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El manejo medico durante el primer mes de vida comienza generalmente por los padres con base en los consejos del pediatra de la maternidad. En la consulta, el papel del medico consiste en detectar a los ninos que presentan una patologia mediante una exploracion fisica completa, pero sobre todo garantizar el correcto crecimiento somatico del lactante, comprobar que la relacion entre el bebe y su madre es normal, detectar los signos de depresion materna posnatal y, por ultimo, fomentar la lactancia materna. Esta consulta permite responder a las numerosas dudas de los padres. Es muy importante, ya que el clima de confianza que en ella se debe crear condiciona frecuentemente la calidad del seguimiento medico del nino durante los primeros 2 anos de vida.

Resume Des equipes dediees realisent des transports medicalises pediatriques et neonatals depuis la fin des annees 70 en France. Le Groupe francophone de reanimation et urgences pediatriques (GFRUP) a realise un etat des lieux en 2017 sur la situation en France metropolitaine. Il en ressort qu’il y a maintenant dans chacune des 12 regions metropolitaines au moins 2 equipes de SMUR pediatrique. Le mode de fonctionnement et l’activite varient beaucoup d’une equipe a l’autre. Cela va de quelques centaines de transports a pres de 2000. Les equipes realisant le plus de transports sont en general dediees, alors que les autres sont detachees « a la demande » de la reanimation a laquelle elles appartiennent. L’âge limite des enfants transportes varie aussi, certains SMUR ont une activite exclusivement neonatale et, d’autres transportent les enfants jusqu’a 18 ans. Les SMUR pediatriques evoluent en « s’appropriant » des techniques reservees jusqu’a present aux services de reanimation, les exemples en sont la ventilation par oscillation a haute frequence, l’hypothermie therapeutique active, l’assistance circulatoire extracorporelle et l’echographie transthoracique. La formation initiale et continue, medicale et paramedicale, fait partie des missions universitaires confiees aux SMUR pediatriques. La place des parents lors des soins est une problematique qui s‘est imposee en reanimation et il en est de meme pour les equipes de transport. En presque un demi-siecle le role des SMUR pediatriques a grandement evolue, de structure de sauvetage en dernier recours ils sont devenus un maillon rationnel de la chaine de soins pediatriques au sein des reseaux regionaux.

The neonatal arterial ischemic stroke is an emergency. Recurrent focal seizures, generally occurring in the first 24-72 hours after birth, are the commonest first clinical signs. When neonatal arterial ischemic stroke is suspected, optimal initial management involves careful supportive care including treatment of clinical and frequent or prolonged subclinical seizures, correction of the possible metabolic disorders and their prevention. Contrary to hypoxic ischemic encephalopathy, therapeutic hypothermia is not indicated. This newborn requires emergent transfer to a neonatal intensive care unit for the confirmation of the diagnosis by means of a specialized neonatal transport team.

International audience; Neonatal arterial ischemic stroke (NAIS) is a rare event that occurs in approximately one in 5000 term or close-to-term infants. Most affected infants will present with seizures. Although a well-recognized clinical entity, many questions remain regarding diagnosis, risk factors, treatment, and follow-up modalities. In the absence of a known pathophysiological mechanism and lack of evidence-based guidelines, only supportive care is currently provided. To address these issues, a French national committee set up by the French Neonatal Society (Société française de néonatologie) and the national referral center (Centre national de référence) for arterial ischemic stroke in children drew up guidelines based on an HAS (Haute Autorité de santé [HAS]; French national authority for health) methodology. The main findings and recommendations established by the study group are: (1) among the risk factors, male sex, primiparity, caesarean section, perinatal hypoxia, and fetal/neonatal infection (mainly bacterial meningitis) seem to be the most frequent. As for guidelines, the study group recommends the following: (1) the transfer of neonates with suspected NAIS to a neonatal intensive care unit with available equipment to establish a reliable diagnosis with MRI imaging and neurophysiological monitoring, preferably by continuous video EEG; (2) acute treatment of suspected infection or other life-threatening processes should be addressed immediately by the primary medical team. Persistent seizures should be treated with a loading dose of phenobarbital 20mg/kg i.v.; (3) MRI of the brain is considered optimal for the diagnosis of NAIS. Diffusion-weighted imaging with apparent diffusion coefficient is considered the most sensitive measure for identifying infarct in the neonatal brain. The location and extent of the lesions are best assessed between 2 and 4 days after the onset of stroke; (4) routine testing for thrombophilia (AT, PC PS deficiency, FV Leiden or FII20210A) or for detecting other biological risk factors such as antiphospholipid antibodies, high FVIII, homocysteinemia, the Lp(a) test, the MTHFR thermolabile variant should not be considered in neonates with NAIS. Testing for FV Leiden can be performed only in case of a documented family history of venous thromboembolic disease. Testing neonates for the presence of antiphospholipid antibodies should be considered only in case of clinical events arguing in favor of antiphospholipid syndrome in the mother; (5) unlike childhood arterial ischemic stroke, NAIS has a low 5-year recurrence rate (approximately 1 %), except in those children with congenital heart disease or multiple genetic thrombophilia. Therefore, initiation of anticoagulation or antithrombotic agents, including heparin products, is not recommended in the newborn without identifiable risk factors; (6) the study group recommends that in case of delayed motor milestones or early handedness, multidisciplinary rehabilitation is recommended as early as possible. Newborns should have physical therapy evaluation and ongoing outpatient follow-up. Given the risk of later-onset cognitive, language, and behavioral disabilities, neuropsychological testing in preschool and at school age is highly recommended.; L’accident vasculaire cérébral ischémique artériel néonatal (AVCian) est une pathologie rare. Afin d’actualiser les connaissances sur ce sujet, un groupe de travail multidisciplinaire s’est constitué sous l’égide de la Société française de néonatologie et le Centre national de référence de l’AVC de l’enfant afin de proposer des recommandations sur les facteurs de risque, les modalités de transfert et de prise en charge pré-hospitalière, les modalités diagnostiques et thérapeutiques, le traitement, le pronostic et la prise en charge à court et moyen terme. Ces recommandations ont été réalisées selon la méthodologie de la Haute autorité de santé et en fonctions des thématiques proposées par un comité d’experts. Les principales recommandations issues de ce travail sont : (1) l’orientation du patient vers une unité de réanimation ou de soins intensifs néonatals disposant d’une imagerie par résonance magnétique (IRM) facilement accessible et de la possibilité de réaliser une surveillance continue par électro-encéphalogramme ; (2) le phénobarbital est le médicament de première ligne pour le traitement des crises convulsives ; (3) l’IRM réalisée entre j2 et j4 après la survenue de l’AVCian est la meilleure technique pour confirmer le diagnostic et préciser son extension ; (4) un facteur biologique de risque thrombotique ne doit pas être systématiquement recherché après un AVCian, sauf en cas d’antécédent thrombotique veineux familial ; (5) un traitement thrombolytique n’est pas recommandé ; (6) une prise en charge rééducative précoce est recommandée en cas de déficience motrice évidente.

