Post-ligation cardiac syndrome after surgical versus transcatheter closure of patent ductus arteriosus in low body weight premature infants: a multicenter retrospective cohort study

Transcatheter patent ductus arteriosus (PDA) closure is a safe and effective alternative to surgical ligation in low-body-weight infants. Post-ligation cardiac syndrome (PLCS) is defined as severe hemodynamic and respiratory collapse within 24 h of PDA closure, requiring initiation or an increase of an inotropic agent by > 20% of preligation dosing and an absolute increase of at least 20% in ventilation parameters compared with the preoperative value. Whilst PLCS is routinely observed after surgery, its incidence remains poorly described following transcatheter closure. This study aimed to compare the incidence of PLCS after surgical versus transcatheter closure of PDA in low-body-weight premature infants. Propensity scores were used to compare surgical (N = 78) and transcatheter (N = 76) groups of preterm infants who underwent PDA closure at a procedural weight less than 2000 g in two tertiary institutions between 2009 and 2021. The primary outcome was the incidence of PLCS. Secondary outcomes included overall mortality before discharge, risk factors for PLCS, and post-procedural complications. Procedural success was 100% in both groups. After matching, transcatheter group experienced no PLCS vs 15% in the surgical group (p = 0.012). Furthermore, overall mortality (2% vs 17%; p = 0.03) and major complications (2% vs 23%; p = 0.002) were higher in the surgical group. Surgery (100% vs 47%; p < 0.01), gestation age (25 ± 1 vs 26 ± 2 weeks, p < 0.05) and inotropic support before closure (90% vs 29%; p < 0.001) were associated with PLCS occurrence.          Conclusion: Transcatheter PDA closure may be equally effective but safer than surgical PDA closure in low-body-weight premature infants. What is Known: • Post-ligation cardiac syndrome is a serious and common complication of surgical closure of the ductus arteriosus in preterm infants. • Transcatheter closure of preterm ductus arteriosus is a safe and effective technique that is becoming more and more common worldwide. What is New: • Device closure is safer than surgical ligation for patent ductus arteriosus closure in preterm infants and may be the first-line non-pharmacological therapeutic option in this indication in experienced teams. • Our findings should encourage neonatologists and pediatric cardiologists to start and/or strengthen a durable interventional program for transcatheter PDA closure in premature infants.

Usefulness of routine early œsophagogram after primary repair of œsophageal atresia: a multicenter study

BACKGROUND

Advances in surgical and neonatal care have led to improved survival of patients with œsophageal atresia (OA) over time. Morbidity remains significant, with one-third of patients being affected by a postoperative complication. Several aspects of management are not consensual, such as the use of œsophagogram before starting oral feeding.

METHODS

We conducted a multicenter retrospective study, including all children with OA that underwent a primary anastomosis in the first days of life, between 2012 and 2018 in five French centers, to determine the usefulness of postoperative œsophagogram during the 10 days after early primary repair of OA to diagnose the anastomotic leak and congenital œsophageal stenosis.

RESULTS

Among 225 included children, 90 (40%) had a routine œsophagogram and 25 (11%) had an anastomotic leak, clinically diagnosed before the scheduled œsophagogram in 24/25 (96%) children at median postoperative day 4. Ten patients had associated congenital œsophageal stenosis diagnosed on the œsophagogram in only 30% of cases.

CONCLUSION

Early œsophagogram is rarely useful in the diagnosis of an anastomotic leak, which is clinically diagnosed before performing an œsophagogram in the majority of cases. The need for a postoperative œsophagogram should be evaluated on a case-by-case basis.

IMPACT

Early œsophagogram is not helpful in the diagnosis of an anastomotic leak in the majority of cases. An anastomotic leak is most often diagnosed clinically before performing an œsophagogram. Early postoperative œsophagogram could be helpful for the diagnosis of congenital œsophageal stenosis. However, dysphagia occurs later and early diagnosis of congenital œsophageal stenosis has no impact on the management and outcome of asymptomatic children. Indication of postoperative œsophagogram has to be evaluated on a case-by-case basis.

Long-term surveillance of group B Streptococcus strains isolated from infection and colonization in pregnant women and newborns

Introduction. Group B Streptococcus (GBS) remains the leading cause of bacterial neonatal infections worldwide, despite the spread of recommendations on vaginal screening and antibiotic prophylaxis.Hypothesis/Gap Statement. There is a need to evaluate the potential changes in GBS epidemiology over time following the introduction of such guidelines.Aim. Our aim was to perform a descriptive analysis of the epidemiological characteristics of GBS by conducting a long-term surveillance of strains isolated between 2000 and 2018, using molecular typing methods.Methodology. A total of 121 invasive strains, responsible for maternal infections (20 strains), fetal infections (8 strains) and neonatal infections (93 strains), were included in the study, representing all the invasive isolates during the period; in addition, 384 colonization strains isolated from vaginal or newborn samples were randomly selected. The 505 strains were characterized by capsular polysaccharide (CPS) type multiplex PCR assay and the clonal complex (CC) was assigned using a single nucleotide polymorphism PCR assay. Antibiotic susceptibility was also determined.Results. CPS types III (32.1 % of the strains), Ia (24.6 %) and V (19 %) were the most prevalent. The five main CCs observed were CC1 (26.3 % of the strains), CC17 (22.2 %), CC19 (16.2 %), CC23 (15.8 %) and CC10 (13.9 %). Neonatal invasive GBS diseases were predominantly due to CC17 isolates (46.3 % of the strains), which mainly express CPS type III (87.5 %), with a very high prevalence in late-onset diseases (76.2 %).Conclusion. Between 2000 and 2018, we observed a decrease in the proportion of CC1 strains, which mainly express CPS type V, and an increase in the proportion of CC23 strains, mainly expressing CPS type Ia. Conversely, there was no significant change in the proportion of strains resistant to macrolides, lincosamides or tetracyclines. The two molecular techniques used in our study provide almost as much information as classical serotyping and multilocus sequence typing, but are quicker, easy to perform, and avoid long sequencing and analysis steps.

Risk-Benefit Balance Associated With Obstetric, Neonatal, and Child Outcomes After Metabolic and Bariatric Surgery

Importance

Metabolic and bariatric surgery (MBS) is the most efficient therapeutic option for severe obesity. Most patients who undergo MBS are women of childbearing age. Data in the scientific literature are generally of a low quality due to a lack of well-controlled prospective trials regarding obstetric, neonatal, and child outcomes.

Objective

To assess the risk-benefit balance associated with MBS around obstetric, neonatal, and child outcomes.

Design, Setting, and Participants

The study included 53 813 women on the French nationwide database who underwent an MBS procedure and delivered a child between January 2012 and December 2018. Each women was their own control by comparing pregnancies before and after MBS.

Exposures

The women included were exposed to either gastric bypass or sleeve gastrectomy.

Main Outcomes and Measures

The study team first compared prematurity and birth weights in neonates born before and after maternal MBS with each other. Then they compared the frequencies of all pregnancy and child diagnoses in the first 2 years of life before and after maternal MBS with each other.

Results

A total of 53 813 women (median [IQR] age at surgery, 30 [26-35] years) were included, among 3686 women who had 1 pregnancy both before and after MBS. The study team found a significant increase in the small-for-gestational-age neonate rate after MBS (+4.4%) and a significant decrease in the large-for-gestational-age neonate rate (-12.6%). The study team highlighted that compared with pre-MBS births, after MBS births had fewer occurrences of gestational hypertension (odds ratio [OR], 0.16; 95% CI, 0.10-0.23) and gestational diabetes for the mother (OR, 0.39; 95% CI, 0.34-0.45), as well as fewer birth injuries to the skeleton (OR, 0.27; 95% CI, 0.11-0.60), febrile convulsions (OR, 0.39; 95% CI, 0.21-0.67), viral intestinal infections (OR, 0.56; 95% CI, 0.43-0.71), or carbohydrate metabolism disorders in newborns (OR, 0.54; 95% CI 0.46-0.63), but an elevated respiratory failure rate (OR, 2.42; 95% CI, 1.76-3.36) associated with bronchiolitis.

Conclusions and Relevance

The risk-benefit balance associated with MBS is highly favorable for pregnancies and newborns but may cause an increased risk of respiratory failure associated with bronchiolitis. Further studies are needed to better assess the middle- and long-term benefits and risks associated with MBS.

