Pulmonary function at 1 year of age in survivors of neonatal respiratory distress: a multivariate analysis of factors associated with sequelae.

We studied pulmonary function 1 year after neonatal respiratory distress (RD) in 54 infants who had been treated at birth in the same neonatal intensive care unit. RD was related to hyaline membrane disease in 36 cases (group I) and to other causes in 18 cases (group II). Compared with predicted values, dynamic lung compliance (CL) was lower (less than -2 SD) and total pulmonary resistance (RL) was higher (+2 SD) in 18 (33%) and 12 (22%) infants, respectively. The relationships between these functional abnormalities at 1 year of age and the characteristics of the neonatal respiratory disease were assessed using a multifactorial analysis (multiple correspondences analysis). We found that elevated RL (greater than +2 SD) at 1 year of age was very significantly related with hyaline membrane disease, involving both high rate of positive pressure ventilation and prolonged intubation, and with the presence of both tachypnea and abnormal chest X rays at the time of discharge. Compared with elevated RL, the relationships between low CL (less than -2 SD) and the same neonatal characteristics were less significant; in particular, there was no strong link between low CL and hyaline membrane disease. Finally, birth before 30 weeks gestation was an index of severity.

Pulmonary function in infancy and in childhood following mechanical ventilation in the neonatal period.

Pulmonary function was evaluated in both infancy and childhood in the same 19 prematurely born infants, who required mechanical ventilation (MV) during the neonatal period. Results of our patients were compared with those of control subjects. Upon first evaluation, we found that lung resistance (RL) was significantly elevated (24.85 +/- 6.06 vs. 17.77 +/- 2.39 cmH2O/L/s; P less than 0.01). The mean value of dynamic lung compliance (CLdyn) was low, but the difference compared to controls did not reach significance. From infancy to childhood, elevated RL persisted (9.33 +/- 2.51 vs. 6.52 +/- 1.52 cm H2O/L/s; P less than 0.01), and the decrease of CLdyn became significant (46.86 +/- 12.84 vs. 59.34 +/- 15.68 mL/cmH2O; P less than 0.05). In addition, maximum flow at functional residual capacity was significantly decreased (0.824 +/- 0.284 vs. 1.215 +/- 0.358 L/s; P less than 0.01); whereas pulmonary diffusing capacity for carbon monoxide was similar in the patients (7.62 +/- 2.16 mL/min/mm Hg) and in the controls (8.38 +/- 1.6). Pulmonary dysfunction following premature birth, respiratory distress, and prolonged MV may not resolve from infancy to childhood.

[Sudden infant death. Family and socio-cultural state and psycho-affective balance]. / La mort subite du nourrisson. Situation familiale, socio-culturelle, équilibre psychoaffectif.

This analysis presents 400 cases of children at risk for sudden infant death syndrome (SIDS) who were followed at the Port-Royal SIDS-clinic from 1981 to 1984. The 400 cases included: 107 children seen after a severe accident ("near-miss"), 20 twins from pairs stricken by 1 SIDS and 9 twins from near-miss pairs, 264 SIDS-siblings. The following risk factors were searched for: a) low socioeconomical level, b) marital difficulties, c) psychological or psychiatric disturbances in mother and/or father, d) pathological gynecologic and/or obstetric history (sterility, gestational and/or delivery accidents), e) unwanted pregnancy, f) perinatal morbidity. In deaths from SIDS or near-miss infants, 34% cumulated 2 factors, 26% 3 factors, 8% 4 factors; only 2% had no known factor. In addition, a few deaths or severe accidents occurred within a short delay after a travel or a change in daycare; the role of these coincidences should be studied; meanwhile, the authors emphasize the need for a special attention to the quality of the child's environment, as a basic factor for a harmonious development.

Long term outcome of small versus appropriate size for gestational age co-twins/triplets.

