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Blakely ML, Krzyzaniak A, Dassinger MS, Pedroza C, Weitkamp JH, Gosain A, Cotten M, Hintz SR, Rice H, Courtney SE, Lally KP, Ambalavanan N, Bendel CM, Bui KCT, Calkins C, Chandler NM, Dasgupta R, Davis JM, Deans K, DeUgarte DA, Gander J, Jackson CCA, Keszler M, Kling K, Fenton SJ, Fisher KA, Hartman T, Huang EY, Islam S, Koch F, Lainwala S, Lesher A, Lopez M, Misra M, Overbey J, Poindexter B, Russell R, Stylianos S, Tamura DY, Yoder BA, Lucas D, Shaul D, Ham PB, Fitzpatrick C, Calkins K, Garrison A, de la Cruz D, Abdessalam S, Kvasnovsky C, Segura BJ, Shilyansky J, Smith LM, Tyson JE. Effect of Early vs Late Inguinal Hernia Repair on Serious Adverse Event Rates in Preterm Infants: A Randomized Clinical Trial. JAMA 2024; 331:1035-1044. [PMID: 38530261 DOI: 10.1001/jama.2024.2302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Importance Inguinal hernia repair in preterm infants is common and is associated with considerable morbidity. Whether the inguinal hernia should be repaired prior to or after discharge from the neonatal intensive care unit is controversial. Objective To evaluate the safety of early vs late surgical repair for preterm infants with an inguinal hernia. Design, Setting, and Participants A multicenter randomized clinical trial including preterm infants with inguinal hernia diagnosed during initial hospitalization was conducted between September 2013 and April 2021 at 39 US hospitals. Follow-up was completed on January 3, 2023. Interventions In the early repair strategy, infants underwent inguinal hernia repair before neonatal intensive care unit discharge. In the late repair strategy, hernia repair was planned after discharge from the neonatal intensive care unit and when the infants were older than 55 weeks' postmenstrual age. Main Outcomes and Measures The primary outcome was occurrence of any prespecified serious adverse event during the 10-month observation period (determined by a blinded adjudication committee). The secondary outcomes included the total number of days in the hospital during the 10-month observation period. Results Among the 338 randomized infants (172 in the early repair group and 166 in the late repair group), 320 underwent operative repair (86% were male; 2% were Asian, 30% were Black, 16% were Hispanic, 59% were White, and race and ethnicity were unknown in 9% and 4%, respectively; the mean gestational age at birth was 26.6 weeks [SD, 2.8 weeks]; the mean postnatal age at enrollment was 12 weeks [SD, 5 weeks]). Among 308 infants (91%) with complete data (159 in the early repair group and 149 in the late repair group), 44 (28%) in the early repair group vs 27 (18%) in the late repair group had at least 1 serious adverse event (risk difference, -7.9% [95% credible interval, -16.9% to 0%]; 97% bayesian posterior probability of benefit with late repair). The median number of days in the hospital during the 10-month observation period was 19.0 days (IQR, 9.8 to 35.0 days) in the early repair group vs 16.0 days (IQR, 7.0 to 38.0 days) in the late repair group (82% posterior probability of benefit with late repair). In the prespecified subgroup analyses, the probability that late repair reduced the number of infants with at least 1 serious adverse event was higher in infants with a gestational age younger than 28 weeks and in those with bronchopulmonary dysplasia (99% probability of benefit in each subgroup). Conclusions and Relevance Among preterm infants with inguinal hernia, the late repair strategy resulted in fewer infants having at least 1 serious adverse event. These findings support delaying inguinal hernia repair until after initial discharge from the neonatal intensive care unit. Trial Registration ClinicalTrials.gov Identifier: NCT01678638.
