Patrick Truffert

Re-hospitalization in infants younger than 29 weeks' gestation in the EPIPAGE cohort.

Aim: To estimate the re‐hospitalization rate of extremely preterm children during infancy and associated factors after the recent improvement in survival rates. Method: The cohort included all children born before 29 wk of gestation in nine French regions in 1997. All admissions between discharge from initial hospitalization and 9 mo after birth were considered. Factors studied included the childs characteristics at birth and during neonatal hospitalization, risk factors for infection after discharge and parents socio‐demographic characteristics. Adjusted odds ratios (aOR) for re‐hospitalization for all reasons and for respiratory disorders were obtained from logistic regression models. Results: Of the 376 children, 178 were re‐admitted at least once (47.3%; 95% CI: 42.3–52.4). Fifty‐five percent of the hospitalized children were admitted at least once for respiratory disorders. The re‐hospitalization rate was higher for children who had had chronic lung disease (aOR: 2.2; 95% CI: 1.3–3.7), those initially discharged between August and October (aOR: 2.5; 95% CI: 1.2–5.1) or between November and January (aOR: 3.2; 95% CI: 1.5–6.8), and children living with other children under six (aOR: 3.4; 95 %CI: 1.6–7.5). Re‐hospitalizations were associated with neither gestational age nor the duration of neonatal hospitalization. Adjusted odds ratios for re‐hospitalization for respiratory tract disorders were very similar to those for the overall hospitalizations.

Outborn status with a medical neonatal transport service and survival without disability at two years. A population-based cohort survey of newborns of less than 33 weeks of gestation.

OBJECTIVEnPrenatal events are thought to play an important role in long-term handicap, but the specific role of perinatal factors remains controversial. Our study, conducted in the context of this debate, aimed to break down the various components of perinatal management and to assess the relationship between these components and survival without disability at the age of two years.nnnSTUDY DESIGNnA prospective geographically-defined study was conducted in 1985 in the Paris metropolitan area. It covered 53430 births (stillbirths and live births), including 539 that occurred between 25 and 32 weeks gestation. The relationship between perinatal management and survival without disability was studied by a multivariate analysis (logistic regression). The analysis was restricted to a group of 202 infants born at 31 or 32 weeks gestation, to avoid indication bias.nnnRESULTSnAn inborn status (delivery in a tertiary care facility) exerted a protective effect on survival without disability at the age of two years (Adjusted Odds Ratio (OR)=7.51 [1.51; 37.4]), even though the area we studied possessed an excellent Medical Neonatal Transport Service. Multiple pregnancies also seemed to have a protective effect (Adjusted OR=2.45 [0.96; 6.27]). No statistically significant association was seen between survival without disability at two years and the presence of a hospital staff paediatrician in the delivery room.nnnCONCLUSIONnThese results lead us to consider what the concept of inborn/outborn represents in the perinatal management of infants at high risk.

Neurodevelopment of children born very preterm and free of severe disabilities: the Nord-Pas de Calais Epipage cohort study: Neurodevelopment of children born very preterm and free of severe disabilities

Aim:u2002 To describe the development of very preterm children free of cerebral palsy or severe sensory impairment in the domains of gross and fine motor functions, language and sociability at a corrected age of 2u2003years; to identify factors associated with performances in each domain.

Treatment strategies for bronchopulmonary dysplasia with postnatal corticosteroids in Europe: the EURAIL survey

Aim: To survey practices in 14 European countries and describe strategies for the prevention and treatment of bronchopulmonary dysplasia with postnatal steroids (PNS). Methods: In 1999–2000 questionnaires covering the use of PNS were sent to every neonatal unit taking very preterm newborns in charge, in population‐based areas covering at least 20000 births annually. One questionnaire was sent to surveyed unit. The participating areas were chosen by an expert from each country participating in the Europe Against Immature Lung (EURAIL) study group. Results: Responses to 331 questionnaires were received; the mean response rate by countries was 84% (range 64–100%). Teaching hospitals accounted for 19% of the responding units. The number of extremely premature newborns (less than 28 wk of gestation) admitted yearly to these units was 0 in 16%, < 20 in 62%, 20–39 in 11% and > 39 in 11%. Overall, 67% of the centres used PNS: 48% initiated treatment in non‐intubated infants and 53% at 7–14 d. Treatment duration was 4–15 d in 62% and > 15 d in 21%. PNS administration was limited to intubated infants less often in smaller units [odds ratio (OR) 0.2, 95% confidence interval (95% CI) 0.1–0.6] and more often in non‐teaching hospitals (OR 2.5, 95% CI 2.5–5.0).

