Clusters of preterm live births and respiratory distress syndrome-associated neonatal deaths: spatial distribution and cooccurrence patterns.

BACKGROUND: Prematurity and respiratory distress syndrome (RDS) are strongly associated. RDS continues to be an important contributor to neonatal mortality in low- and middle-income countries. This study aimed to identify clusters of preterm live births and RDS-associated neonatal deaths, and their cooccurrence pattern in São Paulo State, Brazil, between 2004 and 2015.  METHODS: Population-based study of all live births with gestational age ≥ 22 weeks, birthweight ≥ 400 g, without congenital anomalies from mothers living in São Paulo State, Brazil, during 2004-2015. RDS-associated neonatal mortality was defined as deaths < 28 days with ICD-10 codes P22.0 or P28.0. RDS-associated neonatal mortality and preterm live births rates per municipality were submitted to first- and second-order spatial analysis before and after smoothing using local Bayes estimates. Spearman test was applied to identify the correlation pattern between both rates. RESULTS: Six hundred forty-five thousand two hundred seventy-six preterm live births and 11,078 RDS-associated neonatal deaths in São Paulo State, Brazil, during the study period were analyzed. After smoothing, a non-random spatial distribution of preterm live births rate (I = 0.78; p = 0.001) and RDS-associated neonatal mortality rate (I = 0.73; p = 0.001) was identified. LISA maps confirmed clusters for both, with a negative correlation (r = -0.24; p = 0.0000). Clusters of high RDS-associated neonatal mortality rates overlapping with clusters of low preterm live births rates were detected. CONCLUSIONS: Asymmetric cluster distribution of preterm live births and RDS-associated neonatal deaths may be helpful to indicate areas for perinatal healthcare improvement.

Acquisition of Behavioral Skills after Manikin-Based Simulation of Neonatal Resuscitation by Fellows in Neonatology.

OBJECTIVE: Behavioral performance of health professionals is essential for adequate patient care. This study aimed to assess the behavioral skills of fellows in neonatology before and after a simulation training program on neonatal resuscitation. STUDY DESIGN: From March 2019 to February 2020, a prospective cohort with 12 second-year fellows in neonatology were evaluated during three training cycles (16 hours each) in manikin-based simulation of neonatal resuscitation with standardized scenarios. Each cycle lasted 1 month, followed by a 3-month interval. One video-recorded scenario of approximately 10 minutes was performed for each fellow at the beginning and at the end of each training cycle. Therefore, each fellow was recorded six times, before and after each one of three training cycles. Anxiety of the fellows was assessed by the Beck Anxiety Inventory applied before the first training cycle. The videos were independently analyzed in a random order by three trained facilitators using the Behavioral Assessment Tool. The behavioral performance was evaluated by repeated measures of analysis of variance adjusted for anxiety and for previous experience in neonatal resuscitation. RESULTS: Fellows' overall behavioral performance improved comparing the moment before the first training and after the second training. The specific skills, such as communication with the team, delegation of tasks, allocation of attention, use of information, use of resources, and professional posture, showed a significant improvement after the second month of training. No further gains were noted with the third training cycle. Anxiety was observed in 42% of the fellows and its presence worsened their behavioral performance. CONCLUSION: An improvement in behavioral performance was observed, comparing the moment before the first training and after the second training, without further gains after the third training. It is worth noting the important role of anxiety as a modulator of acquisition and retention of behavioral skills in health professionals in training. KEY POINTS: · Simulation training should improve technical and behavioral skills of providers. · Behavioral skills improve after a first cycle of training, but not after a repeat cycle. · Anxiety modulates trainees' behavioral performance.

Temporal Trend and Risk Factors for Respiratory Distress Syndrome-Associated Neonatal Mortality in Preterm Infants: A Population-Based Study in a Middle-Income Country.

