC-related surgical intervention were included. Overall mortality rate was 22.5%. There were no significant differences in the number of NICU beds (p = 0.135) or NICU intensivists (p = 0.469) between high and low volume hospitals. Following risk adjustment, no difference in mortality rate was observed between high and low volume hospitals respectively (24.0% vs. 20.3%, p = 0.555).

CONCLUSIONS

Our observation that neonates with NEC treated at low-volume centers have no increased risk of mortality may be explained by similar availability of NICU and intensivists resources across hospitals.