Optimal Delivery Management for the Prevention of Early Neonatal SARS-CoV-2 Infection: Systematic Review and Meta-analysis

OBJECTIVE

 Delivery management interventions (DMIs) were recommended to prevent delivery-associated transmission of maternal SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) to infants without evidence of effect on early neonatal SARS-CoV-2 infection (ENI) and neonatal death <28 days of life (ND). This systematic review describes different DMI combinations and the frequency of ENI and ND.

STUDY DESIGN

 Individual patient data were collected from articles published from January 1, 2020 to December 31, 2021 from Cochrane review databases, Medline, and Google Scholar. Article inclusion criteria were: documented maternal SARS-CoV-2 polymerase chain reaction (PCR)-positive status 10 days before delivery or symptomatic at delivery with a positive test within 48 hours, known delivery method, and known infant SARS-CoV-2 PCR result. Primary outcomes were ENI (positive PCR at 12 hours to 10 days) and ND. All characteristics were pooled using the DerSimonian-Laird inverse variance method. Primary outcome analyses were performed using logit transformation and random effect. Pooled results were expressed as percentages (95% confidence intervals). Continuity correction was applied for all pooled results if any included study has 0 event.

RESULTS

 A total of 11,075 publications were screened. 117 publications representing 244 infants and 230 mothers were included. All publications were case reports. ENI and ND were reported in 23.4% (18.2-29.18) and 2.1% (0.67-4.72) of cases, respectively. Among cases with available information, DMIs were reported for physical environment (85-100%), delivery-specific interventions (47-100%), and infant care practices (80-100%). No significant comparisons could be performed between different DMI combinations due to small sample size.

CONCLUSION

 The evidence supporting any DMI in SARS-CoV-2-infected mothers to prevent ENI or ND is extremely limited. Limitations of this meta-analysis include high risk of bias, small sample size, and large confidence intervals. This identifies the need for multinational database generation and specific studies designed to provide evidence of DMI guidelines best suited to prevent transmission from mother to neonate.

KEY POINTS

· In this review we analyzed 2 years of maternal SARS-CoV-2 published cases.. · We assessed association of delivery management interventions with infant SARS-CoV-2 infection.. · We found no evidence supporting any DMI for that purpose..

Risk factors associated with necrotizing enterocolitis in preterm infants: A case-control study

BACKGROUND

Necrotizing enterocolitis (NEC) is the most common life-threatening gastrointestinal emergency in prematurity. The pathophysiology is multifactorial and remains incompletely understood. Early diagnosis and treatment could reduce the risk of mortality and morbidity. We aimed to identify factors associated with NEC in preterm newborns.

METHOD

This case-control study included all preterm newborns presenting with NEC and managed between January 1, 2009 and December 31, 2018 in the neonatal intensive care unit of Nancy. For each case, two controls were matched according to three criteria: gestational age (WG), date of birth, and mode of delivery. Antenatal, peripartum, and postnatal risk factors prior to NEC were analyzed.

RESULTS

A total of 292 infants were involved in the study, 113 of whom had NEC. Mean gestational age for newborns with NEC was 29 WG, and mean birth weight, 1340 g. Only early-onset infection was identified as a significant risk factor for NEC (15% vs. 6.6% for infection p<0.04, and 28.3% vs. 16.4% p<0.02 for infection and sepsis, NEC vs. controls, respectively). Late-onset feeding and initial continuous enteral feeding were significantly associated with the occurrence of more severe NEC (p<0.02 and p = 0.03, respectively).

CONCLUSION

The results of this study are consistent with intestinal dysbiosis being a risk factor for NEC. Early-onset infection was found to be a significant risk factor. Enteral feeding practice may also be associated with NEC.

Cognitive Training for Visuospatial Processing in Children Aged 5½ to 6 Years Born Very Preterm With Working Memory Dysfunction: A Randomized Clinical Trial

Importance

Compared with term-born peers, children born very preterm generally perform poorly in executive functions, particularly in working memory and inhibition. By taking advantage of neuroplasticity, computerized cognitive training of working memory in those children could improve visuospatial processing by boosting visual inhibition via working memory.

Objective

To evaluate the long-term effect of cognitive working memory training on visuospatial processing in children aged 5½ to 6 years born very preterm who have working memory impairment.

Design, Setting, and Participants

This multicenter (18 French university hospitals), open-label randomized clinical trial with 2 parallel groups (EPIREMED) was conducted from November 2016 to April 2018, with the last follow-up during August 2019. Eligible children from the EPIPAGE 2 cohort were aged 5½ to 6 years, were born between 24 and 34 weeks' gestation, and had a global intelligence quotient greater than 70 and a working memory index less than 85. Data were analyzed from February to December 2020.

Intervention

Children were randomized 1:1 to standard care management and a working memory cognitive training program (Cogmed software) for 8 weeks (25 sessions) (intervention) or to standard management (control).

Main Outcomes and Measures

The primary outcome was the visuospatial index score from the Wechsler Preschool and Primary Scale of Intelligence, 4th Edition. Secondary outcomes were working memory, intellectual functioning, executive and attention processes, language skills, behavior, quality of life, and schooling. Neurobehavioral assessments were performed at inclusion and after finishing training at 6 months (intermeditate assessment; secondary outcomes) and at 16 months (final assessment; primary outcome).

Results

There were 169 children randomized, with a mean (SD) age of 5 years 11 months (2 months); 91 (54%) were female. Of the participants, 84 were in the intervention group (57 of whom [68%] completed at least 15 cognitive training sessions) and 85 were in the control group. The posttraining visuospatial index score was not different between groups at a mean (SD) of 3.0 (1.8) months (difference, -0.6 points; 95% CI, -4.7 to 3.5 points) or 12.9 (2.6) months (difference, 0.1 points; 95% CI, -5.4 to 5.1 points). The working memory index score in the intervention group significantly improved from baseline at the intermediate time point (difference, 4.7 points; 95% CI, 1.2-8.1 points), but this improvement was not maintained at the final assessment.

Conclusions and Relevance

This randomized clinical trial found no lasting effect of a cognitive training program on visuospatial processing in children aged 5½ to 6 years with working memory disorders who were born very preterm. The findings suggest that this training has limited long-term benefits for improving executive function. Transient benefits seemed to be associated with the developmental state of executive functions.

Trial Registration

ClinicalTrials.gov Identifier: NCT02757794.

Infant exposure to Fluvoxamine through placenta and human milk: a case series - A contribution from the ConcePTION project

Introduction

Fluvoxamine is widely used to treat depression during pregnancy and lactation. However, limited data are available on its transfer to the fetus or in human milk. This case series provides additional information on the infant exposure to fluvoxamine during pregnancy and lactation.

Case presentation

Two women, aged 38 and 34 years, diagnosed with depression were treated with 50 mg fluvoxamine during pregnancy and lactation. At delivery a paired maternal and cord blood sample was collected for each woman. The first mother exclusively breastfed her child for 4 months and gave one foremilk and one hindmilk sample at 2 days and 4 weeks post-partum, whereas the second mother did not breastfeed.

