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Objective:To assess the long-term neurodevelopment of children exposed in utero to selective serotonin reuptake inhibitors (SSRIs) that developed a neonatal abstinence syndrome (NAS).Study Design:Neurodevelopmental evaluation was performed at the age of 2 to 6 years. Children who developed NAS were compared with those who did not using univariate and logistic regression analyses.Result:Thirty children with NAS and 52 without NAS participated in the study. Both groups were similar in mean cognitive ability (106.9±14.0 vs 100.5±14.6, P=0.12) and developmental scores (98.9±11.4 vs 95.7±9.9, P=0.21). However, there was a trend towards small head circumference in the NAS group (20 vs 6%, P=0.068). NAS was associated with an increased risk of social-behavior abnormalities (odds ratio (OR) 3.03, 95% confidence interval (CI) 1.07 to 8.60, P=0.04) and advanced maternal age (OR 1.12, 95% CI 1.00 to 1.25, P=0.04).Conclusion:Infants who developed NAS had normal cognitive ability, but were at an increased risk for social-behavioral abnormalities. Follow-up evaluation of symptomatic neonates should be considered. [ABSTRACT FROM AUTHOR]

Despite publication of guidelines for the prevention and management of hyperbilirubinemia in term and late-preterm newborn infants, kernicterus, although rare, continues to occur. Guidelines written for use in one country may not always be universally appropriate. Bearing this in mind, a committee appointed by the Israel Neonatal Society has formulated a set of guidelines, based on those of the American Academy of Pediatrics (2004), but adapted to the realities of the Israeli scene. The guidelines include methods of surveillance of jaundice, prediction of jaundice, assessment of risk factors, discharge planning and post-discharge follow-up, in addition to therapeutic guidelines including indications for phototherapy, exchange transfusion and the use of intravenous immune globulin. Availability of these guidelines to the international community may offer direction to physicians of other countries who may be setting up guidelines for use in their own communities.Journal of Perinatology (2008) 28, 389–397; doi:10.1038/jp.2008.20; published online 6 March 2008 [ABSTRACT FROM AUTHOR]

The article describes a study among all 2,477 pregnant women, who gave birth in Rabin Medical Center during November 1999–April 2000. Its purposes were to identify the scope of alcohol use during pregnancy, and check children prenatally exposed to alcohol (daily drinking/binge drinking) for possible alcohol effects. Upon arrival, the women were given the hospital non-anonymous admission questionnaire, which included socio-demographic and obstetric variables. Three questions related to cigarette smoking during pregnancy, alcohol use during pregnancy and alcohol use in the family were added. Those who drank were given another questionnaire, which included a question concerning the preferred type of alcoholic beverage, the TWEAK questionnaire, and three questions related to the frequency of drinking, the typical amounts consumed and the highest consumption level in each trimester. Relatively high rates of amnio centesis (26.52%), maternal-serum alpha-feto protein examination (72.22%), screening ultrasound (98.34%) and targeted ultrasound (27.77%) were found, and 8.8% reported smoking. However, in the light of the results of self-report maternal alcohol use studies in various countries, and the fact that half of the Israeli women 18–40-year-old drink alcohol, the article tries to explain the reasons for the results obtained in the current study: abstinence among pregnant women (1.13% reported alcohol drinking during pregnancy) and nonexistence of alcohol drinking in the family (0.84% reported drinking by a family member), and suggests recommendations for future research. [ABSTRACT FROM AUTHOR]

The genital mycoplasmas: Ureaplasma urealyticum and Mycoplasma hominis have recently assumed an increasing importance as neonatal pathogens. The aim of the present survey was to determine the prevalence of infections with these organisms in preterm infants in two neonatal intensive care units in Israel. Among 99 preterm infants, 24 (24%) harboured mycoplasmas in their throats shortly after birth. U. urealyticum was the most common organism. M. hominis was isolated only from 3 infants. Six out of 27 (22%) mechanically ventilated infants secreted U. urealyticum in their lower airways. The rate of colonization was inversely correlated with gestational age; 80% of infants younger than 28 weeks gestation were found to be colonized as opposed to 17.9% at 28-36 weeks of gestation. No mycoplasmas were isolated in blood cultures drawn from 146 infants and CSF cultures obtained from 47 preterm infants. Neonatal mortality, respiratory complications and intraventricular haemorrhage grade 3-4 were significantly increased in colonized infants. However, above gestational age of 27 weeks, colonization with mycoplasmas was not associated with a worse prognosis. We conclude that colonization with U. urealyticum is common in Israeli preterm infants, correlates inversely with gestational age and has no detrimental effect on neonatal morbidity and mortality of infants older than 27 wks of gestation. [ABSTRACT FROM AUTHOR]

