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Objective: To estimate the prevalence of flatus-only and faecal incontinence, to describe their risk factors and to analyse the association between anal incontinence and psychological distress over the first year postpartum.Design: Cohort study from pregnancy to 12 months postpartum.Setting: Two university hospital maternity wards in France.Population: A total of 2002 pregnant women were recruited between 2003 and 2006. Data on anal incontinence were available for the 1632 women who comprise the sample for analysis.Methods: Women were enrolled during pregnancy. A postal questionnaire was sent at 4 and 12 months postpartum.Main Outcome Measures: Anal (flatus-only and faecal) incontinence was assessed at 4 months postpartum. Mental health was assessed at 4 and 12 months postpartum by the Edinburgh Postpartum Depression Scale (EPDS) and use of antidepressant drugs as well as by self-rated mental health.Results: At 4 months postpartum, the prevalence for flatus-only incontinence was 14.4% and for faecal incontinence 1.7%; multivariate analysis, restricted to women reporting no anal incontinence before the index pregnancy, showed that continuing breastfeeding at 4 months was related to a higher risk of de novo postpartum anal incontinence (OR = 2.23). Women who reported anal incontinence at 4 months were more frequently depressed (EPDS ≥10 or antidepressant use) at 12 months postpartum: 36.0% of those with faecal incontinence were depressed, 23.3% of those with flatus-only incontinence and only 14.8% of the continent women.Conclusion: Postnatal faecal incontinence was rare but associated with poorer maternal mental health. Postnatal screening should be encouraged, and psychological support offered.Tweetable Abstract: Postnatal faecal incontinence was associated with depression; postnatal screening should be encouraged and psychological support offered. [ABSTRACT FROM AUTHOR]

Objective: To investigate the impact of gestational age (GA) at diagnosis of fetal growth restriction (FGR) on obstetric management and rates of live birth and survival for very preterm infants with early-onset FGR.Design: Population-based cohort study.Setting: All maternity units in 25 French regions in 2011.Population: Fetuses diagnosed with FGR before 28 weeks of gestation among singleton births between 22 and 31 weeks of gestation without severe congenital anomalies.Methods: We studied the effects of GA at diagnosis on perinatal management and outcomes. We used multivariable regression to identify antenatal factors (maternal characteristics, ultrasound measurements and sex) associated with the probability of live birth.Main Outcomes Measures: Live birth and survival to discharge from neonatal care.Results: A total of 436 of 3698 fetuses were diagnosed with FGR before 28 weeks (11.8%); 66.9% were live born and 54.4% survived to discharge. 50% were live born when diagnosis occurred before 25 weeks, 66% at 25 weeks and >90% at 26 and 27 weeks of gestation. In all, 94.1% of live births were by prelabour caesarean, principally for maternal indications before 26 weeks. Low GA at diagnosis, an estimated fetal weight or abdominal circumference below the third centile and male sex were adversely associated with live birth in adjusted models.Conclusion: Gestational age at FGR diagnosis had an impact on the probability of live birth and survival, after consideration of other perinatal characteristics. Investigations of the outcomes of births with early-onset FGR need to include stillbirths and information on the GA at which FGR is diagnosed.Tweetable Abstract: Evaluations of active management of pregnancies with early onset growth restriction should include stillbirths. [ABSTRACT FROM AUTHOR]

Objective: To analyse the delivery room management of babies born between 22 and 26 weeks of completed gestational age and to identify the factors associated with the withholding or withdrawal of intensive care.Study Design: Population-based cohort study.Patients and Methods: Our study population comprised 2145 births between 22 and 26 completed weeks enrolled in the EPIPAGE-2 study, a French cohort of very preterm infants born in 2011. The primary outcome measure was withholding or withdrawal of intensive care in the delivery room.Results: Among infants born alive at 22-23 weeks, intensive care was withheld or withdrawn for >90%. At 24 weeks, resuscitative measures were withheld or withdrawn for 38%, at 25 weeks for 8% and at 26 weeks for 3%. Other factors besides gestational age at birth associated with this withholding or withdrawal for infants born at 24-26 weeks were birth weight <600 g, emergency delivery (within 24 h of the mother's admission) and singleton pregnancy. Although rates of withholding or withdrawal of intensive care varied substantially between maternity units (from 0% to 100%), the variability was primarily explained by differences in distributions of gestational age at birth.Conclusions: Although gestational age is only one factor predicting survival of preterm infants, practices in France appear to be based primarily on this factor, which thus has direct effects on the survival of extremely preterm infants. The ethical implications of basing life and death decisions only on gestational age before 25 weeks require further examination. [ABSTRACT FROM AUTHOR]

Germa A, Kaminski M, Nabet C. Impact of social and economic characteristics on orthodontic treatment among children and teenagers in France. Community Dent Oral Epidemiol 2010. © 2009 John Wiley & Sons A/S Objectives: This study aimed to estimate the prevalence of orthodontic treatment in France among children and teenagers aged 8–18 years, by sex and by age, and to investigate the specific role of social and economic characteristics on use of orthodontic treatment. Methods: We analyzed data from the cross-sectional national health survey conducted in France in 2002–2003, which included a sample of 5988 children aged 8–18 years. All data were collected by interview including the question on orthodontic treatment. Other data used in our study were family social status and income, maternal educational attainment and place of birth, whether the child was covered by a supplementary health insurance and whether the residence was urban or rural. We also calculated the density of orthodontists in the district. Multivariate logistic regression analyses were used to study the relationships between these social and economic factors and orthodontic treatment. Results: The prevalence of orthodontic treatment was 14% of all children aged 8–18, 15% for girls, and 13% for boys, and 23% in the 12 to 15-year age group. Children were less likely to have orthodontic treatment when parents were service or sales workers compared with children whose parents were managers or professionals (aOR = 0.50; 95%CI: [0.34;0.76]), when family income was in the lowest, compared with highest quartile (aOR = 0,62; 95% CI: [0.45;0.85]), when children had no supplementary insurance compared with children covered by private insurance (aOR = 0.53; 95% CI: [0.34; 0.81]), or when they lived in rural compared with urban areas (aOR = 0.70; 95% CI: [0.54; 0.91]). Conclusion: There are social inequalities in orthodontic treatment in France, associated mainly with social status, annual income, supplementary insurance, and the residence area. [ABSTRACT FROM AUTHOR]

Objective: Very preterm born children are at risk for impairments in multiple neurodevelopmental domains, but outcomes vary between individuals. The present study aimed to distinguish subgroups with distinct profiles of functioning across motor, cognitive, behavioral, and psychosocial domains. These profiles were related to neonatal and social/environmental factors., Method: The sample included 1977 children born very preterm (<32 weeks' gestation) in 2011 from the French population-based EPIPAGE-2 cohort. Using latent profile analysis, subgroups of children were distinguished based on their functioning at 5.5 years. The relation between outcome profiles and neonatal and social/environmental factors was tested using multivariable multinomial logistic regression analysis., Results: Four subgroups with distinct outcome profiles were distinguished: no deficit in any domain (45%); motor and cognitive deficits without behavioral/psychosocial deficits (31%); primarily behavioral and psychosocial deficits (16%); and deficits in multiple domains (8%). Male sex (odds ratio [OR] = 2.1-2.7), bronchopulmonary dysplasia (OR = 2.1-2.8), low parental education level (OR = 1.8-2.1), and parental non-European immigrant status (OR = 2.3-3.0) were independently associated with higher odds for all suboptimal outcome profiles compared to the favorable outcome profile., Conclusion: Among 5.5-year-old very preterm born children, subgroups can be distinguished with distinct outcome profiles that vary in severity, type, and combinations of deficits. This information is important for the development of interventions that are tailored to the needs of large subgroups of children across multiple domains of functioning. General neonatal and social/environmental factors may be useful for early identification of very preterm born children at risk for general rather than domain-specific impairments., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

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., (© 2021 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Aim: To describe maternal employment and the socio-economic status of the household up to 8 years after the very preterm birth of a child, according to the presence and type of motor or cognitive impairment., Method: A total of 1885 families from the French EPIPAGE cohort of children who were born very preterm between 1997 and 1998 were included. Motor and cognitive impairments were identified in children between the ages of 2 and 8 years in 770 families and were classified according to type. The 1115 families with children born very preterm without these impairments were considered the reference group., Results: Mothers of children with severe motor or cognitive impairments were less often working at 5 years after the birth than the reference mothers (21% and 30% vs 57%; p<0.001). Those working before birth returned to work less often and those not working started to work less often after the birth than did reference mothers. At 8 years, mothers of children with severe impairments reported financial difficulties more often than mothers of children without impairments., Interpretation: Despite a fairly protective regulatory framework in France, families of infants born very preterm with severe motor or cognitive impairments are socially underprivileged. Measures to maintain an acceptable standard of living for these families and their children are needed., (© 2020 Mac Keith Press.)

