Pediatricians' focus of sight at pain assessment during a neonatal heel puncture / Foco do olhar do pediatra na avaliação da dor neonatal durante uma punção de calcanhar

ABSTRACT Objective: To evaluate the focus of pediatricians' gaze during the heel prick of neonates. Methods: Prospective study in which pediatricians wearing eye tracker glasses evaluated neonatal pain before/after a heel prtick. Pediatricians scored the pain they perceived in the neonate in a verbal analogue numerical scale (0=no pain; 10=maximum pain). The outcomes measured were number and time of visual fixations in upper face, lower face, and hands, in two 10-second periods, before (pre) and after the puncture (post). These outcomes were compared between the periods, and according to pediatricians' pain perception: absent/mild (score: 0-5) and moderate/intense (score: 6-10). Results: 24 pediatricians (31 years old, 92% female) evaluated 24 neonates. The median score attributed to neonatal pain during the heel prick was 7.0 (Interquartile range: 5-8). Compared to pre-, in the post-periods, more pediatricians fixed their gaze on the lower face (63 vs. 92%; p=0.036) and the number of visual fixations was greater on the lower face (2.0 vs. 5.0; p=0.018). There was no difference in the number and time of visual fixations according to the intensity of pain. Conclusions: At bedside, pediatricians change their focus of attention on the neonatal face after a painful procedure, focusing mainly on the lower part of the face.

RESUMO Objetivo: Avaliar o foco do olhar do pediatra durante a punção do calcanhar de neonatos. Métodos: Estudo prospectivo no qual pediatras, utilizando óculos de rastreamento visual, avaliaram a dor neonatal antes/depois de uma punção de calcanhar. Os pediatras pontuaram a dor de acordo com a sua percepção por meio de uma escala analógica verbal (0=sem dor; 10=dor máxima). Os desfechos analisados foram o número e o tempo das fixações visuais na face superior, face inferior e mãos, em dois períodos de 10 segundos, antes (PRÉ) e depois da punção (PÓS). Os resultados foram comparados entre os períodos e segundo a percepção da dor do pediatra: ausente/leve (escore: 0-5) e moderada/grave (escore: 6-10). Resultados: Vinte e quatro pediatras (31 anos, 92% sexo feminino) avaliaram 24 neonatos. A mediana do escore atribuído à dor do recém-nascido durante a punção do calcanhar foi 7,0 (intervalo interquartil: 5-8). Comparado ao período PRÉ, no período PÓS, o maior número de pediatras fixou o olhar na face inferior (63 vs. 92%; p=0,036) e o número de fixações visuais foi maior na face inferior (2,0 vs. 5,0; p=0,018). Não houve diferença no número e no tempo das fixações visuais de acordo com a intensidade da dor. Conclusões: À beira do leito, os pediatras mudam seu foco de atenção visual na face do recém-nascido após um procedimento doloroso, focando o olhar principalmente na parte inferior da face.

Growth phenotypes of very low birth weight infants for prediction of neonatal outcomes from a Brazilian cohort: comparison with INTERGROWTH

Abstract Objective: To assess the predictive value of selected growth phenotypes for neonatal morbidity and mortality in preterm infants < 30 weeks and to compare them with INTERGROWTH-21st (IG21). Methods: Retrospective analysis of data from the Brazilian Neonatal Research Network (BNRN) database for very low birth weight (VLBW) at 20 public tertiary-care university hospitals. Outcome: the composite neonatal morbidity and mortality (CNMM) consisted of in-hospital death, oxygen use at 36 weeks, intraventricular hemorrhage grade 3 or 4, and Bell stage 2 or 3 necrotizing enterocolitis. Selected growth phenotypes: small-for-gestational-age (SGA) defined as being < 3rd (SGA3) or 10th (SGA10) percentiles of BW, and large-for-gestational-age (LGA) as being > 97th percentile of BW. Stunting as being < 3rd percentile of the length and wasting as being < 3rd percentile of BMI. Single and multiple log-binomial regression models were fitted to estimate the relative risks of CNMM, comparing them to IG21. Results: 4,072 infants were included. The adjusted relative risks of CNMM associated with selected growth phenotypes were (BNRN/IG21): 1.45 (0.92-2.31)/1.60 (1.27-2.02) for SGA; 0.90 (0.55-1.47)/1.05 (0.55-1.99) for LGA; 1.65 (1.08-2.51)/1.58 (1.28-1.96) for stunting; and 1.48 (1.02-2.17) for wasting. Agreement between the two references was variable. The growth phenotypes had good specificity (>95%) and positive predictive value (70-90%), with poor sensitivity and low negative predictive value. Conclusion: The BNRN phenotypes at birth differed markedly from the IG21 standard and showed poor accuracy in predicting adverse neonatal outcomes.

What Facial Features Does the Pediatrician Look to Decide That a Newborn Is Feeling Pain?

