Introduction
Methods
Multidisciplinary team
Scope determination
Literature search
Study selection and data synthesis
Recommendation grading
(a) Quality of evidence | Definition |
---|---|
High quality | Further research is very unlikely to change confidence in the estimate of effect |
Moderate quality | Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate |
Low quality | Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate |
Very low quality | Any estimate of effect is very uncertain |
(b) Recommendation strength | Definition |
---|---|
Strong | When the desirable effects of an intervention clearly outweigh the undesirable effects, or clearly do not |
Weak (“conditional” or “discretionary”) | When the trade-offs are less certain—either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced |
Results
Item | Recommendation | Quality | Strength |
---|---|---|---|
Surgical practices | Perform primary anastomosis as the first choice in patients with uncomplicated intestinal atresia | Very low | Weak |
Antimicrobial prophylaxis | Administer appropriate preoperative antibiotic prophylaxis within 60 min prior to skin incision | Low | Weak |
Discontinue postoperative antibiotics within 24 h of surgery, unless ongoing treatment is required | Low | Weak | |
Preventing intraoperative hypothermia | Continuously monitor intraoperative core temperature and take pre-emptive measures to prevent hypothermia (<36.5 °C) and maintain normothermia | Low | Strong |
Perioperative fluid management | Use perioperative fluid management to maintain tissue perfusion and prevent hypovolemia, fluid overload, hyponatremia, and hyperglycemia | Moderate | Weak |
Perioperative analgesia | Unless contraindicated, administer acetaminophen regularly during the early postoperative period (not on an “as needed” basis) to minimize opioid use | High | Strong |
Use an opioid-limiting strategy is recommended in the postoperative period. Manage breakthrough pain with the lowest effective dose of opioid with continuous monitoring | Moderate | Strong | |
Use regional anesthesia and acetaminophen perioperatively in combination with general anesthesia. Multimodal strategies including regional techniques should be continued postoperatively | High | Strong | |
Provide lingual sucrose/dextrose to reduce pain during naso/orogastric tube placement and other minor painful procedures | High | Strong | |
Optimal Hemoglobin | Restrict transfusions to maintaining HgB ≥ 90 (9 g/dL for a term neonate with no oxygen requirement. Term neonates within the first week of life, intubated or with an oxygen requirement should be transfused to maintain a HgB ≥ 110 (11 g/dL) | Low | Weak |
Use written transfusion guidelines and take into account not only a target hemoglobin threshold, but also the clinical status of the neonate and local practices | Low | Weak | |
Perioperative Communication | Implement perioperative multidisciplinary team communication with a structured process and protocol (“pre- and postoperative huddle”) utilizing established checklists | Moderate | Strong |
Parental involvement | Facilitate hands on care and purposeful practice by parents that is individualized to meet the unique needs of parents early during the admission. Sustain these to build the knowledge and skills of parents to take on a leading role as caregivers and facilitate their readiness for discharge | High | Strong |
Postoperative nutritional care | Start early enteral feeds within 24-48 h after surgery when possible. Do not wait for formal return of bowel function | High | Weak |
Use breast milk as the first choice for nutrition | High | Strong | |
Monitor urinary sodium in all neonates with a stoma. Target urinary sodium should be greater than 30 mmol/L and exceed the level of urinary potassium | Low | Weak | |
Mucous fistula refeeding | Use mucous fistula refeeding in neonates with enterostomy to improve growth | Moderate | Weak |
Evidence base and recommendations (online resource 5)
Surgical practices
Recommendation: | Perform primary anastomosis as the first choice in patients with uncomplicated intestinal atresia |
Evidence Quality: | Very low |
Recommendation Strength: | Weak |
Antimicrobial prophylaxis
Antibiotics within 60 min
Recommendation: | Administer appropriate preoperative antibiotic prophylaxis within 60 min prior to skin incision |
Evidence Quality: | Low |
Recommendation Strength: | Weak |
Duration of postoperative antibiotics
Recommendation: | Discontinue postoperative antibiotics within 24 h of surgery, unless ongoing treatment is required |
Evidence Quality: | Low |
Recommendation Strength: | Weak |
Preventing intraoperative hypothermia
Recommendation: | Continuously monitor intraoperative core temperature and take pre-emptive measures to prevent hypothermia (<36.5 °C) and maintain normothermia |
Evidence Quality: | Low |
Recommendation Strength: | Strong |
Perioperative fluid management
Recommendation: | Use perioperative fluid management to maintain tissue perfusion and prevent hypovolemia, fluid overload, hyponatremia, and hyperglycemia |
Evidence Quality: | Moderate |
Recommendation Strength: | Weak |
Perioperative analgesia
Acetaminophen
Recommendation: | Unless contraindicated, administer acetaminophen regularly during the early postoperative period (not on an “as needed” basis) to minimize opioid use |
Evidence Quality: | High |
Recommendation Strength: | Strong |
Opioid use
Recommendation: | Use an opioid-limiting strategy is recommended in the postoperative period. Manage breakthrough pain with the lowest effective dose of opioid with continuous monitoring |
Evidence Quality: | Moderate |
Recommendation Strength: | Strong |
Standard analgesia protocol
Recommendation: | Use regional anesthesia and acetaminophen perioperatively in combination with general anesthesia. Multimodal strategies including regional techniques should be continued postoperatively |
Evidence Quality: | High |
Recommendation Strength: | Strong |
Lingual sucrose/dextrose
Recommendation: | Provide lingual sucrose/dextrose to reduce pain during naso/orogastric tube placement and other minor painful procedures |
Evidence Quality: | High |
Recommendation Strength: | Strong |
Optimal hemoglobin
Recommendation: | Restrict transfusions to maintaining HgB≥90 (9 g/dL for a term neonate with no oxygen requirement. Term neonates within the first week of life, intubated or with an oxygen requirement should be transfused to maintain a HgB≥110 (11 g/dL) |
Evidence Quality: | Low |
Recommendation Strength: | Weak |
Recommendation: | Use written transfusion guidelines and take into account not only a target hemoglobin threshold, but also the clinical status of the neonate and local practices |
Evidence Quality: | Low |
Recommendation Strength: | Weak |
Perioperative communication
Recommendation: | Implement perioperative multidisciplinary team communication with a structured process and protocol (“pre- and postoperative huddle”) utilizing established checklists |
Evidence Quality: | Moderate |
Recommendation Strength: | Strong |
Parental involvement
Recommendation: | Facilitate hands on care and purposeful practice by parents that is individualized to meet the unique needs of parents early during the admission. Sustain these to build the knowledge and skills of parents to take on a leading role as caregivers and facilitate their readiness for discharge |
Evidence Quality: | High |
Recommendation Strength: | Strong |
Postoperative nutrition
Early feeding
Recommendation: | Start early enteral feeds within 24–48 h after surgery when possible. Do not wait for formal return of bowel function |
Evidence Quality: | High |
Recommendation Strength: | Weak |
Breast milk as first nutrition
Recommendation: | Use breast milk as the first choice for nutrition |
Evidence Quality: | High |
Recommendation Strength: | Strong |
Urinary sodium monitoring
Recommendation: | Monitor urinary sodium in all neonates with a stoma. Target urinary sodium should be greater than 30 mmol/L and exceed the level of urinary potassium |
Evidence Quality: | Low |
Recommendation Strength: | Weak |
Mucous fistula refeeding
Recommendation: | Use mucous fistula refeeding in neonates with enterostomy to improve growth |
Evidence Quality: | Moderate |
Recommendation Strength: | Weak |