Impact of early-onset preeclampsia on feeding tolerance and growth of very low birth weight infants during hospitalization / Efeito da pré-eclâmpsia precoce na tolerância alimentar e no crescimento de recém-nascidos de muito baixo peso durante a hospitalização

ABSTRACT Objective: The provision of adequate enteral nutrition to preterm infants is a great challenge, and preeclampsia (PE) may have a detrimental effect on the safety of nutrition supply. This study aims to investigate the influence of early-onset PE on preterm infants' enteral feeding tolerance and growth during hospitalization. Methods: This is a prospective study with 55 preterm infants <34 weeks born to PE mothers matched by gestational age with 55 preterm infants born to normotensive mothers from 2013 to 2016. We evaluated maternal, gestational, and neonatal clinical data. The outcomes were feeding intolerance and growth during hospitalization. Comparison between groups was performed by Student's t-test or Mann-Whitney U test, chi-square test, or Fisher's exact test. Multiple logistic regression was used to investigate whether PE was an independent risk factor for feeding intolerance. Results: The mean gestational age was 30 weeks. Preterm infants of mothers with PE had lower birth weight and were smaller at discharge. Feeding intolerance was frequent, but necrotizing enterocolitis was rare in this sample (PE=4% vs. control=2%) with no difference between groups. Preterm infants of mothers with PE had worse growth outcomes; however, PE was not an independent risk factor for feeding intolerance. The increase in gestational age was a protective factor, and being born small for gestational age (SGA) increased the risk of feeding intolerance by six times. Conclusions: Preterm infants of mothers with early-onset PE were more likely to be born SGA and had a worse growth trajectory during hospitalization. In adjusted analyses, however, low gestational age and SGA were independent predictors of feeding intolerance.

RESUMO Objetivo: A nutrição enteral adequada para recém-nascidos prematuros é um grande desafio, e a pré-eclâmpsia (PE) pode comprometer a segurança da oferta alimentar. O objetivo deste estudo é investigar a influência da PE de início precoce na tolerância alimentar e no crescimento de prematuros durante a hospitalização. Métodos: Estudo prospectivo, com 55 prematuros <34 semanas de mães com PE pareados por idade gestacional e com 55 prematuros de mães normotensas, de 2013 a 2016. Foram avaliados dados clínicos maternos, gestacionais e neonatais. Os desfechos foram intolerância alimentar e crescimento durante a hospitalização. Na comparação entre grupos, utilizaram-se teste t de Student ou de Mann-Whitney e teste qui-quadrado ou exato de Fisher. Regressão logística múltipla foi usada para investigar se a PE é fator de risco para intolerância alimentar. Resultados: A idade gestacional média foi de 30 semanas. Prematuros de mães com PE tiveram menor peso ao nascer e eram menores na alta. A intolerância alimentar foi frequente, mas a enterocolite necrosante foi rara nesta amostra (PE=4% vs. controle=2%), sem diferença entre grupos. Prematuros de mães com PE tiveram pior crescimento, mas a PE não foi fator independente de risco para intolerância alimentar. O aumento da idade gestacional foi fator de proteção, e nascer pequeno para a idade gestacional (PIG) aumentou em seis vezes o risco de intolerância alimentar. Conclusões: Prematuros de mães com PE de início precoce tiveram maior probabilidade de nascer PIG e pior trajetória de crescimento na hospitalização. Em análises ajustadas, baixa idade gestacional e PIG foram preditores independentes de intolerância alimentar.

Impact of early-onset preeclampsia on feeding tolerance and growth of very low birth weight infants during hospitalization.

OBJECTIVE: The provision of adequate enteral nutrition to preterm infants is a great challenge, and preeclampsia (PE) may have a detrimental effect on the safety of nutrition supply. This study aims to investigate the influence of early-onset PE on preterm infants' enteral feeding tolerance and growth during hospitalization. METHODS: This is a prospective study with 55 preterm infants <34 weeks born to PE mothers matched by gestational age with 55 preterm infants born to normotensive mothers from 2013 to 2016. We evaluated maternal, gestational, and neonatal clinical data. The outcomes were feeding intolerance and growth during hospitalization. Comparison between groups was performed by Student's t-test or Mann-Whitney U test, chi-square test, or Fisher's exact test. Multiple logistic regression was used to investigate whether PE was an independent risk factor for feeding intolerance. RESULTS: The mean gestational age was 30 weeks. Preterm infants of mothers with PE had lower birth weight and were smaller at discharge. Feeding intolerance was frequent, but necrotizing enterocolitis was rare in this sample (PE=4% vs. control=2%) with no difference between groups. Preterm infants of mothers with PE had worse growth outcomes; however, PE was not an independent risk factor for feeding intolerance. The increase in gestational age was a protective factor, and being born small for gestational age (SGA) increased the risk of feeding intolerance by six times. CONCLUSIONS: Preterm infants of mothers with early-onset PE were more likely to be born SGA and had a worse growth trajectory during hospitalization. In adjusted analyses, however, low gestational age and SGA were independent predictors of feeding intolerance.

