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Lu P, Gong X, Gu X, Jiang S, Cao Y, Sun C, Du J, Lei X, Lee SK. Mortality and extrauterine growth restriction of necrotizing enterocolitis in very preterm infants with heart disease: a multi-center cohort study. Eur J Pediatr 2024:10.1007/s00431-024-05599-z. [PMID: 38822834 DOI: 10.1007/s00431-024-05599-z] [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: 03/27/2024] [Revised: 04/28/2024] [Accepted: 05/03/2024] [Indexed: 06/03/2024]
Abstract
Congenital heart disease (CHD) and patent ductus arteriosus (PDA) are risk factors of necrotizing enterocolitis (NEC) in infants. However, it is unclear whether the prognosis of NEC is different between very preterm infants (VPIs) with and without heart diseases. This was an observational cohort study that enrolled VPIs (born between 24+0 and 31+6 weeks) admitted to 79 tertiary neonatal intensive care units (NICU) in the Chinese Neonatal Network (CHNN) between 2019 and 2021. The exposure was CHD or isolated PDA, and VPIs with NEC were divided into three groups: complicated with CHD, with isolated PDA, and without heart diseases. The primary outcomes were NEC-related adverse outcomes (death or extrauterine growth restriction (EUGR)). Logistic regression models were used to adjust potential confounders and calculate the odds ratios (ORs) and 95% confidential intervals (CIs) for each outcome. A total of 1335 VPIs with NEC were enrolled in this study, including 65 VPIs with CHD and 406 VPIs with isolated PDA. The VPIs with heart diseases had smaller gestational ages and lower body weights at birth, more antenatal steroids use, and requiring inotrope prior to the onset of NEC. While suffering from NEC, there was no significant increased risks in NEC-related death in VPIs with either CHD (adjusted OR [aOR]: 1.10; 95% CI: 0.41-2.50) or isolated PDA (aOR: 1.25; 95% CI 0.82-1.87), and increased risks in EUGR were identified in either survival VPIs with CHD (aOR: 2.35; 95% CI: 1.31-4.20) or isolated PDA (aOR: 1.53; 95% CI: 1.16-2.01) in survivors. The composite outcome (death or EUGR) was also more often observed in VPIs with either CHD (aOR: 2.07; 95% confidence interval [CI]: 1.20-3.60) or isolated PDA (aOR: 1.51; 95% CI: 1.17-1.94) than that without heart diseases. VPIs with either CHD or isolated PDA were associated with significantly prolonged duration of fasting, extended time to achieve full enteral feeding, and longer ventilation duration and hospitalization duration. Similar characteristics were also seen in VPIs with isolated PDA, with the exception that VPIs with CHD are more likely to undergo surgical intervention and maintain a prolonged fast after NEC. Conclusion: In VPIs with NEC, CHD and isolated PDA are associated with an increased risk in worse outcomes. We recommend that VPIs with cardiac NEC be managed with aggressive treatment and nutrition strategies to prevent EUGR. What is Known: • CHD and PDA are risk factors for NEC in infants, which can lead to adverse outcomes such as death and EUGR. • NEC in infants with heart disease differs clinically from that in infants without heart disease and should be recognized as a separate disease process. What is New: • CHD and isolated PDA are associated with increased risks of EUGR in VPIs with NEC. • Risk factors associated with VPIs with cardiac NEC suggested these patients should be managed with aggressive treatment and nutrition strategies to adverse outcomes.
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Affiliation(s)
- Pei Lu
- Department of Neonatology, School of Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, 355 Luding Road, Putuo District, Shanghai, 200062, China
| | - Xiaohui Gong
- Department of Neonatology, School of Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, 355 Luding Road, Putuo District, Shanghai, 200062, China.
| | - Xinyue Gu
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
| | - Siyuan Jiang
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
- Division of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Yun Cao
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
- Division of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Chengjun Sun
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Juan Du
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, 100045, China
| | - Xiaoping Lei
- Division of Neonatology, Department of Pediatrics, the Affiliated Hospital, Southwest Medical University, 8 Kangcheng Road, Luzhou, Sichuan, China.
| | - Shoo K Lee
- Maternal-Infant Care Research Centre, Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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Xie YL, Lai SH, Liu SJ, Xiu WL. Risk factors of necrotizing enterocolitis in twin preterm infants. BMC Pediatr 2024; 24:210. [PMID: 38521896 PMCID: PMC10960427 DOI: 10.1186/s12887-024-04701-6] [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: 10/07/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024] Open
Abstract
PURPOSE This study was aimed to investigate the risk factors of necrotizing enterocolitis (NEC) in twin preterm infants. METHODS The clinical data of 67 pairs of twin preterm infants admitted to the neonatal department of our hospital from January 2010 to December 2021 were retrospectively collected. One of the twins had NEC (Bell II and above) and the other twin without NEC. They were divided into NEC group and control group according to whether NEC occurred or not. RESULTS Univariate analysis showed that NEC was associated with congenital heart disease, small for gestational age, mild asphyxia at birth and feeding intolerance (P < 0.05). CONCLUSION Occurrence of NEC was associated with congenital heart disease, small for gestational age, and asphyxia at birth. For twin preterm infants with congenital heart disease, small for gestational age, or asphyxia at birth, special attention should be paid to the occurrence of NEC to minimize and avoid the occurrence of NEC.
