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Objective To assess patent ductus arteriosus treatment variation between Swiss perinatal centers and to determine its effect on outcome in a population-based setting. Study design This was a retrospective cohort study of infants born less than 28 weeks of gestation between 2012 and 2017. Outcomes between surgically ligated and pharmacologically treated infants as well as infants born in centers performing ≤10% ligation (“low” group) and >10% (“high” group) were compared using logistic regression and 1:1 propensity score matching. Matching was based on case-mix and preligation confounders: intraventricular hemorrhages grades 3-4, necrotizing enterocolitis, sepsis, and ≥28 days’ oxygen supply. Results Of 1389 infants, 722 (52%) had pharmacologic treatment and 156 (11.2%) received surgical ligation. Compared with infants who received pharmacologic treatment, ligated infants had greater odds for major morbidities (OR 2.09, 95% CI 1.44-3.04) and 2-year neurodevelopmental impairment (OR 1.81, 95% CI 1.15-2.84). Mortality was comparable after restricting the cohort to infants surviving at least until day 10 to avoid survival bias. In the “low” group, 34 (4.9%) of 696 infants were ligated compared with 122 (17.6%) of 693 infants in the “high” group. Infants in the “high” group had greater odds for major morbidities (OR 1.49, 95% CI 1.11-2.0). Conclusions Our analysis identified a burden on infants receiving surgical ligation vs pharmacologic treatment in a population-based setting where there was no agreed-on common procedure. These results may guide a revision of patent ductus arteriosus treatment practice in Switzerland.

Der vorliegende Beitrag basiert auf dem Schweizer interprofessionellen Reanimationskurs fur Neugeborene start4neo sowie auf den 2017 revidierten Empfehlungen der Schweizerischen Gesellschaft fur Neonatologie (SGN) zur Unterstutzung der Adaptation und Reanimation des Neugeborenen. Das Vorgehen bei einer normalen Adaptation sowie die Indikation zu Stabilisierungs- und weiterfuhrenden Reanimationsmasnahmen bei gestorter Adaptation werden strukturiert anhand des T‑ABCD(„thermoregulation, airway, breathing, circulation, drugs“)-Algorithmus erlautert. Im Hinblick auf die fur das Neugeborene wichtige „golden first minute“ wird der Fokus auf die korrekte Beurteilung von Atmung und vor allem Herzfrequenz gelegt, da diese klinischen Parameter wegweisend sind fur den zeitgerechten Einsatz etwaiger Unterstutzungsmasnahmen. Die praktische Anwendung des im Beitrag referierten Wissens und die Fahigkeit zur situativen Beurteilung sollen basierend auf einer induktiven Lernmethode in praktischen Kursmodulen erarbeitet werden, um kompetentes Handeln in neonatalen Betreuungs- oder Reanimationssituationen zu gewahrleisten.

Summary Background Neonatal deaths now account for 47% of all deaths in children younger than 5 years globally. More than a third of newborn deaths are due to preterm birth complications, which is the leading cause of death. Understanding the causes and factors contributing to neonatal deaths is needed to identify interventions that will reduce mortality. We aimed to establish the major causes of preterm mortality in preterm infants in the first 28 days of life in Ethiopia. Methods We did a prospective, cross-sectional, observational study in five hospitals in Ethiopia. Study participants were preterm infants born in the study hospitals at younger than 37 gestational weeks. Infants whose gestational age could not be reliably estimated and those born as a result of induced abortion were excluded from the study. Data were collected on maternal and obstetric history, clinical maternal and neonatal conditions, and laboratory investigations. For neonates who died of those enrolled, consent was requested from parents for post-mortem examinations (both complete diagnostic autopsy and minimally invasive tissue sampling). An independent panel of experts established the primary and contributory causes of preterm mortality with available data. Findings Between July 1, 2016, to May 31, 2018, 4919 preterm infants were enrolled in the study and 3852 were admitted to neonatal intensive care units. By 28 days of post-natal age, 1109 (29%) of those admitted to the neonatal intensive care unit died. Complete diagnostic autopsy was done in 441 (40%) and minimally invasive tissue sampling in 126 (11%) of the neonatal intensive care unit deaths. The main primary causes of death in the 1109 infants were established as respiratory distress syndrome (502 [45%]); sepsis, pneumonia and meningitis (combined as neonatal infections; 331 [30%]), and asphyxia (151 [14%]). Hypothermia was the most common contributory cause of preterm mortality (770 [69%]). The highest mortality occurred in infants younger than 28 weeks of gestation (89 [86%] of 104), followed by infants aged 28–31 weeks (512 [54%] of 952), 32–34 weeks (349 [18%] of 1975), and 35–36 weeks (159 [8%] of 1888). Interpretation Three conditions accounted for 89% of all deaths among preterm infants in Ethiopia. Scale-up interventions are needed to prevent or treat these conditions. Further research is required to develop effective and affordable interventions to prevent and treat the major causes of preterm death. Funding Bill & Melinda Gates Foundation.

Aim: This study aimed to investigate the safety of transfusing red blood cell concentrates (RBCCs) through small [24 gauge (24G)] and extra-small [28 gauge [28G)] peripherally inserted central catheters (PICCs), according to guidelines of transfusion practice in Switzerland.Methods: We performed a non-inferiority in vitro study to assess the safety of transfusing RBCC for 4 h at a 4 ml/h speed through 24G silicone and 28G polyurethane PICC lines, compared with a peripheral 24G short catheter. The primary endpoint was hemolysis percentage. Secondary endpoints were catheter occlusion, inline pressure, and potassium and lactate values.Results: For the primary outcome, hemolysis values were not statistically different among catheter groups (0.06% variation, p = 0.95) or over time (2.75% variation, p = 0.72). The highest hemolysis values in both 24G and 28G PICCs were below the non-inferiority predefined margin. We did not observe catheter occlusion. Inline pressure varied between catheters but followed the same pattern of rapid increase followed by stabilization. Potassium and lactate measurements were not statistically different among tested catheters (0.139% variation, p = 0.98 for potassium and 0.062%, p = 0.96 for lactates).Conclusions: This study shows that RBCC transfusion performed in vitro through 24G silicone and 28G polyurethane PICC lines is feasible without detectable hemolysis or pressure concerns. Also, it adds that, concerning hemolysis, transfusion of RBCC in small and extra-small PICC lines is non-inferior to peripheral short 24G catheters. Clinical prospective assessment in preterm infants is needed to confirm these data further.