OBJECTIVE: The study aimed to analyze the gaze fixation of pediatricians during the decision process regarding the presence/absence of pain in pictures of newborn infants. STUDY DESIGN: Experimental study, involving 38 pediatricians (92% females, 34.6 ± 9.0 years, 22 neonatologists) who evaluated 20 pictures (two pictures of each newborn: one at rest and one during a painful procedure), presented in random order for each participant. The Tobii-TX300 equipment tracked eye movements in four areas of interest of each picture (AOI): mouth, eyes, forehead, and nasolabial furrow. Pediatricians evaluated the intensity of pain with a verbal analogue score from 0 to 10 (0 = no pain; 10 = maximum pain). The number of pictures in which pediatricians fixed their gaze, the number of gaze fixations, and the total and average time of gaze fixations were compared among the AOI by analysis of variance (ANOVA). The visual-tracking parameters of the pictures' evaluations were also compared by ANOVA according to the pediatricians' perception of pain presence: moderate/severe (score = 6-10), mild (score = 3-5), and absent (score = 0-2). The association between the total time of gaze fixations in the AOI and pain perception was assessed by logistic regression. RESULTS: In the 20 newborn pictures, the mean number of gaze fixations was greater in the mouth, eyes, and forehead than in the nasolabial furrow. Also, the average total time of gaze fixations was greater in the mouth and forehead than in the nasolabial furrow. Controlling for the time of gaze fixation in the AOI, each additional second in the time of gaze fixation in the mouth (odds ratio [OR]: 1.26; 95% confidence interval [CI]: 1.08-1.46) and forehead (OR: 1.16; 95% CI: 1.02-1.33) was associated with an increase in the chance of moderate/severe pain presence in the neonatal facial picture. CONCLUSION: When challenged to say whether pain is present in pictures of newborn infants' faces, pediatricians fix their gaze preferably in the mouth. The longer duration of gaze fixation in the mouth and forehead is associated with an increase perception that moderate/severe pain is present. KEY POINTS: · Neonatal pain assessment is intrinsically subjective.. · Visual tracking identifies the focus of attention of individuals.. · Adults' gaze in neonates' mouth and forehead is associated with pain perception..

Comparison of mortality and survival without major morbidities of very preterm infants with very low birth weight from Japan and Brazil / Comparação entre mortalidade e sobrevida sem morbidades importantes dos recém-nascidos prematuros de muito baixo peso entre o Japão e o Brasil

Abstract Objective: This study was carried out to understand the disparities in mortality and survival without major morbidities among very premature and very low birth weight infants between participating Neonatal Intensive Care Units (NICUs) from the Brazilian Network on Neonatal Research (RBPN) and the Neonatal Research Network of Japan (NRNJ). Methods: Secondary data analysis of surveys by the RBPN and NRNJ was performed. The surveys were conducted in 2014 and 2015 and included 187 NICUs. Primary outcome was mortality or survival without any major morbidity. Logistic regression analysis adjustment for confounding factors was used. Results: The study population consisted of 6,406 infants from the NRNJ and 2,319 from the RBPN. Controlling for various confounders, infants from RBPN had 9.06 times higher adjusted odds of mortality (95%CI 7.30-11.29), and lower odds of survival without major morbidities (AOR 0.36; 95%CI 0.32-0.41) compared with those from the NRNJ. Factors associated with higher odds of mortality among Brazilian NICUs included: Air Leak Syndrome (AOR 4.73; 95%CI 1.26-15.27), Necrotizing Enterocolitis (AOR 3.25; 95%CI 1.38-7.26), and Late Onset Sepsis (LOS) (AOR 4.86; 95%CI 2.25-10.97). Conclusions: Very premature and very low birth weight infants from Brazil had significantly higher odds for mortality and lower odds for survival without major morbidities in comparison to those from Japan. Additionally, we identified the factors that increased the odds of in-hospital neonatal death in Brazil, most of which was related to LOS.

RESUMO Objetivo: Este estudo foi realizado para compreender as disparidades na mortalidade e sobrevivência sem as principais morbidades entre recém-nascidos muito prematuros e de muito baixo peso entre Unidades de Terapia Intensiva Neonatal (UTINs) participantes da Rede Brasileira de Pesquisas Neonatais (RBPN) e Rede de Pesquisa Neonatal do Japão (NRNJ). Métodos: Foi realizada uma análise dos dados secundários dos bancos de dados da RBPN e da NRNJ. As pesquisas foram realizadas em 2014 e 2015 e incluíram 187 UTINs. O desfecho primário foi mortalidade ou sobrevida sem qualquer morbidade importante. Utilizou-se a análise de regressão logística com ajuste para os fatores de confusão. Resultados: A população do estudo foi composta por 6.406 recém-nascidos do NRNJ e 2.319 do RBPN. Ajustando para diversos fatores de confusão, os prematuros da RBPN tiveram 9,06 vezes maiores chances de mortalidade (IC95% 7,30-11,29) e menores chances de sobrevivência sem morbidades importantes (AOR 0,36; IC95% 0,32-0,41) em comparação com os da NRNJ. Fatores associados a maiores chances de mortalidade entre as UTINs brasileiras incluíram: síndrome de escape de ar (AOR 4,73; IC95% 1,26-15,27), enterocolite necrosante (AOR 3,25; IC95% 1,38-7,26) e sepse de início tardio (AOR 4,86; IC95% 2,25-10,97). Conclusões: Os recém-nascidos muito prematuros e de muito baixo peso do Brasil apresentaram chances significativamente maiores de mortalidade e menores chances de sobrevivência sem as principais morbidades em comparação aos do Japão. Além disso, identificamos os fatores que aumentam as chances da morte neonatal no Brasil, sendo a maioria relacionada à sepse tardia.

Comparative analysis of pulmonary function in children born preterm and full-term at 6-9 years of age / Análise comparativa da função pulmonar em crianças de 6 a 9 anos de idade nascidas pré-termo e a termo

