Surfactant with and without bronchoalveolar lavage in an experimental model of meconium aspiration syndrome.

OBJECTIVES: To assess the effect of surfactant administration, preceded or not by bronchoalveolar lavage (BAL) with dilute surfactant, on pulmonary function in experimental severe meconium aspiration syndrome. METHODS: Twenty-one newborn pigs received 20% meconium in saline intratracheally and were randomly allocated to one of three groups: I, control; II, surfactant only (poractant alfa, 200 mg/kg); or III, dilute surfactant BAL followed by 125 mg/kg surfactant. Arterial blood gases (ABGs), lung compliance, and resistance were assessed. RESULTS: Thirty minutes after treatment, mean PaO2 (mm Hg) increased to 72 in group I, to 106 in group II and to 172 in group III (P=0.01). After 3 h, mean PaO2 (mm Hg) was 70 in group I, 95 in group II and 198 in group III (P<0.01). After 6 h, it was 79 in group I, 110 in group II, and 217 in group III (P=0.01). From the 30-min point onward, there were significant differences among treatment groups in all other parameters and at every point of assessment, except for compliance and resistance 3 h after treatment. CONCLUSIONS: BAL with dilute surfactant, followed by an additional dose of surfactant, produced significant improvements in ABGs and pulmonary mechanics as compared with a single dose of surfactant.

Influence of Acute Kidney Injury Defined by the Pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease Score on the Clinical Course of PICU Patients.

OBJECTIVE: To evaluate the predictive value of the pediatric-modified Risk, Injury, Failure, Loss, End-stage renal disease criteria for disease course severity in patients with or without acute kidney injury admitted to a PICU. DESIGN: Retrospective cohort study. SETTING: A 12-bed PICU at a tertiary referral center in Southern Brazil. PATIENTS: All patients admitted to the study unit over a 1-year period. INTERVENTIONS: A database of all eligible patients was analyzed retrospectively. MEASUREMENTS AND MAIN RESULTS: Patients were classified by pediatric-modified Risk, Injury, Failure, Loss, End-stage renal disease score at admission and worst pediatric-modified Risk, Injury, Failure, Loss, End-stage renal disease score during PICU hospitalization. The outcomes of interest were length of PICU stay, duration of mechanical ventilation, duration of vasoactive drug therapy, and mortality. The Pediatric Index of Mortality 2 was used to assess overall disease severity at the time of PICU admission. Of 375 patients, 169 (45%) presented acute kidney injury at the time of admission and 37 developed acute kidney injury during PICU stay, for a total of 206 of 375 patients (55%) diagnosed with acute kidney injury during the study period. The median Pediatric Index of Mortality 2 score predicted a mortality rate of 9% among non-acute kidney injury patients versus a mortality rate of 16% among acute kidney injury patients (p = 0.006). The mortality of patients classified as pediatric-modified Risk, Injury, Failure, Loss, End-stage renal disease F was double that predicted by Pediatric Index of Mortality 2 (7 vs 3.2). Patients classified as having severe acute kidney injury (pediatric-modified Risk, Injury, Failure, Loss, End-stage renal disease I + F) exhibited higher mortality (14.1%; p = 0.001) and prolonged PICU length of stay (median, 7 d; p = 0.001) when compared with other patients. Acute kidney injury is a very frequent occurrence among patients admitted to PICUs. CONCLUSIONS: The degree of acute kidney injury severity, as assessed by the pediatric-modified Risk, Injury, Failure, Loss, End-stage renal disease criteria, is a good predictor of morbidity and mortality in this population. Pediatric Index of Mortality 2 tends to underestimate mortality in pediatric patients with severe acute kidney injury.

Surfactant deficiency in infants with severe acute viral bronchiolitis.

OBJECTIVES: To evaluate surfactant content and function through the lamellar body count (LBC) and stable microbubble test (SMT) in mechanically ventilated infants with severe acute viral bronchiolitis. STUDY DESIGN: Controlled cross-sectional study of 32 infants receiving mechanical ventilation: 16 with a diagnosis of acute viral bronchiolitis and 16 with normal lungs. Tracheal fluid was collected and LBC was performed in an automated cell counter. Samples were kept frozen and thawed for testing. At the time of analysis, samples were diluted in a dithiothreitol solution, vortexed for 10 seconds, and aspirated by the cell counter. SMT was performed using the Pattle technique. RESULTS: In the bronchiolitis group, the median (IQR) LBC was significantly lower than in the control group: 130,000 (61,250-362,250) vs. 518,000 (180,250-896,000) lamellar bodies/µL; P = .003. Median (IQR) SMT values were also significantly lower in the bronchiolitis group: 10 (2-13) vs. 400 (261-615) microbubbles/mm2; P < .001. CONCLUSIONS: Infants with acute viral bronchiolitis have reduced surfactant content and function. We speculate that these simple tests may be useful to identify infants with bronchiolitis who would benefit from surfactant replacement therapy.

