C-reactive Protein/Albumin Ratio as a Prognostic Indicator for Predicting Surgical Intervention in Neonates With Necrotizing Enterocolitis: A Prospective Cohort Study

Background Necrotizing enterocolitis (NEC) is a major cause of neonatal gastrointestinal morbidity and mortality. Early prediction of the need for surgical intervention remains challenging due to reliance on late clinical or radiological signs. The C-reactive protein and albumin ratio (CRP/Albumin), reflecting both inflammation and nutritional status, may serve as a dynamic biomarker to guide timely surgical decision-making. Objective The main objective of this study is to evaluate the prognostic utility of the CRP/Albumin ratio, and its temporal progression over the first three days of illness, in predicting surgical intervention and mortality in neonates. Methods In this prospective cohort study at a tertiary care hospital, Lahore, 66 neonates diagnosed with Bell's Stage I-IIIa NEC were enrolled over a year. CRP and albumin levels were measured daily for three consecutive days, and the CRP/Albumin ratio was calculated. Patients were grouped into progression trends: decreasing, increasing, stable, or variable. Outcomes included surgical intervention and mortality. Statistical analysis included receiver operating characteristic (ROC) curve analysis, sensitivity, specificity, and comparative group analysis. Results Among 66 neonates (mean gestational age: 37.2 ± 3.2 weeks), 42.4% required surgery. Neonates with an increasing CRP/Albumin ratio trend had a significantly higher rate of surgical intervention (89.5%) and mortality (26.3%) compared to those with a decreasing trend (8.1% surgery and 2.6% mortality) (p < 0.001). The CRP/Albumin ratio demonstrated excellent predictive accuracy for surgery, with area under the curve (AUC) values of 0.926, 0.954, and 0.959 on Days 1-3, respectively. Optimal cut-offs on Days 2 and 3 yielded sensitivities and specificities above 85%. Serial monitoring of the ratio outperformed single-time-point measurements in prognostic value. Conclusions CRP/Albumin is a simple, reliable, and cost-effective biomarker that can lead to early identification of neonates at risk of surgical intervention and poor outcomes in NEC. Monitoring its temporal progression, rather than relying on single measurements, appears to enhance its predictive accuracy and may support timely decision-making in clinical settings.