Parents who refuse to vaccinate their infants: paediatricians' feelings and treatment intentions.

AIM: The aim of this study was to evaluate paediatricians' attitudes and emotions towards parents who refuse to vaccinate their infants and to assess their reactions, suggestions and practices. DESIGN: The study group consisted of 376 paediatricians in Israel, who completed the emailed research questionnaire anonymously. RESULTS: Although the vast majority of paediatricians agreed that vaccination was in the baby's best interest (92.2%), only a small percentage (3.5%) felt that there should be some scientific justification behind a parent's refusal. The majority (70.7%) of those surveyed expressed negative feelings towards refusing parents. Despite this, more than a third (36.9%) agreed that parents have the right to decide (28.9% disagreed) and a third (36.8%) agreed that vaccinations should be officially enforced (35.8% disagreed). Only a very small percentage of the paediatricians (1.8%) said they would object to treating infants who had not been vaccinated. CONCLUSION: Paediatricians face a conflict between two opposing values: the importance of immunization versus the parents' rights to decide what is best for their own child. Therefore, they are in favour of gentle persuasion or official enforcement. We believe that experts in modern communication could help paediatricians to convey the positive benefits of vaccination to parents.

Impaired platelet function in neonates born to mothers with diabetes or hypertension during pregnancy.

OBJECTIVE: In a recent pilot study, platelet function of 4 neonates born to mothers with pregnancy-induced hypertension (PIH) was found to display lower platelet adhesion compared to healthy neonates. The present study aimed at confirming and validating these findings. STUDY DESIGN: Platelet adhesion was measured using a Cone Platelet Analyzer (CPA). The platelet function in the cord blood of 35 term infants born to mothers with PIH or gestational diabetes (GD) was compared with the platelet function of 196 infants born to healthy mothers. All neonates were monitored for perinatal complications until hospital discharge. RESULTS: Neonates born to mothers with PIH and with GD displayed poorer platelet function, with decreased platelet surface coverage as tested by CPA (control group 8.53+/-3.81%; PIH: 5.9+/-3.91%, p=0.003; GD: 6.64+/-3.64%, p=0.005). No association was found between CPA values and post-natal complications. CONCLUSIONS: Maternal PIH or GD is associated with impaired platelet function in neonates. The clinical impact of these findings is yet to be studied.

Clot formation of neonates tested by thromboelastography correlates with gestational age.

Evaluation of clot formation in neonates is troublesome. Our aim was to investigate cord blood clot formation of pre-term versus full-term infants and adults, using rotating thromboelastogram (ROTEM), Pentafarm, Munich, Germany). ROTEM was investigated in cord blood of 184 full-term and 47 pre-term infants. Measurements of the clotting time (CT), clot formation time (CFT) and maximal clot firmness (MCF) were obtained in order to asses reference values for this age group, and compare between full-term and pre-term neonates and compared to adult controls. For each infant demographic information and data regarding pregnancy and delivery were gathered. Infants were prospectively followed until discharge. CT and CFT were significantly shorter among pre-term and term infants as compared to adults [median CT: 185, 194, 293 seconds respectively, p pound0.001, CFT: 80, 76, 103 seconds respectively, p pound0.001). MCF was lower in pre-term and term as compared to adults (p pound0.001) with significantly lower values in pre-term as compared to full-term neonates (p=0.004). Clotting time and MCF correlated with gestational age (R=0.132, p=0.045, R= 0.259, p<0.001, respectively). No association was found between any ROTEM values and the occurrence of post-natal complications in infants of our study group. This is the first study assessing clot formation by ROTEM in pre-term infants. Clot formation parameters of term and premature infants correlated with gestational age. The predictive value of clot formation tests in neonates deserves further attention.

Prenatal diagnosis of congenital agenesis of the fetal portal venous system.

