[Air or oxygen for neonatal resuscitation in the delivery room?]. / Air ou oxygène pour le nouveau-né en salle de naissance?

Most of the contemporary guidelines on newborn resuscitation are based on experience but lack scientific evidence. The use of 100% oxygen is one of the more evident. Today, these practices are questioned, particularly for the resuscitation of moderately depressed full term or near term newborns. Results of recent meta-analysis of trials that compared ventilation with air versus pure oxygen at birth suggests current practices should be revisited. On the basis of these data, air can be the initial gas to use for these babies. Large scale trials, including preterm and cause and/or severity of initial asphyxia, must now be undertaken before the publication of new guidelines for these populations. Particularly severely asphyxiated infants might require supplemental oxygen with titration of oxygen delivery and continuous monitoring of oxygen saturation.

Intravenous immunoglobulin therapy for prevention of infection in high-risk premature infants: report of a multicenter, double-blind study.

The effectiveness of intravenously administered immunoglobulin (Ig) therapy for prophylaxis of infection was evaluated in high-risk preterm infants. Two hundred thirty-five premature newborns were randomly assigned, in a double-blind controlled trial, to treatment and placebo groups. Thirty-five infants (29%) of the Ig group and 29 (25%) of the placebo group had one or more episodes of certain infection. Thirty infants (25%) of the Ig group and 18 (16%) of the placebo group had one or more episodes of probable infection. No significant differences were observed in the incidence of certain or probable infection in treated and control infants. Nevertheless, among the infants who had one or more certain or probable episodes of infection, more of them belonged to the Ig group than to the placebo group. The possible deleterious effect of the administration of large amounts of polyspecific Ig is discussed.

Trigeminal airstream stimulation. Maturation-related cardiac and respiratory responses during REM sleep in human infants.

Thirty-three premature and full-term infants (PCA, 31.5 to 50 weeks) who were free from neurologic and cardiopulmonary disease at the time of testing underwent a standardized TAS test during polygraphically controlled REM sleep. The R-R interval and the TTOT were measured before and during TAS. The R-R interval and TTOT changes during TAS were compared to the preceding 60-second mean R-R interval and TTOT in each infant and expressed as a percentage of mean control values (ie, % RR and % TTOT). During TAS, there was a significant negative correlation between cardiac and respiratory responses and postconceptional age (p less than 0.001 and p less than 0.0001, respectively). Prolongation of both the R-R interval and the TTOT elicited by TAS was significantly blunted by maturation.

Enterovirus in sudden unexpected deaths in infants.

BACKGROUND: Conventional approaches to virus detection failed to provide convincing evidence of a viral etiology in sudden unexplained deaths in infants (SUDI). Many viruses may not have been detected by the routinely used methods; among them enteroviruses (EV) have seldom been found in SUDI. METHODS: In this study EV were sought directly in stools, in pharyngeal and tracheal samples and in myocardial and lung tissues, by using a nested PCR; they were also sought indirectly by detecting IgM antibodies with a new capture immunoassay. Twenty-four SUDI cases were divided into two groups: Group I, certainly associated with; or Group II, not associated with clinical, biologic or histologic signs of viral infection. RESULTS: EV were found in stools but their prevalence was not significantly different between Group I and Group II (20 and 22.2%, respectively). On the contrary EV were detected in respiratory tract and/or lung samples in 53.8% of infants of Group I and in none of Group II. Anti-EV IgM antibodies were detected in 55.5% of infants of Group I and in none of Group II. CONCLUSIONS: These results indicate that EV infection may be specifically associated with the subgroup of SUDI with viral signs, raising the question of its role in this condition.

Methylprednisolone, an alternative to dexamethasone in very premature infants at risk of chronic lung disease.

OBJECTIVE: To evaluate the benefits and the medium-term side effects of methylprednisolone in very preterm infants at risk of chronic lung disease. STUDY DESIGN: Forty-five consecutive preterm infants (< 30 weeks' gestation) at risk of chronic lung disease were treated at a mean postnatal age of 16 days with a tapering course of methylprednisolone. The outcome of treatment was assessed by comparison with 45 consecutive historical cases of infants treated with dexamethasone; the infants did not differ in baseline characteristics. RESULTS: There were no differences between groups in the rate of survivors without chronic lung disease. Infants treated with methylprednisolone had a higher rate of body weight gain during the treatment period (median 120 g, range 0 to 190, vs. 70 g, range -110 to 210, P = 0.01) and between birth and the age of 40 weeks (median 1660 g, range 1170-2520, vs. 1580 g, range 1,040 to 2,120, P = 0.02). The incidence of both glucose intolerance requiring insulin (0 % vs. 18 %, P = 0.006) and cystic periventricular leukomalacia (2 % vs. 18%, P = 0.03) was lower among methylprednisolone-treated infants. CONCLUSION: Our observations confirm methylprednisolone to be as effective as dexamethasone and to have fewer side effects. A randomized control trial is needed to further study the efficacy and safety of methylprednisolone in very premature infants at risk of chronic lung disease.

