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.

[Emergence of invasive nonvaccine pneumococcal serotypes: 2 cases involving 19A and 10A serotypes]

The authors report 2 cases of invasive pneumococcal disease. One case consisted in occult bacteremia due to a 19A serotype in a child who had received 3 doses and a booster dose of the heptavalent pneumococcal conjugate vaccine (Prevenar). The 2nd case was pneumococcal meningitis due to a 10A serotype. The incidence of nonvaccine serotypes is increasing, notably the 19A serotype. They must be closely monitored because of the high antimicrobial resistance of certain strains.

Prophylactic ibuprofen versus placebo in very premature infants: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Patent ductus arteriosus is a common complication of prematurity that frequently requires surgical or medical treatment. The benefit of prophylactic treatment by indometacin, a cyclo-oxygenase inhibitor, remains uncertain compared with curative treatment. This benefit could be improved with ibuprofen, another cyclo-oxygenase inhibitor with fewer adverse effects than indometacin on renal, mesenteric, and cerebral perfusion. We aimed to compare prophylactic and curative ibuprofen in the treatment of this abnormality in very premature infants.

METHODS

We did a randomised controlled trial in infants younger than 28 weeks of gestation, who were randomly assigned to receive either three doses of ibuprofen or placebo within 6 h of birth. After day 3, symptomatic patent ductus arteriosus was treated first by open curative ibuprofen, then back-up indometacin, surgery, or both. The primary endpoint was need for surgical ligation. Analysis was per protocol.

FINDINGS

The study was stopped prematurely after 135 enrollments because of three cases of severe pulmonary hypertension in the prophylactic group. 65 infants received prophylactic ibuprofen, and 66 received placebo. Prophylaxis reduced the need for surgical ligation from six (9%) to zero (p=0.03), and decreased the rate of severe intraventricular haemorrhage from 15 (23%) to seven (11%) (p=0.10). However, survival was not improved (47 [71%] placebo vs 47 [72%] treatment, p=1.00), because of high frequency of adverse respiratory, renal, and digestive events.

INTERPRETATION

In premature infants, prophylactic ibuprofen reduces the need for surgical ligation of patent ductus arteriosus, but does not reduce mortality or morbidity. Therefore, it should not be preferred to early curative ibuprofen.

Lower respiratory tract illness and RSV prophylaxis in very premature infants

AIMS

To determine the frequency of and the risk factors for readmissions for any lower respiratory tract illness (LRTI) and for respiratory syncytial virus (RSV) documented LRTI in children born very prematurely who had or had not received RSV prophylaxis.

METHODS

Multicentre prospective longitudinal cohort study of 2813 infants, born between April 2000 and December 2000 at less than 33 weeks of gestational age, and followed until the end of the epidemic season.

RESULTS

Among the 2256 children who had no bronchopulmonary dysplasia at 36 weeks of postmenstrual age and were not submitted to RSV prophylaxis, 27.4% were readmitted at least once for any reason during the epidemic season; 15.1% and 7.2% were readmitted at least once for any LRTI and RSV related LRTI, respectively. Children born at less than 31 weeks' gestation, having an intrauterine growth restriction, or living in a single mother family were at a significantly higher risk of readmission for LRTI in general as well as for RSV related LRTI. Of the 376 children submitted to prophylaxis, 28.2% were readmitted at least once for any LRTI and 6.1% for RSV related LRTI.

CONCLUSION

One out of four children who had received no prophylaxis, was born very prematurely, and was without bronchopulmonary dysplasia at 36 weeks of postmenstrual age, was readmitted at least once for any reason. Roughly 50% and 20% of these readmissions were related to a LRTI and an RSV infection, respectively. Further epidemiological studies are warranted to assess the aetiology and impact of other respiratory pathogens on post-discharge readmission and respiratory morbidity in this population.

Efficacité de la kinésithérapie respiratoire chez des enfants intubés ventilés atteints de bronchiolite aiguë

OBJECTIVES

Despite the lack of clinical studies, chest physiotherapy (CP) is widely used in children with acute bronchiolitis. The main goal of this study was to evaluate its short-term efficacy in children under mechanical ventilation for acute bronchiolitis.

