RESUMO
AIM: Studies have provided insights into factors that may facilitate or inhibit parent-infant closeness in neonatal units, but none have specifically focused on the perspectives of senior neonatal staff. The aim of this study was to explore perceptions and experiences of consultant neonatologists and senior nurses in five European countries with regard to these issues. METHODS: Six small group discussions and three-one-to-one interviews were conducted with 16 consultant neonatologists and senior nurses representing nine neonatal units from Estonia, Finland, Norway, Spain and Sweden. The interviews explored facilitators and barriers to parent-infant closeness and implications for policy and practice, and thematic analysis was undertaken. RESULTS: Participants highlighted how a humanising care agenda that enabled parent-infant closeness was an aspiration, but pointed out that neonatal units were at different stages in achieving this. The facilitators and barriers to physical closeness included socio-economic factors, cultural norms, the designs of neonatal units, resource issues, leadership, staff attitudes and practices and relationships between staff and parents. CONCLUSION: Various factors affected parent-infant closeness in neonatal units in European countries. There needs to be the political motivation, appropriate policy planning, legislation and resource allocation to increase measures that support closeness agendas in neonatal units.
Assuntos
Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Neonatologistas/psicologia , Enfermeiros Neonatologistas/psicologia , Poder Familiar , Europa (Continente) , Família , Humanos , Apego ao ObjetoRESUMO
OBJECTIVE: To predict mortality or length of stay (LOS) >109 days (90th percentile) among infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN: We conducted a retrospective analysis using the Children's Hospital Neonatal Database during 2010 to 2014. Infants born >34 weeks gestation with CDH admitted at 22 participating regional neonatal intensive care units were included; patients who were repaired or were at home before admission were excluded. The primary outcome was death before discharge or LOS >109 days. Factors associated with this outcome were used to develop a multivariable equation using 80% of the cohort. Validation was performed in the remaining 20% of infants. RESULTS: The median gestation and age at referral in this cohort (n=677) were 38 weeks and 6 h, respectively. The primary outcome occurred in 242 (35.7%) infants, and was distributed between mortality (n=180, 27%) and LOS >109 days (n=66, 10%). Regression analyses showed that small for gestational age (odds ratio (OR) 2.5, P=0.008), presence of major birth anomalies (OR 5.9, P<0.0001), 5- min Apgar score ⩽3 (OR 7.0, P=0.0002), gradient of acidosis at the time of referral (P<0.001), the receipt of extracorporeal support (OR 8.4, P<0.0001) and bloodstream infections (OR 2.2, P=0.004) were independently associated with death or LOS >109 days. This model performed well in the validation cohort (area under curve (AUC)=0.856, goodness-of-fit (GF) χ(2), P=0.16) and acted similarly even after omitting extracorporeal support (AUC=0.82, GF χ(2), P=0.05). CONCLUSIONS: Six variables predicted death or LOS ⩾109 days in this large, contemporary cohort with CDH. These results can assist in risk adjustment for comparative benchmarking and for counseling affected families.
Assuntos
Hérnias Diafragmáticas Congênitas/mortalidade , Tempo de Internação/estatística & dados numéricos , Bases de Dados Factuais , Feminino , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Estudos Retrospectivos , Risco Ajustado/métodos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To characterize infants affected with perinatal hypoxic ischemic encephalopathy (HIE) who were referred to regional neonatal intensive care units (NICUs) and their related short-term outcomes. STUDY DESIGN: This is a descriptive study evaluating the data collected prospectively in the Children's Hospital Neonatal Database, comprised of 27 regional NICUs within their associated children's hospitals. A consecutive sample of 945 referred infants born ⩾36 weeks' gestation with perinatal HIE in the first 3 days of life over approximately 3 years (2010-July 2013) were included. Maternal and infant characteristics are described. Short-term outcomes were evaluated including medical comorbidities, mortality and status of survivors at discharge. RESULT: High relative frequencies of maternal predisposing conditions, cesarean and operative vaginal deliveries were observed. Low Apgar scores, profound metabolic acidosis, extensive resuscitation in the delivery room, clinical and electroencephalographic (EEG) seizures, abnormal EEG background and brain imaging directly correlated with the severity of HIE. Therapeutic hypothermia was provided to 85% of infants, 15% of whom were classified as having mild HIE. Electrographic seizures were observed in 26% of the infants. Rates of complications and morbidities were similar to those reported in prior clinical trials and overall mortality was 15%. CONCLUSION: Within this large contemporary cohort of newborns with perinatal HIE, the application of therapeutic hypothermia and associated neurodiagnostic studies appear to have expanded relative to reported clinical trials. Although seizure incidence and mortality were lower compared with those reported in the trials, it is unclear whether this represented improved outcomes or therapeutic drift with the treatment of milder disease.