Results

The cord to plasma concentration ratios were 0.62 and 0.48, respectively. At 2 weeks post-partum, relative infant doses (RID) were 0.47 and 0.57% based on fluvoxamine concentrations in foremilk and hindmilk, respectively. At 4 weeks post-partum, the RIDs were 0.35 and 0.90%, respectively. The child from the first mother was born healthy and showed a normal development at the 6th, 18th and 36th month follow-ups. One of the twins from the second woman was hospitalized for hypoglycemia that was attributed to gestational diabetes and low birth weight. The second one was born healthy.

Conclusion

These results suggest a minimal exposure to fluvoxamine during lactation which is in accordance with previously published data. Larger clinical and pharmacokinetic studies assessing the long-term safety of this drug during lactation and the variability of its exposure through breastmilk are warranted.

Microbiota and Human Milk Oligosaccharides in Premature Infants

Gut microbiota plays an important role in infants' health. The prevalence of bifidobacteria in the gastrointestinal tract of term breastfed infants has been associated with reduced infection rates compared with formula-fed infants. However, few studies evaluated microbiota in premature infants. In an observational study of 577 preterm newborns born below 32 weeks gestation, gut microbiota was not driven by bifidobacteria but could be classified into six different clusters with regard to the most abundant bacteria present. Clusters were related to infants' maturity, perinatal determinants, and were associated with short- and long-term outcome. In another study, the effects of caesarean birth on infant gut microbiota could be alleviated by human milk oligosaccharides (HMOs) in mothers' milk. In addition, 58 infants fed with a formula enriched with 2 HMOs had microbiota closer to breastfed infants than 63 infants receiving the same formula without HMOs. The question then arose of the benefit of HMO supplementation for microbiota in premature infants. Thus, a multicenter randomized controlled intervention study of the effect of a liquid supplement containing 2 HMOs was set up. Ongoing data analysis will evaluate gastrointestinal tolerance parameters, intake of HMOs from human milk, long-term growth outcomes, fecal microbiota, and fecal biomarkers of gut maturation and immunity.

Neurodevelopment at seven years and parents' feelings of prematurely born children

BACKGROUND

The evolution of knowledge and technical advances in neonatal resuscitation have improved the survival of very premature babies. However, the long-term neurodevelopmental prognosis and cognitive and learning abilities are still uncertain.

OBJECTIVE

This study aimed to evaluate the neurodevelopment and learning abilities of 7-year-old children born prematurely, and their parents' feelings at 8 years of age.

PATIENTS AND METHODS

Data from children born before 33 weeks gestation in a level III maternity hospital and involved in a regional follow-up network were analyzed at 7 years of age. Neurodevelopmental abnormalities were defined as cerebral palsy, hearing or visual impairment, and/or behavioral abnormalities. School performance was evaluated by the EDA test. A parents' questionnaire assessed their feelings about the child's and family's quality of life at 8 years of age.

RESULTS

At 7 years of age, 51% of the 238 children presented neurodevelopmental abnormalities: 3.3% with cerebral palsy, 6.2% with hearing impairments, 50.7% with visual impairments, and 11.3% with behavioral disorders. The children with neurodevelopmental abnormalities had lower gestational age (29.0 ± 2.0 vs. 30.0 ± 2.1 weeks, p = 0.003) and more EEG abnormalities during the neonatal period (31.1% vs. 19.8%, p = 0.048) than the children without abnormalities. Ninety-four percent of the children with abnormalities were enrolled in normal schools, 33% with special support. In the overall cohort, 31% of the children had all academic performance scores in the normal range of the reference population. At 8 years old, 39% of the parents of children with neurodevelopmental abnormalities felt that their child's situation significantly impacted their quality of life compared to 14% of parents of children without neurodevelopmental abnormality (p = 0.022).

CONCLUSION

Half of children born very prematurely present with long-term neurodevelopmental abnormalities, which their parents feel significantly impacts their quality of life.

Influence of body mobility on attention networks in school-aged prematurely born children: A controlled trial

School-aged prematurely born children (PC) have a higher risk of academic difficulties, which may be partly explained by attention difficulties. It has been suggested that children's attentional performance might be influenced by their body posture and spontaneous body motion. The aim of this study (ClinicalTrials.gov - NCT03125447) was to test the influence of three body mobility conditions on the three functions of attention (alertness, orienting, and executive control) among school-aged PC vs. term-born children (TC). Notably, 21 PC and 21 TC performed the Attention Network Test for Children in three body mobility conditions, namely, sitting and standing imposed fixed postures and a free-to-move condition. The children's median reaction times were compared between trials (1) with and without alerting cues, (2) with valid and invalid orienting cues, and (3) with and without distracting information, to calculate the performance of alertness, orienting, and executive control, respectively. Results showed that with distracting information, PC exhibited significantly slower responses in the standing-still posture than in the sitting-still posture (1,077 ± 240 vs. 1,175 ± 273 ms, p < 0.05), but not TC. No difference was observed with the free-to-move condition. PC and TC did not significantly differ in alertness or orienting, regardless of body mobility condition. These data suggest that PC must use executive resources to stand still and maintain position, which impairs their performance during executive tasks. We speculate that these results may be related to less developed postural control and motor inhibition in PC.

Use of a Liquid Supplement Containing 2 Human Milk Oligosaccharides: The First Double-Blind, Randomized, Controlled Trial in Pre-term Infants

There is growing evidence supporting the benefit of human milk oligosaccharides (HMOs) on reducing risk of illnesses and improving immune function in newborn infants, but evidence in pre-term infants is lacking. This randomized, double-blind, placebo-controlled trial (NCT03607942) of pre-term infants evaluated the effects of HMO supplementation on feeding tolerance, growth, and safety in 7 neonatal units in France. Pre-term infants (27-33 weeks' gestation, birth weight <1,700 g) were randomized early after birth to receive HMO supplement (n = 43) [2'-fucosyllactose (2'FL) and lacto-N-neotetraose (LNnT) in a 10:1 ratio (0.374 g/kg body weight/day)] or an isocaloric placebo (n = 43) consisting of only glucose (0.140 g/kg/day) until discharge from the neonatal unit. Anthropometric z-scores were calculated using Fenton growth standards. Primary outcome was feeding tolerance, measured by non-inferiority (NI) in days to reach full enteral feeding (FEF) from birth in HMO vs. placebo group (NI margin = 4+ days). Mean number of days on intervention prior to FEF was 8.9 and 10.3 days in HMO and placebo, respectively. Non-inferiority in time to reach FEF in HMO (vs. placebo) was achieved [LS mean difference (95% CI) = -2.16 (-5.33, 1.00); upper bound of 95% CI < NI margin] in full analysis set and similar for per protocol. Adjusted mean time to reach FEF from birth was 2 days shorter in HMO (12.2) vs. placebo (14.3), although not statistically significant (p = 0.177). There was no difference in weight-for-age z-scores between groups throughout the FEF period until discharge. Length-for-age z-scores were higher in HMO at FEF day 14 [0.29 (0.02, 0.56), p = 0.037] and 21 [0.31 (0.02, 0.61), p = 0.037]. Head circumference-for-age z-score was higher in HMO vs. placebo at discharge [0.42 (0.12, 0.71), p = 0.007]. Occurrence of adverse events (AEs) was similar in both groups and relatively common in this population, whereas 2.3 and 14.3%, respectively, experienced investigator-confirmed, related AEs. HMO supplementation is safe and well-tolerated in pre-term infants. After 9 days of supplementation, the HMO group reached FEF 2 days earlier vs. placebo, although the difference was not statistically significant. In addition, HMO supplementation supports early postnatal growth, which may have a positive impact on long-term growth and developmental outcomes.

