Serious Bacterial Infections in Preterm Infants: Should Their Age Be "Corrected"?

Adjusting the chronological age of preterm infants according to their gestational age is a widely accepted practice in the field of neurodevelopment. It has been suggested for the assessment of preterm infants with suspected infection, but has been poorly validated. Correcting for chronological age is especially critical in infants with a chronological age above 3 months, but a corrected age below 3 months due to the differences in assessment protocols. This study assessed the difference in incidence of serious bacterial infection (SBI) according to chronological and corrected age in preterm infants. A retrospective analysis of pediatric emergency department (PED) presentations was conducted for all 448 preterm infants born in between January 2010 and August 2019. Of the 448 preterm infants, 204 (46%) presented at one of 3 PEDs in Jerusalem, Israel, during their first year of life. Overall, 141 (31.4%) presented with fever and were included in the study. The infants were divided into 3 age groups: 1-corrected age >3 months; 2-chronological age >3 months, but corrected age <3 months; 3-chronological and corrected age <3 months. SBI was diagnosed in 2.6%, 16.7%, and 33.3% of the infants in groups 1, 2 and 3, respectively; (p < 0.01, p = 0.17, p < 0.001). The incidence of SBI in the control group of 300 term infants <3 months presenting to the PED due to fever was 15.3%. Preterm infants with a corrected age <3 months are at increased risk for SBI, similarly to term infants <3 months of age. Age correction should thus be considered for preterm infants presenting with fever.

The Validity of Positive Coagulase-Negative Staphylococcus Cultures for the Diagnosis of Sepsis in the Neonatal Unit

OBJECTIVE

 Coagulase-negative Staphylococcus (CoNS) is the most frequent pathogen causing late-onset sepsis (LOS) in neonatal intensive care units (NICUs). Technical difficulties hinder blood culture (BC) collection and obtaining only one culture before initiating antibiotic therapy is a common practice. We sought to assess specific clinical information and CoNS cultures for the diagnosis of true bacteremia in the NICU.

STUDY DESIGN

 This historical cohort study was conducted in NICUs at the Hadassah-Hebrew University Medical Center of Jerusalem in Israel. Clinical and laboratory data in every CoNS bacteremia were collected and compared between bacteremia groups as follows: true positive, two positive BCs; contaminant, one positive BC out of two; undefined, one BC obtained and found positive.

RESULTS

 For 3.5 years, CoNS was isolated in 139 episodes. True positive was identified in 44 of 139 (31.7%), contaminant in 42 of 139 (30.2%), and the event was undefined in 53 of 139 (38.1%). Vancomycin treatment was more frequent in the true positive and undefined groups than the contaminant group (100, 90.6, and 73.8% respectively, p = 0.001); treatment was also prolonged in these two groups (p < 0.001). No clinical variables were associated with true bacteremia on multivariable analysis.

CONCLUSION

 Diagnosis should definitely be based on at least two positive BCs, despite objective difficulties in obtaining BCs in neonates.

KEY POINTS

· CoNS is a frequent pathogen causing LOS in neonates.. · Due to technical difficulties, often only one culture is collected prior to antibiotic therapy.. · No clinical/laboratory variables were associated with the diagnosis of true CoNS bacteremia.. · Diagnosis should definitely be based on at least two positive BCs..

Diabetes during Pregnancy: A Maternal Disease Complicating the Course of Pregnancy with Long-Term Deleterious Effects on the Offspring. A Clinical Review

In spite of the huge progress in the treatment of diabetes mellitus, we are still in the situation that both pregestational (PGDM) and gestational diabetes (GDM) impose an additional risk to the embryo, fetus, and course of pregnancy. PGDM may increase the rate of congenital malformations, especially cardiac, nervous system, musculoskeletal system, and limbs. PGDM may interfere with fetal growth, often causing macrosomia, but in the presence of severe maternal complications, especially nephropathy, it may inhibit fetal growth. PGDM may also induce a variety of perinatal complications such as stillbirth and perinatal death, cardiomyopathy, respiratory morbidity, and perinatal asphyxia. GDM that generally develops in the second half of pregnancy induces similar but generally less severe complications. Their severity is higher with earlier onset of GDM and inversely correlated with the degree of glycemic control. Early initiation of GDM might even cause some increase in the rate of congenital malformations. Both PGDM and GDM may cause various motor and behavioral neurodevelopmental problems, including an increased incidence of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). Most complications are reduced in incidence and severity with the improvement in diabetic control. Mechanisms of diabetic-induced damage in pregnancy are related to maternal and fetal hyperglycemia, enhanced oxidative stress, epigenetic changes, and other, less defined, pathogenic mechanisms.

