Transient pseudohypoaldosteronism: a potentially severe condition affecting infants with urinary tract malformation.

BACKGROUND: Secondary pseudohypoaldosteronism (S-PHA) is a life-threatening condition affecting young children with urinary tract malformation (UTM). OBJECTIVE: The aim of the study was to highlight the diagnosis of S-PHA in children with UTM and propose appropriate management. STUDY DESIGN: The authors retrospectively reviewed cases of S-PHA related to UTM observed at the institution and searched the PubMed® database to review the literature. RESULTS: A total of 116 cases of S-PHA associated with UTM, including the four cases from the institution, were reviewed. One hundred six cases (92.2%) were younger than 6 months, and 95 cases (81.9%) occurred in boys. Urinary tract infection was associated in 105 cases (90.5%). All types of UTM were observed. In the absence of urinary tract infection, S-PHA was related to bilateral UTM or solitary kidney. In 89 cases (76.5%), S-PHA resolved with medical treatment only. In cases of UTM requiring immediate surgery, electrolyte imbalance related to S-PHA also resolved after surgery. Children with associated urinary tract infection and bilateral UTM are at higher risk of developing S-PHA. DISCUSSION: The pathogenesis of S-PHA has not been fully elucidated. Renal tubular immaturity may be one of the factors involved, in view of the young age of the population being affected. A high rate of bilateral UTM (or UTM on solitary kidney) was observed (50.9%), suggesting an association with S-PHA. In the absence of urinary tract infection (UTI), S-PHA appeared to occur more frequently in the presence of bilateral UTM. Although the indication for early surgery remains unclear, it may have a role in the prevention of UTI and prevention of recurrence of S-PHA. Serum electrolytes should be checked in children with UTM before urological surgery, and/or presenting urinary tract infection, before the age of 6 months. The results of this study must be interpreted cautiously because of its retrospective nature and the fact that data were derived from various articles. Few articles on S-PHA related to UTM have been published in the literature. To the best of the authors' knowledge, the study constitutes the largest series published to date. CONCLUSIONS: S-PHA results in potentially severe electrolyte imbalance and affects children younger than 6 months with UTI and/or UTM. Electrolyte abnormalities related to S-PHA often resolve after administration of appropriate intravenous electrolyte solution and treatment of UTI and/or surgery.

Prospective follow-up of a cohort of preterm infants<33 WG receiving ketamine for tracheal intubation in the delivery room: Neurological outcome at 1 and 2 years.

OBJECTIVE: Although ketamine analgesia is effective in reducing pain and facilitating the tracheal intubation of newborns in the delivery room, no data on the neurological effects of this treatment are available. This study compared the neurodevelopmental outcomes at 2 years of age in a cohort of preterm newborns having received ketamine prior to tracheal intubation at birth (the ketamine group) and in a control group. METHODS: We included newborns delivered at less than 33 weeks gestational age (WGA) having undergone tracheal intubation at birth. The Ages and Stages Questionnaire (ASQ) was completed at 1 and 2 years of age. The development quotient (DQ) was calculated from the revised Brunet-Lezine score assessed at a corrected age of 2 years. RESULTS: There were no statistically significant differences between the ketamine group (n=54 at 1 year and n=51 at 2 years) and the control group (n=16 at 1 and 2 years) in terms of the mean±standard deviation DQ at the age of 2 (98±12 vs. 103±9, respectively; P=0.17) and the ASQ score at the age of 2 (221±44 vs. 230±39, respectively; P=0.55). DISCUSSION: This prospective cohort of 51 preterm newborns having received ketamine at birth did not reveal any differences in terms of neurological development at the age of 2 (relative to a control group and the literature data). These preliminary results must be confirmed in a randomized trial with longer follow-up.

[Clinical criteria for pathogen bacteria in term newborn suspected of neonatal sepsis]. / Critères cliniques en faveur d'un portage de germe pathogène chez le nouveau-né à terme suspect d'infection néonatale bactérienne précoce.

