The Impact of Religious Beliefs on Early Lactation in Israeli Mothers.

Objective: To explore the influence of religious beliefs and faith on breastfeeding initiation among mothers in Israel. Materials and Methods: The study, conducted from February 2022 to July 2023 at Bnai Zion Medical Center (located in Haifa district) and Laniado hospital (located in Netanya, Sharon plain), included mothers and their partners who voluntarily completed questionnaires. The survey, comprising 26 questions, delves into religion, faith, religiosity, and infant feeding approaches, while considering various socioeconomic and health-related factors. Results: Religious and secular mothers exhibited a higher inclination toward exclusive breastfeeding compared with the traditional mothers (p < 0.001). Notably, more maternal education years were associated with more exclusive breastfeeding (odds ratio [OR] 1.59; 95% confidence interval [CI] 1.09-2.32; p = 0.017). However, older age of youngest sibling (OR 0.56; 95% CI 0.32-0.98; p = 0.041), cesarean delivery (OR 0.64; 95% CI 0.44-0.94; p = 0.023), and no desire to breastfeed during pregnancy (OR 0.67; 95% CI 0.57-0.80; p < 0.001) emerged as significant factors decreasing exclusive breastfeeding. Conclusion: The study indicates that the level of religiosity and prenatal intention to breastfeed impact breastfeeding practices, along with maternal education, age of the youngest sibling, and delivery mode. These insights provide valuable guidance for initiatives aimed at boosting breastfeeding rates, particularly in sectors where rates are comparatively low.

Fetal Renal Duplicated Collecting System at 14-16 Weeks of Gestation.

(1) Background: To examine the incidence of the prenatal diagnosis of the renal double-collecting system (rDCS) and describe its clinical outcome and associated genetic abnormalities. (2) Methods: This retrospective study included women who attended the obstetric clinic for early fetal anatomic sonography with findings of a renal DCS. Diagnosis was conducted by an expert sonographer using defined criteria. (3) Results: In total, 29,268 women underwent early ultrasound anatomical screening at 14-16 weeks, and 383 cases of rDCS were diagnosed (prevalence: 1:76). Associated abnormalities were diagnosed in eleven pregnancies; four had chromosomal aberrations. No chromosomal abnormalities were reported in isolated cases. Ectopic uretrocele and dysplastic kidney were diagnosed in 6 (1.5%) and 5 (1.3%) fetuses, respectively. One girl was diagnosed with vesicoureteral reflux and recurrent UTIs, and two boys were diagnosed with undescended testis. The recurrence rate of rDCS was 8% in subsequent pregnancies. (4) Conclusions: In light of its benign nature, we speculate that isolated rDCS may be considered a benign anatomic variant, but a repeat examination in the third trimester is recommended to assess hydronephrosis.

"Light" on Phototherapy-Complications and Strategies for Shortening Its Duration, A Review of the Literature.

Neonatal hyperbilirubinemia is an extremely common metabolic complication of the neonatal period which may be associated with bilirubin encephalopathy and even death. Adverse neurological consequences are preventable if a timely diagnosis and treatment are provided. Phototherapy is usually the preferred option to decrease hyperbilirubinemia. Although considered to be safe, evidence in recent years has shown that this treatment may not be free of side effects and short- and long-term unfavorable outcomes. These are usually mild or rare, but should be decreased or avoided if possible. Many useful complementary measures and treatments have been described that could shorten the duration of exposure to phototherapy. However, there is no current unequivocal recommendation to use any of the methods presented in this review. Our review aims to depict the wide range of possible complementary treatments to phototherapy, and to provide the scientific and clinical evidence available regarding their usefulness. It is essential that, while utilizing the full potential of phototherapy to treat hyperbilirubinemia, caregivers are aware of its side effects and possible inherent dangers, and seek ways to minimize the exposure to phototherapy to what is really needed for the newborn. Further studies are needed to clarify the preferred complementary treatments that could reduce the duration of exposure to phototherapy without impairing its effectiveness.

