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Aly S, Qattea I, Kattea MO, Aly HZ. Neonatal outcomes in preterm infants with severe congenital heart disease: a national cohort analysis. Front Pediatr 2024; 12:1326804. [PMID: 38725988 PMCID: PMC11079131 DOI: 10.3389/fped.2024.1326804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/01/2024] [Indexed: 05/12/2024] Open
Abstract
Background Prematurity and congenital heart disease (CHD) are the leading causes of neonatal mortality and morbidity. Limited data are available about the outcomes of premature infants with severe CHD. Methods We queried The National Inpatient Database using ICD-10 codes for premature patients (<37 weeks) with severe CHD from 2016 to 2020. Severe CHDs were grouped into three categories: A. left-sided lesions with impaired systemic output, B. Cyanotic CHD, and C. Shunt lesions with pulmonary overcirculation. Patients with isolated atrial or ventricular septal defects and patent ductus arteriosus were excluded. We also excluded patients with chromosomal abnormalities and major congenital anomalies. Patients' demographics, clinical characteristics, and outcomes were evaluated by comparing premature infants with vs. without CHD adjusting for gestational age (GA), birth weight, and gender. Results A total of 27710 (1.5%) out of 1,798,245 premature infants had severe CHD. This included 27%, 58%, and 15% in groups A, B, and C respectively. The incidence of severe CHD was highest between 25 and 28 weeks of gestation and decreased significantly with increasing GA up to 36 weeks (p < 0.001). Premature infants with severe CHD had a significantly higher incidence of neonatal morbidities including necrotizing enterocolitis (NEC) [OR = 4.88 (4.51-5.27)], interventricular hemorrhage [OR = 6.22 (5.57-6.95)], periventricular leukomalacia [OR = 3.21 (2.84-3.64)] and bronchopulmonary dysplasia [OR = 8.26 (7.50-10.06) compared to preterm infants of similar GA without CHD. Shunt lesions had the highest incidence of NEC (8.5%) compared to 5.3% in cyanotic CHD and 3.7% in left-sided lesions (p < 0.001). Mortality was significantly higher in premature infants with CHD compared to control [11.6% vs. 2.5%, p < 0.001]. Shunt lesions had significantly higher mortality (11.0%) compared to those with left-sided lesions (8.3%) and cyanotic CHD (6.4%), p < 0.001. Conclusion Premature infants with severe CHD are at high risk of neonatal morbidity and mortality. Morbidity remains increased across all GA groups and in all CHD categories. This significant risk of adverse outcomes is important to acknowledge when managing this patient population and when counseling their families. Future research is needed to examine the impact of specific rather than categorized congenital heart defects on neonatal outcomes.
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Affiliation(s)
- Safwat Aly
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Ibrahim Qattea
- Department of Pediatrics, Nassau University Medical Center, East Meadow, NY, United States
| | - Mohammad O. Kattea
- Department of Pediatrics, Nassau University Medical Center, East Meadow, NY, United States
| | - Hany Z. Aly
- Department of Neonatology, Cleveland Clinic, Cleveland, OH, United States
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Weis VG, Cruz-Diaz N, Rauh JL, Ellison MA, Yamaleyeva LM, Welch CD, Zeller KA, Weis JA. Photoacoustic Imaging as a Novel Non-invasive Biomarker to Assess Intestinal Tissue Oxygenation and Motility in Neonatal Rats. J Pediatr Surg 2024; 59:528-536. [PMID: 37858392 PMCID: PMC10922103 DOI: 10.1016/j.jpedsurg.2023.09.034] [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: 06/29/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Within the premature infant intestine, oxygenation and motility play key physiological roles in healthy development and disease such as necrotizing enterocolitis. To date, there are limited techniques to reliably assess these physiological functions that are also clinically feasible for critically ill infants. To address this clinical need, we hypothesized that photoacoustic imaging (PAI) can provide non-invasive assessment of intestinal tissue oxygenation and motility to characterize intestinal physiology and health. METHODS Ultrasound and photoacoustic images were acquired in 2-day and 4-day old neonatal rats. For PAI assessment of intestinal tissue oxygenation, an inspired gas challenge was performed using hypoxic, normoxic, and hyperoxic inspired oxygen (FiO2). For intestinal motility, oral administration of ICG contrast agent was used to compare control animals to an experimental model of loperamide-induced intestinal motility inhibition. RESULTS PAI demonstrated progressive increases in oxygen saturation (sO2) as FiO2 increased, while the pattern of oxygen localization remained relatively consistent in both 2-day and 4-day old neonatal rats. Analysis of intraluminal ICG contrast enhanced PAI images yielded a map of the motility index in control and loperamide treated rats. From PAI analysis, loperamide significantly inhibited intestinal motility, with a 32.6% decrease in intestinal motility index scores in 4-day old rats. CONCLUSION These data establish the feasibility and application of PAI to non-invasively and quantitatively measure intestinal tissue oxygenation and motility. This proof-of-concept study is an important first step in developing and optimizing photoacoustic imaging to provide valuable insight into intestinal health and disease to improve the care of premature infants.
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Affiliation(s)
- Victoria G Weis
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, NC, USA
| | - Nildris Cruz-Diaz
- Department of Surgery-Hypertension, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Cardiovascular Sciences Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jessica L Rauh
- Department of General Surgery, Section of Pediatric Surgery, Atrium Health Wake Forest Baptist, Winston Salem, NC, USA
| | - Maryssa A Ellison
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, NC, USA
| | - Liliya M Yamaleyeva
- Department of Surgery-Hypertension, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Cardiovascular Sciences Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Cherrie D Welch
- Division of Neonatology, Department of Pediatrics, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Kristen A Zeller
- Department of General Surgery, Section of Pediatric Surgery, Atrium Health Wake Forest Baptist, Winston Salem, NC, USA
| | - Jared A Weis
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Comprehensive Cancer Center, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA; School of Biomedical Engineering and Sciences, Virginia Tech-Wake Forest University, Blacksburg, VA, USA.
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Pradhan S, Strohacker C, Schachtner S, Palm K, Trauth A, Gao Z, Marcuccio E. Management of Hematochezia in Infants with Congenital Heart Disease Admitted to the Acute Care Cardiology Unit: A Multicenter Retrospective Pilot Study. J Pediatr 2024; 269:113992. [PMID: 38417782 DOI: 10.1016/j.jpeds.2024.113992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE To assess the evaluation and prevalence of benign hematochezia (BH) vs necrotizing enterocolitis (NEC) in infants with congenital heart disease (CHD) <6 months old admitted to the acute care cardiology unit. STUDY DESIGN This was a multicenter retrospective review of patient characteristics and evaluation of all hematochezia events in patients with CHD <6 months admitted to acute care cardiology unit at 3 high-volume tertiary care centers from February 2019 to January 2021. NEC was defined by the Bell staging criteria. Patients with gastrointestinal disorders were excluded. RESULTS In total, 180 hematochezia events occurred in 121 patients; 42 patients had more than 1 event. In total, 61% of affected patients had single-ventricle physiology (38% hypoplastic left heart syndrome). Median age and weight at hematochezia were 38 days (IQR 24, 79) and 3.7 kg (IQR 3.2, 4.4). In total, 77% of hematochezia events were BH, and 23% were NEC. There were no surgical interventions for NEC or deaths from NEC. Those with NEC were significantly younger (34 vs 56 days, P < .01) and smaller (3.7 vs 4 kg, P < .01). Single-ventricle physiology was significantly associated with NEC. Initial bloodwork and diagnostic imaging at each center were assessed. There was no significant difference in white blood cell count or C-reactive protein in those with NEC compared with BH. Blood culture results were all negative. CONCLUSIONS The majority of infants with CHD with hematochezia have BH over NEC, although single-ventricle and surgical patients remain at greater risk. Infants <45 days are more vulnerable for developing NEC. Bloodwork was noncontributory in the identification of cardiac NEC. Expansion to a prospective study to develop a treatment algorithm is important to avoid overtreatment.
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Affiliation(s)
- Sarah Pradhan
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, Temerty School of Medicine, University of Toronto, Toronto, ON, Canada; Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Courtney Strohacker
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Susan Schachtner
- The University of Pennsylvania Perelman School of Medicine and the Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kelsey Palm
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Amiee Trauth
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Zhiqian Gao
- Heart Institute Research Core, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Elisa Marcuccio
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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Kerstein JS, Klepper CM, Finnan EG, Mills KI. Nutrition for critically ill children with congenital heart disease. Nutr Clin Pract 2023; 38 Suppl 2:S158-S173. [PMID: 37721463 DOI: 10.1002/ncp.11046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 09/19/2023] Open
Abstract
Children with congenital heart disease often require admission to the cardiac intensive care unit at some point in their lives, either after elective surgical or catheter-based procedures or during times of acute critical illness. Meeting both the macronutrient and micronutrient needs of children in the cardiac intensive care unit requires complex decision-making when considering gastrointestinal perfusion, vasoactive support, and fluid balance goals. Although nutrition guidelines exist for critically ill children, these cannot always be extrapolated to children with congenital heart disease. Children with congenital heart disease may also suffer unique circumstances, such as chylothoraces, heart failure, and the need for mechanical circulatory support, which greatly impact nutrition delivery. Guidelines for neonates and children with heart disease continue to be developed. We provide a synthesized narrative review of current literature and considerations for nutrition evaluation and management of critically ill children with congenital heart disease.
