Contemporary Outcomes of Infants with Gastroschisis in North America: A Multicenter Cohort Study

doi:10.1016/j.jpeds.2017.06.013

The Journal of Pediatrics

Volume 188, September 2017, Pages 192-197.e6

https://doi.org/10.1016/j.jpeds.2017.06.013 Get rights and content

Objective

To quantify outcomes and analyze factors predictive of morbidity and mortality in infants with gastroschisis.

Study design

Clinical data regarding neonates with gastroschisis born between 2009 and 2014 were prospectively collected at 175 North American centers. Multivariate regression was used to assess risk factors for mortality and length of stay (LOS).

Results

Gastroschisis was diagnosed in 4420 neonates with median birth weight 2410 g (IQR 2105-2747). Survival (discharge home or alive in hospital at 1 year) was 97.8% with a 37 day median LOS (IQR 27-59). Sepsis, defined by positive blood or cerebrospinal fluid culture, was the only significant independent predictor of mortality (P = .04). Significant independent determinants of LOS and the percentage of neonates affected were as follows: bowel resection (9.8%, P < .0001), sepsis (8.6%, P < .0001), presence of other congenital anomalies (7.6%, including 5.8% with intestinal atresias, P < .0001), necrotizing enterocolitis (4.5%, P < .0001), and small for gestational age (37.3%, P = .0006). Abdominal surgery in addition to gastroschisis repair occurred in 22.3%, with 6.4% receiving gastrostomy or jejunostomy tubes and 6.3% requiring ostomy creation. At discharge, 57.0% were less than the 10th percentile weight for age. The mode of delivery (52.4% cesarean delivery) was not associated with any differences in outcome.

Conclusions

Although neonates with gastroschisis have excellent overall survival they remain at risk for death from sepsis, prolonged hospitalization, multiple abdominal operations, and malnutrition at discharge. Outcomes appear unaffected by the use of cesarean delivery. Further opportunities for quality improvement include sepsis prevention and enhanced nutritional support.

Section snippets

Methods

The Vermont Oxford Network (VON) is a nonprofit voluntary collaboration of health professionals dedicated to improving the care of high-risk infants and their families (www.vtoxford.org). In support of this mission, the Network maintains databases for use in quality improvement. Member hospitals have 2 options. They may report data for very low birth weight (VLBW) infants only (defined as either a gestational age of 22-29 weeks or a birth weight of 401-1500 g) or report data for all neonatal

Results

Gastroschisis was diagnosed in 4420 neonates with median birth weight 2410g (IQR 2105-2747). Survival was 97.8% with a 37-day median LOS among surviving infants (IQR 27-59). VLBW infants (<1500 g) and infants <29 weeks gestation were excluded from this analysis; the 193 excluded infants had a 20.2% mortality rate and survivors had a 80-day median LOS (IQR 53, 111). Patient characteristics and the characteristics of the reporting facility for each infant are listed in Table III; 95.5% of infants

Discussion

This large multicenter cohort demonstrates that neonates with gastroschisis have excellent survival but prolonged hospitalizations, with weight <10th percentile for age in the majority of infants at the time of discharge. More than 1 in 5 requires abdominal operations in addition to gastroschisis closure. Noteworthy facts for anticipatory guidance to families include the proportion of infants who required surgical placement of a feeding tube (6%) and the proportion who require a stoma (6%).

References (31)

D.M. Hook-Dufresne et al.
The economic burden of gastroschisis: costs of a birth defect
J Surg Res
(2015)
A. Rosenstock et al.
Adolescent parenting in the neonatal intensive care unit
J Adolesc Health
(2014)
K. Murthy et al.
The association of type of surgical closure on length of stay among infants with gastroschisis born>/=34 weeks' gestation
J Pediatr Surg
(2014)
B.J. Dicken et al.
Medical management of motility disorders in patients with intestinal failure: a focus on necrotizing enterocolitis, gastroschisis, and intestinal atresia
J Pediatr Surg
(2011)
S.A. Butterworth
Lalari V, Dheensaw K. Evaluation of sodium deficit in infants undergoing intestinal surgery
J Pediatr Surg
(2014)
A. Nguyen-Vermillion et al.
Time course of C-reactive protein and inflammatory mediators after neonatal surgery
J Pediatr
(2011)
E.L. Harris et al.
The long term physical consequences of gastroschisis
J Pediatr Surg
(2014)
L.A. Lusk et al.
Multi-institutional practice patterns and outcomes in uncomplicated gastroschisis: a report from the University of California Fetal Consortium (UCfC)
J Pediatr Surg
(2014)
A. Sandler et al.
A “plastic” sutureless abdominal wall closure in gastroschisis
J Pediatr Surg
(2004)
J.R. Swanson
Surgical necrotizing enterocolitis: time for a definition
J Am Coll Surg
(2015)

T. Jaksic

Further research required to define outcomes in neonates: in reply to Swanson

J Am Coll Surg

(2015)

J.M. Hoff et al.

Arthrogryposis multiplexa congenita: an epidemiologic study of nearly 9 million births in 24 EUROCAT registers

Eur J Obstet Gynecol Reprod Biol

(2011)

A.M. Jones et al.

Increasing Prevalence of Gastroschisis—14 States, 1995-2012

MMWR Morb Mortal Wkly Rep

(2016)

R.S. Kirby et al.

