Neonatal renal replacement therapy: An ethical reflection for a crucial decision

CONTEXT

Technological advances in fetal and neonatal medicine, recent changes in the French legal framework, and encouraging results of the long-term outcomes in children with neonatal renal failure provide elements for an ethical reflection.

METHODS

We led a nationwide enquiry among French pediatric nephrologists, intensivists, and neonatologists, exploring the decision-making process when contemplating starting renal replacement therapy (RRT) or delivering palliative care to neonates or infants with pre-end-stage or end-stage renal disease; and the ethical quandaries at hand in such scenarios.

RESULTS

A total of 134 responses with complete national coverage were obtained. Care to be delivered to an infant in pre-end-stage or end-stage renal disease did not achieve consensus. Pediatric nephrologists were more prone to initiate a dialysis/graft program than pediatric intensivists. When chronic kidney disease was associated with comorbidities, especially neurological impairment, physicians, regardless of their subspecialty, were more reluctant to initiate conservative treatment. Many of the doctors surveyed did not give their opinion in these prenatal and/or postnatal situations, considered to be unique and warranting a multidisciplinary reflection.

CONCLUSION

Such ethical dilemmas are challenging for parents and physicians. They can only be overcome by taking into account both concrete on the ground realities and general principles and values acknowledged to be a basis for respecting the individual. In this way, it ensures humaneness and humanization of a practice that must meet a variety of challenges, one by one. The answer is not simple; it is always unique to each child and can only be approached by a multidisciplinary, time-consuming, open discussion, which will never totally erase uncertainty.

Extremely premature infants: How does death in the delivery room influence mortality rates in two level 3 centers in France?

OBJECTIVES

Mortality rates of very preterm infants may vary considerably between healthcare facilities depending on the neonates' place of inclusion in the cohort study. The objective of this study was to compare the mortality rates of live-born extremely preterm neonates observed in two French tertiary referral hospitals, taking into account the occurrence of neonatal death both in the delivery room and in the neonatal intensive care unit (NICU).

METHODS

Retrospective observational study including all pregnancy terminations, stillbirths and live-born infants within a 22- to 26-week ^0/6 gestational age range was registered by two French level 3 university centers between 2009 and 2013. The mortality rates were compared between the two centers according to two places of inclusion: either the delivery room or the NICU.

RESULTS

A total of 344 infants were born at center A and 160 infants were born at center B. Among the live-born neonates, the rates of neonatal death were similar in center A (54/125, 43.2%) and center B (33/69, 47.8%; P=0.54). However, neonatal death occurred significantly more often in the delivery room at center A (31/54, 57.4%) than at center B (6/33, 18.2%; P<0.001). Finally, the neonatal death rate of live-born very preterm neonates admitted to the NICU was significantly lower in center A (25/94, 26.6%) than in center B (27/63, 42.9%; P=0.03).

CONCLUSIONS

This study points out how the inclusion of deaths in the delivery room when comparing neonatal death rates can lead to a substantial bias in benchmarking studies. Center A and center B each endorsed one of the two models of preferential place of neonatal death (delivery room or NICU) detailed in European studies. The reasons behind the two different models and their impact on how parents perceive supporting their neonate need further investigation.

[Oxytocin administration during spontaneous labour: Guidelines for clinical practice. Guidelines short text]

OBJECTIVES

To define the different stages of spontaneous labour. To determine the indications, modalities of use and the effects of administering synthetic oxytocin. And to describe undesirable maternal and perinatal outcomes associated with the use of synthetic oxytocin.

METHOD

A systematic review was carried out by searching Medline database and websites of obstetrics learned societies until March 2016.

RESULTS

The 1st stage of labor is divided in a latence phase and an active phase, which switch at 5cm of cervical dilatation. Rate of cervical dilatation is considered as abnormal below 1cm per 4hour during the first part of the active phase, and below 1cm per 2hours above 7cm of dilatation. During the latent phase of the first stage of labor, i.e. before 5cm of cervical dilatation, it is recommended that an amniotomy not be performed routinely and not to use oxytocin systematically. It is not recommended to expect the active phase of labor to start the epidural analgesia if patient requires it. If early epidural analgesia was performed, the administration of oxytocin must not be systematic. If dystocia during the active phase, an amniotomy is recommended in first-line treatment. In the absence of an improvement within an hour, oxytocin should be administrated. However, in the case of an extension of the second stage beyond 2hours, it is recommended to administer oxytocin to correct a lack of progress of the presentation. If dynamic dystocia, it is recommended to start initial doses of oxytocin at 2mUI/min, to respect at least 30min intervals between increases in oxytocin doses delivered, and to increase oxytocin doses by 2mUI/min intervals without surpassing a maximum IV flow rate of 20mUI/min. The reported maternal adverse effects concern uterine hyperstimulation, uterine rupture and post-partum haemorrhage, and those of neonatal adverse effects concern foetal heart rate anomalies associated with uterine hyperstimulation, neonatal morbidity and mortality, neonatal jaundice, weak suck/poor breastfeeding latch and autism.

