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1
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Jacobsen RB, Hebelka H, Gatzinsky V, Elfvin A, Dangardt F. Ultra-high-frequency ultrasound (48-70 MHz) is a promising tool for improved gastrointestinal diagnostics in infants. Acta Paediatr 2024. [PMID: 38953873 DOI: 10.1111/apa.17342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/20/2024] [Accepted: 06/24/2024] [Indexed: 07/04/2024]
Abstract
AIM To investigate the clinical feasibility of ultra-high-frequency abdominal ultrasound (UHFUS) scans of preterm and term infants. METHODS Prospectively, 19 healthy term newborn infants were examined with conventional ultrasound (CUS) (Toshiba, Aplio i700, linear probe 14L5) and UHFUS (Visualsonics VevoMD, linear probes UHF48 and UHF70) according to a standardised protocol. Measurements of wall thickness were performed for; stomach, small intestine, colon and peritoneum. Five preterm infants, with or without suspected necrotising enterocolitis (NEC), were also examined with UHF48. Of these, only one was later diagnosed with NEC. RESULTS Differences between CUS and UHFUS (UHF48) were found in measurements of thickness; for peritoneum 0.25 versus 0.13 mm (p < 0.001), small intestine 0.76 versus 0.64 mm (p = 0.039) and colon 0.7 versus 0.47 mm (p < 0.001) in healthy term infants. Gaining frequency from 46 to 71 MHz showed a mean reduction in measurements of peritoneum from 0.13 to 0.09 mm (p < 0.001). One preterm infant with NEC showed a fivefold and twofold increase in peritoneal and gastrointestinal wall thickness respectively, compared to healthy preterm infants. CONCLUSION UHFUS was a clinically feasible, promising method with potential to improve gastrointestinal diagnostics in infants. Lower peritoneum thickness and gastrointestinal wall thickness were demonstrated with UHFUS compared to CUS, suggesting an overestimation by CUS.
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Affiliation(s)
- Ronni Bengtson Jacobsen
- Department of Paediatrics, Neonatal Department, Aalborg University Hospital, Aalborg, Denmark
- Region Västra Götaland, Department of Paediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hanna Hebelka
- Department of Radiology, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Vladimir Gatzinsky
- Region Västra Götaland, Department of Paediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Elfvin
- Region Västra Götaland, Department of Paediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Frida Dangardt
- Region Västra Götaland, Paediatric Heart Center, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Pinheiro JMB, Fisher M, Munshi UK, Khalak R, Tauber KA, Cummings JJ, Cerone JB, Monaco-Brown M, Geis G, Chowdhry R, Fay M, Paul AA, Levine C, Pan P, Horgan MJ. A Multifunctional, Low Cost and Sustainable Neonatal Database System. CHILDREN (BASEL, SWITZERLAND) 2024; 11:217. [PMID: 38397329 PMCID: PMC10887617 DOI: 10.3390/children11020217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/19/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Abstract
Continuous improvement in the clinical performance of neonatal intensive care units (NICU) depends on the use of locally relevant, reliable data. However, neonatal databases with these characteristics are typically unavailable in NICUs using paper-based records, while in those using electronic records, the inaccuracy of data and the inability to customize commercial data systems limit their usability for quality improvement or research purposes. We describe the characteristics and uses of a simple, neonatologist-centered data system that has been successfully maintained for 30 years, with minimal resources and serving multiple purposes, including quality improvement, administrative, research support and educational functions. Structurally, our system comprises customized paper and electronic components, while key functional aspects include the attending-based recording of diagnoses, integration into clinical workflows, multilevel data accuracy and validation checks, and periodic reporting on both data quality and NICU performance results. We provide examples of data validation methods and trends observed over three decades, and discuss essential elements for the successful implementation of this system. This database is reliable and easily maintained; it can be developed from simple paper-based forms or used to supplement the functionality and end-user customizability of existing electronic medical records. This system should be readily adaptable to NICUs in either high- or limited-resource environments.