International audience; Introduction Variability of arterial blood pressure (ABP) has been associated with intraventricular hemorrhage in very preterm neonates (VPT) and may predict other brain lesions assessed at term-equivalent of age (TEA). Methods This was a prospective single-center study including VPT with early invasive continuous ABP monitoring and assessed at TEA using brain magnetic resonance imaging (TEA-MRI). The association between early mean ABP (MABP) and TEA-MRI findings was modeled by multivariate logistic regression analysis using covariates selected by the LASSO method. Results Among 99 VPT, the LASSO procedure selected consecutive periods of lowest MABP of 30 min on day 1 (d1) and 10 min on day 2 (d2) as the most relevant durations to predict TEA-MRI findings (OR [95% CI], 1.11 [1.02-1.23], p = 0.03 and 1.13 [1.01-1.27], p = 0.03, respectively). ROC curve analysis showed optimal thresholds at 30.25 mmHg on d1 and 33.25 mmHg on d2. This significant association persisted after adjustment with covariates including birthweight, gestational age, sex, and inotrope exposure. Final models selected by LASSO included the decile of the birthweight and lowest MABP for 30 min on d1 and 10 min on d2, for which the areas under the ROC curve were 74% and 75%, respectively. Conclusion Early continuous ABP monitoring may predict brain TEA-MRI findings in VPT. Impact Early arterial blood pressure monitoring may contribute to predicting brain damage upon MRI at term-equivalent of age for infants born very preterm. Careful blood pressure continuous monitoring in very preterm infants may identify infants at risk of long-term brain damage. Umbilical artery catheterization provides the best option for continuously monitoring arterial blood pressure in very preterm infants.

Background and importance Neonatal pharmacotherapy is challenging and often based on little evidence. Off label use of drugs is common practice and patients are at a high risk of medication errors and drug-related problems. Prescription-screening tools are used in geriatrics, internal medicine and pediatrics to optimize drug prescribing. Aim and objectives Our aim was to develop a prescription-screening tool specific to neonatology. Materials and methods Clinical guidelines on neonatal pharmacotherapy were identified by a literature review and synthetized into short statements. A 2-rounds Delphi consensus method was used to establish the content validity of Neocheck. The statements were submitted to a group of 23 experts in 10 Swiss neonatology centers. The level of agreement was evaluated on a 5-point Likert scale (1 being the highest level of agreement). Statements for which >65% of experts gave the statement a rating of 1 or 2 were selected at round 1. This cut off was raised to >75% at round two. Results A total of 1375 clinical guidelines were identified from the literature search. After synthesis, 158 statements were submitted to the group of 23 Swiss experts. The mean agreement rating was 1.62 (95% CI 1.55 to 1.70) during the 1st round of Delphi and 1.32 (95% CI 1.28 to 1.37) during the 2nd round. The final Neocheck tool is composed of 141 statements on 11 medical domains and 49 neonatal diseases. On average, 95% (95% CI 94%-96%) of experts either totally agreed or slightly agreed with the validated statements. Conclusion and relevance A prescription-screening tool specific to neonatalogy was developed and validated by a group of 23 Swiss experts. The impact of Neocheck on the optimization of drug use in neonates and its potential interest as a teaching tool for young physicians and clinical pharmacists need to be evaluated in the future.

Background. Globally, prematurity is the leading cause of neonatal mortality, and hypothermia is one of its contributing factors. The goal of this study was to determine the association between hypothermia and mortality. Methods. A prospective, multi-center, descriptive clinical study was conducted in 5 hospitals in Ethiopia. Axillary temperatures were taken at the time of admission to the newborn intensive care units (NICU) and followed during the NICU stay. Results. A total of 3852 premature neonates (

Infantile hemangioma (IH) is the most common vascular tumor in infancy, and its physiopathology is not fully understood. Nevertheless, a hypoxic insult may be an essential element for the formation of an IH. Herein, we describe a case of a 25-week premature newborn who developed an IH after a post-burn scar and its evolution.

Background Differences in perception and potential disagreements between parents and professionals regarding the attitude for resuscitation at the limit of viability are common. This study evaluated in healthcare professionals whether the decision to resuscitate at the limit of viability (intensive care versus comfort care) are influenced by the way information on incurred risks is given or received. Methods This is a prospective randomized controlled study. This study evaluated the attitude of healthcare professionals by testing the effect of information given through graphic fact sheets formulated either optimistically or pessimistically. The written educational fact sheet included three graphical presentations of survival and complication/morbidity by gestational age. The questionnaire was submitted over a period of 4 months to 5 and 6-year medical students from the Geneva University as well as physicians and nurses of the neonatal unit at the University Hospitals of Geneva. Our sample included 102 healthcare professionals. Results Forty-nine responders (48%) were students (response rate of 33.1%), 32 (31%) paediatricians (response rate of 91.4%) and 21 (20%) nurses in NICU (response rate of 50%). The received risk tended to be more severe in both groups compared to the graphically presented facts and current guidelines, although optimistic representation favoured the perception of “survival without disability” at 23 to 25 weeks. Therapeutic attitudes did not differ between groups, but healthcare professionals with children were more restrained and students more aggressive at very low gestational ages. Conclusion Written information on mortality and morbidity given to healthcare professionals in graphic form encourages them to overestimate the risk. However, perception in healthcare staff may not be directly transferable to parental perception during counselling as the later are usually naïve to the data received. This parental information are always communicated in ways that subtly shape the decisions that follow.