Conservative management of patent ductus arteriosus in preterm infants.

We report our experience of medical treatment, chiefly based on prolonged artificial ventilation, of 33 preterm infants with PDA and heart failure whose survival rate was 88%. All of them had clinical criteria used by others to indicate surgical ligation of the ductus arteriosus. This conservative approach seems to give better results than surgical ligation, despite a high frequency of bronchopulmonary dysplasia among survivors.

Effects of sleep deprivation on respiratory events during sleep in healthy infants.

This study was designed to determine the effects of sleep deprivation on respiratory events during sleep in healthy infants. Ten unsedated full-term infants (1-6 mo) were monitored polygraphically during "afternoon naps" on a control day and on the day after sleep deprivation. Respiratory events, i.e., central apnea, obstructive apnea and hypopnea, and periodic breathing were tabulated. Results for respiratory events were expressed as 1) indexes of the total number of respiratory events and of specific respiratory events per hour of total sleep (TST), "quiet" sleep (QS) and "active" sleep (AS) times; 2) total duration of total and specific respiratory events, expressed as a percentage of TST, QS, and AS times. After sleep deprivation, significant increases were observed for 1) respiratory event (P less than 0.001), central apnea (P less than 0.05), and obstructive respiratory event (P less than 0.01) indexes; 2) respiratory event time as a percentage of TST (P less than 0.002) and as a percentage of AS time (P less than 0.001); 3) obstructive respiratory event time as a percentage of TST (P less than 0.01), QS (P less than 0.05), and AS times (P less than 0.002). The present study shows that short-term sleep deprivation in healthy infants increases the number and timing of respiratory events, especially obstructive events in AS.

Microbiology in sudden infant death syndrome (SIDS) and other childhood deaths.

The usefulness of post-mortem microbiology in the assessment of sudden unexpected deaths in infants and children has been debated by many pathologists. In our centre, microbiological investigations have been part of the post-mortem protocol for investigation of sudden deaths in infants and children for the past 12 years. The objective of this study was to review the microbiological findings for infants and children examined by our unit during the past 4 years in relation to gross and histological findings of the autopsy and the medical and social histories of the children. We reviewed 57 consecutive sudden deaths in infants and children examined by our Referral Centre between November 1994 and October 1998. These 57 sudden deaths were aged from 1 day to 4 years and 9 months including 40 cases of sudden infant death syndrome (SIDS) and 17 non-SIDS deaths. Results of the microbiological investigations of tissues and body fluids were assessed during the case review with reference to histological shock signs, severe gastric aspiration, and signs of acute thymic involution. Bacteria alone or in association with viruses were identified in 45/57 (79%) cases including 34/40 (85%) SIDS. The most frequent bacterial isolate was Escherichia coli (27), and the virus identified most frequently was enterovirus (8). C-reactive protein was increased in 10 out of the 42 cases tested including 8/32 (25%) SIDS. Significant gastric content aspiration was found in 17/57 (29.8%) including 13/40 (32.5%) SIDS. Histological signs of shock were present in 33/55 (60%) cases including 22/39 SIDS (56.4%). The microbiological findings were positive for 27/33 (81.8%). We conclude that post-mortem microbiology is essential in sudden death investigation. The conclusion that a death is unexplained if no microbiology was done is not valid, even if in some cases it may be difficult to know precisely in what way the pathogen contributed to the death.

Task force report on the outcome of pregnancies and children conceived by in vitro fertilization (France: 1987 to 1989).

OBJECTIVE: To describe the outcome of pregnancies conceived by IVF and the follow-up of the children after a minimum of 1 year of life. DESIGN: Survey of clinical pregnancies and follow-up of the children and comparison with national statistics. SETTINGS: All clinical pregnancies from 11 French centers between January 1987 and June 1989. PATIENTS: A total of 1,637 pregnancies resulting in 1,263 deliveries and 1,669 live-born or still-born children and 1,411 alive children after 1 year. MAIN OUTCOME MEASURES: Gestational age of birth, birth weight, mortality rates, prevalence of congenital malformation, and prevalence of disorders during the follow-up of the children. RESULTS: The preterm birth rate was 22.7% of all deliveries and 12.2% of single deliveries compared with 5.6% in France, and 34.7% of babies weighed < 2,500 g compared with 5.2% in France. The rate of perinatal, neonatal, and infant mortality were higher than the national average. The rate of malformation (2.86%) was comparable with national survey (2.08%). The health of children diseased during the whole follow-up was approximately 2%. CONCLUSION: The health of children after 1 year of live is close normal.

