[Short, middle and long-term outcome of major peri-intraventricular hemorrhages]

Within 4 years 10 months (1981-1985), the Port-Royal Neonatal Intensive Care Unit admitted 2,400 neonates, one third with a birthweight below 1,501 g; 4,631 cranial ultrasound studies were performed in 1,488 of those neonates, mostly less than 1,501 g, detecting 392 consecutive peri-intraventricular hemorrhages (PIVH), of which 130 were major forms (from unilateral grade III to bilateral grade IV PIVH). Overall survival rates were 91% in grade I, 85% in grade II, 42% in grade III, 26% in grade IV; survival rate was significantly lower in bilateral than in unilateral grade II and III PIVH. In major PIVH, deaths occurred early (58% in the first week after birth). Post-hemorrhagic dilatation was constant but mostly regressive; true active hydrocephalus appeared in 1 unilateral grade III PIVH and 8 bilateral grade III PIVH, with ventriculo-peritoneal shunt in the second month of life in 5 infants (2 died), and 4 deaths (surgery not feasible). The neurological and developmental outcome of 42 of 46 survivors (4 losts to follow-up) was evaluated beyond one year of age in 12 unilateral grade III PIVH (10 normal children, 1 minor sequela, 1 moderate sequela), 16 bilateral grade III PIVH (7 normal children, 3 minor sequelae, 1 moderate sequela, 5 major sequelae), 13 unilateral grade IV PIVH (8 normal children, 1 minor sequela, 3 moderate sequelae, 1 major sequela), 1 bilateral grade IV PIVH (major sequela). A persistent major dilatation after 6-9 months of age bore an ominous prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Sleep apneas in normal neonates and infants during the first 3 months of life

Sleep polygraphic recording was carried out on 52 normal full-term babies. 16 infants were recorded at 2 - 7 days of age, 14 at 2 to 5 weeks, 13 at 6 to 9 weeks and 9 at 10 - 13 weeks. Central apneas of 2 sec and over were analysed in Active Sleep (AS), Quiet Sleep (QS) and Transitional Sleep (TS). Apnea Index (AI, percent of non-breathing) and Number of Apneas (NA) per 100 min of sleep state (for 2 - 4 sec, greater than or equal to 5 sec, greater than or equal to 6 sec and greater than or equal to 10 sec apneas) were determined. Obstructive and mixed apneas were tabulated separately. % of Periodic Breathing (PB) was also determined. These results were statistically tested using different methods. AI and number of less than 5 sec apneas are higher in AS than in QS during the period studied. A decrease of AI and NA occurs before the end of the 2nd month both in AS and QS. During the first five weeks of postnatal life the AI, the NA and the % of PB are higher in infants born at 38 - 39 weeks of Gestational Age (GA) than in infants born at 40 - 42 weeks. A positive correlation between short apneas (less than 5 sec) and apneas greater than or equal to 5 sec was found in AS and in total sleep. Obstructive and mixed apneas were very infrequent. Apneas are not affected by recording technique, sex or sleeping position of infants. There is a great interindividual variability of NA, particularly during the first month of life. Little normative data has been published so far concerning the incidence of respiratory apneas during day sleep in full-term infants recorded by polygraphy.

[Convulsions in neonates. Clinical, electrographic, etiopathogenic and prognostic aspects]

121 cases of neonatal convulsions, including 79 cases of status epilepticus and 42 cases of isolated convulsions are studied. The great number of premature infants (40/121 newborns born before a gestational age of 37 weeks) must be pointed out. The clinical symptoms and EEG activity occurring during the first 24 hours following the onset of convulsions are analysed. Their descriptions confirm previous ones. Comparison of the populations of preterm and term infants demonstrates that the pre- and post-ictal neurological states are equally severe in both groups and that there is no difference between groups in the more or less precocious onset of convulsions. The value of the interictal EEG already described in status epilepticus of terms infants as predicting a poor prognosis, is confirmed. In addition, the very poor prognosis of an abnormal EEG pattern of the premature newborn, i.e. an EEG lacking any pattern corresponding to any gestational age, is demonstrated. Such EEGs of very poor prognosis have been detected in 46 cases. They reveal the degree of severity of the cerebral lesions, EEG abnormalities and cerebral lesions varying with gestational age. This study confirms the relatively mild severity of isolated convulsions as compared to status epilepticus. It demonstrates the severity of convulsions in premature newborns and of the electrographical discharges without simultaneous clinical event. The prognostic value of the absence or presence of a sleep cycle as early as the 24 hours following the onset of convulsions must be noted. Most of the neonatal convulsions are secondary to birth hypoxia or asphyxia and to meningo-encephalitis. In this study the small number of seizures due to metabolic factors is striking and contrasts with their great frequency in other series. The cause of the seizures is unknown in 12% of the cases; some of these cases of unknown origin correspond to the description of the 'convulsions of the 5th day'. The prognosis in full-term newborns has been improved greatly in recent years, probably due to improvement in obstetrical and neonatal intensive care.

