Review shows that using surfactant a number of times or as a vehicle for budesonide may reduce the risk of bronchopulmonary dysplasia

AIM

Bronchopulmonary dysplasia (BPD) remains the most common respiratory morbidity in immature infants. This review describes the diagnosis of BPD has evolved and summarises the therapeutic approaches that have made it possible to limit the incidence of BPD.

METHOD

We reviewed the literature from the first definition of BPD by Northway in 1967 to the surfactant treatment policies that are currently in use, drawing on more than 50 papers up to 2017.

RESULTS

Our review showed that improvements in neonatal survival have been associated with an increased risk of severe BPD, significant levels of long-term morbidity and the increased use of healthcare resources. These issues have encouraged researchers to explore potential new treatments that limit the incidence of BPD. Repeated surfactant instillation and the use of surfactant as a vehicle for budesonide are promising strategies for alleviating the burden of chronic lung disease. Ongoing research on surfactant or stem cell therapy may further improve the respiratory prognosis for prematurely born children.

CONCLUSION

Considerable research has been carried out into the increase in BPD, which has resulted from improvements in neonatal survival. Key areas of research include repeated surfactant administration, using surfactant as a vehicle for budesonide and stem cell 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.

Perinatal factors affecting survival and survival without disability of extreme premature infants at two years of age

OBJECTIVE

To study obstetrical factors leading to very preterm delivery (between 24 and 28 weeks) and to relate these factors to neonatal outcome and psychomotor development at two years.

STUDY DESIGN

Among 144 infants born alive before 28 weeks of gestation at a single perinatal center between January 1993 and December 1996, we analyzed the influence on neonatal outcome and on psychomotor development at 24 months of a variety of perinatal and neonatal factors. Psychomotor development at two years was classified as: normal, borderline, or moderately or severely handicapped.

RESULTS

During the study period, 114 women delivered live infants before 28 weeks' gestation: 87 singletons, 25 sets of twins, 1 set of triplets and 1 set of quadruplets. All 144 live-born infants received neonatal resuscitation: 50 died before discharge. At two years of age, 6 of the 94 survivors were lost to follow-up. Assessments of the psychomotor development of the other 88 was normal for 52%; borderline for 20%, moderately handicapped for 20%, and severely handicapped for 8%. Multivariate analysis found that two factors affected survival: birthweight and fetal heart rate. (The 42% of infants with a birthweight below 700 g survived versus 83% above 900 g, P<0.001, OR=5.2, 95% CI (confidence interval) [2.4-11.2].)

CONCLUSION

These data show the influence of perinatal factors on the outcome of very preterm infants; birthweight and fetal heart rate are strongly correlated with survival. Gestational age is a good predictor of psychomotor development at two years.

Late-onset cystic periventricular leukomalacia in premature infants: a threat until term

The purposes of this study are (1) to describe a "late-onset" form of cystic periventricular leukomalacia eventually appearing in premature infants whose neurological assessments were normal in the first month of life; (2) to retrospectively evaluate its incidence among a large population of premature infants; (3) to suggest that a few unexpected complications of prematurity may trigger the development of white matter damage, even several weeks after birth. Retrospective study in a population of 1452 surviving infants after 5 days born before 33 weeks. We identified 10 cases of late-onset cystic periventricular leukomalacia appearing beyond the first 5 weeks of life. In 8 cases, an intercurrent event associated with a systemic inflammatory response preceded the appearance of cysts: necrotizing enterocolitis (n = 5), septicemia (n = 2 cases), strangulated inguinal hernia in one infant. Neurological surveillance should be repeated until discharge in very preterm infants, especially after the occurrence of an intercurrent complication coming along with a systemic inflammatory response.

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.