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Affiliation(s)
- Joaquim M. B. Pinheiro
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA; (M.F.); (U.K.M.); (R.K.); (K.A.T.); (J.J.C.); (J.B.C.); (M.M.-B.); (G.G.); (R.C.); (M.F.); (A.A.P.); (M.J.H.)
| | - Marilyn Fisher
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA; (M.F.); (U.K.M.); (R.K.); (K.A.T.); (J.J.C.); (J.B.C.); (M.M.-B.); (G.G.); (R.C.); (M.F.); (A.A.P.); (M.J.H.)
| | - Upender K. Munshi
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA; (M.F.); (U.K.M.); (R.K.); (K.A.T.); (J.J.C.); (J.B.C.); (M.M.-B.); (G.G.); (R.C.); (M.F.); (A.A.P.); (M.J.H.)
| | - Rubia Khalak
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA; (M.F.); (U.K.M.); (R.K.); (K.A.T.); (J.J.C.); (J.B.C.); (M.M.-B.); (G.G.); (R.C.); (M.F.); (A.A.P.); (M.J.H.)
| | - Kate A. Tauber
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA; (M.F.); (U.K.M.); (R.K.); (K.A.T.); (J.J.C.); (J.B.C.); (M.M.-B.); (G.G.); (R.C.); (M.F.); (A.A.P.); (M.J.H.)
| | - James J. Cummings
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA; (M.F.); (U.K.M.); (R.K.); (K.A.T.); (J.J.C.); (J.B.C.); (M.M.-B.); (G.G.); (R.C.); (M.F.); (A.A.P.); (M.J.H.)
| | - Jennifer B. Cerone
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA; (M.F.); (U.K.M.); (R.K.); (K.A.T.); (J.J.C.); (J.B.C.); (M.M.-B.); (G.G.); (R.C.); (M.F.); (A.A.P.); (M.J.H.)
| | - Meredith Monaco-Brown
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA; (M.F.); (U.K.M.); (R.K.); (K.A.T.); (J.J.C.); (J.B.C.); (M.M.-B.); (G.G.); (R.C.); (M.F.); (A.A.P.); (M.J.H.)
| | - Gina Geis
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA; (M.F.); (U.K.M.); (R.K.); (K.A.T.); (J.J.C.); (J.B.C.); (M.M.-B.); (G.G.); (R.C.); (M.F.); (A.A.P.); (M.J.H.)
| | - Rehman Chowdhry
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA; (M.F.); (U.K.M.); (R.K.); (K.A.T.); (J.J.C.); (J.B.C.); (M.M.-B.); (G.G.); (R.C.); (M.F.); (A.A.P.); (M.J.H.)
| | - Mary Fay
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA; (M.F.); (U.K.M.); (R.K.); (K.A.T.); (J.J.C.); (J.B.C.); (M.M.-B.); (G.G.); (R.C.); (M.F.); (A.A.P.); (M.J.H.)
| | - Anshu A. Paul
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA; (M.F.); (U.K.M.); (R.K.); (K.A.T.); (J.J.C.); (J.B.C.); (M.M.-B.); (G.G.); (R.C.); (M.F.); (A.A.P.); (M.J.H.)
| | - Carolyn Levine
- Neonatology, Ellis Hospital, Schenectady, NY 12308, USA; (C.L.); (P.P.)
| | - Phillip Pan
- Neonatology, Ellis Hospital, Schenectady, NY 12308, USA; (C.L.); (P.P.)
| | - Michael J. Horgan
- Division of Neonatology, Department of Pediatrics, Albany Medical College, Albany, NY 12208, USA; (M.F.); (U.K.M.); (R.K.); (K.A.T.); (J.J.C.); (J.B.C.); (M.M.-B.); (G.G.); (R.C.); (M.F.); (A.A.P.); (M.J.H.)
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Hu X, Liang H, Li F, Zhang R, Zhu Y, Zhu X, Xu Y. Necrotizing enterocolitis: current understanding of the prevention and management. Pediatr Surg Int 2024; 40:32. [PMID: 38196049 PMCID: PMC10776729 DOI: 10.1007/s00383-023-05619-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 01/11/2024]
Abstract
Necrotizing enterocolitis (NEC) is one of the diseases in neonates, with a high morbidity and mortality rate, especially in preterm infants. This review aimed to briefly introduce the latest epidemiology, susceptibility factors, and clinical diagnosis and presentation of NEC. We also organized new prevention strategies by risk factors according to different pathogeneses and then discussed new treatment methods based on Bell's staging and complications, and the classification of mild to high severity based on clinical and imaging manifestations. Such a generalization will help clinicians and researchers to gain a deeper understanding of the disease and to conduct more targeted classification, grading prevention, and exploration. We focused on prevention and treatment of the early and suspected stages of NEC, including the discovery of novel biomarkers and drugs to control disease progression. At the same time, we discussed its clinical application, future development, and shortcomings.
