Neonatal Abstinence Syndrome and Corresponding Pharmacotherapy Approaches from 2 University-affiliated Neonatal Intensive Care Units in Puerto Rico (2018-2020).

OBJECTIVE: Neonatal abstinence syndrome (NAS) is a set of drug withdrawal symptoms suffered by neonates exposed to drugs in utero. Several studies have widely described NAS incidence and treatment approach; however, little is known regarding the incidence and manifestations of this disease in Puerto Rico (PR). The principal aim of this study was to describe NAS incidence in the neonatal units of hospitals affiliated with the University of PR in terms of occurrence, clinical manifestations, and treatment approaches. METHODS: Our study evaluated the medical records of NAS babies diagnosed from 2018 through 2020 at 2 hospitals affiliated with the University of PR Medical Sciences Campus. Descriptive and inferential statistics were employed to analyze trends. RESULTS: We identified 12 neonates diagnosed with NAS, 5 with low birthweights (<2500 g); for a NAS incidence of 2 cases per 1000 admitted for the 3 years of recollected data. The urine toxicology results revealed that 9 had experienced intrauterine polydrug exposure. Phenobarbital loading dose were determined on the day of diagnosis (indicated by Finnegan score). The first manifestation of NAS symptoms varied: 8 neonates showed symptoms within 48 hours after birth, whereas 4 had withdrawal symptoms within 72-120 hours of their births. Differences between dosing practices and guidelines were observed, ranging from a 0.69% to a 25% difference during treatment initiation. CONCLUSION: Further research on the incidence of NAS in PR (national level) is needed for a deeper understanding that we hope will lead to the development of enhanced treatment protocols in PR.

Cumulative risk factors and mental health of mothers of infants admitted to the neonatal intensive care unit.

Purpose: The present study examined predictive linkages between multiple risk factors and their contribution to the development of anxiety and depression in Puerto Rican mothers of infants admitted to the Neonatal Intensive Care Unit (NICU).Method: The scales used were: the Hamilton Anxiety Rating Scale, the Edinburgh Postpartum Depression Scale, the Hollingshead, and a Demographic Questionnaire was constructed to obtain information about mother and infant characteristics.Results: Both the cumulative psychosocial risk factor (B = 0.267, p = .011) and the cumulative neonatal risk factor (B = -0.220, p = .039) were significant predictors of mothers' anxiety.Discussion: It could be beneficial to create psychosocial interventions in the NICU to address parents' needs and promote emotional resilience. Also, training staff to provide an adequate explanation to mothers, regarding the infants' recovery process is of particular importance.

Congenital Zika Syndrome in Puerto Rico, Beyond Microcephaly, A Multiorgan Approach.

OBJECTIVE: Zika virus (ZIKV) infection was identified in Puerto Rico on December 2015, and the outbreak encouraged us to characterize clinical manifestations and laboratory findings of intrauterine exposed infants. METHODS: Retrospective medical record review of infants born to mothers with confirmed ZIKV infection during pregnancy was performed from January 2016-June 2017. We included patients admitted to UPH Neonatal Intensive Care Unit or referred for follow-up at UPH High Risk Clinics. The database was approved by the University of Puerto Rico, Medical Sciences Campus, IRB. RESULTS: 191 infants born to ZIKV positive mothers during pregnancy were identified. Normal head sonogram was found in 93% of the normo cephalic infants. Ocular findings were reported in 50% of the patients with microcephaly and 31% of the normo-cephalics. Fifteen newborns (7.8%) presented with microcephaly, of which 73% showed calcifications in head sonogram, and had severe anomalies on brain MRI. Auditory brainstem response test was performed on all newborns, 80% were within normal limits. CONCLUSION: Among the group of infants born to mothers with Zika positive test 4% had microcephaly. Of concern to us is the fact that 31% of normo cephalic infants had ocular manifestations and 7% of them had findings on head sonogram. While microcephaly is the severest form of Congenital Zika Syndrome, ocular manifestations might characterize the spectrum of disease. These findings reiterate the importance of detailed neonatal evaluations of exposed infants.

