French Neonatal Units Research Articles

Prescriptions of anti-reflux drugs in neonatology and neonatal intensive care units: A large multicentre observational study (2014-2022).

Gastro-oesophageal reflux is common in newborns, especially in premature infants. Treatment by medication is controversial as the drugs prescribed have not been consistently proven to be effective and are known to have adverse effects. This study sought to identify trends in the prescription of anti-reflux medication in a large group of French neonatal units. Data on prescriptions of anti-reflux treatments-proton pump inhibitors (PPIs), antacids, histamine-2 receptor antagonists (H2RAs), and prokinetics-from 2014 to 2022 for infants with a corrected gestational age <45 weeks, were extracted from a prescription database (Logipren®) used by 63 French neonatal units, and then analysed. Of all infants recorded in the database during the study period (n =152 743), 10.2% (n = 15 650) were prescribed anti-reflux medication (95% confidence interval [CI] 10.0-10.4%), mainly as monotherapy (77.5%). The rate was higher in the subgroup of preterm infants born before 28 weeks of gestation (n = 9493) (20.6%, 95% CI 19.8-21.4%; n = 1956). PPIs were the most commonly prescribed anti-reflux medications (6.9% of infants, 95% CI 6.8-7.0), followed by antacids (5.2%, 95% CI 5.1-5.3%), while H2RAs and prokinetics were rarely prescribed. Over the period, the prescription rate remained stable for PPIs, decreased for H2RAs (τ = -0.86, P = .02), and, among preterm infants born at gestational ages of 28-31 or 32-36 weeks, increased for antacids. Anti-reflux medications were frequently prescribed by neonatal units, especially for extremely premature infants. Most of these prescriptions were for PPIs and antacids.

Father's perceptions and care involvement for their very preterm infants at French neonatal intensive care units.

We aimed to evaluate (1) fathers' perceptions and care involvement for their very premature infants and their views of the hospitalization period based on parental reports and (2) their evolution over time. We used an online parental survey to assess answers from parents of very preterm infants who were successfully discharged from French neonatal units. We analysed answers from February 2014 to January 2019 to an anonymous internet-based survey from the GREEN committee of the French Neonatal Society. Responses were compared for period 1 (P1, 1998 to 2013) and period 2 (P2, 2014 to 2019). We analyzed 2,483 surveys, 124 (5%) from fathers and 2,359 (95%) from mothers. At birth, 1,845 (80%) fathers were present in the hospital, but only 879 (38%) were near the mother. The presence of fathers in the NICU increased from P1 to P2 (34.5% vs. 43.1%, p = 0.03). Nearly two thirds of fathers accompanied their infants during transfer to the NICU (1,204 fathers, 60.6%). Fathers and mothers had similar perceptions regarding relationships with caregivers and skin-to-skin contact with their infants. However, more fathers than mothers felt welcome in the NICU and in care involvement regarding requests for their wishes when they met their infant (79% vs. 60%, p = 0.02) and in the presentation of the NICU (91% vs. 76%; p = 0.03). Mothers and fathers significantly differed in the caring procedures they performed (p = 0.01), procedures they did not perform but wanted to perform (p < 0.001), and procedures they did not perform and did not want to perform (p < 0.01). Most fathers were present at the births of their very preterm infants, but fewer fathers were near the mother at this time. Less than two thirds of fathers accompanied their infants to the NICU. There should be further changes to better meet the specific needs of the fathers of infants requiring care in the NICU. Continuing assessment with an online questionnaire may be useful to monitor changes over time in father's involvement in NICUs.

Need for standardized vancomycin dosing for coagulase-negative staphylococci in hospitalized infants

