[Underwater delivery. Consensus of the Spanish Neonatology Society and the Perinatal Section of the Spanish Obstetrics and Gynecology Society]. / Atención del parto en el agua. Consenso de la Sociedad Española de Neonatología y de la Sección de Medicina Perinatal de la Sociedad Española de Obstetricia y Ginecología.

Immersion in water during labor and delivery as an alternative to traditional delivery is a practice that has increased in many countries. This technique is effective in reducing pain and duration of labor. The American Academy of Pediatrics and The American College of Obstetricians and Gynecologists have published a clinical report which indicates the potential maternal benefits during the first stage of labor but, questions the performance of this technique during delivery and birth of the newborn. In this report, the Spanish Society of Neonatology and the Spanish Society of Obstetrics and Gynecology analyze the current scientific evidence on water immersion delivery, and the impact this practice could have in the mother and especially in the wellbeing of newborn.

[Bronchopulmonary dysplasia: definitions and classifications]. / Displasia broncopulmonar: definiciones y clasificación.

Bronchopulmonary dysplasia is the most common sequelae related to very low birth weight infants, mostly with those of extremely low birth weight. Even with advances in prevention and treatment of respiratory distress syndrome associated with prematurity, there is still no decrease in the incidence in this population, although a change in its clinical expression and severity has been observed. There are, however, differences in its frequency between health centres, probably due to a non-homogeneously used clinical definition. In this article, the Committee of Standards of the Spanish Society of Neonatology wishes to review the current diagnosis criteria of bronchopulmonary dysplasia to reduce, as much as possible, these inter-centre differences.

[Recommendations for neonatal transport]. / Recomendaciones sobre transporte neonatal.

During pregnancy, it is not always possible to identify maternal or foetal risk factors. Infants requiring specialised medical care are not always born in centres providing intensive care and will need to be transferred to a referral centre where intensive care can be provided. Therefore Neonatal Transport needs to be considered as part of the organisation of perinatal health care. The aim of Neonatal Transport is to transfer a newborn infant requiring intensive care to a centre where specialised resources and experience can be provided for the appropriate assessment and continuing treatment of a sick newborn infant. Intrauterine transfer is the ideal mode of transport when the birth of an infant with risk factors is diagnosed. Unfortunately, not all problems can be detected in advance with enough time to safely transfer a pregnant woman. Around 30- 50% of risk factors will be diagnosed during labour or soon after birth. Therefore, it is important to have the knowledge and resources to resuscitate and stabilise a newborn infant, as well as a specialised neonatal transport system. With this specialised transport it is possible to transfer newly born infants with the same level of care that they would receive if they had been born in a referral hospital, without increasing their risks or affecting the wellbeing of the newborn. The Standards Committee of the Spanish Society of Neonatology reviewed and updated recommendations for intrauterine transport and indications for neonatal transfer. They also reviewed organisational and logistic factors involved with performing neonatal transport. The Committee review included the type of personnel who should be involved; communication between referral and receiving hospitals; documentation; mode of transport; equipment to stabilise newly born infants; management during transfer, and admission at the referral hospital.

[Health care levels and minimum recommendations for neonatal care]. / Niveles asistenciales y recomendaciones de mínimos para la atención neonatal.

A policy statement on the levels of care and minimum recommendations for neonatal healthcare was first proposed by the Standards Committee and the Board of the Spanish Society of Neonatology in 2004. This allowed us to define the level of care of each center in our country, as well as the health and technical requirements by levels of care to be defined. This review takes into account changes in neonatal care in the last few years and to optimize the location of resources. Facilities that provide care for newborn infants should be organized within a regionalized system of perinatal care. The functional capabilities of each level of care should be defined clearly and uniformly, including requirements for equipment, facilities, personnel, ancillary services, training, and the organization of services (including transport) needed to cover each level of care.

[Screening for cytomegalovirus infection in very low birth weight infants]. / Cribado de la infección por citomegalovirus en recién nacidos de muy bajo peso.

