OBJECTIVE To compare the amount of medical interventions on very preterm neonates (24-31 weeks of gestation) in two French university tertiary care centers, one of which is involved in a Neonatal Developmental Care program. A secondary objective is to assess whether this difference in medical interventions can be linked to a difference in mortality and morbidity rates. METHODS We prospectively included all very preterm neonates free from lethal malformation born live in these two centers between 2006 and 2010. These inclusion criteria were met by 1286 patients, for whom we compared the rate of five selected medical interventions: birth by caesarean section, chest intubation in the delivery room, surfactant therapy, pharmacological treatment of patent ductus arteriosus, and red blood cell transfusion. RESULTS The rates of the five medical interventions were systematically lower in the center that is involved in Neonatal Developmental Care. There was no significant difference in survival at discharge with no severe cerebral ultrasound scan abnormalities between the two centers. There were, however, significantly higher rates of bronchopulmonary dysplasia and nosocomial sepsis and longer hospital stays when the patients were not involved in a Neonatal Developmental Care program. DISCUSSION This benchmarking study shows that in France, in the first decade of the 21st century, there are as many ways to handle very preterm neonates as there are centers in which they are born. This brings to light the concept of medical stance, which is the general care approach prior to the treatment itself. This medical stance creates the overall framework for the staff's decision-making regarding neonate care. The different parameters structuring medical stance are discussed. Moreover, this study raises the problematic issue of the aftermath of benchmarking studies when the conclusion is an increase of morbidity in cases where procedure leads to more interventions.

OBJECTIVE: To evaluate the effects of maternal smoking during pregnancy on foetal growth in preterm infants with gestational age (GA) <33 weeks. POPULATION AND METHODS:Prospective observational cross-sectional study from two French perinatal networks cohort of preterm infants. Cases were 358 very preterm infants (GA 24–32 weeks) divided into two groups as maternal smokers (129) and non-smokers (229). 361 term infants (GA 37–41 weeks) also divided into two groups as maternal smokers (129) and non-smokers (232) served as comparison group (controls). We studied the influence of maternal smoking on foetal anthropometric growth parameters (BW, BL and head circumference defined according to AUDIPOG curves) in groups and compared cases and controls. Other causes of foetal growth restriction were excluded. RESULTS: Maternal characteristics (age, height, pre-pregnancy body weight, parity, foetus sex) were similar in both groups and sub-groups. Mothers who smoked were younger (P <0.001), more likely to be unemployed (P <0.001) and to have undergone less school education (P <0.001). Smoking did not alter foetal growth in preterm infants: maternal smokers versus non-smokers BW (P = 0.52), BL (P = 0.44) and HC (P = 0.81). Growth restriction was marked in term infants with BW (P <0.001), BL (P <0.001) and HC (P <0.01). In multivariate analysis, after adjustment for other confounding factors, foetal growth appeared to be significantly altered by maternal smoking during pregnancy only in term infants. CONCLUSION: Our study suggests that effects of maternal smoking during pregnancy on foetal growth are gestational age-dependent.

OBJECTIVE:To assess the risk of tracheal intubation at birth in very premature neonates related to the type of maternal anesthesia in case of elective cesarean.POPULATION AND METHODS:All 219 live-born very premature neonates (28-32 weeks of gestation), delivered after an elective cesarean in the 27 maternity wards of 2 French semi-rural neonatal networks. Eighty-three percent (182/219) were delivered in level III maternity wards in university hospitals.RESULTS:Of the very preterm neonates, 33.3% (73/219) were intubated in the delivery room, either for respiratory distress syndrome or a low APGAR score. Very preterm neonates delivered after maternal general anesthesia were more often intubated than those delivered after spinal anesthesia (48.7% vs 25.2%; OR: 2.8; 95% CI: 1.8-5.1). The risk of intubation related to maternal general anesthesia remained statistically significant after an adjustment for gestational age, fetal growth retardation, respiratory distress syndrome, type of maternity ward, and a propensity score that took into account maternal sociodemographic characteristics and the causes of very preterm birth (aOR: 3.4; 95% CI: 1.4-8.2). The risk of intubation related to general anesthesia was lower after adjusting for the 5-min APGAR score (aOR: 2.8; 95% CI: 1.0-7.3).CONCLUSION:Very preterm neonates delivered after cesarean with general anesthesia require tracheal intubation in the delivery room more often than those delivered with spinal anesthesia. This study cannot assess a causal link between anesthesia and the need for neonatal intubation. However, neonatologists have to be aware of the type of maternal anesthesia because it may interfere with the non-invasive ventilation support policy of the very preterm neonate.

