[Ante- and postnatal growth charts in France - guidelines for clinical practice from the Collège national des gynécologues et obstétriciens français (CNGOF) and from the Société française de néonatologie (SFN)]. / Les courbes de croissance anté- et postnatales en France ­ recommandations pour la pratique clinique du Collège national des gynécologues et obstétriciens français (CNGOF) et de la Société française de néonatologie (SFN).

OBJECTIVE: To recommend the most appropriate biometric charts for the detection of antenatal growth abnormalities and postnatal growth surveillance. METHODS: Elaboration of specific questions and selection of experts by the organizing committee to answer these questions; analysis of the literature by experts and drafting conclusions by assigning a recommendation (strong or weak) and a quality of evidence (high, moderate, low, very low) and for each question; all these recommendations have been subject to multidisciplinary external review (obstetrician gynecologists, pediatricians). The objective for the reviewers was to verify the completeness of the literature review, to verify the levels of evidence established and the consistency and applicability of the resulting recommendations. The overall review of the literature, quality of evidence and recommendations were revised to take into consideration comments from external reviewers. RESULTS: Antenatally, it is recommended to use all WHO fetal growth charts for EFW and common ultrasound biometric measurements (strong recommendation; low quality of evidence). Indeed, in comparison with other prescriptive curves and descriptive curves, the WHO prescriptive charts show better performance for the screening of SGA (Small for Gestational Age) and LGA (Large for Gestational Age) with adequate proportions of fetuses screened at extreme percentiles in the French population. It also has the advantages of having EFW charts by sex and biometric parameters obtained from the same perspective cohort of women screened by qualified sonographers who measured the biometric parameters according to international standards. Postnatally, it is recommended to use the updated Fenton charts for the assessment of birth measurements and for growth monitoring in preterm infants (strong recommendation; moderate quality of evidence) and for the assessment of birth measurements in term newborn (expert opinion). CONCLUSION: It is recommended to use WHO fetal growth charts for antenatal growth monitoring and Fenton charts for the newborn.

Comparison of the performance of estimated fetal weight charts for the detection of small- and large-for-gestational age newborns with adverse outcomes: a French population-based study.

OBJECTIVE: To compare the performance of estimated fetal weight (EFW) charts at the third trimester ultrasound for detecting small- and large-for-gestational age (SGA/LGA) newborns with adverse outcomes. DESIGN: Nationally representative observational study. SETTING: French maternity units in 2016. POPULATION: 9940 singleton live births with an ultrasound between 30 and 35 weeks of gestation. METHODS: We compared three prescriptive charts (INTERGROWTH-21st, World Health Organization (WHO), Eunice Kennedy Shriver National Institute of Child Health and Human Development [NICHD]), four descriptive charts (Hadlock, Fetal Medicine Foundation, two French charts) and a French customised growth model (Epopé). MAIN OUTCOME MEASURES: SGA and LGA (birthweights <10th and >90th percentiles) associated with adverse outcomes (low Apgar score, delivery-room resuscitation, neonatal unit admission). RESULTS: 2.1% and 1.1% of infants had SGA and LGA and adverse outcomes, respectively. The sensitivity and specificity for detecting these infants with an EFW <10th and >90th percentile varied from 29-65% and 84-96% for descriptive charts versus 27-60% and 83-96% for prescriptive charts. WHO and French charts were closest to the EFW distribution, yielding a balance between sensitivity and specificity for SGA and LGA births. INTERGROWTH-21st and Epopé had low sensitivity for SGA with high sensitivity for LGA. Areas under the receiving operator characteristics curve ranged from 0.62 to 0.74, showing low to moderate predictive ability, and diagnostic odds ratios varied from 7 to 16. CONCLUSION: Marked differences in the performance of descriptive as well as prescriptive EFW charts highlight the importance of evaluating them for their ability to detect high-risk fetuses. TWEETABLE ABSTRACT: Choice of growth chart strongly affected identification of high-risk fetuses at the third trimester ultrasound.

