[Evaluation of an educational intervention on the standard of neonatal resuscitation: orotracheal versus nasotracheal intubation]. / Quelle technique d'intubation enseigner dans un programme de formation à la réanimation en salle de naissance : voie orotrachéale ou nasotrachéale ?

UNLABELLED: Proficiency in endotracheal intubation is an essential step in the neonatal resuscitation process. This skill is difficult to acquire and its mastery requires experience. Recent changes in neonatal resuscitation guidelines (ILCOR 2006) have resulted in a decrease in the opportunities to practice intubations. Appropriate education and training is therefore essential. The goal of this study was to assess the skills of neonatal care professionals in performing intubation via orotracheal (OT) and nasotracheal (NT) routes. METHODS: OT and NT intubation attempts were compared during training on a neonatal mannequin (Laerdal, Neonatal Resuscitation Baby((R))) at each course of an educational intervention on neonatal resuscitation organized in level 1-3 institutions of the Maternités en Yvelines Perinatal Network. The duration of these attempts was noted; intubation in less than 30s was considered successful. RESULTS: Thirty-two midwifery students (STD), 103 midwives (MW) and 25 pediatricians (PED) participated in the study. The median (IQR) time for intubation was less with the OT route than with the NT route for STD (12.0 vs 23.0s; p=0.001), MW (14.0 vs 25.0s; p=0.001), and PEDs (13.0 vs 20.0s; p=0.007). The success rates for intubation in less than 30s were higher for the OT than the NT routes for STD (100% vs 66%; p=0.001), MW (97% vs 69%; p=0.001) and PED (92% vs 88%; p=NS). CONCLUSION: This study confirms that OT intubation training resulted in a higher success rate and lower duration for intubation. Practical courses in neonatal resuscitation should include training with OT intubation.

[Medication errors in neonatology: a review]. / Les erreurs de prescriptions en néonatologie: incidence, types d' erreurs, détection et prévention.

Of all medical errors, medication errors are the most common as well as the most frequent cause of adverse events, the majority of them being preventable. Errors are possible at any step of the process from ordering, dispensing and administration. Neonates are reported to be at greater risk of medication error than older children and adults. The type and frequencies of reported errors are a function of the method of detection. Drug errors are a consequence of human and system errors, and preventive strategies are possible through system analysis. Interventions to decrease medication-related adverse events in neonatal intensive care unit should aim to increase staff awareness of medication safety issues and focus on medication administration process.

[Correct procedure in the presence of a fetal goiter associated with hypothyroidism. Observations from three cases]. / Conduite à tenir en présence d'un goitre foetal hypothyroïdien. A propos de trois observations.

Fetal goiter is a rare occurrence of which neonatal consequences are not always predictable. Concerning three cases of goiters associated with hypothyroidism discovered in utero, the authors describe the way to take care of in this bad codified situation. They insist upon the major role of ultrasound for goiter diagnosis and its impacts and for control of treatment efficiency. They also discuss intra amniotic L-Thyroxine injection and insist upon the necessity to obtain quick and definite thyroid evaluation after birth before decision to abstain from neonatal therapy.

Benefit of antenatal glucocorticoids according to the cause of very premature birth.

In this observational study performed in a large cohort of very preterm singletons, respiratory outcome was found to be strongly dependent on the cause of premature delivery. Although less apparent in infants born to mothers with chorioamnionitis, exposure to antenatal glucocorticoids remained significantly associated with a decrease in the incidence of respiratory distress syndrome after adjustment for the main cause of premature birth.

[Oxygen therapy in the neonatal period]. / Oxygénothérapie en période néonatale.

Although oxygen has been widely used in the neonatal period for many years, and although serious complications such as retinopathy of the premature infant have been directly attributed to its use, there persists a degree of uncertainty about the optimal level of oxygen which should be used or target levels to achieve. There is a great variability in current practices. Some theoretical data and recent clinical results question uncontrolled use of oxygen during the neonatal period. Controlled studies comparing the effects of strategies with different target levels for oxygen saturation are planned to provide evidence-based answers to these questions.

Population pharmacokinetics of midazolam in neonates.

