Potential Impact of Umbilical-Cord-Blood Procalcitonin-Based Algorithm on Antibiotics Exposure in Neonates With Suspected Early-Onset Sepsis.

Context: The incidence of early-onset neonatal infection has greatly decreased, but a new diagnostic approach is needed to avoid overdiagnosis and overtreatment. The aim of this study was to assess the potential impact of an algorithm incorporating umbilical-cord-blood procalcitonin (PCT) level on neonatal antibiotics prescription rate as compared with current practice. Material and methods: We conducted a prospective study in three maternity wards in France. All term and preterm neonates with the usual risk factors for neonatal group B Streptococcus infection were eligible for umbilical-cord-blood PCT testing. We compared the proportion of neonates who were exposed early to antibiotics (before 6 days of life) to that of neonates for whom antibiotics prescription would be indicated according to the PCT-based algorithm. Results: Among the 3,080 neonates included, 1 neonate presented with certain infection and 38 neonates with probable infection. The global antibiotics prescription rate was 4.6% [95% confidence interval (CI), 4.1-5]. With the PCT-based algorithm, the potential decrease in prescription rate would be 1.8% (95% CI, 1.3-2.3), corresponding to a 39% (95% CI, 37.3-40.7) relative reduction in antibiotics exposure (p < 0.05). Conclusion: These results suggest that the umbilical-cord-blood PCT-based algorithm could significantly help the clinicians in their antibiotic prescription decision to decrease neonatal antibiotics exposure as compared with current practice. If validated in a larger interventional randomized study, this approach could help clinicians stratify the risk of early-onset neonatal infection and initiate early antibiotics treatment in newborns at high risk of infection while limiting the deleterious effects of useless prescriptions in non-infected newborns.

Mother-infant interaction assessment at discharge and at 6 months in a French cohort of infants born very preterm: The OLIMPE study.

OBJECTIVES: The principal aim was to investigate the feasibility of assessing mother-infant interactions at discharge and at 6 months infant corrected age in singletons born before 32 weeks of gestation. The secondary aims were to describe these interactions and their disorders, explore the association between maternal emotional state and the interactions, and assess the relationship between disordered interactions and infant social withdrawal behaviour. METHODS: OLIMPE is an ancillary study of the population-based study EPIPAGE 2, which recruited preterm neonates in France in 2011. 163 dyads participated at discharge and 148 at 6 months. Interactions were observed with the Attachment During Stress (ADS) scale, which includes two behavioural subscales, for the mother (m-ADS) and her infant (i-ADS). Two professionals independently completed the ADS scales for one third of the observations. Maternal emotional state was assessed using self-administered questionnaires of depression, anxiety, and stress. Infant's social withdrawal behaviour at 6 months was measured by the Alarm Distress Baby scale. RESULTS: At discharge, 15.3% of the m-ADS scales and 43.3% of the i-ADS scales had at least one unobserved component. At 6 months, all items on both scales were noticeable in >90% of the dyads. Reliability, estimated by the kappa coefficient, ranged between 0.39 and 0.76 at discharge, and between 0.21 and 0.69 at 6 months. Disordered interactions were indicated on 48.6% of the m-ADS scales and 36.5% of the i-ADS scales at discharge. At 6 months, these rates were 32.6% and 26.0%. Disordered interactions at 6 months were associated with identified disorder at discharge. Insecure infant attachment was not influenced by maternal mental health but was strongly associated with infant social withdrawal behaviour. CONCLUSIONS: The ADS scale can be used to screen for early interaction disorders after premature birth and may help to target dyads that would most benefit from early intervention.

Hyperbilirubinemia and neurodevelopmental outcome of very low birthweight infants: results from the LIFT cohort.

