Manon Quintane

Le

Madame Le Docteur Bernier

Maud Jury

Monsieur Le Professeur

Cambonie Gilles

Madame Le Docteur Badr

Maliha Monsieur Le Docteur Baleine

Julien-Frédéric Madame Le Docteur Bernier

Maud Remerciements

Odile

Maud Vincent Florence

Sabine Renaud

Pénélope, Laurène, Odile Plan, Maliha, Damien, Bénédicte, Stéphanie Héléna Arthur

Christophe

Julien

Chloé, Sita Sophie Anaïs

Floriane Marie-Gabrielle Cyril

Angéline, Charline, Clémence, Hélène, Marie Alex Agnès

Marion, Stéphanie, Stéphanie Marie-Pierre Sylvain

Marie Grégoire

Rina Mélanie

ValenPn Merci Pierre

D'

Marion, Solène, Morgane Aziz

Quenpn

Florine Corenpn

Olivia Léna

DOCTEUR EN MEDECINE Présentée et soutenue publiquement Par

teaching and research institutions in France or abroad, or from public or private research centers.

Floriane et Alexandra, les cafés sont beaucoup moins savoureux sans vous, j'ai hâte de vous retrouver.

Au service de réanimaGon pédiatrique et néonatale de Nantes, au Pr Cyril Flamant : merci pour la qualité de votre accueil pour ce semestre. J'ai énormément de chance de poursuivre ma formaGon parmi vous.

A ma famille

Papa, merci de m'avoir inventé des histoires, de m'avoir appris le piano, d'avoir corrigé mes idenGtés remarquables et mes intégrales. Merci pour ton courage, ta déterminaGon, ta confiance et tout ton amour.

Maman, merci pour le marsupilami et le carton-glouton, pour les histoires du soir et les Harry PoFer, pour nos séjours entre filles et nos cafés au soleil. Mais surtout, merci pour ton équilibre et merci d'être toujours d'aussi bon conseil.

On en a vécu des aventures tous les trois, et merci d'être mes meilleurs coéquipiers.

A tous mes grands-parents, j'aurais tant aimé que vous soyez là. Merci de m'avoir enseigné la rigueur, le sens du travail et surtout merci de m'avoir couvert d'amour. Vous me manquez.

Fanfou et Luc, merci pour la place si parGculière que vous m'avez fait dans votre vie et pour celle que vous avez dans la mienne.

Marie, merci pour le modèle que tu es, merci pour tes conseils, merci pour ta bienveillance Anna, merci pour tous ces secrets partagés, merci pour tous ces moments de complicité Merci tous les quatre de toujours être là, et de toujours m'accompagner Romain, Amandine, Chloé et MarPn, malgré la distance et les épreuves de la vie, merci de partager un bout de la mienne. Même de loin je suis fière de vous.

Paul, depuis notre sujet de TPE sur les piles, merci d'être à mes côtés, de m'avoir supporté

A -Prématurité

La prématurité se définit comme la naissance d'un enfant avant le terme de 37 semaines d'aménorrhée (SA) et les extrêmes prématurés sont les enfants nés en deçà du terme de 28 SA.

B -Golden Hour

Emprunté à la médecine adulte et plus parGculièrement à la prise en charge d'un polytraumaGsme, le concept de Golden Hour (GH) souligne l'importance d'une prise en charge opGmale dans la première heure suivant un traumaGsme. [START_REF] Clark | the 'Golden Hour,' the 'Momentary Pause,' and the 'Third Space[END_REF] En effet, une prise en charge adaptée dans ce laps de temps confère une augmentaGon de la survie sans morbidité sévère aux paGents.

I. Introduction

Prematurity represents a growing proporGon of births in France as it concerns 55,000 births each year. [START_REF]Prématurité ⋅ Inserm[END_REF] It is the main cause of neonatal morbidity and mortality.

The highest risks are seen with the most premature infants. Indeed, there is an increase in morbidity-free survival proporGonal to the term : 0% of < 24 weeks, 54.5% at 25 weeks, 82.9% at 28 weeks. [START_REF] Ancel | Survival and morbidity of preterm children born at 22 through 34 weeks' gestation in France in 2011: results of the EPIPAGE-2 cohort study[END_REF] Clinical events that occur during the physiologic transiGon from intrauterine to extrauterine life are especially significant for the populaGon of extreme premature -extreme low birth weight (EP-ELBW) infants.