BACKGROUND: Small for gestational age (SGA) extremely low birthweight (ELBW < 1000 g) survivors often remain small and/or have subnormal school performance. Some are twins/triplets with larger appropriate size for gestational age (AGA) co-twins/triplets. OBJECTIVE: To assess whether SGA ELBW twins/triplets remain different from their AGA co-twins/triplets. DESIGN, SETTING: During 1981-1999, 353 SGA ELBW neonates were admitted to our neonatal intensive care unit: 267 survived, 54/267 were twins/triplets, and 36/54 had AGA surviving co-twins/triplets. This longitudinal study describes the growth, neurodevelopmental outcome, and school performance of these 36 sets (3-17 years). The children were classified as normal, or having minor, moderate, or severe deficiencies. RESULTS: Values for birth weight (mean intrapair z score difference 2.26), length (2.74), and head circumference (2.62) were lower in SGA neonates than in AGA co-twins/triplets. SGA survivors remained smaller at 3-6 years of age: mean intrapair z score difference in weight, 1.37, height, 1.54, head circumference, 1.21. From 6 to 17 years, smaller differences persisted. Former SGA children had a tendency to have motor deficiencies (nine SGA v three AGA) and mental retardation (seven v four), same hearing loss (two v two), but significantly more visual abnormalities (15 v 11), behavioural disturbances (14 v five), and speech problems (14 v eight). Twenty four sets were in the same normal level class, often supported by familial/professional help. CONCLUSIONS: Although raised in the same environment, SGA ELBW survivors remained smaller and had more visual/behavioural/speech problems, but most maintained grade level parity with their AGA siblings, with appropriate help.

[Maternal effects and perinatal safety of labetalol in the treatment of hypertension in pregnancy. Comparison with methyldopa in a randomized cooperative trial]. / Effets maternels et sécurité périnatale du labétalol dans le traitement des hypertensions de la grossesse. Comparaison à la methyldopa par un essai coopératif randomisé.

Labetalol was compared with methyldopa in a randomised trial involving 176 pregnant women with mild to moderate hypertension. Effective blood pressure control (diastolic pressure below 86 mmHg) was obtained in a similar proportion of mothers given labetalol or methyldopa, but the addition of a complementary treatment to achieve control was less frequently needed in the labetalol than in the methyldopa group (12/91 vs 22/85 p less than 0.05). Side effects were mild and resulted in discontinuation of the randomised treatment in 1 mother given labetalol. Pregnancy was terminated by intrauterine death in 4 mothers given methyldopa, and one neonate born to a patient allocated to labetalol died at day 1. The average birthweight and the proportion of premature delivery or of small for gestational age newborns were similar in both treatment groups. Heart rate, blood pressure, respiratory rate and blood glucose did not differ between infants born to the mothers of the labetalol and the methyldopa groups, irrespective of gestational age at birth or birthweight. Blood pressure control is more frequently achieved in hypertensive pregnancies with labetalol than with methyldopa as a first line treatment. Labetalol is safe to the fetus and newborn and might offer a better prevention of intrauterine death than methyldopa.

[Importance of fetal sensorial capacity in the establishment of mother-child exchange during pregnancy]. / Importance de la sensorialité foetale dans l'établissement d'un échange mère-enfant pendant la grossesse.

The very early establishment of certain sensory faculties turns the fetus into a being capable of perceiving multiple stimuli. This perceptive capability participates in the many interchanges between the mother and her developing child. The good quality of psychoaffective communication between the mother and her child during pregnancy appears to be decisive for the fetal, perinatal, and later development of the child, especially for an harmonious brain growth. The risks of sensory and sensori-affective overstimulation are considered.

[Kangaroo method and care]. / Méthode et soins kangourou.

The kangaroo-mother method was initiated by colombian pediatricians in 1979. The method is based on a permanent skin to skin contact of low birth weight infants with their mother. It has spread out in many developing countries as an alternative cheap method for the care of low birth weight infants with several advantages: temperature regulation, prolonged breast-feeding, promotion of mother-infant interaction, decreased mortality. The kangaroo method has been adapted in European countries as kangaroo care that consists in daily mother-infant skin to skin contact during few hours. Introducing the incubator in the mother's room is an other derivative of the method which allows prolonged early contact of the mother with her infant. A major interest of these methods is that they favour parent-infant interaction; however this requires qualified and devoted staffs.

[Evaluation of peri-intraventricular hemorrhages in newborn infants taking into account laterality and parenchymal location. Application to 323 consecutive cases]. / Cotation des hémorragies péri-intraventriculaires (HPIV) du nouveau-né avec prise en compte de la latéralité et de la localisation parenchymateuse. Application à 323 cas consécutifs.

