Recommendation for hygiene and topical in neonatology from the French Neonatal Society.

We sought to establish guidelines for hygiene care in newborns based on a systematic review of the literature and grading of evidence using the Groupe de Réflexion et d'Evaluation de l'Environement des Nouveau-nés (GREEN) methodology. We examined 45 articles and 4 reports from safety agencies. These studies recommend a tub bath (rather than a sponge bath) for full-term infants and a swaddle bath for preterm newborns. They also recommend against daily cleansing of preterm infants. The literature emphasized that hygiene care must consider the clinical state of the newborn, including the level of awareness and behavioral responses. Hospitalized newborns treated with topical agents may also experience high exposure to potentially harmful excipients of interest. Caregivers should therefore be aware of the excipients present in the different products they use. In high-resource countries, the available data do not support the use of protective topical agents for preterm infants.Conclusions: We recommend individualization of hygiene care for newborns. There is increasing concern regarding the safety of excipients in topical agents that are used in neonatology. A multidisciplinary approach should be used to identify an approach that requires lower levels of excipients and alternative excipients. What is known: • Hygiene care is one of the most basic and widespread types of care received by healthy and sick newborns worldwide. • There is no current guideline on hygiene for preterm or hospitalized term newborn. What is new: • The French Group of Reflection and Evaluation of the environment of Newborns (GREEN) provided here guidelines based on the current body of evidence. • Caregivers should be aware of the many issues related to hygiene care of newborns including newborns' behavioral responses to hygiene care, exposition to excipients of interest, and the potential risk of protective topical agents in a preterm infant. provided here guidelines based on the current body of evidence. • Caregivers should be aware of the many issues related to hygiene care of newborns including newborns' possible behavioral responses to hygiene care, exposition to excipients of interest and the potential risk of protective topical agents in a preterm infant.

[Iatrogenic skin lesions: a prospective study in premature infants born at less than 33 weeks of amenorrhea at Besançon university hospital]. / Lésions cutanées iatrogènes : étude prospective chez les prématurés de moins de 33 semaines de l'hôpital universitaire de Besançon.

BACKGROUND: Advances in neonatology have markedly improved prognosis for premature babies in recent years. However, they have also entailed the need for recourse to considerable intensive care involving potentially iatrogenic diagnostic and therapeutic acts. Among the resulting iatrogenic events, cutaneous lesions are the most frequent but have been the subject of very few studies. Our own study thus aimed to assess the rate of iatrogenic cutaneous events in premature infants born at less than 33 weeks of amenorrhea and hospitalised at Besançon university hospital and to identify the factors associated with the occurrence of these events. PATIENTS AND METHODS: This was a prospective study carried out in the department of paediatric intensive care and neonatology at Besançon university hospital between May 2011 and April 2012. All babies born before 33 weeks of amenorrhea hospitalised over this period were included. An iatrogenic event was defined as "an adverse event related to a medical procedure". Iatrogenic cutaneous events were reported to the dermatologist by medical and paramedical staff. RESULTS: One hundred and thirthteen newborn babies were included during the study period. Twenty-six iatrogenic cutaneous events were recorded in 19 infants, representing 16.8% of the population involved: nine were associated with ventilation techniques, six with the use of intravenous catheters, five with electrodes, two involved pressure sores, two were linked to the birth, one to disinfectants and one to dressings. The main risk factor was low birth weight (P=0.016). High prematurity and the duration of ventilation increased the risk, although not significantly. The death rate was higher in children with iatrogenic events but the difference was not significant. The duration of hospitalisation was unaffected by the presence or absence of an iatrogenic event. CONCLUSION: The frequency of iatrogenic cutaneous events is high in hospital departments in charge of very premature infants. Awareness by the medical and paramedical staff of the frequency of such iatrogenic events should improve the quality of care.

Microdeletion at chromosome 4q21 defines a new emerging syndrome with marked growth restriction, mental retardation and absent or severely delayed speech.

