Neonatal respiratory distress syndrome revealing a cervical bronchogenic cyst: a case report.

BACKGROUND: Bronchogenic cyst is a congenital malformation, rarely located in the cervical region and almost never involved in a neonate with acute respiratory distress in the delivery room. CASE PRESENTATION: A female newborn with respiratory distress syndrome caused by a large left cervical mass. Intubation was difficult due to tracheal deviation. Magnetic resonance imaging confirmed a left cervical cyst displacing the trachea and esophagus laterally. Surgical excision was performed via a cervical approach on the 5th day, and pathological examination revealed a bronchogenic cyst. The patient's course was complicated by left vocal cord paralysis and necrotic lesions in the glottic and subglottic regions; she required a tracheostomy on the 13th day. Inflammatory stenosis in the subglottic region required balloon dilation once, 20 days later. Proximal esophageal stenosis induced transient upper airway obstruction with salivary stasis. Decannulation was performed at 2 months and the patient was discharged 10 days later. CONCLUSION: A bronchogenic cyst can exceptionally obstruct the airways in the neonatal period. Surgical excision is necessary, but postoperative complications may occur if the cyst is in close contact with the trachea and esophagus, including necrotic and stenotic lesions of the upper aerodigestive tract. In those situations, tracheostomy may be necessary for mechanical ventilation weaning and the initiation of oral feeding.

Can a clinical decision rule help ductus arteriosus management in preterm neonates?

AIM: Patent ductus arteriosus (DA) occurs frequently in premature neonates with respiratory distress syndrome. We assessed a combination of clinical, biological and echocardiographic parameters to derive a decision rule for selecting candidates for treatment based on the criteria in use in our unit. METHODS: Hundred and forty neonates with a mean (SD) gestational age of 28 (2.3) weeks and a mean birth weight of 1159 (386) g, all requiring invasive ventilation with FiO(2) > 0.3 or catecholamines for severe hypotension, were assessed prospectively using echocardiography in conjunction with N-terminal pro-B-type natriuretic peptide (NTpBNP) levels within 24-72 h of birth. Independent predictors of DA treatment were identified with univariate analysis and combined in a clinical decision rule. RESULTS: Early treatment of significant DA was adopted for 26 (18.6%) neonates. A clinical decision rule suggesting treatment in patients with NTpBNP > 8500 pg/mL, ductal diameter >1.5 mm and, for infants with a birth weight > 830 g, left pulmonary artery end-diastolic velocity >0.20 m/sec showed 88% sensitivity and 94% specificity. CONCLUSIONS: A decision rule using realistic and/or commonly used parameters for significant patent ductus arteriosus assessment could be derived. External validation of this rule is needed before any application.

Rapid exome sequencing in critically ill infants: implementation in routine care from French regional hospital's perspective.

This monocentric study included fifteen children under a year old in intensive care with suspected monogenic conditions for rapid trio exome sequencing (rES) between April 2019 and April 2021. The primary outcome was the time from blood sampling to rapid exome sequencing report to parents. All results were available within 16 days and were reported to parents in or under 16 days in 13 of the 15 individuals (86%). Six individuals (40%) received a diagnosis with rES, two had a genetic condition not diagnosed by rES. Eight individuals had their care impacted by their rES results, four were discharged or died before the results. This small-scale study shows that rES can be implemented in a regional University hospital with rapid impactful diagnosis to improve care in critically ill infants.

Dissemination of newborn behavior observation skills after Newborn Individualized Developmental Care and Assessment Program (NIDCAP) implementation.

AIM: To assess nurses' ability to observe newborn behaviour after in situ training provided by caregivers with advanced practice certification in the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). DESIGN: Prospective observational study. METHODS: Twelve nurses viewed 20-min films showing the behaviour of 10 premature newborns before, during and after the usual caregiving. The behaviour was rated on an observation sheet with 88 items distributed into six systems. The responses were compared to the reference ratings established by two professionals certified for this programme. RESULTS: Despite less accurate observations during care and for some components, the nurses generally showed a satisfactory ability to observe newborn behaviour after training by NIDCAP expert professionals. The dissemination of observation skills among caregivers may result in an improved quality of patient care and better communication among professionals in a department of neonatology.

15-Year trends in respiratory care of extremely preterm infants: Contributing factors and consequences on health and growth during hospitalization.

