Limitations of the risk factor based approach in early neonatal sepsis evaluations.

AIM: Guidelines for detection of early neonatal sepsis employ a risk factor approach combined with laboratory parameters. In an era of increasing intrapartum antibiotic prophylaxis (IAP), we re-assessed the approach as a whole and each of the risk factors individually. METHOD: This retrospective study included infants with risk factors for sepsis or those treated with antibiotics or who had documented early sepsis. Safety of the protocol was assessed by the number of cases of either missed or partially treated late sepsis or meningitis and the sepsis-related mortality rate. Predictive value of each clinical and laboratory factor was calculated. RESULTS: Of the 22,215 neonates, 2096 were assessed. IAP among infants with risk factors rose from 68% in 2005 to 78% in 2008 (p = 0.001). A total of 1662 asymptomatic infants had risk factors, 635 received antibiotics and one (0.06%) had sepsis. A total of 434 symptomatic infants were treated with antibiotics and of these 234 had risk factors and 20 (4.6%) had sepsis. No cases of partially treated or missed sepsis were detected. Poor predictive value was found for all risk factors except prematurity and leukopenia. CONCLUSION: The risk factor based approach in asymptomatic infants cannot be justified. In-hospital observation of asymptomatic infants for 2-3 days with antibiotic treatment being reserved only for symptomatic infants may be a reasonable alternative.

Not all newborns born to mothers with clinical chorioamnionitis need to be treated.

PURPOSE: The 2010 recommendations of the Centers for Disease Control and Prevention (CDC) for prevention of perinatal group B Streptococcal Disease (GBS) is that symptomatic newborns suspect for early onset sepsis (EOS), or newborns born to mothers with clinical chorioamnionitis should receive antibiotic treatment. Our protocol was changed accordingly during 2015. We prospectively assessed the safety of the protocol and evaluated the need to treat all newborns born to mothers with clinical chorioamnionitis and retrospectively evaluated the performance of the EOS risk calculator. METHODS: The study period was from May 2015 to April 2016 at the Kaplan Medical Center (KMC). Inclusion criteria were: gestational age of 35 weeks and above, newborns that were treated with antibiotic, newborn born to mothers with risk factors for EOS or with maternal clinical chorioamnionitis, or to mothers that were given intra-partum antibiotic prophylaxis (IAP). RESULTS: In the study period, 7058 newborns were born, 1341 (19%) neonates were included according to the inclusion criteria. Six newborns had EOS (0.85 per 1000 live born). 123/1341 (9%) of the neonates were symptomatic of whom six (4.9%) had proven EOS with RR 10.9 (CI 3.5-33.39, p < .0001), NNT was 22.6. Of them, 89/1341 (6.6%) were treated for maternal clinical chorioamnionitis, two (2.25%) had proven EOS, but they were also symptomatic. The RR was 5.03 (CI 1.03-24.6 p = .045) and the NNT was 55.5. Symptomatic newborns were at an increased risk of 2.2 to have EOS compared with newborns with maternal clinical chorioamnionitis. During the study period, 201 (15%) newborns received antibiotic treatment, while if we had only used the calculator, 111 (8%) newborns would have been treated (p<.001). Only one (out of three with maternal risk factors) newborn was symptomatic during the first hour of life. Three of the mothers whose newborn developed EOS, had no risk factors so there was no need for the calculator. The calculated EOS risk at birth for the other three ranged from 0.37 to 0.67. CONCLUSIONS: We suggest that asymptomatic newborns born to mothers with clinical chorioamnionitis should not receive antibiotic treatment automatically.

The red reflex examination in neonates: an efficient tool for early diagnosis of congenital ocular diseases.