BACKGROUND Genome-wide screening of large patient cohorts with mental retardation using microarray-based comparative genomic hybridisation (array-CGH) has recently led to identification several novel microdeletion and microduplication syndromes. METHODS Owing to the national array-CGH network funded by the French Ministry of Health, shared information about patients with rare disease helped to define critical intervals and evaluate their gene content, and finally determine the phenotypic consequences of genomic array findings. RESULTS In this study, nine unrelated patients with overlapping de novo interstitial microdeletions involving 4q21 are reported. Several major features are common to all patients, including neonatal muscular hypotonia, severe psychomotor retardation, marked progressive growth restriction, distinctive facial features and absent or severely delayed speech. The boundaries and the sizes of the nine deletions are different, but an overlapping region of 1.37 Mb is defined; this region contains five RefSeq genes: PRKG2, RASGEF1B, HNRNPD, HNRPDL and ENOPH1. DISCUSSION Adding new individuals with similar clinical features and 4q21 deletion allowed us to reduce the critical genomic region encompassing two genes, PRKG2 and RASGEF1B. PRKG2 encodes cGMP-dependent protein kinase type II, which is expressed in brain and in cartilage. Information from genetically modified animal models is pertinent to the clinical phenotype. RASGEF1B is a guanine nucleotide exchange factor for Ras family proteins, and several members have been reported as key regulators of actin and microtubule dynamics during both dendrite and spine structural plasticity. CONCLUSION Clinical and molecular delineation of 4q21 deletion supports a novel microdeletion syndrome and suggests a major contribution of PRKG2 and RASGEF1B haploinsufficiency to the core phenotype.

[Air embolism on central venous access in a premature neonate, beware of the infusion device assembly! ]. / Embolie gazeuse sur cathéter central chez un nouveau-né prématuré, méfiez-vous de votre montage de perfusion !

A fatal pulmonary air embolism, confirmed by an oriented necropsy, is described in a 25-day-old premature and small-for-gestational-age neonate. The embolism was suspected after air bubbles were detected in the infusion line. The air bubbles originated from a male Luer-lock to male Luer-lock connector, which was part of a specific assembly of the perfusion line. A solution to this problem is thereby proposed. We recommend caution in using complex infusion line assemblies because such complications are probably underestimated.

[Very preterm birth: should we be interested in maternal pre-pregnancy body mass index?]. / Grande prématurité : faut-il s'intéresser à la corpulence maternelle ?

UNLABELLED: Link between maternal body mass index (BMI) and pregnancy outcome is not clear. OBJECTIVE: To appreciate the impact of prepregnancy maternal BMI on very preterm birth (22-32 gestation's weeks). SECONDARY OBJECTIVE: To assess how maternal BMI does explain the mechanism of very preterm birth among live births. METHODS: Population-based study, including each mother with a live or stillborn baby was included in a geographically defined (Poitou-Charentes and Franche-comté, France) case-control study in 2004 to 2006. Leanness (BMI<18.5kg/m(2)) and overweight and obesity (BMI> or =25kg/m(2)) were defined according to World Health Organization's standards. Statistical analysis consisted in a polynomial regression on 832 mothers of very preterm babies and 431 mothers of full-term babies, taking account for confounders as maternal age, birth country, educational level, maternal work and smoking during the pregnancy. RESULTS: Leanness is a risk factor for very preterm live birth (aOR=1.73 [1.12-2.68]), overweight is a risk factor for stillbirth. (aOR=1.71 [1.03-2.84]). Among mothers of live born babies, leanness is a risk factor for spontaneous preterm birth (aOR=2.12 [1.20-3.74]), whereas overweight is a risk factor for very preterm birth on medical decision due to gestational hypertension (aOR=2.85 [1.80-4.52]). CONCLUSION: Morbid maternal stoutness before pregnancy is a complex risk factor for very preterm delivery. Women and couples should be informed and practitioners should be aware in order to prevent and manage this pathological status.

