[Identical, for better and for worse].

We report on identical premature twins (monochorionic diamniotic). As fetuses, they both demonstrated sonographic and MRI evidence of cerebral bilateral ventriculomegaly. Neonatal brain US showed bilateral ventriculomegaly, similar in both twins. During follow-up, these physical and imaging similarities persisted. To the best of our knowledge, this is the first report on similar bilateral ventriculomegaly in Identical Twins (IT). A genetic origin of this finding in our IT is suggested. Should more cases of ventriculomegaly be reported in the future in several sets of IT, cerebral ventriculomegaly can then be added to the list of similar CNS features observed in identical twins.

Early-onset group B Streptococcus sepsis in high risk neonates born after prolonged rupture of membranes.

BACKGROUND: According to the U.S. Centers for Disease Control guidelines, prolonged rupture of membranes mandates intrapartum antimicrobial prophylaxis for group B Streptococcus whenever maternal GBS status is unknown. OBJECTIVES: To evaluate the local incidence, early detection and outcome of early-onset GBS sepsis in neonates born at 35-42 weeks gestation after PROM to women with unknown GBS status who were not given intrapartum antimicrobial prophylaxis. METHODS: During a 1 year period we studied all neonates born beyond 35 weeks gestation with maternal PROM > or =18 hours, unknown maternal GBS status and without prior administration of IAP. Complete blood count, C-reactive protein, blood culture and polymerase chain reaction amplification of bacterial 16S rRNA gene were performed in blood samples collected immediately after birth. Unfavorable outcome was defined by one or more of the following: GBS bacteremia, clinical signs of sepsis, or positive PCR. RESULTS: Of the 3616 liveborns 212 (5.9%) met the inclusion criteria. Only 12 (5.7%) of these neonates presented signs suggestive of sepsis. PCR was negative in all cases. Fifty-eight neonates (27.4%) had CRP > 1.0 mg/dl and/or complete blood count abnormalities, but these were not significantly associated with unfavorable outcome. Early-onset GBS sepsis occurred in one neonate in this high risk group (1/212 = 0.47%, 95% CI 0.012-2.6). CONCLUSIONS: In this single-institution study, the incidence of early-onset GBS sepsis in neonates born after PROM of 18 hours, unknown maternal GBS status and no intrapartum antimicrobial prophylaxis was 0.47%.

Parental and perinatal factors affecting childhood anthropometry of very-low-birth-weight premature infants: a population-based survey.

BACKGROUND: The perinatal-neonatal course of very-low-birth-weight (VLBW) infants might affect their childhood growth. We evaluated the effect of parental anthropometry and perinatal and neonatal morbidity of VLBW neonates on their childhood growth. METHODS: We obtained parental anthropometry, height and weight at age 6-10.5 years of 334 children born as VLBW infants. Parental, perinatal and neonatal data of these children were tested for association with childhood anthropometry. RESULTS: (1) Maternal and paternal weight standard deviation score (SDS) and discharge weight (DW) SDS were associated with childhood weight SDS (R(2)= 0.111, p < 0.00001); (2) Maternal and paternal height SDS, corrected gestational age (GA) at discharge, maternal assisted reproduction and SGA status were associated with childhood height SDS (R(2)= 0.208, p < 0.00001); (3) paternal weight SDS, DW SDS and surfactant therapy were associated with childhood body mass index (BMI) SDS (R(2)= 0.096, p < 0.00001). 31.1% of VLBW infants had DW SDS < -1.88, and are to be considered small for gestational age ('SGA'). One quarter of these infants did not catch up by age 6-10.5 years. CONCLUSION: Childhood anthropometry of VLBW infants depends on parental anthropometry, postnatal respiratory morbidity and growth parameters at birth and at discharge. Almost one-third of VLBW premature infants had growth restriction at discharge from neonatal intensive care unit (NICU), a quarter of whom did not catch up by age 6-10.5 years.