Abstract Objective: To compare pulmonary function parameters and the prevalence of altered pulmonary function in children born preterm and full-term, using the Global Lung Initiative reference values. Methods: This is a cross-sectional study with 6-9-year-old children submitted to measurement of airway resistance (Rint) and spirometry according to the American Thoracic Society and European Respiratory Society Technical Statement. The inclusion criteria were, among the preterm group: gestational age <37 weeks and birth weight <2000g; among the full-term group: schoolchildren born full-term with birth weight >2500g, recruited at two public schools in São Paulo, Brazil, matched by sex and age with the preterm group. As exclusion criteria, congenital malformations, cognitive deficit, and respiratory problems in the past 15 days were considered. Results: A total of 112 children were included in each group. Preterm children had gestational age of 30.8±2.8 weeks and birth weight of 1349±334g. Among them, 46.6% were boys, 46.4% presented respiratory distress syndrome, 19.6% bronchopulmonary dysplasia, and 65.2% were submitted to mechanical ventilation in the neonatal unit. At study entry, both groups were similar in age and anthropometric parameters. Parameters of pulmonary function (Z scores) in preterm and full-term groups were: Rint (0.13±2.24 vs. -1.02±1.29; p<0.001); forced vital capacity (FVC) (-0.39±1.27 vs. -0.15±1.03; p=0.106), forced expiratory volume in one second (FEV1)/FVC (-0.23±1.22 vs. 0.14±1.11; p=0.003), FEV1 (-0.48±1.29 vs. -0.04±1.08; p=0.071), and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75) (1.16±1.37 vs. 2.08±1.26; p=0.005), respectively. The prevalence values of altered airway resistance (16.1 vs. 1.8%; p<0.001) and spirometry (26.8 vs. 13.4%, p=0.012) were higher in preterm infants than in full-term ones. Conclusions: Preterm children had higher prevalence of altered pulmonary function, higher Z scores of airway resistance, and lower Z scores of FEV1/FVC and FEF25-75 compared with those born full-term.

RESUMO Objetivo: Comparar parâmetros de função pulmonar e a prevalência de função pulmonar alterada em crianças nascidas pré-termo e a termo, utilizando a referência Global Lung Function Initiative. Métodos: Estudo transversal com crianças de 6-9 anos submetidas à medida de resistência de vias aéreas (Rint) segundo o American Thoracic Society and the European Respiratory Society Technical Statement. Como critérios de inclusão, entre o grupo pré-termo, estavam os nascidos com idade gestacional <37 semanas e peso <2000g; e entre o grupo termo, escolares de duas escolas públicas do município de São Paulo, nascidos a termo com peso >2500g, pareados por sexo e idade com o grupo pré-termo. Excluíram-se malformações congênitas, déficit cognitivo e problemas respiratórios havia menos de 15 dias. Resultados: Incluíram-se 112 crianças em cada grupo. Os prematuros (46,4% masculinos) apresentaram idade gestacional de 30,8±2,8 semanas e peso de 1349±334g. Entre eles, 46,4% tiveram síndrome de desconforto respiratório, 19,6% displasia broncopulmonar, e 65,2% receberam ventilação mecânica na unidade neonatal. À inclusão no estudo, os dois grupos apresentaram idade e dados antropométricos semelhantes. Os valores (escores Z) em nascidos pré-termo e a termo foram, respectivamente: Rint (0,13±2,24 vs. -1,02±1,29; p<0,001), capacidade vital forçada (CVF) (-0,39±1,27 vs. -0,15±1,03; p=0,106), volume expiratório forçado no primeiro segundo (VEF1)/CVF (-0,23±1,22 vs. 0,14±1,11; p=0,003), VEF1 (-0,48±1,29 vs. -0,04±1,08; p=0,071) e fluxo expiratório forçado em 25-75% da capacidade vital (FEF25-75) (1,16±1,37 vs. 2,08±1,26; p=0,005). A prevalência de alterações na resistência de vias aéreas (16,1 vs. 1,8%, p<0,001) e na espirometria (26,8 vs. 13,4%, p=0,012) foi maior nos prematuros. Conclusões: As crianças nascidas pré-termo apresentaram maior prevalência de alteração pulmonar, maiores escores Z de resistência de vias aéreas e menores escores Z de VEF1/CVF e FEF25-75 quando comparadas às nascidas a termo.

Comparative analysis of pulmonary function in children born preterm and full-term at 6-9 years of age.

OBJECTIVE: To compare pulmonary function parameters and the prevalence of altered pulmonary function in children born preterm and full-term, using the Global Lung Initiative reference values. METHODS: This is a cross-sectional study with 6-9-year-old children submitted to measurement of airway resistance (Rint) and spirometry according to the American Thoracic Society and European Respiratory Society Technical Statement. The inclusion criteria were, among the preterm group: gestational age <37 weeks and birth weight <2000g; among the full-term group: schoolchildren born full-term with birth weight >2500g, recruited at two public schools in São Paulo, Brazil, matched by sex and age with the preterm group. As exclusion criteria, congenital malformations, cognitive deficit, and respiratory problems in the past 15 days were considered. RESULTS: A total of 112 children were included in each group. Preterm children had gestational age of 30.8±2.8 weeks and birth weight of 1349±334g. Among them, 46.6% were boys, 46.4% presented respiratory distress syndrome, 19.6% bronchopulmonary dysplasia, and 65.2% were submitted to mechanical ventilation in the neonatal unit. At study entry, both groups were similar in age and anthropometric parameters. Parameters of pulmonary function (Z scores) in preterm and full-term groups were: Rint (0.13±2.24 vs. -1.02±1.29; p<0.001); forced vital capacity (FVC) (-0.39±1.27 vs. -0.15±1.03; p=0.106), forced expiratory volume in one second (FEV1)/FVC (-0.23±1.22 vs. 0.14±1.11; p=0.003), FEV1 (-0.48±1.29 vs. -0.04±1.08; p=0.071), and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75) (1.16±1.37 vs. 2.08±1.26; p=0.005), respectively. The prevalence values of altered airway resistance (16.1 vs. 1.8%; p<0.001) and spirometry (26.8 vs. 13.4%, p=0.012) were higher in preterm infants than in full-term ones. CONCLUSIONS: Preterm children had higher prevalence of altered pulmonary function, higher Z scores of airway resistance, and lower Z scores of FEV1/FVC and FEF25-75 compared with those born full-term.

Looking at neonatal facial features of pain: do health and non-health professionals differ?