OBJECTIVE: To describe the prenatal diagnosis and review our experience of fetal congenital agenesis of the portal venous system (CAPVS) and to review the current literature on this poorly documented vascular malformation. METHODS: This was a retrospective survey covering the 12-year period between 1996 and 2008. The database of a single, large, ultrasonographic tertiary academic referral center in Israel was analyzed and cases with a prenatal diagnosis of CAPVS were identified. All fetuses underwent detailed biometric and structural ultrasound examinations and a precise anatomical description of the fetal umbilical, portal and hepatic venous system was noted, as well as the presence of aberrant vessels, shunt location and the presence or absence of the DV. Results of fetal echocardiography, karyotyping and toxoplasma, rubella, cytomegalovirus and herpes evaluations were determined. Medical records were evaluated. Diagnosis was confirmed by pathology, postmortem venography or neonatal ultrasound or venography. Liveborns were examined by a certified neonatologist and long-term follow-up from pediatric gastroenterology units was determined. RESULTS: Nine cases with CAPVS were studied. In all cases an aberrant umbilical-portal vein was the primary indication for detailed portal system evaluation. Five fetuses demonstrated total CAPVS (Type I) and four showed partial agenesis of the portal vein (Type II). Among the five Type I fetuses, there was a shunt from the umbilical vein to the inferior vena cava in three (60%), to the right atrium in one and to the coronary sinus in one. In this group, in only one case could we delineate a common confluence between the splenic vein and the superior mesenteric vein shunting to the inferior vena cava. In four cases termination of pregnancy was performed due to additional findings: one case with hydrothorax, ascites and mitral atresia, one with cleft lip/palate and one with trisomy 21. One case had no additional anomalies, but the parents elected to terminate the pregnancy. All four of the Type II fetuses had a portosystemic shunt: in two cases to the right atrium, in one to the iliac vein and in one to the right hepatic vein. In three, the shunt resolved spontaneously. In only one case was abnormal liver function present over a follow-up period of 2-10 years. CONCLUSION: CAPVS can be detected prenatally. An abnormal course of the umbilical vein necessitates prompt sonographic evaluation of the umbilical-portal venous system and meticulous investigation for additional anomalies. Complete CAPVS may be associated with remote clinical consequences of which the parents should be informed. Partial CAPVS has a favorable prognosis.

Platelet function of newborns as tested by cone and plate(let) analyzer correlates with gestational Age.

UNLABELLED: The issue of platelet function in infants and neonates is of interest, and current data are debatable. A new method for assessing platelet function involves using the cone and plate(let) analyzer (CPA), applicable for small (0.2 ml) whole blood volumes. We used polystyrene surface-coated plates to evaluate cord blood neonatal platelet function under flow. One hundred and sixty full-term and 29 preterm infants born at the Sheba Medical Center between March 2003 and January 2004 were evaluated for platelet adhesion measured as surface coverage (SC; the percentage of total area covered by platelets) and platelet aggregation, defined as the average size (AS) of the aggregates. Platelets from preterm infants displayed less platelet adhesion than did those from full-term infants. Platelet SC correlated with gestational age in all infants (p < 0.05), and both groups exhibited similar aggregation (AS). AS values, however, were significantly lower than the normal adult range in our laboratory. Infants born to mothers with pregnancy-induced hypertension displayed significantly lower SC. No association was found between CPA and postnatal complications. CONCLUSION: CPA provides a rapid, feasible option for testing platelet function in neonates. Its potential predictive value deserves further attention, and more extensive studies are warranted.

Maternal selective serotonin reuptake inhibitor intake does not seem to affect neonatal platelet function tests.

Recently, concerns have been raised regarding the potential impairment of neonatal platelet function and the potential risk of bleeding in neonates born to mothers treated with selective serotonin reuptake inhibitors (SSRI). Our aim was to test whether the platelet function of neonates born to SSRI-treated mothers was impaired when compared to non-SSRI-exposed neonates. In a single-center prospective study, platelet function was evaluated using a cone and platelet analyzer (CPA) device and compared between mother-infant pairs as well as normal non-SSRI-exposed infants. Twenty-seven SSRI-exposed and 27 non-SSRI-exposed full-term neonates and their 23 mothers were tested. No correlation was found between SSRI exposure among either neonates or mothers and parameters of surface coverage (SC) and average size (AS), manifesting platelet function as tested by CPA. SC was similar among SSRI-exposed babies as compared to those in the control group, whereas the size of platelet aggregates (AS) was higher among controls. Neither maternal diseases nor SSRI intake were associated with impaired platelet function and lower SC values, nor were any perinatal conditions. None of the babies suffered from bleeding. We conclude that maternal SSRI therapy does not impair whole-blood CPA-tested platelet function of healthy full-term neonates.

