Somatic growth from birth to 6 months in low birth weight, in Bukavu, South Kivu, Democratic Republic of the Congo.

BACKGROUND: Low birth weight (LBW) is one of the leading causes of perinatal and infant morbidity and mortality, as well as of impaired growth and neurocognitive development. This study aimed to evaluate the evolution of anthropometric parameters and the nutritional status of LBW infants and to analyze factors influencing the growth failure during their first 6 months of life (or adjusted age). METHODS: This was a prospective cohort study for 6 months, including 100 infants born with LBW and 100 infants born at full-term and with normal weight. The z-scores weight for age, height for age, head circumference for age and weight for height were computed with the software Epinut and WHO Anthro 2005. Descriptive statistics, bivariate analysis and multivariable logistic regression analyses were employed to identify factors associated with growth failure. Growth failure was defined as a decrease in weight z-score (standard deviation score) of over 0.67 during one of the study's periods. The statistical significance threshold was fixed at 0.05. FINDINGS: At 6 months of life (or adjusted age), 15.3% of LBW were underweight, 51.4% were stunted, 4.2% had an emaciation and 25% had a head circumference for age<-2 z-scores. Risk factor for growth failure was male sex (OR=1.56 [95% CI: 1.03-2.23]). The symmetrical intra-uterine growth retardation was a protector factor for growth failure (OR=0.49 [95% CI: 0.25-0.98]). CONCLUSION: In the short term, LBW infants may have growth disorders. It is necessary to emphasize the importance of growth assessment of LBW children and proper education of their mothers about nutrition of their children for early and timely diagnosis and management of growth retardation and prevention of subsequent problems.

[How I EXPLORE ... AN APPARENT LIFE THREATENING EVENT OF THE INFANT]. / COMMENT J'EXPLORE ... le malaise du nourrisson.

The ALTE (Apparent Life Threatening Event) of the infant is a frequent presenting complaint. The clinical presentation is varied, ranging from an innocuous event (as a change in skin color) to something as tragic as a sudden infant death. In all circumstances, it is always a very worrying event for the parents and the family circle. Many etiologies can explain the ALTE, and their investigation can be complicated. In this paper, the etiologies and diagnostic tests will be briefly introduced, with a reminder of the sudden infant death syndrome.

[How to assess and manage the acute phase of an asthma episode in children]. / Comment je traite ... un asthme bronchique inaugural ou déstabilisé de manière aiguë chez l'enfant.

Asthma is the most common chronic respiratory disease in childhood. An acute crisis can occur during an episode of exacerbation or may be the onset of the disease in a non-asthmatic child. Acute asthma is most often manifested by signs of respiratory distress that will lead the child to the doctor. Regardless of the context, the crisis has to be quickly and efficiently handled. The assessment of the crisis severity, immediate care, treatment and monitoring will be discussed in this article.

[How to explore...nosocomial infections in neonatology]. / Comment j'explore...Les infections nosocomiales en néonatologie.

Nosocomial infections (NI) remain a major problem of public health, giving rise to a serious morbi-mortality and significant costs. They represent a consequence of the medical progress and of the misuse of broad-spectrum antibiotics. Obviously, premature newborn of low birth weight present an increased risk of NI related to their degree of immaturity, as well as the invasive procedures use, and long-lasting hospitalizations.. Epidemiological data concerning NI in neonatology remain imprecise due to diagnostic difficulties. Responsible germs are related to the territory and its local ecology. Bacterial NI are the most frequent even if viral and Candida NI are widely underestimated and gradually gain ground.The medical and economic consequences of these infections justify prevention measures such as prematurity prevention and management of pregnancy taking into account the NI risk. Finally, simple measures such as a strict hygiene in newborn care and the limitation of invasive procedures in terms of frequency and duration have to be a priority.

[Septic arthritis of undetermined origin in children: a proposal for the assessment and its therapy]. / Une arthrite septique d'origine indéterminée chez l'enfant.

Septic arthritis is not a frequent, but quite classical pathology in children. It can be followed by a severe outcome in case of delayed and/or inadequate treatment. The drainage of the infected joint associated with a prompt and adapted antibiotherapy are together the cornerstones of this treatment. The isolation and identification of the causative microorganism is also of the highest importance. Up to now, unfortunately, a large proportion of septic arthritis are treated by antibiotics although all culture remain negative. This paper has two objectives: one is to present the different steps to optimize the assessment and diagnosis; the second, to increase the sensitivity of the pathogen identification. At last, we present our proposal for empirical antibiotherapy.

