The Good, the Bad, the Marginal: respiratory management of <29 weeks infants according to subjective assessment of perinatal adaptation.

Background Even if a primary CPAP strategy gives benefits in extremely preterm infants, many still require intubation at birth. Half of those initially managed with primary CPAP will require further support: surfactant administration or mechanical ventilation. Those infants have increased risks of death and neonatal morbidities, and will require longer duration of respiratory support. Identifying them early, during the birth stabilization process, might lead to improvements in respiratory care. A subjective classification of perinatal adaptation as Good, Bad or Marginal has been suggested but requires further evaluation. We aimed to evaluate respiratory management according to perinatal adaptation. Methods Premature infants of less than 29 weeks and admitted between 01/2013 and 07/2014 were retrospectively studied. Neonatal database and discharge summaries provided neonatal care and outcome data. Good perinatal adaptation (GPA) was considered for infants with good respiratory drive, tone and low oxygen requirement in the delivery room. Infants with marginal (M) PA had intermittent respiratory drive, normocardia with ventilation, and decreasing FiO2. Bad (B) PA is considered with hypotonia, bradycardia, apnea and high FiO2. Data are presented as mean +/- SD, median (interquartile range) or incidence and analyzed with ANOVA, Kuskal-Wallis test or Chi2. Results Sixteen infants had GPA, 19 MPA and 23 BPA. GA was 26 4/7 wk (24-28) and BW was 885 187g. Risk factors for bad adaptation are (NS) male gender, lower GA, and no complete antenatal steroid exposure. Apgar at 1 min. increases with better PA [B3 (2-5); M6 (3-7) and G8 (7-8)*] (*p<.05 vs B & M), and improves at 5 min.: [B7 (6-7); M7 (6-8); G 9 (8-9)*]. Risk of intubation at birth is associated with poorer adaptation (B 87%; M 47%; G 12%, p<.01) Primary CPAP success was not different according to group (B 3/3; M66%; G56%). Surfactant while on CPAP (LISA method) was given to 11/16 patients, including 7 delivery room administrations. If intubated by day 3, duration of first invasive ventilation was shorter (NS) for GPA (9h) [MPA (15h), BPA (29h)]. Early neonatal death tended to decrease with better PA: 26%, 16% and 0% (p=.08). There is no difference in BPD -36 wk (B 19%, M13%, G 12%). Conclusions Infants with better perinatal adaptation have increased chances of being initially managed with CPAP. Primary CPAP success may be improved with less invasive surfactant therapy. Outside of the delivery room, perinatal adaptation assessment tends to identify risk of early neonatal death, but is not predictive of respiratory outcomes

Early enterovirus neonatal infection: when should we think about it?

peer reviewedEnterovirus (EV) may cause a broad spectrum of clinical syndromes and even cause a sepsis-like picture. Although they are responsible for high morbidity and mortality rates, viral testing does not appear in the algorithms for the evaluation of neonatal infections. During the month of June 2013, we identified 3 cases of EV meningitis in our unit of neonatology. All three infants had fever during the first week of life and their clinical examination revealed an irritability. The EV infection was detected by Real-Time Polymerase Chain Reaction (RT-PCR) EV on the cerebrospinal fluid (CSF). Two of the patients also had a positive RT-PCR EV in the blood. The 3 newborns were discharged from the hospital after a few days with no adverse outcome. Our clinical observations and the literature review suggest that EV infections in neonates ought to be identified as soon as possible by an early RT-PCR EV on the blood, and on the CSF if a lumbar puncture is indicated. This could help reduce the administration of antibiotics and the length of hospital stay.Les entérovirus (EV), peuvent causer des infections néonatales dont les manifestations sont extrêmement variables, mimant parfois celles d’un sepsis bactérien. Bien qu’elles soient responsables d’un taux élevé de morbidité et de mortalité, leur recherche ne fait pas partie du bilan classique devant une suspicion d’infection néonatale. Au cours du mois de juin 2013, nous avons identifié 3 cas de méningite à EV dans le service de néonatologie. La symptomatologie était dominée par une irritabilité, dans un contexte de fièvre, au cours de la première semaine de vie. Le diagnostic a été posé par Real-Time Polymerase Chain Reaction (RT-PCR) EV sur le liquide céphalo-rachidien (LCR). La RT-PCR était également positive sur le sang chez les 2 patients testés. Dans les 3 cas, l’évolution a été rapidement favorable

