Early inotropes use is associated with higher risk of death and/or severe brain injury in extremely premature infants.

Introduction: Extremely premature infants are susceptible to fluctuations in cerebral blood flow due to immaturity of cerebral autoregulation. Inotropes may cause rapid changes to systemic blood pressure and consequently cerebral blood flow, especially within the first 72 hours of life. This period is recognized to carry the greatest risk for cerebral hemorrhage. This study evaluates the incidence of death and/or severe brain injury in extremely preterm infants treated with inotropes in the first 72 hours of life.Methods: Prospective cohort study of infants born ≤29+0 weeks gestational age (GA) between January 2013 and December 2016. Severe brain injury was defined based on head ultrasound as presence of: grade III or IV intraventricular hemorrhage (IVH), moderate to severe post-hemorrhagic ventricular dilatation (PHVD), or cystic periventricular leukomalacia (cPVL). The association between inotrope use and death and/or brain injury was explored via logistic regression controlling for predefined confounding risk factors.Results: Of 497 eligible infants, 97 (19.5%) received inotropes during the first 72 hours. GA at birth, birth weight (BW), and 5-minute Apgar scores were lower among infants who received early inotropes compared to those not treated with inotropes. A stepwise logistic regression of the predefined confounding factors showed GA, exposure for antenatal steroids, and admission hypothermia to be significant confounding factors. Adjusting for those factors, early use of inotropes was associated with increased risk of death and/or severe brain injury (AOR 4.5; 95%CI: 2.4-8.5), severe brain injury (AOR 4.2; 95% CI: 1.9-8.9), and IVH of any grade (AOR 2.9; 95%CI: 1.7-4.9).Conclusion: Early inotropes use was associated with higher risk of death and/or severe brain injury. Strict indications and strategies for minimizing inotrope use while preventing hypotension should be implemented in the early postnatal care of infants at risk for severe brain injury.

Smoke-free legislation and neonatal and infant mortality in Brazil: longitudinal quasi-experimental study.

OBJECTIVE: To examine the associations of partial and comprehensive smoke-free legislation with neonatal and infant mortality in Brazil using a quasi-experimental study design. DESIGN: Monthly longitudinal (panel) ecological study from January 2000 to December 2016. SETTING: All Brazilian municipalities (n=5565). PARTICIPANTS: Infant populations. INTERVENTION: Smoke-free legislation in effect in each municipality and month. Legislation was encoded as basic (allowing smoking areas), partial (segregated smoking rooms) or comprehensive (no smoking in public buildings). Associations were quantified by immediate step and longer term slope/trend changes in outcomes. STATISTICAL ANALYSES: Municipal-level linear fixed-effects regression models. MAIN OUTCOMES MEASURES: Infant and neonatal mortality. RESULTS: Implementation of partial smoke-free legislation was associated with a -3.3 % (95% CI -6.2% to -0.4%) step reduction in the municipal infant mortality rate, but no step change in neonatal mortality. Comprehensive smoke-free legislation implementation was associated with -5.2 % (95% CI -8.3% to -2.1%) and -3.4 % (95% CI -6.7% to -0.1%) step reductions in infant and neonatal mortality, respectively, and a -0.36 (95% CI -0.66 to-0.06) annual decline in the infant mortality rate. We estimated that had all smoke-free legislation introduced since 2004 been comprehensive, an additional 10 091 infant deaths (95% CI 1196 to 21 761) could have been averted. CONCLUSIONS: Strengthening smoke-free legislation in Brazil is associated with improvements in infant health outcomes-particularly under comprehensive legislation. Governments should accelerate implementation of comprehensive smoke-free legislation to protect infant health and achieve the United Nation's Sustainable Development Goal three.

Impacts of the Regional Greenhouse Gas Initiative (RGGI) on infant mortality: a quasi-experimental study in the USA, 2003-2014.

