[Cranial osteopathy as a complementary treatment of postural plagiocephaly]. / Place de l'ostéopathie dans la correction des déformations crâniennes du nouveau-né et du jeune enfant.

For the majority of neonates and young infants, appropriate postures and standard physiotherapy succeed in preventing or correcting acquired cranial deformations (fetal due to restricted mobility in utero or postnatal secondary to exclusive dorsal decubitus). However in some cases, when postural management is not efficient, pediatricians will be asked by the parents about the potential benefits of osteopathy. What is osteopathic treatment? At first, diagnostic palpation will identify which suture is normally mobile with the respiratory cycle, and which has limited or absent mobility secondary to abnormal postures. Later on, the goal of the therapeutic phase is to mobilise impaired sutures, by various gentle maneuvers depending on the topography of the impairment. The treatment is not restricted to the skull but extended to the spine, pelvis and lower extremities which contribute to the deformative sequence. Osteopathic treatment belongs to complementary medicine, therefore demonstration of its scientific value and favorable results have to be provided. Based on randomized studies, the answer is yes, it significantly decreases the degree of asymmetry. Do postural deformations matter to the development of an healthy infant? It seems that the prejudice is not only esthetic but also functional, however more research is necessary. In conclusion, pediatricians should be more aware of the method and expectations: major deformative sequence since birth and increasing deformations despite preventive postures and standard physiotherapy are reasonable indications for such complementary treatment. "Preventive" osteopathy in maternity is not justified. Moreover osteopathy has no place in the treatment of craniosynostosis ; the latter belong to malformations, completely distinct from postural deformations.

[Follow-up network for newborns with a handicap risk: experience of the Pays-de-la-Loire network]. / Réseau de suivi des nouveau-nés à risque de développer un handicap: l'exemple du réseau Grandir ensemble en Pays-de-la-Loire

Newborns are given attentive perinatal care but the organization of further follow-up can be haphazard. The main consequences are the difficulties parents have in finding appropriate medical assistance for caring for high-risk infants and the absence of appropriate surveillance or efficient care. An inpatient-outpatient healthcare network enables early care of these infants and can reduce the consequences of neurosensorial sequelae. The overall impact of the regional perinatal care can also be evaluated. Such a network has been implemented in the Pays de Loire region in France since early 2003. In six months, among 1000 initially included infants, 500 were followed by pediatricians working in an outpatient (40%) or inpatient (60%) setting. This organization enables correction of over-centralization of neonatal care and the absence of coordination for follow up.

Neurodevelopmental status at 1 year predicts neuropsychiatric outcome at 14-15 years of age in very preterm infants.

BACKGROUND: Neurodevelopmental and behavioural problems have been repeatedly reported in very preterm survivors, often showing themselves later in childhood as poor school performance. Early identification of problems would mean that appropriate remedial therapy can be implemented. We have previously shown that neurodevelopmental status at 1 year was predictive of outcome at 8 years in a cohort of preterm infants. The aim of this paper was to see if neurodevelopmental outcome in adolescence could be predicted by assessment by 1 year in the same cohort of preterm infants. STUDY DESIGN: Prospective cohort study. SUBJECTS: 150 adolescents, born before 33 weeks gestation. OUTCOME MEASURES: Neurological examination, developmental quotient, vision and hearing by 1 year. At 14-15 years, neurological examination, school performance questionnaire, Schonnell test of reading age, a premorbid adjustment score, Rutter behavioural score and for those born from 1981, cognitive tests (WISC-R). RESULTS: A highly significant relationship existed between neurological status by 1 year and the need for extra educational provision, overall neurodevelopmental status, cognitive function in those that had their IQs measured and premorbid adjustment score of prepsychotic symptoms in adolescence. However, status at 1 year was not predictive of adolescent reading age or behavioural score. CONCLUSIONS: Neurodevelopmental assessment at 1 year is predictive of school performance and outcome in the adolescent period.

Correlation between prenatal velocity waveforms in the aortic isthmus and neurodevelopmental outcome between the ages of 2 and 4 years.

