Gabriel Duc

Sucrose reduces pain reaction to heel lancing in preterm infants: a placebo-controlled, randomized and masked study.

ABSTRACT: In term infants sucrose given by mouth has been reported to reduce duration of crying after a heel prick. This study was designed primarily to investigate the effect of sucrose administered orally immediately before heel lancing on the nociceptive reaction in preterm infants as assessed by change in heart rate and duration of crying. A secondary objective was to document changes in cerebral blood volume during acute pain. We used a randomized, masked, placebo-controlled, crossover trial in a neonatal intermediate care unit in a level 3 perinatal center. The patients studied were 16 preterm infants; birth weight, 900–1900 g; gestational wk, 27–34; corrected postmenstrual age at time of investigation, 33–36 wk. Each infant was assessed twice receiving 2 mL of sucrose 50% or 2 mL of distilled water in random order immediately before heel lance. Heart rate, thoracic movements, and transcutaneous blood gases were monitored continuously. Crying during the procedure was documented by a video-camera. A change in cerebral blood volume was assessed by near-infrared spectroscopy. We found the heart rate increased by a mean of 35 beats/min (bpm) after sucrose and 51 bpm after placebo (median difference 16 bpm, interquartile range 1–30 bpm, p = 0.005). Infants cried 67% of time after sucrose and 88% after placebo (median difference 10%, interquartile range 3–33%, p = 0.002). Cerebral blood volume decreased in 5 of 14 infants after sucrose and in 6 of 14 infants after placebo (difference not significant). We concluded that sucrose administered orally before a heel lance reduces the pain reaction in preterm infants. Response of cerebral blood volume to pain does not seem to be altered by sucrose.

Comparison between near infrared spectroscopy and 133Xenon clearance for estimation of cerebral blood flow in critically ill preterm infants

ABSTRACT: Estimations of cerebral blood flow were performed by both near infrared spectroscopy and 133xenon clearance on 12 occasions in nine critically ill premature infants (26–29 gestational wk) who required mechanical ventilation and supplemental oxygen. For each study, one determination of cerebral blood flow by 133xenon was compared with the mean of two to five measurements by near infrared done within 1–19 (median 5) h. 133Xenon measurements ranged from 9.6–16.9 mL/100 g/min, and mean near infrared measurements ranged from 8.6–25.0 mL/100 g/min. There was a significant correlation between the two sets of measurements (r = 0.80, p < 0.001). The mean difference between the methods was 1.6 mL/100 g/min, and the 95% limits of agreement were −0.5–3.8 mL/100 g/min. This study showed that cerebral blood flow can be measured noninvasively in critically ill premature infants at the cotside by near infrared spectroscopy and by the 133xenon clearance technique. The methods give comparable results.

Diagnostic and prognostic value of cerebral 31P magnetic resonance spectroscopy in neonates with perinatal asphyxia

The impact of depressed neonatal cerebral oxidative phosphorylation for diagnosing the severity of perinatal asphyxia was estimated by correlating the concentrations of phosphocreatine (PCr) and ATP as determined by magnetic resonance spectroscopy with the degree of hypoxic-ischemic encephalopathy(HIE) in 23 asphyxiated term neonates. Ten healthy age-matched neonates served as controls. In patients, the mean concentrations ±SD of PCr and ATP were 0.99 ± 0.46 mmol/L (1.6 ± 0.2 mmol/L) and 0.99 ± 0.35 mmol/L (1.7 ± 0.2 mmol/L), respectively (normal values in parentheses). [PCr] and [ATP] correlated significantly with the severity of HIE (r = 0.85 and 0.9, respectively, p < 0.001), indicating that the neonatal encephalopathy is the clinical manifestation of a marred brain energy metabolism. Neurodevelopmental outcome was evaluated in 21 children at 3, 9, and 18 mo. Seven infants had multiple impairments, five were moderately handicapped, five had only mild symptoms, and four were normal. There was a significant correlation between the cerebral concentrations of PCr or ATP at birth and outcome (r = 0.8, p < 0.001) and between the degree of neonatal neurologic depression and outcome (r= 0.7). More important, the outcome of neonates with moderate HIE could better be predicted with information from quantitative 31P magnetic resonance spectroscopy than from neurologic examinations. In general, the accuracy of outcome predictability could significantly be increased by adding results from31 P magnetic resonance spectroscopy to the neonatal neurologic score, but not vice versa. No correlation with outcome was found for other perinatal risk factors, including Apgar score.

