Hypothermia for neonatal hypoxic-ischemic encephalopathy: Retrospective descriptive study of features associated with poor outcome.

AIM: To investigate the clinical, laboratory, electrophysiological, and imaging features associated with death or neurological impairment at 1 year of age in term neonates with hypoxic-ischemic encephalopathy (HIE) treated by therapeutic hypothermia (TH). METHODS: This was a single-center retrospective and descriptive study conducted over a period of 2 years. We included consecutive term newborns with moderate or severe HIE who were treated by TH initiated within the sixth hour after birth and continued for 72 h,. For all patients, brain magnetic resonance imaging (MRI) was performed before the eighth day and a score was established; furthermore, at least two electroencephalograms were recorded. RESULTS: Among the 33 patients included, 20 neonates had a favorable outcome and 13 had an unfavorable outcome. Early clinical seizures (15% vs. 53.8%, p = 0.047), the persistence of a poor prognosis according to the electroencephalogram pattern after TH (0% vs. 69.2%, p = 0.0001), and an elevated score on the early brain MRI (2 vs. 11, p < 0.001) combined with a high lactate/N-acetyl-aspartate ratio (0.52 vs. 1.33, p = 0.008) on spectroscopy were associated with death and a poor outcome. CONCLUSION: A combination of tools can help the medical team to establish the most reliable prognosis for these full-term neonates, to guide care, and to inform parents most appropriately and sincerely.

Withholding and withdrawing treatment in pediatric intensive care. Update of the GFRUP recommendations.

In 2005, the French-speaking task force on pediatric critical and emergency care [Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP)] issued recommendations on withholding and withdrawing treatments in pediatric critical care. Since then, the French Public Health Code, modified by the laws passed in 2005 and 2016 and by their enactment decrees, has established a legal framework for practice. Now, 15 years later, an update of these recommendations was needed to factor in the experience acquired by healthcare teams, new questions raised by practice surveys, the recommendations issued in the interval, the changes in legislation, and a few legal precedents. The objective of this article is to help pediatric critical care teams find the closest possible compromise between the ethical principles guiding the care offered to the child and the family and compliance with current regulations and laws.

[Acute respiratory distress syndrome in childhood: Changing definition and news from the Pediatric Consensus Conference]. / Syndrome de détresse respiratoire aiguë de l'enfant : évolution de la définition et nouveautés de la conférence de consensus pédiatrique.

Acute respiratory distress syndrome (ARDS) is a rapidly progressive hypoxemic respiratory insufficiency induced by alveolar filling mainly caused by alveolocapillary wall disruption, following direct or indirect pulmonary injury. Much less frequent in children than in adults, pediatric intensivists had long applied adult guidelines to their daily practice. In 2015, experts from the Pediatric Acute Lung Injury Consensus Conference (PALICC) published the first international guidelines specifically dedicated to pediatric ARDS. After a short summary of the history of the ARDS definition since its first report in 1967, we describe the main diagnostic and therapeutic guidelines for PALICC.

Factor V and VIII combined deficiency: clinical perioperative management for tonsillectomy in a child.

Combined factors V (FV) and VIII (FVIII) deficiency is a rarely seen hereditary coagulation disease. Experience of its management in surgery with a high-risk of bleeding is rare. The interest of this case report is to propose a strategy of perioperative management for such a deficit, but also to recall that a careful preoperative anesthetic evaluation with questioning and physical examination permits to detect unsuspected coagulation disorders and to schedule the preventive treatment. The protocol for the perioperative period consisted of the administration of desmopressin and fresh frozen plasma one hour before surgery. The administration of desmopressin was continued for 48hours. Fresh frozen plasma and tranexamic acid were administered during the first 9 postoperative days. A local bleeding occurred at 8 days (scab coming off) and required systematically a surgical hemostasis and an intensification of the therapeutic protocol. Recombinant plasmatic factor VIII was administered for 7 days together with a daily perfusion of fresh frozen plasma for a total treatment period of 14 days.

[Acute fatty liver in pregnancy: revealing fetal fatty acid oxidation disorders]. / Atteinte hépatique gravidique : mode de révélation d'une anomalie de la bêta-oxydation des acides gras chez l'enfant.

