The economic burden of gastroschisis: costs of a birth defect

Hospital care in the first 10 years of life of children with congenital anomalies in six European countries: data from the EUROlinkCAT cohort linkage study

OBJECTIVE

To quantify the hospital care for children born with a major congenital anomaly up to 10 years of age compared with children without a congenital anomaly.

DESIGN, SETTING AND PATIENTS

79 591 children with congenital anomalies and 2 021 772 children without congenital anomalies born 1995-2014 in six European countries in seven regions covered by congenital anomaly registries were linked to inpatient electronic health records up to their 10th birthday.

MAIN OUTCOME MEASURES

Number of days in hospital and number of surgeries.

RESULTS

During the first year of life among the seven regions, a median of 2.4% (IQR: 2.3, 3.2) of children with a congenital anomaly accounted for 18% (14, 24) of days in hospital and 63% (62, 76) of surgeries. Over the first 10 years of life, the percentages were 17% (15, 20) of days in hospital and 20% (19, 22) of surgeries. Children with congenital anomalies spent 8.8 (7.5, 9.9) times longer in hospital during their first year of life than children without anomalies (18 days compared with 2 days) and 5 (4.1-6.1) times longer aged, 5-9 (0.5 vs 0.1 days). In the first year of life, children with gastrointestinal anomalies spent 40 times longer and those with severe heart anomalies 20 times longer in hospital reducing to over 5 times longer when aged 5-9.

CONCLUSIONS

Children with a congenital anomaly consume a significant proportion of hospital care resources. Priority should be given to public health primary prevention measures to reduce the risk of congenital anomalies.

Perinatal deaths from birth defects in Hunan Province, China, 2010-2020

OBJECTIVE

To describe the perinatal mortality rate (PMR) of birth defects and to define the relationship between birth defects (including a broad range of specific defects) and a broad range of factors.

METHODS

Data were obtained from the Birth Defects Surveillance System in Hunan Province, China, 2010-2020. The prevalence rate (PR) of birth defects is the number of birth defects per 1000 fetuses (births and deaths at 28 weeks of gestation and beyond). PMR is the number of perinatal deaths per 100 fetuses. PR and PMR with 95% confidence intervals (CI) were calculated using the log-binomial method. Chi-square trend tests (χ2trend) were used to determine trends in PR and PMR by year, maternal age, income, education level, parity, and gestational age of termination. Crude odds ratios (ORs) were calculated to examine the association of each maternal characteristic with perinatal deaths attributable to birth defects.

RESULTS

Our study included 1,619,376 fetuses, a total of 30,596 birth defects, and 18,212 perinatal deaths (including 16,561 stillbirths and 1651 early neonatal deaths) were identified. The PR of birth defects was 18.89‰ (95%CI: 18.68-19.11), and the total PMR was 1.12%(95%CI: 1.11-1.14). Birth defects accounted for 42.0% (7657 cases) of perinatal deaths, and the PMR of birth defects was 25.03%. From 2010 to 2020, the PMR of birth defects decreased from 37.03% to 2010 to 21.00% in 2020, showing a downward trend (χ2trend = 373.65, P < 0.01). Congenital heart defects caused the most perinatal deaths (2264 cases); the PMR was 23.15%. PMR is highest for encephalocele (86.79%). Birth defects accounted for 45.01% (7454 cases) of stillbirths, and 96.16% (7168 cases) were selective termination of pregnancy. Perinatal deaths attributable to birth defects were more common in rural than urban areas (31.65% vs. 18.60%, OR = 2.03, 95% CI: 1.92-2.14) and in females than males (27.92% vs. 22.68%, OR = 1.32, 95% CI: 1.25-1.39). PMR of birth defects showed downward trends with rising maternal age (χ2trend = 200.86, P < 0.01), income (χ2trend = 54.39, P < 0.01), maternal education level (χ2trend = 405.66, P < 0.01), parity (χ2trend = 85.11, P < 0.01) and gestational age of termination (χ2trend = 15297.28, P < 0.01).

CONCLUSION

In summary, birth defects are an important cause of perinatal deaths. Rural areas, female fetuses, mothers with low maternal age, low income, low education level, low parity, and low gestational age of termination were risk factors for perinatal deaths attributable to birth defects. Future studies should examine the mechanisms. Our study is helpful for intervention programs to reduce the PMR of birth defects.

The role of feeding advancement strategy on length of stay and hospital costs in newborns with gastroschisis

BACKGROUND

Infants with gastroschisis require prolonged hospitalization for surgical repair and gradual advancement of feeds. The present study explores the effect of a change in a protocolized enteral feeding regimen with length of hospital stay (LOS) and total costs in newborns with gastroschisis.

METHODS

A retrospective review was performed in neonates with uncomplicated gastroschisis at a free-standing pediatric institution from 2012 to 2020. The effect of two different enteral feed advancement protocols on clinical outcomes and hospital costs was analyzed.

RESULTS

Seventy-four patients were identified, of which 50 (68%) underwent 10 ml/kg/day feeding advancements, and 24 (32%) underwent 20 ml/kg/day feeding advancements. Compared to neonates who underwent 10 ml/kg/day enteral advancements, neonates receiving 20 ml/kg/day advancements reached goal feeds faster (14 vs 20 days, p<0.001), were younger at goal feeds (26 vs 34 days, p = 0.001), required fewer days of parenteral nutrition (22 vs 29 days, p = 0.001), and had shorter LOS (30 vs 36 days, p = 0.001). On multivariable analysis, total costs decreased by 9.77% in the 20 ml/kg/day advancement cohort (p = 0.071).

