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The outcome of 60 premature infants weighing less than 1,000 g at birth and consecutively born during the years 1986 to 1988 is reported. Forty-two (70%) of them were inborn. The overall mortality rate was 42%, but only 26% in the inborn group instead of 78% in the outborn group (P less than 0.001). The mortality rate was higher for the appropriate for gestational age infants (56%) than for the growth retarded infants (14%, P less than 0.01). The main neonatal problems were the following: hyaline membrane disease (63%), patent ductus arteriosus (7%), bronchopulmonary dysplasia (8%), necrotizing enterocolitis (15%), intraventricular hemorrhages (45%) and periventricular leukomalacia (12%). Twenty percent (7/35) of the surviving infants showed abnormal neurodevelopmental outcome, with only one (3%) having major handicap. No correlation was found between gestational age and neuro-developmental outcome.

Seventeen premature babies were ventilated with high frequency oscillation (HFO) for severe hyaline membrane disease. The results were compared to a group of 16 babies ventilated with classical positive pressure ventilation and presenting with hyaline membrane disease of the same severity. The results demonstrated an improvement of the mortality rate with HFO without any significant difference of pulmonary or neurologic complications. Furthermore, a controlled study in order to demonstrate an improvement of this type of ventilation is required.

In 2 very low birth weight infants, a Nelcor 100 pulse oximeter was used during surgery. These 2 babies were anesthetized during the first 3 weeks of life, one for patent ductus arteriosus ligation and the other for ventriculo-peritoneal derivation. SaO2 was maintained between 85-95% in the straight portion of hemoglobin dissociation curves, where PaO2 values are from 7 to 10 KPal. During anesthesia, FiO2 was kept between 21 and 30%. Oximeters which have a fast response time seem to be a useful tool for monitoring blood oxygenation when it is difficult to estimate normoxia but very important to avoid hypoxia or over-oxygenation.

A continuous measurement of the energetic consumption and a nutritional evaluation were performed over 24 hours in two comparable groups of children under cyclic or continuous total parenteral nutrition (TPN). Over the 24 hours, energetic consumptions and nitrogenous retentions were equal in both groups. In cases submitted to continuous TPN, a similar utilization of nutriments was observed during the day and night periods, with global predominance of carbohydrate oxidation and of lipogenesis. In cases submitted to cyclic TPN, night and day utilization of nutriments was significantly different, with important utilization of glycogen and lipid stocks during the day. Thus, cyclic TPN allows a more important mobilization of the energetic stocks and physical activity during the day than continuous TPN and might change the quality of the weight gain and avoid an unnecessary storage of lipid deposits.

Survival rate of 96 low-birth-weight infants less than 32 weeks post-conceptional age at birth was studied in relation with the mode of delivery. Twenty-two infants were delivered by elective cesarean section because of abnormalities during pregnancy with 3 neonatal deaths. Seventy-four infants were born after untreatable premature onset of labor with 9 intrapartum and 7 neonatal deaths. Poor prognosis was associated with gestational age (less than 29 weeks), non cephalic vaginal delivery and multiple births. In these cases, cesarean section should be discussed.

The authors report the results of 59 caesarean operations in which 74 children were born before the end of the 32nd week of amenorrhoea. The gross mortality was 21.9% and the corrected mortality 18.5%. 7.9% of the infants had major neurological sequellae and 8.6% mild sequellae. 65.2% are alive and well with normal psychomotor development. The follow-up has been between 1 and 5 years. The factors that influence survival and the indications for caesarean section at this time are reviewed and discussed.

Between 1981 and 1983, 251 premature infants with a birth weight of less than 1 500 grams were admitted to the Neonatal Pathology Unit of the E. Herriot hospital (malformations excluded). Forty two (17%) died during the neonatal period. These premature births resulted essentially from pathological pregnancies: multiple pregnancies (1/5 cases), renal pathology (1/3 cases), placental abnormalities (10%) and fetoplacental infections (10%). In half of all cases delivery was by cesarian section, indicated in 85% of cases because of acute or chronic fetal distress. These premature infants suffered from respiratory (including 40% hyaline membrane disease), neurological (abnormal cerebral echotomography with dilatation or intracranial haemorrhage in 35% of cases), infectious (6%) and digestive (6% necrosing enterocolitis) pathology. Of the 208 surviving children, 12 (i.e. 6% of the survivors) had major sequelae (with follow-up of one year or more).

