[Correct procedure in the presence of a fetal goiter associated with hypothyroidism. Observations from three cases]. / Conduite à tenir en présence d'un goitre foetal hypothyroïdien. A propos de trois observations.

Fetal goiter is a rare occurrence of which neonatal consequences are not always predictable. Concerning three cases of goiters associated with hypothyroidism discovered in utero, the authors describe the way to take care of in this bad codified situation. They insist upon the major role of ultrasound for goiter diagnosis and its impacts and for control of treatment efficiency. They also discuss intra amniotic L-Thyroxine injection and insist upon the necessity to obtain quick and definite thyroid evaluation after birth before decision to abstain from neonatal therapy.

Periventricular leukomalacia and mode of delivery in twins under 1500 g.

BACKGROUND: The optimal mode of delivery in twin gestations remains undefined, particularly for twins weighing less than 1500 g. OBJECTIVE: To evaluate the impact of the mode of delivery on neonatal outcome in twins below 1500 g. MATERIALS AND METHODS: In this multicenter cohort study during 1999, 66 sets of twins born in hospital and weighing below 1500 g formed our study group. Antenatal and neonatal parameters and their relationship to mode of delivery were studied, based on a factor analysis. Analysis of covariance was used to assess the effect of the mode of delivery on postnatal factors, with antenatal parameters used as covariates. RESULTS: Statistical analysis showed that infants delivered vaginally had significantly more periventricular leukomalacia than those children delivered by Cesarean section (p = 0.03). The estimated odds for leukomalacia were higher in the vaginal than in the Cesarean group when adjusted for covariates (OR = 4.7; 95% CI = 1.0, 25.15). CONCLUSION: Routine Cesarean section should be recommended in twin gestations with infants weighing less than 1500 g, regardless of gestational age or fetal presentation.

[APN: evaluation behavioral scale of acute pain in newborn infants]. / DAN: une échelle comportementale d'évaluation de la douleur aiguë du nouveau-né.

AIM: This study was designed to validate a behavioral acute pain rating scale for term and preterm neonates (APN). METHODS: From January through June 1996, neonates requiring a heel lance or a venous puncture for blood sampling at the intensive care unit and the nursery of Poissy Hospital were recruited into the study. After a pilot study, a pain rating scale was developed. The scale score pain ranged from 0 to 10 and it evaluated three items: facial expression, limb movements, and vocal expression with ratings per item ranging from 0 to 4, 0 to 3 and 0 to 3, respectively. Two observers evaluated independently each infant during a painful procedure (puncture for a blood sample) and during a dummy procedure (rubbing the thigh softly). RESULTS: Forty-two neonates born between 25 and 41 weeks gestational age were included in the study. Medians (quartiles) of gestational age, birth weight, and corrected postmenstrual age at time of investigation were 34 (29-39) weeks, 1,850 (1,055-3,093) g, and 35.5 (31-39) weeks, respectively. Ten infants were intubated. The scale showed to be sensitive because all possible scores were obtained; during painful procedures scores ranged from 1 to 10, with 95% of scores > or = 3 while during dummy procedures they ranged from 0 to 5, with 88% of scores < or = 2. The medians (95% confidence interval) of scores were for painful procedures 5 (5 to 7) and for dummy procedures 1 (0 to 1). This indicates a good specificity of the scale. High intercorrelation of items (internal consistency) was confirmed by a Cronbach's coefficient alpha of 0.88. Inter-rater agreement was high since the Krippendorff R test was 91.2. CONCLUSION: This behavioral acute pain rating scale for newborns demonstrated a good specificity and sensitivity, internal consistency and inter-rater reliability. This scale could be used to test the analgesic effects of different therapies during painful procedures.

[Use of a polyethylene bag: a way to improve the thermal environment of the premature newborn at the delivery room]. / Utilisation d'un sac en polyéthylène: un moyen d'améliorer l'environnement thermique du prématuré en salle de naissance.

