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Chandel K, Jain R, Bhatia A, Saxena AK, Sodhi KS. Bleeding per rectum in pediatric population: A pictorial review. World J Clin Pediatr 2022; 11:270-288. [PMID: 35663002 PMCID: PMC9134156 DOI: 10.5409/wjcp.v11.i3.270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/09/2021] [Accepted: 03/17/2022] [Indexed: 02/06/2023] Open
Abstract
Bleeding per rectum in children can be seen in congenital as well as acquired conditions that may require medical or surgical management. The present review article is aimed to discuss the imaging findings of some common and uncommon causes of bleeding per rectum in children.
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Affiliation(s)
- Karamvir Chandel
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Rishabh Jain
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Anmol Bhatia
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Akshay Kumar Saxena
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Kushaljit Singh Sodhi
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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2
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Chandel K, Jain R, Bhatia A, Saxena AK, Sodhi KS. Bleeding per rectum in pediatric population: A pictorial review. World J Clin Pediatr 2022; 11:271-289. [DOI: 10.5409/wjcp.v11.i3.271] [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] [Indexed: 02/06/2023] Open
Abstract
Bleeding per rectum in children can be seen in congenital as well as acquired conditions that may require medical or surgical management. The present review article is aimed to discuss the imaging findings of some common and uncommon causes of bleeding per rectum in children.
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Affiliation(s)
- Karamvir Chandel
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Rishabh Jain
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Anmol Bhatia
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Akshay Kumar Saxena
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Kushaljit Singh Sodhi
- Department of Radio Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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3
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van der Heide M, Mebius MJ, Bos AF, Roofthooft MTR, Berger RMF, Hulscher JBF, Kooi EMW. Hypoxic/ischemic hits predispose to necrotizing enterocolitis in (near) term infants with congenital heart disease: a case control study. BMC Pediatr 2020; 20:553. [PMID: 33287760 PMCID: PMC7722324 DOI: 10.1186/s12887-020-02446-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 11/25/2020] [Indexed: 12/29/2022] Open
Abstract
Background Necrotizing enterocolitis (NEC) is a devastating disease that is relatively frequently diagnosed in term infants with congenital heart disease (CHD), compared with term infants without CHD, in whom NEC is rare. The exact pathogenesis of NEC in term infants with CHD is unknown, but it is hypothesized that ischemia of the intestines plays a pivotal role. We aimed to explore whether (near) term CHD infants, who develop NEC, exhibit more clinical signs of hypoxia/ischemia and low body perfusion directly after birth and during the first 48 hours after admission to the neonatal intensive care unit, when compared with (near) term CHD infants who did not develop NEC. Methods 956 infants with CHD born after ≥ 35 weeks of gestational age were retrospectively reviewed for this case-control study between January 1999 and February 2020. We included infants with radiographically confirmed pneumatosis intestinalis and controls matched by type of CHD. Seven infants were diagnosed with transposition of the great arteries, six with left and four with right ventricular outflow tract obstruction. Several parameters suggestive of (relative) hypoxia/ischemia were used for analyses. Results We included sixteen CHD infants with NEC and selected sixteen controls. There were no significant demographic differences between both groups. Apgar score at one and five minutes (median [IQR]) were lower in infants who developed NEC compared with control infants (8 [7-8]) vs. (9 [8-9], P = .011) and (8 [8-9]) vs. (9 [9-10], P = .009). A higher proportion of infants with NEC required respiratory support in the delivery room (11(69) vs. 2(13), P = .001). The (median [IQR]) diastolic blood pressure on the second day after admission (39 mmHg [34–42], vs. 43 mmHg [37–51], P = .112) and lowest (median [IQR]) pH in the 48 hours after admission (7.24 [7.17–7.35] vs. 7.38 ([7.27–7.43], P = .157) were not significantly lower in NEC infants but both demonstrated a similar direction towards (relative) hypoxia/ischemia in NEC infants. Conclusions Our clinical results support a hypoxic/ischemic pathophysiology of NEC in (near) term CHD infants, with lower Apgar scores, more respiratory support in the delivery room and a tendency towards a lower diastolic blood pressure and pH in CHD infants who develop NEC.