Prevention or Amelioration of Autism-Like Symptoms in Animal Models: Will it Bring Us Closer to Treating Human ASD?

Since the first animal model of valproic acid (VPA) induced autistic-like behavior, many genetic and non-genetic experimental animal models for Autism Spectrum Disorder (ASD) have been described. The more common non-genetic animal models induce ASD in rats and mice by infection/inflammation or the prenatal or early postnatal administration of VPA. Through the establishment of these models, attempts have been made to ameliorate or even prevent ASD-like symptoms. Some of the genetic models have been successfully treated by genetic manipulations or the manipulation of neurotransmission. Different antioxidants have been used (i.e., astaxanthin, green tea, piperine) to reduce brain oxidative stress in VPA-induced ASD models. Agents affecting brain neurotransmitters (donepezil, agmatine, agomelatine, memantine, oxytocin) also successfully reduced ASD-like symptoms. However, complete prevention of the development of symptoms was achieved only rarely. In our recent study, we treated mouse offspring exposed on postnatal day four to VPA with S-adenosine methionine (SAM) for three days, and prevented ASD-like behavior, brain oxidative stress, and the changes in gene expression induced by VPA. In this review, we describe, in addition to our data, the existing literature on the prevention/amelioration of ASD-like symptoms. We also discuss the possible mechanisms underlying some of these phenomena. Finally, we describe some of the clinical trials in children with ASD that were carried out as a result of data from animal studies, especially those with polyunsaturated fatty acids (PUFAs).

High sucrose low copper diet in pregnant diabetic rats induces transient oxidative stress, hypoxia, and apoptosis in the offspring's liver

BACKGROUND

Hyperglycemia-related oxidative stress and hypoxia are important mechanisms responsible for diabetes-induced embryopathy and other complications. High sucrose low copper diet (HSD), but not regular diet (RD), induces type 2 diabetes in the inbred Cohen diabetic sensitive (CDs) rats but not in the Sabra control rats. We recently demonstrated long-term changes of DNA methylation and gene expression in various groups of genes, including genes involved in oxidant-antioxidant activity in the liver of 2-4-week-old CDs offspring of diabetic dams. We now studied the postnatal effects of diabetes and/or HSD on several liver metabolic parameters in these offspring.

METHODS

we studied lipid peroxidation, activity of the antioxidants enzymes superoxide dismutase (SOD) and Catalase (CAT). By immunohistochemistry: protein oxidation by nitrotyrosine staining, hypoxia inducing factor1α (HIF1α), apoptosis [caspase 3, bcl-2-like protein (BAX)], proliferation [proliferating cell nuclear antigen (PCNA)] and NF-κB.

RESULTS

In the Sabra rats fed HSD only few, early and transitional changes were observed in lipid peroxidation, SOD and CAT activity. In the CDs fed HSD more significant changes in lipid and protein oxidation, HIF1α, apoptosis and proliferation were observed, persisting for longer.

CONCLUSIONS

The changes in the Sabra rats HSD were attributed to the pro-oxidant effects of the diet and those in the diabetic CDs to the HSD and maternal diabetes. In light of the DNA methylation changes in the liver of the CDs HSD, we presume that changes in gene expression are responsible for our findings, and that similar changes may lead to the metabolic syndrome at adulthood.

