Brian Reichman

Excess mortality and morbidity among small-for-gestational-age premature infants: a population-based study

OBJECTIVE We examined the effect of intrauterine growth restriction on mortality and morbidity in the Israel cohort of very low birth weight premature infants. METHODS The study population included 2764 singleton very low birth weight infants without congenital malformations born from 24 to 31 weeks of gestation during 1995 to 1999. Four hundred six (15%) were born small for gestational age (SGA). The effect of SGA on death, bronchopulmonary dysplasia, and retinopathy of prematurity was assessed using multiple logistic regression analysis. RESULTS After adjustment for perinatal risk factors, SGA infants had a 4.52-fold risk for death (95% CI, 3.24-6.33), a 3.42-fold risk for bronchopulmonary dysplasia (95% CI, 2.29-5.13), and a 2.06-fold risk for grade 3 to 4 retinopathy of prematurity (95% CI, 1.15-3.66). CONCLUSIONS SGA premature infants had an increased risk for death, and major morbidity among survivors was increased.

The improving outcome of triplet pregnancies.

During the period 1975 to 1988, 78 triplet pregnancies that reached a gestational age greater than or equal to 20 weeks were treated in our department--a prevalence of 1/849 deliveries. A total of 69 (88%) of the pregnancies occurred after treatment with ovulation-induction agents. The most common complication of pregnancy was premature contractions. Elective cervical cerclage neither prolonged gestation nor decreased fetal loss. The mean gestational age at delivery was 33.2 weeks + 3.8 weeks and 86% of the patients were delivered of premature infants. The perinatal and neonatal mortality rates were 93/1000 and 51/1000, respectively. Our results show a higher proportion of low Apgar scores and respiratory disorders in the third vaginally delivered infants. Follow-up of very low birth weight infants revealed four infants (10.5%) with severe neurologic handicaps. Results of this study suggest that cesarean section is the preferred mode of delivery in triplet pregnancies. Maternal, fetal, and neonatal risks of triplet gestations are relatively low and compare favorably with recent reports on twin pregnancies.

Topical iodine-containing antiseptics and subclinical hypothyroidism in preterm infants

The influence of topical iodine-containing antiseptics on thyroid function test results of premature infants was determined in two separate studies. Thyroxine and thyrotropin levels were measured on blood-spotted filter paper. Samples were obtained from 128 premature infants on their tenth day of life; the infants were treated in two neonatal intensive care units. Both units used similar treatment protocols; however, one routinely used topical iodinated antiseptic agents (n = 73), whereas the other used chlorhexidine-containing antiseptics (n = 55). There was no difference in the mean T4 levels between the two groups. The mean thyrotropin levels were elevated in preterm babies exposed to iodine (15.4 vs 7.8 mIU/L, p < 0.01). Among the iodine-exposed infants, elevated thyrotropin levels (> 30 mIU/L) were found in 13.7% of infants, compared with none in the chlorhexidine-treated group (p < 0.01). We then studied an additional 46 premature infants who were treated in one neonatal intensive care unit. Iodine-containing solutions were used in 24 infants and chlorhexidine was used in 22 infants. T4 and thyrotropin levels were measured weekly during the first 28 days, one every 2 weeks until the age of 60 days, and at the age of 90 days. Among iodine-exposed infants, 20.8% had thyrotropin values > 30 mIU/L, whereas none of the infants in the chlorhexidine group had elevated thyrotropin values (p < 0.05). The elevated thyrotropin levels correlated positively with the area of disinfection. Elevated urine iodine levels were present reflecting an abnormally high iodine absorption. This study suggests that iodine absorption from topical iodine-containing antiseptics may cause disturbances in thyroid function test results in premature infants. We recommend that caution be exercised in the use of iodine-containing antiseptics in premature infants.