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Affiliation(s)
- Jason S Kerstein
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusettes, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
| | - Corie M Klepper
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusettes, USA
| | - Emily G Finnan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusettes, USA
| | - Kimberly I Mills
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusettes, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
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5
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Zaikova EK, Kaplina AV, Petrova NA, Pervunina TM, Kostareva AA, Kalinina OV. SIGIRR gene variants in term newborns with congenital heart defects and necrotizing enterocolitis. Ann Pediatr Cardiol 2023; 16:337-344. [PMID: 38766461 PMCID: PMC11098289 DOI: 10.4103/apc.apc_30_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/28/2023] [Accepted: 08/03/2023] [Indexed: 05/22/2024] Open
Abstract
Background Necrotizing enterocolitis (NEC) is a common gastrointestinal emergency among neonates which is characterized by acute intestinal inflammation and necrosis. The main risk factors for NEC are prematurity, low birth weight, and some preexisting health conditions such as congenital heart defects (CHDs). Investigation of the potential genetic predisposition to NEC is a promising approach that might provide new insights into its pathogenesis. One of the most important proteins that play a significant role in the pathogenesis of NEC is Toll-like receptor 4 (TLR4) which recognizes lipopolysaccharide found in Gram-negative bacteria. In intestinal epithelial cells, a protein encoded by the SIGIRR gene is a major inhibitor of TLR4 signaling. A few SIGIRR variants, including rare p.Y168X and p.S80Y, have already been identified in preterm infants with NEC, but their pathogenic significance remains unclear. This study aimed to investigate the spectrum of SIGIRR genetic variants in term newborns with CHD and to assess their potential association with NEC. Methods and Results A total of 93 term newborns with critical CHD were enrolled in this study, 33 of them developed NEC. SIGIRR genetic variants were determined by Sanger sequencing of all exons. In total, eight SIGIRR genetic variants were identified, two of which were found only in newborns with NEC (P = 0.12). The rare missense p.S80Y (rs117739035) variant in exon 4 was found in two infants with NEC stage IIA. Two infants with NEC stage III and stage IB carried a novel duplication c. 102_121dup (rs552367848) variant in exon 10 that has not been previously associated with any clinical phenotype. Conclusions The presence of both variants only in neonates who developed NEC, together with earlier published data, may suggest their potential contribution to the risk of developing NEC in term infants with CHD and allow planning larger cohort studies to clarify their relevance.
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Affiliation(s)
- Ekaterina Konstantinovna Zaikova
- World-Class Research Centre for Personalized Medicine, Almazov National Medical Research Centre, Research Laboratory of Autoimmune and Autoinflammatory Diseases, St. Petersburg, Russia
| | - Aleksandra Vladimirovna Kaplina
- Almazov National Medical Research Centre, Research Laboratory of Physiology and Diseases of Newborns, St. Petersburg, Russia
| | - Natalia Aleksandrovna Petrova
- Almazov National Medical Research Centre, Research Laboratory of Physiology and Diseases of Newborns, St. Petersburg, Russia
| | | | | | - Olga Viktorovna Kalinina
- Almazov National Medical Research Centre, Research Laboratory of Physiology and Diseases of Newborns, St. Petersburg, Russia
- Department of Laboratory Medicine and Genetics, Institution of Medical Education, Almazov National Medical Research Centre, St. Petersburg, Russia
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Kataria-Hale J, Gollins L, Bonagurio K, Blanco C, Hair AB. Nutrition for Infants with Congenital Heart Disease. Clin Perinatol 2023; 50:699-713. [PMID: 37536773 DOI: 10.1016/j.clp.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Perioperative malnutrition in infants with congenital heart disease can lead to significant postnatal growth failure and poor short- and long-term outcomes. A standardized approach to nutrition is needed for the neonatal congenital heart disease population, taking into consideration the type of cardiac lesion, the preoperative and postoperative period, and prematurity. Early enteral feeding is beneficial and should be paired with parenteral nutrition to meet the fluid and nutrient needs of the infant.
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Affiliation(s)
- Jasmeet Kataria-Hale
- Department of Pediatrics, Division of Neonatology, Mission Hospital, 509 Biltmore Avenue, Asheville, NC 28801, USA
| | - Laura Gollins
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, MC: A5590, Houston, TX 77030, USA
| | - Krista Bonagurio
- University of Texas Health Science Center, San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Cynthia Blanco
- University of Texas Health Science Center, San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Amy B Hair
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, MC: A5590, Houston, TX 77030, USA.
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7
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Weis VG, Cruz-Diaz N, Rauh JL, Ellison MA, Yamaleyeva LM, Welch CD, Zeller KA, Weis JA. Photoacoustic Imaging as a Novel Non-Invasive Biomarker to Assess Intestinal Tissue Oxygenation and Motility in Neonatal Rats. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.06.27.545971. [PMID: 37425813 PMCID: PMC10326976 DOI: 10.1101/2023.06.27.545971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Background Within the premature infant intestine, oxygenation and motility play key physiological roles in healthy development and disease such as necrotizing enterocolitis. To date, there are limited techniques to reliably assess these physiological functions that are also clinically feasible for critically ill infants. To address this clinical need, we hypothesized that photoacoustic imaging (PAI) can provide non-invasive assessment of intestinal tissue oxygenation and motility to characterize intestinal physiology and health. Methods Ultrasound and photoacoustic images were acquired in 2-day and 4-day old neonatal rats. For PAI assessment of intestinal tissue oxygenation, an inspired gas challenge was performed using hypoxic, normoxic, and hyperoxic inspired oxygen (FiO2). For intestinal motility, oral administration of ICG contrast agent was used to compare control animals to an experimental model of loperamide-induced intestinal motility inhibition. Results PAI demonstrated progressive increases in oxygen saturation (sO2) as FiO2 increased, while the pattern of oxygen localization remained relatively consistent in both 2-day and 4-day old neonatal rats. Analysis of intraluminal ICG contrast enhanced PAI images yielded a map of the motility index in control and loperamide treated rats. From PAI analysis, loperamide significantly inhibited intestinal motility, with a 32.6% decrease in intestinal motility index scores in 4-day old rats. Conclusion These data establish the feasibility and application of PAI to non-invasively and quantitatively measure intestinal tissue oxygenation and motility. This proof-of-concept study is an important first step in developing and optimizing photoacoustic imaging to provide valuable insight into intestinal health and disease to improve the care of premature infants. Highlights Intestinal tissue oxygenation and intestinal motility are important biomarkers of intestinal physiology in health and disease of premature infants.This proof-of-concept preclinical rat study is the first to report application of photoacoustic imaging for the neonatal intestine.Photoacoustic imaging is demonstrated as a promising non-invasive diagnostic imaging method for quantifying intestinal tissue oxygenation and intestinal motility in premature infants. Graphical abstract
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Ghosh S, Balachandran R, Neema PK, Kottayil BP, Bhaskaran R, Sudhakar A, Krishna Kumar R. Impact of Type of Enteral Feeds on Early Postoperative Outcomes After Congenital Heart Surgery in Neonates and Young Infants: A Single Center Experience in a Limited Resource Environment. World J Pediatr Congenit Heart Surg 2023; 14:300-306. [PMID: 36823964 DOI: 10.1177/21501351231154207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Background: Breast milk is known to prevent infections and is recommended for enteral feeding of infants after congenital heart surgery (CHS). During the Covid-19 pandemic, expressed breast milk (EBM) was not always available; hence, feeding after CHS was maintained with EBM or infant formula (IF) or both; we evaluated the impact of enteral feed type on early postoperative outcomes after CHS. Methods: In a prospective observational study, consecutive neonates and infants <4 months undergoing CHS were divided into EBM, IF, or EBM+IF groups; incidences of postoperative infections, ventilation duration, intensive care unit (ICU) stay, and mortality were studied. Results: Among 270 patients; 90 (33.3%) received EBM, 89 (32.9%) received IF, and 91 (33.7%) received EBM+IF. IF group had more neonates (78.7%[IF] vs 42.2%[EBM] and 52.7%[EBM+IF], P < 0.001) and greater surgical complexity. Postoperative infections were 9 (10.0%) in EBM; 23 (25.8%) in IF; and 14 (15.4%) in EBM+IF (P = .016). IF group (OR 2.58 [1.05-6.38], P = .040), absence of preoperative feeding (OR 6.97 [1.06-45.97], P = .040), and increase in cardiopulmonary bypass time (OR 1.005 [1.001-1.010], P = .027) were associated with postoperative infection. Ventilation duration in hours was 26 (18-47.5) in EBM; 47 (28-54.5) in IF; and 40 (17.5-67) in EBM+IF (P = .004). ICU stay in days was 4 (3-7) in EBM; 6 (5-9) in IF; and 5 (3-9) in EBM+IF (P = .001). Mortality did not differ (P = .556). Conclusion: IF group had a greater proportion of neonates with higher surgical complexity. Patients who received EBM after CHS had fewer postoperative infections and better postoperative outcomes compared to those receiving IF or EBM+IF.
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Affiliation(s)
- Sreepurna Ghosh
- Department of Cardiac Anesthesia, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Rakhi Balachandran
- Department of Cardiac Anesthesia, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Praveen Kumar Neema
- Department of Cardiac Anesthesia, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Brijesh P Kottayil
- Department of Cardiovascular and Thoracic Surgery, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Renjitha Bhaskaran
- Department of Biostatistics, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Abish Sudhakar
- Department of Pediatric Cardiology, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - R Krishna Kumar
- Department of Pediatric Cardiology, 29286Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
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Bell D, Suna J, Marathe SP, Perumal G, Betts KS, Venugopal P, Alphonso N. Feeding Neonates and Infants Prior to Surgery for Congenital Heart Defects: Systematic Review and Meta-Analysis. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121856. [PMID: 36553299 PMCID: PMC9776823 DOI: 10.3390/children9121856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/19/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Necrotising enterocolitis (NEC) is a significant cause of mortality and morbidity in neonates requiring cardiac surgery. Feeding practices vary significantly across institutions and remain controversial. We conducted a systematic review of the literature and a meta-analysis to identify associations between feeding practices and necrotising enterocolitis. METHODS This study was carried out in accordance with the PRISMA guidelines. A literature search was performed in November 2022 using the Cochrane Central Register, Embase, and Pubmed. Two investigators then independently retrieved eligible manuscripts considered suitable for inclusion. Data extracted included gestational age, birth weight, sex, nature of congenital heart lesion, type of operation performed, time on ventilator, ICU stay, hospital stay, post-operative feeding strategy, and complications. The methodological quality was assessed using the Downs and Black score for all randomised control trials and observational studies. RESULTS The initial search yielded 92 studies. After removing duplicates, there were 85 abstracts remaining. After excluding ineligible studies, 8 studies were included for the meta-analysis. There was no significant risk of NEC associated with pre-operative feeding [OR = 1.22 (95% CI 0.77,1.92)] or umbilical artery catheter placement [OR = 0.91 (95% CI 0.44, 1.89)] and neither outcome exhibited heterogeneity [I2 = 8% and 0%, respectively]. There was a significant association between HLHS and NEC [OR = 2.56 (95% CI 1.56, 4.19)] as well as prematurity and NEC [OR 3.34 (95% CI 1.94, 5.75)] and neither outcome exhibited heterogeneity [I2 = 0% and 0%, respectively]. CONCLUSIONS There was no association between NEC and pre-operative feeding status in neonates awaiting cardiac surgery. Pre-operative feeding status was not associated with prolonged hospital stay or need for tube assisted feeding at discharge. HLHS and prematurity were associated with increased incidence of NEC.
