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Saint Denny K, Lamore K, Nandrino JL, Rethore S, Prieur C, Mur S, Storme L. Parents' experiences of palliative care decision-making in neonatal intensive care units: An interpretative phenomenological analysis. Acta Paediatr 2024; 113:992-998. [PMID: 38229540 DOI: 10.1111/apa.17109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/18/2023] [Accepted: 01/08/2024] [Indexed: 01/18/2024]
Abstract
AIM This work explores the experiences and meaning attributed by parents who underwent the decision-making process of withholding and/or withdrawing life-sustaining treatment for their newborn. METHODS Audio-recorded face-to-face interviews were led and analysed using interpretative phenomenological analysis. Eight families (seven mothers and five fathers) whose baby underwent withholding and/or withdrawing of life-sustaining treatment in three neonatal intensive care units from two regions in France were included. RESULTS The findings reveal two paradoxes within the meaning-making process of parents: role ambivalence and choice ambiguity. We contend that these paradoxes, along with the need to mitigate uncertainty, form protective psychological mechanisms that enable parents to cope with the decision, maintain their parental identity and prevent decisional regret. CONCLUSION Role ambivalence and choice ambiguity should be considered when shared decision-making in the neonatal intensive care unit. Recognising and addressing these paradoxical beliefs is essential for informing parent support practices and professional recommendations, as well as add to ethical discussions pertaining to parental autonomy and physicians' rapport to uncertainty.
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Affiliation(s)
- Kelly Saint Denny
- Department of Neonatology, Lille University Hospital, Lille, France
- Cognitive and Affective Sciences, SCALab UMR CNRS 9193, University of Lille, Lille, France
| | - Kristopher Lamore
- Cognitive and Affective Sciences, SCALab UMR CNRS 9193, University of Lille, Lille, France
| | - Jean-Louis Nandrino
- Cognitive and Affective Sciences, SCALab UMR CNRS 9193, University of Lille, Lille, France
| | - Sabine Rethore
- Department of Neonatology, Valenciennes Hospital, Valenciennes, France
| | - Charlotte Prieur
- Regional Resource Team for Pediatric Palliative Care, Lille University Hospital, Lille, France
- Department of Neonatology, Lens Hospital, Lens, France
| | - Sebastien Mur
- Department of Neonatology, Lille University Hospital, Lille, France
| | - Laurent Storme
- Department of Neonatology, Lille University Hospital, Lille, France
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2
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Current attitudes and beliefs toward perinatal care orientation before 25 weeks of gestation: The French perspective in 2020. Semin Perinatol 2022; 46:151533. [PMID: 34865886 DOI: 10.1016/j.semperi.2021.151533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The survival rate of infants born before 25 weeks of gestational age in France is extremely low compared with that of many other countries: 0%, 1%, and 31% at 22, 23, and 24 weeks' in the last national cohort study. A non-optimal regionalization and variations in practice are prevalent. Some parents in social media and support groups have reported feeling lost and confused with mixed messages leading to lack of trust. These data kindled a major debate in France around perinatal management leading to an investigation exploring neonatologists' perspectives and ways to improve care. The majority (81%) of the responding neonatologists reported more active care and higher survival rates than in 2011, although others continued preferring delivery room comfort care and limited NICU treatment at or before 24 weeks. The desire to improve was an overarching theme in all the respondents' answers to open-ended questions. Barriers to active care included an absence of expertise and of benchmarking to guide optimal care, and limited resources in the NICU and during follow-up - all leading to self-fulfilling prophecies of poor prognosis. Optimization of regionalization, perinatal teamwork and parental involvement, fostering experience by creating specific perinatal centers, stimulating benchmarking, and working with policy makers to allow better long-term outcomes could enable higher survival.
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3
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Bührer C. Frühgeborene an der Grenze der Lebensfähigkeit. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-021-01294-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lamau MC, Ruiz E, Merrer J, Sibiude J, Huon C, Lepercq J, Goffinet F, Jarreau PH. A new individualized prognostic approach to the management of women at risk of extreme preterm birth in France: Effect on neonatal outcome. Arch Pediatr 2021; 28:366-373. [PMID: 34059380 DOI: 10.1016/j.arcped.2021.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/19/2021] [Accepted: 04/16/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION After discussion with the parents, periviable infants can receive either active treatment or palliative care. The rate of active treatment in France is lower than in other developed countries, as is the survival rate of infants in this gestational age range. This study's main objective was to assess the effect of a standardized perinatal management protocol (EXPRIM) on the neonatal outcome of children born before 27 weeks of gestation. METHODS A before-and-after study was conducted in the two level-3 hospitals of the Risks and Pregnancy DHU to compare two 16-month periods. The EXPRIM protocol was based on routine administration of prenatal corticosteroid therapy and a scheduled combined obstetric-pediatric group prenatal prognostic evaluation, not based solely on gestational age. The study included all births between 22 weeks and 26 weeks+6 days of gestation, except in utero deaths diagnosed at admission and medical terminations of pregnancy for fetal malformation, both excluded. The principal endpoint was survival without severe neonatal morbidity. RESULTS The study included 267 women: 116 (128 newborns) in period 1 and 151 (172 newborns) in period 2. The median gestational age at admission to the maternity unit was 2.5 days younger in period 2, and the number of women admitted at 22-23 weeks doubled in period 2 (59 vs 29, respectively). Overall, the rates of live births, NICU transfer, and survival without severe morbidity were similar during the two periods. More infants were liveborn between 22 and 24 weeks in period 2 (66 vs 43). Of all newborns transferred to the NICU, 26 (29%) survived without severe morbidity in period 1 and 46 (39%) in period 2. After multivariate analysis, survival without severe morbidity did not differ significantly. CONCLUSION Implementation of the EXPRIM protocol led to active treatment of more mothers and their children at the border of viability, and increased the number of children who survived without severe morbidity even if, overall, there was no statistically significant difference in percentage.
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Affiliation(s)
- M C Lamau
- Maternité Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France
| | - E Ruiz
- Service de médecine et réanimation néonatales de Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France
| | - J Merrer
- Clinical Research Unit of Paris Descartes Necker Cochin, AP-HP, 123, Bd de Port-Royal, 75014 Paris, France; Université de Paris, INSERM U1153, Équipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Centre de Recherche Épidémiologie et Biostatistique Sorbonne Paris Cité (CRESS), 123, Bd de Port-Royal, 75014 Paris, France
| | - J Sibiude
- Service de Gynécologie-Obstétrique, AP-HP, Nord-Université de Paris, Hôpital Louis Mourier, DMU Gynécologie-Périnatalité, FHU PREMA, Colombes, France, IAME-INSERM, Paris, France
| | - C Huon
- Service de Néonatologie, AP-HP, APHP. Nord-Université de Paris, Hôpital Louis Mourier, DMU Gynécologie-Périnatalité, FHU PREMA, 178, rue des Renouillers, 92700 Colombes, France
| | - J Lepercq
- Maternité Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France
| | - F Goffinet
- Maternité Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France; Université de Paris, INSERM U1153, Équipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Centre de Recherche Épidémiologie et Biostatistique Sorbonne Paris Cité (CRESS), 123, Bd de Port-Royal, 75014 Paris, France
| | - Pierre Henri Jarreau
- Service de médecine et réanimation néonatales de Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France; Université de Paris, INSERM U1153, Équipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Centre de Recherche Épidémiologie et Biostatistique Sorbonne Paris Cité (CRESS), 123, Bd de Port-Royal, 75014 Paris, France.
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5
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Sorin G, Dany L, Vialet R, Thomachot L, Hassid S, Michel F, Tosello B. How doctors communicated with parents in a neonatal intensive care: Communication and ethical issues. Acta Paediatr 2021; 110:94-100. [PMID: 32364306 DOI: 10.1111/apa.15339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 01/15/2023]
Abstract
AIM Doctors have a moral and legal obligation to keep patients and their families informed, and this is an integral part of care. We explored the communication strategies used by doctors when they spoke to parents in a French neonatal intensive care unit (NICU). METHODS This was a single-centre qualitative pilot study carried out from October 2015 to January 2016. We asked five doctors (three female) to audiotape their discussions with the parents of newborn infants during their NICU stay. The doctors' mean age was 43 years, and they had a mean of 14 years of NICU experience. Each discussion was subjected to thematic content analysis. RESULTS We analysed 40 discussions carried out between doctors on 26 newborn infants. Five communication strategy themes emerged: building understanding, how the communication was constructed, the role of the doctor, and of the parents, in the overall care of the newborn infant and how the information given to the parents developed over time. CONCLUSION Analysing the content of the information discussed with parents provided us with the opportunity to understand the communication and ethical issues surrounding the delivery of information in a NICU. This could be used to improve future discussions between doctors and parents.