Unlabelled: The aim of this paper is to critically review neonatal polycythaemia (NP) literature, in terms of definition, diagnosis and management. We reviewed all Medline articles on NP up to December 2009. (i) The textbook definition of NP [venous haematocrit (HCT) > 65%] is empirical and not based on statistical definition, symptoms or complications. (ii) Measurement of viscosity is not better than HCT in predicting complications. (iii) Normovolaemic NP because of increased erythropoiesis may be different from hypervolaemic polycythaemia because of excessive foetal transfusion. (iv) Coexisting hypoglycaemia may worsen long-term outcome. (v) Four clinical trials (CTs) studied partial exchange transfusion (PET) on outcomes. In all trials, PET was performed after 6 h of life. There is no evidence that PET improves neurodevelopmental outcome of asymptomatic NP, and it might increase the risk of necrotizing enterocolitis. These CTs have inherent design flaws: (a) CNS 'damage' may occur before PET. (b) Confounding variables that may affect outcome have not been studied. (vi) If PET is performed, normal saline is the best alternative. (vii) The long-term effect of PET on symptomatic infants has not been studied., Conclusion: Current definition and management of NP are little evidence based, thus the need for a consensus based on expert opinion., (© 2011 The Author(s)/Acta Paediatrica © 2011 Foundation Acta Paediatrica.)

Objectives: Prolongation of the QT interval is a risk factor for sudden death. Selective serotonin-reuptake inhibitor antidepressants can prolong the QT interval and are widely used by pregnant women. Whether antenatal exposure to selective serotonin-reuptake inhibitor causes QT prolongation in offspring is unknown. The aim of this study was to determine the effect of maternal use of selective serotonin-reuptake inhibitor antidepressants during pregnancy on the QTc interval of the offspring., Methods: Between January 2000 and December 2005, we collected data on all of the newborns born at a single tertiary care hospital. Electrocardiograms of infants exposed to selective serotonin-reuptake inhibitor antidepressants in utero were compared with those of healthy control newborns matched on gestational age. The tracings were interpreted by a pediatric cardiologist who was unaware of the drug exposure., Results: We identified 52 newborns exposed to selective serotonin-reuptake inhibitor antidepressants in the immediate antepartum period and 52 matched control subjects. The mean QTc was significantly longer in the group of newborns exposed to antidepressants as compared with control subjects (409 +/- 42 vs 392 +/- 29 milliseconds). Five (10%) newborns exposed to selective serotonin-reuptake inhibitor antidepressants had a markedly prolonged QTc interval (>460 milliseconds) compared with none of the unexposed newborns. The longest QTc interval observed among exposed newborns was 543 milliseconds. All of the drug-associated repolarization abnormalities normalized in subsequent electrocardiographic tracings., Conclusions: Antepartum use of selective serotonin-reuptake inhibitor antidepressants is associated with QTc interval prolongation in exposed neonates. Additional research using a standardized protocol is needed to determine whether exposure to selective serotonin-reuptake inhibitor antidepressants in late pregnancy is also associated with arrhythmias.

Objective: The neonatal mortality rate is disproportionately influenced by preterm infants and does not reflect the rate in full-term infants. Our objectives were to estimate the full-term neonatal mortality rate and to identify causes of death in full-term infants during the first month of life., Study Design: A retrospective study of full-term infant deaths during a 6-year period from 2000 to 2005, in a tertiary medical center., Result: During the study period there were 44,703 full-term births and 31 deaths, representing a mortality rate of 0.69 per 1,000 live births. The main cause of death was congenital anomalies (64.5%), specifically cardiac anomalies. Other causes were chromosomal anomalies or syndromes (12.9%), labor complications (12.9%), infections (3.2%), congenital diseases (3.2%) and metabolic disorders (3.2%)., Conclusion: The mortality rate of full-term infants may be lower than previous estimates. Efforts aimed at decreasing mortality among full-term infants should focus on prenatal diagnosis.