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Affiliation(s)
- Douglas Bell
- The Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Jessica Suna
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital, Brisbane, QLD 4101, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland, Brisbane, QLD 4072, Australia
- Children’s Health Research Centre, University of Queensland, Brisbane, QLD 4101, Australia
| | - Supreet P. Marathe
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital, Brisbane, QLD 4101, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland, Brisbane, QLD 4072, Australia
- Children’s Health Research Centre, University of Queensland, Brisbane, QLD 4101, Australia
| | | | - Kim S. Betts
- Children’s Health Research Centre, University of Queensland, Brisbane, QLD 4101, Australia
| | - Prem Venugopal
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital, Brisbane, QLD 4101, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland, Brisbane, QLD 4072, Australia
- Children’s Health Research Centre, University of Queensland, Brisbane, QLD 4101, Australia
| | - Nelson Alphonso
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital, Brisbane, QLD 4101, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland, Brisbane, QLD 4072, Australia
- Children’s Health Research Centre, University of Queensland, Brisbane, QLD 4101, Australia
- Correspondence: ; Tel.: +61-7-3068-3486
| | - QPCR Group
- QPCR Collaborators: Janelle Johnson, Tom R Karl, Children’s Health Research Centre, University of Queensland, Brisbane, QLD 4101, Australia
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Stewart DL, Elsayed Y, Fraga MV, Coley BD, Annam A, Milla SS. Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes. Pediatrics 2022; 150:190110. [PMID: 37154781 DOI: 10.1542/peds.2022-060053] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/29/2022] Open
Abstract
Point-of-care ultrasonography (POCUS) refers to the use of portable imaging performed by the provider clinician at the bedside for diagnostic, therapeutic, and procedural purposes. POCUS could be considered an extension of the physical examination but not a substitute for diagnostic imaging. Use of POCUS in emergency situations can be lifesaving in the NICU if performed in a timely fashion for cardiac tamponade, pleural effusions, pneumothorax, etc, with potential for enhancing quality of care and improving outcomes.
In the past 2 decades, POCUS has gained significant acceptance in clinical medicine in many parts of the world and in many subspecialties. Formal accredited training and certification programs are available for neonatology trainees as well as for many other subspecialties in Canada, Australia, and New Zealand. Although no formal training program or certification is available to neonatologists in Europe, POCUS is widely available to providers in NICUs. A formal institutional POCUS fellowship is now available in Canada. In the United States, many clinicians have the skills to perform POCUS and have incorporated it in their daily clinical practice. However, appropriate equipment remains limited, and many barriers exist to POCUS program implementation.
Recently, the first international evidence-based POCUS guidelines for use in neonatology and pediatric critical care were published. Considering the potential benefits, a recent national survey of neonatologists confirmed that the majority of clinicians were inclined to adopt POCUS in their clinical practice if the barriers could be resolved.
This technical report describes many potential POCUS applications in the NICU for diagnostic and procedural purposes.
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Affiliation(s)
- Dan L Stewart
- Department of Pediatrics and International Pediatrics, Norton Children's Neonatology Affiliated with University of Louisville School of Medicine, Louisville, Kentucky
| | - Yasser Elsayed
- Department of Pediatrics and Child Health, Max Rady College of Medicine, University of Manitoba-Canada, Health Sciences Centre-Winnipeg, Winnipeg, Manitoba, Canada
| | - María V Fraga
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian D Coley
- Departments of Radiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Aparna Annam
- Departments of Radiology and Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Vascular Anomalies Center, Aurora, Colorado
| | - Sarah Sarvis Milla
- Departments of Radiology and Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
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11
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Mills KI, Kim JH, Fogg K, Goldshtrom N, Graham EM, Kataria-Hale J, Osborne SW, Figueroa M. Nutritional Considerations for the Neonate With Congenital Heart Disease. Pediatrics 2022; 150:189883. [PMID: 36317972 DOI: 10.1542/peds.2022-056415g] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
The importance of nutrition in managing critically ill infants with congenital heart disease (CHD) is foundational to optimizing short- and long-term health outcomes. Growth failure and malnutrition are common in infants with CHD. The etiology of growth failure in this population is often multifactorial and may be related to altered metabolic demands, compromised blood flow to the intestine leading to nutrient malabsorption, cellular hypoxia, inadequate energy intake, and poor oral-motor skills. A dearth of high-quality studies and gaps in previously published guidelines have led to wide variability in nutrition practices that are locally driven. This review provides recommendations from the nutrition subgroup of the Neonatal Cardiac Care Collaborative for best evidence-based practices in the provision of nutritional support in infants with CHD. The review of evidence and recommendations focused on 6 predefined areas of clinical care for a target population of infants <6 months with CHD admitted to the ICU or inpatient ward. These areas include energy needs, nutrient requirements, enteral nutrition, feeding practice, parenteral nutrition, and outcomes. Future progress will be directed at quality improvement efforts to optimize perioperative nutrition management with an increasing emphasis on individualized care based on nutritional status, cardiorespiratory physiology, state of illness, and other vulnerabilities.
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Affiliation(s)
- Kimberly I Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts.,Contributed equally as co-first authors
| | - Jae H Kim
- Division of Neonatology, Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio.,Contributed equally as co-first authors
| | - Kristi Fogg
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Nimrod Goldshtrom
- Division of Neonatology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York
| | - Eric M Graham
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Jasmeet Kataria-Hale
- Division of Neonatology, Department of Pediatrics, Mission Children's Hospital, Asheville, North Carolina
| | - Scott W Osborne
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mayte Figueroa
- Division of Cardiology and Critical Care, Department of Pediatrics, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri
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12
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Reddy RK, McVadon DH, Zyblewski SC, Rajab TK, Diego E, Southgate WM, Fogg KL, Costello JM. Prematurity and Congenital Heart Disease: A Contemporary Review. Neoreviews 2022; 23:e472-e485. [PMID: 35773510 DOI: 10.1542/neo.23-7-e472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Congenital heart disease (CHD) is the most commonly reported birth defect in newborns. Neonates with CHD are more likely to be born prematurely, and a higher proportion of preterm neonates have CHD than their term counterparts. The implications of preterm birth on the cardiac and noncardiac organ systems are vast and require special management considerations. The feasibility of surgical interventions in preterm neonates is frequently limited by patient size and delicacy of immature cardiac tissues. Thus, special care must be taken when considering the appropriate timing and type of cardiac intervention. Despite improvements in neonatal cardiac surgical outcomes, preterm and early term gestational ages and low birthweight remain important risk factors for in-hospital mortality. Understanding the risks of early delivery of neonates with prenatally diagnosed CHD may help guide perioperative management in neonates who are born preterm. In this review, we will describe the risks and benefits of early delivery, postnatal cardiac and noncardiac evaluation and management, surgical considerations, overall outcomes, and future directions regarding optimization of perinatal evaluation and management of fetuses and preterm and early term neonates with CHD.
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Affiliation(s)
- Reshma K Reddy
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Deani H McVadon
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Sinai C Zyblewski
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Taufiek K Rajab
- Division of Pediatric Cardiothoracic Surgery, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Ellen Diego
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - W Michael Southgate
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Kristi L Fogg
- Department of Food and Nutrition, Sodexo, Medical University of South Carolina, Charleston, SC
| | - John M Costello
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
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13
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Pham M, Dean P, McCulloch M, Vergales J. Association Between Pulsatility Index and the Development of Necrotizing Enterocolitis in Infants with Congenital Heart Disease. Pediatr Cardiol 2022; 43:1156-1162. [PMID: 35192021 DOI: 10.1007/s00246-022-02839-7] [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] [Received: 12/22/2021] [Accepted: 01/27/2022] [Indexed: 11/26/2022]
Abstract
Infants with congenital heart disease are known to have higher rates of necrotizing enterocolitis (NEC) which is associated with poorer outcomes. Although the etiology is recognized as distinct from the premature neonatal population, there is not a universal consensus regarding etiology or specific risk factors. In this retrospective single-institution case-control study, we assessed whether aortic pulsatility index (PI) as detected via ultrasound might be associated with NEC in neonates undergoing cardiac surgical repair within the first month of life. The study identified 30 participants who developed NEC and 50 matched controls. Baseline demographic and surgical characteristics were similar between groups. Patients who developed NEC had higher mortality (26% vs 4%, p < 0.01). Standard PI and the modified pulsatility values were calculated manually and underwent logistic regression. The median log PI of the NEC cohort was higher compared to the lowest control PI (0.68 vs 0.48, p = 0.03); the median log PI of the NEC cohort was significantly lower than the highest PI of the control cohort (0.61 vs 0.98, p = 0.05). The modified pulsatility index demonstrated similar trends with the median log MODPI of the NEC cohort being significantly greater than that of the control cohort (3.9 vs. 3.1, p = 0.01). Infants with congenital heart disease who develop NEC have a higher PI and MODPI when compared to the lowest control PI. This suggests that infants with a higher baseline PI may be at increased risk for developing NEC.
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Affiliation(s)
- Michael Pham
- Department of Pediatric Cardiology, University of Virginia, Charlottesville, VA, USA.
| | - Peter Dean
- Department of Pediatric Cardiology, University of Virginia, Charlottesville, VA, USA
| | - Michael McCulloch
- Department of Pediatric Cardiology, University of Virginia, Charlottesville, VA, USA
| | - Jeffrey Vergales
- Department of Pediatric Cardiology, University of Virginia, Charlottesville, VA, USA
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14
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Gunasekaran A, Devette C, Levin S, Chaaban H. Biomarkers of Necrotizing Enterocolitis: The Search Continues. Clin Perinatol 2022; 49:181-194. [PMID: 35210000 DOI: 10.1016/j.clp.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Necrotizing enterocolitis (NEC) is the most common gastrointestinal (GI) emergency in the neonatal intensive care unit. Despite advances in medical care, mortality and morbidity from NEC have not changed. This is likely due to the lack of a clear understanding of this multifactorial disease, and reliable biomarkers for accurate diagnosis of NEC. Currently, the diagnosis of NEC is made by a combination of nonspecific clinical signs, symptoms, and radiological findings. Though biomarkers have been studied extensively, none offer an acceptable sensitivity or specificity to be used. This review will focus on the available literature on biomarkers for preterm NEC, acknowledging the limitations in studies including the variability of inclusion criteria, and most importantly, the lack of gold standard case definition for NEC.