How Do the Different Types of Maternal Diabetes during Pregnancy Influence Offspring Outcomes?

Background/Aim of the study: Exposure to maternal diabetes is considered one of the most common in utero insults that can result in an increased risk of complications later in life with a permanent effect on offspring health. In this study, we aim to assess the level of risk associated with each type of maternal diabetes on obesity, glucose intolerance, cardiovascular diseases (CVD), and neurodevelopmental disorders in offspring. Methods: We conducted a systematic review of the literature utilizing PubMed for studies published between January 2007 and March 2022. Our search included human cohorts and case control studies following offspring exposed at least to two different types of maternal diabetes clearly identified during pregnancy. Collected outcomes included prevalence, incidence, odds ratio, hazard ratio and risk ratio. Results: Among 3579 published studies, 19 cohorts were eligible for inclusion in our review. The risks for overweight, obesity, type 2 diabetes (T2D), glucose intolerance, metabolic syndrome, and CVD were increased for all types of maternal diabetes during pregnancy. The risk of overweight or obesity in infancy and in young adults was similar between gestational diabetes mellitus (GDM) and type 1 diabetes (T1D). The risk for T2D or abnormal glucose tolerance was double for offspring from GDM mothers compared to offspring from T1D mothers. In contrast, the risk for T1D in offspring at any age until young adulthood was increased when mothers had T1D compared to GDM and T2D. The risk for CVD was similar for all types of maternal diabetes, but more significant results were seen in the occurrence of heart failure and hypertension among offspring from T2D mothers. The risk of autism spectrum disorders and attention deficit/hyperactivity disorders was mainly increased after in utero exposure to preexisting T1D, followed by T2D. Conclusions: Offspring of diabetic mothers are at increased risk for multiple adverse outcomes with the highest risk detected among offspring from T2D mothers. Future work warrants large multiethnic prospective cohort studies that aim to identify the risks associated with each type of maternal diabetes separately.

Feeding disorders in children with oesophageal atresia: a cross-sectional study

INTRODUCTION

With advances in surgical and neonatal care, the survival of patients with oesophageal atresia (OA) has improved over time. Whereas a number of OA-related conditions (delayed primary anastomosis, anastomotic stricture and oesophageal dysmotility) may have an impact on feeding development and although children with OA experience several oral aversive events, paediatric feeding disorders (PFD) remain poorly described in this population. The primary aim of our study was to describe PFD in children born with OA, using a standardised scale. The secondary aim was to determine conditions associated with PFD.

METHODS

The Feeding Disorders in Children with Oesophageal Atresia Study is a national cohort study based on the OA registry from the French National Network. Parents of children born with OA between 2013 and 2016 in one of the 22 participating centres were asked to complete the French version of the Montreal Children's Hospital Feeding Scale.

RESULTS

Of the 248 eligible children, 145 children, with a median age of 2.3 years (Q1-Q3 1.8-2.9, min-max 1.1-4.0 years), were included. Sixty-one children (42%) developed PFD; 13% were tube-fed (n=19). Almost 40% of children with PFD failed to thrive (n=23). The presence of chronic respiratory symptoms was associated with the development of PFD. Ten children with PFD (16%) had no other condition or OA-related complication.

CONCLUSION

PFD are common in children with OA, and there is no typical profile of patients at risk of PFD. Therefore, all children with OA require a systematic screening for PFD that could improve the care and outcomes of patients, especially in terms of growth.

Low Maternal DLK1 Levels at 26 Weeks Is Associated With Small for Gestational Age at Birth

Detecting SGA (small for gestational age) during pregnancy improves the fetal and neonatal prognosis. To date, there is no valid antenatal biomarker of SGA used in clinical practice. Maternal circulating DLK1 (delta-like non-canonical notch ligand 1) levels have been shown to be significantly lower in pregnant women at 36 weeks of gestation (WG) who delivered a SGA newborn than in controls. Data in the literature are contradictory on the association between maternal circulating DLK1 levels and placental vascular dysfunction. The objective was to determine if maternal DLK1 levels in the second trimester of pregnancy are predictive of SGA, and to assess whether the measurement of DLK1 levels in maternal blood could be a means to distinguish SGA with placental vascular dysfunction from that due to other causes. We conducted a nested cased-control study within the EDEN mother-child cohort. 193 SGA (birth weight < 10^th percentile) and 370 mother-child control (birth weight between the 25^th and 75^th percentile) matched pairs were identified in the EDEN cohort. Maternal circulating DLK1 levels at 26 WG were significantly lower for children born SGA than for controls (27.7 ± 8.7 ng/mL vs 30.4 ± 10.6 ng/mL, p = 0.001). Maternal blood DLK1 levels in the first quartile (DLK1 < 22.85 ng/mL) were associated with an odds ratio for SGA of 1.98 [1.15 - 3.37]. DLK1 was less predictive of SGA than ultrasound, with an area under the curve of 0.578. Maternal circulating DLK1 levels were not significantly different in cases of SGA with signs of placental vascular dysfunction (n = 63, 27.1 ± 9.2 ng/mL) than in those without placental dysfunction (n = 129, 28.0 ± 8.5 ng/mL, p = 0.53). The level of circulating DLK1 is reduced in the second trimester of pregnancy in cases of SGA at birth, independently of signs of placental vascular dysfunction. However, DLK1 alone cannot predict the risk of SGA.

Association Between Early Amino Acid Intake and Full-Scale IQ at Age 5 Years Among Infants Born at Less Than 30 Weeks' Gestation

IMPORTANCE

An international expert committee recently revised its recommendations on amino acid intake for very preterm infants, suggesting that more than 3.50 g/kg/d should be administered only to preterm infants in clinical trials. However, the optimal amino acid intake during the first week after birth in these infants is unknown.

OBJECTIVE

To evaluate the association between early amino acid intake and cognitive outcomes at age 5 years.

DESIGN, SETTING, AND PARTICIPANTS

Using the EPIPAGE-2 (Epidemiologic Study on Small-for-Gestational-Age Children-Follow-up at Five and a Half Years) cohort, a nationwide prospective population-based cohort study conducted at 63 neonatal intensive care units in France, a propensity score-matched analysis was performed comparing infants born at less than 30 weeks' gestation who had high amino acid intake (3.51-4.50 g/kg/d) at 7 days after birth with infants who did not. Participants were recruited between April 1 and December 31, 2011, and followed up from September 1, 2016, to December 31, 2017. Full-scale IQ (FSIQ) was assessed at age 5 years. A confirmatory analysis used neonatal intensive care unit preference for high early amino acid intake as an instrumental variable to account for unmeasured confounding. Statistical analysis was performed from January 15 to May 15, 2021.

EXPOSURES

Amino acid intake at 7 days after birth.

MAIN OUTCOMES AND MEASURES

The primary outcome was an FSIQ score greater than -1 SD (ie, ≥93 points) at age 5 years. A complementary analysis was performed to explore the association between amino acid intake at day 7 as a continuous variable and FSIQ score at age 5 years. Data from cerebral magnetic resonance imaging at term were available for a subgroup of preterm infants who participated in the EPIRMEX (Cerebral Abnormalities Detected by MRI, Realized at the Age of Term and the Emergence of Executive Functions) ancillary study.

RESULTS

Among 1789 preterm infants (929 boys [51.9%]; mean [SD] gestational age, 27.17 [1.50] weeks) with data available to determine exposure to amino acid intake of 3.51 to 4.50 g/kg/d at 7 days after birth, 938 infants were exposed, and 851 infants were not; 717 infants from each group could be paired. The primary outcome was known in 396 of 646 exposed infants and 379 of 644 nonexposed infants who were alive at age 5 years and was observed more frequently among exposed vs nonexposed infants (243 infants [61.4%] vs 206 infants [54.4%], respectively; odds ratio [OR], 1.33 [95% CI, 1.00-1.71]; absolute risk increase in events [ie, the likelihood of having an FSIQ score >-1 SD at age 5 years] per 100 infants, 7.01 [95% CI, 0.06-13.87]; P = .048). In the matched cohort, correlation was found between amino acid intake per 1.00 g/kg/d at day 7 and FSIQ score at age 5 years (n = 775; β = 2.43 per 1-point increase in FSIQ; 95% CI, 0.27-4.59; P = .03), white matter area (n = 134; β = 144 per mm2; 95% CI, 3-285 per mm2; P = .045), anisotropy of the corpus callosum (n = 50; β = 0.018; 95% CI, 0.016-0.021; P < .001), left superior longitudinal fasciculus (n = 42; β = 0.018; 95% CI, 0.010-0.025; P < .001), and right superior longitudinal fasciculus (n = 42; β = 0.014 [95% CI, 0.005-0.024; P = .003) based on magnetic resonance imaging at term. Confirmatory and sensitivity analyses confirmed these results. For example, the adjusted OR for the association between the exposure and the primary outcome was 1.30 (95% CI, 1.16-1.46) using the instrumental variable approach among 978 participants in the overall cohort, and the adjusted OR was 1.35 (95% CI, 1.05-1.75) using multiple imputations among 1290 participants in the matched cohort.

