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

Antenatal Growth, Gestational Age, Birth, Enteral Feeding, and Blood Citrulline Levels in Very Low Birth Weight Infants

Early enteral nutrition using reliable biomarkers of intestinal function must be established to improve neurodevelopmental outcomes in very low birth weight infants (VLBWIs). Serum citrulline levels reflect the intestinal function in adults. To elucidate the relationship among antenatal growth, postnatal enteral nutrition, and blood citrulline levels, a retrospective single-center observational study was conducted on 248 VLBWIs born between April 2014 and March 2021. A mixed effect model and post hoc simple slope analysis were used to estimate the correlations between clinical variables and citrulline levels at Early (day 5.1) and Late (day 24.3) postnatal ages. Greater gestational age, birth weight, and amount of enteral nutrition at the time of blood sampling were associated with lower citrulline levels at the Early postnatal age and higher citrulline levels at the Late postnatal age. Provided that Early citrulline levels predominantly reflect the consequence of antenatal citrulline metabolism, it is suggested that fetal growth and maturation are likely to promote citrulline catabolism in utero and its synthesis after birth. With additional insights into the temporal transition point wherein the maturation-dependent balance of citrulline metabolism shifts from catabolism-dominant to synthesis-dominant, citrulline emerges as a potential biomarker for assessing intestinal function and gastrointestinal disorders.

Association of anemia and platelet activation with necrotizing enterocolitis with or without sepsis among low birth weight neonates: a case-control study

Background

This study aims to evaluate the value of the proportion of large platelets (PLCR) and platelet crit (PCT) in predicting necrotizing enterocolitis (NEC) in low birth weight (LBW) neonates.

Methods

A total of 155 LBW (<2,500 g) neonates with NEC, who were admitted to the neonatal intensive care unit (NICU) of the hospital from January 1, 2017, to November 30, 2019, were included in the case group. According to the 1:3 case-control study design, a total of 465 LBW neonates without NEC (three for each LBW neonate with NEC), who were admitted to the NICU and born ≤24 h before or after the birth of the subjects, were included in the control group.

Results

During the study period, a total of 6,946 LBW neonates were born, of which 155 had NEC, including 92 who also had sepsis. Neonatal sepsis was the most important risk factor and confounding factor for NEC in LBW neonates. Further stratified analysis showed that in LBW neonates without sepsis, anemia [P = 0.001, odds ratio (OR) = 4.367, 95% confidence interval (CI): 1.853-10.291], high PLCR (P < 0.001, OR = 2.222, 95% CI: 1.633-3.023), and high PCT (P = 0.024, OR = 1.368, 95% CI: 1.042-1.795) increased the risk of NEC and the receiver operating characteristic curve area of PLCR, sensitivity, specificity, and cutoff value were 0.739, 0.770, 0.610, and 33.55, respectively.

Conclusions

The results showed that 2/100 LBW neonates were at risk for NEC, and the stratified analysis of the confounding factors of sepsis identified the risk factors of NEC in LBW neonates. This study first reported the significance of PLCR in the early prediction of NEC occurrence in LBW neonates without sepsis.

Point-of-care Ultrasound to Diagnose and Monitor the Course of Necrotizing Enterocolitis

Context

Neonatal gut ultrasound (US) is an emerging clinical tool for quick diagnosis and prognosis in various abdominal pathologies. In this review, we summarize normal gut US findings and concentrate on the specifications of diagnosing necrotizing enterocolitis.

Evidence

A comprehensive literature search was conducted across numerous sources with relevant keywords along with the specified age group of 0-28 days of life.

Findings

This review describes the normal gut US picture with the basic technicalities needed to master the art of point-of-care (POC) abdominal US. This modality is gaining importance due to its accuracy, applicability, safety, and affordability. Key findings include altered bowel perfusion, decreased peristalsis, and bowel wall thickening with better precision compared to abdominal X-ray (AXR). Many meta-analyses and narrative reviews have already demonstrated their usefulness. The high specificity and positive predictive value could make this tool a guide for early identification and prompt surgical intervention in the dreaded diagnosis of necrotizing enterocolitis.

Conclusion

Emerging evidence and expertise in the field of abdominal US will make it a valuable tool for early diagnosis and prognosis of necrotizing enterocolitis.

Application of abdominal ultrasonography in surgical necrotizing enterocolitis: a retrospective study

Background

Necrotizing enterocolitis (NEC) is a severe inflammatory bowel disease that may lead to perforation, causing high morbidity and mortality in preterm infants. Abdominal ultrasound (AUS) has been shown to provide benefits in diagnosing and managing NEC in recent years.

Objective

This study focused on the utility of AUS in the diagnosis and evaluation of surgical NEC.

Patients and methods

In this retrospective study, available data of the patients diagnosed from January 2019 to June 2022 were reviewed. The sensitivity and specificity of AUS in diagnosing a perforation were analyzed. Typical cases for the application of AUS in monitoring and evaluating the progression, complications, and sequela of NEC were described.

Results

There were 69 neonates diagnosed with NEC and examined by AUS, of whom eight patients developed a perforation. AUS was used for diagnosing a perforation in eight patients with key features of pneumoperitoneum and/or complex ascites, allowing us to find four locations of perforation, with a sensitivity and specificity of 100%.

Conclusion

AUS plays an important role in diagnosing and evaluating surgical NEC in newborn infants, with good sensitivity and specificity.

Endoscopy in a Pediatric Patient After Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a gastrointestinal condition usually found in premature neonates. Our case involves a full-term, 3-month-old male who was found to have pneumatosis after surgical repair of congenital cardiac defects. After cessation of enteral feeds, nasogastric tube decompression, and broad-spectrum antibiotics, breast milk was reintroduced 8 days after his procedure. Hematochezia developed, but repeat abdominal X-rays were normal with benign abdominal examinations, stable vital signs, and improved laboratory findings. Although feeds were slowly restarted with an amino acid-based formula, hematochezia persisted. Meckel's scan was negative, and Computerized Tomography revealed diffuse bowel inflammation. Esophagogastroduodenoscopy and flexible sigmoidoscopy were performed for further evaluation which showed stricture and ulceration at the descending colon. This procedure was complicated by perforation with subsequent resection of this segment and diverting ileostomy. Due to the risk of complications, it is suggested to wait at least 6 weeks from acute events such as NEC before performing an endoscopy.

Morbidity associated with laparotomy-confirmed spontaneous intestinal perforation: A prospective multicenter analysis

BACKGROUND

Differences in morbidities between spontaneous intestinal perforation (SIP) and necrotizing enterocolitis (NEC) are unknown.

