Improved method for revising the Israel birthweight references.

OBJECTIVES: Birthweight is often used as an indicator of fetal health. Categorization of infants as small or large for gestational age has clinical significance. Due to growth differences between countries, it is important to have local reference data. The aim of the study was to describe an Israel population-based reference of birthweight by gestational age stratified for singletons/multiple births and gender. METHODS: Data on birthweight and gestational age were obtained for the years 2010-2019 from the Ministry of Health Birth Registry. Implausible birthweight and gestational age values were excluded in a two step process. First, overtly implausible values were excluded using visual mapping. Then, infants whose birthweight was below or above the fifth interquartile range for each completed week were excluded. RESULTS: During the 10-year period there were 1,761,884 infants delivered in Israel; 1,689,696 were included in the analysis. 4.4% of the live born infants were from multiple births. The mean birthweight of singletons (3251 g) was 947 ± 4 g higher than that of multiples (2304 g). The birthweight of the male multiple births began to differ from that of the singletons at 30 weeks; female multiple births began to deviate at 31 weeks. The increase in birthweight of singletons leveled after 42 weeks and those born after 43 weeks weighed less than infants born earlier. Comparison of the curves for singletons from the present study to those reported for the years 1993-2001 reveal a similar median but significant differences in the distribution of lower and higher percentiles. CONCLUSIONS: Improved data collection and validation permitted inclusion of 96% of births for analysis. Use of interquartile range distribution to exclude values of birthweight/gestational age that were implausible improved validity. Compared to curves reported previously, changes were found in the distribution of birthweights for the upper and lower percentiles. Periodic updates of growth curve references are important.

Quality of care indicator performance was minimally changed in 2020 despite the COVID-19 pandemic.

BACKGROUND: In 2020, the COVID-19 pandemic affected healthcare systems throughout the world, including the management of patients and compliance rates of quality indicators. OBJECTIVE: To measure the impact in Israel of the COVID-19 pandemic on the indicator-relevant caseload and compliance rates of the quality indicators reported by medical services providers within the Israeli National Program for Quality Indicators (NPQI). METHODS: Data was collected from the reports made to the NPQI by participating hospitals and medical service providers. The indicator results for the number of cases and compliance rates for 2019 were compared to those from 2020. We assessed and compared the results of the quality indicators in general hospitals, geriatric hospitals and departments, psychiatric hospitals and departments, emergency medical services (EMS), and Mother and Baby health centers. RESULTS: We found a decrease in measurable cases in 2020 relative to 2019, especially in geriatric hospitals. In most indicators, compliance rates rose in 2020. Few indicators had lower compliance rates associated with COVID-19 pandemic regulations. CONCLUSIONS AND POLICY IMPLICATIONS: Routine medical activity decreased in Israel in 2020 in comparison to 2019, as reflected by a decrease in cases, but compliance rates were better in most indicators. The results of our study imply that the functioning of healthcare quality measurement programs should not be interrupted during a pandemic. This not only allows measuring of the healthcare system's performance during a crisis, but also may assist in maintaining a high level of healthcare quality.

[TEACHING RESUSCITATION SKILLS ON A NEWLY DEAD INFANT].

INTRODUCTION: Trainees in pediatrics and neonatology have to learn and remain updated regarding current lifesaving intubation procedures. The decrease in clinical indications for neonatal intubation limits their ability to practice and perfect procedures. Alternative methods for training, e.g., the use of manikins, do not satisfy the intended goal. Legitimization of the use of newly deceased infants for practice purposes is morally acceptable and may save lives. The requirement of mandatory parental consent for this type of training may result in reduced resuscitation capabilities and in loss of lives.

Eradication of Cytomegalovirus from Human Milk by Microwave Irradiation: A Pilot Study.