CONCLUSION

In neonates with uncomplicated gastroschisis who underwent primary repair, a nutritional protocol that incorporated 20 ml/kg/day feeding advancements was safe and resulted in faster attainment of goal feeds and shorter LOS.

LEVEL OF EVIDENCE

II/III.

Medicaid healthcare expenditures for infants with birth defects potentially related to Zika virus infection in North Carolina, 2011-2016

BACKGROUND

In 2016, Zika virus (ZIKV) was recognized as a human teratogen. North Carolina (NC) had no local transmission of ZIKV but infants with relevant birth defects, including severe brain anomalies, microcephaly, and eye abnormalities, require specialized care and services, the costs of which have not yet been quantified. The objective of this study is to examine NC Medicaid healthcare expenditures for infants with defects potentially related to ZIKV compared to infants with no reported defects.

METHODS

Data sources for this retrospective cohort study include NC birth certificates, Birth Defects Monitoring Program data, and Medicaid enrollment and paid claims files. Infants with relevant defects were identified and expenditure ratios were calculated to compare distributions of estimated expenditures during the first year of life for infants with relevant defects and infants with no reported defects.

RESULTS

This analysis included 551 infants with relevant defects and 365,318 infants with no reported defects born 2011-2016. Mean total expenditure per infant with defects was $69,244 (median $30,544) for the first year. The ratio of these expenditures relative to infants with no reported defects was 14.5. Expenditures for infants with select brain anomalies were greater than those for infants with select eye abnormalities only.

CONCLUSIONS

Infants with defects potentially related to ZIKV had substantially higher Medicaid expenditures than infants with no reported defects. These results may be informative in the event of a future outbreak and are a resource for program planning related to care for infants in NC.

Outcome and management in neonates with gastroschisis in the third millennium-a single-centre observational study

Gastroschisis is one of the most common congenital malformations in paediatric surgery. However, there is no consensus regarding the optimal management. The aims of this study were to investigate the management and outcome and to identify predictors of outcome in gastroschisis. A retrospective observational study of neonates with gastroschisis born between 1999 and 2020 was undertaken. Data was extracted from the medical records and Cox regression analysis was used to identify predictors of outcome measured by length of hospital stay (LOS) and duration of parenteral nutrition (PN). In total, 114 patients were included. Caesarean section was performed in 105 (92.1%) at a median gestational age (GA) of 36 weeks (range 29-38) whereof (46) 43.8% were urgent. Primary closure was achieved in 82% of the neonates. Overall survival was 98.2%. One of the deaths was caused by abdominal compartment syndrome and one patient with intestinal failure-associated liver disease died from sepsis. None of the deceased patients was born after 2005. Median time on mechanical ventilation was 22 h. Low GA, staged closure, intestinal atresia, and sepsis were independent predictors of longer LOS and duration on PN. In addition, male sex was an independent predictor of longer LOS.

CONCLUSION

Management of gastroschisis according to our protocol was successful with a high survival rate, no deaths in neonates born after 2005, and favourable results in LOS, duration on PN, and time on mechanical ventilation compared to other reports. Multicentre registry with long-term follow-up is required to establish the best management of gastroschisis.

WHAT IS KNOWN

• Gastroschisis is one of the most common congenital malformations in paediatric surgery with increasing incidence. • There is no consensus among clinicians regarding the optimal management of gastroschisis.

WHAT IS NEW

• Although primary closure was achieved in 82% of the patients, mortality rate was very low (1.8%) with no deaths in neonates born after 2005 following the introduction of measurement of intraabdominal pressure at closure. • Low gestational age, staged closure, intestinal atresia, sepsis, and male sex were independent predictors of longer length of hospital stay.

The medical and surgical management of gastroschisis

Gastroschisis (GS) is a full-thickness abdominal wall defect in which fetal intestine herniates alongside the umbilical cord into the intrauterine cavity, resulting in an intestinal injury of variable severity. An increased prevalence of gastroschisis has been observed across several continents and is a focus of epidemiologic study. Prenatal diagnosis of GS is common and allows for delivery planning and treatment in neonatal intensive care units (NICUs) by collaborative interdisciplinary teams (neonatology, neonatal nursing and pediatric surgery). Postnatal treatment focuses on closure of the defect, optimized nutrition, complication avoidance and a timely transition to enteral feeding. Babies born with complex GS are more vulnerable to complications, have longer and more resource intensive hospital stays and benefit from standardized care pathways provided by teams with expertise in managing infants with intestinal failure. This article will review the current state of knowledge related to the medical and surgical management and outcomes of gastroschisis with a special focus on the role of the neonatologist in supporting integrated team-based care.

Regional variation in gastroschisis: a nationwide database review of demographics and outcomes

BACKGROUND

Gastroschisis is an index neonatal malformation with an increasing incidence from earlier decades. The aim of this study was to investigate regional variations in patient demographics, outcomes, and costs in gastroschisis.

MATERIALS AND METHODS

The 2016 kid's inpatient database (KID) obtained from the Healthcare Cost and Utilization Project (HCUP) was used to obtain gastroschisis birth, demographic, and outcome data across four U.S. geographical regions: Northeast, Midwest, South, and West. Categorical variables were analyzed with Pearson's Chi-squared test. Odds ratios (OR) with 95% confidence intervals (CI) were reported for variables with significance (p < 0.05). Appropriate logistic regressions were used for comparing categorical, cardinal, and continuous data.