The golden hour (GH) is a concept taken from adult medicine that emphasizes the importance of care provided immediately following a trauma. [START_REF] Sampalis | Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients[END_REF] Applied to neonatology, the golden hour represents a criGcal window of Gme following birth instantly, during which many tasks must be performed: cardiopulmonary resuscitaGon, post-resuscitaGon care, transport to the intensive care unit, and placement of the infant in its incubator. 5

The quality of care provided during GH is known to decrease short-term complicaGons in this populaGon: hypothermia, hypoglycemia, hyperoxia, respiratory failure, hypotension. It is also known to have an impact in a longer term on bronchopulmonary dysplasia, 9 intracerebral hemorrhage 10 , reGnopathy of prematurity and mortality.

These cares are the subject of internaGonal recommendaGons based on the InternaGonal Liaison

CommiFee on ResuscitaGon (ILCOR 11 ) 2020 Consensus on Science and Treatment RecommendaGons (CoSTR) for Neonatal Life Support and are frequently updated. These give details on cardiorespiratory management, but also on the body temperature and glycemia objecGves to be reached. [START_REF] Madar | European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth[END_REF] Maintaining an euthermic body temperature is primordial for EP/ELBW infants, as hypothermia and hyperthermia are associated with severe morbidiGes such as broncho-dysplasia, nosocomial infecGon, neurologic injury and necroGzing enterocoliGs. 12 , 13

In addiGon, the body temperature during GH is also a reflecGon of the quality of care provided. [START_REF] Trevisanuto | Maintaining normothermia: Why and how? Semin. Fetal[END_REF] In spite of standardized recommendaGons concerning the maintenance of normothermia in these fragile children, there is a great heterogeneity of management between different units (depending on the means available, the geographical locaGon or the lowest gestaGonal age of the resuscitated children). [START_REF] Jani | Thermoregulation and golden hour practices in extremely preterm infants: an international survey[END_REF] This heterogeneity is found at a lesser level within the same care team.

ImplemenGng a golden hour protocol that bundles evidence-based pracGces and standardize their applicaGon to the first few minutes a~er birth has shown to improve the quality and consistency of care for EP-ELBW infants.

II. Methods

Design and populaPon:

We designed a single-center prospecGve study to compare pre and post-protocol cohorts.

Data were collected over two periods: pre-protocol (May to October 2021) and post protocol (October 2022 to April 2023). The period between October 2021 and October 2022 was deliberately excluded as it corresponded to the Gme required to establish and implement the protocol in the delivery-room (DR) and neonatal intensive care unit NICU (wash-out period).

We included all extremely premature (EP) infants with gestaGonal age (GA) < 28 weeks and/or extremely low birth weight (ELBW = <1000g), born in our insGtuGon, acGvely managed in the delivery room, and admiFed in the NICU during both periods of the study. The exclusion criteria were antenatal diagnosis of congenital abnormaliGes, outborn birth, and birth during the washout period (October 2021 to October 2022).

Study locaPon

The study was performed in a terGary perinatal center located in a single site: Arnaud de Villeneuve Hospital, Montpellier University Hospital, France.

Context:

Before elaboraGng the golden hour protocol, the study team conducted a comprehensive review of the literature to idenGfy care pracGces during the golden hour that have the most significant impact on neonatal outcomes for EP/ELBW infants. Based on this review and the data collected and analyzed during the pre-protocol phase (Period I), a mulGdisciplinary team of NICU providers including neonatologists, neonatal emergency nurses operaGng in the delivery-room and NICU nurses designed the evidence-based bundles included in the protocol.

The protocol divided the Gme from birth to complete stabilizaGon into 5 phases (Figure 1):

-1. Adaptation Updates formaGons were provided throughout the project to maintain stakeholder engagement.

IntervenGons realized during GH in both study periods are summarized in table 1.

B I R T H

IntervenPons:

Data collecPon

Process measures that directly contributed to thermoregulaGon, glycemic control, and Gme to compleGon of GH stabilizaGon were collected prospecGvely for each premature infant in the delivery room and upon transfer to the NICU using a dedicated form (App. 3 and 4).

Other perinatal data were collected in our unit database, created for neonates born before 33 weeks' GA and/or with a birthweight less than 1,500 g and admiFed to the department of neonatal medicine. The database uses a predetermined form, with detailed definiGons of each item.