Assuntos
Hipotermia Induzida , Hipóxia-Isquemia Encefálica/terapia , Convulsões/terapia , Acidose , Estudos de Coortes , Eletroencefalografia , Feminino , Grupos Focais , Hospitais Pediátricos , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Masculino , Ressuscitação , Resultado do TratamentoRESUMO
BACKGROUND/OBJECTIVES: It is estimated that zinc deficiency affects 17% of the world's population, and because of periods of rapid growth children are at an increased risk of deficiency, which may lead to stunting. This paper presents a systematic review and meta-analysis of the randomised controlled trials (RCTs) that assess zinc intake and growth in children aged 1-8 years. This review is part of a larger systematic review by the European Micronutrient Recommendations Aligned Network of Excellence that aims to harmonise the approach to setting micronutrient requirements for optimal health in European populations (www.eurreca.org). SUBJECT/METHODS: Searches were performed of literature published up to and including December 2013 using MEDLINE, Embase and the Cochrane Library databases. Included studies were RCTs in apparently healthy child populations aged from 1 to 8 years that supplied zinc supplements either as capsules or as part of a fortified meal. Pooled meta-analyses were performed when appropriate. RESULTS: Nine studies met the inclusion criteria. We found no significant effect of zinc supplementation of between 2 weeks and 12 months duration on weight gain, height for age, weight for age, length for age, weight for height (WHZ) or WHZ scores in children aged 1-8 years. CONCLUSIONS: Many of the children in the included studies were already stunted and may have been suffering from multiple micronutrient deficiencies, and therefore zinc supplementation alone may have only a limited effect on growth.
Assuntos
Estatura/efeitos dos fármacos , Peso Corporal/efeitos dos fármacos , Deficiências Nutricionais , Suplementos Nutricionais , Transtornos do Crescimento/etiologia , Oligoelementos/farmacologia , Zinco/farmacologia , Criança , Deficiências Nutricionais/tratamento farmacológico , Europa (Continente) , Crescimento/efeitos dos fármacos , Transtornos do Crescimento/prevenção & controle , Humanos , Oligoelementos/deficiência , Oligoelementos/uso terapêutico , Zinco/deficiência , Zinco/uso terapêuticoRESUMO
OBJECTIVE: To characterize the population and short-term outcomes in preterm infants with surgical necrotizing enterocolitis (NEC). STUDY DESIGN: Preterm infants with surgical NEC were identified from 27 hospitals over 3 years using the Children's Hospitals Neonatal Database; infants with gastroschisis, volvulus, major congenital heart disease or surgical NEC that resolved prior to referral were excluded. Patient characteristics and pre-discharge morbidities were stratified by gestational age (<28 vs 28(0/7) to 36(6/7) weeks' gestation). RESULT: Of the 753 eligible infants, 60% were born at <28 weeks' gestation. The median age at referral was 14 days; only 2 infants were inborn. Male gender (61%) was overrepresented, whereas antenatal steroid exposure was low (46%). Although only 11% had NEC totalis, hospital mortality (<28 weeks' gestation: 41%; 28(0/7) to 36(6/7) weeks' gestation: 32%, P=0.02), short bowel syndrome (SBS)/intestinal failure (IF) (20% vs 26%, P=0.06) and the composite of mortality or SBS/IF (50% vs 49%, P=0.7) were prevalent. Also, white matter injury (11.7% vs 6.6%, P=0.02) and grade 3 to 4 intraventricular hemorrhages (23% vs 2.7%, P<0.01) were commonly diagnosed. After referral, the median length of hospitalization was longer for survivors (106 days; interquartile range (IQR) 79, 152) relative to non-survivors (2 days; IQR 1,17; P<0.001). These survivors were prescribed parenteral nutrition infrequently after hospital discharge (<28 weeks': 5.2%; 28(0/7) to 36(6/7) weeks': 9.9%, P=0.048). CONCLUSION: After referral for surgical NEC, the short-term outcomes are grave, particularly for infants born <28 weeks' gestation. Although analyses to predict outcomes are urgently needed, these data suggest that affected infants are at a high risk for lengthy hospitalizations and adverse medical and neuro-developmental abnormalities.
