Expert consensus building using e-Delphi for necrotizing enterocolitis risk assessment

Recurrent Necrotizing Enterocolitis in Late Preterm and Full-Term Babies: A Case Report and Literature Review

Necrotizing enterocolitis (NEC) is a serious inflammatory condition of the intestines that primarily affects premature infants, though it can also occur in full-term infants. Diagnosing and managing recurrent NEC in full-term infants can be particularly challenging, with most requiring surgical intervention upon presentation if medical treatment is insufficient. An approach that emphasizes active medical management while minimizing excessive bowel resection tends to result in better postoperative outcomes, highlighting the need for increased awareness within the healthcare community regarding the complexities of NEC cases. The Security Forces Hospital Program in Riyadh, Saudi Arabia, conducted a study on two cases of necrotizing enterocolitis. The cases involved a full-term baby and a late preterm baby, both of whom had challenging hospital courses and required active care. The study presents a chronological order of the clinical presentation, in-hospital course, and difficulties encountered. The study also includes a brief literature review using PubMed and ProQuest databases. The first case is of a 34+6-week-old baby boy, weighing 2.26 kg at birth, who experienced a normal vaginal delivery but faced complications due to group B Streptococcus. Initially, he showed signs of hypoactivity and a distended abdomen, leading to a diagnosis of sepsis versus necrotizing enterocolitis (NEC). After medical treatment, he was discharged but later returned with worsening symptoms, prompting an ultrasound and subsequent surgery that revealed extensive NEC. Following a stoma procedure and treatment for bowel obstruction, the patient made a full recovery and had a successful stoma closure 10 weeks later. Now, almost four years old, he is thriving and doing well. In the second case, the mother gave birth to a full-term 39 + 2 weeks-old baby boy via normal spontaneous vaginal delivery, weighing 2.51 kg, with no significant antenatal issues. At 10 days old, the baby developed necrotizing enterocolitis (NEC), which was treated before discharge. However, at two months, he was readmitted with sepsis, and an abdominal X-ray showed a thickened bowel loop but no signs of NEC. An ultrasound later indicated ileocolic intussusception, leading to exploratory surgery that revealed NEC and Meckel's diverticulum, but no intussusception was found. The surgery involved creating stomas, and the baby recovered well, with plans for stoma closure 52 days later. He has since been discharged and is making progress in speech therapy after experiencing some delayed speech. Recurrent necrotizing enterocolitis is a rare condition in full-term infants, and its occurrence in de novo cases remains unclear. This condition presents significant challenges in diagnosis and management, potentially leading to long-term gastrointestinal issues or even death, highlighting the importance of prompt diagnosis and appropriate treatment. While medical management is the primary approach, surgical intervention may be required in cases where medical treatment fails, and it is crucial to avoid excessive bowel resection and ensure long-term follow-up for affected infants.

Effect of gestational age on clinical features in necrotizing enterocolitis-associated intestinal perforation

Purpose

To investigate the clinical features of necrotizing enterocolitis-associated intestinal perforation (NEC-IP) in neonates with different gestational ages (GAs). Furthermore, we also want to identify the risk factors of poor prognosis for these patients.

Methods

The retrospective study of patients with NEC-IP was conducted with basic information, comorbidity, intraoperative findings, related treatment, and prognosis. According to the GA, patients were divided into three groups: early (GA: 28-<32 weeks, Group 1), mid-term (GA: 32-<34 weeks, Group 2), and late (GA: 34-<37 weeks, Group 3). The clinical features of the three groups were analyzed, and risk factors for poor prognosis were identified.

Results

Of the 113 cases, the number of cases in Groups 1 to 3 was 36 (31.9%), 44 (38.9%), and 33 (29.2%), respectively; and the overall proportion of poor prognosis was 19.4% (22/113). For basic information, the birth weight of Group 1 was lower than that of Group 2 and Group 3, while the postnatal day at the time of surgery of NEC and the onset age were higher than that of Group 2 (onset age: G1 12.0[7.00;20.5], G2 9.00[4.00;13.0]; postnatal day at the time of surgery: G1 22.0[13.8;27.2], G2 13.0[8.00;21.0]) (P < 0.016). For comorbidity, the incidence of sepsis, coagulopathy, type of (congenital heart disease) CHD, and hypoproteinemia in Group 1 was higher than that in Group 2 (all P < 0.016), and the incidence of respiratory failure, hypoproteinemia in Group 1 was higher than that in Group 3 (all P < 0.016). For related treatment, the usage rate of vasoactive substances and mechanical ventilation in Group 1 was higher than that of Group 2 and Group 3 (all P < 0.016). By Lasso and Logistic regression analysis, we found that GA (OR: 0.274, 95%CI: 0.078-0.796), sepsis (OR: 7.955, 95%CI: 1.424-65.21), coagulopathy (OR: 19.51, 95%CI: 3.393-179.1), CHD (OR: 6.99, 95%CI: 1.418-54.83) and diseased bowel segment (OR: 2.804, 95%CI: 1.301-7.316) were the independent factors for poor prognosis (all P < 0.05).