BACKGROUND: Neonatal early onset sepsis (EOS) remains an important etiology of neonatal morbidity and mortality. Diagnosis is difficult due to a lack of sensitivity and specificity markers. In France, the management of newborn infants suspected of infection includes the analysis of gastric suction. The objective of the study was to identify early clinical signs in newborn infants with suspected neonatal sepsis to differentiate a likely infection with pathogen bacteria in the gastric suction culture (Streptococcus agalactiae or Escherichia coli) from a possible infection without such pathogen bacteria. METHODS: We conducted a retrospective study in the Amiens University Hospital. All term newborn infants born between 1 January and 31 December 2013 and hospitalized for suspected EOS were included. Suspicion of EOS was considered when there were arguments to treat by antibiotics for a period of at least 5 days. RESULTS: Fifty-eight newborn infants were included, 25 had a likely EOS and 33 a possible EOS. Newborn infants with a likely EOS were less mature (P<0.01) with more clinical signs at birth (P<0.01). The most common clinical signs were: hyperthermia (P=0.01), somnolence (P<0.01), and hypotonia (P=0.01). After adjusting for the term, the presence of hyperthermia was no longer significantly different between the two groups (P=0.059), the other clinical signs remained significantly different. CONCLUSION: The presence of neonatal symptoms at birth appears to be a useful clinical marker of probable neonatal EOS.

Plasticity of neonatal neuronal networks in very premature infants: Source localization of temporal theta activity, the first endogenous neural biomarker, in temporoparietal areas.

Temporal theta slow-wave activity (TTA-SW) in premature infants is a specific signature of the early development of temporal networks, as it is observed at the turning point between non-sensory driven spontaneous local processing and cortical network functioning. The role in development and the precise location of TTA-SW remain unknown. Previous studies have demonstrated that preterms from 28 weeks of gestational age (wGA) are able to discriminate phonemes and voice, supporting the idea of a prior genetic structural or activity-dependent fingerprint that would prepare the auditory network to compute auditory information at the onset of thalamocortical connectivity. They recorded TTA-SW in 26-32 wGA preterms. The rate of TTA-SW in response to click stimuli was evaluated using low-density EEG in 30 preterms. The sources of TTA-SW were localized by high-density EEG using different tissues conductivities, head models and mathematical models. They observed that TTA-SW is not sensory driven. Regardless of age, conductivities, head models and mathematical models, sources of TTA-SW were located adjacent to auditory and temporal junction areas. These sources become situated closer to the surface during development. TTA-SW corresponds to spontaneous transient endogenous activities independent of sensory information at this period which might participate in the implementation of auditory, language, memory, attention and or social cognition convergent and does not simply represent a general interaction between the subplate and the cortical plate. Hum Brain Mapp 38:2345-2358, 2017. © 2017 Wiley Periodicals, Inc.

[Noise level in the NICU: Impact of monitoring equipment]. / Nuisances sonores en réanimation néonatale : impact d'un outil de monitorage.

BACKGROUND: The sound level in the neonatal intensive care unit (NICU) may induce adverse effects for neonates, their family, and the staff. This study evaluated the sound level in a NICU before and after the implementation of an educational program. MATERIAL AND METHODS: A baseline audit determined the most exposed area of the NICU and the most exposed periods over 24 h. Then an educational program started, including sound level measurement methods, side effects for neonates, results from the baseline audit, and new visual monitoring equipment (SoundEar®). Sound levels were measured before, 1, 2, and 3 months after starting the educational program and the use of SoundEar®. The NICU staff was blind to the periods of sound level measurements. RESULTS: The base noise level was high, especially near the central part of the NICU and during transmission time (mean Leq: 60.6±3.6dB(A); sound peaks: 94.8±6.8dB(A)). A decrease in the sound level (P<0.001) was found 1 and 2, but not 3 months after starting the educational program. It remained high compared to the guidelines. CONCLUSION: Human activity was responsible for most of the sound level. An educational program was effective in reducing the sound level, but did not reach the guideline's target. The continuous use of sound-monitoring equipment after starting the project reduced the sound level for 2 months, but no longer. Therefore, a continuous educational program about the sound level in the NICU including feedback monitoring every 2-3 months should be encouraged.

[Neonatal morbidity of newborns less than 32 weeks of gestation who have a TSH rate higher than 10 mIU/L]. / Évolution néonatale précoce des nouveau-nés prématurés de moins de 32 semaines d'aménorrhée ayant une TSH plasmatique supérieure à 10mUI/L.

