Anquiloglosia neonatal. ¿Existe un exceso de indicación intervencionista? / Neonatal ankyloglossia. Is there an excess of interventionist indication?

Introducción: El objetivo de este estudio es analizar a los pacientes remitidos a cirugía para practicar una frenotomía en el periodo neonatal y revisar su correcta indicación, ya que en la actualidad no existe consenso en el diagnóstico y tratamiento de la anquiloglosia. Material y métodos: Se realizó un estudio retrospectivo de 136 pacientes con anquiloglosia derivados a la consulta de cirugía plástica pediátrica. Se recogieron datos sobre la remisión a la consulta, problemas de lactancia y experiencia anterior y posterior a la intervención. Resultados: Los principales motivos de consulta se relacionaron con problemas en la técnica de lactancia materna (69 pacientes [65,7%]). El dolor durante la toma era el síntoma más habitual, aunque 33 pacientes (31,4%) no presentaban síntomas. En la mayoría de los casos, la remisión a cirugía la realizó el pediatra de zona (85 pacientes [80%]). El tipo más frecuente de anquiloglosia en la muestra fue el tipo II. Sólo se detectó 1 caso de recidiva. La ansiedad debida a la separación durante la frenotomía fue la experiencia negativa más frecuente entre las madres. Discusión: La falta de indicaciones establecidas para la frenotomía, así como la relativa facilidad de la aplicación de la técnica en la edad neonatal y el auge de las campañas de lactancia materna, está derivando en un exceso de indicación quirúrgica como tratamiento de la anquiloglosia. Debe promoverse la creación de guías que definan unos criterios adecuados de tratamiento, así como favorecer la remisión a la consulta de lactancia como un paso previo a la cirugía (AU)

Introduction: The aim of this study is to analyze patients referred to frenotomy surgery during neonatal period and to review their correct indication, as nowadays there is no consensus on the diagnosis and treatment of ankyloglossia. Material and methods: A retrospective study of 136 patients with ankyloglossia referred to pediatric plastic surgery. Data collection was based on the consultation, breastfeeding problems and experiences before and after intervention. Results: The main reasons to attend consultation were related to breastfeeding technique (69 patients [65.7%]), and pain in between takes the more frequent symptom, nevertheless 33 patients (31.4%) had no symptoms. In most cases, referral to surgery was done by the pediatrician (85 patients [80%]). The most common type of ankyloglossia in the sample was type II. Only one case of recurrence was detected. Separation anxiety during frenotomy was the most frequent negative experience among mothers. Discussion: The lack of guidelines established for frenotomy and the relative ease of application of the technique in the neonatal age and the rise of breastfeeding campaigns, is leading to an excess of surgical indication as treatment of ankyloglossia. To create guidelines defining an appropriate criteria of treatment should be promoted, and to facilitate referrals to lactation consultation as a step prior to surgery (AU)

Incoherencia entre el nivel asistencial de las Unidades Neonatales y los pacientes atendidos / Inconsistency between the level of care in Neonatal Units and the patients in care

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Accidentes de tráfico, actuación desde la consulta de Atención Primaria / Traffic accidents, actions from the Primary Health clinic

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Actividades preventivas en los mayores / Preventive activities in the elderly

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Limitaciones de la procalcitonina como marcador único de sepsis neonatal de origen nosocomial / Limitations of procalcitonin as single marker of nosocomial neonatal sepsis

