[Use of EMLA cream in premature and full-term newborn infants. Study of efficacy and tolerance]

BACKGROUND

Mild methemoglobinemia is a known side-effect of one of the constituents of EMLA cream, this topical local anesthetic is used with great caution in neonates.

POPULATION AND METHODS

One hundred and sixteen neonates admitted from January to July 1994 in an intensive care unit were included in the study. All required skin punctures which were performed 1 h 30-2 hours after EMLA had been applied on the skin. A reaction score (0 to 5) to skin puncture was established 157 times (120 after and 37 without local anesthesia); methemoglobin (Met Hb) concentrations were measured in 47 blood samples, 18-24 hours (40.4% of samples) or 2-3 days (36.2%) after application of EMLA.

RESULTS

Ninety-four neonates were quiet before puncture (score 0-1). Among them, 57% of those who were given EMLA had a low score (2 or less) vs 18% without EMLA. A low reaction was observed in 65% when the dressings had been kept in place for at least 90 minutes vs 15% with a shorter application. A lower reaction was noted in 78.8% of cases after venopuncture (41% after arterial puncture). No Met Hb level was above 5% and 7 (15%), in five neonates, were between 3 and 5%. There was no clear relationship between methemoglobinemia and gestational age or duration of dressing.

CONCLUSION

EMLA cream is effective and safe in neonates including preterms, when it is applied in a small amount once a day.

Bronchopulmonary Dysplasia: Crosstalk Between PPARγ, WNT/β-Catenin and TGF-β Pathways; The Potential Therapeutic Role of PPARγ Agonists

Bronchopulmonary dysplasia (BPD) is a serious pulmonary disease which occurs in preterm infants. Mortality remains high due to a lack of effective treatment, despite significant progress in neonatal resuscitation. In BPD, a persistently high level of canonical WNT/β-catenin pathway activity at the canalicular stage disturbs the pulmonary maturation at the saccular and alveolar stages. The excessive thickness of the alveolar wall impairs the normal diffusion of oxygen and carbon dioxide, leading to hypoxia. Transforming growth factor (TGF-β) up-regulates canonical WNT signaling and inhibits the peroxysome proliferator activated receptor gamma (PPARγ). This profile is observed in BPD, especially in animal models. Following a premature birth, hypoxia activates the canonical WNT/TGF-β axis at the expense of PPARγ. This gives rise to the differentiation of fibroblasts into myofibroblasts, which can lead to pulmonary fibrosis that impairs the respiratory function after birth, during childhood and even adulthood. Potential therapeutic treatment could target the inhibition of the canonical WNT/TGF-β pathway and the stimulation of PPARγ activity, in particular by the administration of nebulized PPARγ agonists.

[Beta mannosidosis: a new case]

BACKGROUND

Only 11 cases of beta mannosidase deficiency have been reported until now. We report a new case.

CASE HISTORY

J was born at full term to consanguineous parents; her weight was 2,080 g and her height was 44 cm. During the first months of life she was hypotonic and had feeding difficulties. At the age of 7 months, she was admitted to an intensive care unit because of a serious inhalation. Standard blood analysis, chest X-ray, abdominal ultrasonography, electroencephalogram, cerebral nuclear magnetic resonance and electromyography were normal. Blood and urine amino acids and urine organic acids were also normal. The only detected abnormality was a marked deficiency of beta mannosidase in her serum and leukocytes. Later on, she suffered from recurring respiratory infections, and she had abnormalities of esophageal mobility, hypotoria of the lower esophageal sphincter, and at the age of 2 years, achalasia requiring surgery. To date, her motor development is retarded.

CONCLUSIONS

The main clinical manifestations of beta mannosidosis are various degrees of mental retardation, speech disorders and hearing loss. Our patient presented with abnormalities of swallowing and esophageal motility resulting in recurring respiratory infections, previously reported in some other cases.

[Analgesia with saccharose during heel capillary prick. A randomized study in 37 newborns of over 33 weeks of amenorrhea]

BACKGROUND

To evaluate the efficiency of intraoral saccharose administration for analgesia among neonates born after at least 33 weeks of gestation.

POPULATION AND METHOD

Thirty-seven neonates from two neonatal units were tested using an objective scale of infants' pain. A double blind study of the heel prick response after saccharose vs. water administration was performed.

RESULTS

Prior administration of saccharose significantly reduced the pain reaction (1.24 vs. 2.24, P < 10(-5)).

CONCLUSION

The analgesia obtained after an intraoral saccharose administration can be useful for repeated punctures for which common procedures of analgesia are ineffective. Beyond its use for heel prick, this procedure could be proposed for venous punctures when ELMA analgesia is not possible.

