Bénéfices et limites de la corticothérapies anténatale dans la prise en charge de la grande prématurité

LE KREMLIN-B.- PARIS 11-BU Méd (940432101) / SudocSudocFranceF

Problèmes diagnostiques devant des douleurs abdominales récidivantes chez un adolescent

PARIS-BIUM (751062103) / SudocCentre Technique Livre Ens. Sup. (774682301) / SudocSudocFranceF

Ages and stages questionnaires: Feasibility of postal surveys for child follow-up

International audienceBackground: The Ages and Stages Questionnaire (ASQ), completed by parents and caregivers, has been shown to be an accurate tool for screening children who need further developmental assessment.Aims: to assess the feasibility of using the French Canadian translation of the ASQ in an epidemiological cohort of children from the French general population.Study design: follow-up study by postal questionnaire at 12 and 36 months, using the ASQ. Subjects: 339 French families recruited at the birth of their child in 2006 in two hospitals in the Paris suburbs.Outcome measure: response rates and French ASQ results at 12 and 36 months. The ASQ was scored as indicated in the manual.Results: A high response rate of 79% was observed at the children's 1st and 3rd birthdays. Parents were enthusiastic about participating; half of them wrote comments on the questionnaires, most of them positive. Low scores at the 12-month assessment were associated with birth characteristics such as prematurity and transfer to the neonatology unit after birth, whereas at 36 months they tended to be associated with both birth and family socio-demographic characteristics.Conclusions: Use of the French ASQ in a research cohort appears feasible as response rates were high. Moreover, known links between child development measured by ASQ and birth and social characteristics were observed. However, further French studies are needed to understand differences observed in 12-month ASQ gross motor scores compared with US norms. For research purposes, further analysis of the ASQ in innovative, quantitative approaches, is needed

Delivery room deaths of extremely preterm babies: an observational study.

Place: EnglandOBJECTIVE: 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

Intensity of perinatal care for extremely preterm babies and outcomes at a higher gestational age: evidence from the EPIPAGE-2 cohort study

International audienceBACKGROUND: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

Chorionicity and neurodevelopmental outcomes at 5½ years among twins born preterm: the EPIPAGE2 cohort study

Abstract Objective To compare the neurodevelopmental outcomes of preterm twins at 5½ years by chorionicity of pregnancy. Design Prospective nationwide population‐based EPIPAGE2 (Etude Epidémiologique sur les Petits Âges Gestationnels) cohort study. Setting A total of 546 maternity units in France, between March and December 2011. Population A total of 1126 twins eligible for follow‐up at 5½ years. Methods The association of chorionicity with outcomes was analysed using multivariate regression models. Main outcome measures Survival at 5½ years with or without neurodevelopmental disabilities (comprising cerebral palsy, visual, hearing, cognitive deficiency, behavioural difficulties or developmental coordination disorders) were described and compared by chorionicity. Results Among the 1126 twins eligible for follow‐up at 5½ years, 926 (82.2%) could be evaluated: 228 monochorionic (MC) and 698 dichorionic (DC). Based on chronicity and gestational age of birth, we found no significant differences for severe neonatal morbidity. The rates of moderate/severe neurobehavioral disabilities were similar in infants from DC pregnancies versus infants from MC pregnancies (OR 1.22, 95% CI 0.65–2.28). By gestational age and without twin–twin transfusion syndrome (TTTS), no difference according to chorionicity was found for all neurodevelopmental outcome measures. Conclusions The neurodevelopmental outcomes among preterm twins at 5½ years is similar, irrespective of chorionicity

Birth outcomes between 22 and 26 weeks' gestation in national population‐based cohorts from Sweden, England and France

Aim: We investigated the timing of survival differences and effects on morbidity for foetuses alive at maternal admission to hospital delivered at 22 to 26 weeks’ gestational age (GA). Methods: Data from the EXPRESS (Sweden, 2004–07), EPICure-2 (England, 2006) and EPIPAGE-2 (France, 2011) cohorts were harmonised. Survival, stratified by GA, was analysed to 112 days using Kaplan-Meier analyses and Cox regression adjusted for population and pregnancy characteristics; neonatal morbidities, survival to discharge and follow-up and outcomes at 2–3 years of age were compared. Results: Among 769 EXPRESS, 2310 EPICure-2 and 1359 EPIPAGE-2 foetuses, 112-day survival was, respectively, 28.2%, 10.8% and 0.5% at 22–23 weeks’ GA; 68.5%, 40.0% and 23.6% at 24 weeks; 80.5%, 64.8% and 56.9% at 25 weeks; and 86.6%, 77.1% and 74.4% at 26 weeks. Deaths were most marked in EPIPAGE-2 before 1 day at 22–23 and 24 weeks GA. At 25 weeks, survival varied before 28 days; differences at 26 weeks were minimal. Cox analyses were consistent with the Kaplan-Meier analyses. Variations in morbidities were not clearly associated with survival. Conclusion: Differences in survival and morbidity outcomes for extremely preterm births are evident despite adjustment for background characteristics. No clear relationship was identified between early mortality and later patterns of morbidity