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Affiliation(s)
- Ying-Ling Xie
- Department of Neonatology, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Shu-Hua Lai
- Department of Neonatology, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Su-Jia Liu
- Department of Neonatology, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Wen-Long Xiu
- Department of Neonatology, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
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Lembo C, El-Khuffash A, Fusch C, Iacobelli S, Lapillonne A. Nutrition of the preterm infant with persistent ductus arteriosus: existing evidence and practical implications. Pediatr Res 2023:10.1038/s41390-023-02754-4. [PMID: 37563451 DOI: 10.1038/s41390-023-02754-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/01/2023] [Accepted: 07/09/2023] [Indexed: 08/12/2023]
Abstract
The persistence of a patent ductus arteriosus (PDA) is a common condition in preterm infants with a prevalence inversely proportional to gestational age. PDA is associated with mild-to-severe gastrointestinal complications such as feeding intolerance, gastrointestinal perforation, and necrotizing enterocolitis, which represent a major challenge for the nutritional management in preterm infants. In this context, the Section on Nutrition, Gastroenterology and Metabolism and the Circulation Section of the European Society for Pediatric Research have joined forces to review the current knowledge on nutritional issues related to PDA in preterm infants. The aim of the narrative review is to discuss the clinical implications for nutritional practice. Because there is little literature on postnatal nutrition and PDA in preterm infants, further research with well-designed studies on this topic is urgently needed. Guidelines should also be developed to clearly define the implementation and course of enteral nutrition and the target nutritional intake before, during, and after pharmacologic or surgical treatment of PDA, when indicated. IMPACT: Persistent ductus arteriosus (PDA) is associated with gastrointestinal complications such as feeding intolerance, gastrointestinal perforation, and necrotizing enterocolitis, which pose a major challenge to the nutritional management of preterm infants. In PDA infants, fluid restriction may lead to inadequate nutrient intake, which may negatively affect postnatal growth and long-term health. The presence of PDA does not appear to significantly affect mesenteric blood flow and splanchnic oxygenation after enteral feedings. Initiation or maintenance of enteral nutrition can be recommended in infants with PDA.
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Affiliation(s)
- Chiara Lembo
- Department of Neonatology, APHP, Necker-Enfants Malades Hospital, Paris, France
| | - Afif El-Khuffash
- Department of Pediatrics (School of Medicine), Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Christoph Fusch
- Neonatology, Department of Pediatrics, General Hospital, Paracelsus Medical School, Nuernberg, Germany
- McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Silvia Iacobelli
- Réanimation Néonatale et Pédiatrique, CHU La Réunion, Saint-Pierre, France
| | - Alexandre Lapillonne
- Department of Neonatology, APHP, Necker-Enfants Malades Hospital, Paris, France.
- EHU 7328 PACT, Paris Cite University, Paris, France.
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Prediction of High Bell Stages of Necrotizing Enterocolitis Using a Mathematic Formula for Risk Determination. CHILDREN 2022; 9:children9050604. [PMID: 35626781 PMCID: PMC9139239 DOI: 10.3390/children9050604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/23/2022] [Accepted: 04/22/2022] [Indexed: 11/16/2022]
Abstract
Necrotizing enterocolitis (NEC) continues to cause high morbidity and mortality. Identifying early predictors for severe NEC is essential to improve therapy and optimize timing for surgical intervention. We present a retrospective study of patients with NEC, treated between 2010 and 2020, trying to identify factors influencing the severity of NEC. Within the study period, 88 affected infants with NEC or NEC-like symptoms are analyzed. A multiple logistic regression analysis reveals the following three independent predictors for NEC in Bell stage III: red blood cell transfusion (p = 0.027 with odds ratio (OR) = 3.298), sonographic findings (p = 0.037; OR = 6.496 for patients with positive vs. patients without pathological findings) and cardiac anatomy (p = 0.015; OR = 1.922 for patients with patent ductus arteriosus (PDA) vs. patients with congenital heart disease (CHD); OR = 5.478/OR = 2.850 for patients with CHD/PDA vs. patients without cardiac disease). Results are summarized in a clinical score for daily application in clinical routine. The score is easy to apply and combines clinically established parameters, helping to determine the timing of surgical intervention.