Objective. To assess the risk of tracheal intubation at birth in very premature neonates related to the type of maternal anesthesia in case of elective cesarean.Population and methods. All 219 live-born very premature neonales (28-32 weeks of gestation), delivered after an elective cesarean in the 27 maternity wards of 2 French semi-rural neonatal networks. Eighty-three percent (182/219) were delivered in level I I I maternity wards in university hospitals.Results. Of the very preterm neonates, 33.3% (73/219) were intubated in the delivery room, either for respiratory distress syndrome or a low APGAR score. Very preterm neonates delivered after maternal general anesthesia were more often intubated than those delivered after spinal anesthesia (48.7% vs 25.2%; OR: 2.8; 95% CI:.1.8-5.1.). The risk of intubation related to maternal general anesthesia remained statistically significant after an adjustment for gestational age, fetal growth retardation, respiratory distress syndrome, type of maternity ward, and a propensity score that took into account maternal siociodemographic characteristics and the causes of very preterm birth (aOR: 3.4; 95% CI:.1.4-8.2). The risk of intubation related to general anesthesia was lower after adjusting for the 5-min APGAR score (aOR: 2.8: 95% CI: 1.0-7.3).Conclusion. Very preterm neonates delivered after cesarean with general anesthesia require tracheal intubation in the delivery room more often than those delivered with spinal anesthesia. This study cannot assess a causal link between anesthesia and the need for neonatal intubation. However, neonatologists have to be aware of the type of maternal anesthesia because it may interfere with the noninvasive ventilation support policy of the very preterm neonate. (C) 2009 Elsevier Masson SAS. All rights reserved.

A fatal pulmonary air embolism, confirmed by an oriented necropsy, is described in a 25-day-old premature and small-for-gestational-age neonate. The embolism was suspected after air bubbles were detected in the infusion tine. The air bubbles originated from a male Luer-lock to male Luer-lock connector, which was part of a specific assembly of the perfusion line. A solution to this problem is thereby proposed. We recommend caution in using complex infusion line assemblies because such complications are probably underestimated. (C) 2008 Elsevier Masson SAS. All rights reserved.

Extranodal thyroid lymphomatous involvement is rare in childhood. We report here 2 children, 1 with vertical transmission-acquired human immunodeficiency virus (HIV), presenting with lymphomatous infiltration of the thyroid gland at diagnosis. One child had infra-clinical endocrine impairment and both responded well to chemotherapy. Although the cases are too scarce to be affirmative, thyroid gland involvement doesn't seem to alter the good prognosis of childhood Burkitt's lymphoma. The third child's cancer in frequency is Non-Hodgkin Lymphomas. Presenting as the initial AIDS event in 1 patient, this case report also highlights the need to systematically propose antiretroviral therapy in vertically HIV infected children.

Based upon a three necessities basis: public health, biological and medico-legal, this article presents the state of the art about teaching neonatal resuscitation in the delivery room. The educational process is present worldwide; main experiences are described. Evaluation of these actions varies in the literature. We analyze the evaluation of the process of the trained professionals, their satisfaction, the changes in their practices, their theoretical and practical levels, and the impact on newborns' health. We propose a few measures to make official this kind of teaching in France, with a certificate for instructors and trained professionals.

We report the case of a 10 year-old girl who had Stevens-Johnson syndrome and cholestasis after ibuprofen therapy. Liver histology was compatible with vanishing bile duct syndrome. She received ursodeoxycholic acid, and liver tests normalized within 7 months. This report confirms that ibuprofen may induce acute vanishing bile duct syndrome.

L'extraction instrumentale permet l'accouchement assisté d'un fœtus dont l'état nécessite une naissance rapide ou lorsque les efforts expulsifs maternels ne permettent pas l'accouchement spontané. La ventouse obstétricale est une des alternatives techniques permettant l'extraction fœtale par les voies naturelles. Cet instrument, encore minoritairement utilisé en France, semble d'apprentissage moins difficile que le forceps et son utilisation aboutit à moins de lésions périnéales que les autres instruments. L'application des règles de la mécanique obstétricale guide son utilisation et influe son efficacité, le respect des indications en limite les risques fœtaux.