Objectives: To evaluate the effectiveness of policies and recommendations on folic acid aimed at reducing the occurrence of neural tube defects., Design: Retrospective cohort study of births monitored by birth defect registries., Setting: 13 birth defects registries monitoring rates of neural tube defects from 1988 to 1998 in Norway, Finland, Northern Netherlands, England and Wales, Ireland, France (Paris, Strasbourg, and Central East), Hungary, Italy (Emilia Romagna and Campania), Portugal, and Israel. Cases of neural tube defects were ascertained among liveborn infants, stillbirths, and pregnancy terminations (where legal). Policies and recommendations were ascertained by interview and literature review., Main Outcome Measures: Incidences and trends in rates of neural tube defects before and after 1992 (the year of the first recommendations) and before and after the year of local recommendations (when applicable)., Results: The issuing of recommendations on folic acid was followed by no detectable improvement in the trends of incidence of neural tube defects., Conclusions: Recommendations alone did not seem to influence trends in neural tube defects up to six years after the confirmation of the effectiveness of folic acid in clinical trials. New cases of neural tube defects preventable by folic acid continue to accumulate. A reasonable strategy would be to quickly integrate food fortification with fuller implementation of recommendations on supplements.

Evidence has emerged that assisted reproduction technology (ART) may be associated with an increased risk of congenital malformations, low birth weight, and genetic imprinting disorders. The aim of the study was to determine, the prevalence of major malformations in newborns conceived by standard in vitro fertilization (IVF) in 1986-1994 and newborns conceived by different types of ART procedures in 1995-2002. Data were collected from the IVF Registry and Israel Birth Defects Monitoring System for all infants (live births, stillbirths and terminations of pregnancy) delivered after 20 weeks' gestation who achieved a fetal weight of at least 500 g. The control groups consisted of all spontaneously conceived babies (live births, stillbirths and terminations of pregnancy) born in our center during the same time periods. During the first period, a total of 31,007 babies were born at our center, of whom 278 were conceived by standard IVF. Twenty-six of the IVF infants had major malformations, for a prevalence rate of 9.35%, which was 2.3-fold higher than that in the general population (4.05%). During the second period, 53,208 infants were born, of whom 1632 were conceived by ART. Major malformations were found in 147 ART infants, for a prevalence rate of 9.0%, which was 1.75-fold higher than in the general population (5.18%). Analysis of the clinical characteristics of the ART infants with major malformations showed that 70.3% were born preterm, 76.5% had low birth weight, 58.6 were twins, and 11.7% were triplets. The use of ART procedures increased by a factor of 3.4 in the second period. Two important outcomes of ART were observed: an increased prevalence of major malformations about double the general population in both periods, and a high frequency of adverse clinical characteristics among ART infants with major malformations. Infertile couples should be adequately counseled regarding the real risk of having a child with malformations or a preterm or low birth weight infant.

Background: The mild errors or morphogenesis (MEMs) are well known and accepted markers of alterations in embryonic development with predictive value in identification of major malformations, specific genetic syndromes, metabolic and psychiatric disease and childhood malignancy., Objective: The goal of this study was to assess the contribution of auricular MEMs as part of total MEMs in an effort to study the factors influencing the different potential informative value of different types of MEMs and their variability with perinatal factors., Method: Three thousand one hundred and seven consecutive born neonates were screened for auricular and non-auricular MEMs, inregistered concomitantly with major malformations and postural defects. The study was accomplished by our specially designed computerized program in a relatively large nonhomogeneous ethnic population, in the metropolitan area of Haifa, Israel., Results: The general prevalence of auricular MEMs was 43.1%; the most frequent pathogenetic type was the postural one. Significantly higher rates of auricular MEMs were associated with male sex, small- and large-for-gestational age, IVF pregnancy, triplet pregnancy, maternal diabetes and parental consanguinity., Conclusion: We conclude that the presence, number, and association or concomitance of auricular MEMs in the same neonate may have important clinical, diagnostic, pathogenetic, screening, and therapeutic value.

Neural tube defects (NTDs) are severe congenital malformations and can be fatal. Intake of 0.4 mg folic in the periconceptional period reduces the risk of NTD by 50-70%. Consanguinity in the Arab population in Israel is a prevalent custom. The aim of this study was to assess the level of awareness regarding folic acid and its effect in the prevention of NTD among Arab Israeli women of childbearing age. We conducted a cross-sectional study. Of the 653 women (18-45 years) who were randomly selected for interview while visiting their family physician or well-baby clinic, 624 women completed the questionnaire. Fifty-three percent (n = 333) of the respondents had heard of folic acid; 14% (n = 89) were familiar with the protective effect of NTD and 3% (n = 18) had taken folic acid in the first months of pregnancy whereas none of them had used it in the preconception period. Highly educated women, women with one or two children, paramedics, and women of high socioeconomic status were more knowledgeable about the protective effects of folic acid (P < 0.001). Age and religion had no significant effect. An urgent need exists to improve the awareness of this population to the protective effect of folic acid. Daily supplementation and fertification of food with folic acid should be considered as the best way to improve the balance of folic acid in women of childbearing age of this special population (high prevalence of consanguinity).

