[Moderate hypoglycemia in the preterm infant: is it relevant?]. / Les hypoglycémies modérées de l'enfant né prématurément: est-ce vraiment important?

Glucose monitoring and management of hypoglycaemia in preterm infants remain controversial. However, recent animal studies have shown that hypoglycaemia is associated to increased generation of reactive oxygen and nitrogen species, to inhibition of cellular maturation and to apoptosis in brain. Despite potential consequences of hypoglycaemia on brain development in preterm infants, only few studies are available on this topic. Available clinical studies on neurological development of hypoglycaemic preterm infants are not conclusive but suggest detrimental effect of repeated mild hypoglycaemia on brain development. Both experimental and clinical arguments are sufficient to mind to this problem with great awareness. Therefore, routine repeated measurements of blood glucose concentration are necessary and active intervention is proposed if glucose plasma level decreases below 2.5 mmol/l.

Perineal lipoma in a newborn boy--a case report.

We report the case of a newborn presenting with a pediculated mass arising from the anal margin. Antenatal sonogram and magnetic resonance imaging were unable to diagnose the precise nature of the lesion. Sacrococcygeal teratoma, an enterogenous cyst, a polyp, a prolapse or other perineal tumors were all proposed as possible entities. At birth, no other anatomic anomaly than this homogenous 2 cm para-anal lesion was seen. Excision of the mass was performed under general anesthesia. The postoperative histological exam showed mature fat cells. Reviewing the literature, there have been few previously reported cases of congenital perineal lipoma. It is a rare, benign and easy-to-treat condition that can be evocated by morphological sonography or magnetic resonance imaging (MRI).

High-frequency ventilation and conventional mechanical ventilation in newborn babies with respiratory distress syndrome: a prospective, randomized trial.

OBJECTIVE: Morbidity and mortality remain high amongst babies ventilated for a respiratory distress syndrome (RDS). Whether newly developed ventilators allowing high frequency ventilation such as high frequency flow interrupted ventilation (HFFIV) could decrease the morbidity and the mortality was investigated in a randomized study. DESIGN: Preterm babies weighing < or = 1800 g suffering from RDS and ventilated by conventional mechanical ventilation (CMV) were randomized to be further ventilated either by CMV (group CMV) or by HFFIV (group HFFIV) when peak inspiratory pressure (PIP) on CMV was > or = 20 cmH2O. SETTING: The study was undertaken in the neonatal intensive care unit of the Erasmus Hospital. PATIENTS: 24 patients entered into the investigation and were randomized but 2 patients were removed from the study because the switch over to HFFIV failed. Eight of the 12 CMV patients and 5 of the 10 HFFIV patients completed the study. MEASUREMENTS AND RESULTS: Clinical variables, blood gas analysis and ventilatory variables were looked at. There were no differences in mortality, in incidence of air leaks and pulmonary complications or in blood gas analysis. Bronchopulmonary dysplasia was not decreased by the use of HFFIV. CONCLUSION: It is concluded that HFFIV is safe although it offers no concrete advantages over CMV when applied as we did in a low pressure approach.

Central venous catheter-related bacteraemia in critically ill neonates: risk factors and impact of a prevention programme.

Risk factors for central venous catheter (CVC)-related bacteraemia among infants admitted to a neonatal intensive care unit (NICU) were analysed and the impact of surveillance and continuing education on the incidence of this complication investigated. Among patients admitted to a NICU, CVC-related bacteraemia increased from 1/15 (7%) in 1987 to 11/26 (42%) in 1988 (P = 0.01). Coagulase-negative staphylococci isolated from bacteraemia patients showed clonal diversity by plasmid and chromosomal fingerprinting. A review of CVC care procedures suggested breaches in aseptic techniques. Catheter-care technique was revised to ensure maximal aseptic precautions, including the use of sterile gloves, gown and drapes. The new policy was promoted by a continuing education programme and regular feed-back of CVC-related bacteraemia incidence to NICU staff. In the four-year follow-up period, the attack-rate of CVC-related bacteraemia decreased to 18/156 (12%) patients [relative risk (RR): 0.27, 95% confidence interval (CI); 0.15-0.51; P < 0.001 vs the previous period]. By using the Cox's model proportional hazards, very low birthweight and the period before use of strict aseptic CVC care were found to be predictors of increased risk of catheter-related bacteraemia after adjustment for duration of catheterization. These data provide further evidence that strict aseptic precautions during the maintenance and utilization of CVC can contribute to lower the risk of catheter infection in critically ill neonates. Regular feedback of surveillance data was associated with a progressive decrease in incidence of infection, suggesting that it improved staff compliance with aseptic precautions.