Les grossesses gémellaires monochoriales monoamniotiques correspondent au développement de deux fœtus dans la même cavité amniotique et provenant de la division tardive d’un seul embryon. Nous avons réalisé une étude rétrospective dans notre service sur près de 19 années d’activité permettant de retrouver 16 cas de jumeaux monoamniotiques. Nous avons analysé le devenir obstétrical et néonatal de ces grossesses monoamniotiques en les comparant aux données de la littérature. Le pronostic obstétrical après 28 semaines d’aménorrhée ne semble pas être influencé par ce type de gémellité, et nous montrons dans cette série que l’accouchement par voie vaginale est possible et non délétère.

Monoamniotic twin gestations result from a late division of the fertilized ovum with development of the two embryos within a common amnionic sac. We performed a retrospective study in our university hospital on nearly 19 years of clinical activities; we found 16 cases of monoamniotic twins. Obstetrical and neonatal outcomes were analyzed and compared to the data in the literature. The pronosis after 28 weeks of gestation does not appear to be influenced by this type of twin gestation and we demonstrate in this study that vaginal delivery is possible and not deleterious.

Les ≪ cholestases intrahépatiques fibrogènes familiales ≫ (CIFF) correspondent à une entité hétérogène rapportée sous les termes de progressive familial intrahepatic cholestasis ou de maladie de Byler. Il s'agit d'une cholestase héréditaire d'origine hépatocellulaire débutant le plus souvent à la période néonatale et évoluant vers l'insuffisance hépatocellulaire, souvent avant l'adolescence. Les données génétiques suggèrent un mode de transmission autosomique récessive. Elle serait due à une anomalie du métabolisme hépatocytaire des acides biliaires. On distingue trois types sur des critères cliniques, biochimiques et histologiques. Dans le premier type, la cholestase est caractérisée par un début souvent néonatal, un prurit féroce, une activité sérique toujours normale de la gamma-glutamyl transpeptidase (GGT), une cholestérolémie normale, une concentration sérique élevée d'acides biliaires associée à une concentration effondrée d'acides biliaires dans la bile et une absence de prolifération ductulaire. L'évolution se fait vers l'insuffisance hépatocellulaire et le décès à des âges variant de quelques mois à l'adolescence. Son mécanisme physiopathologique est probablement en rapport avec une anomalie du transport hépatocytaire des acides biliaires, hypothèse renforcée par la localisation récente d'un locus dans une région du chromosome 18 identique à celle du gène de la cholestase récurrente bénigne. Le second type ressemble au premier, mais il en diffère par une absence de prurit et des traces d'acides biliaires primaires dans le sérum. Il est établi qu'il s'agit d'un déficit de synthèse des acides biliaires primaires. Le troisième type débute plus tard dans la vie et est souvent compliqué par l'apparition d'hypertension portai et d'insuffisance hépatocellulaire tardive. Il est caractérisé par un prurit inconstant et modéré, une activité sérique élevée de la GGT, une concentration modérément élevée d'acides biliaires sériques, une concentration normale d'acides biliaires dans la bile, et une prolifération ductulaire malgré des voies biliaires normales. Les patients ont une anomalie d'expression du gène MDR3. Un pourcentage non négligeable d'enfants atteints de CIFF bénéficie d'un traitement par les acides biliaires. Dans certains cas, une dérivation biliaire externe partielle ou une transplantation hépatique doit être proposée.Progressive familial intrahepatic cholestasis (PFIC), also known as Byler disease, is an inherited cholestasis of hepatocellular origin which is characterized by cholestasis presenting often in the neonatal period leading to death due to liver failure at ages ranging from infancy to adolescence. The pattern of appearance of affected children within families is consistent with autosomal recessive inheritance. The etiology is poorly understood but several studies have recently provided support for an heterogeneity with at least three subcategories among the spectrum of PFIC. The first subtype is characterized by an early onset, often during the neonatal period, a severe pruritus, normal serum gammaglutamyltransferase (GGT) activity and cholesterol level, high concentration of serum primary bile acids, absence or very low levels of primary bile acids, absence or very low levels of primary bile acids in bile, and absence of ductular proliferation on standard optical liver histology. Its leads to death due to liver failure within a few years, rarely after adolescence. It is possibly due to an inborn error in primary bile acid secretion and recently, a locus for this subtype has been mapped in the original Byler pedigree to 18q21–q22, the benign recurrent intrahepatic cholestasis region. In the second subtype, affected children exhibit also normal serum GGT activity and cholesterol level and absence of duaular proliferation, but have no pruritus and only traces of primary bile acids in serum. An inborn error in primary bile acid synthesis has been demonstrated in this subtype. The third subtype presents later in life, carries a higher risk of portal hypertension and gastrointestinal bleeding and ends in liver failure at a later age. It is characterized by a mild and unconstant pruritus, high GGT serum activity, moderately raised concentrations of serum primary bile acids, normal concentration of biliary primary bile acids, and ductular proliferation and inflammatory infiltrate with patency of intra and extrahepatic bile ducts. An abnormal expression of the MDR3 gene is involved. A fair proportion of children affected with all subtypes of PFIC may benefit from oral bile acid therapy. In some cases partial external biliary diversion or liver transplantion should be proposed.