RESULTS

2043 gastroschisis cases were obtained from the 2016 KID database with a weighted incidence of 5.1 per 10,000 live births. Incidence of gastroschisis across regions was similar when controlling for a number of hospitals reporting to KID. Prematurity was common, with 59% (1204) of neonates with gastroschisis born at less than 37 weeks. 52% (N = 1067) of gastroschisis infants were male. 46% (955) were White, 9% (178) African American, 22% (450) Hispanic, and 8% (155) other. The overall mortality of gastroschisis in this database was 3.6% (75). The average length of stay was 39 days and average cost of treatment was $357,436. Though without significant differences in mortality, there were significant differences in demographics, costs, and lengths of stay between regions.

CONCLUSIONS

There has been a significant increase in gastroschisis incidence over the last three decades. This significant increase appears to be related to an increase in socioeconomic inequality and an alteration in the population demographics in the United States. Further study of regional variations will facilitate the development of best practice guidelines that benefit all.

EUROlinkCAT protocol for a European population-based data linkage study investigating the survival, morbidity and education of children with congenital anomalies

INTRODUCTION

Congenital anomalies (CAs) are a major cause of infant mortality, childhood morbidity and long-term disability. Over 130 000 children born in Europe every year will have a CA. This paper describes the EUROlinkCAT study, which is investigating the health and educational outcomes of children with CAs for the first 10 years of their lives.

METHODS AND ANALYSIS

EUROCAT is a European network of population-based registries for the epidemiological surveillance of CAs. EUROlinkCAT is using the EUROCAT infrastructure to support 22 EUROCAT registries in 14 countries to link their data on births with CAs to mortality, hospital discharge, prescription and educational databases. Once linked, each registry transforms their case data into a common data model (CDM) format and they are then supplied with common STATA syntax scripts to analyse their data. The resulting aggregate tables and analysis results are submitted to a central results repository (CRR) and meta-analyses are performed to summarise the results across all registries. The CRR currently contains data on 155 594 children with a CA followed up to age 10 from a population of 6 million births from 1995 to 2014.

ETHICS

The CA registries have the required ethics permissions for routine surveillance and transmission of anonymised data to the EUROCAT central database. Each registry is responsible for applying for and obtaining additional ethics and other permissions required for their participation in EUROlinkCAT.

DISSEMINATION

The CDM and associated documentation, including linkage and standardisation procedures, will be available post-EUROlinkCAT thus facilitating future local, national and European-level analyses to improve healthcare. Recommendations to improve the accuracy of routinely collected data will be made.Findings will provide evidence to inform parents, health professionals, public health authorities and national treatment guidelines to optimise diagnosis, prevention and treatment for these children with a view to reducing health inequalities in Europe.

Failure of primary closure predicts prolonged length of stay in gastroschisis patients

PURPOSE

Current literature regarding outcomes of gastroschisis closure methods do not highlight differences in patients who successfully undergo primary closure with those who fail and require silo placement. We hypothesize that failure of primary closure has significant effects on clinical outcomes such as length of stay and time to enteral feeding.

METHODS

We conducted a retrospective review between 2009 and 2018 of gastroschisis patients at a tertiary pediatric referral hospital. We compared patients successfully undergoing primary closure to patients who failed an initial primary closure attempt. Bivariate and multivariate linear regression models were used to assess the association of closure method on clinical outcomes.

RESULTS

Sixty-eight neonates were included for analysis, with 44 patients who underwent primary closure and 24 who failed primary closure. On multivariate regression analysis, primary closure patients had shorter estimated time to starting and to full enteral feeds and decreased LOS as compared to those who failed primary closure. Two patients (4.44%) had complications related to primary closure.

CONCLUSION

Patients able to undergo primary closure for gastroschisis were more likely to have a shorter length of stay, shorter time to enteral feeds, and use much fewer medical resources. Initial primary closure is a safe method for most patients.

Estimating Length of Stay for Simple Gastroschisis

BACKGROUND

Length of stay (LOS) is an important measure of quality; however, estimating LOS for rare populations such as gastroschisis is problematic. Our objective was to identify explanatory variables for LOS and build a model to estimate LOS in neonates with simple gastroschisis.

METHODS

In 73 neonates with simple gastroschisis (47% female, 67% White), statistical correlations for 31 potential explanatory variables for LOS were evaluated using multivariate linear regression. Poisson regression was used to estimate LOS in predetermined subpopulations, and a life table model was developed to estimate LOS for simple gastroschisis.

RESULTS

Female sex (-2.4 d), "time to silo placement" (0.9 d), total parenteral nutrition days (0.6 d), need for any nasogastric feedings (11.4 d) and at discharge (-7 d), "feeding tolerance" (0.4 d), days to first postoperative stool (-0.3 d), and human milk exposure (-3.4 d) associated with LOS in simple gastroschisis. Estimated LOS for preterm neonates was longer than term infants (5.4 versus 4.6 wk) but similar for estimates based on sex and race. Based on these associations, we estimate that >50% of neonates with simple gastroschisis will be discharged by hospital day 35.

CONCLUSIONS

We identified several associations that explained variations in LOS and developed a novel model to estimate LOS in simple gastroschisis, which may be applied to other rare populations.

