Using topical benzocaine before lingual frenotomy did not reduce crying and should be discouraged.

AIM: The US Food and Drug Administration has said that oral preparations containing benzocaine should only be used in infants under strict medical supervision, due to the rare, but potentially fatal, risk of methemoglobinemia. This study aimed to determine the analgesic effect of topical application of benzocaine prior to lingual frenotomy in infants with symptomatic tongue-tie. We hypothesised that the duration of crying immediately following frenotomy with topical benzocaine would be shorter than with no benzocaine. METHODS: This randomised controlled study compared the length of crying after lingual frenotomy in term infants who did, or did not, receive topical application of benzocaine to the lingual frenulum prior to the procedure. RESULTS: We recruited 21 infants to this study. Crying time was less than one minute in all of the subjects. The average length of crying in the benzocaine group (21.6 ± 13.6 sec) was longer than the length of crying in the control group (13.1 ± 4.0 sec), p = 0.103. CONCLUSION: Contrary to our hypothesis, infants who were treated with topical benzocaine did not benefit from topical analgesia in terms of crying time. The use of benzocaine for analgesia prior to lingual frenotomy in term infants should therefore be discouraged.

Genetics of conotruncal malformations: review of the literature and report of a consanguineous kindred with various conotruncal malformations.

Genetic predisposition in congenital heart disease is considered to be a component of multifactorial inheritance. Recently, monogenic inheritance in conotruncal malformations has been suggested. We describe a consanguineous kindred with various conotruncal malformations, the presence of which lends support to the idea that this spectrum of malformation is monogenically inherited. Theoretical background and experimental and clinical data are reviewed and discussed.

Nucleated red blood cells in healthy infants of women with gestational diabetes.

OBJECTIVE: To evaluate whether absolute nucleated red blood cell (RBC) counts are elevated in large-for-gestational-age (LGA) infants of women with gestational diabetes compared with appropriate-for-gestational-age (AGA) infants of women with or without gestational diabetes. METHODS: We compared absolute nucleated RBC counts during the first 12 hours of life in three groups of term, vaginally delivered infants, LGA infants of women with gestational diabetes (n = 20), AGA infants of women with gestational diabetes (n = 20), and AGA infants of nondiabetic women (n = 30). We excluded infants of women with hypertension, smoking, alcohol or drug abuse, and those with fetal heart rate abnormalities in labor, low Apgar scores, hemolysis, blood loss, or chromosomal anomalies. RESULTS: There were no significant differences among groups in gestational age, gravidity, parity, maternal analgesia, 1- and 5-minute Apgar scores, and lymphocyte counts. Corrected white blood cell counts and hematocrit were significantly higher in LGA infants of women with gestational diabetes than in the other groups. The median nucleated RBC count was significantly higher in LGA infants of women with gestational diabetes (0.56 x 10(9)/L, range 0-1.8 x 10(9)/L) than AGA infants of women with gestational diabetes (0.13 x 10(9)/L, range 0-0.65 x 10(9)/L) and controls (0.0005 x 10(9)/L, range 0-0.6 x 10(9)/L) (P < .001). Multiple regression analysis showed that absolute nucleated RBC count was significantly correlated with birth weight (or macrosomia) and maternal diabetic status (r2 = .25, P < .001 for the multiple regression, contribution of birth weight r2 = .19, and diabetes r2 = .06). CONCLUSION: At birth, term LGA infants born to women with gestational diabetes had higher absolute nucleated RBC counts compared with AGA infants born to women with gestational diabetes and controls.

Nucleated red blood cells in meconium aspiration syndrome.

OBJECTIVE: To evaluate whether the absolute nucleated red blood cell (RBC) count is higher in infants who had meconium aspiration with respiratory symptoms compared with infants with asymptomatic meconium aspiration and controls. METHODS: We compared the absolute nucleated RBC counts during the first 12 hours of life in three groups of term, vaginally delivered infants, including those who had meconium aspiration with respiratory symptoms (n = 11), asymptomatic meconium aspiration (n = 45), and control healthy infants (n = 32). We excluded infants of women with diabetes in pregnancy; hypertension; alcohol, tobacco, or drug abuse; and those with hemolysis, blood loss, or chromosomal anomalies. RESULTS: There were no significant differences among groups in gestational age; gravidity; parity; maternal analgesia; lymphocyte, platelet, and granulocyte counts; and hematocrit. The median nucleated RBC count was significantly higher in the meconium aspiration group with respiratory symptoms (0.007 x 10(9)/L) than the asymptomatic meconium aspiration group (0.004 x 10(9)/L) or controls (0.003 x 10(9)/L). CONCLUSION: At birth, infants with meconium aspiration syndrome had higher absolute nucleated RBC counts compared with infants with asymptomatic meconium aspiration and normal infants.