CONCLUSION

The widespread use of oxytocin during spontaneous labour must not be considered as simply another inoffensive prescription without any possible deleterious consequences for mother or foetus. Conditions for administering the oxytocin must therefore respect medical protocols. Indications and patient consent have to be report in the medical file.

[Variables determining the amount of care for very preterm neonates: the concept of medical stance]

OBJECTIVE

To compare the amount of medical interventions on very preterm neonates (24-31 weeks of gestation) in two French university tertiary care centers, one of which is involved in a Neonatal Developmental Care program. A secondary objective is to assess whether this difference in medical interventions can be linked to a difference in mortality and morbidity rates.

METHODS

We prospectively included all very preterm neonates free from lethal malformation born live in these two centers between 2006 and 2010. These inclusion criteria were met by 1286 patients, for whom we compared the rate of five selected medical interventions: birth by caesarean section, chest intubation in the delivery room, surfactant therapy, pharmacological treatment of patent ductus arteriosus, and red blood cell transfusion.

RESULTS

The rates of the five medical interventions were systematically lower in the center that is involved in Neonatal Developmental Care. There was no significant difference in survival at discharge with no severe cerebral ultrasound scan abnormalities between the two centers. There were, however, significantly higher rates of bronchopulmonary dysplasia and nosocomial sepsis and longer hospital stays when the patients were not involved in a Neonatal Developmental Care program.

DISCUSSION

This benchmarking study shows that in France, in the first decade of the 21st century, there are as many ways to handle very preterm neonates as there are centers in which they are born. This brings to light the concept of medical stance, which is the general care approach prior to the treatment itself. This medical stance creates the overall framework for the staff's decision-making regarding neonate care. The different parameters structuring medical stance are discussed. Moreover, this study raises the problematic issue of the aftermath of benchmarking studies when the conclusion is an increase of morbidity in cases where procedure leads to more interventions.

Height at 2 and 5 years of age in children born very preterm: the EPIPAGE study

OBJECTIVES

To evaluate growth for children born very preterm with particular focus on those born small-for-gestational age (SGA) or with ex utero growth restraint (GR), and to identify risk factors for short stature at 5 years of age.

STUDY DESIGN

Population-based study of children born at less than 33 completed weeks of gestation (Étude Epidémiologique sur les Petits Ages Gestationnels (EPIPAGE)). Short stature was defined as height <-2SD on WHO growth curves. Ex utero GR was considered to have occurred in children with appropriate size for gestational age at birth and with a height and/or weight below -2SD at 2 years of corrected age. Logistic regression models were used to test associations between risk factors and short stature.

RESULTS

The authors measured height at 5 years of age for 1,597 of 2,193 children (73%), 5.6% (95% CI 4.6 to 6.9) of whom were diagnosed as having a short stature. Height was measured at 2 and 5 years of age in 1417 children. Among these, 24% of those born SGA and 36% of those with ex utero GR (p=0.002) had a short stature at 5 years. Predictors of short stature were SGA or birth length <-2SD, maternal height ≤ 160 cm, gestational age <29 weeks and systemic corticosteroids. Breastfeeding at discharge decreased the risk of short stature.

CONCLUSIONS

Short stature at 5 years of age is common in children born preterm. The highest incidence was observed in the group with ex utero GR. Systemic steroids have a long-term impact on growth and should be used with caution. Breastfeeding at discharge appeared to be protective.

Does plasma IGF-BP3 measurement contribute to the diagnosis of growth hormone deficiency in children?

OBJECTIVE

To audit the contribution of plasma IGF-PB3 measurement to the diagnosis of growth hormone deficiency (GHD) in children.

POPULATION AND METHODS

Retrospective case study including boys and girls aged 0 to 18 years who attended our paediatric endocrinology clinic for short stature and/or post-irradiation follow-up, and had at least one GH provocative testing. Children with hypothyroidism, Laron or Kowarski syndromes, severe malnutrition, chronic renal failure and liver failure were excluded.

RESULTS

Fifty-eight children were enrolled and grouped as GHD [+] (19 cases) and GDH [-] (39 cases). IGF-I and IGF-BP3 assay was carried out in 88% and 62% cases respectively, both groups were comparable for age, sex, BMI, target height, pubertal stage and bone age. There was a significant difference in peak GH between GDH [-] and GHD [+] groups (41.8 mUI/L ± 21.7 versus 11.5 ± 5.9 mUI/L, P<0.00001, respectively). No difference was found between groups with regards to IGF-I Z-scores and IGF-BP3 Z-scores. There was, however, a positive correlation between IGF-I Z-scores and IGF-BP3 Z-scores (r=0.50; P<0.0016). IGF-BP3 measurement could not differentiate between GHD [+] and GHD [-] groups.

CONCLUSIONS

Measurement of plasma IGF-BP3 level contributes poorly to the diagnosis of GHD. We do not recommend it in routine use.