METHODS

Prospectively collected multicenter data regarding very low birth weight (VLBW) infants 2015-2019 were analyzed. Diagnosis of SIP or NEC was laparotomy-confirmed in all patients. Multivariable regression modeling was used to assess adjusted length of stay (LOS; primary outcome) and adjusted risk ratios (ARR) for weight <10th percentile at discharge, and supplemental oxygen requirement at discharge.

RESULTS

Of 201,300 VLBW infants at 790 hospitals, 1523 had SIP and 2601 had NEC. Adjusted LOS was similar for SIP and NEC (92 vs 88 days, p = 0.08561), but significantly higher than seen without SIP or NEC (68 days, p<0.0001). The risk of growth morbidity at discharge was similar between SIP and NEC (74.2% vs 75.3%; ARR:1.00;0.94,1.06), but higher than infants without SIP or NEC (47.7%; ARR:0.50;0.47,0.53). Infants with NEC were less likely to require supplemental oxygen at discharge than infants with SIP (24.4% vs 34.9%; ARR:0.80; 0.71,0.89).

CONCLUSIONS

Although mortality is known to be lower in VLBW infants with SIP than NEC, this study highlights the similarly high morbidity experienced by both groups of infants. These benchmark data can help align counseling of families with expected outcomes.

LEVEL OF EVIDENCE

Level II.

TYPE OF STUDY

Prognosis study (Cohort Study).

Predictive factors for the surgical treatment of necrotizing enterocolitis in preterm infants: a single-center retrospective study

Background

Necrotizing enterocolitis (NEC) is a gastrointestinal disease that tends to occur in premature infants. Some features may be associated with an increased probability that preterm infants with NEC will require surgical treatment. This study aimed to identify the factors that increased the probability of surgical treatment in infants with NEC.

Methods

We retrospectively analyzed the data of premature infants with NEC who were hospitalized at The Affiliated Hospital of Qingdao University from April 2011 to April 2021. According to the treatments received, these patients were divided into medical NEC group and surgical NEC group. The perinatal characteristics, clinical manifestations, and laboratory values before the onset of NEC were subjected to univariate and multivariate analyses.

Results

A total of 623 preterm infants with NEC (> Bell’s stage I) were included in this study, including 350 (56%) who received surgical treatment and 273 (44%) who received conservative medical treatment. Multivariate analysis showed that lower gestational age (P = 0.001, odds ratio (OR) (95% CI) = 0.91[0.86–0.96]), early occurrence of NEC (P = 0.003, OR (95% CI) = 0.86 [0.77–0.95]), hemodynamically significant patent ductus arteriosus (P = 0.003, OR (95% CI) = 7.50 [2.03–28.47]), and low serum bicarbonate (P = 0.043, OR (95% CI) = 0.863 [0.749–0.995]) were associated with an increased probability of surgical treatment in preterm infants with NEC.

Conclusions

Our findings were applied to identify potential predictors for surgical treatment in preterm infants with NEC, which may facilitate early decisive management.

Abdominal Ultrasound Assists the Diagnosis and Management of Necrotizing Enterocolitis

BACKGROUND

Abdominal x-ray (KUB) routinely aids in detecting necrotizing enterocolitis (NEC), one of the most serious neonatal intestinal diseases. However, a KUB may miss up to 50% of the early signs of NEC. Recent advances in abdominal ultrasound (AUS) can expedite this diagnosis and improve clinical management.

PURPOSES

To illustrate AUS findings that suggest NEC through 3 case examples. To review current literature regarding advantages and limitations of AUS compared with KUB.

RESULTS

The added visualization of intra-abdominal structures with AUS compared with KUB improves the diagnosis and management of NEC. Some AUS features are highly suggestive of impending bowel perforation, while others can confirm bowel perforation despite a negative radiograph.

IMPLICATIONS FOR PRACTICE

AUS expedites time to diagnosis of NEC and helps to stratify patients who may fail medical management and require surgical intervention.

IMPLICATIONS FOR RESEARCH

More quality improvement studies are needed to validate an AUS protocol for the management of NEC. Advances in technology, such as contrast-enhanced ultrasound, may improve NEC detection with AUS in the future.Video Abstract available athttps://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

Using machine learning analysis to assist in differentiating between necrotizing enterocolitis and spontaneous intestinal perforation: A novel predictive analytic tool

PURPOSE

Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are devastating diseases in preterm neonates, often requiring surgical treatment. Previous studies evaluated outcomes in peritoneal drain placement versus laparotomy, but the accuracy of the presumptive diagnosis remains unknown without bowel visualization. Predictive analytics provide the opportunity to determine the etiology of perforation and guide surgical decision making. The purpose of this investigation was to build and evaluate machine learning models to differentiate NEC and SIP.

METHODS

Neonates who underwent drain placement or laparotomy NEC or SIP were identified and grouped definitively via bowel visualization. Patient characteristics were analyzed using machine learning methodologies, which were optimized through areas under the receiver operating characteristic curve (AUROC). The model was further evaluated using a validation cohort.

RESULTS

40 patients were identified. A random forest model achieved 98% AUROC while a ridge logistic regression model reached 92% AUROC in differentiating diseases. When applying the trained random forest model to the validation cohort, outcomes were correctly predicted.

CONCLUSIONS

This study supports the feasibility of using a novel machine learning model to differentiate between NEC and SIP prior to any intended surgical interventions.

LEVEL OF EVIDENCE

level II TYPE OF STUDY: Clinical Research Paper.

Surgical Versus Medical Management of Necrotizing Enterocolitis With and Without Intestinal Perforation: A Retrospective Chart Review

Background

Necrotizing enterocolitis (NEC) is a debilitating disease that predominantly afflicts premature neonates, although it can also affect term neonates. The clinical features of the ailment vary widely and range from transient feed intolerance to life-threatening complications such as septicemia and disseminated intravascular coagulation. While surgery is usually only reserved for severe cases, such as those presenting with intestinal perforation, the role of surgical management in cases of NEC without perforation remains elusive.

Methods

A retrospective chart review of patients, three years in duration, was conducted and studied confirmed cases of NEC. The clinical presentations studied included cases of NEC with pneumatosis intestinalis, fixed bowel loop, pneumoperitoneum, and abdominal wall erythema. The patients were divided with regards to their intestinal perforation status and with pertinence to the treatment modality employed (medical or surgical). The results in either group were eventually analyzed in terms of the overall survival rate.

Results

A total of 48 patients were included in the study, of which 79.16% presented without perforation and 20.83% with perforation. Of the study participants included, 26 were females and 22 were males. Pertinently, no gender predominance was appreciated. In patients without perforation, medical management was noted to boast a lower mortality rate when compared with surgical intervention (15.6% vs 50.0%, respectively). In patients with perforation, the overall mortality was noted to hover at 50.0%, which was higher than that encountered in the non-perforation group.