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Affiliation(s)
- Martin van der Heide
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - Mirthe J Mebius
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Arend F Bos
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Marcus T R Roofthooft
- Division of Pediatric Cardiology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - Rolf M F Berger
- Division of Pediatric Cardiology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - Jan B F Hulscher
- Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elisabeth M W Kooi
- Division of Neonatology, University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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Schömig CS, Robinson MÈ, von Oettingen JE. Treatment of congenital hypothyroidism in a newborn with malabsorption after subtotal ileum resection. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM170156. [PMID: 29497539 PMCID: PMC5825887 DOI: 10.1530/edm-17-0156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 01/26/2018] [Indexed: 12/17/2022] Open
Abstract
Congenital hypothyroidism requires prompt treatment to prevent adverse health outcomes. Poor intestinal levothyroxine absorption can complicate management. We present a case of a term female newborn with necrotizing enterocolitis (NEC) requiring subtotal ileum resection. Congenital hypothyroidism was diagnosed by newborn screening. Treatment was complicated by intestinal malabsorption of levothyroxine. Intravenous levothyroxine substitution restored euthyroidism and supraphysiologic PO doses subsequently maintained a euthyroid state. After several months, the required levothyroxine dose was weaned down to typical recommended dosing. In conclusion, small bowel resection secondary to NEC may lead to malabsorption of oral levothyroxine. An intravenous levothyroxine dose of approximately 50% typical PO dosing is effective in providing rapid normalization of free T4 and TSH. High PO doses may be required to maintain euthyroidism. Close thyroid function monitoring and immediate therapy adjustment are essential as the individual absorption may vary widely. Normal absorption levels may be regained due to adaption of the neonatal intestines.
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Affiliation(s)
| | - Marie-Ève Robinson
- Division of EndocrinologyDepartment of Pediatrics, McGill University Health Center, Montreal, Canada
| | - Julia E von Oettingen
- Division of EndocrinologyDepartment of Pediatrics, McGill University Health Center, Montreal, Canada
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McMahon AW, Wharton GT, Thornton P, De Leon DD. Octreotide use and safety in infants with hyperinsulinism. Pharmacoepidemiol Drug Saf 2016; 26:26-31. [PMID: 27910218 DOI: 10.1002/pds.4144] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 10/25/2016] [Accepted: 11/06/2016] [Indexed: 11/05/2022]
Abstract
BACKGROUND Octreotide is a synthetic peptide analog of naturally occurring somatostatin. Octreotide is used off-label in children <6 years of age for hyperinsulinism, chylothorax, and gastrointestinal bleeding. There is a lack of controlled data on efficacy or potential adverse events from this off-label use. METHODS Three pediatric hospitals participated in this study. Patients were hospitalized January 2007-December 2010 and administered octreotide for congenital hyperinsulinism (CHI) at least 1 day. Variables assessed included octreotide dosage, patient demographics, medical interventions, concomitant medicines, serious adverse events (SAEs) including necrotizing enterocolitis (NEC), and mortality. RESULTS The 103 patient sample had a median gestational age of 38 weeks. During the study period, two patients died: one from NEC and the other from cardiomyopathy/sepsis. There were 11 other SAEs in the 101 surviving patients. CONCLUSION This study highlights potential risks in administering octreotide off-label. This study, like several other published studies, has highlighted NEC in a full-term infant treated with octreotide. It is important to study the efficacy and the safety of octreotide for hyperinsulinism. In the interim, it might be prudent to prescribe octreotide in CHI neonates only in the absence of other risk factors for NEC. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Ann W McMahon
- Office of Pediatric Therapeutics, Food and Drug Administration, Silver Spring, MD, USA
| | - Gerold T Wharton
- Office of Pediatric Therapeutics, Food and Drug Administration, Silver Spring, MD, USA
| | | | - Diva D De Leon
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Moore SA, Nighot P, Reyes C, Rawat M, McKee J, Lemon D, Hanson J, Ma TY. Intestinal barrier dysfunction in human necrotizing enterocolitis. J Pediatr Surg 2016; 51:1907-1913. [PMID: 27720222 PMCID: PMC5245981 DOI: 10.1016/j.jpedsurg.2016.09.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 09/12/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND Intestinal barrier dysfunction has been implicated in necrotizing enterocolitis (NEC), but has not been directly measured in human NEC. METHODS Small intestines removed during surgery were immediately mounted in an Ussing chamber. mRNA expression of tight junction (TJ) proteins was measured with RT-PCR. RESULTS Fifteen infants were included, 5 with NEC and 10 with other diagnoses. Average transepithelial resistance (TER) was 11.61±1.65Ω/cm2 in NEC specimens, 23.36±1.48Ω/cm2 at resection margin, and 46.48±5.65Ω/cm2 in controls. Average flux of permeability marker mannitol was 0.23±0.06μMol/cm2 per h in NEC, 0.04±0.01 μMol/cm2 per h at resection margin, and 0.017±0.004 μMol/cm2 per h in control tissue (p<0.05). RT-PCR analysis showed marked decrease in mRNA expression of a TJ protein occludin in NEC affected tissue (p<0.03 vs. control). Additionally, mRNA expression of myosin light chain kinase (MLCK), an important regulator of TJ permeability, was increased in NEC specimens. CONCLUSION These studies show for the first time that NEC intestinal tissue have increased intestinal permeability, even at grossly healthy-appearing resection areas. The increase in intestinal permeability in NEC appeared to be related in part to a decrease in occludin and an increase in MLCK expression. LEVEL OF EVIDENCE Level 2.