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Affiliation(s)
- Gaelle Sorin
- Hospital La Timone Aix‐Marseille University/EFS/CNRS, UMR 7268 ADÉS, Espace Éthique Méditerranéen Marseille France
- Department of Neonatal Medicine, North Hospital Assistance Publique‐Hôpitaux de Marseille Marseille France
| | - Lionel Dany
- Aix‐Marseille University Aix‐en‐Provence France
- Department of Oncology Hospital La Timone Assistance Publique‐Hôpitaux de Marseille Marseille France
| | - Renaud Vialet
- Department of Neonatal Medicine, North Hospital Assistance Publique‐Hôpitaux de Marseille Marseille France
| | - Laurent Thomachot
- Department of Neonatal Medicine, North Hospital Assistance Publique‐Hôpitaux de Marseille Marseille France
| | - Sophie Hassid
- Department of Neonatal Medicine, North Hospital Assistance Publique‐Hôpitaux de Marseille Marseille France
| | - Fabrice Michel
- Hospital La Timone Aix‐Marseille University/EFS/CNRS, UMR 7268 ADÉS, Espace Éthique Méditerranéen Marseille France
- Department of Pediatric Intensive Care Unit Hospital La Timone Assistance‐Publique des Hôpitaux de Marseille Marseille France
| | - Barthélémy Tosello
- Hospital La Timone Aix‐Marseille University/EFS/CNRS, UMR 7268 ADÉS, Espace Éthique Méditerranéen Marseille France
- Department of Neonatal Medicine, North Hospital Assistance Publique‐Hôpitaux de Marseille Marseille France
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6
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Bührer C, Felderhoff-Müser U, Gembruch U, Hecher K, Kainer F, Kehl S, Kidszun A, Kribs A, Krones T, Lipp V, Maier RF, Mitschdörfer B, Nicin T, Roll C, Schindler M. Frühgeborene an der Grenze der Lebensfähigkeit
(Entwicklungsstufe S2k, AWMF-Leitlinien-Register Nr. 024/019, Juni
2020). Z Geburtshilfe Neonatol 2020; 224:244-254. [PMID: 33075837 DOI: 10.1055/a-1230-0810] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Redaktionskomitee
Federführende Fachgesellschaft
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Affiliation(s)
- Christoph Bührer
- Klinik für Neonatologie, Charité - Universitätsmedizin Berlin, Berlin
| | | | - Ulrich Gembruch
- Zentrum für Geburtshilfe und Frauenheilkunde, Universitätsklinikum Bonn, Bonn
| | - Kurt Hecher
- Klinik für Geburtshilfe und Pränatalmedizin, Universitätskrankenhaus Eppendorf, Hamburg
| | - Franz Kainer
- Abteilung für Geburtshilfe und Pränatalmedizin, Klinik Hallerwiese, Nürnberg
| | - Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen
| | - André Kidszun
- Zentrum für Kinder- und Jugendmedizin, Universitätsmedizin Mainz, Mainz
| | | | - Tanja Krones
- Klinische Ethik, Universitätsspital Zürich, Zürich
| | - Volker Lipp
- Lehrstuhl für Bürgerliches Recht, Zivilprozessrecht, Medizinrecht und Rechtsvergleichung, Juristische Fakultät / Institut für Notarrecht / Zentrum für Medizinrecht, Universität Göttingen, Göttingen
| | - Rolf F Maier
- Zentrum für Kinder- und Jugendmedizin, Universitätsklinikum Marburg, Marburg
| | | | - Tatjana Nicin
- Klinik für Gynäkologie und Geburtshilfe, Klinikum Hanau, Hanau
| | - Claudia Roll
- Abteilung Neonatologie, Pädiatrische Intensivmedizin, Schlafmedizin, Vestische Kinder- und Jugendklinik Datteln, Universität Witten/Herdecke, Datteln
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7
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Abstract
Babies born at the limit of viability have a high risk of morbidity and mortality. Despite great advances in science, the approach to these newborns remains challenging. Thus, this study reviewed the literature regarding the treatment of newborns at the limit of viability. There are several interventions that can be applied before and after birth to increase the baby's survival with the least sequelae possible, but different countries make different recommendations on the gestational age that each treatment should be given. There is more consensus on the extremities of viability, being that, at the lower extremity, comfort care is preferred and active care in newborns with higher gestational age. The higher the gestational age at birth, the higher the survival and survival without morbidity rates. At all gestational ages, it is important to take into account the suffering of these babies and to provide them the best quality of life possible. Sometimes palliative care is the best therapeutic approach. The parents of these babies should be included in the decision-making process, if they wish, always respecting their needs and wishes. Nevertheless, the process of having such an immature child can be very painful for parents, so it is also important to take into account their suffering and provide them with all the necessary support. This support should be maintained even after the death of the newborn.
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Affiliation(s)
- Ana Lemos
- Faculty of Medicine, University of Porto, Porto, Portugal -
| | - Henrique Soares
- Faculty of Medicine, University of Porto, Porto, Portugal.,Neonatal Intensive Care Unit, Department of Pediatrics, São João University Hospital, Porto, Portugal
| | - Hercília Guimarães
- Faculty of Medicine, University of Porto, Porto, Portugal.,Neonatal Intensive Care Unit, Department of Pediatrics, São João University Hospital, Porto, Portugal.,Unit of Cardiovascular Research and Development, Faculty of Medicine, University of Porto, Porto, Portugal
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8
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Morgan AS, Khoshnood B, Diguisto C, Foix L'Helias L, Marchand-Martin L, Kaminski M, Zeitlin J, Bréart G, Goffinet F, Ancel PY. Intensity of perinatal care for extremely preterm babies and outcomes at a higher gestational age: evidence from the EPIPAGE-2 cohort study. BMC Pediatr 2020; 20:8. [PMID: 31910799 PMCID: PMC6945524 DOI: 10.1186/s12887-019-1856-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/25/2019] [Indexed: 11/10/2022] Open
Abstract
Background Perinatal decision-making affects outcomes for extremely preterm babies (22–26 weeks’ gestational age (GA)): more active units have improved survival without increased morbidity. We hypothesised such units may gain skills and expertise meaning babies at higher gestational ages have better outcomes than if they were born elsewhere. We examined mortality and morbidity outcomes at age two for babies born at 27–28 weeks’ GA in relation to the intensity of perinatal care provided to extremely preterm babies. Methods Fetuses from the 2011 French national prospective EPIPAGE-2 cohort, alive at maternal admission to a level 3 hospital and delivered at 27–28 weeks’ GA, were included. Morbidity-free survival (survival without sensorimotor (blindness, deafness or cerebral palsy) disability) and overall survival at age two were examined. Sensorimotor disability and Ages and Stages Questionnaire (ASQ) result below threshold among survivors were secondary outcomes. Perinatal care intensity level was based on birth hospital, grouped using the ratio of 24–25 weeks’ GA babies admitted to neonatal intensive care to fetuses of the same gestation alive at maternal admission. Sensitivity analyses used ratios based upon antenatal steroids, Caesarean section, and newborn resuscitation. Multiple imputation was used for missing data; hierarchical logistic regression accounted for births nested within centres. Results 633 of 747 fetuses (84.7%) born at 27–28 weeks’ GA survived to age two. There were no differences in survival or morbidity-free survival: respectively, fully adjusted odds ratios were 0.96 (95% CI: 0.54 to 1.71) and 1.09 (95% CI: 0.59 to 2.01) in medium and 1.12 (95% CI: 0.63 to 2.00) and 1.16 (95% CI: 0.62 to 2.16) in high compared to low-intensity hospitals. Among survivors, there were no differences in sensorimotor disability or ASQ below threshold. Sensitivity analyses were consistent with the main results. Conclusions No difference was seen in survival or morbidity-free survival at two years of age among fetuses alive at maternal hospital admission born at 27–28 weeks’ GA, or in sensorimotor disability or presence of an ASQ below threshold among survivors. There is no evidence for an impact of intensity of perinatal care for extremely preterm babies on births at a higher gestational age.
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Affiliation(s)
- Andrei Scott Morgan
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France. .,UCL Elizabeth Garrett Anderson Institute for Women's Health, 74 Huntley Street, London, WC1E 6AU, UK. .,SAMU 93 - SMUR Pédiatrique, CHI André Gregoire, Groupe Hospitalier Universitaire Paris Seine-Saint-Denis, Assistance Publique des Hôpitaux de Paris, Montreuil, France.
| | - Babak Khoshnood
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - Caroline Diguisto
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France.,Maternité Olympe de Gouges, Centre Hospitalier Regional Universitaire Tours, Tours, France.,Université François Rabelais, Tours, France
| | - Laurence Foix L'Helias
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France.,UPMC Université Paris 6, Sorbonne Universités, Paris, France.,Service de Néonatologie, Hopital Armand Trousseau, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Laetitia Marchand-Martin
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - Monique Kaminski
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - Jennifer Zeitlin
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - Gérard Bréart
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - François Goffinet
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France.,Maternité Port-Royal, University Paris-Descartes, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Pierre-Yves Ancel
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France.,URC CIC P1419, DHU Risk in Pregnancy, Cochin Hotel Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France
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9
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Papadimitriou V, Tosello B, Pfister R. Effect of written outcome information on attitude of perinatal healthcare professionals at the limit of viability: a randomized study. BMC Med Ethics 2019; 20:74. [PMID: 31640670 PMCID: PMC6806555 DOI: 10.1186/s12910-019-0413-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 09/27/2019] [Indexed: 11/11/2022] Open
Abstract
Background Differences in perception and potential disagreements between parents and professionals regarding the attitude for resuscitation at the limit of viability are common. This study evaluated in healthcare professionals whether the decision to resuscitate at the limit of viability (intensive care versus comfort care) are influenced by the way information on incurred risks is given or received. Methods This is a prospective randomized controlled study. This study evaluated the attitude of healthcare professionals by testing the effect of information given through graphic fact sheets formulated either optimistically or pessimistically. The written educational fact sheet included three graphical presentations of survival and complication/morbidity by gestational age. The questionnaire was submitted over a period of 4 months to 5 and 6-year medical students from the Geneva University as well as physicians and nurses of the neonatal unit at the University Hospitals of Geneva. Our sample included 102 healthcare professionals. Results Forty-nine responders (48%) were students (response rate of 33.1%), 32 (31%) paediatricians (response rate of 91.4%) and 21 (20%) nurses in NICU (response rate of 50%). The received risk tended to be more severe in both groups compared to the graphically presented facts and current guidelines, although optimistic representation favoured the perception of “survival without disability” at 23 to 25 weeks. Therapeutic attitudes did not differ between groups, but healthcare professionals with children were more restrained and students more aggressive at very low gestational ages. Conclusion Written information on mortality and morbidity given to healthcare professionals in graphic form encourages them to overestimate the risk. However, perception in healthcare staff may not be directly transferable to parental perception during counselling as the later are usually naïve to the data received. This parental information are always communicated in ways that subtly shape the decisions that follow.
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Affiliation(s)
- V Papadimitriou
- Neonatal and Paediatric Intensive Care Unit, University Hospitals of Geneva, and Geneva University, 1211, Genève, Switzerland
| | - B Tosello
- Neonatal and Paediatric Intensive Care Unit, University Hospitals of Geneva, and Geneva University, 1211, Genève, Switzerland. .,Aix-Marseille Université, CNRS, EFS, ADES, Marseille, France.
| | - R Pfister
- Neonatal and Paediatric Intensive Care Unit, University Hospitals of Geneva, and Geneva University, 1211, Genève, Switzerland
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10
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Levaillant C, Caeymaex L, Béhal H, Kaminski M, Diguisto C, Tosello B, Azria E, Claris O, Bétrémieux P, Foix L’Hélias L, Truffert P. Prenatal parental involvement in decision for delivery room management at 22-26 weeks of gestation in France - The EPIPAGE-2 Cohort Study. PLoS One 2019; 14:e0221859. [PMID: 31465428 PMCID: PMC6715208 DOI: 10.1371/journal.pone.0221859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 08/18/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Our main objective was to examine if parental prenatal preferences predict delivery-room management of extremely preterm periviable infants. The secondary objectives were to describe parental involvement and the content of prenatal counseling given to parents for this prenatal decision. DESIGN Prospective study of neonates liveborn between 22 and 26 weeks of gestation in France in 2011 among the neonates included in the EPIPAGE-2 study. SETTING 18 centers participating in the "Extreme Prematurity Group" substudy of the EPIPAGE-2 study. PATIENTS 302 neonates liveborn between 22-26 weeks among which 113 with known parental preferences while parental preferences were unknown or unavailable for 186 and delivery room management was missing for 3. RESULTS Data on prenatal counseling and parental preferences were collected by a questionnaire completed by professionals who cared for the baby at birth; delivery room (DR) management, classified as stabilization or initiation of resuscitation (SIR) vs comfort care (CC). The 113 neonates studied had a mean (SD) gestational age of 24 (0.1) weeks. Parents of neonates in the CC group preferred SIR less frequently than those with neonates in the SIR group (16% vs 88%, p < .001). After multivariate analysis, preference for SIR was an independent factor associated with this management. Professionals qualified decisions as shared (81%), exclusively medical (16%) or parental (3%). Information was described as medical with no personal opinion (71%), complete (75%) and generally pessimistic (54%). CONCLUSION Parental involvement in prenatal decision-making did not reach satisfying rates in the studied setting. When available, prenatal parental preference was a determining factor for DR management of extremely preterm neonates. Potential biases in the content of prenatal counselling given to parents need to be evaluated.
