Laure Maury

Necrotizing Enterocolitis (NEC) and the Risk of Intestinal Stricture: The Value of C-Reactive Protein

Necrotizing enterocolitis (NEC) is a severe complication frequently seen during the neonatal period associated with high mortality rate and severe and prolonged morbidity including Post-NEC intestinal stricture. The aim of this study is to define the incidence and risk factors of these post-NEC strictures, in order to better orient their medicosurgical care. Sixty cases of NEC were retrospectively reviewed from a single tertiary center with identical treatment protocols throughout the period under study, including systematic X-ray contrast study. This study reports a high rate of post-NEC intestinal stricture (n = 27/48; 57% of survivors), either in cases treated surgically (91%) and after the medical treatment of NEC (47%). A colonic localization of the strictures was more frequent in medically-treated patients than in those with NEC treated surgically (87% vs. 50%). The length of the strictures was significantly shorter in case of NEC treated medically. No deaths were attributable to the presence of post-NEC stricture. The mean hospitalization time in NICU and the median age at discontinuation of parenteral nutrition were longer in the group with stricture, but this difference was not significant. The median age at discharge was significantly higher in the group with stricture (p = 0.02). The occurrence of post-NEC stricture was significantly associated with the presence of parietal signs of inflammation and thrombopenia (<100 000 platelets/mm3). The mean maximum CRP concentration during acute phase was significantly higher in infants who developed stricture (p<0.001), as was the mean duration of the elevation of CRP levels (p<0.001). The negative predictive value of CRP levels continually <10 mg/dL for the appearance of stricture was 100% in our study. In conclusion, this retrospective and monocentric study demonstrates the correlation between the intensity of the inflammatory syndrome and the risk of secondary intestinal stricture, when systematic contrast study is performed following NEC.

A Long-term Competent Chimeric Immune System in a Dizygotic Dichorionic Twin

We present here a rare case that involved the long-term coexistence of 2 mature, functional, and equilibrated immune systems in a single child after fetofetal transfusion between dizygotic twins. A dichorionic diamniotic pregnancy complicated by twin anemia-polycythemia sequence resulted in the demise of 1 twin. The detection of abnormal vessels on the dichorionic plate strongly suggested the existence of functional vascular anastomoses leading to blood chimerism in the survivor. Genetic, phenotypic, and immunologic analyses at 2 years revealed chimeric lymphoid and myeloid cells in the surviving twin, although no tissue mosaicism was detected, which indicates that early transfusion led to mutual immune tolerance.

Is intraabdominal pressure a good predictor of mortality in necrotizing enterocolitis

Sir: Intraabdominal pressure (IAP) is elevated in many pediatric patients with critical illnesses, injuries, or surgery. Several methods for measuring intravesical pressure (IVP) have been described [1, 2]. At the acute phase of necrotizing enterocolitis, both fluid resuscitation and medications lead to the development of a third abdominal compartment and, therefore, to IAP elevation, which worsens the bowel ischemia. We are prospectively evaluating IVP as a predictor of death in neonates with necrotizing enterocolitis, and we report our preliminary results. All neonates admitted to our pediatric ICU for severe necrotizing enterocolitis were enrolled prospectively from December 2004 to December 2005. Necrotizing enterocolitis was diagnosed when pneumatosis intestinalis was visible on the abdominal radiographs. A Foley catheter was placed to monitor the urine output. Surgery was performed when radiographs showed free intraperitoneal gas or the medical treatment induced no response. IVP was measured via a transurethral bladder catheter as first suggested by Kron et al. [3] and described recently by Davis et al. [4]. Intra-vesical pressure was used instead of gastric pressure because we felt that manipulating the nasogastric tube of patients who required continuous suction for an occlusive condition was problematic. Furthermore, nasogastric tube placement varies widely, especially in very premature babies. The tube is often obstructed by the gastric mucosa because of the low levels of Gomco suction used. IVP was measured every 3 h for 48 h (ten values per patient). Quantitative data were described as median (range) and qualitative data as number (percentage). Spearman’s correlation coefficient was computed to assess correlations between the ten IVP values and the ten mean pressure values, both summarized as the mean in each patient. The relationship between IVP and mortality was evaluated using the generalized estimating equation method. Statistical tests were performed using SAS 9.1 (Cary, NC). P values \ 0.10 were considered statistically significant. There were seven patients (Table 1) with a median gestational age of 32.9 weeks (range, 27–41) and a median birth weight of 1,689 g (range, 840–3,340). Surgery was needed in five patients. Another patient (no. 4) responded well to medical treatment. Patient 5 was too unstable for surgery. Three patients died (3/7, 43%). IVP was associated with mortality (odds ratio for a 1-mmHg increase, 1.22; 95% confidence interval, 0.96–1.55; P = 0.098). Individual mean IVP correlated with individual mean value of mean ventilatory pressure (rho = 0.68, P = 0.094). Mean IVP value did not correlate with FiO2 or mean fluid resuscitation volume. IVP measurement to assess IAP may help to predict mortality in premature babies with necrotizing enterocolitis. Furthermore, a study in