Conclusions

The clinical features of NEC-IP patients differ based on GA, particularly in terms of CHD type, postnatal day at the time of surgery, utilization of vasoactive substances, and prognosis. Furthermore, GA, sepsis, coagulopathy, CHD, and diseased bowel segment are independent factors for poor prognosis of patients with NEC-IP.

Factors influencing necrotizing enterocolitis in premature infants in China: a systematic review and meta-analysis

BACKGROUND

Necrotizing enterocolitis (NEC) is a multifactorial gastrointestinal disease with high morbidity and mortality among premature infants. However, studies with large samples on the factors of NEC in China have not been reported. This meta-analysis aims to systematically review the literature to explore the influencing factors of necrotizing enterocolitis in premature infants in China and provide a reference for the prevention of NEC.

METHODS

PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), China Biomedical Literature Database (CBM), Wanfang and VIP databases were systematically searched from inception to February 2023. We used Stata14.0 software to perform the systematic review and meta-analysis. We used fixed or random effects models with combined odds ratios (ORs) and 95% confidence intervals (CIs), and quality was evaluated using the Newcastle‒Ottawa Scale (NOS).

RESULTS

The total sample was 8616 cases, including 2456 cases in the intervention group and 6160 cases in the control group. It was found that 16 risk factors and 3 protective factors were related to necrotizing enterocolitis in premature infants. Septicemia (OR = 3.91), blood transfusion (OR = 2.41), neonatal asphyxia (OR = 2.46), pneumonia (OR = 6.17), infection (OR = 5.99), congenital heart disease (OR = 4.80), intrahepatic cholestasis of pregnancy (ICP) (OR = 2.71), mechanical ventilation (OR = 1.44), gestational diabetes mellitus (GDM) (OR = 3.08), respiratory distress syndrome (RDS) (OR = 3.28), hypoalbuminemia (OR = 2.80), patent ductus arteriosus (PDA) (OR = 3.10), respiratory failure (OR = 7.51), severe anemia (OR = 2.86), history of antibiotic use (OR = 2.12), and meconium-stained amniotic fluid (MSAF) (OR = 3.14) were risk factors for NEC in preterm infants in China. Breastfeeding (OR = 0.31), oral probiotics (OR = 0.36), and prenatal use of glucocorticoids (OR = 0.38) were protective factors for NEC in preterm infants.

CONCLUSIONS

Septicemia, blood transfusion, neonatal asphyxia, pneumonia, infection, congenital heart disease, ICP, GDM, RDS, hypoproteinemia, PDA, respiratory failure, severe anemia, history of antibiotic use and MSAF will increase the risk of NEC in premature infants, whereas breastfeeding, oral probiotics and prenatal use of glucocorticoids reduce the risk. Due to the quantity and quality of the included literature, the above findings need to be further validated by more high-quality studies.

Metabolomics in NEC: An Updated Review

Necrotizing enterocolitis (NEC) represents the most common and lethal acute gastrointestinal emergency of newborns, mainly affecting those born prematurely. It can lead to severe long-term sequelae and the mortality rate is approximately 25%. Furthermore, the diagnosis is difficult, especially in the early stages, due to multifactorial pathogenesis and complex clinical pictures with mild and non-specific symptoms. In addition, the existing tests have poor diagnostic value. Thus, the scientific community has been focusing its attention on the identification of non-invasive biomarkers capable of prediction, early diagnosis and discriminating NEC from other intestinal diseases in order to intervene early and block the progression of the pathology. In this regard, the use of "omics" technologies, especially metabolomics and microbiomics, could be a fundamental synergistic strategy to study the pathophysiology of NEC. In addition, a deeper knowledge of the microbiota-host cross-talk can clarify the metabolic pathways potentially involved in the pathology, allowing for the identification of specific biomarkers. In this article, the authors analyze the state-of-the-art concerning the application of metabolomics and microbiota analysis to investigate this pathology and discuss the future possibility of the metabolomic fingerprint of patients for diagnostic purposes.