[Very preterm birth: is maternal anesthesia a risk factor for neonatal intubation in the delivery room?]

OBJECTIVE

To assess the risk of tracheal intubation at birth in very premature neonates related to the type of maternal anesthesia in case of elective cesarean.

POPULATION AND METHODS

All 219 live-born very premature neonates (28-32 weeks of gestation), delivered after an elective cesarean in the 27 maternity wards of 2 French semi-rural neonatal networks. Eighty-three percent (182/219) were delivered in level III maternity wards in university hospitals.

RESULTS

Of the very preterm neonates, 33.3% (73/219) were intubated in the delivery room, either for respiratory distress syndrome or a low APGAR score. Very preterm neonates delivered after maternal general anesthesia were more often intubated than those delivered after spinal anesthesia (48.7% vs 25.2%; OR: 2.8; 95% CI: 1.8-5.1). The risk of intubation related to maternal general anesthesia remained statistically significant after an adjustment for gestational age, fetal growth retardation, respiratory distress syndrome, type of maternity ward, and a propensity score that took into account maternal sociodemographic characteristics and the causes of very preterm birth (aOR: 3.4; 95% CI: 1.4-8.2). The risk of intubation related to general anesthesia was lower after adjusting for the 5-min APGAR score (aOR: 2.8; 95% CI: 1.0-7.3).

CONCLUSION

Very preterm neonates delivered after cesarean with general anesthesia require tracheal intubation in the delivery room more often than those delivered with spinal anesthesia. This study cannot assess a causal link between anesthesia and the need for neonatal intubation. However, neonatologists have to be aware of the type of maternal anesthesia because it may interfere with the non-invasive ventilation support policy of the very preterm neonate.

Impact of the use of antenatal corticosteroids on mortality, cerebral lesions and 5-year neurodevelopmental outcomes of very preterm infants: the EPIPAGE cohort study

OBJECTIVE

To assess the impact of antenatal corticosteroids (ACS) on neonatal mortality, cerebral lesions and 5-year neurodevelopmental outcome of infants born at 24-27 and 28-32 weeks of gestational age (GA).

DESIGN

Observational population-based study including all births at GAs between 22 and 32 weeks in 1997 in nine regions of France. Survivors were assessed at the age of 5 years.

SAMPLE AND METHODS

The population enrolled in the follow up comprised 2323 infants; there were 23 deaths before age 5 years and outcome at 5 years was available for up to 1781 subjects. Two GA subgroups (24-27 and 28-32 weeks of GA) were analysed separately. Propensity scores were used to reduce bias in the estimation of the association between ACS treatment and outcomes.

MAIN OUTCOME MEASURES

Neonatal death, neonatal white matter injury, cerebral palsy, mental processing composite (MPC) of the Kaufman Assessment Battery for Children test and behavioural difficulties at 5 years.

RESULTS

In the 28- to 32-week GA subgroup, there was a significant association between ACS and a decreased risk of both neonatal death (OR = 0.61 [0.41-0.91]) and white matter injury (OR = 0.60 [0.46-0.79]) but only a nonsignificant trend for improved 5-year outcome (cerebral palsy, MPC < 70). In the 24- to 27-week GA subgroup, ACS was associated with a significant decrease risk of neonatal death (OR = 0.43 [0.27-0.68]) but there was only a trend for a lower risk of white matter injury and no beneficial impact on outcome at 5 years. Limiting the analysis to only those who received complete courses of ACS did not modify the results.

CONCLUSION

The study shows that ACS therapy greatly increases the survival of very preterm infants, including the most immature, but there is little evidence that ACS affects long-term neurodevelopmental and behavioural outcome in 28- to 32-week survivors, and none in <28-week survivors.

[Very preterm birth less than 33 weeks' gestation: how setting-up of a perinatal network does influence the activity of the neonatal tertiary care unit? The experience of the Poitou-Charentes region, France]

OBJECTIVES

To evaluate the impact of regional perinatal network setting on very preterm neonates (gestational age<33 weeks) referral and activity of regional level 3 NCIU, and short-term outcome of infants cared for.

POPULATION AND METHODS

Comparison of data from medical records of hospital days and hospital outcome of very preterm neonates born before and after the setting-up of regional perinatal network (2002-2005).

RESULTS

The setting-up of the Poitou-Charentes perinatal network has led to a 45% rise in number of very preterm neonates admitted to the level 3 neonatal care (114 in 2002, 166 in 2005), number of hospitalisation days has also increased by 31% in neonatology unit (2181 days in 2002, 2864 days in 2005) but remained stable in intensive care unit. A transient rise in neonatal mortality was observed, although the incidence of severe ultrasonographic cerebral abnormalities and that of bronchopulmonary dysplasia were lowered.

CONCLUSION

Setting-up of perinatal network in Poitou-Charentes (France) has led to improved access to level 3 neonatal care, with rise in very preterm neonates survival and low incidence of short-term sequelae.

