Breast milk is an excellent nutritional source for newborns, and a change in its color can be alarming to both mother and physician, and may prevent breastfeeding. Different colors of breast milk have been reported such as blood-stained, blue, and bluish-green. We present the first case of green breast milk caused by maternal ingestion of blue-green algae pills immediately before and after delivery. The score on the Naranjo Adverse Drug Reaction Probability Scale was 5, indicating a probable adverse drug reaction. Laboratory analysis yielded no other abnormalities in the milk. The mother stopped taking the supplement, and the milk returned to its normal appearance 3 days later. This report should alert physicians to include supplement intake as part of the anamnesis for new mothers who present with breast milk changes.

AIMS The present study evaluates the effect of antenatal lamotrigine exposure, on short- and long-term paediatric outcome. METHODS The study included the children of 83 epileptic women treated with lamotrigine during pregnancy, at a tertiary medical centre between 2004-2014. All newborns were monitored for vital signs, congenital malformations and Finnegan score. In addition, the parents completed a questionnaire regarding their child's development and health up to the age of 12 years. RESULTS No major malformations were found in the newborns. None of the newborns had significant withdrawal symptoms by Finnegan score. The children were followed-up to the age of 12 years (56.6% were 6-12 years at the time of evaluation). There were no significant findings in the incidence of neurodevelopmental disorders. CONCLUSIONS According to our experience, lamotrigine is generally safe for pregnancy use, associated with minimal short-term complications with no long-term effects on the outcome.

Neonatal serum detection of cytomegalovirus (CMV) immunoglobulin M (IgM) has low sensitivity in identifying congenital cytomegalovirus (cCMV). Several reports have endeavored to associate the presence/absence of IgM to disease severity. Data were collected for all infants with cCMV followed in our clinic. Infant outcome after birth was compared between infants who tested positive or negative. Sensitivity of positive IgM in diagnosing cCMV was 40.7%. The rate of symptomatic disease in those who tested positive was statistically higher (67.7%, P < .001). Odds ratio for symptomatic disease in infants with positive IgM born after a maternal primary infection was 3.47 (95% confidence interval = 1.7-7.1). Positive IgM was found in only 48.8% of symptomatic and 22.1% of asymptomatic children. Our results demonstrated a low sensitivity of IgM in diagnosing cCMV. However, while a positive IgM antibody for CMV is associated with a more symptomatic disease, it does not serve as a precise laboratory marker for a severity.

Objective To assess the association of gestational age at delivery with perinatal outcome in low-risk term deliveries complicated by meconium-stained amniotic fluid (MSAF).Methods We retrospectively analyzed all singleton deliveries that underwent a trial of labor in a single hospital (2007-2013). Exclusion criteria included pregnancy-related complications (e.g., hypertensive disorders, diabetes, oligohydramnios, and fetal anomalies). First, only deliveries with MSAF were analyzed. Perinatal outcome of deliveries at 37(0/7) to 38(6/7) weeks (early term) and 41(0/7) to 41(6/7) weeks (late term) were compared with those at 39(0/7) to 40(6/7) weeks of gestation (full term). Additionally, a gestational age based comparison was made between the risk for neonatal respiratory morbidity in deliveries with clear amniotic fluid and MSAF.Results During the study period, 28,248 deliveries were considered as low risk. Of them, 3,399 (12.0%) were diagnosed with MSAF and were divided to full term (n = 2,413), early term (n = 405), and late term (n = 581). In multivariate analysis, MSAF at early term was associated with neonatal jaundice, need for phototherapy, and neonatal sepsis. In a gestational age based stratification, when comparing between deliveries with clear amniotic fluid and those with MSAF, late term had the highest odds (4.2 vs. 0.5%; p < 0.001) for neonatal respiratory morbidity.Conclusion Gestational age was associated with specific complications in deliveries complicated by MSAF and otherwise low-risk deliveries.

