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

  • Michael Cowap
    Affiliations
    Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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  • Danielle Stepnuk
    Affiliations
    Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada

    Obstetrics, Gynecology & Reproductive Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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  • Christopher Stockl
    Affiliations
    Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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  • Emma Wolfe
    Affiliations
    Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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  • Matthew Levesque
    Affiliations
    Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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  • Anna C. Shawyer
    Affiliations
    Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada

    Departments of Surgery and Pediatrics & Child Health, Division of Pediatric Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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  • Rob Balshaw
    Affiliations
    Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
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  • Suyin A. Lum Min
    Affiliations
    Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada

    Departments of Surgery and Pediatrics & Child Health, Division of Pediatric Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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  • Richard Keijzer
    Correspondence
    Corresponding Author: Address: Health Sciences Centre AE402-820 Sherbrook Street Winnipeg, Manitoba, Canada R3A 1S1 Tel.: +1 204 787 1246
    Affiliations
    Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada

    Departments of Surgery and Pediatrics & Child Health, Division of Pediatric Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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      Summary

      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 1991-2016 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.

      Keywords

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