INTRODUCTION: Cytomegalovirus (CMV) is the most common congenital and acquired vertically transmitted viral infection in humans. The aim of the study is to determine the clinical relevance of this infection in very low birth weight (VLBW) infants in our area. PATIENTS AND METHOD: Preterm infants (gestational age ≤ 31 weeks) with a birth weight ≤ 1500g treated between March 2006 and December 2010 were included. They underwent the screening protocol for diagnosing CMV infection. CMV serology was performed on the mothers. When it was positive, their breast milk was frozen at -20°C for 72hours from the 7th day of birth. At 5 weeks, the urine of the newborn was tested for CMV-DNA. In case of a positive result, CMV-DNA was performed in breast milk and in the dry blood sample from metabolic screening. RESULTS: A total of 342 preterm infants were studied, with 53 (15.5%) infected by CMV: 8 (2.3%) with congenital infection, 35 (10.2%) with acquired infection, and 10 (2.9%) in which it was impossible to determine precisely. IgM-CMV+in the mother was found in two congenital infections and two acquired infections. Newborns affected by congenital CMV infection showed a lower birth weight, more intrauterine growth restriction, thrombopenia, need for platelet transfusions, early sepsis (including clinical sepsis), and cerebral ultrasound anomalies. Late sepsis was more frequent in cases of acquired CMV infection. CONCLUSIONS: Congenital or acquired CMV infections are frequent in VLBW infants, and our protocol enables them to be diagnosed and probably prevents some acquired CMV infections by selecting which patients should freeze the breast milk.

[Retinopathy of prematurity. Prevention, screening and treatment guidelines]. / Retinopatía de la prematuridad. Recomendaciones para la prevención, el cribado y el tratamiento.

ROP screening is carried out at all the Spanish hospitals, but there is little agreement on the criteria used for its screening and other aspects related to its practice. Our aim is to report on recommendations for prevention, screening, treatment and follow-up of the retinopathy of prematurity in Spain. Prevention strategies and recommendations for screening, exploration and treatment of ROP, as well as of the organisation of the services to carry out it are reviewed. The most recent bibliography on the basis of the scientific evidence is considered, taking as reference, the guidelines published by the American Academy of Pediatrics (AAP) in 2006 and the recommendations updated in 2007 in the United Kingdom. The recommended prevention strategies are based on the best neonatal practice. The standards, as far as the screening is concerned, are established by birth weight (< or =1,500 g), gestational age (< or =32 weeks) and unstable neonatal clinical course. Indirect ophthalmoscopy is the standard technique for exploration and laser therapy the treatment of choice.

Attempt to normalize simulated exhaled nitric oxide according to ventilatory settings.

BACKGROUND: Simulated exhaled nitric oxide (eNO) depends on ventilatory settings used in different experimental conditions. OBJECTIVES: To normalize the simulated minute exhaled nitric oxide according to different ventilatory settings. WORKING HYPOTHESIS: Different ventilatory settings influence the concentrations of exhaled nitric oxide and these results can be normalized. METHODOLOGY AND STUDY DESIGN: We used a rubber lung model (50 ml) with an orifice through which a 3 mm endotracheal tube was introduced. The NO, which simulated that of endogenous production, was delivered through the base of the lung using a unidirectional rotameter and obtaining a concentration of around 25 ppb. The sample of gas was recorded through a 6 F arterial catheter introduced into the endotracheal tube to its tip. The ventilator used was a Babylog 8000. Air delivered was compressed and filtered and had an NO content of under 0.3 ppb. The NO level assessed was the plateau value given by the software of the Sievers NOA apparatus. Each experiment involved sampling during 1 min, three times. Normalization was done using a multiple cubic regression formula. RESULTS: An increase in respiratory frequency or in peak of inspiratory pressure were accompanied by a decrease in eNO (ppb). Minute volume was adjusted for the percentage of leakage given by the ventilator. Normalization was obtained analyzing 518 respirations with different ventilatory settings. The coefficient of variation fell from 15.5% to 0.27%. Validation of the normalization formula was performed in other three groups (320, 372, and 372 respirations) with different simulated NO concentrations (25, 16, and 50 ppb), resulting in reduction of the coefficient of variation from 42.7% to 9.3%, from 42.3% to 10.6% and from 45.2% to 9.6%, respectively. CONCLUSIONS: Normalization of simulated minute eNO according to ventilatory settings is possible using the equipment and experimental set-up reported. Extrapolation to patients is not possible without constraints.