METHODS

Twenty children were studied. All were under mechanical ventilation on a pressure-controlled mode. Oxygen saturation, transcutaneous PCO2 and tidal volume were measured before any intervention, after endotracheal suction, after CP and endotracheal suction and 1 h later.

RESULTS

Thirty-eight analyses were performed. Baseline tidal volume, oxygen saturation and transcutaneous PCO2 were not modified after endotracheal suction. Immediately and 1 h after CP, SpO2 (98% vs. 94.5%), and tidal volume (66 vs. 55 ml) significantly increased.

CONCLUSION

The increase of O2 saturation and tidal volume may be linked to the improvement of bronchial sputum clearance. Further studies are needed to estimate the long-term efficacy of CP in acute bronchiolitis.

Effect of emulsifiers on surface properties of sucrose by inverse gas chromatography

Inverse gas chromatography (IGC) was employed to characterize the changes in surface properties of sucrose particles coated with either lecithin or polyglycerol polyricinoleate. IGC was performed using polar and non-polar adsorbates at infinite dilution with the sucrose particles as the solid stationary phase. Coating the sugar surface with emulsifiers induced an increase in the lipophilicity of the sugar particles, i.e. a sharp decrease in the acidity of the surface. Yet the two emulsifiers induced a slightly different increase in the surface basicity. It was hypothesized that this observation was due to a difference in the molecular structure of the emulsifiers.

Molecular cytogenetic analysis of a duplication Xp in a female with an abnormal phenotype and random X inactivation

We describe a female infant with severe abnormal phenotype with a de novo partial duplication of the short arm of the X chromosome. Chromosome painting confirmed the origin of this X duplication. Molecular cytogenetic analysis with fluorescence in situ hybridization (FISH) was performed with YAC probes, further delineating the breakpoints. The karyotype was 46, X dup(X)(p11-p21.2). Cytogenetic replication studies showed that the normal and duplicated X chromosomes were randomly inactivated in lymphocytes. In most females with structurally abnormal X chromosomes, the abnormal chromosome is inactivated and they are phenotypically apparently normal relatives of phenotypically abnormal males having dupX. Therefore, in this case, there is functional disomy of Xp11-p21.2 in the cells with an active dup(X), most likely resulting in abnormal clinical findings in the patient.

[Neonatal hyperparathyroidism secondary to unknown maternal hypoparathyroidism]

Vitamin D or its analogue (calcitriol) is an effective treatment for hypoparathyroidism during pregnancy. Normal babies are delivered and very few cases of associated neonatal hyperparathyroidism are reported.

CASE REPORT

We report the case of a baby born to a mother suffering unknown hypoparathyroidism. He was delivered prematurely by cesarean section for birth asphyxia. His mother had had recurrent bouts of impetigo herpetiformis for several months. Severe demineralization associated with decreased plasma calcium level were observed at birth. The PTH level was very high (955 ng/mL) in the baby and very low in the mother, leading to the diagnosis. The baby was given intravenous calcium gluconate, oral 1 alpha-hydroxyvitamin D and mechanical ventilation. Normal plasma calcium level was reached on day 2. PTH level improved by one month of age. Because of impaired respiratory mechanics and bronchopulmonary dysplasia, the baby was kept on ventilation for 58 days. By 20 months of age, he was in good health despite a small height for his age.

CONCLUSION

In such cases 1 alpha-hydroxyvitamin D seems to be very effective but plasma and urinary calcium levels need careful monitoring.

[Spontaneous neonatal arterial thrombosis treated with tissue plasminogen activator]

BACKGROUND

Spontaneous neonatal arterial thrombosis is a rare entity with serious and potentially fatal complications. A wide spectrum of management has been proposed.

CASE REPORT

Ophélie was born after premature delivery at 33 weeks. She was referred soon after birth in the neonatal intensive care unit for respiratory distress syndrome. Spontaneous acute ischemia of the right lower limb was noted soon after admission. Iliac thrombosis was confirmed by ultrasonography and colour coded doppler. Thrombolysis was achieved with systemic infusion of recombinant tissue plasminogen activator (rtPA). Full recovery was obtained within 12 hours of treatment without any complication. No rethrombosis occurred with heparin prophylaxis. No predisposing disorder to thrombosis was found.

