Esophageal atresia and tracheoesophageal fistula: prenatal sonographic manifestation from early to late pregnancy.

OBJECTIVE: Esophageal atresia and/or tracheoesophageal fistula (EA/TEF) remains one of the most frequently missed congenital anomalies prenatally. The aim of our study was to elucidate the sonographic manifestation of EA/TEF throughout pregnancy. METHODS: This was a retrospective study of data obtained from a tertiary center over a 12-year period. The prenatal ultrasound scans of fetuses with EA/TEF were assessed to determine the presence and timing of detection of three principal signs: small/absent stomach and worsening polyhydramnios, both of which were considered as 'suspected' EA/TEF, and esophageal pouch, which was considered as 'detected' EA/TEF. We assessed the yield of the early (14-16 weeks' gestation), routine mid-trimester (19-26 weeks) and third-trimester (≥ 27 weeks) anomaly scans in the prenatal diagnosis of EA/TEF. RESULTS: Seventy-five cases of EA/TEF with available ultrasound images were included in the study. A small/absent stomach was detected on the early anomaly scan in 3.6% of fetuses scanned, without a definitive diagnosis. On the mid-trimester scan, 19.4% of scanned cases were suspected and 4.3% were detected. On the third-trimester anomaly scan, 43.9% of scanned cases were suspected and 33.9% were detected. An additional case with an esophageal pouch was detected on magnetic resonance imaging (MRI) in the mid-trimester and a further two were detected on MRI in the third trimester. In total, 44.0% of cases of EA/TEF in our cohort were suspected, 33.3% were detected and 10.7% were suspected but, eventually, not detected prenatally. CONCLUSIONS: Prenatal diagnosis of EA/TEF on ultrasound is not feasible before the late second trimester. A small/absent stomach may be visualized as early as 15 weeks' gestation. Polyhydramnios does not develop before the mid-trimester. An esophageal pouch can be detected as early as 22 weeks on a targeted scan in suspected cases. The detection rates of all three signs increase with advancing pregnancy, peaking in the third trimester. The early and mid-trimester anomaly scans perform poorly as a screening and diagnostic test for EA/TEF. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

The use of short message services (SMS) to provide medical updating to parents in the NICU.

OBJECTIVE: Premature delivery and prolonged hospitalization of infants in the neonatal intensive care unit (NICU) are very stressful for parents. As technology has advanced, short message services (SMS) have been used increasingly in the medical disciplines. To date, the use of SMS for updating patients and families regarding medical information has not been reported. We implemented the SMS technique to daily update the parents regarding the health status of their preterm infant. The objective of this study was to evaluate the use of SMS technology and to assess its impact on the parents and the nursing staff. STUDY DESIGN: Parents and nurses completed questionnaires at two time periods: pre-SMS implementation (pre-SMSi) and post-SMS implementation (post-SMSi). The parent questionnaires included statements about medical information delivery, communication and trust between parents and medical staff, parental anxiety and overall satisfaction. The nurse questionnaires included statements about the expected and actual impact on their workload. RESULTS: Comparison of the parents' responses at the two time periods indicated that in the post-SMSi time period, they felt that the physician was more available when needed (P=0.002), they were more comfortable about approaching the physician (P=0.001) and more satisfied with the medical information provided by the staff (P=0.03). In the post-SMSi period, 78.1% of the nurses noted that the SMS communication is a convenient and user-friendly method. CONCLUSIONS: SMS updating is an easy and user-friendly technology that enriches the modalities of information delivery to parents of hospitalized preterm infants. It is a complementary and useful tool for encouraging and improving personal communication between parents and medical staff and should be considered part of quality improvement in health care.

Neonatal isolated rectal bleeding and the risk of hypersensitivity syndromes.

