YIELD AND COSTS OF SCREENING GROWTH-RETARDED INFANTS FOR TORCH INFECTIONS

ABSTRACT

Many infants with intrauterine growth retardation (IUGR) are screened for TORCH infections. The yield and costs of such a practice may not be justifiable. Medical charts of infants with IUGR who had a workup for toxoplasmosis, other (infections), rubella, cytomegalovirus (infection), and herpes (simplex) (titer) (TORCH) infections were reviewed for the presence of clinical findings, laboratory and head ultrasound abnormalities associated with intrauterine infections. Maternal charts and reports of placental pathology were reviewed for identifying maternal illnesses and placental causes associated with IUGR. Seventy-five out of 182 infants (41%) with IUGR had a workup for TORCH infection. Maternal conditions associated with IUGR included: pregnancy-induced hypertension (19%), tobacco use (43%), alcohol abuse (21%), illicit drug use (24%), chronic hypertension, diabetic vasculopathy or collagen vascular disease (12%), and multiple gestation (3%). Placental pathology was available in 53/75 cases. Thirty-six of fifty-three (67%) placentae had abnormalities associated with IUGR: placental infarcts (22 of 36), vasculitis/villitis (15 of 36), placenta previa (1 of 36), abruptio placenta (2 of 36), and velamentous insertion of umbilical cord (1 of 36). Clinical findings among infants included hepatosplenomegaly, cataract or rash (1 of 75), thrombocytopenia and/or neutropenia and/or direct hyperbilirubinemia (11 of 75). Seven out of 75 infants had dysmorphic features. None of the infants (0 of 75) had positive IgM titers for toxoplasma, rubella, cytomegalovirus (CMV), or herpes simplex virus (HSV). No infants (0 of 43) had elevated total IgM titers; one infant (1 of 57) had a positive urine culture for CMV. One infant had evidence of calcifications on head ultrasound and a second infant had hydrocephalus (2 of 43). The costs associated with workup for TORCH infections among 75 infants included: TORCH titers determination: $17,816, total IgM titers: $1318, urine culture for CMV: $5734, and head ultrasound: $28,165. The yield of workup for TORCH infection among infants with IUGR is poor and does not justify the incurred costs.

KEYWORD

Intrauterine infection - intrauterine growth retardation - costs - TORCH titers

REFERENCES

• 1 Battaglia F C, Lubchenco L O. A practical classification of newborn infants by weight and gestational age.  J Pediatr . 1967;  71 159-163
• 2 Grannum P A, Berkowitz R L. Ultrasonography in the antepartum patient. In: Bolognese RJ, Schwartz R, eds. Perinatal Medicine: Management of the High Risk Fetus and Neonate Baltimore: Williams & Wilkins 1982: 153-183
• 3 Galbraith R S, Karchmar E J, Pievey W N. The clinical prediction of intrauterine growth retardation.  Am J Obstet Gynecol . 1979;  133 281-286
• 4 Fitzhardinge P M, Steven E M. The small-for-date infant. II. Neurological and intellectual sequelae.  Pediatrics . 1972;  50 50-57
• 5 Michaelis R, Schulte F, Nolte R. Motor behavior of small for gestational age newborn infants.  J Pediatr . 1970;  76 208-213
• 6 Lubchenco L O, Hansman C, Dressler M, Boyd E. Intrauterine growth as estimated from liveborn birth-weight data at 24 to 42 weeks of gestation.  Pediatrics . 1963;  32 793-800
• 7 Daikoku N H, Tyson J E, Graf C. The relative significance of human placental lactogen in the diagnosis of retarded fetal growth.  Am J Obstet Gynecol . 1979;  135 516-521
• 8 Seeds J W. Impaired fetal growth: definition and clinical diagnosis.  Obstet Gynecol . 1984;  64 303-310
• 9 Pollack R N, Divon M Y. Intrauterine growth retardation: definition, classification, and etiology.  Clin Obstet Gynecol . 1992;  35 99-107
• 10 Knox G E. Influence of infection on fetal growth and development.  J Reprod Med . 1978;  21 352-358
• 11 Klein J O, Remington J S. Current concepts of infections of the fetus and newborn infant. In: Remington JS, Klein JO, eds. Infectious Disease of the Fetus and Newborn Infant, 4th ed Philadelphia: WB Saunders Co 1995: 1-16
• 12 Nahmias A J, Walls K W, Stewart J A, Herrmann K L, Flynt W J. The TORCH complex: perinatal infections associated with toxoplasma and rubella, cytomegalo- and herpes simplex viruses.  Pediatr Res . 1971;  5 405-406
• 13 Lubchenco L O, Hansman C, Boyd E. Intrauterine growth in length and head circumference as estimated from live births at gestational ages from 26 to 42 weeks.  Pediatrics . 1966;  37 403-408
• 14 Gleaves C A, Smith T F, Shuster E A, Pearson G R. Rapid detection of cytomegalovirus in MRC-5 cells inoculated with urine specimens by using low-speed centrifugation and monoclonal antibody to an early antigen.  J Clin Microbiol . 1984;  19 917-919
• 15 Commey J OO, Fitzhardinge P M. Handicap in the preterm SGA infant.  J Pediatr . 1979;  94 779-786
• 16 Primhak R A, Simpson R M. Screening small for gestational age babies for congenital infection.  Clin Pediatr . 1982;  21 417-420
• 17 Cullen A, Brown S, Cafferkey M, O'Brien N, Griffin N. Current use of the TORCH screen in the diagnosis of congenital infection.  J Infect . 1998;  36 185-188
• 18 LeLand D, French M LV, Kleinman M B, Schreiner R L. The use of TORCH titers.  Pediatrics . 1983;  72 41-43
• 19 Stagno S. Diagnosis of viral infections of the newborn infant.  Clin Perinatol . 1981;  8 579-589
• 20 Best J M, Sutherland S. Diagnosis and prevention of congenital and perinatal infections. TORCH screening should be discouraged.  Br Med J . 1990;  301 888-889
• 21 Kinney J S, Kumar M L. Should we expand the TORCH complex?.  <~>A description of clinical and diagnostic aspects of selected old and new agents. Clin Perinatol . 1988;  15 727-745
• 22 Alford C A, Schaefer J, Blankenship W J. A corrolative immunologic, microbiologic, and clinical approach to the diagnosis of acute and chronic infections in newborn infants.  N Engl J Med . 1967;  277 437-449
• 23 Matthews T G, O'Herlihy C. Significance of raised immunoglobulin M levels in cord blood of small-for-gestational-age infants.  Arch Dis Child . 1978;  53 895-898
• 24 Greenough A. The TORCH screen and intrauterine infections.  Arch Dis Child . 1994;  70 F163-1651