UNLABELLED: Thyroid hormones are involved in the development of human vital functions, especially in preterm infants. Hypothyroidism may have consequences in cardiac, respiratory, digestive, and neurological outcomes in this population. The main objective of this study was to evaluate neonatal morbidity in preterm newborns less than 32 weeks of gestation (WG), according to their thyroid stimulating hormone (TSH) rate. Secondly, we assessed the value of a treatment with synthesis thyroid hormones. METHOD: In a retrospective study, two groups were compared as to whether they had a TSH rate higher or lower than 10 mIU/L. A second analysis was performed to evaluate the advantages of a treatment with L-thyroxine. Perinatal data and morbidity (hemodynamic support, respiratory failure, digestive and neurological functions) were evaluated. RESULTS: From January 2006 to September 2011, 274 newborns under 32 WG were screened. Twenty-five newborns had a TSH rate greater than 10 mIU/L and were matched with 25 preterms having a TSH rate under 10 mIU/L. The incidence of patent ductus arteriosus was significantly higher in the group with TSH over 10 mIU/L (22 vs 6; P<0.001). In the group with TSH over 10 mIU/L, 13 newborns were treated. These were more oxygen-dependent at 28 days of life (7 vs 3; P=0.03) and were full fed later (14 days; 5.5 vs 12 days; 2; P=0.05). CONCLUSION: A TSH rate higher than 10 mIU/L was associated with a higher incidence of patent ductus arteriosus in preterm newborns under 32 WG. Thyroid synthesis treatment does not improve respiratory or digestive short-term outcome.

Haemodynamic changes during seizure-like activity in a neonate: a simultaneous AC EEG-SPIR and high-resolution DC EEG recording.

OBJECTIVE: We sought to define the interaction between neonatal epileptic discharges and the haemodynamic activities in a control situation (i.e. in the absence of cardiorespiratory perturbation or any interaction with normal, ongoing, synchronized neuronal activity). METHOD: Alternating-current electroencephalography (AC EEG), near-infrared spectroscopy (NIRS), and high-resolution direct-current (HR DC) EEG were performed in a curarized, ventilated neonate with a flat interictal EEG. The seizure-like discharges (SLD) first spike was used as a trigger for further averaging of NIRS, AC and DC EEG. Source localization was performed on the averaged spike and the averaged, negative DC shift. RESULTS: SLD were of maximal amplitude in centroparietal areas and induced a change in local haemodynamic parameters characterized by a first increase in [HHb] followed by an increase in [HbO(2)] and [HbT]. [HHb] returned to baseline at the end of the seizure and decreased thereafter. The negative DC shift started before the first spike and the increase in haemodynamic parameters. It then became positive and returned to baseline at the end of the seizure. Source localization revealed different positions for the first spike and the negative DC shift. DISCUSSION: Pure SLD in neonates might induce a negative blood oxygen level-dependent (BOLD) effect on the cortex, which occurs after the negative DC shift and which has a closer temporal relationship with the neuronal discharge than a positive BOLD effect.

Coupled oxygenation oscillation measured by NIRS and intermittent cerebral activation on EEG in premature infants.

Electroencephalography of premature neonates shows a physiological discontinuity of electrical activity during quiet sleep. Near infrared spectroscopy (NIRS) shows spontaneous oscillations of hemoglobin oxygenation and volume. Similar oscillations are visible in term neonates and adults, with NIRS and other functional imaging techniques (fMRI, Doppler, etc.), but are generally thought to result from vasomotion and to be a physiological artifact of limited interest. The origin and possible relationship to neuronal activity of the baseline changes in the NIRS signal have not been established. We carried out simultaneous EEG-NIRS recordings on six healthy premature neonates and four premature neonates presenting neurological distress, to determine whether changes in the concentration of cerebral oxy- and deoxy- and total hemoglobin were related to the occurrence of spontaneous bursts of cerebral electric activity. Bursts of electroencephalographic activity in neonates during quiet sleep were found to be coupled to a transient stereotyped hemodynamic response involving a decrease in oxy-hemoglobin concentration, sometimes beginning a few seconds before the onset of electroencephalographic activity, followed by an increase, and then a return to baseline. This pattern could be either part of the baseline oscillations or superimposed changes to this baseline, influencing its shape and phase. The temporal patterns of NIRS parameters present an unique configuration, and tend to be different between our healthy and pathological subjects. Studies of physiological activities and of the effects of intrinsic regulation on the NIRS signal should increase our understanding of these patterns and EEG-NIRS studies should facilitate the integration of NIRS into the set of clinical tools used in neurology.

Ventricular dilation as an instability of intracranial dynamics.