Late-onset sepsis in very low birth weight infants: a Brazilian Neonatal Research Network Study.

BACKGROUND: Late-onset sepsis (LOS) is an important cause of morbidity and mortality in very low birth weight (VLBW) infants. AIM: To determine the incidence, risk factors and etiology of LOS. METHODS: LOS was investigated in a multicenter prospective cohort of infants at eight public university neonatal intensive care units (NICUs). Inclusion criteria included inborn, 23-33 weeks of gestational age, 400-1499 g birth weight, who survived >3 days. RESULTS: Of 1507 infants, 357 (24%) had proven LOS and 345 (23%) had clinical LOS. Infants with LOS were more likely to die. The majority of infections (76%) were caused by Gram-positive organisms. Independent risk factors for proven LOS were use of central venous catheter and mechanical ventilation, age at the first feeding and number of days on parenteral nutrition and on mechanical ventilation. CONCLUSION: LOS incidence and mortality are high in Brazilian VLBW infants. Most risk factors are associated with routine practices at NICU.

Exact Gestational Age, Term Versus Early Term, Is Associated with Different Breastfeeding Success Rates in Mothers Delivered by Elective Cesarean Section.

Objectives: The study was intended to verify the association between the gestational age of newborns classified as term and the success of breastfeeding in babies born by elective cesarean section. Also, to analyze how the variability of gestational age within the term influences breastfeeding. Materials and Methods: Retrospective study of a cohort, which included full-term newborns and their mothers, whose deliveries occurred by elective cesarean section. Among the inclusion criteria are delivery due to elective cesarean section and minimum gestational age of 37 weeks. The database consisted of medical birth information and interviews with mothers. Results: This study included 954 full-term newborns born by elective cesarean section. Exclusive breastfeeding at 3 months and being breastfed at 6 months showed a statistically significant association in the correlation with the variability of gestational age. There was a statistically significant association between exclusive breastfeeding at 3 months and breastfeeding at 6 months in the correlation between early term and full term. The trend test showed a significant progressive in the breastfeeding curve versus gestational age. Conclusion: Full-term newborns show better results of exclusive breastfeeding at 3 months and continued breastfeeding at 6 months, compared with those born at early term. Gestational age, even in term, has an influence on the success of breastfeeding in newborns undergoing elective cesarean delivery.

Evaluation of the effectiveness of antenatal corticoid in preterm twin and single pregnancies: a multicenter cohort study.

BACKGROUND: The effects of antenatal corticosteroids (ANSs) on twins are not well established. OBJECTIVE: To determine the impact of ANS use according to the number of fetuses. METHODS: Retrospective cohort study of newborns between 23 and 33 weeks of gestational age, birth weight from 400 to 1499 g, without malformations, delivered at 20 public university hospitals from 2010 to 2014.Exposed group: Received ANS (any time, any dose) and no exposed group: no received ANS. Analysis of birth conditions and clinical outcomes. Association of variables, relative risks, and 95% confidence intervals estimated from the adjustment of log-binomial regression models. RESULTS: About 7165 premature infants were analyzed: 5167 singleton, 937 twins, and 104 triplets. Characteristics of gestations with one, two, or three fetuses not receiving ANS were similar. Reduced hemodynamic instability in single and twins gestations in the first 72 h were observed (Adj R2 Twins = 0.78; 95% CI = 0.69-0.86) (Adj R2 Singles = 0.79; 95% CI = 0.62-0.99). Reduced peri-intraventricular hemorrhage (Adj R2 Twins = 0.54; 95% CI = 0.36-0.78) (Adj R2 singles = 0.54; 95% CI = 0.36-0.78); and early sepsis reduction on single and triplex gestations (Adj R2 triplex = 0.51; 95% CI = 0.27-0.94) (Adj single R2 = 0.51; 95% CI = 0.27-0.94) were observed. CONCLUSIONS: This study demonstrates ANS produces an important protective factor for severe intraventricular hemorrhage and hemodynamic instability in single and multiple pregnancies. ANS had a protective effect on death and birth conditions improvement just in single gestations. Regarding respiratory aspects was not observed the protective effect in the single or multiple gestations.