Nucleated red blood cells in infants of smoking mothers.

OBJECTIVE: To evaluate whether the absolute nucleated red blood cell (RBC) count is elevated in term, appropriate for gestational age (AGA) infants born to smoking women. METHODS: We compared absolute nucleated RBC counts taken during the first 12 hours of life in two groups of term, vaginally delivered, AGA infants, one group born to mothers who smoked during pregnancy (n = 30) and the other born to mothers who did not smoke (n = 30). We excluded infants of women with diabetes, hypertension, or alcohol or drug abuse, and infants with heart rate abnormalities, hemolysis, blood loss, or chromosomal anomalies. RESULTS: There were no differences between the groups in birth weight, gestational age, maternal age, gravidity, parity, maternal analgesia during labor, 1- and 5-minute Apgar scores, corrected white blood cell counts, lymphocyte counts, or hematocrits. The median absolute nucleated RBC count in infants of smoking mothers was 0.5 x 10(9)/L (range 0 to 5.0) versus 0.0005 x 10(9)/L (range 0 to 0.6) in nonsmoking controls (P < .002). Regression analysis that included Apgar scores, gestational age, and number of cigarettes smoked per day showed a significant correlation of absolute nucleated RBC count only with the number of cigarettes smoked per day (P < .001). CONCLUSION: At birth, term AGA infants born to smoking mothers have increased circulating absolute nucleated RBC counts compared with controls. The absolute nucleated RBC count in newborns correlates with the number of cigarettes smoked during pregnancy.

Haemophilus influenzae type b purpura fulminans treated with hyperbaric oxygen.

We report the case of a 4-month-old child with purpura fulminans caused by Haemophilus influenzae type b. In addition to conventional therapy, she was treated with hyperbaric oxygen, and made a full recovery. Hyperbaric oxygen as an adjunct to other therapy in purpura fulminans is discussed.

Effect of ethnicity on mortality of very low birthweight infants in Israel.

BACKGROUND: Multiple demographic, genetic, and environmental factors differ between Muslim and Jewish infants in Israel. OBJECTIVE: To evaluate whether, after adjustment for perinatal factors associated with mortality, excess mortality occurs in very low birthweight (VLBW) Muslim compared with Jewish infants. DESIGN: The Israel National VLBW infant database includes data on 99% of all VLBW births in Israel. The study population comprised 5015 Jewish and 1549 Muslim VLBW infants of more than 23 weeks gestation, born between 1995 and 1999. The Mantel-Haenszel test was used for stratified analysis and logistic regression analysis to assess the effect of ethnic origin on mortality. RESULTS: The death rate was significantly higher among Muslim infants (22.7% v 17.2%; crude odds ratio 1.42; 95% confidence interval 1.24 to 1.63). Excess mortality in Muslims occurred mainly in the 32-33 week (8.0% v 2.8%) and >33 week (14.7% v 4.7%) gestational age groups, and in birthweight groups of 1000-1249 g (17.6% v 9.3%) and 1250-1500 g (9.1% v 3.6%). In VLBW infants without congenital malformations, there was a significantly higher risk of mortality among Muslim infants (odds ratio 1.28; 95% confidence interval 1.04 to 1.57) compared with Jewish infants, after adjustment for gestational age, birth weight, small for gestational age, prenatal care, prenatal steroid treatment, plurality, mode of delivery, and Apgar score. CONCLUSIONS: Excess mortality was present among Muslim VLBW infants without congenital malformations. Perinatal factors associated with increased risk of mortality were more prevalent in the Muslim VLBW population. The pattern of disparities suggests inadequate access to, or utilisation of, effective perinatal technology in the Muslim population in Israel.

Nosocomial cutaneous abscesses in septic infants.