Small manometers improve bag and mask ventilation: a manikin study

INTRODUCTION: Self-inflating bags (SIB) remain widely used for neonatal resuscitation. Insufflation pressures from SIB are difficult to assess and can be inadequate. Ventilation monitoring improves pressure control, but is not accessible to most resuscitators. Small spring manometer or a pressure line to a needle and dial manometer can be connected through a side port on the SIB. Those devices are cheap and easily available, but their efficacy needs to be assessed. Observation of the manometer could also be considered as a distraction, with increased risk of leak or inadequate insufflation rate. We therefore aimed to evaluate the effect of mechanical manometers on the quality of insufflations with a SIB. MATERIALS AND METHODS: Participants to the Belgian Pediatric Society meeting were invited to ventilate a manikin with a 300 ml SIB. The leak-free manikin was modified with a flow-meter at tracheal level connected to a neonatal test lung. Participants had to aim for a 25 mbar pressure and a rate of 40-60 during 3 sequences of 45 seconds. A spring (S), a dial (D) manometer or nothing (N) was added to the SIB in random sequence. Pressure data from the SIB and flow data from the manikin were obtained through a ventilation monitor. Peak pressure (PIP), tidal volume (VTi), and insufflations rate (RR) were calculated for each breath. Theoretical leak was evaluated by subtracting real from theoretical volumes derived from a leak free calibration (taped facemask). Data were analyzed with ANOVA and posthoc Bonferroni. RESULTS Five neonatologists (Neo), 15 pediatricians (Ped) and 11 residents ventilated the manikin for a total of 5279 insufflations. Manometer use was associated with an increase in PIP (N: 17+-6 mbar; S: 18+-4 mbar*; D: 19+-4 mbar*#) [*p<.05 vs N; #:p<.05 vs S]. Changes in VTi (N: 3+-1 ml; S: 3.1+-1 ml*; D: 3.2+-1 ml*) and RR (77-82 bpm) were small. Leak did not increase. The effect of manometer use on PIP, VTi and leak was more important with Neo (PIP-N: 16+-7 mbar; S and D: 20+-4 mbar*) and Ped. With residents, no change occurred in PIP (~17 mbar), Vti (2.9 ml) or leak (31-35%). However, for first sequences of ventilation, manometer use was associated with higher PIP (N: 12+-4 mbar; S: 16+-3 mbar*; D: 20+-4 mbar*#), VTi (N:2+-1 ml; S:3+-0.8 ml*; D:3.3+-1 ml*#) and lower leaks (N: 38+-16%; S: 27+-12%*; D: 34+-13%*#). This observation for first sequences was found in all 3 categories of providers. CONCLUSIONS Bag and mask ventilation remains difficult. In this model, the addition of a manometer is associated with improved pressures and VTi, and with decreased theoretical leak. This effect is predominant for initial (“naïve”) ventilation with a dial manometer, and is also related to operator experience. Small, inexpensive manometers have the potential to improve SIB ventilation of newborn infants

Différents manomètres pour améliorer la ventilation au masque et ballon

peer reviewedINTRODUCTION Les pressions employées lors de la ventilation au ballon sont difficiles à évaluer et souvent inadéquates. Les ballons disposent d’un connecteur où brancher un manomètre (manom) à ressort ou une ligne vers un manom à cadran. Cependant, l’addition d’une variable à surveiller pourrait constituer une interférence et majorer le risque de fuite ou de rythme ventilatoire inadéquat. Cette étude évalue l’influence de manom simples sur la qualité de la ventilation. MÉTHODES Les participants aux Journées Belges de Pédiatrie pouvaient ventiler un mannequin aux voies respiratoires étanches avec un capteur de débit trachéal. Une pression de 25 mbar et une fréquence de 40 à 60/’ étaient visées. Une séquence de 45’’ avec un manom à ressort (R), une séquence avec un manom à cadran (C) et une sans (O) étaient réalisées dans un ordre aléatoire. La pression de pointe du ballon (P), le volume inspiratoire (VTi), et la fréquence de ventilation (FR) de chaque insufflation ont été analysées. La fuite autour du masque fut estimée en comparant VTi à un volume théorique dérivé d’une calibration avec masque scellé. RÉSULTATS Cinq néonatologues (Néo), 15 pédiatres et 11 internes ont réalisé 5279 insufflations. Les P obtenues avec un manom étaient plus élevées (O:176 mbar; R:184 mbar*; C:194 mbar*#) [*p<.05 vs O; #:p<.05 vs R] VTi augmentait légèrement (O:31 ml; R:3.11 ml*; C:3.21 ml*) FR était systématiquement trop élevé (77-82 bpm). L’usage d’un manom ne modifiait pas les paramètres pour les internes. Pour les Néo, ajouter un manom améliorait P, VTi et la fuite (P -O: 167 mbar; R and C: 204 mbar*) Sur les premières séquences de ventilation, le manom améliorait les paramètres (P-O: 124 mbar;R: 163 mbar*; C: 204 mbar*#), (VTi-O:21 ml; R:30.8 ml*; C:3.31 ml*#), (Fuite-O: 3816%; R: 2712%*; C: 3413%*#). CONCLUSIONS La ventilation au ballon reste difficile. Les pressions obtenues étaient éloignées de l’objectif, et le rythme souvent trop élevé. Si le manomètre permet d’améliorer les pressions et volumes obtenus, surtout en cas de ventilation sans feed-back préalable, cet effet bénéfique s’observe surtout pour les opérateurs expérimentés. Enfin, un congrès scientifique permet de recruter une population variée pour une étude de simulation simple