OBJECTIVE: This article aimed to report a temporal series of respiratory distress syndrome (RDS)-associated neonatal mortality rates in preterm live births in São Paulo state, Brazil, and to identify social, maternal, and neonatal characteristics associated with these deaths. STUDY DESIGN: This is a population-based study of all live births with gestational age (GA) between 22 and 36 weeks, birth weight ≥400 g, without congenital anomalies from mothers living in São Paulo state during 2004 to 2015. RDS-associated neonatal mortality was defined as death up to 27 days after birth with ICD-10 codes P22.0 or P28.0. RDS-associated neonatal mortality rate (annual percent change [APC] with 95% confidence intervals [95% CIs]) was analyzed by Prais-Winsten. Kaplan-Meier estimator identified the time after birth that the RDS-associated neonatal death occurred. Poisson's regression model compared social maternal and neonatal characteristics between preterm live births that survived the neonatal period and those with RDS-associated neonatal deaths, with results expressed in incidence rate ratio and 95% CI. RESULTS: A total of 645,276 preterm live births were included in the study, of which 612,110 survived and 11,078 had RDS-associated neonatal deaths. RDS-associated neonatal mortality rate was 17.17 per thousand preterm live births, with a decreasing annual trend (APC: -6.50%; 95% CI: -9.11 to -3.82%). The median time of these deaths was 48 hours after birth. The following risk factors for RDS-associated neonatal death were identified: maternal schooling ≤7 years (1.18; 1.09-1.29), zero to three prenatal care visits (1.25; 1.18-1.32), multiple pregnancy (1.24; 1.16-1.33), vaginal delivery (1.29; 1.22-1.36), GA 22 to 27 weeks (106.35; 98.36-114.98), GA 28 to 31 weeks (20.12; 18.62-21.73), male sex (1.16; 1.10-1.22), and 5-minute Apgar scores of 0 to 3 (6.74; 6.08-7.47) and 4 to 6 (3.97; 3.72-4.23). CONCLUSION: During the study period, RDS-associated neonatal mortality rates showed significant reduction. The relationship between RDS-associated neonatal deaths and social, maternal, and neonatal factors suggests the need for perinatal strategies to reduce prematurity and to improve the initial management of preterm infants. KEY POINTS: · RDS is associated with preterm live births.. · Impact of RDS-associated neonatal mortality in middle-income countries is scarce.. · Qualified perinatal care can reduce RDS-associated neonatal mortality..

Neonatal mortality associated with perinatal asphyxia: a population-based study in a middle-income country.

BACKGROUND: It is challenging to decrease neonatal mortality in middle-income countries, where perinatal asphyxia is an important cause of death. This study aims to analyze the annual trend of neonatal mortality with perinatal asphyxia according to gestational age in São Paulo State, Brazil, during a 10-year period and to verify demographic, maternal and neonatal characteristics associated with these deaths. METHODS: Population-based study of neonatal deaths associated with perinatal asphyxia from 0 to 27 days in São Paulo State, Brazil, from 2004 to 2013. Perinatal asphyxia was considered as associated to death if intrauterine hypoxia, birth asphyxia or neonatal aspiration of meconium were noted in any line of the Death Certificate according to ICD-10. Poisson Regression was applied to analyze the annual trend of neonatal mortality rate according to gestational age. Kaplan-Meier curve was used to assess age at death during the 10-year study period. Hazard ratio of death during the neonatal period according to gestational age was analyzed by Cox regression adjusted by year of birth and selected epidemiological factors. RESULTS: Among 74,002 infant deaths in São Paulo State, 6648 (9%) neonatal deaths with perinatal asphyxia were studied. Neonatal mortality rate with perinatal asphyxia fell from 1.38‰ in 2004 to 0.95‰ in 2013 (p = 0.002). Reduction started in 2008 for neonates with 32-41 weeks, in 2009 for 28-31 weeks, and in 2011 for 22-27 weeks. Median time until 50% of deaths occurred was 25.3 h (95%CI: 24.0; 27.2). Variables independently associated with higher risk of death were < 7 prenatal visits, 1st minute Apgar score 0-3, and death at the same place of birth. Cesarean delivery compared to vaginal was protective against death with perinatal asphyxia for infants at 28-36 weeks. CONCLUSIONS: There was an expressive reduction in neonatal mortality rates associated with perinatal asphyxia during this 10-year period in São Paulo State, Brazil. Variables associated with these deaths highlight the need of public health policies to improve quality of regionalized perinatal care.

Annual trend of neonatal mortality and its underlying causes: population-based study - São Paulo State, Brazil, 2004-2013.