[What diagnostic tools can be used to assess antenatal exposure to smoking? Pediatric experience]

In France, one out of four infants is born to a smoking mother. The short-, mid-, and long-term effects of antenatal exposure to smoking are only partially known. En Europe, it is generally accepted that most smoking mothers are aware of their smoking habit. Nevertheless, certain mothers deny their smoking or minimize the number of cigarettes smoked. The impact of anti-smoking campaigns on the frequency of maternal smoking and its recognition are unknown. The question is determine whether an objective marker of smoking in the neonatal period would be useful for individual care or epidemiological research. Cotinine and CO are the most widely used neonatalagy.

Does smoking in pregnancy modify the impact of antenatal steroids on neonatal respiratory distress syndrome? Results of the Epipage study

OBJECTIVES

To assess the relation between cigarette smoking during pregnancy and neonatal respiratory distress syndrome (RDS) in very preterm birth, and to analyse the differential effect of antenatal steroids on RDS among smokers and non-smokers.

DESIGN

A population based cohort study (the French Epipage study).

SETTING

Regionally defined births in France.

METHODS

A total of 858 very preterm liveborn singletons (27-32 completed weeks of gestation) of the French Epipage study were included in this analysis. The odds ratio for RDS in relation to smoking in pregnancy was estimated using a logistic regression to control for gestational age. The odds ratio for RDS in relation to antenatal steroids was estimated taking into account an interaction between antenatal steroids and cigarette smoking, using multiple logistic regression to control for gestational age, birthweight ratio, main causes of preterm birth, mode of delivery, and sex.

RESULTS

The odds ratio for RDS in relation to smoking in pregnancy adjusted for gestational age (aOR) was 0.59 (95% confidence interval (CI) 0.44 to 0.79). The aOR for RDS in relation to antenatal steroids was 0.31 (95% CI 0.19 to 0.49) in babies born to non-smokers and 0.63 (95% CI 0.38 to 1.05) in those born to smokers; the difference was significant (p = 0.04).

CONCLUSIONS

Cigarette smoking during pregnancy is associated with a decrease in the risk of RDS in very preterm babies. Although antenatal steroids reduce the risk of RDS in babies born to both smokers and non-smokers, the reduction is smaller in those born to smokers.

Re-hospitalization in infants younger than 29 weeks' gestation in the EPIPAGE cohort

AIM

To estimate the re-hospitalization rate of extremely preterm children during infancy and associated factors after the recent improvement in survival rates.

METHOD

The cohort included all children born before 29 wk of gestation in nine French regions in 1997. All admissions between discharge from initial hospitalization and 9 mo after birth were considered. Factors studied included the child's characteristics at birth and during neonatal hospitalization, risk factors for infection after discharge and parents' socio-demographic characteristics. Adjusted odds ratios (aOR) for re-hospitalization for all reasons and for respiratory disorders were obtained from logistic regression models.

RESULTS

Of the 376 children, 178 were re-admitted at least once (47.3%; 95% CI: 42.3-52.4). Fifty-five percent of the hospitalized children were admitted at least once for respiratory disorders. The re-hospitalization rate was higher for children who had had chronic lung disease (aOR: 2.2; 95% CI: 1.3-3.7), those initially discharged between August and October (aOR: 2.5; 95% CI: 1.2-5.1) or between November and January (aOR: 3.2; 95% CI: 1.5-6.8), and children living with other children under six (aOR: 3.4; 95 %CI: 1.6-7.5). Re-hospitalizations were associated with neither gestational age nor the duration of neonatal hospitalization. Adjusted odds ratios for re-hospitalization for respiratory tract disorders were very similar to those for the overall hospitalizations.

CONCLUSION

Infants born before 29 wk have a very high risk of re-hospitalization. The associated factors can help define high-risk groups at discharge from the neonatal unit who need special surveillance.

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.

[Smoking, fertility and very preterm birth]

In France, many couples in procreating age continue to smoke, despite recommendations to stop smoking before or during pregnancy. We reviewed the epidemiological associations between maternal or paternal smoking and both infertility and very preterm birth. It appears clearly that maternal smoking impairs natural and assisted fecundity. Furthermore, maternal smoking enhances the rate of ectopic pregnancies and spontaneous abortions. The role of maternal smoking on very preterm birth before 33 weeks of completed gestation appears in recent population based-study or case-control studies that include several hundred very preterm neonates. But the role of smoking on very preterm birth among hypertensive mothers and primiparae is still debated. The detrimental effect of smoking on fecundity appears to be reversible when the mother and father stop smoking. The real effect of interventions promoting cessation of smoking during pregnancy in reducing the rate of very preterm births remains to be studied.

[Terminal and pre-terminal chronic renal insufficiency in newborns in French neonatal intensive care units: survey of the French pediatric nephrologic society of resuscitation and emergency]

OBJECTIVES

The aim of this study was to describe the intensive care unit neonatologists' attitudes about a neonate with terminal or pre-terminal renal failure.

