A simple presurgical necrotizing enterocolitis-mortality scoring system

Biomarkers in the Severity of Necrotizing Enterocolitis in Preterm Infants: A Pilot Study

Background

The occurrence of necrotizing enterocolitis (NEC) is a common and severe disease of the digestive system in neonates. This study aims to assess the value of the intestinal tissue oxygen saturation (rintSO2) combined with the levels of procalcitonin (PCT) and mean platelet volume (MPV) in predicting the severity of NEC in preterm infants.

Methods

This experiment was a retrospective cohort study conducted in the Department of Pediatrics, Hongqi Hospital Affiliated to Mudanjiang Medical University between January 2017 and July 2022. Premature neonates with NEC were enrolled and divided into mild-moderate NEC group and severe NEC group according to Bell's stage. The general information data, rintSO2 and blood parameters such as the white blood cell (WBC) count, platelet count (PLT), PCT, MPV, red blood cell distribution width (RDW), hemoglobin (Hb), C-reactive protein (CRP) were compared between the two groups.

Results

A total of 122 patients were enrolled, including 79 mild-moderate NEC and 43 severe NEC. The rintSO2 was lower in severe group than in mild-moderate group (P = 0.042), the PCT and MPV were both higher in severe group than in mild-moderate group (P = 0.048, P = 0.049). The results of logistic regression suggested that the rintSO2 (OR = 1.491, P = 0.003), PCT (OR = 3.071, P = 0.001) and MPV (OR = 4.027, P = 0.015) were independent predictive factors for severity of NEC. The area under the curve (AUC) of the rintSO2 combined with PCT and MPV showed good diagnostic ability in the severity of NEC.

Conclusion

The rintSO2 combined with PCT and MPV may be considered as the early biomarkers in the severity of NEC and could help us to diagnose the case early with early treatment with better prognosis.

Association between Serum Lactate and Morbidity and Mortality in Neonates: A Systematic Review and Meta-Analysis

OBJECTIVE

Lactate is a marker of hypoperfusion in critically ill patients. Whether lactate is useful for identifying and stratifying neonates with a higher risk of adverse outcomes remains unknown. This study aimed to investigate the association between lactate and morbidity and mortality in neonates.

METHODS

A meta-analysis was performed to determine the association between blood lactate levels and outcomes in neonates. Ovid MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov were searched from inception to 1 May 2021. A total of 49 observational studies and 14 data accuracy test studies were included. The risk of bias was assessed using the Newcastle-Ottawa Scale for observational studies and the QUADAS-2 tool for data accuracy test studies. The primary outcome was mortality, while the secondary outcomes included acute kidney injury, necessity for renal replacement therapy, neurological outcomes, respiratory morbidities, hemodynamic instability, and retinopathy of prematurity.

RESULTS

Of the 3184 articles screened, 63 studies fulfilled all eligibility criteria, comprising 46,069 neonates. Higher lactate levels are associated with mortality (standard mean difference, -1.09 [95% CI, -1.46 to -0.73]). Using the estimated sensitivity (0.769) and specificity (0.791) and assuming a prevalence of 15% for adverse outcomes (median of prevalence among studies) in a hypothetical cohort of 10,000 neonates, assessing the lactate level alone would miss 346 (3.46%) cases (false negative) and wrongly diagnose 1776 (17.76%) cases (false positive).

CONCLUSIONS

Higher lactate levels are associated with a greater risk of mortality and morbidities in neonates. However, our results do not support the use of lactate as a screening test to identify adverse outcomes in newborns. Research efforts should focus on analyzing serial lactate measurements, rather than a single measurement.

Risk factors for mortality in preterm infants with necrotizing enterocolitis: a retrospective multicenter analysis

