In vitro fertilisation and use of ovulation enhancers may both influence childhood height in very low birthweight infants

CONTEXT

Term-born children conceived by in vitro fertilisation (IVF) are reportedly taller than naturally conceived (NC) children. High levels of growth promoting hormones and epigenetic imprinting have been suggested as pathogenetic mechanisms.

HYPOTHESIS

Tall stature in prematurely born IVF-conceived (IVF-C) children suggests pre- or early implantation imprinting rather than a postnatal effect.

METHODS

We studied 334 very low birthweight (VLBW: birth weight <1500 g) children born prematurely during 1995-1999 and obtained their anthropometric measures at 6-10 years of age. Perinatal and neonatal data were obtained from the Israeli VLBW database. We compared IVF-C, ovulating agents conceived (OA-C) and naturally conceived (NC) groups of children with respect to their and their parents' anthropometry and their perinatal/neonatal variables.

RESULTS

Childhood height standard deviation scores (SDSs) were greatest in IVF-C (-0.12 (SD 1.25); p<0.022) and insignificantly greater in OA-C (-0.37 (SD 1.02)) as compared to NC (-0.58 (SD 1.36)) children. The IVF-C and NC groups were significantly different regarding 17 parental and perinatal variables; however, multiple regression analysis including these variables showed that, as compared with NC, IVF-C children had significantly older mothers at birth with earlier follow-up during pregnancy and more multi-fetal pregnancies.

CONCLUSIONS

IVF-C and to a lesser extent OA-C prematurely born children are taller than otherwise NC children. After ruling out postnatal and parental causes, we speculate that pre- or early implantation factors might have contributed to the taller stature of IVF-C children.

Neonatologists are using much less dexamethasone

Two historical cohorts (1993-1994 and 2001) of preterm infants ventilated for respiratory distress syndrome were compared. Dexamethasone administration fell from 22% to 6%. Chronic lung disease in survivors rose slightly from 13% to 17%, and mortality fell from 21% to 15% (other causes). The effect of restriction of dexamethasone use on chronic lung disease and mortality remains to be seen.

Early postnatal dexamethasone treatment and increased incidence of cerebral palsy

OBJECTIVE

To study the long term neurodevelopmental outcome of children who participated in a randomised, double blind, placebo controlled study of early postnatal dexamethasone treatment for prevention of chronic lung disease.

METHODS

The original study compared a three day course of dexamethasone (n = 132) with a saline placebo (n = 116) administered from before 12 hours of age in preterm infants, who were ventilated for respiratory distress syndrome and had received surfactant treatment. Dexamethasone treatment was associated with an increased incidence of hypertension, hyperglycaemia, and gastrointestinal haemorrhage and no reduction in either the incidence or severity of chronic lung disease or mortality. A total of 195 infants survived to discharge and five died later. Follow up data were obtained on 159 of 190 survivors at a mean (SD) age of 53 (18) months.

RESULTS

No differences were found between the groups in terms of perinatal or neonatal course, antenatal steroid administration, severity of initial disease, or major neonatal morbidity. Dexamethasone treated children had a significantly higher incidence of cerebral palsy than those receiving placebo (39/80 (49%) v. 12/79 (15%) respectively; odds ratio (OR) 4.62, 95% confidence interval (95% CI) 2.38 to 8.98). The most common form of cerebral palsy was spastic diplegia (incidence 22/80 (28%) v. 5/79 (6%) in dexamethasone and placebo treated infants respectively; OR 4.45, 95% CI 1.95 to 10.15). Developmental delay was significantly more common in the dexamethasone treated group (44/80 (55%)) than in the placebo treated group (23/79 (29%); OR 2. 87, 95% CI 1.53 to 5.38). Dexamethasone treated infants had more periventricular leucomalacia and less intraventricular haemorrhage in the neonatal period than those in the placebo group, although these differences were not statistically significant. Eleven children with cerebral palsy had normal ultrasound scans in the neonatal period; all 11 had received dexamethasone. Logistic regression analysis showed both periventricular leucomalacia and drug assignment to dexamethasone to be highly significant predictors of abnormal neurological outcome.