A prediction model for neonatal necrotizing enterocolitis in preterm and very low birth weight infants

Objectives

Neonatal necrotizing enterocolitis (NEC) is a severe gastrointestinal disease that primarily affects preterm and very low birth weight infants, with high morbidity and mortality. We aim to build a reliable prediction model to predict the risk of NEC in preterm and very low birth weight infants.

Methods

We conducted a retrospective analysis of medical data from infants (gestational age <32 weeks, birth weight <1,500 g) admitted to Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region. We collected clinical data, randomly dividing it into an 8:2 ratio for training and testing. Multivariate logistic regression was employed to identify significant predictors for NEC. Principal component analysis was used for dimensionality reduction of numerical variables. The prediction model was constructed through logistic regression, incorporating all relevant variables. Subsequently, we calculated performance evaluation metrics, including Receiver Operating Characteristic (ROC) curves and confusion matrices. Additionally, we conducted model performance comparisons with common machine learning models to establish its superiority.

Results

A total of 292 infants were included, with 20% (n = 58) randomly selected for external validation. Multivariate logistic regression revealed the significance of four predictors for NEC in preterm and very low birth weight infants: temperature (P = 0.003), Apgar score at 5 min (P = 0.004), formula feeding (P = 0.007), and gestational diabetes mellitus (GDM, P = 0.033). The model achieved an accuracy of 82.46% in the test set with an F1 score of 0.90, outperforming other machine learning models (support vector machine, random forest).

Conclusions

Our logistic regression model effectively predicts NEC risk in preterm and very low birth weight infants, as confirmed by external validation. Key predictors include temperature, Apgar score at 5 min, formula feeding, and GDM. This study provides a vital tool for NEC risk assessment in this population, potentially improving early interventions and child survival. However, clinical validation and further research are necessary for practical application.

Prediction of GutCheck NEC and Its Relation to Severity of Illness and Measures of Deterioration in Necrotizing Enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) risk has been shown to arise from multiple sources and risk awareness may be supported using bedside tools.

PURPOSE

The purpose of this research was to examine the extent to which GutCheck NEC was associated with scores for clinical deterioration, severity of illness, and clinical outcome, and further to examine how scores might improve NEC prediction.

METHODS

A retrospective, correlational case-control study with infant data from 3 affiliated neonatal intensive care units was conducted.

RESULTS

Of 132 infants (44 cases, 88 controls), most were 28 weeks of gestation at birth and less (74%). Median age at NEC onset was 18 days (range: 6-34 days), with two-thirds diagnosed before 21 days. At 68 hours of life, higher GutCheck NEC scores were associated with NEC requiring surgery or resulting in death (relative risk ratio [RRR] = 1.06, P = .036), associations that persisted at 24 hours prior to diagnosis (RRR = 1.05, P = .046), and at the time of diagnosis (RRR = 1.05, P = .022) but showed no associations for medical NEC. GutCheck NEC scores were significantly correlated with pediatric early warning scores (PEWS) ( r > 0.30; P < .005) and SNAPPE-II scores ( r > 0.44, P < .0001). Increasing numbers of clinical signs and symptoms were positively associated with GutCheck NEC and PEWS at the time of diagnosis ( r = 0.19, P = .026; and r = 0.25, P = .005, respectively).

IMPLICATIONS FOR PRACTICE AND RESEARCH

GutCheck NEC provides structure to streamline assessment and communication about NEC risk. Yet, it is not intended to be diagnostic. Research is needed on how GutCheck NEC impacts timely recognition and treatment.

