Translating Neonatal Resuscitation Guidelines Into Practice in Brazil.

BACKGROUND AND OBJECTIVES: The Brazilian Neonatal Resuscitation Program releases guidelines based on local interpretation of international consensus on science and treatment recommendations. We aimed to analyze whether guidelines for preterm newborns were applied to practice in the 20 Brazilian Network on Neonatal Research centers of this middle-income country. METHODS: Prospectively collected data from 2014 to 2020 were analyzed for 8514 infants born at 230/7 to 316/7 weeks' gestation. The frequency of procedures was evaluated by gestational age (GA) category, including use of a thermal care bundle, positive pressure ventilation (PPV), PPV with a T-piece resuscitator, maximum fraction of inspired oxygen (Fio2) concentration during PPV, tracheal intubation, chest compressions and medications, and use of continuous positive airway pressure in the delivery room. Logistic regression, adjusted by center and year, was used to estimate the probability of receiving recommended treatment. RESULTS: For 3644 infants 23 to 27 weeks' GA and 4870 infants 28 to 31 weeks' GA, respectively, the probability of receiving care consistent with guidelines per year increased, including thermal care (odds ratio [OR], 1.52 [95% confidence interval (CI) 1.44-1.61] and 1.45 [1.38-1.52]) and PPV with a T-piece (OR, 1.45 [95% CI 1.37-1.55] and 1.41 [1.32-1.51]). The probability of receiving PPV with Fio2 1.00 decreased equally in both GA groups (OR, 0.89; 95% CI, 0.86-0.93). CONCLUSIONS: Between 2014 and 2020, the resuscitation guidelines for newborns <32 weeks' GA on thermal care, PPV with a T-piece resuscitator, and decreased use of Fio2 1.00 were translated into clinical practice.

Brazilian Translation, Cross-Cultural Adaptation, Validity, and Reliability of the EMpowerment of PArents in THe Intensive Care 30 (EMPATHIC-30) Questionnaire to Measure Parental Satisfaction in PICUs.

OBJECTIVES: To conduct the Brazilian translation, cross-cultural adaptation, validation, and reliability testing of the EMpowerment of PArents in THe Intensive Care (EMPATHIC-30). DESIGN: Prospective study. SETTING: PICU of a tertiary-care teaching hospital. PATIENTS: Parents (n = 141) completed the translated EMPATHIC-30 questionnaire 72 hours after their child's PICU discharge. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The translation and cultural adaptation were performed in accordance with the principles of good practice for the translation and cultural adaptation process for patient-reported outcomes measures. Sentences were adapted according to the Brazilian syntax. Total content validity coefficient was above the established average (> 0.8). Reliability was evaluated with the coefficients McDonald omega and Cronbach alpha. The lowest Cronbach alpha found was 0.47 (CI 95%, 0.35-0.59) in the organization domain, where the lowest response rate was also concentrated. The values of the other domains were as follows: 0.64 (95% CI, 0.55-0.73) for information, 0.77 (95% CI, 0.71-0.83) for care and treatment, 0.72 (95% CI, 0.66-0.78) for parent participation, and 0.72 (95% CI, 0.65-0.79) for professional attitudes. The total internal consistency independent of the domain was 0.90 (CI 95%, 0.88-0.92). With regard to McDonald Omega, values were identified: 0.68 (95% CI, 0.49-0.88) for information, 0.73 (95% CI, 0.61-0.85) for care and treatment, 0.85 (95% CI, 0.47-0.80) for parent participation, 0.85 (95% CI, 0.76-0.93), and 0.72 (95% CI, 0.58-0.86) for professional attitudes. CONCLUSIONS: EMPATHIC-30 has been translated and culturally adapted for the Brazilian population. Validation demonstrated an above-average total content validity coefficient, confirming the instrument content validity. A sufficient reliability was observed in both analyzed coefficients. The results support the use of the Brazilian version of EMPATHIC-30 for the evaluation of parents' satisfaction of children admitted to the PICU.