[How to explore and treat ... a mucous otitis in the child]. / Comment j'explore ... une otite séromuqueuse chez l'enfant.

About nine children out of ten present at least one episode of otitis media with effusion (OME) before school age and near a third suffer from persistent or repetitive OME, which involves a higher risk of speech difficulties and of reduced learning abilities. The care of children with repeated or persistent OME remains a debated topic. The assessment of the risk of speech difficulties should go beyond the quantification of the hearing deficit. It should also take into account the context in which the disorder has developped and detect any comorbidity from which the child might suffer. Based on these various considerations, it will be necessary to assess the value of an immediate surgical treatment as opposed to the risks of a prolonged observation period.

[How to improve therapeutic compliance in the asthmatic pediatric patient]. / Comment pouvons-nous pratiquement améliorer l'observance thérapeutique dans l'asthme de l'enfant et de l'adolescent?

Asthma is a chronic disease the control of which often requires a day-to-day treatment. The compliance in childhood asthma is estimated at 50%. It is therefore mandatory to resort to strategies for good compliance. Starting from a literature review and the concept of Guided Self-Management defined in the GINA 2009 report, our pneumo-paediatric unit offers a local, useful and efficient strategy based on close collaboration with the family doctor, an Internet asthma school or DVD and the edition of a clear asthma treatment plan, which can easily be filled in by the physicians.

[Inertia or overtreatment in children. When sleeping time is disturbed in infants: how to improve the family's distress]. / Inertie ou excès thérapeutique chez l'enfant: lorsque le sommeil de l'enfant n'est pas de tout repos pour lui, ses parents et le médecin.

Sleeping disorders are frequently encountered in infants and adolescents. They often induce a distress in the family, an individual sadness possibly leaving at time to maltreatment. In the normal infant or the medically fragile infant due to prematurity or an acute episode, complaints from the patient or family sources force the medical team to find an explanation or a treatment, which are not always adequate. In other conditions such as asthma, obesity, anorexia nervosa, autism, cerebral palsy, hyperactivity, the sleeping disorders may be so unnoticed or remain insufficiently investigated. Globally, in this domain, the clinical description is often imprecise and sleep studies underused. A more accurate assessment should lead to a better educative approach and more appropriate therapy.

[How to explore ... a cervical mass in the child]. / Comment j'explore ... une masse cervicale chez l'enfant.

The discovery of a cervical mass in a child suggests several possible diagnoses ranging from benign conditions to more severe pathologies, even cancer. Parents often worry and consult a physician when such a mass fails to regress after a few weeks. Palpation of small and solid lymph nodes is commonplace and generally trivial in children. A detailed clinical history and a careful examination often allow a distinction to be made between a benign and a serious condition. Additional tests are needed in case of doubt or in the prospect of reaching an precise aetiological diagnosis. These exams should be selected according to a decision algorithm. The investigation remains delicate. When the physician is convinced of the benign nature of the lymphadenopathy, there is no real need to identify the aetiology with the greatest precision, especially in acute cases with bilateral nodes that are commonly benign and spontaneously resolve.

[Practical pediatric aspects of palivizumab]. / Anticorps monoclonaux en pédiatrie. Palivizumab (Synagis): indications et aspects pratiques.

Palivizumab (Synagis) is a monoclonal antibody directed against the respiratory syncytial virus (RSV), for reducing mortality and morbidity in infants at risk of cardio-respiratory impairement due to bronchiolitis: 1. prematurity less than 28 weeks and less than 1 year of age; 2. between 28 and 32 weeks plus mechanical ventilation and less than 6 months of age; 3. chronic lung deficiency and less than 2 years of age; 4. congenital cardiopathy with either desaturation, pulmonary hypertension or cardiac failure. Another group of infants is those having a severe imnnunodeficiency. These infants are listed in a hospital recognized to have a competence in neonatal intensive care or a cardio-thoracic care program. The specialist in those disciplines prescribe the palivizumab which is delivered by the pharmacy of the competent hospital. The infant receives it by IM route at a dose of 15 mg/kg, monthly between October or November and February or March. Reduction of mortality and morbidity have been observed in the infants at risk. However, this costly pharmacological preventive approach needs to come after other simple preventive measures such as avoiding contact with potential carriers of nasal viruses and passive smoking, for bronchiolitis is not solely due to RSV.