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Affiliation(s)
- Cerise Levaillant
- CHU Lille Neonatal unit, EA Epidemiology and Quality of Care, Lille, France
- * E-mail:
| | - Laurence Caeymaex
- Department of Neonatology, Centre Hospitalier Intercommunal de Creteil, Créteil, France
- CEDITEC, University Paris Est Creteil, France
| | - Hélène Béhal
- Department of biostatistics, Univ. Lille, CHU Lille, Lille, France
| | - Monique Kaminski
- Inserm UMR, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Caroline Diguisto
- Maternité Olympe de Gouges, Centre Hospitalier Regional Universitaire Tours, France
| | - Barthélémy Tosello
- Department of Neonatology, Assistance Publique-Hôpitaux de Marseille, Nord Hospital, Marseille, France
- Aix-Marseille University, CNRS, EFS, ADES, Marseille, France
| | - Elie Azria
- Inserm UMR, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
- Maternity Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Olivier Claris
- Department of Neonatology, Hospices Civils de Lyon, Hôpital Femme Mère Enfants
- Claude Bernard University, EAM, France
| | | | - Laurence Foix L’Hélias
- Inserm UMR, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
- Sorbonne Université Paris, France, Service de Néonatologie, Hôpital Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Patrick Truffert
- CHU Lille Neonatal unit, EA Epidemiology and Quality of Care, Lille, France
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Guillois B. [Evolution of practices in neonatology]. SOINS. PEDIATRIE, PUERICULTURE 2019; 40:16-21. [PMID: 31331596 DOI: 10.1016/j.spp.2019.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The care of newborns has benefited from significant progress over the last twenty years. The discovery of new treatments and technologies, the development of care centred on the infants and their family, ethical reflection, the organisation of support and training for professionals are just some examples. The place of the parents in decision-making processes however needs to be reinforced.
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Affiliation(s)
- Bernard Guillois
- Centre hospitalier universitaire de Caen, Service de néonatalogie, Avenue de la Côte de Nacre, 14000 Caen, France; Université Caen Normandie, UFR de médecine, 2 rue des Rochambelles, Caen, CS 14032, France.
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12
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Wang D, Yasseen AS, Marchand-Martin L, Sprague AE, Graves E, Goffinet F, Walker M, Ancel PY, Lacaze-Masmonteil T. A population-based comparison of preterm neonatal deaths (22-34 gestational weeks) in France and Ontario: a cohort study. CMAJ Open 2019; 7:E159-E166. [PMID: 30872267 PMCID: PMC6420330 DOI: 10.9778/cmajo.20180199] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The management and outcomes of preterm births can vary greatly even among developed nations with the same access to medicine, technology and expertise. We aimed to compare aspects of obstetrical management and mortality for preterm infants in France and Ontario, Canada. METHODS The Better Outcomes Registry & Network (BORN) Information System in Ontario and Épidémiologique sur les petits âges gestationnels (EPIPAGE-2) in France collected information on maternal demographics, obstetrical characteristics, obstetrical interventions and neonatal outcomes for infants born between 22 and 34 weeks gestation. We used standardized covariate definitions and extracted data from 2011 (for EPIPAGE-2) and from 2012 and 2013 (for BORN) to conduct a cohort study comparing the 2 data sets (stratified into gestational age groups of 22-26, 27-31 and 32-34 wk) using multivariable logistic regression models. RESULTS Mothers in the BORN cohort were older (30.7 yr v. 29.6 yr) but less likely to have gestational hypertension (13.4% v. 17.9%) than those in the EPIPAGE-2 cohort. Infants from EPIPAGE-2 had lower birth weights (1.3 kg v. 1.5 kg) and were more likely to be born in an institution with level 3 care (71.9% v. 55.8%). After adjustment for these differences, there was significantly higher neonatal mortality among infants from EPIPAGE-2 in the 22-26 week gestation age group (adjusted odds ratio 2.81; 95% confidence interval 1.17 to 6.74). INTERPRETATION Even after we adjusted for both intrinsic population differences and differences in management between Ontario and France, we found a higher rate of neonatal mortality at earlier gestational ages in France. This may be related to differences in ethical approaches and/or postnatal management and should be explored further.
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Affiliation(s)
- Dianna Wang
- Northern Alberta Neonatal Program (Wang), Edmonton, Alta.; Better Outcomes Registry & Network Ontario (Yasseen, Sprague, Walker); Children's Hospital of Eastern Ontario Research Institute (Yasseen, Sprague), Ottawa, Ont.; Obstetrical, Perinatal and Pediatric Epidemiology Team (Marchand-Martin, Goffinet, Ancel), Centre for Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center (U1153), Institut national de la santé et de la recherche médicale; Paris Descartes University (Marchand-Martin, Goffinet, Ancel), Paris, France; ICES (Graves), Toronto, Ont.; Département Hospitalo-Universitaire on Risks in Pregnancy (Goffinet), Assistance Publique - HÔpitaux de Paris, Paris, France; Department of Obstetrics and Gynecology (Walker), University of Ottawa, Ottawa, Ont.; Clinical Research Unit (Ancel), Center for Clinical Investigation P1419, Cochin Broca Hôtel-Dieu Hospital, Paris, France; Department of Pediatrics (Lacaze-Masmonteil), Cumming School of Medicine, University of Calgary; Alberta Children's Hospital Research Institute (Lacaze-Masmonteil), Calgary, Alta.
| | - Abdool S Yasseen
- Northern Alberta Neonatal Program (Wang), Edmonton, Alta.; Better Outcomes Registry & Network Ontario (Yasseen, Sprague, Walker); Children's Hospital of Eastern Ontario Research Institute (Yasseen, Sprague), Ottawa, Ont.; Obstetrical, Perinatal and Pediatric Epidemiology Team (Marchand-Martin, Goffinet, Ancel), Centre for Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center (U1153), Institut national de la santé et de la recherche médicale; Paris Descartes University (Marchand-Martin, Goffinet, Ancel), Paris, France; ICES (Graves), Toronto, Ont.; Département Hospitalo-Universitaire on Risks in Pregnancy (Goffinet), Assistance Publique - HÔpitaux de Paris, Paris, France; Department of Obstetrics and Gynecology (Walker), University of Ottawa, Ottawa, Ont.; Clinical Research Unit (Ancel), Center for Clinical Investigation P1419, Cochin Broca Hôtel-Dieu Hospital, Paris, France; Department of Pediatrics (Lacaze-Masmonteil), Cumming School of Medicine, University of Calgary; Alberta Children's Hospital Research Institute (Lacaze-Masmonteil), Calgary, Alta
| | - Laetitia Marchand-Martin
- Northern Alberta Neonatal Program (Wang), Edmonton, Alta.; Better Outcomes Registry & Network Ontario (Yasseen, Sprague, Walker); Children's Hospital of Eastern Ontario Research Institute (Yasseen, Sprague), Ottawa, Ont.; Obstetrical, Perinatal and Pediatric Epidemiology Team (Marchand-Martin, Goffinet, Ancel), Centre for Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center (U1153), Institut national de la santé et de la recherche médicale; Paris Descartes University (Marchand-Martin, Goffinet, Ancel), Paris, France; ICES (Graves), Toronto, Ont.; Département Hospitalo-Universitaire on Risks in Pregnancy (Goffinet), Assistance Publique - HÔpitaux de Paris, Paris, France; Department of Obstetrics and Gynecology (Walker), University of Ottawa, Ottawa, Ont.; Clinical Research Unit (Ancel), Center for Clinical Investigation P1419, Cochin Broca Hôtel-Dieu Hospital, Paris, France; Department of Pediatrics (Lacaze-Masmonteil), Cumming School of Medicine, University of Calgary; Alberta Children's Hospital Research Institute (Lacaze-Masmonteil), Calgary, Alta
| | - Ann E Sprague
- Northern Alberta Neonatal Program (Wang), Edmonton, Alta.; Better Outcomes Registry & Network Ontario (Yasseen, Sprague, Walker); Children's Hospital of Eastern Ontario Research Institute (Yasseen, Sprague), Ottawa, Ont.; Obstetrical, Perinatal and Pediatric Epidemiology Team (Marchand-Martin, Goffinet, Ancel), Centre for Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center (U1153), Institut national de la santé et de la recherche médicale; Paris Descartes University (Marchand-Martin, Goffinet, Ancel), Paris, France; ICES (Graves), Toronto, Ont.; Département Hospitalo-Universitaire on Risks in Pregnancy (Goffinet), Assistance Publique - HÔpitaux de Paris, Paris, France; Department of Obstetrics and Gynecology (Walker), University of Ottawa, Ottawa, Ont.; Clinical Research Unit (Ancel), Center for Clinical Investigation P1419, Cochin Broca Hôtel-Dieu Hospital, Paris, France; Department of Pediatrics (Lacaze-Masmonteil), Cumming School of Medicine, University of Calgary; Alberta Children's Hospital Research Institute (Lacaze-Masmonteil), Calgary, Alta
| | - Erin Graves
- Northern Alberta Neonatal Program (Wang), Edmonton, Alta.; Better Outcomes Registry & Network Ontario (Yasseen, Sprague, Walker); Children's Hospital of Eastern Ontario Research Institute (Yasseen, Sprague), Ottawa, Ont.; Obstetrical, Perinatal and Pediatric Epidemiology Team (Marchand-Martin, Goffinet, Ancel), Centre for Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center (U1153), Institut national de la santé et de la recherche médicale; Paris Descartes University (Marchand-Martin, Goffinet, Ancel), Paris, France; ICES (Graves), Toronto, Ont.; Département Hospitalo-Universitaire on Risks in Pregnancy (Goffinet), Assistance Publique - HÔpitaux de Paris, Paris, France; Department of Obstetrics and Gynecology (Walker), University of Ottawa, Ottawa, Ont.; Clinical Research Unit (Ancel), Center for Clinical Investigation P1419, Cochin Broca Hôtel-Dieu Hospital, Paris, France; Department of Pediatrics (Lacaze-Masmonteil), Cumming School of Medicine, University of Calgary; Alberta Children's Hospital Research Institute (Lacaze-Masmonteil), Calgary, Alta
| | - François Goffinet
- Northern Alberta Neonatal Program (Wang), Edmonton, Alta.; Better Outcomes Registry & Network Ontario (Yasseen, Sprague, Walker); Children's Hospital of Eastern Ontario Research Institute (Yasseen, Sprague), Ottawa, Ont.; Obstetrical, Perinatal and Pediatric Epidemiology Team (Marchand-Martin, Goffinet, Ancel), Centre for Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center (U1153), Institut national de la santé et de la recherche médicale; Paris Descartes University (Marchand-Martin, Goffinet, Ancel), Paris, France; ICES (Graves), Toronto, Ont.; Département Hospitalo-Universitaire on Risks in Pregnancy (Goffinet), Assistance Publique - HÔpitaux de Paris, Paris, France; Department of Obstetrics and Gynecology (Walker), University of Ottawa, Ottawa, Ont.; Clinical Research Unit (Ancel), Center for Clinical Investigation P1419, Cochin Broca Hôtel-Dieu Hospital, Paris, France; Department of Pediatrics (Lacaze-Masmonteil), Cumming School of Medicine, University of Calgary; Alberta Children's Hospital Research Institute (Lacaze-Masmonteil), Calgary, Alta
| | - Mark Walker