[Pediatric follow-up network in the south Ile-de-France]

Regional organization of perinatal care, with maternal tranfers, has largely contributed to the increasing survival rate of very preterm infants. Nevertheless, follow-up and care the of these surviving children at risk of neurodevelopmental impairment are insufficiently organized. For this reason, a pediatric network of care and follow-up has been set up in continuity of a regional perinatal network ("réseau périnatal et réseau pédiatrique du sud-ouest de l'Ile de France"). Two missions are devoted to this network: organize local follow-up and care of infants at risk of abnormal outcome and collect follow-up data with specific forms. One form per year of age is to be filled with Items concerning growth, health, cognitive and motor development, family and society integration, quality of life.

[Anoxic encephalopathy of the term neonate and brain hypothermia]

The outcome of term newborns with birth asphyxia and moderate to severe hypoxic ischemic encephalopathy remains very poor. After the primary phase of energy failure during asphyxia, neuronal cell metabolism may deteriorate in a secondary phase of brain injury. The window between these two phases opens the way to potential neuroprotective treatments such as brain cooling. Promising experimental data on controlled hypothermia need to be examined with clinical trials.

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.

Severe congenital dyserythropoietic anaemia type I: prenatal management, transfusion support and alpha-interferon therapy

We report a case of congenital dyserythropoietic anaemia, type I, with severe pre- and postnatal manifestations. Exchange transfusions were required for fetal anaemia (3.5 g/dl) at 28 and 30 weeks of gestation. Transfusions were administered at birth (Caesarean section at week 35) and at regular intervals thereafter. At 14 months, alpha-interferon therapy was initiated (106 units three times a week). This resulted in stabilization of the haemoglobin at or above 11 g/dl and a reduction in the percentage of erythroblasts with ultrastructurally abnormal heterochromatin. After 9 months, the dose of alpha-interferon was decreased to 106 units twice a week. No relapse of anaemia was noted during an additional 4 months of follow-up.

The relationships between antenatal management, the cause of delivery and neonatal outcome in a large cohort of very preterm singleton infants

OBJECTIVE

To determine whether the cause of very preterm delivery influences neonatal outcome.

DESIGN

A cohort study of 685 consecutive singletons born before 33 weeks of gestation.

METHODS

Causes of birth and perinatal outcome variables were correlated for statistical significance by uni- and multi-variate analyses.

RESULTS

Intrauterine growth retardation or pre-eclampsia were associated with a higher rate of respiratory distress syndrome compared with prolonged rupture of membranes, after controlling for gestational age, antenatal corticosteroid therapy, antenatal antibiotic administration, mode of delivery and origin (inborn or outborn) (adjusted OR 3.12; 95% CI 1.55-6.28). The prevalence of grade 3-4 intraventricular haemorrhage or cystic periventricular leukomalacia was 25% in newborn babies born after intrauterine infection or prolonged rupture of membranes. Among infants born after intrauterine growth retardation/pre-eclampsia, the rate of severe intraventricular haemorrhage was 3.2% and the rate of periventricular leukomalacia was 0.9%. Compared with intrauterine infection and after controlling for potential confounding covariates, intrauterine growth retardation/pre-eclampsia was associated with a lower rate of periventricular leukomalacia (adjusted OR 0.08; 95% CI 0.02-0.41). In the same multiple logistic regression model, antenatal corticosteroid administration was associated with a lower incidence of periventricular leukomalacia (adjusted OR 0.36; 95% CI 0.16-0.79).

CONCLUSIONS

The cause of very preterm delivery has an important influence on neonatal outcome.

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.

Prenatal blockade of vasoactive intestinal peptide alters cell death and synaptic equipment in the murine neocortex