Objective To determine the independent association of post-term pregnancy with neonatal outcome in low-risk newborns. Design Retrospective cohort. Setting Tertiary university-affiliated medical centre. Patients All newborns of low-risk singleton pregnancies born at 39+0 to 44+0 weeks’ gestation over a 5-year period. Exclusion criteria: multiple gestation, maternal hypertensive disorder, diabetes or cholestasis, placental abruption or intrapartum fever (>38°C), small for gestational age (<10th centile) and major congenital or chromosomal anomalies. Interventions None. Outcome measures Admission to the neonatal intensive care unit (NICU), hospital length of stay, 5-min Apgar score, birth trauma, respiratory, neurological, metabolic and infectious morbidities and neonatal mortality. The adverse outcome rate was compared among three groups based on gestational age at birth: post-term (≥42+0 weeks), late term (41+0 to 41+6 weeks) and full term (39+0 to 40+6 weeks). Results Of the 23 524 eligible neonates, 747 (3.2%) were born post-term, 4632 (19.7%) late term and 18 145 (77.1%) full term. Women in the post-term group versus the late-term group had a significantly higher rate of caesarean section (8.9% vs 5.6%, p<0.001) and operative vaginal delivery (9.6% vs 7.4%, p=0.024). Post-term pregnancy versus full-term pregnancy was associated with an increased risk of NICU admission (OR 2.0, 95% CI 1.4 to 2.8), respiratory morbidity (OR 2.2, 95% CI 1.3 to 3.8) and infectious morbidity (OR 1.88, 95% CI 1.32 to 2.69). Post-term pregnancy versus late-term pregnancy was similarly associated with an increased risk of NICU admission (OR 2.0, 95% CI 1.4 to 2.9), respiratory morbidity (OR 2.7, 95% CI 1.5 to 5.0) and infectious morbidity (OR 1.8, 95% CI 1.2 to 2.7) and with hypoglycaemia (OR 2.6, 95% CI 1.2 to 5.4). Post-term delivery was not associated with neonatal mortality. Conclusions Post-term pregnancy is an independent risk factor for neonatal morbidity even in low-risk singleton pregnancies.

Poliovirus and rotavirus share notable similarities. Although rotavirus is not amenable to eradication because of animal reservoirs, live, attenuated oral vaccines have been the bedrock of both prevention and control programs, providing intestinal and humoral immunity. Both programs have also encountered safety concerns and suboptimal immune responses to oral vaccines in low-income settings that have been challenges, prompting the search for alternative solutions. In this paper, we review the progress made by polio prevention and eradication efforts over the past six decades. Specifically, we discuss the roles of the oral polio vaccine (OPV) and the inactivated polio vaccine (IPV) in achieving polio eradication, and explore potential application of these lessons to rotavirus. Recent scientific evidence has confirmed that a combined schedule of IPV and OPV adds synergistic value that may give the polio eradication effort the tools to end all poliovirus circulation worldwide. For rotavirus, oral vaccine is the only currently licensed and recommended vaccine for use in all children worldwide, providing heterologous protection against a broad range of strains. However, parenteral rotavirus vaccines are in the pre-clinical and clinical trial stage and insight from polio provides strong justification for accelerating the development of these vaccines. While challenges for parenteral rotavirus vaccines will need to be addressed, such as achieving protection against a broad range of strains, the principle of combined use of oral and parenteral rotavirus vaccines may provide the necessary humoral and intestinal immunity necessary to close the efficacy gaps between developing and developed countries, therefore controlling rotavirus worldwide. This strategy may also potentially reduce risk of intussusception.