Prevalence, mortality and risk factors associated with very low birth weight preterm infants: an analysis of 33 years / Prevalência, mortalidade e fatores de risco associados ao prematuro de muito baixo peso ao nascer: uma análise de 33 anos

Abstract Objective: To assess the prevalence, mortality and risk factors associated with the birth of very low birth weight preterm infants over a period of 33 years. Methods: Four cross-sectional studies were analyzed, using data from perinatal interviews of birth cohorts in the city of Pelotas collected in 1982, 1993, 2004, and 2015. Based on perinatal questionnaires, anthropometric measurements of newborns and death certificates were analyzed to obtain the prevalence rate, neonatal mortality, and risk factors (maternal age, income and type of delivery) for very low birth weight. Results: A total of 19,625 newborns were included in the study. In the years 1982, 1993, 2004, and 2015, there were, respectively, 5909, 5232, 4226, and 4258 births. The prevalence of very low birth weight was, respectively, 1.1% (n = 64), 0.9% (n = 46), 1.4% (n = 61), and 1.3% (n = 54). There was no statistical evidence of an increasing trend over time (p = 0.11). Among the risk factors, family income in the three poorest quintiles was associated with prevalence rates that were approximately twice as high as in the richest quintile (p = 0.003). Mortality per 1000 live births for neonates weighing <1500 g decreased from 688 to 259 per thousand from 1982 to 2015 (p < 0.001), but still represented 61% of neonatal deaths in the latter year. Conclusion: Although mortality in very low birth weight decreased by more than 60% in recent years, this group still contributes with more than half of neonatal deaths. Low family income remains an important risk factor in this scenario.

Resumo Objetivo: Verificar a prevalência, mortalidade e fatores de risco associados aos nascimentos de prematuros de muito baixo peso ao nascer (MBPN) ao longo de 33 anos. Métodos: Série de quatro estudos transversais com o uso de dados das entrevistas perinatais das coortes de nascimento da cidade de Pelotas coletados em 1982, 1993, 2004 e 2015. A partir de questionários perinatais, medidas antropométricas dos recém-nascidos e certidões de óbito, foram analisadas a prevalência, a mortalidade neonatal e os fatores de risco (idade materna, renda e tipo de parto) para prematuros de muito baixo peso ao nascer. Resultados: Foram incluídos no estudo 19.625 recém-nascidos. Em 1982, 1993, 2004 e 2015 ocorreram, respectivamente, 5.909, 5.232, 4.226 e 4.258 nascimentos. A prevalência de prematuros de muito baixo peso ao nascer naqueles anos foi, respectivamente, de 1,1% (n = 64), 0,9% (n = 46), 1,4% (n = 61) e 1,3% (n = 54). A tendência de aumento durante o período não alcançou significância estatística (p = 0,11). Entre os fatores de risco, a renda familiar nos três quintis mais pobres esteve associada a prevalências cerca de duas vezes mais altas do que no quintil mais rico (p = 0,003). A mortalidade por 1.000 nascidos vivos para os neonatos com peso < 1500 g caiu de 688 para 259 por mil ao longo dos anos (p < 0,001), mas ainda representa 61% dos óbitos neonatais em 2015. Conclusão: Embora a mortalidade nos prematuros de muito baixo peso ao nascer tenha diminuído em mais de 60% nos últimos anos, esse grupo ainda contribui com mais da metade dos óbitos neonatais. A baixa renda familiar continua a ser fator de risco importante nesse cenário.

Prediction of Poor Outcomes for Septic Children According to Ferritin Levels in a Middle-Income Setting.