OBJECTIVE: To describe the pharmacokinetics of midazolam, a water-soluble benzodiazepine with a short half-life, in critically ill neonates. HYPOTHESIS: Midazolam clearance is reduced in neonates compared with clearance in children, and the doses currently in use, which are derived from pediatric studies, are excessive. PATIENTS AND METHODS: This population study was conducted in 187 neonates requiring intravenous sedation for artificial ventilation. The 531 midazolam concentration measurements obtained were analyzed by use of NONMEM and a two-compartment model with four parameters: clearance (CL), central volume (Vc), peripheral volume (Vp), and intercompartmental clearance (Q). The influence of birth weight (range, 700 to 5200 gm), gestational age (range, 26 to 42 weeks), postnatal age (range, 0 to 10 days), and comedications were investigated. RESULTS: CL and Vc (mean +/- SE) were found to be directly proportional to birth weight (CL = 0.070 +/- 0.013 L/kg/hr; VC = 0.591 +/- 0.065 L/kg). The CL was 1.6 times higher in neonates with a gestational age of more than 39 weeks. It was 0.7 times lower in neonates receiving inotropic support. The postnatal age had no apparent effect on midazolam kinetics. The Vp and Q (mean +/- SE; 0.42 +/- 0.11 L and 0.29 +/- 0.08 L/hr, respectively) were not influenced by any of the covariates studied. There was a large interindividual variability for the pharmacokinetic parameters. CONCLUSION: The mean midazolam doses required for critically ill neonates are lower than those required for older infants.

[Erythrocyte transfusion in the newborn]. / La transfusion érythrocytaire chez le nouveau-né.

The main aim of erythrocyte transfusion in the newborn infant is to improve oxygen transport to the tissues. However, clear evidence for its effectiveness in this objective is lacking. In addition, the potential complications (mainly viral infections) of transfusion have led to a limitation of its use. Indications and modes of application are presented based upon the recommendations of the French national agency for health practice assessment (ANAES).

[APN: evaluation behavioral scale of acute pain in newborn infants]. / DAN: une échelle comportementale d'évaluation de la douleur aiguë du nouveau-né.

AIM: This study was designed to validate a behavioral acute pain rating scale for term and preterm neonates (APN). METHODS: From January through June 1996, neonates requiring a heel lance or a venous puncture for blood sampling at the intensive care unit and the nursery of Poissy Hospital were recruited into the study. After a pilot study, a pain rating scale was developed. The scale score pain ranged from 0 to 10 and it evaluated three items: facial expression, limb movements, and vocal expression with ratings per item ranging from 0 to 4, 0 to 3 and 0 to 3, respectively. Two observers evaluated independently each infant during a painful procedure (puncture for a blood sample) and during a dummy procedure (rubbing the thigh softly). RESULTS: Forty-two neonates born between 25 and 41 weeks gestational age were included in the study. Medians (quartiles) of gestational age, birth weight, and corrected postmenstrual age at time of investigation were 34 (29-39) weeks, 1,850 (1,055-3,093) g, and 35.5 (31-39) weeks, respectively. Ten infants were intubated. The scale showed to be sensitive because all possible scores were obtained; during painful procedures scores ranged from 1 to 10, with 95% of scores > or = 3 while during dummy procedures they ranged from 0 to 5, with 88% of scores < or = 2. The medians (95% confidence interval) of scores were for painful procedures 5 (5 to 7) and for dummy procedures 1 (0 to 1). This indicates a good specificity of the scale. High intercorrelation of items (internal consistency) was confirmed by a Cronbach's coefficient alpha of 0.88. Inter-rater agreement was high since the Krippendorff R test was 91.2. CONCLUSION: This behavioral acute pain rating scale for newborns demonstrated a good specificity and sensitivity, internal consistency and inter-rater reliability. This scale could be used to test the analgesic effects of different therapies during painful procedures.

[Jargon of the neonatal intensive care unit]. / Le jargon de la réanimation néonatale.

Jargon, the specialized vocabulary and idioms, is frequently used by people of the same work or profession. The neonatal intensive care unit (NICU) makes no exception to this. As a matter of fact, NICU is one place where jargon is constantly developing in parallel with the evolution of techniques and treatments. The use of jargon within the NICU is very practical for those who work in these units. However, this jargon is frequently used by neonatologists in medical reports or other kinds of communication with unspecialized physicians. Even if part of the specialized vocabulary can be decoded by physicians not working in the NICU, they do not always know the exact place that these techniques or treatments have in the management of their patients. The aim of this article is to describe the most frequent jargon terms used in the French NICU and to give up-to-date information on the importance of the techniques or treatments that they describe.

