Administering atropine and ketamine before less invasive surfactant administration resulted in low pain scores in a prospective study of premature neonates.

AIM: Less invasive surfactant administration (LISA) can avoid tracheal intubation for neonatal respiratory distress syndrome, but can be painful because it requires laryngoscopy. The aim of this study was to assess the efficacy and tolerance of intravenous atropine plus ketamine administration before LISA. METHODS: We conducted a prospective observational study of all premature infants hospitalised in our French neonatal intensive care unit treated with LISA between March 2015 and March 2016. Ketamine was titrated by 0.5 mg/kg increments. The technical conditions, pain scores, emergent intubations and vital signs were collected and analysed. RESULTS: Values are reported as medians (interquartile ranges). We included 29 patients with a gestational age of 29.6 (28.6-30.9) weeks and birth weight of 1290 (945-1600) grams. Technical conditions were satisfying for 24 infants (83%). The Faceless Acute Neonatal Pain Scale score was 2 (2-4); seven infants (24%) required tracheal intubation before LISA could be performed; 17 (59%) had a pulse oxymetry value under 80% that lasted more than 60 seconds. Heart rate and mean arterial blood pressure transiently increased. CONCLUSION: Atropine plus ketamine before LISA resulted in low pain scores and stable haemodynamic parameters, but prolonged desaturations or apnoea leading to tracheal intubation were frequently observed.

Combination therapy with ciprofloxacin and third-generation cephalosporin versus third-generation cephalosporin monotherapy in Escherichia coli meningitis in infants: a multicentre propensity score-matched observational study.

OBJECTIVES: Escherichiacoli is the second cause of bacterial meningitis in neonates. Despite the use for 35 years of third-generation cephalosporins (3GCs), high morbidity and mortality rates with E. coli meningitis continue to occur. Because ciprofloxacin has good microbiologic activity against E. coli and good penetration in cerebrospinal fluid and brain, some authors have suggested adding ciprofloxacin to a 3GC regimen. The objective of this study was to assess combining 3GCs with ciprofloxacin versus 3GCs alone in a cohort of infants with E. coli meningitis. METHODS: We included all cases of E. coli meningitis diagnosed in infants <12 months of age that were prospectively collected through the French paediatric meningitis surveillance network between 2001 and 2016. The main outcome was the proportion of short-term neurologic complications with versus without ciprofloxacin. The analysis was conducted retrospectively by multivariable regression and propensity score (PS) analysis. RESULTS: Among the 367 infants enrolled, 201 (54.8%) of 367 had ciprofloxacin and 3GC cotreatment and 166 (45.2%) of 367 only a 3GC. Median age and weight were 15 days (range, 1-318 days) and 3.42 kg (range, 0.66-9.4 kg). A total of 86 (23.4%) of 367 infants presented neurologic complications (seizures, strokes, empyema, abscesses, hydrocephalus, arachnoiditis); 57 received ciprofloxacin cotreatment. Complications were associated with ciprofloxacin cotreatment on multivariable analysis (odds ratio (OR) = 1.9; 95% confidence interval (CI), 1.1-3.4) and PS analysis (OR = 1.9; 95% CI, 1.1-3.3). Mortality rate did not differ with and without ciprofloxacin: 22 (10.9%) of 201 versus 16 (9.6%) of 166 deaths (OR = 0.7; 95% CI, 0.3-1.6; PS analysis). CONCLUSIONS: Ciprofloxacin added to 3GCs at least offers no advantage for neurologic outcome and mortality in infants with E. coli meningitis.

Klebsiella pneumoniae and Klebsiella oxytoca meningitis in infants. Epidemiological and clinical features.

BACKGROUND: The incidence of meningitis caused by Klebsiella pneumoniae (Kp) and Klebsiella oxytoca (Ko) in high-income countries is unknown, and no series have been published to date. METHODS: We conducted a nationwide multicenter observational study in France between 2006 and 2016. All children from the French national registry for paediatric bacterial meningitis under the age of 1 year and hospitalized for Kp or Ko meningitis were included. Virulence factors of four Klebsiella spp. strains were explored by whole genome sequencing. RESULTS: Of 1859 cases of meningitis in children under the age of 1 year, 13 cases (0.7%) of Klebsiella spp. meningitis (nine for Kp meningitis and four for Ko meningitis) were registered in the French national registry. Three of the patients died and 50% of the survivors had developmental delays. CONCLUSIONS: Prematurity, low birth weight, and congenital anomalies of the urinary tract appear to be risk factors for Klebsiella spp. meningitis as well as virulence factors of the strain.

