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Abstract: Background: Little is known about the influence of anaesthesia for caesarean section on outcome in very preterm infants. Methods: A prospective, population-based, cohort study (the EPIPAGE cohort) included all births before 33 weeks in nine French regions in 1997. Of 2360 infants live-born between 27 and 32 weeks, 1338 were delivered by caesarean section with general anaesthesia (n=711, 53.1%), spinal anaesthesia (n=419, 31.3%), or epidural anaesthesia (n=208, 15.6%). Neonatal mortality was compared among these three groups using bi- (according to gestational age and to anaesthetic technique) and multivariate analyses. Results: Neonatal mortality was 10.1% with general anaesthesia, 12.2% with spinal anaesthesia and 7.7% with epidural anaesthesia. After adjustment for gestational age and characteristics of pregnancy, delivery and neonate, spinal anaesthesia was associated with a higher risk of neonatal death than general anaesthesia (adjusted odds ratio, 1.7; 95% confidence interval 1.1 to 2.6). Conclusion: In this population-based study, spinal anaesthesia was associated with an increased risk of neonatal mortality in very preterm infants compared to general anaesthesia (and epidural anaesthesia), independently from gestational age and characteristics of the pregnancies, deliveries and neonates. Although this multivariate analysis does not prove a causal relationship, the results suggest it could exist, particularly if maternal haemodynamics are poorly controlled. With recent significant change in the conduct of spinal anaesthesia, further studies are needed to investigate potential harmful effects of anaesthesia on very preterm infants delivered by caesarean section. [Copyright &y& Elsevier]

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Copyright of EMC-Pediatrie is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The setting up of the so-called “decrees on perinatal safety” on October 1998 has been associated with many difficulties which were apparently related to the lack of beds for intensive care units, special care units and neonatal medicine. This led to a national survey.Objectives. – The aim of the survey was : (1) to collect the number of neonates requiring hospitalization in NICU and special care units over a 1-week period in metropolitan France and overseas departments and territories; (2) to assess the needs in equipments and care-givers.Methods. – The writs to be included in the survey were previously identified. Each day of hospitalization was classified as needing an intensive care unit, a special care unit or a neonatal unit. Then it was classified as well fitted or badly fitted.Results. – Two hundred and forty units (90% of the French units) from 204 hospitals participated in the survey and 3678 neonates were included and accumulated 17 583 days of hospitalization (NICU: 2728; special care: 5047; neonatal medicine: 9808). One thousand and five hundred and ninety hospitalization days did not fit well either with the technical level required by the neonate or/and with the location of the parents’ home (9.2%): 23.1% in overseas departments and territories; 12% in metropolitan France. The main reasons for maladjustment were: a too high technical level: (59%); an insufficient technical level: (21%) (19 neonates could not be admitted in a NICU as they needed). The survey included 158 NICU and special care units. Taking into consideration the French law: the lack in equipment was: 294 ventilators, 231 cardio-respiratory monitors, 116 pulse oxymeters and 513 blood pressure monitors; 561 additional pediatricians were needed to allow a medical night duties including seven doctors in each NICU and each special care unit; 1878 additional nurses were also needed. Making the assumption that the mean occupation rate of the neonatal beds should be 70%, the needs were calculated for 1000 live births: metropolitan France: 0.76 (0.74; 0.78) in NICU; 1.45 (1.43–1.47) in special care units; overseas departments and territories: 2 (1.8–2.5) in NICU; 3.5 (3.2–3.8) in special care units.Conclusion. – Finally, the main deficit was not related to the number of beds but to the equipment and number of care-givers. The status of overseas departments and territories was particularly worrying. [Copyright &y& Elsevier]