Risk Perception and Decision Making about Early-Onset Sepsis among Neonatologists: A National Survey.

OBJECTIVE: Many newborns are investigated and empirically treated for suspected early-onset sepsis (EOS). This study aimed to describe neonatologists' self-identified risk thresholds for investigating and treating EOS and assess the consistency of these thresholds with clinical decisions. STUDY DESIGN: Voluntary online survey, available in two randomized versions, sent to neonatologists from 20 centers of the Brazilian Network on Neonatal Research. The surveys included questions about thresholds for investigating and treating EOS and presented four clinical scenarios with varying calculated risks. In survey version A, only the scenarios were presented, and participants were asked if they would order a blood test or start antibiotics. Survey version B presented the same scenarios and the risk of sepsis. Clinical decisions were compared between survey versions using chi-square tests and agreement between thresholds and clinical decisions were investigated using Kappa coefficients. RESULTS: In total, 293 surveys were completed (145 survey version A and 148 survey version B). The median risk thresholds for blood test and antibiotic treatment were 1:100 and 1:25, respectively. In the high-risk scenario, there was no difference in the proportion choosing antibiotic therapy between the groups. In the moderate-risk scenarios, both tests and antibiotics were chosen more frequently when the calculated risks were included (survey version B). In the low-risk scenario, there was no difference between survey versions. There was poor agreement between the self-described thresholds and clinical decisions. CONCLUSION: Neonatologists overestimate the risk of EOS and underestimate their risk thresholds. Knowledge of calculated risk may increase laboratory investigation and antibiotic use in infants at moderate risk for EOS. KEY POINTS: · Neonatologists overestimate the risk of EOS.. · There is wide variation in diagnostic/treatment thresholds for EOS.. · Clinical decision on EOS is not consistent with risk thresholds.. · Knowledge of risk may increase investigation and treatment of EOS..

The effect of early-onset preeclampsia on the intestinal blood flow of preterm infants.

BACKGROUND: Preeclampsia is associated with important vascular maternal changes. However, its repercussions on newborns' circulation have hardly been reported. OBJECTIVE: To investigate whether early-onset preeclampsia is associated with altered blood flow of the superior mesenteric artery (SMA) in preterm infants. MATERIALS AND METHODS: Prospective study with 60 preterm infants of mothers with early-onset preeclampsia (PE) and 60 of normotensive mothers, paired according to the gestational age, from 2013 to 2016. Maternal, gestational, and neonatal clinical data were evaluated. The outcome of interest was the blood flow velocity in SMA, evaluated by the peak systolic velocity and end-diastolic velocity and by the resistance index and pulsatility index, through the Doppler ultrasound in the first 72 h of life. Covariance analysis was used to determine the PE effect on the SMA blood flow, controlling for possible confounding variables. RESULTS: The mean gestational age was 30 weeks. Infants of mothers with PE had significantly lower values of peak systolic and end-diastolic velocity (57.75 ± 17.49 and 12.29 ± 5.74) compared with the control group (67.17 ± 29.57 and 15.03 ± 7.52), even after control of covariates. CONCLUSION: Early-onset preeclampsia is associated with decreased blood flow of SMA in preterm infants on the first days of life.

Evaluation of usability of a neonatal health information system according to the user's perception / Avaliação da usabilidade de um sistema de informação em saúde neonatal segundo a percepção do usuário

ABSTRACT Objective: To measure the level of satisfaction regarding the usability of a neonatal health information system and identify if demographic factors can influence the usability of a health information system. Methods: A cross-sectional, exploratory study was carried out with a convenience sample of 50 users of the Brazilian Neonatal Research Network. The instrument chosen for the usability evaluation was the System Usability Scale between February and March 2017. The statistical analysis of the collected variables was carried out in order to describe the sample, to quantify the level of satisfaction of the users and to identify the variables associated with the level of satisfaction. Results: The female gender represented 75% of the sample. The mean age was 52.8 years; 58% had a doctoral degree, average time of graduation was 17 years, with area of practice in medicine (neonatology), with intermediate knowledge in computer science (74%) and mean system use time of 52 months. Regarding usability, 94% rated the system as "good", "excellent" or "better than imaginable". The usability of the system was not associated with age, gender, education, profession, area of practice, knowledge in computer science and time of system use. Conclusion: The level of satisfaction of the computerized health system user was considered good. No demographic factors were associated with the satisfaction of the users.