CONCLUSIONS AND RELEVANCE

In this cohort study, high amino acid intake at 7 days after birth was associated with an increased likelihood of an FSIQ score greater than -1 SD at age 5 years. Well-designed randomized studies with long-term follow-up are needed to confirm the benefit of this nutritional approach.

Screening of patients born small for gestational age with the Silver-Russell syndrome phenotype for DLK1 variants

Silver-Russell syndrome (SRS) is a rare imprinting disorder associated with prenatal and postnatal growth retardation. Loss of methylation (LOM) on chromosome 11p15 is observed in 40 to 60% of patients and maternal uniparental disomy (mUPD) for chromosome 7 (upd(7)mat) in ~5 to 10%. Patients with LOM or mUPD 14q32 can present clinically as SRS. Delta like non-canonical Notch ligand 1 (DLK1) is one of the imprinted genes expressed from chromosome 14q32. Dlk1-null mice display fetal growth restriction (FGR) but no genetic defects of DLK1 have been described in human patients born small for gestational age (SGA). We screened a cohort of SGA patients with a SRS phenotype for DLK1 variants using a next-generation sequencing (NGS) approach to search for new molecular defects responsible for SRS. Patients born SGA with a clinical suspicion of SRS and normal methylation by molecular testing at the 11p15 or 14q32 loci and upd(7)mat were screened for DLK1 variants using targeted NGS. Among 132 patients, only two rare variants of DLK1 were identified (NM_003836.6:c.103 G > C (p.(Gly35Arg) and NM_003836.6: c.194 A > G p.(His65Arg)). Both variants were inherited from the mother of the patients, which does not favor a role in pathogenicity, as the mono-allelic expression of DLK1 is from the paternal-inherited allele. We did not identify any pathogenic variants in DLK1 in a large cohort of SGA patients with a SRS phenotype. DLK1 variants are not a common cause of SGA.

How can we improve perinatal care in isolated multiple intestinal atresia? A retrospective study with a 30-year literature review

INTRODUCTION

Multiple intestinal atresia (MIA) is a rare cause of neonatal intestinal obstruction. To provide an overview of the current prenatal, surgical, and nutritional management of MIA, we report our experience and a literature review of papers published after 1990.

METHODS

All cases of isolated MIA (non-hereditary, not associated with apple-peel syndrome or gastroschisis) treated at our institution between 2005 and 2016 were reviewed and compared with cases found in the literature.

RESULTS

Seven patients were prenatally suspected of having intestinal obstruction and were postnatally diagnosed with MIA, with a mean 1.7 (1-2) resections-anastomoses (RA) and 6 (1-10) strictureplasties performed, resulting in a mean resected bowel length of 15.1cm (15-25 cm). Median time to full oral feed was 46 days (14-626 days). All patients were alive and none had orality disorder after a mean follow-up of 3.1 years (0.2-8.1 years). Three surgical strategies were found in the literature review: multiple RA (68%, 34/50) including Santulli's technique in four of 34 (12%) and anastomoses over a transanastomotic tube (32%, 16/50), with a 98% survival rate, and short-bowel syndrome for only two patients.

CONCLUSION

Bowel-sparing surgery and appropriate medical management are key to ensuring a favorable nutritional and gastrointestinal outcome and a good prognosis. Prenatal assessment and standardization of the surgical course of treatment remain challenging.

Relative Contribution of Gestational Weight Gain, Gestational Diabetes, and Maternal Obesity to Neonatal Fat Mass

Maternal nutritional and metabolic status influence fetal growth. This study investigated the contribution of gestational weight gain (GWG), gestational diabetes (GDM), and maternal obesity to birthweight and newborn body fat. It is a secondary analysis of a prospective study including 204 women with a pregestational body mass index (BMI) of 18.5-24.9 kg/m² and 219 women with BMI ≥ 30 kg/m². GDM was screened in the second and third trimester and was treated by dietary intervention, and insulin if required. Maternal obesity had the greatest effect on skinfolds (+1.4 mm) and cord leptin (+3.5 ng/mL), but no effect on birthweight. GWG was associated with increased birthweight and skinfolds thickness, independently from GDM and maternal obesity. There was an interaction between third trimester weight gain and GDM on birthweight and cord leptin, but not with maternal obesity. On average, +1 kg in third trimester was associated with +13 g in birthweight and with +0.64 ng/mL in cord leptin, and a further 32 g and 0.89 ng/mL increase in diabetic mothers, respectively. Maternal obesity is the main contributor to neonatal body fat. There is an independent association between third trimester weight gain, birthweight, and neonatal body fat, enhanced by GDM despite intensive treatment.

How Can Maternal Lifestyle Interventions Modify the Effects of Gestational Diabetes in the Neonate and the Offspring? A Systematic Review of Meta-Analyses

Gestational diabetes (GDM) has deleterious effects on the offspring. Maternal obesity and excessive gestational weight gain (GWG), often associated with diabetes, also contribute to these adverse outcomes.

OBJECTIVES

To assess the benefit for the offspring of maternal lifestyle interventions, including diets and physical activity, to prevent or to improve GDM and to limit excessive GWG.

METHOD

Systematic review of meta-analyses published in English between December 2014 and November 2019.

RESULTS

Lifestyle interventions to reduce the risk of GDM reported a decreased risk of 15% to 40%, with a greater effect of exercise compared to diet. Combined lifestyle interventions specifically designed to limit GWG reduced GWG by 1.6 kg in overweight and obese women, and on average by 0.7 to 1 kg in all pregnant women. In these trials, adverse neonatal outcomes were poorly studied. Combined lifestyle interventions in women with GDM significantly reduced fetal growth. Altogether, lifestyle interventions reduced the risk of preterm birth and shoulder dystocia, but individually, diets or exercise alone had no effect on neonatal adverse outcomes.

CONCLUSION

Specific maternal, neonatal and offspring benefits of lifestyle interventions during pregnancy to prevent or improve GDM control or to limit GWG still require clarification.

Characteristics of prescription in 29 Level 3 Neonatal Wards over a 2-year period (2017-2018). An inventory for future research

Objectives

The primary objective of this study is to determine the current level of patient medication exposure in Level 3 Neonatal Wards (L3NW). The secondary objective is to evaluate in the first month of life the rate of medication prescription not cited in the Summary of Product Characteristics (SmPC). A database containing all the medication prescriptions is collected as part of a prescription benchmarking program in the L3NW.

Material and methods

The research is a two-year observational cohort study (2017–2018) with retrospective analysis of medications prescribed in 29 French L3NW. Seventeen L3NW are present since the beginning of the study and 12 have been progressively included. All neonatal units used the same computerized system of prescription, and all prescription data were completely de-identified within each hospital before being stored in a common data warehouse.

Results

The study population includes 27,382 newborns. Two hundred and sixty-one different medications (International Nonproprietary Names, INN) were prescribed. Twelve INN (including paracetamol) were prescribed for at least 10% of patients, 55 for less than 10% but at least 1% and 194 to less than 1%. The lowest gestational ages (GA) were exposed to the greatest number of medications (18.0 below 28 weeks of gestation (WG) to 4.1 above 36 WG) (p<0.0001). In addition, 69.2% of the 351 different combinations of an medication INN and a route of administration have no indication for the first month of life according to the French SmPC. Ninety-five percent of premature infants with GA less than 32 weeks received at least one medication not cited in SmPC.

Conclusion

Neonates remain therapeutic orphans. The consequences of polypharmacy in L3NW should be quickly assessed, especially in the most immature infants.