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Affiliation(s)
- Sarah A. Moore
- Department of Surgery, University of New Mexico, MSC10 5610 1 UNM, Albuquerque, NM 87131
| | - Prashant Nighot
- Department of Internal Medicine, University of New Mexico, MSC10-5550, Albuquerque, NM 87131
| | - Cynthia Reyes
- Department of Surgery, University of New Mexico, MSC10 5610 1 UNM, Albuquerque, NM 87131.
| | - Manmeet Rawat
- Department of Internal Medicine, University of New Mexico, MSC10-5550, Albuquerque, NM 87131
| | - Jason McKee
- Department of Surgery, University of New Mexico, MSC10 5610 1 UNM, Albuquerque, NM 87131
| | - David Lemon
- Department of Surgery, University of New Mexico, MSC10 5610 1 UNM, Albuquerque, NM 87131
| | - Joshua Hanson
- Department of Pathology, University of New Mexico, MSC08-4640, Albuquerque, NM 87131
| | - Thomas Y. Ma
- Department of Internal Medicine, University of New Mexico, MSC10-5550, Albuquerque, NM 87131,Correspondence to: T. Ma, Division of Gastroenterology & Hepatology, University of New Mexico Health Sciences Center, Albuquerque, NM. Tel.: +1 505 272 4755. (T.Y. Ma)
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Hawkes CP, Adzick NS, Palladino AA, De León DD. Late Presentation of Fulminant Necrotizing Enterocolitis in a Child with Hyperinsulinism on Octreotide Therapy. Horm Res Paediatr 2016; 86:131-136. [PMID: 26867223 PMCID: PMC4982848 DOI: 10.1159/000443959] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 01/12/2016] [Indexed: 12/12/2022] Open
Abstract
Congenital hyperinsulinism (HI) is the most common cause of persistent hypoglycemia in infants and children. In cases of diazoxide-unresponsive HI, alternative medical and surgical approaches may be required to reduce the risk of hypoglycemia. Octreotide, a somatostatin analog, often has a role in the management of these children, but a dose-dependent reduction in splanchnic blood flow is a recognized complication. Necrotizing enterocolitis (NEC) has been reported within the first few weeks of initiating predominantly high doses of octreotide. We describe the case of an infant with Beckwith-Wiedemann syndrome and diazoxide-unresponsive HI, who had persistent hypoglycemia after two pancreatectomy surgeries. She developed NEC 2 months after beginning octreotide therapy at a relatively low dose of 8 µg/kg/day. This complication has occurred later, and at a lower dose, than has previously been described. We review the case and identify the known and suspected multifactorial risk factors for NEC that may contribute to the development of this complication in patients with HI.
