Objective Adherence to the International Liaison Committee on Resuscitation (ILCOR) algorithm optimizes the initial management of critically ill neonates. In this randomized controlled trial, we assessed the impact of a customizable sequential digital cognitive aid (DCA), adapted from the 2020 ILCOR recommendations, compared with a poster cognitive aid (standard of care [SOC]), on technical and nontechnical performance of junior trainees during a simulated critical neonatal event at birth. Methods For this prospective, bicentric video-recorded study, students were recruited on a voluntary basis, and randomized into groups of 3 composed of a pediatric resident and two midwife students. They encountered a simulated cardiac arrest at birth either (1) with DCA use and ILCOR algorithm poster displayed on the wall (intervention group) or (2) with sole ILCOR algorithm poster (poster cognitive aid [SOC]). Technical and nontechnical skills (NTS) between the two groups were assessed using a standardized scoring of videotaped performances. A neonate specific NTS score was created from the adult Team score. Results 108 students (36 groups of three) attended the study, 20 groups of 3 in the intervention group and 16 groups of 3 in the poster cognitive aid (SOC) group. The intervention group showed a significant improvement in the technical score (P < 0.001) with an average of 24/27 points (24.0 [23.5-25.0]) versus 20.8/27 (20.8 [19.9-22.5]) in poster cognitive aid (SOC) group. No nontechnical score difference was observed. Feedback on the application was positive. Conclusions During a simulated critical neonatal event, use of a DCA was associated with higher technical scores in junior trainees, compared with the sole use of ILCOR poster algorithm.

Abstract The effect of protein intake on growth velocity in infancy may be mediated by insulin-like growth factor-1 (IGF-1). This study aimed to determine the effects of formulae containing 1·8 (F1·8) or 2·7 g (F2·7) protein/418·4 kJ (100 kcal) on IGF-1 concentrations and growth. Healthy term infants were randomly assigned to receive F1·8 (n 74) or F2·7 (n 80) exclusively for the first 4 months of life. A group of breast-fed infants (n 84) was followed-up simultaneously (reference). Growth and body composition were measured at 0·5, 4, 6, 12, 36, 48 and 60 months of life. The IGF-1 concentrations at 4 months (primary outcome) were similar in the F1·8 (67·1 (sd 20·8) ng/l; n 70) and F2·7 (71·2 (sd 27·5) ng/l; n 73) groups (P=0·52). Both formula groups had higher IGF-1 concentrations than the breast-fed group at 4 and 9 months of age (P≤0·0001). During the first 60 months of life, anthropometric parameters in the F1·8 group were lower compared with the F2·7 group, and the differences were significant for head circumference from 2 to 60 months, body weight at 4 and 6 months and length at 9, 12 and 36 months of age. There were no significant differences in body composition between these two groups at any age. We conclude that, in formula-fed infants, although increased protein intake did not affect the IGF-1 concentration during the first 12 months of life, it did affect length and head circumference growth, suggesting that factors other than IGF-1 could play roles in determining growth velocity.

Background & aims: Recent studies have suggested that the gut microflora has metabolic effects. We aimed to evaluate postnatal growth in preterm infants who received different probiotic supplements, and to assess the safety of probiotic administration.Methods: This prospective, randomized, double-blind, controlled trial was performed at three tertiary care neonatal units. Preterm infants were randomly assigned to receive daily supplementation over 4-6 weeks with placebo (group C) or probiotics (group P). Group P comprised three subgroups: P1 received Bifidobacterium lactis, P2 received Bifidobacterium longum, and P3 received B. lactis and B. longum. We assessed postnatal growth during the supplementation period and up to a corrected gestational age (GA) of 41 weeks when body composition was assessed using whole-body dual-energy X-ray absorptiometry. Aerobic and anaerobic blood cultures were performed on suspicion of late-onset sepsis.Results: The study comprised 199 preterm infants with a mean GA of 29.1 +/- 1.4 weeks and a mean birth weight of 1173 +/- 210 g, who received a placebo (group C, n = 52) or probiotics (group P, n = 147) from the first week of life. At the end of the supplementation period, no statistically significant differences were seen between the groups in relation to the mean body weight (group C = 1906 23 g, group P = 1875 +/- 14 g, p = 0.25), length, or head circumference. The incidence rates of necrotizing enterocolitis and late-onset sepsis were similar in the two groups. At the corrected GA of 41 weeks, there were no differences between the groups with respect to anthropometric measurements or body composition analysis.Conclusions: Preterm infants receiving Bifidobacterium supplements did not exhibit better postnatal growth compared with those who received placebo treatment. No adverse effects were associated with probiotic administration. Crown Copyright (C) 2015 Published by Elsevier Ltd.