Resume L’accouchement inopine hors maternite represente, en France, environ 0,5 % de la totalite des accouchements. La parturiente est surveillee de facon continue par un moniteur multiparametrique. La surveillance du rythme cardiaque du fœtus est realisee a l’aide d’un Doppler fœtal. L’analgesie n’est realisee que par l’inhalation au masque a haute concentration d’un melange equimoleculaire d’oxygene et de protoxyde d’azote. Dans certaines situations, en raison d’un terme premature, d’une grossesse gemellaire ou d’une pathologie maternelle ou parfois d’anomalies du rythme cardiaque fœtal, l’assistance d’un SMUR pediatrique peut etre necessaire. La conduite des efforts expulsifs ne doit debuter que lorsque l’on voit apparaitre la presentation a la vulve et seulement si la dilatation est complete et la poche des eaux rompue. L’expulsion ne doit pas durer plus de 30 minutes. Il ne faut pas pratiquer d’episiotomie de facon systematique. Il est recommande de pratiquer une delivrance dirigee. En cas de liquide amniotique clair, et si le nouveau-ne a terme respire, crie, et a un bon tonus, des soins de routine sont realises : rechauffement, essuyage et sechage doux. Trois criteres, evalues toutes les 30 secondes, guident ensuite la prise en charge : la frequence cardiaque, la qualite de la respiration et le tonus musculaire. La redaction d’un certificat de naissance est une obligation legale et incombe au medecin qui a pratique l’accouchement.

In caso di difficolta di adattamento alla vita extrauterina, e, oggi, prioritaria una rianimazione respiratoria di qualita durante i primi minuti di vita. Nel neonato a termine, essa si basa attualmente sulla ventilazione in pressione positiva iniziale sotto aria e, in caso di fallimento, sull’intubazione endotracheale. Oltre alla clinica, la misurazione della CO 2 espirata con capnografia e la metodica piu affidabile per confermare la buona posizione della sonda di intubazione. Le compressioni toraciche esterne (massaggio cardiaco esterno) e l’adrenalina per via venosa hanno solo un ruolo limitato. Se il neonato nasce in un liquido amniotico meconiale ed e «non vigoroso», e importante eseguire un’aspirazione dell’orofaringe e, quindi, della trachea. Nel prematuro, l’apporto di ossigeno sara adattato ad ogni caso, secondo il valore della saturazione in ossigeno misurata con ossimetria pulsata sopraduttale, grazie a un miscelatore aria/ossigeno e all’aggiunta di una pressione espiratoria precoce in ventilazione spontanea e ugualmente benefica. Gli estremi prematuri (eta gestazionale inferiore a 28 settimane) devono nascere con una temperatura ambiente di almeno 26 °C ed essere posizionati immediatamente (senza asciugatura preventiva) in un sacco in polietilene. Si incontrano difficili dilemmi etici in caso di assenza di attivita cardiaca rilevabile per piu di 10 minuti o di nascita ai limiti della vitalita. I neonati a termine che presentano un’encefalopatia ipossi-ischemica lieve o grave devono poter beneficiare di un’ipotermia, prima della 6 a ora di vita, nel quadro di protocolli, e di un follow-up prolungato all’interno delle reti perinatali. Le tecniche di simulazione sono raccomandate come complemento delle metodiche tradizionali per la formazione e il mantenimento delle competenze del personale che lavora in sala parto.

