Hyponatremia at the onset of necrotizing enterocolitis is associated with intestinal surgery and higher mortality

Abstract

It has previously been shown that hyponatremia reflects the severity of inflammation in pediatric gastrointestinal diseases. Interpretation of electrolyte disorders is a common, but not well studied challenge in neonatology, especially in the context of early detection of necrotizing enterocolitis and bowel necrosis. The aim of this study was to assess if hyponatremia, or a decrease in plasma sodium level, at the onset of necrotizing enterocolitis (NEC) is associated with intestinal ischemia/necrosis requiring bowel resection and/or NEC-related deaths. This was a retrospective cohort study including patients with verified NEC (Bell’s stage ≥ 2) during the period 2009–2014. Data on plasma sodium 1–3 days before and at the onset of NEC were collected. The exposure was hyponatremia, defined as plasma sodium < 135 mmol/L and a decrease in plasma sodium. Primary outcome was severe NEC, defined as need for intestinal resection due to intestinal ischemia/necrosis and/or NEC-related death within 2 weeks of the onset of NEC. Generalized linear models were applied to analyze the primary outcome and presented as odds ratio. A total of 88 patients with verified NEC were included. Fifty-four (60%) of them had severe NEC. Hyponatremia and a decrease in plasma sodium at onset of NEC were associated with increased odds of severe NEC (OR crude 3.91, 95% CI (1.52–10.04) and 1.19, 95% CI (1.07–1.33), respectively). Also, a sub-analysis, excluding infants with pneumoperitoneum during the NEC episode, showed an increased odds ratio for severe NEC in infants with hyponatremia (OR 23.0, 95% CI (2.78–190.08)).Conclusions: The findings of hyponatremia and/or a sudden decrease in plasma sodium at the onset of NEC are associated with intestinal surgery or death within 2 weeks. What is Known:• Clinical deterioration, despite optimal medical treatment, is a relative indication for surgery in infants with necrotizing enterocolitis.• Hyponatremia is a common condition in preterm infants from the second week of life. What is New:• Hyponatremia and a decrease in plasma sodium level at the onset of necrotizing enterocolitis are positively associated with need of surgery or death within 2 weeks.• In infants with necrotizing enterocolitis, without pneumoperitoneum, where clinical deterioration despite optimal medical treatment is the only indication for surgery, hyponatremia, or a decrease in plasma sodium level can predict the severity of the disease.

Case report: Acute severe hyponatremia-induced seizures in a newborn: a community-acquired case and literature review

“…The most common cause of euvolemic hyponatremia is the syndrome of inappropriate antidiuretic hormone (SIADH) secretion, which can be significantly exacerbated by systemic inflammation. Additionally, CRP is associated with hyponatremia (Park and Shin, 2013;Baez et al, 2023). This infant exhibited elevated white blood cell count and CRP, indicating the presence of an infection-related inflammatory response.…”

Survey on surgical treatment of neonatal necrotizing enterocolitis in China 2022

“… 7 13 Interpretation of electrolyte disorders should be given more attention. 13 WBC, CRP, PCT, and IL-6 are all non-specific mediators of inflammation; CRP is the most commonly used biomarker as a late-warning biomarker, whereas IL-6, an early-warning biomarker, has not been frequently employed in clinical settings because many hospitals do not have relevant detection capability. 14 15 Since the cut-off values for fecal calprotectin cannot be identified and it is significantly influenced by gestational and postnatal age, it is rarely used in routine clinical practice.…”

Correlation of systemic immune-inflammation Index with surgical necrotizing enterocolitis

“…Recently, there are various methods used to predict surgical NEC, among which inflammatory markers were more common because inflammatory mediators play a critical role in the occurrence of NEC. Early predictors that have been reported are as follows: C-reactive protein/albumin ratio, serum albumin concentration, interleukin (IL) 6 and coagulation function at NEC diagnosis, trends in C-reactive protein and lactate within 72 h of NEC diagnosis, IL-8 and IL-10 within 72 h of life (infants born less than 1500 g), and hyponatremia and/or the sudden decrease in plasma sodium at the onset of NEC (2,16,(31)(32)(33)(34). However, these methods have at least one of the following deficiencies, which limit clinical use and promotion: lack of enough sensitivity and specificity, expensive, inconvenience.…”

“…Over the past several decades, selection of treatment strategies for NEC remains a challenge for pediatric surgeons and neonatologists. When inflammation and intestinal injury are limited, NEC can be treated medically, includes bowel rest and careful use of antibiotics, but surgery is needed if the patient continue to deteriorate after medical treatment or develop bowel perforation ( 2 ). Epidemiologic data revealed that about 30% of neonates with NEC may require surgical intervention with an overall case-fatality rate of 15% ( 3 ).…”