Prevalence and correlates of gastroschisis in 15 states, 1995 to 2005

Obstet Gynecol

(2013)

Centers for Disease C, Prevention

Hospital stays, hospital charges, and in-hospital deaths among infants with selected birth defects—United States, 2003

MMWR Morb Mortal Wkly Rep

(2007)

Cited by (60)

Mexican-American Women's Lifelong Residence in the United States Is Associated with an Increased Risk of Gastroschisis: A Population-Based Study
2023, Journal of Pediatrics
To determine whether nativity is associated with abdominal wall defects among births to Mexican-American women.
Using a cross-sectional, population-based design, stratified and multivariable logistic regression analyses were performed on the 2014-2017 National Center for Health Statistics live-birth cohort dataset of infants of US-born (n = 1 398 719) and foreign-born (n = 1 221 411) Mexican-American women.
The incidence of gastroschisis was greater among births to US-born compared with Mexico-born Mexican-American women: 36.7/100 000 vs 15.5/100 000, RR = 2.4 (2.0, 2.9). US-born (compared with Mexico-born) Mexican-American mothers had a greater percentage of teens and cigarette smokers, P < .0001. In both subgroups, gastroschisis rates were greatest among teens and decreased with advancing maternal age. Adjusting for maternal age, parity, education, cigarette smoking, pre-pregnancy body mass index, prenatal care usage, and infant sex), OR of gastroschisis for US-born (compared with Mexico-born) Mexican-American women was 1.7 (95% CI 1.4-2.0). The population attributable risk of maternal birth in the US for gastroschisis equaled 43%. The incidence of omphalocele did not vary by maternal nativity.
Mexican-American women’s birth in the US vs Mexico is an independent risk factor for gastroschisis but not omphalocele. Moreover, a substantial proportion of gastroschisis lesions among Mexican-American infants is attributable to factors closely related to their mother's nativity.
Special Populations—Surgical Infants
2023, Clinics in Perinatology
Current short bowel syndrome management: An era of improved outcomes and continued challenges
2023, Journal of Pediatric Surgery
Prior to the late 1960s, pediatric short bowel syndrome was a frequently fatal disease. Currently, pediatric interdisciplinary bowel rehabilitation centers report very high survival rates. The mortality trends, up-to-date definitions, incidence, causes, and clinical manifestations of short bowel syndrome are reviewed. Emphasis is placed upon the nutritional, medical, and surgical advances that have contributed to the dramatic improvement in outcomes for pediatric short bowel syndrome patients. Recent findings and remaining challenges are highlighted.
Early growth and body composition assessed by air displacement plethysmography in infants born with simple gastroschisis
2023, Journal of Pediatric Surgery
Citation Excerpt :
After multiple regression analyses, male sex negatively affected FM, prematurity negatively affected FFM, the duration of TPN positively affected FFM at discharge, and EBM diets positively affected FM percentage at 3 months. Our findings confirm the negative association between gastroschisis and growth failure during the initial hospital stay shown by previous studies [1,2,25,26]. Potential explanations for suboptimal weight gain during hospitalization among infants with gastroschisis include an increased caloric demand following surgery, the delayed introduction of enteral feeding (due to intestinal dysmotility) [4], the altered intestinal absorption of nutrients, inadequate parenteral nutrition, and suboptimal transition from parenteral to enteral nutrition [27].
Gastroschisis is an abdominal wall malformation usually associated with impaired growth.
To evaluate the growth and body composition of infants born with simple gastroschisis in a referral center.
This was a single-center, prospective case series of infants with simple gastroschisis who were measured at birth, at discharge, and at 3 months. Body composition was assessed via air-displacement plethysmography at discharge and at 3 months. The results were compared with those reported for healthy infants at an equivalent gestational age.
Simple gastroschisis infants were lighter and smaller at birth and remained similar at 3 months. All anthropometric z scores decreased from birth to discharge, followed by an increase but not a full recovery toward 3 months. Overall, gastroschisis infants had a similar FM percentage, FM% (11.1 ± 4.7), but a lower FFM, FFM (2481 ± 478 g), at discharge. FM% (18.5 ± 5.3) decreased at 3 months, and FFM remained lower (3788 ± 722 g) but improved between the two exams. Boys had significantly more FFM than girls at both evaluations. The multiple regression analysis showed that male sex, prematurity, total parenteral nutrition duration, and exclusive breast milk diets were associated with differences in body composition.
Infants with simple gastroschisis cared for in a referral center experienced growth failure at discharge and showed a similar FM% but lower FFM than healthy infants. At 3 months, they exhibited smaller FM% and FFM, but FFM improved after the first exam, representing a better protein accretion.
Prognostic.
IV.
Necrotizing Enterocolitis and Short Bowel Syndrome
2023, Avery's Diseases of the Newborn
Abdominal Wall Defects
2023, Avery's Diseases of the Newborn

View all citing articles on Scopus

: B.F. received support from the Boston Children's Hospital Chair's Surgical Research Fellowship. K.M., R.S., and J.H. are employees of the Vermont Oxford Network. E.E. is supported by a grant from the Vermont Oxford Network to the University of Vermont. The other authors declare no conflicts of interest.

: Portions of this study were presented during the New England Surgical Society Annual Meeting, Boston, Massachusetts, September 16-18, 2016

View full text

Original ArticlesContemporary Outcomes of Infants with Gastroschisis in North America: A Multicenter Cohort Study

Objective

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

J Surg Res

J Adolesc Health

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Am Coll Surg

J Am Coll Surg

Eur J Obstet Gynecol Reprod Biol

Increasing Prevalence of Gastroschisis—14 States, 1995-2012

MMWR Morb Mortal Wkly Rep

Prevalence and correlates of gastroschisis in 15 states, 1995 to 2005

Obstet Gynecol

Hospital stays, hospital charges, and in-hospital deaths among infants with selected birth defects—United States, 2003

MMWR Morb Mortal Wkly Rep

Original Articles
Contemporary Outcomes of Infants with Gastroschisis in North America: A Multicenter Cohort Study