Has the introduction of high-flow nasal cannula modified the clinical characteristics and outcomes of infants with bronchiolitis admitted to pediatric intensive care units? A retrospective study.

BACKGROUND: This study aimed to assess how the emergence of high-flow nasal cannula (HFNC) has modified the demographic and clinical characteristics as well as outcomes of infants with bronchiolitis admitted to a pediatric intensive care unit (PICU). METHODS: This was a single-center retrospective study including infants aged 1 day to 6 months with bronchiolitis requiring HFNC, noninvasive ventilation (NIV), or invasive ventilation on admission. RESULTS: A total of 252 infants (mean age 53±36 days) were included in the study. The use of HFNC increased from 18 (21.4%) during 2013-2014 to 53 infants (55.2%) during 2015-2016. The length of stay in the PICU decreased over time from 4.7±2.9 to 3.5±2.7 days (P<0.01) but the hospital length of stay remained similar (P=0.17). On admission, patients supported by HFNC as the first-line therapy were older. The PICU length of stay was similar according to the type of respiratory support (P=0.16), but the hospital length of stay was longer for patients supported by HFNC (P=0.01). CONCLUSION: The distribution of respiratory support has significantly changed over time for patients with bronchiolitis and HFNC is increasingly used. The demographic and clinical characteristics of the have not changed over time. However, the PICU length of stay decreased significantly.

Neurodevelopmental impairment at 2 years of age in children born before 29 weeks' gestation with bronchopulmonary dysplasia.

INTRODUCTION: Very preterm children are at a high risk for neurological impairment, especially those with bronchopulmonary dysplasia (BPD). The main goal of this study was to describe the neurodevelopmental impairment (NDI) at 2 years of corrected age in children born before 29 weeks' gestation between 2010 and 2015 and affected by BPD at 28 days of life. We also searched for risk factors associated with NDI, especially postnatal steroid (PNS) administration. MATERIAL AND METHODS: This was a retrospective study comprising a cohort of children hospitalized at the university hospital in Grenoble, born before 29 weeks' gestation between 2010 and 2015, and included in the monitoring network "Naitre et Devenir" (RND). Infants at 2 years of corrected age were classified as having NDI if they had at least one of the following outcomes: a global developmental quotient (DQ) on the revised Brunet-Lézine scale of<85, blindness, deafness, or cerebral palsy (CP) graded as level 3 or more according to the Gross Motor Function Classification System. RESULTS: A total of 129 children were included, of whom 99 were monitored at the age of 2 years: 31.3% of the population had NDI and 4% had CP. The median DQ test result was 90 (interquartile 82-97). Factors associated with NDI in univariate analysis were low gestational age, low birth weight, a cord pH<7.2, chorioamnionitis, treatment for persistent ductus arteriosus, longer oxygen therapy, and outborn status, which almost reached statistical significance. In multivariate analysis, low gestational age and outborn status remained statistically significant, while chorioamnionitis was found to have some association with NDI. While 13.1% of the followed-up population was treated with PNS, this risk factor was not associated with NDI. CONCLUSION: In a population of very preterm children, one third had NDI at 2 years of corrected age. Low gestational age, outborn status, and perinatal inflammation are associated with this unfavorable outcome. The frequency of sequelae confirms the importance of following up these children.

Antenatal detection of fetal growth restriction and risk of stillbirth: population-based case-control study.

