[The mother-infant encounter at birth must be protected]. / Il faut protéger la rencontre de la mère et de son nouveau-né autour de la naissance.

The medical decision to separate a newborn baby from his or her mother is frequent. This medical practice must be evaluated. The scientific literature regarding humans and other mammals was reviewed in order to describe the physiology of the interactions between mother and offspring and the consequences of disrupting their interactions around birth. Mother-infant bonding is common to all mammals. Attachment is the result of three mechanisms: behavioral programing, secretion of neuroendocrine substrates, and activation of sensory cues. Breastfeeding is a fourth component that plays a crucial role. Experimental research provides evidence that early-life maternal separation can alter biological responses to stress, disturb learning behaviors, and impair social skills. Recent advances in epigenetic research may partly explain how neonatal maternal deprivation at birth can lead to biological and behavioral disorders in adulthood. Therefore, the decision to separate a newborn infant from his or her mother is not harmless and must be carefully considered. In order to better take into account these data, the organization of perinatal care in France should be revised.

The French Society of Neonatology's proposals for neonatal end-of-life decision-making.

BACKGROUND: Opinions and practice regarding end-of-life decisions in neonatal medicine show considerable variations between countries. A recent change of the legal framework, together with an ongoing debate among French neonatologists, led the French Society of Neonatology to reconsider and update its previous recommendations. OBJECTIVES: To propose a set of recommendations on the ethical principles to be respected in the making and application of end-of-life decisions. METHODS: A multidisciplinary working group on ethical issues in perinatal medicine composed of neonatologists, obstetricians and ethicists. RESULTS: Withholding or withdrawing life-sustaining treatment may be acceptable, and unreasonable therapeutic obstinacy is condemned. This implies that the child's best interests must always be the central consideration. Although the parents must be involved in the decision process so that they form an alliance with the healthcare team, and a collegial approach is of utmost importance, any crucial decision affecting the patient's life calls for individual medical responsibility. Because every newborn is rightfully an integral member of a human family, his or her dignity must be preserved. The goal of palliative care is to preserve the quality of a life, also at its end. The intention underlying an act has to be analyzed perceptively. Euthanasia, i.e. to perform an act with the deliberate intention to cause or hasten a patient's death, is legally and morally forbidden. Conversely, to withhold or withdraw a life-sustaining treatment can be justified when the intention is to cease opposing, in an unreasonable manner, the natural course of a disease. CONCLUSIONS: This statement provides the principles identified by French neonatologists on which to base their decisions concerning the ending of life. Arguments are set forth, discussed and compared with international statements and previously published considerations.

[Very premature births: Dilemmas and management. Part 1. Outcome of infants born before 28 weeks of postmenstrual age, and definition of a gray zone]. / Naissances très prématurées : dilemmes et propositions de prise en charge. Première partie : pronostic des naissances avant 28 semaines, identification d'une zone grise.

With very preterm deliveries, the decision to institute intensive care, or, alternatively, to start palliative care and let the baby die, is extremely difficult, and involves complex ethical issues. The introduction of intensive care may result in long-term survival of many infants without severe disabilities, but it may also result in the survival of severely disabled infants. Conversely, the decision to withhold resuscitation and/or intensive care at birth, which is an option at the margin of viability, implies allowing babies to die, although some of them would have developed normally if they had received resuscitation and/or intensive care. Withholding intensive care at birth does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. The likelihood of survival without significant disabilities decreases as gestational age at birth decreases. In addition to gestational age, other factors greatly influence the prognosis. Indeed, for a given gestational age, higher birth weight, singleton birth, female sex, exposure to prenatal corticosteroids, and birth in a tertiary center are favorable factors. Considering gestational age, there is a gray zone that corresponds to major prognostic uncertainty and therefore to a major problem in making a "good" decision. In France today, the gray zone corresponds to deliveries at 24 and 25 weeks of postmenstrual age. In general, babies born above the gray zone (26 weeks of postmenstrual age and later) should receive resuscitation and/or full intensive care. Below 24 weeks, palliative care is the only option offered in France at the present time. Decisions within the gray zone will be addressed in the 2nd part of this work.

[Very premature births: Dilemmas and management. Second part: Ethical aspects and recommendations]. / Naissances très prématurées : dilemmes et propositions de prise en charge. Seconde partie : enjeux éthiques, principes de prise en charge et recommandations.

In the first part of this work, the outcome following very premature birth was assessed. This enabled a gray zone to be defined, with inherent major prognostic uncertainty. In France today, the gray zone corresponds to deliveries occurring at 24 and 25 weeks of postmenstrual age. The management of births occurring below and above the gray zone was described. Withholding intensive care at birth for babies born below or within the gray zone does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. Given the high level of uncertainty, making good decisions within the gray zone is problematic. Decisions should be based on the infant's best interests. Decisions should be reached with the parents, who are entitled to receive clear and comprehensive information. Possible decisions to withhold intensive care should be made following the procedures described in the French law of April 2005. Guidelines, based on gestational age and the other prognostic elements, are proposed to the parents before birth. They are applied in an individualized fashion, in order to take into account the individual features of each case. At 25 weeks, resuscitation and/or full intensive care are usually proposed, unless unfavorable factors, such as severe growth restriction, are associated. A senior neonatologist will attend the delivery and will make decisions based on both the baby's condition at birth and the parents' wishes. At 24 weeks, in the absence of unfavorable associated factors, the parents' wishes should be followed in deciding between initiating full intensive care or palliative care. Below 24 weeks, palliative care is the only option to be offered in France at the present time.