Low prevalence of hearing impairment among very low birthweight infants as detected by universal neonatal hearing screening.

OBJECTIVES: To (a) study the prevalence of hearing impairment in a cohort of very low birthweight (VLBW) infants and (b) evaluate the effectiveness of transient evoked otoacoustic emissions (TEOAE) as a first stage in-hospital hearing screening tool in this population. STUDY DESIGN: The study group was a cohort of 346 VLBW infants born in 1998-2000 at The Sheba Medical Center. The prevalence of hearing impairment in the study group was compared with that of all other newborn infants participating in a universal newborn hearing screening programme during the same period. To evaluate the effectiveness of TEOAE, a control group of 1205 healthy newborns who had no known risk factors for hearing impairment was selected. The results and follow up of hearing screening for these infants were examined retrospectively. RESULTS: Only one VLBW infant (0.3%) was diagnosed with bilateral sensory-neural hearing loss. In addition, nine infants (2.7%) were diagnosed with conductive hearing loss. Bronchopulmonary dysplasia and low Apgar score were the most significant factors for predicting the occurrence of conductive hearing loss. The percentage of VLBW infants who successfully passed the in-hospital TEOAE screening was 87.2, compared with 92.2% in the full term control group. No false negative cases were detected on follow up. CONCLUSIONS: The study shows a low incidence of sensory-neural hearing loss in a cohort of VLBW infants and a relatively high incidence of conductive hearing loss. TEOAE screening was found to be an effective first stage in-hospital hearing screening tool in this population.

Fetal lung dysplasia: clinical outcome based on a new classification system.

OBJECTIVE: To evaluate the clinical application of a new classification system of fetal lung anomalies. METHODS: Forty fetal diagnoses of lung lesions were analyzed according to our proposed classification system in which each lung component is considered using two-dimensional ultrasound and color and power Doppler technology. Medical files, natural history and neonatal follow-up were recorded. RESULTS: Type I dysplasia: Four cases of agenesis of the lung were diagnosed, three with right lung agenesis and one with left lung agenesis. Three of the four patients elected to undergo termination of pregnancy (TOP). The surviving fetus was diagnosed with scimitar syndrome and postnatal embolization of the aberrant vessel was performed. Type II dysplasia: One case of normal lung with abnormal systemic feeding artery was diagnosed with normal neonatal outcome. Type III dysplasia: Abnormal lung with abnormal vascularity was found in 14 cases, presenting in most cases as echogenic lung masses. Seven were supradiaphragmatic, six subdiaphragmatic and one case was of undetermined position. All 14 fetuses showed an aberrant systemic artery emerging from the aorta. Abnormal venous drainage could be identified in only five (36%) of the fetuses: three had prominent azygos vein, one showed drainage to the inferior vena cava and one had multiple intrapulmonary veins forming a huge arteriovenous (A-V) shunt. Two cases in this group underwent TOP, the case with A-V shunt following development of hydrops, and one on maternal request. The remaining 12 fetuses (86%) survived and were alive and well at the time of writing; only one of them needed immediate postnatal embolization of the bilateral aberrant feeding arteries. Type IV dysplasia: Abnormal lung with no vascular abnormality was diagnosed in 20 fetuses. In this group there was one case of intrauterine fetal death, two patients underwent TOP, one complicated with hydrops and one on maternal request. The survival rate in this group was 85%. Only two cases needed immediate surgical repair. Type V miscellaneous dysplasia: One fetus demonstrated echogenic lung with split notochord syndrome and survived. CONCLUSIONS: Congenital bronchopulmonary and related vascular anomalies can be categorized using the new classification system. This new approach enabled prenatal evaluation of each lung component and facilitated cogent management of the fetus with congenital lung dysplasia.

Assessment of medial olivocochlear system function in pre-term and full-term newborns using a rapid test of transient otoacoustic emissions.