L’accouchement inopine hors d’une maternite represente, en France, environ 0,5 % de la totalite des accouchements. La parturiente est installee en decubitus dorsal en travers du lit, fesses au bord du lit, bassin sureleve par les oreillers et les pieds reposant chacun sur une chaise. Elle est surveillee de facon continue par un moniteur multiparametrique. La surveillance du rythme cardiaque du foetus est realisee a l’aide d’un Doppler foetal. L’analgesie n’est realisee que par l’inhalation au masque a haute concentration d’un melange equimoleculaire d’oxygene et de protoxyde d’azote. Dans certaines situations, en raison d’un terme premature, d’une grossesse gemellaire ou d’une pathologie maternelle ou parfois d’anomalies du rythme cardiaque foetal, l’assistance d’un service medical d’urgence et de reanimation (SMUR) pediatrique peut etre necessaire. La conduite des efforts expulsifs ne doit debuter que lorsque l’on voit apparaitre la presentation a la vulve et seulement si la dilatation est complete et la poche des eaux rompue. L’expulsion ne doit pas durer plus de 30 minutes. Il ne faut pas pratiquer une episiotomie de facon systematique. Il est recommande de pratiquer une delivrance dirigee. En cas de liquide amniotique clair, et si le nouveau-ne a terme respire, crie et a un bon tonus, des soins de routine sont realises: rechauffement, essuyage et sechage doux. Trois criteres, evalues toutes les 30 secondes, guident ensuite la prise en charge: la frequence cardiaque, la qualite de la respiration et le tonus musculaire. La redaction d’un certificat de naissance est une obligation legale et incombe au medecin qui a pratique l’accouchement.

Neonatal arterial ischemic stroke (NAIS) is a rare event that occurs in approximately one in 5000 term or close-to-term infants. Most affected infants will present with seizures. Although a well-recognized clinical entity, many questions remain regarding diagnosis, risk factors, treatment, and follow-up modalities. In the absence of a known pathophysiological mechanism and lack of evidence-based guidelines, only supportive care is currently provided. To address these issues, a French national committee set up by the French Neonatal Society (Société française de néonatologie) and the national referral center (Centre national de référence) for arterial ischemic stroke in children drew up guidelines based on an HAS (Haute Autorité de santé [HAS]; French national authority for health) methodology. The main findings and recommendations established by the study group are: (1) among the risk factors, male sex, primiparity, caesarean section, perinatal hypoxia, and fetal/neonatal infection (mainly bacterial meningitis) seem to be the most frequent. As for guidelines, the study group recommends the following: (1) the transfer of neonates with suspected NAIS to a neonatal intensive care unit with available equipment to establish a reliable diagnosis with MRI imaging and neurophysiological monitoring, preferably by continuous video EEG; (2) acute treatment of suspected infection or other life-threatening processes should be addressed immediately by the primary medical team. Persistent seizures should be treated with a loading dose of phenobarbital 20mg/kg i.v.; (3) MRI of the brain is considered optimal for the diagnosis of NAIS. Diffusion-weighted imaging with apparent diffusion coefficient is considered the most sensitive measure for identifying infarct in the neonatal brain. The location and extent of the lesions are best assessed between 2 and 4 days after the onset of stroke; (4) routine testing for thrombophilia (AT, PC PS deficiency, FV Leiden or FII20210A) or for detecting other biological risk factors such as antiphospholipid antibodies, high FVIII, homocysteinemia, the Lp(a) test, the MTHFR thermolabile variant should not be considered in neonates with NAIS. Testing for FV Leiden can be performed only in case of a documented family history of venous thromboembolic disease. Testing neonates for the presence of antiphospholipid antibodies should be considered only in case of clinical events arguing in favor of antiphospholipid syndrome in the mother; (5) unlike childhood arterial ischemic stroke, NAIS has a low 5-year recurrence rate (approximately 1 %), except in those children with congenital heart disease or multiple genetic thrombophilia. Therefore, initiation of anticoagulation or antithrombotic agents, including heparin products, is not recommended in the newborn without identifiable risk factors; (6) the study group recommends that in case of delayed motor milestones or early handedness, multidisciplinary rehabilitation is recommended as early as possible. Newborns should have physical therapy evaluation and ongoing outpatient follow-up. Given the risk of later-onset cognitive, language, and behavioral disabilities, neuropsychological testing in preschool and at school age is highly recommended.

Since 35 years, transportation of critically ill children is provided by neonatal and paediatric specialized mobile intensive care units (SMUR), which significantly improved patient support and transfer. Since 2005, the French regulation progressed when the Directorate for Hospitalization and Organization of Care classified interhospital transport into three categories according to the health care provider present during the transport (doctor in medicine, nurse or paramedics). It also detailed the objectives as well as the human and material resources required for each kind of transport. Further, a study conducted in 2011 by the French-speaking group of paediatric intensive care and emergency medicine (GFRUP) showed that most of the French regions have already got specialized SMUR teams, although their organization and activity reports still considerably varied according to their location. The dedicated medical staffs remained limited, while nursing staffs increased. Currently, the main paediatric SMUR teams perform primary transports and secondary transports of older children and take part in the regulation of paediatrician calls. The national group of paediatric SMUR coordinates various projects, aiming to develop teaching, evaluation and research within the speciality.