[Use of a polyethylene bag: a way to improve the thermal environment of the premature newborn at the delivery room]. / Utilisation d'un sac en polyéthylène: un moyen d'améliorer l'environnement thermique du prématuré en salle de naissance.

BACKGROUND: Early interventions, such as occlusive wrapping of very low birth weight infants at delivery reduce postnatal temperature fall. This new intervention was implemented in our hospital on January 2000. The aim of this study was to investigate retrospectively the effect of polyethylene wrap, applied immediately at birth, on thermoregulation. PATIENTS AND METHODS: Matched pair analysis was conducted for 60 infants delivered inborn at less than 33 weeks' gestation and 60 premature infants who were born during the second half of 1999 fulfilling the same criteria. The only difference in the management (medical and environmental) was wrapping with a polyethylene bag in the delivery room. Rectal temperature and other vital parameters were taken, after removal of wraps, on admission to NICU. RESULTS: The perinatal characteristics of both groups were comparable. Use of wrapping resulted in a significantly higher admission rectal temperature (difference in means = 0.8 degree C, p < 0.0001), this difference was also significant in infants < 30 weeks. The incidence of hypothermia (< 35.5 degrees C) was less frequent in infants enclosed in plastic bags (8.3% vs 55%). No side effects (skin burns, infection or hyperthermia) were attributable to the intervention. The heart rate was higher in the wrapping group (163 +/- 16 vs 150 +/- 17 b/min, p < 0.01), as well as the capillary glycemia (62 +/- 26 vs 45 +/- 30 mg/dl, p < 0.01). There was no significant difference on arterial pressure. CONCLUSION: Occlusive wrapping with a polyethylene bag at birth prevented low rectal temperature in premature infants in the immediate postnatal period. This method is easy, practical and effective, and does not interfere with current practice for resuscitation.

[Early cardiovascular effects of corticotherapy for bronchopulmonary dysplasia]. / Effets cardiovasculaires précoces de la corticothérapie pour dysplasie bronchopulmonaire.

OBJECTIVES: The aim of this study was to analyze the time course of cardiovascular effects in glucocorticoid-treated premature infants with bronchopulmonary dysplasia (BPD). METHODS: In a retrospective case study, 63 ventilator-dependent very-low-birth-weight neonates (mean gestational age = 27.9 +/- 2 weeks and mean birth weight = 920 +/- 275 g) treated with dexamethasone (52%) or betamethasone (48%) were studied. The average value for each study day was calculated for systolic arterial blood pressure and heart rate. RESULTS: At initiation of treatment, blood pressures increased significantly from pre-treatment to day 1 and continued to increase during the first week: as a percentage of pre-treatment baseline the mean increase for systolic arterial blood pressure was 19% (95% confidence interval [CI] = 16, 22) on day 2 (P < 0.001). The maximum amplitude of variation was observed before day 2 for 75% of the study group. As a group as a whole, the heart rate value significantly decreased on day 1 (mean difference = -14.6 beats/min; 95% CI = -16.5, -12.6; P < 0.001), and then reached pre-treatment value within one week. Cardiovascular response was independent of gestational age, birth weight and postnatal age at the beginning of treatment. CONCLUSION: During postnatal steroid therapy a rise in blood pressure is a common side effect, but bradycardia is mentioned very occasionally. The present study shows a marked increase in blood pressure during the first 48 hours concomitant with a decrease in heart rate. The inverse relationship between systolic arterial blood pressure and heart rate suggests a baroreflex response.

[Water intoxication following preparation for barium enema]. / Intoxication par l'eau après une préparation pour un lavement baryté.

BACKGROUND: Induction of water intoxication from tap water enemas was reported a few years ago. Its treatment is still debated. CASE REPORT: A 4 1/2 year-old boy was admitted because he suffered from coma grade I. A barium enema had been prescribed for fecal incontinence and the patient had been given orally about 4 liters of water during the 24 hours preceding this investigation. Blood examination showed;: Na 122 mEq/l; K 3 mEq/l; Cl 87 mEq/l. Brain CT scan was normal. The patient was placed under restriction of fluid and was given i.v. 5.8% NaCl solution (2 mM/kg) for 3 hours. Convulsions appeared despite this treatment requiring intubation and ventilation plus increasing doses of NaCl: 20% solution (2 mM/kg) for 30 minutes followed by 2 mM/kg for 3 hours, associated with mannitol and furosemide infusion. CONCLUSION: Use of hypertonic saline solutions in the treatment of water intoxication is discussed. Acute hyponatremia must be rapidly corrected using hypertonic saline solution plus restriction of fluid and diuretic.