It is difficult to predict the risk of mortality in necrotizing enterocolitis (NEC). This study aimed at identifying risk factors for severe NEC (Bell stage III) and mortality in preterm children with NEC. In this multicenter retrospective study, we analyzed multiple data from 157 premature children with confirmed NEC in the period from January 2007 to October 2018. We performed univariate, multivariate, stepwise logistic regression, and receiver operator characteristics (ROC) analyses. We were able to demonstrate that low Apgar scores (notably at 1' and 5'), low hemoglobin concentration (Hgb), and high lactate level at disease onset and during disease correlated with NEC severity and mortality (P < 0.05, respectively). Severe NEC was related to congenital heart disease (CHD - OR 2.6, CI95% 1.2-5.8, P 0.015) and patent ductus arteriosus (PDA - OR 3.3, CI95% 1.6-6.9, P 0.0012), whereas death was related to the presence of PDA (OR 5.5, CI95% 2.3-14, P < 0.001).Conclusion: Low Apgar scores, low Hgb, high lactate levels, and the presence of CHD or PDA correlated with severe NEC or mortality in children with NEC. What is Known: • It remains difficult to predict which infant that suffers from necrotizing enterocolitis at risk of death. • Several clinical and laboratory parameters tools to predict fatal outcome in NEC. What is New: • The following laboratory parameters were associated with the risk of death from NEC: Hemoglobin concentration, base excess and lactate level. • The following clinical variables were associated with the risk of death from NEC: Apgar scores, as well as the presence of congenital heart disease and patent ductus arteriosus.

Intestinal Oxygenation and Survival After Surgery for Necrotizing Enterocolitis: An Observational Cohort Study

OBJECTIVE

To assess whether regional intestinal oxygen saturation (rintSO2) and regional cerebral oxygen saturation (rcSO2) measurements aid in estimating survival of preterm infants after surgery for NEC.

SUMMARY OF BACKGROUND DATA

Predicting survival after surgery for NEC is difficult yet of the utmost importance for counseling parents.

METHODS

We retrospectively studied prospectively collected data of preterm infants with surgical NEC who had available rintSO2 and rcSO2 values measured via near-infrared spectroscopy 0-24 hours preoperatively. We calculated mean rintSO2 and rcSO2 for 60-120 minutes for each infant. We analyzed whether preoperative rintSO2 and rcSO2 differed between survivors and non-survivors, determined cut-off points, and assessed the added value to clinical variables.

RESULTS

We included 22 infants, median gestational age 26.9 weeks [interquartile range (IQR): 26.3-28.4], median birth weight 1088 g [IQR: 730-1178]. Eleven infants died postoperatively. Preoperative rintSO2, but not rcSO2, was higher in survivors than in non-survivors [median: 63% (IQR: 42-68) vs 29% (IQR: 21-43), P < 0.01), with odds ratio for survival 4.1 (95% confidence interval, 1.2-13.9, P = 0.02) per 10% higher rintSO2. All infants with rintSO2 values of >53% survived, whereas all infants with rintSO2 <35% died. Median C-reactive protein [138 mg/L (IQR: 83-179) vs 73 mg/L (IQR: 12-98), P < 0.01), lactate [1.1 mmol/L (IQR: 1.0-1.6) vs 4.6 mmol/L (IQR: 2.8-8.0), P < 0.01], and fraction of inspired oxygen [25% (IQR: 21-31) vs 42% (IQR: 30-80), P < 0.01] differed between survivors and non-survivors. Only rintSO2 remained significant in the multiple regression model.

CONCLUSIONS

Measuring rintSO2, but not rcSO2, seems of added value to clinical variables in estimating survival of preterm infants after surgery for NEC. This may help clinicians in deciding whether surgery is feasible and to better counsel parents about their infants' chances of survival.

Clinical Characteristics of Necrotizing Enterocolitis in Preterm Patients With and Without Persistent Ductus Arteriosus and in Patients With Congenital Heart Disease

Background: Diagnosis and management of NEC is based on clinical, radiological, and laboratory findings. Discrimination of pathogens for an improved understanding of NEC in preterm infants and NEC in infants with congenital heart disease has been previously discussed and enables evaluation of further NEC biomarkers. Patients and Methods: Within a study period of 11 years (2008-2019), we identified 107 patients with a diagnosis of NEC at our primary care center. Thirty-six out of 54 patients suffering from NEC in high Bell stages who underwent surgery met inclusion criteria. These patients were classified according to their cardiac status, and analyses of clinical factors influencing NEC were conducted. Additionally, clinical factors associated with a fulminant course of NEC were examined. Univariable and multivariable analyses were performed. Results: The study populations consisted of 12 preterm infants with NEC but without patent ductus arteriosus (PT-NEC), seven preterm infants with NEC and patent ductus arteriosus (PDA-NEC), and 17 infants with NEC and congenital heart disease (CHD-NEC). Blood flow in intestinal vessels was impaired in infants with PDA-NEC and CDH-NEC. Therefore, we used logistic regression to compare PDA-NEC and CDH-NEC infants with PT-NEC infants: positive bacterial culture of intraoperative swabs (p = 0.0199; odds ratio: 21.9) and macroscopic intestinal necrosis (p = 0.0033; odds ratio: 43.5) were observed more frequently in the first group. Furthermore, multiple regression analysis determined the NEC localization (p = 0.0243) as a significant factor correlated with a fulminant course. Compared to a NEC exclusively localized in the colon, there is a 5.8-fold increased risk of a fulminant course when the small intestine is affected and a 42-fold increase of risk when both small intestine and colon were affected. Conclusion: An early diagnosis and timely surgical intervention of NEC, especially in infants with PDA and CDH may be considered to avoid major bowel necrosis (resulting in loss of intestinal tissue) and multiple operations.