OBJECTIVES: To review 15-year trends in respiratory care of extremely preterm infants managed in a tertiary perinatal center; to identify the factors contributing to their evolution; and to determine whether these changes had an impact on infant mortality, severe morbidity, and growth. METHODS: Retrospective cohort study of infants born at 23 to 26 weeks' gestation between 2003 and 2017. Changes in respiratory care were assessed in three 5-year periods. Logistic regression was used to examine the factors associated with prolonged duration (ie, greater than the median) of invasive mechanical ventilation (IMV), noninvasive ventilation (NIV), and overall respiratory support (ORS), and those associated with adequate weight and head circumference growth. RESULTS: Of the 396 actively treated neonates, 268 (68%) survived to discharge. Between the first and third periods, IMV duration decreased from 22 (6-37) to 4 (1-14.0) days (P < .001), that of NIV increased from 24 (14-34) to 56 (44-66) days (P < .001), and that of ORS from 50 (34-68) to 63 (52-77) days (P < .001). Study period (2003-2007 vs 2013-2017) was the main factor associated with prolonged IMV (P < .001). Use of high-flow nasal cannula was the main factor associated with prolonged NIV (P = .02) and ORS (P = .02). NIV duration was associated with adequate postnatal weight (P = .003) and head circumference (P = .03) growth. Severe morbidities in survivors, including bronchopulmonary dysplasia, and survival at hospital discharge were comparable across the study periods. CONCLUSIONS: Respiratory management was characterized by a marked reduction in IMV. NIV withdrawal protocols are necessary to limit ORS duration while respecting postnatal growth requirements.

Betamethasone impairs cerebral blood flow velocities in very premature infants with severe chronic lung disease.

OBJECTIVE: To assess betamethasone (BM) effects on the cerebral hemodynamics of neonates with severe chronic lung disease (CLD). STUDY DESIGN: Intravenous BM was given once daily for 6 consecutive days to 12 infants (birth weight: 698 g [range, 650-884 g], gestational age: 25.3 weeks [range, 25-26.4 weeks]) at a postnatal age of 34 days (range, 28-36 days). Cerebral blood flow velocities (CBFVs) were recorded prospectively in the anterior cerebral artery (ACA) and the lenticulostriate artery (LSA) before, during, and after treatment, using Doppler flowmetry. RESULTS: The decrease in systolic and diastolic velocities was maximum on the 5th day, reaching 32% (95% confidence interval [CI], 23%-42%) and 58% (95% CI, 39%-64%) from baseline in the ACA, and 44% (95% CI, 29%-50%) and 57% (95% CI, 33%-66%) in the LSA, respectively. The resistance index (RI) increased significantly in both arteries during treatment. Return to baseline values was observed after BM was stopped. The change in velocities and RI was independent of arterial blood gas and blood pressure variations. CONCLUSIONS: BM decreased the CBFVs of premature infants, suggesting a vasoconstrictor effect in both superficial and deep arterial vessels. Caution is recommended when BM is used to treat preterm infants with severe CLD.

Intubation in the delivery room: experience with nasal midazolam.

BACKGROUND: Neonates are often intubated in the delivery room (DR) without anesthesia because vascular access is impossible. AIMS: To assess neonatal comfort and adverse events after use of nasal midazolam (nMDZ) for intubation in the DR. STUDY DESIGN: Prospective data collection over 6months on the intubation of neonates with respiratory distress requiring tracheal instillation of surfactant. SUBJECTS: Twenty-seven neonates with median (Q25-75) gestational age and birthweight of, respectively, 29 (27-33)weeks and 1270 (817-1942)g received a 0.1mg/kg dose of nMDZ, and intubation was performed at the onset of tonus resolution or apnea. OUTCOME MEASURES: Comfort was assessed with a scale of hetero-pain assessment and electrical skin conductance monitoring. Continuous pulse oximetry was recorded in the first postnatal hour, with oscillometric blood pressure measurement every 10min. RESULTS: Seventy percent of the patients required a single dose, with intubation performed 4.8 (3-9)min after administration. Combined electro-clinical assessment found adequate comfort during the procedure in 68% of neonates. Mean blood pressure decreased from 39 (34-44)mmHg before to 31 (25-33)mmHg 1h following nMDZ (p=0.011). CONCLUSION: nMDZ provided rapid and effective sedation to intubate neonates in the DR but potentially exposed them to hypotension, thus requiring close hemodynamic monitoring.

Staphylococcus aureus in a neonatal care center: methicillin-susceptible strains should be a main concern.

