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Objective The diagnosis of early-onset neonatal sepsis (EOS) remains difficult. The early administration of antibiotic therapy though not without risk is still the most common practice. The main aim was to study the effect of a new algorithm for EOS, which includes the level of procalcitonin (PCT) in umbilical cord blood, on the exposure to antibiotic therapy of premature neonates of gestational age below 33 weeks of gestation who show signs of a risk of EOS.Materials and methods This is a monocentric, observational and retrospective study “before and after” of the evaluation of daily professional practices. The study was performed over two periods from the 1st of May to the 30th of November 2015, for the group of neonates not receiving PCT “no PCT” and from the 1st of November 2016 to the 30th of May 2017 for the group of neonates receiving PCT “PCT”. The duration and dose of antibiotic therapy provided as well as the morbidity and mortality were compared.Results Sixty neonates were included in the “no PCT” group and 54 in the “PCT” group. Antibiotic therapy was stopped after 24 hours for 18 neonates in the “PCT” group and 4 in the “no PCT” group (p = 0.001), and after 48 hours for 26 neonates in the “PCT” group and 10 in “no PCT” group (p = 0.0009). The average number of days of antibiotics was 3 for the “no PCT” group and one for the “PCT” group.Conclusion The implementation of a new decision making algorithm including PCT in the umbilical cord blood of preterm neonates at less than 33 weeks of gestation significantly reduced exposure to antibiotics without modifying mortality or morbidity.

Objectives: To evaluate the positive threshold of PCT for neonates of Design: Retrospective and bicentric study from May 2016 to April 2018.Setting: Two groups were established, neonates evaluated for PCT at birth (CordPCT) and within 6 h of life (delPCT).Patients: Two hundred and sixty neonates of Main Outcomes Measures: The value of the PCT positive threshold was determined for the total population and each groups thanks ROC curves.Results: The threshold level of PCT for the total population was 0.98 ng/mL. The threshold value of cordPCT group was 1.00 vs. 0.98 ng/mL for delPCT group. The area under the Receiver Operating Characteristics curve for PCT sampled in delPCT group was significantly higher than in cordPCT group (0.94 compared to 0.75).Conclusions: The threshold level of PCT was higher in this cohort of neonates of

OBJECTIVES: Central venous access in critically ill, small infants remains technically challenging even in experienced hands. Several vascular accesses exist, but the subclavian vein is often preferred for central venous catheter insertion in infants where abdominal malformation and/or closure of the vein preclude the use of umbilical venous catheters, as catheterization of the subclavian vein is easier in very short necks than the internal jugular vein for age-related anatomical reasons. The subclavian vein approach is yet relatively undescribed in low birth weight infants (i.e., \textless 2,500 g), and this study aims to explore the feasibility of this technique in very small infants. DESIGN: Retrospective data collection of prospectively registered data on central venous catheter insertion in infants. SETTING: Neonatal ICU and PICU at a university hospital. PATIENTS: One hundred and five newborn children hospitalized in at the ICU. INTERVENTIONS: An ultrasound-guided supraclavicular approach was applied on all infants who had an subclavian vein catheterization during a 30-month period from January 2013 to July 2015. MEASUREMENTS AND MAIN RESULTS: One hundred seven supraclavicular subclavian vein catheters were placed in 105 children weighing less than 5,000 g. Among those, 40 patients weighed less than 2,500 g and 10 patients weighed less than 1,500 g. Successful central venous catheter insertion, defined as the correct placement of a functional double-lumen catheter (3F or 4F), was obtained in 97.3%. All three registered failed attempts were due to hematomas from venous bleeding and occurred in infants weighing greater than 2,500 g. No case of accidental arterial puncture or pleural puncture was registered. CONCLUSIONS: This large series of subclavian vein catheterizations in small infants demonstrates the feasibility of subclavian vein catheterizations even in very small neonates weighing less than 1,500 g.

Background Congenital diaphragmatic hernia (CDH) is a rare congenital anomaly and remains among the most challenging ICU-managed disease. Beside severe pulmonary hypertension, lung hypoplasia and major abdominal surgery, infective complications remain major determinants of outcome. However, the specific incidence of sepsis as well as associated risk factors is unknown. Methods This prospective, 4-year observational study took place in the pediatric intensive care and neonatal medicine department of the Paris South University Hospitals (Le Kremlin-Bicêtre, France), CDH national referral center and involved 62 neonates with CDH. Main results During their ICU stay, 28 patients (45%) developed 38 sepsis episodes. Ventilator-associated pneumonia (VAP: 23/38; 31.9 VAP per 1000 days of mechanical ventilation) and central line-associated blood stream infections (CLABSI: 5/38; 5.5 per 1000 line days) were the most frequently encountered infections. Multivariate analysis showed that gestational age at birth and intra-thoracic position of liver were significantly associated with the occurrence of sepsis. Infected patients had longer duration of mechanical and noninvasive ventilation (16.2 and 5.8 days, respectively), longer delay to first feeding (1.2 days) and a longer length of stay in ICU (23 days), but there was no difference in mortality. Conclusions Healthcare-associated infections, and more specifically VAP, are the main infective threat in children with CDH. Sepsis has a significant impact on the duration of ventilator support and ICU length of stay but does not impact mortality. Low gestational age and intra-thoracic localization of the liver are two independent risk factors associated with sepsis. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0254-9) contains supplementary material, which is available to authorized users.