- Northern Alberta Neonatal Program (Wang), Edmonton, Alta.; Better Outcomes Registry & Network Ontario (Yasseen, Sprague, Walker); Children's Hospital of Eastern Ontario Research Institute (Yasseen, Sprague), Ottawa, Ont.; Obstetrical, Perinatal and Pediatric Epidemiology Team (Marchand-Martin, Goffinet, Ancel), Centre for Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center (U1153), Institut national de la santé et de la recherche médicale; Paris Descartes University (Marchand-Martin, Goffinet, Ancel), Paris, France; ICES (Graves), Toronto, Ont.; Département Hospitalo-Universitaire on Risks in Pregnancy (Goffinet), Assistance Publique - HÔpitaux de Paris, Paris, France; Department of Obstetrics and Gynecology (Walker), University of Ottawa, Ottawa, Ont.; Clinical Research Unit (Ancel), Center for Clinical Investigation P1419, Cochin Broca Hôtel-Dieu Hospital, Paris, France; Department of Pediatrics (Lacaze-Masmonteil), Cumming School of Medicine, University of Calgary; Alberta Children's Hospital Research Institute (Lacaze-Masmonteil), Calgary, Alta
| | - Pierre-Yves Ancel
- Northern Alberta Neonatal Program (Wang), Edmonton, Alta.; Better Outcomes Registry & Network Ontario (Yasseen, Sprague, Walker); Children's Hospital of Eastern Ontario Research Institute (Yasseen, Sprague), Ottawa, Ont.; Obstetrical, Perinatal and Pediatric Epidemiology Team (Marchand-Martin, Goffinet, Ancel), Centre for Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center (U1153), Institut national de la santé et de la recherche médicale; Paris Descartes University (Marchand-Martin, Goffinet, Ancel), Paris, France; ICES (Graves), Toronto, Ont.; Département Hospitalo-Universitaire on Risks in Pregnancy (Goffinet), Assistance Publique - HÔpitaux de Paris, Paris, France; Department of Obstetrics and Gynecology (Walker), University of Ottawa, Ottawa, Ont.; Clinical Research Unit (Ancel), Center for Clinical Investigation P1419, Cochin Broca Hôtel-Dieu Hospital, Paris, France; Department of Pediatrics (Lacaze-Masmonteil), Cumming School of Medicine, University of Calgary; Alberta Children's Hospital Research Institute (Lacaze-Masmonteil), Calgary, Alta
| | - Thierry Lacaze-Masmonteil
- Northern Alberta Neonatal Program (Wang), Edmonton, Alta.; Better Outcomes Registry & Network Ontario (Yasseen, Sprague, Walker); Children's Hospital of Eastern Ontario Research Institute (Yasseen, Sprague), Ottawa, Ont.; Obstetrical, Perinatal and Pediatric Epidemiology Team (Marchand-Martin, Goffinet, Ancel), Centre for Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center (U1153), Institut national de la santé et de la recherche médicale; Paris Descartes University (Marchand-Martin, Goffinet, Ancel), Paris, France; ICES (Graves), Toronto, Ont.; Département Hospitalo-Universitaire on Risks in Pregnancy (Goffinet), Assistance Publique - HÔpitaux de Paris, Paris, France; Department of Obstetrics and Gynecology (Walker), University of Ottawa, Ottawa, Ont.; Clinical Research Unit (Ancel), Center for Clinical Investigation P1419, Cochin Broca Hôtel-Dieu Hospital, Paris, France; Department of Pediatrics (Lacaze-Masmonteil), Cumming School of Medicine, University of Calgary; Alberta Children's Hospital Research Institute (Lacaze-Masmonteil), Calgary, Alta
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13
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Morgan AS, Foix L'Helias L, Diguisto C, Marchand-Martin L, Kaminski M, Khoshnood B, Zeitlin J, Bréart G, Durrmeyer X, Goffinet F, Ancel PY. Intensity of perinatal care, extreme prematurity and sensorimotor outcome at 2 years corrected age: evidence from the EPIPAGE-2 cohort study. BMC Med 2018; 16:227. [PMID: 30514388 PMCID: PMC6280378 DOI: 10.1186/s12916-018-1206-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/01/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Emerging evidence suggests intensity of perinatal care influences survival for extremely preterm babies. We evaluated the effect of differences in perinatal care intensity between centres on sensorimotor morbidity at 2 years of age. We hypothesised that hospitals with a higher intensity of perinatal care would have improved survival without increased disability. METHODS Foetuses alive at maternal admission to a level 3 hospital in France in 2011, subsequently delivered between 22 and 26 weeks gestational age (GA) and included in the EPIPAGE-2 national prospective observational cohort study formed the baseline population. Level of intensity of perinatal care was assigned according to hospital of birth, categorised into three groups using 'perinatal intensity' ratios (ratio of 24-25 weeks GA babies admitted to neonatal intensive care to foetuses of the same GA alive at maternal admission to hospital). Multiple imputation was used to account for missing data; hierarchical logistic regression accounting for births nested within centres was then performed. RESULTS One thousand one hundred twelve foetuses were included; 473 survived to 2 years of age (126 of 358 in low-intensity, 140 of 380 in medium-intensity and 207 of 374 in high-intensity hospitals). There were no differences in disability (adjusted odds ratios 0.93 (95% CI 0.28 to 3.04) and 1.04 (95% CI 0.34 to 3.14) in medium- and high- compared to low-intensity hospitals, respectively). Compared to low-intensity hospitals, survival without sensorimotor disability was increased in the population of foetuses alive at maternal admission to hospital and in live-born babies, but there were no differences when considering only babies admitted to NICU or survivors. CONCLUSIONS No difference in sensorimotor outcome for survivors of extremely preterm birth at 2 years of age was found according to the intensity of perinatal care provision. Active management of periviable births was associated with increased survival without sensorimotor disability.
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Affiliation(s)
- Andrei S Morgan
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France. .,Institute for Womens' Health, UCL, 74 Huntley Street, London, WC1E 6AU, UK. .,SAMU 93 - SMUR Pédiatrique, CHI André Gregoire, Groupe Hospitalier Universitaire Paris Seine-Saint-Denis, Assistance Publique des Hôpitaux de Paris, Montreuil, France.
| | - Laurence Foix L'Helias
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France.,UPMC Université Paris 6, Sorbonne Universités, Paris, France.,Service de Néonatologie, Hôpital Armand Trousseau, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Caroline Diguisto
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France.,Maternité Olympe de Gouges, Centre Hospitalier Regional Universitaire Tours, Tours, France.,Université François Rabelais, Tours, France
| | - Laetitia Marchand-Martin
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France
| | - Monique Kaminski
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France
| | - Babak Khoshnood
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France
| | - Jennifer Zeitlin
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France
| | - Gérard Bréart
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France
| | - Xavier Durrmeyer
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France.,Service de Médecine Néonatale, Centre Hospitalier Intercommunal de Creteil, Clinical Research Center CHI Créteil, Créteil, France
| | - François Goffinet
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France.,Maternité Port-Royal, University Paris-Descartes, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Pierre-Yves Ancel
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France.,URC CIC P1419, DHU Risk in Pregnancy, Cochin Hotel Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France
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14
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[Antenatal management in case of preterm premature rupture of membranes before fetal viability: CNGOF Preterm Premature Rupture of Membranes Guidelines]. ACTA ACUST UNITED AC 2018; 46:1076-1088. [PMID: 30409732 DOI: 10.1016/j.gofs.2018.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To evaluate the maternal, perinatal and long-term prognosis in the event of previable premature rupture of the membranes (PROM) and to specify the interventions likely to reduce the risks and improve the prognosis. METHODS The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS Previable PROM is a rare event whose frequency varies from 0.3 to 1% according to estimates (NP4). When occurring as a complication of amniocentesis, the prognosis is generally better than when spontaneous (NP3). Between 23 and 39% of women will deliver in the week following PROM and nearly 40% of women will not have given birth 2 weeks after (NP3). The frequency of medical termination of pregnancy varies greatly according to the studies (NP4), as does that of fetal death (NP4). Hospital survival and survival rates without major morbidity as a proportion of conservatively treated patients range from 17-55% and 26-63%, respectively (NP4). Neonatal prognosis is largely dominated by prematurity and its complications (NP3). The frequency of maternal sepsis varies from 0.8 to 4.8% in the most recent studies (NP4). Only one case of maternal death is reported, although 3 cases were identified in France between 2007 and 2012 (NP3). Information is a major component of the care to be provided to women and their partners (Professional consensus). An initial period of hospitalization may be proposed after previable PROM (Professional consensus). Thereafter, there is no argument to recommend hospital management rather than extra-hospital management when there is no argument in favour of intrauterine infection (Professional consensus). An evaluation of the amount of amniotic fluid by ultrasound may be proposed at the initial consultation and after a period of 7 to 14 days if pregnancy continues (Professional consensus). Prophylactic antibiotic treatment is recommended as soon as PROM is diagnosed (Professional consensus). The gestational age at which corticosteroid therapy may be proposed will depend on the thresholds selected for neonatal resuscitation care. In particular, it will take into account parental positioning (Professional consensus). From the time of the decision to perform neonatal resuscitation until the gestational age of 32 weeks, it is recommended to administer MgSO4 to the woman whose delivery is imminent (Grade A). Tocolysis is not recommended in this context (Professional consensus). In certain situations, meeting strictly the conditions mentioned by the CSP article L. 2213-1, a maternal request for medical interruption of pregnancy may be discussed. CONCLUSION The levels of evidence of scientific work on the management of previable PROM are low, therefore, most of the recommendations proposed here are based on professional agreement by "reasonable" extension of recommendations valid for later gestational ages.
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Ethical implications of the use of decision aids for antenatal counseling at the limits of gestational viability. Semin Fetal Neonatal Med 2018; 23:25-29. [PMID: 29066179 DOI: 10.1016/j.siny.2017.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Shared decision-making is a recent priority in neonatology. However, its implementation is at an early stage. Decision aids are tools designed to assist in shared decision-making. They help patients competently participate in making healthcare decisions. There are limited studies in neonatology on the formal use of decision aids as used in adult medicine. Decision aids are relatively new, even in adult medicine where they were pioneered; therefore, there is a lack of systematic oversight to their development and use. Despite evidence reporting a powerful effect on patients' decisions, decision aids are not subject to quality control, leading to potentially enormous ethical implications. These include: (i) possible introduction of developers' biases; (ii) use of outdated or incorrect information; (iii) misuse to steer a patient towards less expensive treatments; (iv) clinician liability if negative patient outcomes occur, since decision aids are currently not standard of care.