In high-income countries, coagulase-negative staphylococci (CoNS) are the most commonly implicated pathogens in late-onset sepsis (LOS) (sepsis occurring after 72 hours of age) in neonates [ [1] Jean-Baptiste N. Benjamin Jr., D.K. Cohen-Wolkowiez M. Fowler Jr., V.G. Laughon M. Clark R.H. et al. Coagulase-negative staphylococcal infections in the neonatal intensive care unit. Infect Control Hosp Epidemiol. 2011; 32: 679-686https://doi.org/10.1086/660361 Crossref PubMed Scopus (68) Google Scholar ]. They are responsible for more than 50% of neonatal LOS cases [ [2] Cailes B. Kortsalioudaki C. Buttery J. Pattnayak S. Greenough A. Matthes J. et al. Epidemiology of UK neonatal infections: the neonIN infection surveillance network. Arch Dis Child Fetal Neonatal Ed. 2018; 103: F547-F553https://doi.org/10.1136/archdischild-2017-313203 Crossref PubMed Scopus (77) Google Scholar ]. Overall mortality rates from LOS caused by CoNS are low; however, low birth-weight and preterm infants carry the highest burden. Morbidity related to LOS caused by CoNS has been associated with poor neurodevelopment, visual impairment, chronic lung disease, and necrotizing enterocolitis and can prolong the length of hospitalization [ [3] Dong Y. Speer C.P. Glaser K. Beyond sepsis: Staphylococcus epidermidis is an underestimated but significant contributor to neonatal morbidity. Virulence. 2018; 9: 621-633https://doi.org/10.1080/21505594.2017.1419117 Crossref PubMed Scopus (47) Google Scholar ]. CoNS are frequently multi-drug resistant, and the emergence of the multi-drug resistant Staphylococcus capitis NRCS-A clone worldwide, found almost exclusively as a pathogen within neonatal units, is concerning [ [4] Laurent F. Butin M. Staphylococcus capitis and NRCS-A clone: the story of an unrecognized pathogen in neonatal intensive care units. Clin Microbiol Infect. 2019; 25: 1081-1085https://doi.org/10.1016/j.cmi.2019.03.009 Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar ]. A recent survey of French neonatal units demonstrated that S capitis accounted for 14.2% of nosocomial bloodstream infections, with most infections being attributed to the NRCS-A clone [ [5] Decalonne M. Dos Santos S. Gimenes R. Goube F. Abadie G. Aberrane S. et al. Staphylococcus capitis isolated from bloodstream infections: a nationwide 3-month survey in 38 neonatal intensive care units. Eur J Clin Microbiol Infect Dis. 2020; 39: 2185-2194https://doi.org/10.1007/s10096-020-03925-5 Crossref PubMed Scopus (1) Google Scholar ].

Early Use of Mother's Own Raw Milk, Maternal Satisfaction, and Breastfeeding Continuation in Hospitalised Neonates: A Prospective Cohort Study

Background: Despite the critical importance of breast milk for preterm and sick neonates, there is no consensus regarding the use of raw mother's own milk (MOM) in neonatal units. Objectives: This study aimed to describe the use of raw MOM in hospitalised neonates before day 7 (early use), and to investigate: (i) related factors, (ii) maternal satisfaction, and (iii) the association with breastfeeding continuation. Methods: This prospective cohort included 516 neonates intended to be breastfed in 2 French neonatal units. Neonates receiving raw MOM before day 7 were compared to those who did not. The association between early use of MOM and breastfeeding continuation at hospital discharge, and up to 6 months later, was measured by logistic regression. Results: More than one-third (36.2%) of breastfed neonates did not receive any MOM during their first week, mainly due to organisational constraints and staff reluctance. Maternal satisfaction related to early raw MOM use was high (96%), and was coupled with a more frequent maternal feeling of being supported in breastfeeding (p = 0.003). There was a significant association between early use of MOM and breastfeeding continuation at discharge (OR 2.92, 95% CI 1.94-4.40, p < 0.0001), which persisted 6 months later (OR 2.70, 95% CI 1.21-6.03, p = 0.023). This association appeared independent in multivariable analyses (at discharge: aOR 2.03, 95% CI 1.27-3.25, p = 0.003; 6 months later: aOR 2.46, 95% CI 1.02-5.92, p = 0.045). Conclusion: While the early use of raw MOM in hospitalised neonates can be limited by multiple factors, it appears supportive for mothers, and might represent a simple opportunity to improve breastfeeding in neonatal units.

Policy of feeding very preterm infants with their mother's own fresh expressed milk was associated with a reduced risk of bronchopulmonary dysplasia.

Since 2005, the French Food Safety Agency has recommended that very preterm or low-birthweight babies should be fed with pasteurised, expressed breastmilk, and feeding policies on this vary widely in French neonatal units. We investigated the differences between using a mother's expressed milk, in fresh or pasteurised forms, for very preterm infants. This observational multicentre study analysed data on 926 very preterm infants: 636 from neonatal units who used the mother's own fresh milk and 290 who used the mother's milk after pasteurisation. We analysed necrotising enterocolitis, bronchopulmonary dysplasia, in-hospital mortality, late-onset sepsis, weight gain, length of hospital stay, the duration of parenteral nutrition and the duration of enteral feeding with a nasogastric tube. Multivariate analyses were conducted to assess the impact of maternal milk policies. After adjustment, there was a reduced risk of bronchopulmonary dysplasia in the fresh milk group with an odds ratio of 0.40 and 95% confidence interval of 0.27-0.67 (p < 0.001). No other statistically significant differences were observed. Feeding very preterm infants with their mother's expressed fresh milk was associated with a reduced risk of bronchopulmonary dysplasia, and further investigations are needed to evaluate the clinical impact of this practice.