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Affiliation(s)
- Martin L Blakely
- Department of Surgery, Institute for Clinical Research and Learning Healthcare and Institute for Implementation Science, University of Texas Health Science Center, Houston
| | | | - Melvin S Dassinger
- Division of Pediatric Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Claudia Pedroza
- Department of Pediatrics, Institute for Clinical Research and Learning Healthcare, University of Texas Health Science Center, Houston
| | | | - Ankush Gosain
- Division of Pediatric Surgery, University of Colorado, Aurora
| | - Michael Cotten
- Division of Neonatology, Duke University, Durham, North Carolina
| | - Susan R Hintz
- Division of Neonatology, Stanford University, Palo Alto, California
| | - Henry Rice
- Division of Pediatric Surgery, Duke University, Durham, North Carolina
| | - Sherry E Courtney
- Division of Neonatology, University of Arkansas for Medical Sciences, Little Rock
| | - Kevin P Lally
- Department of Pediatric Surgery, University of Texas Health Science Center, Houston
| | | | | | - Kim Chi T Bui
- Division of Neonatology, Kaiser Permanente, Los Angeles, California
| | - Casey Calkins
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee
| | - Nicole M Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jonathan M Davis
- Division of Neonatology, Tufts Medical Center, Boston, Massachusetts
| | - Katherine Deans
- Department of Pediatric Surgery, Nemours Children's Hospital, Wilmington, Delaware
| | - Daniel A DeUgarte
- Division of Pediatric Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Jeffrey Gander
- Division of Pediatric Surgery, University of Virginia, Charlottesville
| | - Carl-Christian A Jackson
- Division of Pediatric Surgery, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Martin Keszler
- Division of Neonatology, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Karen Kling
- Rady Children's Hospital and Division of Pediatric Surgery, University of California, San Diego
| | - Stephen J Fenton
- Division of Pediatric Surgery, University of Utah, Salt Lake City
| | | | - Tyler Hartman
- Division of Neonatology, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Eunice Y Huang
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Saleem Islam
- Division of Pediatric Surgery, University of Florida, Gainesville
- Department of Surgery, Aga Khan University, Sindh, Pakistan
| | - Frances Koch
- Division of Neonatology, Medical University of South Carolina, Charleston
| | - Shabnam Lainwala
- Division of Neonatology, Connecticut Children's Medical Center, Hartford
| | - Aaron Lesher
- Division of Pediatric Surgery, Medical University of South Carolina, Charleston
| | - Monica Lopez
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meghna Misra
- Pediatric Surgery, Elliot Hospital, Manchester, New Hampshire
| | - Jamie Overbey
- Division of Neonatology, Naval Medical Center, San Diego, California
| | - Brenda Poindexter
- Division of Neonatology, School of Medicine, Emory University, Atlanta, Georgia
| | - Robert Russell
- Division of Pediatric Surgery, University of Alabama at Birmingham
| | - Steven Stylianos
- Division of Pediatric Surgery, Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, New York
| | - Douglas Y Tamura
- Division of Pediatric Surgery, Valley Children's Hospital, Madera, California
| | | | - Donald Lucas
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Division of Pediatric Surgery, Naval Medical Center, San Diego, California
| | - Donald Shaul
- Division of Pediatric Surgery, Kaiser Permanente, Los Angeles, California
| | - P Ben Ham
- Division of Pediatric Surgery, University at Buffalo, Buffalo, New York
| | - Colleen Fitzpatrick
- Division of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York
| | - Kara Calkins
- Division of Neonatology, David Geffen School of Medicine, University of California, Los Angeles
| | - Aaron Garrison
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Diomel de la Cruz
- Division of Neonatology, School of Medicine, University of Florida, Gainesville
| | - Shahab Abdessalam
- Division of Neonatology, University of Nebraska Medical Center, Omaha
| | | | - Bradley J Segura
- Division of Pediatric Surgery, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis
| | - Joel Shilyansky
- Department of Pediatric Surgery, University of Iowa Stead Family Children's Hospital, Iowa City
| | | | - Jon E Tyson
- Department of Pediatrics, Institute for Clinical Research and Learning Healthcare, University of Texas Health Science Center, Houston
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Gipson DR, Chang AL, Lure AC, Mehta SA, Gowen T, Shumans E, Stevenson D, de la Cruz D, Aghaeepour N, Neu J. Reassessing acquired neonatal intestinal diseases using unsupervised machine learning. Pediatr Res 2024:10.1038/s41390-024-03074-x. [PMID: 38413766 DOI: 10.1038/s41390-024-03074-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/11/2023] [Accepted: 01/02/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Acquired neonatal intestinal diseases have an array of overlapping presentations and are often labeled under the dichotomous classification of necrotizing enterocolitis (which is poorly defined) or spontaneous intestinal perforation, hindering more precise diagnosis and research. The objective of this study was to take a fresh look at neonatal intestinal disease classification using unsupervised machine learning. METHODS Patients admitted to the University