DefiniPons

-Euthermic range was defined as a temperature between 36.5 and 37.5°C 22 -Hypoglycemia was defined by a serum glucose concentration <0,47g/L. [START_REF] Van Kempen | Lower versus Traditional Treatment Threshold for Neonatal Hypoglycemia[END_REF] -Time to completion of admission stabilization included DR resuscitation, transport to the NICU, installation, initiation of therapeutics if needed and providing decreased environmental stimulation to approximate the intrauterine environment.

-Severe morbidity was defined by at least one of the following conditions: (a) severe bronchopulmonary dysplasia (BPD), defined as administration of oxygen for at least 28

Outcomes

-The primary endpoint was the comparison between the 2 periods of the variation of temperature from the conditioning in DR to the arrival in NICU.

The secondary endpoints included:

-Proportion of infants with a severe temperature variation (defined as a loss ≥ 0,5°C) -Incidence of hypoglycemia -Time between birth and end of stabilization (= end of NICU installation)

Analysis

A pre-post design was used to compare outcomes for preterm infants prior to and a~er implementaGon of the Golden Hour protocol (Period I and Period 2 respecGvely).

An overall descripGon of the sample was made by giving the frequencies and percentages of the different categories for the qualitaGve variables.

As the distribuGons of the quanGtaGve variables are not always Gaussian, the descripGon of these variables was done using the mean and the standard deviaGon but also the median and the Q25 and Q75 values.

The comparison between the groups was carried out for the qualitaGve variables using a chisquare test and when the condiGons of validity of the chi-square were not respected, it was replaced by Fisher's exact test.

For quanGtaGve variables, the comparison was made using the Student or Wilcoxon (Mann-Whitney) tests of comparison of means, depending on the distribuGon.

The significance level was set at 5% for all the tests used. p < 0.05 was considered staGsGcally significant.

StaGsGcal analysis was performed with SAS Enterprise Guide so~ware version 7.13.

III. Results

We included a total of 51 children (GA <28 weeks and/or <1000 g), divided into 30 in Period I (May 2021 to October 2021) and 21 in Period II (October 2022 to April 2023) Fig. 2 Figure 2 -Flow chart of our study 37

Children had a median term of 27 SA in period I, and 26 SA in period II (27 [25-29] vs 26 [25-28], p = 0,71) with a median birth weight of 975 g in period I and 830 g in period II (975 [900-1135] vs 830 [720-970], p = 0,96). There was no difference between the characteristics of the two groups (Table 2). Regarding the primary endpoint, there was no staGsGcally significant difference between the two groups. The global variaGon of temperature between condiGoning in DR and arrival in NICU was (-0,5°C) [-0,6; -0,2] in period I versus (-0,6°C) [-1,1; +0,1] in period II (p = 0,3), (table 3, figure 3).

The median body temperature at the end of the resuscitaGon room care was 36.8°C [36. 4-

39

Regarding the secondary endpoints:

We observed a significant difference between the number of children who had a severe temperature variaGon (loss > 0.5 °C) between the two periods during transport: 11/13 (85%) in period I vs 7/20 (35%) in period II, (p 0.01). (Table 4 -Figure 4 ). 40 About glycemia at the NICU admission we had a mean blood glucose level in period I of 0.60 g/L (+/-0,24 g/L) and in period II of 0.77 g/L (+/-0,40, p = 0.08). We did not observe a staGsGcally significant difference between the two groups, although the trend was towards a decrease in the number of hypoglycemia with 9/23 (39%) in period I versus 5/21 (24%) in period II (p = 0.34).

(Table 5) Finally, we did not find any significant difference between the two periods on the duraGon of care (Table 6).

Factors that could influence children's temperature have been studied during period 1 in order to elaborate the management protocol. We also studied these factors in the second period (Table 7). 19 [15-24] n= 24

(+/-21)

19 [15-26] n= 17

22 (+/-16)

18 [15-22] 0.87

IV. Discussion

Our objecGve was to implement a systemaGc, evidence-based protocol for EP/ELBW infants' care during their first hour of life. Our primary endpoint was to decrease temperature variaGon throughout the golden hour care.