OBJECTIVE: Experimental studies on fetal lambs have shown that during an increase in the resistance to placental flow the delivery of oxygen to the brain is preserved as long as net flow through the aortic isthmus is antegrade. Our purpose was to determine whether the same changes in aortic isthmus flow in human subjects have any impact on neurodevelopmental outcome. STUDY DESIGN: Forty-four fetuses were retrospectively included in this study on the basis of an abnormal Doppler velocity in the umbilical artery. Mean gestational age at delivery was 33.0 +/- 2.0 weeks and mean birth weight 1386 +/- 435 g. The neurodevelopmental condition was assessed between the ages of 2 and 4 years. The developmental score was analyzed in relation to the flow patterns in the fetal aortic isthmus, which were classified as follows: group A, net isthmic flow antegrade (defined as the ratio of the systolic antegrade to the diastolic retrograde velocity integrals) (n = 39); group B, net isthmic flow retrograde (n = 5). RESULTS: Nonoptimal neurodevelopment was observed in 19 (49%) of 39 fetuses in group A and in all 5 fetuses (100%) in group B. This difference is significant and leads to a relative risk of 2.05 (95% confidence interval, 1.49-2.83) for neurodevelopmental deficit when predominantly retrograde flow is observed in the fetal aortic isthmus before birth. CONCLUSION: Measuring the ratio of antegrade to retrograde velocity integrals in the aortic isthmus could help in the indirect assessment of cerebral oxygenation during placental circulatory insufficiency.

Early brain proton magnetic resonance spectroscopy and neonatal neurology related to neurodevelopmental outcome at 1 year in term infants after presumed hypoxic-ischaemic brain injury.

This study investigated the accuracy of prediction of neurodevelopmental outcome at 1 year using cerebral proton magnetic resonance spectroscopy (MRS) and structured neonatal neurological assessment in term infants after presumed hypoxic-ischaemic brain injury. Eighteen control infants and 28 infants with presumed hypoxic-ischaemic brain injury underwent proton MRS investigation. Studies were carried out as soon as possible after the cerebral insult, most within 48 hours. Infants had an early structured neurological assessment at a median of 19 hours (range 0 hours to 9 days) from the presumed hypoxic-ischaemic insult and a late assessment at a median of 7 days (range 3 to 25 days) during recovery. The maximum cerebral peak-area ratio lactate:N-acetylaspartate measured by proton MRS accurately predicted adverse outcome at 1 year with a specificity of 93% and positive predictive value of 92%. Neurological assessment had a tendency for false-positive predictions. However, both early and late neurological examination can be used as a reliable indicator for a favourable outcome at 1 year having negative predictive values of 100% and 91% respectively.

Neurological and physical maturation in normal growth singletons from 37 to 41 weeks' gestation.

An evaluator blinded to gestational age (GA) assessed a cohort of 397 singletons born at between 37 and 41 week's gestation, by looking at 11 criteria exploring neurological maturity and 12 criteria exploring physical maturity. The analysis of correlation coefficients shows various degrees of association between GA and each of the criteria examined. A highly significant correlation (p < 0.001) was found for 4 neurological criteria defining passive tone in limbs and sucking reflex. The activity of flexor muscles of the neck and crossed extension reflex were also associated with maturity but weakly (p < 0.01). A highly significant correlation (p < 0.001) was found for 8 of the physical criteria, skin colour and texture, lanugo, ear firmness, genitalia, breast size, nipple formation and plantar skin creases. Oedema, skull firmness and ear form were also associated but weakly. With multivariate analysis combining the neurological and physical criteria, predictive values ranked in the following order: 1) plantar skin, 2) breast size, 3) sucking reflex, 4) scarf sign, 5) skin colour, 6) genitalia, 7) popliteal angle, 8) return to flexion of forearms, 9) dorsiflexion angle. In conclusion, a score based on physical and neurological criteria is associated with duration of pregnancy (r2 = 0.32) between 37 and 41 weeks' gestation. Such an instrument allows us to study fetal maturity as a variable independent of GA, and therefore makes it possible to identify various influences that may modify maturational rate during the last weeks of pregnancy.

Clinical neurology in neonatal units.

Clinical assessment is often neglected in neonatal intensive care units due to technical difficulties. When a child is in a more stable situation and when maturation progresses with postnatal weeks, neurologic assessment becomes more and more important, as it is related to the upper hemispheric functions. Several aspects are discussed here: 1) identification of maturation stages measured at 2-week intervals; 2) assessment of optimal central nervous system function in fullterm neonates at 40 corrected weeks; and 3) identification of neurologic signs and symptoms, evolutive profile, and estimation of severity. Early intervention programs and follow-up have to be based on these clinical findings in order to focus on the infants who really need these services.

Does neurological assessment still have a place in the NICU?

