Necrotizing Enterocolitis Risk State of the Science

College of Nursing, University of Arizona, Tucson, 85721, USA.
Advances in Neonatal Care 04/2012; 12(2):77-87; quiz 88-9. DOI: 10.1097/ANC.0b013e31824cee94
Source: PubMed

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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    ABSTRACT: Purposes/Aims: To describe a method using Electronic Health Record (EHR) data to derive, validate and test prediction of GutCheckNEC, a composite risk index for Necrotizing Enterocolitis (NEC) and describe opportunities to build the science and practice of risk identification by applying this method in other practice-based evidence contexts. Rationale/ Conceptual Basis/ Background: NEC leads to death in 30-50% of cases, accounts for nearly 20% of US neonatal intensive care (NICU) costs, and is a leading cause of neonatal death. Early identification of NEC is a formidable challenge. Infants who die from NEC are diagnosed, on average, 3 days later than survivors. Composite risk for NEC has not been rigorously tested, although several risk factors have been described. Standardizing communication of NEC risk across multiple handoffs using a risk score could improve treatment for the most vulnerable, improving nurse’s ability to rescue infants with NEC. Methods: Design: A 2-step process of empiric derivation and validation following Pollack’s technique used to derive and test the PRISM III pediatric severity of illness measure was used. Sample: De-identified infant data contained in the Pediatrix BabySteps Clinical Data Warehouse, representing 20% of US NICU admissions from 284 NICUs with discharge dates from 2007-2011 was analyzed including all infants was born before 36 weeks and weighing < 1500 grams (N=58,818). Analysis: The dataset was randomly split into 2/3 for derivation (n=35,005) and 1/3 for validation (n=23,813). Derivation: Risk items were entered into a logistic model according to a theoretical model determined by E-Delphi of experts in Phase I. Risk items significant in univariate analysis (p< .10) were then entered into a multivariate model and then retained or deleted (p< .05). Validation: Beta weights for independent predictors were multiplied by 10, rounded up to the nearest integer value, then a summed risk score was computed. Prediction was tested using Receiver Operator Characteristic (ROC) Curve analysis. Results: Broad variations in NEC rates were identified across the 284 units. Retained items included 9 risk factors (gestational age, transfusion, Unit NEC risk, late onset sepsis, multiple infections, hypotension treated with Inotropic medications, Black or Hispanic race, birth in a different NICU, metabolic acidosis) and 2 risk reducers (human milk feeding on both day 7 and day 14 of life, probiotics). Prediction was good in the validation set for all NEC (AUC=.76, 95% CI .75-.78) and very good for surgical NEC (AUC=.84, 95% CI .82-.84) and NEC leading to death (AUC=.83, 95% CI .81-.85). At a cut-point of 33 (range 0-58), GutCheckNEC was sensitive (.78) and specific (.74). Unit NEC risk carried the most weight in the summed score. Implications: Future research is needed to explore institutional variation in NEC incidence, to inform a NEC-prevention bundle, complete psychometric testing of GutCheckNEC, and automate it for clinical use. Using Electronic Health Record (EHR) data holds promise across settings to build and test clinically usable risk assessments to support just-in-time clinical rescue.
    2014 Western Institute of Nursing Annual Communicating Nursing Research Conference; 04/2013
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    ABSTRACT: Risk for neonatal necrotizing enterocolitis (NEC) is complex, reflecting its multifactorial pathogenesis.
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    ABSTRACT: Objetivo: investigar a incidência e gravidade das complicações pós-operatórias precoces e identificar fatores de risco para o seu desenvolvimento em recém-nascidos submetidos ao tratamento cirúrgico, sob anestesia geral. Métodos: análise retrospectiva dos dados de 437 neonatos com doença crítica submetidos à cirurgia neonatal num centro cirúrgico pediátrico terciário, entre janeiro de 2000 e dezembro de 2010. A gravidade das complicações ocorridas nos primeiros 30 dias de pós-operatório foi classificada utilizando o sistema de Clavien-Dindo para complicações cirúrgicas, sendo considerados graves os graus III a V. Por análise estatística uni e multivariada avaliaram-se variáveis pré e intraoperatórias com potencial preditivo de complicações pós-operatórias graves. Resultados: a incidência de, pelo menos, uma complicação grave foi 23%, com uma mediana de uma complicação por paciente 1:3. Ao todo, ocorreram 121 complicações graves. Destas, 86 necessitaram de intervenção cirúrgica, endoscópica ou radiológica(grau III), 25 puseram em risco a vida, com disfunção uni ou multi-órgão (grau IV) e dez resultaram na morte do paciente (grau V). As principais complicações foram técnicas (25%), gastrointestinais (22%) e respiratórias (21%). Foram identificados quatro fatores de risco independentes para complicações pós-operatórias graves: reoperação, operação por hérnia diafragmática congênita, prematuridade menor que 32 semanas de idade gestacional e cirurgia abdominal. Conclusão: a incidência de complicações pós-operatórias graves após cirurgias neonatais, sob anestesia geral, permaneceu elevada. As condições consideradas fatores de risco independentes para complicações graves após a cirurgia neonatal podem ajudar a definir o prognóstico pós-operatório em neonatos com doença cirúrgica e orientar as intervenções para melhoria de resultados.
    Revista do Colégio Brasileiro de Cirurgiões 01/2013; 40(5):363-369. DOI:10.1590/S0100-69912013000500003


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