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Affiliation(s)
- Aarthi Gunasekaran
- Neonatal-Perinatal Medicine, The University of Oklahoma Health Sciences Center, 1200 N Everett Drive, Oklahoma City, OK 73104, USA
| | - Christa Devette
- Department of Pediatrics, The University of Oklahoma Health Sciences Center, 1200 N Everett Drive, Oklahoma City, OK 73104, USA.
| | - Samuel Levin
- Neonatal-Perinatal Medicine, The University of Oklahoma Health Sciences Center, 1200 N Everett Drive, Oklahoma City, OK 73104, USA.
| | - Hala Chaaban
- Neonatal-Perinatal Medicine, The University of Oklahoma Health Sciences Center, 1200 N Everett Drive, Oklahoma City, OK 73104, USA.
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15
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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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16
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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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17
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Han N, Pan Z, Liu G, Yang R, Yujing B. Hypoxia: The "Invisible Pusher" of Gut Microbiota. Front Microbiol 2021; 12:690600. [PMID: 34367091 PMCID: PMC8339470 DOI: 10.3389/fmicb.2021.690600] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 06/25/2021] [Indexed: 12/20/2022] Open
Abstract
Oxygen is important to the human body. Cell survival and operations depend on oxygen. When the body becomes hypoxic, it affects the organs, tissues and cells and can cause irreversible damage. Hypoxia can occur under various conditions, including external environmental hypoxia and internal hypoxia. The gut microbiota plays different roles under hypoxic conditions, and its products and metabolites interact with susceptible tissues. This review was conducted to elucidate the complex relationship between hypoxia and the gut microbiota under different conditions. We describe the changes of intestinal microbiota under different hypoxic conditions: external environment and internal environment. For external environment, altitude was the mayor cause induced hypoxia. With the increase of altitude, hypoxia will become more serious, and meanwhile gut microbiota also changed obviously. Body internal environment also became hypoxia because of some diseases (such as cancer, neonatal necrotizing enterocolitis, even COVID-19). In addition to the disease itself, this hypoxia can also lead to changes of gut microbiota. The relationship between hypoxia and the gut microbiota are discussed under these conditions.
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Affiliation(s)
- Ni Han
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Zhiyuan Pan
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Guangwei Liu
- Key Laboratory of Cell Proliferation and Regulation Biology, Ministry of Education, Institute of Cell Biology, College of Life Sciences, Beijing Normal University, Beijing, China
| | - Ruifu Yang
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
| | - Bi Yujing
- State Key Laboratory of Pathogen and Biosecurity, Beijing Institute of Microbiology and Epidemiology, Beijing, China
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18
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Cibulskis CC, Maheshwari A, Rao R, Mathur AM. Anemia of prematurity: how low is too low? J Perinatol 2021; 41:1244-1257. [PMID: 33664467 DOI: 10.1038/s41372-021-00992-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/20/2021] [Accepted: 02/04/2021] [Indexed: 12/11/2022]
Abstract
Anemia of prematurity (AOP) is a common condition with a well-described chronology, nadir hemoglobin levels, and timeline of recovery. However, the underlying pathophysiology and impact of prolonged exposure of the developing infant to low levels of hemoglobin remains unclear. Phlebotomy losses exacerbate the gradual decline of hemoglobin levels which is insidious in presentation, often without any clinical signs. Progressive anemia in preterm infants is associated with poor weight gain, inability to take oral feeds, tachycardia and exacerbation of apneic, and bradycardic events. There remains a lack of consensus on treatment thresholds for RBC transfusion which vary considerably. This review elaborates on the current state of the problem, its implication for the premature infant including association with subphysiologic cerebral tissue oxygenation, necrotizing enterocolitis, and retinopathy of prematurity. It outlines the impact of prophylaxis and treatment of anemia of prematurity and offers suggestions on improving monitoring and management of the condition.
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Affiliation(s)
- Catherine C Cibulskis
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Akhil Maheshwari
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rakesh Rao
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Amit M Mathur
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA.
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19
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Abstract
Cardiac critical care has become an increasingly complex subspecialty, involving multiple subspecialists to support patients with congenital heart disease. This requires understanding of their physiology and the impact of medical interventions. The purpose of this article is to provide a concise review of the current strategies utilized by cardiac intensivists to optimize outcomes for this vulnerable patient population, with the goal of broadening the knowledge of other members of the multi-disciplinary team.
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20
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Abstract
Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.
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21
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Martini S, Beghetti I, Annunziata M, Aceti A, Galletti S, Ragni L, Donti A, Corvaglia L. Enteral Nutrition in Term Infants with Congenital Heart Disease: Knowledge Gaps and Future Directions to Improve Clinical Practice. Nutrients 2021; 13:nu13030932. [PMID: 33805775 PMCID: PMC8002077 DOI: 10.3390/nu13030932] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 03/09/2021] [Indexed: 12/18/2022] Open
Abstract
Optimal nutrition is essential to improve short- and long-term outcomes in newborns with congenital heart disease (CHD). Nevertheless, several issues on nutritional management and concerns about the potential risk of complications related to enteral feeding exist. This narrative review aims to summarize and discuss the available literature on enteral feeding in term infants with CHD. A wide variability in feeding management exists worldwide. Emerging approaches to improve nutritional status and outcomes in infants with CHD include: implementation of a standardized enteral feeding protocol, both preoperative and postoperative, clearly defining time of initiation and advancement of enteral feeds, reasons to withhold, and definitions of feeding intolerance; early minimal enteral feeding; enteral feeding in stable term infants on hemodynamic support; evaluation of enteral feeding in term infants with umbilical arterial catheters and during prostaglandin infusion; assessment and support of oro-motor skills; and promotion and support of breastfeeding and provision of mother's own milk or donor milk when mother's own milk is not available. As evidence from term infants is scarce, available observations and recommendations partially rely on studies in preterm infants. Thus, well-designed studies assessing standardized clinically relevant outcomes are needed to provide robust evidence and shared recommendations and practices.
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Affiliation(s)
- Silvia Martini
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
| | - Isadora Beghetti
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
| | - Mariarosaria Annunziata
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
| | - Arianna Aceti
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Correspondence: ; Tel./Fax: +39-051-342754
| | - Silvia Galletti
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Luca Ragni
- Pediatric Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.R.); (A.D.)
| | - Andrea Donti
- Pediatric Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.R.); (A.D.)
| | - Luigi Corvaglia
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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22
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Simpson J, Brasher MI, Arnold J, Endom E, Doughty CB. Simulation of an Atypical Presentation of Necrotizing Enterocolitis in the Emergency Department. Cureus 2021; 13:e12604. [PMID: 33585094 PMCID: PMC7872491 DOI: 10.7759/cureus.12604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/07/2021] [Indexed: 11/05/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is a gastrointestinal emergency most commonly seen in premature infants, but equally important to recognize in term infants. Early diagnosis and management is critical to achieving optimal patient outcomes. This report outlines a simulation of the challenging scenario of a term infant presenting to the emergency center with NEC as a result of bacteremia and sepsis due to a urinary tract infection (UTI). This simulation can be used for teaching different levels of learners including novice, intermediate, and advanced. It focuses on the presentation, diagnosis, and emergent management of NEC, and additionally incorporates Pediatric Advanced Life Support (PALS) for more advanced learners.
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Affiliation(s)
- Jennifer Simpson
- Pediatric Emergency Medicine, Baylor College of Medicine, Houston, USA
| | - Maya I Brasher
- Neonatal and Perinatal Medicine, University of Texas Health Science Center at Houston, Houston, USA
| | - Jennifer Arnold
- Neonatal Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, USA
| | - Erin Endom
- Pediatric Emergency Medicine, Baylor College of Medicine, Houston, USA
| | - Cara B Doughty
- Pediatric Emergency Medicine, Baylor College of Medicine, Houston, USA
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23
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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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24
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The Relationship Between Preoperative Feeding Exposures and Postoperative Outcomes in Infants With Congenital Heart Disease. Pediatr Crit Care Med 2021; 22:e91-e98. [PMID: 33009358 DOI: 10.1097/pcc.0000000000002540] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the association of preoperative risk factors and postoperative outcomes in infants with complex congenital heart disease. DESIGN Single-center retrospective cohort study. SETTING Neonatal ICU and cardiovascular ICU. PATIENTS Infants of all gestational ages, born at Texas Children's Hospital between 2010 and 2016, with complex congenital heart disease requiring intervention prior to discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 399 patients were enrolled in the study. Preoperative risk factors included feeding, type of feeding, feeding route, and cardiac lesion. Postoperative outcomes included necrotizing enterocolitis, hospital length of stay, and days to full feeds. The occurrence rate of postoperative necrotizing enterocolitis (all stages) was 8%. Preoperative feeding, type of feeding, feeding route, and cardiac lesion were not associated with higher odds of postoperative necrotizing enterocolitis. Cardiac lesions with ductal-dependent systemic blood flow were associated with a hospital length of stay of 19.6 days longer than those with ductal-dependent pulmonary blood flow (p < 0.001) and 2.9 days longer to reach full feeds than those with ductal-dependent pulmonary blood flow (p < 0.001), after controlling for prematurity. Nasogastric feeding route preoperatively was associated with a length of stay of 29.8 days longer than those fed by mouth (p < 0.001) and 2.4 days longer to achieve full feeds (p < 0.001), after controlling for prematurity and cardiac lesion. Preoperative diet itself was not associated with significant change in length of stay or days to reach full feeds. CONCLUSIONS Although cardiac lesions with ductal-dependent systemic blood flow are considered high risk and may increase length of stay and days to achieve full feeds, they are not associated with a higher risk of postoperative necrotizing enterocolitis. Nasogastric route is not associated with a significantly higher risk of necrotizing enterocolitis, but longer length of stay and days to reach full feeds. These findings challenge our perioperative management strategies in caring for these infants, as they may incur more hospital costs and resources without significant medical benefit.