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Affiliation(s)
- Colin Patrick Hawkes
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Division Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew A Palladino
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Diva D De León
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Necrotizing enterocolitis is a devastating intestinal disease that affects ~5% of preterm neonates. Despite advancements in neonatal care, mortality remains high (30–50%) and controversy still persists with regards to the most appropriate management of neonates with necrotizing enterocolitis. Herein, we review some controversial aspects regarding the epidemiology, imaging, medical and surgical management of necrotizing enterocolitis and we describe new emerging strategies for prevention and treatment.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Canada
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Güney LH, Araz C, Beyazpınar DS, Arda İS, Arslan EE, Hiçsönmez A. Abdominal Problems in Children with Congenital Cardiovascular Abnormalities. Balkan Med J 2015; 32:285-90. [PMID: 26185717 DOI: 10.5152/balkanmedj.2015.151045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 01/26/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Congenital cardiovascular abnormality is an important cause of morbidity and mortality in childhood. Both the type of congenital cardiovascular abnormality and cardiopulmonary bypass are responsible for gastrointestinal system problems. AIMS Intra-abdominal problems, such as paralytic ileus, necrotizing enterocolitis, and intestinal perforation, are common in patients who have been operated or who are being followed for congenital cardiovascular abnormalities. Besides the primary congenital cardiovascular abnormalities, ischemia secondary to cardiac catheterization or surgery contributes to the incidence of these problems. STUDY DESIGN Cross-sectional study. METHODS In this study, we aimed to screen the intra-abdominal problems seen in patients with congenital cardiovascular abnormalities who had undergone surgical or angiographical intervention(s). Patients with congenital cardiovascular abnormalities who had been treated medically or surgically between 2000 and 2014 were analyzed retrospectively in terms of intra-abdominal problems. The patients' demographic data, type of congenital cardiovascular abnormalities, the intervention applied (surgical, angiographic), the incidence of intra-abdominal problem(s), the interventions applied for the intra-abdominal problems, and the results were evaluated. RESULTS Fourteen (Group I) of the 76 patients with congenital cardiovascular abnormalities diagnosis were operated due to intra-abdominal problems, and 62 (Group II) were followed-up clinically for intra-abdominal problems. In Group I (10 boys and 4 girls), 11 patients were aged between 0 and 12 months, and three patients were older than 12 months. Group II included 52 patients aged between 0 and 12 months and 10 patients older than 12 months. Cardiovascular surgical interventions had been applied to six patients in Group I and 40 patients in Group II. The most frequent intra-abdominal problems were necrotizing enterocolitis and intestinal perforation in Group I, and paralytic ileus in Group II. Seven of the Group I patients and 22 of the Group II patients died. The patients who died in both groups had more than three congenital cardiovascular abnormalities in the same patient, and 80% of these patients had been operated for congenital cardiovascular abnormalities. CONCLUSION The gastrointestinal system is involved in important complications experienced by patients with congenital cardiovascular abnormalities. The mortality rate was higher in operated patients due to gastrointestinal complications. Gastrointestinal complications are more frequent in patients with cyanotic anomalies. The presence of more than one congenital cardiovascular abnormality in a patient increased the mortality rate.
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Affiliation(s)
- Lütfi Hakan Güney
- Department of Pediatric Surgery, Başkent University Faculty of Medicine, Ankara, Turkey
| | - Coşkun Araz
- Department of Anesthesiology, Başkent University Faculty of Medicine, Ankara, Turkey
| | - Deniz Sarp Beyazpınar
- Department of Cardiovasculer Surgery, Başkent University Faculty of Medicine, Ankara, Turkey
| | - İrfan Serdar Arda
- Department of Pediatric Surgery, Başkent University Faculty of Medicine, Ankara, Turkey
| | - Esra Elif Arslan
- Department of Pediatric Surgery, Başkent University Faculty of Medicine, Ankara, Turkey
| | - Akgün Hiçsönmez
- Department of Pediatric Surgery, Başkent University Faculty of Medicine, Ankara, Turkey
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Kamali K, Hosseini SR, Ardakani SMRN, Farnoodi MR. Complementory Value of Sonography in Early Evaluation of Necrotizing Enterocolitis. Pol J Radiol 2015; 80:317-23. [PMID: 26150903 PMCID: PMC4477821 DOI: 10.12659/pjr.893876] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 03/26/2015] [Indexed: 01/28/2023] Open
Abstract
Background Despite the widespread use of plain films to detect necrotizing enterocolitis (NEC), it is considered a time-consuming method, which exposes patients to radiation. We aimed to assess changes in ultrasonographic variables and to compare sonograhy and chest radiography in detecting early stages of NEC in suspected premature infants. Material/Methods This case-control study was carried out in the years 2012–2013. We enrolled 67 premature neonates using a simple sampling method and divided them into the study and control groups. All patients underwent plain abdominal radiography, gray-scale and color Doppler sonography. Results 34 and 33 neonates were assigned to the study and control groups. No significant gender differences were found between the two groups (P=0.549). The mean bowel wall thickness ranged from 1.2 to 3.2 mm in the control group (132 abdominal quadrants) and 1–3.3 mm in the study group (136 abdominal quadrants, P=0.502). Intra-mural echogenic dots were seen in one neonate in the study group in favour of pneumatosis intestinalis. The mean ±SD bowel wall perfusion in the study and control groups were 3.117±0.975 and 2.878±0.538 dots or lines/cm2, respectively (P=0.218). One neonate in the study group showed internal echoes within the mild amount of free fluid. Twelve neonates in the control group had minimal amounts of intra-abdominal free fluid. Conclusions The two groups differed regarding bowel wall thickness, echogenicity, and perfusion in sonograhy and color Doppler evaluation. Although those differences were not statistically significant, considering the time-consuming nature of abdominal X-ray, the use of sonograhy and color Doppler can improve diagnosis and treatment of NEC as a triage method.