[Information in perinatal medicine: ethical aspects]. / L'information dans le contexte du soin périnatal: aspects éthiques.

Besides the undeniable need to respect parental autonomy, providing information is a legal and moral obligation, to be informed a basic right. The act of informing should be considered as an exchange and necessarily begins by listening to the other. According to the jurisprudence of the Court of Cassation that draws on Article 35 of the Deontological Code, information has to be clear (implying an educational effort, availability and to check that the information has been well understood), appropriate (adapted to each situation and person) and honest (which supposes a moral contract between parents and physicians). Loyalty implies a consideration of the uncertainty underlying medical practice, and of the limitations in arriving at a prognosis. Indeed, caution needs to be exercised in conveying information, taking into account the risk of its becoming self-fulfilling, which could modify the way in which parents take care of their child. The information given has to be coherent, both within the spatial dimension (coherence of information between the different maternity services in the perinatal network) and the temporal dimension (coherence of information between pre- and postnatal stages). It must be acknowledged that information is essentially subjective. There is a fundamental difference between coherence and uniformity, and as regards information, uniformity is neither possible nor desirable. In each situation, priority must be given to oral information delivered in an appropriate material context. The principle of establishing, in the medical file, a written trace of the information given at various stages is one way to guarantee its coherence.

[Parental mourning after a perinatal loss]. / Le deuil des parents après le décès de leur bébé.

The loss of a close friend or relative is always an ordeal. When this loved one is a baby, born or even unborn, a number of specific aspects have been reported by parents and researchers. The specificities of perinatal mourning have been progressively recognized since the 1970s, with increasing literature on this topic. Its complexity should be acknowledged by healthcare professionals who cope with perinatal loss, to allow them to offer adapted familial support. This paper is written by a mother, a founding member of a French nonprofit organization supporting parents in case of a prenatal or postnatal life-limiting disorder (Association SPAMA, soins palliatifs et accompagnement en maternité) with an internet support forum and a neonatologist involved in research with parents after the loss of their baby. It attempts to describe how parents experience this situation and how palliative care provides a source of inspiration to families and helps them give meaning to these situations.

Pharmacocinétique et pharmacodynamie des antibiotiques : est-ce différent en néonatologie ?

Pharmacokinetic and pharmacodynamics (PK/PD) data on antimicrobial agents enable physicians to optimize their use in clinical practice. Neonates exhibit a large inter-individual variability in antibiotic levels due to immaturity and maturational changes in the first weeks of life. This variability explains the large therapeutic margins needed to ensure an optimal efficacy of antibiotics. These pharmacokinetic characteristics have to be taken into account when treating neonatal sepsis, along with pharmacodynamics targets for each antibiotic and notably minimal inhibitory concentration for usual causes of neonatal bacterial infections (group B streptococcus and Escherichia coli). This paper presents PK/PD data of antimicrobial agents mainly used in neonatology (ß-lactamines and aminoglycosides) to help physicians to rationalize their use of antibiotics.

[Parental perception of their involvement in the care of their children in French neonatal units]. / Perception des parents de leur participation aux soins de leur enfant dans les unités de néonatologie en France.

BACKGROUND: The experience of becoming the parent of a sick or premature newborn can be particularly distressing for parents. They often encounter challenges to the development of their parenting roles. Perception of the hospital stay has never been analyzed on a large scale. OBJECTIVE: To analyze parents' perception of their involvement in the care of their newborn. METHODS: An internet-based survey started in France in February 2014 on the basis of a validated questionnaire composed of 222 neonatal care-related items. A quantitative and qualitative analysis was performed on the items dealing with parents' involvement until August 2014. RESULTS: The survey was completed by 1500 parents, 98 % of whom were mothers. The infants had a mean GA of 32 weeks and a mean birth weight of 1600g. Parents rated their first care of their infant with mixed emotions (joy, stress, etc.). Parents were willing to practice new skills through guided participation, even for more complex care. Skin-to-skin care was only proposed after 7 days for 20 % of the parents; 10 % of the parents did not feel secure during this practice. The need for privacy and professional guidance was essential for meaningful skin-to-skin contact. DISCUSSION: Parents' perception of participating actively in their infant's care was positive and they felt guided by the nursing team. Most of them would have been more active with guidance. Skin-to-skin care was appreciated and desired, but could become stressful if the conditions were not optimal.

[Cocaine and trisomy 8 associated with prenatal diagnosis of corpus callosum agenesis]. / Cocaïne et trisomie 8 associées au diagnostic prénatal d'agénésie du corps calleux.