OBJECTIVES: Antenatal surveillance of intrauterine growth aims to detect growth-restricted fetuses (FGR), which face increased risk of stillbirth. Improving their detection could be an effective strategy for prevention of stillbirth. The French REPERE study was conducted to estimate the association between antenatal detection of FGR and risk of stillbirth. METHODS: REPERE is a case-control study performed in three French districts with a combined total of approximately 30 000 births annually. Cases were singleton small-for-gestational-age (SGA) stillbirths ≥ 24 weeks' gestation and without severe congenital anomaly, between 2012 and 2014, identified using a population-based stillbirth registry; controls were live births fulfilling the same inclusion criteria over a 9-week period from 7 April to 8 June 2014. Data were extracted by trained investigators from medical records and ultrasound reports. SGA was defined as birth weight < 10th percentile of French customized standards. FGR was defined by the presence of at least one of seven predefined parameters (suspected FGR mentioned in medical records or in ultrasound report, suspected faltering growth mentioned in an ultrasound report, documented abdominal circumference or estimated fetal weight < 10th percentile, referral for additional ultrasound examination to monitor growth or abnormal umbilical artery Doppler). We used logistic regression to estimate crude and adjusted odds ratios (ORs) for the association between detection of FGR and risk of stillbirth. Included covariables were parity, maternal medical history, vascular complications during pregnancy and birth-weight percentile, which are known to be associated with risk of detection of FGR and of stillbirth. RESULTS: During the study period, there were 92 182 births ≥ 22 weeks' gestation, including 669 stillbirths, of which 79 were singleton SGA stillbirths ≥ 24 weeks and without severe congenital anomaly. Of these cases, 44.3% (35/79) had FGR detected, compared with a detection rate of 36.2% in controls (154/426). The crude OR expressing the association between detection of FGR and risk of stillbirth was 1.4 (95% CI, 0.9-2.3) and the OR adjusted for parity, presence of risk factors for FGR, presence of vascular disorder and birth-weight percentile was 0.6 (95% CI, 0.3-1.0). Among deliveries ≥ 28 weeks, detection rates were 38.3% vs 36.0% for cases and controls, with an adjusted OR of 0.5 (95% CI, 0.2-1.0). CONCLUSION: Antenatal detection of FGR was protective against stillbirth, but over 40% of stillbirths among SGA fetuses occurred despite detection of FGR, pointing to the need to improve management following detection. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Prevalence of Autism Spectrum Disorder in 7-9-Year-Old Children in Denmark, Finland, France and Iceland: A Population-Based Registries Approach Within the ASDEU Project.

We estimated autism spectrum disorder (ASD) prevalence in 7-9 year-old children in 2015 using data from three nationwide health registry systems (Denmark, Finland, Iceland) and two French population-based regional registries. Prevalence ranged from 0.48% in South-East France to 3.13% in Iceland (South-West France: 0.73%, Finland: 0.77%, Denmark: 1.26%). Male/female ratios ranged from 3.3 in Finland to 5.4 in South-West France. Between 12% (Denmark) and 39% (South-West France) of cases were diagnosed with intellectual disability. The variations in population-based ASD prevalence across four European countries with universal health care practices likely reflect variation in detection, referral and diagnosis practices and autism awareness across these areas. Using established population-based data systems is an efficient approach to monitor ASD prevalence trends over time.

Preconception care among low-risk mothers in a French perinatal network: Frequency of utilization and factors associated.

OBJECTIVE: Determine the frequency of preconception care use in France and factors impacting preconception visit. MATERIALS AND METHODS: An epidemiological study was conducted from September 2015 to October 2015 in 5 maternity hospitals within the "Alpes-Isère" perinatal network, comprising of French-speaking women, with uncomplicated pregnancies, who delivered a healthy term baby (≥37 weeks of gestational age). Two groups were compared: patients with and without preconception care. Descriptive, univariate and multivariate analyses were performed for the sociodemographic, the environmental characteristics and the gynecologic obstetric history. RESULTS: Among the 392 patients included in this study, only 62 (15.8% [12.0-20.0]) had used preconception care before their pregnancy. Multivariate analysis showed that the primiparous women (adjusted OR 2.47 [1.37-4.46]) and the women with a high socio-professional category (adjusted OR 2.32 [1.13-4.77]) were more likely to used preconception care. CONCLUSION: Despite the positive effects on mother and baby's health, preconception care is insufficiently used in France. Every effort must be made to improve awareness of preconception care among health workers and patients.

Gestational age at diagnosis of early-onset fetal growth restriction and impact on management and survival: a population-based cohort study.