Body Mobility and Attention Networks in 6- to 7-Year-Old Children

Learning in 6- to 7-year-old children is strongly influenced by three functions of attention: alertness, orienting, and executive control. These functions share a close relationship with body mobility, such as the posture adopted or a request to stay still during tasks. The aim of this study (ClinicalTrials.gov) was to analyze the influence of body posture (standing versus sitting) and the influence of these imposed postures compared to a free body mobility on attention functions in 6- to 7-year-old children. Twenty-one children (11 girls) with a mean age of 6.7±0.6years performed the Attention Network Test for Children in three-body mobility conditions: sitting still, standing still, and free to move. Three attentional scores were calculated which would separately reflect performance of alertness, orienting, and executive control. Overall, no difference in alertness performance was found between the three bodily mobility conditions. In addition, our results suggest a general poor orienting performance in children, whatever the body mobility condition, which might be related to their young age. Finally, children improved their executive control performance when they stood still, probably due to an improvement in arousal and mental state.

Outcome of Very Premature Newborn Receiving an Early Second Dose of Surfactant for Persistent Respiratory Distress Syndrome

Background: Infants presenting respiratory distress syndrome (RDS) not responding to surfactant often receive a second instillation. Few studies evaluated the consequences of this second administration. This study aimed at determining the outcome of infants presenting persistent RDS and receiving an early second dose of surfactant. Methods: Infants below 32 weeks' gestation who received a second dose of 100mg/kg of surfactant within the first 72 h of life, were retrospectively involved in this 42 months' study. They were matched to two controls receiving a single dose of 200mg/Kg based upon gender and gestational age. Results: 52/156 infants receiving two doses (Group 2-doses) were significantly more often SGA [22 (42%) vs. 21 (20%) p = 0.04] and outborn [29 (56%) vs. 13 (12%) p = 0.001]. They had received antenatal corticos teroid therapy less often [26 (50%) vs. 89 (86%) p = 0.001] and presented more severe RDS based upon FiO2 level, oxygenation index and radiography. Group 2-doses survival was lower (65.4% vs. 79.6 % p < 0.1) but surviving infants did not have different morbidity than controls. Discussion: Premature newborn receiving a second dose of surfactant had adverse antenatal characteristics, presented more severe RDS and only partially responded to the first dose. Outcomes of surviving infants who received 2 doses of surfactant were comparable to others.

Impact of introducing a standardized nutrition protocol on very premature infants' growth and morbidity

Background

Inappropriate nutritional intake in premature infants may be responsible for postnatal growth restriction (PGR) and adverse long-term outcomes.

Objective

We evaluated the impact of an updated nutrition protocol on very premature infants’ longitudinal growth and morbidity, and secondly the compliance to this new protocol.

Design

All infants born between 26–32 weeks gestation (GA) were studied retrospectively during two 6-month periods before (group 1) and after (group 2) the introduction of an optimized nutrition protocol, in a longitudinal comparative analysis.

Results

158 infants were included; 72 before and 86 after the introduction of the protocol (Group 1: (mean±SD) birthweight (BW) 1154±276 g, GA 29.0±1.4 weeks; Group 2: BW 1215±332 g, GA 28.9±1.7 weeks). We observed growth improvement in Group 2 more pronounced in males (weight z-score) at D42 (−1.688±0.758 vs. −1.370±0.762, p = 0.045), D49 (−1.696±0.776 vs. −1.370±0.718, p = 0.051), D56 (−1.748±0.855 vs. −1.392±0.737, p = 0.072), D63 (−1.885±0.832 vs. −1.336±0.779 p = 0.016), and D70 (−2.001±0.747 vs. −1.228±0.765 p = 0.004). There was no difference in females or in morbidities between the groups. We observed low compliance to the protocol in both groups: similar energy intake but higher lipid intake in Group 1 and higher protein intake in Group 2.

Conclusion

The quality of nutritional care with a strictly-defined protocol may significantly improve weight gain for very preterm infants. As compliance remained low, an educational reinforcement is needed to prevent PGR.

Clinical trial registration

This retrospective study was registered by ClinicalTrials.gov under number NCT03217045, and by the CNIL (Commission Nationale de l’Informatique et des Libertés) under study number R2015-1 for the Maternity of the CHRU of Nancy.

A population pharmacokinetic model for escitalopram and its major metabolite in depressive patients during the perinatal period: Prediction of infant drug exposure through breast milk

BACKGROUND AND OBJECTIVES

Escitalopram (SCIT) is frequently prescribed to breastfeeding women. Available information on SCIT excretion into breast milk is based on heterogeneous and incomplete data. A population pharmacokinetic model that aimed to better characterize maternal and infant exposure to SCIT and its metabolite was developed.

METHODS

The study population was composed of women treated by SCIT or racemic citalopram and enrolled in the multicenter prospective cohort study SSRI-Breast Milk study (ClinicalTrial.gov NCT01796132). A joint structural model was first built for SCIT and S-desmethylcitalopram (SDCIT) in plasma using NONMEM and the milk-to-plasma ratio (MPR) was estimated by adding the drug breast milk concentrations. The effect of different influential covariates was tested and the average drug exposure with variability through breastfeeding was predicted under various conditions by simulation.

RESULTS

The study enrolled 33 patients treated with SCIT or racemic citalopram who provided 80 blood and 104 milk samples. Mean MPR for both parent drug and metabolite was 1.9. Increased milk fat content was significantly associated with an increased drug transfer into breast milk (+28% for SCIT and +18% for SDCIT when fat amount doubles from 3.1 to 6.2 g/100 mL). Simulations suggested that an exclusively breastfed infant would ingest daily through breast milk 3.3% of the weight-adjusted maternal SCIT dose on average.

CONCLUSION

The moderate between-subject variability in milk concentration of SCIT and the limited exposure to escitalopram through breast milk observed provide reassurance for treated mothers of breastfed healthy infants.

