[Adaptation of Health Care Organization in a level III Maternity Hospital during the COVID-19 pandemic]. / Adaptation de l'organisation des soins d'une maternité de type 3 durant l'épidémie due à la COVID-19.

The COVID-19 pandemic required a rapid adaptation of health care organization. The objective was to ensure the care of patients avoiding contamination at the time of delivery and for the nursing staff. The establishment of parent-child essential links beyond the pandemic was also taken into account. The reorganization of care first relied upon the constitution of a multidisciplinary operational team which allowed for efficient responsiveness. Then, the activities were refocused on the epidemic situation with the deprogramming of non-urgent activities and the articulation with the ambulatory network. A reorganization of the schedules and a specific training in dressing were carried out. The supply of surgical masks, disinfectant gels and wipes has been provided. A triage of admissions was set up with a special circuit and dedicated staff. A specific delivery room and operating theater equipped with strictly essential materials have been associated with a specific neonatal resuscitation station. In neonatology, two sectors where positive pressure has been suspended have been dedicated to families at risk. Wearing a mask and washing hands with disinfection with hydroalcoholic gel was required for all patients. The children were left at their mothers' bedside in a private room. An incentive for breastfeeding was made. Early discharge from 48 hours was systematically organized with relay by midwife at home. In conclusion, this adaptation of the organization of care has made it possible to respond satisfactorily to the specific situation of this pandemic.

Algorithm for predicting threshold retinopathy of prematurity is insufficient and fundus examinations are still needed before 31 weeks.

AIM: We evaluated the weight, insulin-like growth factor-1, neonatal, retinopathy of prematurity (WINROP) algorithm for very premature infants. METHOD: Infants born before 32 weeks who had undergone fundus examinations in the neonatal intensive care unit at the University Hospital of Nancy were included in this French retrospective cohort study from July 2012 to July 2016. We evaluated how well the WINROP software predicted threshold retinopathy of prematurity (ROP). RESULTS: We studied 570 infants with a mean gestational age of 28.7 ± 1.8 weeks and a mean birth weight of 1110 ± 297 g: 28.1% had ROP and 1.2% had threshold ROP. The overall WINROP sensitivity was 57.1%, specificity was 46.0%, predictive positive value was 1.3% and predictive negative value was 98.9%. At more than 30 weeks of gestation or 1250 g, these figures rose to a respective specificity of 100% and 95.7% and respective predictive negative value of 100% and 100%. There were independent associations between the severity of ROP and the Apgar score at five minutes, the duration of oxygen therapy and non-invasive ventilation. CONCLUSION: WINROP worked better on preterm infants born from 31 weeks onwards or weighing over 1250 g. Fundus examinations remain necessary for infants born earlier or lighter.

Review shows that using surfactant a number of times or as a vehicle for budesonide may reduce the risk of bronchopulmonary dysplasia.

AIM: Bronchopulmonary dysplasia (BPD) remains the most common respiratory morbidity in immature infants. This review describes the diagnosis of BPD has evolved and summarises the therapeutic approaches that have made it possible to limit the incidence of BPD. METHOD: We reviewed the literature from the first definition of BPD by Northway in 1967 to the surfactant treatment policies that are currently in use, drawing on more than 50 papers up to 2017. RESULTS: Our review showed that improvements in neonatal survival have been associated with an increased risk of severe BPD, significant levels of long-term morbidity and the increased use of healthcare resources. These issues have encouraged researchers to explore potential new treatments that limit the incidence of BPD. Repeated surfactant instillation and the use of surfactant as a vehicle for budesonide are promising strategies for alleviating the burden of chronic lung disease. Ongoing research on surfactant or stem cell therapy may further improve the respiratory prognosis for prematurely born children. CONCLUSION: Considerable research has been carried out into the increase in BPD, which has resulted from improvements in neonatal survival. Key areas of research include repeated surfactant administration, using surfactant as a vehicle for budesonide and stem cell therapy.

Term newborns at risk for early-onset neonatal sepsis: Clinical surveillance versus systematic paraclinical test.