OBJECTIVE: To investigate the impact of gestational age (GA) at diagnosis of fetal growth restriction (FGR) on obstetric management and rates of live birth and survival for very preterm infants with early-onset FGR. DESIGN: Population-based cohort study. SETTING: All maternity units in 25 French regions in 2011. POPULATION: Fetuses diagnosed with FGR before 28 weeks of gestation among singleton births between 22 and 31 weeks of gestation without severe congenital anomalies. METHODS: We studied the effects of GA at diagnosis on perinatal management and outcomes. We used multivariable regression to identify antenatal factors (maternal characteristics, ultrasound measurements and sex) associated with the probability of live birth. MAIN OUTCOMES MEASURES: Live birth and survival to discharge from neonatal care. RESULTS: A total of 436 of 3698 fetuses were diagnosed with FGR before 28 weeks (11.8%); 66.9% were live born and 54.4% survived to discharge. 50% were live born when diagnosis occurred before 25 weeks, 66% at 25 weeks and >90% at 26 and 27 weeks of gestation. In all, 94.1% of live births were by prelabour caesarean, principally for maternal indications before 26 weeks. Low GA at diagnosis, an estimated fetal weight or abdominal circumference below the third centile and male sex were adversely associated with live birth in adjusted models. CONCLUSION: Gestational age at FGR diagnosis had an impact on the probability of live birth and survival, after consideration of other perinatal characteristics. Investigations of the outcomes of births with early-onset FGR need to include stillbirths and information on the GA at which FGR is diagnosed. TWEETABLE ABSTRACT: Evaluations of active management of pregnancies with early onset growth restriction should include stillbirths.

[Neonatal arterial ischemic stroke: Review of the current guidelines]. / Accidents vasculaires cérébraux ischémiques artériels néonatals : synthèse des recommandations.

Neonatal arterial ischemic stroke (NAIS) is a rare event that occurs in approximately one in 5000 term or close-to-term infants. Most affected infants will present with seizures. Although a well-recognized clinical entity, many questions remain regarding diagnosis, risk factors, treatment, and follow-up modalities. In the absence of a known pathophysiological mechanism and lack of evidence-based guidelines, only supportive care is currently provided. To address these issues, a French national committee set up by the French Neonatal Society (Société française de néonatologie) and the national referral center (Centre national de référence) for arterial ischemic stroke in children drew up guidelines based on an HAS (Haute Autorité de santé [HAS]; French national authority for health) methodology. The main findings and recommendations established by the study group are: (1) among the risk factors, male sex, primiparity, caesarean section, perinatal hypoxia, and fetal/neonatal infection (mainly bacterial meningitis) seem to be the most frequent. As for guidelines, the study group recommends the following: (1) the transfer of neonates with suspected NAIS to a neonatal intensive care unit with available equipment to establish a reliable diagnosis with MRI imaging and neurophysiological monitoring, preferably by continuous video EEG; (2) acute treatment of suspected infection or other life-threatening processes should be addressed immediately by the primary medical team. Persistent seizures should be treated with a loading dose of phenobarbital 20mg/kg i.v.; (3) MRI of the brain is considered optimal for the diagnosis of NAIS. Diffusion-weighted imaging with apparent diffusion coefficient is considered the most sensitive measure for identifying infarct in the neonatal brain. The location and extent of the lesions are best assessed between 2 and 4 days after the onset of stroke; (4) routine testing for thrombophilia (AT, PC PS deficiency, FV Leiden or FII20210A) or for detecting other biological risk factors such as antiphospholipid antibodies, high FVIII, homocysteinemia, the Lp(a) test, the MTHFR thermolabile variant should not be considered in neonates with NAIS. Testing for FV Leiden can be performed only in case of a documented family history of venous thromboembolic disease. Testing neonates for the presence of antiphospholipid antibodies should be considered only in case of clinical events arguing in favor of antiphospholipid syndrome in the mother; (5) unlike childhood arterial ischemic stroke, NAIS has a low 5-year recurrence rate (approximately 1 %), except in those children with congenital heart disease or multiple genetic thrombophilia. Therefore, initiation of anticoagulation or antithrombotic agents, including heparin products, is not recommended in the newborn without identifiable risk factors; (6) the study group recommends that in case of delayed motor milestones or early handedness, multidisciplinary rehabilitation is recommended as early as possible. Newborns should have physical therapy evaluation and ongoing outpatient follow-up. Given the risk of later-onset cognitive, language, and behavioral disabilities, neuropsychological testing in preschool and at school age is highly recommended.