In our study, implemenGng a standardized protocol did not significantly decrease temperature Harriman [START_REF] Harriman | Golden Hour Protocol for Preterm Infants: A Quality Improvement Project[END_REF] and AL found no significant difference when comparing the proporGon of infants GA < 32 weeks whose temperature remained above 36.5 °C during their first hour of life before and a~er the implementaGon of a protocol. Croop 18 SEW, and Al. found a significant decrease in the number of GA < 27 weeks outside the thermal neutral zone on admission to the NICU a~er their protocol of care was implemented: 59% pre-protocol vs. 38% post-protocol (p = 0.001).

Perhaps some of these results can be explained by the difference in delivery room temperatures between our two periods (26°C [25-27] interacGons with the environment it seems reasonable to think that the difference in the delivery room temperature has a major impact on our results.

An other hypothesis to explain our difficulGes to maintain normothermia may be a lack of adherence to the protocol, especially in the NICU (care staGon ready in just 3,3% of cases (1/30) in Period I and just 25% of cases (5/20) in Period II, p = 0,03). Indeed, in this unit, there is a large number of caregivers with high turnover in the nursing team, which makes difficult to implement new measures. We do not have data in previous studies regarding golden hour protocol adherence, but this point remains to be improved. To do so, simulaGon-based learning may be an interesGng opGon. 27 , 28

We didn't have significant results about glycemia but we can observe a trend toward a decrease in the rate of hypoglycemia at the admission in NICU, which is consistent with previous studies.

rooms. This study has highlighted this lack of regulaGon, and future work is planned in our center and could allow us to manage the temperatures of the delivery rooms individually.

Regarding venGlaGon, we noted a significant reducGon in venGlaGon Gme on the T-piece insufflator, offering children a beFer quality venGlaGon more quickly: median Gme of connecGon to the transport incubator of 19,5 min [12-25,5] in Period I versus 11 min [9-18] in Period II (p 0,021). Snorri Donaldson and Al showed that the use of a respiratory support system with short binasal prongs rather than a T-piece insufflator had a posiGve impact on the reducGon of intubaGon of GA < 28 and on their survival. 31

LimitaPons:

Our study has several limitaGons. It only considered paGents born and managed in a single center, with its organizaGonal and geographical specificiGes, and may therefore hardly be extrapolated to other centers.

An other limit is the short observaGon period (about 6 months for each) and small size of our sample, with different number of newborns (30 for period I vs 21 for period II).

Although there was no significant difference between the two groups, we observed a greater number of younger and lower birth weight babies in period II (median term of 27 SA in period I, and 26 SA in period II (27 [25-29] vs 26 [25-28], p = 0.71) with a median birth weight of 975 g in period I and 830 g in period II (975 [900-1135] vs 830 [720-970], p = 0.96). This difference may have an impact on our results since lower term and weight children are more prone to heat loss.

Because of the difference in the temperature of the environment we had to study variaGons of temperature between phases instead of absolute values of temperature. This difference prevents us from comparing our results to those previously described in the literature.

It seems necessary to reinclude children in the same condiGons as in period I to be in equivalent environmental situaGons.

Our study also has a bias because the caregivers involved in the child's resuscitaGon were aware of the temperature data collecGon. We cannot rule out that aFenGon to temperature may have had an unintended impact on the quality of care provided, and on the maintenance of normothermia from Period I. Indeed, by period I 59% of EP/ELBW (17/30) were normothermic at their arrival in NICU, a result doubling our previous observaGons between 2015 and 2019.

IntroducPon :

Les très grands prématurés (< 28 SA) ou les enfants avec un très faible poids de naissance (< 1000 g) représentent une populaGon fragile, à risque élevé de mortalité et de morbidité sévère.

Le mainGen d'une neutralité thermique lors de leur première heure de vie (Golden Hour) est indispensable en phase aiguë, mais également dans la survenue de complicaGons à plus moyen terme.

Matériels et méthodes :

Nous avons mené une étude prospecGve monocentrique avant/après mise en place d'un protocole de prise en charge des extrêmes prématurés (< 28 SA et/ou < 1000 g) naissant dans notre CHU entre avril et octobre 2021 (période I) puis entre octobre 2022 et avril 2023 (période II).

Résultats :

Nous n'avons pas mis en évidence de différence significaGve dans la variaGon de température au cours de la première heure de vie entre nos deux populaGons. La perte de température pendant la période I était de 0,5°C [-0,6 ; -0,2] contre 0,6°C [-1,1 ; 0,1] pendant la période II (p = 0,3).