Abstract Objective: To analyze the regions that trigger the attention of adults' gaze when assessing pain in newborn infants' pictures and to verify if there are differences between health and non-health professionals. Method: Experimental study with 84 health professionals and 59 non-health professionals, who evaluated two images of 10 neonates, one at rest and the other during a painful procedure. Each image was shown for 7 seconds on a computer screen, while eye movements were tracked by the Tobii TX300 EyeTracker. After evaluating each image, participants gave a score from 0 (absent pain) to 10 (maximum pain), according to their perception of neonatal pain. For each image, the number and total time of gaze fixations in the forehead, eyes, nasolabial furrow, and mouth were studied. Comparisons between both groups of adults were made by an intraclass correlation coefficient, Student's t-test, and Bland Altman graphic. Results: Health professionals (93% female; 34 ± 9 years old), compared to non-health professionals (64% female; 35 ± 11 years old), gave lower scores for images at rest (0.81 ± 0.50 vs. 1.59 ± 0.76; p = 0.010), with no difference for those obtained during the painful procedure (6.98 ± 1.08 vs. 6.73 ± 0.82). There was a strong or almost perfect correlation for the number of fixations in the mouth, eyes, forehead, and for the total fixation time in the eyes and forehead. Conclusions: Adults, irrespective of their profession, showed a homogeneous gaze pattern when evaluating pictures of neonates at rest or during a painful procedures.

Inter-observer agreement in the identification of pain faces in full-term and late preterm newborns: cross-sectional study / Concordância interavaliadores na identificação de faces de dor de recém-nascidos a termo e pré-termo tardio: estudo transversal

ABSTRACT BACKGROUND AND OBJECTIVES: Difficulty in neonatal assessment is a challenge for the development of pain prevention and treatment strategies. The objective of this study was to analyze the agreement among health professionals in the identification of facial pain movements in images of neonates submitted or not to a painful procedure and to evaluate the discriminatory capacity of these facial movements regarding the presence of pain. METHODS: Cross-sectional study. Six health professionals trained in neonatal pain assessment evaluated 30 images of newborns undergoing a painful procedure and 30 images of the same newborns at rest, without pain. Each professional evaluated five facial movements that are part of the Neonatal Facial Coding System. Sensitivity, specificity, and positive and negative predictive values were determined. Agreement among professionals was assessed using the kappa coefficient. RESULTS: The six observers correctly assessed 94±9% of the images obtained at rest as absence of pain and 88±28% of the images obtained during the painful procedure as presence of pain. Protruding forehead, narrowed eyelid cleft, deepened nasolabial furrow, and open mouth showed high sensitivity, specificity, and positive and negative predictive values in the diagnosis of pain, with values between 78-90%. The inter-observer agreement for all 60 images showed a kappa coefficient of 0.60 (95%CI 0.55-0.66). CONCLUSION: The evaluation of the forehead, eyelid, nasolabial furrow and mouth of newborns showed high sensitivity and specificity to discriminate the presence and absence of pain in static images. The agreement between the evaluators in identifying facial movements related to the expression of pain in newborns was moderate.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dificuldade na avaliação da dor do recém-nascido é um desafio para o desenvolvimento de estratégias de prevenção e tratamento da dor. O objetivo deste estudo foi analisar a concordância entre profissionais de saúde na identificação de movimentos faciais de dor em imagens de recém-nascidos submetidos ou não a um procedimento doloroso e a capacidade discriminatória quanto à presença de dor desses movimentos faciais. MÉTODOS: Estudo transversal. Seis profissionais de saúde treinados na avaliação da dor neonatal avaliaram 30 imagens de recém-nascidos submetidos a um procedimento doloroso e 30 imagens em repouso dos mesmos recém-nascidos, sem dor. Cada profissional avaliou cinco movimentos faciais que fazem parte do Sistema de Codificação Facial Neonatal. Sensibilidade, especificidade e valores preditivos positivos e negativos foram determinados. A concordância interavaliadores foi avaliada pelo coeficiente kappa. RESULTADOS: Os seis observadores avaliaram corretamente 94±9% das imagens obtidas em repouso como ausência de dor e 88±28% das imagens obtidas durante o procedimento doloroso como presença de dor. Fronte saliente, fenda palpebral estreitada, sulco nasolabial aprofundado e boca aberta mostraram alta sensibilidade, especificidade e valores preditivos positivo e negativo no diagnóstico de dor, com valores entre 78 e 90%. A concordância interavaliadores para todas as 60 imagens mostrou um kappa 0,60 (IC95%0,55-0,66). CONCLUSÃO: A avaliação da fronte, pálpebra, sulco nasolabial e boca de recém-nascidos mostrou alta sensibilidade e especificidade para discriminar a presença e ausência de dor em imagens estáticas. A concordância interavaliadores na identificação de movimentos faciais relacionados à expressão da dor em recém- -nascidos foi moderada.

Aerobic Capacity of Preterm Children with Very Low Birth Weight at School Age and its Associated Factors.

INTRODUCTION: Respiratory morbidities of preterm infants can cause significant ventilatory impairment thus compromising the aerobic capacity in childhood and adolescence. Therefore, the present study was conducted to evaluate the aerobic capacity in school age preterm children with VLBW and its associated factors. METHODS: A cross-sectional study was conducted among preterm born with VLBW and term children, both aged 6-9 years. An individualized symptom-limited treadmill testing protocol performed aerobic capacity. Measured variables: oxygen pulse (PuO2), percentage of maximum heart rate for age (%HR max), tidal volume/inspiratory capacity ratio (TV/IC), oxygen consumption (VO2) peak, and the ratio of the anaerobic threshold of gas exchange to the predicted percentage of maximum VO2 (VO2@LA/%VO2 max.pred.) were compared between groups. Univariate and multiple linear regression analyses were used to determine the factors associated with aerobic capacity. RESULTS: Thirty-four preterm and 32 term children were included. Similar VO2 peak and the other variables were observed. The development of bronchopulmonary dysplasia (BPD) and being obese/overweight was positively associated with %HR max. The Z-score for height/age and birth weight <1000g was positively associated with PuO2 and peak VO2, and negatively associated with overweight/obesity and female sex. CONCLUSIONS: Aerobic capacity was similar in both groups. Sex, development of BPD, birth weight <1000g and factors related to body growth, such as Z-score for height/age and overweight/obesity, were associated with aerobic capacity in preterm children with VLBW.