Vasoactive intestinal peptide (VIP) is a potent growth factor that stimulates murine neocortical astrocyte genesis during the period of ontogenesis corresponding to premature delivery in humans. In rodents, part of the VIP supplied to the fetal brain is maternal VIP that crosses the placenta. If these data also apply to human brain development, premature newborns may be partly VIP-deficient because of loss of the maternal supply, and this may adversely affect their brain development. The goal of the present study was to determine the effects of VIP blockade during mouse neocortical astrocyte genesis on neuritic survival and maturation. VIP blockade by a specific VIP antagonist on embryonic d 17 and 18 induced transient, postnatal depletion of astrocytes in the upper neocortical layers. Combined use of in situ DNA fragmentation analysis (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling method, a marker of cell death); immunohistochemical detection of synaptophysin, microtubule-associated proteins, and neurofilaments; and quantification of mRNA for synaptophysin and N-methyl-D-aspartate R1 receptor subunit revealed that early VIP blockade significantly altered programmed neuritic death and impaired neuritic differentiation. VIP inhibition induced 1) exaggerated postnatal terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling of cortical neurons, 2) long-term overexpression of synaptophysin and N-methyl-D-aspartate R1 receptor subunit, and 3) long-term overexpression of microtubule-associated protein-5 and neurofilament 160 kD. Although the functional consequences of this deviant pattern of murine neocortical development remain to be determined, these data open up new avenues for investigating some of the cognitive deficits observed in human premature infants.

Amniotic fluid concentrations of interleukin-1beta, interleukin-6 and TNF-alpha in chorioamnionitis before 32 weeks of gestation: histological associations and neonatal outcome

OBJECTIVES

To test the association between cytokine levels in the amniotic fluid and (i) the vascular invasion phase of intrauterine infection, (ii) the occurrence of periventricular leukomalacia; to assess the correlation between C-reactive protein levels, a recognised biological marker of inflammation in maternal serum and cytokine levels in the amniotic fluid.

DESIGN

Prospective clinical study.

SETTING

Fetal medicine unit and neonatal intensive care unit, Antoine Beclere Hospital, Clamart, France.

SAMPLE

Thirty-one pregnancies complicated by chorioamnionitis leading to birth before 32 weeks of gestation.

METHODS

Interleukin 1-beta, Interleukin 6 and TNF-alpha prospectively measured in the amniotic fluid. Histological examination of the placenta. Ultrasound examination and magnetic resonance imaging of the brains of the newborn infants performed within the first week of life.

MAIN OUTCOME MEASURES

The occurrence of periventricular leukomalacia was assessed by transfontanellar ultrasound and magnetic resonance imaging.

RESULTS

There was a significant positive correlation between the occurrence of histological chorioamnionitis, vascular extension of infection of the membranes, maternal inflammatory syndrome and neonatal sepsis. A strong association was found between maternal serum C-reactive protein concentrations and cytokine levels in the amniotic fluid. Interleukin-1beta was the best predictor of vascular extension of chorioamnionitis, and TNF-alpha was the best predictor of the development of severe early neonatal infection. There was no association between the amniotic fluid levels of cytokines and the development of periventricular leukomalacia.

CONCLUSIONS

These data suggest that IL-1beta, IL-6 and TNF-alpha are produced in relation to intrauterine inflammation and infection, but cannot be directly implicated in the development of fetal cerebral white matter lesions.

Inhaled salbutamol and beclomethasone for preventing broncho-pulmonary dysplasia: a randomised double-blind study

Early inflammatory lesions and bronchial hyperresponsiveness are characteristics of the respiratory distress in premature neonates and are susceptible to aggravation by assisted ventilation. We hypothesized that treatment with inhaled salbutamol and beclomethasone might be of clinical value in the prevention of bronchopulmonary dysplasia (BPD) in ventilator-dependent premature neonates. The study was double-blinded and placebo controlled. We studied 173 infants of less than 31 weeks of gestational age, who needed ventilatory support at the 10th postnatal day. They were randomised to four groups and received either placebo + placebo, placebo + salbutamol, placebo + beclomethasone or beclomethasone + salbutomol, respectively for 28 days. The major criteria for efficacy were: diagnosis of BPD (with score of severity), mortality, duration of ventilatory support and oxygen therapy. The trial groups were similar with respect to age at entry (9.8-10.1 days), gestational age (27.6-27.8 weeks), birth weight and oxygen dependence. We did not observe any significant effect of treatment on survival, diagnosis and severity of BPD, duration of ventilatory support or oxygen therapy. For instance, the odds-ratio (95% confidence interval) for severe or moderate BPD were 1.04 (0.52-2.06) for inhaled beclomethasone and 1.54 (0.78-3.05) for inhaled salbutamol.