Changes in phospholipid composition of tracheal aspirates from newborns with hyaline membrane disease or transient tachypnoea.

Phospholipid analysis of tracheal aspirates obtained from 37 newborn infants, all intubated for respiratory diseases, was performed in order to compare infants having hyaline membrane disease (HMD) (n = 11), to those presenting with transient tachypnoea (TT) (n = 16) or another respiratory disorder (n = 10) and to determine if distinguishing features could be discovered for HMD or TT. In the HMD group, a significantly lower amount (about 20%) of recoverable phospholipid material was observed. Furthermore, the groups differed in their phospholipid profile: infants with HMD presented with a deficiency in saturated phosphatidylcholine, but had a related increase in unsaturated phosphatidylcholine, and an increased proportion of phosphatidylethanolamine (about 2.5 times more) as compared with both other groups. In infants suffering HMD and TT, phosphatidylglycerol was lower and phosphatidylinositol was higher than in infants with other diseases. This change was the only one displayed in infants with TT. We speculate that the observed changes reflect changes in amount and composition of surfactant and are involved in the etiology of HMD and TT.

Accuracy of two wavelength pulse oximetry in neonates and infants.

In 60 neonates (gestational age, 26.5-40 weeks; postnatal age, 1-14 days) and in 11 infants (gestational age, 26-33 weeks; postnatal age, 4.5-38 weeks), the accuracy of two wavelength pulse oximetry was examined. A total of 112 comparisons between transcutaneous pulse oximetry saturation (StcO2, NELLCOR N-100) and arterial oxygen saturation (SaO2, OSM2 RADIOMETER) were obtained. SaO2 ranged from 80 to 100%. Criteria for comparison between StcO2 and SaO2 were standardized: patients in behavioral state 1, StcO2 stable for 2 min, and arterial samples drawn from an indwelling arterial line. StcO2 was significantly related to SaO2 (P less than 0.01), but the difference, StcO2 - SaO2, significantly increased when SaO2 decreased [StcO2 - SaO2(%) = -0.39 SaO2(%) + 37.95; r = -0.64, P less than 0.01]. No significant relationship was found between StcO2 - SaO2 and either bilirubinemia (range, 5-222 mumol/L) or fetal hemoglobin (HbF) (range, 12-95%). We conclude that StcO2 overestimates SaO2 when SaO2 decreases, and this overestimation is not due to high levels of bilirubin or HbF.

Compliance of the total respiratory system in healthy preterm and full-term newborns.

The compliance of the total respiratory system (CRS) was determined by the occlusion technique during expiration in 19 preterm newborns (NB) over 31 weeks of gestational age (mean, 34 +/- 1.5 SD) and in 20 full-term NB. Postnatal age ranged from 1 to 28 days. No sedation was used during the test. In absolute terms, CRS was significantly greater (P less than 0.01) in full-term than in preterm NB (3.17 +/- 0.71 ml/cm H2O vs 2.37 +/- 0.81 ml/cm H2O). When normalized for body weight, length cubed, [corrected] body surface area, and the Quetelet index (body weight/length squared) [corrected], CRS was similar in preterm and full-term NB. These results suggest that, normalized for biometric data, passive elastic properties of the total respiratory system are similar in full-term and preterm NB, at least in the gestation age range studied.

Passive total respiratory system compliance and gas exchange in newborns with hyaline membrane disease.

Passive total respiratory system compliance (CRS) and gas exchange measurements were performed in nine newborns during the course of hyaline membrane disease. None of the subjects presented bronchopulmonary dysplasia at follow-up investigations. Gestational age ranged from 29 to 37 weeks. CRS was measured by the multiple occlusion technique. Gas exchange parameters were the fraction of inspired oxygen concentration (FIO2) and the arterial/alveolar ratio for oxygen (a/AO2 ratio). In each subject four tests were performed: test 1 during the first day of life; test 2 during the second day of life; test 3 between the fourth and the seventh days of life; test 4 after extubation. CRS/BW (CRS normalized for body weight) was not statistically different at tests 1-3, but it significantly increased (P less than 0.001) between tests 3 and 4. FIO2 and a/AO2 ratio presented no statistical difference at tests 1-2 but several significant differences were noted thereafter: FIO2 decreased significantly (P less than 0.001) when results from tests 2 and 3 were tabulated. The a/AO2 ratio increased significantly between tests 2 and 3 (P less than 0.001), and a further significant increase (P less than 0.01) was also noted when results obtained during tests 3 and 4 were compared. A significant relationship existed during the evolution of the disease between CRS/BW and gas exchange parameters (FIO2 and a/AO2 ratio) (P less than 0.01), but gas exchange improved earlier than lung mechanics.