of Florida Shands Neonatal Intensive Care Unit January 2013-September 2019 diagnosed with an intestinal injury, or had imaging findings of portal venous gas, pneumatosis, abdominal free air, or had an abdominal drain placed or exploratory laparotomy during admission were included. Congenital gastroschisis, omphalocele, intestinal atresia, malrotation were excluded. Data was collected via retrospective chart review with subsequent hierarchal, unsupervised clustering analysis. RESULTS Five clusters of intestinal injury were identified: Cluster 1 deemed the "Low Mortality" cluster, Cluster 2 deemed the "Mature with Inflammation" cluster, Cluster 3 deemed the "Immature with High Mortality" cluster, Cluster 4 deemed the "Late Injury at Full Feeds" cluster, and Cluster 5 deemed the "Late Injury with High Rate of Intestinal Necrosis" cluster. CONCLUSION Unsupervised machine learning can be used to cluster acquired neonatal intestinal injuries. Future study with larger multicenter datasets is needed to further refine and classify types of intestinal diseases. IMPACT Unsupervised machine learning can be used to cluster types of acquired neonatal intestinal injury. Five major clusters of acquired neonatal intestinal injury are described, each with unique features. The clusters herein described deserve future, multicenter study to determine more specific early biomarkers and tailored therapeutic interventions to improve outcomes of often devastating neonatal acquired intestinal injuries.
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Affiliation(s)
- Daniel R Gipson
- University of Florida College of Medicine, Department of Pediatrics, Division of Neonatology, Gainesville, FL, USA.
| | - Alan L Chang
- Stanford University School of Medicine, Department of Anesthesiology, Pain, and Perioperative Medicine, Department of Pediatrics, and Department of Biomedical Data Science, Stanford, CA, USA
| | - Allison C Lure
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Department of Pediatrics, Division of Neonatology, Columbus, OH, USA
- University of Florida College of Medicine, Department of Pediatrics, Gainesville, FL, USA
| | - Sonia A Mehta
- University of Florida College of Medicine, Department of Pediatrics, Gainesville, FL, USA
- University of California, Irvine Medical Center, Department of Pediatrics, Division of Neonatology, Irvine, CA, USA
| | - Taylor Gowen
- University of Florida College of Medicine, Department of Pediatrics, Gainesville, FL, USA
- University of Florida College of Medicine, Department of Anesthesiology, Gainesville, FL, USA
| | - Erin Shumans
- University of Florida College of Medicine, Department of Pediatrics, Gainesville, FL, USA
| | - David Stevenson
- Stanford University School of Medicine, Department of Pediatrics, Division of Neonatology, Stanford, CA, USA
| | - Diomel de la Cruz
- University of Florida College of Medicine, Department of Pediatrics, Division of Neonatology, Gainesville, FL, USA
| | - Nima Aghaeepour
- Stanford University School of Medicine, Department of Anesthesiology, Pain, and Perioperative Medicine, Department of Pediatrics, and Department of Biomedical Data Science, Stanford, CA, USA
| | - Josef Neu
- University of Florida College of Medicine, Department of Pediatrics, Division of Neonatology, Gainesville, FL, USA
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Gabriel K, Hovater K, Gao H, de la Cruz D, Calkins KL, Neu J. Monitoring and management of hypertriglyceridemia in extremely low birth weight neonates receiving intravenous lipid emulsions: A national survey. Early Hum Dev 2023; 186:105872. [PMID: 37862901 DOI: 10.1016/j.earlhumdev.2023.105872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 10/22/2023]
Abstract
AIM To assess the practice variation of defining, monitoring and managing hypertriglyceridemia (HTG) in extremely low birth weight neonates receiving intravenous lipid emulsions (IVLE). METHODS An 8-question survey created via the web survey site Qualtrics was distributed to neonatologists, neonatal nurse practitioners and fellows within the Section of Neonatal-Perinatal Medicine email directory list in the United States and Canada. Survey results were obtained between August and September 2022. RESULTS There were 249 respondents from approximately 4000 members within the Section of Neonatal-Perinatal Medicine. Responses were documented as a frequency (percentage) with a margin of error of plus or minus 6.2 %. Most respondents were neonatologists, individuals practicing for >10 years and reported a unit-based policy for IVLE initiation and advancement. The definitions of HTG varied among respondents, with the majority (42.7 %) reporting a defining threshold of >200 mg/dL. Nineteen percent of respondents reported not routinely monitoring serum triglyceride concentrations with variable triglyceride monitoring intervals reported by other survey respondents. Regarding elevated triglyceride concentrations, 19.0 % reported decreasing the IVLE rate and checking triglyceride concentrations until normalization; 14.6 % reported IVLE discontinuation and monitoring triglyceride concentrations until normalization; 61.9 % reported using a combination of the above practices; and 4.4 % reported individualized practices for IVLE management with elevated triglyceride concentrations. CONCLUSION This survey demonstrates a high variation in defining, monitoring and managing HTG in extremely low birth weight neonates and emphasizes the need for studies to better guide this practice.