METHODS

A questionnaire was sent to all French neonatal intensive care units. Physicians were asked to describe their attitude about neonatal chronic renal failure (Would you agree with dialysis and graft for these children?). Physicians were also presented with two clinical observations involving neonates with varying degrees of renal insufficiency and a complicating comorbidity, including neurological abnormality or socioeconomic circumstances.

RESULTS

Responses were obtained from 92% of the university neonatal care units. The will to take care of a neonate with end-stage renal failure till the renal graft, varied greatly from a centre to another one. Three (9%) university-teams said they had a strong will to bring the baby from the neonatal period to the time of renal graft. Eleven other centres (32%) did not have any will for accompanying the baby till the renal graft. Eight centres (24%) would be rather favourable to the idea of dialysis and graft, and 12 others (35%) would be rather unfavourable.

CONCLUSION

The results of this study show great differences between French neonatologists when they are faced to newborns with end stage renal failure. Ethical, medical and organisational difficulties are matters of controversy. The epidemiological impact of the perinatal discussion could be a 20% variation of all the renal grafts in children.

[An appreciation of maternal smoking with high-performance liquid chromatographic determination of maternal and neonatal urinary cotinine]

OBJECTIVE

To study the correlation of urinary cotinine levels in mothers and newborns with the number of cigarettes smoked at the end of pregnancy. Population and methods. We recorded the smoking habits of 123 mothers attending a university maternity clinic and measured urinary cotitine levels in mothers and their newborns. All mothers were Europeans and gave birth to a normal full-term (37 weeks gestation) infant. Cotinine levels were measured with high-performance liquid chromatography from urine samples taken during the 6-hour period prior to or after delivery for the mothers and 24-h after birth for the newborns.

RESULTS

The average cotinine level for non-smoking mothers, for those who smoked one to nine cigarettes a day and heavy smokers (ten or more cigarettes per day) were 0.21, 2.17 and 4.28 mol/l respectively (p<0.001). The average levels in their newborns were 0.04, 0.39 and 1.36 mol/l respectively (p<0.001). Thirteen percent of the mothers who claimed they did not smoke had cotinine levels higher than the significance cut-off (0.3 mol/l). There was a significant correlation 1) between the number of cigarettes the mothers stated they smoked at the end of pregnancy and their urinary cotinine concentrations (cotinine level=0.213 + 0.349 cigarettes, r=0.78, p<0.001); 2) between the number of cigarettes smoked and newborn's urinary cotinine concentration (cotinine level=0.002 + 0.104 cigarettes/day, r=0.81, p<0.001); and 3) between the mother's and the newborn's urinary cotinine concentrations (newborn cotinine=0.027 + 0.219 maternal cotinine, r=0.77, p<0.001).

CONCLUSION

The number of cigarettes smoked at the end of pregnancy accounts for roughly 50% of the variance in the mother's urinary cotinine level and that in her newborn at birth. The urinary cotinine concentration in newborns is 3 to 5 times lower than that of their mothers. A woman smoking 3 cigarettes per day has a urinary cotinine concentration of 1 mol/l. The urinary cotinine level in newborns is 1 mol/l for mothers smoking 10 cigarettes per day.

Use of energy color Doppler in visualizing fetal pulmonary vascularization to predict the absence of severe pulmonary hypoplasia

OBJECTIVE

The aim of our study was to determine if the assessment of pulmonary vascularization by energy color Doppler during ultrasound examination can predict the absence of pulmonary hypoplasia before birth in situations where it is a high risk.

METHODS

In a prospective study of 12 pregnancies presenting a risk of pulmonary hypoplasia (5 early and prolonged premature ruptures of the membranes, 1 diaphragmatic hernia, 1 chylothorax, 1 pulmonary sequestration, 1 omphalocele, 1 anamnios and 2 Potter's syndromes) energy color Doppler was used to visualize pulmonary vascularization.

RESULTS

In 10 cases where pulmonary vascularization could be visualized, none of the infants had pulmonary hypoplasia. In the 2 cases of Potter's syndrome where pulmonary vascularization was not visualized there was a pulmonary hypoplasia.

CONCLUSION

The visualization of fetal pulmonary vascularization with energy color Doppler in situations with a high risk of pulmonary hypoplasia can predict the absence of severe pulmonary hypoplasia.

[Neurodevelopmental outcome of premature infants born at less than 33 weeks of gestational age and not cerebral palsy at the age of 5 years]

AIM

To appreciate the impact of prematurity, fetal hypotrophy and familial environment on the neurodevelopmental performances of very premature infants without cerebral palsy at the age of five years.

