[Guidelines for multivitamin administration in fortified human milk prepared for preterm infants]. / Protocole d'administration de l'Uvestérol ADEC® au prématuré nourri au lait de femme enrichi.

BACKGROUND: To reach nutritional standards, human milk has to have 2g/dL of protein. In 2013, Lafeber stated that when human milk is fortified up to 2g/dL, it may increase its osmolality up to 500 mOsm/kg. He also warned that care must be taken when adding a drug or vitamins to human milk. AIM: We studied, for the first time, the impact of adding multivitamins (ADEC) on human fortified milk osmolality. METHOD: The osmolality of 36 pasteurized, fortified human milk samples was measured. The amount of milk required as a solvent to maintain osmolality below 500 mOsm/kg was then determined. RESULTS: The osmolality of 2mL of fortified human milk reached up to 750 mOsm/kg when the multivitamins ADEC was added. The osmolality decreased proportionately as the solution was diluted and if vitamins are added in two half-doses each time. It is only with 20mL of milk that the osmolality lowers to its initial rate of 430 mOsm/kg. The stronger the milk's fortification is, the greater impact it has on the milk's osmolality. CONCLUSION: New nutritional recommendations for premature infants are needed. In the meantime, when the fortified milk intake is under 20mL, it is preferable to extend parenteral intakes with fat-soluble vitamins or reduce doses of vitamins in milk. Also, we should use enriched human milk as a fortifier and be cautious with indiscriminate fortification or when adding drugs and electrolyte solutions.

[Maternal factors influencing breastfeeding on a neonatal intensive care unit]. / Impacts des facteurs maternels sur l'allaitement maternel en réanimation néonatale.

OBJECTIVE: Admission at birth to a Neonatal Intensive Care Unit (NICU) complicates breastfeeding especially for preterm babies despite hospital staff trained to encourage breastfeeding. The aim of this study was to find factors related to the mother, the pregnancy or the neonate influencing breastfeeding rate on a NICU. PATIENTS AND METHODS: This was a retrospective study including neonatal admissions to the NICU at Antoine-Béclère University Hospital from 1st May 2009 to 30th April 2010. Data was collected from medical notes. The breastfeeding rate (at initiation and at discharge) was analysed with regards to maternal age, method of procreation, type of pregnancy (single or multiple), parity, mode of delivery (vaginal delivery or C-section), birthweight, gestational age and intra-uterine growth restriction (IUGR). RESULTS: The study was based on 460 neonates having complete documentation. The average maternal age was 32 years. Premature infants represented 74.8% of the population (median gestational age=34 weeks) of which 57% were less than 33 weeks (42.6% of all infants, n=196). The median birthweight was 1900 g with 17.6% of IUGR infants. Breastfeeding rate at initiation was 58.7 and 43.9% at discharge (mean admission days: 17.1 [0-180], median=8 days). For infants born of multiple pregnancies (24.3% of the population) 51.6% were born of medically assisted pregnancies (MAP) and 17.6% of spontaneous pregnancies. Breastfeeding rate among these infants was 57.1% at initiation and 45.5% at discharge. It was higher in infants born of MAP at initiation (70.3% versus 55.8% for spontaneous pregnancies, P<0.05) and at discharge (49.5% versus 42.5% for spontaneous pregnancies). For these infants, average maternal age was higher for breastfed infants (33.9 versus 32.1 years for the formula-fed, P<0.05). Breastfeeding rate in infants born to primipares was higher at initiation (64.9% versus 53.6% for multipares, P<0.05) and at discharge (48.5% versus 40.8% for multipares, P<0.05). The rate of infants breastfed was influenced neither by maternal age alone (31.8 ± 5.6 versus 31.4 ± 5.7 years for formula-fed), nor by type of delivery (56.7% for infants born by C-section versus 62.5% for infants born by vaginal delivery), nor gestational age (33.2 ± 4.3 weeks for breastfed, versus 33.4 ± 4.2 weeks for formula-fed infants), nor birthweight (2060 ± 978 g for breastfed versus 2055 ± 909 g for formula-fed infants), nor IUGR (58% versus 58.8% for eutrophes). DISCUSSION: Our maternal population was different as 16.7% of deliveries were accounted for by MAP, superior to the French average (<10%). We describe for the first time MAP as a positive influencing factor on breastfeeding rates in newborns admitted to a NICU. A better breastfeeding information policy during pregnancy, higher maternal age and increased multiple pregnancies would explain a higher breastfeeding rate among the women who had MAP. An impact of increasing maternal age was found on the rate of breastfed infants born of MAP. Primiparity was also a contributing factor for breastfeeding. Professional formation for all hospital staff concerned would be essential to give out clear and consistent information to families and to encourage support and intimacy throughout hospitalisation as well as at discharge.