Late postnatal systemic steroids predispose to retinopathy of prematurity in very-low-birth-weight infants: a comparative study.

BACKGROUND AND OBJECTIVE: Retinopathy of prematurity (ROP) develops mostly in very-low-birth-weight (VLBW) premature infants. Besides prematurity and hyperoxia, other variables have been brought up as risk factors for ROP. We aimed to search risk factors for ROP by comparing two groups of preemies, one with and the other without ROP. PATIENTS AND METHODS: During 2004-2006, 27 VLBW premature infants developed ROP (ROP group). For each neonate in the ROP group, we chose a neonate born at similar gestational age (GA) (+/-1 week) but without ROP (control group). For each neonate of both groups, we recorded demographic, maternal, gestational, intrapartum, neonatal, interventional, growth and ophthalmologic data from patients' medical records. RESULTS: Eleven of the tested variables were significantly different between the ROP and control groups in univariate analysis. However, only seven of these variables remained significantly different between groups when controlling each variable for GA: bronchopulmonary dysplasia (BPD, p=0.04), duration of hospitalization (p=0.017), high-frequency oscillatory ventilation (HFOV, p=0.033), duration of oxygen therapy (p=0.023), surfactant therapy (p=0.045), inhaled steroids (p=0.015) and systemic steroids for BPD (p=0.007). These seven significant variables were related to respiratory morbidity and interventions. Multiple stepwise logistic regression including all significant variables in the univariate analysis showed that only systemic steroids remained significantly different between groups (p=0.007, OR 5.42, 95% CI 1.60-18.34). CONCLUSION: Significantly more neonates in the ROP group received late postnatal systemic steroids as compared to controls. We speculate that steroids, by altering insulin growth factor-1 (IGF-1) and vascular endothelial growth factor (VEGF) expression, might contribute to the pathogenesis of ROP.

Approach to term neonates born after maternal intrapartum fever and unknown maternal group B Streptococcus status: value of serum C-reactive protein and 16S rRNA gene PCR amplification.

Thirty-six term neonates born after maternal intrapartum fever, with premature rupture of membranes <18 hours and unknown maternal group B Streptococcus status had blood samples for complete blood count, C-reactive protein, culture, and 16S rRNA gene polymerase chain reaction amplification. Only 2 neonates were symptomatic and none had leukopenia, C-reactive protein >1.0 mg/dL, bacteremia, or positive polymerase chain reaction.

Infected subgaleal hematoma in a neonate.

Subgaleal hematoma (SGH) is an infrequent finding in neonates, occurring mostly after vacuum extraction deliveries. SGH can cause anemia, hypovolemic shock, and death. To date, only one case of neonatal infected SGH has previously been reported. We describe a term neonate with severe polymicrobial infection complicating SGH, including anaerobic bacteria, and with unique imaging features.

Candidal versus bacterial late-onset sepsis in very low birthweight infants in Israel: a national survey.

Candidal infections are one of the common causes of late-onset sepsis (LOS) among very low birthweight (VLBW) infants, and are associated with substantial morbidity and mortality. The aim of this study was to evaluate the perinatal and neonatal risk factors for fungal LOS compared with bacterial LOS in VLBW infants. This was a population-based observational study of VLBW infants in 28 neonatal intensive care units across Israel, with information on 11,830 infants born between 1995 and 2002 from the Israeli National VLBW infant database. The study population comprised 3054 infants with one or more episodes of LOS. Univariate analysis and logistic regression models were used to compare perinatal and neonatal risk factors between infants with fungal sepsis only (N=179) and those with bacterial sepsis only (N=2630). The mean birthweight and gestational age of infants with candidal LOS were significantly lower (940 g; 27.1 weeks) than those in the bacterial LOS group (1027 g; 28.3 weeks) (P<0.001). Logistic regression analysis showed that candidal sepsis, in contrast to bacterial sepsis, was independently associated with decreasing gestational age and bronchopulmonary dysplasia (BPD). In addition, BPD only [odds ratio (OR) 1.84; 95% confidence intervals (CI) 1.03-3.23] and BPD with postnatal steroid therapy (OR 2.66; 95% CI 1.59-4.46) were independently associated with an increased risk for candidal sepsis.