An abbreviated scoring system for PIVH was derived from Papile's one: completed by a 0 for normal pattern, abcd divisions of each cerebral hemisphere for localization of parenchymal haemorrhages, and scoring of each side separately. The scoring system was applied to a consecutive series of 323 PIVH (1981-1984). Unilateral haemorrhages (123) accounted for 38% of all PIVH; they were almost exclusively grade I and II, and more frequently left-sided: 90 left and 33 right H. Of 200 bilateral haemorrhages, 127 were of equal severity on both sides, but left H. were more severe than right ones in 46/73 asymmetrical bilateral H. The survival rate was 91% in overall grade I H., 84% in overall grade II H., with little difference between uni- and bilateral H., 43% in overall grade III H. (34% in bilateral grade III), 28% in overall grade IV H. (1/11 in bilateral grade IV H). The extent of parenchymal H. only bore a partial relationship to the severity of the associated SEH-IVH, only half of the parenchymal haemorrhages being associated with grade III IVH on the same side, and only half of the unilateral PH being associated with a more severe SEH-IVH on the same side. The various former scoring systems have been reviewed. The interest of assessing both cerebral hemispheres separately and of evaluating the extent and location of PH is stressed.

[Acute retinopathy of prematurity following oxygen therapy: current concepts (author's transl)]. / Données actuelles sur la rétinopathie aiguë du prématuré sous oxygénothérapie.

Five cases of retinopathy of prematurity have been observed among 1,750 premature infants at the Florence Geller Center in Cochin-Port-Royal--C.H.U. over a period of four years. In all cases, arterial PaO2 was more than 100 mmHg at least once. In the two worst cases, oxygen therapy given only during the first had been hours of life. The authors insist on the dangers of oxygen overdose immediately after birth or during transport to a Premature Infants Center. Laser photocoagulation was employed in four eyes: 2 with regression, 1 with cicatrisation, 1 with fibroplasia. Retinopathy of prematurity remains a danger in France, even if it is not as frequent as in the U.S.A. or Japan. Indirect ophthalmoscopy is essential for diagnosis and fluorography very useful to determine prognosis and treatment.

[Neonatal cystic leukomalacia. Perinatal case histories of 30 survivors]. / Leucomalacies kystiques néonatales. Anamnèse périnatale chez 30 survivants.

In 30 surviving neonates, close prolonged ultrasonographic brain studies demonstrated cystic periventricular leucomalacias (CPVL) of varying degree (11 minor forms, 12 moderate forms, 7 severe forms). Clinical histories were reviewed for each case. There were 18 boys, 4 twins, 2 small-for-dates. Mean gestational age was 31 +/- 2 weeks, mean birthweight was 1532 +/- 356 g. No pregnancy was normal, but prenatal events were of a common occurrence in 26/30 cases (premature labor, toxaemia, twins...). Immediate perinatal events included cord difficulties in 5 cases (3 tight cords around the neck, 1 prolapse, 1 case where loose cord around the neck came down with the head), abruptio placentae (2), acute fetal distress (10, of which 8 were severe), Apgar scores 0-1 (9, of which 7 occurred after fetal distress and 2 were unexpected). In four cases, CPVL were of antenatal origin (already in the cystic stage on days 1-2). In 2 cases, CPVL occurred postnatally (infective shock on day 1 and day 46). Plausible mechanisms for anoxic-ischaemic lesions could only be found in 13 cases and remained unknown in the other 17. However, clinical histories suggested the following; cumulative minor events might become as damaging as single major events; "minor" fetal distresses should be scrutinized; pregnant women should be taught not to wait until late to arrive at hospital because this results in non-monitored delivery. No obvious relationship was found between the severity of known events and the degree of CPVL, but a number of pre- and perinatal periods were poorly monitored. The legal importance of early ultrasonographic studies was stressed.

[In vitro fertilization neonates transferred to neonatal medicine. Mid-and long-term outcome in 99 families]. / Nouveau-nés de FIV transférés en Médecine Néonatale: devenir de 99 familles à moyen et long-terme.

