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Am J Perinatol 2024; 41(S 01): e3401-e3412
DOI: 10.1055/s-0043-1778666
Original Article

A Novel Integrated Clinical–Biochemical–Radiological and Sonographic Classification of Necrotizing Enterocolitis

Yasser Elsayed 
1   Section of Neonatology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
,
Deepak Louis 
1   Section of Neonatology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
,
Martha Hinton
2   Department of Pediatrics, Biology of Breathing Theme, Children's Hospital Research Institute of Manitoba, Manitoba, Winnipeg, Canada
,
Mary Seshia
1   Section of Neonatology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
,
Ruben Alvaro
1   Section of Neonatology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
,
Shyamala Dakshinamurti
1   Section of Neonatology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
2   Department of Pediatrics, Biology of Breathing Theme, Children's Hospital Research Institute of Manitoba, Manitoba, Winnipeg, Canada
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Funding None.
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Abstract

Objective To evaluate the sensitivity and specificity of clinical, laboratory, and radiological markers and the neonatologist-performed intestinal ultrasound (NP-IUS) for treatment interventions in preterm neonates who developed necrotizing enterocolitis (NEC).

Study Design This was a case–control study of preterm neonates < 35 weeks with a diagnostic workup for NEC. The diagnostic workup included NP-IUS performed by trained neonatologists using a standard protocol, abdominal roentgenogram (AXR), and laboratory investigations. Intestinal ultrasound (IUS) performed by two neonatologists was standardized to detect 11 injury markers. AXRs were read independently by experienced pediatric radiologists. The investigators who retrospectively interpreted the IUS were blinded to the clinical and treatment outcomes.

Results A total of 111 neonates were assessed. Fifty-four did not require intervention and formed the control group. Twenty cases were treated medically, 21 cases were treated with late surgery for stricture or adhesions, and 16 were treated with early surgery. The integrated model of cumulative severity of ultrasound markers, respiratory and hemodynamic instability, abdominal wall cellulitis, and C- reactive protein > 16 mg/L had an area under the curve (AUC) of 0.89 (95% confidence interval [CI]: 0.83–0.94%, p < 0.0001) for diagnosing NEC requiring surgical intervention. We also investigated the utility of Bell's classification to diagnose either the need for surgery or death, and it had an AUC of 0.74 (95% CI: 0.65–0.83%, p < 0.0001).

Conclusion In this cohort, a combination of specific IUS markers and clinical signs of instability, abdominal wall cellulitis, plus laboratory markers were diagnostic of NEC requiring interventions.

Key Points

  • The diagnosis of necrotizing enterocolitis requires a combination of markers.

  • The combination of specific ultrasound markers, clinical signs, and laboratory markers were diagnostic of NEC requiring intervention.

  • The intestinal ultrasound performed by a trained neonatologist was the most sensitive diagnostic marker of NEC requiring surgical intervention.

Keywords

necrotizing enterocolitis - NICU - preterm infants - intestinal ultrasound

Note

There is no single predictive marker for diagnosing NEC, and the conventional X-ray is inaccurate in the radiological assessment of NEC. Neonatologists performed an intestinal ultrasound integrated into clinical and laboratory markers, which is predictive of management interventions of NEC in preterm infants.


Authors' Contributions

All authors contributed substantially to the manuscript and the design of the work: Y.E. conceptualized and designed the study, wrote the first draft, and finalized the manuscript. M.H. analyzed data and generated figures. D.L. analyzed the intestinal ultrasound images and edited the manuscript. M.S. reviewed and edited the manuscript, R.A. edited the manuscript, and S.D. analyzed data wrote and substantially edited the manuscript. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.


Ethical Approval

The Ethical Committee approved this study at the University of Manitoba for data collection and publication.


Supplementary Material



Publication History

Received: 22 January 2023

Accepted: 19 December 2023

Article published online:
11 January 2024

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