Objective: This study was undertaken to assess age-specific effects of maternal education on patterns of prenatal testing.Study Design: We used data from a sample of all births in France in 1998. Statistical analysis included logistic regression and likelihood ratio tests.Results: The rate of amniocentesis of women without serum screening was 7.3% for those with 12 years or less, and 16.7% for those with more than 12 years of education. Women with lower levels of education were about 50% more likely to have an amniocentesis if they had serum screening (odds ratio [OR], 1.5; 95% CI, 1.2-1.8). In contrast, women with higher levels of education were less likely to have an amniocentesis with screening (OR, 0.7; 95% CI, 0.6-0.8); the education effect persisted across maternal age groups.Conclusion: Many women eligible for reimbursed serum screening, in particular those with higher levels of education, obtain amniocentesis without serum screening. This might limit the use of antenatal screening as a solution to the growing number of amniocenteses. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to assess how the French legislation requiring physicians to offer human immunodeficiency virus screening routinely at the beginning of prenatal care has been implemented and to explore areas in which improvement is required.Study Design: The survey included all births in France during a 7-day period in February 1995. A total of 12,341 women were asked whether they knew whether they had undergone a human immunodeficiency virus antibody test before or during the pregnancy. Factors that could have influenced their knowledge of whether they had been tested were also assessed.Results: Of the women questioned, 87.3% stated that they had been tested before or during pregnancy, 7.6% said that they had not been tested, and 5.1% stated that they did not know whether a test had been performed. Among those who said that they had not been tested before the pregnancy in question, 84. 9% reported that they were tested during the pregnancy. The multivariate analysis revealed that women from North Africa differed significantly from French women in both unawareness of screening status and the proportion who reported not being screened (odds ratio 2.1 with 95% confidence interval 1.6-2.9 and odds ratio 2.4 with 95% confidence interval 1.8-3.1, respectively). There was, however, no significant difference between women from sub-Saharan Africa and French women in these variables. A lower educational level was an important predictor of unawareness of screening status (odds ratio 2.6 with 95% confidence interval 2.0-3.4). Associations were observed between reporting of unscreened status and low levels of use of prenatal care services (<6 prenatal consultations odds ratio 1.3 with 95% confidence interval 1.0-1.6, <3 ultrasonographic examinations odds ratio 1.7 with 95% confidence interval 1.3-2.0, and no prenatal consultation at the maternity hospital odds ratio 1. 5 with 95% confidence interval 1.2-1.8).Conclusion: The 1995 National Perinatal Survey, which appears to indicate extensive human immunodeficiency virus screening of pregnant women in France, shows that the nonmandatory nature of the French policy of systematically offering prenatal human immunodeficiency virus screening has not prevented a high proportion of women from learning their screening status. The less comprehensive screening among women in certain subgroups suggests that human immunodeficiency virus information should be better adapted for these women. [ABSTRACT FROM AUTHOR]