Preterm infants with peri/intraventricular hemorrhage have poorer habituation responses to external stimuli / Neonatos prematuros com hemorragia peri-intraventricular apresentam respostas de habituação piores a estímulos externos

ABSTRACT Objective: To evaluate the association between intra-ventricular hemorrhage and habituation responses to external stimuli in preterm infants at 36-38 weeks post-conceptual age. Methods: Cross-sectional study of infants with gestational age <32 weeks. Intra-ventricular hemorrhage was identified by cranial ultrasonography and classified according to Papile et al. (1978). The luminous (flashlight), sound (rattle, bell), and tactile stimuli were presented, and the responses were scored according to Lester and Tronik (2004). Habituation response scores were compared between groups by Student's t-test. The association between IVH and habituation scores was evaluated by linear regression adjusted for GA, clinical severity score, post-conceptual age at habituation assessment, sepsis, and bronchopulmonary dysplasia. Results: Sixty-five infants were studied, 20 with intra-ventricular hemorrhage (16 grades I/II; four grades III/IV) and 45 without intra-ventricular hemorrhage. Infants with intra-ventricular hemorrhage had lower gestational age (28.2 ± 2.2 vs. 29.7 ± 1.7 weeks) and birth weight (990 ± 305 vs. 1275 ± 360 g). Infants with intra-ventricular hemorrhage at 36-38 weeks post-conceptual age had lower habituation scores to light (4.21 ± 2.23 vs. 6.09 ± 2.44), rattle (3.84 ± 2.12 vs. 6.18 ± 2.27), and bell (3.58 ± 1.74 vs. 5.20 ± 2.47) after controlling for confounders. No differences were found for tactile stimulus. Conclusion: Infants with gestational age <32 weeks and intra-ventricular hemorrhage had poorer habituation responses to external stimuli than those without intra-ventricular hemorrhage at 36-38 weeks post-conceptual age.

RESUMO Objetivo: Avaliar a associação entre hemorragia intraventricular e as respostas de habituação a estímulos externos em neonatos prematuros com idade pós-conceptual de 36-38 semanas. Métodos: Estudo transversal com neonatos com idade gestacional < 32 semanas. A hemorragia intraventricular foi identificada por ultrassonografia craniana e classificada de acordo com Papile et al. (1978). Os estímulos luminosos (lanterna), sonoros (chocalho, sino) e táteis foram apresentados e as respostas foram pontuadas de acordo com Lester & Tronik (2004). Os escores das respostas de habituação foram comparadas entre os grupos pelo teste t de Student. A associação entre a hemorragia intraventricular e os escores de habituação foi avaliada por regressão linear ajustada para a idade gestacional, escore de gravidade clínica, idade pós-conceptual na avaliação da habituação, sepse e displasia broncopulmonar. Resultados: 65 neonatos foram estudados, 20 com hemorragia intraventricular (16 graus I/II;4 graus III/IV) e 45 sem hemorragia intraventricular. Os neonatos com hemorragia intraventricular apresentaram menor idade gestacional (28,2 ± 2,2 vs. 29,7 ± 1,7 semanas) e peso ao nascer (990 ± 305 vs. 1275 ± 360 g). Os neonatos com hemorragia intraventricular na idade pós-conceptual de 36-38 semanas apresentaram escores de habituação menores a luz (4,21 ± 2,23 vs. 6,09 ± 2,44), chocalho (3,84 ± 2,12 vs. 6,18 ± 2,27) e campainha (3,58 ± 1,74 vs. 5,20 ± 2,47) após controle para variáveis de confusão. Nenhuma diferença foi encontrada para os estímulos táteis. Conclusão: Neonatos com idade gestacional < 32 semanas e hemorragia intraventricular apresentaram respostas de habituação piores a estímulos externos que os sem hemorragia intraventricular, na idade pós-conceptual de 36-38 semanas.

Preterm infants with peri/intraventricular hemorrhage have poorer habituation responses to external stimuli.

OBJECTIVE: To evaluate the association between intra-ventricular hemorrhage and habituation responses to external stimuli in preterm infants at 36-38 weeks post-conceptual age. METHODS: Cross-sectional study of infants with gestational age <32 weeks. Intra-ventricular hemorrhage was identified by cranial ultrasonography and classified according to Papile et al. (1978). The luminous (flashlight), sound (rattle, bell), and tactile stimuli were presented, and the responses were scored according to Lester and Tronik (2004). Habituation response scores were compared between groups by Student's t-test. The association between IVH and habituation scores was evaluated by linear regression adjusted for GA, clinical severity score, post-conceptual age at habituation assessment, sepsis, and bronchopulmonary dysplasia. RESULTS: Sixty-five infants were studied, 20 with intra-ventricular hemorrhage (16 grades I/II; four grades III/IV) and 45 without intra-ventricular hemorrhage. Infants with intra-ventricular hemorrhage had lower gestational age (28.2±2.2 vs. 29.7±1.7 weeks) and birth weight (990±305 vs. 1275±360g). Infants with intra-ventricular hemorrhage at 36-38 weeks post-conceptual age had lower habituation scores to light (4.21±2.23 vs. 6.09±2.44), rattle (3.84±2.12 vs. 6.18±2.27), and bell (3.58±1.74 vs. 5.20±2.47) after controlling for confounders. No differences were found for tactile stimulus. CONCLUSION: Infants with gestational age <32 weeks and intra-ventricular hemorrhage had poorer habituation responses to external stimuli than those without intra-ventricular hemorrhage at 36-38 weeks post-conceptual age.