Is there a role for fetal interventions in gastroschisis management? - An updated comprehensive review

We conducted a comprehensive evidence-based review on the epidemiology and current standard of care of gastroschisis management as well as the pathophysiology, rationale and feasibility of fetal therapy as a viable alternative. Gastroschisis is a periumbilical abdominal wall defect characterized by abdominal viscera herniation in utero. It affects 4 in 10 000 live births, but the prevalence has steadily increased in recent years. Gastroschisis is typically diagnosed on routine second-trimester ultrasound. The overall prognosis is favorable, but complex gastroschisis, which accounts for about 10% to 15% of cases, is associated with a higher mortality, significant disease burden and higher healthcare costs due to long- and short-term complications. The current standard of care has yet to be established but generally involves continued fetal surveillance and multidisciplinary perinatal care. Postnatal surgical repair is achieved with primary closure, staged silo closure or sutureless repair. Experimental animal studies have demonstrated the feasibility of in utero closure, antiinflammatory therapy and prenatal regenerative therapy. However, reports of early preterm delivery and amnioinfusion trials have failed to show any benefit in humans. Further experimental studies and human trials are necessary to demonstrate the potential benefit of fetal therapy in gastroschisis.

Impact of Clinical Factors on the Intestinal Microbiome in Infants With Gastroschisis

BACKGROUND

Infants with gastroschisis require operations and lengthy hospitalizations due to intestinal dysmotility. Dysbiosis may contribute to these problems. Little is known on the microbiome of gastroschisis infants.

METHODS

The purpose of this study was to investigate the fecal microbiome in gastroschisis infants. Microbiome profiling was performed by sequencing the V4 region of the 16S rRNA gene. The microbiome of gastroschisis infants was compared with the microbiome of healthy controls, and the effects of mode of birth delivery, gestational age, antibiotic duration, and nutrition type on microbial composition and diversity were investigated.

RESULTS

The microbiome of gastroschisis infants (n = 13) was less diverse (Chao1, P < .001), lacked Bifidobacterium (P = .001), and had increased Staphylococcus (P = .007) compared with controls (n = 83). Mode of delivery (R² = 0.04, P = .001), antibiotics duration ≥7 days (R² = 0.03, P = .003), age at sample collection (R² = 0.03, P = .009), and gestational age (R² = 0.02, P = .035) explained a small portion of microbiome variation. In gastroschisis infants, Escherichia-Shigella was the predominate genus, and those delivered via cesarean section had different microbial communities, predominantly Staphylococcus and Streptococcus, from those delivered vaginally. Although antibiotic duration contributed to the variation in microbiome composition, there were no significant differences in taxa distribution or α diversity by antibiotic duration or nutrition type.

CONCLUSION

The microbiome of gastroschisis infants is dysbiotic, and mode of birth delivery, antibiotic duration, and gestational age appear to contribute to microbial variation.

Variation in hospital costs for gastroschisis closure techniques

BACKGROUND

In newborns with gastroschisis, both primary repair and delayed fascial closure with initial silo placement are considered safe with similar outcomes although cost differences have not been explored.

METHODS

A retrospective review was performed of newborns admitted with gastroschisis at a single center from 2011 to 2016. Demographic, clinical, and cost data during the initial hospitalization were collected. Differences between procedure costs and clinical endpoints were analyzed using multivariable linear regression adjusting for prematurity, complicated gastroschisis, and performance of additional operations.

RESULTS

80 patients with gastroschisis met inclusion criteria. Rates of primary fascial, primary umbilical cord closure, and delayed closure were 14%, 65%, and 21%, respectively. Delayed closure was associated with an increase in total hospital costs by 57% compared to primary repair (p < 0.001). In addition, delayed closure was associated with increased total and NICU LOS (p < 0.05), parenteral nutrition duration (p = 0.02), ventilator days (p < 0.001), time to goal enteral feeds (p = 0.01), and all cost sub-categories except ward room costs (p < 0.01).

CONCLUSION

Delayed fascial closure was associated with significantly greater hospital costs during the index admission.

Central line associated blood stream infections in gastroschisis patients: A nationwide database analysis of risks, outcomes, and disparities

PURPOSE

The aim of this study was to determine the risk of central line associated blood-stream infections (CLABSI) in neonatal gastroschisis patients, risk factors, outcomes, and financial implications.

METHODS

The 2016 Healthcare Cost and Utilization Project (HCUP)'s kid's inpatient database (KID), a national database of pediatric inpatient admissions across the United States, was used to obtain a large sample of gastroschisis admissions. Incidence of CLABSI in the gastroschisis patient population was compared to the incidence of CLABSI in the database. To further study the factors influencing CLABSI in gastroschisis, demographic and clinical features of patients were analyzed. Categorical variables were analyzed using Fisher's exact test or Pearson's chi-squared test. Odds ratios (OR) with 95% confidence intervals (CI) for variables found to have significance (p < 0.05) were calculated.

FINDINGS

Incidence of CLABSI in this database for pediatric inpatients was 4449 out of 298,862 central line insertions [1.48%] and was 81 out of 2032 [3.9%] (OR 2.83, 95% CI 2.26-3.54, p < 0.001) in the gastroschisis cohort. African American neonates had a significantly higher risk of CLABSI with gastroschisis. Prematurity and low birth-weight in gastroschisis were protective from CLABSI, along with patients from suburban areas or admitted in the Southern USA. Average costs were greater in gastroschisis patients with CLABSI, increasing from $281,779 to $421,970 (p = 0.008). The average length of stay increased from 31 days to 38 days with a CLABSI (p < 0.001).

CONCLUSIONS

In gastroschisis patients, CLABSI incidence is high and adds great morbidity and expense. For uncertain reasons, premature and low birth weight babies appear to be protected.

LEVEL OF EVIDENCE

Level III.

Examination of Prenatal Sonographic Findings: Intra-Abdominal Bowel Dilation Predicts Poor Gastroschisis Outcomes

BACKGROUND

Gastroschisis is an anterior abdominal wall defect with variable outcomes. There are conflicting data regarding the prognostic value of sonographic findings.