Parturition itself is the basis for fetal adrenal involution.

CONTEXT: Newborn infants show a postnatal decline in androgen levels as the fetal adrenal glands involute. HYPOTHESIS: Placental factors up-regulate dehydroepiandrosterone sulfate (DHEA-S) generation. Hence, regardless of age, parturition will result in fetal adrenal involution and decline in DHEA-S levels. SUBJECTS AND METHODS: Premature neonates (n = 30) with gestational age 26-35 wk were studied. Adrenal volume by ultrasonography and serum DHEA-S, cortisol, and androstendione levels were followed weekly between d 1 and 28 of life. RESULTS: Serum DHEA-S was high on d 1 of life, declining rapidly regardless of gestational age during the first week of life (P < 0.001), and serum androstenedione and cortisol levels followed a similar pattern. Androstenedione levels showed a rise as of d 21 of life in boys but not in girls. The adrenals decreased in ultrasonographic volume from d 1 to 14 of life (P < 0.001), regardless of gestational age. CONCLUSIONS: Involution of the adrenal is faster than previously reported and, regardless of gestational age, occurs within the first week of life in terms of hormone secretion and within 2 wk in adrenal size. Involution involves a decline in DHEA-S but also in androstenedione and cortisol secretion, with a change in enzymatic activity. Males and females differ in their androstenedione levels and enzymatic activity. Parturition itself is the basis for fetal adrenal involution, supporting a key role for placental factors in maintaining the fetal adrenal and generating adrenal androgens.

Values of C-reactive protein, procalcitonin, and Staphylococcus-specific PCR in neonatal late-onset sepsis.

AIM: To evaluate the predictive value of relevant clinical and laboratory parameters (complete blood count (CBC), C-reactive protein (CRP), procalcitonin (PCT) and Staphylococcus-specific polymerase chain reaction (PCR)) in neonates with suspected late-onset sepsis (LOS). METHODS: NICU neonates were prospectively followed for septic events. One hundred and eleven neonates developed 148 suspected septic events beyond 3 d of age. We recorded the clinical signs and laboratory abnormalities at onset of sepsis, serum CRP and PCT, Staphylococcus-specific PCR, microbiological data, and empiric antimicrobial therapy. RESULTS: Variables significantly associated with subsequently confirmed LOS included hypotension (relative risk (RR) = 5.6, 95% CI 3.29-9.53), mechanical ventilation (RR = 2.46, 95% CI 1.24-4.86), immature/total neutrophil ratio (I/T) > 0.2 (RR = 5.13, 95% CI 2.54-10.31), CRP > 1.0 mg/dl (RR = 2.85, 95% CI 1.32-6.15), and small-for-gestational-age (SGA) status (RR = 2.13, 95% CI 1.03-4.38). PCT was not significantly associated with LOS. For detection of staphylococcal bacteremia, Staphylococcus-specific PCR showed: sensitivity 57.1%, specificity 94.7%, positive predictive value 53.3%, and negative predictive value 95.4%. CONCLUSION: Hypotension, mechanical ventilation, I/T > 0.2, CRP > 1.0 mg/dl, and SGA status at onset of sepsis are significant predictors of proven neonatal LOS. Staphylococcus-specific PCR might be of value in ruling out staphylococcal sepsis.

[Predictors and empiric anti-microbial therapy of late-onset sepsis in the neonatal intensive care unit].