BACKGROUND: Early interventions, such as occlusive wrapping of very low birth weight infants at delivery reduce postnatal temperature fall. This new intervention was implemented in our hospital on January 2000. The aim of this study was to investigate retrospectively the effect of polyethylene wrap, applied immediately at birth, on thermoregulation. PATIENTS AND METHODS: Matched pair analysis was conducted for 60 infants delivered inborn at less than 33 weeks' gestation and 60 premature infants who were born during the second half of 1999 fulfilling the same criteria. The only difference in the management (medical and environmental) was wrapping with a polyethylene bag in the delivery room. Rectal temperature and other vital parameters were taken, after removal of wraps, on admission to NICU. RESULTS: The perinatal characteristics of both groups were comparable. Use of wrapping resulted in a significantly higher admission rectal temperature (difference in means = 0.8 degree C, p < 0.0001), this difference was also significant in infants < 30 weeks. The incidence of hypothermia (< 35.5 degrees C) was less frequent in infants enclosed in plastic bags (8.3% vs 55%). No side effects (skin burns, infection or hyperthermia) were attributable to the intervention. The heart rate was higher in the wrapping group (163 +/- 16 vs 150 +/- 17 b/min, p < 0.01), as well as the capillary glycemia (62 +/- 26 vs 45 +/- 30 mg/dl, p < 0.01). There was no significant difference on arterial pressure. CONCLUSION: Occlusive wrapping with a polyethylene bag at birth prevented low rectal temperature in premature infants in the immediate postnatal period. This method is easy, practical and effective, and does not interfere with current practice for resuscitation.

[Water intoxication following preparation for barium enema]. / Intoxication par l'eau après une préparation pour un lavement baryté.

BACKGROUND: Induction of water intoxication from tap water enemas was reported a few years ago. Its treatment is still debated. CASE REPORT: A 4 1/2 year-old boy was admitted because he suffered from coma grade I. A barium enema had been prescribed for fecal incontinence and the patient had been given orally about 4 liters of water during the 24 hours preceding this investigation. Blood examination showed;: Na 122 mEq/l; K 3 mEq/l; Cl 87 mEq/l. Brain CT scan was normal. The patient was placed under restriction of fluid and was given i.v. 5.8% NaCl solution (2 mM/kg) for 3 hours. Convulsions appeared despite this treatment requiring intubation and ventilation plus increasing doses of NaCl: 20% solution (2 mM/kg) for 30 minutes followed by 2 mM/kg for 3 hours, associated with mannitol and furosemide infusion. CONCLUSION: Use of hypertonic saline solutions in the treatment of water intoxication is discussed. Acute hyponatremia must be rapidly corrected using hypertonic saline solution plus restriction of fluid and diuretic.

[Intraosseous infusion in children]. / Perfusion intraosseuse chez l'enfant.

BACKGROUND: Intravenous access in critically ill patients may be very difficult to obtain. The intraosseous route is an alternate way to administer fluids and drugs. CASE REPORT: A five month old infant was brought to the emergency department in profound hypovolemia requiring immediate tracheal intubation. A peripheral venous access was established and 35 ml of colloid were rapidly infused. Unfortunately, fluid extravasated and the intravenous line had to be removed. As further attempts to gain intravenous access were unsuccessful, an intraosseous needle was inserted into the left tibia 1 cm below the tibial tuberosity, and colloid and human albumin solution were infused rapidly, followed by 1.4% sodium bicarbonate. After ninety minutes of intraosseous rehydration, 2 peripheral venous lines were inserted, and the intraosseous needle was removed. Bacteriological and viral cultures were negative. Four days after admission, the child was discharged in good condition. CONCLUSIONS: Intraosseous infusion provides safe, rapid and reliable access to the circulation for administration of fluids and drugs in the critically ill child or during cardiac arrest.

[Peritoneal tuberculosis in children: report of two cases]. / Tuberculose péritonéale de l'enfant: à propos de deux cas.

