Congenital fetal and neonatal visceral chylous effusions: neonatal chylothorax and chylous ascites revisited. A multicenter retrospective study

This retrospective study was carried out at eight Neonatal Intensive Care Units (NICU) Centers worldwide on 33 newborns presenting at birth with pleural, pericardial, or abdominal chylous effusions. Diagnosis of chylous effusion is based on findings of fluid with a milk-like appearance, a concentration of triglycerides in pleural effusion >1.1 mmol/l, and a total cell count >1,000 cells/ml with a predominance of >80% lymphocytes. Thirty-three newborns met the inclusion criteria and were studied. Six subjects who presented at birth with fetal effusion were treated by in-utero pleuro-amniotic shunt. Five of these patients are alive at follow-up. At birth, pleural drainage was performed in 29/33 patients and abdominal drainage was carried out in 3/33. Total parenteral nutrition (TPN) was given to 32/33 patients; 19/23 patients were fed a medium-chain triglycerides (MCT). No adverse effects were observed. Eight patients were treated with Octreotide at dosages ranging from 1 to 7 mcg/kg/hour for 8 to 35 days. All patients showed decreased chylous production. Two patients were treated by pleurodesis. Twenty-two babies are alive after at least 6 months follow-up, 9/33 are deceased, and 2 were lost to follow-up. Clinical conditions of survivors are basically good except for lung involvement [chronic lung disease (CLD) or lung lymphangiectasia] and lymphedema. All patients were using a MCT diet at follow-up with good control of chylous effusion. Visceral chylous effusions of the fetus and neonate are rare disorders, and there currently is only partial agreement on decision-making strategies. We suggest the need for an international prospective trial in an effort to establish the efficacy and effectiveness of diagnostic and therapeutic options described in this article.

Diagnosis and management of central-line-associated thrombosis in newborns and infants

Although the use of central lines has many valuable applications in neonates and infants, they may cause serious mechanical, infectious and thrombotic complications. In fact, the use of central lines is the main cause for thrombosis in this age group. The frequency of central-line-related thrombosis in neonates and infants is reported to be as low as 1% when including only symptomatic cases, around 44% when systematically screened for thrombosis, and as high as 65% in autopsy studies. The risk factors for line-related thrombosis in neonates and infants include those associated with the underlying medical conditions, the duration of the line in situ, the placement of the umbilical artery catheter and the therapy used through the line. The contribution of inherited and acquired thrombophilia to central-line-related thrombosis is controversial, and the data are not sufficiently consistent to make a firm recommendation for thrombophilia screening for neonates and infants with central-line-related thrombosis. Most experts will recommend pursuing a thrombophilia work-up in the setting of a significant thrombosis event and will recommend avoiding thrombophilia work-up in subclinical and asymptomatic central-line-related thrombosis. The management of line-related thrombosis is based on expert opinion guidelines and is largely dependent on the type of the catheter and the further requirement of the catheter. Continuous heparin infusion through the central lines prevents catheter occlusion, but has no effect on occurrence of thrombosis. Currently no definitive recommendations exist for thromboprophylaxis in children, infants and neonates with central lines.

Gastrointestinal colonization with ESBL-producing Klebsiella in preterm babies--is vancomycin to blame?

In this study, we examine the possible association between treatment with vancomycin and colonization with extended-spectrum beta-lactamase (ESBL)-producing Klebsiella in our neonatal intensive care unit (NICU). Variables compared between newborns which developed rectal colonization and those who did not include: gestational age, birth weight, gender, and total length of hospital stay until positive stool culture or discharge, treatment with vancomycin, and positive blood culture for coagulase-negative Staphylococcus. We found that lower birth weight, younger gestational age, and treatment with vancomycin were statistically significant risk factors for gastrointestinal colonization with ESBL-producing Klebsiella. When applying a multivariate model, treatment with vancomycin, both for a full 10-day course and for a short 3-day empirical treatment, remained statistically significant. Treatment with vancomycin is a risk factor for gastrointestinal colonization with ESBL-producing Klebsiella in premature babies.

Neonatal sepsis following maternal amnionitis by Edwardsiella tarda: a case report and a review of the literature

Edwardsiella tarda, a gram-negative bacterium, is a rare pathogen in the neonatal period. We present a term newborn that developed E. tarda septicemia following maternal amnionitis. The severe neurological outcome in this case, as well as in all other reported cases, highlights the need for meticulous neurological evaluation in neonates presenting with E. tarda septicemia even in the absence of bona fide meningitis.