BACKGROUND: In the context of a methicillin-susceptible Staphylococcus aureus (MSSA) outbreak, we aimed to improve our knowledge of S. aureus (SA) epidemiology in the neonatal care center (NCC) of a tertiary care teaching hospital. METHODS: We performed a complete one-year review of SA carrier, colonized or infected patients. Monthly prevalence and incidence of SA intestinal carriage, colonization and infection were calculated and the types of infection analysed. During the MSSA outbreak, strains were studied for antimicrobial resistance, content of virulence genes and comparative fingerprint in Pulsed-Field Gel Electrophoresis. Hand hygiene and catheter-related practices were assessed by direct observational audits. Environmental investigation was performed in search of a SA reservoir. RESULTS: Epidemiological analyses showed 2 or 3 prevalence peaks on a background of SA endemicity. In the NCC, during 2009, overall MSSA prevalence did not decrease below 5.5%, while mean MRSA prevalence was about 1.53%. Analysis of infection cases revealed that the outbreak corresponded to the emergence of catheter-related infections and was probably related to the relaxation in infection control practices in a context of high colonization pressure. Health care workers' white coats appeared as a potential environmental reservoir that could perpetuate SA circulation in the ward. CONCLUSION: This report emphasizes the importance of integrating MSSA along with methicillin-resistant SA in a program of epidemiological surveillance in the NCC.

Validation of nosocomial infection in neonatology: a new method for standardized surveillance.

BACKGROUND: Nosocomial infections (NIs) are a leading cause of mortality and morbidity in premature infants. We present a new method for detecting and confirming NIs in a neonatal intensive care unit. METHODS: Newborns with birth weight < 1,500 g or gestational age (GA) < 33 weeks were included prospectively over 2 years in a single-center tertiary neonatal intensive care unit. The computerized physician order entry system (CPOE) generated alerts when antibiotics were prescribed for at least 5 consecutive days and these cases were reviewed by an expert group following international recommendations. RESULTS: Four hundred sixty-one neonates were included, with a mean GA of 30 weeks (range, 26-32 weeks) and mean birth weight 1,270 g (range, 950-1600 g). The CPOE flagged 158 cases of potential NI, 85.1% of which were classified as true NI and 14.9% of which were false positive. Incidence and device-associated nosocomial bloodstream infection rates were 21.9% and 10.8 per 1,000 central venous catheter days, respectively. GA ≤ 28 weeks (odds ratio, 2.18; 95% confidence interval, 1.2-4) and > 7 central venous catheter days (odds ratio, 1.47; 95% confidence interval, 1.3-1.7) were independently associated with the risk of nosocomial bloodstream infection. CONCLUSION: Combining CPOE and interdisciplinary review may improve the accuracy of NI recording in a neonatal intensive care unit.

Validation of a neonatal pain scale adapted to the new practices in caring for preterm newborns.

UNLABELLED: BACKGROUND Neonatal pain assessment generally requires access to facial expression. Improved neonatology practices, such as greater protection against bright lights and non-invasive mask ventilation, have made facial observation more difficult. OBJECTIVE: To validate a 'faceless' acute neonatal pain scale (FANS), which does not depend on facial expression. METHODS: In a prospective, multicentre study, 24-40-week-old neonates were videotaped during a painful procedure (heel prick). Three investigators then scored the pain using FANS and a previously validated scale: DAN (Douleur aiguë du Nouveau-né). FANS is based on assessment of limb movement, cry and autonomic reaction. Reliability was assessed by inter-rater agreement and internal consistency (Cronbach's alpha). Validity was evaluated by agreement between scales (intraclass correlation coefficient (ICC)). The Wilcoxon test evaluated the FANS score differences between conditions. Results are expressed as medians (25th and 75th percentiles). Ranges are presented for outcome parameters. RESULTS: From April 2006 to September 2007, 53 preterms of 32 (30-35) gestational weeks and 1500 (1000-2200) g were observed. Cronbach's alpha was 0.72. The ICC was 0.92 (0.9-0.98) for inter-rater agreement and 0.88 (0.76-0.93) for agreement between scales. CONCLUSION: FANS, which is reliable and valid, is the first scale to score pain in preterm newborns when facial expression is not accessible.

Werner mesomelic dysplasia with Hirschsprung disease.

Mesomelic dysplasia type Werner is defined by absence of tibiae and preaxial polysyndactyly of hands and feet. Occasional findings are triphalangeal thumbs, absence of patella(e), and dislocated fibula(e). The molecular basis is unknown and autosomal dominant inheritance with variable expressivity is currently postulated. Hirschsprung disease was reported previously in one case. We report here on a new case of mesomelic dysplasia Werner type associated with Hirschsprung disease and bilateral cryptorchidism. We discuss the overlap with the triphalangeal thumb polysyndactyly syndrome located in chromosome 7q36.