CONCLUSION

Systemic rtPA is an alternative to thrombectomy and urokinase in critically ill neonates. This treatment should be considered if no major risk of bleeding is found during the pretherapeutic screening.

[Use of intravenous midazolam in status epilepticus in children]

BACKGROUND

Status epilepticus is usually treated by benzodiazepines such as diazepam or clonazepam in association with phenytoin and phenobarbital. Midazolam (MDZ) is a recently developed short-elimination half-life benzodiazepine.

CASE REPORTS

Four children, aged 3 days to 4 years, were hospitalized in the pediatric intensive care unit for life-threatening illness and developed status epilepticus. They were given an i.v. bolus dose of 300 to 500 micrograms/kg of MDZ immediately followed by a continuous i.v. infusion at the dose of 100 to 300 micrograms/kg/h. All seizures stopped within 1 hour after the bolus dose administration. No acute adverse events of MDZ were noted. Withdrawal symptoms in one patient were controlled by progressive reduction of MDZ doses. Neurologic sequelae were noted in three children, secondary to their primitive illness.

CONCLUSIONS

High doses of MDZ are effective for treating refractory status epilepticus; optimal dosage and duration of treatment remains to be determined.

Placebo-controlled trial of midazolam sedation in mechanically ventilated newborn babies

Although midazolam is used for sedation of mechanically ventilated newborn babies, this treatment has not been evaluated in a randomised trial. We have done a prospective placebo-controlled study of the effects of midazolam on haemodynamic variables and sedation as judged by a five-item behaviour score. 46 newborn babies on mechanical ventilation for respiratory distress syndrome were randomly assigned to receive midazolam (n = 24) or placebo (n = 22) as a continuous infusion. Doses of midazolam were calculated to obtain plasma concentrations between 200 and 1000 ng/mL within 24 h of starting treatment and to maintain these values throughout the study. Haemodynamic and ventilatory variables were noted every hour, as were complications and possible side-effects of treatment. Mean (SD) duration of inclusion was 78.7 (30.9) h. 1 patient in the treatment group and 7 in the placebo group were withdrawn because of inadequate sedation (p < 0.05). Midazolam gave a significantly better sedative effect than placebo, as estimated by the behaviour score (p < 0.05). Heart rate and blood pressure were reduced by treatment but remained within the normal range for gestational age and there was no effect on ventilatory indices. The incidence of complications was similar in the two groups. No midazolam-related side-effects were noted. Continuous infusion of midazolam at doses adapted to gestational age induces effective sedation in newborn babies on mechanical ventilation, with positive effects on haemodynamic variables. The course of the respiratory distress syndrome was not influenced by this treatment. Midazolam was given over only a few days and the limited effects on heart rate and blood pressure that we report should not encourage long-term administration.

[Cervical intraspinal enterogenous cyst: a rare cause of neonatal syncope]

BACKGROUND

Enterogenous cysts are benign embryogenic tumors that developed close to the central nervous system. They are rarely symptomatic in neonates. This report describes such a cyst in a young infant that was discovered because of the discomfort it produced.

CASE REPORT

A 16 day-old boy suffered from discomfort during bathing followed by deviation of the eyes. He was given diazepam rectally. At admission, he had generalized hypotonia and hyperreflexia. CSF examination showed 1.7 g/l protein. A prolonged apnea with cyanosis and bradycardia required his admission to the intensive care unit, where a spastic quadriparesis with bilateral phrenic nerve paralysis was found. EEG and brain ultrasonography were normal. MR imaging showed an intraspinal cyst, locating from C1 to C3, that was compressing the spinal cord. The cyst was rapidly excised and histological examination confirmed that it was an enterogenous cyst.

CONCLUSION

This cyst was not associated with vertebral abnormalities but did produce early symptoms. It was diagnosed by MR imaging.

[Right intraventricular thrombus. Rare complication of caval catheterization]

BACKGROUND

Thrombus formation is one of the main complications of the catheterization used for total parenteral nutrition. Its location inside the right ventricle is exceptional. This paper describes such a case.