Networks as culture: understanding and accounting for risks within networks of medico-social actors

The anthropological part of the present research project addresses the issue of risk and uncertainties relating to perinatality and disability, and draws from the discourses of professionals in a perinatal network in the French Lorraine region. From an anthropological point of view, it is necessary to determine how and to what extent the views of professionals determine the network's management policies. The place conferred to 'the user' in these representations is one of several important issues to be analysed in order to gain better understanding of the management of relationships that result from it. What is the position of professionals who 'negotiate' and 'organise' the cost of the risk of disability when grasped in connection with their images of the 'users' (children and parents)? This qualitative study consisted of 40 semi-structured interviews conducted with 20 medical, social, and community professionals, all involved directly or indirectly with the network. The results demonstrate the importance of a network assessment as a 'culture' from the social and cultural relations of network professionals. These relations form the cement of a structure made of interpersonal ties and rooted in particular histories around a 'user' that are conveyed through individual narratives.

Thyroxine Threshold Is Linked to Impaired Outcomes in Preterm Infants

Transient hypothyroxinaemia of prematurity (THOP) presents as decreased free thyroxine without an increase in thyroid stimulating hormone. Thyroxine availability is important in case of premature birth, and THOP could be associated with impaired adaptation to extra-uterine life but the association of thyroxine level and clinical status has not yet been clearly defined. Aim: To defined a free thyroxine threshold likely associated with neonatal clinical impairment and outcomes at age three years. Methods: This retrospective cohort study included infants born before or at 28 weeks' gestation at the Regional Maternity in Nancy, France. We defined a free thyroxine threshold as a function of clinical impairment by Receiver Operating Curve analysis, validated by log likelihood iteration in binary logistic regression, in infants born from October 2008 to December 2012 and meeting neonatal clinical impairment criteria. This threshold was validated in a distinct cohort of infants born from January 2014 to December 2016. Clinical impairment was defined as assisted ventilation requirement at seven days of age plus four minor clinical disorders among heart rate, blood pressure, temperature, serum sodium and potassium, APGAR score at five minutes, vasopressor treatment and patent ductus arteriosus. The first cohort was assessed at age three years for neurodevelopmental outcomes. Results: We identified a ≤10 pmol/L threshold with 85.7% sensitivity and 51% specificity. From the first and second cohorts, 196 and 176 infants respectively had available data, and 85% (97/112) and 26% (20/78) with free thyroxine ≤10 pmol/L met clinical impairment criteria. For infants with values >10 pmol/L, 41% (35/84) and 3% (3/98) from the first and second cohorts met impairment criteria. Of 147 children with available data at age 3 years, 65% (58/89) with neonatal free thyroxine ≤10 pmol/L had adverse neurodevelopmental outcomes vs. 34% (20/58) with >10 pmol/L (OR 3.55; 95% confidence interval, 1.77-7.13; p < 0.001). Conclusion: A free thyroxine level ≤10 pmol/L in infants is associated with neonatal clinical impairment and poor outcome at age three years.

Case Series of COVID-19 Asymptomatic Newborns With Possible Intrapartum Transmission of SARS-CoV-2

Background: Despite the pandemic, data are limited regarding COVID-19 infection in pregnant women and newborns. This report aimed to bring new information about presentation that could modify precautionary measures for infants born of mothers with a remote history of COVID-19. Methods: We report two infants with possible maternofetal transmission, and four mothers without immunologic reactions. Data were collected from the patient files. Results: One mother exhibited infection signs 10 days before uncomplicated delivery, with negative RT-PCR and no antibody detection thereafter. Another mother exhibited infection 6 weeks pre-delivery, confirmed by nasopharyngeal swab testing with positive RT-PCR, and positive antibody detection (IgM and IgG). Both newborns were asymptomatic but tested positive for nasopharyngeal and stool RT-PCR at 1 and 3 days of age for the first one and at 1 day of age for stool analysis for the second one. Two additional mothers exhibited infection confirmed by positive RT-PCR testing at 28- and 31-days pre-delivery but did not present detectable antibody reaction at the time of delivery. Conclusion: These observations raise concerns regarding contamination risk by asymptomatic newborns and the efficacy of immunologic reactions in pregnant mothers, questioning the reliability of antibody testing during pregnancy.

Algorithm for predicting threshold retinopathy of prematurity is insufficient and fundus examinations are still needed before 31 weeks

AIM

We evaluated the weight, insulin-like growth factor-1, neonatal, retinopathy of prematurity (WINROP) algorithm for very premature infants.

METHOD

Infants born before 32 weeks who had undergone fundus examinations in the neonatal intensive care unit at the University Hospital of Nancy were included in this French retrospective cohort study from July 2012 to July 2016. We evaluated how well the WINROP software predicted threshold retinopathy of prematurity (ROP).

RESULTS

We studied 570 infants with a mean gestational age of 28.7 ± 1.8 weeks and a mean birth weight of 1110 ± 297 g: 28.1% had ROP and 1.2% had threshold ROP. The overall WINROP sensitivity was 57.1%, specificity was 46.0%, predictive positive value was 1.3% and predictive negative value was 98.9%. At more than 30 weeks of gestation or 1250 g, these figures rose to a respective specificity of 100% and 95.7% and respective predictive negative value of 100% and 100%. There were independent associations between the severity of ROP and the Apgar score at five minutes, the duration of oxygen therapy and non-invasive ventilation.

CONCLUSION

WINROP worked better on preterm infants born from 31 weeks onwards or weighing over 1250 g. Fundus examinations remain necessary for infants born earlier or lighter.

Visual Maturation at Term Equivalent Age in Very Premature Infants According to Factors Influencing Its Development

Introduction: Visual impairment is a concern in premature infants as perinatal factors may alter maturation during visual development. This observational study aimed at evaluating visual maturation at term equivalent age and factors associated with impaired visual maturation.

Methods: Infants born before 32 weeks’ gestation were evaluated with routine brain MRI, visual acuity, refraction, fundus, and clinical eye examination. Environmental factors were collected from infant’s files.

Results: Fifty-four infants (29.5 ± 1.7 weeks’ gestation, birth weight 1194 ± 288 g) were studied at term equivalent age. Visual acuity was higher in premature infants at term equivalent age than in a reference publication with the same method in term newborns at birth (1.54 ± 0.67 vs. 0.99 ± 0.40 cycles/degree, p = 0.008). In multivariate analysis, abnormal brain MRI was the only factor associated with visual acuity (r²= 0.203; p = 0.026). Incomplete retinal vascularization was observed in 29/53 of infants at term equivalent age and associated with MRI abnormalities of the posterior fossa (p = 0.027) and larger refractive sphere difference between both eyes (1.2 ± 0.8 vs. 0.6 ± 0.4 diopters; p = 0.0005). Retinopathy of prematurity was associated with indices of smaller cerebral volume (p = 0.035).

Conclusion: Higher visual acuity in premature infants at term equivalent age than in term newborns at birth may be related to longer visual experience from birth. Lower visual acuity was correlated with abnormal MRI in preterm infants at term equivalent age.

Mobility may impact attention abilities in healthy term or prematurely born children at 7-years of age: protocol for an intervention controlled trial

BACKGROUND

Seven years of age is a milestone for learning basic knowledge that is strongly related to attention abilities such as Alerting, Orienting, and Inhibition function, allowing for appropriate adaptation to primary school. These attention abilities are also influenced by gestational age at birth in a complex manner, indicating an area of weakness in prematurely born children. Furthermore, recent studies suggest that allowing children to have freedom of movement during learning may improve their attention level and school performance. The purpose of the present study is to determine the influence of mobility on the attentional components that may impact learning abilities in children aged 7-years who were born at term and prematurely.

