Executive functions assessment in very preterm children at school age: A pilot study about a clinical and experimental approach.

While the survival rate of very preterm (VPT) infants has increased in the last decades, they are still at risk of developing long-term neurodevelopmental impairments, especially regarding self-regulatory abilities, and goal-directed behaviors. These skills rely on executive functions (EFs), an umbrella term encompassing the core capacities for inhibition, shifting, and working memory. Existing comprehensive tests are time-consuming and therefore not suitable for all pediatric neuropsychological assessments. The Flanker task is an experimental computer game having the advantage to last less than ten minutes while giving multiple EFs measures. Here, we tested the potency of this task in thirty-one VPT children aged 8-10 years during their clinical assessment. First, we found that VPT children performed in the norm for most clinical tests (i.e., WISC-V, BRIEF, and NEPSY) except for the CPT-3 where they were slower with more omission errors, which could indicate inattentiveness. Second, some Flanker task scores were correlated with standardized clinical testing without resisting to multiple comparisons correction. Finally, compared to full-term children, VPT children showed poorer performance in global EFs measure and lower accuracy in the Flanker task. These findings suggest that this child-friendly version of the Flanker task demonstrated a reasonable sensitivity in capturing EFs with good discrimination between VPT and term children despite VPT children's mild difficulties. It may represent a promising tool for neuropsychological assessments and be suitable as a screening test, providing further validating larger studies. Moreover, while VPT schoolchildren globally display normal intelligence, subtle difficulties that seem to relate to EFs are observed.

Parenteral Nutrition Process Management for Newborn and Preterm Infants - A Preliminary Risk Analysis.

BACKGROUND: There are variable practices in the management of the parenteral nutrition (PN) process in hospitals having a neonatal intensive care unit (NICU). In our hospital, PN is prepared partially on the neonatal ward by nurses but also at the central pharmacy by trained pharmacy technicians. A previous study showed a concentration non-conformity of 34% of on-ward PN preparations potentially resulting in under- or overfeeding of the patients. OBJECTIVE: The objectives were to perform preliminary risk analyses (PRA) in preparation for our hospital's transition to universal central pharmacy PN compounding. METHODS: A working group including pharmacists, neonatologists, nurses, and pharmacy technicians performed two PRA. The risks of 9 management steps of the PN process were identified, evaluated, and quoted. A comparison of the number of risks and their criticality index (CI) was conducted. RESULTS: A total of 36 and 39 risks were identified for PN preparation in the NICU and the pharmacy, respectively. For the NICU, ten risks (28%) had an "acceptable" CI, 15 risks (42%) were "under control" and eleven (31%) were defined as "non-acceptable". For the pharmacy, 14 risks (36%) had an "acceptable" CI, 19 risks (49%) were "under control" and six (15%) were defined as "non-acceptable". Risks directly related to the preparation process, including the steps preparation hood, PN preparation and analytical quality control, represented a cumulated CI of 145 for eleven NICU-risks vs 108 for twelve pharmacy risks (-26%). The implementation of immediate improvement measures, eg, an electronic prescription form, reduces the total CI by 5.7% and 2.2% for the NICU and the pharmacy, respectively. CONCLUSION: This PRA highlighted the safety differences between PN preparation in the NICU vs the pharmacy at our institution, and facilitated our moving forward with a process change that should improve the care of our neonatal patients. Nevertheless, long-term improvement measures have to be implemented to further reduce risks related to the PN management process.

Breastfeeding peer counselling for mothers of preterm neonates: protocol of a stepped-wedge cluster randomised controlled trial.

INTRODUCTION: Among preterm infants, mother's own milk feeding reduces neonatal morbidity and decreases the length of hospital stay. However, breastfeeding rates and duration are lower than among term infants. It is reported that peer counselling is effective in increasing breast feeding in term infants in low-income and middle-income countries, but results are mixed in high-income countries. We aim to investigate herein whether peer counselling may be a feasible and effective breastfeeding support among preterm infants in French-speaking high-income countries. METHODS AND ANALYSIS: Eight European centres will participate in this stepped-wedge cluster randomised controlled trial. We plan to include 2400 hospitalised neonates born before 35 gestational weeks. Each centre will begin with an observational period. Every 3 months, a randomised cluster (centre) will begin the interventional period with peer counsellors until the end of the study. The counsellors will be trained and supervised by the trained nurses. They will have a weekly contact with participating mothers, with a face-to-face meeting at least once every fortnight. During these meetings, peer counsellors will listen to mothers' concerns, share experiences and help the mother with their own knowledge of breast feeding. The main outcome is breastfeeding rate at 2 months corrected age. Secondary outcomes are breastfeeding rates at hospital discharge and at 6 months, breastfeeding duration and severe neonatal morbidity and mortality. The mental health of the mother, mother-infant bonding and infant behaviour will be assessed using self-report questionnaires. A neurodevelopmental follow-up, a cost-effectiveness analysis and a cost-consequence at 2 years corrected age will be performed among infants in a French subgroup. ETHICS AND DISSEMINATION: French, Belgian and Swiss ethics committees gave their agreement. Publications in peer-reviewed journals are planned on breast feeding, mental health and economic outcomes. TRIAL REGISTRATION NUMBER: NCT03156946.