[High-dose intravenous immunoglobulin therapy and neonatal jaundice due to red blood cell alloimmunization]. / Immunoglobulines polyvalentes intraveineuses et ictère néonatal par allo-immunisation érythrocytaire.

Neonatal jaundice resulting from immunological hemolysis is not uncommon. While it is possible to prevent a large number of Rh-isoimmune hemolytic diseases by administration of specific anti-D immunoglobulins to the mother, the prevention of incompatibility in the ABO groups is not feasible. In spite of advances made in the use of phototherapy, and in order to avoid kernicterus, the treatment of these jaundices can require one or several exchange transfusions (ET), a therapy which is not devoid of risk. For some time now, the data concerning the efficiency of high-dose intravenous immunoglobulin therapy (HDIIT) in the treatment of these jaundices have been increasing. A review of the literature shows that, if used as soon as possible in newborn infants over 32 weeks of gestation age, afflicted with Rh or ABO hemolytic disease, the HDIIT brings about, with no undesirable side effects, a significant decrease in the ET number as well as a significant reduction in the length of phototherapy and hospitalization. The data suggesting that HDIIT could increase the risk of late transfusion is open to controversy.

Very early neonatal apparent life-threatening events and sudden unexpected deaths: incidence and risk factors.

AIM: To evaluate the incidence of neonatal apparent life-threatening events and sudden unexpected deaths during the first 2 h after birth. METHODS: A prospective study was conducted over a 1-year period in all the maternities of the French region of Provence, Alpes, Côte d'Azur, which included all presumably healthy full-term neonates. Twenty-three previously published cases were also studied in order to identify possible risk factors. RESULTS: Sixty two thousand nine hundred sixty-eight live births were recorded over the study period. There were two neonatal apparent life-threatening events and no neonatal sudden unexpected death. The overall rate of neonatal apparent life-threatening events and unexpected deaths was thus 0.032 per 1000 live births. Three potential risk factors were identified: skin-to-skin contact, primiparous mother and mother and baby alone in the delivery room. CONCLUSION: A neonatal apparent life-threatening event or sudden unexpected death during the first 2 h of life is very uncommon. Skin-to-skin contact between mother and infant left alone in the delivery room may constitute the main risk situation. This must not lead to reconsider skin-to-skin contact that has been proven beneficial and seems per se almost safe, but must induce maternity staff to pay particular attention to a skin-to skin infant when left alone with its mother.

[End of life in neonatal medicine under the direction of French law]. / Fin de vie en médecine néonatale à la lumière de la loi.

Two recent laws have significantly reformed the French Public Health Code: the law of March 4th 2002, related to the patient's rights and the quality of the health care system and the law of April 22nd 2005, related to the patient's rights and the end of life. These changes have prompted health care professionals involved in perinatal and neonatal medicine to update their considerations on the ethical aspects of the end of life in neonatal medicine. Therefore, the authors examined the clauses of the law related to the patient's rights and to the end of life, confronting them with the distinctive features of neonatal medicine. In this paper, the medical practices, which are either prohibited or authorized in the course of end of life are considered: prohibition of euthanasia, authorization for alleviating pain at the risk of shortening life, authorization for restricting, withholding or withdrawing treatments. Next, the justifications provided by the legislation to authorize these practices are analysed: prohibition of unreasonable obstinacy and respect for individual wishes. Then, the conditions required by the law to determine and to implement these acts are discussed: consultation with the healthcare staff and justified advice from a consulting physician, consideration of parental opinion, registration of the decision and its justifications into the patient's medical file, protection of the dying patient's dignity and preservation of his life quality by providing palliative care. Lastly, we report the terms of the ethical dilemma which may occur in the area of neonatal medicine in spite of genuine and persevering efforts in order to conciliate legal requirement and ethical responsibility.

Management of seat-belt syndrome in children. Gravity of 2-point seat-belt.

We present our experience with a management of seat-belt syndrome in three children and draw particular attention to the severity of two-point fixation seat-belt injuries after a motor vehicle accident with 5 passengers whose vehicle was struck head-on by an oncoming vehicle. The parents were sitting in front, Adeline had a 2-point lap seat-belt, the 2 other children had 3-point seat-belts. The parents both had humerus fractures. The 4-year-old brother suffered a cervical and abdominal trauma with renal and splenic contusions and intestinal perforations. Adeline suffered multiple injuries, notably to the head, spine and abdominal viscera with erosions at the site of lap-seat-belt contact. The spinal injury was an L2 angular Chance fracture associated with paraplegia on the 7th day. Operative findings included a transverse tear of the left rectus abdominus muscle, an incomplete transection of the stomach and perforation of the ileum. The injuries were ultimately fatal. Given associated abdominal pain, skin erosions at the site of seatbelt contact, spinal fracture, and rectal muscle disruption apparent on emergency laparotomy, early diagnosis is important for better prognosis.