AIM Epidemiological data on the incidence and risk factors of extravasation of peripheral intravenous catheters (PIVC) in neonates and children are scarce and that is what this study explored. METHODS This was a one-year retrospective study of all neonates and paediatric intensive care patients with at least one recorded PIVC at the Geneva University Hospitals, Switzerland, in 2013. The extravasation rate was determined for all patients, including neonates below 28 days, and for all PIVCs. Multivariate analysis of the associated risk factors was performed. RESULTS We analysed 1300 PIVC in 695 paediatric patients with a median age of 1.5 years. The overall extravasation incidence was 17.6% for all patients and 11.7% for PIVC. The overall incidence rate of PIVC extravasation was 4.5 per 100 catheters days, and the risk was highest in the 201 neonates, at 28.4%. The incidence rate four days after insertion of the PIVC was around three times higher than on day one. Neonates and the in situ duration of PIVCs were associated risk factors (p < 0.001). CONCLUSION Extravasation was frequent and neonates were particularly at risk. Younger age and longer in situ PIVC duration were independent risk factors for extravasation.

Background The current standard treatment of neonates with intestinal perforation is surgery. However, the mortality rate after surgical treatment for intestinal perforation is very high for very low birth weight (VLBW) and extremely low birth weight (ELBW) neonates. In this review, conservative treatment of pneumoperitoneum among VLBW and ELBW neonates is investigated. Methods Between January 2015 and December 2017, data from all of the VLBW and ELBW neonates with pneumoperitoneum who survived without surgical treatment were collected from Shenzhen Maternity and Child Healthcare Hospital in Guangdong, China. Twenty-two neonates with birth weight less than 1500 g were diagnosed with pneumoperitoneum. Following careful evaluation and discussion, eleven were treated conservatively and this was successful in eight. Details of the eight neonates including birth weight, gestational age, gender, risk factors, time of the perforation, treatment and prognosis were retrospectively recorded. A literature review was performed of previously reported cases that had used conservative treatment. Results The median gestational age and birth weight of the eight neonates were 27+ 1 weeks (range 24w+ 3 to 31w+ 6) and 855 g (range 650 g to 1440 g), respectively. Pneumoperitoneum was confirmed by X-ray in all at a median of 8 days of life. They received full parenteral support for a median of 22 days. All eight neonates received a combination of piperacillin-tazobactam and meropenem as first-choice antibiotics, two of them also received fluconazole as anti-fungal medication. Median duration of hospitalisation was 80 days. Conclusions Conservative treatment with careful surveillance may be a practical choice for the VLBW and ELBW neonates with intestinal perforation. Further studies are needed for confirmation.

Amniotic fluid embolism (AFE) is a rare, unpredictable and unpreventable event with high maternal and fetal morbidity and mortality. Its clinical presentation is nonspecific ranging from moderate organ dysfunction to cardiovascular collapse with disseminated intravascular coagulation (DIC), which can lead to death. In a situation of severe systemic disease, maternal survival is largely dependent on the combined efficacy of gynecological and anesthetic teams. We report a case of AFE in a healthy woman admitted to the delivery room for labor induction. Due to a loss of consciousness soon after epidural anesthesia associated to fetal bradycardia, an emergency caesarean section was performed which was complicated by uterine atony and DIC requiring hysterectomy. The outcome was favorable due to fast and efficient multidisciplinary care, emphasizing the benefit of having been trained for such situations through simulation and team training programs for obstetrical emergency management.

Periventricular white matter injury is common in very preterm infants and it is associated with long term neurodevelopmental impairments. While evidence supports the protective effects of erythropoetin (EPO) in preventing injury, we currently lack the complete understanding of how EPO affects the emergence and maturation of anatomical brain connectivity and function. In this case-control study, connectomic analysis based on diffusion MRI tractography was applied to evaluate the effect of early high-dose EPO in preterm infants. A whole brain, network-level analysis revealed a sub-network of anatomical brain connections in which connectivity strengths were significantly stronger in the EPO group. This distributed network comprised connections predominantly in the frontal and temporal lobe bilaterally, and the effect of EPO was focused on peripheral and feeder connections of the core structural connectivity network. EPO resulted in a globally increased clustering coefficient, higher global and average local efficiency, while higher strength and increased clustering was found for regions in the frontal lobe and cingulate gyrus. The connectivity network most affected by the EPO treatment showed a steeper increase graph theoretical measures with age compared to the placebo group. Our results demonstrate a weak but widespread effect of EPO on the structural connectivity network and a possible trophic effect of EPO reflected by increasing network segregation, predominantly in local connections., Highlights • Erythropoietin (EPO) is a potential neuroprotective agent in very preterm infants. • EPO leads to increased structural brain connectivity in fronto-temporal regions. • Clustering coefficient, local and global efficiency increases after EPO treatment.

Background: Preterm birth is the leading cause of neonatal deaths. Neonatal deaths account for 46% of all under-five deaths. Just over a third of neonatal deaths are a result of preterm-related causes. With the increasing contribution of neonatal deaths to overall child mortality, urgent action is needed to determine the major causes of preterm mortality. Methods: This was a multi-centre prospective observational study in 5 tertiary hospitals in Ethiopia over a period of nearly 2 years to determine the causes of preterm mortality. An independent panel of experts determined the primary and contributory causes of preterm mortality using data on socioeconomic status, maternal/obstetric history, clinical conditions, laboratory investigations and post-mortem examinations (both complete diagnostic autopsy [CDA] and minimally invasive tissue sampling [MITS]). Findings: A total of 4,919 preterm infants were enrolled in the study. Of these 3,852 were admitted to NICU's and of these 1109 died. The main causes of death were RDS (45%), sepsis, pneumonia and meningitis (30%) and asphyxia 14%. Hypothermia was the most common contributory cause of preterm mortality. Interpretation: Three conditions were the primary causes for 89% of all deaths: RDS - 45%, infections - 30 % and asphyxia - 14%. There is a need to scale up interventions against these conditions and in particular those specific to RDS such as continuous positive airway pressure (CPAP), and blended oxygen to contribute to neonatal mortality. Funding Statement: This study was funded by grants from the Bill & Melinda Gates Foundation (OPP1136965). We would like to acknowledge the support we received from the administrative, clinical, nursing, microbiology and pathology technical staff of all study hospitals. Declaration of Interests: The authors declare no conflicts of interest. Ethics Approval Statement: The study was approved by the Institutional Review Board of each hospital and at the College of Health Sciences of the Addis Ababa University. Written consent for participation in the study was obtained, with a separate written consent for autopsy and MITS, in cases of death. Consent was obtained in English, Amharic and Oromifa languages, as appropriate. Confidentially of the information was maintained.