BACKGROUND: Cytomegalovirus (CMV)-infected human milk (HM) can lead to significant CMV morbidity and mortality in preterm very-low-birth weight infants. The eradication of CMV in HM while preserving its properties poses a major clinical challenge. OBJECTIVE: We aimed to compare two methods used to neutralize the virus in HM, one recognized as partially effective (freezing) and another not tested to date (microwave exposure). MATERIALS AND METHODS: We sampled HM from 31 CMV-seropositive mothers whose infants were hospitalized at the Lis Maternity Hospital. Fifteen samples that were positive for CMV antigen were divided into five 5 mL aliquots: the first a control, the second was frozen at -20°C for 1 day, the third was frozen at -200°C for 3 days, and the fourth and fifth aliquots were exposed for 30 seconds to microwave radiation at a low-power setting (500 W) and high-power setting (750 W), respectively. RESULTS: Only microwave radiation at a high-power setting led to complete neutralization of CMV in all samples. Low-power microwave irradiation had a 13% failure rate while 3-day freezing and 1-day freezing had failure rates of 7% and 20%, respectively. CONCLUSION: It is possible to eradicate CMV successfully in HM by using microwave radiation at a high-power setting. Further studies are needed to evaluate the effect of microwave heating on breast milk properties.

[ISRAEL NEONATOLOGY: PRESENT AND FUTURE].

The practice of neonatology in Israel debuted in the 1970s as local enterprises by individual hospitals that needed to provide sick and preterm newly born infants with up-to-date and effective care. Descriptions of research and advances in humane and gentle treatment during neonatal care for preterm infants and their families, as well as prevention of neonatal infections, follow-up of preterm infants and care of full-term infants are presented in this issue. The Israel National Very Low Birth Weight (VLBW) Infant database provides an excellent source of knowledge, which has led to multiple scientific publications. Recent international comparisons of the outcome of preterm VLBW infants, made possible by this unique database in Israel, has provided the neonatal community and the Ministry of Health with insights as to the differences in prognosis between Israel and other countries, especially among extremely low birth weight infants. At the border of viability, mortality in Israelis significantly higher than that reported in other countries and proactive steps undertaken to examine these differences and prompt correctional action should be pursued. The Israel Ministry of Health started positive initiatives and should ensure that their steps are implemented at the preterm infant's bedside.

[A PROSPECTIVE FOLLOW-UP OF NON-PALPABLE TESTES IN NEONATES].

INTRODUCTION: Cryptorchidism is the most common genitourinary disorder in male neonates, with an incidence of 2-5% in term neonates and 30% in preterm infants. Known complications of this condition include impaired fertility and an increased risk of malignancy. This leads to a high frequency of imaging tests, specifically ultrasonography. Use of ultrasound aims to identify non-palpable testis, however current literature does not support such an approach. GOALS: To evaluate the efficacy of clinical follow-up of cryptorchidism in neonates and to evaluate the need for ultrasonography. METHODS: This prospective study was performed at the Lis Maternity Hospital in the Tel Aviv Sourasky Medical Center during a 14 month period. During that period some 4,500 male neonates were born at our hospital. Every newborn was examined within 8 hours of delivery by a pediatrician skilled in neonatal physical examinations. Excluded from the study were preterm infants, neonates in which prenatal examination demonstrated genitourinary abnormalities and neonates with additional congenital abnormalities. Healthy term babies in which one or both testes were not palpable were re-examined within a day by a senior neonatologist (M.B.) to establish their diagnosis, and then reexamined daily by the same physician until their discharge from the hospital. Babies who had one or both testis which were not palpable on discharge were followed-up weekly at a hospital clinic for 2 more weeks. RESULTS: Of 4,500 male neonates born during the study period, 41 (0.9%) were diagnosed with a non-palpable testis, and 8 (0.18%) had bilateral non-palpable testes; 5 babies were lost to followup and excluded from the analysis; 26 of 44 testes (29%) became palpable before discharge from the nursery, by the 3rd day of life. After a weekly follow up from discharge, 13 (29%) additional testes became palpable over the 4-14th day of life. Overall, 88% of non-palpable testes became palpable by 14 days of age. CONCLUSIONS: Close clinical follow-up during the first weeks after birth allows localizing most congenitally non-palpable testing and clarifying the need for performing imaging studies not routinely necessary to diagnose and refer babies with cryptorchidism for further treatment.

[THE ISRAEL NATIONAL VERY LOW BIRTH WEIGHT INFANT DATABASE].