The embryotoxicity of sera from patients with autoimmune diseases on post-implantation rat embryos in culture persists during remission and is not related to oxidative stress

We evaluated the embryolethality and embryotoxicity of sera from patients suffering from autoimmune diseases during remission on post-implantation rat embryos cultured on these sera and determined the association between the patients' clinical history, high blood levels of specific antibodies, medications, and oxidative stress parameters. One hundred and eighty, 10.5-day-old rat embryos were cultured in their yolk sacs in 33 sera of systemic lupus erythematosus (SLE)/antiphospholipid syndrome (APS) patients, and compared with 84 embryos cultured in rat sera and 88 embryos cultured in control human sera. The sera proved to be lethal and embryotoxic but not teratogenic resulting in smaller yolk sacs and embryos, lower protein level and lower developmental score. Significantly less embryos cultured in 'toxic' SLE/APS sera had peak 2 of low molecular weight antioxidants (LMWA) wave, implying a delayed maturation of the antioxidant defense. Lower peak 1 of LMWA correlated with a history of recurrent abortions. Embryonic levels of superoxide dismutase (SOD) and catalase (CAT) did not correlate with sera toxicity, patients' clinical history or specific antibodies. We conclude that SLE/APS patients' clinical remission did not prevent death or developmental delay accompanied by later appearance of peak 2 of LMWA in post-implantation rat embryo cultures. The normal levels of the antioxidant enzymes evaluated may indicate that sera toxicity is not related to oxidative stress.

Interleukin-6 and N-terminal pro-brain natriuretic peptide cord blood levels in premature infants: correlations with perinatal variables

BACKGROUND

Elevated cord blood levels of interleukin-6 and N-terminal pro-brain natriuretic peptide were associated with neonatal complications; however, simultaneously obtained values have not been compared to date.

OBJECTIVES

To study the association of cord blood levels of IL-6 and NT-proBNP with perinatal variables of premature infants and examine the relationship between the obtained values.

METHODS

Cord blood IL-6 (89 samples) and NT-proBNP (66 samples) levels obtained from infants delivered before 32 weeks of gestation were analyzed for associations with perinatal variables and possible correlation between both samples.

RESULTS

Lower gestational age, no antenatal exogenous steroids, low Apgar scores at 1 minute and delivery at a high birth order, were all associated with more infants having elevated IL-6 levels (P = 0.02, P = 0.03, P = 0.03 and P = 0.001, respectively). None of the infants with necrotizing enterocolitis (n=6) had high IL-6 levels (P = 0.01). Increased NT-proBNP levels were associated with low Apgar scores at 1 minute (P = 0.01) and the presence of clinical chorioamnionitis (P = 0.06). Controlling for gestational age, a weak positive correlation was demonstrated between IL-6 and NT-proBNP levels in infants of 24-27 weeks gestational age (R2 = 0.151, P = 0.08), but not among the more mature infants.

CONCLUSIONS

Although both IL-6 and NT-proBNP values were significantly associated with low I minute Apgar scores, our results do not support utilization of these cord blood levels as the sole tool to predict neonatal outcome.

Alcohol abuse in pregnant women: effects on the fetus and newborn, mode of action and maternal treatment

Offspring of mothers using ethanol during pregnancy are known to suffer from developmental delays and/or a variety of behavioral changes. Ethanol, may affect the developing fetus in a dose dependent manner. With very high repetitive doses there is a 6-10% chance of the fetus developing the fetal alcoholic syndrome manifested by prenatal and postnatal growth deficiency, specific craniofacial dysmorphic features, mental retardation, behavioral changes and a variety of major anomalies. With lower repetitive doses there is a risk of "alcoholic effects" mainly manifested by slight intellectual impairment, growth disturbances and behavioral changes. Binge drinking may impose some danger of slight intellectual deficiency. It is advised to offer maternal abstinence programs prior to pregnancy, but they may also be initiated during pregnancy with accompanying close medical care. The long term intellectual outcome of children born to ethanol dependent mothers is influenced to a large extent by the environment in which the exposed child is raised.