[Long-term cognitive dysfunctions in preterm subjects with intraventricular haemorrhage]. / Disfunciones cognitivas a largo plazo en sujetos prematuros con hemorragia intraventricular.

INTRODUCTION: Intraventricular hemorrhage (IVH) in the neonatal period has been associated to developmental impairment or delay in preterm born children and adolescents. To our knowledge there is no study in literature which describes the effects of neonatal IVH in preterm subjects on different specific cognitive functions in adolescent samples. AIM. To explore general as well as specific cognitive performance in preterm adolescents with neonatal IVH, through a comprehensive neuropsychological assessment. SUBJECTS AND METHODS: Sixteen preterm born adolescents with IVH in the newborn period and thirty matched controls were recruited for neuropsychological testing. The intelligence quotient, learning, memory, visuospatial and visuoperceptive abilities, and frontal functions were evaluated. RESULTS: Significant differences were observed for full and performance intelligence quotient, as well as for several specific cognitive functions. After controlling for full intelligence quotient, and compared with preterm adolescents without IVH, differences remained significant for verbal learning and verbal memory. Subjects with IVH grades III-IV scored significantly lower than those with IVH grades I-II in verbal learning, everyday memory and visuoconstructive and visuospatial abilities. CONCLUSIONS: The present study suggests that long-term difficulties are evident for general cognitive performance as well as for specific cognitive abilities in preterm subjects with IVH in the newborn period. These data could explain the academic problems shown by these individuals and may suggest concrete intervention programs to minimize the effects of such deficits.

[Long-term cognitive dysfunctions related to prematurity]. / Disfunciones cognitivas a largo plazo relacionadas con la prematuridad.

INTRODUCTION: Little is understood about the effects of prematurity on long-term cognitive functioning. No detailed studies have been carried out in a Spanish population to investigate the cognitive performance of adolescents who were born preterm. AIMS: To utilise the Wechsler intelligence scales to examine the performance of a broad sample of adolescents who were born preterm, to describe the clinical significance of this performance and to analyse the discriminatory powers of the different subtests. SUBJECTS AND METHODS: The intelligence quotients of 62 preterm subjects and 62 controls were evaluated by administering the full Wechsler intelligence scales. A number of specific neuropsychological functions were also assessed. RESULTS: Significant differences were observed in the overall, verbal and manipulative intelligence quotients, as well as in most of the subtests, although less than 30% of the preterm subjects displayed any alterations in their performance. The subtests that were most sensitive to the poor performance of the preterm subjects were vocabulary, coding and picture arrangement. The significant differences in learning, memory, cognitive flexibility and verbal fluency were not upheld on controlling for general cognitive performance. CONCLUSIONS: Adolescents with a history of prematurity as a group offer low performance on the Wechsler intelligence scale, although most of them achieve scores within the range of what can be considered to be normal. The different subtests that make up this scale do not exhibit the same degree of sensitivity when evaluating the possible difficulties preterm adolescents have in cognitive performance.

Behavioral gender differences in the neonatal period according to the Brazelton scale.

The aim of the present study was to analyze gender differences in neonatal behavior. A sample of 188 healthy full-term newborns (88 boys and 100 girls) was assessed. The behavioral evaluations were performed using the Brazelton Neonatal Behavioral Assessment Scale (NBAS), when the infants were between 48 and 80 hours old. Girls had higher scores than boys in 4 out of the 34 behavioral items of the NBAS. These are the following: Orientation Animate Auditory (t=2.486; P=0.014), Alertness (t=2.546; P=0.012), Quality of Alertness (t=3.091; P=0.002), and State Regulation (t=2,343; P=0.020). Boys had higher scores in the Irritability item (t=-2.186; P=0.030). We have analyzed also the possible effects of the medication during delivery because mothers of boys were more likely to have used this medication but no differences have been found among the mentioned items. These results appear to confirm that similarities between boys and girls are much more the norm than differences related to gender, but even though they are quite subtle, differences do exist in the way newborn infants react and behave in the neonatal period.