Extremely premature infants: How does death in the delivery room influence mortality rates in two level 3 centers in France?

OBJECTIVES: Mortality rates of very preterm infants may vary considerably between healthcare facilities depending on the neonates' place of inclusion in the cohort study. The objective of this study was to compare the mortality rates of live-born extremely preterm neonates observed in two French tertiary referral hospitals, taking into account the occurrence of neonatal death both in the delivery room and in the neonatal intensive care unit (NICU). METHODS: Retrospective observational study including all pregnancy terminations, stillbirths and live-born infants within a 22- to 26-week 0/6 gestational age range was registered by two French level 3 university centers between 2009 and 2013. The mortality rates were compared between the two centers according to two places of inclusion: either the delivery room or the NICU. RESULTS: A total of 344 infants were born at center A and 160 infants were born at center B. Among the live-born neonates, the rates of neonatal death were similar in center A (54/125, 43.2%) and center B (33/69, 47.8%; P=0.54). However, neonatal death occurred significantly more often in the delivery room at center A (31/54, 57.4%) than at center B (6/33, 18.2%; P<0.001). Finally, the neonatal death rate of live-born very preterm neonates admitted to the NICU was significantly lower in center A (25/94, 26.6%) than in center B (27/63, 42.9%; P=0.03). CONCLUSIONS: This study points out how the inclusion of deaths in the delivery room when comparing neonatal death rates can lead to a substantial bias in benchmarking studies. Center A and center B each endorsed one of the two models of preferential place of neonatal death (delivery room or NICU) detailed in European studies. The reasons behind the two different models and their impact on how parents perceive supporting their neonate need further investigation.

[Involvement of thyroid gland at non-Hodgkin lymphoma initial diagnosis: 2 pediatric cases]. / Goitre thyroïdien révélateur d'un lymphome non hodgkinien: à propos de 2 cas.

Extranodal thyroid lymphomatous involvement is rare in childhood. We report here 2 children, 1 with vertical transmission-acquired human immunodeficiency virus (HIV), presenting with lymphomatous infiltration of the thyroid gland at diagnosis. One child had infra-clinical endocrine impairment and both responded well to chemotherapy. Although the cases are too scarce to be affirmative, thyroid gland involvement doesn't seem to alter the good prognosis of childhood Burkitt's lymphoma. The third child's cancer in frequency is Non-Hodgkin Lymphomas. Presenting as the initial AIDS event in 1 patient, this case report also highlights the need to systematically propose antiretroviral therapy in vertically HIV infected children.

Prophylactic ibuprofen versus placebo in very premature infants: a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Patent ductus arteriosus is a common complication of prematurity that frequently requires surgical or medical treatment. The benefit of prophylactic treatment by indometacin, a cyclo-oxygenase inhibitor, remains uncertain compared with curative treatment. This benefit could be improved with ibuprofen, another cyclo-oxygenase inhibitor with fewer adverse effects than indometacin on renal, mesenteric, and cerebral perfusion. We aimed to compare prophylactic and curative ibuprofen in the treatment of this abnormality in very premature infants. METHODS: We did a randomised controlled trial in infants younger than 28 weeks of gestation, who were randomly assigned to receive either three doses of ibuprofen or placebo within 6 h of birth. After day 3, symptomatic patent ductus arteriosus was treated first by open curative ibuprofen, then back-up indometacin, surgery, or both. The primary endpoint was need for surgical ligation. Analysis was per protocol. FINDINGS: The study was stopped prematurely after 135 enrollments because of three cases of severe pulmonary hypertension in the prophylactic group. 65 infants received prophylactic ibuprofen, and 66 received placebo. Prophylaxis reduced the need for surgical ligation from six (9%) to zero (p=0.03), and decreased the rate of severe intraventricular haemorrhage from 15 (23%) to seven (11%) (p=0.10). However, survival was not improved (47 [71%] placebo vs 47 [72%] treatment, p=1.00), because of high frequency of adverse respiratory, renal, and digestive events. INTERPRETATION: In premature infants, prophylactic ibuprofen reduces the need for surgical ligation of patent ductus arteriosus, but does not reduce mortality or morbidity. Therefore, it should not be preferred to early curative ibuprofen.