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Affiliation(s)
- Krystina Gabriel
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32608, United States.
| | - Kylie Hovater
- Bachelor of Science Student, College of Liberal Arts and Sciences, University of Florida, 102 Griffin-Floyd Hall, Gainesville, FL 32611, United States
| | - Hanzhi Gao
- Research Design and Data Coordinating Center, Clinical and Translational Science Institute, University of Florida, 2004 Mowry Rd, Gainesville, FL 32610, United States
| | - Diomel de la Cruz
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32608, United States
| | - Kara L Calkins
- Department of Pediatrics, Division of Neonatology & Developmental Biology, Neonatal Research Center of the UCLA Children's Discovery and Innovation Institute, David Geffen School of Medicine UCLA, 757 Westwood Plaza, Los Angeles, CA 90095, United States
| | - Josef Neu
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, 1600 SW Archer Rd, Gainesville, FL 32608, United States
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Nataraj P, Rajderkar D, de la Cruz D, Weiss MD. Early Term Infant with Prenatal Brain Abnormalities and Decreased Oral Intake. Neoreviews 2022; 23:e856-e860. [PMID: 36450646 DOI: 10.1542/neo.23-12-e856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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de la Cruz D, Lure A, Neu J. [Enterocolitis necrotizante]. World Rev Nutr Diet 2022; 122:395-407. [PMID: 36174528 DOI: 10.1159/000526554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Diomel de la Cruz
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Allison Lure
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Josef Neu
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
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Abstract
Appropriate nutrition is essential for optimal development and growth of preterm infants. Infants less than 25 weeks corrected gestational age are frequently the most difficult group for which to provide adequate nutrition due to minimal energy stores and high fluid losses. Nutrient delivery becomes an integral, but also very challenging part in their management. Early administration of intravenous nutrients provides a critical bridge to full enteral nutrition. However, enteral feeding is challenging due to immaturities of the intestinal tract, feeding intolerance and the risk of catastrophic gastrointestinal disease such as necrotizing enterocolitis (NEC). Decreased gastric acid production, increased gut permeability, reduced immunoglobulins, immature intestinal epithelia and a decreased mucin barrier all contribute to weakness to gastrointestinal insult. This review aims to illustrate the importance of enteral feeding and the common challenges and approaches in the nutrition of infants born at this age.
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Affiliation(s)
- Laura Patton
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Diomel de la Cruz
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA.
| | - Josef Neu
- Department of Pediatrics, Division of Neonatology, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
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Lewis AN, de la Cruz D, Wynn JL, Frazer LC, Yakah W, Martin CR, Yang H, Itriago E, Unger J, Hair AB, Miele J, Sullivan BA, Husain A, Good M. Evaluation of the Neonatal Sequential Organ Failure Assessment and Mortality Risk in Preterm Infants with Necrotizing Enterocolitis. Neonatology 2022; 119:334-344. [PMID: 35313308 PMCID: PMC9117503 DOI: 10.1159/000522560] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 02/10/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The neonatal sequential organ failure assessment (nSOFA) score is a tool for calculating mortality risk of infants in the neonatal intensive care unit. The utility of the nSOFA in determining the risk of mortality or the association with surgical intervention among infants with necrotizing enterocolitis (NEC) has not been investigated. METHODS We performed a retrospective, cohort study of preterm (<37 weeks) infants with NEC Bell's stage ≥ IIA at six hospitals from 2008 to 2020. An nSOFA score (range 0-15) was assigned to each patient at nine time points from 48 h before or after clinical illness was suspected. RESULTS Of the 259 infants, nSOFA scores for infants who died (n = 39) or had the composite outcome of surgery or death (n = 114) were significantly higher (p < 0.05) early in the NEC course compared to nSOFA scores for infants who survived medical NEC. Twelve hours after evaluation, the area under the receiver operating characteristic curve was 0.87 (95% confidence interval [CI], 0.80-0.93) to discriminate for mortality and 0.84 (95% CI, 0.79-0.90) for surgery or death (p < 0.001). A maximum nSOFA score of ≥4 at -6, 0, 6, or 12 h following evaluation was associated with a 20-fold increase in mortality and 19-fold increase in surgery or death compared with a score of <4 (p < 0.001). CONCLUSION In this multicenter cohort, the nSOFA score was able to discriminate well for death as well as surgery or death among infants with NEC. The nSOFA is a clinical research tool that may be used in infants with NEC to improve classification by objective quantification of organ dysfunction.