METHODS

This prospective, randomized, controlled trial will focus on psychometric testing of attentional abilities assessed with the Attention Network Test for Child (Child ANT) and involves a mixed measurement design. Forty-eight children aged 7-years, half of whom were premature at birth and in their expected grade without learning difficulties will be included after parental consent. They will be equipped with a head-mounted display in which the Child ANT will be presented. The association of different flankers and pre-cues will allow the measurement of the development level of Alerting, Orienting, and Inhibition function. The task will be composed of one experimental block of trials randomly performed per posture: seated, standing, or free.

DISCUSSION

This study will assess the contribution of mobility in specific attentional contexts that are usually present during fundamental learning in children. New pedagogical formats of teaching could consider these findings, and new pedagogical tools enabling free spontaneous child mobility might be designed. Moreover, a small percentage of children integrating into the educational system are born prematurely. These children, often considered immature and hyperactive, could benefit from educational innovations that enhance their attention abilities, thereby improving their adaptation to primary school.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov ( NCT03125447 ).

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.

Stereoselective determination of citalopram and desmethylcitalopram in human plasma and breast milk by liquid chromatography tandem mass spectrometry

A high performance liquid chromatography (HPLC) tandem mass spectrometry (MS/MS) method was developed for the simultaneous, stereoselective quantification of the antidepressant citalopram and its active metabolite desmethylcitalopram in human plasma and breast milk. Sample preparation was performed by a two-step approach, including generic protein precipitation with acetonitrile followed by solid phase extraction. Enantiospecific separation of analytes was achieved on a Phenomenex^® Lux Cellulose-2 column (4.6mm×150mm; 5μm), using reversed phase chromatography conditions characterized by a gradient elution of ammonium acetate buffer (pH 9.0; 20mM) and acetonitrile at a flow rate of 0.6ml/min. The compounds were detected by a tandem quadrupole mass spectrometer equipped with an electrospray ionization source and operating in multiple reaction monitoring mode. The method was fully validated in both biological fluids over a large concentration range of 0.1-100ng/ml for S-(+)- and R-(-)-citalopram, and 0.3-100ng/ml for S-(+)- and R-(-)-desmethylcitalopram. Trueness (90.0-113.3% and 97.1-103.6%), repeatability (0.9-15.9% and 0.9-8.4%) and intermediate precision (1.3-17.8% and 0.9-9.6%) in plasma and breast milk, respectively, meet international guidelines for method validation. Internal standard-normalized matrix effects ranged between 99 and 101% and 98-105%, respectively. The accuracy profiles (total error of trueness and precision) were mostly within the acceptance limits for biological samples defined as ±30%. The method was successfully applied to patient samples in a clinical trial setting.

Late Surfactant Administration in Very Preterm Neonates With Prolonged Respiratory Distress and Pulmonary Outcome at 1 Year of Age: A Randomized Clinical Trial

IMPORTANCE

Although immature neonate survival has improved, there is an increased risk of developing bronchopulmonary dysplasia, leading to significant respiratory morbidity. Measures to reduce bronchopulmonary dysplasia are not always effective or have important adverse effects.

OBJECTIVE

To evaluate the effect of late surfactant administration in infants with prolonged respiratory distress on ventilation duration, respiratory outcome at 36 weeks' postmenstrual age, and at 1 year postnatal age.

DESIGN, SETTING, AND PARTICIPANTS

Double-blind randomized clinical trial at 13 level III French perinatal centers. Participants included 118 neonates at less than 33 weeks' gestation who still required mechanical ventilation on day 14 (SD, 2) with fraction of inspired oxygen of more than 0.30. All survivors were eligible for follow-up. We performed an intent-to-treat analysis.

INTERVENTIONS

Infants received 200 mg/kg of poractant alfa (surfactant) or air after randomization. At 1 year, after parents' interview, infants underwent physical examination by pediatricians not aware of the randomization.

MAIN OUTCOMES AND MEASURES

The duration of ventilation was the primary outcome. The combined outcome of death or bronchopulmonary dysplasia at 36 weeks' postmenstrual age and respiratory morbidity at 1 year of age were the main secondary outcome measures.

RESULTS

Of the 118 infants who participated in the study, 65 (55%) were male. Fraction of inspired oxygen requirements dropped after surfactant, but not air, for up to 24 hours after instillation (0.36 [0.11] vs 0.43 [0.18]; P < .005). Severe bronchopulmonary dysplasia/death rates at 36 weeks' postmenstrual age were similar (27.1% vs 35.6%; P = .32). Less surfactant-treated infants needed rehospitalization for respiratory problems after discharge (28.3% vs 51.1%; P = .03); 39.5% vs 50% needed respiratory physical therapy (P = .35). No difference was observed for weight (7.8 [1.2] kg vs 7.6 [1.1] kg), height (69 [5] cm vs 69 [3] cm), and head circumference (44.4 [1.7] cm vs 44.2 [1.7] cm) measured at follow-up, nor for neurodevelopment outcome.

CONCLUSIONS AND RELEVANCE

Late surfactant administration did not alter the early course of bronchopulmonary dysplasia. However, surfactant-treated infants had reduced respiratory morbidity prior to 1 year of age.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01039285.

Placental Complications and Bronchopulmonary Dysplasia: EPIPAGE-2 Cohort Study

OBJECTIVE

To investigate the relationship between placenta-mediated pregnancy complications and bronchopulmonary dysplasia (BPD) in very preterm infants.

METHODS

National prospective population-based cohort study including 2697 singletons born before 32 weeks' gestation. The main outcome measure was moderate to severe BPD. Three groups of placenta-mediated pregnancy complications were compared with no placenta-mediated complications: maternal disorders only (gestational hypertension or preeclampsia), fetal disorders only (antenatal growth restriction), and both maternal and fetal disorders.

RESULTS

Moderate to severe BPD rates were 8% in infants from pregnancies with maternal disorders, 15% from both maternal and fetal disorders, 23% from fetal disorders only, and 9% in the control group (P < .001). When we adjusted for gestational age, the risk of moderate to severe BPD was greater in the groups with fetal disorders only (odds ratio [OR] = 6.6; 95% confidence interval [CI], 4.1-10.7), with maternal and fetal disorders (OR = 3.7; 95% CI, 2.5-5.5), and with maternal disorders only (OR = 1.7; 95% CI, 1.0-2.7) than in the control group. When we also controlled for birth weight, the relationship remained in groups with fetal disorders only (OR = 4.2; 95% CI, 2.1-8.6) and with maternal and fetal disorders (OR = 2.1; 95% CI, 1.1-3.9).

CONCLUSIONS

Placenta-mediated pregnancy complications with fetal consequences are associated with moderate to severe BPD in very preterm infants independently of gestational age and birth weight, but isolated maternal hypertensive disorders are not. Fetal growth restriction, more than birth weight, could predispose to impaired lung development.