We report the case of a newborn presenting an agenesis of corpus callosum (ACC) discovered in the prenatal period and initially related to cocaine exposure during the first trimester of gestation. The cytogenetic analysis revealed a trisomy 8 mosaicism. The putative role of prenatal cocaine exposure and mosaicism for chromosome 8 in ACC are discussed. This report emphasizes the specific analysis of chromosome 8 by using fluorescence in situ hybridization as a complement to routine cytogenetic analysis for prenatal diagnosis of ACC.

[Retro-tracheal left pulmonary artery. Report of 2 cases]. / Artère pulmonaire gauche rétro-trachéale. A propos de 2 cas.

The authors report the cases of two neonates with retro-tracheal left pulmonary arteries (pulmonary artery sling). In the first case, there was rapid onset of cardiac failure with signs of airway compression. Echocardiography showed the vascular anomaly associated with a large ventricular septal defect (VSD). After standard radiological investigation and bronchoscopy to exclude an associated tracheo-bronchial malformation, the VSD was repaired surgically with reimplantation of the left pulmonary artery. Unfortunately, the patient died of major airways obstruction in the postoperative period. Autopsy showed tracheo-bronchial anomalies which had not been diagnosed preoperatively. The second patient presented with hypoventilation of the right lung. After echocardiographic diagnosis of the anomaly, a thorough investigation (thoracic CT, helicoidal scan, bronchoscopy) was carried out and no associated bronchial malformations were observed. Reimplantation of the left pulmonary artery was successful and the postoperative course was uneventful. Retro-tracheal left pulmonary artery is a rare malformation Which is difficult to diagnose. It requires extensive pulmonary investigations and a multi-disciplinary approach. The prognosis is poor when there are associated tracheo-bronchial malformations.

[Chronic cor pulmonale and refractory hypoxemia following pulmonary embolism in a six-month-old infant: surgical management by thromboendarterectomy]. / Coeur pulmonaire chronique postembolique et hypoxémie réfractaire chez un nourrisson de six mois: prise en charge chirurgicale par thromboendartériectomie.

UNLABELLED: A diagnosis of pulmonary embolism is uncommon in the infant and the child, and chronic cor pulmonale secondary to pulmonary embolism is an even rarer occurrence. CASE REPORT: In this study, a case of pulmonary embolism in a 6-month-old male infant has been reported. His past history included preterm birth, and severe bronchopulmonary dysplasia, with prolonged oxygen dependency. The positive diagnosis was based on cardiac ultrasound examination, with the direct imaging of a right pulmonary arterial thrombus. Surgical thromboendarterectomy was performed, with a long-term favorable outcome. CONCLUSION: After excluding from the diagnosis those hemostatic disorders known to be thrombogenic, the most likely hypothesis was retained, i.e., that it was catheter-related. A central venous catheter had been inserted during the neonatal period, and was probably responsible for the embolism. The clinical characteristics and the diagnostic and therapeutic aspects of chronic postembolic cor pulmonale have been discussed in the light of the present findings.

[Neurological prognosis of term infants with perinatal asphyxia]. / Pronostic neurologique des asphyxies périnatales à terme.

Neonatal encephalopathies following birth asphyxia are the first features of cerebral insult. They never miss when asphyxia is directly involved in cerebral impairment. Mild encephalopathies have constantly a good prognosis. Conversely, moderate and severe encephalopathies are associated with poor outcome (death or severe handicap) in 25% to 100% of cases. Prognosis of these moderate and severe encephalopathies can be assessed during the first ten days of life by 3 complementary ways: clinical exam, electrophysiology and imaging. The most information is obtained from the EEG and MRI which together nearly reach 100% for both predictive positive and negative values for severe neurological sequelae.

[Experience of parents after the loss of a newborn twin in the NICU: a qualitative study 3 years after the death]. / Vécu de parents ayant perdu un jumeau en réanimation néonatale : étude qualitative, 3 ans après le décès.