Surfactant deficiency in transient tachypnea of the newborn.

OBJECTIVE: To evaluate surfactant production and function in term neonates with transient tachypnea of the newborn (TTN). STUDY DESIGN: Samples of gastric aspirates collected within 30 minutes of birth from 42 term newborns with gestational age ≥ 37 weeks (21 patients with TTN and 21 control subjects), delivered via elective cesarean delivery, were analyzed with lamellar body count and stable microbubble test. RESULTS: Results of lamellar body counts and stable microbubble tests were significantly lower in the TTN group than in control subjects (P = .004 and .013, respectively). Lamellar body counts were significantly lower in infants with TTN requiring oxygen for ≥ 24 hours after birth than in infants requiring oxygen for < 24 hours (P = .029). When the cutoff point was 48 hours, the stable microbubble count was significantly lower in the group requiring oxygen for ≥ 48 hours than in the group requiring oxygen for < 48 hours (P = .047). CONCLUSIONS: Term infants with TTN had low lamellar body counts associated with decreased surfactant function, suggesting that prolonged disease is associated with surfactant abnormalities.

Red blood cell transfusions are independently associated with intra-hospital mortality in very low birth weight preterm infants.

OBJECTIVE: To test the hypothesis that red blood cell (RBC) transfusions in preterm infants are associated with increased intra-hospital mortality. STUDY DESIGN: Variables associated with death were studied with Cox regression analysis in a prospective cohort of preterm infants with birth weight <1500 g in the Brazilian Network on Neonatal Research. Intra-hospital death and death after 28 days of life were analyzed as dependent variables. Independent variables were infant demographic and clinical characteristics and RBC transfusions. RESULTS: Of 1077 infants, 574 (53.3%) received at least one RBC transfusion during the hospital stay. The mean number of transfusions per infant was 3.3 ± 3.4, with 2.1 ± 2.1 in the first 28 days of life. Intra-hospital death occurred in 299 neonates (27.8%), and 60 infants (5.6%) died after 28 days of life. After adjusting for confounders, the relative risk of death during hospital stay was 1.49 in infants who received at least one RBC transfusion in the first 28 days of life, compared with infants who did not receive a transfusion. The risk of death after 28 days of life was 1.89 times higher in infants who received more than two RBC transfusions during their hospital stay, compared with infants who received one or two transfusions. CONCLUSION: Transfusion was associated with increased death, and transfusion guidelines should consider risks and benefits of transfusion.

Prospective operationalization and feasibility of a glycemic control protocol in critically ill children.

OBJECTIVE: To evaluate the feasibility and safe operationalization of a pediatric glycemic control protocol in the setting of a general pediatric intensive care unit in a developing country. DESIGN: Prospective, observational cohort study carried out over 12 months. SETTING: Fourteen-bed pediatric intensive care unit in Brazil. PATIENTS: Children requiring mechanical ventilation with at least one organ system dysfunction were included. INTERVENTIONS: Glucose was monitored and insulin used for persistent hyperglycemia (glucose >140 mg/dL [7.8 mmol/L] for at least two observations separated by at least a 1-hr interval), with a target glucose during insulin use of 60-140 mg/dL (3.3-7.8 mmol/L). RESULTS: Out of 410 admissions, 144 children met the criteria for applying the protocol. One hundred fourteen of 144 (79%) children had at least one peak glucose level that was hyperglycemic, but only 44 (31%) children required insulin. Insulin infusion was most frequently started on day 1 (61%), with a glucose level at the time of 229 ± 79 mg/dL (12.7 ± 4.4 mmol/L). The mean glucose level after 6 hrs of insulin was 172 ± 87 mg/dL (9.6 ± 4.8 mmol/L), and the time to achieve the target glucose range was 9.5 (2-20) hrs (median [interquartile range]). The overall duration of insulin was 24.5 (10-48) hrs, and the average dose required was 0.06 ± 0.03 U/kg/hr. In the whole series, the peak glucose level was 202 ± 93 mg/dL (11.2 ± 5.2 mmol/L), with no difference between survivors and nonsurvivors. There was no difference in mortality when different glucose bands were considered and no association between glucose level and mortality. The overall rate of hypoglycemia (glucose <40 mg/dL [2.2 mmol/L]) was 8.3%, and it was more common in those receiving insulin (20% vs. 3%, p < .05). CONCLUSIONS: Hyperglycemia is frequent in critically ill children managed in a pediatric intensive care unit in a developing country. Using a glycemic control protocol, one-third of these children required insulin, but attendants should be aware of a significant risk of hypoglycemia in this setting. Based on these data, a trial to detect a 20% relative reduction in mortality (power 90%, p = .05) associated with insulin in a similar population would need to screen >10,000 patients.

