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OBJECTIVE: We constructed a transcutaneous bilirubin (TcB) nomogram to represent major sectors of the Israeli population. We studied the risk of hyperbilirubinemia, defined as meeting the requirements for phototherapy, per percentile risk category. STUDY DESIGN: Newborns ⩾36 weeks gestation were tested daily for TcB, using Drager JM-103 devices, during birth hospitalization. A nomogram was constructed and divided into four risk groups and validated by calculating the need for phototherapy for each group. RESULTS: A total of 3303 measurements were performed on 1059 consecutive newborns including Ashkenazi, Sephardic and mixed Ashkenazi/Sephardic Jews, Arab and Ethiopian Jewish. Phototherapy risk increased progressively and more than 100-fold, from 0/225 in the <40th percentile group through 27/120 (22.5%) for those >95th percentile (relative risk (95% confidence interval) 102 (6 to 1669) for those >95th percentile compared with those <40th percentile). The optimal risk for discriminating the need for phototherapy was >75th percentile (sensitivity 93.33, specificity 59.47). CONCLUSION: The risk of significant hyperbilirubinemia increased progressively with increasing percentile. Newborns >75th percentile groups are at high risk for phototherapy and should be closely monitored.

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BACKGROUND: Guidelines for the management of cardiac arrest during pregnancy exist but they are based on little research. The study hypothesis was that experienced medical clinicians who specialise in obstetric care would not follow current International Liaison Committee on Resuscitation/American Heart Association recommendations in this situation. METHODS: Following waiver of informed consent by the institutional review board, an anonymous structured scenario questionnaire survey was conducted among relevant hospital clinicians. Demographic details included field of expertise and resuscitation experience. A single case vignette of maternal cardiac arrest was presented, followed by nine questions to examine knowledge of existing recommendations for maternal cardiopulmonary resuscitation. Statistical analyses were performed using SPSS version 12 software (SPSS Inc, Chicago, IL). RESULTS: The overall response rate was 67% (30/45 questionnaires). Specialist obstetricians, midwives and anaesthetists from 17 hospitals participated. Forty-three percent (n=13) claimed broad experience, 50% (n=15) claimed some experience and 6.7% (n=2) claimed no experience in adult resuscitation. Participants were divided in their opinions regarding every choice of action: positioning, need to administer cricoid pressure during mask ventilation, timing of intubation, location of external chest compression, location of paddle placement for delivery of shock during ventricular fibrillation, the timing of defibrillation versus fetal delivery, medication doses and the need to rupture the membranes at an early phase of the resuscitation. CONCLUSION: Specialist clinicians who treat pregnant women in hospital on a daily basis possess a limited knowledge of the recommendations for treating maternal cardiac arrest.

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AIM: To determine the incidence of post-phototherapy neonatal plasma total bilirubin (PTB) rebound. METHODS: A prospective clinical survey was performed on 226 term and near-term neonates treated with phototherapy in the well baby nursery of the Shaare Zedek Medical Center from January 2001 to September 2002. Neonates were tested for PTB 24 hours (between 12 and 36 hours) after discontinuation of phototherapy, with additional testing as clinically indicated. The main outcome measure, significant bilirubin rebound, was defined as a post-phototherapy PTB > or =256 micromol/l. Phototherapy was not reinstituted in all cases of rebound, but rather according to clinical indications. RESULTS: A total of 30 (13.3%) neonates developed significant rebound (mean (SD) PTB 287 (27) micromol/l, upper range 351 micromol/l). Twenty two of these (73%) were retreated with phototherapy at mean PTB 296 (29) micromol/l. Multiple logistic regression analysis showed significant risk for aetiological risk factors including positive direct Coombs test (odds ratio 2.44, 95% CI 1.25 to 4.74) and gestational age <37 weeks (odds ratio 3.21, 95% CI 1.29 to 7.96). A greater number of neonates rebounded among those in whom phototherapy was commenced < or =72 hours (26/152, 17%) compared with >72 hours (4/74, 5.4%) (odds ratio 3.61, 95% CI 1.21 to 10.77). CONCLUSION: Post-phototherapy neonatal bilirubin rebound to clinically significant levels may occur, especially in cases of prematurity, direct Coombs test positivity, and those treated < or =72 hours. These risk factors should be taken into account when planning post-phototherapy follow up.

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Rectal temperature of 126 term infants was measured on admission to the nursery following variable periods of stay with the mother in the delivery room. Fifty-nine infants who wore woolen hats after delivery had higher rectal temperature than 67 infants whose head was covered by loosely applied cotton diapers (36.5+/-0.5 degrees C vs. 36.3+/-0.5 degrees C, respectively; p=0.03). Among them there were fewer infants who were admitted with rectal temperature 36 degrees C (12 vs. 26, respectively; p=0.03). In multiple regression analyses accounting for head covering with woolen hats, birth weight, gender, delivery room temperature and length of stay with the mother, only birth weight and head covering with woolen hats were significantly associated with rectal temperature at arrival in the nursery (p=0.002 and 0.03, respectively), and only head covering with cotton diapers was significantly associated with rectal temperature 36 degrees C (p=0.03). Our data imply that covering heads of term newborns with simple woolen hats may reduce or prevent heat loss following delivery, and that adequate warming of infants is achieved during prolonged stay with the mother.