The increased frequency of early discharge of newborns has led to questions of its safety. Most studies have looked at mortality and rehospitalization, not all missed diagnoses. The purpose of this study was to determine diagnoses in newborn infants that would have been missed if the infant had been discharged in <24 h. The design was a cohort study at Rabin Medical Center-Beilinson Campus (average monthly deliveries 1996 [250], 1997 [500]), a university-affiliated community hospital with all in-born term (> or = 37 weeks) infants born September through November 1996 and June 1997. The main outcome measures were medical diagnoses (except trivial physical descriptions) noted at discharge (generally at > or =48 h) exam, not noted on admission exam (<24 h). The results showed that 54 infants (5.1%) had diagnoses that were not detected before the infant was 24 h of age. The leading diagnosis was hyperbilirubinemia. Other potentially missed diagnoses included congenital heart disease (n = 10), morbidity of birth trauma (n = 9), metabolic disturbances (n = 2), hip dislocation (n = 1), suspected sepsis (n = 2), excessive weight loss (n = 2), polycythemia (n = 2), inguinal hernia (n = 1), and abducens paresis (n = 1). It is concluded that diagnoses can be missed by discharging infants in 24 h or less. These diagnoses have the potential for adverse sequela. Even if early discharge is felt to be cost effective, parents should be counseled that it is not risk free. Better mechanisms should be put in place for assuring the safety of such infants.

The influence of the merger of two major medical centres on the emotional well-being of nurses was investigated by use of a questionnaire on emotional distress, perception of threat, self-efficacy and emotional reactivity. Evaluations were carried out 1 month prior to the merger at the official announcement, and again half a year after the merger took place. Before the merger, threat perception was higher in the transferring nurses, but the difference was of borderline significance (P = 0.05). There was a significant positive correlation between threat perception and both emotional reactivity and emotional distress, and a significant negative correlation between self-efficacy and both threat perception and emotional distress (P < 0.001 for all). After the merger, the transferring nurses showed more emotional distress (P = 0.009). There was a significant positive correlation between threat perception, emotional distress and negative outcome variables such as burnout and stress (P < 0.001), and a significant negative correlation between threat perception and positive outcome variables such as growth (P < 0.01). This study identifies some personal characteristics that can affect the way nurses deal with hospital mergers and need to be considered during organizational changes in order to maintain job satisfaction.

Nausea and vomiting are very common during pregnancy, mainly throughout the first trimester. Metoclopramide is a dopamine receptor blocking drug that is commonly used to treat nausea and vomiting. The aim of this prospective study was to investigate the effect on the fetus of intrauterine exposure to metoclopramide. One hundred and seventy-five women who received metoclopramide and consulted 6 teratogen information centers in Israel, Italy, Brazil, and Canada were studied. Women exposed to metoclopramide were paired for age, smoking and alcohol consumption habits with women exposed to nonteratogens. Women in the metoclopramide group had a significantly higher rate of premature births (8.1%) as compared with the control group (2.4%) ( p = 0.02, relative risk = 3.37, 95% confidence interval 1.12-10.12). Rates of major malformations in the metoclopramide group (4.4%) did not differ from controls (4.8%) ( p = 0.84, relative risk = 0.91, 95% confidence interval 0.34-2.45). According to our findings, metoclopramide use during the first trimester of pregnancy does not appear to be associated with an increased risk of malformations, spontaneous abortions, or decreased birth weight, however, larger studies are needed to confirm these observations.

