Neonatal end-of-life decision-making almost 20 years after the EURONIC study: A French survey.

Nearly 20 years ago the EURONIC study reported that French neonatologists sometimes deemed it legitimate to terminate the lives of newborn infants when the prognosis appeared extremely poor. Parents were not always informed of these decisions. Major change has occurred since then and is described herein. MATERIAL AND METHODS: A survey was conducted in the Île-de-France region, from 1 January to 31 January 2016. Professionals from 15 neonatal intensive care units (NICUs) were invited to complete a questionnaire. RESULTS: A total of 702 questionnaires were collected and 670 responses were analyzed. Knowledge of the law differed according to professional status, with 71% of MDs (medical staff, MS), compared with 28% of nonmedical staff (NMS) declaring that they had good knowledge of the law. Most MDs and NMS believed that withholding or withdrawing life-sustaining treatments (WWLST) could be decided and implemented after a delay. Half of them thought that WWLST would always result in death. Although required by law, a consulting MD attended the collegial meeting required before deciding on WWLST in only half of the cases. Parents were almost always informed of the decision thereafter by the physician in charge of their infant. The most frequent disagreement with parents was observed when WWLST was the option selected. In this case, most professionals suggested postponing WWLST, continuing intensive care and dialogue with parents, aiming at a final shared decision. Major differences were observed between NICUs with regard to the withdrawal of artificial nutrition and hydration. Finally, 14% of MDs declared that infant active terminations of life still occurred in their NICU. Major differences concern WWLST and active termination of life, whose meaning has been partly modified since 2001. CONCLUSION: Several major changes were observed in this survey: (1) treatment withdrawal decisions are made today in agreement with the law; (2) parents' information and involvement in the decision process have profoundly changed; (3) active termination of life (euthanasia) very rarely occurs; only at the end of a process in accordance with ethical principles and within the law is this decision made.

Perinatal grief following neonatal comfort care for lethal fetal condition.

BACKGROUND: The objective of the study was to assess perinatal grief experienced after continuing pregnancy and comfort care in women diagnosed with lethal fetal condition compared with termination of pregnancy for fetal anomaly (TOPFA). METHODS: This was a retrospective observational study which included women who chose to continue their pregnancy after the diagnosis of lethal fetal condition with comfort care support at birth at the Prenatal Diagnosis Center of Rennes Hospital from January 2007 to January 2017. Women were matched with controls who underwent TOPFA for the same type of fetal anomaly, gestational age at diagnosis and year. Women were evaluated by a questionnaire including the Perinatal Grief Scale. RESULTS: There were 28 patients in the continuing pregnancy group matched with 56 patients in the TOPFA group. Interval between fetal loss and completion of questionnaire was 6±3 years. Perinatal grief score was similar at 61±22 vs 58±18 (p = 0.729) in the continuing pregnancy and TOPFA groups, respectively. Women in the TOPFA group expressed more guilt. The cesarean-section rate in the continuing pregnancy group was 25%. CONCLUSION: Perinatal grief experienced by women opting for continuing pregnancy and comfort care after diagnosis of a potentially lethal fetal anomaly is not more severe than for those choosing TOPFA.

[End of life in neonatal medicine under the direction of French law]. / Fin de vie en médecine néonatale à la lumière de la loi.

Two recent laws have significantly reformed the French Public Health Code: the law of March 4th 2002, related to the patient's rights and the quality of the health care system and the law of April 22nd 2005, related to the patient's rights and the end of life. These changes have prompted health care professionals involved in perinatal and neonatal medicine to update their considerations on the ethical aspects of the end of life in neonatal medicine. Therefore, the authors examined the clauses of the law related to the patient's rights and to the end of life, confronting them with the distinctive features of neonatal medicine. In this paper, the medical practices, which are either prohibited or authorized in the course of end of life are considered: prohibition of euthanasia, authorization for alleviating pain at the risk of shortening life, authorization for restricting, withholding or withdrawing treatments. Next, the justifications provided by the legislation to authorize these practices are analysed: prohibition of unreasonable obstinacy and respect for individual wishes. Then, the conditions required by the law to determine and to implement these acts are discussed: consultation with the healthcare staff and justified advice from a consulting physician, consideration of parental opinion, registration of the decision and its justifications into the patient's medical file, protection of the dying patient's dignity and preservation of his life quality by providing palliative care. Lastly, we report the terms of the ethical dilemma which may occur in the area of neonatal medicine in spite of genuine and persevering efforts in order to conciliate legal requirement and ethical responsibility.