Transcutaneous CO2 Monitoring in Extremely Low Birth Weight Premature Infants.

Extremely low birth weight (ELBW) premature infants are particularly susceptible to hypocarbia and hypercarbia, which are associated with brain and lung morbidities. Transcutaneous CO2 (TcCO2) monitoring allows for continuous non-invasive CO2 monitoring during invasive and non-invasive ventilation and is becoming more popular in the NICU. We aimed to evaluate the correlation and agreement between CO2 levels measured by a TcCO2 monitor and blood gas CO2 (bgCO2) among ELBW infants. This was a prospective observational multicenter study. All infants < 1000 g admitted to the participating NICUs during the study period were monitored by a TcCO2 monitor, if available. For each bgCO2 measured, a simultaneous TcCO2 measurement was documented. In total, 1828 pairs of TcCO2-bgCO2 values of 94 infants were collected, with a median (IQR) gestational age of 26.4 (26.0, 28.3) weeks and birth weight of 800 (702, 900) g. A moderate correlation (Pearson: r = 0.64) and good agreement (bias (95% limits of agreement)):(2.9 [-11.8, 17.6] mmHg) were found between the TcCO2 and bgCO2 values in the 25-70 mmHg TcCO2 range. The correlation between the TcCO2 and bgCO2 trends was moderate. CO2 measurements by TcCO2 are in good agreement (bias < 5 mmHg) with bgCO2 among premature infants < 1000 g during the first week of life, regardless of day of life, ventilation mode (invasive/non-invasive), and sampling method (arterial/capillary/venous). However, wide limits of agreement and moderate correlation dictate the use of TcCO2 as a complementary tool to blood gas sampling, to assess CO2 levels and trends in individual patients.

Neurodevelopmental Outcome of Very Low Birth Weight Infants in the Northern District of Israel: A Cross-Sectional Study.

BACKGROUND: Currently, no local database in Israel collects neurodevelopmental outcomes of very low birth weight (VLBW) preterm infants. We investigated neurodevelopmental outcomes in one district of the largest healthcare organization in Israel. METHODS: A cross-sectional study including all VLBW (<1500 g) preterm infants born between 1 January 2006 and 31 December 2016 who were followed in any of seven child development centers in Israel's Northern District. Data were retrospectively collected from the computerized medical record database. RESULTS: Out of 436 participants, 55.1% had normal developmental outcomes. A total of 8.9% had cerebral palsy (CP), 12.2% had a global developmental delay (GDD), and 33.4% had a language delay. Out of the extremely preterm infants (n = 109), 20.2% had CP, 22.0% had GDD, and 44.9% had language delay. We found a statistically significant higher rate of abnormal neurodevelopment outcomes in non-Jews compared to Jews (57% vs. 37.8%, respectively, p < 0.0001). CONCLUSIONS: We found a relatively high overall rate of CP in our local population and a significant difference in neurodevelopmental outcomes between Jews and non-Jews. This study emphasizes the need for an expanded and detailed national database collecting post-discharge outcomes, as well as an assessment of national healthcare resource allocation and inequalities in preterm infants' post-discharge care.

Intrapartum Maternal Prophylactic Antimicrobial Treatment and Neonatal Jaundice.

Intrapartum antibiotics are widely used and may potentially affect bilirubin levels and neurotoxicity in the newborn. The aim of this study was to examine the effect of intrapartum antibiotic exposure on neonatal jaundice. We retrospectively collected data from 972 neonates born to 963 mothers. Five hundred forty-five mothers (56.6%) received intrapartum antibiotics. There were no statistically significant differences in maximum bilirubin level (7.82 ± 3.65 vs 7.63 ± 3.71, P = .43) or need for phototherapy (9 [1.62%] vs 4 [0.94%], P = .52) between exposed and non-exposed newborns. The rate of phototherapy was significantly higher only in the group of infants born to mothers who received broad-spectrum antibiotics at 2 to 3.9 hours prior to delivery (χ2 = 10.453, P = .015) and was not higher in the group of exposure >4 hours, which may represent a short transient effect of antibiotics exposure on bilirubin turnover. Further studies are needed to validate this finding.

