The C in TORCH: a cost-effective alternative to screening small-for-gestational-age infants.

BACKGROUND: Infants born with birth weights under the 10th percentile for their gestational age are classified as small for gestational age (SGA). TORCH infections are reported to be associated with SGA infants. With the low incidence of infections, screening is likely to be expensive and of low utility. OBJECTIVE: The objective of this study was to determine the utility and cost-effectiveness of screening SGA infants with TORCH serology titers, urine cytomegalovirus (CMV) cultures and cranial ultrasounds. METHODS: A retrospective review was conducted on all infants admitted to the neonatal intensive care unit (NICU) at Los Angeles County and University of Southern California (LAC+USC) Medical Center from January 2003 to December 2011 with a diagnosis of SGA or intrauterine growth restriction. Birth characteristics such as birth weight, length, head circumference and gestational age were recorded. TORCH titer results, urine CMV results and cranial ultrasound findings were collected. RESULTS: Between 2003 and 2011, 232 SGA infants were admitted to the NICU at LAC+USC Medical Center. Of these, 117 infants (50%) had TORCH titer testing performed; there was only 1 positive CMV IgM and 1 positive HSV IgM result. Repeat urine CMV testing was performed on 109 infants (47%), with a total of 296 urine CMV samples collected from these infants; 6 infants had positive results, of whom 3 had repeat positive urine CMV samples. Overall, 149 of the infants had a cranial ultrasound done, none of which were positive for calcifications. CONCLUSIONS: TORCH titer testing, urine CMV screening and cranial ultrasound screening are of low yield in screening clinically asymptomatic SGA infants for TORCH infections. Given the low number of positive results, a cost-effective alternative of selective TORCH testing may be limited to infants with additional clinical findings. This study serves as a reminder to periodically examine testing practices and patient population to maximize cost-effectiveness.

Iatrogenic skin injury in the neonatal intensive care unit.

Although neonatal care has become more and more meticulous with significant changes in technology in the neonatal intensive care unit (NICU) in the past 50 years, iatrogenic cutaneous injuries continue to occur. Although the incidence of severe injuries is decreasing because the more difficult procedures are being replaced by improved techniques, skin injuries have not yet been completely eliminated. However, the nature and causes of cutaneous injuries have changed, and the injuries are frequent but generally minor. The major risk factors are low birth weight, gestational age, length of stay, a central venous line, mechanical ventilation, and support with continuous positive airway pressure. The rate of iatrogenic events is about 57% at gestational ages of 24-27 weeks, compared with 3% at term. There are no current comprehensive reviews of iatrogenic cutaneous injury. The purpose of this review is to describe the iatrogenic cutaneous injuries that may occur in the newborns as a consequence of perinatal and postnatal medical procedures. With increased survival of extremely-low-birth-weight (ELBW) infants and changing modes of management in the NICU, neonatologists must make every effort to recognize injuries and prevent their occurrence in the NICU.