Motor and cognitive outcome at school age of children with surgically treated intestinal obstructions in the neonatal period

https://doi.org/10.1016/j.earlhumdev.2012.09.014Get rights and content

Abstract

Background

The motor and cognitive outcome at school age of newborn children with surgically treated intestinal obstructions is unknown. Physiological stress and anesthesia may potentially be harmful in the period of early brain development in newborn infants.

Objective

To determine motor and cognitive outcome at school age in children with surgically treated intestinal obstructions as newborns, and to identify clinical risk factors for adverse outcome.

Study design

Cohort study of infants born between 1995 and 2002 with atresia, stenosis, or intestinal malrotation. At 6 to 13 years we assessed their motor functions, intelligence, attention, visual perception, visuomotor integration, and verbal memory.

Results

Of 44 children three (7%) died. Twenty-seven survivors (66%) were included for follow-up (median gestational age 36.7 weeks, birth weight 3000 g). Motor outcome was abnormal (< 5th percentile) in 22% of the children, which was significantly more than in the norm population (P < 0.01). Scores on selective attention were abnormal in 15% of the children (P < 0.01). Other cognitive functions were not affected. Lower birth weight and intestinal perforation were risk factors for poorer motor outcome (R2 = 53.0%), intrauterine growth restriction was a risk factor for poorer selective attention (R2 = 36.6%).

Conclusions

Children treated surgically for intestinal obstructions in the neonatal period had an increased risk for poor motor functioning and selective attention at school age. Low birth weight, intrauterine growth restriction and intestinal perforation were risk factors for adverse outcome. We recommend to closely follow the motor and attentional development of these children.

Introduction

An intestinal obstruction is a gastrointestinal complication that leads to impaired bowel passage. It occurs in approximately 9 out of every 10,000 newborn infants [1], [2]. It can be caused by congenital malformations of the intestine such as an intestinal atresia or stenosis, or by a malrotation of the intestine. Infants who present with such an obstruction often require surgery in the neonatal period to remove the obstruction, promote normal bowel function and allow oral feeding.

During the neonatal period, a period of rapid cerebral growth, major surgery and anesthesia is associated with developmental delay at 1 to 2 years [3]. Specific groups at risk are preterm infants [4], [5], infants undergoing cardiac surgery [6], and term infants undergoing noncardiac surgery for a variety of congenital anomalies such as intestinal atresias, esophageal atresia, congenital diaphragmatic hernia, and hypertrophic pyloric stenosis [6]. Potentially harmful factors include physiological stress occurring during surgery [7], anesthesia-induced apoptosis of developing neurons [8], the nature of the underlying congenital anomaly [3], [6], and the surgical procedure in itself, whether it consists for example of resection of the ileocoecal valve or the creation of an ostomy [9].

Although these factors are recognized risk factors for adverse neurodevelopmental outcome, the motor and cognitive outcome at school age of newborn infants with surgically treated intestinal obstructions is unknown. Our main aim was therefore to determine the outcome of such infants by assessing their motor and cognitive performance at school age. Motor and cognitive outcomes measured at school age are known to be more robust and predictive for later life than outcomes measured at pre-school age. Our secondary aim was to explore which clinical factors were associated with adverse outcome.

Section snippets

Patients

We selected all infants who had been admitted to the Neonatal Intensive Care Unit of the University Medical Center Groningen between 1995 and 2002, and who were diagnosed by laparotomy with duodenal, jejunal, ileal or colon atresia, intestinal stenosis, or a malrotation of the intestine. We excluded patients with major chromosomal and congenital anomalies other than single atresias or stenoses.

Follow-up

The children were invited prospectively to participate in this follow-up study, which was an extension

Patient characteristics

A database search resulted in 44 children who met our inclusion criteria, three (7%) of them had died in the neonatal period. Twenty-seven (66%) out of the 41 survivors were included in the follow-up study. The parents of seven children declined the invitation to participate; the parents of all of these children reported that their child attended formal education and did not encounter any neurological or behavioral problems. Seven other children could not be traced. Table 1 shows the patient

Discussion

This study showed that at school age more than twenty percent of children with surgically treated intestinal obstructions in the neonatal period had abnormal motor functioning and fifteen percent had abnormal selective attention. This was significantly more than the norm population. Intelligence, visual perception, visuomotor integration, and verbal memory were not affected. Low birth weight, IUGR, and the presence of an intestinal perforation were risk factors for adverse outcomes in infants

Conclusion

The identification of patients with intestinal obstruction being at highest risk for developmental impairments is an important issue, with potential consequences for future organization of long-term follow up programs. This study demonstrates that children with intestinal obstructions surgically treated in the neonatal period showed abnormal motor functioning and abnormal selective attention at school age compared to the norm population. Intelligence, visual perception, visuomotor integration,

Conflict of interest

All authors declare that they have nothing to disclose, financially or otherwise. There is no conflict of interest. This study was not the result of a clinical trial. No study sponsor was involved. The first draft of the manuscript was written by R.M. Elsinga. No honorarium, grant, or other form of payment was given to anyone to produce the manuscript.

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