Use of extensively hydrolysed formula for refeeding neonates postnecrotising enterocolitis: a nationwide survey-based, cross-sectional study

ObjectiveTo evaluate the prevalence of and reasons for using extensively hydrolysed formulas (EHFs) of cow's milk proteins in the French neonatal units as well as the modality of their prescription...

Soins palliatifs en néonatologie : analyse et évolution des pratiques sur 5 ans dans un centre de niveau 3

The "Patients' rights and end-of-life care" act known as "Leonetti's Law" promulgated in 2005 has promoted the use of palliative care to avoid unreasonable obstinacy when life-sustaining treatment appears disproportionate. Very little is known about this new practice for newborns in French neonatal units. To describe and evaluate the practice of palliative care in the newborn (mode of entry, characteristics, and modalities) and its evolution over time. Ambispective observational study conducted in a level III neonatal center. We included all newborns presenting conditions for which palliative care was introduced. Quantitative and qualitative analyses of routinely collected data, recorded from medical and nursing charts. We compared the recorded data between periods P1 (2006-2007) and P2 (2008-2010) using the Chi(2) test to assess changes over time. A total of 93 newborns benefited from palliative care during the study period. The main medical conditions motivating palliative care initiation in the newborns were severe complications of prematurity (36/93, 39%), anoxic-ischemic encephalopathy (19/93, 20.5%), severe malformations (8/93, 8.5%), severe congenital heart disease (8/93, 8.5%), and other various etiologies (22/93, 23.5%). Both the number of newborns in palliative care/total number of births and the number of deaths after palliative care/total number of neonatal deaths remained stable. In case of prenatal diagnosis (n=31), there was an increase in the number of "palliative care from birth projects" (13/22 in P2 vs. 1/9 in P1, P=0.02). Collective meetings during the decision process were significantly more frequently reported in the infants' charts in P2 (48/59 in P2 vs. 18/34 in P1, P<0.01). Withdrawing and withholding life-sustaining treatment and limiting procedures of care and/or procedures of surveillance/monitoring were more frequent in P2 as compared to P1, respectively 12/34 vs. 37/59 (P=0.02) and 14/34 vs. 39/59 (P=0.03). A titration of level III analgesics treatment was high in both periods and remained stable. However, a trend toward an increase of systematic pain evaluation over time was observed (81.6% in P2 vs. 64.5% in P1; P=0.085). A significant number of newborns affected by various pathologies undergo neonatal palliative care. Despite their recent introduction in neonatal medicine, palliative care practices have changed significantly. These practices are mostly in compliance with the "patients' rights and end-of-life care" act promulgated in France in 2005.

Highlights in this issue

Antenatal corticosteroids to women at risk of preterm delivery is well established therapy to prevent respiratory stress syndrome (RDS) etc. It has also been found to reduce neonatal death. Hanna Norberg et al report in this issue (pp. 364–369) that multiple causes of antenatal corticosteroids significantly reduce birth weight, birth length and head circumference even after adjusting for possible confounders. Studies of the long-term outcome are under way. Preterm newborns are highly sensitive to odours. Ambient odours in the incubator may modify the behaviour. Therefore, Pierre Kuhn et al have conducted a nationwide survey to evaluate the nature and the variability of frequency with which odour products are used in French neonatal units. Although many of the products are necessary for the care of newborn infants, they can probably be used in a wiser way to avoid harm (see pp. 334–339). Children with certain disabilities, particularly behaviour and mental health problems are more often subjected to physical abuse. See article by Birgitta Svensson et al (pp. 407–412). These children are also more often subjected to bullying in school, since they are regarded as clumsy. See also article by Susanne Bejerot et al (pp. 413–419). Special prevention programmes identifying these children are necessary to protect and empower them. Paid paternity leave for fathers was first introduced in Sweden in 1974. This has been followed by some other countries. However, fathers seem to receive less support from child health nurses, and many nurses were ambivalent about fathers’ caring abilities according to Pamela Massoudi et al (see pp. 396–401). The authors conclude that methods must be developed to involve both parents in child health care. The most popular preparation of monoclonal antibodies palivizumab received a blockbuster status with sales of USD 1.2 billion in 2008 over United States. Immunoprophylaxis was found to reduce RSV hospitalizations in patients with bronchopulmonary dysplasia (BPD) and acyanotic congenital heart disease. However, the results regarding patients with cyanotic heart disease or preterm infants without BPD were inconclusive. No effect was found with regard to the mechanical ventilation or death. The findings are reported by Joan MV Pons et al (pp. 324–329).