Early pattern recognition in severe perinatal asphyxia : a prospective MRI study

On the basis of MRI examination in 88 neonates and infants with perinatal asphyxia, we defined 6 different patterns on T2-weighted images: pattern A-scattered hyperintensity of both hemispheres of the telencephalon with blurred border zones between cortex and white matter, indicating diffuse brain injury; pattern B-parasagittal hyperintensity extending into the corona radiata, corresponding to the watershed zones; pattern C-hyper-and hypointense lesions in thalamus and basal ganglia, which relate to haemorrhagic necrosis or iron deposition in these areas; pattern D-periventricular hyperintensity, mainly along the lateral ventricles, i.e. periventricular leukomalacia (PVL), originating from the matrix zone; pattern E-small multifocal lesions varying from hyper-to hypointense, interpreted as necrosis and haemorrhage; pattern F-periventricular centrifugal hypointense stripes in the centrum semiovale and deep white matter of the frontal and occipital lobes. Contrast was effectively inverted on T1-weighted images. Patterns A, B and C were found in 17%, 25% and 37% of patients, and patterns D, E and F in 19%, 17% and 35%, respectively. In 49 patients a combination of patterns was observed, but 30% of the initial images were normal. At follow-up, persistent abnormalities were seen in all children with patterns A and D, but in only 52% of those with pattern C. Myelination was retarded most often in patient with diffuse brain injury and PVL (patterns A and D).

End-of-life decisions in delivery room and neonatal intensive care unit.

Background: The increase in neonatal survival in recent decades has been followed by an increase in later disabilities. This has given rise to many new ethical issues. In different countries, efforts are being made to define ethical guidelines regarding withholding or withdrawing intensive care and end‐of‐life decisions in critically ill newborn infants. These guidelines have to be differentiated from ethical decision‐making models which structure the process of decision making for an individual child. Such a framework has been in existence in our clinic for 10 years. Aim: The aims of this study were to evaluate how end‐of‐life decisions are taken in our perinatal centre and to analyse whether these decisions are consistent with our framework for structured ethical decision making.

Intellectual outcome, speech and school performance in high risk preterm children with birth weight appropriate for gestational age

Intellectual development, speech and school performance of preterm infants with birth weight appropriate for gestational age are reported in two separate investigations: a longitudinal study of 97 preterm children and 93 term children as a control group, and a cross-sectional study of 249 preterm children. Both preterm groups were regarded as high risk groups with respect to number of outborns, distribution of gestational age and perinatal risk factors. Intellectual outcome at 5 and 7 years of age in the majority of the preterm children was comparable to that of the term children. However, 8% of the preterm boys and 2% of the preterm girls achieved lower IQ scores than any of the term children. Between 15% and 17% of the preterm boys and 9%–12% of the preterm girls did not attend school at grade level, compared to 4% and 2% in the term group, respectively. Intellectual and neurological development and school performance were higher interrelated in the preterm than in the term children. Articulation defects, stuttering and dysgrammatism occurred more frequently in the preterm than in the term children and in boys more so than in girls.

Cerebral blood flow in preterm infants affected by sex, mechanical ventilation, and intrauterine growth

Sex differences in cerebral blood flow (CBF) values have been demonstrated in adults but not in newborns. This study evaluated the influence of sex, intrauterine growth, and need of mechanical ventilation on resting cerebral blood flow in preterm neonates. Sixty-eight preterm infants with gestational ages of less than 34 weeks and birth weights of less than 1,500 gm were enrolled into the study. Cerebral blood flow was measured by the noninvasive intravenous xenon 133 method 3 times. Measurements were classified into 3 groups: group 1: measurement at 2-36 hours (n = 46); group 2: measurement at 36-108 hours (n = 39); and group 3: measurement at 108-240 hours (n = 41). In all 3 groups, the CBF in girls was significantly lower than in boys (group 1: 11.5 +/- 2.8 ml/100 gm/min vs 14.0 +/- 4.1 ml/100 gm/min; group 2: 13.4 +/- 2.9 ml/100 gm/min vs 16.3 +/- 4.3 ml/100 gm/min; group 3: 12.9 +/- 3.2 ml/100 gm/min vs 15.3 +/- 3.1 ml/100 gm/min). In group 1, the CBF in neonates requiring mechanical ventilation was significantly lower (P < .05) than in patients who were spontaneously breathing (11.5 +/- 3.7 ml/100 gm/min vs 14.2 +/- 3.1 ml/100 gm/min), and the CBF in neonates who were too small for gestational age was significantly higher (P < .005) than in children with appropriate intrauterine growth (16.1 +/- 4.1 ml/100 gm/min vs 11.5 +/- 2.6 ml/100 gm/min). It is concluded that in preterm neonates CBF is substantially affected by sex, intrauterine growth retardation, and the need of mechanical ventilation.