Conclusion

In patients with NEC without perforation, surgical treatment confers no comparative therapeutic advantage when compared with medical management alone. Conservative management with broad-spectrum antibiotics including metronidazole yields equally favorable outcomes in such cases.

Case Report: A Rare Condition of Abdominal Pain: Chemotherapy Induced Portal Vein Pneumatosis Mimicking the Bowel Necrosis

Portal vein pneumatosis is the presence of air in the portal venous system, which is one of the classic radiologic features of bowel ischemia or necrosis. However, there are several other morbidities that can have portal vein pneumatosis as a complication. This is a case of a 44-year-old man who suffered from severe abdominal pain after chemotherapy for soft tissue sarcoma of his left hip. The physical signs, laboratory findings, as well as the portal venous pneumatosis sign of the CT scan strongly indicated the probability of bowel necrosis and subjected the treatment decision of the patient finally to laparotomy. However, nothing abnormal except a segment of swollen small intestine was detected. Caution should be kept in mind when encountering a patient with suspected bowel necrosis following chemotherapy since several chemotherapeutic agents could cause portal vein pneumatosis. Diagnostic laparoscopy might be a better option for such cases.

Implementation of bowel ultrasound practice for the diagnosis and management of necrotising enterocolitis

Necrotising enterocolitis (NEC) is a serious inflammatory bowel disease of prematurity with potentially devastating complications and remains a leading cause of morbidity and mortality among premature infants. In recent years, there has been accumulating data regarding benefits of using bowel ultrasound (BUS) in the diagnosis and management of NEC. Despite this, adoption of robust BUS programmes into clinical practice has been slow. As BUS is a relatively new technique, many barriers to implementation exist, namely lack of education and training for sonographers and radiologists, low case volume and unfamiliarity by clinicians regarding how to use the information provided. The aim of this manuscript is to provide a framework and a roadmap for units to implement BUS in day-to-day practice for NEC diagnosis and management.

Predictors of Mortality Among Very Low Birth Weight Infants With Gastrointestinal Perforation

BACKGROUND

Gastrointestinal (GI) perforation is a risk factor for mortality in very low birth weight (VLBW) infants. Little data exist regarding pretreatment factors and patient characteristics known to independently correlate with risk of death.

MATERIALS AND METHODS

A retrospective review of all VLBW infants who sustained GI perforation between 2011 and 2018 was conducted. Birth, laboratory, and disease-related factors of infants who died were compared to those who survived.

RESULTS

42 VLBW infants who sustained GI perforations were identified. Eleven (26.19%) died. There were no significant differences in birth-related factors, hematological lab levels at diagnosis, presence of pneumatosis, or bacteremia. Portal venous gas (P = .03), severe metabolic acidosis (P < .01), and elevated lactate at diagnosis (P < .01) were statistically more likely to occur among infants who died.

DISCUSSION

Portal venous gas, severe metabolic acidosis, and elevated lactate were associated with an increased risk of mortality among VLBW infants who develop a GI perforation. Further research is required to better identify risk factors.

Low serum albumin concentration predicts the need for surgical intervention in neonates with necrotizing enterocolitis

PURPOSE

To investigate whether serum albumin (SA) concentration can predict the need for surgical intervention in neonates with necrotizing enterocolitis (NEC).

METHODS

Retrospective review of all cases with NEC Bell's stage 2 and 3 that were treated in a single center between 2009 and 2015. Data on patient demographics, clinical parameters, laboratory findings and surgical status were recorded. Receiver operating characteristics analysis was used to evaluate optimal cutoffs and predictive values.

RESULTS

Overall, 151 neonates with NEC were identified. Of these, 132 (87.4%) had confirmed NEC Bell's stage 2. The median gestational age was 28.4 (range, 23.1-39.0) weeks and 69 (52.3%) had a birth weight of ≤1000 g. Sixty-eight (51.5%) underwent surgery, showing a sustained reduction in SA over time with significantly lower median SA levels compared to 64 (48.5%) cases that responded well to medical treatment (18.3 ± 3.7 g/L vs. 26.0 ± 2.0 g/L; P < 0.001). SA concentration of ≤20 g/L on day 2 of NEC diagnosis was a significant predictor for surgery (OR 3.41; P = 0.019) with a positive predictive value of 71.4%.

CONCLUSIONS

An SA concentration of ≤20 g/L on day 2 of the NEC disease process is associated with a higher likelihood for surgical intervention in neonates with NEC Bell's stage 2. SA, in combination with other clinical parameters and serological markers, may be a useful predictive tool for surgery in NEC.

LEVEL OF EVIDENCE

II.

Point-of-care ultrasound in the neonatal ICU

PURPOSE OF REVIEW

Point-of-care ultrasound (POCUS) is an emerging clinical tool in the neonatal intensive care unit (NICU). Recent literature describing the use of POCUS for various applications in the NICU has garnered increased interest among neonatologists.

RECENT FINDINGS

Diagnostic applications for POCUS in the NICU include the evaluation and serial monitoring of common pulmonary diseases, hemodynamic instability, patent ductus arteriosus (PDA), persistent pulmonary hypertension of the newborn (PPHN), necrotizing enterocolitis (NEC), and intraventricular hemorrhage (IVH), among others. Procedural applications include vascular access, endotracheal intubation, lumbar puncture, and fluid drainage.

SUMMARY

Experience with POCUS in the NICU is growing. Current evidence supports the use of POCUS for a number of diagnostic and procedural applications. As use of this tool increases, there is an urgent need to develop formal training requirements specific to neonatology, as well as evidence-based guidelines to standardize use across centers.

Urinary I-FABP, L-FABP, TFF-3, and SAA Can Diagnose and Predict the Disease Course in Necrotizing Enterocolitis at the Early Stage of Disease

Necrotizing enterocolitis (NEC) is a severe gastrointestinal disease affecting mainly preterm newborns. It is characterized by unexpected onset and rapid progression with specific diagnostic signs as pneumatosis intestinalis or gas in the portal vein appearing later in the course of the disease. Therefore, we analyzed diagnostic and prognostic potential of the markers of early NEC pathogenesis, such as excessive inflammatory response (serum amyloid A (SAA)) and gut epithelium damage (intestinal and liver fatty acid-binding protein (I-FABP and L-FABP, respectively) and trefoil factor-3 (TFF-3)). We used ELISA to analyze these biomarkers in the urine of patients with suspected NEC, either spontaneous or surgery-related, or in infants without gut surgery (controls). Next, we compared their levels with the type of the disease (NEC or sepsis) and its severity. Already at the time of NEC suspicion, infants who developed NEC had significantly higher levels of all tested biomarkers than controls and higher levels of I-FABP and L-FABP than those who will later develop sepsis. Infants who will develop surgery-related NEC had higher levels of I-FABP and L-FABP than those who will develop sepsis already during the first 6 hours after the abdominal surgery. I-FABP was able to discriminate between infants who will develop NEC or sepsis and the SAA was able to discriminate between medical and surgical NEC. Moreover, the combination of TFF-3 with I-FABP and SAA could predict pneumatosis intestinalis, and the combination of I-FABP, L-FABP, and SAA could predict gas in the portal vein or long-term hospitalization and low SAA predicts early full enteral feeding. Thus, these biomarkers may be useful not only in the early, noninvasive diagnostics but also in the subsequent NEC management.