CONCLUSION

This randomised prospective trial does not support the use of treatment with inhaled beclomethasone, salbutamol or their combination in the prevention of BPD in premature ventilated neonates.

Single blood donor exposure programme for preterm infants: a large open study and an analysis of the risk factors to multiple donor exposure

As the need for blood transfusions of very preterm infants remains considerable, various strategies are considered to minimize exposure to multiple blood donors along with blood wastage. In a large population of very preterm infants born between 24 and 31 weeks' gestation, we undertook an open study to assess the efficacy of a single blood donor exposure programme and to determine, among the population enrolled in this programme, the risk factors for exposure to multiple donors. One hundred and forty-two neonates were included in a single donor exposure programme with a 35-day expiry date blood unit. Though no inflation in the total number of transfusions was noticed, there was a 55% overall reduction in the total number of required donors. To determine the risk factors for exposure to multiple donors in this population, 114 neonates alive after the expiry date of the first unit of packed red blood cells were selected. The greatest and the most extending transfusion requirements were observed in very preterm infants born before 28 weeks' gestation and in those born after but with an intra-uterine growth retardation below the 10th percentile. Indeed, 70% of those high-risk infants were exposed to a second blood donor and more than 85% of the group exposed to a second donor belonged to this high-risk population.

CONCLUSION

Neonates with a very high risk of a more-than-one donor exposure were born before 28 weeks' gestation or between 28 and 31 weeks but with an intra-uterine growth retardation below the 10th percentile.

[Periventricular leukomalacia and brain protection. II. Diagnosis, sequelae and neuroprotection]

The term 'periventricular leukomalacia' (PVL) usually covers necrotic and/or gliotic lesions from perinatal origin occurring in the periventricular ring of telencephalic white matter. Carrying motor and neuropsychological consequences, PVLs could be the most severe danger for very premature brains. Positive rolandic sharp waves recorded on EEG and precocious abnormally echogenous periventricular images on ultrasound suggest prospective periventricular cysts. Cystic periventricular cavitations certify the diagnosis of PVL. More subtle lesions of PVL do not reach the cystic grade and their diagnosis is confirmed by MRI. Treatment of infections is already available and potentially a tool for prevention. When the overwhelming glutamatergic signal has been triggered, neuroprotective agents turning off the excitotoxic cascade, including calcium blockers, growth factors and others, are promising therapeutic tools.

[Periventricular leukomalacia. I. Histological and pathophysiological aspects]

The term 'periventricular leukomalacia' (PVL) usually covers necrotic and/or gliotic lesions from perinatal origin occurring in the periventricular ring of telencephalic white matter. PVLs are found post-mortem in one third of brains from autopsies of premature infants; PVLs are diagnosed in 4 to 10% of infants born before 33 weeks of gestation and remaining alive more than 3 days after birth. PVL is very rare in at term infants. The proportion of PVLs from prenatal origin is estimated between one third and one half of cases. Recent progresses in neuroepidemiology, developmental neurobiology and imaging methods permit to revisit the pathophysiology of PVLs on a multifactorial basis. The final result of these multiple factors seem to be calcium influx due to glutamatergic overactivation triggered by cytokines, infection and inflammation, and deficit in neurotrophic factors. Periventricular topography can be explained by properties of intracerebral vascular wall at this stage of angiogenesis and by perfusion failure/hypoxia.

The early diagnosis of periventricular leukomalacia in premature infants with positive rolandic sharp waves on serial electroencephalography

OBJECTIVE

The objective of this study was to determine the specificity and the sensitivity of electroencephalography's positive rolandic sharp waves (PRSW) for the diagnosis of cystic and noncystic periventricular leukomalacia (PVL).

