Necrotizing Enterocolitis and Associated Mortality in Neonates With Congenital Heart Disease: A Multi-Institutional Study

Abstract

Objective: There are scarce data about the prevalence and mortality of necrotizing enterocolitis in neonates with congenital heart disease. The purpose of this study is to provide a multi-institutional description and comparison of the overall prevalence and mortality of necrotizing enterocolitis in neonates with congenital heart disease. Design: Retrospective multi-institutional study. Setting: The Pediatric Health Information System database. Patients: Neonates with congenital heart disease between 2004 and 2014. Interventions: None. Measurements and Main Results: The primary study measure is the prevalence of necrotizing enterocolitis. Secondary measures include in-hospital mortality, hospital charges, ICU length of stay, hospital length of stay, and 30-day readmission. The prevalence of necrotizing enterocolitis was 3.7% (1,448/38,770) and varied significantly among different congenital heart disease diagnoses. The lowest prevalence of necrotizing enterocolitis was in transposition of the great arteries (n = 104, 2.1%). Compared with transposition of the great arteries, necrotizing enterocolitis occurred more frequently in neonates with hypoplastic left heart syndrome (odds ratio, 2.7; 95% CI, 2.1–3.3), truncus arteriosus (odds ratio, 2.6; 95% CI, 1.9–3.5), common ventricle (odds ratio, 2.1; 95% CI, 1.5–2.8), and aortic arch obstruction (odds ratio, 1.4; 95% CI, 1.1–1.7). Prematurity is a significant risk factor for necrotizing enterocolitis and for mortality in neonates with necrotizing enterocolitis, conferring varying risk by cardiac diagnosis. Unadjusted mortality associated with necrotizing enterocolitis was 24.4% (vs 11.8% in neonates without necrotizing enterocolitis; p < 0.001), and necrotizing enterocolitis increased the adjusted mortality in neonates with transposition of the great arteries (odds ratio, 2.5; 95% CI, 1.5–4.4), aortic arch obstruction (odds ratio, 1.8; 95% CI, 1.3–2.6), and tetralogy of Fallot (odds ratio, 1.6; 95% CI, 1.1–2.4). Necrotizing enterocolitis was associated with increased hospital charges (p < 0.0001), ICU length of stay (p = 0.001), and length of stay (p = 0.001). Conclusions: The prevalence of necrotizing enterocolitis among neonates with congenital heart disease is 3.7% and is associated with increased in-hospital mortality, length of stay, and hospital charges. The prevalence and associated mortality of necrotizing enterocolitis in congenital heart disease vary among different heart defects.

Clinical Characteristics of Necrotizing Enterocolitis in Preterm Patients With and Without Persistent Ductus Arteriosus and in Patients With Congenital Heart Disease

“…Incidence rates are estimated at 3-15% (2), whereas 7-20% of all NEC cases occur in term infants (3). Velazco et al (4) identified CHD in almost 20% of NEC patients with a birth weight of more than 2,500 g. NEC prevalence in patients with congenital heart disease (CHD) is estimated at 3.7% (5). Nowadays, incidence rates are decreasing due to specialized preventive care (2).…”

Causes of neonatal and postneonatal death among infants with birth defects in Texas

“…These conditions, such as atelectasis (incomplete lung expansion), respiratory distress of the newborn, chronic respiratory disease, and lung hypoplasia (listed within the congenital malformation category), could be due to prematurity and/or may be related to anomalies affecting diaphragm and lung development preventing adequate lung development and expansion (Dominguez & Alvares, 2018;Gallacher, Hart, & Kotecha, 2016). Similarly, both preterm birth and birth defects are associated with NEC, which ranked higher as a cause of death in our study population than among all live births in the US population (Fullerton et al, 2017;McElhinney et al, 2000;Rose & Patel, 2018;Spinner et al, 2020). In our study, a higher proportion of infants with lung hypoplasia/dysplasia and NEC listed among the causes of death were born preterm compared to the preterm proportion in the overall cohort of infants with birth defects that died during the first year of life.…”

“…Birth defects affect about 3% of infants in the United States (US), and an estimated 5-8% of live born infants with birth defects will die in infancy, compared to approximately 0.6% of live born infants in the US (Agha, Williams, Marrett, To, & Dodds, 2006; Centers for Disease Control and Prevention [CDC], 2008;Heron, 2019;Texas Department of State Health Services, 2013). Infants with a birth defect have an increased likelihood of being born preterm or low birthweight (Baer et al, 2019;Miquel-Verges, Mosley, Block, & Hobbs, 2015;Rasmussen, Moore, Paulozzi, & Rhodenhiser, 2001;Swanson & Sinkin, 2013) and developing necrotizing enterocolitis (NEC) and sepsis (Ascher et al, 2012;Fullerton et al, 2017;McElhinney et al, 2000;Spinner et al, 2020). For some defects, surgery and extended hospital-based care may be necessary, increasing the risk of surgery-related complications and nosocomial infections (CDC, 2007;Adams-Chapman et al, 2013;Colvin & Bower, 2009;Moffitt, Case, Farag, & Canfield, 2016).…”

Necrotizing Enterocolitis: The Future

“…With ischemic intestinal necrosis secondary to heart disease, the colon is the most commonly involved site. Hypoplastic left heart syndrome, truncus arteriosus, aortic arch obstruction and aortopulmonary window account for most cases of cardiogenic ischemic intestinal necrosis [25]. I propose that this disease should be classified as an individual entity and not be diagnosed as “NEC.” A more apt diagnostic moniker would be “cardiogenic ischemic necrosis of the intestine.”…”