OBJECTIVES: High-fidelity simulation is an effective tool in teaching neonatal resuscitation skills to professionals. We aimed to determine whether in situ simulation training (for ∼80% of the delivery room staff) improved neonatal resuscitation performed by the staff at maternities. METHODS: A baseline evaluation of 12 maternities was performed: a random sample of 10 professionals in each unit was presented with 2 standardized scenarios played on a neonatal high-fidelity simulator. The medical procedures were video recorded for later assessments. The 12 maternities were then randomly assigned to receive the intervention (a 4-hour simulation training session delivered in situ for multidisciplinary groups of 6 professionals) or not receive it. All maternities were evaluated again at 3 months after the intervention. The videos were assessed by 2 neonatologists blinded to the pre-/postintervention as well as to the intervention/control groups. The performance was assessed using a technical score and a team score. RESULTS: After intervention, the median technical score was significantly higher for scenarios 1 and 2 for the intervention group compared with the control group (P = .01 and 0.004, respectively), the median team score was significantly higher (P < .001) for both scenarios. In the intervention group, the frequency of achieving a heart rate >90 per minute at 3 minutes improved significantly (P = .003), and the number of hazardous events decreased significantly (P < .001). CONCLUSIONS: In situ simulation training with multidisciplinary teams can effectively improve technical skills and teamwork in neonatal resuscitation.

Aim To evaluate the impact of an improved nutritional policy for extremely low birthweight (ELBW) infants on nutritional deficits and postnatal growth. Method We compared two groups of 37 ELBW infants, born before and after the introduction of an improved nutritional policy in April 2006. Group A (born 2005 to early 2006) and group B (born 2009) stayed in a French neonatal intensive care unit (NICU) for at least 7weeks. Optimal energy and protein intakes were 120 and 3.5g/kg/day, respectively, and used to calculate cumulative deficits. Delta z-scores for weight, length and head circumference were calculated between birth and 36weeks of postmenstrual age (PMA). The improved nutritional policy focused on earlier and higher parenteral intake of lipids and proteins, earlier and higher human milk fortification and earlier transition to preterm formula. Results The two groups did not differ in gestational age and birthweight. However, protein and energy deficits were significantly reduced in group B. Between birth and 36weeks of PMA, delta z-scores were significantly reduced for length (p=0.012) but not for weight (p=0.09) or head circumference (p=0.83). Conclusion Higher parenteral intake and close attention to enteral feeding reduced nutritional deficits and linear growth restriction in infants admitted to a French NICU.

We report on a child with Jacobsen syndrome (JBS, OMIM 147791) and abnormalities consistent with Beckwith–Wiedemann syndrome (BWS, OMIM 130650). The constitutional karyotype was apparently normal, but FISH analysis with probes specific for the short and long arms of chromosome 11 found 11qter deletion with 11pter trisomy in 80% of the cells studied. Array‐CGH identified breakpoints in the 11p15.3 and 11q24.1 regions consistent with Jacobsen and Beckwith–Wiedemann syndromes. We suggest that this chromosome imbalance results from a pericentric inversion of chromosome 11 inherited from the father, with mosaicism resulting from meiotic recombination of a paternal inversion followed by mitotic recombination during the first embryonic divisions. This hypothesis is supported by the results of microsatellite marker analysis. Three previous cases of pericentric inversion and recombination of chromosome 11 have been reported. Our case is unusual in that it combines the Jacobsen and Beckwith–Wiedemann syndromes with mosaicism. © 2013 Wiley Periodicals, Inc.