Background: Very preterm infants are particularly susceptible to nutrient deficiencies. Although a lot of attention has been focused on the early nutrient supply, they are at high risk of long-chain polyunsaturated fatty acid deficiency. Objectives: To estimate docosahexaenoic acid (DHA) intake, the metabolizable (i.e. absorbed) DHA, the DHA available for accretion and to quantify the DHA deficit, if any, during the first month of life of preterm infants born ≤28 weeks of gestation. Methods: Monocentric study. Nutritional data for the first 28 days of life were collected in 40 preterm infants born with a gestational age ≤28 weeks. Results: The metabolizable DHA intake (i.e. parenteral DHA + absorbed DHA) during the 1st, 2nd, 3rd and 4th weeks of life increased significantly over time (p < 0.0001), but corresponded to 7, 21, 30 and 39% of the fetal DHA accretion rate, respectively. Assuming endogenous synthesis, all infants exhibited a severe DHA deficit which reached on average 661 ± 100 mg/kg, which represents at least half of the DHA that should have been accumulated. The DHA deficit was highly correlated with birth weight, demonstrating that the smaller the infant, the larger the DHA deficit. Conclusions: The current nutritional management of preterm infants is likely to lead to an early and severe DHA deficit which may represent, at 1 month of age, about half of the fetal DHA accumulation.

The utility of transcutaneous bilirubin measurements (TcB) in screening for hyperbilirubinemia in preterm infants (34 weeks) and in non-white infants remains a matter of debate.To evaluate accuracy of TcB in preterm and term infants of different ethnic backgrounds, using a second generation bilirubinometer.The Draeger JM-103® device was used to measure TcB. Eighty five measurements of TcB and total serum bilirubin (TSB) were retrospectively compared. Neonates were stratified into groups according to gestational age:34 weeks (group 1, n=44) and34 weeks (group 2, n=41), and according to ethnic origin: Caucasians (group A, n=49) and non-Caucasians (group B, n=36). Statistical analysis, using Pearson's correlation coefficient (r) and Bland-Altman analysis were performed to evaluate correlation and agreement between TSB and TcB values. Multiple linear regression was used to control for confounders for TSB values.Correlation between TSB and TcB was high. Pearson's correlation coefficients were over 0.9 in all groups (0.910, 0.908, 0.916 and 0.934, p0.0001 in groups 1, 2, A, and B respectively). Bland-Altman plots showed acceptable and close limits of agreements (56.8/-57.7, 54.2/-67.2, 57.7/-55.8, and 51.3/-69.9μmol/L in groups 1, 2, A and B respectively) with a trend for TcB to overestimate TSB in groups 2 and B. Birth term and skin color were not identified as confounding factors for predicting TSB in multiple linear regression.TcB measurements using the Draeger JM-103® device correlate significantly with TSB, regardless of term and skin color. Transcutaneous bilirubinometry seems to be a safe and cost-effective screening method for severe hyperbilirubinemia in newborns of different terms and ethnic origins.

Background The rapid growth of the developing brain during early post-natal life makes it particularly vulnerable to a nutritional deficit. The neurological development of the very low birth weight preterm infant could be related to early lipid supply. Aims To evaluate in preterm infants of gestational age ≤ 28 weeks of amenorrhea (WA) the relations between the neurological development determined at a corrected age of one year using the test of Brunet-Lezine and 1) the cumulative intakes of proteins, carbohydrates, lipids and energy during the first 28 days of life and 2) the weight gain in the first 28 days of life. Materials and methods Study of a mono-centric cohort of 48 premature infants of gestational age ≤ 28 WA consecutively hospitalized and followed longitudinally up to a corrected age of one year. Results In simple univariate analysis, there was a significant correlation between the developmental quotient (DQ) at a corrected age of one year and the cumulative intake of energy and lipids at 14 days of life (p = 0.02, p = 0.01, respectively), the number of days to reach the minimum weight (p = 0.02) and the weight gain from birth to D28 of life (p = 0.04). There was no correlation between the DQ and early intake of proteins or carbohydrates. In multivariate analysis, only the association between the DQ at one year of corrected age and the cumulative lipid intake at 14 days of life remained statistically significant (p = 0.04). Conclusion Our study demonstrates the importance of early lipid supply during the first two weeks of life for the neurological development at a corrected age of one year of very low birth weight preterm infants.