Ocular Outcome of Brazilian Patients With Congenital Toxoplasmosis.

BACKGROUND: Retinochoroiditis is the most frequent manifestation of congenital toxoplasmosis. We aimed to describe the ocular outcome and factors that may influence the visual prognosis of these patients. METHODS: Cohort of patients with confirmed congenital toxoplasmosis seen between 1996 and 2017 in Porto Alegre, southern Brazil. RESULTS: Seventy-seven patients were included, of which 65 (85.5%) were identified by routine screening. Median age at the end of the follow-up was 10 years (minimum 2, maximum 25). Retinochoroiditis was present in 55 patients (71.4%). New retinochoroidal lesions developed after the first year of life in 77.8% of the patients who began treatment after the fourth month of life, compared with 35.2% among those treated before 4 months of life (relative risk = 0.45, 95% confidence intervals: 0.27-0.75, P = 0.02) and 33.3% among those treated before 2 months of life (relative risk = 0.42, 95% confidence intervals: 0.25-0.72, P = 0.01). There was a peak incidence of new retinochoroidal lesions between 4 and 5 years and another peak between 9 and 14 years, the latter only among girls. Thirty-four patients with retinochoroiditis were followed up for 10 years or more, and the school performance was appropriate in 28 (82.4%). CONCLUSIONS: The high incidence of new retinochoroidal lesions during the follow-up period indicates the importance of long-term follow-up of patients with congenital toxoplasmosis. Initiating treatment within the first 4 months of life, especially within the first 2 months, was a protective factor against the later development of retinochoroiditis. Despite the usual favorable prognosis, the high morbidity of congenital toxoplasmosis in Brazil was confirmed.

Accuracy of cerebrospinal fluid ferritin for purulent meningitis.

OBJECTIVE: To evaluate the use of cerebrospinal fluid (CSF) ferritin levels in the diagnosis of purulent meningitis (PM). METHOD: We studied 81 children between 28 days and 12 years of age who presented with clinical suspicion of meningitis to the emergency department. CSF ferritin levels were measured and compared between diagnostic groups (PM, aseptic meningitis (AM) and no meningitis). RESULTS: The median age was 24 (IQR 8-69) months. There were 32 patients with AM (39%), 23 with PM (28%) and 26 with no meningitis (32%). Median CSF ferritin was 4.2 ng/mL (IQR 3.0-6.5), 52.9 ng/mL (IQR 30.7-103 ng/mL) and 2.4 ng/mL (IQR 2-4), respectively. CSF ferritin was higher in children with PM compared with AM (p<0.001) or no meningitis (p<0.001). There was no difference between AM and no meningitis. CONCLUSION: CSF ferritin may be a useful biomarker to discriminate PM in children with clinical symptoms of this disease.

End-of-life practices in patients admitted to pediatric intensive care units in Brazil: A retrospective study.

OBJECTIVE: To determine the prevalence of life support limitation (LSL) in patients who died after at least 24h of a pediatric intensive care unit (PICU) stay, parent participation and to describe how this type of care is delivered. METHODS: Retrospective cohort study in a tertiary PICU at a university hospital in Brazil. All patients aged 1 month to 18 years who died were eligible for inclusion. The exclusion criteria were those brain death and death within 24h of admission. RESULTS: 53 patients were included in the study. The prevalence of a LSL report was 45.3%. Out of 24 patients with a report of LSL on their medical records only 1 did not have a do-not-resuscitate order. Half of the patients with a report of LSL had life support withdrawn. The length of their PICU stay, age, presence of parents at the time of death, and severity on admission, calculated by the Pediatric Index of Mortality 2, were higher in patients with a report of LSL. Compared with other historical cohorts, there was a clear increase in the prevalence of LSL and, most importantly, a change in how limitations are carried out, with a high prevalence of parental participation and an increase in withdrawal of life support. CONCLUSIONS: LSLs were associated with older and more severely ill patients, with a high prevalence of family participation in this process. The historical comparison showed an increase in LSL and in the withdrawal of life support.