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

BACKGROUND

Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children.

METHODS

Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document.

RESULTS

Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C).

CONCLUSIONS

Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

How to use abdominal X-rays in preterm infants suspected of developing necrotising enterocolitis

Necrotising enterocolitis (NEC) in preterm babies is a serious gastrointestinal emergency with potentially devastating consequences. Prompt and accurate diagnosis continues to be a challenge for health professionals. Early identification of clinical warning signs is extremely important, but the diagnosis relies heavily on the interpretation of abdominal radiographs. Postgraduate training of paediatricians and neonatologists in neonatal abdominal radiography is scarce, and there is variability of radiological input to neonatal services. Lack of a standardised approach and descriptive terminology for interpretation may result in inadequate communication between clinical and surgical teams, inaccurate diagnosis, inappropriate treatment, and unnecessary cessation of feeds and transfers to surgical units. This paper offers a guide designed for the doctor who on a busy night shift needs to interpret an abdominal radiograph and decide on a differential diagnosis of NEC in a preterm baby. It helps to provide structure and standardisation to interpretation of radiological signs using a comprehensive but simple method to support the clinical diagnosis. Our aim is to enhance the correct diagnosis of NEC.

Bowel Dilatation on Initial Plane Abdominal Radiography May Help to Assess the Severity of Necrotizing Enterocolitis in Preterm Infants

BACKGROUND

Necrotizing enterocolitis (NEC) is the most common life-threatening gastrointestinal emergency associated with prematurity. Timely diagnosis and adequate treatment are crucial to reduce the morbidity and mortality of the affected infants. The aim of this study was to evaluate the diagnostic yield of bowel dilatation on plane abdominal radiography (AR) in the early diagnosis and NEC severity in preterm infants.

METHODS

We retrospectively reviewed initial ARs of 50 preterm infants with NEC ≥ stage II admitted to the neonatal intensive care unit (NICU) in a tertiary-care hospital. The largest bowel loops diameters (AD), the latero-lateral diameters of the peduncle of the first lumbar vertebra (L1), and the distance of the upper edge of the first lumbar vertebra and the lower edge of the second one, including the disc space (L1-L2), were measured. All anteroposterior ARs were done in a supine projection on the day of onset of the initial symptoms of NEC.

RESULTS

Preterm infants with surgical NEC showed a statistically significant increase in the AD/L1 ratio (p < 0.001) and AD/L1-L2 ratio (p < 0.001) compared with preterm infants with medical NEC. We found no significant association between the site of the most distended bowel loop and the severity of NEC (p > 0.05).

CONCLUSION

Bowel loop distension on initial AR may serve as an additional diagnostic tool in the early diagnosis and severity of stages II/III NEC. Further prospective clinical studies should validate the results from this study.

Laparoscopy to Assist Surgical Decisions Related to Necrotizing Enterocolitis in Preterm Neonates

Aim of the Study: Necrotizing enterocolitis (NEC) is a devastating intestinal disease that mainly affects preterm infants. Despite advancements in neonatal care, mortality of NEC remains high and controversies exist regarding the most appropriate time for surgical intervention and challenging of diagnosing NEC. Using a pig model of NEC, we aimed to examine if laparoscopy is feasible for diagnosis of NEC. Methods: Preterm caesarean-delivered piglets (n = 42) were fed with increasing amounts of infant formula up to 5 days to induce NEC. On days 3-5, we examined the intestine by laparoscopy under general anesthesia. The bowel was examined by tilting the pigs from supine position to the left and right side. Macroscopic NEC lesions were identified and graded according to a macroscopic scoring system, then a laparotomy was performed to rule out any organ injury and missed NEC lesions. Results: Visible NEC lesions (scores 4-6) were found in 26% (11/42) of the piglets. A positive predictive value of 100% was found for laparoscopy as a diagnostic marker of NEC in both colon and the small intestine. One piglet had a higher NEC score in the small intestine found at laparotomy, than at laparoscopy, resulting in a sensitivity of 67%, and a specificity of 100% for the small intestine. Conversely, both the sensitivity and specificity for colon was 100%. Acceptable levels of agreement was found, with minimal proportional bias in both colon and the small intestine for laparoscopy and laparotomy. Ultrasound examination had a lower sensitivity of 67% and specificity of 63%. All piglets were respiratory and circulatory stable during the procedure. Conclusions: In preterm piglets, laparoscopy is a feasible tool to diagnose NEC with a high positive predictive value and a high specificity.

Association of Intestinal Alkaline Phosphatase With Necrotizing Enterocolitis Among Premature Infants

IMPORTANCE

Necrotizing enterocolitis (NEC) in preterm infants is an often-fatal gastrointestinal tract emergency. A robust NEC biomarker that is not confounded by sepsis could improve bedside management, lead to lower morbidity and mortality, and permit patient selection in randomized clinical trials of possible therapeutic approaches.

OBJECTIVE

To evaluate whether aberrant intestinal alkaline phosphatase (IAP) biochemistry in infant stool is a molecular biomarker for NEC and not associated with sepsis.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter diagnostic study enrolled 136 premature infants (gestational age, <37 weeks) in 2 hospitals in Louisiana and 1 hospital in Missouri. Data were collected and analyzed from May 2015 to November 2018.

EXPOSURES

Infant stool samples were collected between 24 and 40 or more weeks postconceptual age. Enrolled infants underwent abdominal radiography at physician and hospital site discretion.

MAIN OUTCOMES AND MEASURES

Enzyme activity and relative abundance of IAP were measured using fluorometric detection and immunoassays, respectively. After measurements were performed, biochemical data were evaluated against clinical entries from infants' hospital stay.