Background: Long-chain polyunsaturated fatty acids (LC-PUFA) are nutritionally important constituents of breast milk to support normal growth, immune function and central nervous system development of newborn infants. Both linoleic acid (18: 2 n-6; LA) and alpha-linolenic acid (18: 3 n-3; ALA), the essential fatty acids, precursors of n-6 and n-3 LC-PUFA,are also present in breast milk. Although the total amount of fat in human milk is fairly constant, the fatty acid composition can vary substantially depending on the diet of the mother. Large variations in the LA, ALA and DHA (22: 6 n-3) contents are observed among countries. As reported by previous studies (1993-2001), the ALA consumption of the French population was 2-3 times lower than the recommended value. Since this period, the food industry offers more food products enriched in n-3 fatty acids. Objective: The present study aimed to investigate whether current recommendations and improved n-3 PUFA content of food products comply with the actual breast-milk PUFA composition. For this purpose, the PUFA content of a large number of human milk samples collected in 2007 in different French regions were compared with previous data obtained in studies conducted in the nineties years (1993-1998). Moreover, this study aimed to confirm expected reduction of the trans fatty acid (TFA) intake resulting from decreased level of TFA in margarine and other dietary fats during the same period. Study design and methods: Mature (postpartum day >= 30) human milk samples (n = 145) were provided in 2007 by eight French regional human milk banks (Bordeaux : n = 20; Dijon: n = 21; Ile-de-France: n = 18; Lyon: n = 20; Montpellier: n = 18; Nantes: n = 21; St Etienne: n = 6; Tours: n = 21), from healthy women volunteers with no particular health history. The fatty acid composition of breast milk was analysed by high-resolution gas-liquid chromatography. Statistical analysis was performed with Kruskall Wallis and Mann and Whitney U tests (p < 0.05). Results: Fatty acid composition of human milk samples did not differ significantly among the eight French regions. The proportions of saturated fatty acids were relatively similar (means ranging from 44.9% to 48.7% of total fatty acids). Monounsaturated fatty acids also varied little, from 36.9% to 39.7%. Total n-6 and n-3 PUFA accounted for 12.5%-15.2%, with an n-6/ n-3 PUFA ratio close to 10, similar among the collect centers. Considering the overall results, LA represented between 10.4% and 12.7%, and ALA varied from 0.72% to 0.95%. Comparison of our results to previous data (1993-1998) showed opposite changes for LA and ALA. During the last decade, the LA level has decreased by 17%, whereas the ALA level has increased by 45%, and hence in 2007, the LA/ALA ratio was close to 14 versus 24 in 1993-1998. The LC-PUFA content remained unchanged. Concerning total TFA, their content was lower (- 37%; p < 0.0001) in 2007 than in 1997, respectively 1.3% and 2.1% of total fatty acids of breast milk. Conclusion: Basing on the PUFA composition of human milk, this large French study shows favourable changes in consumption of both omega-6 and omega-3 fatty acid precursors, and in TFA, in the course of last decade.

A single-center prospective cohort study was designed to identify alterations of renal function during childhood in children born prematurely. A cohort of 143 such babies born over a 4-year period (birth weight less than 1000 g and/or less than 30 weeks of gestation) was prospectively included at birth. A mailing was sent to all parents to propose renal evaluation. Among the 50 included children, 23 had intrauterine and 16 had extrauterine growth retardation. When comparing both of these groups to 11 children with appropriate pre- and postnatal growth at a mean follow-up of 7.6 years, both groups of growth-restricted children had slightly but significantly lower glomerular filtration rates, measured by inulin clearance, although both groups were still within the normal range for their ages. There were no differences for other renal parameters, neonatal therapies or complications, except for postnatal corticosteroid exposure. Children with extrauterine growth restriction were found to have significantly lower protein-energy intake during their first week of life than the intrauterine growth-restricted or the normotrophic children. Our study found that children with either intra- or extrauterine growth retardation are at risk of decreased glomerular filtration rates during childhood. Extrauterine growth restriction represents a new risk factor for long-term renal impairment in premature children.