METHODS

A retrospective study was performed on a population of 765 premature infants alive after 5 days who were divided into two groups; 166 infants born before 28 weeks (group 1) and 599 born between 28 and 32 completed weeks' gestation (group 2). Each infants underwent repeated ultrasound scanning and electroencephalography recordings during the first weeks of life. Magnetic resonance imaging was performed in infants with persisting hyperechoic periventricular densities on ultrasonography.

RESULTS

A total of 83 (10.8%) newborns had PVL; 65 (8.5%) had cystic PVL PRSW, observed in 55 (7.2%) infants, always preceded the ultrasonic detection of cysts. PRSW were very specific markers of PVL in both groups (100% in group 1, 99.8% in group 2). PRSW sensitivity was found dependent on gestational age: 32.4% in group 1 in contrast to 87.8% in group 2.

CONCLUSION

PRSW are an early and very specific marker of PVL in premature infants.

Involvement of pituitary adenylate cyclase-activating polypeptide II vasoactive intestinal peptide 2 receptor in mouse neocortical astrocytogenesis

At the end of neuronal migration, the neopallial germinative zone produces glial cells destined to colonize the upper layers of neocortex. High densities of binding sites for vasoactive intestinal peptide (VIP) have been found in the rodent germinative zone just after completion of neuronal migration, suggesting a possible role of VIP in neocortical astrocytogenesis. In the present study, administration of a VIP antagonist at embryonic days 17 and 18 to pregnant mice was followed by a dramatic depletion of astrocytes in the upper cortical layer of the offspring. The depletion of astrocytes was dose-dependent, with a 42% reduction in the density of astrocytes observed with 50 microg of antagonist. The antagonist effect was reversed by cotreatment with VIP or pituitary adenylate cyclase-activating polypeptide (PACAP), suggesting the involvement of a receptor common to these two neuropeptides. VIP antagonist-induced inhibition of astrocytogenesis was also blocked by Ro 25-1553, a long-acting cyclic VIP analogue selective for the PACAP II VIP2 receptor subclass. Our results demonstrate that VIP and/or PACAP play a crucial physiological role in neocortical astrocytogenesis, possibly through interaction with PACAP II VIP2 receptors.

Are neonatal brain lesions due to intrauterine infection related to mode of delivery?

Studies of antenatal and intrapartum factors involved in the development of cerebral palsy have identified intrauterine infection and chorioamnionitis as high risk situations for white matter damage, especially periventricular leukomalacia. To characterise adverse or protective perinatal factors further, we undertook a multiple regression analysis of selected perinatal events in a population of 110 inborn premature neonates with documented chorioamnionitis. In the total population of 110 infants delivered at between 25 and 32 weeks, 101 (92%) survived the first week of life and two were subsequently excluded. Of the 99 remaining infants, 20 (20%) developed periventricular leukomalacia including 16 (80%) cystic lesions. Forty-five (45%) babies were born by lower segment caesarean section, and for 37 of these, this was carried out before labour. Fetal presentation at delivery was breech in 14 (26%) of those born vaginally and 23 (52%) of those born by lower segment caesarean section (OR 3 [95% CI 1.3-7]). Among predetermined perinatal risk factors for periventricular leukomalacia, logistic regression analysis showed that delivery by caesarean section was associated with a dramatic decrease in the incidence of periventricular leukomalacia (OR 0.15 [95% CI 0.04-0.57]). These preliminary results warrant confirmation and preferably a prospective study before considering caesarean section as a protective perinatal factor of periventricular leukomalacia.

[Maternofetal disseminated candidiasis and high-grade prematurity]

BACKGROUND

Despite the frequency of vaginal yeast colonization, serious candidiasis infections in pregnant patients or neonates remain rare. Four cases of disseminated congenital candidiasis in very preterm infants are reported.