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Song WS, Kim CY, Lee BS, Kim EAR, Kim KS, Jung E. Morbidity and Mortality of Very Low Birth Weight Infants with Congenital Heart Disease. Korean Circ J 2020; 50:1113-1123. [PMID: 33258320 PMCID: PMC7707980 DOI: 10.4070/kcj.2020.0135] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES This study aimed to provide morbidity and mortality information on very low birth weight (VLBW) infants with congenital heart disease (CHD-VLBWs). METHODS The study used a 10-year cohort of VLBW infants from a single institution. CHD was classified according to International Classification of Diseases, Version 9, Clinical Modification. Mortality and neonatal outcomes were assessed by comparing the CHD-VLBWs with gestational age- and birth weight-matched controls. RESULTS The prevalence of CHD-VLBWs was 7.5% (79/1,050), mean gestational age was 31.1±3.2 weeks, and mean birth weight was 1,126.2±268.3 g; 50.6% of the infants were small for the gestational age. The CHD-VLBWs more commonly had bronchopulmonary dysplasia (BPD), and the longer they were exposed to oxygen, the more frequently they developed BPD. Those with cyanotic heart disease developed severe BPD more frequently. Necrotizing enterocolitis (NEC) occurred frequently in the CHD-VLBWs and was not associated with their feeding patterns. CHD-VLBWs had a higher mortality rate; prematurity-related diseases were the leading cause of death before surgery, while heart-related problems were the leading cause of death after surgery. We found no significant difference in mortality from prematurity-related disease between the CHD-VLBWs and controls. In the subgroup analysis of CHD, the cyanotic CHD group had a higher incidence of BPD and higher mortality rate than the acyanotic CHD group. CONCLUSIONS CHD-VLBWs showed higher BPD, NEC, and mortality rates than those without CHD. There was also a higher incidence of BPD and mortality in VLBW infants with cyanotic CHD than in those with acyanotic CHD.
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Affiliation(s)
- Woo Sun Song
- Department of Pediatrics, University of Eulji College of Medicine, Daejeon, Korea
| | - Chae Young Kim
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Byong Sop Lee
- Division of Neonatology, Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Ellen Ai Rhan Kim
- Division of Neonatology, Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Ki Soo Kim
- Division of Neonatology, Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Euiseok Jung
- Division of Neonatology, Department of Pediatrics, Asan Medical Center Children's Hospital, Seoul, Korea.
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Tsintoni A, Dimitriou G, Karatza AA. Nutrition of neonates with congenital heart disease: existing evidence, conflicts and concerns. J Matern Fetal Neonatal Med 2020; 33:2487-2492. [PMID: 30608033 DOI: 10.1080/14767058.2018.1548602] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Congenital heart disease is one of the most of the groups of congenital anomalies with an incidence of about 1 per 100 live births. Almost one-third of these infants require some type of intervention, usually in the first year of life and increasingly often in the neonatal period. Innovative reparative and palliative surgical procedures and advanced medical support in the Neonatal Intensive Care Unit have significantly reduced the mortality related to congenital heart disease. Achieving survival is not the only target of clinicians for these patients. Appropriate growth, development, and improved quality of life are also very important. Growth failure is a very common problem of these children and nutritional support and management are a challenge for health care providers. Early intervention and identification of at-risk patients have the potential to decrease morbidity and mortality related to malnutrition.Aim/methods: The purpose of this article is to analyze the existing evidence and common concerns about perioperative and postdischarge nutritional management of neonates with congenital heart disease based on the special issues or complications that may arise. Furthermore, we reviewed the recent literature about current practices and proposed policies that could prevent malnutrition and improve the outcomes of neonates with congenital heart disease.Results/conclusion: A standardized institutional protocol and clear guidelines referring to feeding initiation, prompt estimation of caloric needs and provision of adequate and appropriate nutrient intake is likely to benefit these patients. Clear definitions for the nutritional approach in the setting of medical complications and close assessment of growth by pediatricians and specialized nutritionists are crucial for the long-term outlook and quality of life of these infants.
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Affiliation(s)
- Asimina Tsintoni
- Department of Pediatrics, NICU, University of Patras Medical School, Patras, Greece
| | - Gabriel Dimitriou
- Department of Pediatrics, NICU, University of Patras Medical School, Patras, Greece
| | - Ageliki A Karatza
- Department of Pediatrics, NICU, University of Patras Medical School, Patras, Greece
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Pammi M, De Plaen IG, Maheshwari A. Recent Advances in Necrotizing Enterocolitis Research: Strategies for Implementation in Clinical Practice. Clin Perinatol 2020; 47:383-397. [PMID: 32439118 PMCID: PMC7245582 DOI: 10.1016/j.clp.2020.02.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Necrotizing enterocolitis (NEC) is a complex inflammatory necrosis of the neonatal intestine, which is likely to require a multipronged approach for prevention and treatment. Despite identifying and defining NEC as a disease entity several decades back, no major progress has been made toward its early identification, treatment, or prevention. This article reviews the latest research strategies that are currently ongoing for early diagnosis and monitoring and prevention of the disease.
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Affiliation(s)
- Mohan Pammi
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Isabelle G. De Plaen
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Akhil Maheshwari
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Abstract
Neonates with CHD are at increased risk of developing necrotising enterocolitis due to mesenteric hypoperfusion. Necrotising enterocolitis results in repeated feed interruptions contributing to poor growth during the early post-operative phase. Poor weight gain and longer hospital stay are risk factors for death in neonates with CHD. Abdominal radiography is used as a diagnostic tool for necrotising enterocolitis; however, its utility is limited in the early stages of necrotising enterocolitis when pneumatosis intestinalis is absent. Calprotectin is a neutrophil activation biomarker, and elevated levels are evident in inflammatory diseases such as necrotising enterocolitis. The aim of this study was to determine whether there is a correlation between faecal calprotectin concentration and gut inflammation in neonates with CHD. This prospective single-centre study recruited newly diagnosed term patients with duct-dependent CHD between March 2018 and March 2019. Faecal calprotectin concentrations were measured in post-surgical patients using enzyme-linked immunosorbent assay methods. A total of 30 patients were included in the analysis. Calprotectin concentration for patients who developed necrotising enterocolitis was 3528 µg/g compared with 390 µg/g without, compared with 1339 µg/g in patients with suspected necrotising enterocolitis (p = 0.0001). Patients with suspected necrotising enterocolitis had a significantly longer length of hospital stay, on average 18 days longer compared to patients without necrotising enterocolitis (p = 0.03). Faecal calprotectin concentrations may reflect severity of gut inflammation in neonates with CHD. Suspected necrotising enterocolitis contributes to longer days nil by mouth and an increase in length of hospital stay.
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Necrotizing Enterocolitis and Associated Mortality in Neonates With Congenital Heart Disease: A Multi-Institutional Study. Pediatr Crit Care Med 2020; 21:228-234. [PMID: 31568264 DOI: 10.1097/pcc.0000000000002133] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE There are scarce data about the prevalence and mortality of necrotizing enterocolitis in neonates with congenital heart disease. The purpose of this study is to provide a multi-institutional description and comparison of the overall prevalence and mortality of necrotizing enterocolitis in neonates with congenital heart disease. DESIGN Retrospective multi-institutional study. SETTING The Pediatric Health Information System database. PATIENTS Neonates with congenital heart disease between 2004 and 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary study measure is the prevalence of necrotizing enterocolitis. Secondary measures include in-hospital mortality, hospital charges, ICU length of stay, hospital length of stay, and 30-day readmission. The prevalence of necrotizing enterocolitis was 3.7% (1,448/38,770) and varied significantly among different congenital heart disease diagnoses. The lowest prevalence of necrotizing enterocolitis was in transposition of the great arteries (n = 104, 2.1%). Compared with transposition of the great arteries, necrotizing enterocolitis occurred more frequently in neonates with hypoplastic left heart syndrome (odds ratio, 2.7; 95% CI, 2.1-3.3), truncus arteriosus (odds ratio, 2.6; 95% CI, 1.9-3.5), common ventricle (odds ratio, 2.1; 95% CI, 1.5-2.8), and aortic arch obstruction (odds ratio, 1.4; 95% CI, 1.1-1.7). Prematurity is a significant risk factor for necrotizing enterocolitis and for mortality in neonates with necrotizing enterocolitis, conferring varying risk by cardiac diagnosis. Unadjusted mortality associated with necrotizing enterocolitis was 24.4% (vs 11.8% in neonates without necrotizing enterocolitis; p < 0.001), and necrotizing enterocolitis increased the adjusted mortality in neonates with transposition of the great arteries (odds ratio, 2.5; 95% CI, 1.5-4.4), aortic arch obstruction (odds ratio, 1.8; 95% CI, 1.3-2.6), and tetralogy of Fallot (odds ratio, 1.6; 95% CI, 1.1-2.4). Necrotizing enterocolitis was associated with increased hospital charges (p < 0.0001), ICU length of stay (p = 0.001), and length of stay (p = 0.001). CONCLUSIONS The prevalence of necrotizing enterocolitis among neonates with congenital heart disease is 3.7% and is associated with increased in-hospital mortality, length of stay, and hospital charges. The prevalence and associated mortality of necrotizing enterocolitis in congenital heart disease vary among different heart defects.
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Klinke M, Wiskemann H, Bay B, Schäfer HJ, Pagerols Raluy L, Reinshagen K, Vincent D, Boettcher M. Cardiac and Inflammatory Necrotizing Enterocolitis in Newborns Are Not the Same Entity. Front Pediatr 2020; 8:593926. [PMID: 33490000 PMCID: PMC7815686 DOI: 10.3389/fped.2020.593926] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/14/2020] [Indexed: 12/26/2022] Open
Abstract
Background: Necrotizing enterocolitis (NEC) is an often-fatal neonatal disease involving intestinal hyperinflammation leading to necrosis. Despite ongoing research, (1) conflicting results and (2) comorbidities of NEC patients make early NEC detection challenging and may complicate therapy development. Most research suggests that NEC pathogenesis is multifactorial, involving a combination of (1) gut prematurity; (2) abnormal bacterial colonization; and (3) ischemia-reperfusion (I/R) injury. As neutrophil extracellular traps (NETs) partially mediate I/R injury and drive inflammation in NEC, we hypothesized that NETs contribute to NEC development; particularly in cardiac patients. Methods: A retrospective analysis of baseline characteristics, clinical signs, laboratory parameters, and imaging was conducted for surgically verified NEC cases over 10 years. Patients were stratified into two groups: (1) prior medically or surgically treated cardiac disease (cardiac NEC) and (2) no cardiac comorbidities (inflammatory NEC). Additionally, histology was reassessed for neutrophil activation and NETs formation. Results: A total of 110 patients (cNEC 43/110 vs. iNEC 67/110) were included in the study, with cNEC neonates being significantly older than iNEC neonates (p = 0.005). While no significant differences were found regarding clinical signs and imaging, laboratory parameters revealed that cNEC patients have significantly increased leucocyte (p = 0.024) and neutrophil (p < 0.001) counts. Both groups also differed in pH value (p = 0.011). Regarding histology: a non-significant increase in staining of myeloperoxidase within the cNEC group could be found in comparison to iNEC samples. Neutrophil elastase (p = 0.012) and citrullinated histone H3 stained (p = 0.041) slides showed a significant markup for neonates diagnosed with cNEC in comparison to neonates with iNEC. Conclusion: The study shows that many standardized methods for diagnosing NEC are rather unspecific. However, differing leucocyte and neutrophil concentrations for iNEC and cNEC may indicate a different pathogenesis and may aid in diagnosis. As we propose that iNEC is grounded rather in sepsis and neutropenia, while cNEC primarily involves I/R injuries, which involves neutrophilia and NETs formation, it is plausible that I/R injury due to interventions for cardiac comorbidities results in pronounced neutrophil activation followed by a hyperinflammation reaction and NEC. However, prospective studies are necessary to validate these findings and to determine the accuracy of the potential diagnostic parameters.