Very preterm children free of disability or delay at age 2: Predictors of schooling at age 8 A population-based longitudinal study

AIMnTo study the predictive value of a developmental assessment at 2 years corrected age (CA) for schooling at age 8 in children born very preterm and free of disability or delay; to identify other factors associated with schooling in this population.nnnMETHODSn244 children born before 33 weeks in 1997, part of the population-based EPIPAGE cohort study, free of disability or delay, had their developmental quotient (DQ) evaluated with the Brunet-Lezine scale at 2 years CA. The mental processing composite (MPC) score was evaluated at age 5 with the K-ABC battery. Data on schooling were obtained at age 8 by postal questionnaire. Schooling was considered appropriate if the child was attending age-appropriate grade level in a regular classroom environment without support at school.nnnRESULTSnSchooling was appropriate for 172 (70%) children. The predictive value of a DQ≥100 for appropriate schooling was 0.80 [0.75;0.85]. In children with a DQ at age 2<100, schooling varied significantly according to their MPC score at age 5 whereas it didnt in children with a DQ≥100. In multivariate analysis, the rate of appropriate schooling was significantly related to global DQ at age 2 (p<0.01), gestational age≥29 weeks (p<0.05), head circumference at age 2 (p<0.05) and mothers educational level (p<0.05).nnnCONCLUSIONnA DQ≥100 cannot be solely used for the prediction of appropriate schooling at age 8. Mothers educational level, gestational age and head circumference at age 2 could be taken account. These factors could be used to individualise follow-up.

Les hernies congénitales des coupoles diaphragmatiques. Etude rétrospective de 123 observations recueillies dans le service de médecine néonatale du CHRU de Lille entre 1985 et 1996

Resume La prise en charge des hernies diaphragmatiques congenitales au cours de la derniere decennie a beneficie de lapparition de nouvelles techniques. Les mecanismes physiopathologiques responsables de lhypoxemie dans les formes les plus graves sont egalement mieux connus. Objectif Le but de cette etude etait de verifier si la modification de la prise en charge avait eu une influence sur la mortalite des nouveau-nes porteurs dune hernie diaphragmatique congenitale et sur leur devenir a moyen et long terme. Populations et methodes Il sagit dune etude retrospective portant sur les nouveau-nes porteurs dune hernie diaphragmatique congenitale et hospitalises dans le service de medecine neonatale du CHRU de Lille entre le 1 er janvier 1985 et le 31 octobre 1996. Deux populations ont ete comparees, en fonction de la periode de prise en charge: du 1 er janvier 1985 au 31 decembre 1990 dune part, du 1 er janvier 1991 au 31 octobre 1996 dautre part. Les deux groupes ont ete compares en termes de mortalite ainsi quen termes de complications et sequelles. Resultats Cent-vingt-trois enfants ont ete admis pour hernie diaphragmatique congenitale. Neuf ont ete exclus du fait de malformations graves associees. La mortalite au terme de la periode neonatale est passee de 77 % (40 sur 52) durant la periode 1985–1990 a 44 % (27 sur 62) durant la periode 1991–1996 ( p Conclusion Les moyens actuels, loxygenation extracorporelle en particulier, autorisent la survie denfants qui, il y a quelques annees, etaient consideres comme etant au-dela de toute ressource therapeutique. Lamelioration de la survie se fait cependant au prix de sequelles plus frequentes et plus graves. Lidentification de criteres fiables permettant devaluer le degre dhypoplasie pulmonaire permettra de reconnaitre precocement les enfants susceptibles de developper des sequelles.

Antenatal corticosteroids policies in 14 European countries: factors associated with multiple courses. The EURAIL survey.

Aim: To describe antenatal corticosteroids (ANCs) policies in European obstetric units and to determine factors that influence the use of multiple courses. Methods: 641 obstetricians from obstetric departments covering a geographical area in 14 European countries responded to a questionnaire on ANCs policies. Logistic regression was used to identify factors that were related to the use of multiple ANCs courses. Results: The survey response rate was 76% (inter‐country range 33–94%): 11% (0–50%) of the respondents started ANCs from 23 to 24 wk gestation, 82% from 24 to 28 wk (50–100%) and 7% from 28 to 36 wk (0–32%). Eighty‐five percent of the units (63–100%) used multiple ANCs courses. After adjustment for country, number of infants delivered at 24–32 wk annually in the unit, NICU and maternal hypertension, maternal hypertension tended to be an explicative factor (OR 1.97; 95% CI: 0.75–5.17).