Objective To assess the association of anthropometric measurements with neonatal complications in macrosomic newborns of non-diabetic mothers. Design Retrospective cohort study. Patients All liveborn, singleton, full term newborns with birth weight ≥4000 g born to non-diabetic mothers at a tertiary medical centre in 1995–2005 (n=2766, study group) were matched to the next born, healthy, full term infant with a birth weight of 3000–4000 g (control group). Exclusion criteria were multiple birth, congenital infection, major malformations and pregnancy complications. Intervention Data collection by file review. Outcome measures Complication rates were compared between study and control groups and between symmetric and asymmetric macrosomic newborns, defined by weight/length ratio (WLR), Body Mass Index and Ponderal Index. Results The 2766 non-diabetic macrosomic infants identified were matched to 2766 control infants. The macrosomic group had higher rates of hypoglycaemia (1.2% vs 0.5%, p=0.008), transient tachypnoea of the newborn (1.5% vs 0.5%, p<0.001), hyperthermia (0.6% vs 0.1%, p=0.012), and birth trauma (2% vs 0.7%, p<0.001), with no cases of symptomatic polycythaemia, and only one case of hypoglycaemia. Hypoglycaemia was positively associated with birth weight. It was significantly higher in the asymmetric than the symmetric macrosomic newborns, defined by WLR (1.7% vs 0.3%, p<0.001). Conclusions Macrosomic infants of non-diabetic mothers are at increased risk of neonatal complications. However, routine measurements of haematocrit and calcium may not be necessary. Symmetric macrosomic infants (by WLR) have a similar rate of hypoglycaemia as normal-weight infants. Thus, repeat glucose measurements in symmetric macrosomic infants are not justified.

Objective: To assess the association between gestational age at delivery and adverse neonatal outcome among term low-risk singleton neonates.Methods: A retrospective cohort study design was used. The study group included all low-risk singleton term (37 + 0 to 41 + 6 weeks) newborns delivered in a single tertiary university-affiliated medical center over a 5-year period. Outcome of neonates delivered at 37 + 0 to 37 + 6 weeks of gestation (early term) and 41 + 0 to 41 + 6 weeks of gestation (late term) was compared to that of neonates delivered at 39 + 0-39 + 6 weeks of gestation (control).Results: Overall, the outcome of 30 229 neonates was analyzed. The incidence of neonatal mortality was 1.0 per 1000 live-born neonates, with no significant difference between the various gestational age groups. Early term newborns were at higher risk for respiratory morbidity, hypoglycemia, hypocalcemia, thrombocytopenia and unexplained jaundice, and had higher rates of prolonged hospital stay, NICU admission, sepsis workup and antibiotic treatment. On multivariate analysis, early term delivery was an independent predictor for composite respiratory morbidity (OR = 2.4, 95% CI 1.6-3.8, p < 0.001), unexplained jaundice (OR = 2.1, 95% CI 1.7-2.5, p < 0.001), hypoglycemia (OR = 2.5, 95% CI 1.5-4.3, p < 0.001) and NICU admission (OR = 1.9, 95% CI 1.5-2.5, p < 0.001). Late term neonates had a significantly higher rate of large for gestational date, but did not differ from controls with respect to the rate of composite neurologic or respiratory complications, NICU admission, birth trauma or infectious morbidity.Conclusion: Even in low-risk singleton deliveries, early term is associated with an increased risk of neonatal morbidity.

Aim Vancomycin is widely used to treat late onset coagulase-negative Staphylococcus (CoNS) sepsis in very low birth weight (VLBW) infants. Although vancomycin is associated with a risk of toxicity and bacterial resistance, the appropriate duration of use has not been established. This study sought to investigate the association between the duration of vancomycin therapy and clinical outcome in VLBW infants with CoNS sepsis. Methods The files of all VLBW infants treated for CoNS sepsis at a tertiary paediatric medical centre from 1995-2003 were reviewed for clinical data, laboratory variables and outcome. Only patients with two positive diagnostic blood cultures were included. The findings were analyzed by duration of vancomycin treatment after the last positive blood culture. Results The study cohort included 126 infants, 48 treated for 5 days, 32 for 6-7 days, 31 for 8-10 days and 15 for >10 days. There were no differences among the groups in perinatal characteristics, central catheter dwell time, laboratory data including haematologic, renal and liver function tests, or rate of complications of prematurity. Five infants were diagnosed with infective endocarditis or aortic thrombi and were treated for >10 days. CoNS sepsis recurred in two infants (1.6%). No toxicity of vancomycin treatment was observed. Conclusions In VLBW infants with uncomplicated CoNS sepsis, treatment with vancomycin for 5 days after the last positive blood culture appears to be associated with a satisfactory outcome and no adverse effects. A well-controlled prospective multicentre study is needed to confirm these findings.