OBJECTIVE: To retrospectively study the epidemiology of nosocomial cutaneous abscesses in 46 consecutive septic infants. RESULTS: Ten infants had one abscess or more. Surviving infants with abscesses had a longer duration of bacteraemia, which disappeared within 24 hours of drainage. CONCLUSION: Infants with persistent bacteraemia should be examined regularly for the presence of abscesses.

Normoblasts in large for gestational age infants.

Thirty one term large for gestational age (LGA) infants of non-diabetic mothers were compared with 30 appropriate for gestational age controls. Median absolute nucleated red blood cell counts, lymphocyte counts, and packed cell volumes were significantly higher in the LGA infants than the controls. It is possible that LGA babies of non-diabetic mothers are exposed to relative intrauterine hypoxia.

Neonatologists are using much less dexamethasone.

Two historical cohorts (1993-1994 and 2001) of preterm infants ventilated for respiratory distress syndrome were compared. Dexamethasone administration fell from 22% to 6%. Chronic lung disease in survivors rose slightly from 13% to 17%, and mortality fell from 21% to 15% (other causes). The effect of restriction of dexamethasone use on chronic lung disease and mortality remains to be seen.

Early postnatal dexamethasone treatment and increased incidence of cerebral palsy.

OBJECTIVE: To study the long term neurodevelopmental outcome of children who participated in a randomised, double blind, placebo controlled study of early postnatal dexamethasone treatment for prevention of chronic lung disease. METHODS: The original study compared a three day course of dexamethasone (n = 132) with a saline placebo (n = 116) administered from before 12 hours of age in preterm infants, who were ventilated for respiratory distress syndrome and had received surfactant treatment. Dexamethasone treatment was associated with an increased incidence of hypertension, hyperglycaemia, and gastrointestinal haemorrhage and no reduction in either the incidence or severity of chronic lung disease or mortality. A total of 195 infants survived to discharge and five died later. Follow up data were obtained on 159 of 190 survivors at a mean (SD) age of 53 (18) months. RESULTS: No differences were found between the groups in terms of perinatal or neonatal course, antenatal steroid administration, severity of initial disease, or major neonatal morbidity. Dexamethasone treated children had a significantly higher incidence of cerebral palsy than those receiving placebo (39/80 (49%) v. 12/79 (15%) respectively; odds ratio (OR) 4.62, 95% confidence interval (95% CI) 2.38 to 8.98). The most common form of cerebral palsy was spastic diplegia (incidence 22/80 (28%) v. 5/79 (6%) in dexamethasone and placebo treated infants respectively; OR 4.45, 95% CI 1.95 to 10.15). Developmental delay was significantly more common in the dexamethasone treated group (44/80 (55%)) than in the placebo treated group (23/79 (29%); OR 2. 87, 95% CI 1.53 to 5.38). Dexamethasone treated infants had more periventricular leucomalacia and less intraventricular haemorrhage in the neonatal period than those in the placebo group, although these differences were not statistically significant. Eleven children with cerebral palsy had normal ultrasound scans in the neonatal period; all 11 had received dexamethasone. Logistic regression analysis showed both periventricular leucomalacia and drug assignment to dexamethasone to be highly significant predictors of abnormal neurological outcome. CONCLUSIONS: A three day course of dexamethasone administered shortly after birth in preterm infants with respiratory distress syndrome is associated with a significantly increased incidence of cerebral palsy and developmental delay.

Prognostic significance of hyperechogenic lesions in the basal ganglia and thalamus in neonates.

Neonatal cranial ultrasonography at times reveals hyperechogenic lesions in the basal ganglia and thalamus. These lesions have been attributed to a wide variety of pathologic states, among them toxoplasmosis, rubella, cytomegalovirus, and herpes simplex (TORCH) infections, chromosomal abnormalities, and asphyxia. The clinical significance in terms of the neurodevelopmental outcome of this radiologic abnormality is unknown. We performed a developmental evaluation on 16 children aged 2 to 6 years in whom neonatal cranial ultrasonography had demonstrated hyperechogenic lesions in the basal ganglia or thalamus and had no other neurodevelopmental risk factors. There was no significant difference between the average Developmental Quotient of the target population and the normal population in regard to developmental status. We conclude that in our population, an isolated finding of hyperechogenic lesions in the basal ganglia is probably not a predictor of poor neurodevelopmental outcome.