Risk Factors for Necrotizing Enterocolitis in Infants With Patent Arterial Duct. A Retrospective Matched Paired Analysis

Background: The development of necrotizing enterocolitis (NEC) in neonates with patent ductus arteriosus (PDA) is not well-understood. Our aim was to find risk factors for NEC in children with a significant PDA and to assess differences in mortality and duration of hospital stay between patients with PDA and those with PDA and NEC. Methods: We performed a retrospective single center case control study including infants with PDA scheduled for treatment. We compared multiple patient data between patients with PDA and those with PDA and NEC from 2004 to 2018 using 1:2 and 1:1 matching. Results: We used 1:2 matching with 26 NEC patients (cases) and 52 PDA patients without NEC (controls) and 1:1 matching with 5 NEC patients and 5 PDA patients without NEC. NEC patients had lower Apgar score (1'), more congenital malformations, more suspected sepsis, less hypotension, higher minimum platelet count and higher CRP-values during the week before NEC (P < 0.05, respectively). The mortality was higher in NEC cases [29% (9/31)] compared to the control patients [2% (1/57), P < 0.001]. Lower Apgar score (1') was correlated with an increased risk of NEC stage III. Hypotension was inversely correlated with the odds of NEC (OR 0.3). Conclusions: NEC increased mortality in infants with PDA. Hypotension did not increase the risk of NEC in infants with PDA. Routine clinical parameters were not able to predict NEC in infants who suffer from PDA.

Validity of Biomarkers of Early Circulatory Impairment to Predict Outcome: A Retrospective Analysis

Objectives: The definition of circulatory impairment in the premature infant is controversial. Current research suggests overdiagnosis and overtreatment. We aimed to analyse which biomarkers move clinicians to initiate cardiovascular treatment (CVT). The prognostic capacity for adverse outcome (death and/or moderate-severe brain damage by cranial ultrasound at term equivalent) of these biomarkers was evaluated. Study Design: Retrospective data analysis from preterm infants enrolled in a placebo-controlled trial on dobutamine for low superior vena cava (SVC) flow, who showed normal SVC flow within the first 24 h (not randomized). Five positive biomarkers were considered: MABP < gestational age (GA)-1 mmHg; MABP < GA-5 mmHg; lactate > 4 mmol/L; BE < -9 mmol/L; SVC flow <51 ml/kg/min. Results: Ninety eight infants formed the study cohort. Thirty six received CVT (2-95 h). Logistic regression models adjusted for gestational age showed a positive association between CVT and the risk of death or moderate-severe abnormal cranial ultrasound at term equivalent [(OR 5.2, 95%CI: 1.8-15.1) p = 0.002]. MABP < GA-1 mmHg and lactate > 4 mmol/L were the most prevalent biomarkers at start of treatment. Low BE, high serum lactate and low SVC flow at first echocardiography showed a trend toward being associated with adverse outcome, although not statistically significant. Conclusions: Low blood pressure and high lactate are the most prevalent biomarkers used for CVT prescription. Lactic acidosis and low SVC flow early after birth showed a trend toward being associated with adverse outcome. These findings support using a combination of biomarkers for inclusion in a placebo-controlled trial on CVT during transitional circulation.

Preoperative metabolic acidosis in infants with gastroschisis

INTRODUCTION

There is little in literature regarding preoperative management of infants with gastroschisis. It is unclear if these infants develop metabolic acidosis as a consequence of prolonged intrauterine gut compromise or dehydration secondary to increased fluid loss.

AIM

To assess the frequency of preoperative metabolic acidosis in infants with gastroschisis and investigate whether this acidosis reflects degree of gut compromise.