CASE REPORT

A boy was born at the gestational age of 35 weeks, weighing 2,640 g. He developed acute respiratory distress followed by prolonged diarrhea that required parenteral nutrition. A catheter was inserted into his right subclavian vein when he was aged 5 weeks. The patient developed septic shock with multi-visceral failure 8 days later. Blood cultures showed Staphylococcus aureus. Despite symptomatic therapy and antibiotics, the baby developed thrombosis of the superior vena cava with no right atrial thrombus, that required removal of the catheter. Angiography and Doppler echocardiography performed 2 and 3 weeks later showed a thrombus in the right ventricle that disappeared within 2 weeks after prolonged antibiotic and heparin therapy.

CONCLUSION

Repeated Doppler echocardiography is necessary to monitor prolonged total parenteral nutrition. Intracardiac thrombus can be detected; this is more frequently located in the atrium than in the ventricle.

[Anuria after abdominal surgery in 2 newborn infants. Beneficial effect of noradrenaline]

BACKGROUND

Abdominal surgery in neonates may be complicated by acute renal failure that is sometimes due to increased intra-abdominal pressure. Correction of the decreased renal perfusion may be difficult.

CASE REPORTS

Case no 1. A girl weighing 3,000 g was operated on at 3 hours of life for congenital omphalocele. Closing the defect induced increased intra-abdominal pressure and decreased systemic pressure. Despite dopamine, dobutamine, followed by furosemide, anuria persisted without manifestations of heart failure. Noradrenaline (0.1 to 0.7 micrograms/kg/min intravenously) given 24 hours after surgery resulted in normalization of systemic pressure and diuresis. Case no 2. A boy was born at gestational week 30, weighing 1,450 g. At 8 days of age, he was suffering from shock that was attributed to perforation of the bowel due to necrotizing enterocolitis. Surgery was complicated by acute circulatory and renal failure that did not respond to dopamine, dobutamine or furosemide. Infusion of noradrenaline, (0.2 to 0.6 micrograms/kg/min intravenously) induced diuresis within 3 hours.

CONCLUSIONS

Noradrenaline can be useful in patients with postoperative increased intra-abdominal pressure. It should only be given after correction of hypovolemia, control of myocardial function, and when dopamine remains ineffective.

[Continuous arteriovenous hemofiltration. Management in case of neonatal leucinosis]

BACKGROUND

Neonates with classic maple syrup urine disease (MSUD) undergo rapid neurological deterioration by the end of the first week of life. Exchange transfusion and peritoneal dialysis are the usual emergency treatment. Continuous arteriovenous hemofiltration (CAVHF) appears to be safe and more rapidly effective.

CASE REPORT

Martin was born at the 37th week from a normal pregnancy. Abnormal movements of legs and lethargy appeared on the 7th day of life. Progressive brain dysfunction with coma led to intubation on the 13th day. A diagnosis of MSUD was immediately made and CAVHF was initiated and continued for 19 hours. The plasma leucine, valine and isoleucine levels fell from 2,248 to 275, 640 to 91 and 298 to 13 mumol/l, respectively. Neurologic improvement was dramatic, except for moderate hypertonia which lasted for the 2 following days.

CONCLUSION

CAVHF is an appropriate treatment for very young patients with inborn errors of metabolism. It appears safer and more rapidly effective for eliminating branched-chain amino acids than other techniques, such as peritoneal dialysis with or without exchange transfusions. It also permits more rapid introduction of the specific diet.

Pharmacokinetics of midazolam during continuous infusion in critically ill neonates

Midazolam is a water soluble benzodiazepine, with a short elimination half-life in adults and children. An IV bolus (0.2 mg.kg-1) immediately followed by continuous infusion of 0.06 mg.kg-1.h-1 was administered to 15 critically ill neonates at a gestational age of 32.8 weeks, who required sedation for mechanical ventilation. Heart rate and blood pressure were closely monitored. Hypotension occurred in 4 patients after the bolus dose or during the continuous infusion. Three of them had also been given fentanyl. Individual pharmacokinetic parameters were calculated: plasma clearance was 3.9 ml.min-1, elimination half-life was 12.0 h. Because of its short half-life compared to diazepam, midazolam may be used during the neonatal period to achieve rapid, brief sedation. However, it should be administered cautiously to neonates, particularly in premature infants, or if fentanyl is also given.