Association of Zika Virus Exposure in Utero with Ocular Phenotypes in a Group of Newborns in Puerto Rico Exposure with ocular phenotypes in newborns in Puerto Rico.

OBJECTIVE: After the outbreak in January 2016, researchers in Brazil reported the first cases of ophthalmic abnormalities in infants with microcephaly and presumed Zika virus (ZIKV) intrauterine infection. Screening for ocular lesions in all newborns exposed to ZIKV prenatally has been emphasized because of a chorioretinal macular scar found in a number normocephalic patient exposed to ZIKV. METHODS: A retrospective review of the medical records of infants born to mothers found to be ZIKV-positive during their pregnancies (January 2016-July 2017) was performed. We included all newborns and infants admitted to the NICU and/or receiving ambulatory care at the high-risk clinics at the University Pediatric Hospital, San Juan, Puerto Rico. The creation of this database was approved by the IRB of the University of Puerto Rico, Medical Sciences Campus. RESULTS: Records from 234 newborns born to Zika-positive mothers were identified. The ophthalmic evaluations of 95 patients were available. Sixty-three of them had normal findings (66%). Twelve of the 95 patients had microcephaly (12.6% of the cohort). Of the microcephalic group, half had normal ophthalmological findings. Of the normocephalic group (83/95), almost 31% had ocular findings: a small optic nerve in 3%, a double-ring sign in 10%, macular stippling in 8%, mottling in 4%, an oval optic nerve in 2%, a tilted nerve in 1%, and blunted foveal reflex in 1%. CONCLUSION: We report herein ZIKV associated ophthalmologic findings, similar to those published, in 34% of the infants with suspected/confirmed ZIKV fetal exposure. These data underline the importance of ocular examination in patients with suspected congenital Zika but without other findings on physical exam.

Zika Virus Infection in Pregnancy: Maternal, Fetal, and Neonatal Considerations.

An infection with the Zika virus (ZIKV) is usually mild, with nonspecific symptoms and most often asymptomatic. However, because of its causal relationship with severe congenital malformations, the ZIKV epidemic became an imperative for mobilization, renewed strategies for vector control, and biomedical research. A congenital Zika syndrome (CZS) has been characterized with 5 distinctive features that focus on brain development abnormalities (including microcephaly and brain calcifications), retinal manifestations, and defects on extremities including congenital contractures and hypertonia. The CZS could be just "the tip of the iceberg", pending the documentation of a spectrum of disease that could manifest later in life, from mild dysfunction to severe disease. It will be a matter of time for neurodevelopmental abnormalities, learning disabilities, and other unknown but yet-to-be-described outcomes to be associated with intrauterine ZIKV infection. In addition, ZIKV infection during pregnancy has been associated with other adverse outcomes. Reports mostly include ZIKV-affected pregnancies, and it will be difficult to clearly establish causality without appropriate control groups. We are summarizing some of the known or reported consequences of such infection during pregnancy. Women of reproductive age and particularly pregnant women are the most vulnerable to the adverse consequences of the ZIKV epidemic. Vector control programs need to be expanded to curtail new infections. Research is needed to develop safe and effective treatments, a preventive or therapeutic vaccine, and specific and sensitive tests and to diagnose and identify correlates of long-term immunity. Vaccines and treatments should be safe to be used in pregnancy. To do nothing would allow thousands of pregnant women to expose their fetuses to an infection that causes birth defects and other problems. Prenatal diagnosis technology development is necessary to be able to predict or diagnose adverse fetal outcomes related to ZIKV. Moreover, these tests should be used in a manner similar to the testing/screening method for neural tube defects and common chromosomal anomalies during prenatal care.

Trends of Respiratory Syncytial Virus Infections in Children under 2 Years of Age in Puerto Rico.