Comments at discharge from the neonatal intensive care unit tend to concern porencephalic cysts or ventricular dilatation rather than clinical neurological findings. This neglect in collecting clinical information can be understood during the acute stage of neonatal adaptation due to the non-specificity and lability of many neurological signs. However, it does not seem justified when the infant has recovered, can breathe on his/her own and can tolerate handling. To define optimal Central Nervous System function at 40 weeks (just born or corrected), a simple basic assessment composed of nine variables is proposed, with descriptions and illustrations. Rationale for the timing and selection of variables is discussed. The benefit of this clinical approach is to subdivide children with normal ultrasound imaging into two subgroups according to non-optimal or optimal responses. Prospective follow-up of children with non-optimal responses will reduce the number of late diagnoses of developmental disabilities. Rational optimism for the others will diminish parents' anxiety and neurologic clinics' overload.

Relation of early neuromotor and cranial signs with neuropsychological outcome at 4 years.

The persistence and predictive value at 3-5 years of age of three signs detected within the first 18 months of life were investigated: phasic stretch reflex in one or both gastrocnemius muscles, imbalance in passive axial tone with an excess of dorsal extension, and a ridge on the squamous sutures. Phasic stretch reflex and at least one of the other signs were found in 14 children during repeated assessments within the first 18 months. The progress of these children was compared with that of 14 matched controls who had repeatedly normal neurological assessments during the first 18 months in the same clinic in Paris. At the age 3-5 years all the children were then assessed blindly by the second author from a pediatric neurological viewpoint and by two psychologists and two psychomotor therapists as well. The parents of the affected children reported significantly more problems in motor/praxis skills, language development and attention. Abnormal neurological signs were also significantly more frequent than in the controls. Suboptimal cognition did not reach significance. The neurological inclusion criteria were still present at 3-5 years old in 86% (vs. respectively 100% and 93% during the first 18 months of life) of this small group of children, while the cranial suture sign was still present in only 28% (vs. 64%). Findings of these three signs during the first 18 months of life may help in predicting long-term neurobehavioral or long-term neuropsychological problems.

[Perinatal neurology: panoramic view]. / La neurologie périnatale: vue panoramique.

Four of the most typical anatomo-clinical syndrome of perinatal brain damage are schematically described, concerning risk circumstances, pathology, signs and symptoms, investigations and long term prognosis. The goal of this oversimplistic approach is to offer to the obstetricians some clues about expectation and decisions in various categories of risk. The relation Maturation-Brain damage, the respective role of mechanical and asphyxic insult are discussed. A rough estimation of the risk of severe sequelae according to birth weight is proposed, with implications on prevention of brain damage.

Adaptive changes in the developing brain during intrauterine stress.

Maturation of neurological performance in moderately to severely growth-retarded newborn infants (SGA) can be accelerated by 3 to 4 weeks or more when compared to the development of appropriately grown infants (AGA) of the same gestation. This is particularly the case in multiple pregnancies or pregnancies characterized by maternal hypertension. This clinical finding has been confirmed by neurophysiological studies on the maturation of brainstem auditory evoked responses (BAERs). The possible mechanisms which underly this phenomenon are not yet elucidated. Glucocorticoids, other steroid hormones and catecholamines are elevated in pregnancies with placental dysfunction, and it is known that these substances have multiple actions on neuronal maturation, particularly on mechanisms of release of neurotransmitters. These observations suggest that the acceleration of brain maturation, and lung maturation, in SGA infants reflects an adaptation of the fetus to early extrauterine life. However, if the placental dysfunction progresses, these mechanisms of adaptation will be overwhelmed by severe malnutrition and anoxia which result in cerebral lesions and risk of death. The clinical goal at the present time for obstetric management of these risk pregnancies is to distinguish between these two periods.

Measurement of post-operative pain and narcotic administration in infants using a new clinical scoring system.

We developed a clinical neurologic and behavioral scoring system composed of 10 items to measure the post-operative pain levels in infants: (1) sleep during preceeding hour, (2) facial expression of pain, (3) quality of cry, (4) spontaneous motor activity, (5) Spontaneous excitability, (6) flexion of fingers and toes, (7) sucking, (8) global evaluation of tone, (9) consolability and (10) sociability. Using this system, a group of infants ranging from one to seven months in age and undergoing minor surgical procedures was studied. The infants were randomly assigned to two groups: Group I received Fentanyl intravenously (3 micrograms/kg) prior to surgery, and Group II received a placebo. The infants then were studied post-operatively in the recovery room at 30, 60, 90 and 120 min intervals. Over the entire post-operative observation period, 54% of the infants in Group I had satisfactory analgesia compared to 18% in Group II. There were no significant differences in Group I and Group II in oxygenation, carbon dioxide elimination, blood pressure, heart rate or temperature.