The temporal relationship between exposure to bovine milk products and development of surgical necrotising enterocolitis in preterm infants

Necrotising enterocolitis (NEC) continues to be a major cause of neonatal mortality and morbidity. It is less common in breastfed infants suggesting a protective role for breast milk. However NEC is now being seen in fully breast milk fed infants following introduction of fortifiers derived from bovine milk, which suggests a possible causative role for bovine products. This study investigates the relationship between the commencement of feed containing bovine milk products and the development of surgical NEC in preterm infants

Do infants with gastroschisis may have a high incidence of non-IgE-mediated cow's milk protein allergy?

Background/purposeTo determine the frequency and characteristics of suspected cow’s milk protein allergy (CMPA) in infants with gastroschisis and response to change in milk.MethodsA retrospective cohort study of 111 consecutive infants with gastroschisis.Results64 episodes suggesting non-IgE-mediated CMPA occurred in 50 infants (45 %) at a median age of 44 days (9–186) and during the primary admission in 38 %. At the time of the episode the infant feed was breast milk (BM, n = 24), term formula (TF, n = 20) or extensively hydrolysed formula (EHF, n = 6). The feed was changed to EHF (34), amino acid formula (AAF) (14) or BM with maternal CMP-free diet (2). Partial or complete resolution of symptoms occurred in all. There was histological evidence of an allergic reaction to CMP in all four infants in whom tissue was available. Recurrent episodes occurred in 13/50 infants (26 %), 10 of whom were receiving EHF. There were no recurrent episodes in infants being fed with AAF.ConclusionFeatures suggesting non-IgE-mediated CMPA appear common in infants with gastroschisis

The nutritional role of amniotic fluid – clues from infants with congenital obstruction of the digestive tract

AIMS To investigate the role played by amniotic fluid in late fetal nutrition by analysis of infants born with digestive tract atresia. METHODS Birth weight, gestational age and gender of infants born with oesophageal (OA), duodenal (DA), jejunal (JA) and ileal atresia (IA) were recorded and birth weight (BW) Z-scores compared. Infants with incomplete obstruction (stenosis), chromosomal or syndromic conditions, and multiple congenital malformations were excluded. Term infants admitted with suspected postnatal intestinal obstruction in whom no congenital malformation was found were used as a control group. RESULTS A total of 584 infants were identified comprising 148 OA, 60 DA, 26 JA and 57 IA with 293 in the control group. Infants with OA and DA had statistically significantly lower BW Z-score than controls. However, BW Z-score for infants with more distal atresia (JA and IA) was similar to controls. When compared with infants with OA, BW Z-score for infants with more distal atresia was higher than that for OA. BW Z-score in infants with OA was significantly lower in those born at term compared to those born preterm (mean -0.92±SD1.0 vs -0.48±0.87; p=0.01) with a significant negative correlation between BW Z-score and increasing gestational age (R2 = 0.12; p<0.0001). This effect of gestational age was not seen in other atresias. CONCLUSION These observations support the concept that reduced enteral absorption of amniotic fluid due to high digestive tract obstruction in utero reduces fetal growth. The effect is greater when the obstruction is more proximal and with advancing gestation

Emergency laparotomy in infants born at <26 weeks gestation: a neonatal network based cohort study of frequency, surgical pathology and outcomes

Objective Identify the proportion of infants born at &lt;26 completed weeks’ gestation who require emergency laparotomy, and review the surgical pathology, incidence of subsequent surgical procedures and outcome.Design Retrospective cohort review.Setting Tertiary neonatal surgical unit.Patients All infants born at &lt;26 weeks’ gestation in a neonatal network over an 8-year period.Results Of 381 infants, laparotomy was indicated in 61 (16%) and performed in 57. Surgical pathology encountered included spontaneous intestinal perforation (SIP) (28), necrotising enterocolitis (NEC) (14), volvulus without malrotation (1), strangulated inguinal hernia (1), milk curd obstruction (4), NEC stricture (1) and meconium obstruction of prematurity (2). No intestinal pathology was found in six. Four infants with indications for laparotomy and severe comorbidity had intensive care withdrawn without surgery. The most frequent procedure performed was resection with primary anastomosis. Nine infants (16%) required more than one laparotomy. Of the 16 infants who had stoma formation, eight had closure before discharge. Fifteen infants required surgical patent ductus arteriosus ligation following laparotomy, and 17 had laser therapy for retinopathy of prematurity. Overall 42 infants with indication for laparotomy (69%) survived to discharge.Conclusions Nearly one in six infants born at &lt;26 weeks required emergency laparotomy. The most frequent pathology encountered was SIP (49%), followed by NEC (25%). Over one-quarter required subsequent gastrointestinal surgery, with many also requiring cardiothoracic and ophthalmic procedures. These data are important for those caring for extremely preterm infants, the provision of information to parents and organisation of neonatal services.</p

