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Physical examination score predicts need for surgery in neonates with necrotizing enterocolitis

Journal of Perinatology volume 38, pages 1644–1650 (2018)Cite this article

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Abstract

Objective

To evaluate the utility of a standardized physical exam score (PE-NEC) in predicting need for surgery or death in neonates with necrotizing enterocolitis (NEC).

Methods

This prospective, multicenter, observational study was conducted from 3/1/14 to 2/29/16 with three regional perinatal centers in upstate New York. Infants with NEC Bell’s Stage ≥ 2 had physical exams and laboratory data recorded at 12–24 h intervals for 48 h following diagnosis. PE-NEC score was comprised of seven components: bowel sounds, capillary refill time, abdominal wall erythema, girth, discoloration, induration, and tenderness. Surgical timing was determined by surgeons blinded to the PE-NEC score. Optimal sensitivity and specificity of PE-NEC score for surgery/death (primary outcome) was determined by receiver operating characteristic curve analysis.

Results

Of 100 infants with NEC, 5 had pneumoperitoneum at diagnosis and were excluded yielding 95 for analyses. Of those, 35 infants experienced the primary outcome: 3 died from NEC prior to surgery and 32 had surgery (30 laparotomies, 2 drains). The PE-NEC score was found to be sensitive and specific for need for surgery/death (AUC = 0.89, 95% CI 0.82–0.97); a score of ≥3 had a sensitivity of 0.88 (95% CI 0.72–0.97), specificity of 0.81 (95% CI 0.69–0.90). All components of the PE-NEC score were more likely to be present among infants with surgical NEC or who died.

Conclusion

PE-NEC score is sensitive and specific in predicting need for surgery in infants with NEC and should be validated as a clinical decision-making tool.

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References

  1. Mizrahi A, Barlow O, Berdon W, Blanc WA, Silverman WA. Necrotizing enterocolitis in premature infants. J Pediatr. 1965;66:697–705.

    Article  CAS  Google Scholar 

  2. Neu J. Necrotizing enterocolitis: The search for a unifying pathogenic theory leading to prevention. Pediatr Clin North Am. 1996;43:409.

    Article  CAS  Google Scholar 

  3. Uauy RD, Fanaroff AA, Korones SB, Phillips EA, Phillips JB, Wright LL. Necrotizing enterocolitis in very low birth weight infants: biodemographic and clinical correlates. National Institute of Child Health and Human Development Neonatal Research Network. J Pediatr. 1991;119:630–8.

    Article  CAS  Google Scholar 

  4. Stevenson DK, Wright LL, Lemons JA, Oh W, Korones SB, Papile LA, et al. Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1993 through December 1994. Am J Obstet Gynecol. 1998;179:1632–9.

    Article  CAS  Google Scholar 

  5. Flake AW. Necrotizing enterocolitis in preterm infants--is laparotomy necessary? N Engl J Med. 2006;354:2275–6.

    Article  CAS  Google Scholar 

  6. Kosloske AM. Epidemiology of necrotizing enterocolitis. Acta Paediatr Suppl. 1994;396:2–7.

    Article  CAS  Google Scholar 

  7. Kosloske AM. Indications for operation in necrotizing enterocolitis revisited. J Pediatr Surgery. 1994;29:663–6.

    Article  CAS  Google Scholar 

  8. LaGamma EF, Ostertag SG, Birenbaum H. Failure of delayed oral feedings to prevent necrotizing enterocolitis. Results of study in very-low-birth-weight neonates. Am J Dis Child. 1985;139:385–9.

    Article  CAS  Google Scholar 

  9. Lemons JA1, Bauer CR, Oh W, Korones SB, Papile LA, Stoll BJ, et al. Very low birth weight outcomes of the National Institute of Child health and human development neonatal research network, January 1995 through December 1996. NICHD Neonatal Research Network. Pediatr. 2001;107:E1.

    Article  CAS  Google Scholar 

  10. Tepas JJ, Sharma R, Leaphart CL, Celso BG, Pieper P, Esquivia-Lee V. Timing of surgical intervention in necrotizing enterocolitis can be determined by trajectory of metabolic derangement. J Pediatr Surg. 2010;45:310–4.

    Article  Google Scholar 

  11. Kliegman RM, Walker WA, Yolken RH. Necrotizing enterocolitis: research agenda for a disease of unknown etiology and pathogenesis. Pediatr Res. 1993;34:701.