OBJECTIVE: The respiratory syncytial virus (RSV) is the most significant viral pathogen causing bronchiolitis and pneumonia in infants, today. In tropical climates the RSV infection may occur throughout the year. The purpose of this study was to asses RSV infections during the 2009‒2010 RSV season in children under 2 years of age and to evaluate the trend of positive RSV tests in the period of 2007 to 2009. METHODS: A retrospective review of data collected from 6 hospitals in Puerto Rico was performed. Patients with confirmed RSV bronchiolitis were included in the study. RESULTS: A total of 4,678 patients were included. The mean age of the patients was 7 months. Data showed that RSV infection occurred throughout the studied months. CONCLUSION: Data confirms a year-round presence of RSV in Puerto Rico. The RSV surveillance system needs to be reinforced to establish and understand the epidemiology of RSV and to review the current immunoprophylaxis guidelines.

Palivizumab compliance by infants in Puerto Rico during the 2009-2010 respiratory syncytial virus season.

Respiratory syncytial virus (RSV) is the leading viral pathogen responsible for bronchiolitis and pneumonia in infants. We assessed palivizumab prophylaxis compliance for infants in Puerto Rico. We retrospectively studied data from 868 infants (409 females, 459 males) during the 2009-2010 RSV season. The infants had a mean gestational age of 33 weeks (range 23-41) and a mean birth weight of 1,767 g (range 509-4,120). Only 74 % of the infants with indications received prophylaxis. The main reasons for noncompliance were non-approval by the medical insurance (53 %), parents' unavailability (31 %), and infant sickness (11 %). Infants with the government medical insurance were more likely to be denied prophylaxis and to receive fewer doses. Parents need to be educated on the importance of RSV prophylaxis. Physicians should be aware that many infants are not being dosed appropriately and that strategies need to be established to improve compliance.

Mortality and risk factors for invasive fungal infections after the implementation of a fluconazole prophylaxis protocol in very low birth weight infants.

UNLABELLED: Fungal infections are a common cause of late-onset sepsis in very low birth weight infants and can impact mortality and morbidity. The purpose of this study is to determine the impact of systemic fluconazole prophylaxis in the prevalence of fungemia. METHODS: Subjects included 402 very low birth weight premature infants with birth weights between 500 and 1,250 grams admitted to the University Pediatric Hospital NICU over a six year period. The period before and after prophylaxis was retrospectively compared RESULTS: There was a marginal decrease in fungemia in the prophylaxis group (2.6% vs. 6.7%, p = 0.0525). Factors associated to fungemia were chorioamnionitis (p = 0.0240), H2-receptor inhibitors use (p = 0.0109), mechanical ventilati (p = 0.0049), prolonged antibiotic t py (p = 0.0015), and parenteral nutriti (p = 0.0048). Infants with fungemia had longer lengths of stay (p = 0.0143) and lower survival (p = 0.002). CONCLUSION: Prophylaxis with fluconazole decreases mortality and morbidity in an environment with a high incidence of late onset fungal infections. Early identification and prevention of risk factors must be reinforced.

Closure of patent ductus arteriosus in low-birth weight infants based on three management strategies.

UNLABELLED: There is controversy on the most advantageous management for infants with patent ductus arteriosus (PDA) and whether to favor actively closing the PDA or to conservatively observe. We aimed to describe the outcome of infants with PDA based on three management strategies used for its closure (conservative, indomethacin, ligation). METHODS: Retrospective medical record review of data from LBW infants (< 2000 with PDA admitted to NICU-SJCH. RESULTS: The prevalence of PDA was 16%. Based on management strategies: 31% did not require treatment. 19% resolved with conservative measures, 38% resolved with omethacin treatment, and 12% required ligation. There was no difference in birth weight, gestational, clinical criteria, morbidities and mortality in patients managed with the strategies evaluated. CONCLUSION: Results are consistent with previous reports. Development of PDA management guidelines will help standardize the definition of PDA and management criteria instead of treating on a case-by-case basis.

Determinant factors for acceptance of seasonal influenza vaccination among healthcare workers after the 2009 influenza-A (H1N1) pandemia in a hospital at the metropolitan area of Puerto Rico.