[Assessment of developmental outcome of preterm babies]. / Bébé prématuré, bébé particulier? Quel suivi développemental?

Increasing survival of very preterm and sick neonates has lead to more concern about development outcome. Risk factors include antenatal, perinatal and socioeconomic factors. Developmental assessment has to be repeated during infancy till late school age (at term 3, 6, 12, 18, 42 months corrected age ...). Neurological examination, sensorial assessment and cognitive evaluation with special attention to visuo-spatial factors are mandatory.

[Prematurity and infant-parent attachment disturbances. Assessment and intervention]. / Le prématuré confronté aux troubles de l'attachement parents-enfant. Prévention et prise en charge.

Premature birth is a factor of impaired infant-parent attachment. In addition it is frequently associated with other factors of impaired attachment related either to the infant (mainly the various pathologies of the premature infants and the hospitalization) and/or to the parents, specially the mother. The main characteristics of the normal process of infant-parent interaction are described as a basis for the early recognition and assessment of impaired interaction and preventive intervention.

Adaptation in neonatology of the once-daily concept of aminoglycoside administration: evaluation of a dosing chart for amikacin in an intensive care unit.

BACKGROUND: The bactericidal efficacy of aminoglycosides is directly related to peak serum concentration (Cmax), particularly the first one. Transitory high concentrations of aminoglycosides do not result in such a high drug uptake by renal and cochlear tissues because of the saturation of cell binding sites. These observations have led to the concept that less frequent administration of relatively larger doses of aminoglycosides would be of interest in treating infectious diseases. OBJECTIVE: Prospective evaluation of a dosing chart of amikacin (Ak) in high-risk neonates suspected of infection within the first 2 days of life. This dosing chart was based on a previous pharmacokinetic population study published elsewhere, treated accordingly to the new once-daily concept of aminoglycoside administration. STUDY DESIGN: One hundred and seventy-seven neonates (69 females and 108 males; mean gestational age (GA +/-SD: 33.6 +/- 4.1 weeks (W) received Ak regimen dosage according to the following dosing chart: Group (Gr) 1a GA <28 W: 20 mg/kg/42 h; Gr 1b GA 28 /= 37 W: 15.5 mg/kg/24 h. In case of asphyxia, hypoxic episode and intercourse treatment with indomethacin, the interval was systemically increased by 6 h whatever the GA groups. The mean duration time of Ak treatment (+/- 1 SD) was 5.00 +/- 2.01 days (range 2-13). Ak serum concentrations 1 h after completion of 30 min infusion (C1h), and successive Ak serum concentrations just before next administration depending on the difference of interval between each group (so defined minimum serum concentration (Cmin)), were determined in each neonate. Creatininemia during the fist postnatal weeks was used as an index of glomerular filtration rate; brainstem auditory evoked potentials (BEAPs) were used in 139 babies when reaching a postconceptional age of >/= 36 weeks to assess possible ototoxicity, and were compared to values from a group of term and a group of preterm babies, previously defined as our reference control groups. RESULTS: At day 1 of treatment, there was no correlation between the Ak C1hS and the GA at birth (mean 27.8 +/- 5.21 microgram/ml (+/- 1 SD); median 28; r = -0.003; range 10-40). In the same way, there was no correlation between the first Ak CminS and the GA at birth (mean 3.7 +/- 2.0 microgram/ml (+/- 1 SD); median 3.0; r = -0.33; range 0-10). The lack of correlation between these first observed C1hS and CminS and the GA at birth suggests the validity of our previous established dose regimen recommendations. Analyzing the data between groups, the mean value +/- 1 SD of Ak C1hS at day 1 of treatment was not significantly different (p > 0.05). Concerning the first Ak CminS, a significant difference (p < 0.01) was only observed when comparing groups 1a, 1b and 2 to group 4. However, this significant difference disappeared when comparing the successive next Ak CminS between groups while each interval remained the same, suggesting a positive postnatal maturation of the renal clearance. In the same way, creatininemia showed a significant and normal decrease (p < 0.01) in each group during the first postnatal weeks. Threshold values of BEAPs at 30 dB showed no significant difference (p > 0.05) between the treated groups (preterm group and term group) and the corresponding control groups. While the primary aim of the study was not to test the bactericidal efficacy of this new regimen, the recovery was excellent in 37 babies with proven or highly suspected infectious disease, except in 1 of them who died from septic shock (group B Streptococcus). After 5 years of using this kind of Ak administration in the unit, minimal inhibitory concentration profiles tested in 43 successive bacterial strains collected from inborn patients remained adequate. (ABSTRACT TRUNCATED)

High-frequency oscillatory ventilation in neonatal RDS: initial volume optimization and respiratory mechanics.

