[A paediatrician's play kit: example and basic tool for an approach of the infant's global development between 0 and 4 years of age]. / Une mallette de jeux du pédiatre: exemple d'un outil de base pour l'approche du développement global chez l'enfant entre zéro et quatre ans.

The South and West Francilien Pediatric Network (Réseau Pédiatrique du Sud et Ouest Francilien [RPSOF]) has established a protocol for the developmental follow up of infants inspired by the existing developmental scales adapted to the current practice of out patient consultation. The consultation described here collects a set of very simple objects and trade toys that are a support for a qualitative exploration of the development for the infants of less than 4 years of age. Different fields are taken into account: global motor skills, hand-eye coordination, manipulation and construction, communication and language, attentional capacity, relational and social behaviour. The time of exchange and play between the paediatrician and the infant allows a first detection of possible problems: the orientation towards a specialized professional for a consultation, a standard check-up or even a therapeutic care becomes easier and clearer. This playful environment also offers a space for the parents, and supports their participation as primary role players in the development of their child. This time, integral part of the consultation, is completed by the somatic examination and sensory screening tests. At present reserved for children identified as being at risk, this type of consultation could be universalised for all infants.

[Multiple brain abscesses complicating Enterobacter cloacae sepsis in a premature infant]. / Abcès cérébraux multiples à Enterobacter cloacae chez un prématuré. Intérêt de la ciprofloxacine.

A neonatal infection with Enterobacter cloacae was diagnosed at day 21 in a premature infant. Five cerebral abscesses were discovered 6 days while a treatment with cefotaxim and amikacin was administered. We switched for axepim during 4 weeks and ciprofloxacin until complete regression of cerebral abscesses. At 13 months of age, the infant neurodevelopmental outcome was normal. Ciprofloxacin indications and tolerance during neonatal period are discussed.

[Prognosis in newborns after mother's preeclampsia]. / Pronostic des nouveau-nés de mère prééclamptique.

Preeclampsia (PE) is associated with 3 main risks for the fetus: perinatal death, intrauterine growth restriction (IUGR), preterm birth. Perinatal mortality is increased in infants with IUGR or asphyxia. Conversely, mortality and morbidity associated with preterm birth are not altered by PE without IUGR or asphyxia. Very preterm infant with IUGR are exposed to high risk of prolonged respiratory insufficiency. Neurological complications of prematurity are not more frequent in infants born to mothers with PE. Nevertheless birth asphyxia, (i.e. placental abruption) is associated with impaired neurological out-come especially in infants with neonatal encephalopathy. Long term outcome of infants born to mothers with PE is strongly correlated to gestational age. IUGR increases the risk of hypertension and metabolic syndrome in adulthood. Acute fatty liver of pregnancy can by caused by a fetal fatty-acid oxidation disorder.

[Birth asphyxia in term newborns: Diagnosis, prognosis, neuroprotection]. / Asphyxie périnatale à terme : diagnostic, pronostic, éléments de neuroprotection.

Birth asphyxia occurs in 0.5% of term deliveries. Prognosis of newborns with birth asphyxia depends on clinical features of neonatal encephalopathy. The outcome of infants without encephalopathy is excellent. In contrast, neurological outcome of infants with encephalopathy is poor: 40 to 100% of neurodevelopmental disabilities according to the grade of encephalopathy. Prognosis can be more accurately assessed by EEG and MRI. Infants with encephalopathy following birth asphyxia must be referred as soon as possible in centers where neuroprotection by hypothermia is available.

Delayed onset of severe neonatal toxoplasmosis.

We report a case of severe neonatal infection on day 6 of life due to Toxoplasma gondii mimicking septic shock syndrome associated with multiple organ failure such as acute respiratory distress syndrome with persistent pulmonary hypertension, neurological distress, thrombocytopenia with disseminated intravascular coagulopathy and transaminitis. Clinicians facing an unexplained life-threatening condition in the first week of life should take into consideration the possibility of neonatal toxoplasmosis.