RESUMO Objetivo: Mensurar o grau de satisfação de profissionais de saúde quanto à usabilidade de um sistema de informação em saúde neonatal e identificar os fatores que podem influenciar na satisfação do usuário frente à usabilidade. Métodos: Estudo transversal e exploratório realizado com 50 profissionais de saúde integrantes dos centros da Rede Brasileira de Pesquisas Neonatais. Para avaliação da usabilidade foi utilizado o instrumento System Usability Scale entre fevereiro e março de 2017. Realizou-se a análise estatística descritiva e inferencial das variáveis coletadas, com a finalidade de descrever a amostra, quantificar o grau de satisfação dos usuários e identificar as variáveis associadas ao grau de satisfação do usuário em relação à usabilidade. Resultados: Da população avaliada, 75% era do sexo feminino, com idade média 52,8 anos, 58% com pós-graduação (doutorado); tempo médio da última formação de 17 anos; área de atuação em medicina (neonatologia), grau intermediário de conhecimento em informática e tempo de utilização média do sistema de 52 meses. Quanto à usabilidade, 94% avaliaram o sistema como "bom", "excelente" ou "melhor impossível". A usabilidade do sistema não foi associada a idade, sexo, escolaridade, profissão, área de atuação, nível de conhecimento em informática e tempo de uso do sistema. Conclusões: O grau de satisfação do usuário do sistema informatizado de saúde foi considerado bom. Não foram identificados fatores demográficos que influenciassem sua avaliação.

Effect of preeclampsia on human milk cytokine levels.

INTRODUCTION: Preeclampsia (PE) is a systemic inflammatory disease, and its effect on human milk immune components is poorly understood. OBJECTIVE: To investigate whether PE affects human milk cytokine levels. METHODS: This was a prospective observational study involving mothers diagnosed with PE and with singleton pregnancy with no fetal malformation. The following cases were excluded: diabetes, chorioamnionitis, use of illicit drugs and alcohol, mastitis and congenital infection. In total, 228 mothers were studied and divided into two groups matched by gestational age: PE (n = 114) and normotensive (control, n = 114). Colostrum was collected from 24-72 hours postpartum, and mature milk was collected at the end of the first month. Cytokines (IL-1ß, IL-6, IL-8, IL-10, IL-12, and TNF-α) were measured using flow cytometry. A generalized linear model with a gamma distribution was used to analyze the differences between groups versus time interaction. RESULTS: The mean gestational age was 36 weeks. Increased IL-1 and IL-6 levels and reduced IL-12 levels in the colostrum were detected in PE, while in the mature milk, the IL-6 and IL-8 levels were lower than those of the control group. CONCLUSIONS: PE is associated with increased levels of inflammatory cytokines in colostrum and decreased levels in mature milk.

EVALUATION OF USABILITY OF A NEONATAL HEALTH INFORMATION SYSTEM ACCORDING TO THE USER'S PERCEPTION.

OBJECTIVE: To measure the level of satisfaction regarding the usability of a neonatal health information system and identify if demographic factors can influence the usability of a health information system. METHODS: A cross-sectional, exploratory study was carried out with a convenience sample of 50 users of the Brazilian Neonatal Research Network. The instrument chosen for the usability evaluation was the System Usability Scale between February and March 2017. The statistical analysis of the collected variables was carried out in order to describe the sample, to quantify the level of satisfaction of the users and to identify the variables associated with the level of satisfaction. RESULTS: The female gender represented 75% of the sample. The mean age was 52.8 years; 58% had a doctoral degree, average time of graduation was 17 years, with area of practice in medicine (neonatology), with intermediate knowledge in computer science (74%) and mean system use time of 52 months. Regarding usability, 94% rated the system as "good", "excellent" or "better than imaginable". The usability of the system was not associated with age, gender, education, profession, area of practice, knowledge in computer science and time of system use. CONCLUSION: The level of satisfaction of the computerized health system user was considered good. No demographic factors were associated with the satisfaction of the users.

Conteúdo de gordura e energia no colostro: efeito da idade gestacional e do crescimento fetal / Colostrum fat and energy content: effect of gestational age and fetal growth

RESUMO Objetivo: Avaliar se o conteúdo de gordura e o valor energético estimado no colostro diferem em função da idade gestacional e do crescimento fetal. Métodos: Estudo transversal com mães de recém-nascidos pré-termo e a termo nascidos em centro terciário em 2015-2016. Critério de inclusão: gestação única, sem diabetes, corioamnionite e mastite, sem uso de drogas ilícitas e álcool, ausência de malformação ou infecção congênita fetal. Foram constituídos quatro grupos conforme idade gestacional e crescimento fetal: pré-termo pequeno para a idade gestacional (n=33); pré-termo adequado (n=60); a termo pequeno (n=59) e a termo adequado para a idade gestacional (controle, n=73). O colostro foi coletado por extração manual entre 24 e 72 h pós-parto. Foram analisadas variáveis gestacionais e de nascimento. Os desfechos foram o conteúdo de gordura no colostro, pelo método do crematócrito, e o valor energético estimado. Na comparação entre grupos foram utilizados os testes do qui-quadrado ou Exato de Fisher, ANOVA e regressão linear multivariada. Resultados: A idade gestacional média foi de 34 semanas nos neonatos pré-termo e 39 semanas nos a termo. O crematócrito não diferiu entre os grupos, com valores médios de 3,3 a 4,0%; e o valor energético estimado foi de 52 a 56 kcal/dL. Crematócrito ≥4% foi mais frequente no grupo a termo pequeno para idade gestacional. Apenas no grupo de recém-nascidos pré-termo pequenos para a idade gestacional houve correlação entre crematócrito e índice de massa corpórea materno. Conclusões: O conteúdo de gordura e o valor energético estimado do colostro não diferiram em função da idade gestacional e do crescimento fetal.