International audience; BACKGROUND AND OBJECTIVE: Accurate data on the optimal chloride (Cl) intake in premature infants are scarce. The aim of the present study was to describe Cl intakes in the first 10 days of life and to assess the relations between high Cl intakes and corrected serum Cl level or markers of severe acidosis in infants \textless28 weeks' gestation. METHODS: Retrospective cohort study including all of the infants \textless28 weeks admitted to the neonatal intensive care unit during a 3-year period and cared for from birth until day 10 or more. RESULTS: Fifty-six infants were included. Cumulative total Cl intakes reached 9.6 ± 3.7 mmol/kg at day 3 and 49.2 ± 13.5 mmol/kg at day 10. Inadvertent intakes (from intravenous fluids other than parenteral nutrition) represented on average 70% of total Cl intakes in the first 3 days. Difference between Cl and sodium intakes reached 7.8 ± 4.8 mmol/kg at day 10 and mainly originated from parenteral nutrition. By multivariate analysis, cumulative Cl intake \textgreater10 mmol/kg during the first 3 days was an independent risk factor of base excess \textless-10 mmol/L. Cumulative Cl intake \textgreater45 mmol/kg during the first 10 days was an independent risk factor of corrected chloremia \textgreater115 mmol/L and of base excess \textless-10 mmol/L. CONCLUSIONS: Cumulative Cl intake \textgreater10 mmol/kg during the first 3 days (ie, 3.3 mmol · kg (-1) · day(-1) on average) and \textgreater45 mmol/kg during the first 10 days (ie, 4.5 mmol · kg (-1) · day(-1) on average) may have unwanted metabolic consequences and should be avoided. Imbalance between electrolytes provided by the parenteral nutrition solution need to be detected and corrected.

Background Legislative measures have been identified as one effective way of changing attitude or behaviour towards health care. The aim of this study was to describe trends in patients' complaints for medical issues; to evaluate the contribution of a law regarding patients' rights, and to identify factors associated to patients' perception of a medical error. Methods Patients with a complaint letter for medical issues in a French university hospital were included. Trends in complaint rates were analysed. Comparisons were made between a first (1998–2000) and a second (2001–2004) time period, before and after the diffusion of the law, and according to the perception of a medical error. Results Complaints for medical issues increased from 1998 to 2004. Of 164 complaints analysed, 66% were motivated by the perception of a medical error (47% during the first time period vs. 73% during the second time period; p = 0.001). Error or delay in diagnosis/treatment and surgical/medical complication were the main reasons for complaints. Surgical departments had the higher number of complaints. Second time period, substandard care, disability, and adverse effect of a health product were independently associated with the perception of a medical error, positively for the formers, and negatively for the latter. Conclusion This study revealed an increase with time in the number of complaints for medical issues in a university hospital, as well as an increase in the perception of a medical error after the passing of a law regarding patients' rights in France.

Considerable effort should be made to optimise parenteral nutrition of preterm infants in order to limit the development of postnatal growth restriction. A monocentric before-and-after study design was used to determine the effects of computerising parenteral nutrition ordering on the composition of parenteral nutrition (PN) solutions and early clinical outcomes of preterm infants born < or =28 weeks of gestation. Parenteral protein intake during the first week of life and parenteral lipid, glucose and energy intakes during the first and second week of life were significantly higher in infants assessed after the introduction of computerised parenteral nutrition ordering. This led to a significant reduction in the cumulative energy deficit over the first 28 days of life and to an improvement in both early growth and pulmonary outcome. Computerising the PN ordering process improves the nutrient content of the PN solutions and early postnatal outcome.