Randomized management of the second nonvertex twin: Vaginal delivery or cesarean section

Sixty twin deliveries after the thirty-fifth gestational week with vertex-breech and vertex-transverse presentations were managed according to a randomization protocol. Thirty-three parturient women (21 vertex-breech and 12 vertex-transverse presentations) were allocated for vaginal delivery and 27 for cesarean section (18 vertex-breech and nine vertex-transverse). Six pairs of twins in the vaginal delivery group were delivered in a different mode than requested by the protocol (two women underwent cesarean section; in four cases the second twin spontaneously changed to vertex presentation). There were no significant differences between 1- and 5-minute Apgar scores and incidence of neonatal morbidity between the second-born twins in both study groups. Firstborn twins had higher 1-minute Apgar scores than the second-born infants irrespective of route of delivery (p less than 0.05). No case of birth trauma or neonatal death was recorded. Maternal febrile morbidity was significantly higher in the cesarean section group than in the vaginal delivery group (40.7% versus 11.1%, p less than 0.05). These results suggest that in twins with vertex-breech or vertex-transverse presentations after the thirty-fifth week of gestational age the neonatal outcome of the second twin was not significantly influenced by the route of delivery.

Influence of school closure on the incidence of viral respiratory diseases among children and on health care utilization.

We evaluated the effect of school closure on the occurrence of respiratory infection among children ages 6–12 years and its impact on health care services. During this period, there were significant decreases in the diagnoses of respiratory infections (42%), visits to physician (28%) and emergency departments (28%) and medication purchases (35%). The present study provides quantitative data to support school closure during an influenza pandemic.

Pathogen-Specific Early Mortality in Very Low Birth Weight Infants with Late-Onset Sepsis: A National Survey

BACKGROUND Late-onset sepsis (LOS) is an important cause of mortality among very low birth weight (VLBW) infants, and deaths occurring within 3 days after the onset of sepsis can probably be ascribed to sepsis. We examined the association of sepsis due to specific pathogens with the risk for early mortality after the onset of LOS, adjusted for perinatal and neonatal risk factors. METHODS From 1995 through 2001, information about 10,215 infants was gathered and deposited in the Israel National VLBW Infant Database. The study population was composed of 2644 infants, of which each had >or=1 events of LOS (totalling 3462 events). Logistic regression models were used to calculate the crude and adjusted risk for early mortality. RESULTS Early mortality was associated with 179 LOS events (5.2% of 3,462); the range of pathogens associated with these events included coagulase-negative staphylococci (CoNS), which were the cause of 1.8% of LOS events associated with early mortality, and Pseudomonas species, which were the cause of 22.6% of such events. Early mortality after LOS, adjusted for neonatal risk factors, was significantly associated with sepsis due to certain pathogens: Pseudomonas species (odds ratio [OR], 12.3); Klebsiella species (OR, 6.3); Serratia species (OR, 6.2); Escherichia species (OR, 4.3); Enterobacter species (OR, 4.1); and Candida species (OR, 3.2), compared with sepsis due to CoNS . In addition, lower gestational age, lower chronological age, small size for gestational age, and grade 3-4 intraventricular hemorrhage, each had an independent association with early mortality. CONCLUSIONS Klebsiella sepsis and Pseudomonas sepsis were associated with a 6.3-fold and 12.3-fold increased risk of early mortality, respectively, and accounted for 41.9% of all early deaths associated with LOS. Considering the aggressive nature of sepsis caused by these pathogens, empiric antibiotic therapy active against these organisms is worth consideration for VLBW infants with presumed LOS.

Outcome of early-onset sepsis in a national cohort of very low birth weight infants.

BACKGROUND: Early-onset sepsis (EOS) is associated with significant morbidity and mortality among infants with a very low birth weight (VLBW); however, there is a sparse amount of complete data on large cohorts. OBJECTIVE: To evaluate the mortality and major morbidities among VLBW infants with EOS. METHODS: This was a population-based observational study. Data were prospectively collected by the Israel Neonatal Network on all VLBW infants born in Israel from 1995 through 2005. Univariate and multivariable analyses were performed to assess the independent association of EOS on morbidity and mortality of VLBW infants. RESULTS: The study cohort included 15 839 infants, of whom 383 (2.4%) developed EOS. EOS was associated with significantly increased odds for mortality (odds ratio [OR]: 2.57 [95% confidence interval (CI): 1.97–3.35]), severe intraventricular hemorrhage (OR: 2.24 [95% CI: 1.67–3.00]), severe retinopathy of prematurity (OR: 2.04 [95% CI: 1.32–3.16]), and bronchopulmonary dysplasia (OR: 1.74 [95% CI: 1.24–2.43]). EOS was associated with an increased risk of death and/or severe neurologic morbidity (OR: 2.92 [95% CI: 2.27–3.80]). CONCLUSIONS: Although only 2.4% of VLBW infants had an episode of EOS, these infants were at an approximately threefold excess risk of death or major neurologic morbidities.