Objective: To determine the incidence and risk factors for umbilical cord prolapse and to evaluate whether obstetrical interventions increase this risk.Methods: A retrospective, cohort study of all intended vaginal deliveries in a single tertiary university affiliated medical center (33 519 deliveries). Obstetrical and labor characteristics, including labor interventions [as artificial rupture of membranes (ARM) and intrauterine catheter insertion] and short-term pregnancy outcome were obtained. Primary outcome measure was defined as abnormal umbilical cord pH < 7.2 and/or 5-min Apgar score < 7.Results: The rate of umbilical cord prolapse was 37/33 519 (0.11%); of them, 23 (62%) were diagnosed after ARM, three cases (8%) were related to external cephalic version and three cases (8%) were related to intrauterine catheter insertion. The rate of umbilical cord pH < 7.2 and 5-min Apgar score < 7 was higher in the ARM group in comparison to women with spontaneous rupture of membranes (30% versus 21%, p = 0.8). There was no significant difference in mean pH according to mode of delivery. All neonates were discharged within 8 d of delivery with good neonatal outcome and the rate of maternal complications was low.Conclusion: Prompt delivery in cases of umbilical cord prolapse is associated with favorable pregnancy outcome.

Purpose: To identify risk factors for intestinal perforation in very-low-birth-weight (VLBW) infants with necrotizing enterocolitis (NEC).Methods: Retrospective case-control study over a 10-year period, using univariate and multivariate logistic regression analyses to compare all VLBW infants treated for perforated NEC, with two age and weight-matched groups: infants with non-perforated NEC and infants without NEC.Results: Twenty infants with perforated NEC were matched to 20 infants with non-perforated NEC and 38 infants without NEC. Infants with perforated NEC were younger (p<0.01) and had higher rates of abdominal distention, metabolic acidosis, hyperglycemia and elevated liver enzymes (p<0.05). On logistic regression analysis, abdominal distention was associated with an increased risk of intestinal perforation (OR 39.8, 95% CI 2.71-585) and late onset of NEC (one-day increments) was associated with a decreased risk (OR 0.93, 95% CI 0.87-1.0).Conclusion: Identification of abdominal distention at an early age in VLBW infants should lead to increased vigilance for signs of perforated NEC and may enable early intervention. (C) 2013 Elsevier Inc. All rights reserved.

INTRODUCTION:Breastfeeding has a positive influence on physical and mental development. Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral disorder with major social, familial, and academic influences. The present study aimed to evaluate whether ADHD is associated with a shorter duration of breastfeeding.SUBJECTS AND METHODS:In this retrospective matched study, children 6-12 years old diagnosed at Schneider's Children Medical Center (Petach Tikva, Israel) with ADHD between 2008 and 2009 were compared with two control groups. The first one consisted of healthy (no ADHD) siblings of ADHD children; the second control group consisted of children without ADHD who consulted at the otolaryngology clinic. A constructed questionnaire about demographic, medical, and perinatal findings, feeding history during the first year of life, and a validated adult ADHD screening questionnaire were given to both parents of every child in each group.RESULTS:In children later diagnosed as having ADHD, 43% were breastfed at 3 months of age compared with 69% in the siblings group and 73% in the control non-related group (p=0.002). By 6 months of age 29% of ADHD children were breastfed compared with 50% in the siblings group and 57% in the control non-related group (p=0.011). A stepwise logistic regression that included the variables found to be significant in univariate analysis demonstrated a significant association between ADHD and lack of breastfeeding at 3 months of age, maternal age at birth, male gender, and parental divorce.CONCLUSIONS:Children with ADHD were less likely to breastfeed at 3 months and 6 months of age than children in the two control groups. We speculate that breastfeeding may have a protective effect from developing ADHD later in childhood.