Hemispheric brain injury and behavioral deficits induced by severe neonatal hypoxia-ischemia in rats are not attenuated by intravenous administration of human umbilical cord blood cells.

Neonatal hypoxia-ischemia (HI) is an important cause of mortality and morbidity in infants. Human umbilical cord blood (HUCB) is a potential source of cellular therapy in perinatology. We investigated the effects of HUCB cells on spatial memory, motor performance, and brain morphologic changes in neonate rats submitted to HI. Seven-day-old rats underwent right carotid artery occlusion followed by exposure to 8% O(2) inhalation for 2 h. Twenty-four hours after HI, rats received either saline solution or HUCB cells i.v. After 3 wk, rats were assessed using a Morris Water Maze and four motor tests. Subsequently, rats were killed for histologic, immunohistochemical, and polymerase chain reaction (PCR) analyses. HI rats showed significant spatial memory deficits and a volumetric decrease in the hemisphere ipsilateral to arterial occlusion. These deficits and decreases were not significantly attenuated by the injection of HUCB cells. Moreover, immunofluorescence and PCR analysis revealed few HUCB cells located in rat brain. Intravenous administration of HUCB cells requires optimization to achieve improved therapeutic outcomes in neonatal hypoxic-ischemic injury.

Rapid diagnosis of respiratory distress syndrome by oral aspirate in premature newborns.

OBJECTIVE: The stable microbubble test on gastric aspirate and on amniotic fluid has been used for the diagnosis of respiratory distress syndrome in the newborn. However, no study has performed this test on oral aspirates from premature infants. The objective of this study was to evaluate the performance of the stable microbubble test on oral aspirates from preterm newborns to predict respiratory distress syndrome. METHOD: This study included infants with gestational age <34 weeks. Oral fluids were obtained immediately after birth and gastric fluids were collected within the first 30 minutes of life. The samples were frozen and tested within 72 hours. RESULTS: The sample was composed of paired aspirates from 64 newborns, who were divided into two groups: respiratory distress syndrome group (n=21) and control group (n=43). The median (interquartile range) of the stable microbubble count in the oral samples of infants with respiratory distress syndrome was significantly lower than that of infants who did not develop respiratory symptoms: respiratory distress syndrome group=12 (8-22) stable microbubbles/mm2; control group=100 (48-230)microbubbles/mm2 (p<0.001). The correlation between microbubble count in gastric and oral aspirates was 0.90 (95% confidence interval=0.85-0.95; p<0.001). Considering a cut-off point of 25microbubbles/mm2, the sensitivity and the specificity of the stable microbubble test were 81.4% and 85.7%, respectively. CONCLUSION: The study suggests that the stable microbubble test performed on oral aspirate is a reliable alternative to that performed on gastric fluid for the prediction of respiratory distress syndrome in the newborn.

Aleitamento materno de prematuros internados em Unidade de Terapia Intensiva neonatal: coorte prospectiva / Breastfeeding of premature infants hospitalized in a neonatal Intensive Care Unit: a prospective cohort / Lactancia materna de bebés prematuros hospitalizados en la Unidad de Cuidados Intensivos neonatales: cohorte prospectiva

Identificar variáveis com potencial de intervenção que estejam associadas ao volume de leite esgotado das mães de recém-nascidos prematuros. Trata-se de um estudo de coorte, descritivo e exploratório. A coleta de dados ocorreu em um hospital materno-infantil do Sul do Brasil no período de julho de 2021 a janeiro de 2022, por meio de entrevistas a 20 mães de recém-nascidos prematuros. Verificou-se que, em relação ao número de vezes ao dia que foi realizado o esgotamento hospitalar e domiciliar, a mediana foi de 4 vezes. A maioria das mães utilizou dois métodos de esgotamento das mamas (manual e com bomba de sucção). O estudo identificou que o volume de leite esgotado foi abaixo do esperado pelo Ministério da Saúde. Destaca-se a falta de procura do banco de leite para o esgotamento, problemas relacionados à mama, como exemplo o método utilizado para esgotamento.