Identifying personal physiological data risks to the Internet of Everything: the case of facial data breach risks

Personal physiological data is the digital representation of physical features that identify individuals in the Internet of Everything environment. Such data includes characteristics of uniqueness, identification, replicability, irreversibility of damage, and relevance of information, and this data can be collected, shared, and used in a wide range of applications. As facial recognition technology has become prevalent and smarter over time, facial data associated with critical personal information poses a potential security and privacy risk of being leaked in the Internet of Everything application platform. However, current research has not identified a systematic and effective method for identifying these risks. Thus, in this study, we adopted the fault tree analysis method to identify risks. Based on the risks identified, we then listed intermediate events and basic events according to the causal logic, and drew a complete fault tree diagram of facial data breaches. The study determined that personal factors, data management and supervision absence are the three intermediate events. Furthermore, the lack of laws and regulations and the immaturity of facial recognition technology are the two major basic events leading to facial data breaches. We anticipate that this study will explain the manageability and traceability of personal physiological data during its lifecycle. In addition, this study contributes to an understanding of what risks physiological data faces in order to inform individuals of how to manage their data carefully and to guide management parties on how to formulate robust policies and regulations that can ensure data security.

Neonatal surgical outcomes: a prospective observational study at a Tertiary Academic Hospital in Johannesburg, South Africa

PURPOSE

The neonatal period is the most vulnerable period for a child. There is a paucity of data on the burden of neonatal surgical disease in our setting. The aim of this study was to describe the frequency with which index neonatal surgical conditions are seen within our setting and to document the 30-day outcome of these patients.

METHODS

This was a single-centre prospective observational study in which all neonates with paediatric surgical pathology referred to the paediatric surgical unit with a corrected gestational age of 28 days were included.

RESULTS

Necrotising enterocolitis was the most frequent reason for referral to the paediatric surgical unit (n = 68, 34.34%). Gastroschisis was the most frequent congenital anomaly referred (n = 20, 10.10%). The overall morbidity was 57.58%. Surgical complications contributed to 18.51% of morbidities. The development of gram negative nosocomial sepsis was the most frequent cause of morbidity (n = 98, 50.78%). Mortality at 30 days was 21.74% (n = 40). Sepsis contributed to mortality in 35 patients (87.5%), 16 of which had gram negative sepsis.

CONCLUSION

Gram-negative sepsis was a major contributing factor in the development of morbidity and mortality in our cohort. Prevention and improvement in infection control are imperative if we are to improve outcomes in our surgical neonates.

The Role of Instrumental Swallowing Assessment in Adults in Residential Aged Care Homes: A National Modified Delphi Survey Examining Beliefs and Practices

Many adults in residential aged care homes (RACHs) live with oropharyngeal dysphagia (OD) and its physiological, psychosocial, and economic sequalae. Timely, evidence-based assessment of OD can help healthcare teams to create OD management plans that optimize consumer health and minimize healthcare costs. Instrumental swallowing assessment (ISA), specifically flexible endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallowing studies (VFSS), is generally accepted to be an important component of dysphagia assessment and management in older adults. However, its role in RACHs has not been empirically examined. This study aimed to explore the role and use of ISA in adults in RACHs from the perspective of speech-language-pathologists (SLPs) experienced in a RACH setting and/or FEES and VFSS. A three-round electronic Delphi study was conducted to guide 58 SLPs in Australia towards consensus using a combination of multiple-choice questions, statements with five-point Likert scale agreement options, and open-ended questions. Participants' responses were analyzed using descriptive statistics and content analysis after each survey round. Feedback about group responses was provided before subsequent surveys. Consensus was defined as 70% or greater agreement. Participants reached consensus about obstacles and facilitators to the use of ISA in RACHs. Participants agreed that FEES was a valuable tool in RACHs and that a mobile service model may have advantages over standard off-site assessment. SLPs believed that appropriate governance processes, infrastructure and education were necessary to develop a safe, high-quality service. These views support equitable access to ISA across settings, aligning with person-centered care, re-ablement, and care-in-place.

Grading the evidence to identify strategies to modify risk for necrotizing enterocolitis

Although risk for necrotizing enterocolitis (NEC) is often presented from the perspective of a premature infant's vulnerability to nonmodifiable risk factors, in this paper we describe the evidence and present recommendations to manage modifiable risks that are amenable to clinical actions. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, we present recommendations in the context of their supporting evidence in a way that balances risks (e.g. potential harm, cost) and benefits. Across the prenatal, intrapartum, early and late clinical course, strategies to limit NEC risk in premature infants are presented. Our goal is to summarize modifiable NEC risk factors, grade the evidence to offer quality improvement (QI) targets for healthcare teams and offer a patient-family advocate's perspective on how to engage parents to recognize and reduce NEC risk.