CASE REPORTS

Congenital Candida albicans infection has been diagnosed in four very preterm infants. In three cases, the mothers had intrauterine devices in place throughout pregnancy. A careful macroscopic examination of the umbilical cord and placenta after birth has allowed an early management strategy in three cases. In all cases, a serious infectious alveolitis occurred. A pronounced increase in white blood cells (> 50,000/mm3) and high levels of both segmented neutrophil and band cells, despite the frequent normality of the CRP, constituted other features. Infection was controlled by parenteral amphotericin B or fluconazole. In one case, serious thrombocytopenia occurred after the first amphotericin B injection requiring substitution for fluconazole. The outcome was unfavourable in two cases with an extensive periventricular leukomalacia.

CONCLUSION

Congenital candidiasis in these four very preterm neonates has several features in common: intrauterine contraceptive device during pregnancy, characteristic chorioamnionitis and funisitis, high WBC count, infectious alveolitis. Fluconazole as alternative to amphotericine B therapy is proposed.

Periventricular leukomalacia: risk factors revisited

The dramatic improvement in neonatal care during the last decade did not succeed in reducing the incidence of periventricular leukomalacia (PVL), suggesting that prenatal events may be the main target for PVL prevention. The studied cohort included 753 very preterm infants born between 24 and 32 weeks of gestational age, admitted to the intensive care unit and surviving at least 7 days; 69 (9.2%) of these infants had a diagnosis of cystic PVL. The highest PVL frequency was observed among the infants born at 28 weeks of gestation (16%). Inflammatory prenatal events occurring during the last days or weeks before delivery and PVL occurrence are strongly correlated. Indeed, the combination of intra-uterine infection and premature rupture of membranes is associated with a very high risk (22%). Prolongation of pregnancy with tocolysis for more than 24 hours also carries a significant 8% risk of PVL. In contrast, chronic fetal distress of long duration, such as severe intra-uterine growth retardation and pre-eclampsia, is seldom followed by PVL (< 2% risk). Similarly, rapid unexpected deliveries entail a minimal PVL risk (4%). Experimental and epidemiological confirmations of these data would have an influence on the management of both the preterm onset of labour and the premature rupture of membranes.

[What does remain about bronchopulmonary dysplasia?]

Bronchopulmonary dysplasia is defined as prolonged respiratory failure resulting from sequellae after neonatal intensive care in premature infants. Functional impairment continues into adult life. There are two main causal factors: the initial respiratory disease and pulmonary immaturity. Up through the nineties, bronchopulmonary dysplasia was a major problem in neonatal intensive care units; mortality reached 20% of infants requiring artificial ventilation for 1 or 2 months. Despite the rising rate of premature births (currently 2%) considerable progress has been made in the treatment of bronchopulmonary dysplasia. The question is whether the infants in the current generation with still suffer into adult life. Advances in preventive therapy have included antenatal corticosteroid therapy, use of exogenous surfactants and progressive improvement in ventilatory assistance techniques. Improved neonatal care to relieve pain and maintain nutrition have also had an important effect. Specific treatments include the use of salbutamol spray to reduce bronchospasme and improve respiratory compliance. The initial hopes placed in inhaled corticosteroids were unfortunately recently shown to be unfounded. Due to the large number of premature infants it appears difficult to predict the future situation of bronchopulmonary dysplasia, but current data show a clear tendancy towards regression of the disease. Three preventive measures could further reduce the incidence: better coordination between obstetricians and pediatricians, extension of antenatal corticosteroid therapy and the development and improvement of continuous positive pressure ventilation.

[Platelet transfusions in neonatology]

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.

[Pain symptomatology in premature infants]

BACKGROUND

Assessing pain in premature babies is difficult because of their limited capacities to communicate. The aim of this study was to recognize manifestations of acute and chronic pain or, on the contrary, of well-being state, and to validate a "pain scale" for premature babies.

POPULATION AND METHODS

Premature babies less than 28 days of age (most of them less than 32 weeks of gestational age) were carefully observed during their stay in a neonatal intensive care unit by nurses, physicians, physiotherapists and a psychiatrist. All signs and symptoms were collected during situations a priori painful and compared to the behavior of the well-being states. Photographs and videofilms were also analysed.