Quality of life of former preterm adolescents / Qualidade de vida de adolescentes nascidos prematuros

ABSTRACT Objectives: To compare the quality of life of adolescents born prematurely with very-low-birth-weight, reported by adolescents themselves and their caregivers, and analyze associated factors perceived by both. Methods: This cross-sectional study included former preterm adolescents born with gestational age < 37 weeks and birth weigh < 1,500 g, who were being followed up at the premature outpatient clinic of a university institution, from birth to adolescence, and their caregivers. Quality of life was assessed by the WHOQOL-BREF questionnaire. Factors associated with quality of life were analyzed by linear regression. Results: Of 91 eligible adolescents, 73 (80.2%) were included, being 38 (52.1%) male. The mean gestational age was 30.1 ± 2.4 weeks and birth weight was 1134 ± 239 g. Adolescents reported better quality of life than their caregivers (p = 0.011), being respectively: dissatisfied (1.4 vs. 4.1%), neither satisfied nor dissatisfied (20.5 vs. 20.5%), satisfied (56.2 vs. 71.2%) and very satisfied (21.9 vs. 4.1%). Scores attributed by adolescents and caregivers were, respectively: overall quality of life (4.0 ± 0.7 vs. 3.8 ± 0.6, p = 0.032), physical domain (3.6 ± 0.6 vs. 3.5 ± 0.6, p = 0.685), psychological domain (3.4 ± 0.6 vs. 3.6 ± 0.6, p = 0.116), social relationships (3.7 ± 0.7 vs. 3.6 ± 0.8, p = 0.371) and environment (3.4 ± 0.7 vs. 3.2 ± 0.6, p = 0.037). For caregivers, absence of fixed partner and hospitalization in childhood decreased the overall quality of life score; furthermore, the occurrence of respiratory distress syndrome increased this score. In the adolescents' view, leukomalacia reduced this score. Conclusions: Adolescents reported better quality of life than caregivers. For adolescents, only biological factors were associated with quality of life scores; for caregivers, biological and social factors were associated this scores.

RESUMO Objetivos: Comparar a qualidade de vida de adolescentes nascidos prematuros com muito baixo peso na percepção do adolescente e de seu cuidador e analisar os fatores associados na visão de ambos. Métodos: Estudo transversal com adolescentes nascidos com idade gestacional < 37 semanas e peso < 1.500 g, em acompanhamento no ambulatório de prematuros de uma instituição universitária, do nascimento à adolescência, e seus cuidadores. Pesquisou-se a qualidade de vida com o questionário WHOQOL-BREF. Fatores associados à qualidade de vida foram analisados por regressão linear. Resultados: Dos 91 adolescentes elegíveis, 73 (80,2%) foram incluídos, sendo 38 (52,1%) masculinos, nascidos com 30,1 ± 2,4 semanas de gestação e peso de 1.134 ± 239 g. Adolescentes referiram melhor qualidade de vida que seus cuidadores (p = 0,01), sendo, respectivamente: insatisfeitos (1,4 vs. 4,1%), nem satisfeitos, nem insatisfeitos (20,5 vs. 20,5%), satisfeitos (56,2 vs. 71,2%) e muito satisfeitos (21,9 vs. 4,1%). Os escores atribuídos pelos adolescentes e cuidadores foram, respectivamente, qualidade de vida geral (4,0 ± 0,7 vs. 3,8 ± 0,6, p = 0,032), domínio físico (3,6 ± 0,6 vs. 3,5 ± 0,6, p = 0,685), domínio psicológico (3,4 ± 0,6 vs. 3,6 ± 0,6, p = 0,116), relações sociais (3,7 ± 0,7 vs. 3,6 ± 0,8, p = 0,371) e ambiente (3,4 ± 0,7 vs. 3,2 ± 0,6, p = 0,037). Para cuidadores, ausência de parceiro fixo e hospitalização na infância diminuíram os escores de qualidade de vida geral, já a síndrome de desconforto respiratório aumentou esse escore. Na percepção dos adolescentes, a leucomalácia reduziu esse escore. Conclusões: Adolescentes referiram melhor qualidade de vida que seus cuidadores. Para adolescentes, apenas fatores biológicos se associaram aos escores de qualidade de vida; para cuidadores, fatores biológicos e sociais se associaram a esse escore.

Functional capacity during exercise in very-low-birth-weight premature children.

OBJECTIVES: The functional capacity of children born prematurely with very-low-birth weight was compared with that of children born at full-term using the six-minute walk test (6MWT) and the ten-minutes shuttle walk test (10MSWT). The factors affecting walking distance were analyzed. METHODS: A cross-sectional study was conducted with two groups of children aged 6-9 years, matched by sex and age. One group included children born before 37 weeks of gestation weighing <1,500 g and the second group included children born at term. Both groups were submitted to the 6MWT and 10MWST, performed on the same day with an interval of 20 min between tests and the sequence of the tests was randomized, by sealed-envelope technique. Physiological parameters were measured at the beginning and end of each test. The walking distance and factors affecting the walking distance were analyzed. RESULTS: Thirty-seven children born prematurely and 37 born at term were studied. The premature children walked shorter distances in the 6MWT (480.9 ± 80.5 m vs. 518.3 ± 51.8 m, P = 0.010) than term children, and both groups walked similar distances in the 10MSWT (391.5 ± 99.0 m vs. 406.1 ± 79.2 m, P = 0.487). By multiple linear regression analysis, adjusted for confounders, walking distance was associated with height (OR: 3.6) and oxygen dependency at 28 days (OR: -67.7) in the 6MWT (P < 0.001) and with height (OR: 4.9) and oxygen dependency at 28 days (OR: -91.0) in the 10MSWT (P < 0.001). CONCLUSION: In conclusion, this study suggests that children born prematurely with very low birth weight, especially those who had bronchopulmonary dysplasia present limited functional capacity during exercise.