OBJECTIVE: When rectal bleeding occurs in an otherwise asymptomatic child, it can be classified as isolated rectal bleeding (IRB). Among the different etiologies suggested for IRB, one of the most common is a hypersensitivity reaction of the bowel mucosa to digested antigens. The objective of this study was to assess the long-term outcomes and the risk of developing hypersensitivity syndromes among infants following an IRB event. STUDY DESIGN: A historical prospective comparative study was carried out. The study compared 77 infants who were born at the Sheba Medical Center in Israel during the period 2002 to 2009 and who experienced a neonatal IRB event to 77 infants with the same gestational age, but without IRB. Data were obtained from hospital records and from phone interviews with the parents regarding hypersensitivity syndrome between the ages of 3 and 10 years. RESULT: The IRB group was not at an increased risk of developing a hypersensitivity syndrome or gastrointestinal symptoms compared to the control group. Longer duration of breast-feeding was found to be related to a lower incidence of hypersensitivity symptoms. CONCLUSION: An IRB event in the neonatal period does not increase the risk of developing hypersensitivity syndromes or food allergies during childhood.

Prenatal prediction of neonatal morbidity in survivors with congenital diaphragmatic hernia: a multicenter study.

OBJECTIVES: To investigate the value of the observed to expected fetal lung area to head circumference ratio (o/e LHR) and liver position in the prediction of neonatal morbidity in survivors with congenital diaphragmatic hernia (CDH). METHODS: Neonatal morbidity was recorded in 100 consecutive cases with isolated CDH diagnosed in fetal medicine units, which were expectantly managed in the prenatal period, were delivered after 30 weeks and survived until discharge from hospital. Regression analysis was used to identify the significant predictors of morbidity, including prenatal and immediate neonatal findings. RESULTS: The o/e LHR provided significant prediction of the need for prosthetic patch repair, duration of assisted ventilation, need for supplemental oxygen at 28 days, and incidence of feeding problems. An additional independent prenatal predictor of the need for patch repair was the presence of fetal liver in the chest. CONCLUSIONS: In isolated CDH the prenatally assessed size of the contralateral lung is a significant predictor of the need for prosthetic patch repair, the functional consequences of impaired lung development and occurrence of feeding problems.

Maternal selective serotonin reuptake inhibitor intake does not seem to affect neonatal platelet function tests.

Recently, concerns have been raised regarding the potential impairment of neonatal platelet function and the potential risk of bleeding in neonates born to mothers treated with selective serotonin reuptake inhibitors (SSRI). Our aim was to test whether the platelet function of neonates born to SSRI-treated mothers was impaired when compared to non-SSRI-exposed neonates. In a single-center prospective study, platelet function was evaluated using a cone and platelet analyzer (CPA) device and compared between mother-infant pairs as well as normal non-SSRI-exposed infants. Twenty-seven SSRI-exposed and 27 non-SSRI-exposed full-term neonates and their 23 mothers were tested. No correlation was found between SSRI exposure among either neonates or mothers and parameters of surface coverage (SC) and average size (AS), manifesting platelet function as tested by CPA. SC was similar among SSRI-exposed babies as compared to those in the control group, whereas the size of platelet aggregates (AS) was higher among controls. Neither maternal diseases nor SSRI intake were associated with impaired platelet function and lower SC values, nor were any perinatal conditions. None of the babies suffered from bleeding. We conclude that maternal SSRI therapy does not impair whole-blood CPA-tested platelet function of healthy full-term neonates.

Fetal lung dysplasia: clinical outcome based on a new classification system.