OBJECTIVE: To assess the physical and neurodevelopmental status of children born after in vitro fertilization (IVF) as well as the family condition. DESIGN: Follow-up study including physical and developmental examination in available families, and/or interviews of parents/pediatricians/teachers/social workers. SETTING: The Port-Royal neonatal intensive care unit and follow-up clinic. SUBJECTS: From 1.1.1987 to 31.12.1992, in 32 single, 71 twin, 28 triple, and one quadruple pregnancies resulting from IVF (total 132), one or more neonates were admitted to the Port-Royal NICU. The outcome is presented for the 99 families followed longer than two years (199 neonates, 166/199 born prematurely). MAIN OUTCOME MEASURES: Neurological sequelae (minor, moderate, major), developmental quotients, school level, behavioral disturbances, family conditions. RESULTS: From 21 singletons (2 deaths, 1 lost), 18 survivors were followed: 17 were normal above 2 years (10 above 3 years went to school), 1 had a severe cerebral palsy with low IQ. From 57 twin pregnancies (7 fetal and 9 neonatal deaths), the 98 survivors were followed: 78 were normal above 2 years (65 above 3 years went to school), 20 had some neuro-developmental deficits (of 14 above 3 years, 12 went to school); 25 families had had or still had problems (deaths and/or anomalies (9 cases) and/or sequelae); 3 mothers were single parents (2 divorces and one split). From 20 triple pregnancies (1 fetal and 3 neonatal deaths), 54 out of 56 survivors were normal above 2 years (33 above 3 years went to school); 3 siblings (1 deaf and 1 with cataract) were put in foster care after severe maternal beating; 2 mothers were single parents (one divorce and one split); 4 mothers had repeated breakdowns; one father tried suicide. From one quadruple pregnancy (one fetal and one neonatal deaths), the 2 survivors were normal above 3 years and went to school. Most sequelae involved very low birthweight babies, in association with a number of sleep and behavioural disturbances. From 98 mothers, 16 had 18 spontaneous pregnancies (11 full-term newborns, 5 miscarriages, 1 extra-uterine pregnancy, 1 abortion) and 3 mothers had another IVF pregnancy (a few others had IVF failures).

[Mid- and long-term outcome of 77 triplets and their families]. / Devenir à moyen et long-terme de 77 fratries de triplés et de leurs familles.

OBJECTIVE: To compare the family status and neurodevelopment of triplets conceived by spontaneous pregnancy (SP), ovarian stimulation (OS), in vitro fertilization (IVF), and gametal intra-fallopian transfer (GIFT). DESIGN: A follow-up study consisted of neurodevelopmental examination and/or of interviews of parents/pediatricians/teachers and social workers. Outcome of the children was categorized as defective (mild, moderate, severe) or normal. SETTING: The Port-Royal neonatal unit and follow-up clinic. SUBJECTS: From 1/01/1987 to 31/12/94, one to all three neonatal triplets were admitted to the Port-Royal neonatal unit. Pregnancy was SP in 12, OS in 24, IVF in 36, GIFT in 5. All survivors (36 SP, 68 OS, 98 IVF, 14 GIFT) were included and their outcome (at 3 to 10 years of age) was known in 75 families. RESULTS: Prematurity < 32 weeks was highest in the SP pregnancies, with no birth > 37 weeks, and more small-for-dates babies. As of this writing, the neurodevelopmental status was normal or included only a mild deficit (mainly visual corrections) in 82% of SP survivors, 94% of OS survivors, 98% of IVF survivors, all 14 GIFT survivors. Moderate and major deficits were found in one or two siblings of 7 sets of triplets, 5 of which were born < 32 weeks (1 SP, 3 OS, 1 IVF). In all groups, family status was characterized by the need to move, financial problems, maternal exhaustion and parental breakdowns. Five OS mothers, 5 IVF mothers, and one GIFT mother each had one to three subsequent SP pregnancies. In 1997, all families included one to eight children. Because of the cumulative effect of losses, deficits, and other post-natal difficulties, only one of four families had no problems. CONCLUSION: The overall outcome of surviving triplets is good but they are both a prenatal and post-natal hardship for the parents, chiefly the mother. We advocate a more cautious use of OS, no triple implantation at the first IVF, and more social help and guidance for the families during the pregnancy and the first 3 years of life of the triplets.

[Neonatal listeriosis. Apropos of 53 cases]. / Listériose néonatale. A propos de 53 cas.

53 cases of neonatal listeriosis were seen during the last five years at the Intensive Care Unit for newborn infants (Pr Minkowski) and the Neonatal Center (P. Varangot) of the Port-Royal Maternity Hospital. The significant decline in mortality to 22 p. 100, when compared with previous years, was attributed to improvements in the diagnosis during the first hours of life and the contribution of artificial ventilation. The most frequent initial clinical sign was respiratory distress (58 p. 100) whereas meningitis was relatively rare (11 p. 100). Discoloration of the amniotic fluid and a fever in the mother at the time of delivery, were also important diagnostic clues. The macroscopic examination of the placenta and particularly placental smears containing listeria monocytogenes (15 of the specimens) as well as the hematological alterations, particularly an increase of the fibrinogen level above 3-4 g/1 during the first 48 hous of life (72 p. 100 of the cases) contributed to an early diagnosis.