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Affiliation(s)
- Karmella Kamali
- Medical Imaging Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Say'yed Reza Hosseini
- Medical Imaging Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mohammad Reza Farnoodi
- Medical Imaging Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Becker KC, Hornik CP, Cotten CM, Clark RH, Hill KD, Smith PB, Lenfestey RW. Necrotizing enterocolitis in infants with ductal-dependent congenital heart disease. Am J Perinatol 2015; 32:633-8. [PMID: 25486286 PMCID: PMC4449801 DOI: 10.1055/s-0034-1390349] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Infants with congenital heart disease (CHD) receiving prostaglandins (PGEs) may be at an increased risk for necrotizing enterocolitis (NEC). Enteral feeding may further increase the risk of NEC in these patients. We evaluated the incidence of NEC and its association with enteral feeding in infants with ductal-dependent CHD. STUDY DESIGN We examined a cohort of infants with CHD receiving PGE in neonatal intensive care units managed by the Pediatrix Medical Group (Sunrise, FL) between 1997 and 2010. We used logistic regression to evaluate the association between NEC and enteral feeding, as well as other risk factors, including antacid medications, inotropic and ventilator support, and anatomic characteristics, controlling for gestational age. RESULTS We identified 6,710 infants with ductal-dependent CHD receiving PGE for 17,158 infant days. NEC occurred in 21 of the 6,710 (0.3%) infants, of whom 12/21 (57%) were < 37 weeks gestational age. The incidence of NEC was 1.2/1,000 infant days while on enteral feeds versus 0.4/1,000 infant days while not on enteral feeds (p = 0.27). Enteral feeding was not associated with a statistically significant increased odds of NEC on the day of diagnosis (odds ratio [OR] 2.08; 95% confidence interval [CI] 0.38, 11.7). Risk factors associated with a significant increased odds of NEC included a diagnosis of single-ventricle heart defect (OR 2.82; 95% CI 1.23, 6.49), although the overall risk in this population remained low (8/1,631, 0.5%). CONCLUSION The incidence of NEC in our cohort of infants with ductal-dependent CHD on PGE therapy was low and did not increase with enteral feeding.
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Affiliation(s)
| | - Christoph P. Hornik
- Duke Clinical Research Institute, Durham, North Carolina
- Duke University Medical Center, Durham, North Carolina
| | | | - Reese H. Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, Florida
| | - Kevin D. Hill
- Duke Clinical Research Institute, Durham, North Carolina
- Duke University Medical Center, Durham, North Carolina
| | - P. Brian Smith
- Duke Clinical Research Institute, Durham, North Carolina
- Duke University Medical Center, Durham, North Carolina
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Prevention and early recognition of necrotizing enterocolitis: a tale of 2 tools--eNEC and GutCheckNEC. Adv Neonatal Care 2014; 14:201-10; quiz 211-2. [PMID: 24858670 DOI: 10.1097/anc.0000000000000063] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND SIGNIFICANCE Risk for neonatal necrotizing enterocolitis (NEC) is complex, reflecting its multifactorial pathogenesis. PURPOSE To improve risk awareness and facilitate communication among neonatal caregivers, especially nurses, 2 tools were developed. DESIGN GutCheck was derived and validated as part of a formal research study over 3 phases, evidence synthesis, expert consensus building, and statistical modeling. The Wetzel/Krisman tool, eNEC, was developed and tested as part of a quality improvement initiative in a single clinical setting using evidence synthesis, review by internal expert clinicians, and implementation and evaluation of its use by direct line neonatal staff. Refinement of both tools is under way to evaluate their effect on clinical decision making, early identification of NEC and surgical NEC. METHODS AND MAIN OUTCOMES Clinicians can take an active role to reduce NEC in their units by focusing on modifiable risk factors such as adoption of standardized feeding protocols, preferential feeding of human milk, and antibiotic and histamine blocker stewardship. RESULTS Feeding during transfusion remains controversial, but judicious use of transfusions, adoption of transfusion guidelines, and withholding feeding during transfusion are feasible measures with potential benefit to prevent NEC and confer little risk.