Introducción: Recientemente se ha sugerido que la procalcitonina (PCT) tiene capacidad discriminativa en el diagnóstico de sepsis neonatal. El objetivo de este estudio prospectivo multicéntrico es evaluar la utilidad de la PCT como marcador de sepsis neonatal de origen nosocomial. Pacientes y métodos: Se incluyeron 100 neonatos con sospecha de sepsis nosocomial de entre 4 y 28 días de vida ingresados en los servicios de neonatología de 13 hospitales de tercer nivel de España durante un período de 1 año. Se midió la concentración de PCT mediante análisis inmunoluminométrico. Se calculó la eficacia diagnóstica de la PCT en el momento de la sospecha de infección, a las 12-24 h y a las 36-48 h. Resultados: Se diagnosticaron 61 casos de sepsis nosocomial. Las concentraciones de PCT fueron superiores en los casos de sepsis nosocomial frente a los neonatos con sospecha de sepsis no confirmada. Los neonatos con sepsis por estafilococos coagulasa-negativos mostraron niveles de PCT más bajos que aquellos con sepsis nosocomial por otros agentes. Los puntos de corte óptimo para la PCT de acuerdo con las curvas ROC fueron 0,59 ng/mL en el momento de la sospecha de infección (sensibilidad 81,4%, especificidad 80,6%), 1,34 ng/mLa las 12-24 h (sensibilidad 73,7%, especificidad 80,6%) y 0,69 ng/mL a las 36-48 h (sensibilidad 86,5%, especificidad 72,7%) para el diagnóstico de sepsis de origen nosocomial. Conclusiones: La PCT mostró una moderada capacidad diagnóstica para la sepsis neonatal de origen nosocomial desde el momento de la sospecha de infección. Aunque por sí sola no sería suficientemente fiable, podría ser útil como parte de un chequeo de sepsis más completo (AU)

Background: It has recently been suggested that serum procalcitonin (PCT) is of value in the diagnosis of neonatal sepsis, with varying results. The aim of this prospective multicenter study was to assess the usefulness of PCT as a marker of neonatal sepsis of nosocomial origin. Methods: One hundred infants aged between 4 and 28 days of life admitted to the Neonatology Services of 13 acutecare teaching hospitals in Spain over 1-year with clinical suspicion of neonatal sepsis of nosocomial origin were included in the study. Serum PCT concentrations were determined by a specific immunoluminometric assay. The reliability of PCT for the diagnosis of nosocomial neonatal sepsis at the time of suspicion of infection and at 12-24 h and 36-48 h after the onset of symptoms was calculated. Results: The diagnosis of nosocomial sepsis was confirmed in 61 neonates. Serum PCT concentrations were significantly higher at initial suspicion and at 12–24 h and 36- 48 h after the onset of symptoms in neonates with confirmed sepsis than in neonates with clinically suspected but not confirmed sepsis. Optimal PCT thresholds according to ROC curves were 0,59 ng/mL at the time of suspicion of sepsis (sensitivity 81,4%, specificity 80,6%); 1,34 ng/mL within 12-24 h of birth (sensitivity 73,7%, specificity 80,6%), and 0,69 ng/mL within 36-48 h of birth (sensitivity 86,5%, specificity 72,7%). Conclusions: Serum PCT concentrations showed a moderate diagnostic reliability for the detection of nosocomial neonatal sepsis from the time of suspicion of infection. PCT is not sufficiently reliable to be the sole marker of sepsis, but would be useful as part of a full sepsis evaluation (AU)

[Loss to follow-up and cerebral palsy]. / Abandonos en el seguimiento de recién nacidos de muy bajo peso y frecuencia de parálisis cerebral.

BACKGROUND: The longer follow-up programs last, the greater the loss to follow-up. These losses to follow-up may undermine the completion of health care goals and the validity of study results. OBJECTIVES: 1) To compare neonatal characteristics in children easily followed-up and in those lost to follow-up. 2) To trace and assess children lost to follow-up. 3) To estimate the occurrence of cerebral palsy in children easily followed-up and in those lost to follow-up. METHODS: From 1991 to 1997, 601 neonates with a birth weight under 1,500 g were admitted to the Neonatology Department. At discharge, 447 infants were included in the follow-up program. Moderate-to-severe cerebral palsy was assessed when the children were aged 2 years. A specific search strategy was implemented to find those children lost to follow-up. Data on the development of those traced were updated through a standardized telephone questionnaire. RESULTS: Twenty percent of the children were lost to follow-up before the age of 2 years. Fifty-seven percent of those not available at this age were assessed by telephone interview. No differences were found in the neonatal characteristics of infants easily followed-up and those lost to follow-up except in situations of critical social disadvantage: 10 % in followed-up infants, 41 % in infants lost to follow-up. Disabling cerebral palsy was observed in 7 % of children easily followed-up and in 23 % of those lost and traced (relative risk: 3.1, 1.5-5.5). CONCLUSIONS: The risk of having disabling cerebral palsy is three times higher in children lost to follow-up than in those easily followed-up. Dismissing this source of bias may underestimate disability rates when assessing health care programs or when interpreting study results.