A prospective comparison of the outcome of triplet pregnancies managed expectantly or by multifetal reduction to twins

OBJECTIVE Our aim was to compare the outcome of triplet pregnancies managed expectantly or by multifetal reduction to twins. STUDY DESIGN From January 1984 through January 1992, 140 triplet gestations were diagnosed before the ninth gestational week. Multifetal pregnancy reduction was performed at the patients request in 34 women. The remaining 106 triplet pregnancies were managed expectantly. All patients were prospectively followed up and delivered in a single perinatal department. RESULTS Loss of the entire pregnancy before 25 gestational weeks occurred in 20.7% of the triplet pregnancies managed expectantly as compared with 8.7% in the group with reduction to twins. A successful pregnancy as defined by the discharge home of at least one infant occurred in 88.2% of the group with reduction to twins and 74.5% of the triplets managed expectantly. Fetal reduction to twins was associated with a significantly lower incidence of the following: prematurity (p < 0.001), low-birth-weight infants (p < 0.001), and very-low-birth-weight infants (p < 0.001). Pregnancy complications and neonatal morbidity and mortality were less in the group with reduction to twins. CONCLUSIONS Multifetal pregnancy reduction of triplet pregnancies to twins resulted in improved pregnancy outcome without an excess loss of the entire pregnancy as compared with the outcome of triplet gestations managed expectantly.

The relationship between delivery mode and mortality in very low birthweight singleton vertex-presenting infants

Objective  To investigate the factors associated with caesarean delivery and the relationship between mode of delivery and mortality in singleton vertex‐presenting very low birthweight (≤1500 g) live born infants.

Metabolic Consequences of Intrauterine Growth Retardation in Very Low Birthweight Infants

Summary: By the combination of energy and macronutrient balances, continuous open circuit computerized indirect calorimetry, and anthropometry, we have compared small for gestational age (SGA) and appropriate for gestational age (AGA) very low birthweight infants with respect to metabolizable energy intake (mean ± SE: 125.9 ± 2.5 versus 130.4 ± 3.5 kcal/kg·day), energy expenditure (67.4 ± 1.3 versus 62.6 ± 0.9 kcal/kg·day), storage of energy and macronutrients and growth. Fourteen studies in six SGA infants (gestational age, 33.1 ± 0.3 weeks; birthweight, 1120 ± 30 g) and 22 studies in 13 AGA infants (gestational age, 29.3 ± 0.4 weeks; birthweight, 1155 ± 40 g) were performed. The SGA infants had a lower absorption of fat (68.7 ± 3.2 versus 79.7 ± 1.7%) and protein (69.1 ± 3.2 versus 83.4 ± 1.5%) and hence increased (P > 0.001) energy loss in excreta (29.9 ± 2.8 versus 18.2 ± 1.5 kcal/kg·day). The significant hypermetabolism of SGA infants by 4.8 kcal/kg·day was associated with an increased fat oxidation. Despite lower energy storage, SGA infants were gaining weight (19.4 ± 0.9 g/kg·day), length (1.25 ± 0.14 cm/week), and head circumference (1.16 ± 0.9 cm/week) at higher rates than the AGA group. The energy storage per g weight gain was lower (P > 0.001) in the SGA group (3.0 ± 0.14 versus 4.26 ± 0.26 kcal) reflecting higher water, lower fat (22.2 ± 1.8 versus 33.8 ± 2.5%; P > 0.001) and lower protein (7.7 ± 0.5 versus 12.5 ± 0.8%; P > 0.001) contents of weight gain in the SGA group.