Emergence of Enterobacter cloacae as a common pathogen in neonatal units: pulsed-field gel electrophoresis analysis.

In the first week of December 2002, three infants hospitalized in the neonatal department of our hospital had blood cultures positive with Enterobacter cloacae. Screening cultures and genotyping showed that 10 of 25 screened patients also carried E. cloacae and that nine isolates belonged to the same clone as that responsible for all three bacteraemias. This epidemic cluster was limited to one of the two units of the department. Surveillance of both units continued until the end of March 2003; 51 of 159 neonates screened were colonized with E. cloacae, 38 out of 80 (47.5%) in the premature unit (PU) and 13 out of 79 (16.4%) in the paediatric intensive care unit (PICU). Pulsed-field gel electrophoresis (PFGE) analysis of 130 available isolates revealed 30 different pulsotypes, including 24 unique pulsotypes from individual patients and six from multiple patients. Antibiotic (particularly beta-lactam) use did not significantly vary from 1999 to 2003. The consumption of alcohol-based hand rub (four-fold higher in the PICU than in the PU) and nurse-to-patient ratio (1:2 in the PICU and 1:4 in the PU) might explain the higher cross-transmission rate in the PU. Finally, despite an epidemiological survey, we failed to identify the causes of the emergence of E. cloacae in our neonatology units. However, improved hygiene practices combined with restriction of admission led to the progressive disappearance of the epidemic strain. The increasing importance of this type of unit and the dramatic consequences of infections emphasize the need for additional research on the constitution of the flora of newborns and the mode of acquisition Gram-negative multi-resistant bacteria.

[Prion diseases in pediatrics]. / Les maladies à prions en pédiatrie.

Prion diseases are rare neurologic affections with a poor prognosis, occurring in both humans and animals. Creutzfeldt-Jakob disease (CJD) secondary to human extracted growth hormone treatment is the most frequent condition in pediatrics. In 1994, a new type of CJD (variant CJD) was described in young adults in the United Kingdom, only 10 years after the bovine spongiform encephalopathy epidemic, with recent works showing a direct relationship between the bovine epidemic and the human cases. An accumulation of a single protein called the prion protein (PrP) has been discovered in the brain in all of these cases, animal and human, leading to the hypothesis that a new infectious agent could proceed without any nuclear acid information; another hypothesis is that of a still unknown viral agent. The PRNP gene encoding for this PrP protein is well described: some mutations and a polymorphism in the 129th codon have been shown to be implicated in many cases of CJD. PrP is a ubiquitous protein, with yet unknown physiological function. There are still many questions to be answered: shall we expect new pediatric cases of variant CJD? Assuming that animal-human contamination is related to alimentation, are there other ways of contamination.

[Variables determining the amount of care for very preterm neonates: the concept of medical stance]. / Diversité inter-régionale de la quantité de soins délivrés aux grands prématurés : notion de « regard médical ¼