Background.In premature infants, maintaining blood partial pressure of carbon dioxide (pCO2) value within a narrow range is important to avoid cerebral lesions. The aim of this study was to assess the accuracy of a noninvasive transcutaneous method (TcpCO2), compared to blood partial pressure of carbon dioxide (pCO2).Methods.Retrospective observational study in a tertiary neonatal intensive care unit. We analyzed the correlation between blood pCO2and transcutaneous values and the accuracy between the trends of blood pCO2and TcpCO2in all consecutive premature infants born at Results.248 infants were included (median gestational age: 29 + 5 weeks and median birth weight: 1250 g), providing 1365 pairs of TcpCO2and blood pCO2values. Pearson’sRcorrelation between these values was 0.58. The mean bias was −0.93 kPa with a 95% confidence limit of agreement of −4.05 to +2.16 kPa. Correlation between the trends of TcpCO2and blood pCO2values was good in only 39.6%.Conclusions.In premature infants, TcpCO2was poorly correlated to blood pCO2, with a wide limit of agreement. Furthermore, concordance between trends was equally low. We warn about clinical decision-making on TcpCO2alone when used as continuous monitoring.

To assess associations between neonatal intensive care unit (NICU)-level patent ductus arteriosus (PDA) treatment rates (pharmacologic or surgical) and neonatal outcomes.This cohort study included infants born at 24-28 weeks of gestation and birth weight1500 g in 2007-2015 in NICUs caring for ≥100 eligible infants in 6 countries. The ratio of observed/expected (O/E) PDA treatment rates was derived for each NICU by estimating the expected rate using a logistic regression model adjusted for potential confounders and network. The primary composite outcome was death or severe neurologic injury (grades III-IV intraventricular hemorrhage or periventricular leukomalacia). The associations between the NICU-level O/E PDA treatment ratio and neonatal outcomes were assessed using linear regression analyses including a quadratic effect (a square term) of the O/E PDA treatment ratio.From 139 NICUs, 39 096 infants were included. The overall PDA treatment rate was 45% in the cohort (13%-77% by NICU) and the O/E PDA treatment ratio ranged from 0.30 to 2.14. The relationship between the O/E PDA treatment ratio and primary composite outcome was U-shaped, with the nadir at a ratio of 1.13 and a significant quadratic effect (P.001). U-shaped relationships were also identified with death, severe neurologic injury, and necrotizing enterocolitis.Both low and high PDA treatment rates were associated with death or severe neurologic injury, whereas a moderate approach was associated with optimal outcomes.

Background Late preterm (LPT) newborns, defined as those born between 34 0/7 and 36 6/7 gestational weeks, have higher short- and long-term morbidity and mortality than term infants (≥37 weeks). A categorization to justify a non-spontaneous LPT delivery has been proposed to distinguish evidence-based from non-evidence-based criteria. This study aims to describe rates and temporal trends of non-spontaneous LPT neonates delivered according to evidence-based or non-evidence-based criteria and to evaluate the number of avoidable LPT deliveries, including severe neonatal morbidity rates and associated risk factors. Methods Retrospective cohort study including all LPT neonates born at a Swiss university maternity unit between January 1, 2002 and December 31, 2012. Trends of LPT neonates and neonatal complications were assessed across time using Poisson regression and risk factors for neonatal complications by logistic regression. Results Among 40,609 singleton live births, 4223 (10.5%) were preterm and 2017 (4.9%) LPT. In the latter group, 26.2% were non-spontaneous (evidence-based: 12.0%; non-evidence-based: 14.2%). The most frequent indications for evidence-based non-spontaneous LPT delivery were severe preeclampsia (51.8%) and abnormal fetal tracing (24.7%). Indications for non-evidence-based non-spontaneous LPT deliveries were hemorrhage (36.2%) and mild preeclampsia (15.7%). LPT birth rates remained stable over time. The rate of neonatal complications after non-evidence-based LPT birth remained high over time (43.8% vs. 43.5% in 2002 and 2012, respectively; P = 0.645), whereas the annual proportion of neonatal complications overall showed a decreasing trend (from 38.0% in 2002 to 33.5% in 2012; P = 0.051). Conclusions LPT birth rates were stable over time, but neonatal complications remained high, particularly after non-evidence-indicated LPT birth. A total of 287 LPT births could have been potentially avoided if an evidence-based protocol for delivery indications had been used. Efforts should be made to avoid non-spontaneous LPT births in order to reduce neonatal complications.