OBJECTIVES: To evaluate serum ferritin measured within 48 hours of admission as a prognostic marker and examine the association with unfavorable outcomes in a population of pediatric patients with sepsis and high prevalence of iron deficiency anemia in which this biomarker is routinely measured. DESIGN: Retrospective cohort study. SETTING: PICU of a tertiary care teaching hospital in a middle-income country in South America. PATIENTS: All patients 6 months to 18 years old (n = 350) admitted with a diagnosis of sepsis, suspected or proven, were eligible for inclusion. Exclusion criteria were length of PICU stay less than 8 hours and inherited or acquired disorder of iron metabolism that could interfere with serum ferritin levels. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three-hundred twelve patients had their ferritin levels measured within 48 hours, and only 38 did not. The prevalence of iron deficiency anemia (hemoglobin < 11 g/dL and mean corpuscular volume < 80 fl was 40.3%. The median of the highest serum ferritin level within 48 hours was 150.5 ng/mL (interquartile range, 82.25-362 ng/mL), being associated with mortality (p < 0.001; Exp(B), 5.170; 95% CI, 2.619-10.205). A 10-fold increase in ferritin level was associated with a five-fold increase in mortality. There was a monotonic increase in mortality with increasing ferritin levels (p < 0.05). Regarding the discriminatory power of ferritin for mortality, the area under the receiver operating characteristic curve was 0.787 (95% CI, 0.737-0.83; p < 0.0001). CONCLUSIONS: Serum ferritin at lower thresholds predicts mortality in children with sepsis admitted to the ICU in a middle-income country with high prevalence of iron deficiency anemia.

Prevalence, mortality and risk factors associated with very low birth weight preterm infants: an analysis of 33 years.

OBJECTIVE: To assess the prevalence, mortality and risk factors associated with the birth of very low birth weight preterm infants over a period of 33 years. METHODS: Four cross-sectional studies were analyzed, using data from perinatal interviews of birth cohorts in the city of Pelotas collected in 1982, 1993, 2004, and 2015. Based on perinatal questionnaires, anthropometric measurements of newborns and death certificates were analyzed to obtain the prevalence rate, neonatal mortality, and risk factors (maternal age, income and type of delivery) for very low birth weight. RESULTS: A total of 19,625 newborns were included in the study. In the years 1982, 1993, 2004, and 2015, there were, respectively, 5909, 5232, 4226, and 4258 births. The prevalence of very low birth weight was, respectively, 1.1% (n=64), 0.9% (n=46), 1.4% (n=61), and 1.3% (n=54). There was no statistical evidence of an increasing trend over time (p=0.11). Among the risk factors, family income in the three poorest quintiles was associated with prevalence rates that were approximately twice as high as in the richest quintile (p=0.003). Mortality per 1000 live births for neonates weighing <1500g decreased from 688 to 259 per thousand from 1982 to 2015 (p<0.001), but still represented 61% of neonatal deaths in the latter year. CONCLUSION: Although mortality in very low birth weight decreased by more than 60% in recent years, this group still contributes with more than half of neonatal deaths. Low family income remains an important risk factor in this scenario.

Fluid balance in pediatric patients in prone position: a pragmatic study.

OBJECTIVE: To verify the association between prone position, increased diuresis, and decreased cumulative fluid balance in critically ill pediatric patients who underwent mechanical ventilation (MV) for pulmonary causes and describe adverse events related to the use of the position. METHODS: This is a retrospective observational study. Patients aged between 1 month and 12 years who underwent MV for pulmonary causes, between January 2013 and December 2015, were selected and divided between those who were put on prone position (PG) and those who were not (CG) during the hospitalization at the Pediatric Intensive Care Unit (PICU). Data were analyzed longitudinally from D1 to D4. RESULTS: A total of 77 patients (PG = 37 and CG = 40) were analyzed. The general characteristics of both groups were similar. In the comparison between the groups, there was no increase in diuresis or decrease in cumulative fluid balance in the prone group. In the longitudinal analysis of D1 to D4, we saw that the PG presented higher diuresis (p = 0.034) and a lower cumulative fluid balance (p = 0.001) in D2. Regarding the use of diuretics, there was greater use of furosemide (P <0.001) and spironolactone (P = 0.04) in the PG. There was no increase in adverse events during the use of the prone position. CONCLUSION: The prone position was not associated with increased diuresis or decreased cumulative fluid balance in critically ill pediatric patients who underwent to MV for pulmonary causes.