ABSTRACT Objective: To determine whether fat content and energy value change in colostrum according to gestational age and fetal growth. Methods: Cross-sectional study with mothers of preterm and term infants born in a tertiary center in 2015-2016. Inclusion criteria: single pregnancy, absence of diabetes, chorioamnionitis and mastitis, no use of illicit drugs or alcohol, without fetal congenital malformation or infection. Four groups were formed according to gestational age and fetal growth: preterm infants small for gestational age (PT-SGA; n=33) and appropriate for gestational age (PT-AGA; n=60), term infants small for gestational age (T-SGA; n=59) and appropriate for gestational age (T-AGA; control, n=73). Colostrum was collected between 24-72 hours postpartum. Gestational and birth variables were analyzed. Outcome variables were: fat content in colostrum (evaluated by crematocrit method) and estimated energy value. Chi-square or Fisher exact tests, ANOVA, and multivariable linear regression were used for comparison among groups. Results: Mean gestational age was 34 weeks in preterm infants and 39 weeks in term neonates. Crematocrit did not differ between groups, with mean values varying between 3.3 and 4.0%; estimated energy value was 52 to 56 kcal/dL. Crematocrit ≥4% was more frequent in the T-SGA group. Only in the PT-SGA group there was a correlation between crematocrit and body mass index of the mother. Conclusions: The fat content and energy value of colostrum did not change according to gestational age or fetal growth.

COLOSTRUM FAT AND ENERGY CONTENT: EFFECT OF GESTATIONAL AGE AND FETAL GROWTH. / CONTEÚDO DE GORDURA E ENERGIA NO COLOSTRO: EFEITO DA IDADE GESTACIONAL E DO CRESCIMENTO FETAL.

OBJECTIVE: To determine whether fat content and energy value change in colostrum according to gestational age and fetal growth. METHODS: Cross-sectional study with mothers of preterm and term infants born in a tertiary center in 2015-2016. Inclusion criteria: single pregnancy, absence of diabetes, chorioamnionitis and mastitis, no use of illicit drugs or alcohol, without fetal congenital malformation or infection. Four groups were formed according to gestational age and fetal growth: preterm infants small for gestational age (PT-SGA; n=33) and appropriate for gestational age (PT-AGA; n=60), term infants small for gestational age (T-SGA; n=59) and appropriate for gestational age (T-AGA; control, n=73). Colostrum was collected between 24-72 hours postpartum. Gestational and birth variables were analyzed. Outcome variables were: fat content in colostrum (evaluated by crematocrit method) and estimated energy value. Chi-square or Fisher exact tests, ANOVA, and multivariable linear regression were used for comparison among groups. RESULTS: Mean gestational age was 34 weeks in preterm infants and 39 weeks in term neonates. Crematocrit did not differ between groups, with mean values varying between 3.3 and 4.0%; estimated energy value was 52 to 56 kcal/dL. Crematocrit ≥4% was more frequent in the T-SGA group. Only in the PT-SGA group there was a correlation between crematocrit and body mass index of the mother. CONCLUSIONS: The fat content and energy value of colostrum did not change according to gestational age or fetal growth.

OBJETIVO: Avaliar se o conteúdo de gordura e o valor energético estimado no colostro diferem em função da idade gestacional e do crescimento fetal. MÉTODOS: Estudo transversal com mães de recém-nascidos pré-termo e a termo nascidos em centro terciário em 2015-2016. Critério de inclusão: gestação única, sem diabetes, corioamnionite e mastite, sem uso de drogas ilícitas e álcool, ausência de malformação ou infecção congênita fetal. Foram constituídos quatro grupos conforme idade gestacional e crescimento fetal: pré-termo pequeno para a idade gestacional (n=33); pré-termo adequado (n=60); a termo pequeno (n=59) e a termo adequado para a idade gestacional (controle, n=73). O colostro foi coletado por extração manual entre 24 e 72 h pós-parto. Foram analisadas variáveis gestacionais e de nascimento. Os desfechos foram o conteúdo de gordura no colostro, pelo método do crematócrito, e o valor energético estimado. Na comparação entre grupos foram utilizados os testes do qui-quadrado ou Exato de Fisher, ANOVA e regressão linear multivariada. RESULTADOS: A idade gestacional média foi de 34 semanas nos neonatos pré-termo e 39 semanas nos a termo. O crematócrito não diferiu entre os grupos, com valores médios de 3,3 a 4,0%; e o valor energético estimado foi de 52 a 56 kcal/dL. Crematócrito ≥4% foi mais frequente no grupo a termo pequeno para idade gestacional. Apenas no grupo de recém-nascidos pré-termo pequenos para a idade gestacional houve correlação entre crematócrito e índice de massa corpórea materno. CONCLUSÕES: O conteúdo de gordura e o valor energético estimado do colostro não diferiram em função da idade gestacional e do crescimento fetal.