Background: Long-chain polyunsaturated fatty acids (LC-PUFA) are nutritionally important constituents of breast milk to support normal growth, immune function and central nervous system development of newborn infants. Both linoleic acid (18:2 n-6; LA) and alpha-linolenic acid (18:3 n-3; ALA), the essential fatty acids, precursors of n-6 and n-3 LC-PUFA, are also present in breast milk. Although the total amount of fat in human milk is fairly constant, the fatty acid composition can vary substantially depending on the diet of the mother. Large variations in the LA, ALA and DHA (22:6 n-3) contents are observed among countries. As reported by previous studies (1993-2001), the ALA consumption of the French population was 2-3 times lower than the recommended value. Since this period, the food industry offers more food products enriched in n-3 fatty acids. Objective: The present study aimed to investigate whether current recommendations and improved n-3 PUFA content of food products comply with the actual breast-milk PUFA composition. For this purpose, the PUFA content of a large number of human milk samples collected in 2007 in different French regions were compared with previous data obtained in studies conducted in the nineties years (1993-1998). Moreover, this study aimed to confirm expected reduction of the trans fatty acid (TFA) intake resulting from decreased level of TFA in margarine and other dietary fats during the same period. Study design and methods: Mature (postpartum day ≥ 30) human milk samples (n = 145) were provided in 2007 by eight French regional human milk banks (Bordeaux : n = 20; Dijon: n = 21; Ile-de-France: n = 18; Lyon: n = 20; Montpellier: n = 18; Nantes: n = 21; St Etienne: n = 6; Tours: n = 21), from healthy women volunteers with no particular health history. The fatty acid composition of breast milk was analysed by high-resolution gas-liquid chromatography. Statistical analysis was performed with Kruskall Wallis and Mann and Whitney U tests (p < 0.05). Results: Fatty acid composition of human milk samples did not differ significantly among the eight French regions. The proportions of saturated fatty acids were relatively similar (means ranging from 44.9% to 48.7% of total fatty acids). Monounsaturated fatty acids also varied little, from 36.9% to 39.7%. Total n-6 and n-3 PUFA accounted for 12.5%-15.2%, with an n-6/n-3 PUFA ratio close to 10, similar among the collect centers. Considering the overall results, LA represented between 10.4% and 12.7%, and ALA varied from 0.72% to 0.95%. Comparison of our results to previous data (1993-1998) showed opposite changes for LA and ALA. During the last decade, the LA level has decreased by 17%, whereas the ALA level has increased by 45%, and hence in 2007, the LA/ ALA ratio was close to 14 versus 24 in 1993-1998. The LC-PUFA content remained unchanged. Concerning total TFA, their content was lower (– 37%; p < 0.0001) in 2007 than in 1997, respectively 1.3% and 2.1% of total fatty acids of breast milk. Conclusion: Basing on the PUFA composition of human milk, this large French study shows favourable changes in consumption of both omega-6 and omega-3 fatty acid precursors, and in TFA, in the course of last decade.

This paper reviews current knowledge on the role of the long-chain polyunsaturated fatty acids (LC-PUFA), docosahexaenoic acid (DHA, C22:6n-3) and arachidonic acid (AA, 20:4n-6), in maternal and term infant nutrition as well as infant development. Consensus recommendations and practice guidelines for health-care providers supported by the World Association of Perinatal Medicine, the Early Nutrition Academy, and the Child Health Foundation are provided. The fetus and neonate should receive LC-PUFA in amounts sufficient to support optimal visual and cognitive development. Moreover, the consumption of oils rich in n-3 LC-PUFA during pregnancy reduces the risk for early premature birth. Pregnant and lactating women should aim to achieve an average daily intake of at least 200 mg DHA. For healthy term infants, we recommend and fully endorse breastfeeding, which supplies preformed LC-PUFA, as the preferred method of feeding. When breastfeeding is not possible, we recommend use of an infant formula providing DHA at levels between 0.2 and 0.5 weight percent of total fat, and with the minimum amount of AA equivalent to the contents of DHA. Dietary LC-PUFA supply should continue after the first six months of life, but currently there is not sufficient information for quantitative recommendations.

Background: Routine total parenteral nutrition (TPN) in neonatal care can result in hepatic dysfunction in 40–60% of patients, most commonly as fatty liver, but little work has been conducted on the underlying mechanisms causing hepatic dysfunction. Objective: To use a piglet model for the premature human neonate on TPN, supplemented with lipid emulsions, to investigate hepatic responses.Method:Piglets were delivered 2 days prematurely. Six control piglets were fed enterally (E), whilst twelve animals were maintained on TPN. TPN piglets received the standard TPN solution plus the lipid emulsion as either ClinOleic® (C, n = 6) or Intralipid® (I, n = 6). Hepatic lipid content and the fatty acid composition of liver triacylglyercol (TAG) as well as hepatic lipase (HL) activity were determined. Lipoprotein lipase (LPL) activity was measured in the liver, muscle and adipose tissue. The plasma concentrations of choline, bilirubin, TAG and non-esterified fatty acids (NEFA) were also measured. Results:Liver lipid was significantly increased in piglets on TPN and the tissue fatty acid profiles reflected the lipid emulsion. HL and LPL activities were reduced in liver but LPL increased in adipose tissue during TPN. Plasma concentrations of choline, bilirubin, TAG and NEFA were similar across the treatments. Conclusions:The results suggest fatty liver occurs in neonates receiving TPN and the source of the accumulated lipid appears to be the lipid emulsion used. The factors regulating lipase activity during TPN require further study. The piglet can be used as a model for neonatal TPN.