This study was conducted to investigate maturation of the medial olivocochlear efferent system (MOCS) in pre- and full-term neonates using Quickscreen (Otodynamics Ltd) and to confirm previous findings on transient otoacoustic emission (TEOAE) suppression in neonates. MOCS maturation was investigated in 46 neonates born at the Chaim Sheba Medical Center, Tel Hashomer, Israel, using Quickscreen. All neonates were normal with no family history of general or auditory disease and no risk factors for hearing impairment. MOCS function appears gradually in human pre-term neonates and is considered to reach maturity shortly after term birth. The clinical value of MOCS testing in specific populations of newborns at risk for hearing and/or brainstem function can be legitimately raised as activation of the MOCS clearly alters cochlear output. The present results can be interpreted to support the testing of infants at risk of developing abnormal MOCS function using a commercially available rapid TEOAE measurement system.

Characteristics of neonates with isolated rectal bleeding.

OBJECTIVE: To determine the characteristics of full term and preterm neonates with isolated rectal bleeding (IRB), and to follow the outcome of these low risk patients. DESIGN: A retrospective case-control study consisting of 147 cases (83 full term and near term infants and 64 preterm infants) and 147 controls in a single institution. RESULTS: A feeding regimen that did not include breast milk was the only variable found to predict IRB. In full term and near term babies (gestational age >/= 35 weeks), 52.6% of the study group were breast fed compared with 83.1% of the controls (p < 0.0001). In preterm babies (gestational age

Fever in healthy asymptomatic newborns during the first days of life.

OBJECTIVE: To determine the characteristics of febrile full term infants during the first days of life, and to discover the rate of serious bacterial infections among low risk neonates with systemic fever. DESIGN: A retrospective case-control study of 122 cases and 122 controls in a single institution. RESULTS: Weight loss, breast feeding, caesarean section delivery, and high birth weight were found to be the most significant predictors of developing fever during the first days of life. Of the 122 patients in the study group, only one had a serious bacterial infection (a positive urine culture for group B streptococcus). CONCLUSIONS: In low risk full term infants, fever with no other symptoms during the first days of life (but after the first day) is related primarily to dehydration, breast feeding, caesarean section, and high birth weight. Infection is the least common explanation.

Transillumination of the palm for venipuncture in infants.

AIM: To assess the efficacy of transillumination of the palm of the hand in establishing venous access in small infants. METHODS: One hundred infants aged 2 to 36 months were considered for venipuncture under transillumination following failure to find an accessible vein or a failed venipuncture attempt. RESULTS: In 40 of the 100 infants, a vein was visible with transillumination. In 22 of these children, previous attempts to achieve a venous line failed (mean number of failed venipunctures 2.11 +/- 0.6) and in 18 infants, no vein could be identified. Using transillumination, venous access was established with just one venipuncture in 39 of the 40 patients. CONCLUSIONS: Transillumination of the palm can aid in establishing venous access in infants. This can be easily carried out using a common otoscope.

Characterization of cerebral white matter damage in preterm infants using 1H and 31P magnetic resonance spectroscopy.

The biochemical characteristics of white matter damage (WMD) in preterm infants were assessed using magnetic resonance spectroscopy (MRS). The authors hypothesized that preterm infants with WMD at term had a persisting cerebral lactic alkalosis and reduced N-acetyl aspartate (NAA)/ creatine plus phosphocreatine (Cr), similar to that previously documented in term infants weeks after perinatal hypoxiaischemia (HI). Thirty infants (gestational age 27.9 +/- 3.1 weeks, birth weight 1,122 +/- 445 g) were studied at postnatal age of 9.8 +/- 4.1 weeks (corrected age 40.3 +/- 3.9 weeks). Infants were grouped according to the presence or absence of WMD on magnetic resonance (MR) images. The peak area ratios of lactate/Cr, NAA/Cr, myo-inositol/Cr, and choline (Cho)/Cr were measured from an 8-cm3 voxel in the posterior periventricular white matter (WM) using proton MRS. Intracellular pH (pHi) was calculated using phosphorus MRS. Eighteen infants had normal WM on MR imaging; 12 had WMD. For infants with WMD, lactate/Cr and myo-inositol/Cr were related (P < 0.01); lactate/Cr and pHi were not (P = 0.8). In the WMD group, mean lactate/Cr and myo-inositol/Cr were higher (P < 0.001, P < 0.05, respectively) than the normal WM group. There was no difference in the NAA/Cr, Cho/Cr, or pHi between the two groups, although pHi was not measured in all infants. These findings suggest that WMD in the preterm infant at term has a different biochemical profile compared with the term infant after perinatal HI.

