Ilan Arad

Enterobacter sakazakii infection in the newborn.

Enterobacter sakazakii, a Gram‐negative bacillus, previously known as “yellow pigmented Enterobacter cloacae,” is a rare cause of neonatal infection. We describe the detailed clinical presentation of two cases in whom E. sakazakii was isolated in our neonatal service during the course of 1 mo. These include one case of sepsis and meningitis complicated by cerebral infarction, and one case of sepsis. In addition, three cases of intestinal colonization were identified. The source of the organism was thoroughly sought and was found to be a blender in the milk kitchen that was used for preparation of the reconstituted powdered milk formula.

Congenital chylothorax: Clinical course and prognostic significance

To determine the underlying etiology, associated malformations, clinical course, and prognostic significance of congenital chylothorax.

Neonatal bacteremia: Patterns of antibiotic resistance

OBJECTIVE To determine the incidence and evaluate the antimicrobial-susceptibility patterns of bacterial infections in our neonatal units. DESIGN Retrospective surveillance study. SETTING The neonatal units of the Hadassah University Hospitals, Jerusalem, Israel. PATIENTS All newborns admitted from January 1994 through February 1999. METHODS The records of all patients with positive blood and cerebrospinal fluid cultures were reviewed. Bacteremia was considered early-onset (vertical) when occurring within the first 72 hours of life and late-onset (nosocomial) when occurring later. The prevalence and antibiotic-resistance patterns of vertically transmitted and nosocomially acquired strains were compared and studied over time. RESULTS 219 of 35,691 newborn infants had at least one episode of bacteremia (6.13/1,000 live births). There were 305 identified organisms, of which 21% (1.29/1,000 live births) were considered vertically transmitted and 79% nosocomially acquired. The most common organism causing early-onset disease (29.2%) was group B streptococcus (0.38/1,000 live births), whereas coagulase-negative staphylococci (51%) were the most prevalent in late-onset disease. All gram-positive bacteria were susceptible to vancomycin. Most gram-positive organisms other than staphylococci were susceptible to ampicillin. Gram-negative organisms represented 31% of all isolates. Generally, there was a trend of increasing resistance to commonly used antibiotics among nosocomially acquired gram-negative organisms, compared to those vertically transmitted, with statistically significant differences for ampicillin and mezlocillin (P<.05 and P<.01, respectively). Over the years, a trend toward an increasing resistance to antibiotics was observed among gram-negative organisms. CONCLUSIONS The trend of increasing bacterial resistance to commonly used antibiotics necessitates the implementation of a rational empirical treatment strategy, based on local susceptibility data, reserving certain agents for emerging resistant pathogens.

Neonatal outcome of inborn and transported very-low-birth-weight infants: relevance of perinatal factors.

OBJECTIVE To compare the neonatal outcome (survival, intraventricular hemorrhage and bronchopulmonary dysplasia) of inborn and outborn very-low-birth-weight infants accounting for sociodemographic, obstetric and perinatal variables. STUDY DESIGN Ninety-one premature infants with birth weights of 750-1250 g delivered between 1990 and 1994 in a hospital providing neonatal intensive care were compared with 76 premature babies delivered in a referring hospital. In the statistical analysis, variables with a statistically significant association with the outcome variables and dissimilar distributions in the two hospitals were identified and entered together with the hospital of birth as explanatory variables in a logistic regression. RESULTS No statistically significant differences between the outcome variables of the two populations examined were observed, whether before or after accounting for the covariates. The odds ratios (outborns relative to inborns) were 1.18 for mortality, 1.25 for bronchopulmonary dysplasia and 1.53 for severe intraventricular hemorrhage. In the multivariate analyses, respiratory distress syndrome was significantly associated with mortality; both low birth weight and the presence of respiratory distress syndrome were associated with the development of bronchopulmonary dysplasia; the evolvement of severe intraventricular hemorrhage was associated with respiratory distress syndrome, initial low Apgar score, advanced multiparity and delivery at the 28-29th week compared to the 23rd-27th week. Antenatal steroid administration had a protective effect. CONCLUSION Our results concur with the notion that a tertiary center is the optimal location for delivery of the high risk neonate. Improvement in medical and nursing care prenatally and at delivery and transportation, including frequent administration of antenatal steroids and earlier administration of surfactant prior to transportation, may minimize the disadvantage of delivery in a referring hospital.

Diaphragmatic defects in children of consanguineous parents

Congeni ta l d iaphragmat ic defects have been classified by Bingham (1959) into posterolateral defects (foramina of Bochdalek) retrosternal defects ( foramina of Morgagni) , and the rare extensive defects involving most or all of the hemidiaphragm (agenesis). Famil ial occurrence of d iaphragmat ic hernia is rare and in most families in which this has been reported the pat ients have died from extensive defects within a few days of bir th (Daent l and Passarge, 1972). Daent l and Passarge summarized nine reported families in whom 20 of 29 siblings were affected with agenesis of the diaphragm. In view of the rari ty of d iaphragmat ic agenesis it was suggested that this lesion might be etiologically different f rom the other two types of the defect, which do not show increased familial incidence (Passarge et al., 1968). The role of genetic factors in the etiology of familial agenesis of the d iaphragm is unclear. Autosomal recessive and mult ifactorial inheri tance have been suggested (Passarge et al., 1968; ten Kate and Anders, 1970; Jensen and Altrogge, 1971; Daent l and Passarge, 1972). No parenta l consanguin i ty has been reported. In this report we present two affected sisters who are the offspring of a consanguineous marriage.