POPULATION AND METHODS

We followed a regional cohort of 171 very premature infants (< or = 32 weeks of gestation) until they were five years of age. Cognitive functions were tested with the WPPSI test and the development quotient was assessed by the ability to draw a "bonhomme". Twenty-two premature infants suffered from cerebral palsy diagnosed before the age of two years. Another infant had a moderate diplegia at the five-year examination. We had no information for 16 prematures (9.3% of survivors). Twenty-eight premature infants were considered as having no severe disability on phone or mailed contact, and another child had a severe isolated mental retardation. We examined 104/148 infants, and 96/148 survivors without cerebral palsy passed the tests. The cognitive functions of these premature infants are compared to the performances of a control group made up of 108 children born at term > or = 37 weeks, matched for birthplace and single or twin characteristics of the pregnancy.

RESULTS

The values of the different quotients are significantly decreased in the preterm group. The global IQ and the performance IQ are 0.8 SD, verbal IQ is 0.5 SD and the development quotient is 0.4 SD below the values observed in the control group. A performance IQ less than -2 SD for the mean of the control group is observed three times more than in the controls (13.5% vs 3.7%, P < 0.01). Multiple linear regression shows that prematurity explains, independent of hypotrophy and socioeconomic environment, 8% of the variation of the performance IQ (P < 0.01), 2% of the variation of the verbal IQ and 2% of the development quotient (P < 0.05).

CONCLUSION

The five-year neurologic outcome of the children born prematurely in this regional study is similar to the results observed in regional studies conducted in Europe: 13.4% of the survivors have cerebral palsy, and the cognitive functions of the children with no cerebral palsy are significantly lower than the term control group. Other risk factors such as hypotrophy, which modulates the developmental quotient, and the socioeconomic status, which modulates the verbal IQ, are underlined.

[For what reasons is the neurologic status of very premature infants altered between 1 and 2 years in a follow-up study? The contribution of a Frache-Comté region study]

BACKGROUND

The purpose of this population-based study was firstly to compare the neuro-developmental outcome at one and two years of very preterm infants, and secondly, to identify the risk factors for a misdiagnosis of cerebral impairment at the age of one year.

POPULATION AND METHODS

The preterm cohort included 203 infants born between 25 and 32 weeks of gestational age in the region of Franche-Comté (France) during a two-year period. The control group included 196 full-term infants born in the same maternity wards. Neuro-developmental assessments were performed by pediatricians or physicians, both at one and two years of age, on 94% (161/171) surviving preterms and 89% (173/195) full-terms.

RESULTS

There is a fair correlation between the two neurological evaluations of the control group (170/173, 98% have the same classification at the age of one and two). There is a weak correlation (kappa = 0.37) between the two neurological evaluations of the preterm group. Sixteen preterms (10%) had been classified more abnormal at one year than they were at two years. The presence of a broncho-pulmonary dysplasia, linked to male sex and extreme prematurity, was statistically linked to this first kind of misclassification. Seventeen preterms (10%) had been considered more normal at one year than they were at two years. The presence of a diplegia, family precariousness and the examination at one year of age by a general practitioner were statistically linked to this second kind of misclassification.

CONCLUSION

This prospective population-based study identifies structural situations (bronchopulmonary dysplasia linked to extreme prematurity) and environmental situations (family precariousness, examiner's qualifications) linked to a misclassification of the neurological status of one-year-old former preterm infants.

Manifestations and treatment of Schimke immuno-osseous dysplasia: 14 new cases and a review of the literature

Schimke immuno-osseous dysplasia (SIOD) is a rare autosomal recessive spondylo-epiphyseal dysplasia. The characteristic features of SIOD include 1) short stature with hyperpigmented macules and an unusual facies, 2) proteinuria with progressive renal failure, 3) lymphopenia with recurrent infections, and 4) cerebral ischaemia. Although 25 patients have been reported with this disorder, the clinical course and phenotype of SIOD are not well characterized. This report summarizes the clinical findings, course and treatment of reported patients and includes 14 additional patients with SIOD. We emphasize the high incidence of cerebral ischaemia and ocular abnormalities, define the high incidence of thyroid dysfunction and blood cytopenia, and confirm the absence of effective and durable medical therapies.

CONCLUSION

Schimke immuno-osseous dysplasia is a multi-system autosomal recessive disorder with variable expression that affects the skeletal, renal, immune, vascular, and haematopoietic systems. Medical therapy is limited especially for more severely affected individuals.

Some risk factors for cerebral palsy in very premature infants: importance of premature rupture of membranes and monochorionic twin placentation

OBJECTIVE

To delineate the perinatal risk factors of neurodevelopmental disabilities in very preterm birth applying logistic regression analysis.

DESIGN

This prospective, geographically defined collaborative study was carried out in the Franche-Comté region of France.

SUBJECTS

From October 1, 1990 to September 30, 1992, perinatal and follow-up data were collected on 203 consecutive live-born singleton or twin non-malformed infants with strictly ascertained gestational ages of less than 33 weeks.

MAIN OUTCOME MEASURE

The rate of cerebral palsy and/or severe mental retardation as diagnosed by a family physician or pediatrician with a screening-skill test performed at 2 years of age.