RESULTS

Five items, scored from 0 to 4, were established, based on facial activity, movements and posture of the body, quality of sleep, relationship with the examiner, and efficacy of measures of comforting. These items permitted to describe four patterns corresponding to 1: well-being status, 2: acute pain, 3 and 4: durable pain or discomfort either through clinical picture of irritability or motionlessness. A strict concordance of scores for the five items between the different examiners was found in 80% of the 50 babies studied. The sensibility of the scale (studied in 12 babies) appeared accurate (77% of variation of the scores during hospitalization).

CONCLUSIONS

An objective assessment of pain and discomfort in premature babies can be made using a "pain scale" useful for care and therapeutic decisions.

Echocardiographic investigation of inhaled nitric oxide in newborn babies with severe hypoxaemia

Nitric oxide inhalation can benefit newborn babies with right-to-left extrapulmonary shunt (EPS). Using doppler ultrasound, we compared the effects of nitric oxide on systemic oxygenation and mean pulmonary-blood-flow velocity (MPBFV) in severely hypoxic babies with or without EPS. With a median (interquartile range) dose of 20 (32) parts per million, oxygenation index decreased significantly in both groups (EPS, 49 [19] vs 11 [9]; non-EPS, 40 [11] vs 20 [13]). The decrease was significantly greater in the EPS group. MPBFV increased significantly in the EPS group (18 [4] vs 29 [8] m/s) only. Nitric oxide may improve systemic oxygenation in neonates with severe hypoxaemia secondary to EPS by increasing pulmonary blood flow, and in those without EPS by improving ventilation-perfusion matching.

Three new cases of the Schinzel-Giedion syndrome and review of the literature

Three fetuses with normal chromosomes were found to have uni- or bilateral hydronephrosis during the third trimester of pregnancy. At birth, they presented with coarse face, hypertelorism, and a deep groove under the eyes. Fontanelles and sutures were wide open. Genital abnormalities were present in 2 cases. Skeletal radiographs showed delayed bone maturation, broad and dense ribs, and a wide synchondrosis between the exoccipital and supraoccipital bones. The combination of such findings suggested the diagnosis of Schinzel-Giedion syndrome. Two patients died soon after birth, whereas the third one developed severe mental and motor retardation with seizures and spasticity, and died at 18 months. Schinzel-Giedion syndrome is rare and likely to be inherited as an autosomal recessive trait. So far, 13 well-documented cases have been reported allowing major and minor traits of the syndrome to be distinguished. Since no genetic marker is available, the prenatal diagnosis of Schinzel-Giedion syndrome relies on ultrasound examination, especially detection of renal abnormalities.

[Periventricular leukomalacia of late onset in a premature infant]

BACKGROUND

Periventricular leukomalacia in preterm neonates is usually due to abnormal cerebral blood flow before and/or during delivery. It is diagnosed during the first month of life. This study describes a case of late-developing periventricular leukomalacia.

CASE REPORT

A girl was delivered by cesarean section at the 23rd week of gestation that was complicated by placenta previa. She weighted 880 g and immediately required resuscitation. She did not develop respiratory distress syndrome. She was intubated and ventilated for the first two weeks of life and developed bronchopulmonary dysplasia requiring corticosteroid treatment. Extubation was possible on day 43. The neonate had been given antibiotics for the first 10 days of life and indomethacin on day 8 because of a patent ductus arteriosus. Repeated craniosonography showed moderate bilateral intraventricular hemorrhage and occipital areas of hyperechogenicity that disappeared at the end of the first month of life. Repeated electroencephalograms revealed no positive rolandic sharp waves until the infant was 42 days old. Craniosonography on day 48 showed areas of heterogeneous hyperechogenicity and NMR imaging showed bilateral frontoparietal leukomalacia with loss of white matter. The baby died on day 71.

CONCLUSIONS

Late periventricular leukomalacia is exceptional and usually seen after postnatal abnormalities in cerebral blood flow and/or prolonged hypoxemia. Both these risk factors were absent in this patient.