OBJECTIVE: To evaluate the clinical application of a new classification system of fetal lung anomalies. METHODS: Forty fetal diagnoses of lung lesions were analyzed according to our proposed classification system in which each lung component is considered using two-dimensional ultrasound and color and power Doppler technology. Medical files, natural history and neonatal follow-up were recorded. RESULTS: Type I dysplasia: Four cases of agenesis of the lung were diagnosed, three with right lung agenesis and one with left lung agenesis. Three of the four patients elected to undergo termination of pregnancy (TOP). The surviving fetus was diagnosed with scimitar syndrome and postnatal embolization of the aberrant vessel was performed. Type II dysplasia: One case of normal lung with abnormal systemic feeding artery was diagnosed with normal neonatal outcome. Type III dysplasia: Abnormal lung with abnormal vascularity was found in 14 cases, presenting in most cases as echogenic lung masses. Seven were supradiaphragmatic, six subdiaphragmatic and one case was of undetermined position. All 14 fetuses showed an aberrant systemic artery emerging from the aorta. Abnormal venous drainage could be identified in only five (36%) of the fetuses: three had prominent azygos vein, one showed drainage to the inferior vena cava and one had multiple intrapulmonary veins forming a huge arteriovenous (A-V) shunt. Two cases in this group underwent TOP, the case with A-V shunt following development of hydrops, and one on maternal request. The remaining 12 fetuses (86%) survived and were alive and well at the time of writing; only one of them needed immediate postnatal embolization of the bilateral aberrant feeding arteries. Type IV dysplasia: Abnormal lung with no vascular abnormality was diagnosed in 20 fetuses. In this group there was one case of intrauterine fetal death, two patients underwent TOP, one complicated with hydrops and one on maternal request. The survival rate in this group was 85%. Only two cases needed immediate surgical repair. Type V miscellaneous dysplasia: One fetus demonstrated echogenic lung with split notochord syndrome and survived. CONCLUSIONS: Congenital bronchopulmonary and related vascular anomalies can be categorized using the new classification system. This new approach enabled prenatal evaluation of each lung component and facilitated cogent management of the fetus with congenital lung dysplasia.

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

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.

Maternal age and birth weight characteristics of twins born to nulliparous mothers: a population study.

In order to examine birth weight characteristics of twins delivered to nulliparous mothers in relation to maternal age, we used a population-based cohort of Israeli twins delivered between 1993-98 to select all 4793 (37.6%) nulliparas who delivered twins. Maternal age was subdivided as less than 20 years, 20-24, 25-29, 30-34, 35-39, and 40 years or more. We counted the frequencies of each total twin birth weight (twin A + twin B) in each of three categories (less than 3000, 3000-4999, and more than 5000 g) and the frequency of very low birth weight (VLBW, less than 1500 g) neonates in each of the six maternal age categories. There were significantly more nulliparas in the twin population at age groups less 30 years and significantly less at ages 30 years or more. We found a highly significant inverse correlation between the proportion of nulliparas and maternal age group, decreasing from 71.8% at less than 20 years to 18.6% at age 35-39 years (% nulliparas = 85 - 13.7 x age group, Pearson R2 = 0.98). However, this trend changed abruptly to the observed figure of 25.9% nulliparas aged 40 years or more instead of the expected 2.8%. We failed to reveal any significant difference in birth weight characteristics between the maternal age groups (all p > 0.05, all confidence intervals included 1.0). The more than tenfold deviation of the observed from the predicted frequency of nulliparas aged 40 years or more suggests that a different relationship between parity and age occurs at this age group. Maternal age of nulliparas is not associated with different birth weight characteristics of their twins.

Incidence and birth weight characteristics of twins born to mothers aged 40 years or more compared with 35-39 years old mothers: a population study.

OBJECTIVE: To compare the incidence of twin births and their birth weight characteristics in mothers aged > or = 40 years with those of mothers aged 35-39 years. METHODS: We used a population-based cohort of Israeli twins delivered between 1993-98 to compare birth weight characteristics of 510 and 2102 twin pairs delivered to mothers aged > or = 40 years (cases) and 35-39 years (controls), respectively. RESULTS: The incidence of twin mothers aged 40 years or more increased 50% during the study period, ten times more than mothers aged 35-39. There were significantly more nulliparas (P < .001, OR 1.54, 95% CI 1.2, 1.9) and more para > or = 4 (P < .004, OR 1.38, 95% CI 1.1, 1.7) among older mothers. Irrespective of parity, there were no significant differences between mean twin birth weight, total twin birth weight < 3000 g, 3000-4999 g, and > or = 5000 g, and frequencies of very low birth weight neonates. CONCLUSIONS: Twin birth at the age of > or = 40 years is significantly more likely among either nulliparas or para > or = 4. Birth weight characteristics of twins delivered to mothers aged > or = 40 years are not different from those delivered to 35-39 years old mothers.