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Affiliation(s)
- Angela N. Lewis
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis Children’s Hospital, 660 South Euclid, St. Louis, MO 63110, USA
| | - Diomel de la Cruz
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, UF Health Shands Children’s Hospital, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - James L. Wynn
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, UF Health Shands Children’s Hospital, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Lauren C. Frazer
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - William Yakah
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA
| | - Camilia R. Martin
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Heeju Yang
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Elena Itriago
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Jana Unger
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Amy B. Hair
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Jessica Miele
- University of Virginia School of Medicine, UVA Children’s Hospital, 200 Jeanette Lancaster Way, Charlottesville, VA 22903, USA
| | - Brynne A. Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, UVA Children’s Hospital, 200 Jeanette Lancaster Way, Charlottesville, VA 22903, USA
| | - Ameena Husain
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis Children’s Hospital, 660 South Euclid, St. Louis, MO 63110, USA
| | - Misty Good
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis Children’s Hospital, 660 South Euclid, St. Louis, MO 63110, USA
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Lavilla OC, Aziz KB, Lure AC, Gipson D, de la Cruz D, Wynn JL. Hourly Kinetics of Critical Organ Dysfunction in Extremely Preterm Infants. Am J Respir Crit Care Med 2022; 205:75-87. [PMID: 34550843 PMCID: PMC8865589 DOI: 10.1164/rccm.202106-1359oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Rationale: Use of severity of illness scores to classify patients for clinical care and research is common outside of the neonatal ICU. Extremely premature (<29 weeks' gestation) infants with extremely low birth weight (<1,000 g) experience significant mortality and develop severe pathology during the protracted birth hospitalization. Objectives: To measure at high resolution the changes in organ dysfunction that occur from birth to death or discharge home by gestational age and time, and among extremely preterm infants with and without clinically meaningful outcomes using the neonatal sequential organ failure assessment score. Methods: A single-center, retrospective, observational cohort study of inborn, extremely preterm infants with extremely low birth weight admitted between January 2012 and January 2020. Neonatal sequential organ failure assessment scores were calculated every hour for every patient from admission until death or discharge. Measurements and Main Results: Longitudinal, granular scores from 436 infants demonstrated early and sustained discrimination of those who died versus those who survived to discharge. The discrimination for mortality by the maximum score was excellent (area under curve, 0.91; 95% confidence intervals, 0.88-0.94). Among survivors with and without adverse outcomes, most score variation occurred at the patient level. The weekly average score over the first 28 days was associated with the sum of adverse outcomes at discharge. Conclusions: The neonatal sequential organ failure assessment score discriminates between survival and nonsurvival on the first day of life. The major contributor to score variation occurred at the patient level. There was a direct association between scores and major adverse outcomes, including death.
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Affiliation(s)
| | - Khyzer B. Aziz
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - James L. Wynn
- Department of Pediatrics and,Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, Florida; and
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Lure AC, Du X, Black EW, Irons R, Lemas DJ, Taylor JA, Lavilla O, de la Cruz D, Neu J. Using machine learning analysis to assist in differentiating between necrotizing enterocolitis and spontaneous intestinal perforation: A novel predictive analytic tool. J Pediatr Surg 2021; 56:1703-1710. [PMID: 33342603 DOI: 10.1016/j.jpedsurg.2020.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/27/2020] [Accepted: 11/07/2020] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Allison C Lure
- University of Florida College of Medicine, Department of Pediatrics, 1600 SW Archer Rd, Gainesville, FL 32610, United States.
