Odile Pidoux

6 cmH2O continuous positive airway pressure versus conventional oxygen therapy in severe viral bronchiolitis: A randomized trial†

To compare the effects of nasal continuous positive airway pressure (nCPAP) and conventional oxygen therapy on the clinical signs of respiratory distress and the respiratory muscle workload in acute viral bronchiolitis.

Growth and Bone Mineralization in Preterm Infants Fed Preterm Formula or Standard Term Formula after Discharge

OBJECTIVE To evaluate growth and bone mineralization in very low birth weight (VLBW) infants fed preterm formula (PF) or term formula (TF). STUDY DESIGN In a double-blind prospective study, 49 preterm infants of gestational age 33 weeks or less were randomly fed PF or TF for 2 months after discharge, then all of the infants were fed TF for the next 2 months. Anthropometric and dual-energy x-ray absorptiometry data were collected at discharge and at 2 months and 4 months after discharge. Anthropometric data also were collected at 12 months postterm. RESULTS Four months after discharge, both body weight (6139 +/- 1254 g vs 5540 +/- 863 g; P = .03) and bone mineral content (104.4 +/- 29.2 g vs 87.5 +/- 17.1 g; P = .01) were significantly higher in the PF group compared with the TF group. At 12 months postterm, mean body weight, length, and head circumference remained higher in the PF group than in the TF group, and body mass index was similar and within the normal range in the 2 groups. CONCLUSIONS At 4 months after discharge, growth and mineralization were better in the VLBW infants who were fed PF during the first 2 months after discharge compared with those who were fed TF, suggesting that PF may be particularly valuable at this early stage of development.

Continuous-infusion vancomycin therapy for preterm neonates with suspected or documented Gram- positive infections: a new dosage schedule

Background: Intermittent infusion of vancomycin is widely used to treat late-onset sepsis in neonates. On the other hand, the continuous infusion of vancomycin could improve bactericidal efficacy since its action is time dependent. Objective: To evaluate a simplified dosage schedule for continuous-infusion vancomycin therapy. Methods: Prospective study in premature neonates (<34 weeks) with suspected coagulase-negative staphylococci (CoNS) sepsis. Before antibiotics at time zero (T0), serum creatinine was measured and blood cultures were collected. Vancomycin dosage began with 25 mg/kg/day or 15 mg/kg/day (period 1) and 30 mg/kg/day or 20 mg/kg/day (period 2) depending on whether serum creatinine was below or above 90 μmol/l. Two days after beginning treatment (first timepoint: T1), serum vancomycin was measured and second blood cultures were collected. Results: Between June 2002 and December 2005, 145 neonates were evaluated. At birth, the median (interquartile range) body weight was 920 (500–1160) g and gestational age was 28 (26–29) weeks. At T1, serum vancomycin was within the required range in 74.5% of neonates (108/145). Serum vancomycin levels were higher in period 2 than in period 1 (20 mg/l vs 13 mg/l, p<0.05). At T0, 55% (80/145) of blood cultures were positive for CoNS, but 71% (57/80) were negative at T1. Four days after beginning treatment, 92% of subjects had recovered without removing the central venous catheter. Conclusion: Using this simplified dosage schedule, bactericidal efficacy was maintained and most subjects had serum vancomycin concentrations within the therapeutic range.

Nitrous oxide analgesia for intubating preterm neonates: a pilot study.

Aim: To evaluate the administration of an equimolar mixture of N2O and O2 for intratracheal intubation in preterm neonates with respiratory distress syndrome (RDS). Design: Prospective evaluation of N2O/O2 in premature neonates with RDS. Setting: Tertiary neonatal unit from March to August 2003. Patients: Twenty‐six of 79 neonates admitted for RDS within 48 h of birth. Intervention: N2O/O2 was administered until muscle tone was suppressed. Surfactant was given intratracheally. Patients were extubated as soon as possible. Main outcome measures: The time needed for N2O/O2 to suppress muscle tone, an evaluation of sedation/analgesia through movements of the limbs, and indicators of stress‐related haemodynamic change, all recorded by an independent observer. Results: In the 26 patients, gestational age was 30.5 (25th, 75th percentile: 30, 32) wk and median body weight was 1540 (1220, 1900) g. Postnatal age at intubation was 2 (2, 3) h. N2O/O2 administration time was 8 (6, 10) min (range 4–15 min). Sedation/analgesia was complete in 77% of patients. No significant differences between pre‐procedure and post‐procedure values were found for heart rate (p=0.29) or mean arterial blood pressure (p=0.13) (paired Wilcoxon test). Time needed for intubation was 30 (20, 37) s (range 10–60 s). Side effects included transient agitation (3/26) and retching (2/26). Extubation occurred 5 (5, 10) min (range 2–15 min) after surfactant instillation. Apnoeas occurred in 3/26 patients within 2 h after extubation. Two patients required reintubation to repeat surfactant administration within 24 h after extubation.