[Nutrition of the preterm infant]. / La nutrition du prématuré

The quality of nutritional support impacts not only the growth and quality of growth of preterm infants, but also all aspects of their development. In order to provide optimal nutrition, two main rules should be followed: optimise early parenteral nutrition and introduce appropriate enteral nutrition preferably with the mother's milk as early as possible. Recommendations have recently increased early energy and protein intake. The term "aggressive nutrition" has been introduced to qualify these changes, but we prefer the term "optimal nutrition," which more precisely reflects the physiology and needs of the preterm infant. Specific efforts should be continued to improve physician training in neonatal nutrition and to facilitate the dissemination of the most recent recommendations. Standardization of nutritional protocols in neonatal units should be promoted as a way to improve overall nutritional care. A full field of research remains open to determine the most effective nutritional strategy for preterm infants in order to maximize their growth and development.

[Oxygen therapy in newborn: equipments for non-invasive monitoring]. / Oxygénothérapie du nouveau-né: matériels de surveillance non invasive.

In newborn and premature infants whose lung immaturity entails a limited capacity for O2 detoxification, the use of supplemental oxygen should be continuously and non-invasively monitored. Pulse oximetry and transcutaneous O2 monitoring are the systems most used in the NICU. Major limitations of pulse oximetry are motion artifact, sensitivity to excessive light, cutaneous hypoperfusion, hypothermia, venous congestion, arterio-venous shunting, strong skin pigmentation, anemia and high percentage of abnormal hemoglobin. Alarm habituation is a further major risk. New oxymeters show less motion, artifact and higher accuracy during low oxygen saturation. The accuracy during high oxygen saturation is very dependent on the specific oxymeter model used. Transcutaneous O2 monitoring is usually combined with transcutaneous PCO2 monitoring, hence enabling evaluation of oxygenation as well as ventilation. A major risk of this method is related to the heated electrode sensor, which can induce skin burns. A combined ear sensor for pulse oximetry and PCO2 monitoring seems promising.

[Preventing dehydration with oral rehydration therapy (ORT) in less than 15-day-old newborns: safety, efficiency and limits]. / Soluté de réhydratation orale (SRO) et hydratation entérale du nouveau-né dans les 15 premiers jours de vie: tolérance, efficacité et limites.

OBJECTIVES: We conducted a retrospective evaluation of enteral infusion with a marketed hypoosmolar oral rehydration solution (HORS), as an alternative to intravenous infusion. POPULATION AND METHODS: Premature infants, with difficult venous condition, 30 weeks or more during HORS infusion. Enteral ORS started after well-tolerated milk gastric gavage. Gradual increase of enteral feeding. RESULTS: January 1999 to April 2001, 105 neonates 28 weeks to 36 weeks, birth weight 1050 to 2700g, including 71.5% eutrophic newborns 30 to 34 weeks; 13.3% hypotrophic<10th P. More than 90% had a physiological weight curve: weight loss vs birth<15%, back to birth weight at day 15. No significant pathology during ORS. Failure of ORS for 7/105 children. Relative risk increased 8 fold if term was less than 30 weeks, 7 folds in the event of enteropathy before ORS. In 26.7% of the infants, gastric enteral residuals exceeded 1/3 of intake, vomiting and/or abdominal ballooning lasted less than 48 hours. There were 4 deaths during follow-up (periventricular leucomalacia, myocardial infarctus) and 1 necrotizing enterocolitis. At theoretical birth date, 25% of the neonates were hypotrophic<10th P. At one and 2 years of age, less than 5% were still hypotrophic: relative risk increased 18 fold when birth weight was<5th P. CONCLUSION: HORS is an efficient, well-tolerated, low-cost and less invasive alternative to intravenous infusion. It must be reserved for eutrophic neonates born>30 weeks gestation due to risk of failure and insufficient growth. Validation with a multicentric clinical trial is in progress.