RESULTS

Of 136 infants, 68 (50.0%) were male infants, median (interquartile range [IQR]) birth weight was 1050 (790-1350) g, and median (IQR) gestational age was 28.4 (26.0-30.9) weeks. A total of 25 infants (18.4%) were diagnosed with severe NEC, 19 (14.0%) were suspected of having NEC, and 92 (66.9%) did not have NEC; 26 patients (19.1%) were diagnosed with late-onset sepsis, and 14 (10.3%) had other non-gastrointestinal tract infections. For severe NEC, suspected NEC, and no NEC samples, median (IQR) fecal IAP content, relative to the amount of IAP in human small intestinal lysate, was 99.0% (51.0%-187.8%) (95% CI, 54.0%-163.0%), 123.0% (31.0%-224.0%) (95% CI, 31.0%-224.0%), and 4.8% (2.4%-9.8%) (95% CI, 3.4%-5.9%), respectively. For severe NEC, suspected NEC, and no NEC samples, median (IQR) enzyme activity was 183 (56-507) μmol/min/g (95% CI, 63-478 μmol/min/g) of stool protein, 355 (172-608) μmol/min/g (95% CI, 172-608 μmol/min/g) of stool protein, and 613 (210-1465) μmol/min/g (95% CI, 386-723 μmol/min/g) of stool protein, respectively. Mean (SE) area under the receiver operating characteristic curve values for IAP content measurements were 0.97 (0.02) (95% CI, 0.93-1.00; P < .001) at time of severe NEC, 0.97 (0.02) (95% CI, 0.93-1.00; P < .001) at time of suspected NEC, 0.52 (0.07) (95% CI, 0.38-0.66; P = .75) at time of sepsis, and 0.58 (0.08) (95% CI, 0.42-0.75; P = .06) at time of other non-gastrointestinal tract infections. Mean (SE) area under the receiver operating characteristic curve values for IAP activity were 0.76 (0.06) (95% CI, 0.64-0.86; P < .001), 0.62 (0.07) (95% CI, 0.48-0.77; P = .13), 0.52 (0.07) (95% CI, 0.39-0.67; P = .68), and 0.57 (0.08) (95% CI, 0.39-0.69; P = .66), respectively.

CONCLUSIONS AND RELEVANCE

In this diagnostic study, high amounts of IAP protein in stool and low IAP enzyme activity were associated with diagnosis of NEC and may serve as useful biomarkers for NEC. Our findings indicated that IAP biochemistry was uniquely able to distinguish NEC from sepsis.

Challenges in Advancing Necrotizing Enterocolitis Research

Progressing necrotizing enterocolitis research is difficult because the disease is variable in presentation, there are difficulties in making a precise diagnosis, a reliable agreed case-definition is currently lacking, and there is a paucity of preclinical research to identify etiologic targets. The major challenges of the cost of clinical trials and need for long-term outcome ascertainment could be eased through incorporation of novel randomization approaches and data collection into routine care, and collaboration between public-sector and industry funders.

Radiological findings associated with the death of newborns with necrotizing enterocolitis

Objective

The aim of this study was to identify radiological and clinical risk factors for death in newborns with necrotizing enterocolitis.

Materials and Methods

This was a retrospective cohort study, based on radiological examinations and medical charts of 66 infants with necrotizing enterocolitis, as confirmed by a finding of intestinal pneumatosis (stage IIA, according to modified Bell’s staging criteria). Radiological and clinical variables were evaluated.

Results

Of the 66 infants evaluated, 14 (21.2%) presented pneumatosis in the large and small bowel; 7 (10.6%) presented air in the portal system; and 12 (18.2%) died. Bivariate analysis revealed that the following variables were associated with death: bowel perforation; pneumatosis in the large and small bowel; air in the portal system; earlier gestational age; longer time on mechanical ventilation before the identification of pneumatosis; and longer time on mechanical ventilation before discharge or death. In the multivariate regression, the following variables remained as predictors of death: pneumatosis in the large and small intestines (odds ratio [OR] = 12.4; 95% confidence interval [95% CI] = 1.2-127.4; p = 0.035), perforation (OR = 23.2; 95% CI = 2.2-246.7; p = 0.009), and air in the portal system (OR = 69.7; 95% CI = 4.3-[not calculated]; p = 0.003).

Conclusion

The set of factors most strongly associated with death in infants with necrotizing enterocolitis comprised extensive pneumatosis, pneumoperitoneum, and air in the portal system. Our findings confirm the importance of radiological imaging in the diagnosis and monitoring of necrotizing enterocolitis.

The role of imaging in the management of necrotising enterocolitis: a multispecialist survey and a review of the literature

Objectives

To investigate current practices and perceptions of imaging in necrotising enterocolitis (NEC) according to involved specialists, put them in the context of current literature, and identify needs for further investigation.

Methods

Two hundred two neonatologists, paediatric surgeons, and radiologists answered a web-based questionnaire about imaging in NEC at their hospitals. The results were descriptively analysed, using proportion estimates with 95% confidence intervals.

Results

There was over 90% agreement on the value of imaging for confirmation of the diagnosis, surveillance, and guidance in decisions on surgery as well as on abdominal radiography as the first-choice modality and the most important radiographic signs. More variation was observed regarding some indications for surgery and the use of some ultrasonographic signs. Fifty-eight per cent stated that ultrasound was used for NEC at their hospital. Examination frequency, often once daily or more but with considerable variations, and projections used in AR were usually decided individually rather than according to fixed schedules. Predicting the need of surgery was regarded more important than formal staging.

Conclusion

Despite great agreement on the purposes of imaging in NEC and the most important radiographic signs of the disease, there was considerable diversity in routines, especially regarding examination frequency and the use of ultrasound. Apart from continuing validation of ultrasound, important objectives for future studies include definition of the supplementary roles of both imaging modalities in relation to other diagnostic parameters and evaluation of various imaging routines in relation to timing of surgery, complications, and mortality rate.

Key Points

• Imaging is an indispensable tool in the management of necrotising enterocolitis

• Predicting the need of surgery is regarded more important than formal staging

• There is great consensus on important signs of NEC on abdominal radiography

• There is more uncertainty regarding the role of ultrasound

• Individualised management is preferred over standardised diagnostic algorithms

Electronic supplementary material

The online version of this article (10.1007/s00330-018-5362-x) contains supplementary material, which is available to authorized users.

Agreement and reproducibility of radiological signs in NEC using The Duke Abdominal Assessment Scale (DAAS)

PURPOSE

Necrotizing enterocolitis (NEC) is associated with high morbidity and mortality. Abdominal radiography is currently an imaging modality of choice in NEC. Recently, a numeric scale of radiological signs in NEC-The Duke Abdominal Assessment (DAAS) was introduced. The aim of this study was to measure the intra- and inter-observer agreement on the radiological signs of NEC according to DAAS to access the feasibility of this scale.

MATERIALS AND METHODS

We have retrospectively analyzed 87 radiographs performed in a group of 43 high-risk neonates with suspected NEC. Radiographs were assessed by 6 independent observers: two pediatric radiologists, two radiology residents, and two neonatologists. Data were analyzed using κ statistics as a measure of intra- and inter-observer agreement.

RESULTS

Fair-to-good intra-observer agreement was noted for all but one of observers. However, with the wide range in κ values, we found only fair inter-observer agreement detecting signs of NEC according to DAAS. There was a higher intra-group agreement in radiology practitioners, with the highest among experienced pediatric radiologists.