Background: Preterm birth is the leading cause of neonatal deaths. Neonatal deaths account for 46% of under-five deaths. Just over a third of neonatal deaths are a result of preterm-related causes. With the increasing contribution of neonatal deaths to overall child mortality, urgent action is needed to determine the major causes of preterm mortality. Methods: A multi-centre prospective observational study was undertaken in 5 tertiary hospitals in Ethiopia over a period of nearly 2 years to determine the causes of preterm mortality in the first 28 days of life. An independent panel of experts determined the primary and contributory causes of preterm mortality using data on maternal/obstetric history, clinical conditions, laboratory investigations and post-mortem examinations (both complete diagnostic autopsy [CDA] and minimally invasive tissue sampling [MITS]) when consent is obtained. Findings: A total of 4,919 preterm infants were enrolled in the study. Of these 3,852 were admitted to NICU's and of these 1109 died. The main causes of death were RDS (45%), sepsis, pneumonia and meningitis (30%) and asphyxia 14%. Hypothermia was the most common contributory cause of preterm mortality (69%). Interpretation: Three conditions were the primary causes of death among preterm infants accounting for 89% of all deaths. There is a need to scale up interventions against these conditions and in particular those specific to RDS such as continuous positive airway pressure (CPAP), and blended oxygen to contribute to the reduction of neonatal mortality. Funding: This study was funded by grants from the Bill & Melinda Gates Foundation. Declaration of Interest: The authors declare no conflicts of interest. Ethical Approval: The study was approved by the Institutional Review Board of each hospital and at the College of Health Sciences of the Addis Ababa University. Written consent for participation in the study was obtained, with a separate written consent for autopsy and MITS, in cases of death. Consent was obtained in English, Amharic and Oromifa languages, as appropriate. Confidentially of the information was maintained.

Background Many outbreaks due to Serratia marcescens among neonates have been described in the literature but little is known about the role of whole genome sequencing in outbreak analysis and management. Methods Between February and March 2013, 2 neonates and 2 infants previously hospitalised in the neonatal unit of a tertiary care centre in Switzerland, were found to be colonised with S. marcescens. An investigation was launched with extensive environmental sampling and neonatal screening in four consecutive point prevalence surveys between April and May 2013. All identified isolates were first investigated by fingerprinting and later by whole genome sequencing. Audits of best practices were performed and a hand hygiene promotion programme was implemented. Results Twenty neonates were colonised with S. marcescens. No invasive infection due to S. marcescens occurred. All 231 environmental samples were negative. Hand hygiene compliance improved from 51% in April 2013 to 79% in May 2013 and remained high thereafter. No S. marcescens was identified in point prevalence surveys in June and October 2013. All strains were identical in the fingerprinting analysis and closely related according to whole genome sequencing. Conclusions Improving best practices and particularly hand hygiene proved effective in terminating the outbreak. Whole genome sequencing is a helpful tool for genotyping because it allows both sufficient discrimination of strains and comparison to other outbreaks through the use of an emerging international database.

Resume Introduction La sante neonatale demeure une preoccupation dans les pays a faible revenu. Ce travail vise a analyser le profil et le pronostic neonatal de l’asphyxie perinatale dans une structure sanitaire urbaine au sud du Sahara. Patients et methodes Il s’agit d’une etude prospective transversale du 1er juin au 30 novembre 2013,portant sur les nouveau-nes a terme hospitalises pour asphyxie perinatale, dans le service de pediatrie medicale du centre hospitalier universitaire pediatrique Charles-de-Gaulle. Resultats L’asphyxie perinatale a represente 19,8 % des admissions. Le sex-ratio etait de 1,6. Le liquide amniotique etait anormal dans 61 cas (71,8 %). Les signes generaux etaient domines par la detresse respiratoire et l’hyperthermie avec respectivement 65,9 % et 45,9 % des cas. Tous les nouveau-nes ont presente des manifestations neurologiques dominees par les anomalies des reflexes archaiques (92,9 %), suivies de l’hypotonie (88,2 %) et des convulsions (35,3 %). Selon la classification de Sarnat, le stade 2 etait dominant avec 45,9 %. Une insuffisance renale souvent transitoire etait notee chez 38 nouveau-nes (44,7 %) dont 26 (30,6 %) avaient une detresse neurologique de stade 2. Les troubles metaboliques etaient domines par l’hypoglycemie (37,6 %) et l’hyperglycemie (28,2 %). Les echographies transfontanellaire et abdominale etaient anormales avec respectivement 17 (20 %) et 6 cas (7,1 %). Le taux de mortalite etait de 6 (7,1 %) avec quatre nouveau-nes en insuffisance renale. Conclusion L’asphyxie perinatale reste une pathologie grave. La mortalite elevee rappelle qu’il est imperatif de renforcer la prevention par une preparation a une reanimation efficace et satisfaisante.

BACKGROUND Therapeutic hypothermia following hypoxic ischaemic encephalopathy in term infants was introduced into Switzerland in 2005. Initial documentation of perinatal and resuscitation details was poor and neuromonitoring insufficient. In 2011, a National Asphyxia and Cooling Register was introduced. AIMS To compare management of cooled infants before and after introduction of the register concerning documentation, neuromonitoring, cooling methods and evaluation of temperature variability between cooling methods. STUDY DESIGN Data of cooled infants before the register was in place (first time period: 2005-2010) and afterwards (second time period: 2011-2012) was collected with a case report form. RESULTS 150 infants were cooled during the first time period and 97 during the second time period. Most infants were cooled passively or passively with gel packs during both time periods (82% in 2005-2010 vs 70% in 2011-2012), however more infants were cooled actively during the second time period (18% versus 30%). Overall there was a significant reduction in temperature variability (p < 0.001) comparing the two time periods. A significantly higher proportion of temperature measurements within target temperature range (72% versus 77%, p < 0.001), fewer temperature measurements above (24% versus 7%, p < 0.001) and more temperatures below target range (4% versus 16%, p < 0.001) were recorded during the second time period. Neuromonitoring improved after introduction of the cooling register. CONCLUSION Management of infants with HIE improved since introducing the register. Temperature variability was reduced, more temperature measurements in the target range and fewer temperature measurements above target range were observed. Neuromonitoring has improved, however imaging should be performed more often.