[Effect of magnesium sulphate on mortality and neurologic morbidity of the very-preterm newborn (of less than 33 weeks) with two-year neurological outcome: results of the prospective PREMAG trial]. / Effet du sulfate de magnésium sur la mortalité et la morbidité neurologique chez le prématuré de moins de 33 semaines, avec recul à deux ans: résultats de l'essai prospectif multicentrique contre placebo PREMAG.

OBJECTIVE: To evaluate whether magnesium sulphate (MgSO(4)) given to women at risk of very-preterm birth would be neuroprotective in preterm newborns. PATIENTS AND METHODS: In 18 French centres, women with fetuses of gestational age less than 33 weeks whose birth was expected within 24 hours were randomised from 1993 to 2003 with follow-up of infants until two years of age after discharge. They received a single injection of 0.1 mg/l de MgSO(4) (4g) or isotonic 0.9% saline over 30 minutes. This study is registered as an International Standard Randomised Controlled Trial, number 00120588. Analyses were based on intention to treat. RESULTS: Data from 688 infants were analysed of which 606 were followed up and 10 were lost to follow-up. Comparing infants who received MgSO(4) or placebo, respectively, has shown a decrease of all primary endpoints (total mortality, severe white matter injury and their combined outcome) and of all secondary endpoints (motor dysfunction, cerebral palsy, cognitive dysfunction and their combined outcomes at two years of age) in the MgSO(4) group. The decrease was nearly significant or significant for gross motor dysfunction (OR: 0.65 [0.41-1.02]) and combined criteria: death and cerebral palsy (OR: 0.65 [0.42-1.03]); death and gross motor dysfunction (OR: 0.62 [0.41-0.93]); death, cerebral palsy and cognitive dysfunction (OR: 0.68 [0.47-1.00]). No major maternal adverse effects were observed in the MgSO(4) group. DISCUSSION AND CONCLUSION: Given its beneficial effects and safety, the use of prenatal low-dose MgSO(4) for preventing neurodisabilities of very-preterm infants should be discussed either as a stand-alone treatment or as part of a combination treatment, at least in the context of clinical trials.

[Definition of intrapartum asphyxia and effects on outcome]. / Définition de l'asphyxie intrapartum et conséquences sur le devenir.

Intrapartum asphyxia is defined as metabolic acidemia measured at birth with pH less than 7.00 and base deficit greater or equal to 12 mmol/l. Neonatal complications of intrapartum asphyxia include multiorgan failure and neonatal encephalopathy. Most severe consequences are death and neurological or sensorial impairment. Cause of permanent neurological impairment can be attributed to intrapartum asphyxia if three criteria are met: intrapartum history of a threatening event with acute fetal heart rate deterioration, biological markers of asphyxia, neonatal encephalopathy. Moderate to severe neonatal encephalopathy in asphyxiated term infants is associated with a high risk of cerebral palsy (especially quadriplegic or dyskinetic type) and/or cognitive disorders. Prognosis of neonatal encephalopathy can be accurately assessed by MR imaging.

[Neuroprotection with hypothermia for hypoxic ischemic encephalopathy in term newborn: review of the learning]. / Neuroprotection par hypothermie lors des encéphalopathies anoxo-ischémiques du nouveau-né à terme: état des connaissances.

The hypothermia treatment for neonatal hypoxic ischemic encephalopathy is a concept revisited for more than 10 years. With this strategy, animal studies have shown an 80% reduction of brain damage. Conditions for the practice of hypothermia, to obtain neuroprotection, have been described in these studies: rapidity of the onset of cooling after the hypoxic ischemic event, prolonged duration during several hours, ability to obtain neuroprotection with two methods of cooling, selective head cooling or whole body hypothermia. Pilot studies in human newborns have demonstrated the feasibility of these strategies without immediate adverse effects. Two large randomised trials have been conducted in 2005 to test the efficacy. Only with the strategy of whole body cooling, the incidence of poor outcome at 18 months (death or severe disability) was statistically decreased (44% versus 66% in the control group). This reduction seems especially significant in the sub group of intermediate severity (48% versus 66%), whereas severe forms (Grade III in the Sarnat and Sarnat classification) were probably not ameliorated with this treatment. Now, the major problem is to determine the best indications for hypothermia with an early and precise assessment of the grade of the encephalopathy.