Comparison of sucking patterns at introduction of oral feeding and at term in Israeli and American preterm infants

Background: It has been hypothesized that early initiation of oral feeding in premature infants may enhance the maturation of sucking patterns. Aim: To compare preterm infant sucking characteristics in urban level III neonatal care units in the USA and Israel. The two hospitals have different practices regarding the introduction of oral feeding. Methods: Infants were assessed at 34–35 wk postconceptional age (PCA) and at term. Sucking parameters were assessed with the Krons Nutritive Sucking Apparatus. Results: 70 infants (38 Americans and 32 Israelis) participated in the study. Oral feedings were initiated earlier (32.6±4.3 vs 34.5±1.8 wk PCA, p<0.01) and full oral feedings were reached earlier (35.4±2.8 vs 36.5±2.5 wk PCA, p<0.05) in the USA infants. American preterm infants produced significantly more sucks (p<0.001), had a higher suck rate (p<0.001), more sucks per burst (p<0.05), and a shorter interburst width (p<0.01) at 34 wk PCA than Israeli infants. At term, American infants produced significant more sucks (p<0.001), higher suck rate (p<0.001), shorter intersuck width (p<0.001), and a shorter interburst width (p<0.05) than the Israeli infants of the same PCA.

Intravenous immunoglobulin therapy in neonatal immune hemolytic jaundice

Nine cases of newborn patients who developed hyperbilirubinemia due to blood group incompatibility and were treated with high dose (1 gram/Kg) intravenous immunoglobulin (IVIG) are described. In 7 of the 9 patients the rise of bilirubin level was attenuated and exchange transfusion was not required following treatment with IVIG. Of the two patients who did require an exchange transfusion despite IVIG treatment, one had the exchange performed immediately following the IVIG infusion, allowing no time for observation of the therapy effect. Our results suggest that IVIG administration may be efficacious in the treatment of immune hemolytic hyperbilirubinemia of the newborn but further studies are required to validate the efficacy of this treatment.

Carboxyhemoglobin levels in neonatal immune hemolytic jaundice treated with intravenous gammaglobulin

In order to examine the effect of intravenous immunoglobulin (IVIG) on the rate of hemolysis in immune hemolytic hyperbilirubinemia, we measured the carboxyhemoglobin levels of 5 newborn infants who were subjected to IVIG treatment. The pretreatment rate of hemolysis, in the 5 patients with isoimmune hemolytic jaundice (3 patients with Rh hemolytic disease of the newborn and 2 patients with ABO hemolytic disease of the newborn), as reflected by caboxyhemoglobin levels was higher than the rate of hemolysis in normal newborn infants. In 4 out of the 5 patients treated with IVIG, there was a rapid decline (> 30%) of carboxyhemoglobin levels, a pattern which was different from that observed in normal newborn infants with no hemolytic jaundice and in 3 untreated patients with ABO hemolytic disease of the newborn. None of the treated patients required an exchange transfusion. Our preliminary results support the theory that the attenuation of jaundice observed following IVIG treatment in patients with immune hemolytic hyperbilirubinemia is caused, at least in part, by the reduction in hemolysis.

Does parity affect the neonatal outcome of very-low-birth-weight infants ?

OBJECTIVE To evaluate the impact of parity on the neonatal outcome (survival, bronchopulmonary dysplasia and severe intraventricular hemorrhage) of very-low-birth-weight infants, accounting for sociodemographic, obstetric and perinatal variables. STUDY DESIGN One hundred and eleven singleton premature infants with birth weights of 750--1250 grams, delivered between 1990 and 1994 and treated in the Hadassah University Hospitals in Jerusalem, were evaluated. In the analyses, variables with statistically significant association with the outcome variables were identified and entered together with parity as explanatory variables in a logistic regression. The results were analyzed with and without the inclusion of respiratory distress syndrome, representing an index of initial illness severity, in the multivariate model. RESULTS Neonatal mortality was higher in the 2--11 parity group when compared with first born infants. This association was of borderline statistical significance (OR=3.3; P=0.09), and was evident only upon exclusion of respiratory distress syndrome from the equation. There was no association between parity and the development of bronchopulmonary dysplasia. The risk for developing severe intraventricular hemorrhage was higher in offsprings of multiparous women (OR=4.6; P=0,08 for parity 2-4, and OR=7.6; P=0.03 for parity 5--11). Respiratory distress syndrome was significantly associated with all the outcome variables and, to some extent, masked the relevance of pregnancy duration. A short hospitalization period before delivery was associated with increased mortality and with higher incidence of severe intraventricular hemorrhage. High initial Apgar scores appeared protective against severe intraventricular hemorrhage and bronchopulmonary dysplasia. CONCLUSION Our results demonstrate a trend for increased survival of first born premature infants when compared with offsprings of subsequent deliveries, and an association between advanced parity and the development of severe intraventricular hemorrhage. Confirmation of these data by other studies is required before resultant implications are considered.

Aminophylline versus doxapram in weaning premature infants from mechanical ventilation: preliminary report.

A small, double-blind crossover study compared the efficacy of aminophylline and doxapram in ventilator weaning of eight premature infants recovering from respiratory distress syndrome (RDS). Although neither drug was significantly better than the other, four infants were weaned from mechanical ventilation after drug administration. It is suggested that drugs stimulating the respiratory center may aid in shortening the duration of mechanical ventilation in premature infants recovering from RDS.