Short- and long-term complications of in utero exposure to lamotrigine.

AIMS: The present study evaluates the effect of antenatal lamotrigine exposure, on short- and long-term paediatric outcome. METHODS: The study included the children of 83 epileptic women treated with lamotrigine during pregnancy, at a tertiary medical centre between 2004-2014. All newborns were monitored for vital signs, congenital malformations and Finnegan score. In addition, the parents completed a questionnaire regarding their child's development and health up to the age of 12 years. RESULTS: No major malformations were found in the newborns. None of the newborns had significant withdrawal symptoms by Finnegan score. The children were followed-up to the age of 12 years (56.6% were 6-12 years at the time of evaluation). There were no significant findings in the incidence of neurodevelopmental disorders. CONCLUSIONS: According to our experience, lamotrigine is generally safe for pregnancy use, associated with minimal short-term complications with no long-term effects on the outcome.

Meconium-Stained Amniotic Fluid and Neonatal Morbidity in Low-Risk Pregnancies at Term: The Effect of Gestational Age.

Objective To assess the association of gestational age at delivery with perinatal outcome in low-risk term deliveries complicated by meconium-stained amniotic fluid (MSAF). Methods We retrospectively analyzed all singleton deliveries that underwent a trial of labor in a single hospital (2007-2013). Exclusion criteria included pregnancy-related complications (e.g., hypertensive disorders, diabetes, oligohydramnios, and fetal anomalies). First, only deliveries with MSAF were analyzed. Perinatal outcome of deliveries at 370/7 to 386/7 weeks (early term) and 410/7 to 416/7 weeks (late term) were compared with those at 390/7 to 406/7 weeks of gestation (full term). Additionally, a gestational age based comparison was made between the risk for neonatal respiratory morbidity in deliveries with clear amniotic fluid and MSAF. Results During the study period, 28,248 deliveries were considered as low risk. Of them, 3,399 (12.0%) were diagnosed with MSAF and were divided to full term (n = 2,413), early term (n = 405), and late term (n = 581). In multivariate analysis, MSAF at early term was associated with neonatal jaundice, need for phototherapy, and neonatal sepsis. In a gestational age based stratification, when comparing between deliveries with clear amniotic fluid and those with MSAF, late term had the highest odds (4.2 vs. 0.5%; p < 0.001) for neonatal respiratory morbidity. Conclusion Gestational age was associated with specific complications in deliveries complicated by MSAF and otherwise low-risk deliveries.

Duration of vancomycin treatment for coagulase-negative Staphylococcus sepsis in very low birth weight infants.

AIM: Vancomycin is widely used to treat late onset coagulase-negative Staphylococcus (CoNS) sepsis in very low birth weight (VLBW) infants. Although vancomycin is associated with a risk of toxicity and bacterial resistance, the appropriate duration of use has not been established. This study sought to investigate the association between the duration of vancomycin therapy and clinical outcome in VLBW infants with CoNS sepsis. METHODS: The files of all VLBW infants treated for CoNS sepsis at a tertiary paediatric medical centre from 1995-2003 were reviewed for clinical data, laboratory variables and outcome. Only patients with two positive diagnostic blood cultures were included. The findings were analyzed by duration of vancomycin treatment after the last positive blood culture. RESULTS: The study cohort included 126 infants, 48 treated for 5 days, 32 for 6-7 days, 31 for 8-10 days and 15 for >10 days. There were no differences among the groups in perinatal characteristics, central catheter dwell time, laboratory data including haematologic, renal and liver function tests, or rate of complications of prematurity. Five infants were diagnosed with infective endocarditis or aortic thrombi and were treated for >10 days. CoNS sepsis recurred in two infants (1.6%). No toxicity of vancomycin treatment was observed. CONCLUSIONS: In VLBW infants with uncomplicated CoNS sepsis, treatment with vancomycin for 5 days after the last positive blood culture appears to be associated with a satisfactory outcome and no adverse effects. A well-controlled prospective multicentre study is needed to confirm these findings.

[Magnesium and bronchopulmonary dysplasia].