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Affiliation(s)
- Michaela Klinke
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanna Wiskemann
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Bay
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Jörg Schäfer
- Department of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laia Pagerols Raluy
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Deirdre Vincent
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Grizelj R, Sindičić Dessardo N, Bulić K, Luetić T, Mikulić D, Antabak A, Sjekavica I, Alduk AM, Konosić S, Režek Tomašić K, Ćaleta T, Pleško S, Šarić D, Vuković J. Successful separation of xypho-omphalopagus conjoined twins with extrauterine twin-twin transfusion syndrome: a case report. Croat Med J 2019. [PMID: 31483115 PMCID: PMC6734570 DOI: 10.3325/cmj.2019.60.301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Conjoined twining is a rare medical phenomenon, with an overall prevalence of 1.47 per 100 000 births. This report describes a successful separation of xypho-omphalopagus conjoined twins complicated by unbalanced blood shunting through the porto-systemic anastomoses within the shared liver parenchyma. Significant extrauterine twin-twin transfusion syndrome caused by unbalanced shunting is an extremely rare, and probably under-recognized, hemodynamic complication in conjoined twins necessitating urgent separation. Progressive deterioration with a poor outcome can be prevented if the condition is recognized in a timely manner.
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Affiliation(s)
- Ruža Grizelj
- Ruža Grizelj, Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Center Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia,
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Kataria-Hale J, Osborne SW, Hair A, Hagan J, Pammi M. Preoperative Feeds in Ductal-Dependent Cardiac Disease: A Systematic Review and Meta-analysis. Hosp Pediatr 2019; 9:998-1006. [PMID: 31744846 DOI: 10.1542/hpeds.2019-0111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CONTEXT Our aim for this review is to determine if preoperative feeds in neonates with ductal-dependent congenital heart disease are harmful or beneficial. OBJECTIVES To summarize current evidence for preoperative feeding in neonates with ductal-dependent congenital heart disease. DATA SOURCES We used the following databases: Medline, Embase, and Cochrane Central Register of Controlled Trials. STUDY SELECTION We included observational studies in which the following outcomes were addressed: necrotizing enterocolitis (NEC), hospital length of stay (LOS), time to achieve full postoperative enteral feeding, and feeding intolerance. DATA EXTRACTION Two reviewers independently screened each study for eligibility and extracted data. Methodologic quality was assessed by using a standardized item bank, and certainty of evidence for each outcome was assessed by using Grading of Recommendations Assessment, Development and Evaluation criteria. RESULTS Five retrospective cohort studies were eligible for inclusion, for which risk of bias was significant. When comparing neonates who received preoperative feeds with those who did not, there was no significant difference in NEC (pooled odds ratio = 1.09 [95% confidence interval 0.06-21.00; P = .95]; 3 studies, 6807 participants, very low certainty evidence), hospital LOS (mean of 14 days for those not fed versus 9.9 days for those fed preoperatively; P < .01; 1 study, 57 participants, very low certainty evidence), or feeding intolerance (odds ratio = 2.014 [95% confidence interval 0.079-51.703; P = .67]; 1 study, 56 participants, very low certainty evidence). No data were available for the outcome time to achieve full postoperative enteral feeding. All studies were observational and had small sample sizes. CONCLUSIONS There is insufficient evidence to suggest that preoperative enteral feeds in patients with ductal-dependent cardiac lesions adversely influence the rate of NEC, LOS, or feeding intolerance.
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Affiliation(s)
- Jasmeet Kataria-Hale
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Scott Webb Osborne
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Amy Hair
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Joseph Hagan
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mohan Pammi
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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Bubberman JM, van Zoonen A, Bruggink JLM, van der Heide M, Berger RMF, Bos AF, Kooi EMW, Hulscher JBF. Necrotizing Enterocolitis Associated with Congenital Heart Disease: a Different Entity? J Pediatr Surg 2019; 54:1755-1760. [PMID: 30635129 DOI: 10.1016/j.jpedsurg.2018.11.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/24/2018] [Accepted: 11/20/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) predominantly occurs in preterm infants (PT-NEC). In term neonates, NEC occurs more frequently when a congenital heart disease is present (CHDNEC). Our aim was to evaluate differences and similarities in disease characteristics of PT-NEC versus CHD-NEC. METHODS In this retrospective case-control study we identified all CHD infants who developed NEC Bell's stage ≥2 in our center from 2004 to 2014. We randomly selected (1:2 ratio) PT-NEC infants from the same period. Biochemical and clinical variables were retrieved from patient files. RESULTS We found 18 CHD-NEC infants and selected 36 PT-NEC infants (gestational age 28.3 [25-35.6] weeks vs. 38.6 [31.7-40.7] weeks). Postnatal age at onset was significantly lower in CHD-NEC patients (4 [2-24] vs. 11 [4-41] days, p < 0.001). Lowest pH levels were lower (7.21 [7.01-7.47] vs. 7.27 [6.68-7.39], p = 0.02), and highest CRP levels were higher (112.5 mg/L [5.0-425.0] vs. 66.0 [5.2-189.0], p = 0.05) in PT-NEC vs. CHD-NEC. Anatomic localisation of the disease differed: the colon was significantly more often involved in CHD-NEC versus PT-NEC (86% vs. 33%, p = 0.03). Mortality caused by NEC was not different (22% vs. 11%, p = 0.47). CONCLUSION While outcome of NEC in both groups is similar, the predominant NEC localisation differed between CHD-NEC and PT-NEC patients. This suggests that both variants of the disease have a different underlying pathophysiological mechanism that predisposes different intestinal regions to develop NEC. TYPE OF STUDY Retrospective Case-Control Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- J M Bubberman
- University Medical Center Groningen, Department of Surgery, Division of Paediatric Surgery, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - A van Zoonen
- University Medical Center Groningen, Department of Surgery, Division of Paediatric Surgery, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - J L M Bruggink
- University Medical Center Groningen, Department of Surgery, Division of Paediatric Surgery, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - M van der Heide
- University Medical Center Groningen, Department of Paediatrics, Division of Neonatology, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - R M F Berger
- University Medical Center Groningen, Department of Paediatrics, Division of Paediatric Cardiology, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - A F Bos
- University Medical Center Groningen, Department of Paediatrics, Division of Neonatology, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - E M W Kooi
- University Medical Center Groningen, Department of Paediatrics, Division of Neonatology, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands
| | - J B F Hulscher
- University Medical Center Groningen, Department of Surgery, Division of Paediatric Surgery, Hanzeplein 1, 9713, GZ, Groningen, The Netherlands.
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Callegari A, Tharakan SJ, Christmann M. Non–IgE-mediated gastrointestinal food-induced allergic disorders can mimic necrotizing enterocolitis in neonates with congenital heart diseases with left-ventricular outflow tract obstruction. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2019.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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The utility of guaiac stool testing in the detection of gastrointestinal complications in infants with critical congenital heart disease. Cardiol Young 2019; 29:655-659. [PMID: 31155016 DOI: 10.1017/s1047951119000659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Guaiac stool testing has been routinely used as a method to detect gastrointestinal complications in infants with critical congenital heart disease (CHD); however, the sensitivity and specificity have not been established. METHODS A retrospective chart review was performed investigating the presence of heme-positive stools and subsequent gastrointestinal complications as well as time to goal caloric intake and radiograph exposure. RESULTS The presence of heme-positive stools was not a statistically significant factor in patients with critical CHD that experienced gastrointestinal complications. Additionally, patients with heme-positive stools did undergo more abdominal X-rays than those with heme-negative stools. CONCLUSIONS The routine use of guaiac stool testing in infants with critical CHD is not a predictor of possible gastrointestinal complications and leads to more radiograph exposure for the patient. Close clinical monitoring can be used to evaluate feeding tolerance in infants with critical CHD.
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Bowker RM, Yan X, De Plaen IG. Intestinal microcirculation and necrotizing enterocolitis: The vascular endothelial growth factor system. Semin Fetal Neonatal Med 2018; 23:411-415. [PMID: 30213591 DOI: 10.1016/j.siny.2018.08.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Necrotizing enterocolitis (NEC), a leading cause of morbidity and mortality in preterm neonates, is a devastating disease characterized by intestinal tissue inflammation and necrosis. NEC pathogenesis is multifactorial but remains unclear. Translocation of bacteria and/or bacterial products across a weak intestinal barrier in the setting of impaired mucosal immunity leads to an exaggerated inflammatory response and secondary mucosal epithelial injury. In addition to prematurity, other risk factors for NEC include congenital heart disease, maternal pre-eclampsia with placental vascular insufficiency, severe anemia and blood transfusion - all conditions that predispose the intestine to ischemia. We recently found that maldevelopment of the intestinal microvasculature plays an important role in NEC pathogenesis. Here we review the evidence supporting a role for defective development of the intestinal mucosal microvasculature and perturbations of intestinal blood flow in NEC, emphasizing the importance of vascular endothelial growth factor (VEGF) and the VEGF receptor-2 signaling pathway.
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Affiliation(s)
- Rakhee M Bowker
- Section of Neonatology, Department of Pediatrics, Rush University Medical Center, Chicago, IL, USA
| | - Xiaocai Yan
- Division of Neonatology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Isabelle G De Plaen
- Division of Neonatology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA; Center for Intestinal and Liver Inflammation Research, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA.