Congenital chylothorax: clinical course and prognostic significance

OBJECTIVE

To determine the underlying etiology, associated malformations, clinical course, and prognostic significance of congenital chylothorax.

STUDY DESIGN

A retrospective analysis of 11 neonates admitted to our neonatal intensive care unit with congenital chylothorax between January 2000 and June 2008. The post-discharge clinical and developmental course was evaluated by a telephone survey performed in July 2008.

RESULTS

Antenatal diagnosis was established in 9 out of 11 infants by ultrasound examination; 5 had intrauterine pleural drainage. Eight infants had either structural or chromosomal abnormalities. The postnatal treatment included mechanical ventilation, drainage of pleural fluid and feeding with enriched medium chain triglyceride formula. Somatostatin was administered in one case. Six patients developed nosocomial infections. Two patients died after resolution of the chylothorax from deteriorating renal failure. Seven patients were traced for follow up and six of them achieved age appropriate developmental milestones.

CONCLUSION

The recovery from chylothorax and future prognosis were dependent on the underlying etiology. Chylothorax was often a secondary event, with apparently favorable clinical and developmental prognosis when the underlying or/and associated condition was treatable.

Bruising at birth: antenatal associations and neonatal outcome of extremely low birth weight infants

BACKGROUND

Early studies have identified severe cranial bruising as a risk factor for intraventricular hemorrhage (IVH) in premature infants but the nature of this association has not been evaluated.

OBJECTIVE

To identify antenatal predictors and associations with neonatal outcome of bruised extremely low birth weight infants.

METHODS

A cohort study comparing 34 bruised and 116 non-bruised infants (birth weight <or=1,000 g), delivered in two 'Hadassah' university hospitals in Jerusalem between 2000 and 2004. Bruised patients were divided according to the severity of bruising. A univariate model was first applied to examine the associations of the individual independent variables with the outcome variable, followed with a logistic stepwise regression model, performed for each of the outcome variables.

RESULTS

In a stepwise logistic regression on 'Any bruising' and 'Severe bruising', only increasing gestational age and exposure to antenatal steroids prior to delivery maintained a protective association with bruising (OR = 0.74; 95% CI: 0.58-0.94; p = 0.015, OR = 0.38; 95% CI: 0.16-0.90; p = 0.028, respectively, for 'Any bruising', and OR = 0.77; 95% CI: 0.59-1.01; p = 0.055, OR = 0.29; 95% CI: 0.12-0.73; p = 0.008, respectively, for 'Severe bruising'). In a stepwise logistic regression analysis, with 'Any bruising' and 'Severe bruising' as forced-in variables and controlling for gestational age, small for gestational age, Apgar scores, respiratory distress syndrome and pneumothorax, 'Severe bruising', but not 'Any bruising', was found to be associated significantly with severe IVH (OR = 5.60; 95% CI: 1.86-16.82; p = 0.002), whereas both 'Any bruising' and 'Severe bruising' were significantly associated with mortality (OR = 6.31; 95% CI: 2.37-16.83; p = 0.000, OR = 3.33; 95% CI: 1.16-9.52; p = 0.025 respectively).

CONCLUSION

Antenatal exposure to steroids and increasing gestational age are associated with a lower incidence of bruising at birth in extremely low birth weight infants. Severe bruising at birth is associated with increased incidence of severe intraventricular hemorrhage and mortality.

Portal venous gas following trauma in a preterm infant

During the neonatal period, pneumatosis intestinalis (PI) and portal venous gas (PVG) are pathognomonic of necrotizing enterocolitis (NEC). Rare cases of such findings evolving after abdominal trauma have been reported in adults and children, but none in premature infants. We report a case of a 3-week-old premature infant where both PI and PVG were found following a fall from a scale. The presence of these findings prior to the evolvement of clinical symptoms suggestive of NEC strongly supports a traumatic etiology.