Development of the NEC-Zero Toolkit: Supporting Reliable Implementation of Necrotizing Enterocolitis Prevention and Recognition

The goal of the NEC-Zero project is to reduce the burden of necrotizing enterocolitis (NEC) by increasing access to evidence-based tools to help clinicians and parents integrate evidence into daily care. It involves (a) human milk feeding with prioritized mother's own milk; (b) use of a unit-adopted standardized feeding protocol; (c) a unit-adopted strategy for timely recognition that integrates risk awareness and a structured communication tool when symptoms develop; and (d) stewardship of empiric antibiotics and avoidance of antacids. A toolkit for caregivers and parents was developed to make implementation consistent. For clinicians the toolkit includes: the GutCheck^NEC risk score, a structured communication tool, the "Avoiding NEC" checklist, and the NEC-Zero website. For parents, NEC-Zero tools include the website, three educational brochures in English and Spanish, and a collaborative care video produced with the NEC Society. This article describes the toolkit and how it has been accessed and used.

Draft Opioid-Prescribing Guidelines for Uncomplicated Normal Spontaneous Vaginal Birth

Women who experience an uncomplicated vaginal delivery have acute intrapartum pain and variable pain in the immediate postpartum period. Although the Centers for Disease Control and Prevention (CDC) has urged clinicians to improve opioid-prescribing behavior, there are no published clinical practice guidelines for prescribing opioids during labor and delivery and at discharge for patients with uncomplicated normal spontaneous vaginal delivery. To address the knowledge gap regarding guidelines for pain management in this population, we used the national Premiere Health Care Database for deliveries of uncomplicated vaginal births from January 1, 2014, to December 31, 2016, to determine the prevalence of opioid administration. Among the 49,133 women who met inclusion criteria, 78.2% were administered opioids during hospitalization and 29.8% were administered opioids on the day of discharge. Descriptive statistics were generated to document the characteristics of the patients receiving opioids as well as the characteristics of hospitals administering opioids during inpatient labor and delivery and on discharge. Patient-level variables included age group, marital status, race, ethnicity, payer type, and length of stay. Hospital-level variables included bed size, geographic region, teaching status, and urbanicity status. These data were then presented in an electronic Delphi survey to 14 participants. The survey participants were obstetrician-gynecologists identified by the American College of Obstetricians and Gynecologists as being thought leaders in the obstetrics field and who had also demonstrated an active interest in the opioid epidemic and its effect on women's health. After the panelists viewed the opioid administration data, they were presented with an adapted version of the CDC's guidelines for opioid prescribing for chronic pain management. The eight adapted guidelines were constructed to be more relevant and appropriate for the inpatient normal spontaneous vaginal delivery population. After three rounds of the surveying process, seven of the eight adapted guidelines were endorsed by the survey participants. These seven draft consensus guidelines could now be used as a starting point to develop more broadly endorsed and studied guidelines for appropriately managing pain control for women with uncomplicated spontaneous vaginal birth.

Modifiable Risk Factors in Necrotizing Enterocolitis

Multicenter groups have reported reductions in the incidence of necrotizing enterocolitis (NEC) among preterm infants over the past 2 decades. These large-scale prevalence studies have coincided with reports from multicenter consortia and single centers of modifications in practice using quality-improvement techniques aimed at either reducing NEC risk specifically or reducing risk of mortality and multiple morbidities associated with extreme prematurity. The modifications in practice have been based on mechanistic studies, epidemiologic association data, and clinical trials. Recent reports from centers modifying practice to reduce NEC are reviewed and select modified/modifiable practices discussed.

A critical analysis of risk factors for necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the most common serious gastrointestinal morbidity in preterm infants. A number of risk factors for NEC have been reported in the literature. With the exception of decreasing gestational age, decreasing birth weight and formula feeding, there is disagreement on the importance of reported risk factors with uncertain causality. Causal risk factors may be observed at any time before the onset of NEC, including prior to an infant's birth. The purpose of this review is to examine the existing literature and summarize risk factors for NEC. This review may be helpful in understanding the epidemiology of NEC and inform the measurement and assessment of risks factors for NEC in research studies and quality improvement projects.

Diagnosis and Management of Necrotizing Enterocolitis: An International Survey of Neonatologists and Pediatric Surgeons

BACKGROUND

Necrotizing enterocolitis (NEC) is a serious complication of prematurity. Currently, there is limited evidence to guide investigation and treatment strategies.

OBJECTIVES

To evaluate the parameters used to diagnose or exclude NEC, and to identify differences between neonatologists and pediatric surgeons.