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Affiliation(s)
- Xiaohan Hu
- Institute of Pediatric, Children's Hospital of Soochow University, 92 Zhong Nan Street, Suzhou City, Jiangsu Province, China
- Department of Neonatology, Children's Hospital of Soochow University, 92 Zhong Nan Street, Suzhou City, Jiangsu Province, China
| | - Hansi Liang
- Jiangsu Key Laboratory of Gastrointestinal Tumor Immunology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Fang Li
- Department of Human Anatomy and Histology and Embryology, Soochow University, Suzhou, Jiangsu Province, China
| | - Rui Zhang
- Institute of Pediatric, Children's Hospital of Soochow University, 92 Zhong Nan Street, Suzhou City, Jiangsu Province, China
| | - Yanbo Zhu
- Department of Oncology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xueping Zhu
- Institute of Pediatric, Children's Hospital of Soochow University, 92 Zhong Nan Street, Suzhou City, Jiangsu Province, China.
- Department of Neonatology, Children's Hospital of Soochow University, 92 Zhong Nan Street, Suzhou City, Jiangsu Province, China.
| | - Yunyun Xu
- Institute of Pediatric, Children's Hospital of Soochow University, 92 Zhong Nan Street, Suzhou City, Jiangsu Province, China.
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Challis P, Källén K, Björklund L, Elfvin A, Farooqi A, Håkansson S, Ley D, Norman M, Normann E, Serenius F, Sävman K, Hellström-Westas L, Um-Bergström P, Ådén U, Abrahamsson T, Domellöf M. Factors associated with the increased incidence of necrotising enterocolitis in extremely preterm infants in Sweden between two population-based national cohorts (2004-2007 vs 2014-2016). Arch Dis Child Fetal Neonatal Ed 2023; 109:87-93. [PMID: 37788898 PMCID: PMC10804036 DOI: 10.1136/archdischild-2023-325784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/28/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVE To investigate potential risk factors behind the increased incidence of necrotising enterocolitis (NEC) in Swedish extremely preterm infants. DESIGN Registry data from two population-based national cohorts were studied. NEC diagnoses (Bell stage ≥II) were validated against hospital records. PATIENTS All liveborn infants <27 weeks of gestation 2004-2007 (n=704) and 2014-2016 (n=895) in Sweden. MAIN OUTCOME MEASURES NEC incidence. RESULTS The validation process resulted in a 28% reduction of NEC cases but still confirmed a higher NEC incidence in the later epoch compared with the earlier (73/895 (8.2%) vs 27/704 (3.8%), p=0.001), while the composite of NEC or death was lower (244/895 (27.3%) vs 229/704 (32.5%), p=0.022). In a multivariable Cox regression model, censored for mortality, there was no significant difference in early NEC (0-7 days of life) between epochs (HR=0.9 (95% CI 0.5 to 1.9), p=0.9), but being born in the later epoch remained an independent risk factor for late NEC (>7 days) (HR=2.7 (95% CI 1.5 to 5.0), p=0.001). In propensity score analysis, a significant epoch difference in NEC incidence (12% vs 2.8%, p<0.001) was observed only in the tertile of infants at highest risk of NEC, where the 28-day mortality was lower in the later epoch (35% vs 50%, p=0.001). More NEC cases were diagnosed with intramural gas in the later epoch (33/73 (45.2%) vs 6/26 (23.1%), p=0.047). CONCLUSIONS The increase in NEC incidence between epochs was limited to cases occurring after 7 days of life and was partly explained by increased survival in the most extremely preterm infants. Misclassification of NEC is common.