BACKGROUND: Whenever suspicion of late-onset sepsis (LOS) is raised, sepsis workup is performed and empiric anti-microbial therapy (AMT) is initiated. However, the prescribed AMT may often be inappropriate for the eradication of the causative pathogen. STUDY AIM: To evaluate the clinical, interventional and laboratory predictors of LOS, and to evaluate the appropriateness of empiric AMT in late-onset neonatal sepsis. PATIENTS AND METHODS: The medical records of all neonates admitted to a tertiary NICU during a 1-year period were retrospectively reviewed. Out of 352 infants admitted, 84 neonates developed 96 suspected septic events beyond 3 days of age and comprised the study population. LOS was defined as clinical signs of sepsis accompanied with positive blood and/or urine and/or CSF cultures obtained at the onset of the septic event. For each infant, we collected demographic and perinatal characteristics, neonatal diagnoses and interventions, clinical signs and laboratory abnormalities at onset of sepsis, the AMT instituted, and microbiological data. RESULTS: Of the 96 events of suspected LOS, 26 (27.0%) positive blood cultures, w ith coagulase-negative St aphylococcus (CoNS), Klebsiella and Candida accounting for 22/ 26 (84.7%) of these events. In four out of 75 events (5.3%), urine culture was positive. Logistic regression multivariate analysis showed that birth weight (OR=0.9, 95% CI: 0.82-0.99; p=0.031), apnea/bradycardia (OR=3.16, 95% CI: 1.08-9.25; p=0.036), and platelet count < 100,000/mm3 (OR=7.04, 95% CI: 1.21-40.9; p=0.03) were significantly associated with LOS. Out of 29 proven septic events, 14 (48.3%) had received AMT within 3 days prior to onset of LOS. In 26/29 (89.7%) of proven septic events, empirical AMT was started after sepsis work-up, mostly vancomycin 18/29 (62.0%), imipenem 14/29 (48.3%), and amphotericin B 9/29 (31.0%). Out of the 26 proven septic events treated with empiric AMT, the causative pathogen was sensitive to the prescribed AMT in 24 (92.3%) of the cases. CONCLUSIONS: Significant predictors of LOS include lower birth weight, apnea/bradycardia and thrombocytopenia. Empirical AMT was initiated in 90% of proven septic events and was appropriate in 92.3% of these cases. When confronted with suspected LOS in the NICU setting, empiric coverage of CoNS, Klebsiella and fungi should be considered, based on the infant's condition and on local microbiological data.

Fast bedside measurement of blood count and C-reactive protein in neonates with suspected late-onset sepsis.

UNLABELLED: Conventional and fast complete blood count (CBC) and C-reactive protein (CRP) measurements were compared in 56 neonates with suspected sepsis. Mean differences between pairs (conventional minus fast) of the corresponding CBC and CRP values were significant for the six CBC parameters tested (p<0.02), but not for CRP (p=0.18). CONCLUSION: In neonatal sepsis, conventional and fast methods are comparable only for CRP but not for CBC variables.

PCR-based diagnosis of neonatal staphylococcal bacteremias.

We compared PCR with blood cultures in the diagnosis of neonatal staphylococcal sepsis. Significant association was observed between PCR-based and culture-based diagnosis of staphylococcal bacteremia. Positive and negative predictive values for PCR were 100% and 98%, respectively. These data indicate that PCR may serve as a useful adjunct for the rapid diagnosis of staphylococcal sepsis.

Neonatal transient renal failure with renal medullary hyperechogenicity: clinical and laboratory features.