Respiratory variability according to sleep states during mechanical ventilation: a polygraphic study in a baby with bilateral diaphragmatic paralysis

Polygraphic recordings were performed at 1 and 2 months of age in mechanically ventilated baby (25-27 insufflations per min) with bilateral diaphragmatic paralysis. The EEG and the sleep organisation were normal for the given age. The breathing patterns were state dependent. Autonomous breathing movements and phasic inspiratory intercostal EMG were present during both wakefulness and active sleep (AS). In quiet sleep (QS) the respiration was usually passive, completly dependent on the respirator. Small autonomous breathings can occur in some periods of QS, simultaneously with the appearance of numerous skin potential responses. These results are probably related to the differences between the respiratory control in QS and in AS.

[Assisted ventilation of newborn infants during sleep. Study of factors modifying adaptation to ventilation]

During sleep, of ventilated newborns and young infants, spontaneous respiratory movements may occur, unrelated to the ventilation impulsions. The respiratory pattern is then classified as "active". On the contrary, the respiratory pattern is classified as "passive", when all respiratory movements are related to the ventilation insufflation. The factors which influence the dependence on the ventilator are studied in a group of 20 newborn and young infants. Prematurity, some biological data such as hyperoxia, hypocapnia, seem to favor this dependence. A rapid rate of ventilation (superior to 30/minute) is rarely related to an active respiration; a slow rate of ventilation seems favor this respiratory pattern. It is clear that adaptation to artificial ventilation is better during quiet sleep than during active sleep. Some physiopathological considerations are developed.

[Effects of therapy (diazepam, phenobarbital) on the E.E.G. in new-born babies during the first 24 hours of treatment (author's transl)]

The poor prognostic significance of inactive or paroxystic E.E.G. recordings in new-born babies appears to be well established (Monod et al., ibid., 1972, 32, 529-544). However, some cases have been described as having a favourable evolution even though such tracings had been proesent during the neonatal period. The authors studied, therefore, the effects of anticonvulsants (diazepam, phenobarbital) to see if they produced inactive or paroxystic tracings. A total of 19 new-born babies with convulsions of various etiologies were treated with phenobarbital and diazepam and recordings were made less than 24 hours after the beginning of treatment. Plasma levels were measured at the time of recording and varied from 3 to 26 micrograms/ml for phenobarbital and 0 to 2.75 micrograms/ml for diazepam. No paroxystic tracings were noted, but 2 inactive tracings were seen in infants who had been severely asphyxiated at birth, and in whom the plasma levels of the anticonvulants was found to be low. The injection of diazepam during the E.E.G. recording caused suppression of electrical discharges without notably altering the inter-seizure E.E.G. activity. The authors conclude that in the 19 cases studied the changes noted in the E.E.G. were related to the severity of the condition and were not secondary to therapy.

Sleep and heart rate variations in premature and full term babies

Heart rate was studied in 47 newborns babies during 67 polygraphic recordings by histograms and sequential curves of the length of 600 consecutive R-R-intervals selected during sleep stages lasting at least 5 minutes. In normal babies: (14 babies born at Gestational Age, G.A., 37 weeks, 6 babies born between 28 and 36 weeks). Before 37 weeks of G.A., the sequential curves show periodic variations of heart rate (including 15 to 70 beats) present both in active and quiet sleep. After 37 weeks of G.A., slow periodic variations are still present in active sleep but superimposed by fast variations synchronous to respiratory cycles. Fast variations are prevailing in quiet sleep. In pathological babies: Small variability is favoured by prematurity, young age at recording, and hypercapnia but can be very transient. Pronounced variations similar to those of normal babies are observed in 2/3 of the cases with or without respiratory assistance, with or without PEEP.