Adaptive growth restriction as a pattern of birth weight discordance in twin gestations.

OBJECTIVE: To challenge the hypothesis that discordant growth is a normal variation by relating birth weight discordance to total twin birth weight. METHODS Among 12,565 Israeli live-born twin pairs (1993-98), we compared total twin birth weight decile, the frequencies of three levels of discordance in the general population, over 25% discordance between like- versus unlike-sex pairs, and over 25% discordance between pairs delivered by primiparas versus multiparas. RESULTS: We found a marked change in the best-fit correlation function with increased discordance: level 15-24.9% was inversely linear whereas levels 25-34.9% and over 34.9% were inversely logarithmic (R(2) =.47,.88, and.9, respectively). The best-fit correlation of frequencies of more than 25% discordance was inversely logarithmic and similar in like- and unlike-sexed twins across deciles functions (P =.7, odds ratio [OR] 1.0, 95% confidence interval [CI] 0.9, 1.2). The overall frequencies of discordance were also similar (9.3% versus 10.2%, P =.11, OR 0.9, 95% CI 0.8, 1.0). The frequencies of primiparas decreased linearly (R(2) =.98) and the frequencies of more than 25% discordant pairs in multiparas and primiparas across the deciles had similar inversely logarithmic patterns (P =.55, OR 1.0, 95% CI 0.9, 1.2). Discordance over 25% was significantly more frequent among primiparas (P <.001, OR 1.45, 95% CI 1.3, 1.6). CONCLUSION: The observed patterns of birth weight discordance did not substantiate normal variation but an adaptive growth restriction that might explain why the likelihood of discordant growth decreases as total twin birth weight increases.

Risk for one or two very low birth weight twins: a population study.

OBJECTIVE: To calculate the frequencies of very low birth weight (VLBW) neonates among twins in a large population database. METHODS: The database comprised 12,567 live-born twin pairs delivered from 1993 to 1998 in Israel. Low birth weight (LBW) and VLBW were defined as less than 2500 and 1500 g, respectively. We counted the number of pairs with VLBW neonates in three combinations: VLBW-VLBW, VLBW-LBW, and VLBW-over 2500 g. We compared the subsets of nulliparas and multiparas and the frequency of like- versus unlike-sex twins. RESULTS: The frequency of at least one VLBW twin was significantly higher among nulliparas than multiparas (odds ratio [OR] 2.3; 95% confidence interval [CI] 2.1, 2.6; P <.001). For pairs with VLBW-VLBW and VLBW-LBW combinations, a significantly higher frequency was found among nulliparas than multiparas (OR 2.0; 95% CI 1.7, 2.8; P <.001 and OR 2.6; 95% CI 2.2, 3.1; P <.001, respectively). The risk seemed to be accentuated in like-sex twins. Overall, the risk of having at least one VLBW infant was 1:5 among nulliparas and 1:12 among multiparas. The risk of having two VLBW twins among nulliparas (1:11) was double that of multiparas (1:22). CONCLUSION: Nulliparas are at significantly increased risk of delivering one or two VLBW twins.

Feeding tolerance in preterm infants: randomized trial of bolus and continuous feeding.

OBJECTIVE: To test the hypothesis that continuous gastric infusion (CGI) is better tolerated than intermittent gastric bolus (IGB) in small very low birth weight (VLBW) infants. DESIGN: Two-center, prospective, randomized, unmasked clinical trial. PATIENTS: 28 VLBW infants (birth weight <1250 g). A strict feeding protocol was followed. INTERVENTION: Patients were randomized to IGB or CGI. MAIN OUTCOME MEASURES: Time to reach full feeds (160 cc/kg/d)(by design and real), daily weight, caloric intake, residual gastric volume and type of feeding (formula vs. human milk vs. both). RESULTS: Five infants failed to complete the study because of death (n = 4) or protocol violation (n = 1). The two groups did not differ by birth weight or gestational age; infants fed via IGB reached full feeds earlier (p = 0.03) and had less delay in reaching full feeds than infants fed via CGI. CONCLUSION: Contrary to our hypothesis, gravity IGB is more effective than CGI in improving feeding tolerance in small VLBW infants.