Objectives: To describe patterns of care for very preterm (VP) babies across neonatal intensive care units (NICUs) and associations with outcomes., Design: Prospective cohort study, EPIPAGE-2., Setting: France, 2011., Participants: 53 (NICUs); 2135 VP neonates born at 27 to 31 weeks., Outcome Measures: Clusters of units, defined by the association of practices in five neonatal care domains - respiratory, cardiovascular, nutrition, pain management and neurodevelopmental care. Mortality at 2 years corrected age (CA) or severe/moderate neuro-motor or sensory disabilities and proportion of children with scores below threshold on the neurodevelopmental Ages and Stages Questionnaire (ASQ)., Methods: Hierarchical cluster analysis to identify clusters of units. Comparison of outcomes between clusters, after adjustment for potential cofounders., Results: Three clusters were identified: Cluster 1 with higher proportions of neonates free of mechanical ventilation at 24 hours of life, receiving early enteral feeding, and neurodevelopmental care practices (26 units; n=1118 babies); Cluster 2 with higher levels of patent ductus arteriosus and pain screening (11 units; n=398 babies); Cluster 3 with higher use of respiratory, cardiovascular and pain treatments (16 units; n=619 babies). No difference was observed between clusters for the baseline maternal and babies' characteristics. No differences in outcomes were observed between Clusters 1 and 3. Compared with Cluster 1, mortality at 2 years CA or severe/moderate neuro-motor or sensory disabilities was lower in Cluster 2 (adjusted OR 0.46, 95% CI 0.25 to 0.84) but with higher proportion of children with an ASQ below threshold (adjusted OR 1.49, 95% CI 1.07 to 2.08)., Conclusion: In French NICUs, care practices for VP babies were non-randomly associated. Differences between clusters were poorly explained by unit or population differences, but were associated with mortality and development at 2 years. Better understanding these variations may help to improve outcomes for VPT babies, as it is likely that some of these discrepancies are unwarranted., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To investigate the relation between neonatal intensive care unit (NICU) volume and survival, and neuromotor and sensory disabilities at 2 years in very preterm infants., Study Design: The EPIPAGE-2 (Etude Epidémiologique sur les Petits Âges Gestationnels-2) national prospective population-based cohort study was used to include 2447 babies born alive in 66 level III hospitals between 24 and 30 completed weeks of gestation in 2011. The outcome was survival without disabilities (levels 2-5 of the Gross Motor Function Classification System for cerebral palsy with or without unilateral or bilateral blindness or deafness). Units were grouped in quartiles according to volume, defined as the annual admissions of very preterm babies. Multivariate logistic regression analyses with population average models were used., Results: Survival at discharge was lower in hospitals with lower volumes of neonatal activity (aOR 0.55, 95% CI 0.33-0.91). Survival without neuromotor and sensory disabilities at 2 years increased with hospital volume, from 75% to 80.7% in the highest volume units. After adjustment for gestational age, small for gestational age, sex, maternal age, infertility treatment, multiple pregnancy, principal cause of prematurity, parental socioeconomic status, and mother's country of birth, survival without neuromotor or sensory disabilities was significantly lower in hospitals with a lower volume of neonatal activity (aOR 0.60, 95% CI 0.38-0.95) than in the highest quartile hospitals., Conclusions: These results suggest that lower neonatal intensive care unit volume is associated with lower survival without an increase in disabilities at 2 years. These results could be useful to generate improvements of perinatal regionalization., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Our main objective was to examine if parental prenatal preferences predict delivery-room management of extremely preterm periviable infants. The secondary objectives were to describe parental involvement and the content of prenatal counseling given to parents for this prenatal decision., Design: Prospective study of neonates liveborn between 22 and 26 weeks of gestation in France in 2011 among the neonates included in the EPIPAGE-2 study., Setting: 18 centers participating in the "Extreme Prematurity Group" substudy of the EPIPAGE-2 study., Patients: 302 neonates liveborn between 22-26 weeks among which 113 with known parental preferences while parental preferences were unknown or unavailable for 186 and delivery room management was missing for 3., Results: Data on prenatal counseling and parental preferences were collected by a questionnaire completed by professionals who cared for the baby at birth; delivery room (DR) management, classified as stabilization or initiation of resuscitation (SIR) vs comfort care (CC). The 113 neonates studied had a mean (SD) gestational age of 24 (0.1) weeks. Parents of neonates in the CC group preferred SIR less frequently than those with neonates in the SIR group (16% vs 88%, p < .001). After multivariate analysis, preference for SIR was an independent factor associated with this management. Professionals qualified decisions as shared (81%), exclusively medical (16%) or parental (3%). Information was described as medical with no personal opinion (71%), complete (75%) and generally pessimistic (54%)., Conclusion: Parental involvement in prenatal decision-making did not reach satisfying rates in the studied setting. When available, prenatal parental preference was a determining factor for DR management of extremely preterm neonates. Potential biases in the content of prenatal counselling given to parents need to be evaluated., Competing Interests: The authors have declared that no competing interests exist.

Objective: To analyze language skills in children born at 24-34 weeks of gestation at 2 years of corrected age and the association between language and other developmental domains., Study Design: We included 2424 children (64% of the eligible population) from the French population-based EPIPAGE 2 cohort study. At 2 years' corrected age, children were screened with the French short version of the MacArthur-Bates Communication Developmental Inventories and the Ages and Stages Questionnaire completed by parents., Results: Small lexicon size, <10th percentile of the calibration sample (ie, 28 words in a list of 100) was observed in 135 of 300 children (45%) born at 23-26 weeks, 484 of 1513 (32%) born at 27-31 weeks, and 165 of 611 (27%) born at 32-34 weeks of gestation. Small lexicon size was associated with 2 other language measures: word combination use and the Ages and Stages Questionnaire communication domain score. It was also significantly associated with the Ages and Stages Questionnaire score below the threshold in the other developmental domains (gross motor function, fine motor function, problem solving skills, and personal social skills) for all gestational age groups, after adjustment for potential confounders. Overall, 46% of children with a small lexicon size had ≥1 of these domains below the threshold, as compared with only 22% of children without a small lexicon size., Conclusions: These results highlight the usefulness of the MacArthur-Bates Communication Developmental Inventories in preterm children, especially those who do not participate in specialized follow-up. A small lexicon size points to developmental difficulties in language and increased risk for other developmental and neurobehavioral functions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Facilitating factors and barriers to breast milk feeding (BMF) very preterm (VP) infants have been widely studied at the individual level. We aimed to describe and analyse factors associated with BMF at discharge for VP infants, with a special focus on unit policies aiming to support BMF., Methods: We described BMF at discharge in 3108 VP infants enrolled in EPIPAGE-2, a French national cohort. Variables of interest were kangaroo care during the 1st week of life (KC); unit's policies supporting BMF initiation (BMF information systematically given to mothers hospitalised for threatened preterm delivery and breast milk expression proposed within 6 hours after birth) and BMF maintenance (availability of protocols for BMF and a special room for mothers to pump milk); the presence in units of a professional trained in human lactation and regional BMF initiation rates in the general population. Associations were investigated by multilevel logistic regression analysis, with adjustment on individual factors., Results: In total, 47.2% of VP infants received BMF at discharge (range among units 21.1%-84.0%). Unit policies partly explained this variation, regardless of individual factors. BMF at discharge was associated with KC (adjusted odds ratio (aOR) 2.26 (95% confidence interval (CI) 1.40, 3.65)), with policies supporting BMF initiation (aOR 2.19 (95% CI 1.27, 3.77)) and maintenance (aOR 2.03 (95% CI 1.17, 3.55)), but not with BMF initiation rates in the general population., Conclusion: Adopting policies of higher performing units could be an effective strategy for increasing BMF rates at discharge among VP infants., (© 2019 John Wiley & Sons Ltd.)