Assuntos
Enterocolite Necrosante/mortalidade , Enterocolite Necrosante/cirurgia , Mortalidade Hospitalar , Recém-Nascido Prematuro , Causas de Morte , Estudos de Coortes , Bases de Dados Factuais , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Procedimentos Cirúrgicos do Sistema Digestório/mortalidade , Enterocolite Necrosante/diagnóstico , Feminino , Seguimentos , Hospitais Pediátricos , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Masculino , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
OBJECTIVE: To estimate the risk of death or tracheostomy placement (D/T) in infants with severe bronchopulmonary dysplasia (sBPD) born < 32 weeks' gestation referred to regional neonatal intensive care units. STUDY DESIGN: We conducted a retrospective cohort study in infants born < 32 weeks' gestation with sBPD in 2010-2011, using the Children's Hospital Neonatal Database. sBPD was defined as the need for FiO2 ⩾ 0.3, nasal cannula support >2 l min(-1) or positive pressure at 36 weeks' post menstrual age. The primary outcome was D/T before discharge. Predictors associated with D/T in bivariable analyses (P < 0.2) were used to develop a multivariable logistic regression equation using 80% of the cohort. This equation was validated in the remaining 20% of infants. RESULT: Of 793 eligible patients, the mean gestational age was 26 weeks' and the median age at referral was 6.4 weeks. D/T occurred in 20% of infants. Multivariable analysis showed that later gestational age at birth, later age at referral along with pulmonary management as the primary reason for referral, mechanical ventilation at the time of referral, clinically diagnosed pulmonary hypertension, systemic corticosteroids after referral and occurrence of a bloodstream infection after referral were each associated with D/T. The model performed well with validation (area under curve 0.86, goodness-of-fit χ(2), P = 0.66). CONCLUSION: Seven clinical variables predicted D/T in this large, contemporary cohort with sBPD. These results can be used to inform clinicians who counsel families of affected infants and to assist in the design of future prospective trials.
Assuntos
Displasia Broncopulmonar/mortalidade , Traqueostomia/estatística & dados numéricos , Displasia Broncopulmonar/cirurgia , Estudos de Coortes , Feminino , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Unidades de Terapia Intensiva Neonatal , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Respiração Artificial , Estudos Retrospectivos , Medição de RiscoRESUMO
The Children's Hospitals Neonatal Consortium is a multicenter collaboration of leaders from 27 regional neonatal intensive care units (NICUs) who partnered with the Children's Hospital Association to develop the Children's Hospitals Neonatal Database (CHND), launched in 2010. The purpose of this report is to provide a first summary of the population of infants cared for in these NICUs, including representative diagnoses and short-term outcomes, as well as to characterize the participating NICUs and institutions. During the first 2 1/2 years of data collection, 40910 infants were eligible. Few were born inside these hospitals (2.8%) and the median gestational age at birth was 36 weeks. Surgical intervention (32%) was common; however, mortality (5.6%) was infrequent. Initial queries into diagnosis-specific inter-center variation in care practices and short-term outcomes, including length of stay, showed striking differences. The CHND provides a contemporary, national benchmark of short-term outcomes for infants with uncommon neonatal illnesses. These data will be valuable in counseling families and for conducting observational studies, clinical trials and collaborative quality improvement initiatives.