78 cesarean sections (CS) were performed before 32 weeks of gestation over a period of six years in a obstetric clinic; 91 premature infants were born; the rate of CS at this period of time represented 0,47% of total birth. 84 premature infants were transferred to the neonatal unit located in the same clinic; 3 were dead in utero and 4 just after delivery. 69 infants survived (78%) but 6 had severe sequelae (spastic diplegia, epilepsy and RLF) at one year of age and 7 had minor sequelae.

The authors describe the methodology of high frequency ventilation in the newborn infant. Ventilation by oscillator (HFO) actually represents the best method for ventilation in newborn infants; the rate of ventilation is between 15 and 25 Hz/min. They report their experience of HFO use for the treatment of hyaline membrane disease in newborns.

With the renewed interest in the feeding of human milk to preterm infants, we have evaluated the partition of energy metabolism and of macronutrient utilization and accretion in growing very low birth weight infants fed their own mother's milk. Fifteen studies combining macronutrient balance, computerized continuous open-circuit indirect calorimetry, and anthropometric measurements were performed in 11 growing, very low birth weight (less than 1.300 gm) preterm infants. The mean milk intake of 172 ml/kg/day provided a gross energy intake of 111 kcal/kg/day. Energy losses in excreta were 11 kcal/kg/day, and the metabolic energy expenditure was 56 kcal/kg/day. The remainder (44 kcal/kg/day) represented the energy stored in the components of new tissue. The infants were gaining weight (15.3 g/kg/day), length (0.98 cm/wk), and head circumference (0.76 cm/wk) at rates approximating intrauterine growth rates. The metabolic energy expenditure was derived from the oxidation (mean +/- SE) of carbohydrate, 9.5 +/- 0.7 gm/kg/day; fat, 1.63 +/- 0.34 gm/kg/day; and protein, 0.68 +/- 0.07 gm/kg/day. The stored energy comprised 2.98 +/- 0.86 gm/kg/day as carbohydrate, 2.25 +/- 0.54 gm/kg/day as fat, and 1.97 +/- 0.1 gm/kg/day as protein. The accretion rates of fat and protein, as well as the composition of the weight gain (fat, 16.6 +/- 4.1%; protein, 13.4 +/- 0.5%), were similar to those reported for the fetus of comparable gestational age.

32 healthy or sick low birth weight infants (birth weight less than 1,200 g), surviving more than 48 hours with or without respiratory distress were fed by continuous enteral infusion of human milk through a nasoduodenal tube. By this method, oral caloric intake was increased quickly. This allowed early suppression of intravenous supplementation and lowered risks of metabolic and septic disorders. Precautions which are to be followed in order to lower intestinal complications are reported.

To compare the growth and accumulation of protein, fat, and carbohydrate in the formula-fed premature infant and in the fetus of a similar postconceptional age, we performed 22 metabolic studies in 13 infants of very low birth weight (1155 +/- 39 g [mean +/- S.E.]). Measurements combining nutritional balance and indirect calorimetry demonstrated the deposition rates of protein and fat. We found that the formula-fed, very-low-birth-weight infant who gained weight comparably to the fetus retained the same amount of protein (1.92 +/- 0.1 g per kilogram of body weight per day) but accumulated fat at a rate of 5.4 +/- 0.3 g per kilogram per day - about three times that in the fetus, as confirmed by increased skin-fold thickness. How this change in body composition affects the future growth of formula-fed premature infants, and how body composition is altered by other dietary regimens such as the provision of human milk, remain to be determined.