OBJECTIVE: To compare the amount of medical interventions on very preterm neonates (24-31 weeks of gestation) in two French university tertiary care centers, one of which is involved in a Neonatal Developmental Care program. A secondary objective is to assess whether this difference in medical interventions can be linked to a difference in mortality and morbidity rates. METHODS: We prospectively included all very preterm neonates free from lethal malformation born live in these two centers between 2006 and 2010. These inclusion criteria were met by 1286 patients, for whom we compared the rate of five selected medical interventions: birth by caesarean section, chest intubation in the delivery room, surfactant therapy, pharmacological treatment of patent ductus arteriosus, and red blood cell transfusion. RESULTS: The rates of the five medical interventions were systematically lower in the center that is involved in Neonatal Developmental Care. There was no significant difference in survival at discharge with no severe cerebral ultrasound scan abnormalities between the two centers. There were, however, significantly higher rates of bronchopulmonary dysplasia and nosocomial sepsis and longer hospital stays when the patients were not involved in a Neonatal Developmental Care program. DISCUSSION: This benchmarking study shows that in France, in the first decade of the 21st century, there are as many ways to handle very preterm neonates as there are centers in which they are born. This brings to light the concept of medical stance, which is the general care approach prior to the treatment itself. This medical stance creates the overall framework for the staff's decision-making regarding neonate care. The different parameters structuring medical stance are discussed. Moreover, this study raises the problematic issue of the aftermath of benchmarking studies when the conclusion is an increase of morbidity in cases where procedure leads to more interventions.

[Advantage of delayed umbilical cord clamping in the newborn infant]. / Intérêt du clampage retardé du cordon ombilical chez le nouveau-né

The timing of umbilical cord clamping remains controversial. Although most maternity wards use the early clamping (5-15s), randomized studies and meta-analyses have demonstrated the benefit of delayed clamping for term and preterm newborn infants over the past 10 years. Indeed, placentofetal transfusion of 20-30 ml/kg in 2-3 min improves the iron status of term infants and prevents infant hypochromic anemia. Infant anemia is a public health problem in many developing countries. For preterm newborns, placental transfusion for 45 s or milking the cord for 15 s improves cardiovascular adaptation, with better hemodynamic stability, as well as decreased intraventricular hemorrhages, need for transfusion, and late-onset sepsis. A new look at this symbolic act is needed and professionals need to be persuaded of the importance of the "wait a minute" policy for a better physiological delivery.

[Pediatric intermediate care demand, results of a survey in 3 French regions]. / Estimation des besoins en lits d'unité de surveillance continue pédiatrique, résultats d'une enquête sur 3 régions françaises.

In France, recent legislation for pediatric critical care organization endorsed the creation of a new level of pediatric care, the intermediate care units. These units treat children who require close monitoring and/or continuous monitoring due to potential failure of 1 or more organs, yet not to the degree of intensity of pediatric critical care. These rules do not provide precise admission and discharge guidelines for the pediatric patients requiring intermediate care. We conducted a questionnaire survey in all pediatric units in 3 French regions: Franche-Comté, Nord-Pas-de-Calais, and Rhône-Alpes. We obtained a response rate of 62.2% from the pediatric units. We estimated the pediatric intermediate care demand, with a unit occupancy rate of 80%, at 1.2 beds per 10 pediatric medical beds, 2.6 beds per 10 surgical beds, and 4 beds per 10 critical care unit beds or hemato-oncology beds. The intermediate care demand was higher in university-affiliated hospitals. One-third of the children referred to these units were less than 1 year old, 1/4 were less than 6 months old. We also described the diseases and potential organ failures of the patients who were referred to these intermediate care units. This study provides an estimate of the demand for pediatric intermediate care as defined in the French legislation and therefore helps implement projects to create such units. More specific criteria are still needed to oversee the implementation of these projects.

[Very preterm birth: is maternal anesthesia a risk factor for neonatal intubation in the delivery room?]. / Le risque d'intubation des grands prématurés en salle de naissance est-il lié au type d'anesthésie maternelle ? Expérience des réseaux périnatals Poitou-Charentes et Franche-Comté