INTRODUCTION: The mortality rate both before and after birth is higher in twins. Parents face a particularly difficult mourning experience when confronted with the loss of 1 of their newborn twins. The aim of this article is to describe how parents experience and cope with this situation over the long term, how they describe the loss at the time of the death in a neonatal intensive care unit (NICU), the way they are able to become attached to the surviving twin, and the role that NICU caregivers can play to help them. METHOD AND POPULATION: This study is part of a larger qualitative study on parental mourning after the loss of a newborn in 4 NICUs in France. Semi-structured research interviews were conducted 3years after the death. The interviews were recorded, transcribed, and anonymized. Discourse analysis was used to extract the data on different themes. Among the 166 participating parents, 26 had lost a newborn twin. RESULTS: The parents reported their difficulties when faced with simultaneous contradictory events at the time of the death of a twin child in the NICU. Mourning appeared to be more difficult in this particular case: to combine the loss of a deceased child with the care of the surviving newborn was very complicated. The existence of the "co-twin" was described as an essential support for the parents; however, over the long term, this child could not fulfill the feelings of emptiness. The relation with this surviving child was sometimes disturbed by parental anxiety that the accident could recur. Fathers and mothers showed repression of their sadness and despair. The representations of the 2 children in their parents' mind were sometimes very close or even overlapping and some parents were confused with regards to the place each of them could have. In the NICU, the caregivers should be able to listen to the parents expressing their contradictory feelings, to sustain the acknowledgement of the loss of 1 child, and in becoming attached to the surviving child. Parents need to be reassured about their living child's health. CONCLUSION: When faced with the loss of a newborn twin, parents are overwhelmed by the coexistence of contradictory feelings. The role of the medical staff is essential in building separate stories and having different memories for each child.

[Palliative care in the neonatal period. Part one: general considerations]. / Réflexions et propositions autour des soins palliatifs en période néonatale : 1(re) partie considérations générales.

In France, the law dated 22 April 2005 required that all practitioners offer palliative care to patients as an alternative to unreasonable obstinacy. The practical development of palliative care during the neonatal period is not easy, even though obstetricians and neonatologists have always been aware of the ethical necessity of comfort in the dying newborn. The decision leading to palliative care begins with the recognition of patent or potential unreasonable obstinacy, followed by withdrawing treatment and technical support, and finally a palliative care plan is drawn up with the medical team and the parents.

[Very premature births: Dilemmas and management. Part 1. Outcome of infants born before 28 weeks of postmenstrual age, and definition of a gray zone]. / Naissances très prématurées : dilemmes et propositions de prise en charge. Première partie : pronostic des naissances avant 28 semaines, identification d'une zone grise.

With very preterm deliveries, the decision to institute intensive care, or, alternatively, to start palliative care and let the baby die, is extremely difficult, and involves complex ethical issues. The introduction of intensive care may result in long-term survival of many infants without severe disabilities, but it may also result in the survival of severely disabled infants. Conversely, the decision to withhold resuscitation and/or intensive care at birth, which is an option at the margin of viability, implies allowing babies to die, although some of them would have developed normally if they had received resuscitation and/or intensive care. Withholding intensive care at birth does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. The likelihood of survival without significant disabilities decreases as gestational age at birth decreases. In addition to gestational age, other factors greatly influence the prognosis. Indeed, for a given gestational age, higher birth weight, singleton birth, female sex, exposure to prenatal corticosteroids, and birth in a tertiary center are favorable factors. Considering gestational age, there is a gray zone that corresponds to major prognostic uncertainty and therefore to a major problem in making a "good" decision. In France today, the gray zone corresponds to deliveries at 24 and 25 weeks of postmenstrual age. In general, babies born above the gray zone (26 weeks of postmenstrual age and later) should receive resuscitation and/or full intensive care. Below 24 weeks, palliative care is the only option offered in France at the present time. Decisions within the gray zone will be addressed in the 2nd part of this work.

[Very premature births: Dilemmas and management. Second part: Ethical aspects and recommendations]. / Naissances très prématurées : dilemmes et propositions de prise en charge. Seconde partie : enjeux éthiques, principes de prise en charge et recommandations.

In the first part of this work, the outcome following very premature birth was assessed. This enabled a gray zone to be defined, with inherent major prognostic uncertainty. In France today, the gray zone corresponds to deliveries occurring at 24 and 25 weeks of postmenstrual age. The management of births occurring below and above the gray zone was described. Withholding intensive care at birth for babies born below or within the gray zone does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. Given the high level of uncertainty, making good decisions within the gray zone is problematic. Decisions should be based on the infant's best interests. Decisions should be reached with the parents, who are entitled to receive clear and comprehensive information. Possible decisions to withhold intensive care should be made following the procedures described in the French law of April 2005. Guidelines, based on gestational age and the other prognostic elements, are proposed to the parents before birth. They are applied in an individualized fashion, in order to take into account the individual features of each case. At 25 weeks, resuscitation and/or full intensive care are usually proposed, unless unfavorable factors, such as severe growth restriction, are associated. A senior neonatologist will attend the delivery and will make decisions based on both the baby's condition at birth and the parents' wishes. At 24 weeks, in the absence of unfavorable associated factors, the parents' wishes should be followed in deciding between initiating full intensive care or palliative care. Below 24 weeks, palliative care is the only option to be offered in France at the present time.