The ethics and practice of neonatal resuscitation at the limits of viability: an international perspective

Premature infants at the limits of viability raise difficult ethical, legal, social and economic questions. Neonatologists attending an international Collegium were surveyed about delivery room behaviour, and the approach taken by selected countries practicing 'modern' medicine was explored.

CONCLUSION

There were strong preferences for comfort care at 22 weeks and full resuscitation at 24 weeks. Resuscitation was a grey area at 23 weeks. Cultural, social and legal factors also had a considerable impact on decision-making.

[Effects of perinatal nutrition on developmental outcomes]

The multifactorial nature of perinatal growth is now well established. The perinatal environment modulates each infant's genetic potential. Antenatal nutrition is dependent on maternal nutrition and is also subject to environmental factors such as tobacco smoke, which can significantly impact infant development. Current neonatal nutritional guidelines, aimed primarily at ensuring good nutrient tolerance, may no longer be optimal. Indeed, they can lead to malnutrition and growth retardation, and attempts to "catch up" through increased protein and calorie intake may have unwanted effects. Current data point to critical time windows during which nutritional optimization might improve infant development. New approches could help to prevent adult diseases of developmental origin.

Neonatal factors associated with alteration of palatal morphology in very preterm children: the EPIPAGE cohort study

BACKGROUND

Altered palatal morphology has been observed among some preterm children, with possible consequences on chewing, speaking and esthetics, but determinants remain unknown.

AIM

To explore the role of neonatal characteristics and neuromotor dysfunction in alteration of palatal morphology at 5 years of age in very preterm children.

STUDY DESIGN

Prospective population-based cohort study.

SUBJECTS

1711 children born between 22 and 32 weeks of gestation in 1997 or born between 22 and 26 weeks of gestation in 1998 were included in the study. They all had a medical examination at 5 years of age.

OUTCOME MEASURES

Alteration of palatal morphology.

RESULTS

The prevalence of altered palatal morphology was 3.7% in the overall sample, 5.1% among boys and 2.2% among girls (adj OR: 2.52; 95%CI: 1.44-4.42). The risk for altered palatal morphology was higher for lower gestational age (adj OR: 0.85; 95%CI: 0.74-0.97 per week), small-for-gestational age children (adj OR: 2.11; 95%CI: 1.20-3.72) or children intubated for more than 28 days (adj OR: 3.16; 95%CI: 1.11-8.98). Altered palatal morphology was more common in case of cerebral palsy or moderate neuromotor dysfunction assessed at 5 years. Results were basically the same when neuromotor dysfunction was taken into account, except for intubation.

CONCLUSION

Male sex, low gestational age, small-for-gestational age and long intubation have been identified as probable neonatal risk factors for alteration of palatal morphology at 5 years of age in very preterm children. Further studies are needed to confirm these results.

Increased albuminuria in 4-year-old preterm-born children with normal height

OBJECTIVE

To determine risk factors for high blood pressure (BP), increased markers of glomerulosclerosis, and tubular dysfunction in 4-year-old preterm-born children.

STUDY DESIGN

The study group was a longitudinal cohort of 119 children with BP, albuminuria, and β2 microglobulin measurements obtained during the neonatal period and at age 4 years.

RESULTS

Systolic BP was >95(th) percentile in 15 (12.6%) of the children at age 4 years and lower in those born small for gestational age compared with those born appropriate for gestational age. Preterm-born 4-year-olds with height <-1 SD had lower systolic and diastolic BP, and 14.4% of the 4-year-olds had albuminuria. Albuminuria was less prevalent in the 4-year-olds with height <-1 SD than in those with height ≥-1 SD (6.8% vs 19.3%; P=.04). Mean albuminuria level was 1.0±0.7 mg/mmol in 4-year-olds with height <-1 SD and 1.4±1.3 mg/mmol in those with height ≥-1 SD. In multivariate analysis, albuminuria level was increased by 0.4±0.2 mg/mmol in preterm-born children with normal height at age 4, and by 0.5±0.2 mg/mmol in females, after adjustment for gestational age, sex, neonatal morbidity, and intrauterine growth restriction. These results were unchanged after adjustment for body mass index.

CONCLUSION

Normal height at age 4 years may be associated with an increased risk for glomerulosclerosis in preterm-born children.

The renal adverse effects of ibuprofen are not mediated by AQP2 water channels

The aim of this study was to determine (1) whether ibuprofen treatment in very preterm infants causes an increase in the renal water channel aquaporin-2 (AQP2) activity in the collecting duct via prostaglandin synthesis inhibition and (2) whether AQP2 activity remains disturbed long after ibuprofen treatment has ended. This was a prospective study involving premature infants with a gestation age of 27-31 weeks who received treatment between December 2005 and August 2006 in a tertiary Neonatal Intensive Care Unit. Each ibuprofen-treated infant was matched to two controls. Renal glomerular and tubular function were evaluated weekly for 1 month, and urinary AQP2 was measured by immuno-dotting. In total, 166 longitudinal samples were analyzed in 36 infants. Median [interquartile range] gestational age and birthweight were 28 [27.0-29.5] weeks and 1160 [1041-1242] g, respectively. Perinatal factors were similar in both groups. Urine output was significantly decreased in the ibuprofen-treated infants during the treatment. The urinary AQP2 level decreased significantly from day 2 to day 7 in both groups and was similar thereafter for the first month of life in ibuprofen-treated and control groups. Based on our results, we conclude that ibuprofen-induced oligo-anuria is not associated with a change in AQP2 activity and that ibuprofen does not affect AQP2 activity during the first month of life in very preterm neonates.

Hepatitis B e antigen positive mother hepatitis B e antigen long persistence in her non-infected baby

We report the case of a baby born to a hepatitis B virus (HBV) carrier mother. This infant had a hepatitis B e antigen (HBeAg) in the serum until 6 months of age. Serial sera samples were analysed for HBV markers. No breakthrough of HBV infection was detected. The origin of this HBV marker has been questioned.

CONCLUSION

HBeAg can persist at a non-infected baby born to an HBeAg-positive mother up to the age of 6 months.

Inhaled nitric oxide improves oxygenation in very premature infants with low pulmonary blood flow

AIM

Inhaled nitric oxide (iNO) is used to reduce right-to-left extrapulmonary shunting by decreasing pulmonary vascular resistance in term or near-term infants. The objectives of this study were to determine, first, the pulmonary blood flow status of very preterm infants with hypoxaemic respiratory failure, then the response of oxygenation to iNO therapy according to pulmonary blood flow (PBF) and, finally, to verify the lack of adverse side effects of iNO on the ductus arteriosus.

METHODS

Infants below 32 wk gestational age (GA) with hypoxic respiratory failure and aAO2 < 0.22 were randomized as the control or iNO group. PBF was evaluated by pulsed Doppler measurement of mean pulmonary blood flow velocity (MPBFV) in the left pulmonary artery. Low PBF (LPBF) was defined as MPBFV < 0.2 m/s.