METHODS

All infants with gastroschisis born between May 2005 and April 2013 in a single tertiary care center were reviewed. Metabolic acidosis was defined by the presence of pH <7.26 and serum bicarbonate <18.5 or base excess < -8.5 mmol/l. Infants with significant birth depression were excluded. Maternal and neonatal data were collected. Frequency of preoperative metabolic acidosis and its association with gastroschisis prognostic score (GPS), time to first and time to reach full feeds were investigated.

RESULTS

Sixty infants were identified, 11 were excluded (birth depression/lack of preoperative blood gases). Median preoperative total fluid intake was 130 ml/kg/d. Nine infants (18%) had metabolic acidosis at a median age of 1.2 hours. No association was found between metabolic acidosis or serum lactate and GPS, age at first feed or age at full feeds.

CONCLUSION

Preoperative metabolic acidosis was identified in a significant number of patients with gastroschisis despite high fluid intake. It does not appear to be associated with the degree of gut compromise. Using metabolic acidosis as an indication of dehydration in these patients needs more investigation.

Diagnosis and Management of Necrotizing Enterocolitis: An International Survey of Neonatologists and Pediatric Surgeons

BACKGROUND

Necrotizing enterocolitis (NEC) is a serious complication of prematurity. Currently, there is limited evidence to guide investigation and treatment strategies.

OBJECTIVES

To evaluate the parameters used to diagnose or exclude NEC, and to identify differences between neonatologists and pediatric surgeons.

METHODS

A scenario-based survey was sent to neonatologists and pediatric surgeons.

RESULTS

173 physicians from 26 countries completed the survey (55% neonatologists and 45% pediatric surgeons). Bloody stools, abdominal tenderness, low platelet counts, and increased lactate levels increased the likelihood of NEC for 82, 72, 56, and 45% of respondents, respectively. Intestinal pneumatosis, portal venous gas, and pneumoperitoneum on X-ray increased the likelihood of NEC for 99, 98, and 92% of respondents, respectively. Clinical examination and laboratory tests were insufficient to exclude NEC, but normal intestinal movements and normal gut wall thickness on ultrasonography decreased the likelihood of NEC for 38 and 33% of respondents, respectively. Neonatologists more frequently relied on increased gastric residuals and abdominal distension to diagnose NEC (p = 0.04 and p = 0.03, respectively), whereas pediatric surgeons more frequently reported that absence of bloody stools helped to exclude NEC (p = 0.04). In a deteriorating patient with suspected NEC, 39% of respondents would broaden the antibiotic spectrum, and 42% would recommend a laparotomy.

CONCLUSION

Our results indicate a wide variation in the management of NEC, with significant differences between neonatologists and pediatric surgeons. A better appreciation of the relative significance and weighting that should be applied to the clinical features and investigations should reduce the variation in interpretation that appears to exist.

Ultrasonography and radiography findings predicted the need for surgery in patients with necrotising enterocolitis without pneumoperitoneum

AIM

The timing of surgical intervention in patients with necrotising enterocolitis (NEC) without pneumoperitoneum remains unclear. This study aimed to identify the predictors associated with surgical intervention in such patients and to assess how effective imaging reports were as an aid to surgical decision-making.

METHODS

We collected clinical data, laboratory investigations and imaging findings on NEC patients without pneumoperitoneum. A critical imaging report was defined as persistent dilation of bowel loops and evidence of portal venous gas on radiography and thickening of the bowel wall, absent peristalsis and evidence of echogenic-free fluid on sonography. Independent predictors of surgical NEC were identified using multivariate logistic regression analysis. Sensitivity and specificity analyses were performed for the imaging findings, and receiver operator characteristic curve analysis was used to evaluate the predictive accuracy.

RESULTS

Of the 238 neonates studied, 54 (22.69%) required surgical intervention. The multivariate logistic regression analysis showed that abdominal erythema, C-reactive protein levels and the critical imaging report were independent predictors of the need for surgical intervention. The critical imaging report was the most powerful predictor of surgical NEC.

CONCLUSION

Both ultrasonography and radiography findings proved helpful in predicting the need for surgery in NEC without pneumoperitoneum.

Optimizing operational efficiencies in early phase trials: The Pediatric Trials Network experience

Performing drug trials in pediatrics is challenging. In support of the Best Pharmaceuticals for Children Act, the Eunice Kennedy Shriver National Institute of Child Health and Human Development funded the formation of the Pediatric Trials Network (PTN) in 2010. Since its inception, the PTN has developed strategies to increase both efficiency and safety of pediatric drug trials. Through use of innovative techniques such as sparse and scavenged blood sampling as well as opportunistic study design, participation in trials has grown. The PTN has also strived to improve consistency of adverse event reporting in neonatal drug trials through the development of a standardized adverse event table. We review how the PTN is optimizing operational efficiencies in pediatric drug trials to increase the safety of drugs in children.