OBJECTIVES

The aim of this study was to identify prenatal ultrasonographic features associated with poor neonatal outcomes.

METHOD

A retrospective review of 55 patients with gastroschisis from 2007 to 2017 was completed. Ultrasounds were reviewed for extra-abdominal intestinal diameter (EAID) and intra-abdominal intestinal diameter (IAID), echogenicity, visceral content within the herniation, amniotic fluid index, defect size, and abdominal circumference (AC). Ultrasound variables were correlated with full enteral feeding and the diagnosis of a complex gastroschisis.

RESULTS

Bivariate analysis demonstrated an increased time to full enteral feeds with increasing number of surgeries, EAID, and IAID. Additionally, there was a significant relationship between IAID and AC percentile with the diagnosis of complex gastroschisis. On multivariate analysis, only IAID was significant and increasing diameter had a 2.82 (95% CI 1.02-7.78) higher odds of a longer time to full enteral feeds and a 1.2 (95% CI 1.05-1.36) greater odds of the diagnosis of a complex gastroschisis.

CONCLUSIONS

Based on these findings, IAID is associated with a longer time to full enteral feeding and the diagnosis of complex gastroschisis.

The disproportionate cost of operation and congenital anomalies in infancy

BACKGROUND

Congenital anomalies are the leading cause of infant death and pediatric hospitalization, but existing estimates of the associated costs of health care are either cross-sectional surveys or economic projections. We sought to determine the percent of total hospital health care expenditures attributable to major anomalies requiring surgery within the first year of life.

METHODS

Utilizing comprehensive California statewide data from 2008 to 2012, cohorts of infants undergoing major surgery, with birth defects and with surgical anomalies, were constructed alongside a referent group of newborns with no anomalies or operations. Cost-to-charge and physician fee ratios were used to estimate hospital and professional costs, respectively. For each cohort, costs were broken down according to admission, birth episode, and first year of life, with additional stratifications by birth weight, gestational age, and organ system.

RESULTS

In total, 68,126 of 2,205,070 infants (3.1%) underwent major surgery (n = 32,614) or had a diagnosis of a severe congenital anomaly (n = 57,793). These accounted for $7.7 billion of the $18.9 billion (40.7%) of the total health care costs/expenditures of the first-year-of-life hospitalizations, $7.0 billion (48.6%) of the costs for infants with comparatively long birth episodes, and $5.2 billion (54.7%) of the total neonatal intensive care unit admission costs. Infants with surgical anomalies (n = 21,264) totaled $4.1 billion (21.7%) at $80,872 per infant. Cardiovascular and gastrointestinal diseases accounted for most admission costs secondary to major surgery or congenital anomalies.

CONCLUSION

In a population-based cohort of infant births compared with other critically ill neonates, surgical congenital anomalies are disproportionately costly within the United States health care system. The care of these infants, half of whom are covered by Medi-Cal or Medicaid, stands as a particular focus in an age of reform of health care payments.

A Gastroschisis bundle: effects of a quality improvement protocol on morbidity and mortality

OBJECTIVE

Gastroschisis incidence is rising. Survival in developed countries is over 95%. However, in underdeveloped countries, mortality is higher than 15% often due to sepsis. The aim of this study was to evaluate the effect on morbidity and mortality of a Quality Improvement Protocol for out-born gastroschisis patients.

METHODS

The protocol consisted in facilitating transport, primary or staged reduction at the bedside and sutureless closure, without anesthesia, PICC lines and early feeding. Data was prospectively collected for the Protocol Group (PG) treated between June 2014 through March 2016 and compared to the last consecutive patients Historical Group (HG). Primary outcome was mortality.

SECONDARY OUTCOMES

need for and duration of mechanical ventilation (MV), time to first feed (TFF) after closure, parenteral nutrition (TPN), length of stay (LOS) and sepsis. Data were analyzed using χ2 and Mann-Whitney U tests.

RESULTS

92 patients were included (46 HG and 46 PG). Demographic data were homogeneous. Mortality decreased from 22% to 2% (p = 0.007). Mechanical ventilation use decreased from 100% to 57% (p = <0.001), ventilator days from 14 to 3 median days (p = <0.0001), TPN days: 27 to 21 median days (p = 0.026), sepsis decreased from 70% to 37% (p = 0.003) and anesthesia from a 100% to 15% (p = <0.001), respectively. No difference was found in NPO or LOS.

CONCLUSION

A major improvement in the morbidity and mortality rates was achieved, with outcomes comparable to those reported in developed countries. It was suitable for all patients with gastroschisis. We believe this protocol can be implemented in other centers to reduce morbidity and mortality.

LEVEL OF EVIDENCE

III.

Medium and long-term outcomes of gastroschisis

As survival of gastroschisis patients has improved significantly, it has become apparent that longitudinal follow up strategies need to be developed. Problems concerning patients with gastroschisis are usually associated with gastrointestinal morbidity, but there is mounting evidence that also neurodevelopmental, cognitive, behavioral and late-onset auditory sequelae exist. The presence of associated anomalies, as well as complex features (bowel atresia, necrosis, volvulus, perforation) increase morbidity and impact long-term outcomes. Multidisciplinary follow-up is required, and the key elements of such follow-up are presented here.