CONCLUSION

However, with high observer variability in interpretation of all radiologic signs, we did not confirm that Duke Abdominal Assessment Scale could reliable facilitate reporting of abdominal radiographic findings in neonates with suspected NEC.

Risk factors and prevention for surgical intestinal disorders in extremely low birth weight infants

PURPOSE

Surgical intestinal disorders (SID), such as necrotizing enterocolitis (NEC), focal intestinal perforation (FIP), and meconium-related ileus (MRI), are serious morbidities in extremely low birth weight (ELBW, birth weight <1000 g) infants. From 2010, we performed enteral antifungal prophylaxis (EAP) in ELBWI to prevent for SID. The aim of this study was to identify disease-specific risk factors and to evaluate the efficacy of prevention for SID in ELBW infants.

METHODS

A retrospective chart review of all consecutive patients between January 2006 and March 2015, which included 323 ELBW infants who were admitted to Shizuoka Children's Hospital, was conducted.

RESULTS

The number of infants with NEC, FIP, and MRI was 9, 12, and 13, respectively; 28 in 323 ELBW infants died. The control group defined the cases were not SID. In-hospital mortality was higher in infants with NEC relative to those in the control group. On logistic regression analysis, low gestational age and cardiac malformations were associated with increased risk of NEC. IUGR were associated with increased risk of MRI. EAP decreased risk of NEC and FIP. Low gestational weight and NEC were associated with increased risk of death.

CONCLUSION

Survival to hospital discharge after operation for NEC in ELBW infants remains poor. EAP decreased risk of NEC and FIP in ELBW infants.

Protective Effect of Dual-Strain Probiotics in Preterm Infants: A Multi-Center Time Series Analysis

Objective

To determine the effect of dual-strain probiotics on the development of necrotizing enterocolitis (NEC), mortality and nosocomial bloodstream infections (BSI) in preterm infants in German neonatal intensive care units (NICUs).

Design

A multi-center interrupted time series analysis.

Setting

44 German NICUs with routine use of dual-strain probiotics on neonatal ward level.

Patients

Preterm infants documented by NEO-KISS, the German surveillance system for nosocomial infections in preterm infants with birth weights below 1,500 g, between 2004 and 2014.

Intervention

Routine use of dual-strain probiotics containing Lactobacillus acidophilus and Bifidobacterium spp. (Infloran) on the neonatal ward level.

Main outcome measures

Incidences of NEC, overall mortality, mortality following NEC and nosocomial BSI.

Results

Data from 10,890 preterm infants in 44 neonatal wards was included in this study. Incidences of NEC and BSI were 2.5% (n = 274) and 15.0%, (n = 1631), respectively. Mortality rate was 6.1% (n = 665). The use of dual-strain probiotics significantly reduced the risk of NEC (HR = 0.48; 95% CI = 0.38–0.62), overall mortality (HR = 0.60, 95% CI = 0.44–0.83), mortality after NEC (HR = 0.51, 95% CI = 0.26–0.999) and nosocomial BSI (HR = 0.89, 95% CI = 0.81–0.98). These effects were even more pronounced in the subgroup analysis of preterm infants with birth weights below 1,000 g.

Conclusion

In order to reduce NEC and mortality in preterm infants, it is advisable to add routine prophylaxis with dual-strain probiotics to clinical practice in neonatal wards.

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.

Urinary Intestinal Fatty Acid-Binding Protein Can Distinguish Necrotizing Enterocolitis from Sepsis in Early Stage of the Disease

Necrotizing enterocolitis (NEC) is severe disease of gastrointestinal tract, yet its early symptoms are nonspecific, easily interchangeable with sepsis. Therefore, reliable biomarkers for early diagnostics are needed in clinical practice. Here, we analyzed if markers of gut mucosa damage, caspase cleaved cytokeratin 18 (ccCK18) and intestinal fatty acid-binding protein (I-FABP), could be used for differential diagnostics of NEC at early stage of disease. We collected paired serum (at enrollment and week later) and urine (collected for two days in 6 h intervals) samples from 42 patients with suspected NEC. These patients were later divided into NEC (n = 24), including 13 after gastrointestinal surgery, and sepsis (n = 18) groups using standard criteria. Healthy infants (n = 12), without any previous gut surgery, served as controls. Both biomarkers were measured by a commercial ELISA assay. There were no statistically significant differences in serum ccCK18 between NEC and sepsis but NEC patients had significantly higher levels of serum and urinary I-FABP than either sepsis patients or healthy infants. Urinary I-FABP has high sensitivity (81%) and specificity (100%) and can even distinguish NEC from sepsis in patients after surgery. Urinary I-FABP can be used to distinguish NEC from neonatal sepsis, including postoperative one, better than abdominal X-ray.

Definitive peritoneal drainage in the extremely low birth weight infant with spontaneous intestinal perforation: predictors and hospital outcomes

OBJECTIVE

To identify characteristics associated with definitive peritoneal drainage (PD) in the extremely low birth weight infant diagnosed with spontaneous intestinal perforation (SIP). We also sought to determine whether patients requiring a second operation (salvage laparotomy) following PD are at increased risk of adverse hospital outcomes, including increased times to full enteral feedings and decreased 30-day survival.

STUDY DESIGN

We performed a retrospective chart review of infants with a birth weight <1000 g who underwent PD for SIP at a single tertiary neonatal unit from 2003 to 2012. Infants with signs of necrotizing enterocolitis on abdominal plain films, including pneumatosis intestinalis, portal venous gas or fixed, dilated small loops of bowel were excluded from the study. Perinatal and perioperative data and short-term neonatal outcomes prior to hospital discharge were collected. Comparison was made between two groups: infants treated with definitive PD vs infants requiring salvage laparotomy. Data were analyzed using independent samples t-test and Cochrane-Mantel-Haenszel.

RESULT

Eighty-nine infants who fit all inclusion criteria were identified during the study period. PD was definitive in 67 (75.3%) patients. Patients who had definitive PD vs those who required salvage laparotomy were significantly more likely to present at a later day of life (9.6±5.3 vs 5.6±2.7, P<0.0001) and to have a lower birth weight (724.6 g±132.5 vs 809.2 g±143.1, P=0.02). The administration of indomethacin or ibuprofen prior to the diagnosis of SIP was also associated with definitive PD (74.6% vs 50%, P=0.03). Comparison of feeding outcomes revealed that the time to achieve full enteral feeds was significantly longer for those who underwent a salvage laparotomy (95.9±30.2 vs 60.4±30.4 days, P<0.005). Short-term survival (>30 days) was not significantly different between the two groups.