[Prognostic factors related to mortality in newborns with necrotising enterocolitis]

BACKGROUND

Necrotizing enterocolitis is the most frequent and severe acquired gastrointestinal disease in newborns and still has high mortality. There are few published papers about prognostic factors of death in our country.

OBJECTIVE

To know the factors associated with death in patients with necrotizing enterocolitis.

METHODS

Retrospective, descriptive, comparative study with a case-control design was conducted on patients with necrotizing enterocolitis during a 5-year period.

RESULTS

Deceased patients had significantly lower platelet counts compared to survivors (P=0.022) and the prognostic factors associated with mortality were anaemia (P=0.006, OR = 15.62), stage III of necrotizing enterocolitis (P<0.001, OR = 47.5), to require surgical treatment (P<0.001, OR = 47.5), to have intestinal necrosis (P=0.001, OR = 48.5) or perforation (P=0.016, OR =24.25), to have medical complications, specifically intravascular disseminated coagulation (P<.001, RR = 98), and multi-organ failure (P<0.001, RR = 2). It was also found that patients with gastrointestinal symptoms and diagnosis of necrotising enterocolitis when they were hospitalized were more likely to have surgical treatment.

CONCLUSIONS

We must be aware of the factors associated with mortality, as well as those associated with surgical treatment to reduce overall mortality for this condition.

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.

Postoperative sepsis in infants below 6 months of age

BACKGROUND

Sepsis is a threatening postoperative complication especially in small infants. Regarding the advances in perinatal medicine, its incidence is unknown to date. We aimed to investigate the incidence, risk factors, laboratory findings and outcome of postoperative sepsis in infants younger than 6 months old.

METHODS

We examined postoperative sepsis in babies below 6 months of age during a 4-year period at a tertiary pediatric institution.

RESULTS

The rate of postoperative sepsis was 6.9%. Laparotomy with enterotomy, thoracotomy and diaphragmatic hernia repair (P<0.05, respectively) as well as low postnatal age and long operation time (P<0.001, respectively) were correlated with the incidence of sepsis. Significant independent predictors for the development of sepsis were the presence of a central venous catheter and perioperative antibiotic treatment (P<0.001, respectively). Coagulase negative Staphylococci were the major infecting organism associated with postoperative sepsis, accounting for 53% of monomicrobial infections. Complete blood counts with differential were not different between infants with sepsis and controls, who had undergone the same surgical procedures. Outcome was favorable in all cases; however, the length of hospital stay was significantly longer in sepsis patients (P<0.05).

CONCLUSIONS

Postoperative sepsis syndrome is a frequent complication in infants below 6 months of age and causes significant prolongation of hospital stay. Adequate prevention and therapeutic strategies warrant further prospective investigations.

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.

Higher cord blood levels of mannose-binding lectin-associated serine protease-2 in infants with necrotising enterocolitis

Necrotising enterocolitis (NEC) causes significant morbidity and mortality in premature infants. The role of innate immunity in the pathogenesis of NEC remains unclear. Mannose-binding lectin (MBL) recognizes microorganisms and activates the complement system via MBL-associated serine protease-2 (MASP-2). The aim of this study was to investigate whether MBL and MASP-2 are associated with NEC. This observational case-control study included 32 infants with radiologically confirmed NEC and 64 controls. MBL and MASP-2 were measured in cord blood using ELISA. Multivariate logistic regression was performed. Of the 32 NEC cases (median gestational age, 30.5 wk), 13 (41%) were operated and 5 (16%) died. MASP-2 cord blood concentration ranged from undetectable (<10 ng/mL) to 277 ng/mL. Eighteen of 32 (56%) NEC cases had higher MASP-2 levels (> or =30 ng/mL) compared with 22 of 64 (34%) controls (univariate OR 2.46; 95% CI 1.03-5.85; p = 0.043). Higher cord blood MASP-2 levels were significantly associated with an increased risk of NEC in multivariate analysis (OR 3.00; 95% CI 1.17-7.93; p = 0.027). MBL levels were not associated with NEC (p = 0.64). In conclusion, infants later developing NEC had significantly higher MASP-2 cord blood levels compared with controls. Higher MASP-2 may favor complement-mediated inflammation and could thereby predispose to NEC.