RESULTS

167/171 (98%) survivors were evaluated. Twenty-two of the 167 examined infants (13%) showed signs of cerebral palsy, and 10 of these had severe cerebral palsy or mental retardation. Risk factors for disabilities were selected by a multivariate approach: premature rupture of membranes >/=48 h (OR 4.3, 95% CI 1.6-11.8); monochorionic twin placentation (OR 6.0, 95% CI 1.7-21.3), and respiratory distress syndrome (OR 2.8, 95% CI 1.1-7.1).

CONCLUSION

This geographically defined prospective study gives epidemiological data and highly suggests that there is a link between prenatal events (premature rupture of membranes, monochorionic twin placentation), postnatal events (respiratory distress syndrome), and neurological disabilities in former preterm infants.

HLA-DR is strongly associated with Vogt-Koyanagi-Harada disease in Mexican Mestizo patients

PURPOSE

To analyze the genetic background of human leukocyte antigens (HLA) of Vogt-Koyanagi-Harada (VKH) disease in Mexican Mestizo patients in order to establish whether the pathogenesis is related to the same genes or sequences described in other populations.

PATIENTS AND METHODS

In 48 VKH patients, we performed HLA class I and class II typing using the standard microlymphocytotoxicity tests; a group of 100 nonrelated healthy subjects were analyzed for comparison. Antigen and gene frequencies were calculated for every antigen tested in patients and in controls.

RESULTS

The frequency of HLA-DR4 was significantly increased in VKH Mexican patients (x2Y = 19.95; p = 0.00001; pc = 0.0002; RR = 5.3; EF = 0.52); a discrete increase in DR1 was also found (p = 0.02). HLA-DQ8 also showed a significant association with the disease with a lower RR (3.2) and EF (0.41) than DR4.

CONCLUSION

The strong association found with HLA-DR4 and the slight DR1 increase shown in Mexican patients with VKH suggest that a common shared sequence present in the third hypervariable region of DRB1 genes is relevant for the expression of the disease. The stronger association with DR4 than the one with DQ8 suggests that the DR locus carries the primary susceptibility genes involved in the pathogenesis of VKH.

[Neurologic development in premature infants under 33 weeks of gestational age: determination of risk of neurological abnormalities in a prospective regional survey with a control group]

AIM

The purpose of this population-based study was to compare the incidence of neurodevelopmental disability and its risk factors between preterm and full-term infants matched as control group.

POPULATION AND METHODS

The preterm cohort included 203 infants born between 25 and 33 weeks of gestational age in the region of Franche-Comté (France) during a two-year-period. The control group included 196 full-term infants born in the same maternities. Survival up to the date of follow-up was 171/203 (84%) for preterms and 195/196 (99.5%) for full-term infants (uncorrected age, mean 12 months). Neurodevelopmental assessments were performed by pediatricians or physicians on 164/171 surviving preterms (96% follow-up) and 179/195 full-terms (92%).

RESULTS

Thirty-two (19.5%) preterm infants had disability, ten of these (6%) showing severe disability. Five (2.8%) full-term infants had disability, one of these (.5%) having severe disability. Risk factors predicting a disability included in a multivariate approach: prematurity (odds-ratio [OR]: 7.8), maternal age > 37 (OR: 3.0), lack of profession for both parents (OR: 3.7), male gender (OR: 2.9). The pediatrician observed a disability more frequently than the physician (OR: 2.46). Likewise, risk factors predicting a severe disability included: prematurity (OR: 10.8), lack of profession for both parents (OR: 5.8) and monochorial twin-placentation (OR: 4.5).

CONCLUSIONS

Prematurity is not the only risk factor to be taken into account for neurodevelopmental evaluation of premature infants, but its influence still remains widely predominant.

[Antenatal form of Bartter's syndrome]

Six cases of tubular disorder of antenatal onset responsible for biological manifestations characteristic of Bartter syndrome and severe hypercalciuria are reported. In all six cases, severe hydramnios occurred during pregnancy between the 26th and 28th week after the last menstrual period. All six patients were born prematurely; gestational age ranged from 20 to 35 weeks. Major polyuria with dehydration occurred immediately after birth. The amounts of water and sodium needed to compensate urinary losses ranged from 280 to 370 ml/kg/day and 25 to 43 mmol/kg/d, respectively, during the first two postnatal months. Decreased serum potassium levels and increased plasma levels of renin and aldosterone were seen in all six patients. Increased urinary excretion of calcium was evidenced during the first postnatal week in three cases. Urinary calcium excretion in the six patients ranged from 15 to 30 mg/kg/d. Nephrocalcinosis developed in all six patients and two patients developed urinary lithiasis. One patient died at one month of age from necrotizing enteropathy. The five remaining patients gradually developed severe growth failure with measurements between 4 and 5.5 SDs below the mean. These five patients had evidence of hyperparathyroidism including increased serum levels of parathyroid hormone (5/5), increased serum alkaline phosphatase activity (4/5), and roentgenographic bone changes (1/5). Ionized calcium assays performed in three of the five patients disclosed low values (range 1.25-1.47 mmol/l; mean = 1.35; normal values = 1.42-1.62), although total serum calcium levels were normal or high (range 2.16-2.98 mmol/l; mean 2.61; normal values = 2.45-2.65) probably as a result of chronic dehydration.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparison of morbidity and therapeutic load in premature twins and single births]

