We thank you for affording us the opportunity to response to the letter by Manzar in relation to our study describing the role of the score for neonatal acute physiology-perinatal extension-II (SNAPPE-II) and the metabolic derangement acuity score (MDAS) in preterm neonates with necrotizing enterocolitis (NEC).
The goal of our study was to assess the utility of the scoring systems in prediction of surgical intervention in neonates diagnosed with NEC [Citation1]. While the need for such systems is limited when definite surgical indication exists/is straightforward (our 7 study neonates with pneumoperitoneum), the true management dilemma (our 13 surgical neonates without pneumoperitoneum) is to identify those neonates diagnosed with NEC who will need the surgery (with the critical question of surgery timing of these identified neonates) and those who will not and will continue medical management therapy. In other words, the indication for surgery was deterioration despite optimal medical management (worsening of the exam, non-reassuring laboratory and radiographic findings, hemodynamic instability). Since the individual patient trajectory of such deterioration is difficult to predict, to the best of our knowledge, there is no standard time for surgical intervention from the NEC diagnosis to the surgery itself in neonates without the pneumoperitoneum. Of note, in the referenced study by Ibanez et al. [Citation2], the mean interval between the NEC diagnosis and surgery was 2.4 days.
Regarding baseline characteristics and components/use of SNAPPE-II score, corrected gestational age at the time of NEC was 30.9 (±2.5) weeks for surgical NEC and 31.8 (±3.9) for medical NEC in our study. We included SNAPPE-II scores within 12 h of birth as a baseline characteristic between the 2 groups rather than a specific time point; we included birth weight, Apgar score, and small for gestational age for comparison of the actual data scores among the articles referenced in the manuscript, although these 3 components remain constant over the time.
The author rightly pointed out very high mortality rate of 70% in surgical NEC group compared to 40.5% (birth weight <1500 g) and 50.9% (birth weight <1000 g) mortality rates in surgical NEC subgroups reported by recent systematic analysis [Citation3]. One can speculate that instituting of the scoring system would standardize decision making, likely optimize time to surgical intervention in neonates with NEC diagnosis, and eventually reduce the surgical NEC mortality. In agreement with the authors, prospective use of the scoring systems in multicenter trial may answer these questions.
Department of Pediatrics, Albert Einstein College of Medicine/Children’s Hospital at Montefiore, Bronx, NY, USA
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References
- Kliegman RM, Walsh MC. Neonatal necrotizing enterocolitis: pathogenesis, classification, and spectrum of illness. Curr Probl Pediatr. 1987;17(4):213–288.
- Ibáñez V, Couselo M, Marijuán V, et al. Could clinical scores guide the surgical treatment of necrotizing enterocolitis? Pediatr Surg Int. 2012;28(3):271–276.
- Jones IH, Hall NJ. Contemporary outcomes for infants with necrotizing enterocolitis- a systematic review. J Pediatr. 2020;220:86–92.e3.