Parvovirus B19 infection during pregnancy and risks to the fetus

Parvovirus B19 infects 1 to 5% of pregnant women, generally with normal pregnancy outcomes. During epidemics, the rate of infection is higher. Major congenital anomalies among offspring of infected mothers are rare, as the virus does not appear to be a significant teratogen. However, parvovirus B19 infection may cause significant fetal damage, and in rare cases, brain anomalies and neurodevelopmental insults, especially if infection occurs in the first 20 weeks of pregnancy. Parvovirus B19 is also an important cause of fetal loss, especially in the second half of pregnancy when spontaneous fetal loss from other causes is relatively rare. Parvovirus B19 infection may affect many fetal organs and can cause severe anemia, following fetal erythroid progenitor cells infection and apoptosis, especially in fetuses, that have shortened half-life of erythrocytes. Severe anemia may cause high output cardiac failure and nonimmune hydrops fetalis. In addition, parvovirus B19 may directly infect myocardial cells and produce myocarditis that further aggravates the cardiac failure. Intrauterine fetal transfusion is commonly used for the treatment of severe fetal anemia with survival rates of 75 to 90% and significant reduction of fetal morbidity. Only 66 cases were evaluated neurodevelopmentally, of which 10 (16%) had slight or severe neurodevelopmental problems. Because parvovirus B19 infection can cause severe fetal morbidity and mortality, it should be part of the routine work-up of pregnant women who have been exposed to the virus or of pregnancies with suspected fetal hydrops. Assessment for maternal infection during pregnancy is especially important during epidemics, when sero-conversion rates are high. Birth Defects Research 109:311-323, 2017. © 2017 Wiley Periodicals, Inc.

Genetic Syndromes, Maternal Diseases and Antenatal Factors Associated with Autism Spectrum Disorders (ASD)

Autism spectrum disorder (ASD) affecting about 1% of all children is associated, in addition to complex genetic factors, with a variety of prenatal, perinatal, and postnatal etiologies. In addition, ASD is often an important clinical presentation of some well-known genetic syndromes in human. We discuss these syndromes as well as the role of the more important prenatal factors affecting the fetus throughout pregnancy which may also be associated with ASD. Among the genetic disorders we find Fragile X, Rett syndrome, tuberous sclerosis, Timothy syndrome, Phelan-McDermid syndrome, Hamartoma tumor syndrome, Prader-Willi and Angelman syndromes, and a few others. Among the maternal diseases in pregnancy associated with ASD are diabetes mellitus (PGDM and/or GDM), some maternal autoimmune diseases like antiphospholipid syndrome (APLS) with anti-β2GP1 IgG antibodies and thyroid disease with anti-thyroid peroxidase (TPO) antibodies, preeclampsia and some other autoimmune diseases with IgG antibodies that might affect fetal brain development. Other related factors are maternal infections (rubella and CMV with fetal brain injuries, and possibly Influenza with fever), prolonged fever and maternal inflammation, especially with changes in a variety of inflammatory cytokines and antibodies that cross the placenta and affect the fetal brain. Among the drugs are valproic acid, thalidomide, misoprostol, and possibly SSRIs. β2-adrenergic receptor agonists and paracetamol have also lately been associated with increased rate of ASD but the data is too preliminary and inconclusive. Associations were also described with ethanol, cocaine, and possibly heavy metals, heavy smoking, and folic acid deficiency. Recent studies show that heavy exposure to pesticides and air pollution, especially particulate matter < 2.5 and 10 μm in diameter (PM2.5 and PM10) during pregnancy is also associated with ASD. Finally, we have to remember that many of the associations mentioned in this review are only partially proven, and not all are "clean" of different confounding factors. The associations described in this review emphasize again how little we know about the etiology and pathogenesis of ASD. It is obvious that we need more epidemiologic data to establish many of these associations, but if proven, they might be promising avenues for prevention.

Genetic and non-genetic animal models for autism spectrum disorders (ASD)

Autism spectrum disorder (ASD) is associated, in addition to complex genetic factors, with a variety of prenatal, perinatal and postnatal etiologies. We discuss the known animal models, mostly in mice and rats, of ASD that helps us to understand the etiology, pathogenesis and treatment of human ASD. We describe only models where behavioral testing has shown autistic like behaviors. Some genetic models mimic known human syndromes like fragile X where ASD is part of the clinical picture, and others are without defined human syndromes. Among the environmentally induced ASD models in rodents, the most common model is the one induced by valproic acid (VPA) either prenatally or early postnatally. VPA induces autism-like behaviors following single exposure during different phases of brain development, implying that the mechanism of action is via a general biological mechanism like epigenetic changes. Maternal infection and inflammation are also associated with ASD in man and animal models.