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Short SS, Papillon S, Berel D, Ford HR, Frykman PK, Kawaguchi A. Late onset of necrotizing enterocolitis in the full-term infant is associated with increased mortality: results from a two-center analysis. J Pediatr Surg 2014; 49:950-3. [PMID: 24888841 PMCID: PMC4370287 DOI: 10.1016/j.jpedsurg.2014.01.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 01/27/2014] [Indexed: 12/30/2022]
Abstract
PURPOSE The effect of timing of onset of necrotizing enterocolitis (NEC) on outcomes has not been determined for the full-term infant. In this study we aimed to characterize the full-term NEC population and to evaluate onset of NEC. METHODS We performed a two-center retrospective review of all full-term infants (≥ 37weeks) with a diagnosis of NEC between 1990 and 2012. Patients were identified by ICD-9 and age. Early onset for NEC was ≤7days and late onset after 7days of life. Demographics, comorbidities, maternal factors, clinical factors, surgical intervention, complications, and mortality were evaluated. Wilcoxon's test was performed on continuous variables and Fisher's exact test on categorical data. A p-value<0.05 was considered significant. Univariate outcomes with a p-value<0.1 were selected for multivariable analysis. RESULTS Thirty-nine patients (24 boys, 15 girls) with median EGA of 39weeks were identified. Overall mortality was 18%. Univariate predictors of mortality included congenital heart disease and placement of an umbilical artery (UA) catheter. Multivariate analysis revealed late onset of NEC to be an independent predictor of mortality (OR 90.8, 95% CI 2.6-3121). CONCLUSION Full-term infants who develop NEC after 7days of life, have congenital heart disease, and/or need UA catheterization have increased mortality.
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Affiliation(s)
- Scott S. Short
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, and the Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA, Division of Pediatric Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephanie Papillon
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, and the Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Dror Berel
- Division of Pediatric Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Henri R. Ford
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, and the Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Philip K. Frykman
- Division of Pediatric Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Akemi Kawaguchi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, and the Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
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14
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Bain J, Benjamin DK, Hornik CP, Benjamin DK, Clark R, Smith PB. Risk of necrotizing enterocolitis in very-low-birth-weight infants with isolated atrial and ventricular septal defects. J Perinatol 2014; 34:319-21. [PMID: 24434778 PMCID: PMC3969778 DOI: 10.1038/jp.2013.174] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 10/31/2013] [Accepted: 11/20/2013] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Necrotizing enterocolitis (NEC) is associated with a significant morbidity and mortality in premature infants. We sought to identify the frequency of NEC in very-low-birth-weight infants with isolated ventricular septal defects (VSDs) or atrial septal defects (ASDs) using a large multicenter database. STUDY DESIGN We identified a cohort of infants with birth weight <1500 g cared for in 312 neonatal intensive care units (NICUs) managed by the Pediatrix Medical Group between 1997 and 2010. We examined the association between the presence of an ASD or a VSD with development of NEC using logistic regression to control for small-for-gestational age status, antenatal steroid use, antenatal antibiotic use, gestational age, sex, race, Apgar score at 5 min and method of delivery. RESULT Of the 98 523 infants who met inclusion criteria, 1904 (1.9%) had an ASD, 1943 (2.0%) had a VSD and 146 (0.1%) had both. The incidence of NEC was 6.2% in infants without septal defects, 9.3% in those with an ASD, 7.8% in those with a VSD, and 10.3% in infants with both an ASD and a VSD. Compared with infants without septal defects, the adjusted odds ratios for developing NEC for each group-ASD alone, VSD alone and ASD with VSD-were 1.26 (95% confidence interval 1.07 to 1.49), 1.27 (1.07 to 1.51) and 1.79 (1.03 to 3.12), respectively. CONCLUSION The presence of an ASD or a VSD was associated with NEC in this cohort of premature infants.
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Affiliation(s)
- Jesse Bain
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Duke University, Durham, NC, USA
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Duke University, Durham, NC, USA
| | - Christoph P. Hornik
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Duke University, Durham, NC, USA
| | | | - Reese Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL, USA
| | - P. Brian Smith
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
- Department of Pediatrics, Duke University Medical Center, Duke University, Durham, NC, USA
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15
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Ellis CL, Bokulich NA, Kalanetra KM, Mirmiran M, Elumalai J, Haapanen L, Schegg T, Rutledge JC, Raff G, Mills DA, Underwood MA. Probiotic administration in congenital heart disease: a pilot study. J Perinatol 2013; 33:691-7. [PMID: 23599119 PMCID: PMC3758394 DOI: 10.1038/jp.2013.41] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 03/18/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate the impact of probiotic Bifidobacterium longum ssp. infantis on the fecal microbiota and plasma cytokines in neonates with congenital heart disease. STUDY DESIGN Sixteen infants with congenital heart disease were randomly assigned to receive either B. infantis (4.2 × 10(9) colony-forming units two times daily) or placebo for 8 weeks. Stool specimens from enrolled infants and from six term infants without heart disease were analyzed for microbial composition. Plasma cytokines were analyzed weekly in the infants with heart disease. RESULTS Healthy control infants had increased total bacteria, total Bacteroidetes and total bifidobacteria compared to the infants with heart disease, but there were no significant differences between the placebo and probiotic groups. Plasma interleukin (IL)10, interferon (IFN)γ and IL1β levels were transiently higher in the probiotic group. CONCLUSION Congenital heart disease in infants is associated with dysbiosis. Probiotic B. infantis did not significantly alter the fecal microbiota. Alterations in plasma cytokines were found to be inconsistent.