Acute fatty liver of pregnancy (AFLP) and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome are serious maternal illnesses occurring in the third trimester of pregnancy with significant perinatal and maternal mortality. AFLP may result from mitochondrial defects in the beta-oxidation of fatty acids, in particular a deficiency of the long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) in the fetus. Clinical findings in AFLP vary and its diagnosis is complicated by a significant overlap in clinical and biochemical features with HELLP syndrome. We report the case of 2 siblings who died, the first one in the neonatal period of asphyxia with multivisceral presentation and the second one from sudden death at 7 months. Autopsy of the latter infant revealed hepatic steatosis associated with cardiomyopathy, which led to suspicion of a fatty acid oxidation deficiency. Mutation analysis demonstrated that both children were homozygous for the common mutation c.1528G>C and the parents were heterozygous for this same mutation. This case demonstrates the importance of screening mothers with acute fatty liver disease of pregnancy and their children at birth for a metabolic disease. This article proposes several metabolic tests for mother and child suspected of having beta-oxidation of a fatty acid disorder.

[Invasive candidiasis in neonatal intensive care units]. / Candidoses invasives en réanimation néonatale.

In the USA, the incidence of invasive candidiasis in neonates is respectively 0.3% of infants over 2500 g and up to 20% of infants less than 1000 g. Their incidence is increasing. Two populations of newborn infants are particularly vulnerable: the premature infants and newborn infants with severe neonatal digestive diseases. Fifty percent of infants hospitalized in NICU are colonized with Candida at the end of the first week of hospitalization; a direct relationship exists between the importance of colonization and the invasive infection risk. C. albicans is the species most often responsible for invasive candidiasis in the newborn. These infections represent the third cause of related-catheter infection in the USA. Mortality rate in neonates linked to this disease is 20 to 50%; morbidity primarily concerns brain and lungs. Neonatal invasive candidiasis risk factors are known and a primary prevention is possible. The diagnosis of neonatal invasive candidiasis is difficult and often delayed because of a polymorphic clinical expression. Empiric and preemptive treatment are based on the use of amphotericin B. Prophylactic treatment using fluconazole of newborns with birth weight ≤ 1000 grams and/or gestational age ≤ 27 weeks gestation is recommended by the American Academy of Paediatrics and the Infectious Diseases Society of America. A better knowledge of French epidemiological data in this area would improve both the diagnosis and therapeutic management of this disease.

[What non invasive haemodynamic assessment in paediatric intensive care unit in 2009?]. / Quelle évaluation hémodynamique non invasive en réanimation pédiatrique en 2009 ?

The haemodynamic assessment of the patients is a daily activity in paediatric intensive care unit. It completes and is guided by the clinical examination. The will to develop the least invasive possible coverage of the patients is a constant concern. The haemodynamic monitoring, all the more if it is invasive, ceaselessly has to put in balance the profit and the risk of beginning this technique at a fragile patient. In the last three decades, numerous non-invasive haemodynamic tools were developed. The ideal one must be reliable, reproducible, with a time of fast, easily useful answer, with a total harmlessness, cheap and allowing a monitoring continues. Among all the existing tools (oesophageal Doppler ultrasound method, transthoracic echocardiography, NICO, thoracic impedancemetry, plethysmography, sublingual capnography), no one allies all these qualities. We can consider that the transthoracic echocardiography gets closer to most of these objectives. We shall blame it for its cost and for the fact that it is an intermittent monitoring but both in the diagnosis and in the survey, it has no equal among the non-invasive tools of haemodynamic assessment from part the quality and the quantity of the obtained information. The learning of the basic functions (contractility evaluation, cardiac output, cardiac and the vascular filling) useful for the start of a treatment is relatively well-to-do. We shall miss the absence of training in this tool in France in its paediatric and neonatal specificity within the university or interuniversity framework.

Efficiency of fractional anisotropy and apparent diffusion coefficient on diffusion tensor imaging in prognosis of neonates with hypoxic-ischemic encephalopathy: a methodologic prospective pilot study.