[PREDICTION OF LATE ONSET SEPSIS IN VERY LOW BIRTH WEIGHT INFANTS BY A SOFTWARE APPLICATION--ARE WE THERE YET?]

INTRODUCTION

Early prediction of late onset sepsis is imperative in order to improve survival and reduce long-term complications. Since clinical deterioration is detrimental, empiric antibiotic treatment is initiated once sepsis is suspected. Symptoms that may indicate invasive infection are non-specific. Previous risk scores offered to improve clinical decision-making but provided low predictive values.

AIMS

To evaluate the quantitative early alert of software application compared to clinical judgment by the treating physician, and the "gold standard" of positive blood and/or positive cerebrospinal fluid.

METHODS

Weight, heart and respiratory rates, episodes of bradycardia and desaturation, and temperature were collected for each neonate and loaded daily into the system for a period of 30 days by a registered nurse. The medical team and the registered nurse were blind to the system alerts. Analysis of the correlation between the software alerts, the clinical suspicion of sepsis and bacteremia was conducted.

RESULTS

Forty-five very low birth weight consecutively born infants who did not have early onset sepsis and survived, were evaluated, of whom 17 infants had culture proven bloodstream infection. The software positive predictive value was 6%, 23%, 31%, at 12, 24, 48, hours respectively for alerts approximately to positive cultures. The positive predictive value of clinical suspicion of LOS was 28% but increased from 25% with low levels of clinical suspicion to 34% with high levels of clinical suspicion.

DISCUSSION

The software application did not improve sepsis prediction. However, further trials may develop a more accurate algorithm that will alert the physician to be more attentive to infants in special cases.

Very High Intrapartum Fever in Term Pregnancies and Adverse Obstetric and Neonatal Outcomes

BACKGROUND

Intrapartum fever is a well-known risk factor for adverse perinatal outcomes. Maternal intrapartum fever ≥39.0°C at term is a rare event during labor, and there is scarce evidence regarding its implications.

OBJECTIVES

To investigate the association between very high intrapartum maternal fever and perinatal outcomes in term pregnancies.

METHODS

A retrospective cohort analysis including 43,560 term, singleton live births in two medical centers between the years 2003 and 2011 was performed. We compared parturients who experienced a maximal intrapartum fever of <38.0°C with two subgroups of parturients who experienced respective maximal fevers of 38.0-38.9°C and ≥39°C. Adjusted risks for adverse perinatal outcomes were calculated by using multiple logistic regression models to control for confounders.

RESULTS

Compared with normal intrapartum temperature, intrapartum fever ≥39.0°C was associated with an extremely elevated risk for neonatal sepsis 16.08 (95% CI: 2.15, 120.3) as well as with low Apgar scores and neonatal intensive care unit admissions (p < 0.001). Additionally, very high intrapartum fever was related to significantly higher risk for operative delivery (p < 0.001).

CONCLUSIONS

Extremely elevated intrapartum fever is an important indicator of severe neonatal morbidity and operative delivery.

Gestational Diabetes Alters Offspring DNA Methylation Profiles in Human and Rat: Identification of Key Pathways Involved in Endocrine System Disorders, Insulin Signaling, Diabetes Signaling, and ILK Signaling

Gestational diabetes is associated with risk for metabolic disease later in life. Using a cross-species approach in rat and humans, we examined the hypothesis that gestational diabetes during pregnancy triggers changes in the methylome of the offspring that might be mediating these risks. We show in a gestation diabetes rat model, the Cohen diabetic rat, that gestational diabetes triggers wide alterations in DNA methylation in the placenta in both candidate diabetes genes and genome-wide promoters, thus providing evidence for a causal relationship between diabetes during pregnancy and DNA methylation alterations. There is a significant overlap between differentially methylated genes in the placenta and the liver of the rat offspring. Several genes differentially methylated in rat placenta exposed to maternal diabetes are also differentially methylated in the human placenta of offspring exposed to gestational diabetes in utero. DNA methylation changes inversely correlate with changes in expression. The changes in DNA methylation affect known functional gene pathways involved in endocrine function, metabolism, and insulin responses. These data provide support to the hypothesis that early-life exposures and their effects on metabolic disease are mediated by DNA methylation changes. This has important diagnostic and therapeutic implications.

