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.

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.

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.

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.

Standard and low molecular weight heparin have no effect on tissue plasminogen activator induced plasma clot lysis or fibrinogenolysis.

Although heparin is often given as an adjunct to tissue plasminogen activator (t-PA), the effect of heparin on t-PA induced fibrin(ogen)olysis is controversial. To address this controversy, we examined the effects of standard and low molecular weight heparin (enoxaparine) on both t-PA induced clot lysis and t-PA mediated fibrinogenolysis in a human plasma system. Accordingly, 125I-labeled fibrin clots were incubated in t-PA containing citrated plasma in the presence or absence of these glycosaminoglycans, and the extent of thrombolysis was determined by measuring residual radioactivity of the clots, while B beta 1-42 levels were used as a specific index of fibrinogenolysis. Over a wide range of t-PA concentrations (0.1 to 1.6 micrograms/ml), neither heparin nor enoxaparine influences either t-PA induced clot lysis or t-PA mediated B beta 1-42 generation. These findings suggest that either agent could be used as an adjunct to t-PA without compromising either the thrombolytic potential of t-PA or its clot-selectivity.

Serum macro creatine kinase type 2 in asphyxiated newborn infants.

The presence of macro creatine kinase type 2 (MCK2) activity was noted in the serum of seven out of 32 newborn infants with perinatal asphyxia or birth trauma. MCK2 isoenzyme, when present, represented 15-35% of the total creatine kinase (CK) activity. The clinical and biochemical features of the seven MCK2-positive and 25 MCK2-negative newborns were compared. The infants with MCK2 activity were all males and clinically appeared to be more severely injured, requiring longer hospitalization. Total CK activity was similar in the two groups and CK-MB and CK-BB isoenzyme fractions were present in a similar proportion of infants in both groups. Two infants in each group had long-term neurological disorders. Although the presence of MCK2 has been noted in adult patients with end-stage metastatic solid tumors, the presence of this isoenzyme has not previously been reported in newborn infants.

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.

Prognostic value of the immediate response to surfactant.

AIM: To evaluate the association between the immediate response to surfactant treatment and morbidity and mortality in infants with severe respiratory distress syndrome. METHODS: The response to surfactant was defined as the difference in the arterial:alveolar (delta a:A) ratio before and one hour after the first surfactant dose. Measurements were obtained from 253 Israeli infants participating in the multi-centre Curosurf 4 trial of surfactant replacement therapy. RESULTS: Delta a:A ratios ranged from -0.115 to 0.8 and were significantly related to both birth weight and gestational age. Among infants weighing 1001-1500 g mortality decreased from 40% among very bad responders to zero among good responders. The incidence of pneumothorax decreased with better response. Logistic regression analysis showed a hierarchy of predictive power for mortality: birth weight or gestational age; immediate response to surfactant; severity of initial disease. CONCLUSION: The immediate response to surfactant treatment is a significant prognostic indicator for mortality and morbidity.

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

Iodine and hypothyroidism in neonates with congenital heart disease.

AIM: To evaluate the influence of the intravenous injection of iodine during cardiac catheterisation, and of topical iodine antiseptics during surgical procedures, on thyroid function in full term neonates. METHODS: Twenty one full term infants with major cardiac anomalies who survived for more than a month were studied. Thyroxine and thyrotropin concentrations were measured (by radioimmunoassay) before each procedure, 24 hours after the procedure, and every week thereafter until the age of 1 month or until normal. Thyroxine values less than 64.4 nmol/l were considered low, while thyrotropin values greater than 30 mU/l were considered high. RESULTS: Thyroid function tests before iodine exposure were within normal limits in all infants. Following catheterisation or surgery six infants had raised thyrotropin concentrations; three had low thyroxine concentrations. Two of those infants were treated with L-thyroxine. CONCLUSION: Iodine exposure during cardiac catheterisation or surgery may induce transient hypothyroidism in term 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.

Failure of early postnatal dexamethasone to prevent chronic lung disease in infants with respiratory distress syndrome.

OBJECTIVE: To study the effect of early postnatal dexamethasone (days 1-3) on the incidence and severity of chronic lung disease in preterm infants with respiratory distress syndrome. METHODS: A multicentre, randomised, placebo controlled, blinded study was carried out in 18 neonatal intensive care units in Israel. The primary outcome measure was survival to discharge without requirement for supplemental oxygen therapy beyond 28 days of life. The secondary outcome measures were requirement for mechanical ventilation at 3 and 7 days, duration of ventilation or oxygen therapy, need for subsequent steroids for established chronic lung disease and incidence of major morbidities. RESULTS: The study consisted of 248 infants (dexamethasone n = 132; placebo n = 116). No differences were found in the outcome variables except for a reduction in requirement for mechanical ventilation at age 3 days in treated infants (dexamethasone 44%, placebo 67%; P = 0.001). Gastrointestinal haemorrhage, hypertension, and hyperglycaemia were more common in treated infants, but no life threatening complications, such as gastrointestinal perforation, were encountered. CONCLUSIONS: These data do no support the routine use of early postnatal steroids, but may justify further study in a selected, high risk group of infants.

Segmental dilatation of the ileum: an uncommon cause of neonatal intestinal obstruction.

Two cases of congenital segmental dilatation of the ileum are reported. In both cases additional abnormal segments of bowel were not diagnosed during the initial laparotomy, and further surgical exploration was required. Consideration of this entity in the differential diagnosis of neonatal intestinal obstruction may enable definition of the optimal site for bowel resection and anastomosis.

Congenital aorto-caval fistula in the newborn: a case report.

The authors report a rare case of congenital fistula between the distal aspect of the descending aorta and the inferior vena cava. The clinical features of this aortocaval fistula is being described as well as the preoperative diagnostic workup, the intraoperative findings, and the complicated postoperative course and treatment.

Contralateral Acoustic Effect of Transient Evoked Otoacoustic Emissions in Neonates.

Contralateral acoustic stimulation (CAS) has the effect of reducing the amplitude of transient evoked otoacoustic emissions (TEOAE) of the opposite cochlea. This phenomenon is considered to be mediated via the efferent pathway, from the superior olivary complex through the medial olivocochlear system to the contralateral cochlea. The assessment of this suppressive effect provides an objective and noninvasive technique for exploring the function of the efferent auditory system in humans. Two previous studies investigated the suppression effect of TEOAE in newborns and revealed a significant effect in 18 full-term neonates. In this study, the effect of contralateral acoustic stimulation on TEOAE was investigated in 13 full-term neonates (gestational age, 40-42 weeks). The TEOAE were recorded alternately with and without simultaneous, contralateral white noise. The CAS effect of TEOAE was present in all subjects; a mean of 2.21 dB +/- 1.7 (21% +/- 9.3%) was found. Our study demonstrated additional support for the functional maturity of the medial olivocochlear efferent system from birth.

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.