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The aim of this work was to determine the impact of parental consanguinity on congenital malformations in a mixed urban and rural Arab community in Jerusalem, Israel. Arab mothers admitted to four hospitals in west Jerusalem were interviewed after delivery. Demographic and obstetric data were recorded. Neonatal data were extracted from the medical records of the nursery. When malformations were suspected, a 4- to 10-month follow up was achieved for confirming the diagnosis. Of 561 infants, 253 (45%) were born to consanguineous couples. The incidence of major congenital malformations in the offspring was 8.7, 7.1 and 2.6% in cases of first cousins, all consanguineous, and non-consanguineous couples, respectively. No association was found between parental consanguinity and prematurity (p = 0.357) or low birth weight (p = 0.589). Parental consanguinity was also associated with an increased incidence of death in previous siblings (p < 0.000). The increased incidence of congenital malformations and infant mortality in cases of inbreeding prompt the necessity of establishing programs to avoid these complications in the offspring.

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UNLABELLED: Primary ciliary dyskinesia has been reported as a rare cause of respiratory distress during the neonatal period. This diagnosis is readily suspected in cases presenting with accompanying situs inversus. The aim of this study was to report on a pair of siblings with primary ciliary dyskinesia. The first case was an infant diagnosed with primary ciliary dyskinesia at the age of 14 d despite lack of situs inversus. The infant had presented with respiratory distress and atelectasis almost immediately after birth. The sibling, born one year later, presented with situs inversus, therefore allowing diagnosis of primary ciliary dyskinesia to be made immediately after birth. CONCLUSIONS: Diagnosis of primary ciliary dyskinesia should be considered in newborns presenting with respiratory distress or atelectasis. Early institution of an adequate treatment programme and follow-up may reduce or prevent further complications of the disease.

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BACKGROUND: Although bilirubin, which crosses the blood-brain barrier, can cause irreversible brain damage, it also possesses antioxidant properties that may be protective against oxidative stress. Intestinal ischemia-reperfusion (IR) injury results in cell destruction, mediated via the generation of reactive oxygen species. Although increased serum bilirubin is correlated with increased antioxidant potential in the face of hyperoxia, evidence of bilirubin-associated protective effect against IR injury remains nonspecific. We therefore sought to investigate whether hyperbilirubinemia would be protective against IR injury to the intestine. METHODS: Young adult rats were randomly assigned to one of three groups: 1) IR/control (n = 12); 2) IR/hyperbilirubinemia (n = 10), in which IR was generated while the rats were treated with a continuous infusion of bilirubin; and 3) hyperbilirubinemia controls (n = 10). Blood and intestinal tissue samples were obtained to determine serial thiobarbituric acid reducing substances (index of lipid peroxidation) and for xanthine oxidase/xanthine dehydrogenase and glutathione/glutathione disulfide ratios. Intestinal histopathology was graded from 1 (normal) to 4 (severe necrotic lesions). RESULTS: Histopathologic scoring and circulating and tissue thiobarbituric acid reducing substances were highest in the IR/control animals compared with either the IR/hyperbilirubinemics or the controls. All of these are consistent with the most severe injury in this group. Xanthine oxidase/xanthine dehydrogenase ratios were not significantly different among the groups. CONCLUSION: Hyperbilirubinemia ameliorates the extent of intestinal IR injury in our model and appears to act as an antioxidant. This study supports the concept that bilirubin possesses some beneficial properties in vivo, although no direct clinical conclusions can be drawn from these data.

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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.

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We examined a fetus at 38 weeks of gestation because of marked disproportion in size of the left and right ventricles. A membrane was detected at the distal end of the ductus arteriosus with significant flow gradient through it. New echocardiographic technologies such as high frame rate imaging and dynamic beam focusing increase spatial and temporal resolution and enhance more precise anatomical diagnosis in the fetus. This ductal membrane might have been related to the transient tachypnea from which the baby suffered after birth.

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OBJECTIVES: To determine the frequency and pattern of pediatric calls to the delivery room and the actual type of medical care administered to the newborn in the delivery room. STUDY DESIGN: This was a prospective observational study of 2554 births in a university-affiliated tertiary care hospital. Existing protocols required the attendance of a pediatric resident or neonatal fellow at all deliveries other than uncomplicated vaginal term births. The pediatrician's activity in the delivery room was characterized as either "medical care" or "minimal care." Results were analyzed by diagnostic category. RESULTS: Pediatricians attended 646 of the deliveries (25%). Medical care was administered in 204 of the deliveries, representing 31% of the time they were at a delivery and 8% of all deliveries. The three major indications for pediatric delivery room attendance were cesarean sections (n = 253; 39%), presence of meconium in amniotic fluid (n = 117; 18%), and vacuum deliveries (n = 117; 18%). Medical care was required only in 1 of 56 cases of elective repeat cesarean sections, in 1 of 20 cases of a cesarean section for nonprogress of labor, and in 1 of 38 cases when thin meconium was present. In contrast, medical care was needed in 52 of 81 (64%) cases of cesarean sections for fetal distress, in 11 of 11 (100%) of the cesarean sections for multiple births, and in 67 of 89 (85%) cases of thick meconium (p < 0.05). There was a need for medical attendance after the birth in less than 1% of 1908 cases for which the pediatrician was not initially called to delivery room. CONCLUSION: Because their medical skills were needed only one of three times that pediatricians were called to the delivery room, and then mostly in specific risk situations, more selective use of pediatric manpower for delivery room coverage may lead to a more efficient use of medical resources without any apparent increase in patient morbidity.

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Two patients undergoing bone marrow transplantation developed severe gastrointestinal symptoms, one during the peri-transplantation period and the other several months post-transplantation and following documented intestinal graft-versus-host disease. After detection of Giardia lamblia trophozoites in a stool specimen from one patient and a duodenal aspirate from the other, treatment with metronidazole was administered and all symptoms resolved. Giardiasis should be considered in transplant patients with diarrhea. Negative stool examinations do not rule out this possibility, and consideration should be given to examining a sample of small intestinal contents for Giardia trophozoites.

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