Prenatal factors associated with autism spectrum disorder (ASD)

Autism spectrum disorder (ASD) affecting about 1% of all children is associated, in addition to complex genetic factors, with a variety of prenatal, perinatal and postnatal etiologies. We discuss the known associated prenatal factors affecting the fetus throughout pregnancy; whenever relevant, also summarize some animal data. Among the maternal diseases in pregnancy associated with ASD are pregestational and/or gestational diabetes mellitus (PGDM, GDM), maternal infections (i.e. rubella, cytomegalovirus (CMV)), prolonged fever and maternal inflammation, which cause changes in a variety of inflammatory cytokines. Among the drugs are valproic acid, thalidomide, and possibly misoprostol and serotonin reuptake inhibitors (SSRIs). Associations were described with ethanol, and possibly cocaine, heavy metals heavy smoking and Folic acid deficiency. Heavy exposure to pesticides and air pollution during pregnancy was recently associated with ASD. We need more epidemiologic data to establish many of these associations; if proven, they might be promising avenues for prevention.

Congenital fulminant Kaposiform hemangioendothelioma of the leg

Kaposiform hemangioendothelioma is a rare locally aggressive vascular tumor associated with Kasabach Merritt syndrome. We present a case of congenital Kaposiform hemangioendothelioma of the leg in a female infant who was born to a mother treated with various medications including etanercept, a TNF antagonist, due to rheumatoid arthritis. The neonate suffered from a fulminant form of Kasabach Merritt syndrome with disseminated intravascular coagulation (DIC) resulting in multi-organ failure which led to her demise.

Amyand's hernia with perforated appendicitis in a premature infant

We present a case of Amyand's hernia with perforated appendicitis in a premature infant. The favorable outcome compared to perforated abdominal appendicitis is discussed. Despite its rarity, this diagnosis should be considered in the differential diagnosis of a scrotal mass in premature infants.

The association of maternal intrapartum subfebrile temperature and adverse obstetric and neonatal outcomes

BACKGROUND

Subfebrile intrapartum maternal temperature is very common, yet there is sparse evidence regarding its causes or its effects on perinatal outcomes. We examined whether mild temperature elevation during labour is a risk marker for adverse obstetric and neonatal outcomes.

METHODS

A retrospective cohort analysis including 42 601 term, singleton live-births in two medical centres between 2003 and 2010 was performed. This study compared women who experienced a maximal intrapartum temperature of ≤37°C with women who experienced subfebrile intrapartum temperature (37.1-37.9°C). Adjusted risks for adverse obstetric and neonatal outcomes were calculated by using multivariable logistic regression models.

RESULTS

Compared with maternal temperature ≤ 37°C, subfebrile temperature was associated with higher rates of primary caesarean deliveries {adjusted odds ratios [aOR] = 1.36 [95% confidence interval (CI) 1.25, 1.49])} and assisted vaginal deliveries (aOR = 1.20 [95% CI 1.11, 1.30]), as well as with greater risks of early neonatal sepsis (aOR = 2.66 [95% CI 1.88, 3.77]), neonatal intensive care unit admissions (aOR = 1.40 [95% CI 1.08, 1.83]), and neonatal asphyxia or seizures (aOR = 3.18 [95% CI 1.51, 6.70]). Mildly elevated maternal intrapartum temperature (37.1-37.5°C) was also associated with adverse outcomes.

CONCLUSIONS

Maternal intrapartum subfebrile temperature may be an indicator of operative delivery and neonatal morbidity. Further research is needed to confirm these findings and to reveal underlying mechanisms.

