The role of SNAPPE-II and MDAS scores in necrotizing enterocolitis

I read with interest the article by Fijas et al. [1] concluding that the two scoring systems, the score for neonatal acute physiology-perinatal extension-II (SNAPPE-II) and the metabolic derangement acuity score (MDAS), may serve as an ancillary tool in cases of necrotizing enterocolitis (NEC) when the decision for surgical intervention is in question. In ROC analyses, the AUC for MDAS was 0.77 (95% CI 0.65– 0.89) at the optimal threshold of 2.00. The AUC for SNAPPEII was 0.71 (95% CI 0.57–0.85), at the optimal threshold of 29.04. In the surgical NEC group of the cohort, the median MDAS was 2.5 (> the optimal threshold of 2.00) median SNAPPE-II was 38 (the optimal threshold of > 29.04). The goal of the Fijas et al. [1] was to determine if using SNAPPE-II and MDAS scores can facilitate early prediction of patients who are at high risk of requiring surgical management and help decision-making for operative intervention in neonates with NEC. In their cohort, for the surgical intervention group, the median time from the diagnosis to surgical consultation/bedside evaluation was 6 (2.5–10) h, while the median time from the NEC diagnosis to surgery was 17.5 (8.5–61.5) h. As per the data, the opening sentence under results stated that 20 infants developed pneumoperitoneum and/or required surgery (7 had pneumoperitoneum and surgery, and 13 had surgery without radiographic demonstration of pneumoperitoneum). These statements are confusing. If 13 infants had surgery without pneumoperitoneum, what was the indication for surgery? It was unclear why it took so long to perform the surgery. Does the hospital have a pediatric surgery team on call? Could the longer time (3rd Quartile of 61.5 h) taken for surgical intervention be a reason for the mortality of 70% (14 died out of 20) in the surgical NEC group (Figure 1)? With the data on SNAPPE-II and MDAS scores, the authors could convince their NICU team about the need for early surgical intervention to prevent very high institutional NEC-related mortality. SNAPPE-II was evaluated earlier as a mortality risk score [2].

I read with interest the article by Fijas et al. [1] concluding that the two scoring systems, the score for neonatal acute physiology-perinatal extension-II (SNAPPE-II) and the metabolic derangement acuity score (MDAS), may serve as an ancillary tool in cases of necrotizing enterocolitis (NEC) when the decision for surgical intervention is in question. In ROC analyses, the AUC for MDAS was 0.77 (95% CI 0.65-0.89) at the optimal threshold of 2.00. The AUC for SNAPPE-II was 0.71 (95% CI 0.57-0.85), at the optimal threshold of 29.04. In the surgical NEC group of the cohort, the median MDAS was 2.5 (> the optimal threshold of 2.00) median SNAPPE-II was 38 (the optimal threshold of > 29.04).
The goal of the Fijas et al. [1] was to determine if using SNAPPE-II and MDAS scores can facilitate early prediction of patients who are at high risk of requiring surgical management and help decision-making for operative intervention in neonates with NEC. In their cohort, for the surgical intervention group, the median time from the diagnosis to surgical consultation/bedside evaluation was 6 (2.5-10) h, while the median time from the NEC diagnosis to surgery was 17.5 (8.5-61.5) h. As per the data, the opening sentence under results stated that 20 infants developed pneumoperitoneum and/or required surgery (7 had pneumoperitoneum and surgery, and 13 had surgery without radiographic demonstration of pneumoperitoneum). These statements are confusing. If 13 infants had surgery without pneumoperitoneum, what was the indication for surgery? It was unclear why it took so long to perform the surgery. Does the hospital have a pediatric surgery team on call? Could the longer time (3rd Quartile of 61.5 h) taken for surgical intervention be a reason for the mortality of 70% (14 died out of 20) in the surgical NEC group (Figure 1)? With the data on SNAPPE-II and MDAS scores, the authors could convince their NICU team about the need for early surgical intervention to prevent very high institutional NEC-related mortality. SNAPPE-II was evaluated earlier as a mortality risk score [2]. The authors compared the baseline scores within 12 h of birth and then again within 12 h of NEC diagnosis. Earlier, Ibanez et al. [3] computed the scores at the time of diagnosis and then again at the time of clinical deterioration/initial surgical assessment. The three components of SNAPPE-II (birth weight, Apgar score, and small for gestation age) are constant at birth and at the time of NEC. What was the rationale for including scores at birth? Should SNAPPE-II be modified if it is to be used as a tool to assess an infant over time? What was the median time of NEC diagnosis (postmenstrual age/chronological age)?
In conclusion, in their retrospective study, Fijas et al. [1] showed higher mortality with higher SNAPPE-II and MDAS scores in neonates who underwent surgery for NEC. To find if SNAPPE-II and MDAS scores predict surgical management in NEC, prospective studies are needed.

Author contribution
Dr. Manzar conceptualized the study and wrote the draft.

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