Fluid balance in pediatric patients in prone position: a pragmatic study

SUMMARY OBJECTIVE: To verify the association between prone position, increased diuresis, and decreased cumulative fluid balance in critically ill pediatric patients who underwent mechanical ventilation (MV) for pulmonary causes and describe adverse events related to the use of the position. METHODS: This is a retrospective observational study. Patients aged between 1 month and 12 years who underwent MV for pulmonary causes, between January 2013 and December 2015, were selected and divided between those who were put on prone position (PG) and those who were not (CG) during the hospitalization at the Pediatric Intensive Care Unit (PICU). Data were analyzed longitudinally from D1 to D4. RESULTS: A total of 77 patients (PG = 37 and CG = 40) were analyzed. The general characteristics of both groups were similar. In the comparison between the groups, there was no increase in diuresis or decrease in cumulative fluid balance in the prone group. In the longitudinal analysis of D1 to D4, we saw that the PG presented higher diuresis (p = 0.034) and a lower cumulative fluid balance (p = 0.001) in D2. Regarding the use of diuretics, there was greater use of furosemide (P <0.001) and spironolactone (P = 0.04) in the PG. There was no increase in adverse events during the use of the prone position. CONCLUSION: The prone position was not associated with increased diuresis or decreased cumulative fluid balance in critically ill pediatric patients who underwent to MV for pulmonary causes.

RESUMO OBJETIVO: Verificar a associação entre posição prona, aumento da diurese e diminuição do balanço hídrico em pacientes pediátricos criticamente enfermos e submetidos à ventilação mecânica (VM) por causa pulmonar, além de descrever eventuais intercorrências relacionadas à aplicação dessa posição. MÉTODOS: Estudo observacional retrospectivo. Pacientes submetidos à VM por causa pulmonar, com idade entre 1 mês e 12 anos no período entre janeiro de 2013 e dezembro de 2015, foram selecionados e divididos entre os que receberam posição prona (GP) e os que não receberam (GC) durante a internação na Unidade de Terapia Intensiva Pediátrica (Utip). Os dados foram analisados longitudinalmente de D1 a D4. RESULTADOS: Foram analisados77 pacientes (GP=37 e GC=40). Em termos de características gerais, os grupos foram semelhantes entre si. Na comparação entre os grupos, não houve aumento da diurese ou diminuição do balanço hídrico cumulativo no grupo prona. Na análise longitudinal de D1 a D4, evidenciou-se que o GP apresentou maior diurese (p=0,034) e menor balanço hídrico cumulativo (p = 0,001) no D2. Com relação ao uso de diuréticos, houve maior uso de furosemida (P<0,001) e de espironolactona (P=0,04) no GP. Não houve aumento de eventos adversos durante a utilização da posição prona. CONCLUSÃO: A posição prona não demonstrou associação com aumento da diurese ou diminuição de balanço hídrico cumulativo em pacientes críticos pediátricos submetidos à VM por causa pulmonar.

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.

Cardiac dysfunction and ferritin as early markers of severity in pediatric sepsis / Disfunção cardíaca e a ferritina como marcadores precoces de gravidade na sepse pediátrica

Abstract Objective: The aim of this study was to verify the association of echocardiogram, ferritin, C-reactive protein, and leukocyte count with unfavorable outcomes in pediatric sepsis. Methods: A prospective cohort study was carried out from March to December 2014, with pediatric critical care patients aged between 28 days and 18 years. Inclusion criteria were diagnosis of sepsis, need for mechanical ventilation for more than 48 h, and vasoactive drugs. Serum levels of C-reactive protein, ferritin, and leukocyte count were collected on the first day (D0), 24 h (D1), and 72 h (D3) after recruitment. Patients underwent transthoracic echocardiography to determine the ejection fraction of the left ventricle on D1 and D3. The outcomes measured were length of hospital stay and in the pediatric intensive care unit, mechanical ventilation duration, free hours of VM, duration of use of inotropic agents, maximum inotropic score, and mortality. Results: Twenty patients completed the study. Patients with elevated ferritin levels on D0 had also fewer ventilator-free hours (p = 0.046) and higher maximum inotropic score (p = 0.009). Patients with cardiac dysfunction by echocardiogram on D1 had longer hospital stay (p = 0.047), pediatric intensive care unit stay (p = 0.020), duration of mechanical ventilation (p = 0.011), maximum inotropic score (p = 0.001), and fewer ventilator-free hours (p = 0.020). Conclusion: Cardiac dysfunction by echocardiography and serum ferritin value was significantly associated with unfavorable outcomes in pediatric patients with sepsis.