Abandonos en el seguimiento de recién nacidos de muy bajo peso y frecuencia de parálisis cerebral / Loss to follow-up and cerebral palsy

Fundamento: En los programas de seguimiento, a medida que se prolonga el seguimiento aumenta la proporción de abandonos. Estos abandonos limitan la consecución de los objetivos asistenciales y la validez de los estudios. Objetivos: Comparar las características neonatales de los niños seguidos con facilidad y de los que abandonaron el seguimiento. Encontrar y valorar a los niños que abandonaron el seguimiento y estimar la frecuencia de parálisis cerebral moderada-grave en los niños seguidos y en los que abandonaron. Métodos: Desde 1991 a 1997, ingresaron en servicio de neonatología 601 nacidos menores de 1.500 g. Al alta, fueron incluidos 447 niños en el programa. A los 2 años se valoró la presencia de parálisis cerebral moderada-grave en los que acudían a consulta. Se diseñó una estrategia de búsqueda para localizar los niños que habían abandonado y para recuperar datos sobre su evolución. Con un cuestionario telefónico se valoraron los niños localizados en la búsqueda. Resultados: El 20% de los niños abandonaron el seguimiento antes de los 2 años. Pudo recuperarse el 57%. Las características neonatales de los niños seguidos y de los que habían abandonado no difirieron salvo en la presencia de una situación social crítica: 10% en los seguidos y 41% en los perdidos. El 7% de los que se habían seguido presentó parálisis cerebral moderada-grave frente al 23% en los que habían abandonado y se recuperaron y evaluaron posteriormente (riesgo relativo, 3,1 [1,5-5,5]). Conclusiones Los niños que abandonan el seguimiento presentan una frecuencia de parálisis cerebral moderada-grave 3 veces mayor que los seguidos con facilidad. No considerar esta fuente de sesgo puede llevar a infraestimar la frecuencia de discapacidad cuando se valora los resultados de los programas de salud o se interpretan los resultados de los estudios (AU)

El neumococo: ¿un germen nuevo en el recién nacido? / Pneumococci: a new microorganism inthe newborn?

Objetivo: Revisar las características clínicas y sensibilidad antibiótica de las sepsis por Streptococcus pneumoniae en nuestra unidad neonatal. Métodos: Estudio retrospectivo de las sepsis por S. pneumoniaerecogidas en nuestra base de datos en los últimos 12 años. Resultados: Se han identificado un total de 8 casos de infección por S. pneumoniae. La edad gestacional osciló entre las 30 y las 38 semanas (mediana, 34 semanas) y el rango de peso al nacimiento fue entre 1.680 y 4.460g (mediana, 2.480 g). En 7 casos se identificaron factores de riesgo de infección. Aunque en 4 casos la presentación cursó con grave afectación hemodinámica y en otro con meningitis, todos evolucionaron hacia la curación. Se encontró resistencia a penicilina en 3 episodios. Conclusión: El S. pneumoniae es un germen causante de infecciones graves en el recién nacido. El creciente número de resistencias al tratamiento con penicilina y derivados hace que nos planteemos la necesidad de conocer la epidemiología local en cuanto a la proporción de madres portadoras y su relación con la infección neonatal, para elaborar estrategias de prevención y tratamiento (AU)

[Pneumococci: a new microorganism in the newborn?]. / El neumococo: un germen nuevo en el recién nacido?