The Effect of SSRI Exposure in Pregnancy on Early Respiratory and Metabolic Adaptation in Infants Born Preterm.

Selective serotonin reuptake inhibitors (SSRIs) are increasingly used for maternal depression during pregnancy; however, their use has been linked to adverse effects in newborns. Respiratory and feeding problems, jaundice, metabolic and temperature dysregulation and hypoglycemia have been described in term infants. However, scarce data exists on early neonatal adaptation in exposed infants born prematurely. We aimed to assess the effects of SSRI exposure on early neonatal adaptation measures in infants born prematurely. Data from preterm infants exposed to maternal SSRIs during pregnancy and from matched controls were retrospectively collected. Forty-two infants comprised the final cohort: 21 infants with SSRI exposure and 21 matched controls. 1 min Apgar score was significantly lower in the exposed group compared to the non-exposed group (p = 0.043). No differences were found in 5 min Apgar scores, cord pH, need for delivery room resuscitation, rate of hypoglycemia, hyponatremia, hyperbilirubinemia, need for phototherapy, temperature stability and maximal oxygen requirements. No differences were found in the total time of respiratory support, time to reaching full enteral feeds, length of stay and complications of prematurity. Unlike studies in term infants, no significant differences were found in adaptation and short-term outcomes between preterm infants with and without SSRI exposure in pregnancy.

Intracardiac Thrombi in Preterm Infants-A Case Study and Review of the Literature.

Intracardiac thrombi in preterm infants are not common but may lead to fatal outcomes. Predisposing and risk factors include small vessel size, hemodynamic instability, immaturity of the fibrinolytic system, indwelling central catheters and sepsis. In this paper, we present our own experience with a case of a catheter-related right atrial thrombus in a preterm infant, which was successfully treated with an aspiration thrombectomy. Then, we review the literature on intracardiac thrombosis in preterm infants: epidemiology, pathophysiology, clinical signs, echocardiographic diagnostic features and treatment options are discussed.

Prenatal detection of gastrointestinal bubbles since early pregnancy: Clues to correct diagnosis.

OBJECTIVE: To characterize gastrointestinal bubbles detected since early pregnancy and to describe corresponding diagnoses. METHOD: A retrospective cohort review of all cases in which gastrointestinal bubbles were detected starting in early prenatal transvaginal scans at 14-17 weeks of gestation between the years 2007 and 2021. Sonographic features and data regarding associated anomalies, genetic abnormalities, and pregnancy outcome were evaluated. RESULTS: Bubbles were detected in 23 of 27 073 early scans and a total of 31 394 scans. Diagnosis was available in 22 cases. Transient bubbles were detected in 10 cases and represented normal peristalsis. Fixed double bubble was detected in nine cases. Double-walled double bubbles represented duodenal duplications (three cases) and esophageal duplications (two cases). Simple cysts represented duodenal atresia (three cases) and a pancreatic cyst (one case). A triple bubble represented duodenal obstruction from Ladd bands in one case. Quadribubble was detected in two cases and represented jejunal atresia. CONCLUSION: Prenatal detection of gastrointestinal bubbles can accurately diagnose physiological versus pathological upper gastrointestinal conditions. Transient bubbles are physiological. Fixed double bubbles might represent either duodenal atresia or esophageal/duodenal duplications when a double wall is demonstrated. Three or four bubbles might represent more distal intrinsic or extrinsic obstruction.

Improving Communication with Parents in the NICU during the COVID-19 Pandemic, a Study and Review of the Literature.