[Tocolysis with calcium-channel blockers and intraventricular hemorrhage]. / Tocolyse par les inhibiteurs calciques et hémorragies intraventriculaires.

OBJECTIVE: To determine the possible association between intraventricular hemorrhage (IVH) in very premature infants and calcium-channel blockers used as tocolytics. MATERIALS AND METHODS: We performed a case-control study (from October 1999 to December 2002) including 51 premature infants under 30 weeks with IVH (all grade) and 112 premature infants under 30 weeks without IVH. In this study only premature infants issued from spontaneous prematurity were included. The exposure frequency to calcium-channel blockers and to other tocolytics were compared between the two groups by univariate analysis and by logistic regression analysis. RESULTS: Calcium-channel blockers were used in monotherapy before birth in 16% of infants without IVH and in 20% of infants with IVH (P=0.55). An exposure to a bitherapy or a tritherapy with a calcium-channel blocker and one or several other tocolytics has been found in 43% of infants with IVH and in 26% of infants without IVH (P<0.05). However this association disappears after adjustment for gestational age. CONCLUSION: We did not find a significant association between calcium-channel blockers used as tocolytics and an increased risk of intraventricular hemorrhage in premature infants less than 30 weeks.

Magnesium sulphate given before very-preterm birth to protect infant brain: the randomised controlled PREMAG trial*.

OBJECTIVE: To evaluate whether magnesium sulphate (MgSO(4)) given to women at risk of very-preterm birth would be neuroprotective in preterm newborns and would prevent neonatal mortality and severe white-matter injury (WMI). DESIGN: A randomised study. SETTING: Eighteen French tertiary hospitals. Population Women with fetuses of gestational age < 33 weeks whose birth was planned or expected within 24 hours were enrolled from July 1997 to July 2003 with follow up of infants until hospital discharge. METHODS Five hundred and seventy-three mothers were randomly assigned to receive a single 40-ml infusion of 0.1 g/ml of MgSO(4) (4 g) solution or isotonic 0.9% saline (placebo) over 30 minutes. This study is registered as an International Standard Randomised Controlled Trial, number 00120588. MAIN OUTCOME MEASURES: The primary endpoints were rates of severe WMI or total mortality before hospital discharge, and their combined outcome. Analyses were based on intention to treat. RESULTS: After 6 years of enrolment, the trial was stopped. Data from 688 infants were analysed. Comparing infants who received MgSO(4) or placebo, respectively, total mortality (9.4 versus 10.4%; OR: 0.79, 95% CI 0.44-1.44), severe WMI (10.0 versus 11.7%; OR: 0.78, 95% CI 0.47-1.31) and their combined outcomes (16.5 versus 17.9%; OR: 0.86, 95% CI 0.55-1.34) were less frequent for the former, but these differences were not statistically significant. No major maternal adverse effects were observed in the MgSO(4) group. CONCLUSION: Although our results are inconclusive, improvements of neonatal outcome obtained with MgSO(4) are of potential clinical significance. More research is needed to assess the protective effect of MgSO(4) alone or in combination with other neuroprotective molecules.

[Ethical dilemmas of extreme prematurity]. / Les enjeux éthiques de l'extrême prématurité

Caring for extremely premature babies is difficult and costly. Mortality has been reduced with recent medical progress, but at the price of an increased number of surviving infants with handicaps. Should we then fix firm limits (gestational age and/or birthweight) for deciding on whether or not to take medical action? There is however the question of whether it is ethically acceptable to define human life solely on the basis of the length of gestation or birthweight. Moreover, what risk level for death or handicap is legitimate for treating or not a premature baby? The issue thus comes to the worthiness of trying first to save life, then accepting an interruption of curative treatments later on if severe cerebral injuries become evident. Who should make the decisions? Guidelines have been published by medical associations to help professionals to answer these important and puzzling questions.