Bronchopulmonary dysplasia (BPD) is a chronic lung disease that occurs in premature infants who have needed mechanical ventilation and oxygen therapy. BPD is defined as the presence of persistent respiratory symptoms, the need for supplemental oxygen to treat hypoxemia, and an abnormal chest radiograph at 36 weeks gestational age. Proinflammatory cytokines and altered angiogenic gene signaling impair prenatal and postnatal lung growth, resulting in BPD. Postnatal hyperoxia exposure further increases the production of cytotoxic free radicals, which cause lung injury and increase the levels of proinflammatory cytokines. Magnesium is the fourth most abundant metal in the body. It is commonly used for the treatment of preeclamsia, as well as for premature labor alleviation. Magnesium's role in BPD development is not clear. A significant association between high magnesium levels at birth and respiratory distress syndrome (RDS), pulmonary interstitial emphysema in the extremely low birth weight, respiratory failure, and later development BPD was found. Conversely, low magnesium intake is associated with lower lung functions, and hypomagnesemia was found in 16% of patients with acute pulmonary diseases. Magnesium is used for the treatment of asthmatic attacks. Magnesium deficiency in pregnant women is frequently seen due to low intake. Hypomagnesemia was also found among preterm neonates and respiratory distress syndrome (RDS). Experimental hypomagnesemia evokes an inflammatory response, and oxidative damage of tissues. These were accompanied by changes in gene expression mostly involved in regulation of cell cycle, apoptosis and remodeling, processes associated with BPD. It is rational to believe that hypomagnesemia can contribute to BPD pathogenesis.

Anthropometric indices of adolescents who at birth were full-term long and/or overweight for gestational age.

BACKGROUND: Measurements of adolescents who at birth were large (long and/or heavy) for gestational age are scant. OBJECTIVES: To determine the correlation between birth length and weight in female and male neonates born long and/or overweight for gestational age, with their height and weight at age 17. METHODS: We reviewed the records of the Rabin Medical Center for birth data of 96 full-term neonates born long and overweight for gestational age (FT-lo,ow), 33 full-term neonates born long but with normal weight for gestational age (FT-lo,nw), 148 full-term neonates born overweight but with normal length for gestational age (FT-nl,ow), and 401 full-term neonates born with normal birth length and weight (FT-nl,nw). RESULTS: Neonates of both genders born long and overweight at birth (FT-lo,ow) were taller and heavier at age 17 years than those born FT-nl,nw: females 167.8 +/- 5.1 cm and 64.6 +/- 10.3 kg vs. 162.6 +/- 5.5 cm and 59.3 +/- 11.1 kg (P < 0.001 for height and P = 0.026 for weight); and males 182.4 +/- 8.1 cm and 80.6 +/- 20.4 kg vs. 174.5 +/- 6.2 cm and 67.4 +/- 12.3 kg (P < 0.001). The correlations between birth length and height at age 17 for both genders were statistically significant (P < 0.001), as were those between birth weight and the weight and body mass index (BMI) at age 17 for both genders (P < 0.001). There was no correlation between birth length and weight or BMI at age 17. CONCLUSIONS: Full-term neonates of both genders born large for gestational age become tall adolescents and weigh more at age 17 than children with a normal birth length and weight.

Persistent coagulase-negative staphylococci bacteremia in very-low-birth-weight infants.

This study sought to expand current knowledge on the clinical and epidemiological characteristics of persistent coagulase-negative Staphylococcus (CoNS) bacteremia in very-low-birth-weight (VLBW) infants. Background and disease-related data were collected prospectively on 143 VLBW infants diagnosed with CoNS bacteremia at a pediatric tertiary medical center in 1995-2003. Findings were compared between those with persistent (positive blood cultures for >72 h under appropriate treatment ) and nonpersistent disease. Fifty-eight infants (40.6%) were found to have persistent bacteremia. There were no between-group differences in maternal characteristics, mode of delivery, newborn characteristics, dwell time of central venous and umbilical catheters, complications of prematurity, or mean hospital stay. The persistent bacteremia group had significantly higher rates of hypothermia at presentation (37.9% vs. 17.6%, p < 0.04), creatinine >1.2 mg% on treatment day 7 (13.7% vs. 2.4%, p < 0.02; transient phenomenon), and endocarditis (p < 0.03); one infant had an aortic thrombus. Predominantly breast-fed infants had a higher rate of negative cultures within 72 h of appropriate treatment than predominantly formula-fed infants (60% vs. 19%, p < 0.02). In conclusion, persistence of CoNS bacteremia is common in VLBW infants. Endocarditis should be excluded in all infants with persistent disease. Breast-feeding is associated with a shorter disease duration.