Development and initial validation of the EDIN scale, a new tool for assessing prolonged pain in preterm infants.

OBJECTIVE: To develop and validate a scale suitable for use in clinical practice as a tool for assessing prolonged pain in premature infants. METHODS: Pain indicators identified by observation of preterm infants and selected by a panel of experts were used to develop the EDIN scale (Echelle Douleur Inconfort Nouveau-Né, neonatal pain and discomfort scale). A cohort of preterm infants was studied prospectively to determine construct validity, inter-rater reliability, and internal consistency of the scale. RESULTS: The EDIN scale uses five behavioural indicators of prolonged pain: facial activity, body movements, quality of sleep, quality of contact with nurses, and consolability. The validation study included 76 preterm infants with a mean gestational age of 31.5 weeks. Inter-rater reliability was acceptable, with a kappa coefficient range of 0.59-0.74. Internal consistency was high: Cronbach's alpha coefficients calculated after deleting each item ranged from 0.86 to 0.94. To establish construct validity, EDIN scores in two extreme situations (pain and no pain) were compared, and a significant difference was observed. CONCLUSIONS: The validation data suggest that the EDIN is appropriate for assessing prolonged pain in preterm infants. Further studies are warranted to obtain further evidence of construct validity by comparing scores in less extreme situations.

Low levels of pancreatic elastase 1 in stools of preterm infants.

The amount of faecal pancreatic enzyme elastase 1 was significantly lower in 42 preterm newborns than in 12 full term babies at day 2 (89 (3-539) v 354 (52-600) microg/g, p<0.0007) and day 5 (164 (3-600) v 600 (158-600) microg/g, p<0.05) and correlated positively with total nutrient intake during the first week of life in preterm infants. This should probably be taken into account during early feeding.

Survival of very preterm infants: Epipage, a population based cohort study.

OBJECTIVE: To evaluate the outcome for all infants born before 33 weeks gestation until discharge from hospital. DESIGN: A prospective observational population based study. SETTING: Nine regions of France in 1997. PATIENTS: All births or late terminations of pregnancy for fetal or maternal reasons between 22 and 32 weeks gestation. MAIN OUTCOME MEASURE: Life status: stillbirth, live birth, death in delivery room, death in intensive care, decision to limit intensive care, survival to discharge. RESULTS: A total of 722 late terminations, 772 stillbirths, and 2901 live births were recorded. The incidence of very preterm births was 1.3 per 100 live births and stillbirths. The survival rate for births between 22 and 32 weeks was 67% of all births (including stillbirths), 85% of live births, and 89% of infants admitted to neonatal intensive care units. Survival increased with gestational age: 31% of all infants born alive at 24 weeks survived to discharge, 78% at 28 weeks, and 97% at 32 weeks. Survival among live births was lower for small for gestational age infants, multiple births, and boys. Overall, 50% of deaths after birth followed decisions to withhold or withdraw intensive care: 66% of deaths in the delivery room, decreasing with increasing gestational age; 44% of deaths in the neonatal intensive care unit, with little variation with gestational age. CONCLUSION: Among very preterm babies, chances of survival varies greatly according to the length of gestation. At all gestational ages, a large proportion of deaths are associated with a decision to limit intensive care.

[Intraventricular hemorrhage and parenchymatous ischemia in the newborn at term. Report of five cases]. / Hémorragie intraventriculaire et ischémie parenchymateuse chez le nouveau-né à terme à propos de cinq cas.

Although intraventricular hemorrhage associated with cerebral ischemia without severe perinatal asphyxia is rare in full-term newborns, it can be severe, have early or late onset depending on the etiology and be of poor prognosis. Five full-term neonates (37 to 41 weeks of gestational age) without criteria of severe perinatal asphyxia were admitted to the intensive care unit for seizures: four were between seven and 11 days of age and one was only 12 h old. Clinical or electroclinical seizures recorded by continuous EEG monitoring were numerous, leading to status epilepticus in three babies. They were unilateral (at the level of the left hemisphere) in one infant and have not been recorded in the fourth case. Past-ictal EEG abnormalities were numerous rolandic or temporal slow or fast sharp waves of variable polarity. Cranial CT scans showed uni- or bilateral intraventricular hemorrhage with dilatation and subcortical or periventricular ischemic lesions with hemorrhage. Four out of the five infants died during the neonatal period.