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Suspected necrotising enterocolitis after surgery for CHD: an opportunity to improve practice and outcomes. Cardiol Young 2018; 28:639-646. [PMID: 29409546 DOI: 10.1017/s1047951117002815] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Infants with CHD are at increased risk of necrotising enterocolitis, which can interfere with the achievement of adequate nutrition and, ultimately, growth and development. Necrotising enterocolitis is classified by severity as suspected, confirmed, and advanced. We sought to quantify the incidence of all types of necrotising enterocolitis among infants who underwent surgery, with a particular focus on suspected necrotising enterocolitis. This is a retrospective review of all infants <6 months of age who underwent cardiac surgery during 2012 and 2013 at Children's Hospital Colorado. We examined the hospital course of 265 hospitalisations (n=251 patients) and found 18 patients (19 hospitalisations) with suspected necrotising enterocolitis and 16 patients (16 hospitalisations) with confirmed or advanced necrotising enterocolitis. Single-ventricle physiology, lower weight, and younger age were associated with necrotising enterocolitis. Patients with all types of necrotising enterocolitis experienced prolonged length of hospital stay. We found suspected necrotising enterocolitis to be as common as confirmed necrotising enterocolitis, and it frequently occurred early in the post-operative course. We speculate that suspected necrotising enterocolitis may often be overlooked in research owing to a reliance on billing codes. Nevertheless, suspected necrotising enterocolitis poses a substantial barrier to post-operative progression of the CHD patient, as does confirmed necrotising enterocolitis. Following the diagnosis of all types of necrotising enterocolitis, there was wide variability in practice patterns. In response to this variability, we developed care guidelines for the diagnosis and treatment of necrotising enterocolitis in this population.
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Furlong-Dillard J, Neary A, Marietta J, Jones C, Jeffers G, Gakenheimer L, Puchalski M, Eckauser A, Delgado-Corcoran C. Evaluating the Impact of a Feeding Protocol in Neonates before and after Biventricular Cardiac Surgery. Pediatr Qual Saf 2018; 3:e080. [PMID: 30229192 PMCID: PMC6132815 DOI: 10.1097/pq9.0000000000000080] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 04/02/2018] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Feeding difficulties and malnutrition are important challenges when caring for newborns with critical congenital heart disease (CCHD) without clear available guidelines for providers. This study describes the utilization of a feeding protocol with the focus on standardization, feeding modality, and total parenteral nutrition (TPN) utilization postoperatively. METHODS Patients included neonates with CCHD undergoing complex biventricular repair using cardiopulmonary bypass. Data were collected in 2013 preintervention and from 2015 to 2017 postintervention. The feeding protocol outlined guidelines for and postoperative use of TPN. Adverse outcomes data included rates of central line-associated bloodstream infections, necrotizing enterocolitis, chylothorax, and vocal cord dysfunction. Balance outcomes measured were weight for age Z-score at discharge, number of abdominal radiographs obtained, readmission within 90 days, and central venous line utilization. RESULTS We included a total of 121 neonates: 49 in the preintervention group and 72 in the postintervention group. The protocol standardized feeding practices in CCHD neonates undergoing surgery with improved compliance from 70% early in the study period to 90% at the end of the study. Infants were fed enterally more preoperatively (86% versus 67%; P = 0.023), reached a fluid goal sooner (63 hours versus 72 hours; P = 0.035), and postoperative duration of TPN usage was significantly shorter in the postintervention period (48 hours versus 62 hours; P = 0.041) with no increase in adverse outcome events or unintended consequences. CONCLUSIONS By implementing a feeding protocol, we reduced practice variation among providers, increased the number of patients fed enterally preoperatively and reduced postoperative use of TPN without increased complications.
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Affiliation(s)
- Jamie Furlong-Dillard
- From the Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Alaina Neary
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Jennifer Marietta
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Courtney Jones
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Grace Jeffers
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Lindsey Gakenheimer
- Pediatrics Residency, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Michael Puchalski
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Aaron Eckauser
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Claudia Delgado-Corcoran
- From the Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Lau PE, Cruz SM, Ocampo EC, Nuthakki S, Style CC, Lee TC, Wesson DE, Olutoye OO. Necrotizing enterocolitis in patients with congenital heart disease: A single center experience. J Pediatr Surg 2018. [PMID: 29526349 DOI: 10.1016/j.jpedsurg.2018.02.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the characteristics of patients with congenital heart disease (CHD) who developed necrotizing enterocolitis (NEC). METHODS A retrospective review of neonates with CHD at a tertiary care center between January 2006 and January 2016 was performed. Diagnosis of NEC was based on modified Bell's criteria. Patients were grouped by Risk Adjustment for Congenital Heart Surgery (RACHS-1) or by ductal-dependent (DD) lesions that require a patent ductus arteriosus to supply pulmonary or systemic circulation. RESULTS Of 1811 neonates with CHD, 3.4% (n=61) developed NEC. Eighteen (30%) of these required surgical management. The rate of NEC among DD patients was 5% (n=33/653), compared to 2.4% (n=28/1158) in the non-DD group (p=0.003). RACHS-1 score>2 had a higher rate of NEC 6.2% (41/658) compared to RACHS-1≤2 cases, 1.7% (20/1153) (p=0.005). DD patients and complex patients with RACHS-1>2 were more likely to develop NEC after cardiac surgery. Hypoplastic left heart syndrome patients had a rate of 9% (n=16/185). Surgical NEC was more prevalent in the non-DD group. Mortality was similar among groups. CONCLUSION CHD patients with ductal-dependent lesions or complex cases (RACHS-1 score>2) have higher rates of NEC than non-ductal-dependent patients or RACHS-1 score of 2 or less. Mortality is similar regardless of ductal dependence, but surgical NEC was more prevalent in non-DD patients. LEVEL OF EVIDENCE Level IIb.
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Affiliation(s)
- Patricio E Lau
- The Michael E. DeBakey Department of Surgery-Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Stephanie M Cruz
- The Michael E. DeBakey Department of Surgery-Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Elena C Ocampo
- Department of Pediatrics-Division of Cardiology, Baylor College of Medicine, Houston, TX, United States
| | - Sushma Nuthakki
- Department of Pediatrics-Division of Neonatology, Baylor College of Medicine, Houston, TX, United States
| | - Candace C Style
- The Michael E. DeBakey Department of Surgery-Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Timothy C Lee
- The Michael E. DeBakey Department of Surgery-Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX, United States
| | - David E Wesson
- The Michael E. DeBakey Department of Surgery-Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Oluyinka O Olutoye
- The Michael E. DeBakey Department of Surgery-Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX, United States.
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Necrotizing Enterocolitis in Infants with Hypoplastic Left Heart Syndrome Following Stage 1 Palliation or Heart Transplant. Pediatr Cardiol 2018; 39:774-785. [PMID: 29392349 DOI: 10.1007/s00246-018-1820-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 01/20/2018] [Indexed: 10/18/2022]
Abstract
Previous studies of necrotizing enterocolitis (NEC) among infants with hypoplastic left heart syndrome (HLHS) were conducted in single centers or had small sample sizes. This study aimed to determine the mortality rate and the risk factors for NEC among infants with HLHS who were discharged over a 10-year period (2004-2013) from 41 Pediatric Health Information System affiliated children's hospitals. Either stage 1 palliation and/or heart transplant were completed prior to patient's death or hospital discharge. We compared the characteristics of infants with HLHS who did not develop NEC and those who developed medical or surgical NEC and of patients who had medical vs. surgical NEC. The primary outcome was mortality over time and by birth weight category (low birth weight [LBW], birth weight < 2500 vs. ≥ 2500 g). Multivariable analyses were performed to identify the risk factors for developing NEC and for mortality among infants with HLHS. The study evaluated 5720 infants with HLHS including 349 patients (6.1%) with medical or surgical NEC. Fifty-two patients (0.9%) required laparotomy or percutaneous abdominal drainage. On univariable analysis, the overall mortality rate for infants who developed NEC was significantly higher than infants who did not develop NEC (23.5 vs. 13.9%, P < 0.001). On multivariable analysis, neither medical nor surgical NEC was a significant predictor of mortality in the study population. LBW infants were at higher risk for mortality in both the univariable and the multivariable models. Nevertheless, LBW did not significantly predispose infants with HLHS to develop NEC. Our results provide a national benchmark incidence of NEC, its risk factors, and outcomes among a large cohort of infants with HLHS and establish that NEC is not a significant risk factor for mortality in this population.
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Management of undernutrition and failure to thrive in children with congenital heart disease in low- and middle-income countries. Cardiol Young 2017; 27:S22-S30. [PMID: 29198259 DOI: 10.1017/s104795111700258x] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Poor growth with underweight for age, decreased length/height for age, and underweight-for-height are all relatively common in children with CHD. The underlying causes of this failure to thrive may be multifactorial, including innate growth potential, severity of cardiac disease, increased energy requirements, decreased nutritional intake, malabsorption, and poor utilisation of absorbed nutrition. These factors are particularly common and severe in low- and middle-income countries. Although nutrition should be carefully assessed in all patients, failure of growth is not a contraindication to surgical repair, and patients should receive surgical repair where indicated as soon as possible. Close attention should be paid to nutritional support - primarily enteral feeding, with particular use of breast milk in infancy - in the perioperative period and in the paediatric ICU. This nutritional support requires specific attention and allocation of resources, including appropriately skilled personnel. Thereafter, it is essential to monitor growth and development and to identify causes for failure to catch-up or grow appropriately.