Painful procedures and analgesia in the NICU: what has changed in the medical perception and practice in a ten-year period? / Procedimentos dolorosos e analgesia em UTI Neonatal: o que mudou na opinião e na prática profissional em dez anos?

ABSTRACT OBJECTIVE: To compare the use of analgesia versus neonatologists' perception regarding analgesic use in painful procedures in the years 2001, 2006, and 2011. METHODS: This was a prospective cohort study of all newborns admitted to four university neonatal intensive care units during one month in 2001, 2006, and 2011. The frequency of analgesic prescription for painful procedures was evaluated. Of the 202 neonatologists, 188 answered a questionnaire giving their opinion on the intensity of pain during lumbar puncture, tracheal intubation, mechanical ventilation, and postoperative period using a 10-cm visual analogic scale (VAS; pain >3 cm). RESULTS: For lumbar puncture, 12% (2001), 43% (2006), and 36% (2011) were performed using analgesia. Among the neonatologists, 40-50% reported VAS >3 for lumbar puncture in all study periods. For intubation, 30% received analgesia in the study periods, and 35% (2001), 55% (2006), and 73% (2011) of the neonatologists reported VAS >3 and would prescribe analgesia for this procedure. As for mechanical ventilation, 45% (2001), 64% (2006), and 48% (2011) of patient-days were under analgesia; 56% (2001), 57% (2006), and 26% (2011) of neonatologists reported VAS >3 and said they would use analgesia during mechanical ventilation. For the first three post-operative days, 37% (2001), 78% (2006), and 89% (2011) of the patients received analgesia and more than 90% of neonatologists reported VAS >3 for major surgeries. CONCLUSIONS: Despite an increase in the medical perception of neonatal pain and in analgesic use during painful procedures, the gap between clinical practice and neonatologist perception of analgesia need did not change during the ten-year period.

RESUMO OBJETIVO: Confrontar o uso de analgesia versus a percepção de neonatologistas quanto ao emprego de analgésicos para procedimentos dolorosos em 2001, 2006 e 2011. MÉTODOS: Coorte prospectiva de todos recém-nascidos internados em quatro unidades universitárias. Avaliou-se a frequência do emprego de analgésicos para procedimentos dolorosos por um mês dos anos de estudo. Dos 202 neonatologistas atuantes nas unidades nos três períodos, 188 assinalaram em escala analógica visual de 10 cm (dor >3 cm) a intensidade da dor sentida pelo recém-nascido na punção lombar, intubação traqueal, ventilação mecânica e no pós-operatório. RESULTADOS: Para punção lombar, 12%, 43% e 36% foram feitas com analgesia em 2001, 2006 e 2011 e 40-50% dos neonatologistas referiam indicar analgésicos na punção lombar nos três períodos. Na intubação, 30% foram feitas sob analgesia nos três períodos e 35% (2001), 55% (2006) e 73% (2011) dos médicos diziam indicar analgésicos. Quanto à ventilação mecânica, 45-64% dos ventilados-dia estavam sob analgesia nos três períodos e 56% (2001), 57% (2006) e 26% (2011) dos neonatologistas diziam usar analgésicos. Dos pacientes-dia nos três primeiros dias de pós-operatório, 37% (2001), 78% (2006) e 89% (2011) receberam alguma dose de analgésico. Mais de 90% dos médicos referiam usar analgesia para essa situação. CONCLUSÕES: Entre 2001 e 2011, ocorreu aumento no uso de analgésicos para procedimentos dolorosos nas unidades neonatais e uma percepção mais acentuada por parte dos médicos de que o recém-nascido sente dor, mas o lapso entre a prática clínica e a percepção médica quanto à presença de dor persistiu.

Painful procedures and analgesia in the NICU: what has changed in the medical perception and practice in a ten-year period?