BACKGROUND: The American Academy of Pediatrics recently published recommendations for the red reflex assessment in the newborn period to detect and treat ocular disorders as early as possible, and to prevent lifelong visual impairment and even save lives. The test is technically simple to perform, non-invasive, requires minimal equipment and can detect a variety of ocular pathologies including cataracts and retinal abnormalities. No specific national guidelines exist on this issue. OBJECTIVES: To document the implementation of red reflex examination in routine neonatal care and present the findings. METHODS: Our clinical experience following inclusion of the red reflex test into the newborn physical examination in a single center was reviewed. In addition, an electronic mail questionnaire was sent to all neonatology departments in Israel regarding performance of the red reflex test. RESULTS: During 2007-2008, five infants were identified with congenital cataracts at days 2-6 of life prior to discharge from hospital. Surgery was performed in one infant at age 2 months and all infants underwent a thorough follow-up. The incidence of congenital cataract in our center was 1:2300. Less than half the neonatology departments have endorsed the AAP recommendation and perform the red reflex test routinely. CONCLUSIONS: Abnormal red reflex test after delivery enables a rapid ophthalmologic diagnosis, intervention and close followup. We recommend that red reflex screening be performed as part of the newborn physical examination; if abnormal, an urgent ophthalmologic referral should be made.

Reassessing vitamin D supplementation in preterm infants: a prospective study and review of the literature.

Objectives Recommendations for vitamin D (VitD) intake and target serum levels of 25(OH)D in preterm infants are diverse. We hypothesized that preterm infants with low birth weight (BW) have low dietary intake of VitD and therefore should be supplemented with higher amounts of VitD. Methods Infants with BW < 2 kg were supplemented with 600 units of VitD a day during the first 2-6 weeks of life, whereas infants with BW>2 kg continued with the routine supplementation of 400 units of VitD daily. Serum levels of 25(OH)D, calcium, phosphorous, alkaline phosphatase (AP) and parathyroid hormone (PTH) were assessed 24 h after birth and before discharge. The total daily intake of vitD was calculated in each infant. Results Sixty-two infants were enrolled, 49 with BW < 2 kg. After birth, only 24% had sufficient levels of 25(OH)D, whereas before discharge 45 of 54 infants (83%) available for analysis reached sufficient levels of 25(OH)D. All 54 infants demonstrated significant elevation in serum levels of calcium, phosphorous, AP and significant reduction in PTH levels. The total daily intake of VitD was lower than recommended (800-1000 IU/d) in 16 of 45 infants with BW < 2 kg (36%) and in all nine infants with BW>2 kg. Nevertheless, only 2 of 25 infants with insufficient intake of VitD demonstrated insufficient levels of serum 25(OH)D. No case of vitamin D excess was recorded. Conclusions Increased supplementation of VitD (600 IU/d) for premature newborns with BW < 2 kg is effective in increasing both total daily intake of VitD and serum levels of 25(OH)D.

The additional dose to radiosensitive organs caused by using under-collimated X-ray beams in neonatal intensive care radiography.

Radiographic technique and exposure parameters were recorded in five Israeli Neonatal Intensive Care Units for chest, abdomen and both chest and abdomen X-ray examinations. Equivalent dose and effective dose values were calculated according to actual examination field size borders and proper technique field size recommendations using PCXMC, a PC-based Monte Carlo program. Exposure of larger than required body areas resulted in an increase of the organ doses by factors of up to 162 (testes), 162 (thyroid) and 8 (thyroid) for chest, abdomen and both chest and abdomen examinations, respectively. These exposures increased the average effective dose by factors of 2.0, 1.9 and 1.3 for the chest, abdomen and both chest and abdomen examinations, respectively. Differences in exposure parameters were found between the different neonatal intensive care units-tube voltage, current-time product and focal to skin distance differences up to 13, 44 and 22%, respectively. Reduction of at least 50% of neonate exposure is feasible and can be implemented using existing methodology without any additional costs.

Correlation between transcutaneous and serum bilirubin in preterm infants before, during, and after phototherapy.

BACKGROUND: Transcutaneous bilirubinometry (TcB) is routinely used to monitor jaundice in term and near-term infants. However, before 35 weeks gestation, the technique has not been widely adopted. AIM: The aim of this study is to study the correlation between TcB and total serum bilirubin (TsB) before, during, and after phototherapy in preterm infants born before 35 weeks' gestation. METHODS: Jaundice was monitored in infants born before 35 weeks' gestation by simultaneous measurements of TsB and TcB assessed by a Drager Jaundice Meter JM-103 (Draeger Medical, Inc., Telford, PA). RESULTS: About 588 pairs of measurements were recorded in 86 premature infants of 26-34 weeks, weighing 618-2400 grams. The overall correlation coefficient between TcB and TsB was 0.8 (p = .001). Subset analysis revealed lower correlation in infants born before 30 weeks. TcB was consistently estimated around 1 mg% lower than TsB. Neither the cause of the jaundice nor major neonatal morbidities significantly influenced the TcB-TsB correlation. CONCLUSIONS: TcB is a reliable measure of jaundice before 35 weeks' gestation with a mean under-estimation of ≈1 mg%. TcB use may reduce unnecessary invasive blood tests.

