Reply to State of the Art article ‘Bell's is broken’

Abstract

We agree with the suggestion by Gordon et al. (State of the Art article 'Bell's is broken', Journal of Perinatology, e-pub July 5 2007) that a new system for classifying necrotizing enterocolitis (NEC) and other acute neonatal intestinal conditions is required. The authors presented a well-researched review of changing trends in the presentation and clinical course of NEC. We believe that the main difficulty lies in the fact that Bell's classification was never intended as a case-definition. An unambiguous case-definition is crucial to clinical research and surveillance. However, we do not agree that the recommendations put forward by Gordon et al. will provide this. It is not clear why the weight of 1250 g was chosen as the cutoff between different diagnostic categories. This is helpful neither as a diagnostic criterion nor as a component of a case-definition. The author's proposed bedside classification, involving no less than 11 diagnostic criteria, is impractical and will be unlikely to assist in clinical management. It is difficult to distinguish spontaneous intestinal perforation from NEC prior to laparotomy.

Protective Effect of Dual-Strain Probiotics in Preterm Infants: A Multi-Center Time Series Analysis

“…The fact that Bell’s staging was not used for diagnosis or classification of NEC in NEO-KISS is another important issue to discuss [ 29 ]. Even though, accuracy of Bell’s criteria has been discussed before [ 40 , 41 ], it is commonly used in neonatal probiotic literature to quantify severity of NEC [ 10 , 27 ]. Our data did not account for classification of NEC, even though histological diagnosis of NEC might constitute a surrogate parameter.…”

Probiotics and Necrotising Enterocolitis: The Devil (as Always) Is in the Detail

“…The low level of statistical heterogeneity among the studies included does strengthen the conclusions drawn from the meta-analysis of Wang et al [4], but also worthy of note are the very variable baseline NEC rates in the 20 trials, ranging from 0% to a staggering 22.9%, making the effect size uncertain and the continuing lack of an objective case-definition for the condition, reducing confidence in the reliability and consistency of the diagnosis of NEC. It is often forgotten that the Bell criteria were designed to stage the severity of NEC, not to serve a diagnostic function [11,12]. …”