OBJECTIVE: To compare the use of analgesia versus neonatologists' perception regarding analgesic use in painful procedures in the years 2001, 2006, and 2011. METHODS: This was a prospective cohort study of all newborns admitted to four university neonatal intensive care units during one month in 2001, 2006, and 2011. The frequency of analgesic prescription for painful procedures was evaluated. Of the 202 neonatologists, 188 answered a questionnaire giving their opinion on the intensity of pain during lumbar puncture, tracheal intubation, mechanical ventilation, and postoperative period using a 10-cm visual analogic scale (VAS; pain >3cm). RESULTS: For lumbar puncture, 12% (2001), 43% (2006), and 36% (2011) were performed using analgesia. Among the neonatologists, 40-50% reported VAS >3 for lumbar puncture in all study periods. For intubation, 30% received analgesia in the study periods, and 35% (2001), 55% (2006), and 73% (2011) of the neonatologists reported VAS >3 and would prescribe analgesia for this procedure. As for mechanical ventilation, 45% (2001), 64% (2006), and 48% (2011) of patient-days were under analgesia; 56% (2001), 57% (2006), and 26% (2011) of neonatologists reported VAS >3 and said they would use analgesia during mechanical ventilation. For the first three post-operative days, 37% (2001), 78% (2006), and 89% (2011) of the patients received analgesia and more than 90% of neonatologists reported VAS >3 for major surgeries. CONCLUSIONS: Despite an increase in the medical perception of neonatal pain and in analgesic use during painful procedures, the gap between clinical practice and neonatologist perception of analgesia need did not change during the ten-year period.

There is no difference in nitric oxide metabolites and neonatal outcome between premature infants born to pre-eclamptic and those born to normotensive women.

BACKGROUND: The pathophysiology of pre-eclampsia (PE) is complex, and nitric oxide (NO) may be a factor. The neonatal outcome in pregnancies complicated by PE is controversial, and the PE/NO/neonatal diseases relationship has not been well established. AIMS: To measure nitrate and nitrite levels in the placenta, umbilical cord blood, blood and urine of preterm neonates born to pre-eclamptic and normotensive women and to investigate the relationship between placental, fetal and neonatal NO metabolites and neonatal outcome. METHODS: A prospective study was undertaken of 30 preterm infants <34 weeks of gestation, born to pre-eclamptic mothers and matched by gestational age with 30 infants born to normotensive mothers. Samples from the placental tissue, venous cord blood and the newborns' blood on day 4 and urine on days 1 and 4 were assayed for NO metabolites (nitrate and nitrite). Clinical variables and NO metabolites were compared between the groups. Generalised linear models were fitted to associate NO metabolites levels with adverse neonatal outcomes. RESULTS: There were no differences in NO metabolites and neonatal outcomes between the two groups. Increased levels of NO metabolites were found in the placenta and cord blood of small-for-gestational-age infants, and in the cord blood of newborns with necrotising enterocolitis and those who died. CONCLUSION: NO metabolite levels in the placenta and fetal and neonatal circulation were not associated with PE; however, cord blood levels of NO metabolites differed according to fetal growth and neonatal outcome.

Diagnostic accuracy of semi-quantitative and quantitative culture techniques for the diagnosis of catheter-related infections in newborns and molecular typing of isolated microorganisms.

BACKGROUND: Catheter-related bloodstream infections (CR-BSIs) have become the most common cause of healthcare-associated bloodstream infections in neonatal intensive care units (ICUs). Microbiological evidence implicating catheters as the source of bloodstream infection is necessary to establish the diagnosis of CR-BSIs. Semi-quantitative culture is used to determine the presence of microorganisms on the external catheter surface, whereas quantitative culture also isolates microorganisms present inside the catheter. The main objective of this study was to determine the sensitivity and specificity of these two techniques for the diagnosis of CR-BSIs in newborns from a neonatal ICU. In addition, PFGE was used for similarity analysis of the microorganisms isolated from catheters and blood cultures. METHODS: Semi-quantitative and quantitative methods were used for the culture of catheter tips obtained from newborns. Strains isolated from catheter tips and blood cultures which exhibited the same antimicrobial susceptibility profile were included in the study as positive cases of CR-BSI. PFGE of the microorganisms isolated from catheters and blood cultures was performed for similarity analysis and detection of clones in the ICU. RESULTS: A total of 584 catheter tips from 399 patients seen between November 2005 and June 2012 were analyzed. Twenty-nine cases of CR-BSI were confirmed. Coagulase-negative staphylococci (CoNS) were the most frequently isolated microorganisms, including S. epidermidis as the most prevalent species (65.5%), followed by S. haemolyticus (10.3%), yeasts (10.3%), K. pneumoniae (6.9%), S. aureus (3.4%), and E. coli (3.4%). The sensitivity of the semi-quantitative and quantitative techniques was 72.7% and 59.3%, respectively, and specificity was 95.7% and 94.4%. The diagnosis of CR-BSIs based on PFGE analysis of similarity between strains isolated from catheter tips and blood cultures showed 82.6% sensitivity and 100% specificity. CONCLUSION: The semi-quantitative culture method showed higher sensitivity and specificity for the diagnosis of CR-BSIs in newborns when compared to the quantitative technique. In addition, this method is easier to perform and shows better agreement with the gold standard, and should therefore be recommended for routine clinical laboratory use. PFGE may contribute to the control of CR-BSIs by identifying clusters of microorganisms in neonatal ICUs, providing a means of determining potential cross-infection between patients.