BACKGROUND AND PURPOSE: The DTI parameters (FA and ADC) reflect the properties of the brain microstructure. Decreased anisotropy is a common feature of cerebral tissue abnormalities. Our study investigates the neurologic prognostic efficiency of these parameters in white (PLIC, CP) and gray matter (PP) in the first days of life in term neonates with HIE. We hypothesize that lesions in related brain areas could be part of a physiopathologic substratum supporting neurologic deficiencies in this population. MATERIALS AND METHODS: A total of 22 neonates (13 girls and 9 boys; mean gestational age, 40 weeks +/- 9 days; birth weight, 3203 +/- 584 g) underwent brain MR imaging between day 1 and day 6 after birth; 6-noncollinear direction DTI was performed. FA and ADC were measured on specific brain areas. Amiel-Tison score was performed on day 8.5 +/- 4 (group A, favorable outcome [n = 16]; group B, unfavorable outcome [n = 6]). RESULTS: Intraobserver and interobserver comparison in DTI parameter measurements showed a coefficient of variability of less than 5%. In PLIC and PP, the ADC values were lower in group B compared with group A (P = .000027), whereas in PLIC and CP, the FA values were lower in group B compared with group A (P < .02). CONCLUSIONS: These findings indicate that a poor early neurologic outcome in neonates with HIE is associated with lower FA or ADC values in specific areas of white or gray matter. The difference in ADC/FA changes in the different brain areas explored may support possibly different pathologic processes.

[Distribution of neutralizing measles serum antibodies according to age in women of childbearing age in France in 2005-2006]. / Distribution en fonction de l'âge de la concentration sérique des anticorps neutralisants antirougeole chez les femmes en âge de procréer en France en 2005-2006.

UNLABELLED: Measles-vaccine coverage (MVC) increased significantly only beginning in 1983 based on the official recommendations. The majority of women born after 1983 should have vaccine-acquired rather than naturally derived immunity. Passively transferred measles antibodies (Mab) are expected to provide protection to offsprings during their 1st few months of life. OBJECTIVE: Compare neutralizing Mab titers according to age in women aged 12-40 years, i.e., born before and after 1983. METHODS: A multicenter seroepidemiological study was conducted in France in 2005-2006; 210 outpatient or hospitalized women were enrolled and classified into 4 age groups (12-18, 19-22, 23-30, and 31-40 years). Mab titers were assessed using a reference plaque reduction neutralization assay (protection threshold > 120 mIU/ml). RESULTS: Ninety-four percent of subjects had a Mabs titer greater than 120 mIU/ml. Women born before 1983 had significantly higher geometric mean titers (GMTs) of Mabs than those born after 1983(1358 mIU/ml vs. 731 mIU/ml [p<0.001]). The comparison of the 4 cohorts showed a significant decrease (p<0.001) in GMTs of Mab in the female population with increasing age (670, 771, 1173, and 1821 mUI/ml, respectively, in the 12-18, 19-22, 23-30, and 31-40 years age groups). For the 1st time in France, we show in women of childbearing age that in 2005-2006 neutralizing Mab GMTs were far above protective threshold for all age groups. Women in younger age groups (with high MVC) have significantly lower Mab titers. A lower passive transfer of Mab to their offsprings could result in a shorter period of measles protection and question the measles vaccine 1st dose at 1 year.

Surgical management of neuroblastoma-related hepatomegaly: do material and method really count?

The authors report 2 cases of neuroblastoma-associated hepatomegaly, which were treated using a Silastic patch, and discuss in the light of recent reports, the technical aspects and outcome of these children. They were satisfied by the decompression achieved with the patch and believe there is no increased risk in using Silastic rather than other types of material. The outcome for these children depends more on the evolution of the underlying disease than the technical aspects of the abdominal decompression.

[Vaccine prevention in perinatal health care: parents, children and professionals]. / Vaccination en périnatalité : parents, enfants, professionnels.

Recent legislative texts have changed vaccinal policy and reinforced the role of midwives in vaccine prevention in perinatal healthcare. Quite as paediatricians and obstetricians-gynecologists, midwives can now prescribe and carry out, for the mothers, vaccines against rubella, tetanus, poliomyelitis, diphtheria, hepatitis B, influenza and whooping-cough and for the newborns vaccines against hepatitis B and tuberculosis. Concerning vaccinations, practitioners have to respect the vaccination calendar and a collaborative action is useful and necessary. These national guidelines are regularly updated when new vaccines and new recommendations come to light, for example for children (papillomavirus, tuberculosis, pneumococcus...), young adults (varicella, whooping-cough) and health professions in contact with very young children (varicella, measles, influenza and whooping-cough). The recent changes in tuberculosis prevention from routine vaccination of all newborn infants to selective vaccination lead to reinforce measures to detect the infants at higher risk, for them to be vaccinated before discharge at home. Midwives and nurses occupy a central place in family policy and become, with obstetricians-gynecologists and pediatricians, key actors for the effectiveness and the success of vaccine strategies in perinatal health.