Objective: To evaluate the association between active antenatal management and neonatal outcomes in extremely preterm newborns admitted to a neonatal intensive care unit (NICU)., Study Design: This population-based cohort study was conducted in 25 regions of France. Infants born in 2011 between 22 0/7 and 26 6/7 weeks of gestation and admitted to a NICU were included. Infants with lethal congenital malformations or death in the delivery room were excluded. A multilevel multivariable analysis was performed, accounting for clustering by mother (multiple pregnancies) and hospital plus individual characteristics, to estimate the association between the main exposure of no active antenatal management (not receiving antenatal corticosteroids, magnesium sulfate, or cesarean delivery for fetal indications) and a composite outcome of death or severe neonatal morbidity (including severe forms of brain or lung injury, retinopathy of prematurity, and necrotizing enterocolitis)., Results: Among 3046 extremely preterm births, 783 infants were admitted to a NICU. Of these, 138 (18%) did not receive active antenatal management. The risk of death or severe morbidity was significantly higher for infants without active antenatal management (crude OR, 2.60; 95% CI, 1.44-4.66). This finding persisted after adjustment for gestational age (OR, 2.08; 95% CI, 1.19-3.62) and all confounding factors (OR, 1.86; 95% CI, 1.09-3.20)., Conclusions: The increased risk of severe neonatal outcomes for extremely preterm babies admitted to a NICU without optimal antenatal management should be considered in individual-level decision making and in the development of professional guidelines for the management of extremely preterm births., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Our aim is to compare the new French EPOPé intrauterine growth curves, developed to address the guidelines 2013 of the French College of Obstetricians and Gynecologists, with reference curves currently used in France, and to evaluate the consequences of their adjustment for fetal sex and maternal characteristics., Population and Methods: Eight intrauterine and birthweight curves, used in France were compared to the EPOPé curves using data from the French Perinatal Survey 2010. The influence of adjustment on the rate of SGA births and the characteristics of these births was analysed., Results: Due to their birthweight values and distribution, the selected intrauterine curves are less suitable for births in France than the new curves. Birthweight curves led to low rates of SGA births from 4.3 to 8.5% compared to 10.0% with the EPOPé curves. The adjustment for maternal and fetal characteristics avoids the over-representation of girls among SGA births, and reclassifies 4% of births. Among births reclassified as SGA, the frequency of medical and obstetrical risk factors for growth restriction, smoking (≥10 cigarettes/day), and neonatal transfer is higher than among non-SGA births (P<0.01)., Conclusion: The EPOPé curves are more suitable for French births than currently used curves, and their adjustment improves the identification of mothers and babies at risk of growth restriction and poor perinatal outcomes., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objectives: We developed intrauterine growth references, called EPOPé curves, in line with recommendations for screening of intra-uterine growth restriction issued in 2013 by the French College of Obstetricians and Gynecologists., Population and Methods: Using the French Perinatal Survey (FPS) 2010, we adapted the methodology developed by Gardosi (1) to model intrauterine growth and its distribution and (2) to adjust for physiological fetal and maternal factors influencing fetal weight. Based on this model, 3 reference curves (unadjusted, adjusted for fetal sex, and adjusted for fetal sex, and maternal height, weight and parity) were proposed. We applied these models to births in the 2010 FPS and the French hospital discharge database (PMSI) in 2011-2012., Results: Among singleton live births in the FPS and the PMSI, the model adjusted for fetal sex identified 3.2 and 3.3% of births below the 3rd centile respectively, and 10.0 and 10.2% below the 10th. In model adjusted for maternal factors, 4.0% of births from the FPS 2010 were reclassified, but population rates remained at 3.0 and 10.0%., Conclusion: This growth model is appropriate for French births, and allows for the implementation of a homogeneous definition of small for gestational age infants during pregnancy and at birth., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objective: To investigate the association of the cause of preterm birth on in-hospital mortality of preterm neonates born from 24 to 34 weeks of gestation., Methods: L'Etude épidémiologique sur les petits âges gestationnels (EPIPAGE)-2 is a prospective, nationwide, population-based cohort of very preterm births. After dividing causes of preterm birth into six mutually exclusive groups, we analyzed the association of each cause with in-hospital deaths of preterm neonates born alive with adjustment for organizational, maternal, and obstetric factors., Results: The analysis included 3,138 singleton live births from 24 to 34 weeks of gestation with a newborn in-hospital mortality rate of 5.0% (95% confidence interval 4.5-5.7). Preterm labor was the most frequent cause of preterm birth (n=1,293 [43.5%]) followed by preterm premature rupture of membranes (n=765 [23.9%]), hypertensive disorders without suspected fetal growth restriction (n=397 [12.7%]), hypertensive disorders with suspected fetal growth restriction (n=408 [10.9%]), placental abruption after an uncomplicated pregnancy (n=92 [3.0%]), and suspected fetal growth restriction without hypertensive disorders (n=183 [5.9%]). Neonates born because of suspected fetal growth restriction with or without hypertensive disorders (adjusted odds ratio [OR] 3.0 [1.9-4.7] and adjusted OR 2.3 [1.1-4.6], respectively) had higher adjusted risks of in-hospital death than those born after preterm labor. Risks of in-hospital mortality for preterm births caused by preterm premature rupture of membranes (adjusted OR 1.3 [0.9-1.9]), hypertensive disorders without fetal growth restriction (adjusted OR 0.7 [0.4-1.4]), or placental abruption (adjusted OR 1.6 [0.7-3.7]) were similar to those born after preterm labor., Conclusion: Among neonates born alive before 34 weeks of gestation, only those born because of suspected fetal growth restriction have a higher mortality risk than those born after preterm labor.

Background: Screening for fetal growth restriction (FGR) is a major component of prenatal care. We investigated whether the presence of maternal and pregnancy risk factors for FGR improves the antenatal suspicion of FGR for infants born small-for-gestational age (SGA) as well as their impact on screening specificity., Methods: Data are from a representative sample of births from the 2010 French National Perinatal Survey (n = 14 100). Detection of FGR was determined by a suspicion of FGR noted in medical charts. Analyses were performed for singleton infants with birthweight under the 10th percentile (SGA), under the 3rd percentile (severely SGA), and above the 10th percentile (false positives) of French references. We studied risk factors for FGR (medical and obstetric conditions, advanced maternal age, nulliparity, body mass index and smoking) using multivariable Poisson regression to derive adjusted risk ratios (aRR)., Results: Of SGA infants, 21.7% were suspected of FGR. The presence of obstetric and medical risk factors for FGR was associated with higher suspicion among SGA infants [RR 2.1, 95% confidence interval (CI) 1.7, 2.7]. However, despite the presence of these factors, 60% and 40% of SGA and severely SGA infants, respectively, were not suspected of FGR. Two per cent of normal birthweight infants were suspected of FGR, increasing to 5% when obstetric and medical risk factors were present. Smoking and older maternal age were unrelated to suspicion while females were more likely to be suspected of FGR., Conclusion: Our results suggest that better risk assessment could improve antenatal identification of FGR. Sex-specific fetal growth references should be used to avoid systematic bias linked to sex., (© 2015 John Wiley & Sons Ltd.)