To determine whether initial lung volume optimization influences respiratory mechanics, which could indicate the achievement of optimal volume, we studied 17 premature infants with respiratory distress syndrome (RDS) assisted by high-frequency oscillatory ventilation. The continuous distending pressure (CDP) was increased stepwise from 6-8 cmH2O up to optimal CDP (OCDP), i.e., that allowing good oxygenation with the lowest inspired O2 fraction. Respiratory system compliance (Crs) and resistance were concomitantly measured. Mean OCDP was 16.5 +/- 1.2 cmH2O. Inspired O2 fraction could be reduced from an initial level of 0.73 +/- 0.17 to 0.33 +/- 0.07. However, Crs (0.45 +/- 0.14 ml . cmH2O-1 . kg-1 at starting CDP point) remained unchanged through lung volume optimization but appeared inversely related to OCDP. Similarly, respiratory system resistance was not affected. We conclude that there is a marked dissociation between oxygenation improvement and Crs profile during the initial phase of lung recruitment by early high-frequency oscillatory ventilation in infants with RDS. Thus optimal lung volume cannot be defined by serial Crs measurement. At the most, low initial Crs suggests that higher CDP will be needed.

The Provo multicenter early high-frequency oscillatory ventilation trial: improved pulmonary and clinical outcome in respiratory distress syndrome.

OBJECTIVE: To compare the hospital course and clinical outcome of preterm infants with respiratory distress syndrome treated with surfactant and managed with high-frequency oscillatory ventilation (HFOV) or conventional mechanical ventilation (CV) as their primary mode of ventilator support. DESIGN: A prospective randomized clinical trial. SETTING: Three community-based level III neonatal intensive care units. SUBJECTS: A total of 125 neonates who were 35 weeks or less estimated gestation requiring intubation and assisted ventilation for respiratory distress syndrome with arterial to alveolar oxygen ratio less than .50. INTERVENTIONS: Patients were randomized to continue CV (61 patients) or be changed to HFOV (64 patients) after exogenous surfactant administration (100 mg/kg). HFOV was used in a strategy to promote lung recruitment and maintain lung volume. Protocol respiratory care guidelines were followed; otherwise routine care was provided by each neonatal intensive care unit. MEASUREMENTS AND MAIN RESULTS: No differences were noted in demographic features between the two study groups. The study population birth weight was 1.51 +/- .47 kg (mean +/- SD), gestational age was 30.9 +/- 2.5 weeks, and study entry age was 2 to 3 hours. Patients randomized to HFOV demonstrated the following significant findings compared with CV-treated patients: vasopressor support was less intensive; surfactant redosing was not as frequent; oxygenation improved more rapidly and remained higher during the first 7 days; fewer infants required prolonged supplemental oxygen or ventilator support; treatment failure was reduced; more patients survived without chronic lung disease at 30 days; need for continuous supplemental oxygen at discharge was less; frequency of necrotizing enterocolitis illness was lower; there were fewer abnormal hearing tests; and hospital costs were decreased. No differences were seen between the two study groups in the frequency or severity of patent ductus arteriosus, air leak, retinopathy of prematurity, or intraventricular hemorrhage. Length of hospital stay and survival to discharge were similar for HFOV- and CV-treated infants. CONCLUSIONS: When used early with a lung recruitment strategy, HFOV after surfactant replacement resulted in clinical outcomes consistent with a reduction in both acute and chronic lung injury. Benefit was evident for preterm infants both less than or equal to 1 kg and more than 1 kg. In addition, early HFOV treatment may have had a more global effect on patient health throughout the hospitalization, resulting in reduced morbidity and decreased health care cost.

Once-a-day administration of amikacin in neonates: assessment of nephrotoxicity and ototoxicity.