Assuntos
Bases de Dados Factuais , Hospitais Pediátricos/estatística & dados numéricos , Doenças do Recém-Nascido/epidemiologia , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Humanos , Recém-Nascido , Doenças do Recém-Nascido/diagnóstico , Doenças do Recém-Nascido/terapia , Unidades de Terapia Intensiva Neonatal/organização & administração , Estados UnidosRESUMO
OBJECTIVE: To characterize the treatments and short-term outcomes in infants with severe bronchopulmonary dysplasia (sBPD) referred to regional neonatal intensive care units. STUDY DESIGN: Infants born <32 weeks' gestation with sBPD were identified using the Children's Hospital Neonatal Database. Descriptive outcomes are reported. RESULT: A total of 867 patients were eligible. On average, infants were born at 26 weeks' gestation and referred 43 days after birth. Infants frequently experienced lung injury (pneumonia: 24.1%; air leak: 9%) and received systemic corticosteroids (61%) and mechanical ventilation (median duration 37 days). Although 91% survived to discharge, the mean post-menstrual age was 47 weeks. Ongoing care such as supplemental oxygen (66%) and tracheostomy (5%) were frequently needed. CONCLUSION: Referred infants with sBPD sustain multiple insults to lung function and development. Because affected infants have no proven, safe or efficacious therapy and endure an exceptional burden of care even after referral, urgent work is required to observe and improve their outcomes.
Assuntos
Displasia Broncopulmonar/terapia , Recém-Nascido Prematuro , Corticosteroides/uso terapêutico , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Respiração Artificial , Resultado do TratamentoRESUMO
OBJECTIVE: To undertake a critical analysis of the content of six tools, which have been designed to evaluate the breast-feeding interaction. DESIGN: The tools are viewed as discourses and are examined in terms of the insight they give into the assumptions about and attitudes towards breast-feeding inherent in the authors who have produced them. FINDINGS: The findings indicate that there is little agreement between the existing breast-feeding assessment tools as to how to measure a successful breast feed and that the tools appear to place insufficient reliance upon the research evidence related to lactation. KEY CONCLUSIONS: The lack of commonality between evaluation tools appears to reflect a prevailing inconsistency in the advice given by health workers to breast-feeding mothers. Reports of their unreliability may be indicative of the problems inherent when attempting to impose a biomedical model upon an intrinsically natural interaction. IMPLICATIONS FOR PRACTICE: It is suggested that, if evaluations of the breast-feeding interaction are to be useful, a tool which places greater emphasis on the research evidence is called for. Otherwise, given the limitations of such tools, their use may actively hinder the establishment of successful breast feeding.
Assuntos
Aleitamento Materno , Promoção da Saúde/normas , Cuidado do Lactente/normas , Relações Mãe-Filho , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Lactente , Recém-Nascido , Avaliação de Processos em Cuidados de Saúde , Reino UnidoRESUMO
OBJECTIVE: To test the hypothesis that midwives who had completed the 20-hour WHO/UNICEF Breastfeeding Management Course would score significantly higher on a validated, quantitative measure of breast-feeding support skills, the Breastfeeding Support Skills Tool (BeSST), than a control group of midwives who had not undertaken the course. DESIGN: Breast feeding support skills were assessed using a between-subjects design conducted in midwives who had not attended the course and at two weeks following the 20 hour course. PARTICIPANTS AND SETTING: Two groups, consisting of 13 pre- and 15 post-course midwives, were compared. The research was carried out at four hospital sites in the UK, three of which had undertaken the 20 hour course and one which had not adopted the course. FINDINGS: Scores on the BeSST were significantly higher in the post-course group (mean = 29.9) than in the pre-course group (mean = 19.8), t (23.39) = 2.94, P < 0.01. KEY CONCLUSIONS: It is clear that breast-feeding support skills, as demonstrated by the BeSST, are significantly improved two weeks following the 20-hour WHO/UNICEF Breastfeeding Management Course. IMPLICATIONS FOR PRACTICE: By demonstrating the effectiveness of the 20-hour course in teaching breast-feeding support skills, additional hospitals may be encouraged to adopt the course and thereby contribute further to the advancement of optimum breast-feeding practices. Furthermore, this approach to assessment may be transferred to other areas of midwifery practice enabling the effective evaluation of courses and assessment of student learning.