[Non-specific tuberculin reactivity due to sensitization to non-tuberculous mycobacteria (NTM) in children not vaccinated with BCG. Diagnostic value of a comparison of intradermal tests with tuberculin and NTM antigens]. / Réactivité tuberculinique non spécifique par sensibilisation aux mycobactéries non tuberculeuses (MNT) chez des enfants non vaccinés par le BCG. Intérêt diagnostique de la comparaison des tests intradermiques à la tuberculine et aux antigènes de MNT.

Sensitisation to non tuberculous mycobacteria (NTM) may provoke a non specific tuberculin reaction and can cause problems in the interpretation of tuberculin tests in subjects who have not been vaccinated with BCG. The practice of testing for antigens to NTM (sensitins) should be useful for pointing to the right diagnosis. Our study was carried out on 24 asymptomatic children aged between 11 months and 8 years 9 months; these children were considered to be sensitive to NTM based on comparative cutaneous tests (reactions to sensitins > or = 5 mm and > or = 3 mm vs tuberculin) and were selected from a group of 53 children who had either initially achieved a positive tuberculin reaction or who had undergone conversion on subsequent prevaccination testing. The tests were carried out with tuberculin RT 23, tuberculin Merieux and sensitins from M. avium and M. intracellulare. They had been repeated two to four months later in cases of a response to one of the different reactants. At the first examination the tuberculin reactions were most often weak, the Merieux tuberculin induced a stronger response than the RT23 tuberculin. A dominant response for one or both sensitins was present in 18 cases. The tuberculin reactions became weaker whilst the sensitins remained relatively stable. The difference became significant in the six remaining cases. Although tests for tuberculin and sensitins have some diagnostic value which is necessarily imprecise, comparative analysis of the cutaneous reactions to the different antigens may contribute to avoid an erroneous interpretation for tuberculin allergy in asymptomatic young children without any risk factors for tuberculous infection. It is important to identify those subjects having non specific tuberculin reactivity induced by sensitisation to NTM in order to avoid non justified chemoprophylaxis and also to be able to vaccinate these children with BCG.

Nephrocalcinosis and prematurity: importance of urate and oxalate excretion.

Nephrocalcinosis was described in preterm infants by several authors who tried to determine its association with hypercalciuria and furosemide therapy. We evaluated these potential mechanisms along with other lithogenic factors not previously studied in 10 premature babies. Hypercalciuria was an inconsistent finding like in other reports; elevated uric acid excretion and hyperoxaluria were observed in 5 and 6 cases, respectively. The aminocid excretion was normal in all infants. Our data suggest that in addition to hypercalciuria, other lithogenic factors may play a role in the pathophysiology of nephrocalcinosis of premature infants.

Abnormal alpha-aminoadipic acid excretion in a newborn with a defect in platelet aggregation and antenatal cerebral haemorrhage.

alpha-Aminoadipic acid (alpha AA) is an intermediate in lysine metabolism. We report a new case with alpha AA excess in urine and plasma, without alpha-ketoadipic acid, in a full-term male child born to unrelated parents; he presented at 24h of life with seizures that failed to respond to phenobarbital, clonazepam, and Vigabatrin and death occurred on the 38th day of life. Brain imaging suggested antenatal haemorrhage. Small quantities of alpha AA were also detected in the blood and urine of both parents and a healthy brother, all three of whom exhibited the same defect in platelet aggregation as the deceased child. Both parents had decreased levels of plasma neopterin, a finding that might be related to the immunodeficiency described in other cases.

[Pharmacokinetics of netilmicin in the first use in newborn infants with gestational ages greater than 34 weeks]. / Pharmacocinétique de la nétilmicine lors de la première utilisation chez le nouveau-né de plus de 34 semaines de gestation.

BACKGROUND: Neonatal bacterial infections are potentially lethal. The infant must be started on an antibiotic regimen to cover the organisms most frequently implicated. Since the introduction of gentamicin therapy for neonatal infections, attention has focused on aminoglycoside pharmacokinetics in these very young patients. PATIENTS AND METHODS: The pharmacokinetics parameters of netilmicin during its first administration were analysed in 22 newborn infants with a gestational age over 34 weeks, aged 1 to 3 days, in whom a maternofetal infection was suspected. Netilmicin was given intravenously at a dose of 6 mg/kg/day in two daily injections for 35 minutes. Blood concentrations of netilmicin were measured from samples taken 5, 15, 30, 60 minutes and 2 1/2, 5 1/5 and 11 1/2 hours after injection. The patients were also given cefotaxime plus ampicillin. RESULTS: The kinetics were bicompartimental: prematurity, proven infections and other perinatal factors influenced the pharmacologic parameters and it was not possible to define a predictive formula for antibiotic administration. CONCLUSION: The blood levels of netilmicin must be monitored even in infants who were not born prematurely. Because of the large distribution volume and the long half-life, we propose a dose of 6-7.5 mg/kg given once daily.