BACKGROUND: Very low birth weight (VLBW ≤ 1,500g] infants represent approximately 1% of all live births in Israel but are responsible for about 45% of all infant deaths and account for 45% of all hospitalization days in the neonatal special and intensive care units (NICU's). AIM: To identify perinatal and neonatal factors associated with mortality, morbidity and handicap among VLBW infants. METHODS: Since 1995 data for > 99% of VLBW infants were received from all 27 NICU's in Israel. The data includes maternal obstetric history, infant's status at birth, deaths, major neonatal morbidities and treatments during the infant's hospitalization. The data are analyzed, collated and annual national and departmental reports prepared. RESULTS: The database comprises information on 25,800 VLBW infants born from 1995-2011. Approximately 20% of VLBW infants were conceived by in-vitro fertilization, one-third of the births were multiple births and 60% of multiple births were the result of infertility treatments. Mortality declined significantly from 23.7% in 1995-1997 to 16.8% in 2010-2011. During this period significant decreases in major neonatal morbidities were documented: Late onset sepsis (> 3 days) decreased from 29.9% to 23.2% in 2010-2011; severe retinopathy of prematurity from 7.6% to 3.8% and periventricular leukomalacia from 8.3% to 5.0%. The rate of bronchopulmonary dysplasia increased from 9.5% in 1995-1997 to 13% in the period 2001-2006, subsequently declining to 10.8% in the last years. CONCLUSION: Since 1995 the Israel national VLBW infant database has provided information at both national and hospital levels, documenting the improving care and outcomes for VLBW infants. The significant decline in VLBW infant mortality has been associated with a parallel decrease in major neonatal morbidities.

Sensitivity of the Automated Auditory Brainstem Response in Neonatal Hearing Screening.

BACKGROUND: In a 2-stage neonatal hearing screening protocol, if an infant fails the first-stage abstract screening with an otoacoustic emissions test, an automated auditory brainstem response (ABR)test is performed. The purpose of this study was to estimate the rate of hearing loss detected byfirst-stage otoacoustic emissions test but missed by second-stage automated ABR testing. METHODS: The data of 17 078 infants who were born at Lis Maternity Hospital between January 2013 and June 2014 were reviewed. Infants who failed screening with a transient evoked otoacoustic emissions (TEOAE) test and infants admitted to the NICU for more than 5 days underwent screening with an automated ABR test at 45 decibel hearing level (dB HL). All infants who failed screening with TEOAE were referred to a follow-up evaluation at the hearing clinic. RESULTS: Twenty-four percent of the infants who failed the TEOAE and passed the automated ABR hearing screening tests were eventually diagnosed with hearing loss by diagnostic ABR testing (22/90). They comprised 52% of all of the infants in the birth cohort who were diagnosed with permanent or persistent hearing loss .25 dB HL in 1 or both ears (22/42).Hearing loss .45 dB HL, which is considered to be in the range of moderate to profound severity, was diagnosed in 36% of the infants in this group (8/22), comprising 42% of the infants with hearing loss of this degree (8/19). CONCLUSIONS: The sensitivity of the diverse response detection methods of automated ABR devices needs to be further empirically evaluated.

Higher Fat Content in Breastmilk Expressed Manually: A Randomized Trial.

OBJECTIVE: This study aimed to evaluate the effect of milk expression method (manual expression versus electric pump) on the composition of breastmilk. STUDY DESIGN: Data on 21 mothers of 21 newborns 48-72 hours postdelivery were collected and analyzed. The women were randomly assigned to express breastmilk manually followed by pump, or in reverse order. The fat, carbohydrate, and protein contents of the milk samples were analyzed using a human milk analyzer (Miris AB, Uppsala, Sweden). RESULTS: The fat and energy contents of milk obtained through manual expression were higher than those obtained by pump (p=0.024 and p=0.04, respectively, by the Wilcoxon signed rank test). There were no significant differences in protein or carbohydrate content of milk obtained by either method of expression. The difference in fat content between milk obtained by the two methods was not correlated with mother's age, delivery method, gestational age at delivery, parity, or the interval between delivery and the time the sampled milk was obtained. CONCLUSIONS: Manually expressed human milk had higher fat content than milk expressed by electric pump. We speculate that this difference is due to the presence of hindmilk in the manually expressed milk because the technique of massaging the breast during manual expression is more likely than the pump to eject hindmilk, which has been shown to have higher fat content than foremilk.

Reactivity and sleep in infants: a longitudinal objective assessment.