Neonatal outcome in growth-restricted versus appropriately grown preterm infants.

The objective of this paper is to examine whether growth-restricted preterm infants have a different neonatal outcome than appropriately grown preterm infants. All consecutive, singleton preterm deliveries between 27-35 weeks' gestation were included over a 4-year period. Infants with congenital anomalies and infants of diabetic mothers were excluded. Infants were categorized as small-for-gestational-age (SGA) when birth weight was at or below the 10th percentile, and appropriate-for-gestational-age (AGA) when between the 11th and 90th percentiles. Outcome variables included: neonatal death, respiratory distress syndrome (RDS), sepsis, intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC). Neonatal morbidity and mortality were examined by univariate and stepwise multivariate logistic regression analyses. Factors controlled for during the analysis included: maternal age; gestational age; mode of delivery; presence of preeclampsia, HELLP syndrome, prolonged premature rupture of membranes (PROM), placental abruption, placenta previa, prenatal steroid exposure, infant gender, and low Apgar score. Seventy-six infants were included in the SGA group and 209 in the AGA group. SGA infants had a higher mortality rate (p = 0.003). They also had more culture-proven sepsis episodes (p = 0.001). No differences were found with respect to the other outcomes. The results were similar when analyzed separately for the group of infants born at or below 32 weeks' gestation. Growth-restricted preterm infants were found to have both higher mortality and infection rates compared with AGA preterm infants. Growth restriction in the preterm neonate was not found to protect against other neonatal outcomes associated with prematurity. When considering elective preterm delivery for this high-risk group of pregnancies, the increased risks in the neonatal period should be taken into account.

Low melatonin production in infants with a life-threatening event.

This study compares the urinary excretion of the main melatonin metabolite, 6-sulfatoxymelatonin (6SMT), in infants who have and have not experienced a life-threatening event (ALTE). 6SMT was assessed in the following groups of infants: 15 infants with ALTE for whom home monitoring had been recommended, 15 infants who had had an abrupt cyanotic apneic event but did not require mouth-to-mouth resuscitation, 15 siblings of those who had died from sudden infant death syndrome (SIDS), and 35 age-matched healthy comparison infants. All 80 infants were between 48 and 58 weeks of postconceptional age. On a double-blind basis, the total amount of 6SMT excreted over 24 hours and the diurnal rhythm in the rate of 6SMT excretion were assessed using urine samples taken from disposable diapers (nappies). The mean daily excretion of 6SMT was significantly lower in the ALTE (1,588 ng/24 hour) than in the comparison infants (3,961 ng/24 hour). No such difference was found between the infants with a cyanotic apneic event (3,268 ng/24 hour) and the SIDS siblings (2,962 ng/24 hour). The diurnal 6SMT rhythms in the ALTE infants were characterized by lower 24-hour mean and amplitude values, whereas the time of peak and nadir excretion rates (07:15 to 08:45 hours and 14:45 to 16:15 hours respectively) was similar in all four infant groups. Follow-up of the ALTE infants, performed 6 to 8 weeks later (59 to 66 weeks of postconceptional age), revealed that 6SMT excretion increased in all of them, suggesting a delayed ontogeny rather than permanent deficiency of melatonin production in ALTE.

Feeding tolerance in preterm infants: randomized trial of bolus and continuous feeding.

OBJECTIVE: To test the hypothesis that continuous gastric infusion (CGI) is better tolerated than intermittent gastric bolus (IGB) in small very low birth weight (VLBW) infants. DESIGN: Two-center, prospective, randomized, unmasked clinical trial. PATIENTS: 28 VLBW infants (birth weight <1250 g). A strict feeding protocol was followed. INTERVENTION: Patients were randomized to IGB or CGI. MAIN OUTCOME MEASURES: Time to reach full feeds (160 cc/kg/d)(by design and real), daily weight, caloric intake, residual gastric volume and type of feeding (formula vs. human milk vs. both). RESULTS: Five infants failed to complete the study because of death (n = 4) or protocol violation (n = 1). The two groups did not differ by birth weight or gestational age; infants fed via IGB reached full feeds earlier (p = 0.03) and had less delay in reaching full feeds than infants fed via CGI. CONCLUSION: Contrary to our hypothesis, gravity IGB is more effective than CGI in improving feeding tolerance in small VLBW infants.