Background: Self-rated mental health is a useful indicator to examine the positive dimension of mental health and psychological well-being. The primary objective of this study was to estimate the prevalence of poor self-rated mental health during pregnancy in a nationally representative population in France. The second objective was to assess the sociodemographic and medical characteristics associated with this condition and with a health professional's consultation for psychological problems., Methods: The study was based on the 2010 French National Perinatal Survey, which included all singleton live births in French maternity units during a 1-week period (n=14,326 women). Self-rated mental health was assessed using the following single-item question: "During your pregnancy, how did you feel from a psychological point of view: good - fairly good - rather poor - poor?" Women were also asked if they had visited a healthcare professional for psychological problems. They were interviewed between delivery and discharge to collect information on mental health, sociodemographic and medical characteristics, the context of their pregnancy, and their prenatal care., Results: Of the women interviewed, 8.9% [95% CI, 8.5-9.5%] reported poor self-rated mental health during pregnancy. Among them, 18.7% consulted a healthcare professional for psychological problems. Sociodemographic characteristics indicative of social disadvantage were associated with a higher-risk of poor self-rated mental health, and a social gradient was observed. However, more favorable social characteristics were associated with consultation with a healthcare professional for these psychological difficulties. The reaction to the discovery of pregnancy and prenatal care differed significantly depending on self-rated mental health. Women with poor mental health had more complicated pregnancies., Conclusion: This study showed strong associations between many socially disadvantaged characteristics and a positive dimension of mental health. The findings suggest that well-being measures such as self-rated mental health should be routinely assessed during pregnancy so that women can be offered more appropriate support., (Copyright © 2015. Published by Elsevier Masson SAS.)

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.

Objective: Twins have inconsistently shown poorer outcomes than singletons. Although a high proportion of twins are born very preterm, data are sparse on the long-term outcomes in very preterm twins. The objective of this study was to compare mortality and neurodevelopmental outcomes of very preterm singletons and twins and to study outcomes in relation to factors specific to twins., Design: Birth cohort study Etude Epidemiologique sur les Petits Ages Gestationnels (EPIPAGE)., Setting: Nine regions in France., Patients: All very preterm live births occurring from 22 to 32 weeks of gestation in all maternity wards of nine French regions in 1997 (n=2773)., Main Outcomes Measures: Neurodevelopmental status, including cerebral palsy, and a cognitive assessment with the Kaufman Assessment Battery for Children, with scores on the Mental Processing Composite (MPC) scale, was available for 1732 and 1473 children at 5 years of age, respectively., Results: Among live births, twins had higher hospital mortality than singletons (adjusted (a)OR: 1.4 (95% CI 1.1 to 1.9)). Among survivors, there was no crude difference at 5 years between twins and singletons in the prevalence of cerebral palsy (8.0% vs 9.1%, respectively), MPC <70 (9.5% vs 11.1%) and mean MPC (94.6 vs 94.4). However, after adjustment for sex, gestational age, intrauterine growth restriction and social factors, twins were more likely to have lower MPC scores (mean difference: -2.4 (95% CI-4.8 to 0.01)). Live born twins had a higher risk of mortality when birth weight discordance was present (aOR:2.9 (95% CI 1.7 to 4.8)), but there were no differences in long-term outcomes., Conclusions: Compared with very preterm singletons, twins had higher mortality, no difference with respect to severe deficiencies, but slightly lower MPC scores at 5 years.

Objective: To determine whether neonatal infections are associated with a higher risk of adverse neurodevelopment at 5 years of age in a population-based cohort of very preterm children., Methods: We included all live births between 22 and 32 weeks of gestation, from 9 regions in France, in 1997 (EPIPAGE study). Of the 2665 live births, 2277 were eligible for a follow-up evaluation at 5 years of age: 1769 had a medical examination and 1495 underwent cognitive assessment. Cerebral palsy and cognitive impairment were studied as a function of early-onset sepsis (EOS) and late-onset sepsis (LOS), after adjustment for potential confounding factors, in multivariate logistic regression models., Results: A total of 139 (5%) of the 2665 live births included in the study presented with EOS alone (without associated LOS), 752 (28%) had LOS alone (without associated EOS), and 64 (2%) displayed both EOS and LOS. At 5 years of age, the frequency of cerebral palsy was 9% (157 of 1769) and that of cognitive impairment was 12% (177 of 1495). The frequency of cerebral palsy was higher in infants with isolated EOS (odds ratio [OR]: 1.70 [95% confidence interval (CI): 0.84-3.45]) or isolated LOS (OR: 1.71 [95% CI: 1.14-2.56]) than in uninfected infants, and this risk was even higher in cases of combined EOS and LOS (OR: 2.33 [95% CI: 1.02-5.33]). There was no association between neonatal infection and cognitive impairment., Conclusions: Neonatal infections in these very preterm infants were associated with a higher risk of cerebral palsy at the age of 5 years, particularly in infants presenting with both EOS and LOS.

Socio-demographic characteristics of mothers have been associated with exclusive breastfeeding duration, but little is known about the association with maternal full- and part-time employment and return to work in European countries. To study the associations between breastfeeding, any and almost exclusive (infants receiving breast milk as their only milk) breastfeeding, at 4 months of infant's age and the socio-demographic and occupational characteristics of mothers. We used the EDEN mother-child cohort, a prospective study of 2002 singleton pregnant women in two French university hospitals. We selected all mothers (n = 1,339) who were breastfeeding at discharge from the maternity unit. Data on feeding practices were collected at the maternity unit and by postal questionnaires at 4, 8 and 12 months after the birth. Among infants breastfed at discharge, 93% were still receiving any breastfeeding (83% almost exclusive breastfeeding) at the 3rd completed week of life, 78% (63%) at the 1st completed month, and 42% (20%) at the 4th completed month. Time of return to work was a major predictor for stopping breastfeeding: the sooner the mothers returned to work, the less they breastfed their babies at 4 months of infant's age, independently of full-time or part-time employment. The association was stronger for almost exclusive breastfeeding mothers than for any breastfeeding ones. In a society where breastfeeding is not the norm, women may have difficulties combining work and breastfeeding. Specific actions need to be developed and assessed among mothers who return to work and among employers.

Background: Retinoblastoma (RB) is the most frequent eye tumour in children, with an incidence of 1 in 15-20,000 births. It accounts for 11% of all cancers in the first year of life. Except for the hereditary forms, its causes are not well-known. Studies have recently suggested an increased risk of RB among children born after IVF, but the relevant literature is sparse. We assessed the association between infertility treatment, subfertility and RB., Methods: We included all children living in France diagnosed with RB between 1 January 2000 and 31 December 2006 at the Institut Curie, the national reference centre for RB diagnosis and treatment. We used multiple logistic regression to compare them with a national sample of births in France in 1998 and 2003 (n = 28 170)., Results: The study included 244 non-familial RB cases. The risk of RB increased with maternal age [adjusted odds ratio (adj OR) = 2.07, 95% confidence interval (CI) 1.33-3.22 at 35-39 years compared with younger than 25 years and adj OR = 2.42, 95% CI 1.22-4.81 at 40 years or older], but the associations with IVF (adj OR = 1.37, 95% CI 0.64-2.95) and ovarian stimulation or intrauterine insemination (adj OR = 1.35, 95% CI 0.77-2.38) were not statistically significant after adjustment for maternal age and tobacco use. Among women who had no infertility treatment, the risk of RB was significantly increased when time to pregnancy exceeded 24 months (adj OR = 2.02, 95% CI 1.17-3.48) compared with time to pregnancy ≤ 24 months., Conclusions: Our study did not observe a significantly increased risk of RB associated with infertility treatment, in particular with IVF. But we did find an increased risk for women for whom time to pregnancy exceeded 24 months.