OBJECTIVE: To study the clinical characteristics and susceptibility to antimicrobial agents of Streptococcus pneumoniae invasive infection in our neonatal unit. METHODS: Data from newborns with Streptococcus pneumoniae invasive infection in the last 12 years were retrospectively collected. RESULTS: Eight cases of invasive infection were identified. Gestational age ranged from 30 to 38 weeks (median: 34 weeks) and birth weight ranged from 1,680g to 4,460g (median: 2,480g). Risk factors related to infection were identified in 7 patients. Although infection manifested as shock in 4 patients and meningitis in 1, evolution was favorable in all patients. Penicillin resistance was found in 3 patients. CONCLUSIONS: Streptococcus pneumoniae produces serious disease in neonates. Because of the increasing prevalence of penicillin-resistant pneumococci, the relationship between the percentage of mothers colonized with pneumococci and neonatal infection should be determined to develop new prevention and treatment strategies in newborn infants.

Litter size and vagina-cervix catheter penetration length in gilts.

As in other species, the reproductive tract in pigs increases in size with age and body weight, and the development of the reproductive tract depends on a balance between development of the pituitary-ovarian axis and the influence of metabolic hormones. Two experiments were conducted in prepubertal Duroc gilts, 150-180 days of age, to determine whether litter size is related to vaginal-cervix catheter penetration length during insemination. In experiment 1, oestrus was induced in 452 gilts with a combined dose of 400 IU Pregnant Mare Serum Gonadotrophine (PMSG) + 200 IU human chorionic gonadotropin (hCG). The gilts were classified into three catheter penetration length groups: Ih, < or = 21 cm; IIh, > 21 and < 28 cm, IIIh, > 28 cm. The litter size was lowest in group Ih (7.35 +/- 0.15) compared with groups IIh (7.81 +/- 0.12; p < 0.05) and IIIh (10.0 +/- 0.36; p < 0.001). In experiment 2, first oestrus was induced in 162 gilts by boar exposure. The gilts were classified into three catheter penetration length groups at insemination during their second oestrus: In, < or = 24 cm; IIn, > 24 and < 26 cm; IIIn, > 26 cm. As in experiment 1, the litter size was lowest in the group with the shortest catheter penetration length (8.32 +/- 0.19). The litter size was not different among gilts of groups IIn and IIIn (8.84 +/- 0.35 and 9.56 +/- 0.46, respectively), but litter size was lower (p < 0.05) in group In than in group IIn. Based on the combined data from both experiments, the correlation between the catheter penetration length and total number of piglets born was expressed as: y =5.346 +/- 0.104x; r = 0.361 (p < 0.05). Fertility rate was not different among the groups of gilts induced into oestrus by hormone treatment or inseminated in the second oestrus; however, the total fertility rate of boar-exposed gilts was higher (p < 0.0001) than PMSG/hCG treated animals. Thus, it is possible to conclude that litter size at first farrowing is associated with vaginal-cervix catheter penetration length during insemination of the gilt.

[Experience with ventriculitis at a neonatology department]. / Ventriculitis: experiencia en un servicio de neonatología.

OBJECTIVE: To study the characteristics, treatment and follow-up of patients with ventriculitis in our neonatal unit. PATIENTS AND METHODS: Retrospective study of patients diagnosed with ventriculitis from January 1990 to December 1997. Diagnostic criteria were the identification of any bacteria in the ventricular fluid and pleocytosis (> or = 100 leukocytes per microl). Personal history, clinical and analytical findings and evolution after diagnosis were studied. RESULTS: We recorded ten cases of ventriculitis in nine patients. Six of them occurred as a complication of previous meningitis and four occurred after neurosurgical treatment. The mean age at diagnosis was of 38.8 days (range 8-130), and mean gestational age was 29.4 weeks (range 25-38). Clinical and ventricular fluid anomalies were seen in six cases and in four the diagnosis was made at autopsy. Treatment was systemic antibiotics. In two cases intraventricular antibiotics were added. Six patients died, ventriculitis being the direct cause of death in five. Of the three survivors, one had mental retardation and cerebral palsy and the other two had minor disabilities. CONCLUSIONS: During the neonatal period, a high degree of clinical suspicion and techniques for an early diagnosis and treatment are needed for ventriculitis.