BACKGROUND: Population-based studies analyzing neonatal deaths in middle-income countries may contribute to design interventions to achieve the Sustainable Development Goals, established by United Nations. This study goal is to analyze the annual trend of neonatal mortality in São Paulo State, Brazil, over a 10-year period and its underlying causes and to identify maternal and neonatal characteristics at birth associated with neonatal mortality. METHOD: A population-based study of births and deaths from 0 to 27 days between 2004 and 2013 in São Paulo State, Brazil, was performed. The annual trend of neonatal mortality rate according to gestational age was analyzed by Poisson or by Negative Binomial Regression models. Basic causes of neonatal death were classified according to ICD-10. Association of maternal demographic variables (block 1), prenatal and delivery care variables (block 2), and neonatal characteristics at birth (block 3) with neonatal mortality was evaluated by Poisson regression analysis adjusted by year of birth. RESULTS: Among 6,056,883 live births in São Paulo State during the study period, 48,309 died from 0 to 27 days (neonatal mortality rate: 8.0/1,000 live births). For the whole group and for infants with gestational age 22-27, 28-31, 32-36, 37-41 and ≥ 42 weeks, reduction of neonatal mortality rate was, respectively, 18 %, 15 %, 38 %, 53 %, 31 %, and 58 %. Median time until 50 % of deaths occurred was 3 days. Main basic causes of death were respiratory disorders (25 %), malformations (20 %), infections (17 %), and perinatal asphyxia (7 %). Variables independently associated with neonatal deaths were maternal schooling, prenatal care, parity, newborn sex, 1st minute Apgar, and malformations. Cesarean delivery, compared to vaginal, was protective against neonatal mortality for infants at 22-31 weeks, but it was a risk factor for those with 32-41 weeks. CONCLUSIONS: Despite the significant decrease in neonatal mortality rate over the 10-year period in São Paulo State, improved access to qualified health care is needed in order to avoid preventable neonatal deaths and increase survival of infants that need more complex levels of assistance.

Admission hypothermia, neonatal morbidity, and mortality: evaluation of a multicenter cohort of very low birth weight preterm infants according to relative performance of the center.

This prospective cohort study aimed to assess the association of admission hypothermia (AH) with death and/or major neonatal morbidities among very low birth weight (VLBW) preterm infants based on the relative performance of 20 centers of the Brazilian Network of Neonatal Research. This is a retrospective analysis of prospectively collected data using the database registry of the Brazilian Network on Neonatal Research. Center performance was defined by the relative mortality rate using conditional inference trees. A total of 4356 inborn singleton VLBW preterm infants born between January 2013 and December 2016 without malformations were included in this study. The centers were divided into two groups: G1 (with lower mortality rate) and G2 (with higher mortality rate). Crude and adjusted relative risks (RR) and 95% confidence intervals (95%CI) were estimated by simple and multiple log-binomial regression models. An AH rate of 53.7% (19.8-93.3%) was significantly associated with early neonatal death in G1 (adjusted RR 1.41, 95% CI 1.09-1.84) and G2 (adjusted RR 1.29, 95%CI 1.01-1.65) and with in-hospital death in G1 (adjusted RR 1.29, 95%CI 1.07-1.58). AH was significantly associated with a lower frequency of necrotizing enterocolitis (adjusted RR 0.58, 95%CI 38-0.88) in G2.Conclusion: AH significantly associated with early neonatal death regardless of the hospital performance. In G2, an unexpected protective association between AH and necrotizing enterocolitis was found, whereas the other morbidities assessed were not significantly associated with AH. What is Known: • Admission hypothermia is associated with early neonatal death. • The association of admission hypothermia with major neonatal morbidities has not been fully established. What is New: • Admission hypothermia was significantly associated with early neonatal and in-hospital death in centers with the lowest relative mortality rates. • Admission hypothermia was not associated with major neonatal morbidities and with in-hospital death but was found to be a protective factor against necrotizing colitis in centers with the highest relative mortality rates.

First- and fifth-minute Apgar scores of 0-3 and infant mortality: a population-based study in São Paulo State of Brazil.

AIMS: To determine the infant mortality of newborns with 1- and 5-min Apgar scores of 0-3. RESULTS: Population cohort study with neonates with birth weight ≥400 g, gestational age ≥22 weeks and 1- and 5-min Apgar scores of 0-3, without malformations, born in São Paulo State (Brazil) from January 2006 to December 2007. Apgar scores were confirmed in the original certificates of live births and/or medical records. During this period, among 1,027,132 live births, 1640 met the study criteria, with an incidence of 1.6 per 1000 live births. When the 5-min Apgar score was 0, 1, 2 and 3, the infant mortality rate was 97%, 94%, 64% and 47%, respectively. Risk factors associated with infant deaths were 5-min Apgar score of 0 or 1 [odds ratio (OR) 16.6, 95% confidence interval (CI) 11.1-24.8], birth weight <2500 g (OR 7.5, 95% CI 5.7-9.8), birth at hospitals outside the state capital (OR 1.7, 95% CI 1.3-2.3), in private or charitable hospitals (OR 1.6, 95% CI 1.2-2.0), and during the night shift (OR 1.3, 95% CI 1.0-1.7). CONCLUSIONS: For infants with 1- and 5-min Apgar scores of 0-3, the infant mortality is high. Besides the biological variables associated with the chance of dying, the organization of the perinatal care influences the outcome.