Objective: To analyze the risk of admission to neonatal care for newborns of low-risk nullipara and its variation with level of care of the maternity unit.Study Design: The sample included infants born to low-risk nulliparas from the PREMODA study of 138 French maternity units (n=3652). Medical records of children admitted to neonatal care were reviewed to determine the reasons for admission and the severity of morbidity. The risk factors associated with admission to neonatal care, including maternal, infant and delivery unit characteristics, were studied by univariable analysis, followed by a multivariable analysis using a multilevel logistic model.Results: The newborns of 3.5% (n=129) of the nulliparous mothers at low risk were admitted to neonatal care at birth. The two principal reasons were infections (57%) and respiratory diseases (19%). Babies born in level 2 maternity units were twice as likely to be admitted to neonatal care as those born in level 1 units (ORa=2.0 [1.1-3.7]) and those born in level 3 units, 1.5 times more often, although this was not statistically significant (ORa=1.5 [0.8-2.8]). Babies admitted to neonatal care after delivery in level 1 had more severe morbidity (n=4, 26.7%) than those admitted from level 2 (n=4, 5.7%) or level 3 (n=3, 6.8%) facilities (p=0.046).Conclusion: In low-risk populations, the level of care could have an influence on the decision to admit babies to neonatal care at birth. These findings add to the on-going debate about the optimal organization of care for women at low obstetrical risk. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To refine and to re-validate the best current tool (the Nigrovic rule: ‘‘outpatient management may be considered for children without seizure, blood neutrophil count≥10,000/mm3, positive cerebrospinal fluid –CSF– Gram-staining, CSF protein≥80 mg/dl, or CSF neutrophil count≥1,000/mm3’’) proposed to distinguish between aseptic meningitis (AM) and bacterial meningitis (BM) in the emergency department. Methods: Children hospitalized for BM between 1995 and 2004, or AM between 2000 and 2004 were included, and randomly divided into derivation (111 children, 14 BM) and internal validation (57 children, 7 BM) sets. The Nigrovic rule was refined on the derivation set, introducing new variables (purpura, toxic appearance and high serum procalcitonin), changing variables thresholds (CSF protein) and withdrawing some variables (blood neutrophil count, CSF neutrophil count), according to previous results, with the aim to obtain 100% sensitivity user friendly tool. The refined rule was then applied on the internal validation set, stayed blinded during the derivation process. Results: The refined rule was: start antibiotics in case of seizure, purpura, toxic appearance, procalcitonin≥0.5 ng/ml, positive CSF Gram-staining, or CSF protein≥50 mg/dl. The refined rule had 100% sensitivity on the derivation and the internal validation sets (95% confidence interval 78–100, and 65–100, respectively) with 62 and 51% specificity, respectively. Conclusion: The refined rule (called Meningitest®) was a highly sensitive, specific and user friendly tool that could allow to safely avoid>50% a posteriori unuseful antibiotic treatments for patients with AM. [Copyright &y& Elsevier]

Abstract: Rationale : Hip fractures can be separated into cervical and trochanteric fractures. Trochanteric fractures have been associated with up to twice the short-term mortality of cervical fractures in the elderly. There is also evidence suggesting that the mechanisms are different. Evidence from the literature remains limited on the predictive power of bone mineral density (BMD) and quantitative ultrasounds (QUS) for both types of hip fractures. Methods : 5703 elderly women aged 75 years or more, who were recruited from the voting lists in the EPIDOS study, and had baseline calcaneal ultrasounds (QUS) and DXA measurements at the hip and the whole body, were analyzed in this paper. Among those, 192 hip fractures occurred during an average follow-up of 4 years, 108 cervical and 84 trochanteric fractures. Results : Femoral neck, trochanteric and whole body BMD were able to predict trochanteric hip fracture (RR’s and 95% CI were, respectively, 3.2 (2.4–4.2); 4.8 (3.5–6.6); and 2.8 (2.2–3.6)) more accurately than cervical fractures (respectively, 2.1 (1.7–2.7); 2.3 (1.8–3.0); 1.2 (1.0–1.6)). All ultrasound parameters, SOS, BUA, and stiffness index (SI) were significant predictors of trochanteric (RR’s respectively 3.0 (2.2–4.1), 2.5(2.0–3.1), and 3.5(2.6–4.7)) but not cervical fractures. After adjustment for femoral neck or trochanteric BMD ultrasound parameters were still significant predictors of trochanteric fracture, and stiffness tended to be a better predictor of trochanteric fractures than either BUA or SOS with a relative risk of 2.25 (1.6–3.1). Conclusions : A significant decrease of all bone measurements, BMD and QUS, was highly predictive of trochanteric fractures, whereas a decrease of femoral neck and trochanteric BMD were only associated with a slight increase in cervical fracture risk and a low total body BMD or QUS parameters were not significant predictors of cervical fractures. In women who sustained a hip fracture, the decrease of BMD and QUS values increases the risk of trochanteric fracture as compared to cervical fracture. Trochanteric fractures were mostly a consequence of a generalized low BMD and QUS, whereas other parameters might be involved in cervical fractures. [Copyright &y& Elsevier]