| | - Xinsong Du
- University of Florida College of Medicine, Department of Health Outcomes & Biomedical Informatics, 2004 Mowry Rd, Gainesville, FL 32610, United States
| | - Erik W Black
- University of Florida College of Medicine, Department of Pediatrics, 1600 SW Archer Rd, Gainesville, FL 32610, United States; University of Florida College of Education, 1221 SW 5th Ave, Gainesville, FL 32601, United States
| | - Raechel Irons
- University of Florida College of Medicine, Department of Pediatrics, 1600 SW Archer Rd, Gainesville, FL 32610, United States
| | - Dominick J Lemas
- University of Florida College of Medicine, Department of Health Outcomes & Biomedical Informatics, 2004 Mowry Rd, Gainesville, FL 32610, United States
| | - Janice A Taylor
- University of Florida College of Medicine, Department of Surgery, 1600 SW Archer Rd, Gainesville, FL 32610, United States
| | - Orlyn Lavilla
- University of Florida College of Medicine, Department of Pediatrics, 1600 SW Archer Rd, Gainesville, FL 32610, United States
| | - Diomel de la Cruz
- University of Florida College of Medicine, Department of Pediatrics, 1600 SW Archer Rd, Gainesville, FL 32610, United States
| | - Josef Neu
- University of Florida College of Medicine, Department of Pediatrics, 1600 SW Archer Rd, Gainesville, FL 32610, United States
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Aziz KB, Lavilla OC, Wynn JL, Lure AC, Gipson D, de la Cruz D. Maximum vasoactive-inotropic score and mortality in extremely premature, extremely low birth weight infants. J Perinatol 2021; 41:2337-2344. [PMID: 33712712 PMCID: PMC8435049 DOI: 10.1038/s41372-021-01030-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/28/2021] [Accepted: 02/25/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the relationship between maximum vasoactive-inotropic (VISmax) and mortality in extremely premature (<29 weeks completed gestation), extremely low birth weight (ELBW, <1000 g) infants. STUDY DESIGN Single center, retrospective, and observational cohort study. RESULTS We identified 436 ELBW, <29 week, inborn infants cared for during the study period. Compared to infants with VISmax of 0, the frequency of mortality based on VISmax ranged from 3.3-fold to 46.1-fold. VISmax > 30 was associated with universal mortality. Multivariable modeling that included gestational age, birth weight, and VISmax revealed significant utility to predict mortality with negative predictive value of 87.0% and positive predictive value of 84.8% [adjusted AUROC: 0.90, (0.86-0.94)] among patients that received vasoactive-inotropic treatment. CONCLUSION VISmax is an objective measure of hemodynamic/cardiovascular support that was directly associated with mortality in extremely premature ELBW infants. The VISmax represents an important step towards neonatal precision medicine and risk stratification of extremely premature ELBW infants.
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Affiliation(s)
- Khyzer B. Aziz
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Orlyn C. Lavilla
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville, Florida,Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Allison C. Lure
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Daniel Gipson
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Diomel de la Cruz
- Department of Pediatrics, University of Florida, Gainesville, FL, USA.
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11
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Ruoss JL, Bazacliu C, Russell JT, de la Cruz D, Li N, Gurka MJ, Filipp SL, Polin RA, Triplett EW, Neu J. Routine Early Antibiotic Use in SymptOmatic Preterm Neonates: A Pilot Randomized Controlled Trial. J Pediatr 2021; 229:294-298.e3. [PMID: 32979383 PMCID: PMC8958904 DOI: 10.1016/j.jpeds.2020.09.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 02/04/2023]
Abstract
We enrolled 98 infants (gestational age <33 weeks) in a pilot randomized trial of antibiotics vs no antibiotics; 55 were randomized (lower maternal infectious risk; symptoms expected for gestation). Adverse events did not differ significantly between the randomization arms. This trial establishes a framework for a larger multicentered trial.