For apneic or bradycardic babies born at term, it is best to begin ressuscitation in the delivery room with air rather than 100% oxygen. Administration of supplementary oxygen should be regulated by blending oxygen and air, and the concentration delivered should be guided by oximetry. Preterm babies less than 32 weeks gestation may not reach the same arterial blood oxygen saturations in air as those achieved by term babies. Therefore, blended oxygen and air should be given guided by pulse oximetry. Detection of exhaled carbon dioxide in addition to clinical assessment is recommended as the most reliable method to confirm placement of a tracheal tube in neonates. If presented with a floppy, apnoeic baby born through meconium, it is reasonable to rapidly inspect the oropharynx to remove potential secretions. Tracheal intubation and suction may be useful. Therapeutic hypothermia should be considered for infants born at term or near-term with evolving moderate to severe hypoxic-ischemic encephalopathy, with protocol and follow-up coordinated through a regional perinatal system. For preterm babies of less than 28 weeks gestation delivery room temperatures should be at least 26 °C. They should be completely covered in a food-grade plastic bag up to their necks, without drying, immediately after birth. If the heart rate of a newly born baby is not detectable and remains undetectable for 10 min, it is then appropriate to consider stopping resuscitation. Simulation should be used as a methodology in resuscitation education.

Depuis la fin des annees 1970, les transports neonatals sont organises et realises, en France et dans la plupart des pays europeens, par des equipes specialisees, le plus souvent medicalisees. Celles-ci sont soit dediees et disponibles pour une region, soit liees a une unite de reanimation neonatale au sein d’un reseau local ou regional. En France, la legislation a evolue permettant de definir au cours du transfert neonatal, en lien avec les changements d’organisation lies au Plan perinatalite, deux niveaux de soins et de surveillance: medicalise et infirmier. Les Smur pediatriques ont participe dans notre pays a la diffusion des techniques recentes et des protocoles de soins, a l’amelioration des resultats obtenus et a la mise en place de la regionalisation des soins perinatals. Ils ont egalement contribue a evaluer dans plusieurs regions francaises les politiques perinatales des 15 dernieres annees et a former les urgentistes, les pediatres, les sages-femmes et les infirmier(ere)s.

La priorita di una rianimazione respiratoria di qualita durante i primi minuti di vita in caso di difficolta di adattamento alla vita extrauterina e oggi consensuale. La supplementazione iniziale di ossigeno e invece in discussione. Il massaggio cardiaco esterno e i farmaci hanno un ruolo minore. L’adrenalina, nelle sue rare indicazioni, e utilizzata di preferenza per via endovenosa. In caso di nascita in un liquido amniotico meconiale, l’aspirazione sistematica, prima oro- e nasofaringea nel momento della fuoriuscita delle spalle e poi nella trachea, non viene piu raccomandata. L’importanza della ventilazione non invasiva precoce non e stata ancora definitivamente stabilita nel prematuro. Il trasferimento della madre a una maternita vicina a un’unita neonatale di terapia intensiva o di rianimazione e sempre preferibile in caso di minaccia di parto prematuro o di patologia materna che metta in gioco la sicurezza della madre e del bambino. Il trasporto del neonato, quando indicato, deve essere organizzato e realizzato da personale esperto con materiale adatto alla patologia del bambino e nelle condizioni ottimali di comfort e di sicurezza.

La mayoria de las consultas de ninos de menos de un mes la realizan los padres, segun las recomendaciones del pediatra de la maternidad. El medico debe efectuar una exploracion fisica completa para detectar a los ninos que presentan algun trastorno y, sobre todo, controlar el buen crecimiento somatico, verificar si se establece normalmente el vinculo entre el lactante y su madre, identificar los signos de depresion materna puerperal y favorecer el amamantamiento. Esta consulta brinda la ocasion de responder a numerosas preguntas de los padres. El clima de confianza que en ella se cree influira a menudo sobre la calidad del seguimiento medico del nino durante los 2 primeros anos.

Since a decade, some studies had discussed preventive and curative treatment of infants born to mothers with meconium-stained amniotic fluid. Today amnio-infusion, formerly proposed, is reconsidered in countries where midwives and obstetricians carefully monitor the fetal heart rate tracing during labor. Actually routine intrapartum oropharyngeal and nasopharyngeal suctioning, before and after shoulders delivery, followed by tracheal suction, are not recommended for infants born to mothers with meconium stained amniotic fluid.