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Affiliation(s)
- Pontus Challis
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Karin Källén
- Department of Clinical Sciences, Obstetrics and Gynecology, Lund University Faculty of Medicine, Lund, Sweden
| | - Lars Björklund
- Department of Clinical Sciences, Lund, Paediatrics, Lund University, Lund, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
- Department of Pediatrics, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Aijaz Farooqi
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Stellan Håkansson
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - David Ley
- Department of Clinical Sciences, Lund, Paediatrics, Lund University, Lund, Sweden
| | - Mikael Norman
- Division of Pediatrics, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Normann
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Fredrik Serenius
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Karin Sävman
- Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
| | | | - Petra Um-Bergström
- Department of Pediatrics, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Clinical Science and Education at Södersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - Ulrika Ådén
- Division of Pediatrics, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
- Departments of Biomedical and Clinical Sciences and Pediatrics, Linköping University, Linköping, Sweden
| | - Thomas Abrahamsson
- Departments of Biomedical and Clinical Sciences and Pediatrics, Linköping University, Linköping, Sweden
- Department of Pediatrics, Linköping University Hospital, Linköping, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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Impact of Delayed Time to Antibiotics in Medical and Surgical Necrotizing Enterocolitis. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10010160. [PMID: 36670710 PMCID: PMC9856867 DOI: 10.3390/children10010160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023]
Abstract
This study investigated whether delayed receipt of antibiotics in infants with necrotizing enterocolitis (NEC) is associated with disease severity. In this retrospective, single-center cohort study of infants diagnosed with NEC over 4 years, we compared the timing of antibiotic administration in infants (time order placed to time of receipt) in medical and surgical NEC. Cases were independently reviewed, then various clinical factors were compared. Of 46 suspected cases, 25 were confirmed by a panel of radiologists with good interrater reliability (ICC 0.657; p < 0.001). Delays in antibiotic receipt were 1.7× greater in surgical than medical NEC cases (p = 0.049). Every hour after order entry increased the adjusted odds of surgical NEC by 2.4 (1.08−5.23; p = 0.032). Delayed antibiotic receipt was more common in infants with surgical than medical NEC. Larger studies will be needed to investigate if optimizing antibiotic expediency could improve intestinal outcomes.
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Mitha A, Kruth SS, Bjurman S, Rakow A, Johansson S. Neonatal Morbidities and Feeding Tolerance Outcomes in Very Preterm Infants, before and after Introduction of Probiotic Supplementation. Nutrients 2022; 14:nu14173646. [PMID: 36079903 PMCID: PMC9460632 DOI: 10.3390/nu14173646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
While probiotics are reported to reduce the risks of neonatal morbidities, less is known about probiotics and feeding tolerance. With this retrospective cohort study, we investigate whether introduction of probiotic supplementation as the standard of care was associated with fewer neonatal morbidities and improved feeding tolerance in very preterm infants. Using the Swedish Neonatal Quality Register, 345 live-born very preterm infants (28–31 weeks’ gestation), from January 2019–August 2021, in NICUs in Stockholm, Sweden, either received probiotic supplementation (Bifidobacterium infantis, Bifidobacterium lactis, Streptococcusthermophilus) (139) or no supplementation (206); they were compared regarding a primary composite outcome of death, sepsis, and/or necrotising enterocolitis and secondary outcomes: time to full enteral feeding and antibiotics use. Probiotics seemed associated with a reduced risk of the composite outcome (4.3% versus 9.2%, p = 0.08). In the subgroup of 320 infants without the primary outcome, probiotics were associated with shorter time to full enteral feeding (6.6 days versus 7.2 days) and less use of antibiotics (5.2 days versus 6.1 days). Our findings suggest that probiotics improve feeding tolerance and further support that very preterm infants may benefit from probiotic supplementation.
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Affiliation(s)
- Ayoub Mitha
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, 17177 Stockholm, Sweden
- CHU Lille, Paediatric and Neonatal Intensive Care Transport Unit, Department of Emergency Medicine, SAMU 59, Lille University Hospital, F-59000 Lille, France
| | - Sofia Söderquist Kruth
- Women’s Health and Allied Health Professional Theme, Karolinska University Hospital, Solna, 17176 Stockholm, Sweden
- Department of Women’s and Children’s Health, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Sara Bjurman
- Sachs Children and Youth Hospital, Södersjukhuset, 11883 Stockholm, Sweden
| | - Alexander Rakow
- Department of Women’s and Children’s Health, Karolinska Institutet, 17177 Stockholm, Sweden
- Department of Neonatology, Karolinska University Hospital, Solna, 17176 Stockholm, Sweden
| | - Stefan Johansson
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, 17177 Stockholm, Sweden
- Sachs Children and Youth Hospital, Södersjukhuset, 11883 Stockholm, Sweden
- Correspondence: ; Tel.: +46-703495947
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Fecal amine metabolite analysis before onset of severe necrotizing enterocolitis in preterm infants: a prospective case-control study. Sci Rep 2022; 12:12310. [PMID: 35853977 PMCID: PMC9296556 DOI: 10.1038/s41598-022-16351-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 07/08/2022] [Indexed: 11/08/2022] Open
Abstract
Infants developing necrotizing enterocolitis (NEC) have a different metabolomic profile compared to controls. The potential of specific metabolomics, i.e. amino acids and amino alcohols (AAA), as early diagnostic biomarkers for NEC is largely unexplored. In this multicenter prospective case-control study, longitudinally collected fecal samples from preterm infants (born <30 weeks of gestation) from 1-3 days before diagnosis of severe NEC (Bell's stage IIIA/IIIB), were analyzed by targeted high-performance liquid chromatography (HPLC). Control samples were collected from gestational and postnatal age-matched infants. Thirty-one NEC cases (15 NEC IIIA;16 NEC IIIB) with 1:1 matched controls were included. Preclinical samples of infants with NEC were characterized by five increased essential amino acids-isoleucine, leucine, methionine, phenylalanine and valine. Lysine and ethanolamine ratios were lower prior to NEC, compared to control samples. A multivariate model was rendered based on isoleucine, lysine, ethanolamine, tryptophan and ornithine, modestly discriminating cases from controls (AUC 0.67; p < 0.001). Targeted HPLC pointed to several specific AAA alterations in samples collected 1-3 days before NEC onset, compared to controls. Whether this reflects metabolic alterations and has a role in early biomarker development for NEC, has yet to be elucidated.