[Age for sitting and walking in children born weighing less than 1,500 g and normal motor development at two years of age]. / Edad de sedestación y marcha en niños con peso al nacer menor de 1.500 g y desarrollo motor normal a los dos años.

OBJECTIVE: To estimate the corrected age (CA) of acquisition of sitting and walking in very low birth weight infants with normal motor outcome at 2 years of age and to determine whether transient hypertonia is associated with a delay in the acquisition of sitting and walking. METHODS: Follow-up study of very low birth weight infants (under 1500 g) admitted to the Neonatology Department of the Hospital 12 de Octubre from January 1991 to December 1996. At 2 years of age, 260 infants had normal motor outcome and 36% of these had been diagnosed with transient hypertonia. The age at which sitting and walking were attained was recorded by interview with the parents and was confirmed by examination. RESULTS: The mean CA at which sitting was attained was 7.2 +/- 1.4 months. Ninety percent of the infants had acquired sitting at a CA of 9 months. Mean age at which walking was attained was 13.4 +/- 2.8 months. Ninety percent could walk at 16 months. Infants with and without transient hypertonia acquired sitting and walking at the same age. CONCLUSIONS: Ninety percent of very low birth weight infants attained sitting at a CA of 9 months and walking at a CA of 16 months. Transient hypertonia did not modify the pattern of sitting and walking and it could be considered a variation of normality within the development of very premature infants.

Edad de sedestación y marcha en niños con peso al nacer menor de 1.500 g y desarrollo motor normal a los dos años / Age for sitting and walking in very-low-birth-weight infants with normal motor outcome at 2 years of age

OBJETIVO: Describir la cronología de adquisición de la sedestación y la marcha en los niños con un peso al nacer menor de 1.500 g con desarrollo motor normal a los 2 años de edad, y determinar si la presencia de hipertonía transitoria retrasa la adquisición de la sedestación o la marcha. MÉTODOS: Estudio observacional de una cohorte de niños con peso al nacer menor de 1.500 g atendidos entre enero de 1991 y diciembre de 1996 en el Servicio de Neonatología del Hospital 12 de Octubre. A los 2 años 260 niños tenían un desarrollo motor normal y, de éstos, un 36 por ciento habían sido diagnosticados de hipertonía transitoria en la evolución. Las edades de sedestación y marcha se establecieron por entrevista a los padres y se confirmaron por la exploración. RESULTADOS: La edad corregida (EC) media a la que alcanzaron la sedestación fue 7,2 ñ 1,4 meses. El 90 por ciento había alcanzado la sedestación a los 9 meses de EC. Con respecto a la marcha, la edad media a la que se alcanzó fue 13,4 ñ 2,8 meses. El 90 por ciento había alcanzado la marcha a los 16 meses. Los niños con y sin hipertonía transitoria alcanzaron la sedestación y la marcha a la misma EC. CONCLUSIÓN: El 90 por ciento de los niños con un peso al nacer menor de 1.500 g que a los 2 años tienen un desarrollo motor normal ha alcanzado la sedestación a los 9 meses de EC y la marcha a los 16 meses de EC. La hipertonía transitoria no parece modificar la cronología de adquisiciones motoras por lo que se puede considerar una variante de la normalidad en la evolución de los grandes prematuros (AU)

Ventriculitis: experiencia en un servicio de neonatología / Experience of ventriculitis in a neonatology department