Bronchopulmonary dysplasia (BPD) is a chronic lung disease that occurs in premature infants who have needed mechanical ventilation and oxygen therapy. BPD is defined as the presence of persistent respiratory symptoms, the need for supplemental oxygen to treat hypoxemia, and an abnormal chest radiograph at 36 weeks gestational age. Proinflammatory cytokines and altered angiogenic gene signaling impair prenatal and postnatal lung growth, resulting in BPD. Postnatal hyperoxia exposure further increases the production of cytotoxic free radicals, which cause lung injury and increase the levels of proinflammatory cytokines. Magnesium is the fourth most abundant metal in the body. It is commonly used for the treatment of preeclamsia, as well as for premature labor alleviation. Magnesium's role in BPD development is not clear. A significant association between high magnesium levels at birth and respiratory distress syndrome (RDS), pulmonary interstitial emphysema in the extremely low birth weight, respiratory failure, and later development BPD was found. Conversely, low magnesium intake is associated with lower lung functions, and hypomagnesemia was found in 16% of patients with acute pulmonary diseases. Magnesium is used for the treatment of asthmatic attacks. Magnesium deficiency in pregnant women is frequently seen due to low intake. Hypomagnesemia was also found among preterm neonates and respiratory distress syndrome (RDS). Experimental hypomagnesemia evokes an inflammatory response, and oxidative damage of tissues. These were accompanied by changes in gene expression mostly involved in regulation of cell cycle, apoptosis and remodeling, processes associated with BPD. It is rational to believe that hypomagnesemia can contribute to BPD pathogenesis.

Objective: To evaluate the diagnostic and therapeutic approach to full term neonates born to mothers with intrapartum fever. Methods: In a retrospective study, neonates born to mothers with intrapartum fever, (≥37.8°C), were compared to control group matched by gestational age and birthweight. Results: Overall, 159 singleton full term neonates born to women with intrapartum fever (study group) were compared to 159 control infants. No differences in neonatal outcomes were found between the two groups except for a higher rate of meconium-stained amniotic fluid in the maternal-fever group. There were no cases of neonatal infection, severe neonatal morbidity, or neonatal mortality in either of the groups. Full sepsis workup and intravenous antibiotic treatment were provided to 17.6% of the neonates in the study group. Logistic regression analysis revealed that delivery by Cesarean section was the only factor independently associated with the decision to perform a full sepsis work up and antibiotic treatment in cases of maternal intrapartum fever (OR 32.0, 95% CI 9.4–112.1). Conclusions: In low-risk women with asymptomatic intrapartum fever, neonatal infection is uncommon, so that aggressive evaluation and management of these infants may not be necessary and should be balanced against the low risk of neonatal sepsis.

BACKGROUND Measurements of adolescents who at birth were large (long and/or heavy) for gestational age are scant. OBJECTIVES To determine the correlation between birth length and weight in female and male neonates born long and/or overweight for gestational age, with their height and weight at age 17. METHODS We reviewed the records of the Rabin Medical Center for birth data of 96 full-term neonates born long and overweight for gestational age (FT-lo,ow), 33 full-term neonates born long but with normal weight for gestational age (FT-lo,nw), 148 full-term neonates born overweight but with normal length for gestational age (FT-nl,ow), and 401 full-term neonates born with normal birth length and weight (FT-nl,nw). RESULTS Neonates of both genders born long and overweight at birth (FT-lo,ow) were taller and heavier at age 17 years than those born FT-nl,nw: females 167.8 +/- 5.1 cm and 64.6 +/- 10.3 kg vs. 162.6 +/- 5.5 cm and 59.3 +/- 11.1 kg (P < 0.001 for height and P = 0.026 for weight); and males 182.4 +/- 8.1 cm and 80.6 +/- 20.4 kg vs. 174.5 +/- 6.2 cm and 67.4 +/- 12.3 kg (P < 0.001). The correlations between birth length and height at age 17 for both genders were statistically significant (P < 0.001), as were those between birth weight and the weight and body mass index (BMI) at age 17 for both genders (P < 0.001). There was no correlation between birth length and weight or BMI at age 17. CONCLUSIONS Full-term neonates of both genders born large for gestational age become tall adolescents and weigh more at age 17 than children with a normal birth length and weight.