RESULTS

Seventy infants of 23 to 31 wk GA with hypoxic respiratory failure were randomized either to receive or not to receive 5 ppm iNO in addition to optimal care. Twenty-eight infants were diagnosed with LPBF (11/35 in iNO vs 17/35 in the control groups). Thirty minutes after receiving iNO the number of LPBF infants dropped to 8/35. In the iNO group, aAO2 increased significantly from 0.14 +/- 0.05 to 0.24 +/- 0.08 after iNO, but only in the LPBF infants (mean +/- SD; p = 0.027).

CONCLUSION

In infants below 32 wk GA with hypoxic respiratory failure, Doppler echocardiographic assessment of LPBF seems to be able to determine which patients are likely to benefit from iNO therapy on systemic oxygenation.

[EEG and ischemic stroke in full-term newborns]

The aims of this study were to describe EEG anomalies in unilateral neonatal ischemic stroke without hypoxic-ischemic encephalopathy, and to determine possible links between these abnormalities and long-term outcome. In 6 full-term newborns without severe fetal distress ischemic stroke was confirmed by computed tomography and/or magnetic resonance imaging. Twenty EEGs were recorded during the neonatal period, 5 in acute stage and 15 later. The duration of the follow-up ranged from 3 to 9 years. All newborns developed unilateral clonic seizures, right-sided (5 cases) or left-sided (1 case); seizures began between 14 and 48 h of life. At follow-up, 3 children were normal at 2 and 6 years of age, while the 3 others had sequelae: epilepsy at 9 years of age in one, and unilateral mild cerebral palsy in the 2 others (3 and 4 years of age), with behavioral problems in one of them. Critical EEG discharges, rhythmic sharp waves and/or slow waves were recorded on the injured side. Abnormalities of interictal activity were excess of alpha or theta rhythms, transitory EEG discontinuity or low voltage. The 2 children with cerebral palsy had numerous unilateral post-ictal positive rolandic slow sharp waves (PRSSWs), which were similar to the positive rolandic sharp waves of premature infants; the child with behavioral problems had numerous positive left-sided temporal fast sharp waves. PRSSWs could be associated with contralateral motor sequelae, while positive left temporal fast sharp waves were associated with long term behavioral problems. These findings may be used for future prospective studies aimed at specifying the relation between EEG abnormalities and long-term outcome.

[Noninvasive ventilation of premature infants]

In a retrospective study we evaluated a one year use of nasal continuous positive pressure in our intensive care neonatal unit. One hundred and twelve newborns with a mean gestational age of 30.8 weeks were treated with this technique: 41 were treated early after birth for moderate respiratory; 71 were treated later, either following extubation and assisted ventilation, or as treatment of apnoeas. The main adverse effects were bowel gaseous distension and delayed oral nutrition. Nasal continuous positive airway pressure reduced the duration of intubation and assisted ventilation and could be used more frequently as early first line treatment in respiratory distress.

[Management of severe neonatal Rh disease following in utero exchange transfusion: towards a new strategy]

Important changes in the prevention, diagnosis, and in utero treatment, of Rhesus allo-immunization in the past 30 years, have led to new neonatal clinical presentations. Based upon the analysis of 14 successive pregnancies with severe hemolytic disease, requiring in utero exchange-transfusion, it appears that the current management is no longer adapted to the new resulting clinical postnatal presentations. In the acute phase, intensive phototherapy associated with regular blood cell transfusion as required, appears to be a better policy than traditional postnatal systematic exchange transfusions. In addition endogenous erythropoiesis stimulation should be included in order to avoid any unnecessary transfusion.

[Twin-twin transfusion syndrome: report of two cases with hemodynamic complications]

CASE REPORTS

We report two cases of cardiac dysfunction in twin-twin transfusion syndrome (TTTS) evaluated with serial echocardiography. Two cases of TTTS were referred at 27 and 26 weeks. At delivery at 31 weeks, the first recipient twin had evidence of severe cardiac dysfunction with decreased ventricular function and transient systemic hypertension. There was polycythaemia. Favorable outcome was observed after treatment with arterial vasodilating (nicardipine) and inotropic agents (dobutamine, enoximone), and reduction of haematocrit. At 28 weeks the other recipient twin had cardiac dilatation with hypokinetic myocardium. These alterations were cured by dobutamine.

CONCLUSION

These cases show that even severe cardiac dysfunction may be reversed after birth unlike in utero natural evolution.

QT interval lengthening in premature infants treated with doxapram

OBJECTIVE

Doxapram, routinely used in premature infants treated for apnea of prematurity unresponsive to methylxanthines, has been related to cardiac conduction disorders. This study was designed to evaluate doxapram cardiac and general tolerance and its relationship to drug plasma concentrations in very premature infants.

METHODS

Forty infants (mean +/- SEM, 28.9 +/- 0.3 weeks of gestation) who were given intravenous doxapram, 0.5 to 1 mg/kg per hour, at 15.9 +/- 2.4 days of life were evaluated prospectively. Electrocardiograms were monitored before and during the first 3 days of treatment. QT interval corrected for heart rate (QTc) longer than 440 ms was regarded as clinically pertinent, given that it is considered a significant risk of conduction disorder leading to torsades de pointes and sudden death. Other side effects were recorded. Toxic plasma concentration of doxapram and ketodoxapram was set at >4 mg/L.

RESULTS

A statistically significant but moderate lengthening of QTc interval has been observed from 394 +/- 4 ms before doxapram to 409 +/- 4 ms at 48 and 72 hours of treatment (P =.0065). For 6 patients, QTc interval became longer than 440 ms without any other rhythm or conduction disorder. Digestive disorders were observed in 20 infants but 9 presented with concomitant septicemia. No relationship was found between presence or absence of adverse effects and drug plasma concentrations.

CONCLUSION

Our study enlightened the lengthening effect of doxapram on QTc interval in premature infants with a risk of exceeding the 440 ms threshold that is considered life-threatening. This finding emphasizes the need for electrocardiogram follow-up when using doxapram in neonates.

[Neonatal renal vein thrombosis in a heterozygous carrier of both factor V Leiden and prothrombin mutations]

We report a case of renal vein thrombosis, treated with heparin and thrombolytic therapy, in a patient who was heterozygous for both factor V Leiden and prothrombin mutations.

CASE REPORT

A full-term infant was treated with heparin and fibrinolytics at the fourth day of life because of renal vein thrombosis, inferior vena cava thrombosis and adrenal hemorrhage. After four days of treatment, the repermeabilization was complete but a renal atrophy developed. The investigation for congenital coagulation disorders revealed a heterozygous mutation for both factor V Leiden and prothrombin.

CONCLUSION

Search for inborn blood coagulation disorders should be systematic in the newborn infant with venous thrombosis because of the risk of recurrence, even in the presence of a known acquired risk factor. The thrombolytic treatment improves the prognosis.

Normal EEG in very premature infants: reference criteria

OBJECTIVES

Objectives were to precise EEG criteria of normality in very premature infants.