Lung growth and development in the rat : effects of early protein-energy malnutrition

La malnutrition protéino-énergétique du jeune enfant est un des problèmes cruciaux de santé publique dans de nombreux pays. La carence protéique y est prédominante. La croissance et le développement postnatal du poumon humain surviennent principalement au cours des 3 premières années de vie. Chez le rat, cette période correspond aux trois premières semaines de vie, soit à la période de lactation. Elle est caractérisée par un accroissement important du volume des différentes composantes pulmonaires ainsi qu’un réarrangement structurel et fonctionnel dans le sens de la maturation du tissu du parenchyme. J’ai étudié les effets d’une déficience protéino-énergétique chez le rat en croissance intensive sur le restructuration postnatale du parenchyme pulmonaire. La restriction en protéines est instaurée soit dès la période de lactation (période néonatale) soit après le sevrage. LE déficit en protéines entraîne toujours une diminution de la consommation de nourriture ; ce qui aboutit à une carence mixte, protéino-énergétique. Chez les rates allaitantes, cela s’accompagne d’une baisse importante de la production de lait. La croissance pondérale de la progéniture est toujours très affectée. Après réalimentation de 11 semaines, même commencée à la maturité sexuelle (j49), la reprise pondérale est spectaculaire. Cependant les rats soumis à une restriction protéique dès la première semaine de vie ne rattrapent pas complètement le poids des témoins. Dans tous les cas, le retard de croissance du poumon est manifeste ainsi qu’en témoignent la diminution du poids humide, du volume après fixation et de la quantité totale d’ADN. Cependant, lorsque la malnutrition est instaurée après le sevrage, on note une préseervation relative du poumon (poids spécifiques et concentration en ADN plus élevés que chez les rats témoins). La baisse constante de la compliance des poumons gonflés à l’air est compatible avec des anomalies, au moins quantitatives, du surfactant pulmonaire. Avec le sérum physiologique, les poumons des rats carencés dès la période néonatale présentent une diminution de la pression rétractile, ce qui correspond à une baisse de la concentration d’élastine. Le pic d’accumulation de celle-ci qui survient normalement entre j12 et j20 est donc empêchée par une malnutrition précoce. Sur le plan architectural, il est intéressant de constater que les petits poumons des animaux mal nourris présentent un aspect parfaitement mature au sevrage. On voit cependant apparaître un amincissement des septa inter-alvéolaires lorsque la malnutrition est prolongée jusqu’à j49. Malgré la début précoce de la malnutrition et l’important retard de croissance, il n’existe pas d’emphysème nutritionnel. Les densités volumiques et de surface calculées par morphométrie restent normales pour toutes les composantes du parenchyme pulmonaire. La moyenne arithmétique de l’épaisseur des septa est diminuée, alors que la moyenne harmonique de l’épaisseur de la barrière air-sang (tissu+plasma) est inchangée. La capacité anatomique du poumon pur la diffusion de l’oxygène qui est diminuée en termes absolus reste proportionnelle au poids corporel. Après réalimentation, la récupération est quasi compète pour tous les paramètres morphométriques. De même l’aspect morphologique est restauré. Ce rattrapage spectaculaire au delà de la période de restructuration intensive du parenchyme pulmonaire suggère une importante formation de novo des alvéolesThe striking progress in modern technology contrasts with the persistently high prevalence of manultrition over the world. In many countries, this prevalence even tends to increase because of socio-political conflicts. Obviously, children are by far the most immediate victims of this lamentable situation. Based on cross-sectional data gathered between 1980 and 1992, the World Health Organisation estimates that, in developing countries, 43 percent of children under 5 years of age are clinically undernourished (de Onis et al. 1993). About 5 percent among them suffer from advanced and life-threatening forms of malnutrition. Chronically inadequate food consumption is by far the most common cause of nutritional disorders in childhood (i.e. primary malnutrition). Malnutrition can result from other chronic diseases (secondary malnutrition). This is the most prevalent condition for malnourished children in industrialized countries. The analysis of acute and long term consequences of inadequate nutrition during childhood represents an important direction on the study of nutritional disorders. A dramatic observation is that about one half of deaths among children over the world is directly or indirectly related to malnutrition (Frenk 1985). It is easily imaginable that during manutritional states, structure or function of organs can undergo alterations in various ways. While less clinically spectacular, some of these abnormalities expose the subjects to severe and possibly permanent invalidity. Children in the active period of growth are likely to be most sensitive to the deleterious effects of malnutrition. Though there is agreement on the particular susceptibility of the respiratory system during the course of childhood protein-energy deficiendies, this statement is base entirely on the almost constant and often lethal association between malnutrition and respiratory infections (Martin 1987; Rothkopf and Askanazi 1988). Except for that, and comparatively to other vital organs like liver and brain, our knowledge of the potential direct effects of protein-energy deficiency on the structure and function of the respiratory system is scant. Using experimental animals, however, the question has been addressed in various ways from the late seventies. Despite some contradictions, no doubt exists that inadequate food supply can adversely affect the structural and functional integrity of the lung. This has been appropriately summarized in two recent reports (Gaultier 1991; Sahabjami 1993). So far, the problem has been considered most of the time on adults animals (mainly rats), that is in animals with already mature lungs growing at a low rate. In addition, information has mostly been obtained after short periods of food deprivation. This is explained by the fact that, for most investigations, the questions were not related to the specific conditions of primary malnutrition in young children as observed in developing countries. The purpose of the present work is to review, in the light of the literature and of personal contributions, the effects of experimental protein-energy deficiency on the growing lung. Particular focus is brought to bear on prolonged nutritional deprivation with onset in early life. We first consider the general characteristics of primary malnutrition in children. Further, the critical events occurring in the lung during early growth are summarized in the rat, the model we used, and for comparison in the human. Finally, the nutrition-related alterations of the function and the structure of the lung parenchyma, which were essentially studied in excided organs, are discussedThèse d'agrégation de l'enseignement supérieur (Faculté de médecine) -- UCL, 199