INTRODUCTION: Early-onset neonatal sepsis is a rare but potentially lethal infection that is very often suspected in daily practice. Previous national guidelines recommended the use of systematic paraclinical tests for healthy term newborns with suspected infection. These guidelines were updated in 2017 by the French Health Authority (Haute Autorité de santé), and promote initial clinical monitoring taking into account the infectious risk level for term and near-term born infants. OBJECTIVES: To assess the impact of the new recommendations on antibiotic therapy prescription and invasive tests, and on the outcomes of infants born from 36weeks' gestation. MATERIALS AND METHODS: This study compared the management and the outcome of neonates born from 36weeks' gestation at the level III University Hospital of Nancy, according to their infectious risk level during two periods, before and after the update of national recommendations: from July 1 to December 31, 2017, versus July 1 to December 31, 2018. Data were retrospectively collected from the infants' files. This study compared the number and length of antibiotic treatment and the number of invasive tests, the number of documented infections, the number and length of hospitalization, and mortality between the two periods. RESULTS: During the first period, among 1248 eligible newborns, 643 presented an infectious risk factor, versus 1152 newborns with 343 having an infectious risk factor during the second period. Antibiotic treatment was initiated for 18 newborns during the first period (1.4%) and for nine during the second (0.8%) (P=0.13). The mean (SD) duration of the antibiotic treatment was longer in the first than in the second period: 6.3±2days vs. 3.1±2.3days (P=0.003). There was no death related to neonatal infection. A total of 1052 blood samples were collected during the first period versus 51 during the second (P<0.01). There was no documented infection. In the first period, there were 18 newborns (1.4%) hospitalized for suspected infection versus nine (0.8%) in the second period (P=0.13). The duration of hospitalization was 5.7±1.7days in the first period versus 5.2±3days in the second (P=0.33). CONCLUSION: In this study, the application of the new guidelines enabled a reduction of antibiotic exposure and a reduction of invasive tests without additional risk.

Methaemoglobinaemia risk factors with inhaled nitric oxide therapy in newborn infants.

BACKGROUND: Inhaled nitric oxide (iNO), commonly used for hypoxic neonates, may react with haemoglobin to form methaemoglobin (MetHb). MetHb monitoring during iNO therapy has been questioned since low doses of iNO are used. AIM: To evaluate the incidence of and identify risk factors associated with elevated MetHb in neonates treated with iNO. METHODS: Neonates who were treated with iNO and had at least one MetHb measurement were included. Demographic characteristics and methods of iNO administration (dosage, duration) at the time of each MetHb measurement were analysed. RESULTS: Four hundred and fifty-two MetHb measurements from 81 premature and 82 term and near-term infants were analysed. MetHb was above 5% in one-term infant, and between 2.5-5% in 16 infants. A higher maximum dose of iNO (22.7 vs 17.7 p.p.m.), but not gestational age, was a significant risk factor for elevated MetHb. Significantly higher oxygen levels (75.5% vs 51.7%) were associated with higher MetHb in term infants. Preterm infants had no risk for high MetHb when iNO was kept below 8 p.p.m. These data suggest the possibility of limiting blood withdrawal when low doses iNO are used. CONCLUSION: High MetHb is exceptional in neonates treated with low dose iNO. Associated risk factors are related to high iNO dose and the simultaneous use of high concentrations of oxygen.

Knowledge assessment of sudden infant death syndrome risk factors in expectant mothers: A prospective monocentric descriptive study.

In France, approximately 500 deaths per year are related to sudden infant death syndrome (SIDS). After a 75% reduction of SIDS-related deaths in the 1990s, thanks to large prevention campaigns directing parents to put their infants to sleep on their back, the number of SIDS-related deaths remains stable. However, we estimate that 100-200 infant deaths per year in France could be prevented with better education on the risk factors for SIDS. In this prospective, descriptive monocentric study, we aimed to evaluate the level of expectant women's knowledge about SIDS. Questionnaires were distributed during a midwife consultation. A score on sleeping conditions, environmental and protective factors was determined with coefficients attributed according to their relevance to SIDS. Of 296 questionnaires distributed, 202 were completed and included in the analysis from March 1 to September 21, 2018. Scores were distributed from 2 to 46/50. The average score was 28.6/50. Information was principally obtained from media and not health professionals. When the information was delivered by a caregiver, in particular by a paediatrician, we observed better knowledge among these women. This study shows that it is important for health professionals to take the time to inform future mothers about the risk factors for SIDS, especially the least informed population groups such as young mothers and those from lower socioeconomic status, in order to reduce the number of avoidable infant deaths.