Aim: Neonatal resuscitation requires minimal equipment, but the immediate availability of expert staff accounts for the largest proportion of the costs. Despite this, staff requirements and timetables are currently planned without comprehensive epidemiologic data. The aim of this study was to evaluate the staffing required for neonatal resuscitations in the delivery room. Methods: We measured attendance for each specific role in a tertiary university-affiliated hospital and for four possible intervention levels: preparation time, basic paediatric care, moderate resuscitation and extended resuscitation. Results: Between 2005 and 2012, resuscitation staff attended 11 561 of the 32 799 births: 27.2% for preparation time, 17.7% for basic paediatric care, 6.4% for moderate resuscitation and 3.5% for extended resuscitation. Moderate and extended resuscitations occurred in roughly 10% of births and evenly during 24-h periods. Basic paediatric care levels were higher during weekday mornings, and extended resuscitations were uniformly distributed. However, there was a drop in all types of interventions around 7 a.m. to 8 a.m., when staff were changing shifts. Conclusion: Moderate and extended resuscitations occurred evenly over 24 h in roughly 10% of births, stressing the importance of having a highly competent neonatal team constantly available. All activities associated with resuscitation were lower during morning shift changes.

Objective:To evaluate the dynamics of bacterial contamination of healthcare workers' (HCWs) hands during neonatal care.Setting:The 20-bed neonatal unit of a large acute care teaching hospital in Geneva, Switzerland.Methods:Structured observation sessions were conducted. A sequence of care began when the HCW performed hand hygiene and ended when the activity changed or hand hygiene was performed again. Alcohol-based handrub was the standard procedure for hand hygiene. An imprint of the five fingertips of the dominant hand was obtained before and after hand hygiene and at the end of a sequence of care. Regression methods were used to model the final bacterial count according to the type and duration of care and the use of gloves.Results:One hundred forty-nine sequences of care were observed. Commensal skin flora comprised 72.4% of all culture-positive specimens (n = 360). Other microorganisms identified were Enterobacteriaceae (n = 55, 13.8%);Staphylococcus aureus(n = 10, 2.5%); and fungi (n = 7,1.8%). Skin contact, respiratory care, and diaper change were independently associated with an increased bacterial count; the use of gloves did not fully protect HCWs' hands from bacterial contamination.Conclusions:These data confirm that hands become progressively contaminated with commensal flora and potential pathogens during neonatal care, and identify activities at higher risk for hand contamination. They also reinforce the need for hand hygiene after a sequence of care, before starting a different task, and after glove removal.

We report a case of carbamazepine withdrawal syndrome following in utero exposure to carbamazepine related to a pharmacogenetic predisposition factor. The infant was born at 37 1/7 weeks' gestation by cesarean section to a mother treated for epilepsy with carbamazepine. One hour and thirty minutes after birth, the infant presented a respiratory distress with severe oxygen desaturation requiring intubation 5 h after birth. On the third day of life the infant developed clinical signs of a withdrawal syndrome which resolved progressively after 16 days and symptomatic treatment. The infant genotype analysis showed two low activity CYP2C9 allelic variants ((∗)2/(∗)3 heterozygote) predicting a CYP2C9 slow metabolizer phenotype which could explain reduced carbamazepine elimination and a late and long-lasting withdrawal symptoms observed 3 days after birth. The association of a withdrawal syndrome with carbamazepine exposure has not been previously reported and pharmacogenetic tests might therefore be useful in identifying patients at risk.

Background Quality improvement in health care requires identification of areas in need of improvement by comparing processes and patient outcomes within and between health care providers. It is critical to adjust for different case-mix and outcome risks of patient populations but it is currently unclear which approach has higher validity and how limitations need to be dealt with. Our aim was to compare 3 approaches towards risk adjustment for 7 different major quality indicators in neonatal intensive care (21 models). Methods We compared an indirect standardization, logistic regression and multilevel approach. Parameters for risk adjustment were chosen according to literature and the condition that they may not depend on processes performed by treating clinics. Predictive validity was tested using the mean Brier Score and by comparing area under curve (AUC) using high quality population based data separated into training and validation sets. Changes in attributional validity were analysed by comparing the effect of the models on the observed-to-expected ratios of the clinics in standardized mortality/morbidity ratio charts. Results Risk adjustment based on indirect standardization revealed inferior c-statistics but superior Brier scores for 3 of 7 outcomes. Logistic regression and multilevel modelling were equivalent to one another. C-statistics revealed that predictive validity was high for 8 and acceptable for 11 of the 21 models. Yet, the effect of all forms of risk adjustment on any clinic’s comparison with the standard was small, even though there was clear risk heterogeneity between clinics. Conclusions All three approaches to risk adjustment revealed comparable results. The limited effect of risk adjustment on clinic comparisons indicates a small case-mix influence on observed outcomes, but also a limited ability to isolate quality improvement potential based on risk-adjustment models. Rather than relying on methodological approaches, we instead recommend that clinics build small collaboratives and compare their indicators both in risk-adjusted and unadjusted form together. This allows qualitatively investigating and discussing the residual risk-differences within networks. The predictive validity should be quantified and reported and stratification into risk groups should be more widely used to correct for confounding. Electronic supplementary material The online version of this article (doi:10.1186/s12887-017-0861-5) contains supplementary material, which is available to authorized users.

Sepsis is an important cause of morbidity and mortality in neonates and clinicians are typically required to administer empiric antibiotics while waiting for blood culture results. However, prolonged and inappropriate use of antibiotics is associated with various complications and adverse events. Better tools to rapidly rule out bacterial infections are therefore needed.We aimed to assess the negative predictive value of PCR coupled with Electrospray Ionization Mass Spectrometry (PCR/ESI-MS) compared to conventional blood cultures in neonatal sepsis.Prospective observational study.All consecutive neonates (28days old) with clinical suspicion of sepsis. Samples for PCR/ESI-MS analysis were collected at the same time as samples for the blood culture, before the initiation of antibiotics.Our primary objective was to evaluate the negative predictive value of PCR/ESI-MS for the detection of bacteria in the bloodstream of newborns with suspected sepsis. Our secondary objective was the evaluation of the sensitivity, specificity and positive predictive value of the PCR/ESI-MS in such a neonatal population.We analysed 114 samples over 14months. The median age and weight were 32weeks+3days and 1840g, respectively. Two patients had negative PCR/ESI-MS results, but positive blood cultures. Overall, the negative predictive value was 98% (95%CI: 92% to 100%).Based on these results, PCR/ESI-MS analysis of blood samples of neonates with suspected sepsis appears to have a very good negative predictive value when compared to blood cultures as gold standard. This novel test might allow for early reassessment of the need for antibiotics.