Les exacerbations sont fréquentes au cours de la bronchopneumopathie chronique obstructive (BPCO) et contribuent à la morbidité et la mortalité de la maladie. La BPCO est également associée à une prévalence élevée de l'anxiété et de la dépression.Revue systématique de la littérature à propos des données concernant l'association entre anxiété, dépression et exacerbations de la BPCO.Medline sur la période 1980–2017 avec pour mots-clés : chronic obstructive pulmonary disease ou COPD et exacerbation et anxiety ou depression, avec les limites title/abstract ; les langues retenues étaient l'anglais et le français.Parmi 152 articles, 77 résumés sélectionnés ont donné lieu à une double lecture aboutissant à retenir 30 études. La prévalence de l'anxiété et de la dépression variait de 6,7 à 58 % et de 5,5 à 51,5 %, respectivement. Parmi les 30 études de cette revue, 19 (63,3 %) retrouvaient une association positive entre l'anxiété et/ou la dépression et une augmentation du risque d'exacerbations, alors que les 11 autres (36,7 %) ne retrouvaient pas une telle association. L'association entre l'anxiété et/ou la dépression et une augmentation du risque d'exacerbations était beaucoup plus souvent observée dans les études utilisant une définition des exacerbations basée sur les événements (85,7 %) que dans celles basée sur les symptômes (14,3 %). La principale limite de cette revue est l'importante hétérogénéité des études incluses. Une autre limite est la faible proportion de femmes qui y étaient incluses (32,6 %).L'anxiété et/ou la dépression semblent augmenter le risque d'exacerbations de la BPCO. Toutefois, l'importante hétérogénéité des études fait qu'il est difficile de tirer des conclusions définitives sur cette augmentation de risque.Exacerbations are common during the course of chronic obstructive pulmonary disease (COPD) and contribute to its morbidity and mortality. COPD is also associated with high prevalence of anxiety and depression.A systematic literature review of data on the association between anxiety and/or depression and COPD exacerbations.Medline search, for the 1980–2017 period, with the following keywords: "chronic obstructive pulmonary disease" or "COPD" and "exacerbation" and "anxiety" or "depression"; limits: "title/abstract"; the selected languages were English or French.Among 152 articles, 77 abstracts have been preselected for a dual reading and 30 studies have been finally selected. The prevalence of anxiety and depression ranged from 6.7 to 58% and 5.5 to 51.5%, respectively. Among the 30 studies included in this review, 19 (63.3%) revealed positive associations between anxiety and/or depression and increased risk for exacerbations, although 11 (36.7%) failed to support such an association. The association between anxiety and/or depression and an increased risk of COPD exacerbations was more frequently observed in studies using an event-based definition (85.7%) than in those using a symptom-based definition (14.3%). The main limitation of this review is the high heterogeneity of the studies included. Another limitation is the low rate of women included in this review (32.6%).Anxiety and/or depression are associated with a greater risk for exacerbations to occur in COPD. However, a high heterogeneity across the published studies makes it difficult to draw any firm conclusions on the amplitude of this increased risk.