A randomised controlled trial of amnioexchange for fetal gastroschisis

OBJECTIVE

Morbidity in fetuses affected by gastroschisis is mainly the result of bowel ischaemic and inflammatory processes. Experimental studies on animal models show that clearing amniotic fluid from the digestive secretions by amnioexchange procedures reduces the inflammatory process. We evaluated the benefit of the amnioexchange procedure for fetal gastroschisis in humans.

DESIGN

Prospective, interventional, randomised study.

SETTING

Eight referral centres for fetal medicine.

POPULATION

Pregnant women carrying a fetus with gastroschisis.

METHODS

We compared, in utero, amnioexchange with a sham procedure. The protocol included, in both arms, steroid injections at 30 weeks of gestation and the use of postnatal minimal enteral feeding.

MAIN OUTCOME MEASURES

The primary outcome was a composite variable based on the duration of ventilation and parenteral nutrition. Secondary outcomes were the effectiveness and safety of the amnioexchange procedure, including the rate of perinatal death, time to full enteral feeding, primary closure, and late feeding disorders.

RESULTS

Sixty-four patients were randomised. There was no difference in the composite criteria between the amnioexchange and control groups. Based on an intention-to-treat analysis, there were no significant between-group differences in pregnancy outcome or complications. When studying the relationship between digestive compounds and amniotic fluid inflammatory markers, a clear correlation was found between bile acid and both ferritin and interleukin 1β (IL1β).

CONCLUSIONS

In humans, amnioexchange, as described in our protocol, is not an option for fetal care; however, we provide supplementary proof of the involvement of inflammation in the pathogenicity of gastroschisis and suggest that future research should aim at reducing inflammation. ClinicalTrials.gov: NCT00127946.

TWEETABLE ABSTRACT

A prospective, interventional, randomised study shows no benefit of amnioexchange for fetal gastroschisis in humans.

Nutrition of Preterm Infants and Raw Breast Milk-Acquired Cytomegalovirus Infection: French National Audit of Clinical Practices and Diagnostic Approach

Raw breast milk is the optimal nutrition for infants, but it is also the primary cause of acquired cytomegalovirus (CMV) infection. Thus, many countries have chosen to contraindicate to feed raw breast milk preterm infants from CMV-positive mothers before a corrected age of 32 weeks or under a weight of 1500 g. French national recommendations have not been updated since 2005. An audit of the French practices regarding the nutrition with raw breast milk in preterm infants was carried out using a questionnaire sent to all neonatal care units. Diagnosed postnatal milk-acquired CMV infections have been analysed using hospitalisation reports. Seventy-five percent of the neonatal units responded: 24% complied with the French recommendations, 20% contraindicated raw breast milk to all infants before 32 weeks regardless of the mothers' CMV-status, whereas 25% fed all preterm infants unconditionally with raw breast milk. Thirty-five cases of infants with milk-acquired CMV infections have been reported. The diagnosis was undeniable for five patients. In France, a high heterogeneity marks medical practices concerning the use of raw breast milk and the diagnostic approach for breast milk-acquired CMV infection is often incomplete. In this context, updated national recommendations and monitored CMV infections are urgently needed.

Diagnosis and management of postnatal fetal growth restriction

Fetal growth restriction (FGR) can result from multiple causes, such as genetic, epigenetic, environment, hormonal regulation, or vascular troubles and their potential interaction. The physiopathology of FGR is not yet fully elucidated, but the insulin-like growth factor system is known to play a central role. Specific clinical features can lead to the identification of genetic syndromes in some patients. FGR leads to multiple global health concerns, from the perinatal period, with higher morbidity/mortality, through infancy, with neurodevelopmental, growth, and metabolic issues, to the onset of puberty and later in life, with subfertility and elevated risks of cardiovascular and kidney diseases. Adequate follow-up and therapeutics should be offered to these patients. We first review the main molecular etiologies leading to FGR and their specificities. We then highlight the main issues that FGR can raise later in life before concluding with the proposed management of these children.

Review shows that maternal obesity induces serious adverse neonatal effects and is associated with childhood obesity in their offspring

AIM

Obesity at the start of pregnancy has been rising worldwide, increasing the risk of maternal complications. We reviewed the independent effects of maternal obesity during pregnancy on neonatal adverse outcomes and the risk of childhood obesity and adverse cardio-metabolic profiles.

METHODS

We searched MEDLINE for papers published in English between December 2007 and November 2017, focusing primarily on human studies published in the last five years. However, we also chose to highlight examples derived from model animals that could bring mechanistic insight and preventive and therapeutic avenues.

RESULTS

Our review showed that maternal obesity had independent effects on neonatal adverse outcomes such as macrosomia, perinatal mortality and birth defects. Maternal obesity alone increased the risks for adverse neonatal outcomes, including macrosomia, perinatal mortality, induced preterm birth and birth defects. In association with excess gestational weight gain, mainly early in pregnancy, increased the risks of childhood obesity, higher fat mass and, to a smaller extent, adverse cardio-metabolic profiles. Animal models highlighted sexually dimorphic responses to maternal obesity.

CONCLUSION

Maternal obesity induced serious adverse neonatal effects and was associated with childhood obesity in their offspring. The peri-conceptional period is critical for metabolic programming, and obese women need close monitoring from conception.

Efficacy of facilitated tucking combined with non-nutritive sucking on very preterm infants' pain during the heel-stick procedure: A randomized controlled trial

BACKGROUND

Reducing acute pain in premature infants during neonatal care improves their neurophysiological development. The use of pharmacological and non-pharmacological analgesia, such as sucrose, is limited per day, particularly for very preterm infants. Thus, the usual practice of non-nutritive sucking is often used alone. Facilitated tucking could be an additional strategy to non-nutritive sucking for reducing pain. To the best of our knowledge, no randomized trial has compared the combination of facilitated tucking and non-nutritive sucking to non-nutritive sucking alone.

OBJECTIVES

To compare the efficacy of facilitated tucking in combination with non-nutritive sucking (intervention group) to non-nutritive sucking alone (control group) in reducing pain during the heel-stick procedure in very preterm infants.

DESIGN

Prospective, randomized controlled trial.

SETTINGS

Level III and II neonatal care units, including the neurosensory care management program.

METHODS

Very preterm infants (gestational age between 28 and 32 weeks) were randomly assigned by a computer programme to the intervention or control group during a heel-stick procedure within the first 48 h of life. In both groups, infants were placed in an asymmetric position on a cushion; noise and light were limited following routine care. A heel-stick was performed first in the care sequence. In the intervention group, facilitated tucking was performed by a nurse or nursing assistant. The procedure was video recorded from 15 s (T-15 s) before the procedure until three minutes (T + 3 min) after the end of the procedure. Pain was blindly assessed by two independent specialist nurses. The primary outcome was the pain score evaluated 15 s before the procedure and 30 s immediately after by the premature infant pain profile (PIPP) scale. The secondary outcome was the pain score evaluated between T-15 s and T + 3 min by the DAN scale (a French acronym for the acute pain of a newborn).

RESULTS

Sixty infants were included (30 in each group). The PIPP pain scores did not differ between the intervention group (median: 8.0; interquartile range (IQR): 6.0-12.0) and the control group (median: 9.5; IQR: 7.0-13.0, p = 0.32). Pain assessed by the DAN scale at T + 3 min was lower in the intervention group than in the control group (median: 0.3; IQR: 0.0-1.0 and 2.0; IQR: 0.5-3.0, respectively, p = 0.001).

CONCLUSIONS

The combined use of facilitated tucking and non-nutritive sucking did not significantly alleviate pain during the heel-stick procedure. However, the addition of facilitated tucking facilitated faster pain recovery following the heel-stick procedure.

Effect of Glyburide vs Subcutaneous Insulin on Perinatal Complications Among Women With Gestational Diabetes: A Randomized Clinical Trial

IMPORTANCE

Randomized trials have not focused on neonatal complications of glyburide for women with gestational diabetes.

OBJECTIVE

To compare oral glyburide vs subcutaneous insulin in prevention of perinatal complications in newborns of women with gestational diabetes.