Background: Altered palatal morphology has been observed among some preterm children, with possible consequences on chewing, speaking and esthetics, but determinants remain unknown., Aim: To explore the role of neonatal characteristics and neuromotor dysfunction in alteration of palatal morphology at 5 years of age in very preterm children., Study Design: Prospective population-based cohort study., Subjects: 1711 children born between 22 and 32 weeks of gestation in 1997 or born between 22 and 26 weeks of gestation in 1998 were included in the study. They all had a medical examination at 5 years of age., Outcome Measures: Alteration of palatal morphology., Results: The prevalence of altered palatal morphology was 3.7% in the overall sample, 5.1% among boys and 2.2% among girls (adj OR: 2.52; 95%CI: 1.44-4.42). The risk for altered palatal morphology was higher for lower gestational age (adj OR: 0.85; 95%CI: 0.74-0.97 per week), small-for-gestational age children (adj OR: 2.11; 95%CI: 1.20-3.72) or children intubated for more than 28 days (adj OR: 3.16; 95%CI: 1.11-8.98). Altered palatal morphology was more common in case of cerebral palsy or moderate neuromotor dysfunction assessed at 5 years. Results were basically the same when neuromotor dysfunction was taken into account, except for intubation., Conclusion: Male sex, low gestational age, small-for-gestational age and long intubation have been identified as probable neonatal risk factors for alteration of palatal morphology at 5 years of age in very preterm children. Further studies are needed to confirm these results., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Introduction: Little is known on the prevalence of tooth decay among pregnant women. Better knowledge of tooth decay risk indicators during pregnancy could help to develop follow-up protocols for women at risk, along with better prevention strategies. The aim of this study was to assess the frequency of tooth decay and the number of decayed teeth per woman in a large sample of pregnant women in France, and to study associated risk indicators., Methods: A secondary cross-sectional analysis of data from a French multicentre case-control study was performed. The sample was composed of 1094 at-term women of six maternity units. A dental examination was carried out within 2 to 4 days post-partum. Socio-demographic and behavioural characteristics were obtained through a standardised interview with the women. Medical characteristics were obtained from the women's medical records. Risk indicators associated with tooth decay were identified using a negative binomial hurdle model., Results: 51.6% of the women had tooth decay. The mean number of decayed teeth among women having at least one was 3.1 (s.d. = 2.8). Having tooth decay was statistically associated with lower age (aOR = 1.58, 95%CI [1.03,2.45]), lower educational level (aOR = 1.53, 95%CI [1.06,2.23]) and dental plaque (aOR = 1.75, 95%CI [1.27,2.41]). The number of decayed teeth was associated with the same risk indicators and with non-French nationality and inadequate prenatal care., Discussion: The frequency of tooth decay and the number of decayed teeth among pregnant women were high. Oral health promotion programmes must continue to inform women and care providers about the importance of dental care before, during and after pregnancy. Future research should also assess the effectiveness of public policies related to oral health in target populations of pregnant women facing challenging social or economic situations.

Maternal weight change before pregnancy can be considered as an indicator of maternal energy balance and nutritional status before conception, and may be involved in early life programming. We aimed to investigate the association of maternal Weight Change Before Pregnancy (WCBP) with fetal growth and adverse pregnancy outcomes. Data are from the French EDEN mother-child cohort where 1,756 mother-child pairs had information on mother's weight at 20 years, weight just before pregnancy, fetal anthropometry at second and third trimesters, infant's birthweight and pregnancy complications. The average annual WCBP between 20 years and start of pregnancy (in kg/year) was categorized as: "Weight Loss" (n = 320), "Moderate weight gain" (n = 721) and "High weight gain" (n = 715). The associations of WCBP with fetal and newborn characteristics and with adverse pregnancy outcomes were analyzed, adjusting for maternal and pregnancy characteristics, including the mother's prepregnancy BMI. Interactions between WCBP and prepregnancy BMI were tested. Birthweight and estimated fetal weight in the third trimester increased significantly with increasing WCBP in mothers with BMI <25 kg/m(2). In these mothers, weight loss before pregnancy was associated with a higher risk of newborns small for gestational age (SGA). Whatever the prepregnancy BMI, WCBP was positively associated with a maternal risk of gestational diabetes and hypertension. The ponderal history of mothers before pregnancy can impact on fetal growth and on pregnancy outcomes such as gestational diabetes or hypertension. Our analysis is the first to report that in non-overweight women, those who lost weight before pregnancy are at higher risk of having SGA newborns.

Objectives: To evaluate growth for children born very preterm with particular focus on those born small-for-gestational age (SGA) or with ex utero growth restraint (GR), and to identify risk factors for short stature at 5 years of age., Study Design: Population-based study of children born at less than 33 completed weeks of gestation (Étude Epidémiologique sur les Petits Ages Gestationnels (EPIPAGE)). Short stature was defined as height <-2SD on WHO growth curves. Ex utero GR was considered to have occurred in children with appropriate size for gestational age at birth and with a height and/or weight below -2SD at 2 years of corrected age. Logistic regression models were used to test associations between risk factors and short stature., Results: The authors measured height at 5 years of age for 1,597 of 2,193 children (73%), 5.6% (95% CI 4.6 to 6.9) of whom were diagnosed as having a short stature. Height was measured at 2 and 5 years of age in 1417 children. Among these, 24% of those born SGA and 36% of those with ex utero GR (p=0.002) had a short stature at 5 years. Predictors of short stature were SGA or birth length <-2SD, maternal height ≤ 160 cm, gestational age <29 weeks and systemic corticosteroids. Breastfeeding at discharge decreased the risk of short stature., Conclusions: Short stature at 5 years of age is common in children born preterm. The highest incidence was observed in the group with ex utero GR. Systemic steroids have a long-term impact on growth and should be used with caution. Breastfeeding at discharge appeared to be protective.

We investigated time trends in maternal weight before and during pregnancy and in infant birthweight in France, from 1972 to 2003, using data on singleton live term births from the representative National Perinatal Surveys of 1972, 1981, 1995, 1998 and 2003 (n=8,664, 4,494, 11,445, 12,006, 12,692, respectively). Mothers were interviewed a few days after delivery and data on delivery and the newborn were extracted from hospital records. Maternal prepregnancy weight, height, body mass index and pregnancy weight gain all increased from 1972 to 2003; however, birthweight did not show a parallel trend. After taking gestational age, maternal age, parity, country of origin, newborn gender and maternal smoking during pregnancy into account, mean birthweight increased between 1972 and 1995 but decreased thereafter and, consistently, there was an increase in small-for-gestational age (SGA) and a decrease in large-for-gestational age newborns. Further adjustment for induced delivery, an indicator of obstetric practice, did not change the results. A similar variation has been observed very recently in the US and in Germany. Further research is needed to identify the factors responsible for these discordant changes and especially the factors responsible for the recent increase in SGA since this has been shown to be associated with poorer health in later life., (© 2011 Blackwell Publishing Ltd.)

Objectives: A statute enacted in 2005 modified the legislative framework of the rights of terminally ill persons in France. Ten years after the EURONIC study, which described the self-reported practices of neonatal caregivers towards ethical decision-making, a new study was conducted to assess the impact of the new law in neonatal intensive care units (NICU) and compare the results reported by EURONIC with current practices., Setting and Design: The study was carried out in the same two NICU as in the EURONIC qualitative study. A third centre was added to increase the sample size. From February to October 2007, 19 physicians and 17 nurses participated in semistructured interviews very similar to those for EURONIC. Content analysis identified the recurring themes emerging from the interviews., Results: Compared with the EURONIC results, the caregivers reported that they pay greater attention to the views of parents and provided respectful support to the neonates when life-sustaining treatment is withdrawn. Active termination of life has become exceptional. The possibility of withdrawal of treatment, the administration of sedatives to control pain even at the risk of hastening death, the emphasis on sparing parents the burden of decision, and the relative ignorance of the law were very similar to the EURONIC findings., Conclusion: Both the medical and the legal regulation of practices has allowed more dialogue with the parents and more humane care for dying newborns. A new European study is necessary to investigate the possible changes in practices and attitudes also in other countries.