Prevalence of persistent superior vena cava and association with congenital heart anomalies

A contralateral persistent superior vena cava (PSVC) can occur in a normal child or in association with congenital heart defects (CHDs). Its prevalence has been demonstrated in relatively small cohorts. We aim to assess the frequency of a PSVC in a large cohort of children with and without CHDs. To estimate its significance, we have searched for a PSVC in all children referred for echocardiography in our institution during a 16.5-year period. A group of 17,219 children comprised 8,140 children with a structural heart anomaly and 9,079 children with a structurally normal heart. Association between a PSVC and specific classes of CHD were looked for. A total of 288 children (1.7%) had a PSVC; 0.56% (51 of 9,079) in the normal heart group and 2.9% (237 of 8,140) in the congenital heart anomalies group. Odds ratio for having heart anomaly in the presence of PSVC was 5.2 (95% confidence interval 3.7 to 7.0). A PSVC was above all associated with atrioventricular septal defects, conotruncal malformations, and left-sided defects. The odds ratio of having PSVC in the aforementioned malformations compared with the normal heart group was 23.8, 13.6, and 11.0, respectively. In conclusion, although present in normal subjects, PSVC was more often associated with congenital heart and other anomalies, especially with atrioventricular septal defects, conotruncal malformations, and left-sided defects.

Dynamics of pleural fluid effusion and chylothorax in the fetus and newborn: role of the lymphatic system

Pleural fluid effusion particularly chylothorax is a relatively rare occurrence in the newborn, but when it occurs it is often life-threatening. In this article, we describe and illustrate the morphologic features of the visceral and parietal pleura including pleural lymphatics and the physiology and pathophysiology of pleural fluid balance. The role and function of the lymphatic system in controlling the volume and composition of pleural liquid are detailed and a conceptual scheme presented. Finally, the crucial role of inadequate lymphatic drainage (either functional overload from an imbalance in Starling forces or mechanical insufficiency from lymphatic dysplasia) is emphasized.

Perinatal and early postnatal factors underlying developmental delay and disabilities

A delay in meeting developmental milestones may be secondary to perinatal events, involving complicated interactions between mother and fetus during delivery. Maternal factors including weight, diet, and morbidities can affect neonatal adaptation and later development. Prematurity, low birth weight, and previous intrauterine insults as well as complications during delivery of a previously normal fetus increase the risk for perinatal stress. In this article, the literature on perinatal and early postnatal factors that underlie risks for developmental delay and disabilities is reviewed. Studies that concern neuroprotective therapies and prediction of long-term neurologic outcome by clinical examination, neuroimaging techniques, and electroencephalographic studies are reviewed as well.

Continuous surveillance to reduce extended-spectrum β-lactamase Klebsiella pneumoniae colonization in the neonatal intensive care unit

BACKGROUND

Clinical illness caused by resistant bacteria usually represents a wider problem of asymptomatic colonization. Active surveillance with appropriate institution of isolation precautions represents a potential mechanism to control colonization and reduce infection. The neonatal intensive care unit (NICU) is an environment particularly appropriate for such interventions. Neonates are rarely colonized by resistant bacteria on admission and staff enthusiasm for infection control is high.

OBJECTIVE

To reduce extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-KP) acquisition amongst neonates through a continuous active surveillance intervention.

METHODS

Fecal ESBL-KP cultures were performed weekly on all neonates over 4 years. Neonates with positive cultures were managed with contact precautions by dedicated nurses separately from other neonates. ESBL-KP acquisition amongst neonates staying >7 days was compared for the consecutive years. A subset of ESBL-KP isolates was typed with pulsed-field gel electrophoresis (PFGE).

RESULTS

Surveillance cultures were obtained from 1,482/1,763 (84%) neonates over 4 years. ESBL-KP acquisition decreased continuously from 94/397 (24%) neonates in 2006 to 33/304 (11%) in 2009 (p < 0.001, hazard ratio 0.75, 95% confidence interval 0.66-0.85, p < 0.001 for comparison of years). Hospital-wide ESBL-KP acquisition did not decrease outside the NICU. PFGE identified identical ESBL-KP strains from multiple neonates on six occasions and different strains from single neonates on seven occasions.

CONCLUSIONS

ESBL-KP is probably both imported into and spread within the NICU. Continuous long-term surveillance with cohorting was associated with a decrease in ESBL-KP acquisition within the NICU. This low-risk intervention should be considered as a means to decrease neonatal acquisition of resistant bacteria.

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)