Bien que non significaGf, le taux d'hypoglycémie à l'arrivée dans le service était plus bas pendant la période II avec 24% (5/21) contre 39% (9/23) pendant la période I (p = 0,34).

Nous n'avons pas mis en évidence de différence en termes de durée de prise en charge en salle de naissance (32 minutes pendant la période I contre 26 minutes en période II, p = 0,103).

Conclusion :

Il s'agit des résultats intermédiaires d'un travail de plus grande ampleur. Malgré un nombre limité de paGents et des condiGons environnementales différentes entre les deux périodes étudiées, ce travail nous a permis d'être plus aFenGfs à la prise en charge iniGale de ces nouveau-nés.

Il apparaît nécessaire de poursuivre notre étude dans le but d'améliorer nos praGques.

Mots-clés : Extrême prématurité, Golden Hour, Neutralité thermique, Protocole de prise en charge

  ABBREVIATIONS ................................................................................................................................................

-2. Conditioning - 3 .Figure 1 -

 31 Figure 1 -Golden hour stages: from birth to NICU's installa9on

---

  All cares realized with the resuscitation table doors closed (except chest compressions if necessary) Transport incubator -Settings of thermal mattress left to the discretion of the RT -Warmed humidified gases only for Opening of the incubator left to the discretion of the RT -Opening of only one of the incubator windows air temperature, thermal mattress and humidification level left to the discretion of the NICU nurse -Timing of incubator preparation left to the discretion of the NICU nurse -Defined settings of air temperature (37 °C), thermal mattress (37°C) and humidification level (GA 23-24 weeks = 90%, GA 25-28 weeks = 80%) -Incubator preparation started as soon as GA <28 weeks' birth was announced Cares All cares provided with the incubator's doors closed. -Timing of height and head circumference measurements left to the discretion of the NICU nurse -Timing of central catheter insertion left to the discretion of the the discretion of the RT or NICU medical team -Not in the DR if dextrose infusion is possible, delayed to central venous catheter placement -Before leaving the DR if dextrose infusion is impossible Installation team left to the discretion of NICU nurses -Detailed process flowchart (App 2) posted near every incubator -A 2 nurses' team defined to install the infants

25 -

 25 days plus the need for 30% or more oxygen and/or invasive mechanical ventilation or continuous positive airway pressure at 36 weeks' postmenstrual age; (b) grade 3-4 intraventricular hemorrhage (IVH) or cystic periventricular leukomalacia (PVL); (c) stage 2-3 necrotizing enterocolitis (NEC); and (d) severe retinopathy of prematurity (ROP), defined as stage 3 or more and/or laser treatment. 23 , 24 , Severe cerebral lesion was defined by the presence of a grade 3-4 IVH and/or a cystic PVL on cranial ultrasonography.[START_REF] De Vries | Ultrasound abnormalities preceding cerebral palsy in highrisk preterm infants[END_REF]

Figure 4 -

 4 Figure 4 -Loss of T°> 0,5 °C during each phase between the two periods

1

  La prématurité représente la principale cause de morbi-mortalité néonatale, et ce d'autant plus que le terme et le poids de naissance d'un enfant sont bas. Les principales complicaGons de l'extrême prématurité sont la survenue de dysplasie broncho-pulmonaire, d'hémorragie intraventriculaire, d'entérocolite ulcéro-nécrosante et de réGnopathie opGque du prématuré.[START_REF] Ancel | Survival and morbidity of preterm children born at 22 through 34 weeks' gestation in France in 2011: results of the EPIPAGE-2 cohort study[END_REF] Les progrès en néonatalogie ces 20 dernières années ont permis de prendre en charge des enfants de plus en plus jeunes avec un poids de naissance de plus en plus bas et d'améliorer leur mortalité ainsi que leur survie sans morbidité sévère.

L'adaptaGon à la vie extra-utérine est une période de transiGon brutale au cours de laquelle les nombreuses modificaGons physiologiques (respiratoires, circulatoires, thermorégulatrices, épuratrices, nutriGonnelles) auxquelles est soumis un nouveau-né le rendent parGculièrement vulnérable.

  [START_REF] Harriman | Golden Hour Protocol for Preterm Infants: A Quality Improvement Project[END_REF] , 17 , 18 , 19 , 20 ,[START_REF] Peleg | Golden Hour' quality improvement intervention and short-term outcome among preterm infants[END_REF] A retrospecGve study conducted in our neonatal intensive care unit at the University Hospital of Montpellier between 2015 and 2019, found a rate of only 34% of children born before 27 weeks in the thermal neutral zone upon admission in the unit.