Growth and metabolic response of healthy low birth-weight newborns fed a semi-elemental diet.

Twelve normal low birth-weight newborns weighing between 110 and 1765 grams (means +/- SD, 1614 +/- 191) were fed by continuous intragastric drip a semi-elemental diet, providing per kilogram and per day 120 kilocalories, 2.9 grams of proteins, 17.5 grams of carbohydrates, 4.2 grams of fat and 2.4 milliequivalents of sodium. The diet contained a lactalbumin hydrolysate, dextrin maltose, and medium and long chain triglycerides. The newborns regained their birthweight between 6 and 16 days (mean +/- SD, 10.4 +/- 3.1) and gained 14 to 37 grams/day (mean +/- SD, 25.4 +/- 6.8) during the first month of life. The diet proved to be safe and clinically well-tolerated in low birth-weight infants and induced a weight gain similar to the intrauterine growth, once the birthweight had been regained.

Partial bronchial stenosis following inadvertent right bronchial intubation in a neonate.

This case reports difficulties encountered in weaning a premature infant with bronchopulmonary dysplasia from prolonged mechanical ventilation. On chest X-ray alternating atelectasis and hyperinflation of the right lung were observed. This resulted from a short episode of misplaced endotracheal tube that produced a traumatic bronchial stenosis. Treatment by prednisolone allowed the detubation.

Neonatal necrotizing enterocolitis: from reduction of mortality to reduction of morbidity.

A prospective protocol was applied from October 1978 to December 1980 to 22 newborns presenting with necrotizing enterocolitis (Stages II and III). The total mortality was 32% (7/22) with a 100% mortality in the surgical group (4/4). The prospective protocol was changed and applied to 53 newborns from January 81 to December 84, showing a decrease in total mortality: 28% (81 and 82) and 4% (1983 and 1984), with a global mortality of zero in 1983. The main changes in the protocol are: Addition of metronidazole. More precocious and radical two stages surgical procedure. Earlier diagnostic, resuscitation and transfer to the surgical department. Improvement of anaesthesia and intensive care therapy. Duration of hospital stay fell by 50%. Despite significant intestinal resections, most infants were on a normal diet by the age of one year.

[Ultrasonic study of the single umbilical artery syndrome. A series of 80 cases]. / Evaluation échographique du syndrome de l'artère ombilicale unique. Une série de 80 cas.

The authors report on 80 cases of the syndrome of a single umbilical artery (SUA) and compare the anatomo-clinical features with the abnormalities found on ultrasound. The clinical results confirm the information given in the literature which is that there is a higher incidence of poor intra-uterine fetal growth (36.4%), of prematurity (16.3%), of associated congenital abnormalities (42%) and of perinatal mortality (21.3%). Ultrasound examination makes it possible to screen for associated major fetal malformations (26.6%) and of most cases of intra-uterine growth retardation (28.3%). The ultrasound detection of the absence of one of the umbilical arteries and of the associated fetal abnormalities together with the techniques for sampling fetal cells now causes change in the approach to these high risk pregnancies on the cytogenetic level as on the perinatal handling of this syndrome.

[The intensive and non-intensive neonatal care department]. / Le Service de Soins Neónatals Intensifs et Non Intensifs.

To be born very prematurely in 2002 is very different of to be born very prematurely in 1978: the progress of the fetal and perinatal care have, amongst others, decrease the mortality of the neonates with a birthweight below < 1,000 g from 61% to 12%. The technological progresses in artificial ventilation have led to a significant decrease in chronic lung disease down to 5% or less, and of cerebral complications (intraventricular hemorrhages, grade 3 and 4 and/or periventricular leucomalacia) down to 11% or less. The progress in surgery and anesthesiology have allowed us to operate the extremely low birthweight infants in the neonatal unit when needed. This has been possible thanks to a multidisciplinary team approach: many specialists working together from conception to birth and from birth to home try to offer the best to these sometimes very small human beings.