Étude expérimentale des facteurs de variation de la FiO2lors de la ventilation manuelle

Resume La ventilation manuelle du nouveau-ne en salle de naissance a fait l’objet de recommandations contradictoires sur le debit d’oxygene a delivrer pour obtenir une FiO 2 la plus proche de 1. Le but de l’etude etait de determiner les effets de la frequence ventilatoire, des pressions des voies aeriennes et des debits d’oxygene sur la concentration d’oxygene delivree. Materiel et methodes. – Il s’agit d’une etude experimentale sur banc d’essai avec ventilation par un ballon autogonflable Ambu® neonatal, d’un poumon monocompartimental constitue d’un ballon elastique (Drager®) (compliancexa0=xa00,6xa0mL/cmH 2 Oxa0; resistancesxa0=xa085xa0cmH 2 O·L –1 ·s –1 ). Protocolexa01xa0: sans controle de la pressionxa0; six medecins devaient ventiler le modele comme s’ils ventilaient un premature atteint d’une maladie des membranes hyalines tout en suivant la frequence d’un metronome. Le debit d’oxygene etait augmente par paliers de deux a 12xa0L/min. La frequence du metronome etait augmentee par paliers de 30 a 120xa0c/min. Le volume courant, les temps d’insufflation, les pressions et la FiO 2 etaient enregistres. Protocolexa02xa0: les medecins visualisaient en continu la pression d’insufflation (manometre a aiguille). Le reste du protocole etait similaire au premier. Resultats. – Protocolexa01xa0: plus le debit d’oxygene delivre a l’entree de l’Ambu® etait eleve, plus la FiO 2 augmentait. Plus la frequence de ventilation augmentait, plus la FiO 2 baissait. L’etude multivariee montrait qu’en dehors du debit, de la frequence et de l’operateur, le temps d’insufflation (Ti) et le volume courant (Vt) n’apportaient pas d’explication a la variation de la FiO 2 . Protocolexa02xa0: les pressions moyennes d’insufflation etaient nettement inferieures a celles obtenues sans controle visuel (26 contre 40xa0cmH 2 Oxa0; p 2 , proche de 1 etait alors independante des debits d’oxygene delivres a l’Ambu® et des frequences de ventilation. Conclusions. – Un systeme permettant un controle visuel continu de la pression d’insufflation doit etre ajoute a l’appareil de ventilation manuel au cours de son utilisation chez le nouveau-ne. Il limite le risque de surpression et previent les fluctuations de la FiO 2 liees a la frequence ventilatoire.

Enquête multicentrique sur la prise en charge médicamenteuse de la douleur en néonatologie dans le Nord-Pas-de-Calais

Resume Le but de l’etude etait de decrire les modalites de prise en charge de la douleur du nouveau-ne dans les unites de reanimation et de medecine neonatale a l’echelle d’une region, le Nord–Pas-de-Calais. Population et methodes. – Un questionnaire a ete adresse aux 52xa0medecins des 12xa0services accueillant des nouveau-nes, dont 6xa0comportent une unite de reanimation. Il etait concu pour explorer l’evaluation, le traitement et l’organisation de la prevention de la douleur. Resultats. – Quarante reponses (77xa0%) ont ete obtenues. Onze services declaraient etre sensibilises au probleme de la douleur. L’outil d’evaluation de la douleur etait l’Echelle «xa0Douleur et Inconfort du Nouveau-nexa0» (EDIN). Un traitement antalgique etait administre dans 100xa0% des cas pour la pose d’un drain pleural, dans 92xa0% des cas pour la pose d’un catheter central chez l’enfant ventile et dans 91xa0% des cas en presence d’enterocolite ulcero-necrosante, sous ventilation assistee. Les antalgiques prescrits etaient le propacetamol, la nalbuphine ou le fentanyl, associes parfois a une sedation par midazolam ou diazepam. La creme Emla® etait utilisee avant la ponction lombaire dans 80xa0% des cas au sein des services de reanimation neonatale et dans 92xa0% des cas au sein des services de medecine neonatale. Trois services de reanimation neonatale et 4xa0services de medecine neonatale employaient le saccharose lors de prelevements sanguins. Conclusion. – La sensibilisation a la douleur des differents services de reanimation et de medecine neonatale ne garantissait pas, au moment de l’etude, une prise en charge optimale du nouveau-ne algique. L’attitude des neonatologistes face a la douleur restait heterogene.

Pour ou contre une utilisation précoce de la pression positive continue nasale et du surfactant exogène au cours de la maladie des membranes hyalines. Arguments physiopathologiques

Resume Lutilisation de la pression positive continue nasale dans la prise en charge de la maladie des membranes hyalines date du debut des annees 1970. Les auteurs soulignent les arguments physiopathologiques en faveur dune application tres precoce (des la salle de naissance) de cette technique chez le grand premature. Cette indication prophylactique sinscrit dans une strategie de prevention du ≪ derecrutement ≫ alveolaire. Lassociation a linstillation curative tres precoce de surfactant en decoule. Lobjectif de cette strategie est de reduire lincidence et la gravite de la maladie des membranes hyalines. Il pourrait egalement en resulter un effet protecteur vis-a-vis de la survenue de la dysplasie bronchopulmonaire.