Assuntos
Aleitamento Materno , Educação Continuada em Enfermagem/normas , Conhecimentos, Atitudes e Prática em Saúde , Capacitação em Serviço , Tocologia/educação , Tocologia/normas , Adulto , Feminino , Promoção da Saúde/normas , Humanos , Recém-Nascido , Pessoa de Meia-Idade , Recursos Humanos de Enfermagem Hospitalar/educação , Avaliação de Programas e Projetos de Saúde , Reprodutibilidade dos Testes , Reino Unido , Nações Unidas , Organização Mundial da SaúdeRESUMO
OBJECTIVE: To provide insight into the lived experience of breast feeding, in primiparous women. The main focus was upon women's perceptions related to the adequacy of their breast milk, for the purpose of exclusively nourishing their babies. DESIGN: A longitudinal, phenomenological study involving in-depth, interactive interviews, conducted at 6, 12 and 18 weeks following the birth of the women's babies. PARTICIPANTS AND SETTING: A convenience sample of ten primiparous women were recruited prior to discharge from a maternity unit, in the north of England, in 1998. FINDINGS: Two groups of participants emerged, three who became increasingly confident and empowered by breast feeding and the remaining seven whose confidence progressively diminished, with six of them expressing concern that their breast milk was inadequate. Four major themes related to the participants' perceptions emerged from the analysis: the quest to quantify and visualise breast milk; anxiety regarding the adequacy of their diet; breast feeding as a challenging journey, with most feeling that they had 'fallen by the wayside' (this related partly to inadequate and conflicting advice given by health professionals); and finally, unmet needs for support, nurturing and replenishment in return for 'giving out'. CONCLUSION: Perceived breast-milk inadequacy is underpinned by a complex and synergistic interaction between socio-cultural influences, feeding management, the baby's behaviour, lactation physiology and the woman's psychological state. IMPLICATIONS: Education of midwives and health visitors is required in relation to the needs of breast-feeding mothers within a Western industrialised society. Strong social policy is vital in the UK, to initiate socio-cultural changes, which would enable women who commence breast feeding to perceive it as an empowering and fulfilling experience and not one of 'falling by the wayside'.
Assuntos
Transtornos da Lactação/psicologia , Lactação/psicologia , Mães/psicologia , Ansiedade , Feminino , Humanos , Lactente , Pesquisa Metodológica em Enfermagem , Apoio SocialRESUMO
OBJECTIVE: The association between high-frequency ventilation (HFV) and intraventricular hemorrhage (IVH) and periventricular leukomalacia (PVL) has been debated. PURPOSE: To determine if premature neonates treated with HFV are at greater risk for developing IVH and/or PVL than neonates treated with conventional ventilation, we completed a meta-analysis of all prospective randomized control trials comparing HFV and conventional ventilation in the management of respiratory distress syndrome. METHODS: The meta-analysis included nine studies comparing HFV and conventional ventilation in the management of preterm neonates. To summarize the data, we calculated the difference in absolute risk for IVH and PVL between neonates treated with HFV and those treated with standard ventilation. These differences were combined to determine an overall difference in the absolute risk and its confidence interval. We examined the effect of estimated gestational age, birth weight, surfactant, and age at study entry on the results. Because one trial (HIFI study) was much larger than the other studies, it dominated the analysis, so we evaluated the data with and without including data from the HIFI trial. RESULTS: The occurrences of IVH and PVL ranged from 14% to 47% and 5% to 16%, respectively. This variation may be explained by the difference in the populations of neonates treated. The meta-analysis showed that use of HFV was associated with an increased risk of PVL (odds ratio = 1.7 with a confidence interval of 1.06 to 2.74), but not IVH or severe (> or = grade 3) IVH. When the results of the HIFI study were excluded, there were no differences between HFV and conventional ventilation in the occurrence of IVH or PVL. CONCLUSIONS: The association between HFV and adverse neurologic outcomes is primarily influenced by the results of the HIFI trial. Meta-analysis of more recent studies does not confirm the findings of the HIFI trial and suggests that HFV is not associated with increased occurrence of IVH or PVL.