Our objecGve was to implement a systemaGc, evidence-based protocol for EP/ELBW infants' care during the golden hour. Our aims were to decrease temperature variaGon throughout the golden hour care, to decrease the rate of hypoglycemia at admission and to decrease Gme between birth and end of stabilizaGon.

  The department of neonatal medicine has a capacity of 47 beds, including 14 type 3 beds, corresponding to the NICU, 18 type 2b beds, and 15 type 2a beds. The medical team is composed of nine senior pediatricians, three fellows, and five residents. The number of nurses per neonate is framed by the French perinatal decrees of 1998, i.e., one nurse for two neonates for type 3 beds, one nurse for three neonates for type 2b beds, and one nurse for six neonates for type 2a

	beds.
	800 to 900 newborns are admiFed each year in the unit, including 65 to 80 premature infants
	with gestaGonal age <28 weeks.
	NICU is equipped with incubators (Babyleo TN500, Drägerwerk, Lübeck, Germany), two types of
	venGlators for invasive venGlaGon (Servo-n Maquet CriGcal Care, Solna, Sweden) and (Fabian HFO
	acutronic medical systemps AG, Hirzel, Switzerland), two types of venGlators for non-invasive
	venGlaGon (Fabian therapy evoluGon Acutronic medical systems AG, Hirzel, Switzerland) and
	(Infant flow SIPAP, Carefusion corporaGon, Yorba Lina, California), infusion sets (Orchestra module
	DPA, Injector Fresenius Kabi, Brézins, France) and cardiorespiratory monitors (Intellivue MX550,
	Philips Medical Systems, Amsterdam, Netherlands).

The delivery room is located on the ground floor, just below the department of neonatal medicine. The pediatric team in the DR is composed of 1 or 2 senior pediatricians (depending on the neonatal situaGon), 1 resident and 1 experienced nurse, all assigned to provide care to the newborns.

The DR is equipped with a resuscitaGon table (Dräger babyther 8010 Lübeck, Germany), a cardiorespiratory monitor (IntelliVue MP30 or MP5, Philips Medical Systems, Amsterdam, Netherlands), and a T-piece resuscitator (Neopuff®, Fisher&Paykel, Auckland, New-Zealand).

A mobile incubator (Airbone 750i, InternaGonal Biomedical, AusGn, TX) equipped with a venGlator (Fabian, Acutronic Medical Systems, Hirzel, Switzerland), an infusion set (Injectomat Agilia, Fresenius Kabi, Brézins, France), and a cardiorespiratory monitor (IntelliVue X2, Philips Medical Systems, Amsterdam, Netherlands) is available and used during management in the DR if needed (venGlator, infusion set), and then to transport the infant to the NICU over an average distance of approximately 150 m.

Table 1 :

 1 Interventions realized during GH -Period I and Period II

	THERMOREGULATION -DELIVERY ROOM
	Period I	Period II
	-Settings of radiant warmer and
	Resuscitation
	table

Table 2 -

 2 Description of the populationPhase I

Table 3

 3

	-distribution of the temperatures	Total population	Period I	Period II	p
	and variation of temperature between the	N= 51	N= 30	N = 21
	two periods
	End of conditioning T°	n= 48	n= 28	n= 20	0.68
	Mean (+/-DS)	36,8 (+/-0.8)	36,8 (+/-0,9)	36,7 (+/-0,7)
	Median [Q25; Q75]	36.8 [36.4-37.3]	36,9 [36.5-37.4]	36,7 [36,3-37,3]
	Variation of T° during conditioning	n= 47	n= 28	n= 19	0,61
	Mean (+/-DS)	+ 0,3 (+/-0,5)	+ 0,2 (+/-0,5)	+ 0,3 (+/-0.5)
	Median [Q25; Q75]	+ 0,2 [0,1;0,7]	+ 0,2 [0,1;0,7]	+ 0,2 [0,1;0,7]
	End of resuscitation room T°	n= 51	n= 30	n= 21
	Mean (+/-DS)	36,6 (+/-0,6)	36,8 (+/-0,5)	36,4 (+/-0,6)
	Median [Q25; Q75]	36,6 [36.2-36,9]	36,8 [36.4-37.2]	36,5 [36.1-36,7]

