How Should the Neonatal Retrieval Team Respond to the Neonate Referred With Bilious Vomiting: Mark II

BACKGROUND: Bilious vomiting or aspirates (BVA) in the neonatal period may herald malrotation and/or life-threatening volvulus. In New South Wales (NSW), contrast fluoroscopy is not available for neonates in most non-tertiary paediatric centres and transfer is required. The previous study in 2020 showed that 13 retrievals were required to identify one case of time-critical malrotation/volvulus and that improvements could be made in the recognition and referral of neonates with BVA. A statewide consensus clinical pathway was developed and a working group carried out training and education sessions to increase awareness of time-critical transfer to surgical centres. The aim of this study was to evaluate the impact of the pathway on the frequency of retrievals and the identification of malrotation/volvulus. METHODS: Neonatal referrals (≤ 28 days) to NETS NSW between 1 August 2020 and 1 August 2023 with BVA were examined. BVA retrievals between 31 July 2014 and 31 July 2020 acted as a historical control. RESULTS: There were 37 (12/year) cases of malrotation/volvulus among 622 retrievals in the 3-year study period. This was in comparison to 31 (5/year) cases among 391 retrievals in the 6-year historical control. This equates to 3.1-fold increase in BVA retrievals (207/year vs. 65/year), but with similar incidence of malrotation and/or volvulus (6% vs. 8%, respectively, mean risk difference, -1.98%, 95% CI: -5.24, 1.28). The number of retrievals required to identify one case of malrotation/volvulus increased modestly from 13 to 17. CONCLUSIONS: The modified clinical pathway resulted in a threefold increase in BVA retrievals and a twofold increase in the number of life-threatening malrotation/volvulus cases identified per year. No deaths were observed during the study period. Retrieval times were similar between epochs, indicating the pathway's effect on case ascertainment statewide.