CONCLUSION

PD was definitive therapy for the majority of neonates included in this study who were referred for surgical evaluation of SIP. Our data point to trends in being able to identify infants with SIP who are at risk for salvage laparotomy following PD, and thus, adverse nutritional outcomes. Larger, prospective studies are needed to further evaluate this specific patient population and identify those patients who are likely to succeed with PD following the diagnosis of SIP.

[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.

Intestinal fatty acid-binding protein as a diagnostic marker for complicated and uncomplicated necrotizing enterocolitis: a prospective cohort study

Background

Early NEC symptoms are non-specific and diagnostic tests lack discriminative power. Intestinal fatty acid-binding protein (I-FABP), mainly located in small bowel enterocytes, is released into the blood following NEC-associated enterocyte disruption. Aim of this prospective cohort trial was to determine the diagnostic value of I-FABP measured in plasma (I-FABPp) and urine (I-FABPu) for the presence of NEC, to evaluate I-FABP levels during NEC development, and to assess its prognostic value for the progression from suspected to complicated disease.

Methods

Between 2010 and 2012 we prospectively enrolled neonates with suspected NEC. We measured I-FABP levels eight-hourly from onset of suspected NEC for at least 48 hours, or until surgery. NEC diagnosis was confirmed radiologically or during operation. We defined NEC as complicated if it resulted in surgery and/or death. We determined disease course and diagnostic I-FABP cut-off points.

Results

The study comprised 37 neonates (24M, 13F), gestational age 28 (24–36) weeks, birth weight 1190 (570–2,400) grams. We found significantly higher I-FABPp and I-FABPu levels in NEC patients (n = 22) than in patients with other diagnoses (n = 15). Cut-off values for diagnosing NEC were 9 ng/mL I-FABPp and 218 ng/mL I-FABPu, with corresponding likelihood ratios (LRs) of 5.6 (95% CI 0.89–35) and 5.1 (95% CI 0.73–36), respectively. I-FABP levels were highest in the first eight hours after symptom onset and gradually decreased over time. Cut-off values for complicated disease were 19 ng/mL I-FABPp and 232 ng/mL I-FABPu, with LRs of 10 (95% CI 1.6–70) and 11 (95% CI 1.6–81), respectively.

Conclusions

Both plasma and urinary I-FABP levels specifically identify NEC in preterm infants prior to appearance of diagnostic radiological signs suggestive for NEC. Moreover, serial I-FABP measurements accurately predict development of complicated disease.

Predicting disease severity of necrotizing enterocolitis: how to identify infants for future novel therapies

Necrotizing enterocolitis (NEC) remains a very devastating problem within the very low birth weight neonatal population. Several experimental therapies are being tested in animal models and soon may be ready for human trials. Despite this progress, we currently have no way to identify infants who would be optimal targets for therapy. Specifically, we are unable to predict which infants will progress to the more severe Bell's stage of disease that may necessitate surgery. Ideally, an algorithm could be constructed that would encompass multiple neonatal and maternal risk factors as well as potential biologic markers of disease so that these infants could be identified in a more timely fashion. This review summarizes the known risk factors and biomarkers of disease in hopes of stimulating clinical research to identify such an “early warning” NEC algorithm.

Prognostic value of abdominal sonography in necrotizing enterocolitis of premature infants born before 33 weeks gestational age

OBJECTIVE

The purpose of this study was to assess the prognostic value of abdominal sonography in necrotizing enterocolitis (NEC) in preterm infants with a gestational age less than 33 weeks of gestation, using surgery and/or death as the primary outcome and stenosis as the secondary outcome.

METHODS

A retrospective study of 95 premature infants (mean gestational age: 28.6 weeks), presenting with NEC between January 2009 and November 2011 and who underwent plain abdominal radiography and sonography, was performed. In uni- and multivariate analyses, radiographic and sonographic findings were correlated with complications ('surgery and/or death' and 'stenosis').

RESULTS

Sonographic findings of free intraperitoneal air (odd ratio [OR]=8.0; IC, 1.4-44.2), free abdominal fluid (OR 3.5; IC 1.3-9.4), portal venous gas (OR 3.9; IC, 1.2-12.9), and bowel wall thickening (OR 2.8; IC,1.1-7.2) were significantly associated with surgery and/or death. Intramural gas was significantly correlated (OR=11.8; IC, 1.5-95.8) with intestinal stenosis following NEC. None of the radiographic findings were associated with complications.

CONCLUSION

Abdominal sonography is a reliable tool for the prognostic assessment of NEC in preterm infants.

Interleukin-8 predicts 60-day mortality in premature infants with necrotizing enterocolitis

OBJECTIVE

The purpose of this study was to evaluate the predictiveness of circulating interleukin (IL)-8 for 60-day mortality in premature infants with necrotizing enterocolitis (NEC).

BACKGROUND

NEC affects up to 5% of premature infants and remains a leading cause of mortality among neonates.

METHODS

A total of 113 infants with surgically (n=50) or medically (n=63) treated NEC were retrospectively analyzed. Laboratory parameters including serum IL-8 were assessed at the diagnosis of NEC and during the preoperative workup.

RESULTS

The 60-day mortality was 19% (22/113), 10% (6/63) in medical and 33% (16/50) in surgical NEC. IL-8 levels significantly correlated with 60-day mortality (odds ratio: 1.38; CI 1.14-1.67; p=0.001). Median IL-8 levels at diagnosis were significantly higher in neonates who were later treated surgically (median=2625 pg/ml; range: 27-7500) compared with those treated medically (median=156 pg/ml; range: 5-7500; p<0.001). The AUC to discriminate between medical and surgical NEC was 0.82 (CI, 0.74-0.90), and an exploratory IL-8 cutoff point could be established at 1783 pg/ml (sensitivity of 90.5%; specificity of 59.2%).

CONCLUSIONS

Our findings that serum IL-8 (i) correlates directly with 60-day mortality and (ii) differs significantly between medically and surgically treated infants may change the process of therapeutic decision making in NEC.

Epidemiology and trends of necrotizing enterocolitis in Sweden: 1987-2009

OBJECTIVE

To investigate temporal, seasonal, and geographic variations in the incidence of necrotizing enterocolitis (NEC) and its relation to early infant survival in the Swedish population and in subgroups based on gestational age, birth weight, and gender.

METHODS

In the Swedish birth cohort of 1987 through 2009 all children with a diagnosis of NEC were identified in the National Patient Register, the Swedish Medical Birth Register, and the National Cause of Death Register. NEC incidence, early mortality, and seasonality were analyzed with descriptive statistics, Poisson regression, and auto regression.

RESULTS

The overall incidence of NEC was 3.4 in 10,000 live births, higher in boys than in girls (incidence rate ratio 1.22, 95% confidence interval 1.06-1.40, P = .005), with a peak in November and a trough in May, and increased with an average of ~5% a year during the study period. In most subgroups, except the most immature, an initial decrease was followed by a steady increase. Seven-day mortality decreased strongly in all subgroups over the entire study period (annual incidence rate ratio 0.96, 95% confidence interval 0.95-0.96, P < .001). This was especially marked in the most premature and low birth weight infants.