OBJECTIVES: The Regional Greenhouse Gas Initiative (RGGI) is the first mandatory market-based regulatory programme to limit regional carbon dioxide (CO2) emissions in the USA. Empirical evidence has shown that high concentrations of ambient air pollutants such as CO2 have been positively associated with an increased risk of morbidity (eg, respiratory conditions including asthma and lung cancer) and premature mortality. The purpose of this study was to examine the impacts of RGGI on death rates in infancy. DESIGN: A quasi-experimental difference-in-differences design. SETTING AND PARTICIPANTS: We estimated the impacts of RGGI on infant mortality from 2003 through 2014 in the USA (6 years before and after RGGI implementation). Our analytic models included state- and year-fixed effects in addition to a number of covariates. OUTCOME MEASURES: Death rates in infancy: neonatal mortality rates (NMRs), deaths under 28 days as well as infant mortality rates (IMRs), deaths under 1 year. RESULTS: Implementation of RGGI was associated with significant decreases in overall NMRs (a reduction of 0.41/1000 live births) and male NMRs (a reduction of 0.43/1000 live births). However, RGGI did not have a significant effect on female NMRs. Similarly, overall IMRs and male IMRs decreased significantly by 0.37/1000 live births and 0.61/1000 live births, respectively, after implementation of RGGI while female IMRs were not significantly affected by RGGI. CONCLUSIONS: RGGI was associated with decreases in overall infant mortality and boy mortality through reducing air pollutant concentrations. Of note, the impact of this environmental policy on infant girls was much smaller.

Minimally invasive perinatal and pediatric autopsy with laparoscopically assisted tissue sampling: feasibility and experience of the MinImAL procedure.

OBJECTIVE: Less invasive autopsy techniques in cases of fetal or infant death have good acceptability among parents, but the published sampling adequacy in needle biopsy studies is generally poor. Minimally Invasive Autopsy with Laparoscopically assisted sampling (MinImAL) has the potential to increase the diagnostic yield of less invasive autopsy by improving the quality and quantity of tissue samples obtained, whilst permitting visualization, extraction and examination of internal organs through a small incision. The aim of this study was to present the findings of our experience with the MinImAL procedure in cases of fetal, neonatal and pediatric death. METHODS: This was a retrospective analysis of 103 prospectively recruited unselected cases of fetal, neonatal or pediatric death that underwent the MinImAL procedure at a tertiary referral center over a 5-year period. Following preprocedure 1.5-T whole-body postmortem magnetic resonance imaging, MinImAL autopsy was performed. Procedure duration, sampling adequacy and cause of death were assessed. Chi-square analysis was used to compare the 'unexplained' rate of intrauterine deaths in the cohort with that in a previously published cohort of > 1000 cases of intrauterine death examined by standard autopsy. RESULTS: MinImAL autopsy was performed successfully in 97.8% (91/93) of the cases undergoing a complete procedure. There was a satisfactory rate of adequate histological sampling in most major organs; heart (100%, 91 cases), lung (100%, 91 cases), kidney (100%, 91 cases), liver (96.7%, 88 cases), spleen (94.5%, 86 cases), adrenal glands (89.0%, 81 cases), pancreas (82.4%, 75 cases) and thymus (56.0%, 51 cases). Procedure duration was similar to that of standard autopsy in a previously published cohort of intrauterine deaths. The unexplained rate in stillbirths and intrauterine fetal deaths that underwent MinImAL autopsy was not significantly different from that following standard autopsy. CONCLUSIONS: The MinImAL procedure provides good histological yield from major organs with minimal cosmetic damage and can be learned by an autopsy practitioner. The MinImAL procedure is an appropriate minimally invasive alternative for the investigation of perinatal and pediatric deaths in which consent to full autopsy is withheld, and may have applications in both high- and low/middle-income settings. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Maltrato infantil. Presentación de un caso / Child abuse. Presentation of a case

RESUMEN El maltrato infantil constituye un problema de profundas repercusiones psicológicas, sociales, éticas, jurídicas y médicas. La definición de maltrato implica una valoración social en relación a lo que es peligroso o inadecuado para el niño. En eso reside la gran dificultad para definirlo. En este artículo se expone un caso poco común de maltrato infantil, que culminó con la muerte de la víctima de 22 meses de edad, que según los datos aportados por la instrucción policial, en horas de la noche, del día 4 de octubre del 2015, al llegar al cuerpo de guardia, la doctora de asistencia constata que la misma se encontraba fallecida y al examen físico presentó múltiples lesiones recientes y antiguas en el cuerpo. Se recoge el antecedente de maltrato familiar en varias ocasiones, siendo el último ocasionado alrededor de 2 días (AU).

ABSTRACT Child abuse is a problem of deep psychological, social, ethical, juridical and medical repercussions. The definition of abuse implies a social judgment in relation of what is dangerous or inadequate for a child. This is the cause of the enormous difficulty of defining it. An uncommon case of child abuse is described in this article. It ended up with the death of the 22-years-months child who, according with the data given by the police instruction, was death when arrived to the Emergency Unit on October 4th 2015 at night. At the arrival, the caregiver doctor stated that the child was death, and at the physical examination she presented multiple recent and old lesions in the body. It was recorded the antecedent of family abuse in several occasions, being the last one around two days ago (AU).

