Sophie Couderc

Analgesic effect of breast feeding in term neonates: randomised controlled trial

Abstract Objectives: To investigate whether breast feeding is effective for pain relief during venepuncture in term neonates and compare any effect with that of oral glucose combined with a pacifier. Design: Randomised controlled trial. Participants: 180 term newborn infants undergoing venepuncture; 45 in each group. Interventions: During venepuncture infants were either breast fed (group 1), held in their mothers arms without breast feeding (group 2), given 1 ml of sterile water as placebo (group 3), or given 1 ml of 30% glucose followed by pacifier (group 4). Video recordings of the procedure were assessed by two observers blinded to the purpose of the study. Main outcome measures: Pain related behaviours evaluated with two acute pain rating scales: the Douleur Aiguë Nouveau-né scale (range 0 to 10) and the premature infant pain profile scale (range 0 to 18). Results: Median pain scores (interquartile range) for breast feeding, held in mothers arms, placebo, and 30% glucose plus pacifier groups were 1 (0–3), 10 (8.5-10), 10 (7.5-10), and 3 (0–5) with the Douleur Aiguë Nouveau-né scale and 4.5 (2.25-8), 13 (10.5-15), 12 (9–13), and 4 (1–6) with the premature infant pain profile scale. Analysis of variance showed significantly different median pain scores (P<0.0001) among the groups. There were significant reductions in both scores for the breast feeding and glucose plus pacifier groups compared with the other two groups (P<0.0001, two tailed Mann-Whitney U tests between groups). The difference in Douleur Aiguë Nouveau-né scores between breast feeding and glucose plus pacifier groups was not significant (P=0.16). Conclusions: Breast feeding effectively reduces response to pain during minor invasive procedure in term neonates. What is already known on this topic Current pharmacological treatments are not appropriate for pain relief during minor procedures like venepuncture or heel prick in newborn infants Oral sweet solutions, non-nutritive sucking, and skin to skin contact reduce procedural pain in newborn infants What this study adds Breast feeding during a painful procedure effectively reduces the response to pain in newborn infants The analgesic properties of breast feeding are at least as potent as the combination of sweet solutions and a pacifier

The value of middle cerebral artery peak systolic velocity in the diagnosis of fetal anemia after intrauterine death of one monochorionic twin

OBJECTIVEnThe purpose of this study was to assess the value of the fetal middle cerebral artery peak systolic velocity in the prediction of anemia within 24 hours of the death of one monochorionic twin in twin-to-twin-transfusion syndrome and to establish the correlation between middle cerebral artery peak systolic velocity and hemoglobin concentration in fetuses who are at risk for acute anemia.nnnSTUDY DESIGNnDoppler examination of the middle cerebral artery peak systolic velocity was performed in 20 monochorionic survivors of pregnancies that were complicated by twin-to-twin-transfusion syndrome that occurred between 20 and 34 weeks of gestation. Doppler examination was performed before cordocentesis and after intrauterine transfusion when appropriate. Both hemoglobin concentration and middle cerebral artery peak systolic velocity were expressed in multiples of the median. Severe anemia was defined as hemoglobin concentration of <0.55 multiples of the median, and we used the cutoff point of 1.50 times the median values at any gestational age to calculate the sensitivity and specificity of middle cerebral artery peak systolic velocity in detecting moderate or severe anemia.nnnRESULTSnFetal anemia was confirmed in 10 of 20 fetuses. We performed seven intrauterine transfusions. The sensitivity and specificity of middle cerebral artery peak systolic velocity in the prediction of severe fetal anemia were of 90%, with a false-negative rate of 10%. The correlation between peak systolic velocity and hemoglobin concentration both before and after transfusion was evaluated by regression analysis and was strongly significant.nnnCONCLUSIONnIn fetuses who are at risk of acute anemia, the measurement of middle cerebral artery peak systolic velocity was found to be a reliable noninvasive diagnostic tool and may be helpful in counseling and planning invasive assessment.