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Scahill CJ, Graham EM, Atz AM, Bradley SM, Kavarana MN, Zyblewski SC. Preoperative Feeding Neonates With Cardiac Disease. World J Pediatr Congenit Heart Surg 2017; 8:62-68. [PMID: 28033074 DOI: 10.1177/2150135116668833] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The potential for necrotizing enterocolitis (NEC) in neonates requiring cardiac surgery has contributed largely to wide feeding practice variations and a hesitation to initiate enteral feeding during the preoperative period, specifically those patients with hypoplastic left heart syndrome. METHODS A retrospective chart review of neonates undergoing cardiac surgery at a single institution between July 2011 and July 2013 was performed. The primary objective of this study was to determine if preoperative feeding was associated with NEC in neonates requiring cardiac surgery. Univariable and multivariable analyses were performed to evaluate the relationship between preoperative feeding and NEC. Secondary outcomes including growth failure, total ventilator days, total length of stay, and tube-assisted feeds at discharge were analyzed. RESULTS One hundred thirty consecutive neonates who required cardiac surgery were included in the analysis. Preoperative feeding occurred in 61% (n = 79). The overall prevalence of NEC was 9% (12/130), including three neonates with surgical NEC. There was no difference in the prevalence of NEC between the preoperative feeding and nil per os (NPO) groups. Preoperative NPO status was associated with longer ventilator-dependent days ( P = .01) but was not associated with worsened growth failure, longer length of stay, or increased prevalence of tube-assisted feeds at discharge. CONCLUSION In this study cohort, preoperative feeding was associated with a low prevalence of NEC. Larger prospective studies evaluating the safety and benefits of preoperative feeding in cardiac neonates are warranted.
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Affiliation(s)
- Carly J Scahill
- 1 Department of Pediatrics, The Heart Institute, Children's Hospital Colorado, Aurora, CO, USA
| | - Eric M Graham
- 2 Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Andrew M Atz
- 2 Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Scott M Bradley
- 3 Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Minoo N Kavarana
- 3 Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Sinai C Zyblewski
- 2 Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
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Stanescu AL, Liszewski MC, Lee EY, Phillips GS. Neonatal Gastrointestinal Emergencies. Radiol Clin North Am 2017; 55:717-739. [DOI: 10.1016/j.rcl.2017.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
Necrotizing enterocolitis (NEC), a disease most commonly seen in preterm infants, often presents without warning and is associated with very high mortality and morbidity. Progress in the prevention and treatment of NEC has been slow. In this article, we will discuss some of the reasons as to why this progress has been slow. We will describe some of the factors that appear to be highly associated and important components in the pathophysiology of NEC. We will discuss the intestinal microbial environment of the fetus as well as the preterm infant and how interaction of dysbiosis with an immature gastrointestinal tract combined with dietary factors play a role in the pathogenesis of NEC. Testable hypotheses are discussed as well as how these may lead to not only a better understanding of the pathophysiology of the disease but also the preventative strategies.
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Affiliation(s)
- Josef Neu
- Section of Neonatology, Department of Pediatrics, University of Florida, 1600 SW Archer Rd # 2, Gainesville, FL 32610.
| | - Mohan Pammi
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
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Early hybrid approach and enteral feeding algorithm could reduce the incidence of necrotising enterocolitis in neonates with ductus-dependent systemic circulation. Cardiol Young 2017; 27:154-160. [PMID: 28281412 DOI: 10.1017/s1047951116000275] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The reported incidence of necrotising enterocolitis in neonates with complex CHD with ductus-dependent systemic circulation ranges from 6.8 to 13% despite surgical treatment; the overall mortality is between 25 and 97%. The incidence of gastrointestinal complications after hybrid palliation for neonates with ductus-dependent systemic circulation still has to be defined, but seems comparable with that following the Norwood procedure. METHODS We reviewed the incidence of gastrointestinal complications in a series of 42 consecutive neonates with ductus-dependent systemic circulation, who received early hybrid palliation associated with a standardised feeding protocol. RESULTS The median age and birth weight at the time of surgery were 3 days (with a range from 1 to 10 days) and 3.07 kg (with a range from 1.5 to 4.5 kg), respectively. The median ICU length of stay was 7 days (1-70 days), and the median hospital length of stay was 16 days (6-70 days). The median duration of mechanical ventilation was 3 days. Hospital mortality was 16% (7/42). In the postoperative period, 26% of patients were subjected to early extubation, and all of them received treatment with systemic vasodilatory agents. Feeding was started 6 hours after extubation according to a dedicated feeding protocol. After treatment, none of our patients experienced any grade of necrotising enterocolitis or major gastrointestinal adverse events. CONCLUSIONS Our experience indicates that the combination of an "early hybrid approach", systemic vasodilator therapy, and dedicated feeding protocol adherence could reduce the incidence of gastrointestinal complications in this group of neonates. Fast weaning from ventilatory support, which represents a part of our treatment strategy, could be associated with low incidence of necrotising enterocolitis.
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van der Laan ME, Mebius MJ, Roofthooft MTR, Bos AF, Berger RMF, Kooi EMW. Cerebral and Renal Oxygen Saturation Are Not Compromised in the Presence of Retrograde Blood Flow in either the Ascending or Descending Aorta in Term or Near-Term Infants with Left-Sided Obstructive Lesions. Neonatology 2017; 112:217-224. [PMID: 28704832 DOI: 10.1159/000473870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 03/30/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND In infants with left-sided obstructive lesions (LSOL), the presence of retrograde blood flow in either the ascending or descending aorta may lead to diminished cerebral and renal blood flow, respectively. OBJECTIVES Our aim was to compare cerebral and renal tissue oxygen saturation (rSO2) between infants with LSOL with antegrade and retrograde blood flow in the ascending aorta and with and without diastolic backflow in the descending aorta. METHODS Based on 2 echocardiograms, the study group was categorized according to the direction of blood flow in the ascending and descending aorta. We measured cerebral and renal rSO2 using near-infrared spectroscopy and calculated fractional tissue oxygen extraction (FTOE). RESULTS Nineteen infants with LSOL, admitted to the NICU between 0 and 28 days after birth, were included. Infants with antegrade blood flow (n = 12) and infants with retrograde blood flow in the ascending aorta (n = 7) had similar cerebral rSO2 and FTOE during both echocardiograms. Only during the first echocardiogram, infants with retrograde blood flow in the ascending aorta had lower renal FTOE (0.14 vs. 0.32, p = 0.04) and tended to have higher renal rSO2 (80 vs. 65%, p = 0.09). The presence of diastolic backflow in the descending aorta was not associated with cerebral or renal rSO2 and FTOE during the first (n = 8) as well as the second echocardiogram (n = 10). CONCLUSIONS Retrograde blood flow in the ascending aorta was not associated with cerebral oxygenation, while diastolic backflow in the descending aorta was not associated with renal oxygenation in infants with LSOL.
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Affiliation(s)
- Michelle E van der Laan
- Division of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Slicker J, Sables-Baus S, Lambert LM, Peterson LE, Woodard FK, Ocampo EC. Perioperative Feeding Approaches in Single Ventricle Infants: A Survey of 46 Centers. CONGENIT HEART DIS 2016; 11:707-715. [DOI: 10.1111/chd.12390] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 11/27/2022]
Affiliation(s)
| | - Sharon Sables-Baus
- University of Colorado, College of Nursing; Children's Hospital Colorado; Aurora Colo USA
| | | | | | - Frances K. Woodard
- Medical University of South Carolina Children's Hospital; Charleston SC USA
| | - Elena C. Ocampo
- Baylor College of Medicine; Texas Children's Hospital; Houston Tex USA
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Karpen HE. Nutrition in the Cardiac Newborns: Evidence-based Nutrition Guidelines for Cardiac Newborns. Clin Perinatol 2016; 43:131-45. [PMID: 26876126 DOI: 10.1016/j.clp.2015.11.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Both protein and energy malnutrition are common in neonates and infants with congenital heart disease (CHD). Neonates with CHD are at increased risk of developing necrotizing enterocolitis (NEC), particularly the preterm population. Mortality in patients with CHD and NEC is higher than for either disease process alone. Standardized feeding protocols may affect both incidence of NEC and growth failure in infants with CHD. The roles of human milk and probiotics have not yet been explored in this patient population.
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Affiliation(s)
- Heidi E Karpen
- Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA.
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Hehir DA, Easley RB, Byrnes J. Noncardiac Challenges in the Cardiac ICU: Feeding, Growth and Gastrointestinal Complications, Anticoagulation, and Analgesia. World J Pediatr Congenit Heart Surg 2016; 7:199-209. [PMID: 26957404 DOI: 10.1177/2150135115615847] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Outcomes following cardiac intensive care unit (CICU) admission are influenced by many factors including initial cardiac diagnosis, surgical complexity, and burden of critical illness. Additionally, the presence of noncardiac issues may have a significant impact on outcomes and the patient experience during and following an intensive care unit stay. This review focuses on three common noncardiac areas which impact outcomes and patient experience in and beyond the CICU: feeding and growth, pain and analgesia, and anticoagulation. Growth failure and feeding dysfunction are commonly encountered in infants requiring cardiac surgery and have been associated with worse surgical and developmental outcomes. Recent studies most notably in the single ventricle population have demonstrated improved weight gain and outcomes when feeding protocols are implemented. Children undergoing cardiac surgery may experience both acute and chronic pain. Emerging research is investigating the impact of sedatives and analgesics on neurodevelopmental outcomes and quality of life. Improved pain scores and standardized management of pain and withdrawal may improve the patient experience and outcomes. Effective anticoagulation is a critical component of perioperative care but may be complicated by inflammation, multiorgan dysfunction, and patient factors. Advances in monitoring of anticoagulation and emerging therapies are reviewed.
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Affiliation(s)
- David A Hehir
- Nemours Cardiac Center, AI Dupont Hospital for Children, Thomas Jefferson Medical College, Philadelphia, PA, USA
| | - R Blaine Easley
- Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jonathan Byrnes
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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The association of congenital heart disease with necrotizing enterocolitis in preterm infants: a birth cohort study. J Perinatol 2015; 35:949-53. [PMID: 26248130 DOI: 10.1038/jp.2015.96] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 06/22/2015] [Accepted: 06/29/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To test the hypothesis that congenital heart disease (CHD) in preterm infants with severe CHD (cyanotic or left-sided obstructive lesions, or congestive heart failure) is independently associated with necrotizing enterocolitis (NEC, stage II or greater). STUDY DESIGN Single-institution retrospective birth cohort of preterm infants with gestational age 23(0/7) to 34(6/7) weeks delivered between 1 January 2002 and 31 December 2011, excluding infants who received comfort care. Patients were classified into severe CHD, mild CHD and control groups. RESULTS Among 4678 infants, 170 (3.6%) had CHD and 118 (2.5%) developed NEC. The risk for NEC increased with severe CHD (adjusted relative risk (RR)=3.72; 95% confidence interval (CI)=1.37 to 10.10) but not with mild CHD (RR=0.65; CI=0.27 to 1.55). CONCLUSION In this cohort, severe but not mild CHD was independently associated with increased risk for NEC. This finding, if confirmed by other studies, may help identify patients at risk for NEC.
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