Parvovirus B19 in pregnancy

Parvovirus B19 is a widespread infection that may affects 1-5% of pregnant women, mainly with normal pregnancy outcome. The prevalence of infection is higher during epidemics - between 3 and 20% with sero-conversion rate of 3-34%. Infection during pregnancy can cause a variety of other signs of fetal damage. The risk of adverse fetal outcome is increased if maternal infection occurs during the first two trimesters of pregnancy but may also happen during the third trimester. It is a significant cause of fetal loss throughout pregnancy, but has a higher impact in the second half of pregnancy when spontaneous fetal loss from other causes is relatively rare. Parvovirus infection can cause severe fetal anemia as a result of fetal erythroid progenitor cells infection with shortened half life of erythrocytes, causing high output cardiac failure and therefore nonimmune hydrops fetalis (NIHF). The P antigen expressed on fetal cardiac myocytes enables the Parvovirus B19 to infect myocardial cells and produce myocarditis that aggravates the cardiac failure. Although there are several reports of major congenital anomalies among offspring of mothers infected by Parvovirus, the virus does not seem to be a significant teratogen. Since Parvovirus B19 infection can cause severe morbidity and mortality, it should be part of the routine work up of complicated pregnancies. Risk assessment for maternal infection during pregnancy is especially important during epidemics when sero-conversion rates are high.

Intrauterine growth restriction-etiology and consequences: what do we know about the human situation and experimental animal models?

Embryonic and fetal growth depend on genetic and environmental factors, and the process is the result of the interaction between these factors. About 7-9% of live-born infants have a birth weight below normal (below the 10th percentile). The rate and extent of intrauterine growth restriction (IUGR) varies by ethnicity and socio-economic status. Some of the suspected causes of IUGR are as follows. (1) Maternal factors such as inadequate or severe malnutrition, chronic maternal diseases, birth order, multiple births, and parental genetic factors. (2) Placental pathology, mainly placental vascular damage that may lead to placental insufficiency. This is often found in maternal diseases such as pre-eclampsia, and Thrombophilia. (3) Intrauterine infections and specific fetal syndromes, including chromosomal aberrations. (4) Non-classified causes such as adolescent's pregnancy, maternal smoking and alcohol drinking, living at high altitudes. Several existing animal models for IUGR, including uterine artery ligation or gene knock out models, although insightful of potential mechanism(s) underlying intrauterine growth restriction, are limited in that they do not reflect human causality. As the ultimate goal is prevention, we seem still to be distant from achieving this goal.

Persistent NKH with transient or absent symptoms and a homozygous GLDC mutation

Three of four nonketotic hyperglycinemia patients homozygous for a novel GLDC mutation (A802V) were treated by assisted respiration and/or sodium benzoate with or without ketamine and had transient neonatal or absent symptoms and normal developmental outcome, despite persisting biochemical evidence of nonketotic hyperglycinemia. This exceptional outcome may be related to the high residual activity of the mutant protein (32% of wild type) and therapeutic intervention during a critical period of heightened brain exposure and sensitivity to glycine.

Absent ductus venosus in the fetus: review of the literature and first report of direct umbilical venous drainage to the coronary sinus

The ductus venosus connects the portal and umbilical veins with the inferior vena cava and acts as a sphincter to protect the fetus from placental overcirculation. Its absence usually causes hydrops fetalis and is associated with high mortality rate, chromosomal anomalies and congenital malformations. In this condition, the umbilical vein almost always drains directly into right-sided structures such as inferior vena cava or right atrium. We reviewed the literature and describe the first case of a fetus with absent ductus venosus and direct connection of the umbilical vein to the coronary sinus.

A prospective randomized controlled study of phototherapy using blue and blue-green light-emitting devices, and conventional halogen-quartz phototherapy

OBJECTIVE

To determine the efficacy of blue versus blue-green phototherapy using new light sources with narrow luminous spectra. The devices made of high-intensity gallium nitride light-emitting diodes (LEDs) were also compared to conventional halogen-quartz bulbs phototherapy.

DESIGN

Prospective open randomized study.

PARTICIPANTS

A total of 114 jaundiced, but otherwise healthy term infants who met the entry criteria for phototherapy set by the American Academy of Pediatrics' Practice Parameter.

MAIN OUTCOME MEASURES

The duration of phototherapy and the rate of decrease in total serum bilirubin (TSB).