BACKGROUND: Bilirubin-related neurotoxicity is an important clinical issue in very low birthweight (VLBW) infants, and the existing literature is inconsistent. OBJECTIVE: To analyze the relationship between maximal serum unconjugated bilirubin levels (SBL) and neurodevelopmental outcome at 2-year corrected age in VLBW infants. METHODS: Phototherapy was initiated in all infants born before 33 weeks of gestation, according to Maisels' recommendations. Neurodevelopmental assessment at 2-year corrected age was performed in all infants that survived. SBLs collected during the first week of life were used to define three tertiles of max-SBL. The first tertile corresponded to infants with the lowest max-SBL. RESULTS AND CONCLUSIONS: A total of 724 infants were included in the study, and among them, 631 (87%) were evaluated at two years old. The infants of the first tertile were younger and smaller than the infants of the other two tertiles, in accordance with Maisels' recommendations for very small infants. No difference in the risk of impaired functional outcome among the three groups was observed. However, among infants weighing less than 1001 g, those in the third tertile had a poorer neurodevelopmental prognosis as compared to those in the second tertile (adjusted odds ratio = 6.8, 95% CI: 1.2-36.7, p = 0.03). Considering the results obtained, we propose 196 µmol/L (11.5 mg/dL) when birthweight varies between 1001 and 1500 g, and 170 µmol/L (9.9 mg/dL) when birthweight is less than 1001 g, as recommended max-SBLs (defined as maximal levels of 95(th) percentile curves of SBLs in infants with an optimal outcome). When Maisels' recommendations were applied, max SBLs were higher in 8% of infants weighing 1001-1500 g and in 15% of infants weighing less than 1001 g. Our data seems to validate Maisels' recommendations in the overall population of infants born before 33 weeks of gestation, but not in infants weighing less than 1001 g.

[Analgesia and sedation in premature newborns]. / Analgésie et sédation chez le nouveau-né prématuré.

Analgesics and sedatives are routinely prescribed in intensive care on intubated premature newborns, to ensure their comfort and limit pain. The results of two studies show that there is no significant link between prolonged exposure to these treatments and a more unfavourable long-term neurological outcome.

Prolonged sedation and/or analgesia and 5-year neurodevelopment outcome in very preterm infants: results from the EPIPAGE cohort.

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

Shock revealing salt poisoning in a neonate.

BACKGROUND: We report a case of shock, revealing a severe hypernatremia caused by salt poisoning in a 17-day-old male neonate. OBJECTIVE: We consider the physiopathology of salt overload in this context and the diagnostic strategy in neonate with hypernatremia. METHODS: We used patient history, weight, plasma, and urine osmolality to establish the diagnostic strategy. RESULTS: Salt poisoning in neonates manifests as intracellular dehydration without extracellular fluid accumulation. CONCLUSIONS: This poisoning underscores the need for providing appropriate help to mothers at discharge from the maternity ward or neonatology unit.

Effects of hydroxyethyl starch on cardiac output in hypotensive neonates: a comparison with isotonic saline and 5% albumin.

AIM: To evaluate the effects of hydroxyethyl starch (6% HES 200/0.5) on cardiac output in hypotensive neonates with low cardiac output and absence of myocardial dysfunction. METHODS: In a prospective randomized blinded trial, 21 hypotensive neonates (mean gestational age of 29+/-3 wk) were randomly allocated to receive infusions of either 5% albumin (albumin group), isotonic saline (saline group) or hydroxyethyl starch (HES group). Infants had to show low cardiac output and an absence of myocardial dysfunction for inclusion in the study. Cardiac output was assessed by Doppler-derived mean aortic flow velocity. RESULTS: Ten minutes after infusion, 67% of all infants had more than a 10% increase in cardiac output. Increases in mean aortic flow velocity (m/s; median and range) were 0.05 (-0.02, +0.07), 0.03 (-0.03, +0.12) and 0.03 (-0.04, +0.11) for the albumin, saline and HES groups, respectively (p = 0.79). The percentage of blood pressure normalization (95% confidence interval) was 86% (60-100) in the albumin group, 57% (20-94) in the saline group and 71% (37-100) in the HES group (p = 0.50). CONCLUSION: This study did not provide evidence that hydroxyethyl starch is more efficient than isotonic saline or albumin.

Effectiveness of linezolid and imipenem association in the treatment of severe community-acquired pneumonia in children: two case reports.

Two children with severe pneumonia, purulent pleural effusions, and abscess formation unresponsive to appropriate antibiotic therapy recovered promptly after the introduction of linezolid and imipenem association. Linezolid is a new antibiotic with high bioavailability and an outstanding safety profile, synergistic with imipenem, which may deserve a place in the armamentarium for severe pneumonia in children.