Abstract: A neonatal death certificate was introduced in France in 1997. It provides detailed data on the causes of death and the characteristics of newborn, birth and parents. Our aim was to describe the new results of this certificate. Method. – All deaths in 1999 in the first 27 days of life were included (N=2036). Certificates were analysed using the usual process, especially following the International Classification of Diseases. Results. – The neonatal death certificate was used for 87% of deaths. The proportion of documented items was 96% for gestational age and birthweight, 87% for maternal age and parity and 70% for maternal occupation. Almost three quarters of the deaths occurred in the first 6 days (36.9% in the first 24 hours and 35.1% between one and six days). 30.5% of the died infants were born before 27 weeks of gestation and 36.5% between 27 and 36 weeks. A shift in medical care was observed at 26 weeks, with an increase in caesarean sections before labour and newborn referrals. In all, 63.3% of neonatal deaths were due to perinatal conditions, and 27.9% to congenital anomalies. The proportion of deaths explained by congenital anomalies was higher for longer gestational age: 14% of deaths between 25 and 28 weeks of gestation vs 38 to 43% between 33 and 42 weeks. Conclusion. – The neonatal death certificate was well accepted; however the data on detailed causes of death and parent''s characteristics were insufficient. Analysis of the circumstances and the causes of death is facilitated with the neonatal death certificate and it will be developped in the future. [Copyright &y& Elsevier]

Objectives. – To study the frequency with which maternity ward staff complete the perinatal information section of infants’ permanent pediatric health records.Methods. – In 2000, 71 pediatricians in private practice and on staff in a general pediatric ward in a tertiary hospital in Paris carried out an observational study to assess which indicators were reported at what rates. Pediatricians were also asked which information about the perinatal admission they would find helpful in these records.Results. – One thousand seven hundred and eighty-five pediatric health records were studied. The frequency of completed information varied from 5 to 100%, depending on the item. Of the items reported rarely, some, such as thoracic circumference, were obsolete, while others were very important (response to noise, light reflex). The new information desired by office-based pediatricians involved mainly risk factors for vertical infections (maternal fever during delivery, prolonged rupture of the membranes).Conclusion. – Although the rate of completion of information in the pediatric health record was globally good, some important data should be reported more often (sensorial screening), while other items could be deleted. New information about the pregnancy and delivery would be useful. [Copyright &y& Elsevier]

Objectives. – To study the use of mucolytics agents, i.e. acetylcystein and carbocystein, in infants. To evaluate their efficacy and safety for their main indications.Methods. – A prospective one-day survey of prescriptions among 95 office-based pediatricians. A systematic review of the literature.Results. – Among 1327 prescriptions regarding infants, 4.3% were mucolytics agents. Main indications were rhinopharyngitis, isolated cough, and acute bronchitis. Our review did not identify any study of rigorous methodological quality that supported the efficacy or safety of mucolytics agents in infants for their in-label (isolated cough, acute bronchitis) and off-label (rhinopharyngitis) indications. Six cases of infants, aged less than eight months, presenting paradoxical bronchial congestion during a treatment with mucolytics agents, have been reported to the French pharmacovigilance system. No causal relationship was established from these cases because of a possible protopathic bias.Discussion. – Our results concerning mucolytics agents use are similar to those reported by the French Health Care Funds. In addition to the lack of studies on efficacy, no studies on the dose-response relationship were available, leading to suggested dose regimens in the French license of acetylcystein ranging from 44.4 to 16.4 mg kg–1 j–1 between one to 24 months. These dose regimens could predispose to overdosing in the youngest infants as it seems observed in the six reported cases.Conclusion. – In infants, mucolytics agents efficacy has never been demonstrated and some elements suggest poor safety (paradoxical bronchial congestion). [Copyright &y& Elsevier]