Impact of societal factors and health care delivery systems on gastroschisis outcomes

Care of infants with gastroschisis is associated with a significant burden on health care delivery systems. Mortality rates in patients with gastroschisis have significantly improved over the past few decades. However, the condition is still associated with significant short-term and potentially long-term morbidity. Significant variations in clinical outcomes and resource utilization may be explained by several factors including provider and hospital experience, level of neonatal intensive care, variations in hospital regionalization of care, and differences in healthcare delivery systems. Reviewing and assessing these hospital and healthcare system related factors are paramount in addressing variations in gastroschisis care and improving outcomes for these vulnerable infants.

Risk stratification and outcome determinants in gastroschisis

Selection of outcome determinants and risk stratification are necessary to identify patients at higher risk for morbidity and mortality. This facilitates human and material resource allocation and allows for improved family counseling. While several different factors, including prenatal ultrasonographic bowel features, the timing and mode of delivery, and the features of bowel injury have been investigated in gastroschisis, there is still significant debate as to which of these best predicts outcome. This article reviews the different outcome predictors and risk prognostication schemata currently available in the literature to help guide clinicians caring for infants with gastroschisis.

Trends in incidence and outcomes of gastroschisis in the United States: analysis of the national inpatient sample 2010-2014

PURPOSE

Gastroschisis is a severe congenital anomaly associated with a significant morbidity and mortality. There are limited temporal trend data on incidence, mortality, length of stay, and hospital cost of gastroschisis. Our aim was to study these temporal trends using the National Inpatient Sample (NIS).

METHODS

We identified all neonatal admissions with a diagnosis of gastroschisis within the NIS from 2010 through 2014. We limited admission age to ≤ 28 days and excluded all those transferred to other hospitals. We estimated gastroschisis incidence, mortality, length of hospital stay, and cost of hospitalization. For continuous variables, trends were analyzed using survey regression. Cochrane-Armitage trend test was used to analyze trends for categorical variables. P < 0.05 was considered as significant.

RESULTS

The incidence of gastroschisis increased from 4.5 to 4.9/10,000 live births from 2010 through 2014 (P = 0.01). Overall mortality was 3.5%, median length of stay was 35 days (95% CI 26-55 days), and median cost of hospitalization was $75,859 (95% CI $50,231-$122,000). After adjusting for covariates, there was no statistically significant change in mortality (OR = 1.13; 95% CI 0.87-1.48), LOS (β = - 2.1 ± 3.5; 95% CI - 9.0 to 4.8) and hospital cost (β = - 2.137 ± 10.813; 95% CI - 23,331 to 19,056) with each calendar year increase on multivariate logistic regression analysis.

CONCLUSION

The incidence of neonates with gastroschisis increased between 2010 and 2014. Incidence was highest in the West. No difference in mortality and resource utilization was observed.

Outcome of neonates with gastroschisis at different gestational ages using a national database

BACKGROUND/PURPOSE

The optimal time for delivery of neonates with a prenatal diagnosis of gastroschisis (GS) is controversial. We compared the outcomes for GS at three different gestational ages (GAs), 33-34 weeks, 35-36 weeks, and ≥ 37 weeks.

METHODS

We analyze hospital discharge data of neonates with GS using the 2006, 2009 and 2012 Healthcare Cost and Utilization Project Kids' Inpatient Database (HCUPKIDS). Multivariable analysis was used to compare the association between GS outcomes and the three GAs.

RESULTS

Significantly higher number of 33-34 week infants had coexisting morbidities like respiratory distress syndrome, bronchopulmonary dysplasia, small bowel atresia, stenosis, or stricture, large bowel atresia and/or stenosis, malrotation, and atrial septal defect. In multivariable logistic regression, 33-34 week infants had higher NEC (p value = 0.002, 95% CI1.64-10.32), small bowel resection (0.024, 1.12-5.25) and pRBCs transfusion (0.024, 1.05-2.11). No differences were found between 35-36 weeks and ≥37 weeks gest infants for NEC, malabsorption, small bowel resection, TPN cholestasis, sepsis, CLABSI, number of pRBCs transfusion, length of stay and total charges.

CONCLUSION

We did not show benefit for delivering early and in the absence of data, delivery at ≥37 weeks was noninferior to 35-36 weeks. We suggest that waiting for spontaneous onset of labor may be a better approach to balance the effects of prematurity and possible ongoing in utero bowel damage/stillbirth.

LEVELS OF EVIDENCE

Level 3 (Retrospective comparative study).

Maternal Chlamydia infection during pregnancy among younger mothers and risk of gastroschisis in singleton offspring

BACKGROUND

Prevalence of gastroschisis has been increasing in the United States (US) since 1980s. Genital infection with Chlamydia has also been increasing in prevalence, particularly among younger women. The etiology of gastroschisis is unknown. Ongoing research suggests multiple causal factors may be involved, including Chlamydia infection in mothers during pregnancy.

METHODS

Using birth certificate data from 2014 US vital records, we conducted a population-based case-control study to examine the association between prenatal Chlamydia exposure in young women (16-25 years of age) and gastroschisis in singleton offspring. Cases consisted of live births with gastroschisis, and controls had no major birth defects reported in their birth certificate. Logistic regression analysis was used to estimate crude and adjusted odds ratios (cOR and aOR) and 95% confidence intervals (CI).

RESULTS

There were 809 cases (95.6% were isolated cases) and 1,260,293 controls. Chlamydia during pregnancy was reported in 4.5% of case and 3.6% control mothers (p = .21). Case mothers were significantly more likely to be younger (16-20 years of age) at the time of delivery compared to control mothers (p < .0001). We found no significant association between Chlamydia infection during pregnancy and gastroschisis (cOR = 1.24; 95% CI = 0.89-1.73 and aOR = 1.06; 95% CI: 0.66-1.70).