UNLABELLED: Peritoneal tuberculosis is an uncommon presentation of extra-pulmonary tuberculosis in children. It usually presents as ascites, abdominal pain, anorexia and weight loss. CASES REPORT: We report two adolescent patients who presented with ascites, fever, weight loss and abdominal distension. In one case, the diagnosis was late, and confirmed by ascites culture. In the second case, a laparoscopy was performed and showed whitish nodules involving the entire abdominal cavity, compatible with peritoneal tuberculosis, later confirmed bacteriologically. CONCLUSION: Peritoneal tuberculosis presents with nonspecific symptoms. Because laboratory investigations may not be helpful, diagnosis may be difficult. Peritoneal-fluid adenosine deaminase (ADA) determination and coelioscopy seem to be the best way to make a rapid diagnosis.

[Inaugural acute cholestasis of Kawasaki disease]. / Cholestase aiguë inaugurale d'une maladie de Kawasaki.

BACKGROUND: Hepatic dysfunction with mild obstructive jaundice occurs occasionally in Kawasaki disease. Acute episode of cholestasis as a presenting symptom has never been reported. CASE REPORT: A 14 year-old-boy was admitted with fever and cholestasis. He subsequently developed the classical manifestations of Kawasaki disease. No signs of liver cell injury or hepatic failure were present. Bacteriological cultures and seroimmunologic markers for viral infection remained negative. There was no ultrasonic abnormality of bile ducts. The child was given intravenous gamma globulins and salicylate. The outcome was favourable without any cardiovascular complications. CONCLUSION: A persistent febrile cholestasis of unknown etiology should evoke the diagnosis of Kawasaki disease.

[Telephonic advice by an emergency department given in a simulated pediatric case]. / Conseils téléphoniques donnés aux urgences pour un cas pédiatrique simulé.

BACKGROUND: Emergency departments (ED) are requested everyday to dispense medical telephone advice for children. To evaluate the quality of telephone management, a mock scenario simulating a febrile 4 month-old-girl with signs compatible with septicemia was used. METHODS: One hundred randomly selected French emergency departments were called on. Half of the hospitals had a pediatric department with more than 20 beds; the other half did not have a pediatric department. A research technician called and said: "My baby has got fever and I do not know what to do". Additional information was given only on request. RESULTS: Ninety-four ED gave medical advice by telephone: 65% of the cases by a physician, 24.5% by a nurse, 9.5% by a nurse technician and 1% by a secretary. In hospitals without a pediatric department, physicians took calls in 76.5% of the cases, whereas in hospitals with a pediatric department they only took calls in 53% of the cases. The mean number of questions asked per ED was 3.1. The age of the child was requested by 87.2% of the respondents. Advice was given by 36.1% of the ED without asking either the age of the patient or grade of the fever. The advice given by the respondents was: come to the ED immediately (30.9%), see a community physician immediately (51%), come to the ED tomorrow (2.1%), see a community physician tomorrow (8.5%), and manage at home (7.5%). CONCLUSIONS: This study has shown important inadequacies in pediatric telephone advice given by some ED. It suggests that the respondents do not use a protocol to handle the calls; development of such protocols to guide the histories taken and advice given for the most common telephone queries is urged.

[Early cardiovascular effects of corticotherapy for bronchopulmonary dysplasia]. / Effets cardiovasculaires précoces de la corticothérapie pour dysplasie bronchopulmonaire.

OBJECTIVES: The aim of this study was to analyze the time course of cardiovascular effects in glucocorticoid-treated premature infants with bronchopulmonary dysplasia (BPD). METHODS: In a retrospective case study, 63 ventilator-dependent very-low-birth-weight neonates (mean gestational age = 27.9 +/- 2 weeks and mean birth weight = 920 +/- 275 g) treated with dexamethasone (52%) or betamethasone (48%) were studied. The average value for each study day was calculated for systolic arterial blood pressure and heart rate. RESULTS: At initiation of treatment, blood pressures increased significantly from pre-treatment to day 1 and continued to increase during the first week: as a percentage of pre-treatment baseline the mean increase for systolic arterial blood pressure was 19% (95% confidence interval [CI] = 16, 22) on day 2 (P < 0.001). The maximum amplitude of variation was observed before day 2 for 75% of the study group. As a group as a whole, the heart rate value significantly decreased on day 1 (mean difference = -14.6 beats/min; 95% CI = -16.5, -12.6; P < 0.001), and then reached pre-treatment value within one week. Cardiovascular response was independent of gestational age, birth weight and postnatal age at the beginning of treatment. CONCLUSION: During postnatal steroid therapy a rise in blood pressure is a common side effect, but bradycardia is mentioned very occasionally. The present study shows a marked increase in blood pressure during the first 48 hours concomitant with a decrease in heart rate. The inverse relationship between systolic arterial blood pressure and heart rate suggests a baroreflex response.