BACKGROUND: Communication with parents of sick premature and term infants in the NICU is complicated and challenging. Multiple efforts have been made to improve it, including the introduction of new electronic-based measures. AIM: We aimed to study the influence of implementation of a new communication technology on parents' satisfaction with care in the NICU during the COVID-19 pandemic. METHODS: Infants were video-recorded in their incubators or cots without being disturbed. These short films, with voice updates on the infant's condition, were sent on a daily basis to their parents via a WhatsApp application. RESULTS: Parents who chose to join the new communication project (study group) were older, and their infants were more premature. Parents were satisfied with this new communication modality. Satisfaction scores in both study and control groups were high, but not significantly different. CONCLUSIONS: Although the implementation of the new communication project was successful, we could not demonstrate significant improvement in satisfaction scores that were high in study and control groups, reflecting baseline high satisfaction. Further studies are needed employing other assessment tools in order to evaluate other aspects of parents' satisfaction with new modalities of communication introduced to the NICU, and their effects on parents' bonding with their infants.

The Effects of Rudeness on NICU Medical Teams Studied by a New Tool for the Assessment of Decision-Making Group Dynamics.

BACKGROUND: Group decision-making can be placed on a continuum of group dynamics, between Groupthink and Polythink. OBJECTIVE: To present a new assessment tool for the characterization of medical teams' decision-making group dynamics, and test it to study the effects of exposure to rudeness on various types of group dynamics. METHODS: Three judges who watched videotapes of critical care simulations evaluated 24 neonatal intensive care unit teams' decision-making processes. Teams were rated using the new assessment tool, especially designed for this quantitative study, based on items adapted from symptoms of Polythink and Groupthink. RESULTS: Measures of reliability, inter-rater agreement and internal consistency, were reasonably good. Confirmatory factor analysis refined the tool and verified that the symptoms in each category (Polythink or Groupthink) of the refined 14 items' assessment tool were indeed measures of the construct. The average General Score was in the range of the balanced dynamic on the continuum, and without tendency towards one of the extremities (Groupthink or Polythink). No significant effect of exposure to rudeness on group dynamics was found. CONCLUSIONS: This is a first attempt at using quantitative methods to evaluate decision-making group dynamics in medicine, by adapting symptoms of Groupthink and Polythink as items in a structured assessment tool. It suggests a new approach to understanding decision-making processes of medical teams. The assessment tool seems to be a promising, feasible and reasonably reliable research tool to be further studied in medicine and other disciplines engaged in decision-making.

An Observational Study on the Use of Peripheral Intravenous Lines vs. Central Lines in a Neonatal Intensive Care Unit.

BACKGROUND AND OBJECTIVES: There is a debate regarding the preferred intravenous (IV) access for newborns. Our aim was to study practices regarding the choice of vascular access and outcomes. METHODS: A seven-month prospective observational study on IV lines used in all newborns admitted to Bnai Zion Medical Center's neonatal intensive care unit (NICU). RESULTS: Of 120 infants followed, 94 required IV lines. Infants born at ≤32 weeks gestation, or with a head circumference ≤29 cm were more likely to require two or more IV lines or a central line for the administration of parenteral nutrition or medications for longer periods. However, central lines (umbilical or peripherally inserted central catheters (PICC)) were not associated with better nutritional status at discharge based on weight z-scores. Only one complication was noted-a central line-associated bloodstream infection in a PICC. CONCLUSIONS: Our data suggest preferring central IV access for preterm infants born at ≤32 weeks or with a head circumference ≤29 cm. We encourage other NICUs to study their own data and draw their practice guidelines for preferred IV access (central vs. peripheral) upon admission to the NICU.

Utilizing umbilical cord blood - Minimizing blood sampling and pain in healthy infants at risk for polycythemia.