Background: In surrogate pregnancies the genetic parents have little opportunity for early bonding to their infant, either prenatally (in utero) or in the immediate postnatal period. The purpose of this article is to describe a new method for encouraging early parent-infant bonding after surrogate pregnancy by hospitalizing the genetic mother in the maternity ward immediately after the delivery., Methods: Two genetic mothers were hospitalized in the maternity ward (rooming-in system) at the Rabin Medical Center in Israel immediately after delivery of their infants by surrogate arrangement. The first birth was a singleton pregnancy with vaginal delivery and the second, a twin pregnancy with delivery by cesarean section. The genetic parents were counseled by a social worker from the adoption agency, starting 3 months before the estimated date of delivery. The parents were referred to the hospital social worker before the delivery. To assess attachment, we observed the parents' behavior toward their children during two daily 15-minute periods of free, unstructured interaction., Results: The parents showed good primary caregiving functions and established affective verbal and physical contact with the infants. They began to recognize the infants' needs and temperament, and exhibited an aura of self-confidence during their interactions. All expressed satisfaction with the method at discharge and reported on reduction of their fears about returning home with the infants., Conclusions: We believe that early hospitalization of the genetic mother in a surrogate delivery may be desirable to establish good and safe early mother-infant bonding, and that it should be considered for adoption as regular hospital policy. Further randomized studies with larger samples over the long term are warranted.

Objective: The purpose of this work is to clarify by path analysis which of the predictor factors of mortality in a cohort of 423 singletons VLBW infants born at Beilinson Medical Center during the years 1980-1990 (pre-surfactant era) exert direct or indirect effect on mortality. A direct risk factor was defined as a factor having an immediate effect on the outcome without working through an intermediate variable. By contrast, an indirect risk factor was defined as a factor that does not have a direct effect on the risk of mortality but instead works through an intermediate variable. Evaluation of mortality was done at three points over time (pre-delivery, at birth and post-delivery)., Results: In the pre-delivery model, gestational age, appropriateness for gestational age, mother's age and fetal distress work directly on mortality in VLBW infants. At birth, mother's age, birth weight and Apgar score at the fifth minute work directly on the risk of mortality. When the assessment of the risk of death was done post-delivery, mother's age, birth weight, Apgar score at the fifth minute and seizures influence directly on mortality risk, and fetal distress, gestational age and pre-natal induced hypertension (PIH) operate indirectly on the risk of mortality., Conclusion: The methodology we have used can be adopted in other investigations to distinguish and measure the effect of prognostic factors on the risk of an outcome.

Objective: Earlier works have associated neonatal clavicular fracture (0.2-3.5% of all deliveries) with a range of procedural, fetal and maternal risk factors; more recent studies, however, have failed to firmly identify any one or a combination of them. In the present work we sought to determine possible ante/intra-partum risk factors for this condition., Study Design: Using a retrospective case-controlled approach, we examined a series of maternal, fetal and pregnancy or delivery-related variables in 87 cases (out of 403) of fractured clavicle of the newborn diagnosed in our department from 1986 to 1994. All infants were delivered vaginally (in the occipito-anterior position) at term by a specialist obstetrician and underwent peripartum sonographic fetal weight estimation. All variables were compared with those of an equal number of infants born immediately before or after each affected infant and delivered by the same obstetrical team., Results: Fractured clavicles were found in 1.65% of the total number of deliveries during the study period. Neonatal clavicular fracture was significantly and directly related to the duration of the second stage of labor, peripartum sonographic fetal weight estimation, and neonatal length, and inversely related to maternal height; nevertheless, all values in both the study and control groups were within normal range. Logistic regression analysis showed that these antenatal variables significantly affect the chances of clavicular fracture, but due to the high false-positive rate they cannot serve clinically as a comprehensive antenatal prediction index., Conclusions: The majority of clavicular fractures occur in normal newborns following normal labor and delivery. The risk factors we identified statistically do not offer a method for clinical prenatal prediction. This work provides statistical evidence of the nature of this complication of early newborn life.

Intrafamilial marriage is favoured by the Arab community in Israel, almost all of whom live in villages populated by a few (< 20) founding families. A previous study in Taibe, a large Arab village located 30 km from Tel Aviv, showed a significantly high malformation rate among infants of consanguineous parents. The present study examines the reproductive consequences of parental consanguinity in 610 families from the same village, selected retrospectively through infants routinely seen in the local well baby clinic. All mothers were interviewed with regard to previous pregnancy outcomes, including abortions, stillbirths, and neonatal or infant deaths, as well as the degree of consanguinity. In addition, we analysed the anthropometric measurements of the probands. The incidence of infant deaths was significantly higher in the inbred group (p < 0.001). No significant increase in fetal loss between the inbred and outbred groups was observed. There were no differences in anthropometric features, except for a lower birth weight in the consanguineous group (p < 0.035). This study, combined with our previous studies of the same population, indicates a prominent public health problem associated with consanguineous marriage in the Arab community and a need for specific genetic counselling.