[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.

[Orientation after peripartum asphyxia in the maternity ward: which infants should be transferred to pediatric care units?]. / Orientation en salle de naissance après une asphyxie per-partum: quels nouveau-nés garder? quels nouveau-nés transférer?

Per-partum anoxia is a frequent situation facing the pediatrician in the maternity ward. The question is to decide which infants require care in a specialized unit. If transfer is decided, the infant must be referred to an appropriate pediatric unit (intensive care or neonatal unit). Cases of severe anoxia are exceptional. Intermediary situations are however much more frequent and raise difficult evaluation problems due to the lack of any specific test. The pediatrician must rely on a combination of elements from the clinical presentation, the medical history, the clinical course, and laboratory tests. Different elements suggest a prudent approach with referral to a pediatric unit. These elements include: imperfect clinical recovery (5-min Agpar <7), major intensive care at delivery (intubation, ventilation, vasoactive agents), anomalies in the cord blood or first hour blood tests (cord pH<7, base deficit 12, cord or blood lactate 9 mmol/l). Obstetrical circumstances which led to per-partum anoxia must be well identified because those interrupting placental flow (abruptio placenta, uterine rupture) suggest prudence is necessary even if the infant appears to have recovered well. All neonatal disorders (macrosomia, prematurity, infection, respiratory distress) increase the risk of rapid decompensation and may argue for hospitalization. Likewise, if even minimal signs of neurological, respiratory or hemodynamic disorders are present from birth to two hours, surveillance in a specialized unit is required, the level depending on local facilities. Certain situations nevertheless always require referral to a pediatric intensive care unit: use of vasoactive drugs, respiratory distress, abnormal neurological exam, poor recovery (5-min Agpar <4).Finally, it must be remembered that per-partum anoxia is rarely predictable and can occur any at any time of day or night. The pediatrician must also train other delivery room personnel, including the midwives, in intensive care techniques.

[Organization of patient management in level II centers in the Paris area: a prospective survey]. / Organisation de la prise en charge dans les centres de niveau II en région parisienne: enquête prospective.

Perinatal asphyxia is a common emergency for both obstetricians and pediatricians. A prospective study was conducted in 14 maternity hospitals (type II centres) in the Paris suburbs in order to assess pediatric activity and neonatal morbidity associated with supposed perinatal asphyxia in term newborns. Pediatricians were called in at birth very frequently: 1/20 deliveries. Intubation and/or resuscitation procedures were needed in 20% of cases and 20% of infants were referred to a neonatal unit for birth asphyxia or associated pathology. Moderate encephalopathy was observed in 1.5% of all term newborns who needed medical intervention for supposed birth asphyxia.

Pain management in French neonatal intensive care units.

UNLABELLED: The aim of this study was to investigate pain management in neonatal intensive care units (NICUs) in France and to identify factors associated with variability across units. A questionnaire sent to 143 heads of level II or III NICUs investigated the use of pain scores, pain management organization and pharmacological treatment in five clinical situations (endotracheal intubation, prolonged mechanical ventilation, acute stage of necrotizing enterocolitis, central venous catheter insertion and cephalhaematoma). The response rate was 81%. Among the 35 (30%) units that used no pain scores, 40% ascribed this to lack of knowledge. Factors associated with failure to use pain scores were level II status, no university affiliation, no surgical patients and neonatal patients only. Among the units that scored pain, 78% used valid scores for acute pain and 73% for prolonged pain. Written guidelines were available for acute pain in 65% of units and for prolonged pain in 36%. The rate of pharmacotherapy use varied widely across the five clinical situations studied (from 16 to 77%) and across units for a given clinical situation. Also extremely variable were the regimens used in each situation and the dosages of analgesics and sedatives. Only 11% of units adjusted dosages to gestational age. CONCLUSION: Pain assessment was performed in the most French NICUs, but a strong heterogeneity for pain treatment was observed. Reference to recently published pain management guidelines and new randomized trials could be useful to optimize pain treatment in NICUs.