Newborn heart rate monitoring methods at birth and clinical outcomes: A systematic review.

Aim: Compare heart rate assessment methods in the delivery room on newborn clinical outcomes. Methods: A search of Medline, SCOPUS, CINAHL and Cochrane was conducted between January 1, 1946, to until August 16, 2023. (CRD 42021283438) Study Selection was based on predetermined criteria. Reviewers independently extracted data, appraised risk of bias and assessed certainty of evidence. Results: Two randomized controlled trials involving 91 newborns and 1 nonrandomized study involving 632 newborns comparing electrocardiogram (ECG) to auscultation plus pulse oximetry were included. No studies were found that compared any other heart rate measurement methods and reported clinical outcomes. There was no difference between the ECG and control group for duration of positive pressure ventilation, time to heart rate ≥ 100 beats per minute, epinephrine use or death before discharge. In the randomized studies, there was no difference in rate of tracheal intubation [RR 1.34, 95% CI (0.69-2.59)]. No participants received chest compressions. In the nonrandomized study, fewer infants were intubated in the ECG group [RR 0.75, 95% CI (0.62-0.90)]; however, for chest compressions, benefit or harm could not be excluded. [RR 2.14, 95% (CI 0.98-4.70)]. Conclusion: There is insufficient evidence to ascertain clinical benefits or harms associated with the use of ECG versus pulse oximetry plus auscultation for heart rate assessment in newborns in the delivery room.

Fast and accurate newborn heart rate monitoring at birth: A systematic review.

Aim: To examine speed and accuracy of newborn heart rate measurement by various assessment methods employed at birth. Methods: A search of Medline, SCOPUS, CINAHL and Cochrane was conducted between January 1, 1946, to until August 16, 2023. (CRD 42021283364) Study selection was based on predetermined criteria. Reviewers independently extracted data, appraised risk of bias and assessed certainty of evidence. Results: Pulse oximetry is slower and less precise than ECG for heart rate assessment. Both auscultation and palpation are imprecise for heart rate assessment. Other devices such as digital stethoscope, Doppler ultrasound, an ECG device using dry electrodes incorporated in a belt, photoplethysmography and electromyography are studied in small numbers of newborns and data are not available for extremely preterm or bradycardic newborns receiving resuscitation. Digital stethoscope is fast and accurate. Doppler ultrasound and dry electrode ECG in a belt are fast, accurate and precise when compared to conventional ECG with gel adhesive electrodes. Limitations: Certainty of evidence was low or very low for most comparisons. Conclusion: If resources permit, ECG should be used for fast and accurate heart rate assessment at birth. Pulse oximetry and auscultation may be reasonable alternatives but have limitations. Digital stethoscope, doppler ultrasound and dry electrode ECG show promise but need further study.

Congenital diaphragmatic hernia in a middle-income country: Persistent high lethality during a 12-year period.

BACKGROUND: In high- and middle-income countries, mortality associated to congenital diaphragmatic hernia (CDH) is high and variable. In Brazil, data is scarce regarding the prevalence, mortality, and lethality of CDH. This study aimed to analyze, in São Paulo state of Brazil, the temporal trends of prevalence, neonatal mortality and lethality of CDH and identify the time to CDH-associated neonatal death. METHODS: Population-based study of all live births with gestational age ≥ 22 weeks, birthweight ≥400g, from mothers residing in São Paulo State, Brazil, during 2004-2015. CDH definition and its subgroups classification were based on ICD-10 codes reported in the death and/or live birth certificates. CDH-associated neonatal death was defined as death up to 27 days after birth of infants with CDH. CDH prevalence, neonatal mortality and lethality were calculated and their annual percent change (APC) with 95% confidence intervals (95%CI) was analyzed by Prais-Winsten. Kaplan-Meier estimator identified the time after birth that CDH-associated neonatal death occurred. RESULTS: CDH prevalence was 1.67 per 10,000 live births, with a significant increase throughout the period (APC 2.55; 95%CI 1.30 to 3.83). CDH neonatal mortality also increased over the time (APC 2.09; 95%CI 0.27 to 3.94), while the lethality was 78.78% and remained stationary. For isolated CDH, CDH associated to non-chromosomal anomalies and CDH associated to chromosomal anomalies the lethality was, respectively, 72.25%, 91.06% and 97.96%, during the study period. For CDH as a whole and for all subgroups, 50% of deaths occurred within the first day after birth. CONCLUSIONS: During a 12-year period in São Paulo State, Brazil, CDH prevalence and neonatal mortality showed a significant increase, while lethality remained stable, yet very high, compared to rates reported in high income countries.