[Modification of C-reactive protein after instillation of natural exogenous surfactants]

BACKGROUND

Blood C-reactive protein levels have been frequently found to be increased after Curosurf instillation. These variations have been compared to the values after Surfexo therapy and after absence of surfactant therapy.

POPULATION AND METHODS

The files of not infected premature babies, aged 25 to 36 weeks of gestational age, under mechanical ventilation for a hyaline membrane disease (HMD), admitted in our unit between January 1990 to June 1995, have been retrospectively studied. They were separated into three groups: A: 67 infants ventilated for more than 5 days for HMD without surfactant therapy; B: 23 infants treated by Surfexo; C: 60 infants treated by Curosurf. CRP was measured daily between day 0 (DO) and D5. Means and standard deviations were calculated for each day and each group. The mean values of CRP at D1 to D5 in group C were compared to DO. The daily CRP values were compared in the three groups. For group C, the results were studied daily according to the gestational age, dosage and age of the neonate at the first instillation. The statistical results have been given according to the Student t test.

RESULTS

After Curosurf, the mean CRP value rose significantly from D1 to D4 compared to D0. There was no difference of CRP between groups A and B from D0 to D5, Group C had higher values in comparison to group A (between D1 to D5) and to group B (between D1 and D3). There was no significant difference of the CRP values in group C according to the number of instillations or the amount instilled, but CRP was lower in early treated infants (< H6).

DISCUSSION

Curosurf instillation is followed by a significant increase in CRP, maximum at D2. This is not seen after Surfexo. This increase seems less important at D2-D3 when Curosurf is administered early. The CRP increase after Curosurf therapy could be due to an inflammatory reaction to the heterologous proteins it contains.

[Neonatal alloimmune thrombopenia in anti-HPA-3a (Baka) immunization]

BACKGROUND

Neonatal alloimmune thrombocytopenia (NAIT) in the HPA-3a system is responsible for less than 5% of all cases of NAIT.

CASE REPORT

Thomas, a male infant, was born at 39 weeks of gestation after an uncomplicated pregnancy. Delivery was normal. The Apgar score was 9 at 1 minute, and 10 at 5 and 10 minutes. At 1 hour of age, he displayed extensive petechiae and purpura over the back. The platelet count was 8,000/mm3. Hematesis and extensive petechiae were noted, leading to an exchange transfusion followed by a transfusion of 0.5 U/kg of random donor platelets, 0.4 g/kg/d of intravenous immunoglobulin (IVIg) and 10 mg/kg/d of corticosteroids. IVIg were discontinued on d5 and corticosteroids on d10. There was no relapse of thrombocytopenia. A neonatal alloimmune thrombocytopenia with an HPA-3a (Baka) incompatibility was confirmed.

CONCLUSION

HPA-3a incompatibility is certainly more frequent than the rare cases reported and must be searched for in all cases of neonatal thrombocytopenia.

[Value and limits of selective bronchial obstruction in neonatal unilateral interstitial emphysema]

BACKGROUND

Two methods of selective ventilation have been used for treating severe localized pulmonary emphysema in the neonates: controlateral selective intubation and selective bronchial obstruction.

CASE REPORTS

Three neonates with acute respiratory distress required respiratory support that was complicated by development of severe localized pulmonary interstitial emphysema of the right lobe (two cases) and the middle lobe (one case). Selective bronchial obstruction with a Swann Ganz catheter SF was tentatively made: in one case, improvement was moderate and transitory, requiring middle lobectomy. The localized emphysema disappeared within 3 days in the two other cases but a localized emphysema appeared in the controlateral lung in one of them, requiring left inferior lobectomy because the ineffectiveness of selective intubation or selective obstruction.

CONCLUSION

Selective bronchial obstruction may fail but this easy and well tolerated method should be tried in severe localized emphysema, specially in those patients who cannot be ventilated with high-frequency oscillation.

[Pre- or neonatal corticotherapy: what are the long-term consequences?]

This paper is a literature overview on the potential long-term side effects of steroid therapy in the prenatal and neonatal period. Incomplete and transient suppression of adrenal function without growth impairment has been reported in prolonged treatment with steroids for bronchopulmonary dysplasia. There seems to be no secondary chronic immune dysfunction. There is evidence for deleterious effects on lung and brain development in experimental animals. In human preterm neonates, no pulmonary and cerebral secondary effects were observed after short prenatal steroid courses, but it is as yet uncertain whether this applies also to prolonged steroid therapy which requires further long-term investigations, including school performance.