Les progres en medecine perinatale ont largement profite aux prematures de 28 a 32 semaines : leur survie actuelle est d’environ 95 % et leur taux de handicap secondaire est de l’ordre de 10 %. Ces progres sont lies a trois facteurs essentiels : regionalisation des soins perinatals, corticotherapie antenatale et surfactants exogenes. Certaines complications autrefois frequentes (enterocolites, retinopathie du premature) ont pratiquement disparu dans cette population. Les extremes prematures (moins de 28 semaines) ont egalement gagne en survie (70 %), mais leur devenir a moyen et long termes reste problematique. Ils gardent un risque eleve d’insuffisance respiratoire chronique : la dysplasie bronchopulmonaire, qui a des consequences respiratoires et neurodeveloppementales a long terme. Les handicaps, surtout cognitifs, restent frequents chez les extremes prematures. Les progres actuels consistent en une meilleure maitrise de l’iatrogenicite, une meilleure nutrition et des soins de developpement. Des progres importants ont ete realises dans l’appreciation du pronostic neurologique, surtout grâce au developpement de l’imagerie par resonance magnetique. La medecine fœtale et la regionalisation des soins ont aussi permis des progres dans la prise en charge des malformations congenitales.

Resume La prise en charge du nouveau-ne en detresse en salle de naissance est de plus en plus previsible grâce aux progres de la surveillance obstetricale et aux changements importants intervenus dans le domaine de l'organisation des soins perinatals. L'anoxie perinatale et la naissance prematuree, surtout avant un âge gestationnel de 32 semaines, sont les deux situations les plus frequentes exposant le nouveau-ne a des gestes de reanimation des la naissance. Les prealables indispensables a une prise en charge coherente et adaptee a chaque cas sont une bonne connaissance des donnees obstetricales, et un materiel verifie et en bon etat de marche. La priorite de la reanimation respiratoire fait aujourd'hui l'unanimite dans les premieres minutes de vie. Le developpement des methodes de ventilation non invasive et l'utilisation precoce d'un surfactant exogene naturel sont les deux progres les plus recents pour la prise en charge precoce du grand premature en salle de naissance. Le materiel de prise en charge respiratoire (respirateur, monitorage de l'oxygenation par oxymetrie pulsee) permet une amelioration indiscutable de la qualite de la prise en charge. Le transfert maternel est toujours, lorsqu'il est encore possible et non contre-indique, prefere au transport du nouveau-ne en cas de menace d'accouchement premature ou de toute autre pathologie maternelle menacant la securite de la mere et de l'enfant. Le transport du nouveau-ne, quand il n'est pas evitable, doit etre organise et realise par un personnel entraine, avec un materiel adapte a la pathologie de l'enfant dans des conditions optimales de securite et de confort.

Resume La prise en charge du nouveau-ne en detresse en salle de naissance est de plus en plus previsible grâce aux progres de la surveillance obstetricale et aux changements importants intervenus dans le domaine de l’organisation des soins perinatals. L’anoxie perinatale et la naissance prematuree, surtout avant un âge gestationnel de 32 semaines, sont les deux situations les plus frequentes exposant le nouveau-ne a des gestes de reanimation des la naissance. Les prealables indispensables a une prise en charge coherente et adaptee a chaque cas sont une bonne connaissance des donnees obstetricales et un materiel verifie et en bon etat de marche. La priorite de la reanimation respiratoire fait aujourd’hui l’unanimite dans les premieres minutes de vie. Le developpement des methodes de ventilation non invasive et l’utilisation precoce d’un surfactant exogene naturel sont les deux progres les plus recents pour la prise en charge precoce du grand premature en salle de naissance. Le materiel de prise en charge respiratoire (respirateur, monitorage de l’oxygenation par oxymetrie pulsee) permet une amelioration indiscutable de la qualite de la prise en charge. Le transfert maternel sera toujours, lorsqu’il est encore possible et non contre-indique, prefere au transport du nouveau-ne en cas de menace d’accouchement premature ou de toute autre pathologie maternelle menacant la securite de la mere et de l’enfant. Le transport du nouveau-ne, quand il n’est pas evitable, sera organise et realise par un personnel entraine avec un materiel adapte a la pathologie de l’enfant dans des conditions optimales de securite et de confort.

Resume La prise en charge du nouveau-ne en detresse en salle de naissance est de plus en plus previsible grâce aux progres de la surveillance obstetricale et aux changements importants intervenus dans le domaine de l'organisation des soins perinatals. L'anoxie perinatale et la naissance prematuree, surtout avant un âge gestationnel de 32 semaines, sont les deux situations les plus frequentes exposant le nouveau-ne a des gestes de reanimation des la naissance. Les prealables indispensables a une prise en charge coherente et adaptee a chaque cas sont une bonne connaissance des donnees obstetricales et un materiel verifie et en bon etat de marche. La priorite de la reanimation respiratoire fait aujourd'hui l'unanimite dans les premieres minutes de vie. Le developpement des methodes de ventilation non invasive et l'utilisation precoce d'un surfactant exogene naturel sont les deux progres les plus recents pour la prise en charge precoce du grand premature en salle de naissance. Le materiel de prise en charge respiratoire (respirateur, monitorage de l'oxygenation par oxymetrie pulsee) permet une amelioration indiscutable de la qualite de la prise en charge. Le transfert maternel est toujours, lorsqu'il est encore possible et non contre-indique, prefere au transport du nouveau-ne en cas de possibilite d'accouchement premature ou de toute autre pathologie maternelle menacant la securite de la mere et de l'enfant. Le transport du nouveau-ne, quand il n'est pas evitable, est organise et realise par un personnel entraine avec un materiel adapte a la pathologie de l'enfant dans des conditions optimales de securite et de confort.