[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.

Isolated neonatal MRI punctate white matter lesions in very preterm neonates and quality of life at school age.

OBJECTIVE: To study the quality of life at school age of very preterm infants presenting isolated punctate periventricular white matter lesions (IPWL) on late-preterm or term magnetic resonance imaging (MRI). METHODS: In 1996-2000, 16 of the 131 very preterm neonates explored by MRI were found to have IPWL. At the age of 9-14, 12 children from the IPWL group were compared with 54 children born preterm but with a normal MRI (no lesion). Quality of life (Health Status Classification System Pre School questionnaire), school performance, and motor outcome were investigated. RESULTS: Overall quality of life did not differ between the groups (classified as perfect in 2/12 of the IPWL vs 20/54 in the no-lesion). The sub-items mobility and dexterity differed significantly between the two groups, with impairment in the IPWL group (p < 0.001 and p < 0.05). This group also displayed higher levels of motor impairment: they began walking later [20(4) vs. 15(3) months), p < 0.01], had higher frequencies of cerebral palsy (6/12 vs. 2/54, p < 0.05), and dyspraxia (4/12 vs. 0/54, p < 0.001). The rate of grade retention did not differ between the groups (3/12 in the IPWL group vs. 17/54 in the no-lesions group) but, as expected, was higher than that of the French general population (17.4%) during the study period. CONCLUSION: This long-term follow-up study detected no increase in the risk of subsequent cognitive impairment in very preterm infants with IPWL, but suggests that these children may have a significantly higher risk of dyspraxia, and motor impairment.

[Termination of pregnancy without feticide: A French national survey]. / L'interruption médicale de grossesse sans fœticide : une enquête nationale.

PURPOSE: Termination of pregnancy without feticide (TOPWF) is poorly known in France and far less practiced than palliative care after term birth of a child having a lethal pathology. Few teams consider it and its practice remains confidential. This survey tries to describe it. MATERIAL AND METHODS: A national survey was realized in 2014 using a questionnaire sent to 50 centers of prenatal diagnosis depending on a perinatal diagnosis center in France. RESULTS: Thirty-one centers answered the questionnaire. Seven teams shared their experience of TOPWF after 22-24 weeks gestation (WG). This practice concerned fetuses affected by "lethal" pathologies. The absence of feticide followed a parental request or a proposal of the medical team, after individual discussion in a multidisciplinary meeting. All the children born alive after TOPWF benefited of palliative care. The 24 other centers having answered our investigation performed systematically the feticide beyond 22-24 WG. They so wished "to protect" the fetus, the parents and the nursing team. A majority of these teams faced parental demands of abstention of feticide but few of them answered it favorably. CONCLUSION: A robust "palliative culture" seems essential to allow the nursing team to consider the development of TOPWF.

[Antenatal palliative plan following diagnosis of fetal lethal condition: Rennes Teaching Hospital experience]. / Projet palliatif anténatal après diagnostic de malformation fœtale létale : expérience du CHU de Rennes de 2006 à 2012.

OBJECTIVES: To study the pregnancies followed at Rennes University Hospital from 2006 to 2012, after prenatal diagnosis of lethal fetal condition and prenatal project of palliative care at birth consisting of comfort care emphasizing parent-child encounters and bonding. MATERIAL AND METHODS: Retrospective study of 20 pregnancies with diagnosis of lethal fetal condition where parents accepted antenatally the proposal or sought for palliative care at birth. RESULTS: Diagnosis was made at a median age of 20 weeks gestation (12-33). Birth occurred at 37.4 WG, 6 caesarean sections were performed for maternal conditions. Six cases of hypoplastic left heart syndrome (HLHS) share common characteristics: good Apgar score, prolonged survival (26hours to 159days) transfer to neonatology ward (6) or later at home (4). In four multiple pregnancies, the choice of SP mainly contributed to protect healthy twins during pregnancy. In birth room, there was no need for invasive procedure or drugs. Death: one occurred during labor, 8 in birth room before H2, others in neonatal ward before d4 (excluding HLHS). CONCLUSION: These data will enable better antenatal preparation of both teams and parents. Lifetime, however short, allowed parents to meet with their child alive this permitting collection of memory traces and bonding.