Impact of Latency Duration on the Prognosis of Preterm Infants after Preterm Premature Rupture of Membranes at 24 to 32 Weeks' Gestation: A National Population-Based Cohort Study

Objective To assess the impact of latency duration on survival, survival without severe morbidity, and early-onset sepsis in infants born after preterm premature rupture of membranes (PPROM) at 24-32 weeks' gestation. Study design This study was based on the prospective national population-based Etude Epidemiologique sur les Petits Ages Gestationnels 2 cohort of preterm births and included 702 singletons delivered in France after PPROM at 24-32 weeks' gestation. Latency duration was defined as the time from spontaneous rupture of membranes to delivery, divided into 4 periods (12 hours to 2 days [reference], 3-7 days, 8-14 days, and >14 days). Multivariable logistic regression was used to assess the relationship between latency duration and survival, survival without severe morbidity at discharge, or early-onset sepsis. Results Latency duration ranged from 12 hours to 2 days (18%), 3-7 days (38%), 8-14 days (24%), and >14 days (20%). Rates of survival, survival without severe morbidity, and early-onset sepsis were 93.5% (95% CI 91.894.8), 85.4% (82.4-87.9), and 3.4% (2.0-5.7), respectively. A crude association found between prolonged latency duration and improved survival disappeared on adjusting for gestational age at birth (aOR 1.0 [reference], 1.6 [95% CI 0.8-3.2], 1.2 [0.5-2.9], and 1.0 [0.3-3.2] for latency durations from 12 hours to 2 days, 3-7 days, 8-14 days, and >14 days, respectively). Prolonged latency duration was not associated with survival without severe morbidity or early-onset sepsis. Conclusion For a given gestational age at birth, prolonged latency duration after PPROM does not worsen neonatal prognosis

Procalcitonin to reduce the number of unnecessary cystographies in children with a urinary tract infection: A European Validation Study

Objective To validate high serum procalcitonin (PCT) as a predictor of vesicoureteral reflux (VUR) in children with a first febrile urinary tract infection (UTI). Study design This secondary analysis of prospective hospital-based cohort studies included children ages 1 month to 4 years with a first febrile UTI. Results Of the 398 patients included in 8 centers in 7 European countries, 25% had VUR. The median PCT concentration,vas significantly higher in children with VUR than in those without: 1.6 versus 0.7 ng/ml, (P = 10(-4)). High PCT (>= 0.5 ng/ml) was' associated with VUR (OR: 2.3. 95% Cl, 1.3 to 3.9; P = 10(-3)). After adjustment for all cofactors, the association remained significant (OR: 2.5: 95% Cl, 1.4 to 4.4; P = 10(-3)). The strength of the relation increased with tire grade of reflux (P = 10(-5).). The sensitivity of procalcitonin was 75% (95% Cl, 66 to 83) for all-grade VUR and 100% (95% Cl, 81 to 100) for grade >= 4 VUR. both with 43% specificity (95% Cl, 37 to 48). Conclusions High PCT is a strong, independent and now validated predictor of VUR that can be used to identify low-risk patients and thus avoid one third of the unnecessary cystourethrographies in children with a first febrile UTI

Birth outcomes between 22 and 26 weeks' gestation in national population-based cohorts from Sweden, England and France

Aim We investigated the timing of survival differences and effects on morbidity for foetuses alive at maternal admission to hospital delivered at 22 to 26 weeks' gestational age (GA). Methods Data from the EXPRESS (Sweden, 2004-07), EPICure-2 (England, 2006) and EPIPAGE-2 (France, 2011) cohorts were harmonised. Survival, stratified by GA, was analysed to 112 days using Kaplan-Meier analyses and Cox regression adjusted for population and pregnancy characteristics; neonatal morbidities, survival to discharge and follow-up and outcomes at 2-3 years of age were compared. Results Among 769 EXPRESS, 2310 EPICure-2 and 1359 EPIPAGE-2 foetuses, 112-day survival was, respectively, 28.2%, 10.8% and 0.5% at 22-23 weeks' GA; 68.5%, 40.0% and 23.6% at 24 weeks; 80.5%, 64.8% and 56.9% at 25 weeks; and 86.6%, 77.1% and 74.4% at 26 weeks. Deaths were most marked in EPIPAGE-2 before 1 day at 22-23 and 24 weeks GA. At 25 weeks, survival varied before 28 days; differences at 26 weeks were minimal. Cox analyses were consistent with the Kaplan-Meier analyses. Variations in morbidities were not clearly associated with survival. Conclusion Differences in survival and morbidity outcomes for extremely preterm births are evident despite adjustment for background characteristics. No clear relationship was identified between early mortality and later patterns of morbidity