Table 7 -

 7 Factors that can influence newborn

Ashmeade [START_REF] Ashmeade | Outcomes of a Neonatal Golden Hour Implementation Project[END_REF] and Al. measured blood glucose at NICU admission of premature infants GA < 27 weeks before and a~er a protocol implementaGon and found similar results (0,67 g/L preprotocol, 0,72 g/L post-protocol, p = 0,143) [START_REF] Ashmeade | Outcomes of a Neonatal Golden Hour Implementation Project[END_REF][START_REF] Croop | The Golden Hour: a quality improvement initiative for extremely premature infants in the neonatal intensive care unit[END_REF] However, we significantly reduced our dextrose administraGon Gme (25 minutes in Period I [14-34] versus 15 minutes in Period II [9-23], p = 0.04). Sarah N Taylor and AL. [START_REF] Taylor | Fluid, electrolytes, and nutrition: minutes matter[END_REF] had highlighted the posiGve impact of early glucose administraGon in ELBW infants.

Regarding the duraGon of care from birth to the end of NICU installaGon we did not find any significant difference. Croop SEW, and Al. [START_REF] Croop | The Golden Hour: a quality improvement initiative for extremely premature infants in the neonatal intensive care unit[END_REF] found a significant difference in their overall management Gme from birth to the end of stabilizaGon in the NICU (111 min vs. 92 min; p = 0.004), however, no data was available regarding their Gme in the delivery room. We did not achieve our goal of reducing the Gme spent in the delivery room. However, we were able to see that our team was already aFenGve to this point since 82% of the children (23/30) spent < 45 minutes in the delivery room during Period I.

Transport duraGon was also difficult to decrease, perhaps because of the geography of our unit.

Indeed, the DR is located on the ground floor and the neonatal unit on the floor above. Infants are transported over an average distance of approximately 150 m, and our team has to use an elevator to get to the neonatal unit. This distance cannot be shortened. Moreover, the change of team between the delivery room and NICU may also impact transport Gme, as caregivers have to conduct transmissions to best care for the children.

Despite those results, implemenGng this protocol had a posiGve impact on several levels. The implementaGon of a precise and systemaGc protocol seems to lead to a beFer care of the children. [START_REF] Vergales | NASCAR pit-stop model improves delivery room and admission efficiency and outcomes for infants <27 weeks' gestation[END_REF] In our study, anGcipaGng the birth and making adjustments in advance has allowed us to reduce severe temperature losses, especially during transport: 85 % (11/13) in period I versus 35% (7/20) in period II, p = 0,01. Thermal control of the neonate is essenGal since insufficient temperature can cause cold stress which has hemodynamic consequences and can lead to metabolic acidosis. [START_REF] Chitty | Importance of maintaining the newly born temperature in the normal range from delivery to admission[END_REF] EP/EBLW are parGcularly vulnerable to this cold stress, and paying aFenGon to the children's temperature seems to be a prerequisite to manage its variaGons. In our unit, implemenGng this protocol allowed to establish conGnuous monitoring of the temperature of extreme preterm newborns. It also permiFed to standardize care during this golden hour.

The temperature of the operaGng rooms and the delivery rooms being managed by a central thermostat, we did not expect to find an incidence of the season on the temperature of the

V. Conclusion

The goal of our project was to establish and implement a protocol to standardize our pracGces and improve the management of EP/EBLW born in our hospital. In spite of a limited number of paGents and different environmental condiGons between the two periods studied, this work allowed us to pay more aFenGon to the iniGal management of these children in the delivery room and during their transport. It seems necessary to conGnue it by opGmizing some factors, and to extend it to the installaGon and management in the NICU. Ø Je donnerai mes soins gratuits à l'indigent et n'exigerai jamais un salaire au-dessus de mon travail.

Ø Admis (e) dans l'intérieur des maisons, mes yeux ne verront pas ce qui s'y passe, ma langue taira les secrets qui me seront confiés, et mon état ne servira pas à corrompre les moeurs, ni à favoriser le crime.

Ø Respectueux (se) et reconnaissant (e) envers mes Maîtres, je rendrai à leurs enfants l'instruction que j'ai reçue de leurs pères.

Ø Que les hommes m'accordent leur estime si je suis fidèle à mes promesses. Que je sois couvert (e) d'opprobre et méprisé (e) de mes confrères si j'y manque.