Sleep patterns and temperament in the first year of life are closely related. However, research utilizing objective, rather than subjective measurements of sleep and temperament is scarce and results are inconsistent. In addition, a relative lack of longitudinal data prevents inference of causality between the two constructs. In this study, infant sleep was objectively assessed among 95 infants at 3, 6, and 12 months-of-age with an actigraph in the home setting. Reactivity to sound, light, and touch, a specific aspect of temperament, was behaviorally assessed at 3 and 6 months, both during sleep (at home) and during waking (at the laboratory). Expected maturational trends were recorded in sleep, with a temporal increase in sleep efficiency and percent of motionless sleep. Quadratic (i.e., inverse U shape) relations were found, especially among girls, when predicting change in sleep by reactivity thresholds, suggesting that both hyposensitive and hypersensitive infants are at risk for poor sleep quality. These are the first research findings suggesting that low reactivity in infancy might be associated with compromised sleep quality. The observed nonlinear effects may account for null or inconsistent results in previous studies that explored only linear associations between temperament and sleep. Future studies should address both extremes of the temperament continuum when exploring relations with sleep patterns.

Facial Expression in Response to Smell and Taste Stimuli in Small and Appropriate for Gestational Age Newborns.

Small for gestational age newborns can later suffer from eating difficulties and slow growth. Nutritional preferences can be influenced by changes in sensory perception of smell and taste. To determine whether these could be detected at birth, the authors examined the different recognition pattern of smell and taste in small for gestational age newborns compared to appropriate for gestational age controls, as expressed by gusto-facial and naso-facial reflexes. The authors performed video analysis of facial expressions of 10 small for gestational age and 12 control newborns exposed to various tastes and smells. No difference in the facial recognition patterns for taste or smell was demonstrated between small for gestational age and controls, except for perception of distilled water. Newborns show recognizable patterns of facial expression in response to taste and smell stimuli. Perception of taste and smell in small for gestational age newborns is not different from controls, as measured by the method of facial recognition.

Prevalence of breastfeeding difficulties in newborns with a lingual frenulum: a prospective cohort series.

OBJECTIVE: The prevalence of a lingual frenulum in newborn infants is reportedly 0.3-12%. The purpose of this study was to describe the prevalence of a lingual frenulum based on the Coryllos classification in nonselected newborn infants after delivery, hypothesizing that it is higher than the values reported in the literature. STUDY DESIGN: The lingual frenula of 200 healthy infants were evaluated by visual examination and palpation within the first 3 days after delivery. The frenulum was categorized according to the four Coryllos classifications. Each infant's mother responded, immediately after the examination, to a structured questionnaire on the quality and type of feeding. An additional structured telephone interview with the 179 breastfeeding mothers was conducted 2 weeks later. RESULTS: All but one infant (n=199) had an observable or palpable lingual frenulum that was Coryllos type 1 (n=5), type 2 or 3 (n=147), or type 4 (n=47). Although our study was not powered enough to test for any correlation between the cessation of breastfeeding and the type of frenulum, we found no statistical correlation between the Coryllos type of lingual frenulum and the presence of breastfeeding difficulties. CONCLUSIONS: A lingual frenulum is a normal anatomical finding whose insertion point and Coryllos classification are not correlated with breastfeeding difficulties. We suggest that the term "lingual frenulum" should be used for anatomical description and that the term "tongue-tie" be reserved for a lingual frenulum associated with breastfeeding difficulties in newborns.

Lingual frenotomy for breastfeeding difficulties: a prospective follow-up study.

INTRODUCTION: Breastfeeding difficulties are sometimes attributable to tongue-tie with short-term relief after frenotomy. Limited follow-up is available, and predictors for nonsuccessful frenotomy have not yet been found. PATIENTS AND METHODS: We recruited 264 mother-infant dyads who underwent lingual frenotomy for breastfeeding difficulties. Data regarding the indications, anatomy of the tongue, and the response of the infant were noted by the physician. Mothers were contacted by telephone at 2 weeks, 3 months, and 6 months after frenotomy to answer a questionnaire. RESULTS: Two weeks after frenotomy, 89% of mothers were still breastfeeding. An improvement in breastfeeding was reported by three-quarters of the mothers, but, unexpectedly, 3% reported worsening. At 3 and 6 months after the procedure, 68% and 56% of mothers were still breastfeeding, respectively. We could not find any predictor to indicate those infants in whom breastfeeding would not improve. CONCLUSIONS: There are favorable long-term effects of frenotomy on breastfeeding. Lingual frenotomy does not always alleviate breastfeeding difficulties, and rarely worsening ensues. We could not find any predictor for successful breastfeeding after frenotomy. We speculate that because the procedure is minor, in the event of breastfeeding difficulties, lingual frenotomy should be considered as an effective tool to assist in long-term breastfeeding.