[Prognostic value of MR in term neonates with neonatal hypoxic-ischemic encephalopath: MRI score and spectroscopy. About 26 cases]. / Apport pronostique de la résonance magnétique cérébrale dans l'encéphalopathie hypoxique-ischémique du nouveau-né à terme: score d'imagerie, spectroscopie. Etude de 26 cas.

UNLABELLED: Neonatal hypoxic-ischemic encephalopathy remains a major cause of chronic disability in childhood. Early diagnosis and prognosis are necessary for the clinician to adapt the treatment. However, there is yet no reliable test to predict the patient's evolution. OBJECTIVE: The aim of our study was to evaluate the predictive value of a personal magnetic resonance imaging (MRI) scoring system and of magnetic resonance spectroscopy (MRS). MATERIAL AND METHODS: We included 26 term newborns in condition of neonatal brain suffering. MR examination was performed during the first week of life for all patients and MRI and MRS data were collected. Standardised follow-up visits were made for all patients. Finally, prognostic value of the different criteria was evaluated with statistical tests. RESULTS: Our MRI scoring system proved to be linked to prognosis. A high MRI score, abnormal signal in the internal capsule, white matter or basal ganglia abnormalities with diffusion imaging were associated with unfavourable outcome. These results confirmed the data of the literature concerning the MRI predictive value. Our study also confirmed prognostic interest of MR: particularly, ratios using lactate were significantly linked to prognosis in our study. Specificity of the elevation of these ratios was interesting but sensibility was less optimal. CONCLUSION: We suggest using our MRI scoring system which associates standard MRI and diffusion imaging, which is significantly related to outcome. We confirm the prognostic value of MRS in this pathological situation. MR with diffusion sequence and spectroscopy, performed three to four days after birth appears to be an essential tool to manage these patients.

[Clinical features of Pseudomonas aeruginosa infections]. / Aspects cliniques de l'infection a Pseudomonas aeruginosa.

Pseudomonas aeruginosa is a ubiquitous environmental organism usually considered as opportunistic pathogen in immunocompromised subjects. However it can produce disease in healthy children, mainly on moist body sites. Familial, community and nosocomial outbreaks of cutaneous infections have been reported. Ecthyma gangrenosum is possible without bacteremia. P. aeruginosa is also the most common cause of otitis externa in swimmers and osteomyelitis after puncture wound of the foot.

[Central catheters and pericardial effusion: results of a multicentric retrospective study]. / Cathéters centraux et épanchements péricardiques en période néonatale: étude rétrospective multicentrique.

OBJECTIVE: To evaluate the use of neonatal central venous catheters (CVC) in 38 french neonatal units and occurrence of pericardial effusion (PCE) over the past 5 years. MATERIALS AND METHODS: We surveyed 38 units with a questionnaire and studied the cases of PCE in five units. RESULTS: Response rate was 89% (34/38). Accepted CVC tip positions were: junction of right atrium (RA) and vena cava (VC) 76%, VC 58%, RA 11%. Fifty percent of the centers had been exposed to PCE. 16 cases of PCE were studied. Median gestational age was 31 weeks (range: 26.1 to 40 weeks). Median time from insertion: 3.2 days (range: 0.4-13.5). In all cases CVC tip was intracardiac at insertion with inadequate withdrawing in 13 cases. Sudden cardiac collapse was reported in eight cases, and unexplained cardiorespiratory instability in six cases. Echography showed PCE in 14 cases. One diagnosis was post-mortem. CVC was withdrawn in 12 patients and 13 underwent pericardiocentesis. Four patients died and two had neurological sequelae. CONCLUSION: PCE was associated with intracardiac CVC tip. The CVC tip should be controlled with radiography or echography outside the cardiac silhouette. PCE diagnosis must be considered in face of unexplained cardiovascular decompensation of neonate with CVC.