Assuntos
Hemorragia Cerebral/etiologia , Ventilação de Alta Frequência/efeitos adversos , Recém-Nascido Prematuro , Leucomalácia Periventricular/etiologia , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Ensaios Clínicos como Assunto , Idade Gestacional , Humanos , Recém-Nascido , Respiração ArtificialRESUMO
Neuroblastoma, Hirschsprung's disease, and central hypoventilation (Ondine's curse) are considered aberrations of neural crest cell growth, migration, or differentiation, and as such are considered to be under the general heading of neurocristopathy. Their combined occurrence in a newborn infant presenting with total colonic aganglionosis, central hypoventilation, and multifocal neuroblastoma had not been reported previously. A 2.3-kg white full-term girl required endotracheal intubation because of persistent apnea in the first hours of life. She had progressive abdominal distension and failure to pass meconium; a barium enema was performed, which showed microcolon with meconium pellets at the distal ileum. During laparotomy the distal ileum was found to be obstructed with inspissated meconium; an ileostomy and appendectomy were performed. The resected specimens were aganglionic. An additional 20 cm of aganglionic ileum was removed, and a normally innervated ileostomy was constructed. Numerous attempts at extubation failed because of apnea. The results of an extensive apnea workup, including electroencephalogram, magnetic resonance imaging (MRI), bronchoscopy, and pH probe study, were normal. Sleep studies showed congenital central hypoventilation syndrome, and the patient underwent a tracheostomy. At 3 months, an abdominal ultrasound examination performed within a septic workup showed a right suprarenal mass extending across the midline. Thoracic and abdominal MRI scans showed large bilateral adrenal and posterior mediastinal masses. The serum catecholamines and ferritin level were markedly elevated, suggestive of neuroblastoma. In light of the child's multiple problems, the family chose to forgo further workup (including a tissue biopsy) and therapy. In the following 2 months her tumor load rapidly progressed, and she died of respiratory insufficiency.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Neoplasias das Glândulas Suprarrenais/congênito , Doença de Hirschsprung/complicações , Neoplasias do Mediastino/congênito , Neuroblastoma/congênito , Síndromes da Apneia do Sono/congênito , Neoplasias das Glândulas Suprarrenais/complicações , Doenças do Colo/complicações , Doenças do Colo/congênito , Doenças do Colo/cirurgia , Feminino , Seguimentos , Doença de Hirschsprung/cirurgia , Humanos , Doenças do Íleo/etiologia , Recém-Nascido , Obstrução Intestinal/etiologia , Mecônio , Neoplasias do Mediastino/complicações , Crista Neural/patologia , Neuroblastoma/complicações , Síndromes da Apneia do Sono/complicações , Síndromes da Apneia do Sono/cirurgia , TraqueostomiaRESUMO
Extracorporeal membrane oxygenation (ECMO) is a perfusion support procedure that has been used to treat more than 7,000 patients with life threatening cardiac and/or respiratory failure. After 6 months of training and preparation, an ECMO service was opened on January 2, 1991, in Egleston Children's Hospital at Emory University. During the first 2 years, 96 neonatal, 31 pediatric, and 8 cardiac patients have been referred for possible ECMO. Of these 135 patients, 21 had disqualifying conditions. Sixty-four were considered candidates for ECMO but were able to be supported using less invasive therapies; only one of these died. Fifty patients were treated with ECMO of whom 39 survived (78%). Survival rates for neonatal, pediatric, and cardiac cases as separate groups as well as for each diagnostic category within these groups compare favorably with those reported by the international ELSO Registry. Notable in this series is the fact that 26/35 neonatal patients and 7/10 pediatric patients were successfully supported using venovenous (VV) rather than venoarterial (VA) perfusion, with the major indication for venoarterial ECMO being inability to introduce the 14F venovenous catheter into the patient's internal jugular vein. No patient initially managed with VV ECMO required conversion to VA. It is anticipated that avoidance of carotid ligation along with other innovations, such as the impending commercial availability of heparin-coated ECMO circuits, will make ECMO a highly attractive and appropriate therapy for an increasing number of high risk neonatal and pediatric patients in our state and region.