UNLABELLED: Healthcare associated influenza is a serious public health problem that contributes to patient morbidity and mortality. OBJECTIVE: To determine the seasonal influenza vaccination rate and reasons for its acceptance among healthcare workers in a hospital located at the metropolitan area of Puerto Rico. METHODS: Self-administered, anonymous questionnaires were distributed to 120 volunteer healthcare workers and ancillary staff. RESULTS: Immunization rates for the 2009 Influenza A (H1N1), seasonal vaccines 2009 and 2010 seasonal influenza vaccine were 50%, 53% and 65%, respectively. Determinant factors for acceptance of vaccination in 2010 included obtaining the 2009 vaccines, not knowing someone with adverse effect to the vaccine, and believing the vaccine should be mandatory for all healthcare workers. CONCLUSION: Influenza immunization rate is below the recommended rate to decrease healthcare associated influenza infection. Our results serve to confirm that education is needed to improve immunization rates among these healthcare workers and eliminate misconceptions about the vaccine.

Factors associated to parent's willingness to accept the influenza vaccine for their children.

UNLABELLED: Influenza vaccination is the most effective method to prevent influenza virus infection and its potentially serious complications OBJECTIVE: To determine fac tors associated to parents willingness to accept the influenza vaccine for their children. METHODS: An anonymous questionnaire was administered to 297 volunteer parents/caregivers during 2011. RESULTS: Only 40% of the parents planne to have their children vaccinated agains influenza. Most subjects had medical insurance (52% government, 44% private, 4% no insurance). Factors associated to parents willingness to accept the vac cine were having the vaccine previously. thinking that the vaccine was safer this year. not knowing someone who had an influenza vaccine side effect and having a family member who had influenza. CONCLUSION: The 40% planned vaccinatio rate lies below the 80% Healthy Peopl 2020 goal and seems to be unassociated to access to healthcare services. Establishing campaigns that reassure parents of vaccine safety could attain a higher vaccination rate.

Improvement in knowledge of nursing staff after an educational intervention about control of newborn temperature.

UNLABELLED: Newborn infants are at risk for hypothermia. Providing an adequate thermal environment is fundamental OBJECTIVE: To assess nurses knowledge about temperature control in newborns before and after an educational intervention and its effect in the prevalence of hypothermia. METHODS: Registered nurses working in a NICU received an educational intervention. They answered a pretest and posttest. Prevalence of hypothermia was recorded. RESULTS: Subjects included 55 nurses (89% females, 11% males). The subjects showed improvement in knowledge (81% correct answers before. 88% after, p < 0.01) Prevalence of hypothermia was similar before and after the intervention. CONCLUSION: An educational intervention in small group format was successful in improving nurse knowledge about temperature control in newborns. There was no effect in the prevalence of hypothermia. The intervention was aimed to registered nurses but neonatal hypothermia prevention requires interactions by all caregivers, thus educational interventions should be aimed to all personnel involved in neonatal care.

Father attitudes and knowledge about breastfeeding.

UNLABELLED: Studies have identified fathers' attitude as the strongest indicator of whether her partner will breastfeed. OBJECTIVE: To determine the attitudes and knowledge of fathers toward breastfeeding. METHODS: The study included 84 volunteer fathers who answered a survey. RESULTS: Mean age of participants was 27 years. Most fathers (88%) would like their partners to breastfeed. Most men (56%) reported that it is acceptable for a woman to breastfeed in public. Negative attitudes included feeling jealous about breastfeeding (10%), thinking that breastfeeding is bad for breasts (17%), breastfeeding makes breasts look ugly (26%), and breastfeeding separates the baby from the father (7%). A few misconceptions about breastfeeding were identified. CONCLUSIONS: Most fathers have positive attitudes towards breastfeeding. We should emphasize the importance of exclusive breastfeeding and clarify misconceptions that may cause early discontinuation of breastfeeding. Programs directed toward educating fathers will help them serve as sources of support for their partners.

Non-familial stiff baby syndrome cases in the northern central area of Puerto Rico.

Hyperekplexia or Stiff Baby Syndrome is an uncommon disorder of non-epileptic movements with an autosomal dominant inheritance pattern. Neonates present exaggerated startle response to sensory stimuli and temporary muscular rigidity. We report two neonates from the northern center of Puerto Rico who presented involuntary movements, hypertonia and apnea during first days of life, being treated with anticonvulsants without improvement. Both were diagnosed with hyperekplexia due to the clinical evolution associated to normal EEG and head radiologic studies. Electromyography showed persistent muscular activity with periods of rest. Both were managed with clonazepam satisfactorily. We emphasized prompt recognition to prevent seizures misdiagnosis and administering appropriate treatment due to complications of sudden death secondary to stiffness and apnea.