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16
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Abstract
Necrotizing enterocolitis (NEC) is the most common cause of gastrointestinal-related morbidity and mortality in the neonatal intensive care unit (NICU). Its onset is sudden and the smallest, most premature infants are the most vulnerable. Necrotizing enterocolitis is a costly disease, accounting for nearly 20% of NICU costs annually. Necrotizing enterocolitis survivors requiring surgery often stay in the NICU more than 90 days and are among those most likely to stay more than 6 months. Significant variations exist in the incidence across regions and units. Although the only consistent independent predictors for NEC remain prematurity and formula feeding, others exist that could increase risk when combined. Awareness of NEC risk factors and adopting practices to reduce NEC risk, including human milk feeding, the use of feeding guidelines, and probiotics, have been shown to reduce the incidence of NEC. The purpose of this review is to examine the state of the science on NEC risk factors and make recommendations for practice and research.
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17
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Dix L, Roth-Kleiner M, Osterheld MC. Placental vascular obstructive lesions: risk factor for developing necrotizing enterocolitis. PATHOLOGY RESEARCH INTERNATIONAL 2010; 2010:838917. [PMID: 21151528 PMCID: PMC2989861 DOI: 10.4061/2010/838917] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Revised: 02/16/2010] [Accepted: 02/18/2010] [Indexed: 11/20/2022]
Abstract
Necrotizing enterocolitis (NEC) is a severe neonatal disease affecting particularly preterm infants. Its exact pathogenesis still remains unknown. In this study, we have compared the prevalence of vascular obstructive lesions in placentae of premature newborns which developed NEC and of a control group. We further compared separately the findings of placentae of infants of less than 30 weeks of gestation, the age group in which NEC occurs most frequently. We found signs of fetal vascular obstructive lesions in 65% of the placentae of preterm patients developing NEC, compared to only 17% of the placentae of preterm patients in the control group. In the age groups below 30 weeks of gestation, 58.5% of placentae of later NEC patients presented such lesions compared to 24.5% in the control group. The significant difference between NEC and control group suggests a strong association between fetal vascular obstructive lesions and NEC. Therefore, we propose that fetal vascular obstructive lesions might be considered as a risk factor for the development of NEC in premature infants.
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Affiliation(s)
- Laure Dix
- Institute of Pathology, University of Lausanne, CH-1011 Lausanne, Switzerland
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18
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Ellis CL, Rutledge JC, Underwood MA. Intestinal microbiota and blue baby syndrome: probiotic therapy for term neonates with cyanotic congenital heart disease. Gut Microbes 2010; 1:359-66. [PMID: 21468216 PMCID: PMC3056099 DOI: 10.4161/gmic.1.6.14077] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Revised: 09/15/2010] [Accepted: 10/29/2010] [Indexed: 02/03/2023] Open
Abstract
Necrotizing enterocolitis (NEC) is the most common intestinal emergency among premature infants. Risk factors in premature infants include immature intestinal immunity and an intestinal microbiota dominated by hospital-acquired bacteria. Some probiotics have been shown to decrease the incidence of NEC in premature infants. Among term infants, NEC is rare. However, among term infants with cyanotic congenital heart disease (CCHD), the incidence of NEC is similar to that of premature infants but with even greater mortality rates. Mechanisms by which NEC occurs in term infants with CCHD are unknown. Of central interest is the potential role of changes in the intestinal microbiota and whether these can be modified with probiotic bacteria; accordingly, we review the literature, propose hypotheses and present the rationale for future studies involving preliminary probiotic clinical trials.