CONCLUSIONS

A three day course of dexamethasone administered shortly after birth in preterm infants with respiratory distress syndrome is associated with a significantly increased incidence of cerebral palsy and developmental delay.

Failure of early postnatal dexamethasone to prevent chronic lung disease in infants with respiratory distress syndrome

OBJECTIVE

To study the effect of early postnatal dexamethasone (days 1-3) on the incidence and severity of chronic lung disease in preterm infants with respiratory distress syndrome.

METHODS

A multicentre, randomised, placebo controlled, blinded study was carried out in 18 neonatal intensive care units in Israel. The primary outcome measure was survival to discharge without requirement for supplemental oxygen therapy beyond 28 days of life. The secondary outcome measures were requirement for mechanical ventilation at 3 and 7 days, duration of ventilation or oxygen therapy, need for subsequent steroids for established chronic lung disease and incidence of major morbidities.

RESULTS

The study consisted of 248 infants (dexamethasone n = 132; placebo n = 116). No differences were found in the outcome variables except for a reduction in requirement for mechanical ventilation at age 3 days in treated infants (dexamethasone 44%, placebo 67%; P = 0.001). Gastrointestinal haemorrhage, hypertension, and hyperglycaemia were more common in treated infants, but no life threatening complications, such as gastrointestinal perforation, were encountered.

CONCLUSIONS

These data do no support the routine use of early postnatal steroids, but may justify further study in a selected, high risk group of infants.

The incidence of birthmarks in Israeli neonates

BACKGROUND

Several studies have documented cutaneous findings in neonates of various racial groups. Our purpose was to determine the frequency of birthmarks in Israeli neonates of Jewish and Arabic origin.

METHODS

A cohort of 1672 newborn infants under 96 hours of age were examined for the presence of birthmarks. Of these 841 (50.3%) were Jewish and 831 (49.7%) were Arab. The Jewish group was further subdivided into various ethnic groups according to parental ancestry.

RESULTS

Melanocytic brown lesions (Mongolian spots, congenital nevi, and café-au-lait spots), were more common in Arab infants. The vast majority of Jewish infants with Mongolian spots were of Asian or African ancestry. On the other hand, congenital melanocytic nevi were found only in Jewish infants of European ancestry. Vascular lesions (salmon patch and port-wine stain) in Arab neonates exhibited a female preponderance.

CONCLUSIONS

Our data suggest that the prevalence of birthmarks in Israeli neonates is similar to the prevalence reported by others in white neonates.

Giant adrenal cyst in the newborn: perinatal diagnosis and management

Routine ultrasound examination in a pregnant 20-year-old woman at 32 weeks demonstrated a cystic structure in the fetal abdomen. Follow-up till term showed no substantial change in size. After birth the cyst could easily be palpated as an epigastric mass. Ultrasonography followed by a barium meal suggested, among other things, the diagnosis of gastric duplication. At exploratory laparotomy the cyst proved to be of adrenal origin. The diagnosis and therapeutic options are discussed.

Phototherapy-associated diarrhea. The role of bile salts

The concentration of fecal bile salts was measured in 14 jaundiced neonates who received phototherapy (PT group) and their 14 nontreated matched controls (C). Before initiation of phototherapy, mean bile salt concentrations in stool specimens from the two groups were similar. At 12 hours of 'lights on', stool specimens from PT babies showed a significantly increased mean bile salt concentration, whereas in the C babies there was no change (3.65 +/- 0.39 vs 2.62 +/- 0.22 mmol/l; p less than 0.01). At 24 hours after 'lights off', stool specimens from the PT infants had a mean bile salt concentration like that before phototherapy, and not different from C. During phototherapy, nine PT babies had a bile salt concentration in their stools of 3.5 mmol/l and above; 6 of these babies had watery stools with a high sodium content. The high concentration of bile salts found in the colonic contents of neonates during phototherapy would appear to be a factor in the pathogenesis of phototherapy-associated diarrhea in the jaundiced neonate.