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Original Investigation | Journal Club

Surgery and Neurodevelopmental Outcome of Very Low-Birth-Weight Infants

Frank H. Morriss Jr, MD, MPH1; Shampa Saha, PhD2; Edward F. Bell, MD1; Tarah T. Colaizy, MD, MPH1; Barbara J. Stoll, MD3; Susan R. Hintz, MD, MS, Epi4; Seetha Shankaran, MD5; Betty R. Vohr, MD6; Shannon E. G. Hamrick, MD3; Athina Pappas, MD5; Patrick M. Jones, MD7; Waldemar A. Carlo, MD8; Abbot R. Laptook, MD6; Krisa P. Van Meurs, MD4; Pablo J. Sánchez, MD9,10; Ellen C. Hale, RN, BS, CCRC3; Nancy S. Newman, RN11; Abhik Das, PhD12; Rosemary D. Higgins, MD13 ; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network
[+] Author Affiliations
1Department of Pediatrics, University of Iowa, Iowa City
2Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
3Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
4Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California
5Department of Pediatrics, Wayne State University, Detroit, Michigan
6Department of Pediatrics, Women & Infants’ Hospital, Brown University, Providence, Rhode Island
7Department of Pediatrics, University of Texas Medical School, Houston
8Division of Neonatology, University of Alabama, Birmingham
9Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
10now Department of Pediatrics, College of Medicine, The Ohio State University, Columbus
11Department of Pediatrics, Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
12Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, Maryland
13Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
JAMA Pediatr. 2014;168(8):746-754. doi:10.1001/jamapediatrics.2014.307.
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Importance  Reduced death and neurodevelopmental impairment among infants is a goal of perinatal medicine.

Objective  To assess the association between surgery during the initial hospitalization and death or neurodevelopmental impairment of very low-birth-weight infants.

Design, Setting, and Participants  A retrospective cohort analysis was conducted of patients enrolled in the National Institute of Child Health and Human Development Neonatal Research Network Generic Database from 1998 through 2009 and evaluated at 18 to 22 months’ corrected age. Twenty-two academic neonatal intensive care units participated. Inclusion criteria were birth weight 401 to 1500 g, survival to 12 hours, and availability for follow-up. A total of 12 111 infants were included in analyses.

Exposures  Surgical procedures; surgery also was classified by expected anesthesia type as major (general anesthesia) or minor (nongeneral anesthesia).

Main Outcomes and Measures  Multivariable logistic regression analyses planned a priori were performed for the primary outcome of death or neurodevelopmental impairment and for the secondary outcome of neurodevelopmental impairment among survivors. Multivariable linear regression analyses were performed as planned for the adjusted mean scores of the Mental Developmental Index and Psychomotor Developmental Index of the Bayley Scales of Infant Development, Second Edition, for patients born before 2006.

Results  A total of 2186 infants underwent major surgery, 784 had minor surgery, and 9141 infants did not undergo surgery. The risk-adjusted odds ratio of death or neurodevelopmental impairment for all surgery patients compared with those who had no surgery was 1.29 (95% CI, 1.08-1.55). For patients who had major surgery compared with those who had no surgery, the risk-adjusted odds ratio of death or neurodevelopmental impairment was 1.52 (95% CI, 1.24-1.87). Patients classified as having minor surgery had no increased adjusted risk. Among survivors who had major surgery compared with those who had no surgery, the adjusted risk of neurodevelopmental impairment was greater and the adjusted mean Bayley scores were lower.

Conclusions and Relevance  Major surgery in very low-birth-weight infants is independently associated with a greater than 50% increased risk of death or neurodevelopmental impairment and of neurodevelopmental impairment at 18 to 22 months’ corrected age. The role of general anesthesia is implicated but remains unproven.

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