Population pharmacokinetics of midazolam in neonates.

OBJECTIVE: To describe the pharmacokinetics of midazolam, a water-soluble benzodiazepine with a short half-life, in critically ill neonates. HYPOTHESIS: Midazolam clearance is reduced in neonates compared with clearance in children, and the doses currently in use, which are derived from pediatric studies, are excessive. PATIENTS AND METHODS: This population study was conducted in 187 neonates requiring intravenous sedation for artificial ventilation. The 531 midazolam concentration measurements obtained were analyzed by use of NONMEM and a two-compartment model with four parameters: clearance (CL), central volume (Vc), peripheral volume (Vp), and intercompartmental clearance (Q). The influence of birth weight (range, 700 to 5200 gm), gestational age (range, 26 to 42 weeks), postnatal age (range, 0 to 10 days), and comedications were investigated. RESULTS: CL and Vc (mean +/- SE) were found to be directly proportional to birth weight (CL = 0.070 +/- 0.013 L/kg/hr; VC = 0.591 +/- 0.065 L/kg). The CL was 1.6 times higher in neonates with a gestational age of more than 39 weeks. It was 0.7 times lower in neonates receiving inotropic support. The postnatal age had no apparent effect on midazolam kinetics. The Vp and Q (mean +/- SE; 0.42 +/- 0.11 L and 0.29 +/- 0.08 L/hr, respectively) were not influenced by any of the covariates studied. There was a large interindividual variability for the pharmacokinetic parameters. CONCLUSION: The mean midazolam doses required for critically ill neonates are lower than those required for older infants.

Use of DNA fingerprinting and biotyping methods to study a Candida albicans outbreak in a neonatal intensive care unit.

During a 15-day period, 7 premature infants hospitalized in a neonatal intensive care unit presented with sepsis caused by Candida albicans. The local environment and hands of all 54 persons involved in the intensive care unit were examined for the presence of this organism. Five techniques were used in the analysis of the isolates recovered from blood cultures of the children, the hands of personnel and 10 control isolates. The methods used were serotype determination, genetic fingerprinting, morphotyping, resistotyping and killer yeast typing. Morphotyping and genetic fingerprinting proved to be the most discriminatory techniques, and only combined analysis of the results obtained with these various methods allowed the source of the outbreak to be identified. An isolate from the hands of a healthy staff member and isolates from infected children all belonged to the same strain.

Randomised controlled trial of postnatal sodium supplementation on oxygen dependency and body weight in 25-30 week gestational age infants.

AIM: To compare the effects of early against delayed sodium supplementation on oxygen dependency and body weight, in preterm infants of 25-30 weeks of gestational age. METHODS: Infants were stratified by gender and gestation and randomly assigned to receive a sodium intake of 4 mmol/kg/day starting on either the second day after birth or when weight loss of 6% of birthweight was achieved. Daily sodium intake, serum sodium concentration, total fluid intake, energy intake, clinical risk index for babies (CRIB) score and duration of ventilatory support and additional oxygen therapy were recorded. Infants were weighed daily. Weights at 36 weeks and six months of postmenstrual age were also recorded. RESULTS: Twenty four infants received early, and 22 delayed, sodium supplementation. There were no significant differences in total fluid and energy intake between the two groups. There was a significant difference in oxygen requirement at the end of the first week, with 9% of the early group in air in contrast to 35% of the delayed group (difference 26%, 95% confidence interval 2, 50). At 28 days after birth the proportions were 18% of the early group and 40% of the delayed group (difference 22%, 95% CI -5, 49). Proportional hazards modelling showed early sodium supplementation and lower birthweight to be significantly associated with increased risk of continuing oxygen requirement. The delayed sodium group had a greater maximum weight loss (delayed 16.1%; early 11.4%, p=0.02), but there were no significant differences in time to maximum weight loss, time to regain birthweight, and weight at 36 weeks and 6 months of postmenstrual age. CONCLUSION: In infants below 30 weeks of gestation, delaying sodium supplementation until at least 6% of birthweight is lost has a beneficial effect on the risk of continuing oxygen requirement and does not compromise growth.