[Changes of blood flow in the umbilical artery in hypertensive pregnancy and the implications in the neonatal outcomes]. / Alterações do fluxo sanguíneo em artéria umbilical na síndrome hipertensiva gestacional e suas implicações nos resultados neonatais.

PURPOSE: To evaluate the anthropometric characteristics of morbidity and mortality of premature newborns (NB) of hypertensive mothers according to the presence or absence of flow (DZ) or reverse (DR) diastolic flow in the dopplervelocimetry of the umbilical artery. METHODS: A prospective study was conducted on preterm newborns of pregnant women with hypertension between 25 and 33 weeks of gestational age, submitted to umbilical artery Doppler study during the five days before delivery. Delivery occurred at Hospital Regional da Asa Sul, Brasília - Federal District, between November 1st, 2009 and October 31st, 2010. The infants were stratified into two groups according to the results of Doppler velocimetry: Gdz/dr=absent end-diastolic velocity waveform or reversed end-diastolic velocity waveform, and Gn=normal Doppler velocimetry. Anthropometric measurements at birth, neonatal morbidity, and mortality were compared between the two groups. RESULTS: We studied 92 infants, as follows: Gdz/dr=52 infants and Gn=40 infants. In Gdz/dr, the incidence of infants small for gestational age was significantly greater, with a relative risk of 2.5 (95%CI 1.7 - 3.7). In Gdz/dr, infants remained on mechanical ventilation for a longer time: median 2 (0‒28) and Gn median 0.5 (0‒25) p=0.03. The need for oxygen at 28 days was higher in G dz/dr comparing to Gn (33 versus 10%; p=0.01). Neonatal mortality was higher in Gdz/dr compared to Gn (36 versus 10%; p=0.03; relative risk of 1.6; 95%CI 1.2‒2.2). Logistic regression showed that, with each 100 grams lower birth weight, the chance of death increased 6.7 times in G dz/dr (95%CI 2.0 - 11.3; p<0.01). CONCLUSION: In preterm infants of mothers with hypertensive changes in Doppler velocimetry of the umbilical artery, intrauterine growth restriction and neonatal prognosis are often worse, with a high risk of death related to birth weight.

Alterações do fluxo sanguíneo em artéria umbilical na síndrome hipertensiva gestacional e suas implicações nos resultados neonatais / Changes of blood flow in the umbilical artery in hypertensive pregnancy and the implications in the neonatal outcomes

OBJETIVO: Avaliar as características antropométricas, a morbidade e mortalidade de recém-nascidos (RN) prematuros nascidos vivos de mães hipertensas em função da presença ou não de diástole zero (DZ) ou reversa (DR) na doplervelocimetria arterial umbilical. MÉTODOS: Estudo prospectivo, envolvendo RN prematuros nascidos vivos de gestantes hipertensas, com idade gestacional entre 25 e 33 semanas, submetidas à doplervelocimetria da artéria umbilical nos 5 dias que antecederam o parto, realizado no Hospital do Distrito Federal, entre 1º de novembro de 2009 e 31 de outubro de 2010. Os RN foram estratificados em dois grupos, conforme o resultado da doplervelocimetria da artéria umbilical: Gdz/dr=presença de diástole zero (DZ) ou diástole reversa (DR) e Gn=doplervelocimetria normal. Medidas antropométricas ao nascimento, morbidades e mortalidade neonatal foram comparadas entre os dois grupos. RESULTADOS: Foram incluídos 92 RN, assim distribuídos: Gdz/dr=52 RN e Gn=40 RN. No Gdz/dr a incidência de RN pequenos para idade gestacional foi significativamente maior, com risco relativo de 2,5 (IC95% 1,7‒3,7). No grupo Gdz/dr os RN permaneceram mais tempo em ventilação mecânica mediana 2 (0‒28) e no Gn mediana 0,5 (0‒25), p=0,03. A necessidade de oxigênio aos 28 dias de vida foi maior no Gdz/dr do que no Gn (33 versus10%; p=0,01). A mortalidade neonatal foi maior em Gdz/dr do que em Gn (36 versus 10%; p=0,03; com risco relativo de 1,6; IC95% 1,2 - 2,2). Nessa amostra a regressão logística mostrou que a cada 100 gramas a menos de peso ao nascer no Gdz/dr a chance de óbito aumentou 6,7 vezes (IC95% 2,0 - 11,3; p<0,01). CONCLUSÃO: Em RN prematuros de mães hipertensas com alteração na doplervelocimetria da artéria umbilical a restrição do crescimento intrauterino é frequente e o prognóstico neonatal pior, sendo elevado o risco de óbito relacionado ao peso ao nascimento.