Aim: To assess cerebral lesions and other medical as well as social characteristics as predictors of risk of mild and severe cognitive deficiencies in very preterm infants., Methods: As part of the EPIPAGE population-based prospective cohort study, perinatal data and cognitive outcome at 5 years of age were recorded for 1503 infants born before 33 weeks of gestation in nine regions of France in 1997. Mild cognitive deficiency was defined as a Mental Processing Composite score on the Kaufman Assessment Battery for Children test of between 70 and 84, and severe cognitive deficiency as a score of <70., Results: After controlling for cerebral lesions and other medical as well as social factors, low parental socio-economic status and lack of breastfeeding were significant predictors of mild and severe cognitive deficiencies, whereas presence of cerebral lesions, being small for gestational age and having a large number of siblings were predictors of severe cognitive deficiency., Conclusion: Predictors of poor cognitive outcome in very preterm infants are low social status, lack of breastfeeding, presence of cerebral lesions on ultrasound scan, being born small for gestational age and having a high number of siblings. Social factors predicted both mild and severe cognitive deficiencies, whereas medical factors predicted mostly severe cognitive deficiencies., (© 2011 The Author(s)/Acta Paediatrica © 2011 Foundation Acta Paediatrica.)

Objective: To study trends in smoking before and during pregnancy in national samples of pregnant women and changes in characteristics of smokers over time, and describe the current relation between maternal smoking during pregnancy and fetal growth., Population and Methods: Five nationally representative samples of singleton live births in metropolitan France (1972, 1981, 1995, 1998 and 2003) were used to study the change in smoking rates during pregnancy over the past 30 years. We further examined changes in smoking rates between 1998 and 2003 according to maternal characteristics. Finally, we estimated the effect of smoking on fetal growth in 2003., Results: Prevalence of smoking decreased over time, but the rate remained high, 21 % in 2003. The decrease was more important among women at low risk of adverse pregnancy outcomes, resulting in increased social disparities. We confirmed the strong dose-response relation between tobacco use during pregnancy and fetal growth., Conclusion: It is important to verify that smoking during pregnancy is still decreasing and to develop policies to encourage women to quit smoking during pregnancy, especially for highly exposed groups., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Objectives: To investigate school difficulties, special care and behavioral problems in 8 year-old very preterm (VPT) children., Patient and Methods: Longitudinal population-based cohort in nine regions of France of VPT children and a reference group born at 39-40 weeks of gestation (WG). The main outcome measures were information about school, special care and behavioral problems using Strengths and Difficulties Questionnaire from a questionnaire to parents., Results: Among the 1439 VPT children, 5% (75/1439) were in a specialised school or class, 18% (259/1439) had repeated a grade in a mainstream class and 77% (1105/1439) were in the appropriate grade-level in mainstream class; these figures were 1% (3/327) , 5% (16/327) and 94% (308/327) , respectively, for the reference group. Also, 15% (221/1435) of VPT children in a mainstream class received support at school versus 5% (16/326) of reference group. More VPT children between the ages of five and eight years received special care (55% (794/1436)) than children born at term (38% (124/325)); more VPT children (21% (292/1387)) had behavioral difficulties than the reference group (11% (35/319)). School difficulties, support at school, special care and behavioral difficulties in VPT children without neuromotor or sensory deficits varied with gestational age, socioeconomic status, and cognitive score at the age of five., Conclusions: Most 8-year-old VPT children are in mainstream schools. However, they have a high risk of difficulty in school, with more than half requiring additional support at school and/or special care. Referral to special services has increased between the ages of 5 and 8 years, but remained insufficient for those with borderline cognitive scores.

Background: Studies of the effects of air pollutants on birth weight often assess exposure with networks of permanent air quality monitoring stations (AQMSs), which have a poor spatial resolution., Objective: We aimed to compare the exposure model based on the nearest AQMS and a temporally adjusted geostatistical (TAG) model with a finer spatial resolution, for use in pregnancy studies., Methods: The AQMS and TAG exposure models were implemented in two areas surrounding medium-size cities in which 776 pregnant women were followed as part of the EDEN mother-child cohort. The exposure models were compared in terms of estimated nitrogen dioxide (NO2) levels and of their association with birth weight., Results: The correlations between the two estimates of exposure during the first trimester of pregnancy were r = 0.67, 0.70, and 0.83 for women living within 5, 2, and 1 km of an AQMS, respectively. Exposure patterns displayed greater spatial than temporal variations. Exposure during the first trimester of pregnancy was most strongly associated with birth weight for women living < 2 km away from an AQMS: a 10-µg/m3 increase in NO2 exposure was associated with an adjusted difference in birth weight of -37 g [95% confidence interval (CI), -75 to 1 g] for the nearest-AQMS model and of -51 g (95% CI, -128 to 26 g) for the TAG model. The association was less strong (higher p-value) for women living within 5 or 1 km of an AQMS., Conclusions: The two exposure models tended to give consistent results in terms of association with birth weight, despite the moderate concordance between exposure estimates.

Mother-to-child transmission of chikungunya virus was reported during the 2005-2006 outbreak on Reunion Island, France. To determine the effects of this virus on pregnancy outcomes, we conducted a study of pregnant women in Reunion in 2006. The study population was composed of 1,400 pregnant women (628 uninfected, 658 infected during pregnancy, 27 infected before pregnancy, and 87 infected on unknown dates). We compared pregnancy outcomes for 655 (628 + 27) women not infected during pregnancy with 658 who were infected during pregnancy. Infection occurred during the first trimester for 15% of the infected women, the second for 59%, and the third for 26%. Only hospital admission during pregnancy differed between infected and uninfected women (40% vs. 29%). Other outcomes (cesarean deliveries, obstetric hemorrhaging, preterm births, stillbirths after 22 weeks, birthweight, congenital malformations, and newborn admissions) were similar. This virus had no observable effect on pregnancy outcomes.

Objective: Low-dose aspirin (LDA) given during pregnancy may alter brain development in very preterm infants. We report the short- and long-term outcomes of very preterm infants according to LDA treatment., Patients and Methods: Data were from the Etude Epidemiologique des Petites Ages Gestationnels (EPIPAGE) cohort study, which included all infants born before 33 weeks of gestation in 9 French regions in 1997. This study was restricted to 656 children who were born to 584 women with an obstetric history of placental vascular disease or with chronic hypertension or renal or autoimmune diseases. The main outcome measures were mortality, cerebral lesions, and outcome at 5 years of age, which were measured by a diagnosis of cerebral palsy; behavioral difficulties, which were assessed with the Strength and Difficulties Questionnaire; and cognitive impairment, which was measured by the mental processing composite scale of the Kaufman Assessment Battery for Children (an IQ-equivalent measure of cognitive ability in 2 dimensions: sequential and simultaneous processing scores)., Results: LDA treatment was administered to 125 of 584 (21%) mothers and was not significantly associated with mortality, cerebral lesions, cerebral palsy, or global cognitive impairment of the children at 5 years of age. The proportion of low simultaneous processing scores (<70) was lower in the group with LDA (7% vs 19% without LDA; P = .04). This association was not significant after adjustment for propensity score, prognostic factors, and social class (adjusted odds ratio [aOR]: 0.59 [95% confidence interval (CI): 0.17-2.06]). LDA treatment was associated with a reduction, at the limit of significance, in total behavioral difficulties (aOR: 0.44 [95% CI: 0.19-1.02]) and hyperactivity (aOR: 0.43 [95% CI: 0.17-1.05])., Conclusions: LDA was not associated with adverse neonatal or long-term outcomes. Moreover, the results suggest that LDA may be associated with a reduction in neurobehavioral difficulties. More research is needed to assess the effects of aspirin alone or combined with other neuroprotective agents.

Aim: To analyse the association between maternal periodontitis and preterm birth (<37 weeks' gestation) according to the causes of preterm birth., Materials and Methods: Epipap is a case-control multi-centre study of singleton livebirths. One thousand one hundred and eight women with preterm deliveries and 1094 with deliveries at term (> or =37 weeks) at six French maternity units were included. Periodontal examinations after delivery identified localized and generalized periodontitis. Cases were classified according to four causes of preterm birth. Polytomous logistic regression analysis was used to control for confounders (maternal age, parity, nationality, educational level, marital status, employment during pregnancy, body mass index before pregnancy, smoking status) and the examiner., Results: Localized periodontitis was identified in 129 (11.6%) cases and in 118 (10.8%) control women and generalized periodontitis in 148 (13.4%) and 118 (10.8%), respectively. A significant association was observed between generalized periodontitis and induced preterm birth for pre-eclampsia [adjusted odds ratio 2.46 [95% confidence intervals (95% CI)1.58-3.83]. Periodontitis was not associated with spontaneous preterm birth or preterm premature rupture of membranes or with the other causes., Conclusion: Maternal periodontitis is associated with an increased risk of induced preterm birth due to pre-eclampsia.

