Preventing severe necrotizing enterocolitis: Propensity score analysis of interventions associated with surgical NEC or NEC-associated death.

PURPOSE: To determine what modifiable interventions used in the neonatal intensive care unit (NICU) are associated with severe necrotizing enterocolitis (NEC) requiring surgical intervention. METHODS: A retrospective review of patients treated for NEC at a tertiary hospital from 1991 to 2016 was performed. Patient characteristics were used to calculate propensity scores for likelihood of exposure to seven interventions: enteral feeds, use of glucocorticoids, nonsteroidal anti-inflammatory drugs (NSAIDs), antacids, antibiotics, or umbilical arterial (UAC) and venous catheters (UVC). Conditional logistic regression was used to compare the odds of having surgical NEC if exposed to each treatment. RESULTS: We included 195 NEC patients: 69 severe NEC managed with surgery and 126 non-severe NEC managed medically. After propensity score matching based on birth characteristics, exposure to glucocorticoids (OR 5.21, 95%CI: 1.62, 16.70), NSAIDs (OR 4.87, 95%CI: 1.67, 14.17), UVC (OR 2.53 (95%CI: 1.19, 5.73), and UAC (OR 4.91, 95%CI: 2.12, 11.37) were associated with surgical NEC in separate conditional logistic regression analyses. Including these treatments in a second round of propensity matching and conditional logistic regression revealed that glucocorticoids (OR 2.99, 95%CI: 1.01, 8.88), NSAIDs (OR 3.97, 95%CI: 1.41, 11.19), UVC (OR 3.07, 95%CI: 1.46, 6.48), and UAC (OR 5.10, 95%CI: 2.10, 12.36) were still associated with surgical NEC. CONCLUSION: After controlling for birth confounders and common NICU supportive interventions, use of glucocorticoids, NSAIDs and umbilical catheters independently increased the odds of developing severe NEC requiring surgical intervention. LEVEL-OF-EVIDENCE RATING: Case-control, Level III evidence.

Respiratory outcomes in the first 10 years of life in children with gastroschisis: A retrospective cohort study.

BACKGROUND: Little attention has been given to the long-term respiratory outcomes of children with gastroschisis. The purpose of this study was to determine if gastroschisis survivors have more respiratory illnesses in their first 10 years of life compared with age-matched controls. METHODS: We performed a retrospective cohort study of all gastroschisis children born in Manitoba between 1991 and 2017. Gastroschisis cases were identified from a clinical database, and a date of birth-matched control cohort was constructed from a population-based data repository. International Classification of Disease codes were used to compare the risk and frequency of respiratory diagnoses for children with gastroschisis to date of birth-matched controls from 0-5 years of age and 5-10 years of age. RESULTS: The 0-5 years of age analysis included 117 gastroschisis cases and 1205 date of birth-matched controls; children with gastroschisis had a higher risk of asthma (relative risk [RR] = 1.46; 95% confidence interval [CI]: 1.03, 2.55; p = .029), acute bronchitis/bronchiolitis (RR = 1.61; 95% CI: 1.27, 2.03; p < .001), pneumonia (RR = 1.99; 95% CI: 1.45, 2.72; p < .001), viral pneumonia (RR = 5.15; 95% CI: 1.79, 14.81; p = .007), and pneumonia due to unspecified organism (RR = 2.06; 95% CI: 1.45, 2.92; p < .001). Gastroschisis children 0-5 years of age were also diagnosed more frequently with bronchitis/bronchiolitis (RR = 2.14; 95% CI: 1.79, 2.57; p < .001) and viral pneumonia (RR = 8.10; 95% CI: 3.79, 17.31; p < .001). The 5-10 years of age analysis included 73 cases and 738 controls; no difference in the risk of respiratory illness was found for gastroschisis cases and controls in this age group. However, gastroschisis cases were more frequently diagnosed with bacterial pneumonia (RR = 3.03; 95% CI: 1.67, 5.51; p < .001) and influenza (RR = 3.03; 95% CI: 1.67, 5.51; p < .001). CONCLUSION: Our study shows that children with gastroschisis have an increased risk of asthma and respiratory infections compared with children without gastroschisis, most noticeably in the first 5 years of life.

High-frequency vs. conventional ventilation at the time of CDH repair is not associated with higher mortality and oxygen dependency: a retrospective cohort study.