By the combination of energy and macronutrient balances, continuous open circuit computerized indirect calorimetry, and anthropometry, we have compared small for gestational age (SGA) and appropriate for gestational age (AGA) very low birthweight infants with respect to metabolizable energy intake (mean +/- SE: 125.9 +/- 2.5 versus 130.4 +/- 3.5 kcal/kg X day), energy expenditure (67.4 +/- 1.3 versus 62.6 +/- 0.9 kcal/kg X day), storage of energy and macronutrients and growth. Fourteen studies in six SGA infants (gestational age, 33.1 +/- 0.3 weeks; birthweight, 1120 +/- 30 g) and 22 studies in 13 AGA infants (gestational age, 29.3 +/- 0.4 weeks; birthweight, 1155 +/- 40 g) were performed. The SGA infants had a lower absorption of fat (68.7 +/- 3.2 versus 79.7 +/- 1.7%) and protein (69.1 +/- 3.2 versus 83.4 +/- 1.5%) and hence increased (P less than 0.001) energy loss in excreta (29.9 +/- 2.8 versus 18.2 +/- 1.5 kcal/kg X day). The significant hypermetabolism of SGA infants by 4.8 kcal/kg X day was associated with an increased fat oxidation. Despite lower energy storage, SGA infants were gaining weight (19.4 +/- 0.9 g/kg X day), length (1.25 +/- 0.14 cm/week), and head circumference (1.16 +/- 0.9 cm/week) at higher rates than the AGA group. The energy storage per g weight gain was lower (P less than 0.001) in the SGA group (3.0 +/- 0.14 versus 4.26 +/- 0.26 kcal) reflecting higher water, lower fat (22.2 +/- 1.8 versus 33.8 +/- 2.5%; P less than 0.001) and lower protein (7.7 +/- 0.5 versus 12.5 +/- 0.8%; P less than 0.001) contents of weight gain in the SGA group.

Oxygen consumption (VO2) and carbon dioxide production (VCO2) were continuously measured in premature human (mean gestation age of 31 weeks at birth), nursed in incubators within a neutral thermal environment and submitted to a continuous lighting. At a mean postnatal age of 30 days, and for a mean body weight of 1.8 kg, spectral analysis shows VO2 and VCO2 ultradian variations of mean and low frequencies (2 less than f less than 80 c.day--1; i.e. periods 12 greater than t greater than 0.3 hr). It is hypothesized that these periodic variations can be compared to those previously evidenced in small laboratory vertebrates and in macaques.

A pregnant woman suffering from idiopathic hypoparathyroidism was treated with calcitriol [0.5-2 micrograms/day 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3)]. Her twin infants were delivered by cesarian section at 37 weeks of gestation. Laboratory investigations in the perinatal period disclosed: 1) normal serum calcium and phosphorus levels in the mother, 2) normal babies with no clinical or biochemical signs of hyperparathyroidism, 3) a low serum level of 25-hydroxyvitamin D despite a normal serum level of 1,25-(OH)2D in the mother, and 4) a low level of 25-hydroxyvitamin D and a high level of 1,25-(OH)2D in cord serum in both infants. It is suggested that calcitriol is an effective treatment of hypoparathyroidism during pregnancy and produces no ill effects on the baby.

The relative importance and interrelationship of postnatal age, energy intake, and weight gain on metabolic rate is evaluated in 28 studies in 13 formula-fed very low-birth-weight AGA infants. The relationships between metabolic rate, energy intake, weight gain, and age all follow a similar pattern, increasing in the first two weeks of life and subsequently stabilizing. Significant linear correlations are demonstrated between metabolic rate and both energy intake (r = 0.88, P less than 0.001) and weight gain (r = 0.86, P less than 0.001). For each gram of weight gain, 0.67 kcal (2.8 kj) are expended in addition to the maintenance energy requirement of 51 kcal/kg/day. The increase in metabolic rate in the early postnatal period appears to be a consequence of the energy cost of tissue synthesis. Changes in metabolic rate with postnatal age are modulated by increasing energy intake and weight gain.