Assuntos
Oxigenação por Membrana Extracorpórea , Cardiopatias Congênitas/terapia , Garantia da Qualidade dos Cuidados de Saúde , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Insuficiência Respiratória/terapia , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Georgia , Cardiopatias Congênitas/mortalidade , Humanos , Lactente , Recém-Nascido , Masculino , Síndrome do Desconforto Respiratório do Recém-Nascido/mortalidade , Insuficiência Respiratória/mortalidade , Taxa de SobrevidaRESUMO
The heart rate and respirations of twenty healthy full-term infants between 30 and 60 h postnatal age were studied during quiet sleep with the objective of defining spectral indices which represent normal neonatal heart rate variability (HRV) characteristics. Total HRV power and the distribution of power across different frequency bands varied considerably among infants. Cluster analysis on the measured variables indicated that the population divided into two groups that represented significantly different patterns of HRV behavior. In one group (11 subjects), infants had lower breathing rates and HRV power in a band about the respiration frequency [respiratory sinus arrhythmia (RSA) band] was more than 20% of the total power (TP). Additionally, the ratio of low frequency band power to RSA band power was less than 4. The other group of neonates (nine subjects) had relatively higher breathing rates, RSA power less than 20% of total power, and low frequency to RSA power ratio greater than 4. Regression analysis of low frequency versus TP and RSA versus TP graphs gave strong support to the hypothesis that there were indeed two distinct patterns of HRV behavior. Separation of apparently normal neonates into two groups may be attributed partially to differences in respiratory rates and breathing patterns. However, it is possible that differences in the balance between sympathetic and parasympathetic nervous system control, perhaps related to autonomic maturation, also contribute to group separation. The indices developed from HRV spectral analysis in this investigation may be of value in the study of cardiorespiratory control in neonates.
Assuntos
Frequência Cardíaca , Recém-Nascido/fisiologia , Respiração , Arritmia Sinusal , Peso ao Nascer , Idade Gestacional , Humanos , Análise EspectralRESUMO
The natural history, medical management, and outcome in infants with progressive posthemorrhagic hydrocephalus after intraventricular hemorrhage were studied prospectively. Infants with asymptomatic severe posthemorrhagic hydrocephalus were managed with a predetermined protocol. Outcome between groups at 1 to 2 years and at more than 3 years was compared. The natural history study, restricted to the inborn population, revealed that posthemorrhagic hydrocephalus developed in 53 of 409 infants with intraventricular hemorrhage. The progression of hydrocephalus either was arrested or regressed in 35 of 53 infants; progression to severe hydrocephalus occurred in 18 of 53 infants. The severe posthemorrhagic hydrocephalus was asymptomatic in 16 of 18 infants. The management and outcome study included both inborn and outborn infants. Of 50 infants, 12 had symptomatic severe hydrocephalus and 38 had asymptomatic severe hydrocephalus. The 16 infants managed with close observation were as likely to remain shunt free as the 22 infants managed with serial lumbar punctures. Of 38 infants, 20 were managed without shunts. At 3 to 6 years, the outcome of infants in the close observation group did not differ from that in the lumbar puncture group. Long-term outcome of infants with progression to asymptomatic severe hydrocephalus did not differ from that of infants in whom disease progression was arrested. Poor outcome in infants with intraventricular hemorrhage and subsequent posthemorrhagic hydrocephalus was related to severity of hemorrhage and gestational age at birth less than 30 weeks. Because long-term outcome of infants with severe hydrocephalus did not differ from that of infants in whom the progression of hydrocephalus was arrested or whose condition improved before hydrocephalus became severe, we currently attempt medical management of these infants.