PURPOSE: The VICI-trial reported that in patients with congenital diaphragmatic hernia (CDH), mortality or bronchopulmonary dysplasia (BPD) were equivalent using conventional mechanical ventilation (CMV) and high-frequency oscillatory ventilation. The purpose of this study was to determine if the mode of ventilation at the time of CDH repair affected mortality or oxygen dependence at 28 days. METHODS: We performed a retrospective cohort study of infants born wih CDH from 1991 to 2015. A generalized linear model was applied to the data using a propensity score analysis. RESULTS: Eighty patients met the inclusion criteria; at the time of surgery 39 (48.8%) patients were on HFV and 41 (51.3%) patients were on CMV. In the HFV group, 16 (47.1%) patients remained oxygen dependent and there were 5 (12.8%) deaths at 28 days. In the CMV group, 5 (12.2%) patients remained oxygen dependent at 28 days but none had died. The base model demonstrated that the HFV group had increased rates of oxygen dependence [OR = 6.40 (2.13, 22.2), p = 0.002]. However, after propensity score analysis, we found no difference between HFV and CMV. CONCLUSION: Our study suggests that in infants with CDH, there is no significant difference between HFV and CMV in oxygen dependency or death.

Asthma Medication Use in Congenital Diaphragmatic Hernia Survivors: A Retrospective Population Level Data Analysis.

INTRODUCTION: The purpose of this study was to determine if congenital diaphragmatic hernia (CDH) survivors had worse long-term respiratory outcomes compared with age-matched controls, as measured by inhaled bronchodilator use, inhaled steroid use, and asthma-related physician visits. MATERIALS AND METHODS: We performed a retrospective case-control study of infants with isolated CDH from 1991 to 2013. The primary outcome measures were inhaled bronchodilator prescriptions, inhaled steroid prescriptions, and asthma-related physician visits between 0 and 5 years of age and between 5 and 10 years of age. Subgroup analysis compared the same outcomes for CDH patients grouped by: birth weight, gestational age, side of defect, defect size, liver herniation, hernia sac, and pulmonary hypertension. RESULTS: Fifty-six patients with CDH and 753 age-matched controls met the inclusion criteria for the 0 to 5 years of age analysis. Between 0 and 5 years of age, more CDH survivors were prescribed an inhaled bronchodilator (odds ratio [OR] = 2.47[1.38-4.48], p = 0.001) and inhaled steroid (OR = 2.03[1.07-3.74], p = 0.03), and had an asthma-related physician visit (OR = 1.92[1.00-3.56], p = 0.04). Thirty-eight cases and 491 controls met the inclusion criteria for the 5 to 10 years of age analysis. Between 5 and 10 years of age, CDH survivors were not more likely to be prescribed inhaled bronchodilators, inhaled steroids, or have an asthma-related physician visit. Among the CDH patients, we did not find a clinical characteristic associated with increased inhaled bronchodilator or steroid prescriptions at any age. CONCLUSION: A history of CDH is associated with higher rates of inhaled bronchodilator prescriptions, inhaled steroid prescriptions, and asthma-related physician visits from 0 to 5 years of age compared with age-matched controls. However, this difference resolves by 5 to 10 years of age.

The presence of a hernia sac in isolated congenital diaphragmatic hernia is associated with less disease severity: A retrospective cohort study.

INTRODUCTION: We aimed to determine if the presence of a hernia sac in neonates with isolated congenital diaphragmatic hernia (CDH) was associated with better clinical outcomes. METHODS: We performed a retrospective cohort study of infants with isolated CDH from 1991 to 2015. Primary outcome measures were oxygen-dependence and mortality at 28 days. Secondary measures were: inhaled nitric oxide use, vasoactive medication use, ventilator support, and recurrence rates. RESULTS: Seventy-one patients met the inclusion criteria: 14 patients (19.7%) had a hernia sac, and 57 patients (80.3%) did not. Mortality did not differ between the 2 groups [0 of 14 versus 3 of 57 (5.3%) (p = 1.000)]. Hernia sac patients had similar oxygen-dependence after 28 days [1 of 14 (7.1%) versus 14 of 57 (24.6%) (p = 0.273)]. Hernia sac children required less iNO (0.64 ±â€¯2.41 vs. 6.35 ±â€¯12.2 days, p = 0.002), vasoactive medications (2.79 ±â€¯3.07 vs. 5.36 ±â€¯5.52, p = 0.027), and time on ventilation (7.62 ±â€¯6.12 vs. 15.9 ±â€¯19.2, p = 0.010). Hernia sac children had similar recurrence rates within 2 years [0 of 14 versus 7 of 57 (12.3%) (p = 0.331)]. CONCLUSION: The presence of a hernia sac was not associated with lower rates of oxygen dependency or death at 28 days but was associated with decreased inhaled nitric oxide, vasoactive medication, and ventilator use. LEVEL OF EVIDENCE: III.