OBJECTIVE:To study the correlation of urinary cotinine levels in mothers and newborns with the number of cigarettes smoked at the end of pregnancy. Population and methods. We recorded the smoking habits of 123 mothers attending a university maternity clinic and measured urinary cotitine levels in mothers and their newborns. All mothers were Europeans and gave birth to a normal full-term (37 weeks gestation) infant. Cotinine levels were measured with high-performance liquid chromatography from urine samples taken during the 6-hour period prior to or after delivery for the mothers and 24-h after birth for the newborns.RESULTS:The average cotinine level for non-smoking mothers, for those who smoked one to nine cigarettes a day and heavy smokers (ten or more cigarettes per day) were 0.21, 2.17 and 4.28 mol/l respectively (p<0.001). The average levels in their newborns were 0.04, 0.39 and 1.36 mol/l respectively (p<0.001). Thirteen percent of the mothers who claimed they did not smoke had cotinine levels higher than the significance cut-off (0.3 mol/l). There was a significant correlation 1) between the number of cigarettes the mothers stated they smoked at the end of pregnancy and their urinary cotinine concentrations (cotinine level=0.213 + 0.349 cigarettes, r=0.78, p<0.001); 2) between the number of cigarettes smoked and newborn's urinary cotinine concentration (cotinine level=0.002 + 0.104 cigarettes/day, r=0.81, p<0.001); and 3) between the mother's and the newborn's urinary cotinine concentrations (newborn cotinine=0.027 + 0.219 maternal cotinine, r=0.77, p<0.001).CONCLUSION:The number of cigarettes smoked at the end of pregnancy accounts for roughly 50% of the variance in the mother's urinary cotinine level and that in her newborn at birth. The urinary cotinine concentration in newborns is 3 to 5 times lower than that of their mothers. A woman smoking 3 cigarettes per day has a urinary cotinine concentration of 1 mol/l. The urinary cotinine level in newborns is 1 mol/l for mothers smoking 10 cigarettes per day.

Cette étude se propose d'évaluer la concordance des évaluations neurologiques d'une cohorte d'enfants prématurés examinés à un an puis à deux ans, puis d'étudier les facteurs pouvant expliquer une éventuelle modification du statut neurologique au cours du temps.

To appreciate the impact of prematurity, fetal hypotrophy and familial environment on the neurodevelopmental performances of very premature infants without cerebral palsy at the age of five years.We followed a regional cohort of 171 very premature infants (< or = 32 weeks of gestation) until they were five years of age. Cognitive functions were tested with the WPPSI test and the development quotient was assessed by the ability to draw a "bonhomme". Twenty-two premature infants suffered from cerebral palsy diagnosed before the age of two years. Another infant had a moderate diplegia at the five-year examination. We had no information for 16 prematures (9.3% of survivors). Twenty-eight premature infants were considered as having no severe disability on phone or mailed contact, and another child had a severe isolated mental retardation. We examined 104/148 infants, and 96/148 survivors without cerebral palsy passed the tests. The cognitive functions of these premature infants are compared to the performances of a control group made up of 108 children born at term > or = 37 weeks, matched for birthplace and single or twin characteristics of the pregnancy.The values of the different quotients are significantly decreased in the preterm group. The global IQ and the performance IQ are 0.8 SD, verbal IQ is 0.5 SD and the development quotient is 0.4 SD below the values observed in the control group. A performance IQ less than -2 SD for the mean of the control group is observed three times more than in the controls (13.5% vs 3.7%, P < 0.01). Multiple linear regression shows that prematurity explains, independent of hypotrophy and socioeconomic environment, 8% of the variation of the performance IQ (P < 0.01), 2% of the variation of the verbal IQ and 2% of the development quotient (P < 0.05).The five-year neurologic outcome of the children born prematurely in this regional study is similar to the results observed in regional studies conducted in Europe: 13.4% of the survivors have cerebral palsy, and the cognitive functions of the children with no cerebral palsy are significantly lower than the term control group. Other risk factors such as hypotrophy, which modulates the developmental quotient, and the socioeconomic status, which modulates the verbal IQ, are underlined.