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Affiliation(s)
- Collin L Ellis
- Department of Internal Medicine; Division of Cardiovascular Medicine; University of California at Davis; Davis, CA USA,Graduate Programs in Nutritional Biology, Biotechnology and Biophotonics; University of California at Davis; Davis, CA USA
| | - John C Rutledge
- Department of Internal Medicine; Division of Cardiovascular Medicine; University of California at Davis; Davis, CA USA,Graduate Programs in Nutritional Biology, Biotechnology and Biophotonics; University of California at Davis; Davis, CA USA
| | - Mark A Underwood
- Department of Pediatrics; Division of Neonatology; University of California at Davis; Davis, CA USA
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19
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Abstract
Necrotizing enterocolitis (NEC) remains a major cause of neonatal morbidity and death. The pathophysiology is poorly understood. Prevailing evidence suggests that NEC is due to an inappropriate inflammatory response of the immature gut to some undefined insult. The mortality rate (15%-25%) for affected infants has not changed appreciably in 30 years. Many infants with NEC recover uneventfully with medical therapy and have long-term outcomes similar to unaffected infants of matched gestational age. Infants with progressive disease requiring surgical intervention suffer almost all of the mortality and morbidity. Of these, approximately 30%-40% will die of their disease and most of the remainder will develop long-term neurodevelopmental and gastrointestinal morbidity. Recent randomized trials suggest that the choice of operation does not influence patient outcome. Current work is focusing on developing a better understanding of the pathogenesis and improving means to identify which infants are at greatest risk of disease progression.
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Affiliation(s)
- Marion C W Henry
- Section of Pediatric Surgery, Yale University School of Medicine, New Haven, Connecticut 06510, USA
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20
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Hunter CJ, Singamsetty VK, Chokshi NK, Boyle P, Camerini V, Grishin AV, Upperman JS, Ford HR, Prasadarao NV. Enterobacter sakazakii enhances epithelial cell injury by inducing apoptosis in a rat model of necrotizing enterocolitis. J Infect Dis 2008; 198:586-93. [PMID: 18588483 DOI: 10.1086/590186] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is an inflammatory intestinal disorder that affects 2%-5% of all premature infants. Enterobacter sakazakii, a common contaminant of milk-based powdered infant formula, has been implicated as a causative agent of sepsis, meningitis, and NEC in newborn infants, with high mortality rates. However, the role played by E. sakazakii in the pathogenesis of NEC is, to date, not known. Here, we demonstrate for the first time that E. sakazakii can induce clinical and histological NEC in newborn rats. E. sakazakii was found to bind to enterocytes in rat pups at the tips of villi and to intestinal epithelial cells (IEC-6) in culture, with no significant invasion. Exposure to E. sakazakii induced apoptosis and increased the production of interleukin-6 in IEC-6 cells and in the animal model. These data suggest that E. sakazakii could be a potential pathogen that induces NEC and triggers intestinal disease by modulating enterocyte intracellular signaling pathways.
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Affiliation(s)
- Catherine J Hunter
- Department of Surgery, The Saban Research Institute, Childrens Hospital Los Angeles, Los Angeles, CA, USA
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22
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Maayan-Metzger A, Itzchak A, Mazkereth R, Kuint J. Necrotizing enterocolitis in full-term infants: case-control study and review of the literature. J Perinatol 2004; 24:494-9. [PMID: 15229620 PMCID: PMC7099291 DOI: 10.1038/sj.jp.7211135] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To examine the increasing number of full-term infants at our hospital exhibiting necrotizing enterocolitis (NEC) in order to characterize these cases and to discover common risk factors. METHODS Medical charts were reviewed for all full-term infants (gestational age > 36 weeks) that were born in our institution during a 5-year period (from January 1, 1998 to December 31, 2002) and that developed definite NEC. Data regarding the rate of Cesarean section (CS) in our institution over the study period and five years prior to the study was also recorded. RESULTS During the 5 years of the study, 14 full-term infants were found to have NEC. The incidence of NEC in full-term infants increased from 0.16 to 0.71 per 1000 live births in the 5-year period. Mean birth weight was 2829 g. All the NEC infants except one were delivered by CS, and all of them were fed either with a mixture of breast milk and formula or entirely by formula. Seven of the infants (50%) had no major known risk factors predisposing them for NEC. Mean age of disease onset was very early (4.1 days) in most of the infants (12 infants), and the colon was the main NEC site. The short-term outcome was favorable in all but one case, which required explorative laparotomy for intestinal perforation. The number of infants born by CS has been steadily increasing, and was almost three times greater during the study period in comparison to the preceding years. CONCLUSIONS The etiology of NEC in the full-term population seems to differ from the etiology for the preterm group in its intestinal location and in the timing of its onset. The increase in the rate of CS over the years might be related to the concurrent increase in NEC, and this relationship should be further investigated.Journal
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Affiliation(s)
- Ayala Maayan-Metzger
- Department of Neonatology, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer and The Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Israel
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