[Inaugural acute cholestasis of Kawasaki disease]. / Cholestase aiguë inaugurale d'une maladie de Kawasaki.

BACKGROUND: Hepatic dysfunction with mild obstructive jaundice occurs occasionally in Kawasaki disease. Acute episode of cholestasis as a presenting symptom has never been reported. CASE REPORT: A 14 year-old-boy was admitted with fever and cholestasis. He subsequently developed the classical manifestations of Kawasaki disease. No signs of liver cell injury or hepatic failure were present. Bacteriological cultures and seroimmunologic markers for viral infection remained negative. There was no ultrasonic abnormality of bile ducts. The child was given intravenous gamma globulins and salicylate. The outcome was favourable without any cardiovascular complications. CONCLUSION: A persistent febrile cholestasis of unknown etiology should evoke the diagnosis of Kawasaki disease.

[Telephonic advice by an emergency department given in a simulated pediatric case]. / Conseils téléphoniques donnés aux urgences pour un cas pédiatrique simulé.

BACKGROUND: Emergency departments (ED) are requested everyday to dispense medical telephone advice for children. To evaluate the quality of telephone management, a mock scenario simulating a febrile 4 month-old-girl with signs compatible with septicemia was used. METHODS: One hundred randomly selected French emergency departments were called on. Half of the hospitals had a pediatric department with more than 20 beds; the other half did not have a pediatric department. A research technician called and said: "My baby has got fever and I do not know what to do". Additional information was given only on request. RESULTS: Ninety-four ED gave medical advice by telephone: 65% of the cases by a physician, 24.5% by a nurse, 9.5% by a nurse technician and 1% by a secretary. In hospitals without a pediatric department, physicians took calls in 76.5% of the cases, whereas in hospitals with a pediatric department they only took calls in 53% of the cases. The mean number of questions asked per ED was 3.1. The age of the child was requested by 87.2% of the respondents. Advice was given by 36.1% of the ED without asking either the age of the patient or grade of the fever. The advice given by the respondents was: come to the ED immediately (30.9%), see a community physician immediately (51%), come to the ED tomorrow (2.1%), see a community physician tomorrow (8.5%), and manage at home (7.5%). CONCLUSIONS: This study has shown important inadequacies in pediatric telephone advice given by some ED. It suggests that the respondents do not use a protocol to handle the calls; development of such protocols to guide the histories taken and advice given for the most common telephone queries is urged.

[Peritoneal tuberculosis in children: report of two cases]. / Tuberculose péritonéale de l'enfant: à propos de deux cas.

UNLABELLED: Peritoneal tuberculosis is an uncommon presentation of extra-pulmonary tuberculosis in children. It usually presents as ascites, abdominal pain, anorexia and weight loss. CASES REPORT: We report two adolescent patients who presented with ascites, fever, weight loss and abdominal distension. In one case, the diagnosis was late, and confirmed by ascites culture. In the second case, a laparoscopy was performed and showed whitish nodules involving the entire abdominal cavity, compatible with peritoneal tuberculosis, later confirmed bacteriologically. CONCLUSION: Peritoneal tuberculosis presents with nonspecific symptoms. Because laboratory investigations may not be helpful, diagnosis may be difficult. Peritoneal-fluid adenosine deaminase (ADA) determination and coelioscopy seem to be the best way to make a rapid diagnosis.

[Intraosseous infusion in children]. / Perfusion intraosseuse chez l'enfant.