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16
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Jarreau PH, Allal L, Autret F, Azria E, Anselem O, Boujenah L, Crenn-Hebert C, Desfrere L, Girard G, Goffinet F, Huon C, Kayem G, Lamau MC, Legardeur H, Luton D, Menard S, Patkai J, Rajguru-Kasemi M, Tessier V. Prise en charge de la prématurité extrême. Réflexions du département hospitalo-universitaire (DHU) « risques et grossesse ». Arch Pediatr 2017; 24:1287-1292. [DOI: 10.1016/j.arcped.2017.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 06/22/2017] [Accepted: 09/15/2017] [Indexed: 12/31/2022]
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17
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[Analysis of obstetric-pediatric care in the perinatal period. Are births before 31 weeks' gestation in level 2B maternity units avoidable?]. Arch Pediatr 2017; 24:1188-1196. [PMID: 29153908 DOI: 10.1016/j.arcped.2017.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 07/02/2017] [Accepted: 09/12/2017] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Regionalization of perinatal care has been developed to improve the survival of preterm babies. The mortality rate is higher among very premature infants born outside level-3 maternity units. The objective of this study was to evaluate the preventability of these very premature births occurring outside recommendations within level-2B maternity units. The secondary objective was to describe the care of premature infants between 23 and 24 weeks. METHODS This is a single-center retrospective qualitative study of the care delivery pathways. Thirty-one deliveries in which the fetus was alive between 23 and 30 weeks+6 days occurred in a level-2B maternity unit in Thionville, France, between 1 January 2013 and 31 December 2015. After oral presentation of the cases, a level 2-3 multidisciplinary committee of experts in Lorraine evaluated the preventability criteria and reasons, and divided the deliveries into three groups: (i) birth in level-2B institutions avoidable, (ii) inevitable with factors related to the mother or the organization of care, (iii) with no inevitable factors. RESULTS Out of the 31 deliveries included, the committee classified six deliveries as preventable, 14 as inevitable with factors, and 11 as inevitable with no factors. The criteria for preventability of birth in a level-2B unit were underestimation of maternal and fetal risk, an erroneous initial estimate of term or preterm labor, and two births in the upper limits of the French recommendations for in utero transfer. Nineteen of the 35 premature infants before 31 weeks' gestation died, 16 children were transferred to a level-3 maternity ward, and 16 children were allowed to go home. CONCLUSION Analysis of the obstetrical-pediatric care course by an expert committee determined the preventability of the average birth and prematurity in level-2B maternity units in Lorraine for a small but significant number of cases. The local regionalization of neonatal care could be improved by the application of this method of analysis to other maternity wards in the Lorraine network.
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Prise en charge de la prématurité extrême : vision française de l’expérience suédoise. Arch Pediatr 2017; 24:1123-1128. [DOI: 10.1016/j.arcped.2017.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 06/22/2017] [Accepted: 08/18/2017] [Indexed: 11/18/2022]
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19
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Diguisto C, Goffinet F, Lorthe E, Kayem G, Roze JC, Boileau P, Khoshnood B, Benhammou V, Langer B, Sentilhes L, Subtil D, Azria E, Kaminski M, Ancel PY, Foix-L'Hélias L. Providing active antenatal care depends on the place of birth for extremely preterm births: the EPIPAGE 2 cohort study. Arch Dis Child Fetal Neonatal Ed 2017; 102:F476-F482. [PMID: 28667191 DOI: 10.1136/archdischild-2016-312322] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 04/29/2017] [Accepted: 05/02/2017] [Indexed: 11/03/2022]
Abstract
UNLABELLED Survival rates of infants born before 25 weeks of gestation are low in France and have not improved over the past decade. Active perinatal care increases these infants' likelihood of survival. OBJECTIVE Our aim was to identify factors associated with active antenatal care, which is the first step of proactive perinatal care in extremely preterm births. METHODS The population included 1020 singleton births between 220/6 and 260/6 weeks of gestation enrolled in the Etude Epidémiologique sur les Petits Ages Gestationnels 2 study, a French national population-based cohort of very preterm infants born in 2011. The main outcome was 'active antenatal care' defined as the administration of either corticosteroids or magnesium sulfate or delivery by caesarean section for fetal rescue. A multivariable analysis was performed using a two-level multilevel model taking into account the maternity unit of delivery to estimate the adjusted ORs (aORs) of receiving active antenatal care associated with maternal, obstetric and place of birth characteristics. RESULTS Among the population of extremely preterm births, 42% received active antenatal care. After standardisation for gestational age, regional rates of active antenatal care varied between 22% (95% CI 5% to 38%) and 61% (95% CI 44% to 78%). Despite adjustment for individual and organisational characteristics, active antenatal care varied significantly between maternity units (p=0.03). Rates of active antenatal care increased with gestational age with an aOR of 6.46 (95% CI 3.40 to 12.27) and 10.09 (95% CI 5.26 to 19.36) for infants born at 25 and 26 weeks' gestation compared with those born at 24 weeks. No other individual characteristic was associated with active antenatal care. CONCLUSION Even after standardisation for gestational age, active antenatal care in France for extremely preterm births varies widely with place of birth. The dependence of life and death decisions on place of birth raises serious ethical questions.
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Affiliation(s)
- Caroline Diguisto
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,Maternité Olympe de Gouges, Centre Hospitalier Regional Universitaire Tours, Tours, France.,Université François Rabelais, Tours, France
| | - François Goffinet
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,DHU Risk in Pregnancy, Maternité Port Royal Paris Descartes University Cochin Broca Hotel Dieu Hospitals Assistance publique des hopitaux de Paris, Paris, France
| | - Elsa Lorthe
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,UPMC Univ Paris 06, Sorbonne Universités, Paris, France
| | - Gilles Kayem
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,UPMC Univ Paris 06, Sorbonne Universités, Paris, France.,Service de Gynécologie Obstétrique, Paris, France
| | - Jean-Christophe Roze
- Service de Néonatologie, CIC 004, INSERM, Nantes University Hospital, Nantes, France
| | - Pascal Boileau
- Service de Néonatologie, CHI Poissy St-Germain-en-Laye, University Versailles StQuentin-en-Yvelines, Versailles, France
| | - Babak Khoshnood
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Valérie Benhammou
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Bruno Langer
- Pole de Gynécologie Obstétrique, Hôpital de Hautepierre, Strasbourg, France
| | - Loic Sentilhes
- Department of Obstetrics and Gynecology, University Hospital Bordeaux, Bordeaux, France
| | - Damien Subtil
- Hôpital Jeanne de Flandre, CHRU-University, Lille Nord, France
| | - Elie Azria
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,Maternité Notre Dame de Bon Secours, Groupe Hospitalier Paris Saint Joseph, ParisDescartes University, DHU Risk in Pregnancy, Paris, France
| | - Monique Kaminski
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Pierre-Yves Ancel
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,URC CIC P1419, DHU Risk in Pregnancy, Cochin Hotel Dieu Hopital APHP, Paris, France
| | - Laurence Foix-L'Hélias
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,UPMC Univ Paris 06, Sorbonne Universités, Paris, France.,Service de Néonatologie, Hopital Armand Trousseau, APHP, Paris, France
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Pierrat V, Marchand-Martin L, Arnaud C, Kaminski M, Resche-Rigon M, Lebeaux C, Bodeau-Livinec F, Morgan AS, Goffinet F, Marret S, Ancel PY. Neurodevelopmental outcome at 2 years for preterm children born at 22 to 34 weeks' gestation in France in 2011: EPIPAGE-2 cohort study. BMJ 2017; 358:j3448. [PMID: 28814566 PMCID: PMC5558213 DOI: 10.1136/bmj.j3448] [Citation(s) in RCA: 283] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objectives To describe neurodevelopmental outcomes at 2 years corrected age for children born alive at 22-26, 27-31, and 32-34 weeks' gestation in 2011, and to evaluate changes since 1997.Design Population based cohort studies, EPIPAGE and EPIPAGE-2.Setting France.Participants 5567 neonates born alive in 2011 at 22-34 completed weeks' gestation, with 4199 survivors at 2 years corrected age included in follow-up. Comparison of outcomes reported for 3334 (1997) and 2418 (2011) neonates born alive in the nine regions participating in both studies.Main outcome measures Survival; cerebral palsy (2000 European consensus definition); scores below threshold on the neurodevelopmental Ages and Stages Questionnaire (ASQ; at least one of five domains below threshold) if completed between 22 and 26 months corrected age, in children without cerebral palsy, blindness, or deafness; and survival without severe or moderate neuromotor or sensory disabilities (cerebral palsy with Gross Motor Function Classification System levels 2-5, unilateral or bilateral blindness or deafness). Results are given as percentage of outcome measures with 95% confidence intervals.Results Among 5170 liveborn neonates with parental consent, survival at 2 years corrected age was 51.7% (95% confidence interval 48.6% to 54.7%) at 22-26 weeks' gestation, 93.1% (92.1% to 94.0%) at 27-31 weeks' gestation, and 98.6% (97.8% to 99.2%) at 32-34 weeks' gestation. Only one infant born at 22-23 weeks survived. Data on cerebral palsy were available for 3599 infants (81.0% of the eligible population). The overall rate of cerebral palsy at 24-26, 27-31, and 32-34 weeks' gestation was 6.9% (4.7% to 9.6%), 4.3% (3.5% to 5.2%), and 1.0% (0.5% to 1.9%), respectively. Responses to the ASQ were analysed for 2506 children (56.4% of the eligible population). The proportion of children with an ASQ result below threshold at 24-26, 27-31, and 32-34 weeks' gestation were 50.2% (44.5% to 55.8%), 40.7% (38.3% to 43.2%), and 36.2% (32.4% to 40.1%), respectively. Survival without severe or moderate neuromotor or sensory disabilities among live births increased between 1997 and 2011, from 45.5% (39.2% to 51.8%) to 62.3% (57.1% to 67.5%) at 25-26 weeks' gestation, but no change was observed at 22-24 weeks' gestation. At 32-34 weeks' gestation, there was a non-statistically significant increase in survival without severe or moderate neuromotor or sensory disabilities (P=0.61), but the proportion of survivors with cerebral palsy declined (P=0.01).Conclusions In this large cohort of preterm infants, rates of survival and survival without severe or moderate neuromotor or sensory disabilities have increased during the past two decades, but these children remain at high risk of developmental delay.