Biomechanics of milk extraction during breast-feeding.

How do infants extract milk during breast-feeding? We have resolved a century-long scientific controversy, whether it is sucking of the milk by subatmospheric pressure or mouthing of the nipple-areola complex to induce a peristaltic-like extraction mechanism. Breast-feeding is a dynamic process, which requires coupling between periodic motions of the infant's jaws, undulation of the tongue, and the breast milk ejection reflex. The physical mechanisms executed by the infant have been intriguing topics. We used an objective and dynamic analysis of ultrasound (US) movie clips acquired during breast-feeding to explore the tongue dynamic characteristics. Then, we developed a new 3D biophysical model of the breast and lactiferous tubes that enables the mimicking of dynamic characteristics observed in US imaging during breast-feeding, and thereby, exploration of the biomechanical aspects of breast-feeding. We have shown, for the first time to our knowledge, that latch-on to draw the nipple-areola complex into the infant mouth, as well as milk extraction during breast-feeding, require development of time-varying subatmospheric pressures within the infant's oral cavity. Analysis of the US movies clearly demonstrated that tongue motility during breast-feeding was fairly periodic. The anterior tongue, which is wedged between the nipple-areola complex and the lower lips, moves as a rigid body with the cycling motion of the mandible, while the posterior section of the tongue undulates in a pattern similar to a propagating peristaltic wave, which is essential for swallowing.

Weight at weaning of preterm infants from incubator to bassinet: a randomized clinical trial.

OBJECTIVE: To evaluate thermal responses, weight gain, and resting energy expenditure (REE) in preterm infants weaned from an infant incubator to a warming bassinet after reaching a body weight of either 1,500 or 1,600 g, respectively. METHODS: Preterm infants weighing ≤ 1,500 g were randomly allocated for weaning from a convective incubator after reaching 1,500 g body weight (study group) or 1,600 g (controls). Postweaning body temperature was recorded at short intervals. REE was measured before and after weaning, while the weight gain was calculated daily. RESULTS: All 21 enrolled infants were weaned successfully to a bassinet (room temperature). REE inside the incubator and in the warming bassinette was similar between infants weaned at 1,500 g and at 1,600 g (2.9 ± 6.8 vs. 1.1 ± 4.8 kcal/kg/d, respectively (p = 0.7). REE increased slightly after weaning in both groups. Weight gain and days from randomization to discharge did not differ between groups. CONCLUSION: Weaning very low birth weight infants from an incubator to a warming bassinet at a body weight of 1,500 g is feasible and has no significant deleterious effects on weight gain and REE. The many benefits provided by such greater accessibility to premature infants are discussed.

Probiotic supplementation in mothers of very low birth weight infants.

OBJECTIVE: Oral probiotic supplementation reduces the risk of necrotizing enterocolitis (NEC) in preterm infants. Concerns about safety and purity of probiotic preparations have limited their use in preterm infants. The authors administered probiotic bacteria to mothers of preterm infants, thereby avoiding the risks of direct exposure of infants to probiotic bacteria. DESIGN: This prospective, randomized, double blind, placebo-controlled trial at the Tel Aviv Medical Center (June 2007-November 2009) examined the effects of maternal oral probiotic supplementation on the incidence of NEC, death, and sepsis in very low birth weight (VLBW) infants fed with maternal breast milk. Mothers were assigned to supplementation with Lactobacillus acidophilus and Bifidobacteria lactis 2 × 10(E) [DOSAGE ERROR CORRECTED] CFU/d or to placebo starting from 1 to 3 days postpartum. The primary outcome measures were NEC, sepsis, and death. RESULTS: In total 49 mothers of 58 VLBW infants were recruited. A total of 25 infants were in the probiotic group and 33 in the placebo group. The overall incidence of Bell stage II to III NEC was 12%, with an incidence of 4% in the infants of the probiotic group and 18.2% in the placebo group (p = 0.12), respectively. Sepsis and mortality rates were similar. CONCLUSION: Postpartum maternal supplementation with probiotic bacteria may decrease the incidence of NEC in breastfed infants.