Resume Introduction Dans les pays a faibles ressources, l’atteinte du quatrieme objectif du millenaire pour le developpement de l’Organisation mondiale de la sante (OMS) passe par la reduction de la mortalite neonatale. Plusieurs interventions a differents niveaux de la communaute et du systeme sanitaire sont necessaires, y compris dans les hopitaux de district. Methode Etude descriptive dans l’unite de neonatologie de l’hopital de district de Bonassama a Douala (Cameroun), de la mortalite et de la morbidite neonatales pour identifier de possibles leviers d’intervention. Les donnees sociodemographiques, cliniques et le devenir des nouveau-nes ont ete enregistres de novembre 2009 a mai 2012. Resultats Huit cent treize nouveau-nes ont ete hospitalises, dont 71 % nes sur place, 16 % par cesarienne, 20 % prematures, 55 % de sexe masculin et 24 % avec un poids Conclusion Dans les pays en voie de developpement subsahariens, les principales maladies neonatales doivent etre prises en charge dans des hopitaux peripheriques. La connaissance epidemiologique des maladies neonatales a cet echelon permet de planifier les besoins en termes de competences mais aussi d’equipement, et d’evaluer les indications raisonnables au transfert dans une unite de niveau superieur tenant compte du risque eleve du transfert et des moyens limites des centres de reference.

Ces recommandations s’adressent aux institutions d’obstetrique en Suisse, mais egalement aux obstetriciens, aux sages-femmes, aux neonatologues, aux pediatres, aux anesthesistes et au personnel infirmier.

Diese Empfehlungen richten sich an die ­geburtshilflichen Institutionen der Schweiz sowie im Einzelnen an Geburtshelfer, Hebammen, Neonatologen, Padiater, Anasthesisten und Pflegefachpersonen.

Le concept des Soins de soutien au developpement (SSD) est une approche multidisciplinaire et individualisee, qui vise a diminuer les stimulations sensorielles intenses de l’environnement hospitalier et a favoriser le bien-etre du nouveau-ne. Cette approche permet aussi aux parents de devenir les premiers partenaires des soins prodigues a leur enfant.

Das Konzept der Entwicklungsfordernden Pflege (EFP) ist ein multidisziplinarer, individuell angepasster Ansatz, bei dem versucht wird, die intensiven Sinnesreize durch das Klinikumfeld zu mini­mieren und das Wohlbefinden des Neugeborenen zu fordern. Dieser Ansatz erlaubt auch den Eltern, die wichtigsten Partner bei der Betreuung ihres Kindes zu werden.

OBJECTIVE To report the population-based, gestational age (GA)-stratified mortality and morbidity for very preterm infants over 13 years in Switzerland. DESIGN A prospective, observational study including 95% of Swiss preterm infants (GA

Objective To examine the relationships between intensity of delivery room resuscitation and short- and long-term outcomes of very low birth weight infants enrolled in the Caffeine for Apnea of Prematurity (CAP) Trial. Study design The CAP Trial enrolled 2006 infants with birthweights between 500 and 1250 g who were eligible for caffeine therapy. All levels of delivery room resuscitation were recorded in study participants. We divided infants in 4 groups of increasing intensity of resuscitation: minimal, n = 343; bag-mask ventilation, n = 372; endotracheal intubation, n = 1205; and cardiopulmonary resuscitation (chest compressions/epinephrine), n = 86. We used multivariable logistic regression models to compare outcomes across the 4 groups. Results The observed rates of death or disability, death, cerebral palsy, cognitive deficit, and hearing loss at 18 months increased with higher levels of resuscitation. Risk of bronchopulmonary dysplasia, severe retinopathy of prematurity, and brain injury also increased with higher levels of resuscitation. Adjustment for prognostic variables reduced the differences between the groups for most outcomes. Only the adjusted rates of bronchopulmonary dysplasia and severe retinopathy remained significantly higher after more intense resuscitation. Conclusions In CAP Trial participants, the risk of death or neurodevelopmental disability at 18 months did not increase substantially with increasing intensity of delivery room resuscitation.

Background:Few data exist on time trends of antibiotic consumption among neonates.Objectives:To assess secular trends in antibiotic consumption in the context of an antibiotic policy and the effect of antibiotic use on the development of antimicrobial resistance and outcome among neonates in a singl

OBJECTIVE: Clinical indicators are increasingly used to assess safety of patient care. In obstetrics, only a few indicators have been validated to date and none is used across specialties. The purpose of this study was to identify and assess for face and content validity a group of safety indicators that could be used by anaesthetists, obstetricians and neonatologists involved in labour and delivery units. MATERIALS AND METHODS: We first conducted a systematic review of the literature to identify potential measures. Indicators were then validated by a panel of 30 experts representing all specialties working in labour and delivery units. We used the Delphi method, an iterative questionnaire-based consensus seeking technique. Experts determined on a 7-point Likert scale (1=most representative/7=less representative) the soundness of each indicator as a measure of safety and their possible association with errors and complications caused by medical management. RESULTS: We identified 44 potential clinical indicators from the literature. Following the Delphi process, 13 indicators were considered as highly representative of safety during obstetrical care (mean score