Atropine pharmacokinetics and pharmacodynamics following endotracheal versus endobronchial administration in dogs.

Emergency endotracheal and endobronchial drug administration provide an effective alternative for intravenous drug delivery during cardiopulmonary resuscitation. The purpose of the present study was to determine the immediate pharmacokinetic and pharmacodynamic properties of atropine following administration by either of these routes. Atropine (0.02 mg/kg) was given to seven anaesthetized mongrel dogs. Each dog was studied twice: once when atropine was injected into the endotracheal tube, and on another day when atropine was given via a flexible catheter wedged into a peripheral bronchus. Plasma atropine concentrations and blood gases were measured during 60 min following drug administration. Both routes of atropine administration differed significantly in three measures: the maximal atropine concentration (Cmax) was significantly higher with the endobronchial administration 40.0 +/- 7.8 ng/ml compared to 23.9 +/- 5 ng/ml endotracheally (P = 0.008); atropine's elimination (t1/2beta) half-life was significantly longer with the endobronchial route (39.3 +/- 5.2 min vs. 28.0 +/- 7.9 min; P = 0.05); Endobronchial administration resulted in an increase of 16% in heart rate, beginning immediately after drug delivery and peaking after 5 min. Other pharmacokinetic parameters were not significantly different. We conclude that endobronchial administration of atropine has a clear advantage over the endotracheal route.

A simple clinical test for differentiating physiological from pathological head lag in full-term newborn infants.

UNLABELLED: This prospective study was designed to assess the value of a simple clinical test, a "feeding test", on the outcome of head lag among term neonates. Of 5718 infants who were examined before their morning meal, 67 had moderate to severe head lag in the absence of predisposing risk factors for head lag. Fifteen minutes following feeding, 62 infants (92%) showed an improvement in or disappearance of head lag with concomitant rise in serum glucose. All of these infants had normal psychomotor development on follow up. In 4 infants in whom no improvement occurred after feeding, an underlying pathological cause for head lag was subsequently diagnosed. CONCLUSION: Use of the feeding test as a screening procedure in apparently healthy newborns with head lag may rule out pathological conditions in over 90% of the cases.

Effects of theophylline on renal function in premature infants.

Xanthines are frequently being used in the management of premature babies. Studies in adult subjects have demonstrated a diuretic effect of aminophylline due to the inhibition of solute reabsorption in various segments of the nephron. We evaluated the effects of aminophylline on the developing kidney. Nineteen premature infants, with a mean +/- SD gestational age of 31.1 +/- 2.8 weeks and mean birth weight of 1481 +/- 454 g were studied at mean age of 4.5 +/- 4.0 days before and after a 20-minute loading infusion of 6 mg/kg aminophylline, followed by maintenance therapy at a dose of 2 mg/kg every 12 hours. A marked diuresis occurred immediately after the loading dose, the ratio of urinary output to water intake increased from 0.58 +/- 0.36 to 1.19 +/- 0.65. Concomitantly, the fractional excretion of sodium increased from 2.7 +/- 2.6% to 5.7 +/- 4.4% and that of potassium rose from 21 +/- 19% to 31 +/- 21%. Urinary calcium and uric acid excretion were also enhanced: calcium to creatinine ratio rose from 0.31 +/- 0.29 to 0.60 +/- 0.54 and uric acid to creatinine ratio increased from 2.5 +/- 1.5 to 3.8 +/- 2.0. Tubular reabsorption of phosphorus (TRP) was not affected. Most of the effects were no longer evident after 24 hours, despite continuing aminophylline maintenance therapy. In premature infants the aminophylline loading dose, but not maintenance therapy, affected renal functions. Because heart rate, blood pressure, and creatinine clearance did not change, it appears that aminophylline acts directly on tubular reabsorptive functions.