Sonographic findings of renal medullary hyperechogenicity have been observed in the neonate in association with severe perinatal renal injury, kidney malformations or nephrocalcinosis, and, rarely, in newborn infants with transient renal failure. The aim of the study was to describe the entity of neonatal transient renal failure with renal medullary hyperechogenicity (NTRFMH). We studied nine term neonates, born between August 1999 and February 2004 in our institution (0.1% of the live born infants), who developed transient renal dysfunction after birth, and in whom renal sonograms showed bilateral medullary hyperechogenicity. Seven of the infants (78%) had anuria until 30-45 hours of age, and two (22%) had oliguria. Peak serum creatinine levels ranged between 0.61 and 1.62 mg/dL (mean: 1.09+/-0.27 mg/dL) at 2-3 days of life. Additional findings included proteinuria in nine infants (100%), uric acid crystalluria in seven (78%), hyperuricemia in four (44%), and hypertension in one (11%). Hyperuricosuria was demonstrated in one out of the seven patients in whom this parameter was determined. Urinary excretion rates of calcium, phosphorus and oxalic acid were normal, as were urinary levels of amino acids and organic acids. Full clinical recovery accompanied by normalization of all laboratory parameters was observed in all infants by 4-6 days of life. Subsequent follow-up showed normal renal function, no urinary abnormalities, and normal renal sonograms in all infants. Our summary of the nine infants with NTRFMH reported on here and a review of 19 cases of this condition reported in the literature reveal a not-so-rare entity of unclear etiology, but excellent prognosis. Physicians caring for neonates should be aware of this benign and transient condition.

Pathogen-specific early mortality in very low birth weight infants with late-onset sepsis: a national survey.

BACKGROUND: Late-onset sepsis (LOS) is an important cause of mortality among very low birth weight (VLBW) infants, and deaths occurring within 3 days after the onset of sepsis can probably be ascribed to sepsis. We examined the association of sepsis due to specific pathogens with the risk for early mortality after the onset of LOS, adjusted for perinatal and neonatal risk factors. METHODS: From 1995 through 2001, information about 10,215 infants was gathered and deposited in the Israel National VLBW Infant Database. The study population was composed of 2644 infants, of which each had >or=1 events of LOS (totalling 3462 events). Logistic regression models were used to calculate the crude and adjusted risk for early mortality. RESULTS: Early mortality was associated with 179 LOS events (5.2% of 3,462); the range of pathogens associated with these events included coagulase-negative staphylococci (CoNS), which were the cause of 1.8% of LOS events associated with early mortality, and Pseudomonas species, which were the cause of 22.6% of such events. Early mortality after LOS, adjusted for neonatal risk factors, was significantly associated with sepsis due to certain pathogens: Pseudomonas species (odds ratio [OR], 12.3); Klebsiella species (OR, 6.3); Serratia species (OR, 6.2); Escherichia species (OR, 4.3); Enterobacter species (OR, 4.1); and Candida species (OR, 3.2), compared with sepsis due to CoNS . In addition, lower gestational age, lower chronological age, small size for gestational age, and grade 3-4 intraventricular hemorrhage, each had an independent association with early mortality. CONCLUSIONS: Klebsiella sepsis and Pseudomonas sepsis were associated with a 6.3-fold and 12.3-fold increased risk of early mortality, respectively, and accounted for 41.9% of all early deaths associated with LOS. Considering the aggressive nature of sepsis caused by these pathogens, empiric antibiotic therapy active against these organisms is worth consideration for VLBW infants with presumed LOS.

Sonographic biometry of the frontal lobe in normal and growth-restricted neonates.