Early, rapidly progressive enteral nutrition promotes growth of very low birth weight (VLBW) infants.

AIM: This study describes the effects of a quality improvement program to promote improved postnatal nutrition on the growth of very low birth weight (VLBW) infants. METHODS: Daily data regarding nutrition and growth were collected from the medical record of VLBW infants born during 1995-2010. The infants were grouped by year of birth in order to compare infants from before, during and after the policy change. Evaluation of growth included age in days at a return to birth weight and the proportion of infants with weight below the 10th percentile at discharge. RESULTS: The caloric and protein intake improved significantly. The age at a return to birth weight fell (p < 0.01) from 14.6 ± 5 d to 11 ± 8 d after the change. The proportion of infants with a discharge weight below the 10th percentile for corrected age fell (p < 0.01) from 72.1% to 42.1%. Data on enteral feeding showed that increased rate of enteral feeds (EF) was associated with better growth (p < 0.001). CONCLUSION: Increasing awareness led to increase in caloric and protein intake in VLBW infants. Aggressive EF was associated with more rapid weight gain. However, the provision of protein and calories during the first 2 weeks of life still falls short of the latest European Society of Pediatric Gastroenterology, Hepatology and Nutrition recommendations.

Correlation of transcutaneous bilirubinometry (TcB) and total serum bilirubin (TsB) levels after phototherapy.

AIM: To investigate the correlation between transcutaneous bilirubinometry (TcB) and total serum bilirubin (TsB) in jaundiced infants before and after, but not during phototherapy. METHODS: This study prospectively investigated the correlation between TcB and TsB in term and near term infants before and after phototherapy. RESULTS: Overall 673 pairs of measurements (TcB and TsB) were performed on 371 infants of ≥35 weeks gestation and with birth weight above 2000 g. Of these 337 sets were from 200 infants who had not been treated with phototherapy (Group 1) and 336 measurements from 171 infants taken between 1 h and 5 d after phototherapy (Group 2). The correlation coefficient between TcB and TsB in the whole cohort was r = 0.72. The correlation was low during the first 8 h after phototherapy (r = 0.56), but thereafter the correlation returned to the range of 0.65-0.8. Using the Sobel test, no significant difference was found between the correlation coefficients at the different time periods, with the possible exception of the difference between 1 and 8 h and 9 and 16 h which was of borderline significance with a p value of 0.06. CONCLUSION: This study demonstrates good correlation between TcB and TsB by 8 h after phototherapy. This adds validity to community-based screening programs employing TcB measurements plotted on TsB nomograms. Such programs may contribute to prevention of tragic cases of bilirubin-induced neurologic damage.

Comparison of hematologic indices and markers of infection in umbilical cord and neonatal blood.

OBJECTIVE: Evaluation of a neonate for suspected early neonatal sepsis routinely includes blood tests such as complete blood count, C-reactive protein (CRP) and culture. In order to obviate the need for venepuncture, we prospectively compared these tests in paired samples from umbilical cord and peripheral venous blood drawn during the first hours after birth in both preterm and term infants. METHODS: Paired blood samples were studied from asymptomatic neonates with risk factors for early sepsis. Data were collected on maternal and neonatal factors that may have influenced the correlation between the tests. RESULTS: Three hundred fifty pairs of samples were studied. Significant correlation between umbilical cord and peripheral venous samples was found for white blood cell (WBC; r = 0.683) and platelets (PLT) (r = 0.54). Correlation for hemoglobin was lower (r = 0.36). No cases of early neonatal sepsis were detected. However, contamination rates were 12% in umbilical cord blood and 2.5% in peripheral venous blood cultures. WBC rose after birth and the 90th percentile rose from 22 500 in umbilical cord blood to 29 700 in peripheral blood. CONCLUSIONS: Screening for sepsis with umbilical cord CBC may be useful provided normal ranges are adjusted accordingly.