CONCLUSION

With the caveat of possible misclassification of exposure and outcome variables in birth certificate data, we found no significant association between prenatal exposure to Chlamydia and gastroschisis in the offspring born to younger mothers. Future studies should refine measures by focusing on relevant risk period and biomarkers.

Contemporary Outcomes of Infants with Gastroschisis in North America: A Multicenter Cohort Study

OBJECTIVE

To quantify outcomes and analyze factors predictive of morbidity and mortality in infants with gastroschisis.

STUDY DESIGN

Clinical data regarding neonates with gastroschisis born between 2009 and 2014 were prospectively collected at 175 North American centers. Multivariate regression was used to assess risk factors for mortality and length of stay (LOS).

RESULTS

Gastroschisis was diagnosed in 4420 neonates with median birth weight 2410 g (IQR 2105-2747). Survival (discharge home or alive in hospital at 1 year) was 97.8% with a 37 day median LOS (IQR 27-59). Sepsis, defined by positive blood or cerebrospinal fluid culture, was the only significant independent predictor of mortality (P = .04). Significant independent determinants of LOS and the percentage of neonates affected were as follows: bowel resection (9.8%, P < .0001), sepsis (8.6%, P < .0001), presence of other congenital anomalies (7.6%, including 5.8% with intestinal atresias, P < .0001), necrotizing enterocolitis (4.5%, P < .0001), and small for gestational age (37.3%, P = .0006). Abdominal surgery in addition to gastroschisis repair occurred in 22.3%, with 6.4% receiving gastrostomy or jejunostomy tubes and 6.3% requiring ostomy creation. At discharge, 57.0% were less than the 10th percentile weight for age. The mode of delivery (52.4% cesarean delivery) was not associated with any differences in outcome.

CONCLUSIONS

Although neonates with gastroschisis have excellent overall survival they remain at risk for death from sepsis, prolonged hospitalization, multiple abdominal operations, and malnutrition at discharge. Outcomes appear unaffected by the use of cesarean delivery. Further opportunities for quality improvement include sepsis prevention and enhanced nutritional support.

Improved outcomes for inborn babies with uncomplicated gastroschisis

INTRODUCTION

Gastroschisis (GS) is a common abdominal wall defect necessitating neonatal surgery and intensive care. We hypothesized that inborn patients had improved outcomes compared to patients born at an outside hospital (outborn) and transferred for definitive treatment.

METHODS

A single center, retrospective chart review at a pediatric tertiary care center was performed from 2010 to 2015. All patients whose primary surgical treatment of GS was performed at this center were included. We compared patients delivered within our center (inborn) to patients delivered outside of our center and transferred for surgical care (outborn). Babies with complicated gastroschisis were excluded.

RESULTS

During the study period 79 patients with GS were identified. Of these, 53 were inborn and 26 were outborn. Sixteen patients were excluded for complicated GS. The rate of complicated GS was higher in the outborn group (32%) compared to the inborn population (11%) (p=0.03). Duration of stay, readmission rate and time on TPN were all significantly decreased for inborn patients, while time to definitive closure was similar. Mortality was 0% for both inborn and outborn patients.

CONCLUSION

Patients with uncomplicated GS seem to benefit from delivery with immediate pediatric surgical care available eliminating the need for transfer.

LEVEL OF EVIDENCE

III.

Outcome prediction in gastroschisis - The gastroschisis prognostic score (GPS) revisited

PURPOSE

The GPS enables risk stratification for gastroschisis and helps discriminate low from high morbidity groups. The purpose of this study was to revalidate GPS's characterization of a high morbidity group and to quantify relationships between the GPS and outcomes.

METHODS

With REB approval, complete survivor data from a national gastroschisis registry was collected. GPS bowel injury scoring was revalidated excluding the initial inception/validation cohorts (>2011). Length of stay (LOS), 1st enteral feed days (dFPO), TPN days (dTPN), and aggregate complications (COMP) were compared between low and high morbidity risk groups. Mathematical relationships between outcomes and integer increases in GPS were explored using the entire cohort (2005-present).

RESULTS

Median (range) LOS, dPO, and dTPN for the entire cohort (n=849) was 36 (26,62), 13 (9,18), and 27 (20,46) days, respectively. High-risk patients (GPS≥2; n=80) experienced significantly worse outcomes than low risk patients (n=263). Each integer increase in GPS was associated with increases in LOS and dTPN by 16.9 and 12.7days, respectively (p<0.01). COMP rate was also increased in the high-risk cohort (46.3% vs. 22.8%; p<0.01).

CONCLUSION

The GPS effectively discriminates low from high morbidity risk groups. Within the high risk group, integer increases in GPS produce quantitatively differentiated outcomes which may guide initial counseling and resource allocation.

LEVEL OF EVIDENCE

IIb.

Determinants of outcomes in patients with simple gastroschisis

PURPOSE

We analyzed the determinants of outcomes in simple gastroschisis (GS) not complicated by intestinal atresia, perforation, or necrosis.

METHODS

All simple GS patients enrolled in a national prospective registry from 2005 to 2013 were studied. Patients below the median for total parenteral nutrition (TPN) duration (26days) and hospital stay (34days) were compared to those above. Univariate and multivariate logistic and linear regression analyses were employed using maternal, patient, postnatal, and treatment variables.