METHODS

A scenario-based survey was sent to neonatologists and pediatric surgeons.

RESULTS

173 physicians from 26 countries completed the survey (55% neonatologists and 45% pediatric surgeons). Bloody stools, abdominal tenderness, low platelet counts, and increased lactate levels increased the likelihood of NEC for 82, 72, 56, and 45% of respondents, respectively. Intestinal pneumatosis, portal venous gas, and pneumoperitoneum on X-ray increased the likelihood of NEC for 99, 98, and 92% of respondents, respectively. Clinical examination and laboratory tests were insufficient to exclude NEC, but normal intestinal movements and normal gut wall thickness on ultrasonography decreased the likelihood of NEC for 38 and 33% of respondents, respectively. Neonatologists more frequently relied on increased gastric residuals and abdominal distension to diagnose NEC (p = 0.04 and p = 0.03, respectively), whereas pediatric surgeons more frequently reported that absence of bloody stools helped to exclude NEC (p = 0.04). In a deteriorating patient with suspected NEC, 39% of respondents would broaden the antibiotic spectrum, and 42% would recommend a laparotomy.

CONCLUSION

Our results indicate a wide variation in the management of NEC, with significant differences between neonatologists and pediatric surgeons. A better appreciation of the relative significance and weighting that should be applied to the clinical features and investigations should reduce the variation in interpretation that appears to exist.

Expert consensus to weight an adherence score for audit and feedback of practices that prevent necrotizing enterocolitis in very low birth weight infants

OBJECTIVE

Necrotizing enterocolitis (NEC) is a catastrophic abdominal complication threatening the life of premature infants, but adoption of prevention and early recognition practices differs as do NEC rates in Neonatal Intensive Care Units (NICUs). The purpose of this research was to validate and weight an evidence-based adherence score (aka NEC-Zero Adherence Score) to prevent and foster timely recognition of NEC.

STUDY DESIGN

An electronic Delphi (e-Delphi) approach was used to identify consensus. NEC experts were recruited via the NEC Society and surveyed until consensus and stability criteria for the Delphi were met (≥70% consensus and mean responses changed <15% between rounds).

RESULTS

Expert panelists (n=22) were experienced (M=17.6, SD 11years) and predominately physicians (68%) or neonatal nurse practitioners (18%). Consensus (>70% by item) supported a 10 point score. Points were distributed across 1) an exclusive human milk diet (5 points), 2) standardized feeding protocols (3 points), 3) antibiotic stewardship (1 point), and 4) a unit-specified approach to early recognition (1 point). Withholding feeding during transfusion was controversial (M=0.50, SD 0.73) and met consensus criteria to drop from the score.

CONCLUSIONS

Holding feeding during transfusion was dropped from the score. Relationships between the score and unit NEC rates as well as its utility for use in audit and feedback should be studied in the future.

The ConNECtion Between Abdominal Signs and Necrotizing Enterocolitis in Infants 501 to 1500 g

BACKGROUND

Necrotizing enterocolitis (NEC) can become severe quickly, making early recognition a priority and understanding the occurrence of abdominal and clinical signs of impending NEC important.

PURPOSE

The purpose of this study was to examine relationships of abdominal signs up to 36 hours before diagnosis of NEC within subgroups treated medically, surgically, or those who died.

METHODS

A 3-site, descriptive correlational case-control design with retrospective data collection was used matching each NEC case to 2 controls (N = 132).

RESULTS

NEC cases were exposed to less human milk and fed later. Among them, 61% (n = 27) had at least 1 abdominal sign 36 hours before diagnosis, with fewer numbers having 2 (18%; n = 8) or 3 (5%; n = 2). At 36 hours before NEC, abdominal distension, duskiness, higher gastric residual, and greater count of abdominal signs were associated with severe NEC. No medical NEC cases had abdominal signs 36 or 24 hours before diagnosis. Highest severity of NEC was related to more abdominal signs at the times leading up to and at diagnosis of NEC. Gastric residuals were largely unrelated to NEC except for the most severe NEC at 36 hours before diagnosis.

IMPLICATIONS FOR PRACTICE

Communicating a count of abdominal signs may support earlier recognition and treatment of NEC.

IMPLICATIONS FOR RESEARCH

More research is needed to explore timing for clinical worsening of status (eg, surgical and NEC leading to death) and to study effective clinical approaches targeting early recognition to support timely action.