Temporal Trend, Causes, and Timing of Neonatal Mortality of Moderate and Late Preterm Infants in São Paulo State, Brazil: A Population-Based Study.

Moderate and late preterm newborns comprise around 85% of live births < 37 weeks gestation. Data on their neonatal mortality in middle-income countries is limited. This study aims to analyze the temporal trend, causes and timing of neonatal mortality of infants with 320/7-366/7 weeks gestation without congenital anomalies from 2004-2015 in the population of São Paulo State, Brazil. A database was built by deterministic linkage of birth and death certificates. Causes of death were classified by ICD-10 codes. Among 7,317,611 live births in the period, there were 545,606 infants with 320/7-366/7 weeks gestation without congenital anomalies, and 5782 of them died between 0 and 27 days. The neonatal mortality rate decreased from 16.4 in 2004 to 7.6 per thousand live births in 2015 (7.47% annual decrease by Prais-Winsten model). Perinatal asphyxia, respiratory disorders and infections were responsible, respectively, for 14%, 27% and 44% of the 5782 deaths. Median time to death was 24, 53 and 168 h, respectively, for perinatal asphyxia, respiratory disorders, and infections. Bottlenecks in perinatal health care are probably associated with the results that indicate the need for policies to reduce preventable neonatal deaths of moderate and late preterm infants in the most developed state of Brazil.

Epidemiological trends of isolated and non-isolated central nervous system congenital malformations in live births in a middle-income setting.

OBJECTIVES: This study aimed to analyze, in the São Paulo state of Brazil, time trends in prevalence, neonatal mortality, and neonatal lethality of central nervous system congenital malformations (CNS-CM) between 2004 and 2015. METHODS: Population-based study of all live births with gestational age ≥22 weeks and/or birthweight ≥400 g from mothers living in São Paulo State, during 2004-2015. CNS-CM was defined by the presence of International Classification Disease 10th edition codes Q00-Q07 in the death and/or live birth certificates. CNS-CM was classified as isolated (only Q00-Q07 codes), and non-isolated (with congenital anomalies codes nonrelated to CNS-CM). CNS-CM associated neonatal death was defined as death between 0 and 27 days after birth in infants with CNS-CM. CNS-CM prevalence, neonatal mortality, and lethality rates were calculated, and their annual trends were analyzed by Prais-Winsten Model. The annual percent change (APC) with 95% confidence interval (95%CI) was obtained. RESULTS: 7,237,628 live births were included in the study and CNS-CM were reported in 7526 (0.1%). CNS-CM associated neonatal deaths occurred in 2935 (39.0%). Isolated CNS-CM and non-isolated CNS-CM were found respectively in 5475 and 2051 livebirths, with 1525 (28%) and 1410 (69%) neonatal deaths. CNS-CM prevalence and neonatal lethality were stationary, however neonatal mortality decreased (APC -1.66; 95%CI -3.09 to -0.21) during the study. For isolated CNS-CM, prevalence, neonatal mortality, and lethality decreased over the period. For non-isolated CNS-CM, the prevalence increased, neonatal mortality was stationary, and lethality decreased during the period. The median time of CNS-CM associated neonatal deaths was 18 h after birth. CONCLUSIONS: During a 12-year period in São Paulo State, Brazil, neonatal mortality of infants with CNS-CM in general and with isolated CNS-CM showed a decreasing pattern. Nevertheless CNS-CM mortality remained elevated, mostly in the first day after birth.

The burden of inappropriate birth weight on neonatal survival in term newborns: a population-based study in a middle-income setting.