Randomised controlled trial of postnatal sodium supplementation on body composition in 25 to 30 week gestational age infants.

AIMS: To compare the effects of early and delayed sodium supplementation on body composition and body water compartments during the first two weeks of postnatal life. METHODS: Preterm infants of 25-30 weeks' gestation were stratified and randomly assigned according to gender and gestational age, to receive a sodium intake of 4 mmol/kg/day beginning either on the second day after birth or when weight loss of 6% of birthweight had been achieved. Daily sodium intake, total fluid intake, energy intake, urine volume, and urinary sodium excretion were recorded. Total body water was measured by H(2)(18)O dilution on days 1, 7, and 14, and extracellular fluid volume by sodium bromide dilution on days 1 and 14. RESULTS: Twenty four infants received early, and 22 delayed, sodium supplementation. There were no significant differences between the groups in body water compartments on day 1. In the delayed group, but not the early group, there was a significant loss of total body water during the first week (delayed -44 ml/kg, p=0. 048; early 6 ml/kg, p=0.970). By day 14 the delayed, but not the early group, also had a significant reduction in extracellular fluid volume (delayed -53 ml/kg, p=0.01; early -37 ml/kg, p=0.2). These changes resulted in a significant alteration in body composition at the end of the first week (total body weight: delayed 791 ml/kg; early 849 ml/kg, p=0.013). By day 14 there were once again no significant differences in body composition between the two groups. CONCLUSIONS: Body composition after preterm birth is influenced by the timing of introduction of routine sodium supplements. Early sodium supplementation can delay the physiological loss of body water that is part of normal postnatal adaptation. This is likely to be of particular relevance to babies with respiratory distress syndrome. A tailored approach to clinical management, delaying the introduction of routine sodium supplements until there has been postnatal loss of body water, is recommended.

Randomised controlled trial of postnatal sodium supplementation in infants of 25-30 weeks gestational age: effects on cardiopulmonary adaptation.

BACKGROUND: It has previously been shown that, in preterm babies, routine sodium supplementation from 24 hours after birth is associated with increased risk of oxygen dependency and persistent expansion of the extracellular compartment. OBJECTIVE: To explore whether this is mediated by a delayed fall in pulmonary artery pressure (PAP). Postnatal changes in PAP, estimated as the ratio of time to peak velocity to right ventricular ejection time, corrected for heart rate (TPV:RVET(c)), were compared in preterm infants who received routine sodium supplements that were either early or delayed. METHODS: Infants were randomised, stratified according to sex and gestation, to receive a sodium intake of 4 mmol/kg/day starting either from 24 hours after birth or when a weight loss of 6% of birth weight was achieved. Echocardiographic assessment was made on the day of delivery (day 0), and on days 1, 2, 7, and 14. Babies with congenital heart disease were excluded. RESULTS: There was no difference between the two groups in TPV:RVET(c) measured sequentially after birth. On within group testing, when compared with values at birth, the ratio was higher by day 3 in the early supplemented group, suggesting a more rapid fall in PAP compared with the late supplemented group, in whom a significant fall did not occur until day 14. CONCLUSIONS: The timing of sodium supplementation after preterm birth does not appear to affect the rate of fall in PAP as measured by the TPV:RVET(c) ratio. The previous observation linking routine sodium supplementation from 24 hours after birth with increased risk of continuing oxygen requirement therefore does not appear to be mediated by a delayed fall in PAP. Instead, the increased risk of continuing oxygen requirement is likely to be a direct consequence of persistent expansion of the extracellular compartment and increased pulmonary interstitial fluid, resulting from a sodium intake that exceeded sodium excretory capacity. This adds further weight to the view that clinical management, in this case the timing of routine sodium supplementation, should be individually tailored and delayed until the onset of postnatal extracellular volume contraction, marked clinically by weight loss.

Body water content of extremely preterm infants at birth.