Unlabelled: 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.

Objectives: We compared the frequency of behavioral problems in very preterm and term children at 5 years of age. We hypothesized that behavioral problems would be associated with cognitive impairment and environmental factors and that differences between the 2 groups would be reduced but persist after adjusting for cognitive performance and environmental factors., Patients and Methods: The Etude Epidémiologique sur les Petits Ages Gestationnels (EPIPAGE) study was a prospective population-based cohort study that included all births occurring between 22 and 32 weeks' gestation and a control group of infants born at 39 to 40 weeks' gestation in 1997 in 9 French regions. Neonatal and obstetrics data were collected at birth. At 5 years of age, sociodemographic status and neurodevelopmental and cognitive development of the children, as well as maternal mental well-being, were assessed. The behavioral problems of 1102 very preterm and 375 term singletons without major impairments were studied by using the parent-completed Strengths and Difficulties Questionnaire., Results: Parents of very preterm children reported significantly more behavioral problems, with a twofold higher prevalence compared with term children for hyperactivity/inattention, emotional symptoms, and peer problems. Behavioral problems were associated with low cognitive performance, developmental delay, hospitalizations of the child, young maternal age, and poor maternal mental well-being. Very preterm children were still at higher risk of behavioral problems compared with term children after adjustment for cognitive performance and all others factors., Conclusions: Behavioral problems were strongly related to cognitive impairment, but very preterm children were still at higher risk even after adjusting for cognitive performance. Early screening for behavioral problems should be encouraged for all very preterm children, and maternal well-being should also be the focus of special attention.

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.

Recent studies suggest a benefit of seafood and n-3 fatty acid intake on fetal growth and infant development. The objective was to study the association between fatty acid intake and fetal growth in pregnant French women. Pregnant women included in the EDEN mother-child cohort study completed FFQ on their usual diet: (1) in the year before pregnancy and (2) during the last 3 months of pregnancy (n 1439). Conversion into nutrient intakes was performed using data on portion size and a French food composition table. Associations between maternal fatty acid intakes and several neonatal anthropometric measurements were studied using linear regressions adjusted for centre, mother's age, smoking habits, height, parity, gestational age and newborn's sex. Due to significant interaction, analyses were stratified according to maternal pre-pregnancy overweight status. Neither total lipid nor SFA, MUFA or PUFA intake was significantly associated with newborn size. In overweight women only (n 366), a high pre-pregnancy n-3 fatty acid intake (% PUFA) was positively associated with the newborn's birth weight (P=0.01), head, arm and wrist circumferences and sum of skinfolds (P<0.04). A substitution of 1% of n-3 fatty acids per d before pregnancy by other PUFA was related to an average decrease in birth weight of 60 g (P=0.01). Relationships with n-3 fatty acid intake at the end of pregnancy were weaker and not significant. We concluded that a high pre-pregnancy n-3 fatty acid:PUFA ratio may sustain fetal growth in overweight women. Follow-up of the children may help determine whether this has beneficial consequences for the child's health and development.

Studies in countries with high seafood consumption have shown a benefit on fetal growth and child development. The objective of our study was to determine the association between seafood consumption in French pregnant women and fetal growth. Pregnant women included in the EDEN mother-child cohort study completed two food frequency questionnaires on their usual diet in the year before and during the last 3 months of pregnancy (n = 1805). Fetal circumferences were measured by ultrasound and anthropometry at birth. Variables were compared across tertiles of the mother's seafood consumption using multiple linear regression to adjust for confounding variables. Analyses were stratified by maternal overweight status because of an interaction between maternal seafood consumption and her body mass index (P < 0.01). There was no association between seafood intake and fetal growth in the whole sample of women. For overweight women (n = 464), higher consumption of seafood before pregnancy was associated with higher fetal biparietal and abdominal circumferences and anthropometric measures. From the lowest to the highest tertiles, mean birthweight was 167 g higher (P = 0.002). No significant association was found with consumption at the end of pregnancy. In conclusion, high seafood consumption before pregnancy is positively associated with fetal growth in overweight women.

Objective: To describe the long-term outcome of very preterm infants receiving prolonged sedation and/or analgesia and examine the relationship between prolonged sedation and/or analgesia and this long-term outcome., Design: A prospective population-based study (Etude EPIdémiologique sur les Petits Ages GEstationnels [EPIPAGE]). To reduce bias, the propensity score method was used., Setting: Nine regions of France., Participants: The study population included very preterm infants of fewer than 33 weeks' gestational age, born in 1997, who received mechanical ventilation and/or surgery. Main Exposure Prolonged exposure to sedative and/or analgesic drugs in the neonatal period, defined as exposure of more than 7 days to sedative and/or opioid drugs., Main Outcome Measure: Presence of moderate or severe disability at 5 years of age., Results: The analysis concerns 1572 premature infants who received mechanical ventilation for whom information about exposure to prolonged sedation and/or analgesia in the neonatal period was available. A total of 115 were exposed and 1457 were not exposed. There was no significant difference between the number of patients lost to follow-up from the group of very preterm infants who were exposed to prolonged sedation and/or analgesia and the group who were not. Exposed very preterm infants had severe or moderate disability at 5 years (41/97; 42%) more often than those who were not exposed (324/1248; 26%). After adjustment for gestational age and propensity score, this association was no longer statistically significant (adjusted relative risk, 1.0; 95% confidence interval, 0.8-1.2)., Conclusion: Prolonged sedation and/or analgesia is not associated with a poor 5-year neurological outcome after adjustment for the propensity score.

Background: The increasing survival rates of children who are born very preterm raise issues about the risks of neurological disabilities and cognitive dysfunction. We aimed to investigate neurodevelopmental outcome and use of special health care at 5 years of age in a population-based cohort of very preterm children., Methods: We included all 2901 livebirths between 22 and 32 completed weeks of gestation from nine regions in France in Jan 1-Dec 31, 1997, and a reference group of 667 children from the same regions born at 39-40 weeks of gestation. At 5 years of age, children had a medical examination and a cognitive assessment with the Kaufman assessment battery for children (K-ABC), with scores on the mental processing composite (MPC) scale recorded. Data for health-care use were collected from parents. Severe disability was defined as non-ambulatory cerebral palsy, MPC score less than 55, or severe visual or hearing deficiency; moderate deficiency as cerebral palsy walking with aid or MPC score of 55-69; and minor disability as cerebral palsy walking without aid, MPC score of 70-84, or visual deficit (<3/10 for one eye)., Findings: In total, 1817 (77%) of the 2357 surviving children born very preterm had a medical assessment at 5 years and 396 (60%) of 664 in the reference group. Cerebral palsy was diagnosed in 159 (9%) of children born very preterm. Scores for MPC were available for 1534 children born very preterm: 503 (32%) had an MPC score less than 85 and 182 (12%) had an MPC score less than 70. Of the 320 children in the reference group, the corresponding values were 37 (12%) and 11 (3%), respectively. In the very preterm group, 83 (5%) had severe disability, 155 (9%) moderate disability, and 398 (25%) minor disability. Disability was highest in children born at 24-28 completed weeks of gestation (195 children [49%]), but the absolute number of children with disabilities was higher for children born at 29-32 weeks (441 children [36%]). Special health-care resources were used by 188 (42%) of children born at 24-28 weeks and 424 (31%) born at 29-32 weeks, compared with only 63 (16%) of those born at 39-40 weeks., Interpretation: In children who are born very preterm, cognitive and neuromotor impairments at 5 years of age increase with decreasing gestational age. Many of these children need a high level of specialised care. Prevention of the learning disabilities associated with cognitive deficiencies in this group is an important goal for modern perinatal care for children who are born very preterm and for their families.