[A neuropsychological study of triplets with a history of prematurity]. / Estudio neuropsicologico de trillizas con antecedentes de prematuridad.

INTRODUCTION AND AIMS: Prematurity has often been associated with a general intellectual deficit and with different structural brain disorders which can be revealed by volumetric measurements performed by magnetic resonance imaging (MRI). In turn, perinatal asphyxia, even when it is not accompanied by neurological disorders, is related to a deficit in specific neuropsychological functions. CASE REPORT: This study describes the case of three 13 year old female triplets, with a history of extreme prematurity and perinatal asphyxia, the long term effects of which are evaluated in terms of cognitive performance. We studied their performance in the neuropsychological functions of intelligence, memory, and visual perceptual, visual constructive, visual spatial and frontal functions. In two of the subjects, structural MRI and volumetric analysis of the hippocampuses were performed. In all the subjects, intelligence was found to be above average, the most notable result being the superior score in case 1. Verbal learning and the long term retention of verbal material were altered in case 3, where there was also a smaller hippocampal volume. CONCLUSIONS: In the context of a multiple birth, we have seen that extreme prematurity, accompanied by non severe perinatal asphyxia without hypoxic ischemic encephalopathy, can exert very diverse effects on neurocognitive development. It can be normal, and even superior, or show a deficit in some skill. In our case, the functions that were most liable to suffer these antecedents are long term memory and verbal learning. This disorder is accompanied by bilateral involvement of the hippocampus, which can be observed using MRI.

[Neonatal morbidity and mortality in very low birth weight infants according to exposure to chorioamnionitis]. / Patología neonatal en los menores de 1.500 gramos con relación al antecedente de corioamnionitis.

OBJECTIVES: To study differences in the incidence of neonatal morbidity and mortality among newborns weighing less than 1,500 g according to exposure to chorioamnionitis (CA). PATIENTS AND METHODS: A case-control study of 135 newborns weighing less than 1,500 g at birth and born between 1988 and 1998 was performed. The case group was composed of 45 newborns exposed to clinical or subclinical levels of maternal CA. Each newborn in the case group was matched with two controls, both weighing less than 1,500 g, one of them born immediately before and the other one immediately after. Perinatal records, neonatal morbidity and mortality were analyzed. RESULTS: The mean gestational age was 28.5 weeks (range: 24-38 weeks) with a mean weight of 1,131 g (range: 520-1,500 g). The time of membrane rupture was significantly greater in the case group (176 h vs 57 h; p < 0.001). Forty percent of the cases presented sepsis in the first 72 h of life compared with 10 % of the controls (p < 0.0001). No significant differences in morbidity or mortality were found between the groups, although chronic lung disease (20 % vs 13 %) and intraventricular hemorrhage (24 % vs 17 %) were more frequent in infants exposed to CA. Resuscitation (77.8 % vs 45.6 %; p 0.001) and mechanical ventilation (73 % vs 50 %; p 0.016) were required by a great number of cases than controls. CONCLUSIONS: The presence of CA was associated with a higher risk of early onset infection and the need for neonatal resuscitation and mechanical ventilation. No significant differences were found in morbidity or mortality.

[Hyperbilirubinemia in full-term newborns. Predictive factors]. / Estudio de los factores predictivos de la hiperbilirrubinemia en recién nacidos a término.