BACKGROUND: Exposure to pain in early life was associated with long term consequences, therefore strategies for minimizing painful procedures in newborns should be employed. The utility and reliability of cord blood CBC was demonstrated before, however data regarding use of cord blood in healthy infants at risk for polycythemia are lacking. METHODS: A single-center, paired-sampling prospective laboratory study including all healthy asymptomatic infants born after 36 weeks gestation who were SGA (<2500 g), LGA (>4000 g), or born to mothers with diabetes in pregnancy. Blood count indices were compared between umbilical and neonatal capillary or venous blood samples. In order to predict cut-off values for neonatal polycythemia using umbilical hematocrit, receiver operator curves (ROC) were plotted. RESULTS: Paired samples were collected from 433 infants. Mean gestational age and birth-weight were 39.0 ± 1.3 weeks and 3489 ± 682 g. Hemoglobin, hematocrit and WBC values were lower in cord blood compared to neonatal, but PLT count was higher. Pearson r showed only modest correlation between peripheral capillary and umbilical or venous Hct - 0.35 (p < 0.001), and 0.44 (p < 0.001), respectively. In order to try and capture clinically significant polycythemia ROC was plotted for hematocrit >70% and <40%. In our cohort, using the calculated cutoff values (>51% and <35%) could have resulted in a decrease of 72% of neonatal blood draws. CONCLUSION: This analysis should be interpreted with caution, as currently it cannot support the routine use of umbilical samples' hematocrits for making treatment decision in newborns at risk for polycythemia. Further larger studies are needed.

Oral versus intravenous paracetamol for patent ductus arteriosus closure in preterm infants.

BACKGROUND: To examine whether oral administration of paracetamol as a first-line agent had a greater effect on the closure of a patent ductus arteriosus than the intravenous route. METHODS: We performed a retrospective study of preterm infants (<37 weeks of gestation) between 2012 and 2020 treated with oral or intravenous paracetamol as the first line for patent ductus arteriosus (PDA) constriction and compared rates of ductal closure, course duration, cumulative dose, PDA characteristics, and serum levels. RESULTS: Over the study period, 80 preterm infants received paracetamol, of which 50 received paracetamol as first-line treatment to augment constriction of the PDA. Closure rate was higher in the oral group (n = 15/19, 79%) compared to the intravenous group (n = 8/20, 40%, p < 0.01), and remained significant after adjusting for gestational age, length of treatment, and postnatal age (OR 0.14, 95% CI 0.03-0.67, p = 0.014, RR 0.51, 95% CI 0.28-0.91). Eleven preterm infants received a combination of both oral and intravenous paracetamol with a closure rate of 45% (n = 5). CONCLUSIONS: Oral administration of paracetamol as a first-line agent is more efficacious to constrict the PDA than the intravenous route, irrespective of gestational age or course duration. IMPACT: Our retrospective study comparing the use of oral versus intravenous paracetamol as the first line for patent ductus arteriosus (PDA) constriction in preterm infants demonstrates that oral administration of paracetamol is more efficacious to constrict the PDA than the intravenous route, irrespective of gestational age or course duration. To our knowledge, this is the first published study (prospective or retrospective) to compare the efficacy of oral versus intravenous paracetamol as a first-line treatment for PDA closure in preterm infants. Our finding may improve the rate of PDA closure when paracetamol is used as a first-line agent.

Small for gestational age: the familial perspective.

BACKGROUND: There are multiple etiologies for being born small for gestational age (SGA). However, extended familial data in idiopathic cases have been scarcely reported. OBJECTIVE: Our aim was to explore the familial history of SGA newborns and describe the proportion and distribution of SGA in their parents and parental siblings. METHODS: This was a retrospective study performed at an obstetrics clinic holding a detailed reliable electronic database. Between 2008 and 2017, data of 14,003 patients and 20,617 pregnancies were recorded. Parents of SGA infants were identified and extended familial history was obtained by questionnaires, including birth weights (BWs) and gestational age at birth of the parents and parents' siblings. SGA was defined as a BW below the 10th percentile. Proportions of maternal, paternal, and parental siblings' SGA were calculated. Chi-square test was performed to assess the relationship between SGA family member's gender and SGA infants' gender, and between the relative's gender and their family relationship to the infant. RESULTS: About 2100 women had a history of a previous infant born SGA, however, after exclusion the final cohort comprised 926 women with a previous SGA infant. In 473 cases there was at least one other family member of the infant born SGA: father, mother, aunt, or uncle of the infant, representing a prevalence of 51% (473/926) of familial SGA. Out of familial SGA cases, maternal SGA was found in 55% (260/473), and paternal SGA was found in 28.1% (133/473). 27.6% had more than one SGA relative. Eighteen infants had both an SGA father and an SGA mother (3.8%). A history of an SGA aunt or uncle was found in 44% (209/473) of familial SGA cases, which was 22.5% (209/926) of the entire cohort. Parental sibling SGA occurred almost twice in mother's siblings as compared to father's siblings. Chi-square test revealed no association between the SGA relative's gender and their family relationship to the infant. There was no association between the SGA infant's gender and the SGA relative's gender. CONCLUSIONS: A family history of SGA is common in SGA infants, and occurs most often in mothers. This study found 22% SGA in parental siblings, in maternal siblings more than paternal siblings, supporting the possibility of a genetic component in SGA trait transmission. In clinical practice, when counseling parents with a growth-restricted fetus from an unknown etiology, extended familial birthweight history should be obtained and taken into account, which may be helpful in reducing parental anxiety.