[Twins: interpretation of height-weight curves at birth]. / Jumeaux: interprétation des courbes staturo-pondérales à la naissance.

Weight, head circumference and body length curves were established with the data at birth of 770 twins born alive in our hospital. Those curves were compared with the Gairdner-Pearson curves realized on a population of singleton newborns. The twin weight curve shows the expected fall down from 32 weeks of gestation. More than 50% of twins would have been qualified as small for dates on the Gairdner standard for singletons. The head circumference and the body length curves show few differences, except a late fall down, significant from 39 weeks. So the normal twin shows usually an "asymmetrical" hypotrophy if compared with a general newborn population standard. The general weight standards do not allow to assess the normality of a twin and to suspect other reasons of fetal growth restriction that could also be present. These considerations plead for the use of specific twin charts. Yet the evaluation of twins on the general standards has still a place to estimate the immediate and at long-term adverse outcomes of fetal growth restriction. The evaluation of twin measurements would not be completed without the assessment of the weight discordancy inside the twin couple, as a risk factor of morbidity and mortality.

[Prematurity: developments during the last decade at Erasmus Hospital. II. Long-term follow-up]. / Le prématurissime: évolution au cours de la dernière décennie à l'hôpital Erasme. II. Suivi à long terme.

Morbidity and mortality of these preterm infants weighing < 1000 g at birth was reported in another paper. The mortality and neuro-developmental prognosis improved clearly in the last 3 years. A particular attention is given for protecting these babies against brain lesions. These ELBW have a high risk of neurodevelopmental disturbances. Therefore, a multidisciplinary team follows the neurological evolution to assess the quality of neonatal care and detect and treat developmental abnormalities as early as possible. We present the weight and height evolutions, the neurological, social and familial outcome of our 15 survivors. Economical and ethical discussions are open.

[Neurodevelopment of extremely low birthweight infants born in Erasmus Hospital between 1992 and 2001]. / Suivi neurodéveloppemental des prématurissimes nés a l'Hôpital Erasme entre 1992 et 2001.

Survival of extremely low birth weight infants has dramatically improved in the last decade of the twentieth century. The objective of our study was to evaluate the neurological evolution of the surviving infants because frequent motor, sensitive and psychological disturbances are related. Prospective, longitudinal study in a population of newborns, nursed in our neonatal intensive care unit and born between 1992 and 2001 with less than 1.000 g and/or less than 28 weeks of gestational age (GA). Neurological assessment of outcome was made using the neurodevelopmental score (O.M.S. 1988) at 6, 9, 12, 18, 24 and 36 months. Neurological follow-up every year and neuropsychological testing at 3, 5 and 8 years. Only children with at least 2 years of follow-up were included. The children were grouped in 3 categories: M (major neurological handicap), m (minor neurological handicap), N (normal neurological outcome). To evaluate the evolution with time, we compared the results from the first period (1992 to 1996) to the second part of this decade (1997 to 2001). Mortality fell from 38% (27/70) in the first period (1992-1996) to 18% (8/44) in the second one (1997-2001) (p = 0.02) including neonates of less than 25 weeks GA. Neurodevelopmental status improved and severe brain lesions decreased (25% with intraventricular haemorrhage III & IV and cystic periventricular leukomalacia versus 6% in the second period) (p = 0.017). Major handicap fell from 26% (9/34) to 16% (5/31) and normal neurological evolution raised from 15% (5/34) to 48% (15/31) (p = 0.013). With the survival of newborns less than 28 weeks, the severe ocular complications increased: 6% (5/79). In conclusion, mortality and quality of life have significantly improved in the past 10 years in our service. Severe brain lesions have decreased under a better multifactorial management. Nevertheless when the gestational age of the surviving babies diminishes, ocular sequelae increase. We still think that prematurity remains a burden for the child, his family and the society.

[Prematurity: development during the last decade at Erasme Hospital, neonatal evaluation]. / Le prématurissime: évolution au cours de la dernière décennie à l'Hôpital Erasme, bilan néonatal.