Kasabach-Merritt phenomenon and prenatal counseling: a case series.

Kasabach-Merritt phenomenon can be encountered in the perinatal period. No consensus exists regarding prenatal management. We report one prenatal case leading to therapeutic abortion and one neonatal case, successfully treated by a multimodal therapy. Prenatal counseling should include the possibility of neonatal multimodal treatment that can lead to favorable outcomes.

Low phosphatemia in extremely low birth weight neonates: A risk factor for hyperglycemia?

BACKGROUND & AIMS: Hyperglycemia occurs in more than half of the extremely low birth weight (ELBW) neonates during the first weeks of life, and is correlated with an increased risk of morbi-mortality. Hypophosphatemia is another frequent metabolic disorder in this population. Data from animal, adult studies and clinical observation suggest that hypophosphatemia could induce glucose intolerance. Our aim was to determine whether a low phosphatemia is associated with hyperglycemia in ELBW neonates. METHODS: This observational study included ELBW infants admitted in a tertiary neonatal care center (2010-2011). According to the center's policy, they received parenteral nutrition from birth and human milk from day 1. Phosphatemia and glycemia were measured routinely during parenteral nutrition. Hyperglycemia was defined by two consecutives values >8.3 mmol/L (150 mg/dL). Statistical analysis used a joint model combining a mixed-effects and a survival submodels to measure the association between phosphate and hyperglycemia. RESULTS: The study included 148 patients. Mean gestational (Standard Deviation) age was 27.3 (1.6) weeks; mean birth weight was 803 (124) grams; 57% presented hyperglycemia. The multivariate joint model showed that the hazard of hyperglycemia at a given time was multiplied by 3 for each 0.41 mmol/L decrease of phosphate level at this time (p = 0.002) and by 3.85 for the same decreased of phosphate the day before (p = 0.0015). CONCLUSION: To our knowledge, this is the first study suggesting that low phosphatemia can be associated with hyperglycemia in ELBW neonates. Further studies will have to demonstrate whether better control of phosphatemia could help in preventing hyperglycemia.

Being Small for Gestational Age: Does it Matter for the Neurodevelopment of Premature Infants? A Cohort Study.

BACKGROUND: Whether being small for gestational age (SGA) increases the risk of adverse neurodevelopmental outcome in premature infants remains controversial. OBJECTIVE: to study the impact of SGA (birthweight < percentile 10) on cognition, behavior, neurodevelopmental impairment and use of therapy at 5 years old. METHODS: This population-based prospective cohort included infants born before 32 weeks of gestation. Cognition was evaluated with the K-ABC, and behavior with the Strengths and Difficulties Questionnaire (SDQ). Primary outcomes were cognitive and behavioral scores, as well as neurodevelopmental impairment (cognitive score < 2SD, hearing loss, blindness, or cerebral palsy). The need of therapy, an indirect indicator of neurodevelopmental impairment, was a secondary outcome. Linear and logistic regression models were used to analyze the association of SGA with neurodevelopment. RESULTS: 342/515 (76%) premature infants were assessed. SGA was significantly associated with hyperactivity scores of the SDQ (coefficient 0.81, p < 0.04), but not with cognitive scores, neurodevelopmental impairment or the need of therapy. Gestational age, socio-economic status, and major brain lesions were associated with cognitive outcome in the univariate and multivariate model, whereas asphyxia, sepsis and bronchopulmonary dysplasia were associated in the univariate model only. Severe impairment was associated with fetal tobacco exposition, asphyxia, gestational age and major brain lesions. Different neonatal factors were associated with the use of single or multiple therapies: children with one therapy were more likely to have suffered birth asphyxia or necrotizing enterocolitis, whereas the need for several therapies was predicted by major brain lesions. DISCUSSION: In this large cohort of premature infants, assessed at 5 years old with a complete panel of tests, SGA was associated with hyperactive behavior, but not with cognition, neurodevelopmental impairment or use of therapy. Birthweight <10th percentile alone does not appear to be an independent risk factor of neurodevelopmental adverse outcome in preterm children.