Imaging, radiation exposure, and attributable cancer risk for neonates with necrotizing enterocolitis

Abstract Purpose: Neonates with necrotizing enterocolitis (NEC) receive numerous radiologic investigations that potentially increase their lifetime cancer mortality risk. We evaluated our radiologic practice pattern for patients with NEC and estimated cumulative radiation exposure and lifetime cancer risk. Methods: Infants with NEC in a tertiary care NICU had patient demographics, imaging, treatments/ interventions, and outcomes analyzed over 3 years. The number and type of imaging were recorded, including NEC-related imaging (thoraco-abdominal "babygrams" and abdominal radiographs), and all other imaging modalities. Patients were stratified by birth weight: group 1 (b 750 g); group 2 (751-1500 g); and group 3 (N 1501 g). Pre-existing normative data were used to calculate radiation exposure, absorption, and attributable cancer risk from NEC-related imaging. Results: Sixty-four neonates with 72 episodes of NEC were identified. Overall survival was 75.0%. When stratified by birth weight, mean abdominal radiographs and babygrams comprised 51%, 60%, and 74% of total imaging, giving median mGy doses of 2.1, 0.4, and 0.2, respectively. Compared to normative data, radiation dosing, and median cumulative cancer lifetime mortality risk increased by an average of 4.3 × from baseline, with two cases documenting a 20-fold increase. Conclusion: Neonates with NEC are exposed to significant amounts of radiation directly attributable to disease surveillance. Non-radiologic surveillance methods could significantly reduce radiation exposure and cancer risk in these infants

Gastroschisis prognostic score predicts high-risk newborns with gastroschisis in a middle-income country

INTRODUCTION: The Gastroschisis Prognostic Score (GPS) stratifies patients as high or low-risk based on the visual assessment of intestinal matting, atresia, perforation, or necrosis shortly after birth. Its applicability to low and middle-income settings remains unknown. This study aimed to validate the GPS as a prognostic tool in a public hospital within a middle-income country. METHODS: With REB approval, we conducted a prospective study of all newborns with gastroschisis in a Brazilian neonatal public hospital from 2015-2019. Infants were stratified into low and high-risk cohorts based on the GPS. In addition to basic demographics, data collected included duration of parenteral nutrition (TPN), mechanical ventilation (MV), length of stay (LOS), sepsis, and mortality. Univariate and multivariate analyses were conducted to identify which outcomes the GPS independently predicted.RESULTS: Sixty-one newborns with gastroschisis were treated in our center. The mean birth weight, gestational age, and 5’ Apgar score were 2258g, 36weeks, and 9. Accordingly to the GPS, 24 infants (39.3%) were identified as low-risk and 37 (60.7%) as high-risk. The high-risk group presented with prolonged use of TPN (p<0.001), MV (p<0.001), and LOS (p:0.002). There was no association between GPS with sepsis or mortality in this study. CONCLUSION: This is the first study that validates the GPS as a prognostic tool in a middle-income country. Several important outcome measures were predicted by the GPS allowing for better parental counseling and resource allocation. The GPS is a reliable tool that can be used in various resource settings

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030