Depression during gestation in adolescent mothers interferes with neonatal neurobehavior

Objective: To compare the neurobehavior of neonates born to adolescent mothers with and without depression during gestation. Methods: This prospective cross-sectional study included healthy term neonates born to adolescent mothers with untreated depression during gestation, without exposure to legal or illicit drugs, and compared them with infants born to adolescent mothers without psychiatric disorders. Maternal psychiatric diagnoses were assessed by the Composite International Diagnostic Interview (CIDI 2.1) and neonatal neurobehavior by the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) at 24 to 72 hours of life. Neurobehavioral outcomes were analyzed by ANOVA adjusted for confounders. Results: 37 infants born to mothers with depression during gestation were compared to 332 infants born to mothers without psychiatric disorders. Infants of mothers with depression had smaller head circumferences. Significant interactions of maternal depression and male gender, gestational age > 40 weeks, regional anesthesia during delivery, vaginal delivery, and infant head circumference ≥ 34 cm were found. Worse performance was noted in the following neonatal neurobehavioral parameters: arousal, excitability, lethargy, hypotonicity, and signs of stress and abstinence. Conclusion: Infants born to adolescent mothers with depression exhibit some behavioral changes in the first days of life. These changes are associated with infant sex, gestational age, type of anesthesia, mode of delivery, and head circumference. .

Avaliação do neurodesenvolvimento de prematuros de muito baixo peso ao nascer entre 18 e 24 meses de idade corrigida pelas escalas Bayley III / Neurodevelopmental assessment of very low birth weight preterm infants at corrected age of 18-24 months by Bayley III scales

OBJETIVO: Avaliar a prevalência de atraso e fatores associados aos escores de desenvolvimento em crianças nascidas prematuras. MÉTODOS: Estudo transversal para avaliar o desenvolvimento por escalas Bayley III, incluindo-se prematuros de muito baixo peso de 18 a 24 meses de idade corrigida, acompanhados no Ambulatório de Prematuros da instituição. Excluíram-se: malformação congênita, síndrome genética, infecção congênita sintomática ao nascimento, surdez e cegueira. As variáveis numéricas foram comparadas por teste t de Student ou Mann-Whitney, e as categóricas, por qui-quadrado ou teste exato de Fisher. Para análise dos fatores associados aos escores de desenvolvimento, utilizou-se a regressão linear, considerando-se significante p < 0,05. RESULTADOS: Das 58 crianças avaliadas, quatro (6,9%) apresentaram alteração cognitiva; quatro (6,9%), motora; 17 (29,3%), de linguagem; 16 (27,6%), socioemocional; e 22 (37,9%), de comportamento adaptativo. À regressão linear múltipla, os fatores classe socioeconômica CDE (-13,27; IC95% -21,23 a -5,31) e dependência de oxigênio com 36 semanas de idade corrigida (-8,75; IC95% -17,10 a -0,39) diminuíram o escore cognitivo. A leucomalácia periventricular diminuiu o escore cognitivo (-15,21; IC95% -27,61 a -2,81), motor (-10,67; IC95% -19,74 a -1,59) e de comportamento adaptativo (-21,52; IC95% -35,60 a -7,44). O sexo feminino se associou ao maior escore motor (10,67; IC95% 2,77-12,97), de linguagem (15,74; IC95% 7,39-24,09) e socioemocional (10,27; IC95% 1,08-19,46). CONCLUSÕES: Prematuros de muito baixo peso apresentaram com maior frequência alterações na linguagem, comportamento adaptativo e socioemocional. As variáveis classe socioeconômica CDE, leucomalácia periventricular, displasia broncopulmonar e sexo masculino contribuíram para reduzir os escores de desenvolvimento.

OBJECTIVE: To evaluate the prevalence of delay and factors associated with neurodevelopmental scores in premature infants. METHODS: Cross-sectional study to assess the development by Bayley Scales III, including very low birth weight preterm infants aged 18 to 24 months who were under follow-up at the outpatient clinic for preterm infants. Congenital malformation, genetic syndrome, symptomatic congenital infection at birth, deafness, and blindness were excluded. Numerical variables were compared by Mann-Whitney or Student t test and categorical variables by chi-square or Fisher's exact test. Factors associated with developmental scores were analyzed by linear regression, and statistical significance level was established at p < 0.05. RESULTS: Out of the 58 children included, four (6.9%) presented cognitive delay, four (6.9%) motor, 17 (29.3%) language, 16 (27.6%) social-emotional and 22 (37.0%) adaptive-behavior delay. By multiple linear regression, the variables: social classes CDE (-13.27; 95%CI: -21.23 to -5.31), oxygen dependency at 36 weeks of corrected age (-8.75; 95%CI: -17.10 to -0.39) decreased the cognitive developmental score. Periventricular leukomalacia decreased the cognitive (-15.21; 95%CI: -27.61 to -2.81), motor (-10.67; 95%CI:-19.74 to -1.59) and adaptive-behavior scores (-21.52; 95%CI: -35.60 to -7.44). The female sex was associated with higher motor (10.67; 95%CI: 2.77 to 12.97), language (15.74; 95%CI: 7.39 to 24.09) and social-emotional developmental scores (10.27; 95%CI: 1.08 to 19.46). CONCLUSIONS: Very low birth weight preterm infants aged from 18 to 24 months of corrected age presented more frequently language, social-emotional and adaptive-behavior delays. The variables: social classes CDE, periventricular leukomalacia, bronchopulmonary dysplasia and male sex reduced the neurodevelopmental scores.