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Affiliation(s)
- Véronique Pierrat
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France; Paris Descartes University, Paris, France
- CHU Lille, Department of Neonatal Medicine, Jeanne de Flandre Hospital, F-59000 Lille, France
| | - Laetitia Marchand-Martin
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France; Paris Descartes University, Paris, France
| | - Catherine Arnaud
- INSERM UMR 1027, Université Toulouse III Paul Sabatier, Toulouse, France
| | - Monique Kaminski
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France; Paris Descartes University, Paris, France
| | - Matthieu Resche-Rigon
- Biostatistics and Medical Information Department, AP-HP Saint-Louis Hospital, Paris, France
| | - Cécile Lebeaux
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France; Paris Descartes University, Paris, France
| | - Florence Bodeau-Livinec
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France; Paris Descartes University, Paris, France
- École des Hautes Études en Santé Publique (EHESP), Rennes, France
| | - Andrei S Morgan
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France; Paris Descartes University, Paris, France
| | - François Goffinet
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France; Paris Descartes University, Paris, France
- Maternité Port-Royal, Université Paris Descartes, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique-Hôpitaux de Paris, DHU Risques et Grossesse, Paris, France
| | - Stéphane Marret
- Department of Neonatal Pediatrics, Intensive care, and Neuropediatrics, Rouen University Hospital, Rouen, France
- Research Unit U1245, Institute for Research and Innovation in Biomedicine, Rouen, France
| | - Pierre-Yves Ancel
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France; Paris Descartes University, Paris, France
- Clinical Research Unit, Center for Clinical Investigation P1419, Cochin Broca Hôtel-Dieu Hospital, Paris, France
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Durrmeyer X, Scholer-Lascourrèges C, Boujenah L, Bétrémieux P, Claris O, Garel M, Kaminski M, Foix-L'Helias L, Caeymaex L. Delivery room deaths of extremely preterm babies: an observational study. Arch Dis Child Fetal Neonatal Ed 2017; 102:F98-F103. [PMID: 27531225 DOI: 10.1136/archdischild-2016-310718] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 07/14/2016] [Accepted: 07/25/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Many extremely preterm neonates die in the delivery room (DR) after decisions to withhold or withdraw life-sustaining treatments or after failed resuscitation. Specific palliative care is then recommended but sparse data exist about the actual management of these dying babies. The objective of this study was to describe the clinical course and management of neonates born between 22 and 26 weeks of gestation who died in the DR in France. DESIGN, SETTING, PATIENTS Prospective study including neonates, who were liveborn between 22+0 and 26+6 weeks of gestation and died in the DR in 2011, among infants included in the EPIPAGE-2 study at the 18 centres participating in this substudy of extremely preterm neonates. Data were collected by a questionnaire completed by the professional caring for each baby. RESULTS The study included 73 children, with a median (IQR) gestational age of 24 (23-24) weeks. Median (IQR) duration of life was 53 (20-82) min. All but one were both wrapped and warmed. Pain was assessed for 72%, although without using any scale. Gasping was described for 66%. Comfort medications were administered to 35 children (50%), significantly more frequently to babies with gasping (p=0.001). Mother-child contact was reported for 78%, and psychological support offered to parents of 92%. CONCLUSIONS Non-pharmacological comfort care and parental support were routinely given. Comfort medication was given much more frequently than previously reported in other DRs. These data should encourage work on the indications for comfort medication and the interpretation of gasping.
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Affiliation(s)
- Xavier Durrmeyer
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France.,Service de Médecine Néonatale, Centre Hospitalier Intercommunal de Creteil, Clinical Research Center CHI Créteil, Créteil, France
| | - Claire Scholer-Lascourrèges
- Service de Médecine Néonatale, Centre Hospitalier Intercommunal de Creteil, Clinical Research Center CHI Créteil, Créteil, France
| | - Laurence Boujenah
- Department of Néonatologie, Groupe Hospitalier Paris St Joseph 185 rue Raymond Losserand, Paris, France
| | | | - Olivier Claris
- Department of Neonatology, Hospices Civils de Lyon, Hôpital Femme mère enfants, Bron, France.,Claude Bernard University EAM 41-28, Lyon, France
| | - Micheline Garel
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France
| | - Monique Kaminski
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France
| | - Laurence Foix-L'Helias
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France.,Service de Néonatologie, Hôpital Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Pierre et Marie Curie University, Paris, France
| | - Laurence Caeymaex
- Service de Médecine Néonatale, Centre Hospitalier Intercommunal de Creteil, Clinical Research Center CHI Créteil, Créteil, France.,CEDITEC (Centre d'Etude des discours, images, textes, écrits, communications) Université Paris Est Creteil UPEC, Creteil, France
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Viallard ML, Moriette G. [Palliative care for newborn infants with congenital malformations or genetic abnormalities]. Arch Pediatr 2016; 24:169-174. [PMID: 28007510 DOI: 10.1016/j.arcped.2016.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 09/20/2016] [Accepted: 11/18/2016] [Indexed: 11/26/2022]
Abstract
The choice of palliative care can be made today in the perinatal period, as it can be made in children and adults. Palliative care, rather than curative treatment, may be considered in three clinical situations: babies born at the limits of viability, withholding/withdrawing treatments in the NICU, and babies with severe malformations of genetic abnormalities identified during pregnancy. Only the last situation is addressed hereafter. In newborn infants as in older patients, palliative care aims at taking care of the baby and at providing comfort and well-being. The presence of human beings by the newborn infant, most importantly the parents and family, is of utmost importance. The available time should not be used only for care and medical treatments. Sufficient time should be kept for the parents to interact with the baby and for human presence and warmth. The best interests of the newborn infant are the main element for guiding appropriate care. Before birth, the choice of palliative care for newborn infants requires successive steps: (1) establishing a diagnosis of malformation(s) or genetic abnormalities; (2) making a prognosis and ruling out intensive treatments at birth and thereafter; (3) giving the parents appropriate information; (4) assisting the pregnant woman in deciding to continue pregnancy while excluding intensive treatment of the newborn baby; (5) dialoguing with parents about the expected duration of the baby's life and the related uncertainty; (6) planning of palliative care to be implemented at birth; (7) preparing a plan with the parents for discharging the infant from the hospital and for taking care of him over a long time, when it is deemed possible that the baby may live for more than a few days.
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Affiliation(s)
- M-L Viallard
- EA 4569, unité douleur et médecine palliative périnatale, pédiatrique, adulte, hôpital universitaire Necker-Enfants-Malades, AP-HP, université Paris Descartes, PRES Sorbonne Paris Cité, 75015 Paris, France
| | - G Moriette
- Service de médecine et réanimation néonatales de Port-Royal, université Paris Descartes, 53, avenue de l'Observatoire, 75006 Paris, France.
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23
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Delmas O, Garcia P, Bernard V, Fabre M, Vialet R, Boubred F, Fayol L. Devenir à l’âge de 3ans d’une cohorte d’enfants nés à moins de 26 semaines d’aménorrhée. Arch Pediatr 2016; 23:927-34. [DOI: 10.1016/j.arcped.2016.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 02/25/2016] [Accepted: 06/11/2016] [Indexed: 10/21/2022]
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Sehr kleine Frühgeborene an der Grenze der Lebensfähigkeit. Monatsschr Kinderheilkd 2016. [DOI: 10.1007/s00112-016-0122-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sabiri N, Kabiri M, Razine R, Barkat A. Risk factors leading to preterm births in Morocco: a prospective study at the maternity Souissi in Rabat. Pan Afr Med J 2015; 22:21. [PMID: 26600920 PMCID: PMC4646446 DOI: 10.11604/pamj.2015.22.21.5100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 04/07/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Eminent morbidity and mortality of preterm infants is perceived, especially in developing countries. The aim of the study is to identify the main factors involved in the occurrence of premature births in Morocco. METHODS This was a descriptive and analytical study conducted at the maternity Souissi in Rabat, from January 2011 to December 2011. The data were collected using interview with women in the postpartum, and via, the exploitation of obstetric and perinatal records. The data sheet was filled out for each newborn, including socio-demographic, obstetrical, maternal, childbirth and neonatal data, as well as, monitoring and surveillance of pregnancy. RESULTS A total of 1015 births were collected. 954 were full term babies and 61 were preterms. The gestational age was between 33-34 weeks in 57.4%. Relying on Statistical analysis, many risk factors were, significantly, associated with the occurrence of prematurity, namely: low level of maternal education (p < 0.004), absence of pregnancy' monitoring (p < 0.001), multiparity (p < 0.001), maternal chronic diseases (p < 0.001), and drug taking during pregnancy (p < 0.001). CONCLUSION To reduce the incidence of preterm births, reliable programs must be established, devoting all its interest, to educate the young woman in childbearing age about the appropriate ways of monitoring pregnancy, as well as, the qualitative and quantitative development of health care structures.
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Affiliation(s)
- Nargisse Sabiri
- Service medicine and neonatal resuscitation, Children's Hospital, University Hospital, Rabat, Morocco ; Research Team on Health and Nutrition of Mother and Child, University Mohammed V Souissi, Rabat, Morocco
| | - Meryem Kabiri
- Service medicine and neonatal resuscitation, Children's Hospital, University Hospital, Rabat, Morocco ; Research Center in Clinical Study and Therapeutic Rest, Faculty of Medicine and Pharmacy, Rabat, Morocco
| | - Rachid Razine
- Laboratory for Biostatistics and Clinical and Epidemiological Research, Faculty of Medicine and Pharmacy, Rabat, Morocco
| | - Amina Barkat
- Service medicine and neonatal resuscitation, Children's Hospital, University Hospital, Rabat, Morocco ; Research Team on Health and Nutrition of Mother and Child, University Mohammed V Souissi, Rabat, Morocco ; Research Center in Clinical Study and Therapeutic Rest, Faculty of Medicine and Pharmacy, Rabat, Morocco
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Guillén Ú, Weiss EM, Munson D, Maton P, Jefferies A, Norman M, Naulaers G, Mendes J, Justo da Silva L, Zoban P, Hansen TWR, Hallman M, Delivoria-Papadopoulos M, Hosono S, Albersheim SG, Williams C, Boyle E, Lui K, Darlow B, Kirpalani H. Guidelines for the Management of Extremely Premature Deliveries: A Systematic Review. Pediatrics 2015; 136:343-50. [PMID: 26169424 DOI: 10.1542/peds.2015-0542] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Available data on survival rates and outcomes of extremely low gestational age (GA) infants (22-25 weeks' gestation) display wide variation by country. Whether similar variation is found in statements by national professional bodies is unknown. The objectives were to perform a systematic review of management from scientific and professional organizations for delivery room care of extremely low GA infants. METHODS We searched Embase, PubMed, and Google Scholar for management guidelines on perinatal care. Countries were included if rated by the United Nations Development Programme's Human Development Index as "very highly developed." The primary outcome was rating of recommendations from "comfort care" to "active care." Secondary outcomes were specifying country-specific survival and considering potential for 3 biases: limitations of GA assessment; bias from different definitions of stillbirths and live births; and bias from the use of different denominators to calculate survival. RESULTS Of 47 highly developed countries, 34 guidelines from 23 countries and 4 international groups were identified. Of these, 3 did not state management recommendations. Of the remaining 31 guidelines, 21 (68%) supported comfort care at 22 weeks' gestation, and 20 (65%) supported active care at 25 weeks' gestation. Between 23 and 24 weeks' gestation, much greater variation was seen. Seventeen guidelines cited national survival rates. Few guidelines discussed potential biases: limitations in GA (n = 17); definition bias (n = 3); and denominator bias (n = 7). CONCLUSIONS Although there is a wide variation in recommendations (especially between 23 and 24 weeks' GA), there is general agreement for comfort care at 22 weeks' GA and active care at 25 weeks' GA.