[Neonatal Bartter syndrome's special features in very premature newborns]. / Particularités diagnostiques du syndrome de Bartter néonatal chez le nouveau-né grand prématuré

Neonatal Bartter syndrome is a rare condition, usually revealed by alkalosis and hypokalemia. Clinical and biological signs of neonatal Bartter syndrome are quite different from those encountered when this disease is diagnosed in older children. Diagnosis of neonatal Bartter syndrome is even more difficult in very preterm infants. The aim of this study was to highlight specific clinical and biological signs that may help direct physicians towards the diagnosis of neonatal Bartter syndrome when premature infants present with an atypical renal tubular disorder. Our case reports focus on excessive diuresis with elevated renal sodium excretion and severe dehydration. Correcting tubular disorders early may help avoid dehydration in the fragile preterm newborn.

[Impact of very preterm birth on visuospatial processes at 5 years of age]. / Conséquences de la grande prématurité dans le domaine visuo-spatial, à l'âge de cinq ans.

OBJECTIVE: Very preterm children can experience cognitive and behavioral difficulties. The aim of this study was to assess the impact of very preterm birth on visuospatial processes at preschool age. DESIGN AND METHODS: Data come from the Epipage study. Participants underwent a follow-up evaluation at age 5 years. During the psychological evaluation, children took subtests of the K-ABC and the WPPSI-R. Six subtests are based on visuospatial information. RESULTS: The results concern 183 children assessed in the Lorraine region of France, who were born with birthweight appropriate for gestational age and had no neurological sequelae. Thirty-six children were born at term, 112 were born very prematurely (28-32 GW), and 35 were born extremely prematurely (<28 GW). Birth term was significantly correlated with performance on the six subtests. In all cases, the children born at term obtained higher scores compared to the children born very prematurely and extremely prematurely. On two subtests of the K-ABC, the children born extremely prematurely obtained lower scores than those of the children born very prematurely. The mother's level of education was correlated with performance on three subtests. CONCLUSION: The results suggest that a very preterm birth can exert a negative impact on visuospatial and visuomotor processes. These deficits may involve difficulties in some activities at school and in daily life.

[Efficacy of combined active-passive immunization in neonates born to hepatitis B surface antigen positive mothers: a study of 60 cases]. / Efficacité de la sérovaccination chez des nouveau-nés de mères antigènes HBs positif: à propos de 60 observations.

OBJECTIVES: To evaluate the efficacy of hepatitis B serovaccination in neonates born to HBsAg carrier mothers. MATERIALS AND METHODS: This study was performed in neonates born to HBsAg carrier mothers. They received one dose of hepatitis B immunoglobulins (0.3 ml/kg) at birth and four doses of vaccine (0, 1, 2 and 12 months of age). A second dose of hepatitis B immunoglobulins was given at 1 month of age in neonates born to hepatitis B antigen-positive carrier mothers. RESULTS: Sixty infants were included. Fifty-seven infants (95.0%) were not infected. The two infected infants were born to hepatitis Be antigen-positive carrier mothers. One infant was chronically infected by hepatitis B virus antenatal transmission and the second one developed an acute hepatitis by vertical perinatal transmission. One to 3 months after the third vaccinal dose, 16 infants (31.4%) were poor responders to vaccine. CONCLUSION: The hepatitis B serovaccination is efficient with four vaccinal doses. In infants born to hepatitis Be antigen-positive carrier mothers the efficacy could be improved increasing the dose of hepatitis B immunoglobulins (0.6 ml/kg) at birth and adding a second dose (0.6 ml/kg) at 3 weeks of life. A careful serological follow-up could be also suggested.