Growth pattern of infants with gastroschisis in the neonatal period

Background/Aim: Early postnatal growth patterns may have significant long term health effects. Although preterm infants on parenteral nutrition (PN)exhibit poor growth, growth pattern of term or near-term infants requiring PN is not well reported. We aimed to investigate this in infants born with gastroschisis. Methods: Retrospective review of all infants with gastroschisis requiring PN treated at a single centre over a 4 year period. Growth and clinical data were retrieved, and weight SDS scores for corrected gestational age calculated. Weight SDS (mean ± SD)were compared at clinically relevant timepoints and multi-level regression used to model growth trends over time. Main results: During the study period 61 infants with gastroschisis were treated; all were included. Infants were small for gestational age at birth for weight (SDS score −0.87 ± 0.85). Weight SDS decreased significantly during the first 10 days of age (mean decrease 0.81 ± 0.56; p &lt; 0.0001)and between birth and discharge (mean decrease 0.81 ± 0.56; p &lt; 0.0001). Despite tolerating full enteral feeds, weight SDS velocity was negative around the time of transition from parenteral to enteral feed. There was evidence of ‘catch up’ growth between 3 and 6 months of age. Conclusion: Despite nutritional support with PN, infants with gastroschisis demonstrate significant growth failure during the newborn period. Further efforts are required to understand the underlying mechanisms, improve nutritional support and to evaluate the long term consequences of postnatal growth failure in this population.</p

Association between administration of antacid medication and anastomotic stricture formation following repair of oesophageal atresia

Aims of study: Anastomotic stricture is a significant cause of morbidity following repair of oesophageal atresia (OA). Exposure to gastric acid has been postulated to contribute to stricture development and severity leading to prophylactic antacid use by some surgeons. We investigated the association between administration of antacid medication and the development of anastomotic strictures.Methods: Retrospective case-note review of consecutive infants undergoing repair of OA with distal tracheoesophageal fistula (Type C) between Jan 1994 and Dec 2014. Only infants who underwent primary oesophageal anastomosis at initial surgical procedure were included. Stricture related outcomes were compared initially for infants who received prophylactic antacid medication versus no prophylaxis, and the role of prophylactic antacid medication in stricture prevention was explored in a multivariate model. Outcomes were also compared for infants grouped by antacid use at any stage.Results: One hundred fourteen infants were included. Sixteen received prophylactic antacid medication at surgeon preference. Of the remaining 98, 44 subsequently received antacid as treatment for gastro-oesophageal reflux (GOR) and 54 never received antacid medication. There was no statistically significant association between incidence of stricture in the first year (10/16 vs 41/98; p=0.18) nor time to first stricture (median 57 days [41-268] vs 102 days [43-320]; p=0.89) and administration of prophylactic antacid medication. Similarly there were no statistically significant associations between incidence of stricture, age at first stricture and number of dilatations, and administration of antacid medication either as prophylaxis nor when given as treatment for symptoms or signs of GOR.Conclusions: These data do not support the hypothesis that prophylactic antacid medication reduces the incidence or severity of anastomotic stricture following repair of OA. Treatment with antacids may be best reserved for those with symptoms or signs of GOR. Further prospective investigation of the role of antacid prophylaxis on stricture formation following OA repair is warranted.<br/