Infant Deaths and Mortality from Gun Violence: Causal or Casual?

OBJECTIVE: Describe trends in non-Hispanic black infant mortality (IM) in the New York City (NYC) counties of Bronx, Kings, Queens, and Manhattan and correlations with gun-related assault mortality. METHODS: Linked Birth/Infant Death data (1999-2013) and Compressed Mortality data at ages 1 to ≥85 years (1999-2013). NYC and United States (US) Census data for income inequality and poverty. Pearson coefficients were used to describe correlations of IM with gun-related assault mortality and other causes of death. RESULTS: In NYC, the risk of non-Hispanic black IM in 2013 was 49% lower than in 1995 (rate ratio: 0.51; 95% CI: 0.43, 0.61). Yearly declines between 1999 and 2013 were significantly correlated with declines in gun-related assault mortality (correlation coefficient (r) = 0.70, p = 0.004), drug-related mortality (r = 0.59, p = 0.020), major heart disease and stroke (r = 0.85, p < 0.001), malignant neoplasms (r = 0.57, p = 0.026), diabetes mellitus (r = 0.63, p = 0.011), and pneumonia and influenza (r = 0.78, p < 0.001). There were no significant correlations of IM with chronic lower respiratory or liver disease, non-drug-related accidental deaths, and non-gun-related assault. Yearly IM (1995-2012) was inversely correlated with income share of the top 1% of the population (r = -0.66, p = 0.007). CONCLUSIONS: In NYC, non-Hispanic black IM declined significantly despite increasing income inequality and was strongly correlated with gun-related assault mortality and other major causes of death. These data are compatible with the hypothesis that activities related to overall population health, including those pertaining to gun-related homicide, may provide clues to reducing IM. Analytic epidemiological studies are needed to test these and other hypotheses formulated from these descriptive data.

Unexpected infant death secondary to a pulmonary infiltration due to acute myelocytic leukaemia.

Acute myeloid leukaemia (AML) often presents with non-specific symptoms such as fatigue, anaemia or infection. Pulmonary involvement is uncommon in AML during the course of the disease and is usually caused by infection, haemorrhage, leukaemic pulmonary infiltrates and leukostasis. Lung localization of AML is very uncommon and potentially life threatening if not diagnosed and treated rapidly. The authors describe the sudden death of an asymptomatic five-month-infant because of a misdiagnosed lung localization of AML. Autopsy examination followed by histopathological studies showed an extensive leukostasis and extramedullary leukaemic infiltrating the lungs. Special stains and immunohistochemical studies revealed findings consistent with acute myelogenous leukaemia. This case suggests that underlying acute leukaemia should be considered as a cause of flu-like symptoms in infants. Medical personnel are urged to be alert to fever, sore throat, weakness and dyspnea that may be characteristic of serious systemic diseases.

Caracterización anatomopatológica de los neonatos fallecidos durante el quinquenio 2010-2014 / Pathological characterization of dead neonates during 2010-2014

Se realizó un estudio transversal y retrospectivo de los 55 neonatos autopsiados en el Departamento de Anatomía Patológica del Hospital General Dr Juan Bruno Zayas Alfonso de Santiago de Cuba, durante el quinquenio 2010-2014, para identificar las características anatomopatológicas que permitieran determinar las causas de las defunciones y describir los factores maternos y neonatales concurrentes en estas últimas. Entre los principales hallazgos sobresalió el predominio de estos decesos en el 2010, con 16; del sexo masculino (61,81 por ciento); de la muerte neonatal precoz con 32, de los nacidos pretérmino con bajo peso (94,44 por ciento), del parto por cesárea y de la preclampsia como antecedente materno. La causa básica de muerte más frecuente fue nacer antes del término con bajo peso en 30; y la causa directa de muerte, la hipoxia en 15 de ellos

A cross-sectional and retrospective study of the 55 neonates undergoing autopsy was carried out in the Pathology Department of Dr Juan Bruno Zayas Alfonso General Hospital in Santiago de Cuba, during 2010-2014, to identify the pathological characteristics that allowed to determine the causes of deaths and to describe the maternal and neonatal concurrent factors in the latter. Among the main findings the prevalence of these deaths in 2010 was significant, with 16; from male sex (61.81 percent); 32 with neonatal early death, of preterm birth with low birth weight (94.44 percent), of Caesarean delivery and of pre-eclampsia as maternal history. The most frequent basic cause of death was being born before term with low weight in 30 neonates; and the direct cause of death, hypoxia in 15 of them

Independent and combined effects of maternal smoking and solid fuel on infant and child mortality in sub-Saharan Africa.