The neonatal arterial ischemic stroke is an emergency. Recurrent focal seizures, generally occurring in the first 24-72 hours after birth, are the commonest first clinical signs. When neonatal arterial ischemic stroke is suspected, optimal initial management involves careful supportive care including treatment of clinical and frequent or prolonged subclinical seizures, correction of the possible metabolic disorders and their prevention. Contrary to hypoxic ischemic encephalopathy, therapeutic hypothermia is not indicated. This newborn requires emergent transfer to a neonatal intensive care unit for the confirmation of the diagnosis by means of a specialized neonatal transport team.

a ventilation non invasive (VNI) a demontre son effi cacite dans la prise en charge des detresses respiratoires du nouveau-ne, mais egalement de la decompensation respi-ratoire hypercapnique de l’adulte. Elle est en plein essor dans le traitement de l’insuffi sance respiratoire aigue du nourrisson et de l’enfant plus grand. La bronchiolite du nourrisson, infection virale epidemique liee le plus souvent au virus respiration syncytial (VRS), touche de facon presque exclusive les petits nourrissons. C’est la premiere cause de detresse respiratoire a cet âge dans notre pays (environ 460 000 cas par an). Un faible pourcentage de patients developpe une forme severe justifi ant leur transfert en unite de reanimation pediatrique. Il y a quelques annees la ventilation mecanique endo-tracheale invasive etait la seule solution proposee a cette categorie d’enfants, souvent des la phase pre-hospitaliere. L’effet benefi que de la VNI est actuellement bien demontre pour reduire le travail respiratoire actif du patient et ameliorer son oxygenation [1, 2]. Sa mise en route en situation aigue en pre-hospitalier ou avant l’admission en reanimation pediatrique est decrite depuis moins de 5 ans. Les recommandations actuelles des societes savantes preconisent la mise en place de la VNI dans les services d’urgence ou les SMUR pour favoriser son utilisation precoce et en ameliorer les resul-tats [3]. Au cours de l’annee 2003, une nouvelle interface binasale siliconee utilisable chez les nourrissons avec tous les ventilateurs de transport est apparue, a ete evaluee, puis integree par les equipes de transports pediatriques de la region Ile de France [4].L’objectif de ce travail est d’evaluer l’impact de la VNI avant l’arrivee en reanimation, dans la prise en charge des bronchiolites severes, sur deux periodes epidemiques consecutives 2003-2004, premiere annee d’utilisation de cette interface, et 2005-2006, derniere periode que nous avons pu etudier avec suivi des patients en reanimation.

Depuis une dizaine d’annees, la strategie de prise en charge preventive et curative des nouveau-nes naissant dans un liquide meconial est reconsideree. Une veritable desescalade est aujourd’hui proposee remettant en cause la pratique systematique de l’aspiration oro- et nasopharyngee (avant et apres le degagement des epaules), puis endotracheale (sous laryngoscope ou apres intubation de la trachee). La prise en charge actuellement recommandee depend des circonstances de naissance et de l’etat clinique initial de l’enfant.

Unexpected out-of-hospital delivery accounts for 0.5% of the total number of delivery in France. The parturient is placed under constant multiparametric monitoring. Fetus heart rate is monitored thanks to fetal doppler. A high concentration mask containing a 50-to-50 percent mix of O(2) and NO performs analgesia. Assistance of mobile pediatric service can be required under certain circumstances such as premature birth, gemellary pregnancy, maternal illness or fetal heart rate impairment. Maternal efforts should start only when head reaches the pelvic floor, only if the rupture of the membranes is done and the dilation is completed. The expulsion should not exceed 30 min. Episiotomy should not be systematically performed. A systematic active management of third stage of labour is recommended. Routine care such as warming and soft drying can be performed when the following conditions are fulfilled: clear amniotic liquid, normal breathing, crying and a good tonus. Every 30 seconds assessment of heart rate, breathing quality and muscular tonus then guide the care. The redaction of birth certificate is a legal obligation and rests with the attending doctor.

For apneic or bradycardic babies born at term, it is best to begin ressuscitation in the delivery room with air rather than 100% oxygen. Administration of supplementary oxygen should be regulated by blending oxygen and air, and the concentration delivered should be guided by oximetry. Preterm babies less than 32 weeks gestation may not reach the same arterial blood oxygen saturations in air as those achieved by term babies. Therefore, blended oxygen and air should be given guided by pulse oximetry. Detection of exhaled carbon dioxide in addition to clinical assessment is recommended as the most reliable method to confirm placement of a tracheal tube in neonates. If presented with a floppy, apnoeic baby born through meconium, it is reasonable to rapidly inspect the oropharynx to remove potential secretions. Tracheal intubation and suction may be useful. Therapeutic hypothermia should be considered for infants born at term or near-term with evolving moderate to severe hypoxic-ischemic encephalopathy, with protocol and follow-up coordinated through a regional perinatal system. For preterm babies of less than 28 weeks gestation delivery room temperatures should be at least 26 °C. They should be completely covered in a food-grade plastic bag up to their necks, without drying, immediately after birth. If the heart rate of a newly born baby is not detectable and remains undetectable for 10 min, it is then appropriate to consider stopping resuscitation. Simulation should be used as a methodology in resuscitation education.