[Customized and non-customized French intrauterine growth curves. I - Methodology]. / Courbes de croissance in utero ajustées et non ajustées adaptées à la population française. I - Méthodes de construction.

OBJECTIVES: We developed intrauterine growth references, called EPOPé curves, in line with recommendations for screening of intra-uterine growth restriction issued in 2013 by the French College of Obstetricians and Gynecologists. POPULATION AND METHODS: Using the French Perinatal Survey (FPS) 2010, we adapted the methodology developed by Gardosi (1) to model intrauterine growth and its distribution and (2) to adjust for physiological fetal and maternal factors influencing fetal weight. Based on this model, 3 reference curves (unadjusted, adjusted for fetal sex, and adjusted for fetal sex, and maternal height, weight and parity) were proposed. We applied these models to births in the 2010 FPS and the French hospital discharge database (PMSI) in 2011-2012. RESULTS: Among singleton live births in the FPS and the PMSI, the model adjusted for fetal sex identified 3.2 and 3.3% of births below the 3rd centile respectively, and 10.0 and 10.2% below the 10th. In model adjusted for maternal factors, 4.0% of births from the FPS 2010 were reclassified, but population rates remained at 3.0 and 10.0%. CONCLUSION: This growth model is appropriate for French births, and allows for the implementation of a homogeneous definition of small for gestational age infants during pregnancy and at birth.

[Customized and non-customized French intrauterine growth curves. II - Comparison with existing curves and benefits of customization]. / Courbes de croissance in utero ajustées et non ajustées adaptées à la population française. II - Comparaison à des courbes existantes et apport de l'ajustement.

OBJECTIVES: Our aim is to compare the new French EPOPé intrauterine growth curves, developed to address the guidelines 2013 of the French College of Obstetricians and Gynecologists, with reference curves currently used in France, and to evaluate the consequences of their adjustment for fetal sex and maternal characteristics. POPULATION AND METHODS: Eight intrauterine and birthweight curves, used in France were compared to the EPOPé curves using data from the French Perinatal Survey 2010. The influence of adjustment on the rate of SGA births and the characteristics of these births was analysed. RESULTS: Due to their birthweight values and distribution, the selected intrauterine curves are less suitable for births in France than the new curves. Birthweight curves led to low rates of SGA births from 4.3 to 8.5% compared to 10.0% with the EPOPé curves. The adjustment for maternal and fetal characteristics avoids the over-representation of girls among SGA births, and reclassifies 4% of births. Among births reclassified as SGA, the frequency of medical and obstetrical risk factors for growth restriction, smoking (≥10 cigarettes/day), and neonatal transfer is higher than among non-SGA births (P<0.01). CONCLUSION: The EPOPé curves are more suitable for French births than currently used curves, and their adjustment improves the identification of mothers and babies at risk of growth restriction and poor perinatal outcomes.

Fetal growth restriction and intra-uterine growth restriction: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians.