[Role of the speech pathologist: language in the neonatal intensive care unit]. / El rol del patologo del habla: lenguaje dentro de la Unidad de Cuidado Intensivo Neonatal.

In 2004, the American Speech and Language Association (ASHA) established the primary roles and responsibilities of the speech and language pathologists (SLP) in the Neonatal Intensive Care Unit (NICU) breaking down the skills and knowledge needed to become a member of the neonatal team. It establishes as main parameters the evaluation and intervention in communication, feeding and swallowing: parents and caregivers counseling and education: as well as the collaboration and education of the neonatal team. In the NICU, the SLP works in the preparation to initiate the nutritive sucking process and describes maturation levels for nutritive sucking with bottle and breastfeeding The SLP establishes an intervention plan for the development of safe feeding and swallowing skills as well as for the training of parents and caregivers during the process. Research should be promoted to support these interventions and establish the standards for the field.

Factors associated to continuing breastfeeding after returning to work in a group of mothers in Puerto Rico.

UNLABELLED: Working outside the home is related to lower rates of breastfeeding initiation and duration. Enacted laws promote and support breastfeeding in working places. OBJECTIVE: To determine factors associated to breastfeeding after returning to work. METHODS: Anonymous questionnaires distributed among breastfeeding working mothers. RESULTS: The study subjects were 100 mothers. Most of them (77%) worked for the government. Fifty-six percent continued breastfeeding after returning to work. In 33% of the workplaces there was an area designated for milk extraction.Thirty-six percent of employers allowed the 30 minute periods mandated by law for extraction. Factors associated to continuing breastfeeding were: working in the private setting, having a place designated for extraction, knowing that employers were mandated to have such a place, being allowed time for extraction, and knowing the laws protecting breastfeeding. CONCLUSIONS: There is need for more education to working mothers about their rights to continue breastfeeding after returning to work.

Acute rotavirus gastroenteritis in children younger than 5 years of age after initiation of rotavirus immunization schedule.

UNLABELLED: Rotavirus is the most common viral etiology of acute gastroenteritis in children. Oral rotavirus vaccine administration to infants was incorporated in 2007. The objective of this study is to determine the frequency of acute rotavirus gastroenteritis (ARGE) after the initiation of the rotavirus immunization schedule. METHODOLOGY: The study included children younger than 5 years of age admitted to San Jorge Children's Hospital from 2005-2008 with ARGE. RESULTS: There were 7,686 cases of acute gastroenteritis during the study period with 15% caused by Rotavirus. The peak season occurred from January through June. Rotavirus accounted for 22% of the acute gastroenteritis cases in the years pre-vaccination (2005-2006) and only 8.5 % in the post-vaccination years (2007-2008) (p < 0.01) with a 68% reduction in ARGE hospitalizations after vaccination. CONCLUSIONS: Our study supports the significant decline in ARGE after routine administration rotavirus vaccine in Puerto Rico.

Loss of parental role as a cause of stress in the neonatal intensive care unit.

UNLABELLED: Having a baby in the Neonatal Intensive Care Unit (NICU) is a major source of stress for parents. The barriers to parenting and reactions to the environment may negatively influence the parent-infant relationship. OBJECTIVE: To identify NICU-related parental stress and associated factors. METHODS: Parents (N = 156) of newborns admitted to NICU completed the Parental Stressor Scale. RESULTS: Most of the parents (46%) rated the experience to be extremely stressful. The principal cause of stress was the alteration in parental role and being separated from their baby. Stress was not associated to education, marital status, infants' birth weight, gestational age, congenital anomalies or if the parents expected the baby to be in the NICU. CONCLUSION: Identification of areas associated to higher levels of stress in parents may help the NICU staff to establish strategies to help parents cope with the stress caused by being unable to start their parenting role immediately after their babies' birth.