Prospective Identification of Congenital Cytomegalovirus Infection in Newborns Using Real-Time Polymerase Chain Reaction Assays in Dried Blood Spots

BACKGROUNDnCongenital cytomegalovirus (CMV) infection is a public health issue, and implementation of neonatal screening has been debated. Detection of CMV DNA by polymerase chain reaction (PCR) of dried blood spots (DBS) routinely collected for metabolic screening from all newborns has been proposed for congenital CMV infection screening. The goal of this study was to prospectively assess the performance of 2 CMV PCR assays of DBS for CMV neonatal screening in a selected population of neonates.nnnMETHODSnWe studied prospective congenital CMV screening in a population of neonates either born with symptoms compatible with congenital CMV or born to mothers with a history of primary infection during pregnancy. For each neonate, 2 CMV PCR assays of DBS were blindly performed in parallel with a gold standard technique (ie, CMV PCR of a urine sample).nnnRESULTSnTwo hundred seventy-one neonates were studied, and CMV infection, defined by a positive urine sample in the first week of life, was confirmed in 64 (23.6%). Nineteen infected (29.7%) neonates were symptomatic, and 45 (70.3%) were asymptomatic. The ranges of sensitivity, specificity, positive predictive value, and negative predictive value for the 2 CMV PCR assays of DBS were 95.0%-100%; 98.1%-99.0%; 94.1%-96.9%, and 98.5%-100%, respectively.nnnCONCLUSIONSnThe sensitivity and specificity of both CMV PCR assays of DBS to identify congenital CMV were very high in this population of neonates with a high risk of sequelae. These new data should be considered in the ongoing debate on the appropriateness of the use of DBS as a sample to screen for congenital CMV infection.

Feasibility of predicting the outcome of fetal infection with cytomegalovirus at the time of prenatal diagnosis

BACKGROUNDnCongenital cytomegalovirus infection occurs in 0.7% of live births with 15-20% of infected children developing long-term disability including hearing loss and cognitive deficit. Fetal cytomegalovirus infection is established by viral DNA amplification by polymerase chain reaction in amniotic fluid obtained by amniocentesis following maternal seroconversion or after the diagnosis of ultrasound features suggestive of fetal infection. Severe brain ultrasound anomalies are associated with a poor prognosis. The prognosis of an infected fetus showing either no ultrasound features or nonsevere ultrasound anomalies is difficult to establish up until late in the second or third trimester of pregnancy.nnnOBJECTIVEnWe sought to evaluate the prognostic value of fetal ultrasound, amniotic fluid, and fetal blood analysis at the time of prenatal diagnosis of fetal infection.nnnSTUDY DESIGNnWe reviewed all cases of fetal cytomegalovirus infection with a sample of amniotic fluid positive for viral DNA and/or fetal blood analyzed in our laboratory from 2008 through 2013. Prenatal ultrasound features along with cytomegalovirus DNA loads in amniotic fluid and in fetal blood and fetal platelet counts were reviewed in relation to gestational age at maternal infection, neonatal examination, and postnatal follow-up or postmortem examination.nnnRESULTSnIn all, 82 fetuses were infected following maternal infection mainly in the first trimester. At the time of prenatal diagnosis at a median ofxa023 weeks, 19, 22, and 41 fetuses showed severe brain ultrasound abnormalities, nonsevere ultrasound features, and normal ultrasound examination, respectively. Nonsevere ultrasound features, higher DNA load in amniotic fluid, fetal platelet count ≤114,000/mm(3), and DNA load ≥4.93 log10 IU/mL in fetal blood were associated with a symptomatic status at birth in univariate analysis (P < .001, Pxa0= .001, and Pxa0= .018, respectively). Bivariate analysis combining ultrasound results and either adjusted viral load in amniotic fluid or fetal blood profile showed that these were independent prognostic factors of a symptomatic status at birth. Both fetal blood parameters were better predictors than amniotic fluid viral load. At the time of prenatal diagnosis, the ultrasound negative predictive valuexa0for symptoms at birth or at termination of pregnancy was 93%. The combined negative predictive values of ultrasound and viral load in amniotic fluid and that of ultrasound and fetal blood parameters were 95% and 100%, respectively. In fetuses presenting with nonsevere ultrasound features, the positive predictive values of ultrasound alone and in combination with amniotic fluid viral load or with fetal blood parameters were 60%, 78%, and 79%, respectively.nnnCONCLUSIONnRisk assessment of infected fetuses for being symptomatic at birth is possible as early as the time of diagnosis by using a combination of targeted ultrasound examination along with viral load in amniotic fluid and in fetal blood together with platelet count. The advantage of using amniotic fluid is that it is available at prenatal diagnosis. One may wonder if increasing the negative predictive value of the overall assessment of an infected fetus from 95-100% is worth the additional risk of cordocentesis for fetal blood sampling. This can only be an individual decision made by well-informed women and it seems therefore appropriate to use the figures presented here and their confidence intervals for counseling.