Longitudinal measurements of 17alpha-hydroxyprogesterone in premature infants during the first three months of life.

AIMS: To determine normal concentrations of 17alpha-hydroxyprogesterone (17OHP) for premature infants. METHODS: 17OHP was measured in 66 consecutive premature infants once a week during the first month, and once every two weeks thereafter, until the age of 3 months. The 17OHP values in 100 full term healthy neonates on the third day of life served as controls. Blood was sampled on filter paper using a neonatal radioimmunoassay kit. Findings were correlated with gestational age, birthweight, mode of delivery, Apgar scores, presence of respiratory distress syndrome and intake of maternal steroids. RESULTS: Mean 17OHP was raised at 7 days of age (138.9, 46.3, 53.3, 29.9 nmol/l, respectively, for infants whose gestational age was under 29 weeks, 29 to 30 weeks, 31 to 32 weeks, and 33 weeks and above). It fell sharply in the first two weeks after which it gradually decreased further, reaching 32.7, 23.6, 16.9, and 13.0 nmol/l, respectively, by the age of 90 days. The mean (SEM) 17OHP concentration in full term infants on day 3 of life was 17.8 (8.9) nmol/l. These values were independent of the presence and severity of respiratory distress syndrome and of prenatal maternal steroids. CONCLUSIONS: The increased 17OHP concentrations found at birth fell to those found in term infants during the first three months of life in infants over 31 weeks of gestation. Postconceptional age is the most important factor determining 17OHP concentration.

Unexplained fever in neonates may be associated with hepatitis B vaccine.

AIM: To investigate whether hepatitis B vaccination has increased the number of cases of unexplained neonatal fever. METHOD: The files of all infants born from 1 January 1991 to 31 December 1992, in whom a diagnosis of "injected antibiotic" or "disease of temperature regulation" was recorded, were reviewed. Those who had unexplained fever of 38 degrees C or higher during the first three days of life were divided into two groups: infants who did not receive the hepatitis B vaccine (1991) and infants who did (1992). RESULTS: In 1992 the incidence of unexplained fever in hepatitis B vaccinated neonates was significantly higher than in the 1991 group of pre-vaccination neonates (35 out of 5819 (0.6%) vs 14 out of 5010 neonates (0.28%) respectively, p=0.013). CONCLUSIONS: The increase in the number of cases of unexplained neonatal fever seems to be associated with the introduction of routine hepatitis B vaccination on the first day of life. The possibility that an excess number of neonates will undergo unnecessary procedures and treatment to diagnose unexplained fever justifies planning a controlled study to determine whether these preliminary findings point to a significant problem.

The nature of the mother's tie to her infant: maternal bonding under conditions of proximity, separation, and potential loss.

Attachment has generally been examined from the infant's perspective. We focused on mothers' post-partum thoughts and behaviors. Guided by an ethological approach, maternal bonding was examined under conditions of proximity, separation, and potential loss. Ninety-one mothers were interviewed: mothers of full-term infants who maintained continuous proximity to the infant, mothers of healthy premature infants who were separated from the infant, and mothers of very low birthweight infants who experienced potential loss and prolonged separation. Mothers of term infants reported medium-to-high levels of preoccupations with thoughts of infant safety and well-being. Preoccupations increased with separation (Group 2) and significantly decreased with impending loss (Group 3). Attachment behaviors and representations were the highest among mothers of term infants and declined linearly with the duration of mother-infant separation. Maternal trait anxiety and depression were related respectively to higher levels of preoccupations and reduced attachment behaviors and representations, independent of the infant medical condition and mother-child separation. Discussion focused on the comparability of maternal and infant attachment in relation to the neurobiological system underlying bond formation.