Effect of season of inoculation on immune response to rubella vaccine in children.

The yearly seasons are marked by changes in the amount of sunlight. Ultraviolet radiation (UVR) is known to adversely affect the course of viral infections, immunologic memory and cellular and humoral immune responses. Our objectives were to investigate potential differences in the immune response of the rubella vaccine after 3-4 years by season of inoculation. Children aged 4-5 years attending four kindergartens in villages in northern Israel, all of whom had been vaccinated at 1 year of age, were enrolled in the study. Participants were divided into three groups by season of the year in which the inoculation was performed: summer (N = 63), winter (N = 36) and intermediate (N = 104). Main outcome measures were mean geometrical titer of rubella antibodies and complete, partial or no immunity to rubella by season of inoculation. Of the 203 children tested, 186 (91.6%) had adequate antibody levels, 7 (3.4%) had equivocal levels and 10 (4.9%) had inadequate levels. Significantly higher mean geometrical titers were found in the winter-inoculated compared with the summer-inoculated group (73.0 ± 2.6 vs 47.6 ± 2.8; p < 0.05). The same tendency was noted in the percent of infants properly immunized. This preliminary study shows a strong correlation between the immune response to rubella vaccine and the season of vaccination. Immunogenicity may be improved by inoculating children during seasons of less sunlight or by reducing the children's exposure to sunlight following inoculation. This practice is especially important in areas with extreme seasonal variability in solar radiation and tropical areas. Further studies are needed to corroborate and expand these findings.

Postaxial type B polydactyly treated by excision in the neonatal nursery.

BACKGROUND: Postaxial type B polydactyly is characterized by the presence of a rudimentary extra digit on the small finger side attached by a soft tissue stalk. The recommended treatment is ligation in the neonatal nursery. The purpose of this study was to evaluate the result of excision of the supernumerary digit under topical anesthesia. METHODS: The study group included 11 consecutive infants with 15 supernumerary digits on the hand. To ensure complete excision, the digit was retracted by the surgeon and excised at the base of the skin triangle formed on retraction beyond the proximal end of the stalk. The infants were discharged one day later and followed up for 12 months. RESULTS: No immediate or late complications were noted. All hands had an aesthetic appearance at discharge. At follow-up, complete excision was noted, and the scar was hardly seen. CONCLUSIONS: For infants with postaxial type B polydactyly, excision of the extra digit in the neonatal nursery is a safe and simple procedure with a good clinical and cosmetic outcome.

Association of high-dose bifonazole administration during early pregnancy and severe limb reduction defects in the newborn.

BACKGROUND: Neonatal limb reduction defects may be caused by exposure to an external agent. The azole derivatives are used in the treatment of systemic and dermal mycoses. Their relative teratogenic risk is still controversial. CASES: We describe two newborns with severe limb defects who were exposed to high doses of oral (an unacceptable route) and/or intravaginal bifonazole during the entire first trimester of pregnancy. CONCLUSION: Although only two cases are insufficient to establish a relationship, our data suggest that maternal intake of bifonazole in early pregnancy poses a risk of morphogenic malformations. The literature suggests several possible mechanisms.

Treatment of patent ductus arteriosus: indomethacin or ibuprofen?

We compared ibuprofen and indomethacin for the treatment of patent ductus arteriosus (PDA) in preterm infants. A retrospective comparative study was conducted at a pediatric tertiary center in preterm infants diagnosed with PDA. Infants born from January 2000 to June 2003 were treated with indomethacin, whereas infants born from July 2003 to November 2005 were treated with ibuprofen. The two treatment groups were compared. Demographic data and clinical, laboratory, and outcome data were collected from the medical files. Seventy-three infants were included in the ibuprofen group and 46 in the indomethacin group. No significant difference in efficacy was found between indomethacin and ibuprofen. Compared with ibuprofen, indomethacin treatment was associated with significantly higher mean creatinine levels and a higher percent of infants with creatinine >1.2 mg/dL, hyponatremia <120 mmol/L, and platelet level <100,000 platelets/mL(3). There were no significant differences in bilirubin levels, incidence and grade of intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, rate of surgical duct ligation, sepsis, length of hospital stay, or mortality. Indomethacin and ibuprofen are equally effective for PDA closure in premature infants. Treatment with ibuprofen is safer, decreasing the risk of renal failure, thrombocytopenia, and hyponatremia.