The purpose of the present study was to examine the relationship between severe pre-eclampsia/eclampsia (toxaemia) and obesity. We collected sociodemographic, anthropometric, medical and pregnancy outcome data from the hospital records of 248 Israeli women diagnosed with either pregnancy-induced or chronic hypertension, and compared these data to a control group of 236 women. Univariate analysis showed that while there exists a statistically significant positive association between obesity and hypertension (both pregnancy-induced and chronic) obesity presents no added risk to the development of toxaemia. Furthermore, we found a significant decrease in the rate of obesity among primigravid versus multigravid mothers with toxaemia superimposed on pregnancy-induced hypertension. On the other hand, primigravid mothers with PIH were at an increased risk of developing toxaemia as compared to multigravid women. These results suggest that obesity is not a significant factor in the development of toxaemia.

The European Network of the Teratology Information Services (ENTIS) has collected and evaluated data on 689 pregnancies in which exposure to tricyclic and nontricyclic antidepressants occurred. Data were collected prospectively from the time of in utero exposure and all the cases were followed up to the first few weeks of postnatal life using standardized procedures. In most cases, no longer term follow-up data were available. Approximately two-thirds of the mothers were on multidrug therapy, and of those, half took a benzodiazepine. About 95% of the patients were exposed during the first trimester. The most striking feature of the pregnancy outcomes is that 97% of live-born babies were morphologically normal. The incidence of spontaneous abortion and late fetal/neonatal deaths were within the normal range. Fourteen live-born babies and one fetus had either major or minor malformations, and six had minor anomalies. However, there was no increase in either a particular type of malformation or a specific pattern of defects. Another 31 infants without malformations had neonatal problems; these were usually associated with chronic multidrug therapy, especially near term. Elective termination of pregnancy occurred more frequently in the multidrug groups (86 out of 488) than in the monotherapy groups (20 out of 201), but data concerning the condition of the fetus are not available in the majority of the cases. Overall, no causal relationship could be established between in utero exposure to antidepressants and adverse pregnancy outcome.

It is common among Israeli Arabs who live in villages to prefer consanguineous marriages, particularly among first cousins. In addition, such villages are populated by a few (< 20) original families, and inter-family/inter-village marriages are infrequent. The purpose of this study was to examine the incidence of congenital malformation of the central nervous system associated with such "consanguinity" in Taibe, a large Arab village, 30 km from Tel Aviv. Six hundred and ten families were prospectively ascertained through infants who were routinely seen in the local "Well Baby Clinics". A significant increase in the incidence of major malformations was noted in relation to the closeness of the parental relationship. For the index cases group, the prevalence of individuals with major malformations was 5.8% in the product of inter-village marriages, 8.3% in the intra-village non-related matings, 15.1% in the distant consanguineous group, and up to 15.8% in the progeny of first-cousin marriages (P < 0.001). Malformations of the central nervous system consisted of 1/3 to 1/2 of the total malformations in the consanguineous group versus less than 1/5 in the non-consanguineous groups. The study demonstrates a marked high rate of consanguineous marriages, the effect of which leads to a marked increase in major malformations and especially those of the central nervous system. This requires a unique genetic counseling approach.

An outbreak of multiresistant Klebsiella pneumoniae occurring in a neonatal intensive care unit is described. All infections developed at least 5 days after admission to the unit (range, 5-40 days). Four infants had septicaemia and one had urinary tract infection. Three of the infected infants died. All klebsiella isolates were resistant to ampicillin, cefotaxime, cefuroxime, co-amoxiclav, mezlocillin, chloramphenicol, gentamicin, and ceftazidime (except in two); all were susceptible to imipenem, amikacin and quinolones. An extensive case-control study identified the following significant risk factors for colonization: prematurity; presence of indwelling catheters; previous antibiotic treatment; and parenteral nutrition. The outbreak was controlled with re-emphasis on strict handwashing practices, cohorting, closure of the unit to outborn admissions, and changing the regimen of empirical antibiotic therapy. Physicians should be aware of multiresistant Klebsiella spp. and change treatment whenever clinically indicated, even before culture results are available.