Lésions acquises du cervelet chez le grand prématuré: prévalence, facteurs de risque et conséquences fonctionnelles

UNLABELLED Traditionally, the cerebellum has been regarded as a central component of the motor system. Recent studies suggest an important role played by the cerebellum in the development of cognitive and social functions. The objective of this study was to evaluate the incidence of cerebellar injury and to define the obstetrical, neonatal, and radiologic characteristics, as well as the functional outcomes in a population of very preterm infants. METHODS This retrospective study included neonates born before 30 weeks of gestational age between March 2004 and July 2007. Infants underwent MRI studies at a term-adjusted age; for each preterm infant with cerebellar injury, we identified two infants for the control group with normal MRI, matched on the basis of gestational age. We collected pertinent demographic, prenatal, and acute postnatal data for all infants. Follow-up assessment was performed at 2 years, using the Brunet-Lezine scale. RESULTS A total of 148 ex-preterm infants were studied. Cerebellar injury was present in 14 (9 %) cases and associated with supratentorial parenchymal injury in 90 %. Duration of ventilation was longer in children with cerebellar injury, compared to controls (19.5 days vs 16.5 days; P=0.03). The other neonatal criteria analyzed were comparable between the two groups. Global developmental, functional, and social-behavioral deficits were more common and profound in preterm infants with cerebellar injury, with no significant difference. CONCLUSION This study confirms the high incidence of cerebellar injury in very preterm infants and the importance of a specific neurobehavioral follow-up.

Réhospitalisations précoces après sortie de Néonatologie

Le contraste entre la volonté d’une sortie « le plus précoce possible », en particulier pour les prématurés dont le séjour peut être supérieur à 2 mois, et les risques médicaux et psychologiques liés à cette sortie, est aggravé par le taux d’occupation trop élevé des services et la pénurie fréquente de l’hospitalisation à domicile. Le risque de réhospitalisation après sortie de néonatologie des nouveau-nés de faible poids de naissance (PN < 2500 g) et plus particulièrement de très faible poids de naissance (PN < 1500 g) est lié à une augmentation de la morbidité et de la mortalité dans cette population [1,2], mais surtout à l’immaturité insuffi sante (contrôle respiratoire, déglutition, refl ux gastro-œsophagien), aggravée par l’appréhension parentale. L’incidence des nouveau-nés réhospitalisés dans le mois suivant la sortie de néonatologie n’est pas actuellement connue en France, les conditions de sortie de néonatologie ne font l’objet d’aucune recommandation de collège de médecins ou d’organisme de santé, contrairement aux sorties précoces de maternité [3]. Il nous a donc paru important de faire le point actuel sur les causes de réhospitalisations précoces dans le mois qui suit la sortie de néonatologie dans la région Ile-de-France (160 000 naissances par an) et d’identifi er les causes évitables de réhospitalisation de façon à améliorer les conditions de sortie.

Microcéphalie et thrombopénie néonatale

Né d’une mère 2e geste, 2e pare, ce nouveau-né ne présentait pas d’antécédent particulier. La 1ère grossesse avait été suivie au centre de diagnostic anténatal pour dilatation ventriculaire unilatérale modérée avec un bilan préet postnatal normal (ponction de liquide amniotique [PLA], imagerie par résonance magnétique [IRM] fœtale et suivi neurologique). Lors du suivi prénatal de la 2nde grossesse, l’échographie de dépistage de 32 semaines d’aménorrhée (SA) avait montré un diamètre transverse du cervelet inférieur au 10e percentile, sans autre anomalie. Un bilan complémentaire anténatal avait été refusé par les parents. Le suivi de la grossesse n’avait pas révélé d’hypertension artérielle et le

Réhospitalisations précoces après sortie de NéonatologieRehospitalization in the first month after discharge from the Neonatal Intensive Care Unit

Le contraste entre la volonté d’une sortie « le plus précoce possible », en particulier pour les prématurés dont le séjour peut être supérieur à 2 mois, et les risques médicaux et psychologiques liés à cette sortie, est aggravé par le taux d’occupation trop élevé des services et la pénurie fréquente de l’hospitalisation à domicile. Le risque de réhospitalisation après sortie de néonatologie des nouveau-nés de faible poids de naissance (PN < 2500 g) et plus particulièrement de très faible poids de naissance (PN < 1500 g) est lié à une augmentation de la morbidité et de la mortalité dans cette population [1,2], mais surtout à l’immaturité insuffi sante (contrôle respiratoire, déglutition, refl ux gastro-œsophagien), aggravée par l’appréhension parentale. L’incidence des nouveau-nés réhospitalisés dans le mois suivant la sortie de néonatologie n’est pas actuellement connue en France, les conditions de sortie de néonatologie ne font l’objet d’aucune recommandation de collège de médecins ou d’organisme de santé, contrairement aux sorties précoces de maternité [3]. Il nous a donc paru important de faire le point actuel sur les causes de réhospitalisations précoces dans le mois qui suit la sortie de néonatologie dans la région Ile-de-France (160 000 naissances par an) et d’identifi er les causes évitables de réhospitalisation de façon à améliorer les conditions de sortie.