Outborn status with a medical neonatal transport service and survival without disability at two years. A population-based cohort survey of newborns of less than 33 weeks of gestation.

OBJECTIVE: Prenatal events are thought to play an important role in long-term handicap, but the specific role of perinatal factors remains controversial. Our study, conducted in the context of this debate, aimed to break down the various components of perinatal management and to assess the relationship between these components and survival without disability at the age of two years. STUDY DESIGN: A prospective geographically-defined study was conducted in 1985 in the Paris metropolitan area. It covered 53430 births (stillbirths and live births), including 539 that occurred between 25 and 32 weeks gestation. The relationship between perinatal management and survival without disability was studied by a multivariate analysis (logistic regression). The analysis was restricted to a group of 202 infants born at 31 or 32 week's gestation, to avoid indication bias. RESULTS: An inborn status (delivery in a tertiary care facility) exerted a protective effect on survival without disability at the age of two years (Adjusted Odds Ratio (OR)=7.51 [1.51; 37.4]), even though the area we studied possessed an excellent Medical Neonatal Transport Service. Multiple pregnancies also seemed to have a protective effect (Adjusted OR=2.45 [0.96; 6.27]). No statistically significant association was seen between survival without disability at two years and the presence of a hospital staff paediatrician in the delivery room. CONCLUSION: These results lead us to consider what the concept of inborn/outborn represents in the perinatal management of infants at high risk.

Outcome of premature infants delivered after prolonged premature rupture of membranes before 25 weeks of gestation.

OBJECTIVE: To identify factors influencing the outcome of premature infants delivered after prolonged premature rupture of membranes before 25 weeks' gestation. DESIGN AND POPULATION: All premature infants with gestational age <34 weeks, either inborn or outborn, with history of rupture of membranes before 25 weeks' gestation, admitted to our NICU between January 1992 and July 1997, were eligible for this retrospective study. Collected information included birth weight, gestational age at rupture of membranes and at delivery, duration between rupture of membranes and delivery (latency period), severity of oligohydramnios, pre- and post-natal managements, and follow-up of survivors. RESULTS: A total of 28 neonates fulfilled the inclusion criteria. Despite new strategies of ventilation and optimal management, the overall mortality rate was 43% (12/28). Nonsurvivors were significantly less mature at rupture of membranes, and had severe oligohydramnios (anamnios). We also noted less antenatal corticosteroids and antibiotic therapy in this group. Nine of eleven infants (82%) following rupture of membranes before 22 weeks' gestation died shortly after birth. The two remaining infants developed severe bronchopulmonary dysplasia. Nine deaths occurred in thirteen cases (69%) of anamnios. The major death causes were refractory respiratory failure and neurologic complications. Half of all survivors (8/16) developed bronchopulmonary dysplasia. CONCLUSION: The outcome of premature infants following prolonged premature rupture of membranes before 25 weeks' gestation is influenced by gestational age at rupture, severity of oligohydramnios, and antenatal antibiotics and corticosteroids. Neonates with rupture of membranes before 22 weeks have a very low chance of survival at the present time.

[Platelet transfusions in neonatology]. / Transfusions plaquettaires en néonatalogie.

Thrombocytopenia occurs in 20% to 40% of infants admitted to a neonatal intensive care unit. Approximately 30% of the newborns with severe thrombocytopenia below 50.10(9)/l platelets receive platelet transfusions. The etiology may be: bacterial infection, DIC and immune mediated thrombocytopenia. The consequences of thrombocytopenia are significant risks of severe intracranial hemorrhage and neurologic morbidity. Therapeutic platelet transfusions are given to actively bleeding neonates with less than 50.10(9)/l platelets. Prophylactic platelet concentrates are usually given to infants with platelets counts below 20.10(9)/l. The standard platelet concentrate (CMV-negative donor) is the product of choice for newborns. Fetal intracranial hemorrhage is possible as soon as 20 weeks of gestation in allo-immune thrombocytopenia. Actually percutaneous umbilical blood sampling is very useful to measure fetal platelets count in order to decide in utero maternal platelet transfusion. Maternal irradiated plateletpheresis concentrates are preferentially infused in this indication. At the end of pregnancy, cesarean section is preferred to normal vaginal delivery if fetal thrombocytopenia below 100.10(9)/l is observed. In pregnant women with auto-immune thrombocytopenia, the decision to carry out percutaneous umbilical blood samples should be weigh relatively to the 3-5% estimated risk of serious consequences. Platelets transfusions are particularly successful in immune thrombocytopenia but less effective in other clinical circumstances.