Neonates, especially preterms, are known to have low glomerular filtration rates (GFR). This may result in elevated trough concentrations during multiple administration of aminoglycosides (AGs), potentially leading to nephro- and ototoxic reactions. The once-daily administration (q.d.) of AGs has been shown to be equally or better tolerated in adults and children than the conventional schedules (twice daily, b.i.d.; thrice daily, t.i.d.), while offering potential pharmacodynamic and nursing advantages. No data, however, are available for neonates. As a consequence, this pilot study was conducted in order to assess the tolerance of the once-a-day administration of amikacin in comparison with the twice daily dose regimen, in relation to the pharmacokinetics of the drug under these two schedules. 22 Male neonates (gestational age > or = 34 weeks; postnatal age < or = 2 days) were randomized to receive amikacin (AK) (15 mg/kg/day) q.d. (n = 10) or b.i.d. (n = 12) together with ampicillin (50 mg/kg/12 h). AK plasma levels were measured at days 1, 3, 5 and 7 of treatment just before the next dose (trough level) and 1 h after completion of infusion (peak level) and after 3 and 6 h only at day 1. Due to the small size of the samples, no difference in efficacy could be assessed and was not the aim per se. Glomerular dysfunction was assessed by creatinine clearance, and tubular injuries by the urinary excretion of proteins (retinol binding protein, beta 2-microglobulin, clara cell protein (P1) and microalbumin), enzymes (N-acetyl-beta-D-glucosaminidase, alkaline phosphatase, alanine aminopeptidase, and gamma-glutamyltransferase), and total phospholipids (TPL) in urine. Ototoxicity was assessed by brainstem auditory evoked potentials (BAEPs) at days 0, 3 and 9 of therapy. Eight healthy neonates served as controls. All patients showed a normal and similar increase of GFR during the first postnatal days. Proteinuria did not increase, but enzymuria and TPL increased significantly during the treatment in both AK groups without significant difference between groups. BAEPs at day 9 were not significantly different between treated and untreated patients. We conclude from this pilot study that, in the absence of more toxicity, the q.d. administration of AK in neonates of > or = 34 weeks of gestational age may be recommended over its bid schedule in view of its potential advantages.

Maillard reaction products and lysinoalanine: urinary excretion and the effects on kidney function of preterm infants fed heat-processed milk formula.

Heat processing is essential for the preservation of milk-based infant formulas. Heating, however, induces a number of chemical changes during which lysine in the milk proteins reacts with reducing sugars to form Maillard reaction products (MRPs) and also reacts with the dehydroalanine resulting from cystine degradation to form lysinoalanine (LAL). Both products have been reported to induce histological changes in the straight portion of the proximal tubule in the rat kidney. This pilot study was made to investigate the urinary excretion by healthy preterm babies of MRPs and LAL contained in infant formula and to determine their influence on kidney function. Twelve healthy male preterm babies were first fed for 10 days with pooled human milk and then for 5 days with each of two experimental premature infant formulas in a cross-over design. The infant formulas were sterilized either by ultra-high temperature (UHT) treatment or by a conventional retort process to give products with low and high levels of MRPs and LAL, respectively. In total, some 15.6% of the initial lysine had been modified in the in-can-sterilized product, compared to 6.2% in the UHT product. Urinary excretion of MRP lactulosyllysine ranged from 1.3 to 3.9% of the ingested amount, whereas that of LAL ranged from 6.2 to 9.3%. The higher level of MRPs and LAL in the formulas compared to breast milk had no influence on creatinine clearance or electrolyte excretion. There was no evidence of tubular damage as determined by the urinary excretion of four kidney-derived enzymes. Feeding of formula, however, did result in a general increase in urinary microprotein levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Phosphorus intake in preterm babies and variation of tubular reabsorption for phosphate per liter glomerular filtrate.

Inadequate low intake of phosphorus can induce a hypophosphatemic depletion syndrome resulting in hypercalcemia, hypercalciuria, hypophosphatemia, and rickets. Tubular reabsorption for phosphate per liter glomerular filtration rate (TP/GFR) has been proposed as a reliable index of renal phosphate handling for all age groups. In the present study, carried out in 12 healthy premature babies fed unmodified pooled human milk and then a preterm formula for two periods of 10 days, we demonstrated clearly that TP/GFR as well as calciuria can reflect the poor phosphorus intake and that the kidney of preterm babies is able to rapidly adapt itself to an increase in phosphorus diet content.