We describe a newborn girl with multiple malformations associated with an interstitial deletion of chromosome 2q (q24q32). Clinical findings included growth retardation, microcephaly, facial malformations, common atrioventricular canal, digital anomalies of both hands and feet, and ovarian hypoplasia. Bilateral ocular anomalies included down-slanting palpebral fissures, blepharophimosis, microphthalmia, uveal coloboma, and corneal opacity. Chromosomal segment 2q31 may play a major role in the development of the eye and its adnexa.

A 1940-gram male infant was delivered by emergency Caesarean section because of fetal distress at a Level 1 maternity hospital. The mother had no prenatal care and neither her medical history nor her serology was known. The mother presented in active premature labor, presumably at approximately 34 weeks gestation. After resuscitation requiring intubation and tracheal administration of epinephrine, the baby was referred to the neonatal intensive care unit of Debrousse Hospital with a diagnosis of prematurity, respiratory distress syndrome and abdominal distension, possibly secondary to intestinal obstruction. The chest radiograph was consistent with the diagnosis of hyaline membrane disease. Despite exogenous surfactant instillation and a trial of high frequency oscillation, the infant's respiratory function failed to improve. The abdominal distension was thought to exacerbate this problem. The abdominal wall was tender, painful and inflamed. The plain film showed limited gas in the intestinal tract (Fig. 1), and the ultrasound scan showed ascites without dilation of the small bowel.FIG. 1: Abdominal and chest radiographs on first day of life showing limited aeration of the bowel.ANSWER: See page 450Laboratory findings showed metabolic acidosis (pH = 7.16; base excess = 12), leukocytosis (21,000/mL), thrombocytopenia (18,000/L), hypoglycemia (glucose <1.1 mmol/L) and a coagulation deficit (prothrombin activity <50% despite intravenous vitamin K administration). Antibiotics were started and continued in association with transfusion of platelets and fresh frozen plasma. A laparotomy was performed on the second day of life. No obstruction was obvious at laparotomy. The liver was enlarged and dark in color. Culture of the peritoneal fluid was sterile. In absence of obvious diagnosis we performed infectious and metabolic evaluations and bone radiographs (Fig. 2).FIG. 2: Radiograph of the lower extremity of the femur and the upper extremity of the tibia.What is the likely diagnosis? Hirschsprung disease. Congenital syphilis. Infectious liver failure. Inborn errors of metabolism. ANSWER Histologic examination of the appendix excluded an extensive form of Hirschsprung disease. The abdominal distension resolved spontaneously within a week but the liver dysfunction persisted and was associated with an increasing cholestasis. Routine newborn screening for metabolic disorders was negative. Ferritin and hyperammonemia concentrations were elevated. Both culture and serology for hepatotropic viruses (hepatitis A, hepatitis B, hepatitis C, herpes simplex virus and adenovirus) were negative. The presence of bilateral metaphyseal destruction of upper medial tibias defining the Wimberger sign on radiography suggested the diagnosis of congenital syphilis. This diagnosis was confirmed by a positive venereal disease research laboratory test in the mother and a positive immunoglobulin M fluorescent treponemal antibody absorbed test in the infant. The liver function normalized after a 15-day intravenous course of benzyl penicillin. Cholestasis was treated with a 12-month course of ursodeoxycholic acid. One year later growth and both physical and neurologic examinations were normal except for persistent cholestasis. The infant was lost to follow-up beyond this age. The typical signs of congenital syphilis include nonimmune hydrops, jaundice, hepatosplenomegaly, rhinitis, skin rash and pseudoparalysis of an extremity (1). Although intestinal obstruction has previously been reported during fetal (2,3) and neonatal life (4,5), this manifestation of congenital syphilis is uncommon. A review of the literature revealed five cases of neonatal intestinal obstruction in newborns with congenital syphilis (4,5). All were preterm infants; four developed respiratory distress (three pneumonia, one not specified). Two mechanisms are reported: mechanical obstruction by inspissated meconium (4); and stenosis (4,5) secondary to syphilitic vasculitis. Four infants underwent laparotomy, but stenosis was found in only two cases despite markedly dilated bowel loops in all. Of these two, only one had air fluid levels (4) and the other had rectal bleeding as a result of bowel ulcerations (5). In the absence of air fluid levels or life-threatening complication (e.g., pneumoperitoneum, bleeding) conservative management should be considered in cases of intestinal obstruction associated with prematurity, pneumonia and proven or suspected congenital syphilis. Acknowledgments: The authors are indebted to Becky Newsom for skillful secretary assistance. The authors thank Pr.William C. Heird for helpful review of the manuscript.