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Diez S, Besendörfer M, Weyerer V, Hartmann A, Moosmann J, Weiss C, Renner M, Müller H. DMBT1 expression and neutrophil-to-lymphocyte ratio during necrotizing enterocolitis are influenced by impaired perfusion due to cardiac anomalies. Mol Cell Pediatr 2022; 9:1. [PMID: 34989914 PMCID: PMC8739415 DOI: 10.1186/s40348-021-00133-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 12/15/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Deleted in malignant brain tumors 1 (DMBT1) is involved in innate immunity and epithelial differentiation. It has been proven to play a role in various states of inflammation or hypoxia of fetal gastrointestinal and pulmonary diseases. Discrimination of pathogenesis in necrotizing enterocolitis (NEC) based on cardiac status improves the understanding of NEC in different patient subgroups. We aimed at examining DMBT1 expressions regarding their association with cardiac status leading to impaired intestinal perfusion, intraoperative bacteria proof, and a fulminant course of NEC. METHODS Twenty-eight patients with NEC were treated surgically between 2010 and 2019 at our institution. DMBT1 expression was examined in intestinal sections using immunohistochemistry to detect DMBT1 protein. Associations of clinical parameters and DMBT1 expression were analyzed. RESULTS We examined DMBT1 levels in 10 patients without cardiac defects and 18 patients with persisting ductus arteriosus (PDA) and congenital heart defects (CHD). Compared to patients without cardiac malformations, DMBT1 levels tended to score higher in patients with PDA/CHD (p = 0.2113) and were negatively correlated with C-reactive protein in these infants (p = 0.0172; r = - 0.5533). The number of DMBT1-expressing macrophages was elevated in the PDA/CHD-subgroup (p = 0.0399). Ratios of neutrophils and monocytes to lymphocytes were significantly higher in infants with PDA/CHD (p = 0.0319 and 0.0493). DMBT1 expression was significantly associated with positive bacterial culture of intraoperative swabs (p = 0.0252) and DMBT1 expression of the serosa was associated with a fulminant course of NEC (p = 0.0239). CONCLUSIONS This study demonstrates that DMBT1 expression may be influenced by cardiac anomalies with an impaired intestinal perfusion in the neonatal intestine. NEC in PDA/CHD infants is associated with more DMBT1-positive macrophages and a significantly elevated neutrophil-to-lymphocyte ratio.
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Affiliation(s)
- Sonja Diez
- Pediatric Surgery, Department for General Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestraße 15, 91054, Erlangen, Germany.
| | - Manuel Besendörfer
- Pediatric Surgery, Department for General Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestraße 15, 91054, Erlangen, Germany
| | - Veronika Weyerer
- Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 8-10, 91054, Erlangen, Germany
| | - Arndt Hartmann
- Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 8-10, 91054, Erlangen, Germany
| | - Julia Moosmann
- Department of Pediatric Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestraße 15, 91054, Erlangen, Germany
| | - Christel Weiss
- Department of Medical Statistics & Biomathematics, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Haus 3, Ebene 4, 68167, Mannheim, Germany
| | - Marcus Renner
- Institute of Pathology, Heidelberg University, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
| | - Hanna Müller
- Division of Neonatology and Pediatric Intensive Care, Department of Pediatrics, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestraße 15, 91054, Erlangen, Germany.,Neonatology and Pediatric Intensive Care, Department of Pediatrics, University of Marburg, Baldingerstraße, 35033, Marburg, Germany
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Kalteren WS, Bos AF, van Oeveren W, Hulscher JBF, Kooi EMW. Neonatal anemia relates to intestinal injury in preterm infants. Pediatr Res 2022; 91:1452-1458. [PMID: 34907357 PMCID: PMC8670618 DOI: 10.1038/s41390-021-01903-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/03/2021] [Accepted: 11/26/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Anemia is associated with decreased tissue oxygenation in preterm infants and may contribute to developing necrotizing enterocolitis (NEC). We aimed to investigate whether hemoglobin level is associated with intestinal injury, by comparing anemic infants 10 days prior to red blood cell (RBC) transfusion with non-anemic controls. METHODS A nested case-control study in which we matched anemic preterms (gestational age (GA) < 32 weeks) with non-anemic controls (1:1), based on GA, birth weight (BW), and postnatal age. We measured urinary intestinal fatty acid-binding protein, I-FABP, marker for intestinal injury, twice weekly. Simultaneously, we assessed splanchnic oxygen saturation (rsSO2) and rsSO2 variability. RESULTS Thirty-six cases and 36 controls were included (median GA 27.6 weeks, BW 1020 grams). Median I-FABP level was higher in cases from 6 days to 24-h before transfusion (median ranging: 4749-8064 pg/ml versus 2194-3751 pg/ml). RsSO2 and rsSO2 variability were lower in cases than controls shortly before transfusion. Hemoglobin levels correlated negatively with rsSO2 and rsSO2 variability in cases, and negatively with I-FABP in cases and controls together. CONCLUSIONS Urinary I-FABP levels were higher in anemic infants before RBC transfusion than in non-anemic matched controls, suggesting intestinal injury associated with anemia. This may predispose to NEC in some anemic preterm infants. IMPACT Anemia is a common comorbidity in preterm infants and may lead to impaired splanchnic oxygen saturation and intestinal tissue hypoxia, a proposed mechanism for NEC. Lower hemoglobin level is associated with higher urinary I-FABP levels, a marker for intestinal injury, both in anemic preterm infants and in cases and controls together. Lower splanchnic oxygen saturation and reduction of its variability are associated with higher urinary I-FABP levels in anemic preterm infants before their first RBC transfusion. These results support the hypothesis that anemia in very preterm infants results in intestinal cell injury, which may precede NEC development in some.