Validation of a neonatal pain scale adapted to the new practices in caring for preterm newborns

Background Neonatal pain assessment generally requires access to facial expression. Improved neonatology practices, such as greater protection against bright lights and non-invasive mask ventilation, have made facial observation more difficult. Objective To validate a ‘faceless’ acute neonatal pain scale (FANS), which does not depend on facial expression. Methods In a prospective, multicentre study, 24–40-week-old neonates were videotaped during a painful procedure (heel prick). Three investigators then scored the pain using FANS and a previously validated scale: DAN (Douleur aiguë du Nouveau-né). FANS is based on assessment of limb movement, cry and autonomic reaction. Reliability was assessed by inter-rater agreement and internal consistency (Cronbachs α). Validity was evaluated by agreement between scales (intraclass correlation coefficient (ICC)). The Wilcoxon test evaluated the FANS score differences between conditions. Results are expressed as medians (25th and 75th percentiles). Ranges are presented for outcome parameters. Results From April 2006 to September 2007, 53 preterms of 32 (30–35) gestational weeks and 1500 (1000–2200) g were observed. Cronbachs α was 0.72. The ICC was 0.92 (0.9–0.98) for inter-rater agreement and 0.88 (0.76–0.93) for agreement between scales. Conclusion FANS, which is reliable and valid, is the first scale to score pain in preterm newborns when facial expression is not accessible.

Betamethasone Impairs Cerebral Blood Flow Velocities in Very Premature Infants with Severe Chronic Lung Disease

OBJECTIVE To assess betamethasone (BM) effects on the cerebral hemodynamics of neonates with severe chronic lung disease (CLD). STUDY DESIGN Intravenous BM was given once daily for 6 consecutive days to 12 infants (birth weight: 698 g [range, 650-884 g], gestational age: 25.3 weeks [range, 25-26.4 weeks]) at a postnatal age of 34 days (range, 28-36 days). Cerebral blood flow velocities (CBFVs) were recorded prospectively in the anterior cerebral artery (ACA) and the lenticulostriate artery (LSA) before, during, and after treatment, using Doppler flowmetry. RESULTS The decrease in systolic and diastolic velocities was maximum on the 5th day, reaching 32% (95% confidence interval [CI], 23%-42%) and 58% (95% CI, 39%-64%) from baseline in the ACA, and 44% (95% CI, 29%-50%) and 57% (95% CI, 33%-66%) in the LSA, respectively. The resistance index (RI) increased significantly in both arteries during treatment. Return to baseline values was observed after BM was stopped. The change in velocities and RI was independent of arterial blood gas and blood pressure variations. CONCLUSIONS BM decreased the CBFVs of premature infants, suggesting a vasoconstrictor effect in both superficial and deep arterial vessels. Caution is recommended when BM is used to treat preterm infants with severe CLD.

Thoracic computed tomography in absent pulmonary valve syndrome management

A neonate with absent pulmonary valve syndrome (APVS) and features of tetralogy of Fallot presented respiratory distress. The prolonged need for mechanical ventilation was an indication for surgical repair. Preoperative thoracic CT imaging showed nearly complete closure of the distal trachea, compressed by the aneurysmal dilatation of the pulmonary arteries, and its reopening after ventilator pressure was increased. Management of APVS may require high‐pressure ventilation to prevent bronchial collapse due to compression by the pulmonary arteries. In this context, thoracic CT imaging is very useful for adjusting ventilation support so that surgical repair can be performed in optimal conditions.

One-Year Outcome for Congenital Diaphragmatic Hernia: Results From the French National Register

Objective To evaluate the status of congenital diaphragmatic hernia (CDH) management in France and to assess predictors of adverse outcomes. Study design We reviewed the first‐year outcome of all cases of CDH reported to the French National Register in 2011. Results A total of 158 cases were included. Of these, 83% (131) were prenatally diagnosed, with a mortality rate of 39% (44 of 112) for live born infants with a known outcome at hospital discharge. Mortality increased to 47% (60 of 128) including those with termination of pregnancy and fetal loss. This contrasts with the 7% (2 of 27) mortality rate of the patients diagnosed postnatally (P = .002). Mortality worsened with 1 prenatal marker of CDH severity (OR 3.38 [1.30‐8.83] P = .013) and worsened further with 2 markers (OR 20.64 [5.29‐80.62] P < .001). Classic postnatal risk factors of mortality such as side of hernia (nonleft P = .001), prematurity (P < .001), low birth weight (P = .002), and size of the defect (P < .001) were confirmed. Of the 141 live births (114 prenatal and 27 postnatal diagnosis) with known outcomes, 93 (67%) survived to hospital discharge, 68 (60%) with a prenatal diagnosis and 25 (93%) with a postnatal diagnosis. The median time to hospital discharge was 34 days (IQR, 19.25‐62). Of these survivors, 71 (76%) were followed up for 1 year. Conclusions Despite advances in management of CDH, mortality was high and associated with prenatal risk factors. Postnatally, severe persistent pulmonary hypertension was difficult to predict and presented persistent challenges in management.