Our institution admitted 39 ELBW (less than 1 kg) between November 1978 and December 1990. In our center, mortality has decreased from 61% to 33% within a decade. Improvements in neonatal intensive care have lowered the limit for these possible survival to 26 weeks of gestational age and 700g of birthweight. Morbidity is still very high. The mean hospital stay is 96 days. Perinatal asphyxia is frequent (3/4) as well as infections, nutritional problems and renal failure. Sixty-six % of this population suffer from respiratory distress syndrome which is the main cause of death. Morbidity and mortality are explained and compared to the recent literature.

[The focus in neonatology]. / Le point en néonatologie.

During the last years, neonatology has greatly improved. In the last decade, mortality and morbidity have decreased: mortality from respiratory failure of prematurity has decreased from 22% to 12%, mortality of the very low birthweight infants under 1000 g fell from 56% to 35% and mortalities related to asphyxia have diminished from 21% to 12% and to malformations from 33% to 28%. Prematurity is now the first cause of neonatal mortality. During this period, the number of babies under 1000 g has increased 4-fold and the number of multiple births increased more than 2-fold from 3% to 7% of the live births of our hospital. Attitudes towards the premature infant have changed, especially towards the extremely small (called the micropremies). The number of disabled children has increased in parallel with the better survival of the very immature newborns who till recently were not resuscitated.

[Monitoring of fontanelle pressure in neonates and infants. Evaluation of a new measuring technique, determination of normal values and clinical usefulness]. / Monitorage de la pression fontanellaire chez le nouveau-né et le nourrisson. Evaluation d'une nouvelle technique de mesure, détermination des valeurs normales et utilisation clinique.

The experience with 200 measurements of anterior fontanelle pressure with the Rotterdam Teletransducer in newborns and infants is reported. Statistical analysis of 25 comparative measurements between anterior fontanelle pressure and invasive cerebrospinal fluid pressure showed an excellent correlation (rs = 0.95). Measurements were reproducible and the plot quality allowed visualisation of pulse pressure and pressure waves. Normal values of the anterior fontanelle pressure, pulse pressure amplitude and pressure wave maximal amplitude were established in 15 prematures, 27 term newborns and 10 infants. Anterior fontanelle pressure monitoring was performed in 19 term newborns with post-asphyxial encephalopathy, 18 newborns and infants with hydrocephalus, 8 preterm and term newborns with respiratory distress and 19 patients with subdural haematomas, metabolic diseases, meningitis, subarachnoidal haemorrhage, head trauma, post cardiac arrest encephalopathy and abnormal head growth or bulging fontanelle. Abnormal patterns of anterior fontanelle pressure monitoring were found in moderate or severe neonatal post-asphyxial encephalopathy, evolutive hydrocephalus, subdural haematomas, metabolic diseases with hyperammoniemia and other clinical situations. In contrast, anterior fontanelle pressure monitoring yielded normal values in mild post-asphyxial encephalopathy, arrested hydrocephalus, well functioning ventriculo-peritoneal derivation, and in normal infants with rapid head growth or bulging fontanelle. The Rotterdam Teletransducer provides thus accurate and reproducible values of intracranial pressure. Anterior fontanelle pressure monitoring may be of value in many situations in clinical practice.

[Neonatal screening for hemoglobinopathies in the Brussels region]. / Dépistage néonatal des hémoglobinopathies dans la région bruxelloise.

We realised this study in order to determine the frequency of abnormal haemoglobins and to appreciate the need for a neonatal screening for haemoglobinopathies in Brussels. Over a two year-period, 9575 cord blood samples were systematically screened. The study disclosed following results : 40% of newborns were from regions at risk for haemoglobinopathies and abnormal haemoglobins were present in 2.5% of the neonates tested. This frequency is similar to those reported elsewhere in North Europe. The most frequent abnormal haemoglobins were the Hb S, Bart's, C, D and E. Three cases of severe forms of sickle cell anaemia were identified. The frequency of abnormal haemoglobins and Hb S traits combined to the high rate of mixed marriages (16%) justifies the need for a universal screening for haemoglobinopathies in Brussels.