OBJECTIVE: To estimate the independent and combined risks of infant and child mortality associated with maternal smoking and use of solid fuel in sub-Saharan Africa. METHODS: Pooled weighted data on 143 602 under-five children in the most recent demographic and health surveys for 15 sub-Saharan African countries were analysed. The synthetic cohort life table technique and Cox proportional hazard models were employed to investigate the effect of maternal smoking and solid cooking fuel on infant (age 0-11 months) and child (age 12-59 months) mortality. Socio-economic and other confounding variables were included as controls. RESULTS: The distribution of the main explanatory variable in households was as follows: smoking + solid fuel - 4.6%; smoking + non-solid fuel - 0.22%; no smoking + solid fuel - 86.9%; and no smoking + non-solid fuel - 8.2%. The highest infant mortality rate was recorded among children exposed to maternal smoking + solid fuel (72 per 1000 live births); the child mortality rate was estimated to be 54 per 1000 for this group. In full multivariate models, the risk of infant death was 71% higher among those exposed to maternal smoking + solid fuel (HR = 1.71, CI: 1.29-2.28). For ages 12 to 59 months, the risk of death was 99% higher (HR = 1.99, CI: 1.28-3.08). CONCLUSIONS: Combined exposures to cigarette smoke and solid fuel increase the risks of infant and child mortality. Mothers of under-five children need to be educated about the danger of smoking while innovative approaches are needed to reduce the mortality risks associated with solid cooking fuel.

Severe congenital anomalies of the kidney and urinary tract: epidemiology can inform ethical decision-making.

OBJECTIVE: Decision-making for pregnancies complicated by severe congenital anomalies of the kidneys and urinary tract (CAKUT) are ethically challenging, partly because the outcomes are not well studied. STUDY DESIGN: Retrospective cohort study of severe cases of CAKUT over 14 years. RESULTS: Seventy-one of the 108 cases could be completely analyzed. Forty-six percent (n=33) infants were live-born; one-third (n=11) survived to 12 months. Twice as many non-surviving infants received a trial of therapy vs comfort care only. Two-thirds of non-survivors who received a trial of therapy died within the first 9 h of life. Live-born infants faced morbidities such as pneumothorax and neonatal dialysis. CONCLUSIONS: Over half of pregnancies complicated by severe CAKUT ended in termination or stillbirth, but one-third of live-born infants survived to 12 months and the majority of non-survivors died within hours. This may allay concerns about prolonged and futile intensive care for parents considering a trial of therapy.

Agreement on underlying causes of infant death between original records and after investigation: analysis of two biennia in the years 2000 / Concordância sobre causas básicas de morte infantil entre registros originais e após investigação: análise de dois biênios nos anos 2000

Objective: To analyze the agreement between underlying causes of infant deaths obtained from Death Certificates (DC) with those defined after investigation by the Municipal Committee for the Prevention of Maternal and Infant Mortality (CMPMMI), in Londrina, Paraná State, in the biennia 2000-2001 and 2007-2008. Methods: DC of infants and records of investigations were obtained from the CMPMMI. The causes of death registered in both sources were coded according to the International Classification of Diseases, tenth revision (ICD-10), and the underlying causes of deaths were selected. Agreement between underlying causes of deaths was verified by Kappa's (k) test and analyzed according to ICD-10 chapters and blocks of categories in both biennia. Results: In 2000/2001, according to ICD-10 chapters, high agreement rates were observed for conditions originated in the perinatal period (k = 0.85) and for external causes (k = 0.84), while, for congenital malformations, there was a substantial agreement (k = 0.71). In 2007/2008, agreement was considered poor for all analyzed chapters. For blocks of categories, high or substantial agreement rates were observed only in the first biennium for "congenital malformations of the circulatory system" (k = 0.78) and for "other external causes of accidental injury" (k = 0.91). Conclusions: A decrease in agreement between the sources during the study period indicates either an improvement in the process of investigation of infant death by the CMPMMI and/or a worsening in the quality of the DC information. .