Background: Postaxial type B polydactyly is characterized by the presence of a rudimentary extra digit on the small finger side attached by a soft tissue stalk. The recommended treatment is ligation in the neonatal nursery. The purpose of this study was to evaluate the result of excision of the supernumerary digit under topical anesthesia.Methods: The study group included 11 consecutive infants with 15 supernumerary digits on the hand. To ensure complete excision, the digit was retracted by the surgeon and excised at the base of the skin triangle formed on retraction beyond the proximal end of the stalk. The infants were discharged one day later and followed up for 12 months.Results: No immediate or late complications were noted. All hands had an aesthetic appearance at discharge. At follow-up, complete excision was noted, and the scar was hardly seen.Conclusions: For infants with postaxial type B polydactyly, excision of the extra digit in the neonatal nursery is a safe and simple procedure with a good clinical and cosmetic outcome.

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.

The yearly seasons are marked by changes in the amount of sunlight. Ultraviolet radiation (UVR) is known to adversely affect the course of viral infections, immunologic memory and cellular and humoral immune responses. Our objectives were to investigate potential differences in the immune response of the rubella vaccine after 3-4 years by season of inoculation. Children aged 4-5 years attending four kindergartens in villages in northern Israel, all of whom had been vaccinated at 1 year of age, were enrolled in the study. Participants were divided into three groups by season of the year in which the inoculation was performed: summer (N = 63), winter (N = 36) and intermediate (N = 104). Main outcome measures were mean geometrical titer of rubella antibodies and complete, partial or no immunity to rubella by season of inoculation. Of the 203 children tested, 186 (91.6%) had adequate antibody levels, 7 (3.4%) had equivocal levels and 10 (4.9%) had inadequate levels. Significantly higher mean geometrical titers were found in the winter-inoculated compared with the summer-inoculated group (73.0 ± 2.6 vs 47.6 ± 2.8; p < 0.05). The same tendency was noted in the percent of infants properly immunized. This preliminary study shows a strong correlation between the immune response to rubella vaccine and the season of vaccination. Immunogenicity may be improved by inoculating children during seasons of less sunlight or by reducing the children's exposure to sunlight following inoculation. This practice is especially important in areas with extreme seasonal variability in solar radiation and tropical areas. Further studies are needed to corroborate and expand these findings.

This study sought to expand current knowledge on the clinical and epidemiological characteristics of persistent coagulase-negative Staphylococcus (CoNS) bacteremia in very-low-birth-weight (VLBW) infants. Background and disease-related data were collected prospectively on 143 VLBW infants diagnosed with CoNS bacteremia at a pediatric tertiary medical center in 1995–2003. Findings were compared between those with persistent (positive blood cultures for >72 h under appropriate treatment ) and nonpersistent disease. Fifty-eight infants (40.6%) were found to have persistent bacteremia. There were no between-group differences in maternal characteristics, mode of delivery, newborn characteristics, dwell time of central venous and umbilical catheters, complications of prematurity, or mean hospital stay. The persistent bacteremia group had significantly higher rates of hypothermia at presentation (37.9% vs. 17.6%, p < 0.04), creatinine >1.2 mg% on treatment day 7 (13.7% vs. 2.4%, p < 0.02; transient phenomenon), and endocarditis (p < 0.03); one infant had an aortic thrombus. Predominantly breast-fed infants had a higher rate of negative cultures within 72 h of appropriate treatment than predominantly formula-fed infants (60% vs. 19%, p < 0.02). In conclusion, persistence of CoNS bacteremia is common in VLBW infants. Endocarditis should be excluded in all infants with persistent disease. Breast-feeding is associated with a shorter disease duration.