[Early discharge of newborns: what problems should we anticipate?]. / Sorties précoces de maternité : quels problèmes anticiper ?

INTRODUCTION: Following Nordic and Anglo-Saxon countries, France is directing towards an early discharge policy from maternity hospitals. French National Authority for Health has published recommendations focusing on the importance to highlight the dangers of such a policy so as to be able to anticipate them. AIM: To describe the complications diagnosed in the newborn infants from day 2 to the current hospital's discharge (noteworthy, if infants are discharged early, these complications may occur at home) to determine predictive factors and to validate those proposed by the French National Authority for Health. METHOD: Prospective study conducted in the maternity ward of Nancy's level III facility, from January 6th to May 6th 2005. RESULTS: Nine hundred and three newborn infants were included. Forty-two (4.6%) presented with complications diagnosed from day 2 to hospital's discharge, among which 4 required urgent neonatal care. The most frequent complication was hyperbilirubinemia: 23 newborns were treated with phototherapy between day 2 and day 10. Statistically significant risk factors of hyperbilirubinemia after day 2 in multivariate analysis were instrumental vaginal delivery (OR=2.94; CI 95% [1.04-8.34]) and jaundice before day 2 (OR=7.39; CI 95% [2.66-20.55]). According to the French National Authority for Health's policy, 33 among 42 infants presenting with a complication would have been withdrawn from an early discharge program. CONCLUSION: In our population, French National Authority for Health's recommendations were relevant to guide an early discharge project.

[Methodological aspects of economic evaluation in pediatrics: illustration by RSV infection prophylaxis in the French setting]. / Aspects méthodologiques de l'évaluation économique du médicament en pédiatrie : exemple de la prophylaxie de l'infection à VRS en France.

The methodological approach of the economic evaluation of drugs in pediatrics is illustrated by the case study of the prophylaxis for RSV infections using palivizumab in the French setting. The indications for the reimbursement of this treatment have been restricted to premature children with bronchopulmonary dysplasia (BPD) or hemodynamically significant congenital-heart disease. A model was developed primarily using the results of the pivotal clinical studies on palivizumab. Unit costs were estimated (2006 values) in both societal and payer's perspectives. An assumption was made and discussed on the benefits of the prophylaxis on mortality. Based on the different data available and the estimated costs and benefits, different cost-effectiveness ratios (CERs) were estimated from both the society's and payer's points of view. A discount rate of 3% was applied to benefit. The CER obtained in the most unfavorable case is considered acceptable for the innovative-medical technologies in the French-healthcare system. Some of the parameters used by the model will be illustrated from the EPIPAGE study data from 2 of the 9 regions involved in this study: this evaluation suggests that the children not having an RSV infection during their 1st year of life will continue to require significantly fewer hospitalizations in the following years. These additional evaluations also suggest that the model overestimates the costs of the treatment with regard to the true medical situation. This could be explained by the model not using the children's exact weight or the real number of injections because the children had been discharged from the maternity ward based on their date of birth and the epidemic period. In spite of these factors, RSV prophylaxis using palivizumab in premature children with BPD or hemodynamically significant congenital-heart disease can be considered cost-effective in France.

Outcome of children born after pregnancy denial.

INTRODUCTION: Denial of pregnancy remains a phenomenon little known to healthcare professionals. Yet its repercussions are far from negligible. The aim of this study was to assess whether denial of pregnancy has an impact on the infant's development. PATIENTS AND METHOD: This prospective study included 51 full-term infants born in Nancy Regional Maternity Hospital between 1 January 2009 and 30 June 2015. In this study, the development of the children was followed longitudinally. We collected data during the neonatal period, at 9months, and at 2years of age from the infants' file and standardized medical certificates, and current data through a telephone questionnaire. Three fundamental aspects of the infants' development were analyzed: height and weight growth, psychomotor development, and the existence of pathologies. Given that this was a preliminary study aiming at exploring facts, no statistical tests were carried out. RESULTS: The rate of denial of pregnancy was one birth in 300 during the study period. These infants showed proportional intrauterine growth restriction, which leveled out later, with their height and weight growth normal by month 9. The full-term perinatal mortality rate was 5%. The infants showed no sign of increased morbidity; 20% of them presented with delayed psychomotor development at 9months of age, with an increased impact as they grew older. The rate reached 30% after 24months, half of which were language disorders. CONCLUSION: The results of this preliminary study point out the need for thorough monitoring of these infants throughout infancy.