DESIGN, SETTINGS, AND PARTICIPANTS

The Insulin Daonil trial (INDAO), a multicenter noninferiority randomized trial conducted between May 2012 and November 2016 (end of participant follow-up) in 13 tertiary care university hospitals in France including 914 women with singleton pregnancies and gestational diabetes diagnosed between 24 and 34 weeks of gestation.

INTERVENTIONS

Women who required pharmacologic treatment after 10 days of dietary intervention were randomly assigned to receive glyburide (n=460) or insulin (n=454). The starting dosage for glyburide was 2.5 mg orally once per day and could be increased if necessary 4 days later by 2.5 mg and thereafter by 5 mg every 4 days in 2 morning and evening doses, up to a maximum of 20 mg/d. The starting dosage for insulin was 4 IU to 20 IU given subcutaneously 1 to 4 times per day as necessary and increased according to self-measured blood glucose concentrations.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite criterion including macrosomia, neonatal hypoglycemia, and hyperbilirubinemia. The noninferiority margin was set at 7% based on a 1-sided 97.5% confidence interval.

RESULTS

Among the 914 patients who were randomized (mean age, 32.8 [SD, 5.2] years), 98% completed the trial. In a per-protocol analysis, 367 and 442 women and their neonates were analyzed in the glyburide and insulin groups, respectively. The frequency of the primary outcome was 27.6% in the glyburide group and 23.4% in the insulin group, a difference of 4.2% (1-sided 97.5% CI, -∞ to 10.5%; P=.19).

CONCLUSION AND RELEVANCE

This study of women with gestational diabetes failed to show that use of glyburide compared with subcutaneous insulin does not result in a greater frequency of perinatal complications. These findings do not justify the use of glyburide as a first-line treatment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01731431.

Severity of Retrognathia and Glossoptosis Does Not Predict Respiratory and Feeding Disorders in Pierre Robin Sequence

Pierre Robin sequence (PRS) may lead to life-threatening respiratory and feeding disorders. With the aim to analyse the association of the severities of retrognathia and glossoptosis with those of respiratory and feeding disorders, we retrospectively studied a series of 50 infants with retrognathia, glossoptosis, cleft palate, and airway obstruction. The patients were managed from birth to at least 6 years of age by a single pediatric team at the Armand Trousseau Hospital in Paris within a 12 years period (2000-2012). Retrognathia and glossoptosis were graded in the neonatal period according to a specific clinical examination. Ventilation assistance was required for 32/50 (64%) patients, and enteral feeding for 41/50 (82%). The grades of retrognathia and glossoptosis and the severity of respiratory disorders did not differ between patients with isolated PRS and syndromic PRS. Severe respiratory disorders were more common and long-lasting feeding (>12 months) was more frequently required in patients with syndromic PRS compared with isolated PRS (42 vs. 13%, p = 0.04 and 42 vs. 4%, p < 0.01 respectively). Using univariate analysis, neurological impairments and laryngomalacia were associated with severe respiratory disorders [Odds ratio (OR) 5.0, 95% CI 1.3-19.6; and OR 14.6, 95% CI 1.3-161.4; p < 0.05] as well as with long-lasting feeding (>12 months) disorders (OR 18.6, 95% CI 3.9-89.2 and OR 20.4, 95% CI 3,4-122.8; p < 10^-2). Syndromic SPR status was also associated with severe respiratory disorders (OR 4.9, 95% CI 1-32.5; p < 0.05). Using multivariate analysis, only syndromic PRS status was predictive for severe respiratory disorders (adjusted OR 8, 95% CI 1.47-44.57; p < 0.05); and only neurological impairments remained a significant risk for long lasting feeding disorders (>12 months) (adjusted OR 21.72, 95% CI 3.4-138.63; p < 10^-2). The grades of retrognathia and glossoptosis were not predictive factors for the severity of respiratory and feeding disorders. Conclusion: In children with PRS, the severity of clinical conditions may not correlate with anatomic variables but rather with laryngeal abnormalities, neurological impairement and syndromic PRS status.

[G6PD deficiency in females with neonatal revelation. Report of four cases]

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common human erythrocyte enzyme defect, estimated to affect approximately 4 million people worldwide. It is associated with severe neonatal hyperbilirubinemia, which may lead to bilirubin encephalopathy and kernicterus, and with hemolytic crisis. G6PD deficiency is an X-linked enzymopathy affecting hemizygous males, homozygous females, and also a subset of heterozygous females via chromosome X inactivation. We report four cases of female newborns with neonatal hyperbilirubinemia related to a G6PD deficiency and followed by the Centre national de référence en hémobiologie périnatale (CNRHP) from November 2013 to July 2014. Clinical and biological characteristics suggested G6PD deficiency (jaundice observed within the first 24h, severe hyperbilirubinemia, associated with regenerative hemolytic anemia, low response to phototherapy, ethnic origin of the parents from high-incident geographical regions). The family investigations revealed a deficit in G6PD in one of the parents who was unaware of this deficit until then. This article aims to make neonatologists and pediatricians aware of the need to search for an etiology for any severe hyperbilirubinemia and to raise G6PD deficiency in male and female newborns in case of hyperbilirubinemia with hemolysis.

Effect of maternal obesity on birthweight and neonatal fat mass: A prospective clinical trial

OBJECTIVE

To discriminate the effect of maternal obesity and gestational diabetes on birth weight and adipose tissue of the newborn.

METHODS

Normal BMI women (group N, n = 243; 18.5≤ BMI<25 kg/m2) and obese women (group Ob, n = 253; BMI≥30 kg/m2) were recruited in a prospective study between 15 and 18 weeks of gestation. All women were submitted to a 75g oral glucose tolerance test in the second and third trimester. First trimester fasting blood glucose was also obtained from Ob women. All women with one measurement above normal values were considered positive for gestational diabetes and first treated by dietary intervention. When dietary measures were not efficient, they were treated by insulin. Neonatal anthropometrics, sum of skinfolds and cord serum hormones were measured.

RESULTS

222 N and 226 Ob mothers and their newborns were included in the analysis. Diabetes was diagnosed in 20% and 45.2% of N and Ob women, respectively. Birth weight was not statistically different between groups (boys: 3456g±433 and 3392g±463; girls: 3316g±402 and 3391g±408 for N and Ob, respectively). Multivariate analysis demonstrated that skinfold thickness and serum leptin concentrations were significantly increased in girls born to women with obesity (18.0mm±0.6 versus 19.7mm±0.5, p = 0.004 and 11.3ng/mL±1.0 versus 15.3ng/mL±1.0, p = 0.02), but not in boys (18.4mm±0.6 versus 18.5mm±0.5, p = 0.9 and 9.3ng/mL±1.0 versus 9.0ng/mL±1.0, p = 0.9). Based on data from 136 N and 124 Ob women, maternal insulin resistance at 37 weeks was also positively related to skinfold in girls, only, with a 1-point increase in HOMA-IR corresponding to a 0.33mm±0.08 increase in skinfold (p<0.0001).

CONCLUSIONS

Regardless of gestational diabetes, maternal obesity and insulin resistance were associated with increased adiposity in girls only. Persistence of this sexual dimorphism remains to be explored during infancy.

Antenatal antipsychotic exposure induces multigenerational and gender-specific programming of adiposity and glucose tolerance in adult mouse offspring

Second-generation antipsychotics (SGAs) are well known for their metabolic side effects in humans, including obesity and diabetes. These compounds are maintained during pregnancy to prevent the relapse of psychoses, but they readily diffuse across the placenta to the fetus, as documented with the widely-prescribed drug olanzapine (OLZ). However, observational studies have provided conflicting results on the potential impact of SGAs on fetal growth and body weight, and their effects on metabolic regulation in the offspring. For this reason, our study has tested whether antenatal exposure of CD1 mice to OLZ influenced metabolic outcomes in the offspring of the first (F1) and second (F2) generations. In F1 mice, OLZ antenatal treatment caused a decrease in neonatal body weight in both genders, an effect that persisted throughout life only in male animals. Interestingly, F1 female mice also displayed altered glucose homoeostasis. F2 mice, generated by mating normal males with F1 female mice exposed to OLZ during antenatal life, exhibited higher neonatal body weights which persisted only in F2 female animals. This was associated with expansion of fat mass and a concordant pattern of adipose tissue gene expression. Moreover, male and female F2 mice were glucose-intolerant. Thus, our study has demonstrated that antenatal OLZ exposure induces multigenerational and gender-specific programming of glucose tolerance in the offspring mice as adults, and points to the need for careful monitoring of children exposed to SGAs during pregnancy.

