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Surgical Necrotizing Enterocolitis and Spontaneous Intestinal Perforation Lead to Severe Growth Failure in Infants
*
Allison L. Speer1, Kevin P. Lally
1, *Claudia Pedroza
2, *Yuxin Zhang
2, *Barry Eggleston
4, *Brenda Poindexter
3, Walter Chwals
3, *Susan R. Hintz
3, Gail Besner
3, *David K. Stevenson
3, *Robin Ohls
3, *William Truog
3, *Barbara J. Stoll
3, *Matthew A. Rysavy
2, *Abhik Das
4, *Michele Walsh
3, *Jon E. Tyson
2, Martin L. Blakely
11Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX; 2Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX; 3Neonatal Research Network (NRN) NEST Subcommittee, National Institute of Child Health and Human Development (NICHD), Research Triangle Park, NC; 4RTI International, Research Triangle Park, NC
Objectives: Surgical necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) have high mortality and most affected infants have neurodevelopmental impairment (NDI) and poor growth. Existing literature of growth outcomes for these infants is retrospective and sparse. We utilized high-quality, prospectively collected data from the Necrotizing Enterocolitis Surgery Trial (NEST) to determine if the incidence of growth failure differs in infants with NEC versus SIP and whether initial laparotomy (LAP) versus peritoneal drainage (PD) impacted the likelihood of growth failure.
Methods: The NEST was a multicenter, RCT investigating the effect of initial LAP versus PD on death or NDI at 18-22 months in infants with NEC or SIP. This is a preplanned secondary study of NEST survivors (n=219) using the NICHD Neonatal Research Network NEST dataset. Our primary outcome is growth failure (Z-score for weight of <-2.0 at 18-22 months). A Z-score = 0 is 50
th percentile and a Z-score = +1 is one SD above the mean. We used the preoperative and the intraoperative diagnosis of NEC and SIP in analyses (preop diagnosis analyses in this abstract). Groups were compared using Fisher's exact and Pearson's Chi-squared test for categorical variables, and Wilcoxon rank sum test and one-way ANOVA for continuous outcomes. Primary outcome was analyzed with a logistic model including treatment group, preop diagnosis, and their interaction as covariates and center as a random effect.
Results: Among 219 survivors in the NEST, 207 infants had growth data (95%); growth failure occurred in 24/50 (48%) infants with NEC vs 65/157 (42%) with SIP (p = 0.4) at 18-22 months. Mean Z-score for weight at 18-22 months in infants with NEC was -2.05 ± 0.99 vs -1.84 ± 1.09 with SIP (p = 0.2). In infants with NEC, those receiving initial PD had lower Z-scores for weight at all postop timepoints (Figure) and a higher rate of growth failure at 18-22 months (52% vs 44% for LAP) (p = 0.7). Infants with NEC who had initial PD compared to LAP had slower initiation of enteral feeds (24 vs 14 days, p < 0.001), longer time to full enteral feeds (52 vs 38 days, p = 0.008), longer duration of parenteral nutrition (PN) (83 vs 61 days, p = 0.022), and increased PN-associated liver disease (50% vs 36%, p = 0.2). Infants with NEC had higher rates of short bowel syndrome (SBS) (24% vs 7.3% with SIP p = 0.031), and infants with NEC who underwent initial PD had higher rates of gastrostomy tube at discharge (29% vs 16% for LAP and 11-13% for SIP; p = 0.2).
Conclusions: This first ever prospective study of growth outcomes in infants with surgical NEC or SIP demonstrates that growth failure is extremely common, and is most common with NEC, especially after initial PD. Growth failure persists at 18-22 months and is associated with delayed enteral feeds, prolonged PN, and higher rates of PNALD and SBS. These results inform current management and prognostic considerations for these vulnerable infants.
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