[Thrombotic thrombocytopenic purpura in a newborn]. / Purpura thrombotique thrombocytopénique chez un nouveau-né.

A newborn presented with haemolytic anemia, thrombocytopenia, hyperbilirubinemia and renal failure as early as the first hours of life. An early plasmatherapy was undertaken, followed by good outcome. The specific von Willebrand factor-cleaving protease (ADAMTS 13) was found at less than 5%. This is the specific biologic diagnostic element of congenital thrombotic thrombocytopenic purpura or Upshaw-Schulman syndrome. This disease of constitutional thrombotic microangiopathy was well identified and understood only few years ago. It's a rare disease which early diagnosis and treatment are crucial in order to preserve functional and vital capacities of the patient.

[Is it justifiable to administrate vitamin A, E and D for 6 months in the premature infants?]. / Est-il légitime d'administrer des vitamines liposolubles (A, E et D) chez le prématuré pendant 6 mois?

UNLABELLED: Information on the vitamin A and E nutritional status in preterm infants is scarce. POPULATION AND METHODS: In the present prospective and longitudinal study, we measured the plasma concentrations of vitamins A, E, D and of retinol binding protein (RBP) in preterm infants (32-34 weeks of gestation) at birth, and verified whether oral supplementation with these 3 vitamins for 1, 3 and 6 months affected their plasma concentrations. The 17 consecutively recruited premature infants received daily 3000 IU of vitamin A, 5 mg of vitamin E and 1000 IU of vitamin D. RESULTS: At birth, premature infants exhibited a low plasma concentrations of vitamin A (0.66 [0.41-0.96]) micromol/l, vitamin E (8.1 [4.2-16.9] micromol/l), RBP (0.45 [0.22-0.71] micromol/l) and 25 hydroxyvitamine D (25 OHD) (20 [20-40] nmol/l). Plasma vitamin A, E , D and RBP concentrations increased with time, but vitamin A at 1, 3 and 6 months did not attain values considered normal in term infants or adolescents. At 6 months, the plasma 25 OHD was at 92 (71-116) nmol/l, a concentration considered normal and non-toxic. CONCLUSION: We recommend to increase oral administration of vitamin A to 5000 IU/day, at least for the first month of life and, thereafter to administer 3000 IU for 5 months. As for vitamin E and vitamin D, the doses used in this study are sufficient but should be administered for 6 months.

[Antenatal betamethasone during pregnancy with severe diabetes: is better worse than good?]. / Maturation par bêtaméthasone au cours d'une grossesse de femme présentant un diabète compliqué: le mieux est-il l'ennemi du bien?

Diabetic pregnancy is a precarious situation, both for mother and fetus, because it increases the risk of prematurity and respiratory distress. We report 3 cases of severe acute complications following antenatal betamethasone treatment in mothers presenting with severe diabetes. Corticosteroids are strongly recommended to prevent prematurity complications in newborns. We highlight the high risk profile of theses pregnancies, the effect of this treatment on the mother and the child, and question the real benefit of corticotherapy for these fragile newborns. The metabolic and blood pressure balance is dangerously disturbed in such pregnancies by this treatment. This brings the question of how justified are corticosteroids in such cases?

[Secondary right-sided diaphragmatic hernia following neonatal group B Streptococcal septicaemia in a preterm infant]. / Hernie diaphragmatique droite à révélation secondaire et septicémie néonatale à Streptocoque B chez un prématuré.