Eight principles for patient-centred and family-centred care for newborns in the neonatal intensive care unit

Despite the recent improvements in perinatal medical care leading to an increase in survival rates, adverse neurodevelopmental outcomes occur more frequently in preterm and/or high-risk infants. Medical risk factors for neurodevelopmental delays like male gender or intrauterine growth restriction and family sociocultural characteristics have been identified. Significant data have provided evidence of the detrimental impact of overhelming environmental sensory inputs, such as pain and stress, on the developing human brain and strategies aimed at preventing this impact. These strategies, such as free parental access or sleep protection, could be considered 'principles of care'. Implementation of these principles do not require additional research due to the body of evidence. We review the scientific evidence for these principles here.

Study of the Factors Leading to Fetal and Neonatal Dysthyroidism in Children of Patients With Graves Disease

CONTEXT

Neonatal hyperthyroidism was first described in 1912 and in 1964 was shown to be linked to transplacental passage of maternal antibodies. Few multicenter studies have described the perinatal factors leading to fetal and neonatal dysthyroidism.

OBJECTIVE

To show how fetal dysthyroidism (FD) and neonatal dysthyroidism (ND) can be predicted from perinatal variables, in particular, the levels of anti-thyrotropin receptor antibodies (TRAbs) circulating in the mother and child.

DESIGN AND PATIENTS

This was a retrospective multicenter study of data from the medical records of all patients monitored for pregnancy from 2007 to 2014.

SETTING

Among 280,000 births, the medical records of 2288 women with thyroid dysfunction were selected and screened, and 417 women with Graves disease and positive for TRAbs during pregnancy were included.

RESULTS

Using the maternal TRAb levels, the cutoff value of 2.5 IU/L best predicted for FD, with a sensitivity of 100% and specificity of 64%. Using the newborn TRAb levels, the cutoff value of 6.8 IU/L best predicted for ND, with a sensitivity of 100% and a specificity of 94%. In our study, 65% of women with a history of Graves disease did not receive antithyroid drugs during pregnancy but still had infants at risk of ND.

CONCLUSIONS

In pregnant women with TRAb levels ≥2.5 IU/L, fetal ultrasound monitoring is essential until delivery. All newborns with TRAb levels ≥6.8 IU/L should be examined by a pediatrician with special attention for thyroid dysfunction and treated, if necessary.

Gestational diabetes and adverse perinatal outcomes from 716,152 births in France in 2012

AIMS/HYPOTHESIS

The aim of this study was to assess the risk of adverse perinatal outcomes in gestational diabetes mellitus (GDM) in a large national cohort.

METHODS

All deliveries taking place after 22 weeks in France in 2012 were included by extracting data from the hospital discharge database and the national health insurance system. The diabetic status of mothers was determined by the use of glucose-lowering agents and by hospital diagnosis. Outcomes were analysed according to the type of diabetes and, in the GDM group, whether or not diabetes was insulin-treated.

RESULTS

The cohort of 796,346 deliveries involved 57,629 (7.24%) mothers with GDM. Mother-infant linkage was obtained for 705,198 deliveries. The risks of adverse outcomes were much lower with GDM than with pregestational diabetes. After limiting the analysis to deliveries after 28 weeks to reduce immortal time bias, the risks of preterm birth (OR 1.3 [95% CI 1.3, 1.4]), Caesarean section (OR 1.4 [95% CI 1.4, 1.4]), pre-eclampsia/eclampsia (OR 1.7 [95% CI 1.6, 1.7]), macrosomia (OR 1.8 [95% CI 1.7, 1.8]), respiratory distress (OR 1.1 [95% CI 1.0, 1.3]), birth trauma (OR 1.3 [95% CI 1.1, 1.5]) and cardiac malformations (OR 1.3 [95% CI 1.1, 1.4]) were increased in women with GDM compared with the non-diabetic population. Higher risks were observed in women with insulin-treated GDM than those with diet-treated GDM. After limiting the analysis to term deliveries, an increased risk of perinatal mortality was observed. After excluding women suspected to have undiagnosed pregestational diabetes, the risk remained moderately increased only for those with diet-treated GDM (OR 1.3 [95% CI 1.0, 1.6]).

CONCLUSIONS/INTERPRETATION

GDM is associated with a moderately increased risk of adverse perinatal outcomes, which is higher in insulin-treated GDM than in non-insulin-treated GDM for most outcomes.

Prognostic value of cerebral tissue oxygen saturation during neonatal extracorporeal membrane oxygenation

Objectives

Extracorporeal membrane oxygenation support is indicated in severe and refractory respiratory or circulatory failures. Neurological complications are typically represented by acute ischemic or hemorrhagic lesions, which induce higher morbidity and mortality. The primary goal of this study was to assess the prognostic value of cerebral tissue oxygen saturation (StcO₂) on mortality in neonates and young infants treated with ECMO. A secondary objective was to evaluate the association between StcO₂ and the occurrence of cerebral lesions.

Study design

This was a prospective study in infants < 3 months of age admitted to a pediatric intensive care unit and requiring ECMO support.

Measurements

The assessment of cerebral perfusion was made by continuous StcO₂ monitoring using near-infrared spectroscopy (NIRS) sensors placed on the two temporo-parietal regions. Neurological lesions were identified by MRI or transfontanellar echography.

Results

Thirty-four infants <3 months of age were included in the study over a period of 18 months. The ECMO duration was 10±7 days. The survival rate was 50% (17/34 patients), and the proportion of brain injuries was 20% (7/34 patients). The mean StcO₂ during ECMO in the non-survivors was reduced in both hemispheres (p = 0.0008 right, p = 0.03 left) compared to the survivors. StcO₂ was also reduced in deceased or brain-injured patients compared to the survivors without brain injury (p = 0.002).

Conclusion

StcO₂ appears to be a strong prognostic factor of survival and of the presence of cerebral lesions in young infants during ECMO.

Effect of Intra- and Extrauterine Growth on Long-Term Neurologic Outcomes of Very Preterm Infants

OBJECTIVE

To determine whether extrauterine growth is associated with neurologic outcomes and if this association varies by prenatal growth profile.

STUDY DESIGN

For 1493 preterms from the EPIPAGE (Étude Épidémiologique sur les Petits Âges Gestationnels [Epidemiological Study on Small Gestational Ages]) cohort, appropriate for gestational-age (AGA) was defined by birth weight >-2 SD and small for gestational-age (SGA) by birth weight ≤-2 SD. Extra-uterine growth was defined by weight gain or loss between birth and 6 months by z-score change. Growth following-the-curve (FTC) was defined as weight change -1 to +1 SD, catch-down-growth (CD) as weight loss ≥1 SD, and catch-up-growth (CU) as weight gain ≥1 SD. At 5 years, a complete medical examination (n = 1305) and cognitive evaluation with the Kauffman Assessment Battery for Children (n = 1130) were performed. Behavioral difficulties at 5 years and school performance at 8 years were assessed (n = 1095).

RESULTS

Overall, 42.5% of preterms were AGA-FTC, 20.2% AGA-CD, 17.1% AGA-CU, 5.6% SGA-FTC, and 14.5% SGA-CU. Outcomes did not differ between CU and FTC preterm AGA infants. Risk of cerebral palsy was greater for AGA-CD compared with AGA-FTC (aOR 2.26 [95% CI 1.37-3.72]). As compared with children with SGA-CU, SGA-FTC children showed no significant increased risk of cognitive deficiency (aOR 1.41[0.94-2.12]) or school difficulties (aOR 1.60 [0.84-3.03]). Compared with AGA-FTC, SGA showed increased risk of cognitive deficiency (SGA-FTC aOR 2.19 [1.25-3.84]) and inattention-hyperactivity (SGA-CU aOR 1.65 [1.05-2.60]).

CONCLUSION

Deficient postnatal growth was associated with poor neurologic outcome for AGA and SGA preterm infants. CU growth does not add additional benefits. Regardless of type of postnatal growth, SGA infants showed behavioral problems and cognitive deficiency.