Risk Factors for Congenital Cytomegalovirus Infection Following Primary and Nonprimary Maternal InfectionA Prospective Neonatal Screening Study Using Polymerase Chain Reaction in Saliva

BackgroundnThe design of diagnostic and preventive strategies have been prevented by gaps in knowledge of the epidemiology of congenital cytomegalovirus (cCMV) with the type of maternal infection as well as the lack of large-scale neonatal screening tools.nnnMethodsnIn sum, 11715 consecutive newborns were screened for cCMV by polymerase chain reaction (PCR) in saliva. Prevalence, type of maternal infection, sociodemographic, obstetrical, and serological data were analyzed.nnnResultsnPositive predictive value of CMV PCR in saliva was 59%; false positive results were associated with lower viral loads (P < .001). Maternal seroprevalence was 61%, birth prevalence was 0.37%, resulting from primary and nonprimary infections in 52% and 47.7% of cases, respectively. The risk to deliver an infected baby after primary infection was increased in younger (OD = 7.9), parous (OD = 4.1) women born in high resources countries (OD = 5.2) and from higher income groups (P = .019). The only 2 risk factors to deliver an infected baby after nonprimary infection were to be young (OD = 4.6) and unemployed (OD = 5.8). The risk to deliver an infected baby was 4-fold higher in women seronegative before their pregnancy (P = .021).nnnConclusionsnA positive CMV PCR in newborns saliva should always be confirmed in a repeat-sample. Sociodemographic characteristics of women giving birth to an infected baby after primary and nonprimary infection are different. Seronegative, parous women represent the highest risk population for cCMV in countries with low to intermediate seroprevalence. Urgent action is needed to stop the cCMVs epidemic, particularly in this population easily identifiable by maternal serology and amenable to prevention messages.nnnClinical Trials RegistrationnNCT01923636.

OC130: Prospective follow‐up of children with nuchal translucency above the 99th percentile at 11–14 weeks with normal karyotype. Results at 3 years

this study was to investigate the presence and volume of jugular lymphatic sacs (JLS) in first-trimester fetuses with normal and increased nuchal translucency (NT). Study design: In this prospective study 26 fetuses with NT > 95th percentile were compared to 137 fetuses with normal NT. Follow up was complete. After crown-rump length and NT measurement the neck region of the fetus was studied by transvaginal ultrasound. The JLS presented as spheroid translucencies in the antero-lateral region of the neck. The volume of the JLS was calculated using the formula of a spheroid: length * height * width * 3/4 phi. Results: The incidence of JLS significantly differed between fetuses with enlarged NT and control group (p < 0.0001). In the group of 26 fetuses with increased NT 22 fetuses (85%) had clearly visible JLS. Chorion villus sampling revealed aneuploidy in 10 and euploidy in 16 fetuses. In the control group 2 fetuses (1.5%) showed JLS. Both had a NT of 2.8, 2.9 respectively and a normal outcome at birth. Logistic regression analysis in the total population showed that increased NT was significantly associated with the presence of JLS (OR 9.48, CI 2.93–30.75). In the fetuses with present JLS an increment of crown-rump length was significantly correlated with enlargement of the volume of the right sac (r = 0.51; P = 0.01). The left sac showed the same association. However, significance was not reached (r = 0.40, p = 0.09). An enhancement of the NT did not show a significant relation with enlargement of the volume of the JLS. Conclusion: Enlarged nuchal translucency is highly associated with jugular lymphatic sacs on first-trimester ultrasound. In our opinion the pathophysiology of the increased NT can be explained by a disturbed lymphangiogenesis. This disturbance is present in both chromosomally normal and abnormal fetuses.

P10.21: Karyotype and outcome of 43 fetuses diagnosed in the first trimester with cystic hygroma in relation with nuchal translucency measurement

Biometry was analyzed in relation to gestational age (GA)-based charts and our CRL-based charts. Results: Five cases of fetal triploidy were diagnosed at 11–14 weeks. In four out of five cases, there were major abnormalities CRLbased biometry (one case with abdominal circumference (AC) below −2 SD, two cases with head circumference (HC) and biparietal diameter (BP) above + 2 SD, one case with AC below −2 SD and HC and BPD above + 2 SD) although fetal biometry was abnormal in only one of these four cases in relation to GA-based charts. In the last case, fetal biometry was normal but nuchal translucency (NT) was 7 mm although it was normal in the other 4 cases. Conclusion: This study demonstrates that CRL-based first trimester biometry charts allow for early biometry-based screening of triploidy that might have been missed using GA-based charts. This is particularly relevant since NT can be normal in up to 4 out of 5 triploidy.