Search

Resume La famille est primordiale pour les nouveau-nes hospitalises. Elle soutient son developpement, tout en tissant des liens d’attachement solides avec lui. Les soins centres sur l’enfant et sa famille affirment que la famille fait partie de l’equipe soignante de neonatologie. Elle est integree dans le processus de decision medicale et est partenaire dans les soins a son ou ses enfants. Il semble essentiel de preciser la definition de la famille. Nous allons aborder cette definition sous un aspect juridique, sociologique ou philosophique. Le Groupe de Reflexion et d’Evaluation de l’Environnement des Nouveau-nes (GREEN) de la Societe francaise de neonatologie estime qu’il est important de clarifier la definition de la famille d’un nouveau-ne hospitalise, de decrire les difficultes lies a la separation pour l’enfant, ses parents, sa fratrie et sa famille, de faire un etat des lieux sur les pratiques, puis de proposer des recommandations et des strategies d’application.

Resume Le peau a peau est defini par le portage d’un enfant vetu d’une couche et d’un bonnet entre les seins de sa mere ou contre le torse du pere, peau contre peau. Les objectifs du Groupe de Reflexion et d’Evaluation de l’Environnement des Nouveau-nes etaient d’evaluer son rationnel scientifique et d’emettre des recommandations pratiques pour sa realisation en neonatologie et en salle de naissance. Une recherche bibliographique systematique, suivant la methodologie de la Haute Autorite de sante, montre l’existence de benefices sur la stabilite physiologique, le sommeil, la douleur, le developpement neurologique, l’allaitement, l’attachement et le stress parental. Il est recommande que le peau a peau soit propose a tous les bebes prematures hospitalises, le plus precocement et le plus largement possible, des stabilite clinique, avec des procedures ecrites de transfert et surveillance, et un environnement soutenant. Cette pratique semble beneficier aux nouveau-nes extremement prematures et/ou intubes, mais necessite une expertise de l’equipe. Le peau a peau precoce en salle de naissance avec la mere est benefique pour l’allaitement, le comportement, l’adaptation du nouveau-ne a terme ou proche du terme. Le peau a peau avec le pere ameliore aussi le comportement de l’enfant. L’installation immediate en peau a peau avec la mere est fortement recommandee pour le nouveau-ne d’âge ≥ 35 semaines, si son etat clinique le permet. Il est recommande a chaque equipe d’informer et soutenir les parents, d’instaurer des procedures de securite/surveillance adaptees pour soutenir la pratique du peau a peau en securite en salle de naissance.

The 2005 enactment of the "Patients' rights and end-of-life care" act, known as the Leonetti law, has been accompanied by practical changes in the processes of withdrawal and withholding of active life-sustaining treatments. This law has also promoted the implementation of palliative care in perinatal medicine to avoid unreasonable therapeutic interventions and to preserve the dying patient's quality of life and human dignity. Recently, a new law has been voted by the French National Assembly and new reflections on the ethical aspects of the end of life in neonatal medicine should resume again within the French Society of Neonatology in the working group on ethical issues in neonatology. This is why it appears important to discuss the perceived benefits and the persistent difficulties related to the implementation of the Leonetti law in neonatology. Collegiality in the decision-making processes as well as withdrawal and withholding of life-sustaining treatments that were already present in the practices of many centers has been stipulated within a legal framework and promoted in clinical practice. It has brought serenity within perinatal nursing and medical teams. It has helped them face the always-difficult end-of-life situations with parents and deal with decision-making processes in an intense emotional climate. However, new questions inherent to the law have appeared. The most important ones concern the withholding of artificial nutrition and hydration, the time pressure in the management of the decision-making process, and the management of the duration of palliative care. Challenges remain in addressing various persistent ethical dilemmas such as the possible survival of newborns with significant brain lesions detected after the period of life-sustaining treatments that have allowed their survival. The new law carried by Mr. Clayes and Mr. Leonetti should provide answers to some of these ethical issues, but it would probably not solve all of them.

Resume Bien que la prevalence de l’infection neonatale precoce ait nettement diminue en France, passant de 0,65 a 0,23/1000 en dix ans pour les formes invasives, depuis que des recommandations nationales ont ete emises, elle reste un probleme de sante publique d’actualite. Le streptocoque du groupe B (SGB) est toujours la cause principale des infections de l’enfant a terme ou proche du terme. Du fait des strategies de prevention environ 30 % des femmes enceintes et plus de 2 % des nouveau-nes sont traites par antibiotiques. Des interrogations ont ete soulevees sur l’innocuite d’une utilisation aussi large des antibiotiques, notamment quant aux risques de developpement de resistances, d’emergence d’infections a Escherichia coli ou d’effets indesirables a long terme dus aux modifications du microbiote intestinal. Les nouvelles recommandations emises par le Centers for Disease Control and Prevention aux Etats-Unis et par d’autres pays europeens ont pour but d’ameliorer les methodes de depistage du SGB et les algorithmes d’antibioprophylaxie intrapartum chez la femme enceinte, de mieux identifier les nouveau-nes a haut risque et de limiter les evaluations biologiques chez les nouveau-nes a bas risque.

The sensory systems develop in several sequences, with a process specific to each system and with a transnatal continuum. This development is based partly on interactions between the fetus and the newborn and their physical and human environments. These interactions are key drivers of the child development. The adaptation of the newborn's environment is crucial for his survival, his well-being and his development, especially if he is born prematurely. The physical environment of the hospital where immature infants are immersed differs greatly from the uterine environment from which they were extracted prematurely. There are discrepancies between their sensory expectations originating in the antenatal period and the atypical stimuli that newborns encounter in their postnatal nosocomial environment. These assertions are valid for all sensory modalities. Many studies have proven that very preterm infants are highly sensitive to this environment which can affect their physiological and behavioural well being. Moreover, it can alter their perception of important human sensory signals, particularly the ones coming from their mother. The long term impacts of this environment are more difficult to identify due to the multi-sensory nature of these stimuli and the multifactorial origin of the neurological disorders that these children may develop. However, the adaptation of their physical environment is one of the corner stones of specific developmental care programs, like the NIDCAP program that has been shown to be successful to improve their short and medium term outcomes. The architectural design, technical equipment and used health-care products, and the strategies and organizations of care are the main determinants of the physical environment of these children. Recommendations for the hospital environment, integrating a newborn's developmental perspective, have been made available. They should be applied more widely and should be completed. Technological equipment advances are also expected to allow better compliance to them. All these evolutions are completely in accordance with the concept of humane neonatal care.