RESULTS

The mean TSB concentrations at initiation and termination of treatment, as well as the duration of phototherapy and the rate of decrease in TSB, were not statistically different in newborns receiving blue LED, blue-green LED or conventional phototherapy. The average rate of decrease in TSB (slope), after adjustment by a linear regression analysis for confounding factors, was -3.61 micromol/hour (95% confidence limits -5.47, -1.75) in the 25 newborns receiving blue LED phototherapy compared with -2.57 micromol/hour (-4.32, -0.82) in the 22 newborns treated with blue-green LED phototherapy and -3.42 micromol/hour (-5.02, -1.81) in the 57 newborns who received conventional phototherapy.

CONCLUSIONS

When using low light irradiance, there was no statistically significant difference in the effectiveness of phototherapy using blue-green LEDs, blue LEDs or conventional halogen-quartz bulbs.

Effect of publication of the "Practice Parameter for the management of hyperbilirubinemia" on treatment of neonatal jaundice

The aim of this study was to evaluate the change in the treatment of neonatal jaundice following introduction of the "American Academy of Pediatrics' Practice Parameter for the management of hyperbilirubinemia in the healthy term newborn". In a historical control observation cohort study, we examined the rate of phototherapy and exchange transfusions among full-term (> or = 37 wk gestation) and near-term (gestational age between 35 and 37 wk and birthweight > 2000 g) infants in two community hospitals. The study included all consecutive infants born during two 15-mo study periods immediately before and after the introduction of the new guidelines. Data were prospectively recorded in a computerized database. The rate of phototherapy significantly decreased in the second study period from 7.9% (514/6499) to 2.9% (251/8650) (p < 0.0001) among full-term infants, and from 20.9% (102/489) to 9.4% (47/502) (p < 0.0001) in near-term infants. The use of exchange transfusion was significantly higher (p < 0.001) in the first compared to the second period: 0.2% (15/6499) vs 0.03% (3/8650). A significant decrease was found when the data from each hospital were analyzed separately.

CONCLUSION

A significant decrease in the use of phototherapy and exchange transfusion occurred after the publication of the new practice parameters. This trend was observed for both term and preterm newborns, although the new guidelines were not intended for infants born before term.

A new blue light-emitting phototherapy device: a prospective randomized controlled study

OBJECTIVE

To evaluate the efficacy of a new phototherapy light source with a narrow luminous blue spectrum. The device, made with high-intensity gallium nitride light-emitting diodes (LEDs), was compared with conventional phototherapy at similar light intensities.

SETTING

Two university-affiliated community hospitals in Jerusalem.

DESIGN

Prospective open randomized study.

PARTICIPANTS

Sixty-nine jaundiced, but otherwise healthy, term infants who met the entry criteria for phototherapy set by the American Academy of Pediatrics' Practice Parameter.

MAIN OUTCOME MEASURES

The duration of phototherapy and the rate of decrease in total serum bilirubin (TSB) concentration.

RESULTS

The mean TSB concentrations at initiation and termination of treatment did not differ between newborns receiving LED and those receiving conventional phototherapy. The duration of phototherapy and the rate of decrease in TSB concentration were not statistically different in the 2 groups. The average rate of decrease in TSB after adjustment by a linear regression analysis for confounding factors was -3.16 micromol/L/h (95% confidence limits -4.81, -1.51) in newborns receiving LED phototherapy compared with -2.19 micromol/L/h (-3.99, -0.40) in those treated with conventional phototherapy (P <.14). No side effects were noted in any of the newborns.

CONCLUSIONS

The blue gallium nitride LED device is as effective as conventional phototherapy and is readily accepted by nursing staff. Future LED phototherapy devices can provide much higher irradiance, and thus greater efficacy, and offer a new highly versatile approach to the treatment of jaundice.

Predicting the risk of jaundice in full-term healthy newborns: a prospective population-based study

OBJECTIVE

The need to recognize infants that are at high risk for developing significant jaundice is apparent in the era of routine early discharge. The aim of the present study was to prospectively determine the ability to predict severe hyperbilirubinemia in term healthy newborns (defined as total serum bilirubin of > 10.0 mg/dl at day 2, > 14.0 mg/dl at day 3, and > 17.0 mg/dl at days 4 and 5 of life).

DESIGN

Prospective study of 1177 healthy term newborns.

SETTING

Two university-affiliated community hospitals in Jerusalem.