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Granger C, Dermyshi E, Roberts E, Beck LC, Embleton N, Berrington J. Necrotising enterocolitis, late-onset sepsis and mortality after routine probiotic introduction in the UK. Arch Dis Child Fetal Neonatal Ed 2022; 107:352-358. [PMID: 34433587 DOI: 10.1136/archdischild-2021-322252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/04/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare necrotising enterocolitis (NEC), late-onset sepsis (LOS), focal intestinal perforation (FIP) and mortality in infants from a single neonatal unit before and after probiotic introduction. DESIGN Retrospective review of infants <32 weeks admitted January 2009-December 2012 (no probiotic) and January 2013-December 2017 (routine probiotics). Infants included were admitted before day 3, and not transferred out before day 3. NEC, LOS and FIP were defined with standard definitions. PATIENTS 1061 infants were included, 509 preprobiotic and 552 postprobiotic. Median gestation, birth weight and antenatal steroid use did not differ, and proportions of extremely low birthweight infants were similar (37% and 41%). RESULTS Overall unadjusted risk of NEC (9.2% (95% CI 7.1 to 12.1) vs 10.6% (95% CI 8.2 to 13.4), p=0.48), LOS (16.3% (95% CI 13.2 to 19.6) vs 14.1% (95% CI 11.5 to 17.4), p=0.37) and mortality (9.2% (95% CI 7.1 to 12.1) vs 9.7% (95% CI 7.6 to 12.6), p=0.76) did not differ, nor proportion of surgical NEC. In multiple logistic regression, accounting for gestation, birth weight, antenatal steroid, maternal milk, chorioamnionitis and sex, probiotic receipt was not significantly associated with NEC (adjusted OR (aOR) 1.08 (95% CI 0.71 to 1.68), p=0.73), LOS or mortality. In subgroup (645 infants) >28 weeks, aOR for NEC in the probiotic cohort was 0.42 (95% CI 0.2 to 0.99, p=0.047). FIP was more common in the probiotic cohort (OR 2.3 (95% CI 1.0 to 5.4), p=0.04), not significant in regression analysis (2.11 (95% CI 0.97 to 4.95), p=0.05). CONCLUSIONS Probiotic use in this centre did not reduce overall mortality or rates of NEC, LOS or FIP but subgroup analysis identified NEC risk reduction in infants >28 weeks, and LOS reduction <28 weeks.
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Affiliation(s)
- Claire Granger
- Newcastle Neonatal Service, Ward 35 Neonatal Unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Elda Dermyshi
- Newcastle Neonatal Service, Ward 35 Neonatal Unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Eve Roberts
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lauren C Beck
- Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Nicholas Embleton
- Newcastle Neonatal Service, Ward 35 Neonatal Unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Janet Berrington
- Newcastle Neonatal Service, Ward 35 Neonatal Unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK .,Translational and Clinical Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
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Swanson JR, Hair A, Clark RH, Gordon PV. Spontaneous intestinal perforation (SIP) will soon become the most common form of surgical bowel disease in the extremely low birth weight (ELBW) infant. J Perinatol 2022; 42:423-429. [PMID: 35177793 DOI: 10.1038/s41372-022-01347-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 12/12/2022]
Abstract
Recent data have revealed declines in the prevalence rates of NEC over the last decade in premature infants. In contrast, SIP has either remained steady or risen during the same epoch. These trends are consistent with our knowledge of the clinical arena. The ability to discern SIP contamination within NEC datasets has slowly improved. Additionally, quality improvement efforts are being utilized to reduce NEC through stewardship of antibiotics, acid inhibitors, central lines and blood products, as well as optimization of human milk diets. These forces are moving us to a new era, where NEC will no longer be the dominant surgical intestinal disease of the extremely preterm neonate. Indeed, in the extremely low birth weight (ELBW) population, SIP may already be the most prevalent reason for abdominal surgery. In this perspective, the reader will find supporting data and references for these assertions as well as predictions for the future.