[Jargon of the neonatal intensive care unit]. / Le jargon de la réanimation néonatale.

Jargon, the specialized vocabulary and idioms, is frequently used by people of the same work or profession. The neonatal intensive care unit (NICU) makes no exception to this. As a matter of fact, NICU is one place where jargon is constantly developing in parallel with the evolution of techniques and treatments. The use of jargon within the NICU is very practical for those who work in these units. However, this jargon is frequently used by neonatologists in medical reports or other kinds of communication with unspecialized physicians. Even if part of the specialized vocabulary can be decoded by physicians not working in the NICU, they do not always know the exact place that these techniques or treatments have in the management of their patients. The aim of this article is to describe the most frequent jargon terms used in the French NICU and to give up-to-date information on the importance of the techniques or treatments that they describe.

[Pneumothorax revealing pneumoblastoma in an infant]. / Pneumothorax chez un nourrisson révélateur d'un pneumoblastome.

BACKGROUND: Pulmonary blastoma is a tumor with bad prognosis that is exceptionally seen before the age of 2 years. CASE REPORT: A 3 1/2 month-old infant was admitted because she suffered from tachypnea. A left pneumothorax with shift of the mediastinum was recognized that required insertion of a chest tube followed by ventilation and pleural drainage. X rays and CT scan showed a round bullous lesion in the left lung that persisted at the age of 5 months. At that time, clinical deterioration led to thoracotomy allowing excision of a bullous tumor; histological examination showed that this tumor was a pulmonary blastoma. Recurrence of this tumor, 16 months later, required chemotherapy and surgical excision. The patient is normal at the age of 4 years. CONCLUSION: Pulmonary blastoma is exceptional in infancy; it may be revealed by pneumothorax. Its bad prognosis requires aggressive therapy.

[Management of a short femur discovered via ultrasound in utero. Prenatal diagnosis of Stuve-Wiedemann syndrome]. / Conduite à tenir devant la découverte échographique d'un fémur court in utero. A propos d'un diagnostic anténatal de syndrome de Stuve-Wiedemann.

The authors report a case of familial Stuve-Wiedemann syndrome where the diagnosis was made in utero. Following this case the authors discuss the management of short femur discovered by ultrasound. The analysis of the morphology, the ultrasound appearance and the radiographic appearance (X-ray of the uterine contents) may make it possible sometimes to diagnose the syndrome. An important element is a study of the genealogy to discover the way in which a large number of these bone diseases are transmitted. The prognosis for life is very variable according to the severity of the syndrome.

[An unusual etiology of hydramnios: prenatal cerebral vascular accident. Five cases]. / Une étiologie inhabituelle d'hydramnios: l'accident vasculaire cérébral anténatal. A propos de 5 observations.

Neurological anomalies of the fetus are classically reported as causes of hydramnios, but cerebral vascular events occurring in utero in the fetus are rarely mentioned. We observed five newborns with neurological complications during the neonatal period in which anomalies of cerebral vascularization were identified antenatally. The mothers had hydramnios during pregnancy. Several pathophysiological hypotheses have been proposed to explain the mechanism of hydramnios. Magnetic resonance imaging of the brain in the fetus has made it possible to identify such exceptional events with extremely poor prognosis and major sequelae.