We report on a case of a secondary right-sided diaphragmatic hernia following group B streptococcal (GBS) septicaemia in a very low birth weight infant born at 30 weeks. After initial improvement, the diagnosis of a secondary right-sided diaphragmatic hernia was suspected with the persistent radiological pulmonary right-sided image on the chest x-ray and the clinical degradation. The diagnosis was confirmed by ultrasonography on day 43. The postoperative course was simple. Persistent respiratory distress in a neonate, after a GBS septicaemia associated with a right pulmonary opacity on the chest x-ray, should prompt a careful evaluation. A secondary right-sided diaphragmatic hernia should be considered. Treatment is surgery, the prognosis is good in the absence of pulmonary hypoplasia.

[Childhood's ophthalmologic involvement in Sturge-Weber-Krabbe syndrome]. / Atteintes ophtalmologiques de l'enfance dans le cadre du syndrome de Sturge-Weber-Krabbe.

Ophthalmologic involvement in Sturge-Weber-Krabbe syndrome (SWKS) is present in 30-70% of cases and needs to be reviewed because of its impact on visual development. We report a case of a newborn for whom SSWK with ophthalmologic involvement was suspected. She had a right segmental plane angioma associated with right congenital glaucoma and suspected right pial angioma. Ophthalmic involvement in SWKS may be nonocular: iatrogenic by treatment-associated complications and central by leptomeningeal damage. Ophthalmologic involvement can occur throughout childhood and is mainly represented by glaucoma and diffuse choroidal hemangioma and then conjunctival hemangioma, retinal detachment, and iris heterochromia. SWKS requires multidisciplinary care with eye examination and prolonged follow-up as soon as clinical suspicion arises.

[Value of gastric fluid to start antibiotics in premature babies suspected of having early neonatal bacterial infection]. / Intérêt du liquide gastrique dans la décision d'antibiothérapie du nouveau-né prématuré suspect d'infection bactérienne précoce.

The objective of this study was to evaluate the value of direct examination and culture of gastric fluid in the treatment of early neonatal bacterial infections (INBP) in pre-term infants. MATERIALS AND METHODS: Observational study conducted over 6 months in a Type III center. All hospitalized premature babies who had routine gastric fluid sampling at birth during the period of the study were included. They were classified into two groups: premature infants with probable or suspected infection and treated as such (Group 1) and premature infants with no infection or only having colonization (Group 2). RESULTS AND DISCUSSION: In total, 255 pre-term infants were included in the study. Group 1 consisted of 127 newborns and group 2 consisted of 128 newborns. The direct gastric fluid examination was positive in 51 newborns in Group 1 and in 46 newborns in group 2. The culture was positive in 25 newborns in group 1 and eight newborns in group 2. Direct examination of gastric fluid of the 255 children studied had low sensitivity (40.1%) and low specificity (64%) of INBP, with 52.6% positive predictive value (PPV) and 51.8% negative predictive value (NPV). The gastric fluid culture was specific (93.7%) of the INBP, sensitivity was low (19.6%), with PPV at 75.7% and NPV at 54%. CONCLUSION: These results undermine the relevance of the direct examination of gastric fluid in the delicate diagnosis of INBP. This direct examination has a low PPV and NPV. It is advisable not to start or stop antibiotic therapy solely on this argument; however, it can guide the choice of antibiotic therapy and remains useful for this reason. The culture of gastric fluid has very good specificity (93.7%).

[Vitamin K in the neonate: Recommendations update]. / Vitamine K chez le nouveau-né : mise à jour des recommandations.

Hemorrhagic disease of the newborn is not common but may be very serious, with cerebral, hepatic, or adrenal gland bleeding. Its prevention is based upon vitamin K1 administration from birth. Scientific studies to validate appropriate treatment policies are scarce, with recommendations coming from expert opinions, retrospective studies, or controversies on possible side effects. After analysis of recent literature data, we propose an oral administration of three doses of 2mg of vitamin K1 at birth, at discharge from the maternity ward, and at 1 month postnatal age for term infants. For premature infants born with a birth weight above 1500g, a weekly dose of 2mg up to term equivalent age may be recommended. For premature infants below 1500g, a weekly dose of 1mg up to 1500g body weight, then a weekly dose of 2mg up to term equivalent age seems appropriate. If oral administration is not possible, the intravenous or intramuscular route may be used with a 50% reduction in dosing.