A prospective study was performed in order to compare birth weights, gestational ages at birth, perinatal and neonatal morbidity and mortality rates and therapeutic burdens given to 157 premature twins and 389 premature singletons. This study did not show real differences between premature twins and singletons, as if multiple pregnancies do not lead to other significant pathology than prematurity. The only observed differences were higher rates of breech presentation, wet lung disease, and lower rates of materno-foetal infection and pulmonary hypertension syndrome for premature twins.

[Efficacy of anti-digoxin antibodies in a premature neonate]

Through the case report of severe digitalis intoxication in a premature born after 27 weeks of gestation with a birthweight of 800 g, the authors show that anti-digoxin antibodies constitute a very efficacious therapeutic tool which, up to the present, has not been used in prematures.

[Efficacy of nifedipine on refractory hypoxemia associated with diaphragmatic hernia in the newborn infant. Apropos of a case]

A 3,200 g birth weight, 38-week gestational age neonate developed very severe persistent pulmonary hypertension following surgical repair of a left diaphragmatic hernia. Despite administration of dopamine, dobutamine, and tolazoline, a significant alveolar-arterial oxygen difference (660 mmHg) was found at age 41 hours. Nifedipine was then administered sublingually in a dose of 1 mg/kg and produced an immediate and dramatic improvement in the right radial artery pO2 that was sustained despite persistence of the right-to-left shunt. We discuss the mode of action of this vasodilating agent that, when added to major therapeutic agents, proved capable of completely reversing a hazardous neonatal situation.

[Neurologic effects of acyclovir after an allogenic marrow graft]

On the 4th day of acyclovir treatment for Herpes simplex pneumonia, a 28 month-old girl who had received allogenic marrow transplant for stage IV neuroblastoma presented with severe neurologic disorders including coma and choreic movements. These symptoms disappeared 9 days after acyclovir was stopped. The disturbance in acyclovir kinetics because of acute renal failure and/or a cerebral cortex atrophy might explain the poor neurologic tolerance of acyclovir. This reversible neurologic involvement on a prone patient should be known as a differential diagnosis of Herpes simplex encephalitis.

[Anuria in an infant caused by an intrapyelic mycelial bezoar in a solitary kidney]

A 4 month-old premature infant having received prolonged intensive care for necrotizing enterocolitis and Pseudomonas infection, developed anuria with intrapyelic fungus ball developed in a congenital single kidney. Review of the literature found 19 similar cases and emphasized the difficulty of an early diagnosis and the usefulness of renal ultrasonography for its detection. Moreover the opportunity to treat premature neonates carrying candida albicans with IV amphotericin B and flucytosine before the occurrence of an uneasy treatable urological obstacle in discussed.

[Neonatal mortality factors at the Dakar General Hospital]

The authors studied 223 new-borns in an African Pediatric Department over a eight month period. The death rate was 47.5 p. cent (106 cases). It was explained by infectious diseases in 53 cases, respiratory distress syndrome in 37 cases, acute foetal distress in 9 cases, jaundice in 6 cases, and malformation syndrome in one case. A birth-weight less than 2.500 g is correlated with a poor prognosis. The authors define target populations in tropical zones to be looked after by aims of prophylactic and curative actions.

[Importance of the study of allergy and determination of the HLA group in the lipoid nephrosis in children. Study of 8 cases]

Eight children with steroid-response nephrotic syndrome were investigated to study the relation-ship between steroid responsive syndrome, allergy and HLA-antigens. Six of them had clinical and/or biological allergic symptoms. The allergen was identified in four out of six cases (grass-pollen 2 cases, house dust 1 case, frullania 1 case). Six children had DR7 HLA-antigen, five had B12 antigen. Three of the four children with cortico-dependent nephrotic syndrome have associated B12-DR7 HLA antigens. Search of an allergen seems to be of interest in children with steroid-responsive nephrotic syndrome, since eviction of the allergen may be proposed as a complement to cortico-therapy.

[Intolerance to metoclopramide (apropos of 22 case reports of infants of the black race)]

The authors report on 22 observations made from june 1982 to december 1984 in African children having presented an intolerance against metoclopramide. After recalling briefly the pharmacology of this drug, they describe the symptomatology similar to neuroleptic intoxication syndrome: parkinsonian syndrome, motor excitation syndrome. Posology was correct in 2/3 of the cases, when it was known. Overdose was observed in 5 cases only. Recovery was complete after the administration of the drug was stopped, but it was accelerated by antiparkinsonian drugs.