To identify variables with intervention potential that are associated with the volume of depleted milk from mothers of premature newborns. This is a cohort, descriptive, and exploratory study. Data collection occurred in a maternal-infant hospital in southern Brazil from July 2021 to January 2022, through interviews with 20 mothers of premature newborns. It was verified that, in relation to the number of times per day that hospital and home milk expression was performed, the median was 4 times. Most mothers used two methods of breast milk expression (manual and with suction pump). The study found that the volume of expressed milk was lower than expected by the Ministry of Health. We highlight the lack of demand of the milk bank for expression, problems related to the breast, as an example of the method used for expression.

Identificar variables con potencial de intervención que se asocian al volumen de leche agotada de madres de recién nacidos prematuros. Se trata de un estudio de cohortes, descriptivo y exploratorio. La recolección de datos ocurrió en un hospital materno-infantil en el sur de Brasil de julio de 2021 a enero de 2022, a través de entrevistas con 20 madres de recién nacidos prematuros. Se verificó que, en relación al número de veces por día que se realizaba el agotamiento hospitalario y domiciliario, la media fue de 4 veces. La mayoría de las madres utilizaron dos métodos de depleción mamaria (manual y con succión apretada). El estudio identificó que el volumen de leche empobrecida fue menor de que lo esperado por el Ministerio de Salud. Destacamos la falta de demanda del banco de leche por agotamiento, problemas relacionados con la mama, como ejemplo del método utilizado para el agotamiento.

Scores TISS-28 versus NEMS to size the nursing team in a pediatric intensive care unit.

OBJECTIVE: To estimate the workload and size the nursing team using the scales TISS-28 and NEMS in a pediatric intensive care unit. METHODS: An observational prospective study with a quantitative approach was conducted at the pediatric intensive care unit of a university hospital from Jan 1st, 2009 to Dec 31st, 2009. All children who remained hospitalized for more than 8 hours were included, with length of stay of 4 hours in case of death. Clinical data were collected and the Paediatric Index of Mortality 2 and the scores TISS-28 and NEMS were determined. The TISS-28 and NEMS were converted into working hours of the nursing team and sizing complied with the parameters of the Brazilian Federal Nursing Council. Pearson's correlation and the Bland-Altman model were used to verify the association and agreement between the instruments. RESULTS: A total of 459 children were included, totaling 3,409 observations. The average values for the TISS-28 and NEMS were 20.8±8 and 25.2±8.7 points, respectively. The nursing workload was 11 hours by TISS-28 and 13.3 hours by NEMS. The estimated number of professionals by TISS-28 and NEMS was 29.6 and 35.8 professionals, respectively. The TISS-28 and NEMS showed adequate correlation and agreement. CONCLUSION: Time spent in nursing activities and team sizing reflected by the NEMS were significantly greater when compared to the TISS-28.

Surfactant deficiency in full-term newborns with transient tachypnea delivered by elective C-section.

INTRODUCTION: Previous studies have suggested that full-term newborns delivered by elective cesarean section who develop transient tachypnea have low gastric microbubble counts. In the present study, microbubble concentrations in oral fluid samples were used to evaluate pulmonary maturity. OBJECTIVE: To evaluate lung maturity in full-term newborns delivered by elective caesarean section using the stable microbubble test in oral aspirates collected at birth. METHOD: The study involved newborns with gestational age >37 weeks delivered by elective cesarean section. Oral fluid samples were obtained in the delivery room immediately after birth, and gastric fluid was collected within the first hour of life. Samples were frozen and analyzed by two blinded researchers. RESULTS: The sample comprised 544 newborns. Twenty-two were diagnosed with transient tachypnea of the newborn by the assisting physician, and required admission to the Neonatal Intensive or Intermediate Care Unit. The median (interquartile range) of the number of microbubbles in the oral samples of these patients was 67.5 (45-150) microbubbles/mm(2) . The remaining 498 newborns without respiratory difficulties had a count of 350 (150-750) microbubbles/mm(2) -P < 0.001. Gastric fluid tests revealed a count of 150 (82.5-700) microbubbles/mm(2) for neonates with respiratory difficulties, and of 600 (216-1125) microbubbles/mm(2) -P < 0.05 for those without respiratory symptoms. CONCLUSION: The present results suggest that transient tachypnea of the newborn is associated with surfactant dysfunction. Pediatr Pulmonol. 2016;51:596-600. © 2015 Wiley Periodicals, Inc.

Microcephaly and Zika virus: a clinical and epidemiological analysis of the current outbreak in Brazil.