Objetivo: Estudiar las características, tratamiento y evolución de los pacientes diagnosticados de ventriculitis en nuestro servicio de neonatología. Pacientes y métodos: Estudio retrospectivo de los casos de ventriculitis diagnosticados desde enero de 1990 a diciembre de 1997. Los criterios diagnósticos fueron presencia de germen en el líquido cefalorraquídeo (LCR) ventricular y pleocitosis ( >= 100 leucocitos/µl). Se estudiaron los antecedentes de cada paciente, sus hallazgos clínicos y analíticos y su evolución tras el diagnóstico de ventriculitis. Resultados Se registraron 10 episodios de ventriculitis en 9 pacientes. Seis de los episodios cursaron como complicación de una meningitis previa y los cuatro restantes fueron secundarios a intervenciones neuroquirúrgicas. La edad media al diagnóstico fue de 38,8 días (rango, 8-130) y la edad gestacional media de 29,4 semanas (rango, 25-38) Las alteraciones clínicas o del LCR estuvieron presentes en 6 de los episodios, diagnosticándose los otros cuatro por la autopsia. Se trataron con antibioterapia sistémica, y se añadió antibiótico intraventricular en 2 casos. Fallecieron 6 pacientes, siendo la ventriculitis causa directa de la muerte en cinco de ellos. De los 3 pacientes supervivientes, uno presenta retraso psicomotor profundo y leve los otros dos. Conclusión: En el período neonatal, son necesarios un elevado grado de sospecha clínica y ciertas técnicas diagnósticas para la detección precoz y tratamiento adecuado de la ventriculitis (AU)

[Changes in weight, length and head circumference in premature newborn babies weighing less than 1,500 grams at birth]. / Evolución del peso, la longitud--talla y el perímetro craneal en los prematuros de menos de 1.500 gramos al nacimiento.

OBJECTIVE: The objective of this study was to analyze the weight, length and head circumference development in prematurely born babies who weighed less than 1,500 grams and who were included in the follow-up program of our neonatal unit. PATIENTS AND METHODS: Review of data of the cohort included in the follow-up program between May 1990 and September 1995 was carried out. The weight and length were measured from 3 months of corrected age to 4 years of age. The head circumference was measured until 2 years of age. RESULTS: We recruited 259 premature newborns (136 boys and 123 girls). The median gestational age was 30 weeks (23 to 36) and the median weight was 1,150 g (500 to 1,499 g). Twenty-seven percent were underweight for their gestational age (LWGA). The proportion of cases with weight below the 3rd percentile in the follow-up was stable around 25% in the group of adequate weight for gestational age. (AWGA). At 3 months of corrected age this proportion was 70% in the LWGA group, but there was a trend towards catch-up at 2 years of age. The worst results were obtained in the group that weighed less than 750 g at birth. The head circumference was better preserved than longitudinal growth and thus better than weight. All cases of head circumference below the 3rd percentile in the follow-up occurs in the LWGA group. CONCLUSIONS: Weight was the parameter with the worst evolution during follow-up, especially in the group that weighed less than 750 g at birth. The group of LWGA tended to catch-up at 2 years of age.

[Outcome at 3 years of age in a low birth weight cohort]. / Evolución a los 3 años de edad de una cohorte de recién nacidos de muy bajo peso.

OBJECTIVE: The objective of this study was to establish the outcome at 3 years of age for very low birth weight newborns admitted to the Hospital 12 de Octubre from January 1991 to December 1993. PATIENTS AND METHODS: A follow-up study was performed. The pediatric assessment included a neurological, psychological, visual and audiological evaluation. At the end of the follow-up, children were blindly assessed to determine the rate of neurosensory disability. The severity of the neurosensory disability was graded as severe, moderate or mild by a functional classification. The rates of cerebral palsy, blindness and deafness were reported. RESULTS: Two hundred fifty-three infants between 500 and 1,499 g were admitted to the Hospital 12 de Octubre of which 182 survived. Of these, 137 (75% of the survivors) were assessed at 3 years of age. The children who dropped out during the follow-up period had similar characteristics to those with a complete follow-up program except that the drop-out child was more likely to belong to a disadvantaged family. The rate of neurosensory disability was 28.5% (39/137), 16% were mild, 5% moderate and 7% severe. The rate of cerebral palsy was 13% (18/137), blindness 1.4% and deafness 0.7%. CONCLUSIONS: Children from more disadvantaged families are less likely to continue in follow-up programs and this supposes a bias in the follow-up program. At 3 years, neurosensory disability was diagnosed in 1 out of every 4 children and cerebral palsy in 1 out of 8 children.