OBJECTIVE: Nowadays economical criteria lead to early maternal hospital discharge, even before 48 hours after labor, producing an increase in neonatal readmissions for hyperbilirubinemia. We tried to predict the healthy term newborns that may develop a significant hyperbilirubinemia (> or = 17 mg/dl in the first 4 days of life). METHODS: Bilirubin in umbilical cord blood, transcutaneous measurements of bilirubin at 24, 48 and between 60 and 96 hours of life and bilirubin in blood obtained from heel-sticks at 96 hours was analyzed in 610 newborns. Moreover, serum bilirubin was determined at the same time-points in 169 newborns submitted to blood extractions for different reasons. The transcutaneous bilirubinometer used was a Minolta/Air-Shields JM-102. RESULTS: A significant hyperbilirubinemia was present in 2.95% of the newborns. The correlation between serum and transcutaneous bilirubin was high (r = 0.92; p < 0.0001). Umbilical cord blood bilirubin with a cut-off point of 2.2 mg/dl was not an useful predictor of neonatal jaundice. At 24 and 48 hours of life serum bilirubin levels > or = 6 mg/dl and > or = 9 mg/dl, respectively, predicted a subsequent hyperbilirubinemia with a sensitivity of 100% at both time-points, specificity of 47.5% and 64.3%, positive predictive value of 7.3% and 16.4%, respectively, and a negative predictive value of 100% for both. Transcutaneous measurement at 48 hours with a cut-off point of 13 (equivalent to a bilirubinemia of 9 mg/dl) predicts hyperbilirubinemia with a sensitivity of 94.4%, specificity of 51.7%, positive predictive value of 6.0% and negative predictive value of 99.6%. CONCLUSIONS: If the newborn presents a bilirubinemia > or = 6 mg/dl at 24 hours and > or = 9 mg/dl or a transcutaneous measurement > or = 13 at 48 hours a new bilirubin measurement must be performed between 48 and 72 hours of life.

[The effects of acute fetal distress on neonatal behavior measured by the Brazelton scale]. / Estudio del comportamiento neonatal en el sufrimiento fetal agudo mediante la escala de Brazelton.

OBJECTIVE: The purpose of this study was to evaluate the effects of fetal distress associated with metabolic acidosis (pH < 7.15 and BE < -8 in blood samples from umbilical artery) in neonatal behavior. PATIENTS AND METHODS: Infants were evaluated with the Brazelton Neonatal Behavioral Assessment Scale (NBAS) on the third day of life (60-84 hours) in the Clinic Hospital of Barcelona, Spain. Fifteen anoxic neonates (experimental group) were compared to a sample of eight-seven newborns (control group) with the same characteristics, but with normal pH and BE levels (pH > 7.25 and BE > -5). RESULTS: Statistically significant differences were found between the two groups. The control group performed much better than the experimental group in almost all of the NBAS clusters: habituation, orientation, autonomic, regulation of states and motor functioning. There were no differences between the groups in the cluster range of states. The anoxic newborns of this study showed more irritation, stress, hypersensibility and difficulties to modulate states than the neonates without this problem. CONCLUSIONS: The NBAS is a useful evaluation technique as a complement to the physical examination because it gives a detailed description of the newborn behavior and competence. Habituation (p = 0.002), orientation (p = 0.000) and autonomic (p = 0.000) are the clusters who discriminate best between the groups.

[Alcoholic embryofetopathy. Neonatal case reports for the past twelve years]. / Embriofetopatía alcohólica. Casuística neonatal propia en los últimos doce años.

OBJECTIVE: Alcohol embryopathy represents an important pediatric and obstetric problem, not only for the high risk of adverse effects on the neurodevelopment of the fetus and child, but for the imperative need for detecting and preventing alcohol consumption during pregnancy. In this study the clinical manifestations of newborns with maternal antecedents of alcohol consumption are reviewed. PATIENTS AND METHODS: Our experience from 1985 to 1996 with all newborns diagnosed as "children of an alcoholic mother, without associated clinical findings or partial forms (fetal alcohol effect) or as "alcohol embryofetopathy (complete forms) is reviewed. In this study we have reviewed the obstetric and neonatal records of 33 newborns born to 33 alcohol abusers, collecting both maternal (serological tests, alcohol and other substances consumed during pregnancy) and neonatal (gestational age, birth weight, birth length, head circumference, pathology, physical anomalies, cardiovascular defects and acute withdrawal symptoms) data. RESULTS: Our findings are similar to those described in other reports as regards to the incidence (1.9/1,000 newborns) and clinical manifestations, with the exception only in the low proportion of microcephalia. In our experience, alcohol consumption in pregnancy is associated with a high risk of low birth weight (39%) and intrauterine growth retardation (21%), malformations (42%, 9% cardiopathies), prematurity (54%) and maternal drug addiction (24%, with HIV serology positive in 18%). Acute withdrawal symptoms were detected in 24% of these newborns.