Objective To determine whether the benefits of caffeine vary in three subgroups of 2006 participants in the Caffeine for Apnea of Prematurity (CAP) trial. Study design Post-hoc subgroup analyses were performed on the basis of: (1) indication for commencement of study drug: treat apnea, prevent apnea, or facilitate extubation; (2) positive pressure ventilation (PPV) at randomization: endotracheal tube (ETT), noninvasive ventilation, or none; and (3) timing of commencement of study drug: early or late (≤3 versus >3 days). Outcomes assessed were those showing treatment effects in the original analyses. We investigated the consistency of caffeine effects by using regression models that incorporated treatment/subgroup factor interactions. Results There was little evidence of a differential treatment effect of caffeine in subgroups defined by the clinical indication for starting study drug. The size and direction of the caffeine effect on death or disability differed depending on PPV at randomization ( P = .03). Odds ratios (95% CI) were: no support, 1.32 (0.81-2.14); noninvasive support, 0.73 (0.52-1.03); and ETT, 0.73 (0.57-0.94). Adjustment for baseline factors strengthened this effect ( P = .02). Starting caffeine early resulted in larger reductions in days of respiratory support. Postmenstrual age at time of discontinuing PPV was shorter with earlier treatment ( P = .01). Mean differences (95% CI) were: early, 1.35 weeks (0.90-1.81); and late 0.55 weeks (–0.11-0.99). Adjustment for baseline factors weakened this effect ( P = .03). Conclusions There is evidence of variable beneficial effects of caffeine. Infants receiving respiratory support appeared to derive more neurodevelopmental benefits from caffeine than infants not receiving support. Earlier initiation of caffeine may be associated with a greater reduction in time on ventilation.

OBJECTIVE. To determine the age-stratified risk of intrapartum and neonatal mortality as well as morbidities of clinical relevance after elective cesarean delivery (ECD).METHODS. This work was a cohort study including 56 549 prospectively recorded late-preterm and term deliveries. We analyzed the effect of cesarean delivery (CD) before the onset of labor on the following multiple neonatal outcomes before hospital discharge, compared with planned vaginal delivery (PVD) and emergency CD: mortality, birth depression, special care admission, and respiratory morbidity. We adjusted for confounders by multivariate analysis and stratified the risk according to gestational age (GA).RESULTS. Mortality and morbidities had a strong GA-related trend with the lowest incidences consistently found between 38 and 40 weeks of gestation independent of delivery mode. Compared with infants delivered via PVD, infants delivered via ECD had significantly higher rates of mortality (adjusted risk ratio [aRR]: 2.1), risk of special care admission (aRR: 1.4), and respiratory morbidity (aRR: 1.8) but not of depression at birth (aRR: 1.1). Compared with emergency CD, newborns delivered via ECD had less depression at birth (aRR: 0.6) and admission to special care (aRR: 0.8), but mortality (aRR: 0.8) and respiratory morbidity (aRR: 1.0) rates were similar.CONCLUSIONS. Gestational age–specific risk estimates are lowest between 38 and 40 weeks and should be included in the informed-consent process. The information should also be used to allow for appropriate preparation with respect to adequate staff and equipment. ECD is consistently associated with increased intrapartum and neonatal mortality, risk of admission, and respiratory morbidity compared with PVD and has no advantage over emergency CD in terms of mortality. Neonatal morbidities are lower after ECD than emergency CD only with term births. Our data provide evidence that ECD should not be performed before term.

La recherche présentée s'est déroulée en trois phases. Une première recherche rétrospective a permis de constituer une population de référence composée de 18 enfants prématurés et qui bénéficient des soins usuels du service de néonatologie. Cette étude rétrospective analyse la durée et la forme de la transition entre une alimentation complètement passive (par sonde) et une alimentation entièrement active au sein ou au biberon. La CPAP influence cette évolution. Le deuxième groupe d'enfants prématurés (N = 24) a bénéficié d'une mise en forme en enroulement lors du nourrissement et d'un programme qui règle les quantités offertes en actif et en passif. L'effet de la CPAP est évalué. Le troisième groupe (N = 25) a bénéficié d'une mise en forme en enroulement lors du nourrissement, du même programme de transition mais en plus une stimulation périorale et orale est appliquée. L'effet de la CPAP est évalué. Dans les trois groupes, les mêmes analyses ont été réalisées. On montre un raccourcissement significatif et une homogénéisation des temps de transition. La CPAP nasale, si elle est présente plus de sept jours, a un effet négatif significatif, mais les stimulations périorales compensent cet effet délétère. De façon indépendante de l'âge de gestation, la vitesse d'ingestion montre que 90 % de ce que l'enfant est capable de prendre activement est absorbé durant les premières dix minutes. Ce fait permet d'adapter la gestion des repas : durée de l'alimentation passive et durée de l'offre du biberon ou du sein.

Background: Until recently, the preparation of paediatric parenteral nutrition formulations in our institution included re-transcription and manual compounding of the mixture. Although no significant clinical problems have occurred, re-engineering of this high risk activity was undertaken to improve its safety. Several changes have been implemented including new prescription software, direct recording on a server, automatic printing of the labels, and creation of a file used to pilot a BAXA MM 12 automatic compounder. The objectives of this study were to compare the risks associated with the old and new processes, to quantify the improved safety with the new process, and to identify the major residual risks. Methods: A failure modes, effects, and criticality analysis (FMECA) was performed by a multidisciplinary team. A cause-effect diagram was built, the failure modes were defined, and the criticality index (CI) was determined for each of them on the basis of the likelihood of occurrence, the severity of the potential effect, and the detection probability. The CIs for each failure mode were compared for the old and new processes and the risk reduction was quantified. Results: The sum of the CIs of all 18 identified failure modes was 3415 for the old process and 1397 for the new (reduction of 59%). The new process reduced the CIs of the different failure modes by a mean factor of 7. The CI was smaller with the new process for 15 failure modes, unchanged for two, and slightly increased for one. The greatest reduction (by a factor of 36) concerned re-transcription errors, followed by readability problems (by a factor of 30) and chemical cross contamination (by a factor of 10). The most critical steps in the new process were labelling mistakes (CI 315, maximum 810), failure to detect a dosage or product mistake (CI 288), failure to detect a typing error during the prescription (CI 175), and microbial contamination (CI 126). Conclusions: Modification of the process resulted in a significant risk reduction as shown by risk analysis. Residual failure opportunities were also quantified, allowing additional actions to be taken to reduce the risk of labelling mistakes. This study illustrates the usefulness of prospective risk analysis methods in healthcare processes. More systematic use of risk analysis is needed to guide continuous safety improvement of high risk activities.