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Early Postnatal Dexamethasone Increases the Risk of Focal Small Bowel Perforation in Extremely Low Birth Weight Infants. Gordon P, Rutledge J,Sawin R, et al. Journal of Perinatology (1999) 19:573-577.
Two clusters of spontaneous pneumoperitoneums in ELBW infants were observed during the use of a protocol for early dexamethasone prophylaxis (EDP) for bronchopulmonary dysplasia from 1996 to 1997. During surgery, focal small bowel perforation (FSBP) was found in eight of nine cases. A retrospective study was designed to identify risk factors for FSBP in ELBW infants. A case-controlled analysis was performed using all infants born weighing < 1001 grams and admitted to the U. of Washington NICU during a 13 month period. A total of 51 infants were identified and divided into groups based on treatment or not with dexamethasone and indomethacin. These cohorts were homogeneous for gestational age, birth weight and perinatal stability. Relative risk and confidence intervals were calculated for each of the comparisons. Infants who received EDP had a relative risk of perforation that was 12.3 times that of untreated infants. Those treated with indomethacin had a risk that was comparable with that for infants who did not receive indomethacin. Infants who received both EDP and indomethacin tended to have higher rates of pneumoperitoneum than infants who received EDP alone, but comprised a cohort too small for valid analysis. The pathology of surgical specimens revealed FSBP with segmental loss of muscularis externa. There was no evidence of fungal or bacterial infections in any of the surgical specimens.
Comment. It is apparent that ELBW babies given dexamethasone treatment during the first week of life are at increased risk for FSBP. The incidence of this complication in EDP-treated in the present study was 60% (6 of 10). The pathologic appearance of FSBP is different than that seen with necrotizing enterocolitis or ischemic bowel injury. After surgical treatment, all of the babies with FSBP were able to be advanced to full enteral feedings without additional surgical intervention.
While an association between indomethacin treatment and FSBP has previously been reported (J Pediatrics 1985;106:277-281), indomethacin treatment did not appear to be an independent risk factor for FSBP in this study. It should be noted however, that all 6 babies who developed FSBP after EDP had also received indomethacin treatment. Further study is needed to determine if indomethacin treatment facillitates the development of FSBP after EDP.
These results echo the findings of Garland and coworkers who recently reported the results of their randomized prospective trial of EDP to prevent chronic lung disease in ventilated neonates (Pediatrics 1999; 104:91-99). That study also found that EDP was associated with a significant risk of FSBP during the first week of life in ELBW infants. The risk was also independent of indomethacin exposure in their study.
For now, it seems that the risk for developing FSBP outweighs the potential benefits of using EDP in ELBW premature babies. Also, awareness of this potential complication should prompt xray evaluation to exclude pneumoperitoneum when evaluating abdominal distention is premature babies receiving dexamethasone.
Andrew B. Kairalla MD