Introduction: Premature birth, perinatal asphyxia, and infections are the main causes of neonatal death. Growth deviations at birth also affect neonatal survival according to week of gestation at birth, particularly in developing countries. The purpose of this study was to verify the association between inappropriate birth weight and neonatal death in term live births. Methods: This is an observational follow-up study with all term live births from 2004 to 2013 in Sao Paulo State, Brazil. Data were retrieved with the deterministic linkage of death and birth certificates. The definition of very small for gestational age (VSGA) and very large for gestational age (VLGA) used the 10th percentile of 37 weeks and the 90th percentile of 41 weeks + 6 days, respectively, based on the Intergrowth-21st. We measured the outcome in terms of time to death and the status of each subject (death or censorship) in the neonatal period (0-27 days). Survival functions were calculated using the Kaplan-Meier method stratified according to the adequacy of birth weight into three groups (normal, very small, or very large). We used multivariate Cox regression to adjust for proportional hazard ratios (HRs). Results: The neonatal death rate during the study period was 12.03/10,000 live births. We found 1.8% newborns with VSGA and 2.7% with VLGA. The adjusted analysis showed a significant increase in mortality risk for VSGA infants (HR = 4.25; 95% CI: 3.89-4.65), independent of sex, 1-min Apgar score, and five maternal factors. Discussion: The risk of neonatal death in full-term live births was approximately four times greater in those with birth weight restriction. The development of strategies to control the factors that determine fetal growth restriction through planned and structured prenatal care can substantially reduce the risk of neonatal death in full-term live births, especially in developing countries such as Brazil.

Operational Challenges in the Use of Structured Secondary Data for Health Research.

Background: In Brazil, secondary data for epidemiology are largely available. However, they are insufficiently prepared for use in research, even when it comes to structured data since they were often designed for other purposes. To date, few publications focus on the process of preparing secondary data. The present findings can help in orienting future research projects that are based on secondary data. Objective: Describe the steps in the process of ensuring the adequacy of a secondary data set for a specific use and to identify the challenges of this process. Methods: The present study is qualitative and reports methodological issues about secondary data use. The study material was comprised of 6,059,454 live births and 73,735 infant death records from 2004 to 2013 of children whose mothers resided in the State of São Paulo - Brazil. The challenges and description of the procedures to ensure data adequacy were undertaken in 6 steps: (1) problem understanding, (2) resource planning, (3) data understanding, (4) data preparation, (5) data validation and (6) data distribution. For each step, procedures, and challenges encountered, and the actions to cope with them and partial results were described. To identify the most labor-intensive tasks in this process, the steps were assessed by adding the number of procedures, challenges, and coping actions. The highest values were assumed to indicate the most critical steps. Results: In total, 22 procedures and 23 actions were needed to deal with the 27 challenges encountered along the process of ensuring the adequacy of the study material for the intended use. The final product was an organized database for a historical cohort study suitable for the intended use. Data understanding and data preparation were identified as the most critical steps, accounting for about 70% of the challenges observed for data using. Conclusion: Significant challenges were encountered in the process of ensuring the adequacy of secondary health data for research use, mainly in the data understanding and data preparation steps. The use of the described steps to approach structured secondary data and the knowledge of the potential challenges along the process may contribute to planning health research.

Clusters of cause specific neonatal mortality and its association with per capita gross domestic product: A structured spatial analytical approach.

BACKGROUND: Infant mortality rate is a measure of population health and neonatal mortality account for great proportion of these deaths. Underdevelopment might be associated to higher neonatal mortality risk due to assistant related factors. Spatial and temporal distribution of mortality help identifying and developing strategies for interventions. OBJECTIVE: To investigate the cluster areas of asphyxia-associated neonatal mortality and to explore its association with per capita gross domestic product (GDP) in São Paulo State (SP), Brazil. METHODS: Ecological study including live births residents in SP from 2004-2013. Neonatal deaths (0-27 days) with perinatal asphyxia were defined as intrauterine hypoxia, birth asphyxia or meconium aspiration syndrome written in any line of the Death Certificate. Geoprocessing analytical approach included detection of first order effects through quintiles and spatial moving average maps, followed by second order effects by global and local spatial autocorrelation (Moran and LISA, respectively) before and after smoothing with local Bayesian estimates. Finally, Spearman correlation was applied between asphyxia-associated neonatal mortality and mean per capita GDP rates for the municipalities with significant LISA. RESULTS: There were 6,713 asphyxia-associated neonatal deaths among 5,949,267 live births (rate: 1.13/1000) in SP. Spatial moving average maps showed a non-random distribution among municipalities, with presence of clusters (I = 0.048; p = 0.023). LISA map identified clusters of asphyxia-associated neonatal mortality in the south, southeast and northwest. After applying local Bayes estimates, clusters were more pronounced (I = 0.589; p = 0.001). There was a partial overlap of the areas of higher asphyxia-associated neonatal mortality and lower mean per capita GDP. CONCLUSIONS: Spatial analysis identified cluster areas of high asphyxia-associated neonatal mortality and low per capita GDP rates, with a significant negative correlation. This optimized, structured, and hierarchical approach to identify high-risk areas of cause-specific neonatal mortality may be helpful for guiding public health efforts to decrease neonatal mortality.

Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review.

CONTEXT: Parent/family presence at pediatric resuscitations has been slow to become consistent practice in hospital settings and has not been universally implemented. A systematic review of the literature on family presence during pediatric and neonatal resuscitation has not been previously conducted. OBJECTIVE: To conduct a systematic review of the published evidence related to family presence during pediatric and neonatal resuscitation. DATA SOURCES: Six major bibliographic databases was undertaken with defined search terms and including literature up to June 14, 2020. STUDY SELECTION: 3200 titles were retrieved in the initial search; 36 ultimately included for review. DATA EXTRACTION: Data was double extracted independently by two reviewers and confirmed with the review team. All eligible studies were either survey or interview-based and as such we turned to narrative systematic review methodology. RESULTS: The authors identified two key sets of findings: first, parents/family members want to be offered the option to be present for their child's resuscitation. Secondly, health care provider attitudes varied widely (ranging from 15% to >85%), however, support for family presence increased with previous experience and level of seniority. LIMITATIONS: English language only; lack of randomized control trials; quality of the publications. CONCLUSIONS: Parents wish to be offered the opportunity to be present but opinions and perspectives on the family presence vary greatly among health care providers. This topic urgently needs high quality, comparative research to measure the actual impact of family presence on patient, family and staff outcomes. PROSPERO REGISTRATION NUMBER: CRD42020140363.

Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review and meta-analysis.

CONTEXT: The International Liaison Committee on Resuscitation sought to review the initial management of non-vigorous newborns delivered through meconium stained amniotic fluid (MSAF). OBJECTIVE: To complete a systematic review and meta-analysis comparing endotracheal intubation and suctioning to immediate resuscitation without intubation for non-vigorous infants born at ≥34 weeks gestation delivered through MSAF. DATA SOURCES: Medline, EMBASE, the Cochrane Database of Systematic Reviews, and other registries were searched from 1966 to November 7, 2019. STUDY SELECTION: Studies were selected by pairs of independent reviewers in 2 stages. DATA EXTRACTION: Reviewers extracted data, appraised risk of bias, and assessed Grading of Recommendations Assessment, Development and Evaluation certainty of evidence for each outcome. RESULTS: Four randomized controlled trials (RCTs) included 581 patients and one observational study included 231 patients. No significant differences were observed between the group treated with tracheal suctioning compared with immediate resuscitation for survival at discharge (4 RCTs; risk ratio [RR] = 1.01; 95 % CI, 0.96-1.06; p = 0.69; observational study; no deaths), hypoxic ischemic encephalopathy and meconium aspiration syndrome. LIMITATIONS: The certainty of evidence was low for survival at discharge and very low for all other outcomes. CONCLUSIONS: For non-vigorous newborns delivered through MSAF, there is insufficient evidence to suggest routine immediate direct laryngoscopy with tracheal suctioning. PROSPERO: CRD42019122778. CLINICAL TRIALS REGISTRATION: PROSPERO; CRD42019122778.

Early neonatal deaths associated with perinatal asphyxia in infants ≥2500g in Brazil.