Objetivo: Analisar a concordância entre a causa básica de morte infantil informada na Declaração de Óbito (DO) e a definida após investigação pelo Comitê Municipal de Prevenção da Mortalidade Materna e Infantil (CMPMMI), em Londrina, Paraná, nos biênios 2000/2001 e 2007/2008. Método: Foram obtidas as DO e as fichas de investigação do CMPMMI de óbitos infantis. As causas de morte informadas em ambos os documentos foram transcritas para um formulário, sendo posteriormente codificadas segundo a Classificação Internacional de Doenças, décima revisão (CID-10), com seleção das respectivas causas básicas. As concordâncias entre as causas básicas das DO e as do CMPMMI foram verificadas pelo teste Kappa (k), para capítulos e agrupamentos da CID-10, em ambos os períodos. Resultados: Em 2000/2001, observou-se ótima concordância para o capítulo das afecções do período perinatal (k = 0,85) e para o das causas externas (k = 0,84), e boa concordância para o das malformações congênitas (k = 0,71). Em 2007/2008, a concordância entre os registros da DO e os do CMPMMI foi considerada ruim ou fraca para todos os capítulos de causas. Em relação aos agrupamentos, observou-se concordância boa ou ótima apenas no primeiro biênio para "malformações do aparelho circulatório" (k = 0,78) e "outras causas externas acidentais" (k = 0,91). Conclusão: Observou-se diminuição da concordância entre as fontes pesquisadas no período estudado, o que indica melhora do processo de investigação dos óbitos infantis pelo CMPMMI e/ou piora na qualidade da informação original na DO. .

Risk of stillbirth and infant deaths after assisted reproductive technology: a Nordic study from the CoNARTaS group.

STUDY QUESTION: Is the risk of stillbirth and perinatal deaths increased after assisted reproductive technology (ART) compared with pregnancies established by spontaneous conception (SC)? SUMMARY ANSWER: A significantly increased risk of stillbirth in ART singletons was only observed before 28 + 0 gestational weeks. WHAT IS KNOWN ALREADY: The current literature indicates that children born after ART have an increased risk of perinatal death. The knowledge on stillbirth in ART pregnancies is limited. STUDY DESIGN, SIZE, DURATION: A population based case-control study. PARTICIPANTS/MATERIALS, SETTING AND METHODS: A total of 62 485 singletons and 29 793 twins born after ART in Denmark, Finland, Norway and Sweden, from 1982 to 2007, were compared with 362 798 spontaneously conceived (SC) singletons and 132 181 twins. MAIN RESULTS AND THE ROLE OF CHANCE: The adjusted rate ratio for stillbirth at gestational weeks 22 + 0 to 27 + 6 was 2.08 [95% confidence interval (CI) 1.55-2.78] for ART versus SC singletons. After 28 + 0 gestational weeks there was no significant difference in the risk of stillbirth between ART and SC singletons. ART twins had a lower risk of stillbirth compared with SC twins, but when restricting the analysis to opposite-sex twins and excluding all monozygotic twins, there was no significant difference between the groups. Singletons conceived by ART had an overall increased risk of early neonatal death (adjusted odds ratio 1.54, 95% CI 1.28-1.85) and death within the first year after birth (1.45, 1.26-1.68). No difference regarding these two parameters was found when further adjusting for the gestational age [(0.97, 0.80-1.18) and (0.99, 0.85-1.16), respectively]. ART twins had a lower risk of early neonatal and infant deaths than SC twins, but no difference was found when restricting the analyses to opposite-sex twins. LIMITATIONS, REASON FOR CAUTION: We were not able to adjust for potential confounders, such as a prior history of stillbirth, induction of labour, body mass index or smoking. WIDER IMPLICATIONS OF THE FINDINGS: The risk of stillbirth in ART versus SC singletons was only increased for very early gestational ages (before 28 weeks). This might indicate that the current clinical management of ART pregnancies is sufficient regarding prevention of stillbirth during the third trimester. STUDY FUNDING/COMPETING INTEREST(S): No conflict of interest was reported. The European Society for Human Reproduction and Embryology (ESHRE), the University of Copenhagen, Denmark, the Danish Agency for Science, Technology and Innovation and Sahlgrenska University Hospital, Gothenburg, Sweden supported the project. The CoNARTaS group has received travel and meeting funding from the Nordic Society of Obstetrics and Gynecology (NFOG).