Assuntos
Hemorragia Cerebral/complicações , Hidrocefalia/terapia , Recém-Nascido Prematuro , Punção Espinal , Dano Encefálico Crônico/etiologia , Derivações do Líquido Cefalorraquidiano , Seguimentos , Humanos , Hidrocefalia/etiologia , Hidrocefalia/psicologia , Recém-Nascido , Inteligência , Distribuição AleatóriaRESUMO
The relationship between heart rate variability and respiration patterns was investigated using spectral analysis techniques in nine full-term infants whose ages ranged from 39-75 h. All the infants were studied during sleep, although no attempt was made to classify rapid eye movement or nonrapid eye movement states prospectively. The data obtained were examined to determine which aspects of neonatal breathing patterns are correlated with heart rate variability. Three spectral regions of heart rate variability could be identified: a very low frequency region below 0.02 Hz; a low frequency region from 0.02-0.20 Hz; and a high frequency region above 0.20 Hz. The dominant heart rate variability activity in these neonates was seen in the very low and low frequency regions, with little activity in the high frequency regions. In contrast to older infants and adults, respiration and heart rate variability were not strongly related through a high frequency region respiratory sinus arrhythmia but rather through a breath amplitude sinus arrhythmia which occurs in the low frequency region of the spectrum. The prominent very low frequency activity and the low frequency activity ascribed to breath amplitude modulation may result from autonomic nervous system mediation of chemoregulation.
Assuntos
Frequência Cardíaca , Respiração , Arritmias Cardíacas/fisiopatologia , Sistema Nervoso Autônomo/fisiologia , Biometria , Humanos , Recém-Nascido , Microcomputadores , Monitorização Fisiológica/métodosRESUMO
A prospective study was undertaken using a range-gated, pulsed Doppler velocimeter to study flowpressure relationships in the anterior cerebral artery. Serial velocity and pressure studies were performed with each infant serving as his or her own control. The hypothesis tested was that ill preterm infants sustaining subependymal/intraventricular hemorrhage would have absent autoregulation. The hypothesis has been tested in 88 studies on 32 infants. Of 32 infants studied, 15 were judged to be pressure passive; nine of these children bled. The other 17 infants were not pressure passive; eight of these children bled (P greater than .05). From these studies, it may be concluded that the pressure passive state is not the final common link in the genesis of subependymal/intravertricular hemorrhage. Pulsed Doppler ultrasound may provide an extremely useful noninvasive technique for studying both the arterial and venous sides of the cerebral circulation.
Assuntos
Pressão Sanguínea , Hemorragia Cerebral/fisiopatologia , Circulação Cerebrovascular , Doenças do Prematuro/fisiopatologia , Ultrassonografia , Velocidade do Fluxo Sanguíneo , Artérias Cerebrais/fisiopatologia , Ventrículos Cerebrais , Epêndima , Humanos , Recém-Nascido , Estudos ProspectivosRESUMO
Range-gated pulsed Doppler (RGPD) ultrasonography was utilized to study the effect of a patent ductus arteriosus (PDA) on carotid arterial blood flow in small preterm infants. Carotid arterial flow velocity studies were performed on 23 preterm infants, sampling right and left carotid arteries. Studies on seven infants after PDA ligation and on seven who developed no evidence of PDA were used as controls. A strong relationship was demonstrated between diastolic reversal in the carotid arteries and PDA. The results of this study indicate that the RGPD flow velocity curve from the carotid artery is more sensitive than M-mode echocardiography or clinical examination in detecting PDA, and that PDA in small preterm infants is associated with a distinct abnormality in the carotid arterial flow pattern.