The Israeli national neonatal screening program for congenital hypothyroidism (CH) was initiated in May 1978. The overall incidence of persistent primary congenital hypothyroidism (PPCH) during the first 10 years of screening was 1:2,950 live births. The purpose of this study was to ascertain the incidence of congenital extrathyroid anomalies (ETAs) among the infants with PPCH and to compare it with the Israeli Birth Defect Monitoring System data. Among 243 PPCH infants on whom adequate data were available, 38 infants (15.6%) had associated congenital anomalies. Fourteen infants had congenital cardiac anomalies (5.8%): VSD (n = 7), PDA (n = 3), PS (n = 2), one mitral insufficiency, and one congenital atrial flutter. Eight children (3.3%) had congenital dislocation of the hip; their M:F ratio was 3:5 similar to the M:F ratio in CH (unlike the ratio in the general population). Some additional anomalies were considerably more common than in the general population. It is reasonable to assume that teratogenic effects active during organogenesis may affect simultaneously many organs, including the developing thyroid, causing a relatively high percentage of CH infants with congenital ETA.

It is common among Israeli Arabs who live in the villages to prefer consanguineous marriages, particularly among first cousins. In addition, such villages are populated by a few (less than 20) original families, and inter-family/inter-village marriages are infrequent. The purpose of this study was to examine the consequences of such "consanguinity" in Taibe, a large Arab village, 30 km from Tel Aviv. Six hundred ten families were prospectively ascertained through infants who were routinely seen in the local "Well Baby Clinics." A significant increase in the incidence of major malformations was noted in relation to the closeness of the parental relationship. For the index cases group the prevalence of individuals with major malformations were 5.8% in the product of inter-village marriages, 8.3% in the intra-village non-related matings, 15.1% in the distant consanguineous group, and up to 15.8% in the progeny of first-cousin marriages (P less than 0.001). In the siblings of these index cases, the frequency of major malformations was 4.3%, 4.5%, 10.5%, and 10.3%, respectively. Analysis of the major malformations by each body system showed the same trend. The study demonstrates a marked high rate of consanguineous marriages, whose effect leads to a marked increase in major malformations and thus a prominent public health problem in such villages. This requires a unique genetic counseling approach.

Neonatal morbidity was assessed in the offspring of 878 mothers with gestational diabetes mellitus (GDM), 132 mothers with pre-GDM, and 380 control subjects. Compared with the control group, the GDM group had a higher incidence of complications, including macrosomia, hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia, and major congenital anomalies (P less than 0.05). Although our GDM patients were stringently managed with diet or diet plus insulin, as indicated, and maintained almost euglycemic values, these neonatal complications could not be eliminated. Our data may be consistent with observations published during the last decade that even subtle degrees of maternal hyperglycemia can have a detrimental effect on perinatal outcome. Most neonatal complications readily respond to therapy if diagnosed and treated early and promptly. Macrosomia can have a detrimental effect on delivery (trauma) and later long-term implications during childhood. Tight metabolic control with diet and, when indicated, insulin treatment may be advantageous in reducing fetal birth weight. Criteria of how tight the metabolic control should be remain to be accurately defined.

The prevalence of diabetes in pregnancy and its fetal and perinatal consequences in a large population of Israeli pregnant women during the last decade are presented. The study population consisted of 878 gestational diabetic women, 132 pre-gestational diabetic women, and 380 healthy pregnant women who served as controls. Minor congenital anomalies ranging between 19.4 and 20.5%, major congenital anomalies between 1.80 and 6.82%, and neonatal complications, such as macrosomia (5.6-25.0%), hypoglycemia (0.9-7.8%), hyperbilirubinemia (8.2-16.7%), hypocalcemia (2.7-5.5%) and polycythemia (3.8-13.3%), were observed in the study population. Despite meticulous maternal glucose control, we could not entirely eliminate fetal and neonatal complications. The definition of the normal and abnormal fetal intrauterine metabolic environment remains to be elucidated.

The rotational profile of 265 children age 4-8 years who were born at the gestational age of less than or equal to 30 weeks and were nursed prone for several months after birth showed a marked outtoeing gait up to the age of 6 years. Their positive thigh-foot angles were significantly higher than those of the general population. These angles indicate that their outtoeing gaits were caused by marked external tibial rotation.

Cogenital smooth muscle hamartoma is a congenital skin lesion characterized by proliferation of bundles of smooth muscle within the reticular dermis. We report on a group of 15 children with this lesion, confirmed by skin biopsy specimen, its prevalence, the occurrence of associated anomalies, and long- term follow-up. To our knowledge, this is the largest group of patients with this lesion described in the literature. The estimated prevalence is about 1:2600 live births with slight male predominance. The lesion is most frequent in the lumbosacral area (67% [10/15]) and a positive pseudo-Darier's sign is present in 80% (12/15) of patients. During the follow-up period of up to 7 years, the lesions enlarged slightly but became less prominent. No malignant transformation was observed.