Early immunization with inactivated poliovirus vaccine in premature infants.

The antibody titers of 41 premature infants receiving inactivated poliovirus vaccine at 2 months of age (control group) were compared with titers of 39 infants receiving an additional dose at 5 to 10 days of age (study group). At 1 month of age 97.4% of the study group but only 70.8% of the control group had protective antibodies against poliovirus 3 (p < 0.001).

Central venous line thrombosis in premature infants: a case management and literature review.

Increased risk of central venous line thrombosis in tiny premature infants occurs because the size of the catheter relative to the cross-sectional area of the vessel is large, decreased plasma levels of plasminogen and antithrombin III, and relative low flow of the infusate through the catheter, in comparison with larger infants. A potentially fatal complication of central venous catheters is an intracardiac thrombus. The yield of detecting right atrial thrombi by routine echocardiographic monitoring is very low. Persistent positive blood cultures in infants with central venous lines, in spite of appropriate antibiotic therapy, or signs of catheter occlusion, may increase the yield of echocardiographic detection of intracardiac thrombi. Surgical removal of intracardiac thrombi in infants weighing less than 1500 gm carries a high mortality rate because of the need to use cardiopulmonary bypass with total circulatory arrest and profound hypothermia during surgery. It is in these infants that thrombolysis with urokinase should be considered. A successful therapy with urokinase of a complete occlusion of the right pulmonary artery by an embolus originating from the right atrium is described in a premature infant. For thrombolysis, a loading dose of urokinase of 4400 U/kg followed by 4400 to 8800 U/kg/hr for a few days was used. The thrombolytic effect was manifested by decreased thrombus echogenicity followed by its disappearance, by increased fibrinogen split products, and by decreased plasma fibrinogen. Urokinase therapy may cause massive bleeding, dislodge an intracardiac thrombus causing obstruction of cardiac valves or main vessels or causing embolization to the pulmonary or systemic circulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Epinephrine blood concentrations after peripheral bronchial versus endotracheal administration of epinephrine in dogs.

BACKGROUND AND METHODS: Emergency endotracheal drug administration has become an acceptable route for drug delivery during cardiopulmonary resuscitation. The purpose of the present study was to determine whether the site of endotracheal epinephrine injection is an important factor in its absorption. Epinephrine (1:1000), in a dose of 0.02 mg/kg diluted in 2 mL of saline, was given to ten anesthetized mongrel dogs. Each dog was studied twice: once when the epinephrine was injected into the endotracheal tube, and on another day, through the endotracheal tube via a flexible catheter wedged into a peripheral bronchus. Arterial blood samples for plasma epinephrine concentration determinations were collected, before and at 1, 2, 5, 10, 15, and 30 mins after each intratracheal drug administration. RESULTS: Both routes of epinephrine administration significantly increased plasma concentrations within 1 min of injection. Higher plasma epinephrine concentrations were achieved after peripheral bronchial epinephrine administration (maximal concentration 8.9 +/- 3.2 vs. 2.0 +/- 0.4 ng/mL), and the total dose absorbed was significantly (76.5 +/- 13.5 vs. 36.7 +/- 6.5 ng/min/mL, p < .05) higher. The time interval to reach maximal concentration was significantly shorter with the peripheral bronchial dosing than with the endotracheal route (1.3 +/- 0.2 vs. 2.7 +/- 0.5 min, p < .05). Neither group demonstrated a significant change in heart rate, and both had similar, minor decreases in BP for > 2 to 5 mins. There were no significant differences between the arterial blood gases of the two groups at various stages of the experiment. CONCLUSIONS: In dogs, epinephrine administered via the peripheral bronchial route has a clear pharmacologic advantage over the endotracheal route. This advantage may be more important during cardiopulmonary resuscitation conditions and other low flow states, and may account for the failure observed with the endotracheal route in recently published clinical reports.