RESULTS

Using a multiple logistic regression analysis, neonatal jaundice was best predicted (p < 0.0001) by day 1 serum bilirubin (adjusted odds ratio of 3.1 [per mg/dl] [95% confidence limits of 2.4 to 4.1]) and by a change in serum bilirubin from the first to the second day of life (2.4 [per mg/dl] [1.9 to 3.0]). Maternal blood type 0 (2.9 [1.5 to 5.8]), age (1.1 [per year] [1.0 to 1.2]), schooling (0.8 [per year] [0.7 to 0.9]), and full breastfeeding (0.4 [0.2 to 0.9]) were also associated with jaundice (p < 0.005). Other factors considered in the regression model but not found to be significantly related to jaundice included maternal ethnic origin, smoking, hypertension, diabetes mellitus, intranatal administration of oxytocin, meperidine, anesthesia, premature rupture of the membranes, parity, newborn sex, birth weight, gestational age, presentation. Apgar scores, blood type, hematocrit, cephalohematoma, and history of jaundice in other siblings. A model for predicting neonatal jaundice based on the above factors had a sensitivity of 81.8%, a specificity of 82.9%, a false positive rate of 80.2%, and a false negative rate of 1.1%.

CONCLUSION

Individual risk assessment on discharge in association with day 1 total serum bilirubin is of value in identifying infants at greater risk for neonatal jaundice.

Agenesis of tibia with ectrodactyly/Gollop-Wolfgang complex associated with congenital heart malformations and additional skeletal abnormalities

We report on a child with bifid femur, absent tibiae, hypoplastic hallux, bilateral club feet, congenital heart defects, and segmentation anomalies of the spine and ribs. Parents are consanguineous, from a region where other consanguineous families with similarly affected individuals have been reported. Clinical and genetic controversies of the tibial aplasia-ectrodactyly syndrome/Gollop-Wolfgang complex are discussed.

Successful outcome of idiopathic nonimmune hydrops fetalis treated by maternal digoxin

Nonimmune hydrops fetalis (NIHF), occurring in 1 in 2,500-3,000 live births has a reported mortality rate of 50-98%. A similar mortality rate for intrauterine death of fetuses with NIHF probably exists. Many fetal pathological entities have been implicated as causing the condition, but to date, treatment has only been found for cases of fetal tachycardia complicated with hydrops. During a routine ultrasonographic survey of a woman at 32 weeks of gestation, we detected a fetus with severe ascites. There was no apparent etiology, and although no tachycardia was evident, low dosage transplacental digoxin therapy was immediately initiated. The hydropic condition completely resolved within 17 days and at 39 weeks of gestation, a perfectly normal baby was born after a spontaneous and uneventful labor. This is the first report of successful treatment of idiopathic NIHF with maternal digoxin.

Hospital readmission due to neonatal hyperbilirubinemia

Severe neonatal hyperbilirubinemia can occur without apparent reason in term healthy breast-fed infants and some develop kernicterus. The aim of our study was to assess the incidence of severe hyperbilirubinemia in term healthy newborns discharged from the hospital. From January 1 through December 31, 1994, 6705 infants were delivered at Bikur-Cholim and Misgav-Ladach Community Hospitals. All 1448 newborns discharged with a serum bilirubin level > 10.0 mg/dL were instructed to return to the hospital within 3 days for follow-up, as well as bilirubin determination. Twenty-one newborns with a bilirubin level > 18.0 mg/dL were identified and readmitted at mean +/- standard deviation (SD) 5.5 +/- 1.8 (range, 5 to 10 days of life). This represents 1.7% of the 1220 infants who returned for follow-up examination. Mean +/- SD serum bilirubin levels at readmission were 19.6 +/- 2.5 mg/dL. All but one of the infants were breast-fed. No cases of ABO incompatibility were found and two newborns were glucose-6-phosphate dehydrogenase (G6PD)-deficient. Sepsis work-up and direct Coomb's tests were negative in all cases. None had hemolysis or were found to have any cause for hyperbilirubinemia other than breast-feeding. Phototherapy was provided in all but two cases, and an exchange transfusion was performed in one case. Three additional infants, with bilirubin levels < 10 mg/dL at discharge, were readmitted due to hyperbilirubinemia. One was diagnosed with neonatal hepatitis. We conclude that, based on our study population, 0.36% of term infants may subsequently develop severe neonatal hyperbilirubinemia in the first postnatal week.(ABSTRACT TRUNCATED AT 250 WORDS)