A Novel Neonatal Feeding Intolerance and Necrotizing Enterocolitis Risk-Scoring Tool Is Easy to Use and Valued by Nursing Staff

BACKGROUND

Preterm infants are at increased risk of developing feeding intolerance and necrotizing enterocolitis. Comprehensive, targeted nursing assessments can evaluate the risk for and identify early signs of these conditions in an effort to prevent their destructive sequela.

PURPOSE

While the long-term goal is to develop a validated risk-scoring tool for the prediction of feeding intolerance and necrotizing enterocolitis, the objective of the preliminary phase presented here is to assess the ease of use and nurses' attitudes toward a novel feeding intolerance and necrotizing enterocolitis risk-scoring tool.

METHODS

A novel risk-scoring nursing tool was implemented in a University of Illinois-affiliated 48-bed level III neonatal intensive care unit. Data were collected from the electronic medical record of all preterm infants with parental consent during the initial 6-month study period. Scoring accuracy (accuracy of selection of risk factors based on electronic medical record data), ease of use, and nurses' attitudes toward the tool were assessed at the study site and by evaluators at a national neonatal nursing conference.

RESULTS

Fourteen nurses scored 166 tools on the 63 enrolled infants. Sixteen tools (9.6%) contained errors. Mean study site tool ease of use was 8.1 (SD: 2.2) on a 10-point scale. Ninety percent of conference evaluators agreed/strongly agreed that the tool addressed important knowledge gaps.

IMPLICATIONS FOR PRACTICE

The tool is easy to use and valued by nurses. Following validation, widespread implementation is expected to be a clinically feasible means to improve infant clinical outcomes for minimal time and financial cost.

IMPLICATIONS FOR RESEARCH

Tool validation and refinement based on nursing feedback will improve its broad applicability and predictive utility.

Prevention and early recognition of necrotizing enterocolitis: a tale of 2 tools--eNEC and GutCheckNEC

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.

Discrimination of GutCheck(NEC): a clinical risk index for necrotizing enterocolitis

OBJECTIVE

Better measures are needed to identify infants at risk for developing necrotizing enterocolitis (NEC) and facilitate communication about risk across transitions. Although NEC is multi-factorial, quantification of composite risk for NEC in an individual infant is not clearly defined. The objective of this study was to describe the derivation, validation and calibration testing of a novel clinical NEC risk index, GutCheck(NEC). Individual risk factors were weighted to assess composite odds of developing NEC. GutCheck(NEC) is designed to improve communication about NEC risk and coordination of care among clinicians across an infant's clinical course.

STUDY DESIGN

On the basis of a synthesis of research evidence about NEC risk and an e-Delphi study including 35 neonatal experts, we identified NEC risk factors believed by the experts to be most relevant for a NEC risk index, then applied a logistic model building process to derive and validate GutCheck(NEC). De-identified data from the Pediatrix BabySteps Clinical Data Warehouse (discharge date 2007 to 2011) were split into three samples for derivation, validation and calibration. By comparing infants with medical NEC, surgical NEC and those who died to infants without NEC, we derived the logistic model using the un-matched derivation set. Discrimination was then tested in a case-control matched validation set and an un-matched calibration set using receiver operating characteristic curves.

RESULT

Sampled from a cohort of 58 820 infants, the randomly selected derivation set (n=35 013) revealed nine independent risk factors (gestational age, history of packed red blood cell transfusion, unit NEC rate, late-onset sepsis, multiple infections, hypotension treated with inotropic medications, Black or Hispanic race, outborn status and metabolic acidosis) and two risk reducers (human milk feeding on both days 7 and 14 of life, and probiotics). Unit NEC rate carried the most weight in the summed score. Validation using a 2:1 matched case-control sample (n=360) demonstrated fair to good discrimination. In the calibration set (n=23 447), GutCheck(NEC) scores (range 0 to 58) discriminated those infants who developed surgical NEC (area under the curve (AUC)=0.84, 95% confidence interval (CI) 0.82 to 0.84) and NEC leading to death (AUC=0.83, 95% CI 0.81 to 0.85), more accurately than medical NEC (AUC= 0.72, 95% CI 0.70 to 0.74).

CONCLUSION

GutCheck(NEC) represents weighted composite risk for NEC and discriminated infants who developed NEC from those who did not with very good accuracy. We speculate that targeting modifiable NEC risk factors could reduce national NEC prevalence.