OBJECTIVE: To assess the risk of tracheal intubation at birth in very premature neonates related to the type of maternal anesthesia in case of elective cesarean. POPULATION AND METHODS: All 219 live-born very premature neonates (28-32 weeks of gestation), delivered after an elective cesarean in the 27 maternity wards of 2 French semi-rural neonatal networks. Eighty-three percent (182/219) were delivered in level III maternity wards in university hospitals. RESULTS: Of the very preterm neonates, 33.3% (73/219) were intubated in the delivery room, either for respiratory distress syndrome or a low APGAR score. Very preterm neonates delivered after maternal general anesthesia were more often intubated than those delivered after spinal anesthesia (48.7% vs 25.2%; OR: 2.8; 95% CI: 1.8-5.1). The risk of intubation related to maternal general anesthesia remained statistically significant after an adjustment for gestational age, fetal growth retardation, respiratory distress syndrome, type of maternity ward, and a propensity score that took into account maternal sociodemographic characteristics and the causes of very preterm birth (aOR: 3.4; 95% CI: 1.4-8.2). The risk of intubation related to general anesthesia was lower after adjusting for the 5-min APGAR score (aOR: 2.8; 95% CI: 1.0-7.3). CONCLUSION: Very preterm neonates delivered after cesarean with general anesthesia require tracheal intubation in the delivery room more often than those delivered with spinal anesthesia. This study cannot assess a causal link between anesthesia and the need for neonatal intubation. However, neonatologists have to be aware of the type of maternal anesthesia because it may interfere with the non-invasive ventilation support policy of the very preterm neonate.

[Special outpatient services at 5 and 8 years in very-preterm children in the EPIPAGE study]. / Prises en charge éducatives spécifiques de l'enfant grand prématuré à 5 et 8 ans: résultats de l'étude EPIPAGE.

UNLABELLED: The immature brain is highly susceptible to the consequences of very preterm birth with a high rate of long-term neurodisabilities in survivors and high use of specific outpatient services to limit the functional effects of the disabilities. To assess the economic burden for the social and health care system, it is necessary to inventory the community supports and need for special education or rehabilitation used by preterm children. Such studies are few and were done only in extremely low-birthweight or extremely preterm newborns in the United States. OBJECTIVE: To study the rates of specific outpatient services and special education at 5 years of age and between 5 and 8 years of age in a geographically-defined population of children born very preterm. DESIGN, SETTING AND PATIENTS: 2901 liveborn children before 33 weeks'gestation (WG) and one control group of 666 liveborn children at 39-40WG were included in nine regions of France in 1997 corresponding to more than one third of all births. At five years, these children had a medical examination and were evaluated by a psychologist at local centres organised for the study in every region. Cognitive function was assessed by the mental processing composite scale (PMC) of the Kauffmann Assessement Battery for Children test, which is considered to be equivalent to intelligence quotient and behavioral difficulties using the Strength and Difficulties questionnaire completed by the parents. Data for dependence or compensatory aids, i.e. occupational therapy or physical therapy, speech therapy, psychologist or psychiatrist visits, orthoptic therapy, wearing glasses, wearing hearing aid, specific equipment to walk (walker, wheelchair...), orthopaedic treatment or anti-epileptic treatment were collected from parents. At eight years, a postal questionnaire was sent to the parents to collect data on specific outpatient services and special treatments at home and school. Stata software was used (version 9.0). Main outcome measures. Parent Questionnaire for identifying children with chronic conditions and specific health care needs at 5 and 8 years and categorization of developmental neurodisabilities based on examination of children and psychometric evaluation at 5 years. RESULTS: At 5 years data were obtained for respectively 1817 and 396 children born before 33WG or at 39-40WG, which represent 80% of the very preterm children and 71% of the at term children. At 8 years we obtained data for 63% of the very preterm children and 59% of the at term children. At 5 years, care in a rehabilitation center and/or specific outpatient services were required for 41% of children born between 24 and 28WG, 32% of children born between 24 and 32WG and 15% of those born at 39-40WG. Between 5 and 8 years, these figures were respectively 61%, 50% and 36%. In the very preterm group, rates of specific outpatient services were higher than 80% if the child had a motor and/or a neurosensory deficit. In case of cognitive deficiencies (PMC < 85), rates of specific outpatient services were low at 37% at 5 years and increases at 63% between 5 and 8 years. CONCLUSION: Compared to the children born at term, the very preterm children have considerable educational needs, which are inversely related to gestational age at birth and to age of the children at the time of reporting. Despite economic burden, efforts to improve access to services are necessary, in particular in case of cognitive impairment.