This study defines the relationship between heart rate and metabolic rate in newborn infants and evaluates the accuracy of prediction of metabolic rate from heart rate. Continuous measurements of oxygen uptake, CO2 production, respiratory quotient, and cumulative heart rate were performed using computerized, open-circuit indirect calorimetry and on-line electrocardiogram monitoring over periods of 1 to 24 hr (mean 4.5 hr). Metabolic rate was calculated from the individual oxygen uptake and respiratory quotient. Thirty-five studies were performed in 16 infants (birthweight 0.75 to 3.1 kg; gestational age, 26 to 42 wk; mean +/- S.D. age at study, 26.5 +/- 15.7 days; study weight, 1.78 +/- 0.5 kg). Metabolic rate (cal/kg . min) and heart rate (beats/min) were compared minute by minute (8269 measurements) and showed a close third degree polynomial relationship for heart rates of 110 to 230/min (y = -0.0000291x3 + 0.01685x2 -2.93x + 197; r = 0.99; P less than 0.001); however, at heart rates above 140 beats/min, a linear relationship was found (r = 0.997; P less than 0.001). From cumulated heart rate measurements, factors defining metabolic rate per heart beat were also determined: for each beat 51.8 +/- 6.8 microliter of oxygen/kg are consumed and 0.258 +/- 0.03 cal/kg (1.1 J/kg) are expended. Despite the wide variation in birthweight, gestational age, method of feeding, and clinical characteristics, there was a remarkable consistency in the heart rate-metabolic rate relationships. A further 10 studies were performed in a similar group of infants to assess the predictive value of the previously defined relationships and showed a mean percentage deviation of 5.7 +/- 4% from the measured value. We conclude that in the varied group of newborns studied, heart rate correlates closely with metabolic rate and that cumulative heart rate measurements enable the estimation of metabolic rate in newborn infants. This provides a method of monitoring energy expenditure and caloric requirements over long periods.

The authors report a controlled study of the use of 2 types of amino-acid solutions for premature infants nutrition in the first days of life, one of the solution (solution I) being adapted for prematures. The average amino-acid blood levels in prematures receiving solution I were close to those observed in cord blood; Plasma taurine, alanine and arginine concentrations were significantly lower with normalized levels of aromatic amino-acids, lysine, taurine and proline; serum ammonia level was also lower. This study shows that using an amino-acid solution adapted to prematures as a supplement to parenteral nutrition during the first days of life allows to progressively increase the nitrogen intakes without inducing dangerous plasma levels of some amino-acids.

Thirty-three observations of late-onset neonatal hypocalcemia were reviewed retrospectively. Their etiological, clinical and biological features were consistent with a transient congenital hypoparathyroidism, associated with a materno-foetal vitamin D deficiency. 1 alpha-hydroxycholecalciferol was used for rapid correction of calcemia and proved to be satisfactorily metabolized after its oral administration.

In a retrospective study of 83 preterm newborns of 32 weeks of gestation or less, isolated periventricular leukomalacia was found in 7 cases (8.4%). Ultrasonographic diagnosis was made in all cases during the first 3 days of life and cystic lesions always occurred during the first 40 days. Five of the 7 newborns suffered from in utero asphyxia, 4 had an Apgar score below 5 at 5 min, and only 4 presented a respiratory distress syndrome. Thus the diagnosis of periventricular leukomalacia can be established early by ultrasonography. In utero asphyxia seems to be a critical determinant of ischaemic brain lesions.

Twenty-nine newborn infants with diaphragmatic hernia have been received in a neonatal intensive care unit over a seven year period. In three cases, clinical signs appeared after the first day: they all survived. Six infants died before surgery: five of them had major pulmonary hypoplasia. Surgery was performed in twenty cases: nine of these infants died. Death occurred during the first twelve post-surgical hours in six cases with major pulmonary hypoplasia. Fourteen infants were followed from 6 to 24 months; two developed post-anoxic hydrocephaly with poor neurological development in one case. A pH above 7.1 and an adequate hemodynamic status obtained before surgery are simple criteria of a good prognosis. When these criteria are not obtained, prognosis is poor as they are in favor of major pulmonary hypoplasia.

