Discrimination of GutCheckNEC: a clinical risk index for necrotizing enterocolitis

Abstract

Background Better measures are needed to identify infants at risk for developing necrotizing enterocolitis (NEC) and facilitate communication about risk across transitions. Although NEC is multi-factorial, quantification of composite risk for NEC in an individual infant is not clearly defined. Objective This study’s objective was to describe the derivation, validation and calibration testing of a novel clinical NEC risk index, GutCheckNEC. Individual risk factors were weighted to assess composite odds of developing NEC. GutCheckNEC is designed to improve communication about NEC risk and coordination of care among clinicians across an infant’s clinical course. Methods Based on a synthesis of research evidence about NEC risk and an e-Delphi study including 35 neonatal experts, we identified NEC risk factors believed by the experts to be most relevant for a NEC risk index then applied a logistic model building process to derive and validate GutCheckNEC. De-identified data from the Pediatrix BabySteps Clinical Data Warehouse (discharge date 2007-2011) were split into three samples for derivation, validation and calibration. By comparing infants with medical NEC, surgical NEC, and those who died to infants without NEC, we derived the logistic model using the un-matched derivation set. Discrimination was then tested in a case-control matched validation set and an un-matched calibration set using ROC curves. Results Sampled from a cohort of 58 820 infants, the randomly selected derivation set (n= 35 013) revealed 9 independent risk factors (gestational age, history of packed red blood cell transfusion, unit NEC rate, late onset sepsis, multiple infections, hypotension treated with inotropic medications, Black or Hispanic race, outborn status, and metabolic acidosis) and 2 risk reducers (human milk feeding on both days 7 and 14 of life, and probiotics). Unit NEC rate carried the most weight in the summed score. Validation using a 2: 1 matched case-control sample (n=360) demonstrated fair to good discrimination. In the calibration set (n= 23 447), GutCheckNEC scores (range 0-58) discriminated those infants who developed surgical NEC (AUC=0.84, 95% CI 0.82-0.84) and NEC leading to death (AUC=0.83, 95% CI 0.81-0.85), more accurately than medical NEC (AUC= 0.72, 95% CI 0.70-0.74). Conclusion GutCheckNEC represents weighted composite risk for NEC and discriminated infants who developed NEC from those who did not with very good accuracy. We speculate that targeting modifiable NEC risk factors could reduce national NEC prevalence.

Relationship between packed red blood cell transfusion and severe form of necrotizing enterocolitis: A case control study

“…Our study demonstrated an association between PRBC transfusion and onset of NEC in about a quarter of our [16]. A more recent meta-analysis has been more cautious in reaching the same conclusion [17].…”

Predictive monitoring for sepsis and necrotizing enterocolitis to prevent shock

“…Two risk reducers, exclusive human milk feeding and probiotic administration, were also factored into the score. The score was derived from data from about 35,000 infants, calibrated in 23,000 infants, and validated in 120 NEC cases compared to 240 matched controls and shown to discriminate infants that developed severe NEC (receiver operating characteristics area under the curve: 0.83) [13].…”

Early prediction of severity of necrotizing enterocolitis in preterm infants: A composite scoring tool

“…The diagnostic parameters used for creating the predictive scoring tool to define NEC severity were chosen from common clinical symptoms and signs associated with suspicion of NEC [12][13][14][15][20][21][22][23][24][25] and are summarized in Table 1. The scoring tool consisted of clinical presentation, radiological and laboratory findings, feeding characteristics and gastric residuals.…”

“…[12][13][14][15] Gephart et al developed GutCheck, a tool used to predict the occurrence of NEC based on evaluating several known risk factors, including gestational age (GA), history of blood transfusions, sepsis, metabolic acidosis and human milk feeding. [12] Similarly, McKeown et al identified clinical parameters such as respiratory changes immediately preceding a diagnosis of NEC.…”

“…[12][13][14][15] Gephart et al developed GutCheck, a tool used to predict the occurrence of NEC based on evaluating several known risk factors, including gestational age (GA), history of blood transfusions, sepsis, metabolic acidosis and human milk feeding. [12] Similarly, McKeown et al identified clinical parameters such as respiratory changes immediately preceding a diagnosis of NEC. [15] However, these tools do not include a composite of clinical, laboratory or radiological parameters in their scoring system that are temporally related to the time before NEC is suspected, as the purpose for these tools was for prediction of occurrence of NEC, rather than the predicting of disease severity.…”