[Neurologic evolution of premature infants following assisted ventilation, with and without bronchopulmonary dysplasia]. / Evolución neurológica del recién nacido pretérmino ventilado con y sin displasia broncopulmonar.

The aim of this work was to evaluate the influence of bronchopulmonary dysplasia on the neurological outcome of the preterm infant requiring assisted ventilation. Thirty-nine preterm infants requiring ventilation support during 72 hours or more were classified into two groups according to the presence or absence of bronchopulmonary dysplasia (BPD). In the BPD group (n = 11), only the incidence of mild cognitive deficits was significantly higher (36.4 % vs 0 %). Our results suggest that the neurological outcome of the infants with BPD is more closely associated with other neonatal events (intraventricular hemorrhage, periventricular leukomalacia, neonatal seizures, longer ventilation support, maximum serum bilirubin levels, low Apgar score at 10 minutes and poor intake of amino acids) than with the presence of BPD. The data of this study suggest that indomethacin reduces the risk of neurological deficits.

[Pattern of survival and sequelae in very low birth weight infants]. / Evolución de la supervivencia y secuelas del recién nacido de muy bajo peso.

The survival and sequelae of the very low birth weight (VLBW) newborns are reported. Two time-periods have been compared (1980-84 vs 1985-88) as well as two weight groups. (Lower than 1,000 vs 1,000-1,499). A total number of 205 VLBW were admitted, and 74 died. Only 72 were used to study morbidity and sequelae with a minimum follow-up of 12 months after correcting age. Those with a weight lower than 1,000 g have a greater motor impairment, (45.5 vs 16.4%), cognitive deficiency (55.5 vs 14.8%), myopia (27.3 vs 3.3%), neurosensorial deafness (27.3 vs 0%), and overall sequelae. During the period 1985-88, survival was 77.9% of the VLBW have any sequelae (12.5% major sequelae and 15.3% minor sequelae). A 36.4% of the newborns with a weight under 1,000 g have major sequelae comparing with the 8.2% in the others. Growth delay is closely related to neurologic sequelae.

[Prognostic factors of neurosensory sequelae in extremely premature infants]. / Factores pronósticos de las secuelas neurosensoriales en el prematuro extremo.

Modern neonatal intensive care has led to a rise in the survival rate of very low birthweight infants (VLBW), but at the same time is a greater number of neurosensorial sequelae. In this study, 50 VLBW (weight less than 1,500 g) babies followed up for at least 12 months are analysed. 18% showed major sequelae (40% of those weighing less than 1,000 g, 12.5% of those weighing 1,000 g or more). The prognostic factors which were most important in the prediction of sequelae were: low birthweight, major irregularities in the EEG, the presence of sepsis, and prolonged ventilotherapy or antibiotherapy.

[Prognosis factors in hypoxico-ischemic encephalopathy in full term infants]. / Factores pronósticos en la encefalopatía hipoxicoisquémica del recién nacido a término.

This study analyzes 61 full-term neonates affected by hypoxic-ischemic encephalopathy, who were followed for a minimum of 15 months to determine the factors related to the later appearance of neurological sequels. No severe sequels have been detected, while 8.2% showed moderate sequels and 4.9% slight sequels. The degree of cerebral suffering and the intensity of convulsions influence both the appearance of sequels and their severity, contrary to the scores of the Apgar tests after one minute or 5 minutes and the birth weight. By applying the formula (Sequel Rate = 0.2143* Cerebral suffering + 0.3228* Convulsions - 0.2276* EEG RN - 0.0851), if the "sequel rate" is equal to or lower than 0.55, the probability of later sequels is null, whereas a value in excess of this figure indicates a 57.1% probability of their arising.