Les circonstances posant le plus frequemment des questions ethiques difficiles aux equipes de SMUR pediatrique et faisant evoquer l’eventualite de mettre en place des soins palliatifs neonataux sont rares. Les deux plus frequentes sont la survenue d’une asphyxie perinatale severe proche du terme ou a terme, avec reanimation difficile et prolongee du nouveau-ne, et l’extreme prematurite aux limites de viabilite (âge gestationnel < 26 semaines). Nous aborderons la deuxieme circonstance qui a fait l’objet dans notre centre perinatal de type III (incluant une equipe de SMUR pediatrique) de l’elaboration d’une attitude pratique apres une longue reflexion obstetrico-pediatrique.

La priorite en soins palliatifs est centree sur la qualite de vie et le confort de l’enfant. Assurer le confort, c’est mener successivement, ou idealement en parallele, une reflexion sur chaque therapeutique curative mise en œuvre (pouvant conduire a la desescalade therapeutique) et une reflexion sur le soulagement de chaque symptome. Le soulagement des symptomes associe des moyens pharmacologiques, des techniques non medicamenteuses et une amelioration de l’environnement affectif ; ce, tout au long de la vie de l’enfant.

To determine whether the mortality for out-of-hospital (OOH) premature births was higher than for in-hospital premature births and identify additional risk factors.A historical cohort study of a consecutive series of live-born, OOH, births of 24-35 weeks gestation cared for by two Transport Teams working in and around Paris, France 1994-2005. Matching with in-hospital births was according to gestational age, antenatal steroid use, the mode of delivery and nearest year of birth.Eighty-five OOH premature births were identified, of whom 83 met inclusion criteria, and 132 matching in-hospital premature births were selected. There was 18% mortality in the OOH group compared with 8% for the in-hospital group [p = 0.04, OR 2.9, (CI 95% 1.0-8.4)]. Variables significantly associated (p0.05) with the OOH birth were HIV infection, lower maternal age and endo-tracheal intubation, lack of medical follow-up during pregnancy, low temperature and low birth weight.Mortality was more than twice as high in out-of-hospital deliveries than for in-hospital matched controls. Hypothermia was an important associated risk factor. Measures such as oxygen administration to maintain an appropriate saturation for gestational age, the provision of polyethylene plastic wraps and skin-to-skin contact are recommended.

Most of the contemporary guidelines on newborn resuscitation are based on experience but lack scientific evidence. The use of 100% oxygen is one of the more evident. Today, these practices are questioned, particularly for the resuscitation of moderately depressed full-term or near-term newborns. Results of recent meta-analysis of trials that compared ventilation with room air versus pure oxygen at birth suggest current practices should be revisited. On the basis of these data, air can be the initial gas to use for these babies. Large-scale trials, including preterm and cause and/or severity of initial asphyxia, must now be undertaken before the publication of new guidelines for these populations.

Contains fulltext : 81447.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To describe obstetric intervention for extremely preterm births in ten European regions and assess its impact on mortality and short term morbidity. DESIGN: Prospective observational cohort study. SETTING: Ten regions from nine countries participating in the 'Models of Organising Access to Intensive Care for Very Preterm Babies in Europe' (MOSAIC) project. POPULATION: All births from 22 to 29 weeks of gestation (n = 4146) in 2003, excluding terminations of pregnancy. METHODS: Comparison of three obstetric interventions (antenatal corticosteroids, antenatal transfer and caesarean section for fetal indication) rates at 22-23, 24-25 and 26-27 weeks to that at 28-29 weeks and the association of the level of intervention with pregnancy outcome. MAIN OUTCOME MEASURES: Use of antenatal corticosteroids, antenatal transfer and caesarean section by two-week gestational age groups as well as a composite score of these three interventions. Outcomes included stillbirth, in-hospital mortality and intraventricular haemorrhage (IVH) grades III and IV and/or periventricular leucomalacia (PVL) and bronchopulmonary dysplasia (BPD). RESULTS: There were large differences between regions in interventions for births at 22-23 and 24-25 weeks. Differences were most pronounced at 24-25 weeks; in some regions these babies received the same care as babies of 28-29 weeks, whereas elsewhere levels of intervention were distinctly lower. Before 26 weeks and especially at 24-25 weeks, there was an association between the composite intervention score and mortality. No association was observed at 26-27 weeks. For survivors at 24-25 weeks, the intervention score was associated with higher rates of BPD, but not with IVH or PVL. CONCLUSIONS: There are large differences between European regions in obstetric practices at the lower limit of viability and these are related to outcome, especially at 24-25 weeks.