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Affiliation(s)
- Willemien S. Kalteren
- grid.4494.d0000 0000 9558 4598Division of Neonatology, Department of Pediatrics, Beatrix Children’s Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Arend F. Bos
- grid.4494.d0000 0000 9558 4598Division of Neonatology, Department of Pediatrics, Beatrix Children’s Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Jan B. F. Hulscher
- grid.4494.d0000 0000 9558 4598Division of Pediatric Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elisabeth M. W. Kooi
- grid.4494.d0000 0000 9558 4598Division of Neonatology, Department of Pediatrics, Beatrix Children’s Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Roychaudhuri S, Grewal G, Vijayashankar SS, Lavoie P, Maheshwari A. Necrotizing Enterocolitis Associated with Congenital Heart Disease-A Review Article. NEWBORN (CLARKSVILLE, MD.) 2022; 1:170-176. [PMID: 36864827 PMCID: PMC9976612 DOI: 10.5005/jp-journals-11002-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Necrotizing enterocolitis (NEC) is a relatively rare but devastating entity associated classically with the preterm cohort in the neonatal intensive care unit. Preterm and term babies with congenital heart disease are at risk of a number of comorbidities because of the hemodynamic derangements due to a structurally abnormal heart and the corrective procedures adopted. Necrotizing enterocolitis is one of the dreaded complications associated with this cohort and impacts the course of these babies in the hospital in a major way. A large majority of term babies with NEC are in the backdrop of a significant congenital cardiac lesion. This review article summarizes the literature and elaborates this entity including its specific features, risk factors associated with its causality, histopathology and related aspects of hemodynamics, and feeding in this vulnerable population. It also provides insight into modifiable risk factors and early markers of detection of gut necrosis to facilitate prevention and early detection. It highlights the subtle but definite difference in outcome variables to help physicians enable the parents of babies with heart disease to develop a better understanding of the entity and its expected course while counseling.
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Affiliation(s)
- Sriya Roychaudhuri
- Department of Pediatrics, Division of Neonatology, BC Women’s Hospital, Vancouver, Canada
| | - Gurpreet Grewal
- Department of Neonatal-Perinatal Medicine BC Women’s Hospital and Health Centre, British Columbia, Vancouver, Canada
| | | | - Pascal Lavoie
- Department of Neonatal-Perinatal Medicine BC Women’s Hospital and Health Centre, British Columbia, Vancouver, Canada
| | - Akhil Maheshwari
- Department of Neonatal-Perinatal Medicine, Global Newborn Society, Baltimore, Maryland, United States of America
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Harky A, Kashif H, Abuelgasim E, Hussain N, Luyt J. Necrotizing enterocolitis and congenital heart disease. Ann Pediatr Cardiol 2021; 14:507-515. [PMID: 35527771 PMCID: PMC9075549 DOI: 10.4103/apc.apc_30_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/26/2021] [Indexed: 11/25/2022] Open
Abstract
Necrotizing enterocolitis (NEC) remains a prominent surgical emergency among infant population, associated with a significant mortality, as well as various subsequent morbidities. Congenital heart disease (CHD) has an increased associated incidence with NEC in infant population. Recent research has provided insight into the pathophysiology of NEC in patients with CHD and how this differs from those without CHD. The deviation from normal circulatory physiology has a suggested association in the pathophysiology of NEC in CHD, which may have implications for the risk factors of NEC in infants with CHD, the effect on outcomes of NEC, and whether alternative approaches to management may need to be considered in comparison to classical NEC. This review aims to highlight studies that provide insight and awareness into the relationship between NEC and CHD, in order that clinicians may direct themselves more clearly toward optimal management for infants in this category.
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