PURPOSE: To evaluate the anthropometric characteristics of morbidity and mortality of premature newborns (NB) of hypertensive mothers according to the presence or absence of flow (DZ) or reverse (DR) diastolic flow in the dopplervelocimetry of the umbilical artery. METHODS: A prospective study was conducted on preterm newborns of pregnant women with hypertension between 25 and 33 weeks of gestational age, submitted to umbilical artery Doppler study during the five days before delivery. Delivery occurred at Hospital Regional da Asa Sul, Brasília - Federal District, between November 1st, 2009 and October 31st, 2010. The infants were stratified into two groups according to the results of Doppler velocimetry: Gdz/dr=absent end-diastolic velocity waveform or reversed end-diastolic velocity waveform, and Gn=normal Doppler velocimetry. Anthropometric measurements at birth, neonatal morbidity, and mortality were compared between the two groups. RESULTS: We studied 92 infants, as follows: Gdz/dr=52 infants and Gn=40 infants. In Gdz/dr, the incidence of infants small for gestational age was significantly greater, with a relative risk of 2.5 (95%CI 1.7 - 3.7). In Gdz/dr, infants remained on mechanical ventilation for a longer time: median 2 (0‒28) and Gn median 0.5 (0‒25) p=0.03. The need for oxygen at 28 days was higher in G dz/dr comparing to Gn (33 versus 10%; p=0.01). Neonatal mortality was higher in Gdz/dr compared to Gn (36 versus 10%; p=0.03; relative risk of 1.6; 95%CI 1.2‒2.2). Logistic regression showed that, with each 100 grams lower birth weight, the chance of death increased 6.7 times in G dz/dr (95%CI 2.0 - 11.3; p<0.01). CONCLUSION: In preterm infants of mothers with hypertensive changes in Doppler velocimetry of the umbilical artery, intrauterine growth restriction and neonatal prognosis are often worse, with a high risk of death related to birth weight.

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.

Limite de viabilidade no moderno cuidado intensivo neonatal – análise além da idade gestacional / Limits of viability in the Modern Neonatal Intensive Care - Moving beyond Gestational Age

analisar a morbimortalidade de prematuros menores que 28 semanas de idade gestacional no moderno cuidado intensivo neonatal relatados pela literatura científica, em busca do limite de viabilidade.(AU)

To analyze the morbidity and mortality of infants less than 28 weeks gestational age in the modern neonatal intensive care reported in the scientific literature in search of the limit of viability.(AU)

Hipertensão Arterial na Gestação - importância do seguimento materno no desfecho neonatal / Hypertension in Pregnancy importance of maternal follow up for neonatal outcome

Os dados do Ministério da Saúde mostram a hipertensão na gestaçãocomo a maior causa de morte materna e perinatal. Esses alarmantes dadosnacionais mostram a importância do conhecimento desta patologiagestacional tanto para obstetras como neonatologistas. Dentre as síndromes hipertensivas gestacionais, especial atenção deve ser dada à pré-eclâmpsia ou doença hipertensiva específica da gravidez que ocorre como forma isolada ou associada à hipertensão arterial crônica, pois estão ligados aos piores resultados maternos e perinatais.O adequado controle pré-natal com seguimento rigoroso da gestante éa única forma de reduzir a mortalidade materna e perinatal. O uso derecurso de imagem como a dopplervelocimetria permite ao examinador diagnosticar insuficiência placentária e avaliar as condições circulatórias materno-fetal de forma segura e não invasiva. A decisão pela antecipação do nascimento nestas circunstâncias nem sempre é uma proposta segura. A equipe médica e familiares devemestar ciente dos riscos que um recém nascido além de prematuro, apresenta na maioria das vezes grave restrição do crescimento intrauterino. A UTI Neonatal deve estar preparada para oferecer cuidado intensivo e multiprofissional que permita diagnóstico e tratamento das maisvariadas complicações, bem como a disponibilidade de recursos tecnológicosavançados são fundamentais para a melhoria dos resultados neonatais, tanto na sobrevivência, como na qualidade de vida.(AU)

Data from the Ministry of Health showed that hypertension in pregnancyas a major cause of maternal death in Brazil is also noted as a major cause of perinatal death. These alarming national data show the importance of knowledge of this gestation pathology to obstetricians and neonatologists. Among the hypertensive disorders of pregnancy special attention should be given to pre-eclampsia this hypertensive disorders of pregnancy canoccurs as isolated or associated with chronic hypertension, can causethe worse maternal and perinatal outcomes. Only with an adequate prenatal and a close maternal follow up it is theonly way to reduce maternal and perinatal mortality. The use of imageresource as the dopplervelocimetria allows the examiner to diagnoseand assess the placental maternal-fetal circulatory conditions safely andnoninvasively. The decision to anticipation of the birth in these circumstances is not always a safe proposal. Medical staff and family members should be aware of the risks of a premature newborn that often presents severe intrauterine growth restriction.The NICU should be prepared to offer intensive care and multidisciplinarystaff prepare to diagnosis and treatment of various complications, as well as the availability of advanced technological resources are criticalto the improvement of neonatal outcomes no only in survival but inquality of life too.(AU)