Small for gestational age (SGA) is defined by weight (in utero estimated fetal weight or birth weight) below the 10th percentile (professional consensus). Severe SGA is SGA below the third percentile (professional consensus). Fetal growth restriction (FGR) or intra-uterine growth restriction (IUGR) usually correspond with SGA associated with evidence indicating abnormal growth (with or without abnormal uterine and/or umbilical Doppler): arrest of growth or a shift in its rate measured longitudinally (at least two measurements, 3 weeks apart) (professional consensus). More rarely, they may correspond with inadequate growth, with weight near the 10th percentile without being SGA (LE2). Birthweight curves are not appropriate for the identification of SGA at early gestational ages because of the disorders associated with preterm delivery. In utero curves represent physiological growth more reliably (LE2). In diagnostic (or reference) ultrasound, the use of growth curves adjusted for maternal height and weight, parity and fetal sex is recommended (professional consensus). In screening, the use of adjusted curves must be assessed in pilot regions to determine the schedule for their subsequent introduction at national level. This choice is based on evidence of feasibility and the absence of any proven benefits for individualized curves for perinatal health in the general population (professional consensus). Children born with FGR or SGA have a higher risk of minor cognitive deficits, school problems and metabolic syndrome in adulthood. The role of preterm delivery in these complications is linked. The measurement of fundal height remains relevant to screening after 22 weeks of gestation (Grade C). The biometric ultrasound indicators recommended are: head circumference (HC), abdominal circumference (AC) and femur length (FL) (professional consensus). They allow calculation of estimated fetal weight (EFW), which, with AC, is the most relevant indicator for screening. Hadlock's EFW formula with three indicators (HC, AC and FL) should ideally be used (Grade B). The ultrasound report must specify the percentile of the EFW (Grade C). Verification of the date of conception is essential. It is based on the crown-rump length between 11 and 14 weeks of gestation (Grade A). The HC, AC and FL measurements must be related to the appropriate reference curves (professional consensus); those modelled from College Francais d'Echographie Fetale data are recommended because they are multicentere French curves (professional consensus). Whether or not a work-up should be performed and its content depend on the context (gestational age, severity of biometric abnormalities, other ultrasound data, parents' wishes, etc.) (professional consensus). Such a work-up only makes sense if it might modify pregnancy management and, in particular, if it has the potential to reduce perinatal and long-term morbidity and mortality (professional consensus). The use of umbilical artery Doppler velocimetry is associated with better newborn health status in populations at risk, especially in those with FGR (Grade A). This Doppler examination must be the first-line tool for surveillance of fetuses with SGA and FGR (professional consensus). A course of corticosteroids is recommended for women with an FGR fetus, and for whom delivery before 34 weeks of gestation is envisaged (Grade C). Magnesium sulphate should be prescribed for preterm deliveries before 32-33 weeks of gestation (Grade A). The same management should apply for preterm FGR deliveries (Grade C). In cases of FGR, fetal growth must be monitored at intervals of no less than 2 weeks, and ideally 3 weeks (professional consensus). Referral to a Level IIb or III maternity ward must be proposed in cases of EFW <1500g, potential birth before 32-34 weeks of gestation (absent or reversed umbilical end-diastolic flow, abnormal venous Doppler) or a fetal disease associated with any of these (professional consensus). Systematic caesarean deliveries for FGR are not recommended (Grade C). In cases of vaginal delivery, fetal heart rate must be monitored continuously during labour, and any delay before intervention must be faster than in low-risk situations (professional consensus). Regional anaesthesia is preferred in trials of vaginal delivery, as in planned caesareans. Morbidity and mortality are higher in SGA newborns than in normal-weight newborns of the same gestational age (LE3). The risk of neonatal mortality is two to four times higher in SGA newborns than in non-SGA preterm and full-term infants (LE2). Initial management of an SGA newborn includes combatting hypothermia by maintaining the heat chain (survival blanket), ventilation with a pressure-controlled insufflator, if necessary, and close monitoring of capillary blood glucose (professional consensus). Testing for antiphospholipids (anticardiolipin, circulating anticoagulant, anti-beta2-GP1) is recommended in women with previous severe FGR (below third percentile) that led to birth before 34 weeks of gestation (professional consensus). It is recommended that aspirin should be prescribed to women with a history of pre-eclampsia before 34 weeks of gestation, and/or FGR below the fifth percentile with a probable vascular origin (professional consensus). Aspirin must be taken in the evening or at least 8h after awakening (Grade B), before 16 weeks of gestation, at a dose of 100-160mg/day (Grade A).

Poor effectiveness of antenatal detection of fetal growth restriction and consequences for obstetric management and neonatal outcomes: a French national study.