The annual prevalence rates of ten selected informative morphogenetic variants (IMVs) were studied in 31,194 newborn infants over a period of 8 years (1980-1987). Two of them (preauricular sinus and ocular hypertelorism) revealed a highly significant decrease by logistic regression analysis. The other eight presented a stable pattern or small fluctuations which did not reach statistical significance. These data may serve as valuable baseline rates for monitoring IMVs in a specific newborn population. Their potential informative value as indicators of altered morphogenesis and their power for monitoring programs of environmental teratogenicity should be carefully verified.

Eight hundred preterm (PT) and low-birth-weight (LBW) infants, born during a period of 33 months, were examined for erythrocyte glucose-6-phosphate dehydrogenase (G6PD) activity. Each of 17 infants with G6PD deficiency was compared with the next PT or LBW infant born with normal enzyme activity. The groups were similar with respect to gestational age, birth weight, maximal weight loss, breast or formula feeding and the use of oxytocin during labor. Peak bilirubin levels were significantly higher in G6PD-deficient PT and LBW infants (11.7 +/- 1.4 vs. 9.5 +/- 2.1 mg/dl, P less than 0.001). There were no signs of frank hemolysis, and none of the patients underwent exchange transfusion. Early jaundice and the use of phototherapy were somewhat more frequent among the G6PD-deficient group, but not significantly so. It is suggested that PT and LBW infants born to parents of Asian or North African origin be routinely screened for erythrocyte G6PD activity and monitored for possible jaundice.

This study was carried out to evaluate the maternal venous and umbilical cord blood levels of cortisol and aldosterone at spontaneous delivery in three ethnic groups in Israel (Ashkenazic, Sepharadic and Oriental) (n = 47). The mean maternal plasma cortisol level of the Sephardic group was significantly lower than were those of the other groups (P less than 0.01). Cord plasma cortisol level was similar in the three groups. No statistical differences were noted between the maternal and cord plasma cortisol levels in the three groups. The mean maternal and cord plasma aldosterone level was lowest in the Sephardic group. There was a good correlation of maternal and cord aldosterone levels in all of the groups. A positive statistical correlation detected in our study between levels of maternal plasma cortisol and cord plasma aldosterone is of interest, but needs more investigation before an appropriate explanation can be formulated. The ethnic differences in hormonal changes at birth observed in this study are preliminary results, and further investigations are being conducted to clarify these findings.

In order to define standards for sternal length, torso length, and internipple distance in the newborn infant, 198 term and preterm infants (27 to 41 gestational weeks) were examined. In every case, the gestational age was determined chronologically and clinically. Sternal and torso length and internipple distance were measured by two observers using standard measurement techniques. Normal values are presented by plotting the mean +/-2 SD for each gestational week v the gestational age.

The prevalence and time trends of spina bifida and anencephaly in the central area of Israel have been studied using data derived from four hospitals affiliated with the International Clearinghouse for Birth Defects Monitoring Systems. Spina bifida rates show a continuous increase from 1978 (1.1/10,000) to 1986 (7.4/10,000) with a peak in 1984 (7-fold increase compared with 1978). The logistic regression analysis of proportion of cases revealed a significant linear trend over time (P less than 0.005). Anencephaly rates increased from 1978 to 1981 but later decreased continuously until 1986 when the prevalence returned to the initial level of 1978. This time trend of spina bifida may represent a real alarm; the implications of this observation are discussed.

Over a seven year period 23 neonates with spontaneous pneumothorax and/or pneumomediastinum (SPP) were diagnosed in 24,739 live birth infants (0.09 percent). Of these, eight (35 percent) had renal anomalies. Three showed severe renal dysfunction and typical Potter facies and died within 34 hours. Their lungs were shown to be hypoplastic with a reduced lung weight: body weight ratio or a low radial alveolar count. One patient had left hypoplastic and right polycystic kidneys. Four patients with obstructive uropathies did not show the typical facies, and SPP was the only sign leading to their early diagnosis and therapy. We conclude that nephrologic evaluation is indicated in newborns with unexplained SPP and recommend abdominal ultrasound and if indicated renal scan and/or intravenous pyelography as part of the initial evaluation.