Assessing the impact of restricted intrauterine growth on neonatal frontal lobe (FL) dimensions is important. We aimed to create a sonographic nomogram of FL dimensions in neonates at different gestational ages (GA) and evaluate the impact of small head circumference (HC) on FL dimensions. We conducted sonographic biometry of the FL at birth. We included 218 newborn infants born at GA of 24-43 wk: appropriate for GA and normal HC (n = 178), and small for GA and small HC (n = 23). Infants with a 5-min Apgar score <7, severe congenital malformations, or chromosomal abnormalities were excluded. Through a coronal ultrasound scan via the anterior fontanelle at the level where the most lateral point of the left Sylvian fissure was best demonstrated, we drew a triangle connecting the most lateral point of the Sylvian fissure, the corpus callosum, and the subcalvarian point of the interhemispheric fissure. We measured the three sides of the triangle, Sylvian-fontanellar distance, Sylvian-callosal distance, and fontanellar-callosal distance, and calculated the frontal triangular area. All four FL dimensions increased significantly between 24 and 43 wk of gestation in both appropriate for GA-normal HC and small for GA-small HC neonates, and were strongly correlated with HC and birth weight. Regression lines of GA against Sylvian-fontanellar distance, Sylvian-callosal distance, fontanellar-callosal distance, and frontal triangular area in the appropriate for GA-normal HC group differed significantly from those of the small for GA-small HC group (p < 0.05). Male neonates had significantly larger Sylvian-fontanellar and Sylvian-callosal distances than females (p < 0.01 and p < 0.015, respectively). In conclusion, FL measures increased significantly between 24 and 43 wk of gestation, and were strongly correlated with HC. We speculate that a sonographically small fetal HC implies growth restriction of the fetal FL.

Neonatal course and outcome of twins from reduced multifetal pregnancy versus non-reduced twins.

BACKGROUND: Multifetal pregnancy reduction has been implemented for improving the outcome of multifetal pregnancies. Recent studies reported no difference in pregnancy outcome between reduced twins and non-reduced twins, but the neonatal course and subsequent outcome in reduced twin pregnancies were not well documented. OBJECTIVE: To compare the neonatal course and outcome, as well as the gestational and labor characteristics in twins from reduced multifetal pregnancies and in non-reduced twins. METHODS: This is a retrospective case-control study of the neonatal course of twins from reduced multifetal pregnancies. We found 64 mothers with multifetal pregnancy reduction who delivered twins during 1989-1997; 64 gestational age-matched non-reduced twin pregnancies served as controls. The following neonatal variables were examined: major malformations; small birth weight for gestational age; and neonatal morbidities including respiratory distress syndrome, apnea, pneumothorax, bronchopulmonary dysplasia, hyperbilirubinemia, sepsis, necrotizing enterocolitis, retinopathy of prematurity, seizures, intraventricular hemorrhage, periventricular leukomalacia, ventriculomegaly, and hydrocephalus. In addition, we evaluated several neonatal interventions (surfactant replacement, mechanical ventilation, phototherapy, total parenteral nutrition), and some laboratory abnormalities (thrombocytopenia, leukopenia, anemia, and hypoglycemia), duration of hospitalization, and neonatal mortality. RESULTS: Gestational and labor variables were not significantly different between multifetal pregnancies reduced to twins and non-reduced twin pregnancies. The neonatal morbidity and mortality were not significantly different between twin neonates from multifetal pregnancy reduction and non-reduced control twins. CONCLUSIONS: Multifetal pregnancy reduction to twins appears to bear no adverse effect on the intrauterine course of the remaining fetuses or their neonatal course and outcome when born after 28 weeks of gestation.

Congenital limb deficiencies in newborn infants: prevalence, characteristics and prenatal diagnosis.

Congenital limb deficiency (CLD) occurs in 0.54 to 0.59/1000 live-born infants and varies according to its anatomic location, type and cause. Our aim was to present a fetus with a prenatal ultrasonographic diagnosis of CLD (transverse reduction deficiency of the left upper limb), and to determine the prevalence and clinical characteristics of CLD at a tertiary medical centre in Israel. Among 78 500 live-born infants, there were 24 cases of CLD (0.31/1000): 45.8% of the CLD cases with affected upper limbs, 45.8% with affected lower limbs, and 8.4% with both limbs affected; 88.4% of the limb deficiencies were longitudinal and 11.6% were transverse; and, 33.3% (8/24) of the affected newborn infants had additional congenital anomalies. We conclude that CLD is not an infrequent finding in live-born infants. Comprehensive ultrasonography of the fetus allows early prenatal diagnosis of CLD and provides the parents with important information and helps them in their decision regarding the fate of the pregnancy.