We address the question of the ventricles' dilation as a possible instability of the intracranial dynamics. The ventricular system is shown to be governed by a dynamical equation derived from first principles. This general nonlinear scheme is linearized around a well-defined steady state which is mapped onto a pressure-volume model with an algebraic effective compliance depending on the ventricles' geometry, the ependyma's elasticity, and the cerebrospinal fluid (CSF) surface tension. Instabilities of different natures are then evidenced. A first type of structural instability results from the compelling effects of the CSF surface tension and the elastic properties of the ependyma. A second type of dynamical instability occurs for low enough values of the aqueduct's conductance. This last case is then shown to be accompanied by a spontaneous ventricle's dilation. A strong correlation with some active hydrocephalus is evidenced and discussed. The transfer function of the ventricles, compared to a low-pass filter, are calculated in both the stable and unstable regimes and appear to be very different.

Severity of the ductal shunt: a comparison of different markers.

BACKGROUND: When the ductus arteriosus (DA) is patent, the ductal shunt is proportional to the ratio of left ventricular output (LVO) to systemic blood flow. Systemic blood flow can be estimated by measuring flow in the superior vena cava (SVC). OBJECTIVE: To re-evaluate the accuracy of standard echocardiographic markers of patent ductus arteriosus (PDA) using LVO/SVC flow ratio. METHODS: Prospective study. Preterm infants of 24-30 weeks gestational age and postnatal age less than 48 hours. The following echocardiographic criteria were measured: left atrial to aortic root ratio (LA/Ao); DA diameter by B mode and colour Doppler; mean and end diastolic flow velocity of the left pulmonary artery (LPA); LVO; SVC flow. RESULTS: Twenty three preterm infants were enrolled (median gestational age 28 weeks (range 24-30), median birth weight 840 g (500-1440)). The DA was closed in eight (mean (SD) LVO/SVC 2.4 (0.3)) and open in 15 (mean (SD) LVO/SVC 4.5 (0.6)). An LA/Ao ratio > or =1.4, a DA diameter > or =1.4 mm/kg, and a mean and end diastolic flow velocity of LPA respectively > or =0.42 and > or =0.20 m/s identified an LVO/SVC > or =4 with a sensitivity and a specificity above 90%. CONCLUSION: This study indicates that LA/Ao ratio, DA diameter, and mean and end diastolic flow velocity of the LPA are accurate markers of PDA. These standard echocardiographic variables are easy to measure and need less skill and resources than direct measurements of ductal shunt.

Combined effects of inhaled nitric oxide (iNO) and oxidant agents on the production of methemoglobinemia in newborn piglets.

OBJECTIVE: To investigate the effects of the association of inhaled nitric oxide (iNO) and oxidant drugs (acetaminophen, phytomenadione, and EMLA cream) on methemoglobinemia during the neonatal period. DESIGN: Prospective, randomized, experimental study. SETTING: University Experimental Pharmacology laboratory. SUBJECTS: Sixty newborn piglets weighing 1.5-2.0 Kg. INTERVENTIONS: Twelve groups of five piglets were anaesthetized, mechanically ventilated, and studied for 3 hrs. Eight groups received iNO (40 ppm or 80 ppm) alone or in association with a single intravenous dose of acetaminophen (120 mg/kg propacetamol), phytomenadione (5 mg vitamin K1) or EMLA cream (2.5 g) applied to the ventral lower abdomen for 3 hrs. Three other groups received, respectively, acetaminophen, phytomenadione, or EMLA cream without iNO. The last group (control group) received neither drugs nor iNO. MEASUREMENTS AND MAIN RESULTS: Methemoglobinemia was measured before the beginning of each experiment, 30 mins later, and every hour for 3 hrs. There was no significant difference in methemoglobinemia at any time between groups receiving acetaminophen (0.90%+/-0.12%), phytomenadione (0.88%+/-0.11%), or EMLA cream alone (0.97%+/-0.11%) and the control group (0.92%+/-0.12%). At 3 hrs, methemoglobinemia was slightly but significantly increased in group receiving iNO alone (1.04%+/-0.17% at 40 ppm iNO and 1.14%+/-0.16% at 80 ppm iNO; p < .05). Conversely, methemoglobinemia increased as a function of time in groups in which iNO was associated to drug administration and was significantly greater than the control group at 3 hrs (80 ppm iNO + acetaminophen, 2.80%+/-0.47%; 80 ppm iNO + phytomenadione, 2.38%+/-0.45%; 80 ppm iNO + EMLA cream, 2.33%+/-046%; p < .001). CONCLUSIONS: These results demonstrate that if oxidant drugs (acetaminophen, phytomenadione, or EMLA cream) did not increase blood methemoglobinemia in neonatal piglets, their association with iNO caused an increase in methemoglobin. Special care should be taken to monitor methemoglobinemia when iNO is combined to such drugs in newborn infants.