Objectives: To assess the frequency of minor neuromotor dysfunctions (MNDs) at age 5 years according to gestational age, to test their association with behavioral and learning difficulties, and to find determining neonatal factors., Design: Prospective population-based cohort study of children born in 1997 and followed up from birth to age 5 years., Setting: All maternity wards in 9 regions of France., Participants: A total of 1662 children born before 33 completed weeks of gestation and 2 control groups including 245 children born at 33 to 34 weeks and 332 children born at 39 to 40 weeks. Main Exposure Birth before 33 weeks. Main Outcome Measure Short version of the Touwen neurological examination classifying children as healthy, having mild MND (MND-1), or having moderate MND (MND-2) depending on the number of abnormal neuromotor signs found., Results: Of children born before 33 weeks, 41.4% had MND-1 and 3.0% had MND-2. These proportions were 30.8% and 0.5%, respectively, for children born at 33 to 34 weeks and 22.0% and 0.7%, respectively, for children born at 39 to 40 weeks. Minor neuromotor dysfunction was independently associated with learning difficulties at age 5 years (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.2). In very preterm children, factors associated with MND-1 were postnatal corticotherapy (OR, 1.8; 95% CI, 1.3-2.6), multiple births (OR, 0.7; 95% CI, 0.6-0.9), and, in singletons, breastfeeding (OR, 0.8; 95% CI, 0.6-0.99). Being a boy (OR, 3.1; 95% CI, 1.5-6.4), having had acute fetal distress (OR, 2.8; 95% CI, 1.4-5.5) or severe abnormalities on early cranial ultrasonography (OR, 2.7; 95% CI, 1.2-6.2), and having had postnatal corticotherapy (OR, 2.7; 95% CI, 1.2-6.1) increased the risk of MND-2., Conclusions: The high rate of MNDs and their association with an increased risk for learning difficulties justify their screening in case of (even moderate) prematurity.

Objective: Our objective was to explore the practices, attitudes and feelings of obstetricians and midwives in case of extreme prematurity., Population and Methods: A qualitative study was conducted as part of a European Concerted Action (EUROBS) in 1999 and 2000 in three tertiary-care maternity units, located in three cities in the northern, southern and central areas of France respectively. Semi-structured, tape-recorded interviews were conducted and were independently analysed by two different researchers using a content analysis. All full-time obstetricians and half of the full-time midwives were eligible for the study. Overall, 17 obstetricians and 30 midwives participated., Results: Both obstetricians and midwives considered that decision-making in case of very preterm births raised ethical problems concerning the mother and the foetus. Despite some birth weight and gestational age criteria defined in advance, management around delivery appeared to be decided on a case-by-case basis. At birth, the neonatologists made the decisions. They were perceived as more inclined than the obstetrical team to initiate intensive care. If the child was born alive, intensive care was started, knowing that it could be withdrawn later, if appropriate. Parents were sometimes involved in decision-making during pregnancy, less frequently at birth or after birth., Discussion and Conclusion: Compared with obstetricians, midwives tended to have a less favourable perception of the neonatologists' practices, and to deplore the lack of parental information and involvement in decision-making. Decisions about the obstetrical management and resuscitation of extremely preterm infants are essentially always made on a case-by-case basis. Parents are sometimes involved in decision-making. Midwives express serious concerns about the current practices.

Aim: To assess breastfeeding trends in hospital, between 1998 and 2003, according to several characteristics of mothers and maternity units., Methods: Two representative national samples of births, comprising 13,600 live births in 1998 and 14,580 in 2003 were used. Data were collected during hospital stay. All newborns fed entirely or partly on breast milk were considered 'breastfed'. Univariate and multivariate analyses were used to compare the results for the 2 years., Results: Breastfeeding increased in all groups, but this increase varied slightly according to maternal age and the size of the maternity unit. For example, high rates of breastfeeding tended to be concentrated in large maternity units (> or = 1500 deliveries per year) in 1998, but were also found in middle-size units (1000-1499 deliveries per year) in 2003. In 2003, women were more likely to breastfeed if they were at least 25 years old, primiparous, non-French or from a highly qualified occupational group, or if they gave birth in a university hospital or in a maternity unit with more than 1000 deliveries per year., Conclusion: Despite recent efforts to increase the breastfeeding rate, clear social disparities persist and further efforts are required, targeting particular groups of mothers less likely to breastfeed.

Background: Despite the widespread use of highly effective contraception in France, the incidence of abortion is high. A retrospective population-based cohort study was designed to analyse women's contraceptive history., Method: We compared the contraceptive use of 163 women, whose last pregnancy ended in abortion, 6 months before, at the time of, 1 month and 6 months after the event with that of 1787 women who had never had an abortion., Results: A total of 46% of women who experienced an abortion used a highly effective form of contraception 6 months before the event (versus 76% among women who had never had an abortion, P < 0.001). This proportion dropped to 33% at the time of the abortion and increased to 71%, 1 month after. In addition, 50% of women who had an abortion had changed their contraceptive method in the 6 months before the event (compared with 16% in the 6 months before the interview in women who had not had an abortion, P < 0.001). Women with socially deprived backgrounds were less likely to use a highly effective contraception after an abortion., Conclusions: Abortion is a good opportunity for intervention, but especially so for socially disadvantaged women. It is essential to draw the attention of prescribers and women to the higher risk of contraceptive failure at the start of use of a method.

Objective: Perinatal regionalization has been organized into 3 ascending levels of care, fitting increasing degrees of pathology. Current recommendations specify that very premature infants be referred prenatally to level III facilities, yet not all very preterm neonates require level III intensive care. The objective of our study was to determine the antenatal factors that, in association with gestational age, predict the need for neonatal intensive care in preterm infants, to match the size of birth with the level of care required., Methods: Data were analyzed from a cohort of very preterm infants born in nine French regions in 1997. We defined the need for neonatal intensive care as follows: (1) the requirement for specialized management (mechanical ventilation for >48 hours, high frequency oscillation, or inhaled nitric oxide) or (2) poor outcome (transfer to a level III facility within the first 2 days of life or early neonatal death). Triplet pregnancies and pregnancies marked by fetal malformations or intensive care requirements for the mother before delivery were excluded., Results: We focused our study on 1262 neonates aged 30, 31 and 32 weeks' gestation, where the need for intensive care was 42.8%, 33.2%, and 22.8%, respectively. Multivariate analysis showed that the risk factors for intensive care requirement with low gestational age were twin pregnancies, maternal hypertension, antepartum hemorrhage, infection, and male gender. Antenatal steroid therapy and premature rupture of membranes were protective factors against intensive care requirement., Conclusion: Infants <31 weeks' gestation should be referred to level III facilities. From 31 weeks' gestation, some infants can be safely handled in level IIb facilities. However, the quality of perinatal regionalization may only be fully assessed by long-term follow-up.

Objective: To identify the main prenatal risk factors for cerebral palsy in very preterm singletons and twins., Methods: The data were from the Epipage study, which included all very preterm children (< 33 weeks) born in 1997 in 9 regions of France. The analysis included 1,954 children for whom a medical questionnaire was completed at the age of 2 years (83% of the surviving children). The risk factors studied were pregnancy complications and specific factors in twins (type of placenta and death of cotwin). Logistic regression analysis was carried out for singletons and generalized estimating equation models used for twins., Results: The proportion of cerebral palsy was 8% in singletons and 9% in twins. For singletons, spontaneous preterm labor (adjusted odds ratio [OR] 3.4, 95% confidence interval [CI] 1.7-6.7), preterm premature rupture of membranes (PPROM) with short latency (adjusted OR 4.9, 95% CI 2.0-11.8), and prolonged PPROM (adjusted OR 2.7, 95% CI 1.4-5.3) were associated with a higher risk of cerebral palsy than was hypertension. No such link was found between these pregnancy complications and cerebral palsy in twins. For twins, a monochorionic placenta (OR 1.9, 95% CI 1.0-3.6) increased the risk of cerebral palsy, but the OR became nonsignificant after adjustment (OR 1.7, 95% CI 0.8-3.4)., Conclusion: In very preterm singletons, spontaneous preterm labor and PPROM increased the risk of cerebral palsy compared with hypertension.