Differentiating Transient Idiopathic Hyperglycaemia and Neonatal Diabetes Mellitus in Preterm Infants

BACKGROUND/AIMS

Transient idiopathic hyperglycaemia (TIH) is partly due to defective processing of proinsulin to insulin in preterm neonates, whereas transient neonatal diabetes mellitus (TNDM) is a rare genetic form of pancreatic β-cell dysfunction. Distinguishing these two conditions is difficult yet essential to allow personalised management and genetic testing. Here we investigated whether metabolic or therapeutic features contributed to the diagnosis in preterm neonates.

METHODS

We prospectively included 13 preterm neonates with TIH between 2008 and 2011, and we identified 2 patients with TNDM in the French neonatal diabetes cohort registry. All of them were born before 32 weeks of gestation. We compared clinical features, glycaemic profiles, insulin dosages, and nutritional intakes.

RESULTS

TNDM patients had higher day-1 glycaemia levels before insulin therapy [median 23.5 (20-27) vs. 13.6 (10.7-19.8) mmol/l, p = 0.025] and higher insulin requirements [median 1.2 (0.9-1.5) vs. 0.8 (0.3-0.9) IU/kg/day, p = 0.037] compared to TIH. They also required insulin therapy earlier [median 0.75 (0.5-1) vs. 2 (0.5-7) days, p = 0.036] and for a longer time [median 85 (57-113) vs. 11 (4-15) days, p = 0.036].

CONCLUSION

TNDM and TIH are different clinical and genetic entities with specific pathophysiological mechanisms. Metabolic and therapeutic features may help to detect TNDM in preterm neonates as soon as day-1 of hyperglycaemia.

[Oxidative stress after preterm birth: origins, biomarkers, and possible therapeutic approaches]

The survival of preterm babies has increased over the last few decades. However, disorders associated with preterm birth, known as oxygen radical diseases of neonatology, such as retinopathy, bronchopulmonary dysplasia, periventricular leukomalacia, and necrotizing enterocolitis are severe complications related to oxidative stress, which can be defined by an imbalance between oxidative reactive species production and antioxidant defenses. Oxidative stress causes lipid, protein, and DNA damage. Preterm infants have decreased antioxidant defenses in response to oxidative challenges, because the physiologic increase of antioxidant capacity occurs at the end of gestation in preparation for the transition to extrauterine life. Therefore, preterm infants are more sensitive to neonatal oxidative stress, notably when supplemental oxygen is being delivered. Furthermore, despite recent advances in the management of neonatal respiratory distress syndrome, controversies persist concerning the oxygenation saturation targets that should be used in caring for preterm babies. Identification of adequate biomarkers of oxidative stress in preterm infants such as 8-iso-prostaglandin F2α, and adduction of malondialdehyde to hemoglobin is important to promote specific therapeutic approaches. At present, no therapeutic strategy has been validated as prevention or treatment against oxidative stress. Breastfeeding should be considered as the main measure to improve the antioxidant status of preterm infants. In the last few years, melatonin has emerged as a protective molecule against oxidative stress, with antioxidant and free-radical scavenger roles, in experimental and preliminary human studies, giving hope that it can be used in preterm infants in the near future.

What neonatal complications should the pediatrician be aware of in case of maternal gestational diabetes?

In the epidemiologic context of maternal obesity and type 2 diabetes (T2D), the incidence of gestational diabetes has significantly increased in the last decades. Infants of diabetic mothers are prone to various neonatal adverse outcomes, including metabolic and hematologic disorders, respiratory distress, cardiac disorders and neurologic impairment due to perinatal asphyxia and birth traumas, among others. Macrosomia is the most constant consequence of diabetes and its severity is mainly influenced by maternal blood glucose level. Neonatal hypoglycemia is the main metabolic disorder that should be prevented as soon as possible after birth. The severity of macrosomia and the maternal health condition have a strong impact on the frequency and the severity of adverse neonatal outcomes. Pregestational T2D and maternal obesity significantly increase the risk of perinatal death and birth defects. The high incidence of maternal hyperglycemia in developing countries, associated with the scarcity of maternal and neonatal care, seriously increase the burden of neonatal complications in these countries.

Survival and morbidity of preterm children born at 22 through 34 weeks' gestation in France in 2011: results of the EPIPAGE-2 cohort study

IMPORTANCE

Up-to-date estimates of the health outcomes of preterm children are needed for assessing perinatal care, informing parents, making decisions about care, and providing evidence for clinical guidelines.

OBJECTIVES

To determine survival and neonatal morbidity of infants born from 22 through 34 completed weeks' gestation in France in 2011 and compare these outcomes with a comparable cohort in 1997.

DESIGN, SETTING, AND PARTICIPANTS

The EPIPAGE-2 study is a national, prospective, population-based cohort study conducted in all maternity and neonatal units in France in 2011. A total of 2205 births (stillbirths and live births) and terminations of pregnancy at 22 through 26 weeks' gestation, 3257 at 27 through 31 weeks, and 1234 at 32 through 34 weeks were studied. Cohort data were collected from January 1 through December 31, 1997, and from March 28 through December 31, 2011. Analyses for 1997 were run for the entire year and then separately for April to December; the rates for survival and morbidities did not differ. Data are therefore presented for the whole year in 1997 and the 8-month and 6-month periods in 2011.

MAIN OUTCOMES AND MEASURES

Survival to discharge and survival without any of the following adverse outcomes: grade III or IV intraventricular hemorrhage, cystic periventricular leukomalacia, severe bronchopulmonary dysplasia, retinopathy of prematurity (stage 3 or higher), or necrotizing enterocolitis (stages 2-3).

RESULTS

A total of 0.7% of infants born before 24 weeks' gestation survived to discharge: 31.2% of those born at 24 weeks, 59.1% at 25 weeks, and 75.3% at 26 weeks. Survival rates were 93.6% at 27 through 31 weeks and 98.9% at 32 through 34 weeks. Infants discharged home without severe neonatal morbidity represented 0% at 23 weeks, 11.6% at 24 weeks, 30.0% at 25 weeks, 47.5% at 26 weeks, 81.3% at 27 through 31 weeks, and 96.8% at 32 through 34 weeks. Compared with 1997, the proportion of infants surviving without severe morbidity in 2011 increased by 14.4% (P < .001) at 25 through 29 weeks and 6% (P < .001) at 30 through 31 weeks but did not change appreciably for those born at less than 25 weeks. The rates of antenatal corticosteroid use, induced preterm deliveries, cesarean deliveries, and surfactant use increased significantly in all gestational-age groups, except at 22 through 23 weeks.

CONCLUSIONS AND RELEVANCE

The substantial improvement in survival in France for newborns born at 25 through 31 weeks' gestation was accompanied by an important reduction in severe morbidity, but survival remained rare before 25 weeks. Although improvement in survival at extremely low gestational age may be possible, its effect on long-term outcomes requires further studies. The long-term results of the EPIPAGE-2 study will be informative in this regard.

Livedo Reticularis: A Presenting Sign of Escherichia Coli Sepsis in a Newborn

Livedo reticularis is a red cutaneous netlike pattern that is caused by abnormalities of the microvascularization and can be associated with many other potential systemic etiologies. We describe a case of a newborn that presented with livedo reticularis on his first day of life without any obvious systemic signs. The livedo reticularis was associated with Escherichia Coli K1 meningitis as revealed by laboratory tests. Clinical infectious signs developed a few hours later. Despite appropriate antibiotics therapy, he died on his second day because of sepsis and disseminated intravascular coagulation. Cerebrospinal fluid culture, blood culture, and culture of samples from trachea showed the presence of Escherichia Coli serotype K1 with many virulence determinants.

CONCLUSION

In newborn, livedo reticularis must not be considered as physiological, but as a potential sign of unknown severe bacterial infection. Thus, the presence of livedo reticularis must require urgent laboratory tests.

[Nutrition and growth follow-up in the preterm infant]

The nutrition of premature babies is an important issue to improve their short and long-term growth and development. After birth, our target is to achieve the same growth as a foetus of similar gestational age. The recent recommendations insist on the early introduction of enteral and parenteral nutrition, with optimization of protein and energy intakes to avoid the appearance of extra-uterine failure to thrive. The human milk is always the best nutrition for premature babies but it should be adequatly fortified. After hospital discharge, undoubtly breast-feeding still the best choice, but the nutritional intakes should be individualised according to the nutrition state of the baby. A fortification of expressed breat milk or a complement with premature milk formula should be recommended for small for gestational age babies. Then, we should closely follow-up the growth on the regular basis and for a long period, to note that the catch up will be reached frequently at the end of the first year of age.