Infants born to mothers with antibodies againstBorrelia burgdorferi at delivery

A serological survey over a 1-year period of 1416 mothers at delivery and their 1434 offspring for the presence of anti-Borrelia burgdorferi antibodies revealed a prevalence of 0.85%. Clinically active Lyme disease during pregnancy was found in 1 of these 12 women with elevated titres and the child was born with a ventricular septal defect. Of six affected children, two had hyperbilirubinaemia, one muscular hypotonia, one was underweight for gestational age, one was macrocephalic, and one had supraventricular extrasystoles. Anomalous findings could not be attributed toB. burgdorferi due to a lack of serological evidence of intrauterine infection. Our data do not imply the need for serological screening in pregnancy, however, the importance of recognition and treatment of Lyme disease in pregnancy is emphasized.

Loss of CO2 reactivity of cerebral blood flow is associated with severe brain damage in mechanically ventilated very low birth weight infants.

BACKGROUND Early detection of pathophysiological factors associated with permanent and severe brain damage in preterm infants requiring intensive care is a major issue in neonatal neurology. The aim of this study was to investigate if an abnormal CO2 reactivity of cerebral blood flow in high risk very low birth weight infants is associated with severe brain injury demonstrated at autopsy or by neurodevelopment examination at 18 months. METHODS The CO2 reactivity of cerebral blood flow (xenon-133) was measured in 18 mechanically ventilated, severely ill, very low birthweight infants (gestational age 26-32 weeks, birthweight: 630-1360 g) during the first 36 hours of life. Cerebral outcome was assessed on autopsy findings (n = 8) or at the age of 18 months using Bayley developmental scales (n = 10). RESULTS Eight infants with normal development at 18 months (within mean +/- 2.5 SD of reference group) and two infants with normal cerebral autopsy findings had a median CO2 reactivity of 24.4%/kPa CO2 (interquartile range 14.7-41.2). Two infants with abnormal development (> 2.5 SD below mean) and six infants with hypoxic-ischaemic encephalopathy at autopsy has a median CO2 reactivity of 3.4%/kPa CO2 (interquartile range 8.0-11.7). CONCLUSION In mechanically ventilated very low birthweight infants low CO2 reactivity of cerebral blood flow (below 10%/kPa CO2) during the first 36 hours of life was associated with poor neurodevelopmental outcome or hypoxic-ischaemic encephalopathy at autopsy. Loss of CO2 reactivity may play a role in the pathogenesis of hypoxic ischaemic encephalopathy. It is a candidate for predicting early severe brain damage in preterm infants requiring intensive care and for controlling the effect of early interventions.

Neurological outcome in high risk weight appropriate for gestational age preterm children at early school age

Neurological development in preterm children with birth weight appropriate for gestational age is reported in two separate groups: a longitudinal study of 97 preterm children and 93 term children as a control group and a cross-sectional study of 249 preterm children. Both preterm groups were regarded as high risk with respect to number of outborns, distribution of gestational age and perinatal risk factors. Neurological outcome at 5–6 years of age in the majority of the preterm children was comparable to that of the term children. However, 15% of boys and 9% of girls in the preterm group were diagnosed as having cerebral palsy. Mild diplegia was most frequently observed; 4% of the children were severely impaired. Fourteen percent of the preterm vs 2% of the term boys and 6–9% of the preterm vs none of the term girls received motor therapy during early school age. There was a small but consistent sex difference in neurological outcome in favour of the term and preterm girls. Effects of drop out rate and of incompleteness of ascertainment are reported in detail.