The burden of excluding malrotation in term neonates with bile stained vomiting

PURPOSE: To determine the number of term infants with bilious vomiting (BV) referred to a neonatal surgical centre for exclusion of malrotation by upper gastrointestinal contrast (UGI) examination.METHODS: Retrospective review of term (&gt;37/40) neonates &lt;28 days of age undergoing UGI for exclusion of malrotation between Jan 2010 and Dec 2014 in a neonatal network with 30,000 term deliveries annually. Only infants with BV in the absence of alternative clinical/radiological diagnosis were included.RESULTS: One hundred and sixty-six infants met the inclusion criteria. Fourteen (9 %) infants had malrotation diagnosed by UGI and confirmed at laparotomy. Only 1 of 110 infants referred at 0-2 days of age had positive UGI compared to 13 of 56 infants referred after this age (p &lt; 0.01). An increase in referrals followed the death of an infant from midgut volvulus and as a result one in 500 term infants are currently being referred.CONCLUSION: Increasing awareness of the potential consequences of bilious vomiting appears to have resulted in increased referrals with no increase in detection of malrotation. Prospective studies are required to determine whether investigation of all infants with unexplained bilious vomiting is required and if it is possible to select cases for surgical referral

Use of trans-anastomotic tubes in congenital duodenal obstruction

Aim : Despite data to suggest benefit of trans- anastomotic tube (TAT) feeding in infants following repair of congenital duodenal obstruction (CDO), TAT usage is limited. We aimed to report a large series of infants with CDO treated with or without TAT in order to improve the evidence underlying this simple intervention. Method : Single centre retrospective review of all infants CDO over a 20-year period (January 1999 – November 2020, inclusive). Important outcomes were compared between infants treated with or without TAT. Data are median [IQR]. Results : Ninety-six infants were included. A TAT was placed in 54 infants (56%). Median time to full enteral feed was significantly shorter in the TAT group (6 [5-8] days vs 10 [7.5-12], p &lt;0.001). Time to first feed was shorter in the TAT group (2 [2-2.8] days vs 3 [2-5], p&lt;0.001). Significantly fewer infants with a TAT placed received a central venous catheter (CVC, 15% vs 76%, p &lt;0.001). Infants without a TAT received parenteral nutrition (PN) for longer (0 [0-0] vs 7 [0-11] days, p &lt;0.001). There was no change in length of stay between TAT and no TAT group (16 [13-21.8] vs 15 [12-21.8] days, p=0.722). Eight infants (15%) in the TAT group required a CVC and PN. One infant in the TAT group developed a perforation that required surgical management and nine infants in the non-TAT group had complications related to the CVC (21%), including one infant that required general anaesthetic for tunnelled central line placement (2.3%). Conclusion : In infants with CDO, TAT use was associated with earlier establishment of full enteral feeds, reduced need for CVC and PN and reduced complications. Further research should focus on the barriers to wider use of TAT by surgeons and neonatologists in infants with CDO

Intrauterine death rate in gastroschisis following the introduction of an antenatal surveillance programme: a retrospective observational study

Aim: to investigate whether an antenatal surveillance protocol including ultrasound and Cardiotocograph monitoring reduces intra-uterine death (IUD) in cases of gastroschisis.Secondary outcomes included neonatal death rate, mode of delivery and rate of intervention before planned time of delivery.Methods:this was a retrospective observational study of all women with an antenatally diagnosed gastroschisis who were managed according to our surveillance programme between 2002 and 2015 in a tertiary fetal medicine and paediatric surgical centre covering the Wessex Region of England. We reviewed and analysed data from the WANDA database as well as prospectively managed maternity, ultrasound and neonatal databases over the given time period. Case notes were reviewed when delivery was expedited.Results: the intra-uterine death rate was 2.2%, a 58% reduction since the introduction of our surveillance protocol. Delivery was expedited in 35.4% of cases and in 86% of these, delivery was by caesarean section. In women being induced as planned at 38 weeks, the vaginal delivery rate was 88% and for those in spontaneous labour before 38 weeks it was 75%.Conclusions: an antenatal surveillance programme appears to reduce the intra-uterine death in gastroschisis. In a third of cases, delivery was indicated before the planned date of delivery. When expedited delivery was indicated, the chance of caesarean section was high.<br/