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Affiliation(s)
- Jonathan R Swanson
- Division of Neonatology, University of Virginia Children's Hospital, Charlottesville, VA, USA.
| | - Amy Hair
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL, USA
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10
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Low serum albumin concentration predicts the need for surgical intervention in neonates with necrotizing enterocolitis. J Pediatr Surg 2020; 55:2625-2629. [PMID: 32771214 DOI: 10.1016/j.jpedsurg.2020.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 05/22/2020] [Accepted: 07/03/2020] [Indexed: 12/13/2022]
Abstract
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.
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11
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Abstract
Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality in hospitalized infants. First classified through Bell staging in 1978, a number of additional definitions of NEC have been proposed in the subsequent decades. In this review, we summarize eight current definitions of NEC, and explore similarities and differences in clinical signs and radiographic features included within these definitions, as well as their limitations. We highlight the importance of a global consensus on defining NEC to improve NEC research and outcomes, incorporating input from participants at an international NEC conference. We also highlight the important role of patient-families in helping to redefine NEC.
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12
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Neonatal necrotizing enterocolitis: a case series examining clinical diagnosis with discrepant versus concordant autopsy results. J Perinatol 2020; 40:928-934. [PMID: 32066842 DOI: 10.1038/s41372-020-0611-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 01/19/2020] [Accepted: 02/04/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The objective of this study is to determine whether rapidity of death in necrotizing enterocolitis (NEC) increased odds of discordance between clinical and pathological diagnosis. STUDY DESIGN Retrospective case-series study including preterm infants admitted to the NICU. RESULTS Twenty-two infants met the selection criteria. Gross pathologic evidence of NEC was present in 1/6 cases (17%) where demise occurred <12 h after onset of symptoms, 3/5 cases (60%) within 12-24 h, and 8/11 cases (73%) in >24 h. Histological evidence of necrosis was present in 4/6 (67%) cases when death occurred <12 h, 4/5 (80%) in 12-24 h, and 9/11 (82%) in >24 h. The percentage with gross pathologic evidence showed a monotonic trend (P = 0.031), while the trend was less clear for histologic findings (P = 0.496). CONCLUSION Pathologic features of cell death may not have had sufficient time to develop. This study could reassure both healthcare providers and families when pathologic and clinical diagnoses are not consistent.
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13
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Meyer MP, Chow SSW, Alsweiler J, Bourchier D, Broadbent R, Knight D, Lynn AM, Patel H. Probiotics for Prevention of Severe Necrotizing Enterocolitis: Experience of New Zealand Neonatal Intensive Care Units. Front Pediatr 2020; 8:119. [PMID: 32318522 PMCID: PMC7154127 DOI: 10.3389/fped.2020.00119] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 03/06/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Necrotizing enterocolitis (NEC) affects mainly preterm infants, has a multifactorial etiology and is associated with intestinal dysbiosis and disordered immunity. Use of probiotics for prophylaxis is beneficial with studies indicating reduction in NEC ≥ stage 2, late onset sepsis (LOS) and mortality. However, not all studies have shown a reduction, there are questions regarding which probiotic to use, whether infants <1,000 g benefit and the risk of probiotic sepsis. All neonatal intensive care units in New Zealand (NZ) use probiotics and contribute to an international database (Australian and New Zealand Neonatal Network or ANZNN). Objective: To use ANZNN data to investigate the experience of NZ neonatal units with probiotics for NEC prevention in a setting where the baseline incidence of severe NEC was low, to compare results of 2 commonly used probiotic regimes and report on the extremely low birth weight subgroup. Method: Outcomes before (Pre group 2007-2010) and after (Probiotic group 2013-2015) starting routine probiotics for preterm infants <1,500 g or <32 weeks were compared. Clinicians reviewed cases to ensure they met database criteria. Five units used Infloran (Bifidobacterium bifidum and Lactobacillus acidophilus) and 1 unit used Lactobacillus GG (LGG) and bovine lactoferrin (bLF). Results: Four thousand five hundred and twenty nine infants were included and Pre and Probiotic groups were well-balanced with regard to gestation, birth weight and gender. The incidence of NEC in the Probiotic group was 1.6 and 2.7% in the pre group (corrected OR 0.62 CI 0.41-0.94). There was one case of probiotic sepsis. There was no significant difference between the Infloran and LGG/bLF combinations in regard to observed NEC rates. Late onset sepsis rates were significantly lower in the Probiotic group (p < 0.01). Conclusions: Introduction of probiotics for preterm infants in NZ has been associated with significant reductions in NEC and late onset sepsis.