[Risk factors for developing pneumothorax in full-term neonates with respiratory distress]

OBJECTIVES

To describe respiratory distress (RD) in full-term neonates hospitalized in the NICU and to determine risk factors in this population for pneumothorax.

STUDY DESIGN

Retrospective inclusion for 4 years of full-term neonates hospitalized for RD before the 2nd day of life. Neonates were separated into Group I (RD with no pneumothorax) and Group II (RD with pneumothorax). Data collected from maternal and newborn medical records were obstetrical, perinatal, and postnatal. P<0.05 was set as the significance level.

RESULTS

Ninety-six neonates were included. In this population, 64 (66.7%) were male, 45 (46.9%) were born by cesarean section, and 30 (31.3%) by elective cesarean section. Neonatal outcome was 4.6 days of hospital stay, 47.4% odds of mechanical ventilation, and 17.7% of persistent pulmonary hypertension of the neonate (PPHN). A central catheter was needed in 25% of the patients and amine treatment in 3.1%. The number of neonates born by cesarean section was lower as term increased. Those born by cesarean section were more likely to develop PPHN (26.7 vs 9.8%; P=0.03), and those born without labor were more likely to require oxygen (83.3 vs 63.6%; P=0.05). When comparing Group I and Group II (32 neonates), absence of labor (RR 1.5) and birth outside of a level III maternity unit (RR 1.6) were risk factors for pneumothorax. These results were confirmed in multivariate analysis. In Group II, birth before 39 weeks was a risk factor for bilateral pneumothorax (P=0.01). The median length of hospitalization was significantly longer in Group II than in Group I (5.8 days vs 4 days, P=0.03).

CONCLUSIONS

RD at term exposes the infant to high morbidity and pneumothorax, especially if born outside of a level III maternity unit and absence of labor.

The apparent breastfeeding paradox in very preterm infants: relationship between breast feeding, early weight gain and neurodevelopment based on results from two cohorts, EPIPAGE and LIFT

CONTEXT

Supplementation of breast milk is difficult once infants suckle the breast and is often discontinued at end of hospitalisation and after discharge. Thus, breastfed preterm infants are exposed to an increased risk of nutritional deficit with a possible consequence on neurodevelopmental outcome.

OBJECTIVE

To assess the relationship between breast feeding at time of discharge, weight gain during hospitalisation and neurodevelopmental outcome.

DESIGN

Observational cohort study.

SETTING

Two large, independent population-based cohorts of very preterm infants: the Loire Infant Follow-up Team (LIFT) and the EPIPAGE cohorts.

PATIENTS

2925 very preterm infants alive at discharge.

MAIN OUTCOME MEASURE

Suboptimal neurodevelopmental outcome, defined as a score in the lower tercile, using Age and Stages Questionnaire at 2 years in LIFT and Kaufman Assessment Battery for Children Test at 5 years in EPIPAGE. Two propensity scores for breast feeding at discharge, one for each cohort, were used to reduce bias.

RESULTS

Breast feeding at time of discharge concerned only 278/1733 (16%) infants in LIFT and 409/2163 (19%) infants in EPIPAGE cohort. Breast feeding is significantly associated with an increased risk of losing one weight Z-score during hospitalisation (LIFT: n=1463, adjusted odd ratio (aOR)=2.51 (95% CI 1.87 to 3.36); EPIPAGE: n=1417, aOR=1.55 (95% CI 1.14 to 2.12)) and with a decreased risk for a suboptimal neurodevelopmental assessment (LIFT: n=1463, aOR=0.63 (95% CI 0.45 to 0.87); EPIPAGE: n=1441, aOR=0.65 (95% CI 0.47 to 0.89) and an increased chance of having a head circumference Z-score higher than 0.5 at 2 years in LIFT cohort (n=1276, aOR=1.43 (95% CI 1.02 to 2.02)) and at 5 years in EPIPAGE cohort (n=1412, aOR=1.47 (95% CI 1.10 to 1.95)).

CONCLUSIONS

The observed better neurodevelopment in spite of suboptimal initial weight gain could be termed the 'apparent breastfeeding paradox' in very preterm infants. Regardless of the mechanisms involved, the current data provide encouragement for the use of breast feeding in preterm infants.

Analgesic effects of EMLA cream and oral sucrose during venipuncture in preterm infants

OBJECTIVE

The goal of this study was to compare the analgesic effect of sucrose with that of the combination of sucrose and the local anesthetic cream EMLA during venipuncture in preterm neonates.

METHODS

This randomized, double-blind prospective study included infants younger than 37 weeks' gestational age during 1 routine venipuncture for blood sampling. Each child randomly received either sucrose plus application of a placebo cream (S group) or sucrose plus EMLA cream (S+E group) before venipuncture. Venipuncture-induced pain was assessed through videotapes of the procedures by using the Douleur Aiguë Nouveau-né (DAN) behavioral scale. Pain was assessed at 2 phases: during venipuncture (from needle introduction to its removal) and during the recovery period (30 seconds after needle removal). Pain scores over time and between treatments were compared by using repeated-measures analysis of variance.

RESULTS

The study included 76 children (37 in the S group, 39 in the S+E group). Mean (SD) DAN pain scores for the S group and the S+E group were 7.7 (2.1) and 6.4 (2.5), respectively, during venipuncture and 7.1 (2.8) and 5.7 (3.3) during the postinjection period. A significant time and treatment effect in favor of the S+E group was observed.

CONCLUSION

The combination of sucrose and EMLA cream revealed a higher analgesic effect than sucrose alone during venipuncture in these preterm infants.

Foetal and neonatal complications in gestational diabetes: perinatal mortality, congenital malformations, macrosomia, shoulder dystocia, birth injuries, neonatal complications

OBJECTIVE

To evaluate the risks of perinatal complications in infants born to mothers with treated or untreated gestational diabetes mellitus (GDM).

METHODS

A search of the PubMed database was performed and recommendations from NICE and the French National Authority for Health were consulted.

RESULTS

Untreated moderate or severe GDM increases the risk of foetal and neonatal complications (EL1). The risk of malformations slightly increases in newborns of mothers with GDM compared to the general population (EL2). This risk is probably associated with the presence of undiagnosed type 2 diabetes among patients with GDM (EL2). There is a linear relationship between maternal blood glucose levels and an increased birth weight (EL2). Treatment for GDM reduces the incidence of macrosomia (EL1). Although the risk of cardiomyopathy in cases of GDM cannot be accurately estimated based on the available data, severe clinical forms are rare. The risks of neonatal asphyxia and perinatal mortality are no higher in infants born to women with GDM (EL2). Birth injuries and brachial plexus injuries are rare, and no more likely to occur in cases of untreated GDM. It is difficult to assess the risk of respiratory distress, regardless of its cause. It is not possible to establish a link between GDM and neonatal respiratory problems due to insufficient data. Although the risk of neonatal hypoglycaemia is difficult to determine due to the variable definitions reported in the literature, the incidence of hypoglycaemia requiring intravenous therapy is low (EL1). The risks of hypocalcaemia (EL4) and hyperbilirubinemia (EL1) are similar to the general population.

CONCLUSION

Serious perinatal complications specifically associated with GDM are rare. Macrosomia has been demonstrated to be the predominant adverse outcome in cases of GDM. It is the main factor linked to reported cases of complications in GDM. Maternal obesity is an additional risk factor for complications, regardless of diabetes status.

[Description and investigation of an outbreak of extended-spectrum beta-lactamase producing Escherichia coli strain in a neonatal unit]

An outbreak of colonization and infection with an Escherichia coli strain producing extended-spectrum beta-lactamase (ESBL) occurred in a neonatal unit : a high rate of cases was observed, 27/59 neonates were colonized : one of them developed meningitis with favourable outcome and another baby developed conjunctivitis. Despite intensive efforts to control the outbreak by standard methods of hand hygiene, patients screening and isolation, the spread was uncontrolled and the unit was closed to all admission in order to stop the outbreak. The investigation was not able to identify a single outbreak's source. Emergence and spread of ESBL producing E. coli strains from community and hospital acquired infections are a significant public health problem with difficult choice of treatment for serious infections.