End of life decisions: Tragic choices in neo-natalogy

The observation of decision-making processes of end of life within several French neonatal units has revealed a diversity which resists any overall explanation and demands a local interpretation. This article details the characteristics motivating a critical care in neonatal intensive care units. Each service constructs a decision-making framework (based on operating modes, medical criteria, moral positioning, and parents’ role) in order to be able to face the heavy burden of uncertainty and responsibility when faced with the question: “What is a life worth living?”

Utilisation des solutés standard pour l’alimentation parentérale du nouveau-né en France – Résultats d’une enquête nationale

Standard parenteral nutrition solutions have been developed nationwide in France but little is known about their frequency of use and indications. To evaluate the frequency of the use of standardized parenteral nutrition solutions in neonatal units in France, to determine which solutions are currently available and used, and to determine whether the available parenteral nutrition solutions are satisfactory to the prescriber by evaluating the type and number of additions most frequently prescribed. National survey performed in France, using a questionnaire sent to 296 French neonatal departments. Eighty-five percent of level III units and 50% of the level II units responded to the questionnaire. Standardized parenteral nutrition solutions were used in 66% of the responding units and accounted for 45% of the prescriptions of parenteral nutrition in newborns. They were significantly more frequently prescribed by level II than level III units (68% vs. 24%, p<0.0001). Thirteen of the 40 standard solutions declared as solutions for parenteral nutrition did not contain amino acids. The addition of macro- and/or micronutrients was very frequent and often made even if not indicated in the Consumer Medicine Information (CMI). There is great heterogeneity in parenteral nutrition practices among French neonatal units. A large number of the standard solutions used are not appropriate for the nutrition of full-term and/or preterm infants. Their use in everyday practice does not cover the nutritional needs of the newborn or induces at-risk practices such as supplementation with macro- and/or micronutrients.

Utilisation du citrate de caféine pour le traitement des apnées idiopathiques du prématuré dans les équipes françaises de médecine néonatale

Caffeine citrate is commonly used for prophylaxis and treatment of apnea in preterm babies. Objective To evaluate the use of caffeine citrate in french neonatal units. Materials and methods Postal survey in 100 neonatal units. Results Answers were obtained from 81 units. Sixty-three units use systematic prophylactic treatment and the threshold of gestationnal age (weeks gestation) for this systematic treatment is 32 weeks. Caffeine citrate is administered as a loading dose of 20 mg/kg followed by a maintenance dose of 5 mg/kg in 95% of the units. Discontinuing the treatment occurs between 33 and 35 weeks in 37% of the units and between 35 and 37 weeks in 53%. Two third of neonatologits describe recurrent apnea beyond 37 weeks, with the need to continue treatment. Fourteen units sometimes discharge babies at home with ambulatory caffeine citrate treatment and discontinue treatment by 42 to 46 weeks'gestation. A mean duration of 5 days without apnea is required before discharge. Conclusion French teams respect “recommendations” concerning doses and duration without apnea before discharge. Indication of treatment, threshold for systematic treatment, duration of treatment and ambulatory treatment differ among teams.

Cathéters centraux et épanchements péricardiques en période néonatale : étude rétrospective multicentrique

Objective. – To evaluate the use of neonatal central venous catheters (CVC) in 38 french neonatal units and occurrence of pericardial effusion (PCE) over the past 5 years. Materials and methods. – We surveyed 38 units with a questionnaire and studied the cases of PCE in five units. Results. – Response rate was 89% (34/38). Accepted CVC tip positions were: junction of right atrium (RA) and vena cava (VC) 76%, VC 58%, RA 11%. Fifty percent of the centers had been exposed to PCE. 16 cases of PCE were studied. Median gestational age was 31 weeks (range: 26.1 to 40 weeks). Median time from insertion: 3.2 days (range: 0.4–13.5). In all cases CVC tip was intracardiac at insertion with inadequate withdrawing in 13 cases. Sudden cardiac collapse was reported in eight cases, and unexplained cardiorespiratory instability in six cases. Echography showed PCE in 14 cases. One diagnosis was post-mortem. CVC was withdrawn in 12 patients and 13 underwent pericardiocentesis. Four patients died and two had neurological sequelae. Conclusion. – PCE was associated with intracardiac CVC tip. The CVC tip should be controlled with radiography or echography outside the cardiac silhouette. PCE diagnosis must be considered in face of unexplained cardiovascular decompensation of neonate with CVC.