RESULTS

Of 700 patients with simple GS, representing 76.8% of all GS patients, 690 (98.6%) survived. TPN was used in 352 (51.6%) and 330 (48.4%) patients for ≤26 and >26days, respectively. Hospital stay for 356 (51.9%) and 330 (48.1%) infants was ≤34 and >34days, respectively. Univariate analysis revealed significant differences in several patient, treatment, and postnatal factors. On multivariate analysis, prenatal sonographic bowel dilation, older age at closure, necrotizing enterocolitis, longer mechanical ventilation, and central-line associated blood stream infection (CLABSI) were independently associated with longer TPN duration and hospital stay, with CLABSI being the strongest predictor.

CONCLUSIONS

Prenatal bowel dilation is associated with increased morbidity in simple GS. CLABSI is the strongest predictor of outcomes. Bowel matting is not an independent risk factor.

LEVEL OF EVIDENCE

2c.

Infectious outcomes of gastroschisis patients with intraoperative hypothermia

BACKGROUND

Perioperative hypothermia decreases nutrient and oxygen delivery to tissues and, in adult studies, increases the risk of infectious complications (ICs). Gastroschisis (GS) places newborns at risk for hypothermia by nature of exposed viscera and excessive heat loss. Although hypothermia is a known cause of mortality in GS, the rate of ICs in this at-risk cohort has not yet been delineated.

MATERIALS AND METHODS

A retrospective cohort study was performed at our single tertiary-referral hospital, evaluating patient and operative characteristics of all GS infants who underwent operative closure. Intraoperative temperatures were recorded, defining hypothermia as mild (35.5°C-35.9°C), moderate (35.0°C-35.4°C), or severe (<35°C). Temperature nadirs, procedural and anesthesia duration were observed. The primary outcome was 30-d surgical site infections. Secondary measures included other ICs.

RESULTS

Among 43 GS neonates, 21 (48.8%) had intraoperative hypothermia, classified as mild in 2 (4.7%), moderate in 8 (18.6%), and severe in 11 (25.6%). Nineteen ICs occurred in 35.9% of patients, including 10 (23.3%) surgical site infections. There was no association between hypothermia and ICs. Patient and operative characteristics were similar between normothermic and hypothermic groups, except that normothermic infants were more likely to have silos placed with delayed closure than hypothermic patients (63.6% versus 23.8%, P = 0.01).

CONCLUSIONS

Infants with GS are at high risk for hypothermia and ICs, though newborns with silos were less subject to temperature lability. A multiinstitutional study with greater power is needed to further investigate the relationship between perioperative hypothermia and surgical ICs.

The epidemiology, prevalence and hospital outcomes of infants with gastroschisis

OBJECTIVE

The purpose of this study is to evaluate recent trends in prevalence of gastroschisis among infants admitted for neonatal intensive care in the United States.

STUDY DESIGN

Retrospective review of a de-identified patient data. The current study extends our observations through the end of 2007 to 2015.

RESULTS

During the study period (1 January 1997 to 12 December 2015), there were 1 158 755 total discharges; 6023 (5.2/1000) had gastroschisis and 1885 (1.6/1000) had an omphalocele. Between 1997 and 2008, the reported rate of gastroschisis increased from 2.9 to 6.4/1000 discharges. From 2008 to 2011, the values have slowly decreased from 6.4 to 4.7/1000 discharges and since 2011 have been stable. The largest drop in the prevalence was in mothers who were <20 years old. In contrast, the reported rate of omphalocele was stable at 1 to 2/1000 discharges.

CONCLUSION

The prevalence of gastroschisis increased from 1997 to 2008, and then declined thereafter.

Flap versus fascial closure for gastroschisis: a systematic review and meta-analysis

BACKGROUND

Flap closure represents an alternative to fascial closure for gastroschisis. We performed a systematic review and meta-analysis of outcomes comparing these techniques.

METHODS

A registered systematic review (

PROSPERO

CRD42015016745) of comparative studies was performed, querying multiple databases without language or date restrictions. Gray literature was sought. Outcomes analyzed included: mortality, ventilation days, feeding parameters, length of stay (LOS), wound infection, resource utilization, and umbilical hernia incidence. Multiple reviewers independently assessed study eligibility and literature quality. Meta-analysis of outcomes was performed where appropriate (Revman 5.2).

RESULTS

Twelve studies met inclusion criteria, of which three were multi-institutional. Quality assessment revealed unbiased patient selection and exposure, but group comparability was suboptimal in four studies. Overall, 1124 patients were evaluated, of which 350 underwent flap closure (210 immediately; 140 post-silo). Meta-analysis revealed no significant differences in mortality, LOS, or feeding parameters between groups. Flap patients had less wound infections (OR 0.40 [95%CI 0.22-0.74], P=0.003). While flap patients had an increased risk of umbilical hernia, they were less likely to undergo repair (19% vs. 41%; P=0.01).

CONCLUSIONS

Flap closure has equivalent or superior outcomes to fascial closure for patients with gastroschisis. Given potential advantages of bedside closure and reduced sedation requirements, flap closure may represent the preferred closure strategy.

Gastroschisis Complicated by Septo-Optic Dysplasia: Two Distinct Anomalies with a Common Origin

Introduction Gastroschisis is considered to be an isolated abdominal wall defect that is infrequently associated with other anomalies. Case This case describes an infant with gastroschisis who developed refractory shock after an uncomplicated surgery for bowel atresia. He was found to have adrenal insufficiency secondary to septo-optic dysplasia with panhypopituitarism. Conclusion Gastroschisis and septo-optic dysplasia arise from vascular disruptions, therefore presence in the same infant can be more than just a coincidence. While this is not a common occurrence, our case illustrates the need for a high index of suspicion with an unusual clinical course.