Interest of multisite bacterial screening for the diagnosis of congenital listerisosis with negative blood culture: a case report

Listeria monocytogenes (LM) is known to cause severe invasive disease in pregnant women and in newborns. Fortunately, despite the wide natural distribution of this pathogen, clinically overt neonatal infections occurs rarely. As a consequence, listeriosis is not always considered for early onset neonatal infection, especially when blood culture is negative. Indeed, identification of listeria in the blood stream by conventional bacteriological methods remains the reference method for diagnosing listeriosis. We report a case of congenital listeriosis with negative blood culture despite typical chorioamnionitis, where the pathogen was cultured in gastric aspirate.Although the disease is rare, congenital listeriosis still remain a possible challenging condition in neonatal practice as revealed by this case report. This also shows the importance of multisite bacterial culture beside conventional blood and CSF culture, in combination with histological examination of the placenta for the diagnosis of congenital listeriosis

Mathematical bias in assessment of placental residual blood volume

This letter suggest a new computation of the relative placental residual blood volume

Langherans histiocytosis as an unusual cause of Blueberry Muffin Syndrome

peer reviewedLa présentation du Blueberry Muffin Syndrome est typique, et permet de rapidement orienter le bilan étiologique. La biopsie cutanée est importante pour établir le diagnostic, qui lui-même conditionne le pronostic

Lactobezoar mimicking acute abdomen

Le lactobezoar, agglomération pathologique de particules de lait et de mucus, peut causer chez le prématuré une obstruction digestive et mimer un abdomen aigu. La prise en charge est le plus souvent médicale