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Affiliation(s)
- Michael P Meyer
- Neonatal Unit, KidzFirst, Middlemore Hospital, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Sharon S W Chow
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Jane Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.,Neonatal Unit, Auckland City Hospital, Auckland, New Zealand
| | | | | | - David Knight
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.,Neonatal Unit, Auckland City Hospital, Auckland, New Zealand
| | - Adrienne M Lynn
- Neonatal Unit, Christchurch Women's Hospital, Christchurch, New Zealand
| | - Harshad Patel
- Neonatal Unit, Wellington Hospital, Wellington, New Zealand
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14
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Norman M, Källén K, Wahlström E, Håkansson S, Skiöld B, Navér L, Domellöf M, Abrahamsson T, Stigson L, Thernström Blomqvist Y, Nyholm A, Holmström G, Björklund L, Wallin‐Gyökeres A. The Swedish Neonatal Quality Register - contents, completeness and validity. Acta Paediatr 2019; 108:1411-1418. [PMID: 31006126 DOI: 10.1111/apa.14823] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/07/2019] [Accepted: 04/16/2019] [Indexed: 11/28/2022]
Abstract
AIM To describe the Swedish Neonatal Quality Register (SNQ) and to determine its completeness and agreement with other registers. METHODS SNQ collects data for infants admitted to neonatal units during the first four postnatal weeks. Completeness and registers' agreement were determined cross-linking SNQ data with Swedish population registers (the Inpatient, Medical Birth and Cause of Death Registers) for a study period of five years. RESULTS In total, 84 712 infants were hospitalised. A total of 52 806 infants occurred in both SNQ and the population registers; 28 692 were only found in the population registers, and 3214 infants were only found in SNQ. Between gestational weeks 24-34, completeness of SNQ was 98-99%. Below and above these gestational ages, completeness was lower. Infants missing in SNQ were term or near-term in 99% of the cases, and their diagnoses indicated conditions managed in maternity units, or re-admissions for acute infections, managed in paediatric units. For most diagnoses, the agreement between SNQ and population registers was high, but some (bronchopulmonary dysplasia and grade of hypoxic-ischaemic encephalopathy) were often missing in the population registers. CONCLUSION SNQ completeness and agreement against other registers, especially for preterm infants, is excellent. SNQ is a valid tool for benchmarking, quality improvement and research.