BACKGROUND: Preterm birth is often associated with impaired growth. Small for gestational age status confers additional risk. AIM: To determine the body water content of appropriately grown (AGA) and small for gestational age (SGA) preterm infants in order to provide a baseline for longitudinal studies of growth after preterm birth. METHODS: All infants born at the Hammersmith and Queen Charlotte's Hospitals between 25 and 30 weeks gestational age were eligible for entry into the study. Informed parental consent was obtained as soon after delivery as possible, after which the extracellular fluid content was determined by bromide dilution and total body water by H(2)(18)O dilution. RESULTS: Forty two preterm infants were studied. SGA infants had a significantly higher body water content than AGA infants (906 (833-954) and 844 (637-958) ml/kg respectively; median (range); p = 0.019). There were no differences in extracellular and intracellular fluid volumes, nor in the ratio of extracellular to intracellular fluid. Estimates of relative adiposity suggest a body fat content of about 7% in AGA infants, assuming negligible fat content in SGA infants and lean body tissue hydration to be equivalent in the two groups. CONCLUSIONS: Novel values for the body water composition of the SGA preterm infant at 25-30 weeks gestation are presented. The data do not support the view that SGA infants have extracellular dehydration, nor is their regulation of body water impaired.

Haematocrit and red blood cell transport in preterm infants: an observational study.

AIMS: To test whether cardiac output acts as a compensatory response to changes in haematocrit. METHODS: A cohort of 38 preterm infants (27-31 weeks' gestation) was studied with repeated Doppler measurements of left ventricular output during the 1st month of life. Red blood cell transport was calculated when the duct was closed. RESULTS: Multiple regression analysis showed that left ventricular output correlated negatively with haematocrit when the duct was closed (n = 84) and when it was open (n = 59). The influence of an increase of 10% in haematocrit absolute value on mean (SD) left ventricular output was estimated at -55 (11) ml/kg/min. Mean (SD) red blood cell transport was 132 (30) ml/kg/min with a mean (SD) intra-individual variability of 20% (8.8%). Red blood cell transport was increased more frequently by left ventricular output than by haematocrit. Haematocrit and left ventricular output but not red blood cell transport were dependent on postnatal age. CONCLUSION: These results suggest that in preterm infants cardiac output adaptation is effective in attenuating the effects of red blood cell mass variations on systemic oxygen carrying capacity.

Tracheobronchography and balloon dilatation in acquired neonatal tracheal stenosis.

Between 1988 and 1992, 18 mechanically ventilated newborn babies (mean weight 1300 g and gestational age 30 weeks) presented with deteriorating respiratory failure at a mean age of 29 days. All developed increased oxygen requirements, hypoxic and hypercapnic episodes, and radiological changes of fixed lobar emphysema or recurrent atelectasis which sometimes changed sides from one day to another. Tracheobronchography with iopydol-iopydone was normal in five (27%) cases, but in 13 showed tracheobronchial stenosis localised to the lower trachea (seven cases), to the right main bronchus (three cases), or including the left main bronchus (four cases). Eleven of these 13 patients underwent endoscopy and balloon dilatation of the stenotic area. Five patients died, one before endoscopy, one immediately after endoscopies, and three subsequently with severe bronchopulmonary dysplasia. The other six babies recovered without any sequelae after balloon dilatation.

Postnatal weight loss and contraction of the extracellular compartment is triggered by atrial natriuretic peptide.

Following birth there is a contraction in the extracellular compartment, marked clinically by natriuresis, diuresis and weight loss. It is uncertain how these postnatal phenomena, which suggest an interrelationship with cardiopulmonary adaptation, are brought about. The aim of this study was to evaluate the temporal relationship between alterations in circulating atrial natriuretic peptide (ANP), respiratory status, sodium excretion and extracellular fluid volume (ECFV) in preterm babies, in the first days after birth. Eighteen male infants below 34 weeks gestational age were studied longitudinally, measuring urine output, sodium balance, arterial-alveolar oxygen ratio and circulating ANP. Daily changes in ECFV were assessed by endogenous chloride balance, following baseline measurement of bromide space. There was a clear period of improvement in respiratory function in 15 babies and in these there was a highly significant elevation in circulating ANP, either immediately prior to, or during, the period of improvement. In three infants there was no definable period of respiratory improvement. In four babies, two of whom had very mild respiratory distress, there was an immediate decline in ECFV after birth, in contrast to the remaining 14 infants, in whom there was an initial increase. This study demonstrates that there is a temporal relationship between improvement in respiratory function and an acute elevation in circulating ANP. Babies with respiratory distress syndrome are at risk of initial expansion of the extracellular compartment after birth. This is likely to increase morbidity. These observations are of relevance with regard to the clinical management of newborns with respiratory distress syndrome.