OBJECTIVE: To assess the proportion of small for gestational age (SGA) and normal birthweight infants suspected of fetal growth restriction (FGR) during pregnancy, and to investigate obstetric and neonatal outcomes by suspicion of FGR and SGA status at birth. DESIGN: Population-based study. SETTING: All French maternity units in 2010. POPULATION: Representative sample of singleton births (n = 14,100). METHODS: We compared SGA infants with a birthweight of less than the 10th percentile suspected of FGR, defined as mention of FGR in medical charts (true positives), non-SGA infants suspected of FGR (false positives), SGA infants without suspicion of FGR (false negatives) and non-SGA infants without suspicion of FGR (true negatives). Multivariable analyses were adjusted for maternal and neonatal characteristics hypothesised to affect closer surveillance for FGR and our outcomes. MAIN OUTCOME MEASURES: Obstetric management (caesarean, provider-initiated preterm and early term delivery) and neonatal outcomes (late fetal death, preterm birth, Apgar score, resuscitation at birth). RESULTS: 21.7% of SGA infants (n = 265) and 2.1% of non-SGA infants (n = 271) were suspected of FGR during pregnancy. Compared with true negatives, provider-initiated preterm deliveries were higher for true and false positives (adjusted risk ratio [aRR], 6.1 [95% CI, 3.8-9.8] and 4.6 [95% CI, 3.2-6.7]), but not for false negatives (aRR, 1.1 [95% CI, 0.6-1.9]). Neonatal outcomes were not better for SGA infants if FGR was suspected. CONCLUSION: Antenatal suspicion of FGR among SGA infants was low and one-half of infants suspected of FGR were not SGA. The increased risk of provider-initiated delivery observed in non-SGA infants suspected of FGR raises concerns about the iatrogenic consequences of screening.

[Definitions: small for gestational age and intrauterine growth retardation]. / Définitions: petit poids pour l'âge gestationnel et retard de croissance intra-utérin.

OBJECTIVES: Screening for intrauterine growth restriction (IUGR) is a major component of antenatal care, but the debate about the choice of birthweight standards is longstanding. The objective of this first chapter is to provide guidelines about optimal definition of IUGR. MATERIALS AND METHODS: Literature review about available birthweight curves to define IUGR, including the analysis of their diagnosis accuracy and their relevance to identify babies at risk of poor perinatal outcomes. RESULTS: Intrauterine growth curves are more suitable for "normal" growth modeling than birth weight curves, and fetal growth is influenced by individual characteristics, fetal gender being the most important among them (EL2). Infants with a low birth weight are either constitutionally small babies or babies with pathological fetal growth failure. Use of "SGA" for all Small for Gestational Age infants is now recommended, "IUGR" being appropriate only for infants with pathological growth restriction (Professional consensus). Depending on reference curves, identified SGA babies and pregnancy outcomes may be different. Customized birth weight standards are based on an intrauterine growth modeling adjusted for fetal gender, maternal height, weight and parity, and appear to be the most accurate to identify SGA births at risk (EL3). However, their benefit on perinatal morbidity and mortality has not been demonstrated by prospective studies. CONCLUSION: Benefits and drawbacks of customized birth weight curves seem in favor of their use. Their application in ante and postnatal investigations is a real opportunity to standardize clinical practice and make information provided to parents more consistent.

[Breastfeeding: opinion and knowledge of pharmacists. A study in a semi-urban territory]. / Allaitement maternel : opinions et connaissances des pharmaciens dans la métropole lilloise.