The Prevalence of Alcohol, Substance and Cigarettes Exposure among Pregnant Women within a General Hospital and the Compliance to Brief Intervention for Exposure Reduction.

BACKGROUND: Compliance and impact of a time-limited brief intervention (BI) for reducing exposure to alcohol, psychoactive substances and nicotine among women admitted to the hospital during pregnancy were assessed. METHODS: Pregnant women (gestational week ≤30) from a medical center pre-delivery, emergency and high-risk units were interviewed about alcohol (AUDIT and TWEAK questionnaires), smoking (modified Fagerström) and psychoactive substance (modified ASI). All exposed women were invited to participate in a BI and underwent follow-up. Characteristics and rate of exposure were compared to a "standard-group" of non-selected women who arrived to the hospital directly solely to give birth. RESULTS: Forty-six of the 108 study participants (42.6%) were exposed to smoking (85%), alcohol (41%), or drugs (39%), and 41 underwent the BI. Self-report of exposure was reduced significantly following BI but re-elevated post-delivery. Women belonging to the "standardgroup" were better educated, had lower lifetime rates of exposure, and gave birth to newborns with higher birth weights (3254.7±506.9 g vs. 2650.8±785.6 g for the study group). CONCLUSION: Compliance of the exposed women to BI was high and contributed to exposure reduction during pregnancy but relapsed following delivery.

Analysis of facial and inspiratory muscles performance during breastfeeding.

BACKGROUND: Breastfeeding is a dynamic process in which the infant recruits several muscle groups in his face, head and throat. OBJECTIVE: The objective of this study was to explore the relative role of the submental muscle group, the orbicularis oris and the sternocleidomastoid muscles to breastfeeding process and to the relatively high intra-oral vacuum measured during this process. METHODS: Electromyography (EMG) measurements were conducted on 11 infants (mean age 1.91 ± 1.0 days, mean weight 3364 ± 328 g) using surface electrodes. The EMG data were filtered with a low pass filter to yield the linear envelopes (IEMG). The maximal and mean value and the area under each linear envelope curve were examined. RESULTS: During active suckling significantly higher activity (P< 0.05) of the submental muscle group were measured compared with the orbicularis oris and sternocleidomastoid muscles (mean ± SE values of the maximal linear envelope were 24.4 ± 1 µV, 9.6 ± 0.6 µV and 14 ± 0.7 µV, respectively). CONCLUSION: These results confirmed that jaw movements have the primary role during breastfeeding, but also revealed that the inspiratory muscles have a substantial contribution to this process and probably have an important role in the generation of intra oral vacuum measured during breastfeeding.

The effect of advanced maternal age upon human milk fat content.

BACKGROUND: Little is known about the effect of maternal age on human milk (HM) composition. This study was designed to study fat content, estimated by creamatocrit (CMT), in HM collected in the first 2 weeks of life in older (≥ 35 years) compared with younger (<35 years) mothers. STUDY DESIGN AND METHODS: Ninety lactating mothers (48 older, 42 younger) of newborns were recruited within the first 3 days of delivery. CMTs were measured at 72 hours, 7 days, and 14 days after delivery for HM in a capillary tube after centrifugation at 5,366 g for 5 minutes. RESULTS: The groups did not differ in terms of maternal height and diet, infant birth weight, gestational age (GA), or pregnancy weight gain. They differed significantly in terms of maternal age and parity. Mean colostrum CMT was significantly higher in the group of older mothers. Colostrum CMT correlated positively with maternal age (R(2)=0.11, p=0.006) and inversely with GA (R(2)=0.1, p=0.03) but did not relate with either maternal weight or body mass index. CMT at age 7 days and 2 weeks was not affected by maternal age or GA. In multivariate regression analysis colostrum CMT correlated significantly only with maternal age and GA (R(2)=0.3, p<0.001). CONCLUSIONS: Colostrum fat content of older mothers is much higher than that of younger mothers and inversely related with GA at delivery. This increase in colostrum fat content obtained from mothers with advanced age may be due to increased fat synthesis and excretion in milk, reduced water content of milk, or a combination of both.