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Affiliation(s)
- J. Lauren Ruoss
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Catalina Bazacliu
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Jordan T. Russell
- Department of Microbiology and Cell Science, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, FL, USA
| | - Diomel de la Cruz
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Nan Li
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Matthew J. Gurka
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Stephanie L. Filipp
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Richard A. Polin
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Eric W. Triplett
- Department of Microbiology and Cell Science, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, FL, USA
| | - Josef Neu
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
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12
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Russell JT, Lauren Ruoss J, de la Cruz D, Li N, Bazacliu C, Patton L, McKinley KL, Garrett TJ, Polin RA, Triplett EW, Neu J. Antibiotics and the developing intestinal microbiome, metabolome and inflammatory environment in a randomized trial of preterm infants. Sci Rep 2021; 11:1943. [PMID: 33479274 PMCID: PMC7820285 DOI: 10.1038/s41598-021-80982-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 01/01/2021] [Indexed: 01/29/2023] Open
Abstract
Antibiotic use in neonates can have detrimental effects on the developing gut microbiome, increasing the risk of morbidity. A majority of preterm neonates receive antibiotics after birth without clear evidence to guide this practice. Here microbiome, metabolomic, and immune marker results from the routine early antibiotic use in symptomatic preterm Neonates (REASON) study are presented. The REASON study is the first trial to randomize symptomatic preterm neonates to receive or not receive antibiotics in the first 48 h after birth. Using 16S rRNA sequencing of stool samples collected longitudinally for 91 neonates, the effect of such antibiotic use on microbiome diversity is assessed. The results illustrate that type of nutrition shapes the early infant gut microbiome. By integrating data for the gut microbiome, stool metabolites, stool immune markers, and inferred metabolic pathways, an association was discovered between Veillonella and the neurotransmitter gamma-aminobutyric acid (GABA). These results suggest early antibiotic use may impact the gut-brain axis with the potential for consequences in early life development, a finding that needs to be validated in a larger cohort.Trial Registration This project is registered at clinicaltrials.gov under the name "Antibiotic 'Dysbiosis' in Preterm Infants" with trial number NCT02784821.
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Affiliation(s)
- Jordan T. Russell
- grid.15276.370000 0004 1936 8091Department of Microbiology and Cell Science, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, FL USA
| | - J. Lauren Ruoss
- grid.15276.370000 0004 1936 8091Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL USA
| | - Diomel de la Cruz
- grid.15276.370000 0004 1936 8091Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL USA
| | - Nan Li
- grid.15276.370000 0004 1936 8091Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL USA
| | - Catalina Bazacliu
- grid.15276.370000 0004 1936 8091Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL USA
| | - Laura Patton
- grid.15276.370000 0004 1936 8091Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL USA
| | - Kelley Lobean McKinley
- grid.15276.370000 0004 1936 8091Department of Microbiology and Cell Science, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, FL USA
| | - Timothy J. Garrett
- grid.15276.370000 0004 1936 8091Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL USA
| | - Richard A. Polin
- grid.21729.3f0000000419368729Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY USA
| | - Eric W. Triplett
- grid.15276.370000 0004 1936 8091Department of Microbiology and Cell Science, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, FL USA
| | - Josef Neu
- grid.15276.370000 0004 1936 8091Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL USA
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13
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Patton L, Li N, Garrett TJ, Ruoss JL, Russell JT, de la Cruz D, Bazacliu C, Polin RA, Triplett EW, Neu J. Antibiotics Effects on the Fecal Metabolome in Preterm Infants. Metabolites 2020; 10:E331. [PMID: 32823682 PMCID: PMC7464203 DOI: 10.3390/metabo10080331] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/05/2020] [Accepted: 08/10/2020] [Indexed: 12/30/2022] Open
Abstract
Within a randomized prospective pilot study of preterm infants born at less than 33 weeks' gestation, weekly fecal samples from 19 infants were collected and metabolomic analysis was performed. The objective was to evaluate for differences in fecal metabolites in infants exposed to antibiotics vs. not exposed to antibiotics in the first 48 h after birth. Metabolomics analysis was performed on 123 stool samples. Significant differences were seen in the antibiotics vs. no antibiotics groups, including pathways related to vitamin biosynthesis, bile acids, amino acid metabolism, and neurotransmitters. Early antibiotic exposure in preterm infants may alter metabolites in the intestinal tract of preterm infants. Broader multi-omic studies that address mechanisms will guide more prudent antibiotic use in this population.