A randomized, controlled application of the Wallaby phototherapy system compared with standard phototherapy.

The feasibility and efficacy of a fiberoptic blanket (Wallaby Phototherapy System) for the treatment of physiologic jaundice was compared with conventional phototherapy. Forty-two full-term infants with nonhemolytic jaundice were included in the study. Infants in the study group were treated with the fiberoptic blanket and the infants in the control group were placed under a standard phototherapy unit. Both the fiberoptic blanket and the standard phototherapy unit delivered an average irradiance of 7.0 +/- 0.5 muw/cm2/nm. Incremental changes in serial plasma bilirubin levels compared with the initial bilirubin concentration did not differ between the study and control groups. For infants whose initial plasma bilirubin concentration exceeded 200 mumol/L, a statistically significant difference was found in both study and control groups between the average bilirubin level at initiation of phototherapy and the average bilirubin level at termination of treatment. We conclude that phototherapy delivered by the fiberoptic blanket is safe and has efficacy comparable to that of conventional phototherapy, providing a convenient alternative phototherapy application strategy that obviates the need for eye patches and facilitates maternal handling of the infant during therapy.

Prenatal ritodrine administration and the incidence of respiratory distress syndrome in premature infants.

UNLABELLED: Prenatal exposure to ritodrine may be associated with a lower incidence of RDS in premature infants, independent of its effect on prolongation of pregnancy. OBJECTIVE: The purpose of this study was to assess the neonatal respiratory outcome of premature infants according to whether their mothers were treated prenatally with ritodrine. STUDY DESIGN: A retrospective review was done of all 247 infants born at 34 weeks of gestation or less in our hospital during a 6-year period. A multivariate logistic regression was used to adjust for possible confounding variables. RESULTS: Among the ritodrine-exposed infants respiratory distress syndrome developed in 9.5% (4/42) compared with 28% (57/205) in the unexposed group (p < 0.012; adjusted odds ratio 4.88, 95% confidence interval 1.27 to 18.70). The gestational age and birth weight were similar in the two groups. The incidence of transient tachypnea of the newborn and other neonatal complications was not statistically different between the two groups. CONCLUSION: Ritodrine was associated with a significantly lower incidence of respiratory distress syndrome in premature infants, independent of the effect of ritodrine on prolongation of pregnancy.

Is cord blood erythropoietin a marker of intrapartum hypoxia?

A sensitive assay was used to compare the biological activity of cord serum erythropoietin in two groups of infants born with or without labor-induced hypoxia. The mean cord serum erythropoietin activity in 161 infants delivered after vaginal labor was 116 +/- 36 mU/mL, and was indistinguishable from that observed in 23 infants delivered by preplanned, elective cesarean section, 114 +/- 12 mU/mL (P = .75). The bioassay measured effective erythropoietin activity, including the contribution of potentiators in serum. These results indicate that duration and intensity of labor are insufficient to cause a significant increase in effective erythropoietin activity.

Adverse perinatal outcome in the older primipara.

Delayed childbearing has become common and has raised the awareness of the possible risks for the mother and the newborn infant. The increased maternal and neonatal risks have been attributed largely to the lack of proper prenatal care. The aim of this study was to assess whether advanced maternal age is a significant risk factor in mothers who receive good prenatal care. We matched 161 cases 1:1 according to the following criteria: maternal and paternal ethnic origin, chronic diseases, marital status, and smoking during pregnancy. Our results show that the older women had babies with a significantly higher incidence of low birth weight (< 2500 gm, p = 0.001), prematurity (< 37 weeks, p = 0.02), intrauterine growth retardation (p = 0.001), abruptio placentae (p = 0.002), and cesarean section (p < 0.001). The average hospital stay for the babies of the older mothers was longer than that for babies of the younger mothers (8.4 vs 6.1 days, p = 0.003), and the incidence of hospitalization for more than 3 days in the neonatal intensive care unit was increased (10.3% vs 2.2%). Logistic regression did not support maternal age of 35 years and older as being the single significant risk factor for adverse neonatal and maternal outcome. We conclude that maternal age older than 35 years entails a higher risk for the mother and her newborn infant, even when good prenatal care is taken.

Effects of antenatal corticosteroids on blood pressure in very low birth weight infants during the first 24 hours of life.