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Affiliation(s)
- Úrsula Guillén
- Division of Neonatology, Christiana Care Health System, Newark, Delaware;
| | - Elliott M Weiss
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David Munson
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Ann Jefferies
- Department of Paediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mikael Norman
- Department of Neonatal Medicine, Karolinska Hospital, Stockholm, Sweden
| | - Gunnar Naulaers
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Petr Zoban
- Department of Neonatology, Charles University, Prague, Czech Republic
| | - Thor W R Hansen
- Women & Children's Division, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Mikko Hallman
- Department of Pediatrics, Oulu University Hospital and University of Oulu, Oulu, Finland
| | | | - Shigeharu Hosono
- Department of Pediatrics, Nihon University School of Medicine, Tokyo, Japan
| | - Susan G Albersheim
- Division of Neonatology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Constance Williams
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Elaine Boyle
- Department of Pediatrics, University of Leicester, Leicester, United Kingdom
| | - Kei Lui
- Department of Newborn Care, University of New South Wales, Sydney, Australia; and
| | - Brian Darlow
- Department of Pediatrics, University of Otago, Christchurch, New Zealand
| | - Haresh Kirpalani
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Einaudi MA, Gire C, Auquier P, Le Coz P. How do physicians perceive quality of life? Ethical questioning in neonatology. BMC Med Ethics 2015. [PMID: 26204881 PMCID: PMC4512037 DOI: 10.1186/s12910-015-0045-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background The outcome of very preterm infants is marked by the development of complications that can have an impact on the quality of life of the children and their families. The concept of quality of life and its evaluation in the long term raise semantic and ethical problems for French physicians in perinatal care. Our reflection aims to gain a better understanding of the representations surrounding quality of life in neonatal medicine. Discussion If French physicians hesitate to face this concept (through self-interest and apprehension), it is because the debate has become more complex. Formerly, the dilemma was between respect for life versus quality of life. Today, although this dilemma is still with us, the questions raised by French physicians show us that autonomy is given increasing importance. The equation to be solved now contains three variables: respect for life, well-being, autonomy. So we find ourselves between three positions and no longer two: respect for life (the ethics of conviction), quality of life based on autonomy (rationalist and secular deontologism), and quality of life based on the differential between well-being and suffering (utilitarianism). Summary A solution could lie in consequentialism, which integrates the consequences for future generations in terms of both safeguarding of autonomy and quality of life, and puts the sacredness of life in second place but without sacrificing it. By evaluating their future quality of life, we can better respond to the needs of these children.
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Affiliation(s)
- Marie-Ange Einaudi
- UMR 7268 ADéS, Aix-Marseille University-EFS-CNRS, Espace Ethique Méditerranéen, Timone University Hospital, 13385, Marseille, France.
| | - Catherine Gire
- Department of Neonatology, North University Hospital, Marseille, France.
| | - Pascal Auquier
- Aix-Marseille University, EA 3279 Self Perceived Health Assessment Research Unit, Marseille, France.
| | - Pierre Le Coz
- UMR 7268 ADéS, Aix-Marseille University-EFS-CNRS, Espace Ethique Méditerranéen, Timone University Hospital, 13385, Marseille, France.
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Branger B, Rouger V, Berlie I, Beucher A, Flamant C, N'guyen The Tich S, Garcia J, Brossier JP, Montcho Y, Hanf M, Roze JC. [Monitoring network for vulnerable children in the Pays de la Loire ("Grandir ensemble" - Cohort LIFT): 10 years of activity 2003-2013]. Arch Pediatr 2014; 22:171-80. [PMID: 25547193 DOI: 10.1016/j.arcped.2014.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 08/14/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Vulnerable children are at-risk newborns including premature infants and some children with pathologies presented by fear anomalies and deficiencies, most particularly neurological. Monitoring is based on the detection of these abnormalities and their early management. The organization of this monitoring system is based on a network of doctors, mostly pediatricians, trained regularly. The objective of this review was to assess the resources, means, and results of 10 years of follow-up. METHODS The Pays de la Loire network includes 24 maternity wards and 13 neonatal departments. Annual admissions are around 5000 newborns to approximately 45,000 annual births. Upon discharge of newborns, born prematurely at 34 weeks of gestation (WG) or less, or term infants with neurological problems, parents are asked to have their child monitored by a referring doctor. During the consultation, a reference document is filled out by the doctor and sent to the project manager for data collection and specific compensation for private practitioners. Standardized questionnaires were used such as the ASQ (Ages and Stage Questionnaire) completed by parents, the developmental quotient (DQ) with the Lézine Brunet-Revised test (BLR), the intelligence quotient (IQ) with the Wechsler Preschool and Primary Scale of Intelligence (WIPPSI III) completed by psychologists employed in the network, and a questionnaire completed by the teacher at 5 years of age. RESULTS The network started on 1st March 2003, and 28th February 2013, after 10 years of inclusion, 10,800 children had been included. This population accounts for 2.4% of all annual births: 1.1% were included for prematurity less than 33 weeks and 0.25% were term-born infants. The characteristics of children are presented with gestational age, birth weight, and obstetric and neonatal pathologies. The percentage of these children followed was 80% at 2 years and 63% at 5 years. At 2 years, the results are presented according to gestational age with approximately 60% of children without disabilities at 25-26 WG, 73% at 27-28 WG, 77% at 29-30 WG, and 86% at 31-32 WG. Absorptions are diverse and vary according to the age of the child with physical therapy, psychomotor skill work, speech therapy, hearing and vision consultations, and psychology/psychiatry. Assessment tools were refined by specific analyses: the ASQ 24 months (completed by parents) was deemed valid and predictive with respect to IQ (abandoned in 2012), and the grid completed by the teacher was found to predict abnormalities in 5 years. CONCLUSION The Pays de la Loire monitoring network has met its initial objective, namely to detect disabilities early and provide practical help to parents in a population of vulnerable children. Benefits for professionals and other children not followed in the network were observed, with an increase in pediatricians' skills. The benefits of the evaluation results are more difficult to assess with the care than neonatal care in obstetrics. The sustainability of such a network seems assured for healthcare professionals, provided that funding is maintained by the health authorities.
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Affiliation(s)
- B Branger
- « Sécurité naissance-naître ensemble » des Pays de la Loire, 2, rue de la Loire, 1, allée Baco, 44200 Nantes, France.
| | - V Rouger
- « Grandir ensemble », CHU, 44093 Nantes, France
| | - I Berlie
- CAMSP, CHU, 49333 Angers, France
| | | | | | | | - J Garcia
- Maternité, centre hospitalier, 44600 Saint-Nazaire, France
| | - J-P Brossier
- Réseau « Sécurité naissance-naître ensemble » des Pays de la Loire, néonatologie, centre hospitalier, 85925 La Roche-sur-Yon, France
| | - Y Montcho
- Centre hospitalier, 72000 Le Mans, France
| | - M Hanf
- Centre d'investigation clinique - épidémiologie clinique, CHU de Nantes, Nantes, France
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Abstract
Controversy surrounding the decision to resuscitate at the limits or borderline of viability has been at the center of neonatal ethical debate for decades. This debate has led to numerous reports from individual institutions, councils, and advisory committees that all have remarkable consistency in the development of gestational age-based guidelines. This article reviews legal or regulatory concerns that may contradict ethical discussion and guidelines, discriminatory and scientific basis concerns with consensus guidelines, and personal controversy about how to determine best interest. Guidelines are a reasonable place to start in helping determine parental authority and autonomy. The article also addresses controversies raised in counseling and costs.
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Houfflin-Debarge V, Azria E. Place de l’interruption médicale de grossesse et des soins palliatifs en cas de retard de croissance intra-utérin vasculaire. ACTA ACUST UNITED AC 2013; 42:966-74. [DOI: 10.1016/j.jgyn.2013.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Solís Sánchez G, Pérez González C, García López E, Costa Romero M, Arias Llorente RP, Suárez Rodríguez M, Fernández Colomer B, Coto Cotallo GD. [Peri-viability: limits of prematurity in a regional hospital in the last 10 years]. An Pediatr (Barc) 2013; 80:159-64. [PMID: 23849833 DOI: 10.1016/j.anpedi.2013.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 04/05/2013] [Accepted: 05/19/2013] [Indexed: 11/27/2022] Open
Abstract
AIM To determine the preterm viability between 22 and 25 gestational weeks in our hospital in last 10 years. PATIENTS AND METHODS A descriptive retrospective study was conducted on preterms between 22-25 gestational weeks born between 1-1-2002 and 12-31-2011. RESULTS There were 121 newborns, 45 (37%) stillbirths and 76 (63%) live births (16 died in delivery room, and 60 admitted to neonatal intensive unit). Among the 60 admitted, 34 died before hospital discharge, and 26 survived (21% of total, 34% of live births and 43% of those admitted to neonatal intensive unit). The causes of death were: 16 therapeutic effort limitation in delivery room, 8 therapeutic effort limitation in neonatal ward, 7 nosocomial sepsis, 7 NEC, 4 respiratory problems, and 8 of unknown cause. There were no survivors below 24 gestational weeks. Of the 26 survivors, 4 had major neurological disorders, and 11 with a normal neurological outcome. No significant statistical differences were found in the mortality between the two five-year periods analysed. CONCLUSIONS The peri-viability has important clinical and ethical problems for neonatologist.
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Affiliation(s)
- G Solís Sánchez
- Servicio de Neonatología, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, SESPA, Oviedo, España.
| | - C Pérez González
- Servicio de Neonatología, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, SESPA, Oviedo, España
| | - E García López
- Servicio de Neonatología, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, SESPA, Oviedo, España
| | - M Costa Romero
- Servicio de Neonatología, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, SESPA, Oviedo, España
| | - R P Arias Llorente
- Servicio de Neonatología, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, SESPA, Oviedo, España
| | - M Suárez Rodríguez
- Servicio de Neonatología, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, SESPA, Oviedo, España
| | - B Fernández Colomer
- Servicio de Neonatología, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, SESPA, Oviedo, España
| | - G D Coto Cotallo
- Servicio de Neonatología, Área de Gestión Clínica de Pediatría, Hospital Universitario Central de Asturias, SESPA, Oviedo, España
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Tosello B, Le Coz P, Payot A, Gire C, Einaudi MA. [Palliative care birth plan: a field of perinatal medicine to build]. ACTA ACUST UNITED AC 2013; 41:251-4. [PMID: 23578964 DOI: 10.1016/j.gyobfe.2013.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 02/21/2013] [Indexed: 12/27/2022]
Abstract
Some couples may choose to continue the pregnancy unable to decide for termination of pregnancy. Such situations recently occurred in neonatology units and may lead to neonatal palliative care. Faced with all uncertainties inherent to medicine and the future of the baby, medical teams must inform parents of different possible outcome step by step. Consistency in the reflection and intentionality of the care is essential among all different stakeholders within the same health team to facilitate support of parents up to a possible fatal outcome. This issue in perinatal medicine seems to be to explore how caregivers can contribute in the construction of parenthood in a context of a palliative care birth plan.