[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.

Low levels of pancreatic elastase 1 in stools of preterm infants.

The amount of faecal pancreatic enzyme elastase 1 was significantly lower in 42 preterm newborns than in 12 full term babies at day 2 (89 (3-539) v 354 (52-600) microg/g, p<0.0007) and day 5 (164 (3-600) v 600 (158-600) microg/g, p<0.05) and correlated positively with total nutrient intake during the first week of life in preterm infants. This should probably be taken into account during early feeding.

[Anoxic encephalopathy of the term neonate and brain hypothermia]. / Encéphalopathie anoxique du nouveau-né à terme et hypothermie cérébrale.

The outcome of term newborns with birth asphyxia and moderate to severe hypoxic ischemic encephalopathy remains very poor. After the primary phase of energy failure during asphyxia, neuronal cell metabolism may deteriorate in a secondary phase of brain injury. The window between these two phases opens the way to potential neuroprotective treatments such as brain cooling. Promising experimental data on controlled hypothermia need to be examined with clinical trials.

Methylprednisolone, an alternative to dexamethasone in very premature infants at risk of chronic lung disease.

OBJECTIVE: To evaluate the benefits and the medium-term side effects of methylprednisolone in very preterm infants at risk of chronic lung disease. STUDY DESIGN: Forty-five consecutive preterm infants (< 30 weeks' gestation) at risk of chronic lung disease were treated at a mean postnatal age of 16 days with a tapering course of methylprednisolone. The outcome of treatment was assessed by comparison with 45 consecutive historical cases of infants treated with dexamethasone; the infants did not differ in baseline characteristics. RESULTS: There were no differences between groups in the rate of survivors without chronic lung disease. Infants treated with methylprednisolone had a higher rate of body weight gain during the treatment period (median 120 g, range 0 to 190, vs. 70 g, range -110 to 210, P = 0.01) and between birth and the age of 40 weeks (median 1660 g, range 1170-2520, vs. 1580 g, range 1,040 to 2,120, P = 0.02). The incidence of both glucose intolerance requiring insulin (0 % vs. 18 %, P = 0.006) and cystic periventricular leukomalacia (2 % vs. 18%, P = 0.03) was lower among methylprednisolone-treated infants. CONCLUSION: Our observations confirm methylprednisolone to be as effective as dexamethasone and to have fewer side effects. A randomized control trial is needed to further study the efficacy and safety of methylprednisolone in very premature infants at risk of chronic lung disease.

[Esophageal bezoar in a child treated with sucralfate]. / Bézoard oesophagien chez un enfant traité par sucralfate.

BACKGROUND: Sucralfate is widely used in stress bleeding prophylaxis in intensive care units as it causes relatively few side effects. Its use in patients with risk factors may lead to the formation of esophageal bezoar. We describe the first known pediatric case of sucralfate esophageal bezoar. CASE REPORT: A 11-year-old girl presented with severe encephalitis complicated by seizures. She was treated in an intensive care unit by restrictive hydration associated with sucralfate, morphinic compound, phenobarbital and curare. At day 10, enteral feeding through a nasogastric tube was started. Five days later, an esophageal bezoar was diagnosed, which disappeared after discontinuing sucralfate, morphinic compound, curare and enteral feeding. CONCLUSIONS: Risk factors, similar to those reported in adults with esophageal bezoars, were found in this patient ie, plurimedication, dehydration, impaired gastric motility. Caution should be taken when combining enteral feeding and sucralfate whenever any additional risk factor is present.