OBJECTIVE: To assess the annual burden of early neonatal deaths associated with perinatal asphyxia in infants weighing ≥2500g in Brazil from 2005 to 2010. METHODS: The population study enrolled all live births of infants with birth weight ≥2500g and without malformations who died up to six days after birth with perinatal asphyxia, defined as intrauterine hypoxia, asphyxia at birth, or meconium aspiration syndrome. The cause of death was written in any field of the death certificate, according to International Classification of Diseases, 10th Revision (P20.0, P21.0, and P24.0). An active search was performed in 27 Brazilian federative units. The chi-squared test for trend was applied to analyze early neonatal mortality ratios associated with perinatal asphyxia by study year. RESULTS: A total of 10,675 infants weighing ≥2500g without malformations died within six days after birth with perinatal asphyxia. Deaths occurred in the first 24h after birth in 71% of the infants. Meconium aspiration syndrome was reported in 4076 (38%) of these deaths. The asphyxia-specific early neonatal mortality ratio decreased from 0.81 in 2005 to 0.65 per 1000 live births in 2010 in Brazil (p<0.001); the meconium aspiration syndrome-specific early neonatal mortality ratio remained between 0.20 and 0.29 per 1000 live births during the study period. CONCLUSIONS: Despite the decreasing rates in Brazil from 2005 to 2010, early neonatal mortality rates associated with perinatal asphyxia in infants in the better spectrum of birth weight and without congenital malformations are still high, and meconium aspiration syndrome plays a major role.

Early neonatal deaths associated with perinatal asphyxia in infants ≥2500g in Brazil / Óbitos neonatais precoces associados à asfixia perinatal em neonatos ≥2500g no Brasil

Abstract Objective: To assess the annual burden of early neonatal deaths associated with perinatal asphyxia in infants weighing ≥2500 g in Brazil from 2005 to 2010. Methods: The population study enrolled all live births of infants with birth weight ≥2500 g and without malformations who died up to six days after birth with perinatal asphyxia, defined as intrauterine hypoxia, asphyxia at birth, or meconium aspiration syndrome. The cause of death was written in any field of the death certificate, according to International Classification of Diseases,10th Revision (P20.0, P21.0, and P24.0). An active search was performed in 27 Brazilian federative units. The chi-squared test for trend was applied to analyze early neonatal mortality ratios associated with perinatal asphyxia by study year. Results: A total of 10,675 infants weighing ≥2500 g without malformations died within six days after birth with perinatal asphyxia. Deaths occurred in the first 24 h after birth in 71% of the infants. Meconium aspiration syndrome was reported in 4076 (38%) of these deaths. The asphyxia-specific early neonatal mortality ratio decreased from 0.81 in 2005 to 0.65 per 1000 live births in 2010 in Brazil (p < 0.001); the meconium aspiration syndrome-specific early neonatal mortality ratio remained between 0.20 and 0.29 per 1000 live births during the study period. Conclusions: Despite the decreasing rates in Brazil from 2005 to 2010, early neonatal mortality rates associated with perinatal asphyxia in infants in the better spectrum of birth weight and without congenital malformations are still high, and meconium aspiration syndrome plays a major role.

Resumo Objetivo: Avaliar a taxa anual de óbitos neonatais precoces associados à asfixia perinatal em neonatos de peso ≥ 2.500 g no Brasil de 2005 a 2010. Métodos: A população do estudo envolveu todos os nascidos vivos de neonatos com peso ao nascer ≥ 2.500 g e sem malformações que morreram até seis dias após o nascimento por asfixia perinatal, definida como hipóxia intrauterina, asfixia no nascimento ou síndrome de aspiração de mecônio. A causa do óbito foi escrita em qualquer linha do atestado de óbito, de acordo com a Classificação Internacional de Doenças, 10a Revisão (P20.0, P21.0 e P24.0). Foi feita uma pesquisa ativa em 27 unidades federativas brasileiras. O teste qui-quadrado de tendência foi aplicado para analisar os índices de mortalidade neonatal associados a asfixia perinatal até o ano do estudo. Resultados: Morreram 10.675 neonatos com peso ≥ 2.500 g sem malformações até 0-6 dias após o nascimento por asfixia perinatal. Os óbitos ocorreram nas primeiras 24 horas após o nascimento em 71% dos neonatos. A síndrome de aspiração de mecônio foi relatada em 4.076 (38%) dos óbitos. O índice de mortalidade neonatal precoce relacionada à asfixia caiu de 0,81 em 2005 para 0,65 por 1.000 nascidos vivos em 2010 no Brasil (p < 0,001); o índice de mortalidade neonatal precoce relacionada a síndrome de aspiração de mecônio permaneceu entre 0,20-0,29 por 1.000 nascidos vivos durante o período do estudo. Conclusões: Apesar da redução nas taxas no Brasil de 2005 a 2010, as taxas de mortalidade neonatal precoce associadas à asfixia perinatal em neonatos no melhor espectro de peso ao nascer e sem malformações congênitas ainda são altas e a síndrome de aspiração de mecônio desempenha um importante papel.