BACKGROUND: Because of the French delay regarding breastfeeding compared to other Europeans countries, its promotion was one of the 9 specific nutritional goals of the 2001, 2006, and 2011 National Nutritional Health Program. The objective of this study was to establish the opinion and knowledge of pharmacists from a selected semi-urban territory of the Lille metropolitan area on breastfeeding. METHOD: The 33 pharmacies around the city of Villeneuve-d'Ascq were contacted. First, the goal and the principles of the study were presented to the pharmacists and they were invited to participate in a survey. This survey was divided into 6 topics with 26 questions. The topics were: advice on breastfeeding, pain and inflammation during breastfeeding, use of a breast pump, preservation and reheating of breast milk, breastfeeding and medication, breastfeeding and contraception, and breastfeeding promotion. The survey also evaluated their willingness to promote breastfeeding and the assistance needed for undertaking this promotion. By counting the right answers from 13 of the 26 questions, a global grade was calculated reflecting the knowledge of the participants. The maximum grade was 20 because many questions had several correct answers. RESULTS: Twenty-nine pharmacies agreed to participate (participation rate, 88%). The mean grade was 13.4 (95% CI: 12.7-14.0). Professional and personal experience had no influence on the grades. In the opinion of the pharmacists, the 3 topics most frequently raised by women were cracked nipples, mastitis, and painful breast (quoted by 83% of the pharmacists), the infant formula to use as a complete or partial substitute for breastfeeding (66%), and breastfeeding and medication (59%). Fifty-five percent of the participants were aware of the WHO recommendations on exclusive breastfeeding up to 6 months of age. The desire to promote breastfeeding was strong (68%). Thus, all pharmacists favored the distribution of a leaflet giving information on breastfeeding. CONCLUSION: This study shows a strong desire to promote breastfeeding among the pharmacists surveyed. It allows focusing on the themes that could be the target for continuing education, based on mothers' needs.

Evaluation of a decision protocol for type of delivery of infants in breech presentation at term.

OBJECTIVES: To assess the safety of a decision protocol for type of delivery of breech presentations after 37 weeks of gestation. This protocol was based on a comparison of fetal head and maternal pelvic measurements. STUDY DESIGN: Retrospective before-and-after study of 1133 breech infants born between 2000 and 2008 in a tertiary centre, analysing neonatal condition and percentage of vaginal deliveries by study period. RESULTS: Application of the protocol was accompanied by an increase in the percentage of vaginal deliveries of breech presentations from 24.0% in 2000-2004 to 38.5% in 2004-2008 (p<0.001), without impairment of neonatal condition [composite mortality/morbidity variable: 3/567 (0.5%) vs 4/566 (0.7%), respectively; p>0.99; neonatal arterial pH<7.0: 8/521 (1.5%) vs 4/529 (0.8%), respectively; p=0.23]. CONCLUSION: The use of a protocol based on objective criteria at the authors' centre made it possible to increase the percentage of vaginal deliveries of breech presentations without impairing neonatal condition.

Should parity be included in customised fetal weight standards for identifying small-for-gestational-age babies? Results from a French multicentre study.

OBJECTIVE: Parity is one of several parameters used to customise fetal growth norms. However, it is uncertain whether the lower birthweight of babies born to primiparous women reflects physiological or pathological variation. Our aim was to assess the impact of adjusting for parity in identification of small-for-gestational-age (SGA) births. DESIGN: Comparison of two customised definitions of SGA with and without parity. SETTING: Routinely collected data in five tertiary maternity hospitals in France. POPULATION: A total of 51 126 singleton births without malformations from 1997 to 2002. METHODS: Characteristics of mothers and babies and adverse pregnancy outcomes for SGA and non-SGA births were compared using customised definitions with and without parity. MAIN OUTCOME MEASURES: Neonatal morbidity and mortality. RESULTS: SGA births among primiparas increased from 14.9 to 18.0% when parity was excluded. Overall rates of SGA rose from 14.4 to 15.0%. Newly defined cases of SGA were babies of primiparas. They had higher rates of admission to a neonatal unit and caesarean section than babies reclassified as non-SGA. Perinatal mortality was 9.1 per thousand (parity included) and 9.7 per thousand (parity excluded) and did not differ significantly from babies classified as non-SGA by both standards (5.4 per thousand). CONCLUSIONS: Adjustment for parity markedly decreased the proportion of primiparas diagnosed with SGA babies but did not appear to improve the identification of high-risk babies. Removing parity would simplify the customised definition of SGA and would eliminate the need for the assumption that lower birthweight for primiparous women is normal.