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Affiliation(s)
- Laura Patton
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL 32610-0296, USA; (L.P.); (N.L.); (J.L.R.); (D.d.l.C.); (C.B.)
| | - Nan Li
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL 32610-0296, USA; (L.P.); (N.L.); (J.L.R.); (D.d.l.C.); (C.B.)
| | - Timothy J. Garrett
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA;
| | - J. Lauren Ruoss
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL 32610-0296, USA; (L.P.); (N.L.); (J.L.R.); (D.d.l.C.); (C.B.)
| | - Jordan T. Russell
- Department of Microbiology and Cell Science, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, FL 32603, USA; (J.T.R.); (E.W.T.)
| | - Diomel de la Cruz
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL 32610-0296, USA; (L.P.); (N.L.); (J.L.R.); (D.d.l.C.); (C.B.)
| | - Catalina Bazacliu
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL 32610-0296, USA; (L.P.); (N.L.); (J.L.R.); (D.d.l.C.); (C.B.)
| | - Richard A. Polin
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA;
| | - Eric W. Triplett
- Department of Microbiology and Cell Science, Institute of Food and Agricultural Sciences, University of Florida, Gainesville, FL 32603, USA; (J.T.R.); (E.W.T.)
| | - Josef Neu
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, FL 32610-0296, USA; (L.P.); (N.L.); (J.L.R.); (D.d.l.C.); (C.B.)
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14
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Leaderer D, Laconi N, Brown J, Ruoss JL, de la Cruz D, Chan A, Taylor JA. Neonatal Dieulafoy Lesion Requiring Massive Transfusion Protocol and Surgical Intervention. Neonatology 2020; 117:380-383. [PMID: 32325456 DOI: 10.1159/000506704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/21/2020] [Indexed: 11/19/2022]
Abstract
Neonatal Dieulafoy lesion is a rare but severe condition that can be life-threatening if not intervened upon in a timely fashion. In the general population, the majority of lesions are successfully treated with endoscopic or angiographic intervention. Surgery is usually reserved for cases that fail endoscopic or angiographic intervention. We present a case of neonatal Dieulafoy lesion that occurred less than 24 h after delivery with hematemesis. The patient required large volume resuscitation and massive transfusion of blood products for acute blood loss. The lesion was successfully treated with surgical ligation after a failed attempt at endoscopic intervention.
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Affiliation(s)
- Derek Leaderer
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Nicholas Laconi
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Jamie Brown
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - J Lauren Ruoss
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Diomel de la Cruz
- Division of Neonatology, Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Albert Chan
- Division of Gastroenterology, Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Janice A Taylor
- Department of Surgery, University of Florida, Gainesville, Florida, USA,
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15
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Abstract
Enteral feeding and composition play a chief role in the prevention and treatment of necrotizing enterocolitis (NEC). In the face of decades of research on this fatal disease, the exact mechanism of disease is still poorly understood. There is established evidence that providing mother's own breast milk and standardization of feeding regimens leads to a decreased risk for NEC. More recent studies have focused on the provision of donor human milk or an exclusive human milk diet in the endeavor to prevent NEC while still maintaining adequate nutrition to the premature infant. There is growing literature on the provision of specific human milk components and its effect on the incidence of NEC.
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Affiliation(s)
- Diomel de la Cruz
- University of Florida, Department of Pediatrics, Division of Neonatology, Gainesville, FL, USA.
| | - Catalina Bazacliu
- University of Florida, Department of Pediatrics, Division of Neonatology, Gainesville, FL, USA
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16
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Lenfestey MW, de la Cruz D, Neu J. Food Protein-Induced Enterocolitis Instead of Necrotizing Enterocolitis? A Neonatal Intensive Care Unit Case Series. J Pediatr 2018; 200:270-273. [PMID: 29803301 DOI: 10.1016/j.jpeds.2018.04.048] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 04/13/2018] [Accepted: 04/20/2018] [Indexed: 12/19/2022]
Abstract
Necrotizing enterocolitis is an important disease in infants born premature. However, other disease entities present with similar signs and symptoms. This series reviews 5 atypical cases initially diagnosed as necrotizing enterocolitis that may be more consistent with food protein-induced enterocolitis. Food protein-induced enterocolitis may be underdiagnosed in this population.
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Affiliation(s)
- Mary W Lenfestey
- Division of Pediatric Gastroenterology, University of Florida, Gainesville, FL
| | - Diomel de la Cruz
- Department of Pediatrics, Neonatology, University of Florida, Gainesville, FL
| | - Josef Neu
- Department of Pediatrics, Neonatology, University of Florida, Gainesville, FL.
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