METHODS

The neonatal electroencephalograms (EEGs) of 17 neurologically normal very premature infants recorded at a conceptional age (CA) of 26-28 weeks have been analyzed. The normality of the infants was defined as normal neonatal cranial ultrasound scans and normal neurological outcome at a minimum postnatal age of 2 years.

RESULTS

All tracings were discontinuous. The bursts (amplitude >/=30 microV) were interhemispherically synchronous and lasted up to 3 min. The interburst intervals lasted up to 46 s. EEG patterns consisted mainly of slow waves (</=3 Hz), with high amplitude (up to 300 microV), occipital predominance and superimposed alpha, beta and theta rhythms. High amplitude theta rhythms predominated on temporal areas, beta rhythms were mainly central, whereas alpha rhythms were central and occipital. Sleep state differentiation began as early as 26 weeks CA. On a given trace, the existence of more mature graphoelements than expected for the CA reflected a normal increasing maturation.

CONCLUSIONS

EEG has constant and reproductible patterns in normal very premature infants. This can constitute a basis for the determination of EEG criteria for neurological prognosis in infants of 26-28 weeks CA.

[Efficacy and limits of rescue high-frequency oscillatory ventilation in the treatment of hyaline membrane disease in preterm newborns]

Conflicting reports of high-frequency oscillatory ventilation (HFOV) use as an alternative to conventional mechanical ventilation have been published. This retrospective study has evaluated the efficacy and safety of rescue HFOV in preterm infants with severe hyaline membrane disease (HMD) after the failure of conventional mechanical ventilation (CMV).

POPULATION AND METHODS

All newborns hospitalized in our neonatal intensive care unit (NICU) from 10.1.1993 to 15.4.1995 with CMV failure, defined as the need for more than 55% FiO2 without any improvement for at least six hours, have been retrospectively studied. The infants were shared according to the absence (Gr I) or the presence (Gr II) of persistent pulmonary hypertension of neonate (PPHN) in addition to HMD before HFOV.

RESULTS

Gestational age (GA) was 29.2 +/- 3.7 weeks (mean +/- SD) in Gr I and 30.3 +/- 2.8 in Gr II. Birth weight was 1379 +/- 750 g and 1471 +/- 612 g, respectively. As soon as three hours after the onset of HFOV in both groups, a dramatic improvement was observed with a FiO2 drop from 82 +/- 20% to 64.8 +/- 25.5% (P < 0.01). Among the infants, 62% survived without any major disability and 28% died (46% in Gr II vs 12% in Gr I, P < 0.01). A trend towards a worsening of pre-existing brain lesions has been noticed. An increased risk of mortality was observed when a secondary worsening in O2 requirements occurred 24 hours after the onset of HFOV, despite an initial significant improvement. SGA was also associated with a poor prognosis (46% of the deaths vs 29% for AGA infants, P < 0.05).

CONCLUSION

HFOV has been successfully used in premature infants with severe respiratory disease and failure of CMV. Criteria of poor prognosis were PPHN and SGA, or a secondary worsening in oxygen requirements after initial improvement. A trend towards aggravation of pre-existing brain lesions has been noticed after HFOV. This aggravation is more frequent when PPHN is associated with HMD. This observation suggests caution for HFOV use when these conditions are present in premature infants.

[Treatment of apnea in prematurity]

Continuous monitoring of premature infants with apnea is mandatory in order to define the pathophysiology and the type of apnea, and to assess the efficacy and tolerance of the treatment. Etiological treatment must be first considered before deciding on a symptomatic treatment adapted to the type of apnea. In our practice, methylxanthines are the first line treatment considering their efficiency on the 'central' component of apnea of prematurity. In case of treatment failure, doxapram or continuous positive pressure can be associated to methylxanthines, especially when obstructive apnea or hypoventilation are predominant. The first attempt to stop the treatment is undertaken 4 to 5 days after complete resolution of apnea, starting with the last treatment used, the monitoring being maintained 4 to 5 days in order to detect eventual new apnea.

[Outcome of blood gas parameters during the first 24 years after Exosurf administration]

BACKGROUND

There is now good evidence that the clinical course of infants with respiratory distress syndrome can be improved by treatment with exogenous surfactant. However, optimal methods of giving such a treatment are still debated.

POPULATION AND METHODS

The arterial blood gases and the arterial/alveolar oxygen tension ratio (a/A) were recorded during the 24 hours following artificial surfactant (Exosurf) treatment in 400 newborns aged 25 to 42 gestational weeks. A positive response was defined by an a/A ratio > 0.22 or an increase in a/A ratio up to 25%.

RESULTS

After administration of the first dose, a positive response was obtained in 63% of cases during the first 6 hours and 11% during the 6 following hours. The response after the second dose was favourable in 75% of cases. At 24 hours after treatment, 36% of the infants had obtained an a/A ratio > 0.22.

CONCLUSION

Because of the 18% of infants who responded positively only after the second dose, administration of this dose seems justifiable even in case of non-response to the first dose. The quality of the response is related to the severity of the pulmonary illness but is independent of the gestational age.

Effects of fentanyl administration on general and cerebral haemodynamics in sick newborn infants

Despite the wide use of fentanyl for analgesia in newborns, concerns have been raised about potential haemodynamic side-effects. Since sick newborns may lose their cerebral blood flow autoregulation, a drug-induced haemodynamic instability could lead to brain injury. We assessed the effects of a 15-min infusion of fentanyl (3 micrograms/kg) on the general and cerebral haemodynamics in 15 newborns (median gestational age 29 weeks, 25th-75th percentile, range 28-31 weeks; birthweight 1170 g, range 955-1790 g). The heart rate and mean arterial blood pressure were continuously recorded. Mean cerebral blood flow velocity and pulsatility index were measured using pulsed Doppler ultrasound before, during and up to 60 min after the onset fentanyl administration. No significant modification of general or cerebral haemodynamics was observed. In conclusion, the infusion of 3 micrograms/kg of fentanyl did not lead to any deleterious effect on the general or cerebral haemodynamics in sick normovolaemic newborns.

Patent foramen ovale with left to right shunt in bronchopulmonary dysplasia: coincidental or associated complication?

Despite the use of exogenous surfactants, the incidence of bronchopulmonary dysplasia (BPD) has not decreased as much as expected. Of 208 newborns involved in trials with Exosurf at our center, 51 had BPD. Among these newborns, 8 were found retrospectively to have secondary worsening of respiratory distress syndrome after initial improvement with surfactant treatment. Oxygen requirements decreased from 89 +/- 15% to 58 +/- 16% (mean +/- SD), respectively, before and 48 h after surfactant, and then reached a plateau of 34 +/- 10% before dramatic deterioration at 22 +/- 9 days of life. The patients had signs of cardiac failure and increased oxygen requirements of up to 76 +/- 19% within 6 h. A patent foramen ovale (PFO) was demonstrated at echocardiography with a left to right shunt at Doppler. No other cause of worsening was found. Five infants had significant improvement when treated with digoxin and furosemide. This retrospective study raises questions about the relationship between PFO and BPD that should be explored in a prospective study.