OBJECTIVE: We tested the hypothesis that prenatal glucocorticoids significantly increase mean arterial blood pressure in very low birth weight preterm infants during the first 24 hours after birth. STUDY DESIGN: Prospectively collected data from 178 inborn infants with birth weights between 500 and 1499 gm were examined. A total of 80 infants were born to mothers treated with corticosteroids (birth weight: 1057 +/- 271 gm, gestational age: 28.0 +/- 2.6 weeks), and 98 infants were untreated controls (birth weight: 1030 +/- 280 gm, gestational age: 28.0 +/- 2.8 weeks). The study setting was a university-based tertiary care center for newborn intensive care. RESULTS: Mean blood pressures on admission and at 3, 6, 12, 18, and 24 hours were significantly higher in steroid-treated infants. Steroid-treated infants received significantly less volume expansion (3.8 +/- 8.5 ml/kg versus 14.4 +/- 20.7 ml/kg; p < 0.001) than controls. Vasopressor support was also reduced in the steroid group (2.5% versus 11.5%; p < 0.05). CONCLUSION: Antenatal steroids are associated with both a higher mean systemic blood pressure and a decreased use of vasopressors and plasma expanders in very low birth weight infants during the first 24 hours after birth. This effect is not limited to infants of < 1000 gm; it is also significant in infants with a birth weight between 1000 and 1499 gm, and is already detectable in the first hours of life. We speculate that this finding may contribute to the mechanism of steroid protection against conditions such as intraventricular hemorrhage.

Post-partum isolated ovarian abscess in an asplenic host.

A 23-yr-old splenectomized female developed an isolated ovarian abscess, a very rare complication, following a normal delivery. Apart from the palpated 'cyst', findings on pelvic examination were unremarkable, as is often the case with ovarian abscess. The patient recovered after conservative 'cystectomy'. We suggest that the asplenic state plays a role in the development of this very rare complication.

Are multiple cesarean sections safe?

To assess the maternal and neonatal risk associated with high-order cesarean sections, a case-control study was carried out in two university affiliated maternity wards. The outcome of 154 pregnancies of women undergoing cesarean section for the 4th time or more was compared with 148 women sectioned for the 2nd or 3rd time and 132 women of similar age and parity after spontaneous birth. The main outcome measures were maternal operative and postoperative morbidity and neonatal prematurity and its complications, Apgar scores, and the need for intensive care. Women undergoing multiple (> or = 4) cesarean sections had significantly more intra-abdominal adhesions (P < 0.0001) than women sectioned for the 2nd or 3rd time. However, the time interval from incision to delivery and the total duration of operation were similar. The postoperative course was not adversely affected by multiple cesarean sections. A high incidence (16.2%) of preterm cesarean deliveries was noted in the study group. This was due to non-elective repeat cesarean delivery rather than to poor timing of scheduled cesarean sections. The significantly increased (P < 0.05) need for neonatal intensive care was explained by the higher occurrence of prematurity. Low Apgar scores (< or = 7) at 1 and 5 min were significantly (P < 0.01) related to multiple cesarean sections, even after controlling for the effect of gestational age. We conclude that multiple cesarean sections pose little risk for the mother, but may be associated with increased neonatal risk, attributed mainly to preterm non-elective cesarean sections.

Breast-feeding of term infants. Three-hour vs. four-hour non-demand. A randomized controlled reappraisal of hospital-based feeding schedules.

On those maternity wards where "rooming in" is not practiced, infants are fed according to fixed schedules. The purpose of this study was to investigate possible differences between two common feeding regimens, three-hourly vs. four-hourly feeds during the first 3 days of life. A group of 152 singleton, full-term infants with birth weights 2,500-2,990 g, born at Bikur Cholim Hospital in Jerusalem from February 1988, to August 1988, were randomly assigned to one of two breast-feeding groups and followed prospectively. The study group (62 infants) was breast-fed every 4 hours, and the control group (90 infants) every 3 hours. The two groups were statistically similar for mean maternal age, parity, ethnic origin, social class, neonatal Apgar scores, birth percentile, and mean birth weights. Infants who breast-fed every 4 hours did not have greater transitional weight loss or higher serum bilirubin levels compared to infants fed at 3 hour intervals.