Objective – To study the perinatal management of fetal macrosomia (FM) and the obstetrical and neonatal results related to FM in the Iˆle de France area.Materials and methods – Case-control study from the fifteenth of July to the fifteenth of September 1999 in fifteen maternity in Paris and the Iˆle de France area. All singletons, without malformation, weighing more than 4,000 grammes, born after 37 weeks of pregnancy during the study were included. The control group had the same inclusion and exclusion criteria (except the birth-weight) and was defined by the next delivery of same parity.Results – 384 FM and 384 controls have been included. Usual risk factors of macrosomia have been found. The screening of gestational diabetes was realised in 56,8 % and FM was suspected before delivery in 59.3 % in the FM group. In cases of FM, the midwife was alone at the time of delivery in 53.4 % of spontaneous vaginal delivery. FM was associated with a longer labour and a more frequent use of oxytocin. There was six times more severe perineal tears (1.7 vs 0.3 % ; p = 0.05) for women with FM whereas the rate of haemorrhage at delivery was the same in both groups. Cesarean section’ rate before and during labor was higher in the FM group whereas instrumental extraction was not different. In this study, FM was not associated with an excess of fetal morbidity (injury, Apgar score, pH cord) even if we found ten times more shoulder dystocia.Conclusion – Complications related to FM were mainly maternals in this study. Some recommendations accounting fetal macrosomia were not widely adopted as screening of gestational diabetes or necessity to have a whole obstetric team at the time of delivery. [Copyright &y& Elsevier]

Summary: The immature brain is highly susceptible to the consequences of very preterm birth with a high rate of long-term neurodisabilities in survivors and high use of specific outpatient services to limit the functional effects of the disabilities. To assess the economic burden for the social and health care system, it is necessary to inventory the community supports and need for special education or rehabilitation used by preterm children. Such studies are few and were done only in extremely low-birthweight or extremely preterm newborns in the United States. Objective: To study the rates of specific outpatient services and special education at 5 years of age and between 5 and 8 years of age in a geographically-defined population of children born very preterm. Design, Setting and Patients: 2901 liveborn children before 33 weeks’gestation (WG) and one control group of 666 liveborn children at 39-40WG were included in nine regions of France in 1997 corresponding to more than one third of all births. At five years, these children had a medical examination and were evaluated by a psychologist at local centres organised for the study in every region. Cognitive function was assessed by the mental processing composite scale (PMC) of the Kauffmann Assessement Battery for Children test, which is considered to be equivalent to intelligence quotient and behavioral difficulties using the Strength and Difficulties questionnaire completed by the parents. Data for dependence or compensatory aids, i.e. occupational therapy or physical therapy, speech therapy, psychologist or psychiatrist visits, orthoptic therapy, wearing glasses, wearing hearing aid, specific equipment to walk (walker, wheelchair…), orthopaedic treatment or anti-epileptic treatment were collected from parents. At eight years, a postal questionnaire was sent to the parents to collect data on specific outpatient services and special treatments at home and school. Stata software was used (version 9.0). Main outcome measures. Parent Questionnaire for identifying children with chronic conditions and specific health care needs at 5 and 8 years and categorization of developmental neurodisabilities based on examination of children and psychometric evaluation at 5 years. Results: At 5 years data were obtained for respectively 1817 and 396 children born before 33WG or at 39-40WG, which represent 80% of the very preterm children and 71% of the at term children. At 8 years we obtained data for 63% of the very preterm children and 59% of the at term children. At 5 years, care in a rehabilitation center and/or specific outpatient services were required for 41% of children born between 24 and 28WG, 32% of children born between 24 and 32WG and 15% of those born at 39-40WG. Between 5 and 8 years, these figures were respectively 61%, 50% and 36%. In the very preterm group, rates of specific outpatient services were higher than 80% if the child had a motor and/or a neurosensory deficit. In case of cognitive deficiencies (PMC < 85), rates of specific outpatient services were low at 37% at 5 years and increases at 63% between 5 and 8 years. Conclusion: Compared to the children born at term, the very preterm children have considerable educational needs, which are inversely related to gestational age at birth and to age of the children at the time of reporting. Despite economic burden, efforts to improve access to services are necessary, in particular in case of cognitive impairment. [Copyright &y& Elsevier]