    Article  CAS  Google Scholar 

  12. Kliegman RM, Walsh MC. Neonatal necrotizing enterocolitis: pathogenesis, classification, and spectrum of disease. Curr Probl Pediatr. 1987;17:243–88.

    Google Scholar 

  13. Wu S, Caplan M, Lin H. Necrotizing enterocolitis: old problem with new hope. Pediatr Neonatol. 2012;53:158–63.

    Article  Google Scholar 

  14. Gephart SM, Spitzer AR, Effken JA, Dodd E, Halpern M, McGrath JM. Discrimination of GutCheckNEC: a clinical risk index for necrotizing enterocolitis. J Perinatol. 2014;34:468–75.

    Article  CAS  Google Scholar 

  15. Fox JR, Thacker LR, Hendricks-Munoz KD. Early detection tool of intestinal dysfunction: impact on necrotizing enterocolitis severity. Am J Perinatol. 2015;32:927–32.

    Article  Google Scholar 

  16. Ji J, Ling X, Zhao Y, Hu Z, Zheng X, Xu Z, et al. A data-driven algorithm integrating clinical and laboratory features for the diagnosis and prognosis of necrotizing enterocolitis. PLoS ONE. 2014;9:e89860.

    Article  Google Scholar 

  17. Shah NP, Steyerberg EW, Kent DM. Big data and predictive analysis. Recalibrating Expect JAMA. 2018;320:27–28.

    Article  Google Scholar 

  18. Robinson JR, Rellinger EJ, Hatch LD, Weitkamp J-H, Speck KE, Danko M. Surgical necrotizing enterocolitis. Semin Perinatol. 2017;41:70–9.

    Article  Google Scholar 

  19. Kim WY, Kim WS, Kim IO, Kwon TH, Chang W, Lee EK. Sonographic evaluation of neonates with early-stage necrotizing enterocolitis. Pediatr Radiol. 2005;35:1056–61.

    Article  Google Scholar 

  20. Dilli D, Suna Oguz S, Erol R, Ozkan-Ulu H, Dumanli H, Dilmen U. Does abdominal sonography provide additional information over abdominal plain radiography for diagnosis of necrotizing enterocolitis in neonates? Pediatr Surg Int. 2011;27:321–7.

    Article  Google Scholar 

  21. Hashem RH, Mansi YA, Almasah NS, Abdelghaffar S. Doppler ultrasound assessment of the splanchnic circulation in preterms with neonatal sepsis at risk for necrotizing enterocolitis. J Ultrasound. 2017;20:59–67.

    Article  Google Scholar 

  22. Cuna AC, Reddy N, Robinson AL, Chan SS. Bowel ultrasound for predicting surgical management of necrotizing enterocolitis: a systematic review and meta-analysis. Pediatr Radiol. 2018;48:658–66.

    Article  Google Scholar 

  23. Henry MCW, Moss RL. Neonatal necrotizing enterocolitis. Sem Ped Surgery. 2008;17:98–109.

    Article  Google Scholar 

  24. Gordon PV, Swanson JR, Spitzer A. The complete blood cell count in a refined cohort of preterm NEC: the importance of gestational age and day of diagnosis when using the CBC to estimate mortality. J Perinatol. 2016;36:121–5.

    Article  CAS  Google Scholar 

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Acknowledgements

We thank the faculties at Albany Medical Center, the University of Rochester and the University at Buffalo for their help in standardized documentation of physical examinations and Holly Wadkins, Caitlin Fallone, and Ann Marie Scorsone for assistance with data extraction.

Funding

Supported in part by the Clinical and Translational Science Award UL1 TR000445.

Author information

Authors and Affiliations

  1. Albany Medical Center, Albany, NY, USA

    Rubia Khalak

  2. Golisano Children’s Hospital, Rochester, NY, USA

    Carl D’Angio, Hongyue Wang & Jeffrey Meyers

  3. Children’s Hospital of Buffalo, Buffalo, NY, USA

    Bobby Mathew & Stephanie Guilford

  4. Cohen Children’s Medical Center, New Hyde Park, NY, USA

    Elizabeth Thomas

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  1. Rubia Khalak
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  2. Carl D’Angio
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Correspondence to Rubia Khalak.

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Khalak, R., D’Angio, C., Mathew, B. et al. Physical examination score predicts need for surgery in neonates with necrotizing enterocolitis. J Perinatol 38, 1644–1650 (2018). https://doi.org/10.1038/s41372-018-0245-1

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