OBJECTIVE: This study aimed to critically review the literature available regarding the Zika virus outbreak in Brazil and its possible association with microcephaly cases. SOURCES: Experts from Instituto do Cérebro do Rio Grande do Sul performed a critical (nonsystematic) literature review regarding different aspects of the Zika virus outbreak in Brazil, such as transmission, epidemiology, diagnostic criteria, and its possible association with the increase of microcephaly reports. The PubMed search using the key word "Zika virus" in February 2016 yielded 151 articles. The manuscripts were reviewed, as well as all publications/guidelines from the Brazilian Ministry of Health, World Health Organization and Centers for Disease Control and Prevention (CDC - United States). SUMMARY OF FINDINGS: Epidemiological data suggest a temporal association between the increased number of microcephaly notifications in Brazil and outbreak of Zika virus, primarily in the Brazil's Northeast. It has been previously documented that many different viruses might cause congenital acquired microcephaly. Still there is no consensus on the best curve to measure cephalic circumference, specifically in preterm neonates. Conflicting opinions regarding the diagnosis of microcephaly (below 2 or 3 standard deviations) that should be used for the notifications were also found in the literature. CONCLUSION: The development of diagnostic techniques that confirm a cause-effect association and studies regarding the physiopathology of the central nervous system impairment should be prioritized. It is also necessary to strictly define the criteria for the diagnosis of microcephaly to identify cases that should undergo an etiological investigation.

End-of-life practices in patients admitted to pediatric intensive care units in Brazil: A retrospective study

Abstract Objective: To determine the prevalence of life support limitation (LSL) in patients who died after at least 24 h of a pediatric intensive care unit (PICU) stay, parent participation and to describe how this type of care is delivered. Methods: Retrospective cohort study in a tertiary PICU at a university hospital in Brazil. All patients aged 1 month to 18 years who died were eligible for inclusion. The exclusion criteria were those brain death and death within 24 h of admission. Results: 53 patients were included in the study. The prevalence of a LSL report was 45.3%. Out of 24 patients with a report of LSL on their medical records only 1 did not have a donot-resuscitate order. Half of the patients with a report of LSL had life support withdrawn. The length of their PICU stay, age, presence of parents at the time of death, and severity on admission, calculated by the Pediatric Index of Mortality 2, were higher in patients with a report of LSL. Compared with other historical cohorts, there was a clear increase in the prevalence of LSL and, most importantly, a change in how limitations are carried out, with a high prevalence of parental participation and an increase in withdrawal of life support. Conclusions: LSLs were associated with older and more severely ill patients, with a high prevalence of family participation in this process. The historical comparison showed an increase in LSL and in the withdrawal of life support.

Death or survival with major morbidity in VLBW infants born at Brazilian neonatal research network centers.

OBJECTIVE: To analyze unfavorable outcomes at hospital discharge of preterm infants born at Brazilian public university centers. METHODS: Prospective cohort of 2646 inborn infants with gestational age 23-33 weeks and birth weight 400-1499 g, without malformations, born at 20 centers in 2012-2013. Unfavorable outcome was defined as in-hospital death or survival at hospital discharge with ≥1 major morbidities: bronchopulmonary dysplasia (BPD) at 36 corrected weeks, intraventricular hemorrhage (IVH) grades 3-4, periventricular leukomalacia (PVL) or surgically treated retinopathy of prematurity (ROP). RESULTS: Among 2646 infants, 1390 (53%) either died or survived with major morbidities: 793 (30%) died; 497 (19%) had BPD; 358 (13%) had IVH 3-4 or PVL; and 84 (3%) had ROP. Logistic regression adjusted by center showed association of unfavorable outcome with: antenatal steroids (OR 0.70; 95%CI 0.55-0.88), C-section (0.72; 0.58-0.90), gestational age <30 (4.00; 3.16-5.07), being male (1.44; 1.19-1.75), small for gestational age (2.19; 1.72-2.78), 5th-min Apgar <7 (3.89; 2.88-5.26), temperature at NICU admission <36.0 °C (1.42; 1.15-1.76), respiratory distress syndrome (3.87; 2.99-5.01), proven late sepsis (1.33; 1.05-1.69), necrotizing enterocolitis (3.10; 2.09-4.60) and patent ductus arteriosus (1.69; 1.37-2.09). CONCLUSIONS: More than half of the VLBW infants born at public university level 3 Brazilian hospitals either die or survive with major morbidities.