Early prenatal diagnosis of tricuspid valve dysplasia.

OBJECTIVE: To report our experience in early prenatal diagnosis of six cases of tricuspid valve dysplasia (TVD) and to delineate echocardiographic features. METHODS: This was a retrospective study which included all the women who attended our clinic for early fetal screening sonography, between 2001 and 2018. The ultrasound screening was done at 11-16 weeks of gestation, and included an anatomic fetal scan and Doppler imaging. The diagnosis of TVD was done based on sonographic features visualized on four chamber view and color mapping of the valve. Complete fetal echocardiography was carried out to rule out additional heart malformations. RESULTS: Out of 34,933 early prenatal transvaginal ultrasound screening examinations, six cases of TVD were diagnosed. Five of the pregnancies were terminated as per parental request, and one fetus was delivered at term and died shortly after birth. In three fetuses a chromosomal analysis was performed, one had trisomy 21, one had an abnormal CGH, and the third had a normal karyotype. In two fetuses an autopsy was performed and the diagnosis of TVD was confirmed in both. CONCLUSION: Early prenatal detection of TVD is possible and may aid in parental counseling. Larger studies, examining the outcome of TVD should be considered.

Fetal Trigonocephaly (Strawberry Skull) in Early Pregnancy.

Trigonocephaly was previously described prenatally in association with severe abnormalities, mostly observed after 18 weeks of gestation. We describe our experience with this finding in early pregnancy, between 14 and 17 weeks of gestation. Our series includes 18 cases of trigonocephaly with several etiologies; trisomy 18, de novo translocation, thanatophoric dysplasia, and open spina bifida without hydrocephalus. Two fetuses had no other significant abnormalities and a spontaneous normalization of the skull shape was observed on follow-up. Both had normal genetic testing and postnatal outcome. These two cases represent a new phenomenon of an isolated transient form with normal outcome.

Early prenatal diagnosis of double inlet left ventricle.

OBJECTIVE: The aim of this study to describe the presentation of double inlet left ventricle (DILV) very early in prenatal life, to assess its prevalence and to portray the associated anomalies. METHODS: This was a retrospective study which included all the women who attended our clinic for early fetal screening sonography, between 2006 and 2020. Most of the screening was done at 14-16 weeks of gestation (except one high risk pregnancy, which was performed at nine gestational weeks), and included an anatomic fetal scan and Doppler imaging. The diagnosis of DILV was done based on sonographic features of abnormal four-chamber view. Complete fetal echocardiography was carried out to rule out additional heart malformations. RESULTS: Out of 26,805 early prenatal transvaginal ultrasound screening examinations, 14 cases of DILV were diagnosed. The gestational age range of our DILV diagnosis was 9-16 gestational weeks. All pregnancies were terminated as per parental request. In five fetuses, a chromosomal analysis was performed, one had trisomy 21, and the rest fetuses had a normal karyotype. In two fetuses, an autopsy was performed and the diagnosis of DILV was confirmed in both. CONCLUSIONS: Very early prenatal detection of DILV is possible and may have an implication in parent decision regarding their pregnancy future.