Fetal rat lung type II cell differentiation in serum-free isolated cell culture: modulation and inhibition

Undifferentiated fetal rat lung epithelial cells were isolated on gestational days 15 or 17 (term 22 days) and cultured in a defined medium. On plastic, most of the cells developed structurally abnormal lamellar bodies. On a basement membrane matrix (BMM), they sequentially accumulated glycogen and formed typical lamellar bodies. Biochemical analysis of the latter indicated that they had a phospholipid composition typical of surfactant for cells on BMM but not on plastic and that surfactant protein A appeared on BMM only. Progressing maturation from day 1 to day 6 in culture was demonstrated for 17-day cells on BMM by a sevenfold increase of labeled precursor incorporation into surfactant phospholipids. Exposure to medium conditioned by 21-day fetal fibroblasts enhanced incorporation already after a 1-day culture. The antisteroid RU 486 had no effect on differentiation, whereas transforming growth factor-beta, a factor produced by lung mesenchyme at early fetal stages, inhibited it markedly. Alveolar epithelial type II cells appear to be committed early, but their maturational process would be prevented until a definite gestational stage.

[Sudden newborn infant death in maternity. Anatomo-clinical study of 31 cases]

PATIENTS AND METHODS

All cases of sudden and unexpected death occurring in maternity were studied over a period of 6 years (1985-1991). Anamnestic data, results of clinical examination of the body and findings of bacterial screening of body fluids or tissues were collected. The results at necropsy were also collected following the protocol used, with parental consent, in all cases of sudden infant death syndrome.

RESULTS

There were 31 cases of sudden and unexpected death. Of these, 48% occurred before the 24th hour of life, 68% before the 36th hour and 84% before the 72nd hour. The majority of death occurred at night (55% between midnight and 6 AM, 90% between 9 PM and 9 AM). Analysis of the data provided a precise cause of death in 25 cases (81%), and a probable cause in 4 cases (13%). The major causes were perinatal anoxia, generally associated with massive amniotic inhalation (16 cases), and maternal-fetal infection (9 cases). No cause was found in 2 cases. Despite the fact that the death occurred unexpectedly, half of the newborns showed warning signs, some hours before the event. These signs were either not detected or ignored.

CONCLUSION

The incidence of sudden death in neonates is 0.15 to 0.36/1,000 live births. Its causes are generally correlated with common neonatal diseases. Its occurrence at night and the existence of warning signs raise questions concerning the care of neonates in maternity.

[Early prediction of risk of bronchopulmonary dysplasia]

Bronchopulmonary dysplasia (BPD) has become a frequent and worrying issue in neonatal intensive care units (NICU). The aim of this retrospective study was to define more precisely the incidence of BPD within a population of 2,216 newborns admitted at less than 24 hrs of life. 138 cases of BPD were diagnosed. The BPD rates decrease exponentially with regard to gestational ages (GA) [67% at less than 28 weeks (w), 37% at 28-29 w, 22% at 30 w, 9% at 31-32 w, 3% at 33-34 w and 0.4% at greater than or equal to 35 w]. The presence of hyaline membrane disease (HMD) increases the GA related risks by 1.5, 2, 3, 10, 20 and 40 times at less than 28 w, 28-29 w, 30 w, 31-32 w, 33-34 w and greater than or equal to 35 w, respectively. Other factors such as interstitial emphysema, refractory hypoxemia and hypotrophy associated with HMD, have been found associated with increased risks. A chart taking into account all these parameters has been constructed allowing the determination of individual risks of developing BPD during the first days of life.

[Acute chorea revealing lupus erythematosus disseminatus]

A case of systemic lupus erythematosus (SLE) is reported in a 12 year-old girl who presented with chorea. This rare manifestation of SLE was previously recorded as a mode of presentation in half of the 51 reported cases. In view of the relative rarity of rheumatic fever in economically advanced countries, SLE should be entertained as a manifestation of chorea. The possible pathophysiologic mechanisms of this central nervous system involvement are discussed.