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Affiliation(s)
- B Tosello
- Espace éthique Méditerranéen, UMR7268 (anthropologie bio-culturelle, droit, éthique et santé), université Aix-Marseille, hôpital de La Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France.
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Aujard Y. [Ethics practices in mother-and-children's hospitals]. Arch Pediatr 2012; 20:119-22. [PMID: 23266167 DOI: 10.1016/j.arcped.2012.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 11/14/2012] [Indexed: 11/17/2022]
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Cremer R, Fayoux P, Guimber D, Joriot S, Laffargue A, Lervat C, Matthews A, Mention K, Sfeir R, Storme L, Thomas D, Thumerelle C, Vandoolaeghe S. Le médecin consultant pour les limitations et les arrêts de traitement en pédiatrie. Arch Pediatr 2012; 19:856-62. [DOI: 10.1016/j.arcped.2012.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 03/19/2012] [Accepted: 05/16/2012] [Indexed: 10/26/2022]
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Cabaret AS, Charlot F, Le Bouar G, Poulain P, Bétrémieux P. [Very preterm births (22-26 WG): from the decision to the implement of palliative care in the delivery room. Experience of Rennes University Hospital (France)]. ACTA ACUST UNITED AC 2012; 41:460-7. [PMID: 22727563 DOI: 10.1016/j.jgyn.2012.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 03/30/2012] [Accepted: 04/10/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVES After the establishment of a palliative care protocol (PC) in the delivery room, study how the postnatal management decision was taken and in particular how PC was developed. MATERIAL AND METHODS Retrospective analysis of births between 22 and 25+6 WG, in Rennes University Hospital, during 21 months. RESULTS Twenty-seven women meeting the criteria gave birth to 32 live children. Decision making (intensive care or PC) was fast but shared with the parents, mainly on the criterion of the term. The delivery was vaginal for 24 children. Thirteen children were resuscitated. Nineteen children received comfort care, their life was less than 3 hours, 18/19 were supported by their parents. CONCLUSION The management of these births is consistent with current recommendations, decisions are individualized but often informally. The secondary prognostic criteria could be better taken into account. Obstetrical and pediatric management is consistent. The PC protocol is fairly well used but the collective decisions should be more formally organized and transcribed more accurately in the records, the requirements for analgesics should be based on clinical assessments.
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Affiliation(s)
- A-S Cabaret
- Service d'obstétrique, hôpital Sud, CHU, BP 90347, 16 boulevard de Bulgarie, Rennes cedex 2, France.
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Avancées et déconvenues de la médecine néonatale en France. Arch Pediatr 2012; 19:345-50. [DOI: 10.1016/j.arcped.2012.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 01/21/2012] [Indexed: 11/18/2022]
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Guimarães H, Rocha G, Bellieni C, Buonocore G. Rights of the newborn and end-of-life decisions. J Matern Fetal Neonatal Med 2012; 25 Suppl 1:76-8. [PMID: 22372731 DOI: 10.3109/14767058.2012.665240] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Advances in perinatal medicine have dramatically improved neonatal survival. End-of-life decision making for newborns with adverse prognosis is an ethical challenge and the ethical issues are controversial. The newborn is a person with specific rights which he cannot claim, due to his physical and mental immaturity. These rights impose to the society obligations and responsibilities, which health professionals and institutions of all countries must enforce. Every newborn has the right to life with dignity. Providing compassionate family-centered end-of-life care to infants and their families in the NICU should be a mandatory component of an optimally neonatal palliative care.
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Affiliation(s)
- Hercília Guimarães
- Faculty of Medicine, São João Hospital, Porto University, Porto, Portugal.
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Nadroo AM. Ethical dilemmas in decision making at limits of neonatal viability. THE JOURNAL OF IMA 2011; 43:188-92. [PMID: 23610507 PMCID: PMC3516104 DOI: 10.5915/43-3-8972] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The survival rate for extremely preterm infants has improved over the last two decades. Although the incidence of such births is about 2%, the impact of preterm birth on these infants, their families, health-care providers, and society is profound. The birth of an extremely low birth weight (ELBW) and early gestational age infant poses complex medical, social, and ethical challenges to the family and health-care professionals. Survivors have an increased risk of chronic medical problems and disability. It is difficult to make decisions while trying to provide optimal medical care to the infant and supporting the family when delivery occurs at the threshold of viability because outcome at that time is highly unpredictable. Such decisions may have lifelong consequences for those involved. An individualized prognostic strategy appears to be the most appropriate approach. While keeping the patient’s best interest as the primary objective, the goal is to reach, through a process of effective communication between the parents and physicians, a consensual decision that respects the parents’ wishes and promotes physician beneficence.
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Affiliation(s)
- Ali M Nadroo
- Assistant Professor of Clinical Pediatrics, Weill Medical College of Cornell University New York, Associate Director of Neonatal Intensive Care Unit, Associate Program director Pediatrics, New York Methodist Hospital, New York, New York
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39
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Guimarães H, Rocha G, Almeda F, Brites M, Van Goudoever JB, Iacoponi F, Bellieni C, Buonocore G. Ethics in neonatology: a look over Europe. J Matern Fetal Neonatal Med 2011; 25:984-91. [PMID: 21740325 DOI: 10.3109/14767058.2011.602442] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED Advances in perinatal medicine have dramatically improved neonatal survival. End-of-life decision making for newborns with adverse prognosis is an ethical challenge, the ethical issues are controversial and little evidence exists on attitudes and values in Europe. OBJECTIVE to assess the attitudes of the neonatal departments in perinatal clinical practice in the hospitals of European countries. METHODS a questionnaire was send to 55 NICUs from 19 European countries. RESULTS Forty five (81.8%) NICUs were Level III. Religion was Christian in 90.7% and we observed that in north countries the religion is more influent on clinical decisions (p = 0.032). Gestational age was considered with no significant difference for clinical investment. North countries consider birth weight (p = 0.011) and birth weight plus gestational age (p = 0.024) important for clinical investment. In north countries ethical questions should not prevail when the decision is made (p = 0.049) and from an ethical point of view, there is no difference between withdraw a treatment and do not initiate the treatment (p = 0.029). More hospitals in south countries administer any analgesia (p = 0.007). When the resuscitation is not successful 96.2% provide comfort care. CONCLUSION Our study reveals that cultural and religious differences influenced ethical attitudes in NICUs of the European countries.
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40
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Pierre M, Plu I, Hervé C, Bétrémieux P. [Palliative care in delivery room for preterm infants less than 24 weeks of gestation. Analysis of two different behaviors]. Arch Pediatr 2011; 18:1044-54. [PMID: 21396801 DOI: 10.1016/j.arcped.2011.01.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 12/06/2010] [Accepted: 01/29/2011] [Indexed: 11/30/2022]
Abstract
AIMS OF THE STUDY To describe the management of extremely preterm newborns at the threshold of viability before 24 weeks of gestation in the delivery room when the decision has been made not to provide intensive care; to assess the role of palliative care (PC); to report the problems encountered. METHOD A prospective qualitative study was conducted using semi-structured interviews from November 2009 to June 2010 in two level III French maternity hospitals (A and B). In each center, four midwives, two obstetricians, two pediatricians, two anesthetists, and one chief midwife were interviewed. RESULTS In maternity hospital A, a protocol was in place that proposed PC derived from developmental care (noise limitation, drying, warming) provided by parents or staff. The problems reported were related to former euthanasia practices rather than new procedures. In maternity hospital B, no palliative care protocol had been set up. Euthanasia was practiced and accepted fatalistically because the only currently existing alternative (letting the infant die) was considered inhumane. Few problems were reported. The reluctance to carry out PC is conceptual and organizational (the ratio of births per midwife in maternity hospital B was twice that of maternity hospital A). Lexical analysis showed preferential use of the words "fetus" and "expulsion" versus "child" and "delivery" in maternity hospital B (p<0.05) when speaking of the delivery of the extremely preterm infant. Our explanatory hypothesis is that the concept of "fetus ex utero" legitimates euthanasia by assimilating it to feticide. CONCLUSION At the time of this study, two very different approaches to the death of extremely preterm, non-resuscitated newborns in the delivery room coexisted in France. Palliative care is obviously possible, after group reflection, if a true motivation to change, a better understanding of the law, and a clear identification of the respective status of the fetus and the newborn exist in the maternity hospital.
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Affiliation(s)
- M Pierre
- Service de réanimation néonatale, hôpital Sud, CHU de Rennes, 16, boulevard de Bulgarie, BP 90 347, 35203 Rennes cedex 2, France
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Dageville C, Bétrémieux P, Gold F, Simeoni U. The French Society of Neonatology's proposals for neonatal end-of-life decision-making. Neonatology 2011; 100:206-14. [PMID: 21471705 DOI: 10.1159/000324119] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 01/01/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Opinions and practice regarding end-of-life decisions in neonatal medicine show considerable variations between countries. A recent change of the legal framework, together with an ongoing debate among French neonatologists, led the French Society of Neonatology to reconsider and update its previous recommendations. OBJECTIVES To propose a set of recommendations on the ethical principles to be respected in the making and application of end-of-life decisions. METHODS A multidisciplinary working group on ethical issues in perinatal medicine composed of neonatologists, obstetricians and ethicists. RESULTS Withholding or withdrawing life-sustaining treatment may be acceptable, and unreasonable therapeutic obstinacy is condemned. This implies that the child's best interests must always be the central consideration. Although the parents must be involved in the decision process so that they form an alliance with the healthcare team, and a collegial approach is of utmost importance, any crucial decision affecting the patient's life calls for individual medical responsibility. Because every newborn is rightfully an integral member of a human family, his or her dignity must be preserved. The goal of palliative care is to preserve the quality of a life, also at its end. The intention underlying an act has to be analyzed perceptively. Euthanasia, i.e. to perform an act with the deliberate intention to cause or hasten a patient's death, is legally and morally forbidden. Conversely, to withhold or withdraw a life-sustaining treatment can be justified when the intention is to cease opposing, in an unreasonable manner, the natural course of a disease. CONCLUSIONS This statement provides the principles identified by French neonatologists on which to base their decisions concerning the ending of life. Arguments are set forth, discussed and compared with international statements and previously published considerations.
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Affiliation(s)
- C Dageville
- Neonatal Intensive Care Unit, Division of Pediatrics, University Hospital, Nice, France
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