Energy requirements are partitioned between needs for maintenance (including resting metabolism, thermoregulation, and muscular activity) and needs for synthesis and storage of new tissue. The partition of energy utilization was evaluated by 22 metabolic and nutritional balance studies in 13 formula-fed (SMA 20/24), growing, appropriate-for-gestational age, very low-birth-weight infants (mean +/- SE birth weight, 1,155 +/- 39 gm; study weight, 1,271 +/- 60 gm; age at study, 21 +/- 2 days; weight gain, 16.8 +/- 1 gm/kg/day). Continuous open-circuit, indirect calorimetry was performed for periods of 6 +/- 0.25 hours in a thermoneutral environment. Results expressed as mean kilocalories per kilogram per day (+/- SE) were: energy intake, 148.6 (+/- 3.9); stool and urine losses, 18.2 (+/- 1.5); metabolizable energy, 130.4 (+/- 3.5); "basal" metabolic rate, 47.0 (+/- 0.75); energy cost of activity, 4.3 (+/- 0.9); thermic effect of food, 11.3 (+/- 0.65); energy stored in new tissue, 67.8 (+/- 3.0). These results provide a partition of energy utilization in very low-birth-weight infants under thermoneutral conditions. Increased activity and a thermal environment outside the neutral range will augment maintenance energy requirements, thus decreasing the amount of energy available for growth if metabolizable energy intake remains constant. The energy cost of growth (ie, for synthesis of, and storage in, new tissue) was determined as 4.9 kcal/gm of weight gain. To attain the equivalent rate of intrauterine weight gain, a metabolizable energy intake of approximately 60 kcal/kg/day in excess of maintenance requirements of 51.3 kcal/dk/day must be provided.

A comparison has been made of the influence of feeding own mother's milk and formula on the oxidation and accretion of energy and macronutrients in the growing preterm infant of very low birth weight (less than 1,300 g) by using the combined techniques of nutrient balance and computerized indirect calorimetry. There were 22 studies in formula-fed infants and 15 studies in premature infants fed own mother's milk. Despite their lower metabolizable energy intake, the infants fed own mother's milk grew in weight, length, and head circumference at a rate approximating those of the formula-fed group. The metabolic rate was significantly lower in the infants fed own mother's milk (56.0 +/- 0.9 v 62.6 +/- 0.8 kcal/kg/d; P less than .001). The protein intake, oxidation, and accretion were similar in the two groups. The infants fed own mother's milk had a significantly lower fat intake (P less than .001), higher fat oxidation (P less than .025) and consequently lower fat accretion (P less than .001) than the formula-fed infants. The proportional fat content of the daily weight gain was lower in the infants fed own mother's milk (16% v 33%; P less than .001) but protein content was similar (13% v 12%). The accretion of energy, fat, and protein correlated with the respective metabolizable intakes in both groups (r = .81 to .98; P less than .001), suggesting that accretion rates and hence composition of weight gain are dependent on levels of energy and macronutrient intake.

Three cases of necrotizing and calcifying lesions of low urinary tract, buttock and adjacent perineum are reported. These lesions have been induced by direct syringe injection into an umbilical artery of 42% sodium bicarbonate solution at the dose of 5 to 6 ml/kg of body weight. Radiographic examinations are very important to study the urinary tract lesions. These have been surgically controlled in two cases. The follow up ranges from 10 to 21 1/2 months. On the bladder initial necrotizing lesions are followed by calcification and parietal retraction. These bladder lesions induce a more or less important ureterohydronephrosis. To these constant lesions are variably associated urethral calcifications and stenosis, distal ureter calcifications. These lesions seem to be related to the sodium bicarbonate hyperosmolality, to the injection conditions, and to the local hemodynamic features.