Correlates of substance use during adolescent pregnancy in São Paulo, Brazil / Correlatos do uso de substâncias durante a gravidez na adolescência em São Paulo, Brasil

OBJECTIVE: To investigate the association of cocaine and marijuana use during adolescent pregnancy in São Paulo-SP, Brazil, with psychiatric disorders, social status and sexual history. METHOD: One thousand pregnant adolescents were assessed by using the Composite International Diagnostic Interview, and sociodemographic and socio-economic questionnaire at the obstetric center of a public hospital in São Paulo. Hair samples were collected for analysis. RESULTS: The following data were associated with cocaine and/or marijuana use during the third trimester of the pregnancy: being younger than 14 years of age, having a history of more than 3 sexual partners, and having psychiatric disorders, specifically, bipolar disorder, post-traumatic stress disorder, and somatoform disorder. CONCLUSION: In early adolescence pregnancy, having 3 or more sexual partners in life for this population is significantly associated with the use of cocaine or marijuana during gestation. This association suggests that specific intervention programs should target these young women.

OBJETIVO: Investigar, numa população de gestantes adolescentes de uma maternidade pública de São Paulo-SP, Brasil, a associação entre o consumo de cocaína e maconha durante a gravidez com distúrbios psiquiátricos, status social e história sexual. MÉTODO: Mil adolescentes grávidas foram avaliadas por meio do Composite International Diagnostic Interview e de um questionário sociodemográfico e socioeconômico no centro obstétrico de um hospital público de São Paulo. Destas, foi colhida amostra para análise de fios de cabelo. RESULTADOS: Os seguintes dados foram associados com o uso de cocaína e/ou maconha durante o terceiro trimestre de gravidez: ter menos de 14 anos, ter história de mais do que três parceiros sexuais e ter transtornos psiquiátricos, em especial, transtorno afetivo bipolar, transtorno do estresse pós-traumático e transtorno somatoforme. CONCLUSÃO: Na população de adolescentes grávidas avaliada, ter menos de 14 anos e ter três ou mais parceiros sexuais na vida está significativamente associado ao uso de maconha ou cocaína durante a gestação. Esta associação sugere que programas de intervenção específicos devem ser dirigidos a essas jovens.

Prevalence of cocaine and marijuana use in the last trimester of adolescent pregnancy: socio-demographic, psychosocial and behavioral characteristics.

OBJECTIVE: To evaluate the prevalence of cocaine and marijuana use during the third trimester of pregnancy in a population of 1000 teenage women of a public hospital in São Paulo, Brazil using hair analysis in order to avoid underestimation of data that could happen by the use of self-report questionnaires and describe socio-demographic, psychosocial and behavioral characteristics of the drug users. RESULTS: Hair analysis has detected use of cocaine and/or marijuana in the third trimester of pregnancy in 6% of the patients: 4.0% used marijuana, 1.7% used cocaine and 3% used both drugs. They were about 17 years old, from low-income, poorly educated, unemployed, financially dependent and they had not planned the pregnancy. 10% of miscarriages have occurred in this population. CONCLUSION: This study shows the psychosocial impairment associated to teenage pregnancy and use of cocaine and marijuana during gestation by this low-income population with reliable data of prevalence obtained through hair analysis.

Enterocolite necrosante: experiência clínico-cirúrgica de 10 anos na Unidade Neonatal da Universidade Federal de Säo Paulo, Escola Paulista de Medicina (Unifesp-EPM) / Necrotizing enterocolitis: clinical and surgical experiency of ten year at Säo Paulo Hospital - Federal University of Säo Paulo

A enterocolite necrosante (ECN) é a afecçäo gastrointestinal adquirida mais frequentemente no período neonatal, acometendo preferencialmente os neonatos prematuros. O objetivo deste estudo reetrospectivo é analisar a evoluçäo clínico-cirúrgica dos recém-nascidos (RNs) que apresentaram ECN na Unidade Neonatal do Hospital Säo Paulo/Escola Paulista de Medicina, entre janeiro de 1986 e dezembro de 1996. Nesse período houve 14.260 nascidos vivos, dos quais 62 RNs tiveram diagnóstico de ECN (0,43 por cento), sendo 52(por cento) (32/62) do sexo feminino e 48 (por cento) (30/62) do masculino. A idade gestacional média foi de 33,4 semanas e a média do peso de nascimento, de 1.622 gramas. Desse total 24 (por cento) dos pacientes (15/62) eram portadores de malformaçöes cardíacas e 27 (por cento) (16/62) apresentaram asfixia perinatal ao nascimento. O tratamento foi exclusivamente clínico em 72,5 (por cento) dos casos (45/62). Baseados nesses dados, pretendemos estabelecer um protocolo prospectivo de intervençäo diagnóstica e terapêutica com o objetivo de obter maior sobrevidaa e menor morbidade dessa afecçäo no período neonatal, além de estimular a aplicaçäo de medidas preventivas, como o uso do leite humano

Crescimento e desenvolvimento do recém-nascido pré-termo / Growth and developmental outcome of preterm infants

A maior sobrevida de recém-nascidos prematuros de muito baixo peso, que apresentam risco elevado para alteraçöes de crescimento e desenvolvimento, suscitou interesse crescente no estudo da evoluçäo dessas crianças. Analisamos os dados mostrados na literatura e os resultados obtidos na avaliaçäo de prematuros de muito baixo peso acompanhados em nosso serviço. Constatamos que crianças nascidas pré-termo näo atingem o crescimento de peso, estatura e perímetro cefálico observado em crianças nascidas a termo com peso adequado, no final do primeiro ano de vida, mesmo considerando a idade corrigida para o grau de prematuridade. Essas crianças apresentam alto risco de sequelas neurológicas, audiológicas e de linguagem, ressaltando a necessidade de acompanhamento multidisciplinar para permitir o diagnóstico e intervençäo precoce.