Selective intrapartum anti-bioprophylaxy of group B streptococci infection of neonates: a prospective study in 2454 subsequent deliveries.

OBJECTIVE: To investigate the efficacy of a selective intrapartum prophylaxy of group B streptococci (GBS) infection of the neonates. STUDY DESIGN: A prospective protocol of universal antepartum screening of GBS and selective intrapartum treatment from the 1st February 1994 to the 31st December 1995, on 2454 subsequent deliveries was designed. Our policy included: (1) antepartum screening as soon as possible after 28 weeks by a single vaginal and perianal sample for culture; (2) intrapartum recognition of one condition of high risk of fetal contamination during labor (these conditions included: a temperature of 38 degrees C during labor, rupture of membranes for more than 12 h or prolonged labor for more than 12 h with rupture of membranes, prematurity, twins, maternal diabetes, previous pregnancy with GBS infection of the neonate); and (3) intrapartum anti-bioprophylaxy (amoxicillin) for women with positive screening during pregnancy and one condition of high risk of fetal contamination during labor. We studied the outcome of neonates during this period to look for immediate GBS severe infection of the neonates in the form of bacteraemia or meningitis and compared the results with the rate of neonatal infection before this protocol (4.5/1000 live births in 1993). RESULTS: We noted that 11% of pregnant women were carriers, 25% of which led to antibiotic chemoprophylaxis during the labor. We noticed four cases of neonatal bacteraemia of GBS. One case arose from the group of carriers (but no condition of risk of fetal contamination during the labor and no chemoprophylaxy). The three other cases were from women with a negative antepartum screening. There was no case of meningitis and all four babies were in good health at day 10 of life. Comparing with results prior to the study, we noticed that the rate of neonatal bacteraemia dropped from 4.5 to 1.6 per 1000 livebirths (P < 0.0001). CONCLUSION: This protocol of intrapartum anti-bioprophylaxy significantly decreases the rate of GBS neonatal sepsis. We propose to improve the efficacy of this prevention program, especially with regard to the method of antepartum screening of pregnant women colonized with GBS.

Absent end diastolic flow of umbilical artery Doppler: pregnancy outcome in 62 cases.

We retrospectively studied the outcome of pregnancy in 62 cases of absent end diastolic flow (AEDF) of umbilical artery Doppler flow velocity waveform. The history of pregnancies revealed that nearly all were of high risk. Many cases presented cerebral (65%) or uterine (55.5%) Doppler flow abnormalities, or both (38%). We noted 10 fetal deaths and decided 7 pregnancy terminations. Malformation and chromosomal defect rate was 16%. We noted 44 (71%) live-births, a very high rate of cesarean section (86%), prematurity (75%), small for gestational age (39%). Forty-five percent of the neonates had a 1-min Apgar score under 7, which dropped to 27% at 5 min. Neonate mortality rate was 6.9% and the total mortality rate was 34% (21/62). Morbidity was significant (7 cases with severe morbidity, 2 cases with chromosomal abnormality of poor prognosis). We compared different sub-groups with a view to looking for some prenatal factors which predict poor neonatal outcome in case of AEDF.

Late presenting Bochdalek hernia containing colon: misdiagnosis risk.

The case of an eleven-months-old girl is reported: she entered the intensive care unit for fever, vomiting and left pleural effusion. Abdominal echography, CT scan and colonic opacification led to the diagnosis of a colonic Bochdalek hernia. A review of the literature showed that colonic hernias are rare, with only five previous reported cases in which colon was found in the thorax. The authors emphasise that there is a high risk of misdiagnosis due to the fact that small intestine contrast studies are normal; only colonic contrasting may lead to the right diagnosis. The roles of echography and CT scan are discussed.