After the publication of new recommendations for cardiopulmonary resuscitation (2005 guidelines and 2006 French recommendations), we conducted a study amongst EMS teams concerning their approach with children and infants, nationwide. The objective was to measure the level of knowledge of guidelines and practice.The online questionnaire was offered to emergency physicians belonging to the French emergency database, between November 1st and December 15th 2007. Incomplete questionnaires were excluded from the study. We recorded: profile of personnel, knowledge of guidelines, basic CPR and advanced CPR parameters.Four hundred and thirty-nine questionnaires were analyzed. Personnel was aged under 40 in 50.2 %, with 2-5 years experience in prehospital emergency care (57.6 %); 51,3 % declared having had training in pediatric CPR. A minority of subjects declared knowing the 2005 Guidelines (35 %), more the French 2006 recommendations (62.5 %). Basic CPR: transition age child/adult known in 30.3 %. Compression/ventilation ratio: 30/2 for one rescuer in 50.2 % (child), 46.5 % (infant); 15/2 for two or more rescuers in 57.6 % (child), 48 % (infant). AED age for use (1 year old) known in 59.8 %. Advanced CPR: epinephrine dose known in 89.3 % (intravenous) and 34.3 % (tracheal). External shock known in 57.2 %.This study emphasizes the lack of knowledge, especially with regard to first aid. Formations will be developed.

Since a decade, some studies had discussed preventive and curative treatment of infants born to mothers with meconium-stained amniotic fluid. Today amnio-infusion, formerly proposed, is reconsidered in countries where midwives and obstetricians carefully monitor the fetal heart rate tracing during labor. Actually routine intrapartum oropharyngeal and nasopharyngeal suctioning, before and after shoulders delivery, followed by tracheal suction, are not recommended for infants born to mothers with meconium stained amniotic fluid.

Usefulness of nasal continuous positive airway pressure (NCPAP) in severe acute bronchiolitis has been checked. The objective of this descriptive study was to evaluate the feasibility, safety and risk factors of NCPAP failure.One hundred and forty-five infants were hospitalised in our intensive care unit during the 2 last epidemics (2003-2004, 2004-2005). Among them, 121 needed a respiratory support, either invasive ventilation (N=68) or NCPAP (N=53).General characteristics were similar during the 2 periods. Percentage of NCPAP failure, defined by tracheal intubation requirement during the stay in paediatric intensive care unit, was quite similar during the 2 periods (25%), but number of NCPAP increased twofold. Whatever the evolution was in the NCPAP group, we observed a significant decrease in respiratory rate (60+/-16 vs 47.5+/-13.7 cycle/min., P0.001) and PaCO2 (64.3+/-13.8 vs 52.6+/-11.7 mmHg, P=0.001) during NCPAP. Only PRISM calculated at day 1 and initial reduction of PaCO2 were predictive of NCPAP failure. Percentage of ventilator associated pneumonia was similar (22%) between the invasive ventilation group and infants who where intubated because of failure of NCPAP. Duration of respiratory support and stay were reduced in the NCPAP group (P0.002).NCPAP appears to be a safe alternative to immediate intubation in infants with severe bronchiolitis.

Most of the contemporary guidelines on newborn resuscitation are based on experience but lack scientific evidence. The use of 100% oxygen is one of the more evident. Today, these practices are questioned, particularly for the resuscitation of moderately depressed full term or near term newborns. Results of recent meta-analysis of trials that compared ventilation with air versus pure oxygen at birth suggests current practices should be revisited. On the basis of these data, air can be the initial gas to use for these babies. Large scale trials, including preterm and cause and/or severity of initial asphyxia, must now be undertaken before the publication of new guidelines for these populations. Particularly severely asphyxiated infants might require supplemental oxygen with titration of oxygen delivery and continuous monitoring of oxygen saturation.

The objective of this article is to describe the conditions under which very premature babies were born in the Paris region between June 1 and December 31, 1998, that is to say those born prior to reaching 33 weeks of term (SA) and/or having a birth weight less than 1500 grams. The study looked at all pre-term births, including medical terminations of pregnancy (TOP), occurring in one of the 135 maternity units in the Paris region. Between June 1 and December 31, 1998, 1337 mothers gave birth to babies prior to reaching 33 weeks of term (SA) and/or having a birth weight less than 1500 grams in 84 maternity units in the Paris region, 263 of which had a medical termination of pregnancy (20%). These mothers were older than average for the region (25% were 35 years old or older); 4.3% of them do not have social insurance coverage. The remaining 1074 mothers (excluding TOP) gave birth to 1290 children, of which 202 were stillbirths, 46 died in the labor ward and 1042 were admitted to a neo-natal unit. Of the same group of 1074 mothers, 195 (18%) had a multiple pregnancy--175 twins, 19 triplets, and 1 quadruplet 60% of them (599 women) who had very premature or low birth weight babies (excluding TOPs) delivered them in a tertiary perinatal centre (TPC). This proportion varies according to two variables: 1) the community in which the family lives (40% in the Seine-et-Marne department, the eastern region of Paris and a district without TPCs, to 70% in the Hauts-de-Seine, a northern district), and 2) whether the pregnancy is single (58.8%), twin (72.6%) or triple (84.2%). In utero transfer accounts for 62.7% of the mothers who delivered in TPC, who were transferred prior to delivery. This type of study is useful for measuring the implementation of the regionalisation high-risk perinatal care and access to adequate services. It clearly demonstrates that inequities in access to care exist for women by district of residence.