The safety and efficacy of nitric oxide therapy in premature infants.

OBJECTIVES: To assess the safety-efficacy balance of low-dose inhaled nitric oxide (iNO) in hypoxemic premature infants because no sustained beneficial effect has been demonstrated clearly and there are concerns about side effects. STUDY DESIGN: Eight hundred and sixty infants <32 weeks were randomized at birth to receive 5 ppm iNO or placebo when they presented with hypoxemic respiratory failure (HRF) defined by a requirement for mechanical ventilation, fraction of inspired oxygen (FIO 2 ) >40%, and arterio-alveolar ratio in oxygen (aAO 2 ) <0.22. The primary end point was intact survival at 28 days of age. RESULTS: Sixty-one of 415 infants presented with HRF and were compared with 84 of 445 controls who presented with HRF. There was no difference in the primary end point (61.4% in infants [23% with HRF who were treated with iNO] vs 61.1% in controls [21.4% in controls with HRF]; P = .943). For the infants with HRF who were treated with iNO, there was no significant difference from controls for intraventricular hemorrhage (IVH) (6% vs 7%), necrotizing enterocolitis (8% vs 6 %), or patent ductus arteriosus (PDA) (34% vs 37%). Compared with nonhypoxemic infants, the risk of bronchopulmonary displasia (BPD) increased significantly in HRF controls (OR = 3.264 [CI 1.461-7.292]) but not in infants with HRF who were treated with iNO (OR = 1.626 [CI 0.633-4.178]). CONCLUSIONS: iNO appears to be safe in premature infants but did not lead to a significant improvement in intact survival on day 28.

Pulmonary hypertension after ibuprofen prophylaxis in very preterm infants.

We report three cases of severe hypoxaemia after ibuprofen administration during a randomised controlled trial of prophylactic treatment of patent ductus arteriosus with ibuprofen in premature infants born at less than 28 weeks of gestation. Echocardiography showed severely decreased pulmonary blood flow. Hypoxaemia resolved quickly on inhaled nitric oxide therapy. We suggest that investigators involved in similar trials pay close attention to pulmonary pressure if hypoxaemia occurs after prophylactic administration of ibuprofen.

Prospective randomized multicenter comparison of high-frequency oscillatory ventilation and conventional ventilation in preterm infants of less than 30 weeks with respiratory distress syndrome.

BACKGROUND: Early use of high-frequency ventilation and exogenous surfactant is proposed as the optimal mode of ventilatory support in infants with respiratory distress syndrome. In very premature infants, we tested the hypothesis that high-frequency versus conventional ventilation could decrease exogenous surfactant requirements and improve pulmonary outcome, without altering the complication rate, including that of severe intraventricular hemorrhage. METHODS: Preterm infants with a postmenstrual age of 24 to 29 weeks, presenting with respiratory distress syndrome were randomly assigned to high-frequency oscillatory ventilation (lung volume recruitment strategy) or conventional ventilation. RESULTS: Two hundred seventy-three infants were enrolled. One hundred fifty-three had a postmenstrual age of 24 to 27 weeks, and 143 had a birth weight /=2 instillations of exogenous surfactant (30% vs 62%; odds ratio:.27; 95% confidence interval:.16-.44) and no difference in pulmonary outcome. The incidence of severe intraventricular hemorrhage was 24% in the high-frequency group and 14% in the conventional ventilation group (adjusted odds ratio: 1.50; 95% confidence interval:.68-3.30). CONCLUSION: Early use of high-frequency oscillatory ventilation in very premature infants decreases exogenous surfactant requirements, does not improve the pulmonary outcome, and may be associated with an increased incidence of severe intraventricular hemorrhage.