BACKGROUND: Intravenous access in critically ill patients may be very difficult to obtain. The intraosseous route is an alternate way to administer fluids and drugs. CASE REPORT: A five month old infant was brought to the emergency department in profound hypovolemia requiring immediate tracheal intubation. A peripheral venous access was established and 35 ml of colloid were rapidly infused. Unfortunately, fluid extravasated and the intravenous line had to be removed. As further attempts to gain intravenous access were unsuccessful, an intraosseous needle was inserted into the left tibia 1 cm below the tibial tuberosity, and colloid and human albumin solution were infused rapidly, followed by 1.4% sodium bicarbonate. After ninety minutes of intraosseous rehydration, 2 peripheral venous lines were inserted, and the intraosseous needle was removed. Bacteriological and viral cultures were negative. Four days after admission, the child was discharged in good condition. CONCLUSIONS: Intraosseous infusion provides safe, rapid and reliable access to the circulation for administration of fluids and drugs in the critically ill child or during cardiac arrest.

[Pneumothorax revealing pneumoblastoma in an infant]. / Pneumothorax chez un nourrisson révélateur d'un pneumoblastome.

BACKGROUND: Pulmonary blastoma is a tumor with bad prognosis that is exceptionally seen before the age of 2 years. CASE REPORT: A 3 1/2 month-old infant was admitted because she suffered from tachypnea. A left pneumothorax with shift of the mediastinum was recognized that required insertion of a chest tube followed by ventilation and pleural drainage. X rays and CT scan showed a round bullous lesion in the left lung that persisted at the age of 5 months. At that time, clinical deterioration led to thoracotomy allowing excision of a bullous tumor; histological examination showed that this tumor was a pulmonary blastoma. Recurrence of this tumor, 16 months later, required chemotherapy and surgical excision. The patient is normal at the age of 4 years. CONCLUSION: Pulmonary blastoma is exceptional in infancy; it may be revealed by pneumothorax. Its bad prognosis requires aggressive therapy.

[Enteral nutrition: bolus versus continuous feeding]. / Modes de gavage, gavage à la mode.

Published evidence has not yielded clear guidelines about the best method of how to feed the preterm baby. Enteral feeding involves many potentially confounding interventions. Variations in nutritional practices are in part explained by difficulties in measuring outcome. Development and implementation of evidence-based nutrition practices led to improved nutrition outcomes.

[Management of a short femur discovered via ultrasound in utero. Prenatal diagnosis of Stuve-Wiedemann syndrome]. / Conduite à tenir devant la découverte échographique d'un fémur court in utero. A propos d'un diagnostic anténatal de syndrome de Stuve-Wiedemann.

The authors report a case of familial Stuve-Wiedemann syndrome where the diagnosis was made in utero. Following this case the authors discuss the management of short femur discovered by ultrasound. The analysis of the morphology, the ultrasound appearance and the radiographic appearance (X-ray of the uterine contents) may make it possible sometimes to diagnose the syndrome. An important element is a study of the genealogy to discover the way in which a large number of these bone diseases are transmitted. The prognosis for life is very variable according to the severity of the syndrome.

[Induced labor: a risk factor of maternal-fetal contamination during delivery?]. / Déclenchement: facteur de risque de contamination materno-foetale à l'accouchement?

OBJECTIVE: This prospective study was conducted to determine the prevalence of maternal-fetal contamination at delivery in order to evaluate the factors of risk, particularly whether inducing delivery could be of additional help in selecting portage in mothers and infants. METHODS: Over a period of 4 months, samples were obtained from 360 mother/infant pairs. Vaginal sample at the beginning of labour, gastric sample from the infant at birth. RESULTS: Positive samples were obtained from 58 women (16.1%) and from 40 infants (11%). Streptococcus B was largely predominant (60%). The rate of maternal and neonatal carriers was significantly higher in pairs for which labour had been induced (n = 92) than in those with spontaneous labour (n = 268). Taking into account solely the classical factors of risk (opening of the membranes > 12 h, T > or = 38 degrees C, prolonged labour, premature delivery, premature rupture of the membranes), only selected 37% of the infant carriers (1 criteria or more); when induced labour was added as a criteria of risk, 68.4% of the infant carriers were identified. Streptococcus B was the cause of 2 neonatal infections in this series. None of the classic risk factors was observed in either of these cases but labour had been induced in both. CONCLUSION: The fact that labour is induced appears to be an additional factor of risk of maternal and fetal colonization. Routine screening at 12 and 24 hours before inducing labour could lead to the discovery of a large number of maternal colonizations and would allow prophylaxic antibiotics to be prescribed during labour. This protocol should be evaluated in a randomized prospective study involving a large number of cases in order to identify the beneficial effect in terms of neonatal morbidity and mortality.