[Prenatal prevention of infant respiratory distress syndrome. 1st part: experimental data and pharmacological treatment]. / Prévention anténatale du syndrome de détresse respiratoire du prématuré. 1re Partie: Données expérimentales et moyens pharmacologiques.

Pulmonary maturation and growth are two time-related interdependent phenomena. The main regulatory mechanisms of pulmonary maturation are complex and the role of epithelial-mesenchymal interrelationship appear to be determinant in the phenomena leading to morphological growth of the lung and in cellular differentiation of the epithelium during development. At an early stage of morphological development of the fetal lung, endogenous hormones do not directly affect epithelial differentiation but modulate the expression of genes coding for surfactant. Later surfactant production responds to multihormone regulation. Some of these hormones or growth factors (steroids, oestradiol, prolactin, thyroxine, epidermal growth factor, fibroblast pneumocyte factor) are powerful stimulators, favoring biochemical development of the fetal lung. Inversely, other factors (insulin, androgens) limit the production of surfactant. Glucocorticoids play a specific role (stimulation of morphologic and biochemical development of the lung) and potentialize the stimulating effect of other factors. A good understanding of these mechanisms is essential before introducing treatments stimulating natural processes as closely as possible. Experimental results on the use of lung maturation induction, especially with glucocorticoids, have been quite promising. Combining thyroid hormones and thyrotropin-releasing hormone appears to be an interesting proposal, as is the use of growth factors such as epidermal growth factor.

[Prenatal prevention of infant respiratory distress syndrome. 2nd part: clinical applications and indications]. / Prévention anténatale du syndrome de détresse respiratoire du prématuré. 2e Partie: Applicatons cliniques et indications.

Two types of sometimes complementary therapeutic strategies can be developed to prevent infant respiratory distress syndrome antenatally. The first is to administer a treatment aimed at accelerating the maturation process of fetal lung tissue in women at risk of premature birth. This is the only strategy with a goal of antenatal treatment. The second method is to optimize neonatal care, particularly with exogenous surfactants. The use of corticosteroids during the antenatal period has been well studied and is known to be effective with a 50% reduction in the risk of the syndrome before 34 weeks gestation. Prenatal morbidity and mortality are decreased without major adverse effects. Based on a limited number of cases, TRH-corticosteroid combination probably gives better results with no predictable unfavourable neonatal consequences. The synergic action of antenatal treatments, completed with exogenous surfactants at birth, is one of the fundamental aspects of care for very premature infants (< 28 weeks gestation).

[Allo-immune neonatal thrombopenia in the BaK(a) system. Apropos of 2 familial cases]. / Thrombopénie néonatale allo-immune dans le système BaK a. A propos de 2 observations familiales.

The authors report a case of two siblings who developed a neonatal alloimmune thrombocytopenia (NAITP) due to Bak-System incompatibility. They review the platelet antigen systems involved in NAITP and raise the problem of its present antenatal and postnatal management.

[Prenatal treatment of neonatal hemochromatosis with maternal administration of intravenous immunoglobulins (about four cases)]. / Traitement anténatal préventif de l'hémochromatose néonatale par administration maternelle d'immunoglobulines intraveineuses (à propos de quatre observations).

OBJECTIVES: Neonatal hemochromatosis is a very bad prognosis disease; liver transplantation was the only way to avoid an unfavourable evolution. Nowadays, hypothesis of an alloimmune mechanism for this disease has purposed to administrate high doses of immunoglobulins. PATIENTS AND METHODS: In this study, we report four cases of women whose previous child had neonatal hemochromatosis and who received such a treatment during the next pregnancy from 18 weeks to the term. RESULTS: This treatment allowed to lead their pregnancy to success. At birth, all four neonates were alive. Two of them presented transitory biologic symptoms of liver deficiency. All had a favourable evolution later. DISCUSSION AND CONCLUSION: Maternal treatment with high doses of immunoglobulins during pregnancy seems to improve dramatically the prognosis of neonatal hemochromatosis as it has been already reported. It could also apply to other diseases, which proceed from the same mechanism.