[Early tubular involvements in lead poisoning in children]

One of the main targets of lead poisoning is the kidney. Chronic poisoning can lead to kidney failure, and acute poisoning to tubulopathy with Toni-Debré-Fanconi syndrome. The primum movens of this tubulopathy is a distortion of mitochondrial energetic metabolism. We studied 27 children presenting with non symptomatic poisoning. Serum creatinine levels were normal. There was neither proteinuria nor glycosuria and only one child presented with hyperaminoaciduria. One third already presented with signs of tubulopathy, as shown by an increase in beta 2 microglobinuria in 36.5% of the cases studied (8 times in 22 samples) and enzymuria in 30.4% of the cases (23.5% if one excludes the children having had a chelation before the study). Kidney is therefore involved early in lead poisoning in children.

[Nephritis caused by ventriculo-atrial shunt: possible cure without reoperation of the valve?]

A case of ventriculo-atrial shunt nephritis in a 3 year-old child is reported. It was induced by an infection with Staphylococcus Albus. Complete cure of kidney disease was obtained with antibiotics (Oxacilline and Rifampicine) alone without resorting to surgical removal of the valve. Attention is drawn to the fact that a long-term clinical and biological follow-up is necessary to make sure that this conservative attitude does not compromises renal function.

[Neonatal shigellosis]

BACKGROUND

Neonatal shigellosis is rare and is usually encountered in unsanitary countries. It is occasionally responsible for manifestations of bacteremia such as septic shock and rash.

CASE REPORT

A boy was born at 40 weeks of gestational age, while the end of labor was marked by temperature at 38 degrees C. His weight was 3,640 g and his height was 49.5 cm. The temperature of the newborn was 38 degrees C at 1 hour of life. He had hepatomegaly and X-rays showed abdominal distension. Gastric aspirates taken at that time showed Gram-negative bacilli and Gram-positive cocci. The patient was given amoxicillin intravenously and netilmicin intramuscularly. The infant still had a fever at 33 hours of life and produced aqueous stools containing blood and mucus. At H40, he developed shock requiring infusion of human albumin. He was given cefotaxime and was admitted to the intensive care unit, where a hepatosplenomegaly was also noted. He was given respiratory support, albumin infusion, dobutamine and dopamine. Antibiotics included cefotaxime, gentamicin and metronidazole. His total white cell count was 2,400/mm3, with 71% mature neutrophils; his platelet count was 190,000/mm3. Stool cultures showed the presence of Shigella flexneri, but blood cultures did not grow. A generalized rash was seen 4 days later; this persisted for less than 24 hours, while the platelet count was 25,000/mm3. The patient was then given ceftriazone and gentamicin. His stool cultures contained Shigella flexneri on the 4th and 9th day, but not on the 14th day. His mother had diarrhea 7 weeks before delivery, but stool cultures before and after delivery did not grow.

CONCLUSION

Diagnosis of neonatal shigellosis is difficult. Cutaneous manifestations, possibly indicating bacteremia, have been seen in older children but never in the neonates.

[Neonatal hemolytic-uremic syndrome, methylmalonic aciduria and homocystinuria caused by intracellular vitamin B 12 deficiency. Value of etiological diagnosis]

BACKGROUND

A hemolytic-uremic syndrome associated with methylmalonic aciduria and homocystinuria is seen during the first weeks of life. A molecular defect in the CbIC mutation has been found. This report describes a new case with this association.

CASE REPORT

A girl, the second in this family, was born at term: her birth weight was 2,100 g, height was 47 cm and head circumference 31.5 cm. She was admitted at 32 days of age with hemolytic anemia and fragmencytosis, renal failure and thrombocytopenia. The renal failure required peritoneal dialysis followed by hemofiltration. The signs of pancytopenia of central origin and liver failure seen at that time raised the possibility of an intracellular defect of B12 metabolism. Chromatography of the amino acids and organic acids in the urine and plasma revealed homocystinemia, hypomethioninemia, homocystinuria and methylmalonic aciduria. The deficient B12 metabolism was confirmed in fibroblasts which showed deficits in both methyl and adenosyl-cobalamin synthesis. The metabolic disturbances were completely resolved after intravenous administration of hydroxy-cobalamin (2,000 micrograms per day) and folinic acid (25 mg per day) for 5 days. But the neurological abnormalities persisted, with retinitis pigmentosa and major leukodystrophic changes seen by MRI, and the infant died one month later.

CONCLUSION

This new case emphasizes the importance of systematically screening all cases of neonatal hemolytic-uremic syndrome for this autosomal recessive disorder.