CONCLUSIONS

After an initial decrease, the incidence of NEC has increased in Sweden during the last decades. An association with the concurrent dramatically improved early survival seems likely.

Interleukin 8 correlates with intestinal involvement in surgically treated infants with necrotizing enterocolitis

PURPOSE

The aim of this study was to test the predictive value of interleukin (IL) 8 in the assessment of intestinal involvement in necrotizing enterocolitis (NEC).

METHODS

Forty infants with surgically treated NEC were classified into 3 groups based on intestinal involvement during laparotomy: focal (n = 11), multifocal (n = 16), and panintestinal (n = 13). Preoperatively obtained serum levels of IL-8, C-reactive protein, white blood cell count, and platelet count were correlated with intestinal involvement using logistic regression models.

RESULTS

Interleukin 8 correlated significantly with intestinal involvement in infants with surgically treated NEC (odds ratio, 1.74; confidence interval, 1.27-2.39; P < .001). An exploratory IL-8 cutoff value of 449 pg/mL provided a specificity of 81.8% and sensitivity of 82.8% to discriminate focal from multifocal and panintestinal disease. An IL-8 cutoff value of 1388 pg/mL provided a specificity of 77.8% and a sensitivity of 76.9% to discriminate panintestinal disease from focal and multifocal disease.

CONCLUSIONS

To our knowledge, this is the first study to demonstrate a significant correlation of IL-8 with intestinal involvement in advanced NEC in a large patient population. Our results indicate that IL-8 may be a promising biomarker for assessing intestinal involvement in infants with advanced NEC.

Extensive portal venous gas without obvious pneumatosis intestinalis in a preterm infant with necrotizing enterocolitis

Portal venous gas is one of the classic radiologic features of necrotizing enterocolitis and is an uncommon isolated finding because it is most commonly seen in conjunction with pneumatosis intestinalis. In this case study, we present a preterm neonate with necrotizing enterocolitis who had extensive portal venous gas without obvious pneumatosis intestinalis.

Could clinical scores guide the surgical treatment of necrotizing enterocolitis?

PURPOSE

Test the diagnostic reliability of the score for neonatal acute physiology-perinatal extension-II (SNAPPE-II) and the metabolic derangement acuity score (MDAS) as predictors of surgery in patients with necrotizing enterocolitis (NEC).

METHODS

The SNAPPE-II and the MDAS were applied to 99 patients with NEC. Both the scores were calculated at the moment of diagnosis (T(0)) and when surgical assessment was required (T(1)). The main outcome was the need of surgical revision. Comparison between models was made through their receiver operator characteristics (ROC) curves.

RESULTS

Thirty-five patients required surgical treatment (group A) and 64 responded to medical therapy (group B). Median SNAPPE-II was 22 versus 5 for group A (U test 621, p = 0.002) at T(0); and 22 versus 10 for group A (U test 487, p = 0.01) at T(1). Measuring the value of the SNAPPE-II as a predictor of surgery, the ROC curve was 0.69 (CI 95%, 0.57-0.80) at T(0) and 0.67 (CI 95%, 0.55-0.80) at T(1). Median MDAS were 2 for both groups A and B at T(0) (U test 890.5, p = 0.113) and 2 versus 1.5 for group A at T(1) (U test 570, p = 0.043). The ROC curve for MDAS was 0.59 (CI 95%, 0.47-0.71) at T(0) and 0.64 (CI 95%, 0.52-0.77) at T(1).

CONCLUSIONS

The diagnostic performance of the SNAPPE-II offers mild results in the moment of the diagnosis of NEC, and at T(1). The MDAS is non significant at T(0) and obtains moderate results at T(1). These results do not encourage using the SNAPPE-II and the MDAS as definite tools to decide for surgical treatment of the patients affected by NEC.

The Duke Abdominal Assessment Scale: initial experience

Plain abdominal radiographs are the current standard imaging modality of choice in the evaluation of patients with clinically suspected necrotizing enterocolitis. The time interval between radiographic exams varies with the severity of disease and may range from every 6 h to every 24 h. Radiographs are often also obtained at any point of acute clinical deterioration. Evaluation of the abdominal radiographic series is critical as the findings may alter patient management and can be an indication for surgical intervention. For these reasons, it is essential that the radiographic findings are communicated to the referring neonatologist in a clear and consistent manner. Inherent variability and lack of consistency in radiology reporting makes it difficult for the referring clinician to incorporate radiographic reports into his/her treatment algorithm. Assigning abdominal radiographic findings in necrotizing enterocolitis to a numerical scale that increases as the disease progresses provides objective terminology in lieu of subjective descriptors and may facilitate communication to our clinical colleagues. With this task in mind, the Duke Abdominal Assessment Scale was created as a 10-point numerical scale of plain film bowel gas pattern findings designed to reflect progressive disease and increased certainty of the diagnosis of necrotizing enterocolitis.

The role of surgery in management of necrotizing enterocolitis

OBJECTIVE

Necrotizing enterocolitis (NEC) has become the most common gastrointestinal emergency among neonates and preterms admitted to the intensive care units. The aim of this study is to evaluate the surgical management of NEC as well as their outcome.

PATIENTS AND METHODS

Thirty five cases were included in this prospective study (10 full terms, 15 preterm and 10 infants) with the diagnosis of NEC. The severity of NEC episodes were determined according to Bells classification into group A (stage I 10 cases), Group B (stage II 17 cases) and group C (stage III 8 cases). Full history and clinical examination were taken. Radiological studies (abdominal plain X-ray and ultrasound), blood and stool cultures were done.

RESULTS

All risk factors such as sepsis, hypoxia, premature rupture of membrane (PROM) and eclampsia were statistically significantly higher among group C than group A. The commonest presenting symptom was abdominal distension followed by vomiting. All positive radiological signs were statistically significantly higher among both groups B&C than group A except for pneumopritonium sign. Medical treatment was started and complete clinical improvement was achieved in all cases of group A and in 2 cases from group B. The remaining 23 cases (15 cases from group B and the 8 cases of group C) failed to respond to the medical treatment and were operated upon. Resection anastomosis was done for 12 cases from group B while resection with stoma formation was done for 3 cases from group B and 8 cases from group C. The over all mortality was 11 cases out of 35 (31.4%). 5 cases from group B and 6 cases from group C.

CONCLUSIONS

Early diagnosis and intensive medical and surgical treatment with laparotomy and resection of the affected bowel were mandatory to minimize both morbidity and mortality from NEC. Primary anastomosis is the procedure of choice as long as the condition of the remaining bowel is satisfactory.