Introduction : le don de colostrum (premier fluide produit par les lactocytes) précoce chez le nouveau-né prématuré reste à ce jour encore marginal dans les services de néonatologie. Très peu de données confirment l’intérêt théorique de cette administration précoce. Ce suivi d’une cohorte d’enfants nés prématurément (≤ 32 SA) a comme objectif principal de comparer la croissance staturo-pondérale entre les groupes Colostrum (C) et Témoin (T) à la fin de la première année de vie. Les objectifs secondaires sont d’apprécier la survenue d’évènements infectieux immuno-allergiques.Matériels et méthodes : évaluation à la fin de la première année de vie d’une cohorte de nourrissons anciens nouveau-nés grands prématurés, représentant la quatrième phase d’une étude prospective monocentrique interventionnelle et comparative. Deux groupes étaient constitués en période néonatale : le groupe Colostrum (C) ayant bénéficié de l’administration oropharyngée précoce de colostrum et un groupe Témoin (T). Les paramètres anthropométriques ainsi que l’incidence des évènements infectieux et immuno-allergiques ont été comparés à l’âge de 1 an. Résultats : cent treize patients ont été analysés à 12 mois de vie, 71 dans le groupe C et 42 dans le groupe T. Nous retrouvons une tendance à un meilleur gain de poids à l’âge de 1 an, en Z-score, dans le groupe Colostrum (p=0.051). Aucune différence n’a été observée entre les 2 groupes concernant les évènements infectieux et immuno-allergiques. L’allaitement à la sortie d’hospitalisation était plus important (85% vs 47,6%, pConclusion : ce travail souligne l’importance potentielle de l’administration précoce de colostrum à moyen terme chez le nouveau-né grand prématuré en rapportant des résultats encourageants en termes de prise de poids et de poursuite de l’allaitement. De futures études plus ambitieuses, de plus grande échelle (multicentriques), incluant une évaluation neuro-développementale à moyen terme devront être menées afin de confirmer ces résultats.

Background: Procalcitonin (PCT), specific biomarker of early-onset neonatal sepsis (EOS), is rarely studied in premature infants born under 32 weeks.Objectives: Determine the threshold of cord blood PCT and the interest of PCT during the first sixth hours of life in preterm newborns under 32 weeks.Study design: This multicenter retrospective study includes all preterm newborns under 32 weeks, born between May 2016 and April 2018 in the University Hospital of Nice and Paris Sud (Bicêtre), who had PCT measurement and presented infection risk factor(s).Results: Among 260 included neonates, 26 were infected. The threshold of PCT was 0,98 ng/ml (sensitivity 0,65, specificity 0,90, positive predictive value 0,42 and negative predictive value 0,96). The threshold of cord blood PCT was 1 ng/ml (sensitivity 0,63, specificity 0,89, positive predictive value 0,42 and negative predictive value 0,95). The threshold of PCT during the first hours of life was 0,98 ng/ml (sensitivity 0,86, specificity 0,93, positive predictive value 0,5 and negative predictive value 0,99). The median of samples was 60 minutes (20-219). The area under receiver operatingcharacteristics (ROC) curve of PCT collected during the first hours of life was significatively higher than the cord blood PCT (0,94 vs 0,75; p=0,03).Conclusion: The threshold of PCT was higher than on full-term newborns and had a good specificity. PCT collected during the four first hours of life was sensitive and specific in the case of an EOS diagnosis.; Introduction : La procalcitonine (PCT), biomarqueur spécifique des infections néonatales bactériennes précoces (INBP), est rarement étudiée chez les nouveau-nés prématurés de moins de 32 semaines d’aménorrhée (SA). L’objectif principal est de déterminer une valeur seuil de PCT chez les nouveau-nés de moins de 32 SA. L’objectif secondaire est de déterminer l’intérêt de la PCT prélevée dans les six premières heures de vie.Matériels et méthodes : Cette étude rétrospective et multicentrique a inclus tous les nouveau-nés de moins de 32 SA, nés de mai 2016 à avril 2018 dans les centres de périnatalité de niveau III de Nice et de Paris Sud (Bicêtre), ayant eu un prélèvement de PCT avant six heures de vie et présentant un ou des facteurs de risque infectieux.Résultats : Parmi les 260 nouveau-nés inclus, 26 ont présenté une INBP. La valeur seuil de PCT est 0,98 ng/ml (sensibilité de 0,65, spécificité de 0,90, valeurs prédictives positive de 0,42 et négative de 0,96). La valeur seuil de PCT au cordon est 1 ng/ml (sensibilité de 0,63, spécificité de 0,89, valeurs prédictives positive de 0,42 et négative de 0,95). La valeur seuil de PCT prélevée dans les premières heures de vie est 0,98 ng/ml (sensibilité de 0,86, spécificité de 0,93, valeurs prédictives positive de 0,5 et négative de 0,99). La médiane de prélèvement est de 60 minutes (20-219). L’aire sous la courbe Receiver Operating Characteristics (ROC) de la PCT prélevée dans les premières heures de vie est significativement plus grande que celle de la PCT au cordon (0,94 contre 0,75 ; p=0,03).Conclusion : La valeur seuil de PCT est plus élevée que chez le nouveau-né à terme et a une très bonne spécificité. La PCT prélevée dans les quatre premières heures de vie est performante dans le diagnostic d’INBP.