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Affiliation(s)
- Mikael Norman
- Department of Clinical Science, Intervention and Technology Division of Pediatrics Karolinska Institutet Stockholm Sweden
- Department of Neonatal Medicine Karolinska University Hospital Stockholm Sweden
- Swedish Neonatal Quality Register (SNQ) Västerbotten county council Umeå Sweden
| | - Karin Källén
- Swedish Neonatal Quality Register (SNQ) Västerbotten county council Umeå Sweden
- Centre for Reproductive Epidemiology Lund University Lund Sweden
| | | | - Stellan Håkansson
- Swedish Neonatal Quality Register (SNQ) Västerbotten county council Umeå Sweden
- Department of Clinical Sciences Division of Pediatrics Umeå University Umeå Sweden
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15
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Norman M, Hallberg B, Abrahamsson T, Björklund LJ, Domellöf M, Farooqi A, Foyn Bruun C, Gadsbøll C, Hellström-Westas L, Ingemansson F, Källén K, Ley D, Maršál K, Normann E, Serenius F, Stephansson O, Stigson L, Um-Bergström P, Håkansson S. Association Between Year of Birth and 1-Year Survival Among Extremely Preterm Infants in Sweden During 2004-2007 and 2014-2016. JAMA 2019; 321:1188-1199. [PMID: 30912837 PMCID: PMC6439685 DOI: 10.1001/jama.2019.2021] [Citation(s) in RCA: 170] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/19/2019] [Indexed: 12/11/2022]
Abstract
Importance Since 2004-2007, national guidelines and recommendations have been developed for the management of extremely preterm births in Sweden. If and how more uniform management has affected infant survival is unknown. Objective To compare survival of extremely preterm infants born during 2004-2007 with survival of infants born during 2014-2016. Design, Setting and Participants All births at 22-26 weeks' gestational age (n = 2205) between April 1, 2004, and March 31, 2007, and between January 1, 2014, and December 31, 2016, in Sweden were studied. Prospective data collection was used during 2004-2007. Data were obtained from the Swedish pregnancy, medical birth, and neonatal quality registries during 2014-2016. Exposures Delivery at 22-26 weeks' gestational age. Main Outcomes and Measures The primary outcome was infant survival to the age of 1 year. The secondary outcome was 1-year survival among live-born infants who did not have any major neonatal morbidity (specifically, without intraventricular hemorrhage grade 3-4, cystic periventricular leukomalacia, necrotizing enterocolitis, retinopathy of prematurity stage 3-5, or severe bronchopulmonary dysplasia). Results During 2004-2007, 1009 births (3.3/1000 of all births) occurred at 22-26 weeks' gestational age compared with 1196 births (3.4/1000 of all births) during 2014-2016 (P = .61). One-year survival among live-born infants at 22-26 weeks' gestational age was significantly lower during 2004-2007 (497 of 705 infants [70%]) than during 2014-2016 (711 of 923 infants [77%]) (difference, -7% [95% CI, -11% to -2.2%], P = .003). One-year survival among live-born infants at 22-26 weeks' gestational age and without any major neonatal morbidity was significantly lower during 2004-2007 (226 of 705 infants [32%]) than during 2014-2016 (355 of 923 infants [38%]) (difference, -6% [95% CI, -11% to -1.7%], P = .008). Conclusions and Relevance Among live births at 22-26 weeks' gestational age in Sweden, 1-year survival improved between 2004-2007 and 2014-2016.
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Affiliation(s)
- Mikael Norman
- Division of Pediatrics, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
- Swedish Neonatal Quality Register, Umeå University Hospital, Umeå, Sweden
| | - Boubou Hallberg
- Division of Pediatrics, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Abrahamsson
- Departments of Clinical and Experimental Medicine and Pediatrics, Linköping University, Linköping, Sweden
| | - Lars J. Björklund
- Departments of Clinical Sciences and Pediatrics, Lund University and Skåne University Hospital, Lund, Sweden
| | - Magnus Domellöf
- Departments of Clinical Sciences and Pediatrics, Umeå University, Umeå Sweden
| | - Aijaz Farooqi
- Departments of Clinical Sciences and Pediatrics, Umeå University, Umeå Sweden
| | - Cathrine Foyn Bruun
- Departments of Clinical Sciences and Pediatrics, Umeå University, Umeå Sweden
| | - Christian Gadsbøll
- Departments of Clinical and Experimental Medicine and Pediatrics, Linköping University, Linköping, Sweden
- Departments of Clinical Sciences and Pediatrics, Lund University and Skåne University Hospital, Lund, Sweden
| | | | - Fredrik Ingemansson
- Department of Pediatrics, Ryhov County Hospital, Jönköping County Council, Jonkoping, Sweden
| | - Karin Källén
- Centre for Reproductive Epidemiology, Lund University, Lund, Sweden
| | - David Ley
- Departments of Clinical Sciences and Pediatrics, Lund University and Skåne University Hospital, Lund, Sweden
| | - Karel Maršál
- Departments of Clinical Sciences and Obstetrics and Gynecology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Erik Normann
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Fredrik Serenius
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Olof Stephansson
- Division of Clinical Epidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Lennart Stigson
- Department of Pediatrics, Institute for Clinical Sciences, Queen Silvia Children’s Hospital, Sahlgrenska Academy, Göteborg University, Göteborg, Sweden
| | - Petra Um-Bergström
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Sachs’ Children and Youth Hospital, Department of Neonatal Medicine, Södersjukhuset, Stockholm, Sweden
| | - Stellan Håkansson
- Swedish Neonatal Quality Register, Umeå University Hospital, Umeå, Sweden
- Departments of Clinical Sciences and Pediatrics, Umeå University, Umeå Sweden
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