Resumo Objetivo: Verificar a associação do ecocardiograma, da ferritina, da proteína C reativa (PCR) e da contagem de leucócitos com desfechos desfavoráveis na sepse pediátrica. Métodos: Estudo de coorte prospectivo, de março a dezembro de 2014, com pacientes críticos pediátricos entre 28 dias e 18 anos. Critérios de inclusão foram diagnóstico de sepse, necessidade de ventilação mecânica (VM) por mais de 48 horas e uso de drogas vasoativas. Avaliaram‐se os níveis séricos PCR, ferritina, contagem de leucócitos, no recrutamento (D0), 24 horas (D1) e 72 horas (D3) após o recrutamento. No D1 e no D3 todos os pacientes foram submetidos a ecocardiograma transtorácico para determinação da Fração de Ejeção (FE) do ventrículo esquerdo. Os desfechos avaliados foram tempo de internação hospitalar e na Unidade de Terapia Intensiva Pediátrica (UTIP); duração da VM; horas livres de VM; duração do uso de inotrópicos; escore de inotrópicos máximo e mortalidade. Resultados: Vinte pacientes completaram o estudo. Ferritina elevada no D0 associou‐se com menor tempo livre de ventilação (p = 0,046) e maior escore de inotrópicos máximo (p = 0,009). A disfunção cardíaca pelo ecocardiograma no D1 relacionou‐se com maior tempo de internação hospitalar (p = 0,047), de UTIP (p = 0,020), VM total (p = 0,011), escore de inotrópicos máximo (p = 0,001) e menor tempo livre de VM (p = 0,020). Conclusão: A disfunção cardíaca pelo ecocardiograma e o valor de ferritina sérica associaram‐se significativamente com desfechos desfavoráveis nos pacientes pediátricos com sepse.

Cardiac dysfunction and ferritin as early markers of severity in pediatric sepsis.

OBJECTIVE: The aim of this study was to verify the association of echocardiogram, ferritin, C-reactive protein, and leukocyte count with unfavorable outcomes in pediatric sepsis. METHODS: A prospective cohort study was carried out from March to December 2014, with pediatric critical care patients aged between 28 days and 18 years. Inclusion criteria were diagnosis of sepsis, need for mechanical ventilation for more than 48h, and vasoactive drugs. Serum levels of C-reactive protein, ferritin, and leukocyte count were collected on the first day (D0), 24h (D1), and 72h (D3) after recruitment. Patients underwent transthoracic echocardiography to determine the ejection fraction of the left ventricle on D1 and D3. The outcomes measured were length of hospital stay and in the pediatric intensive care unit, mechanical ventilation duration, free hours of VM, duration of use of inotropic agents, maximum inotropic score, and mortality. RESULTS: Twenty patients completed the study. Patients with elevated ferritin levels on D0 had also fewer ventilator-free hours (p=0.046) and higher maximum inotropic score (p=0.009). Patients with cardiac dysfunction by echocardiogram on D1 had longer hospital stay (p=0.047), pediatric intensive care unit stay (p=0.020), duration of mechanical ventilation (p=0.011), maximum inotropic score (p=0.001), and fewer ventilator-free hours (p=0.020). CONCLUSION: Cardiac dysfunction by echocardiography and serum ferritin value was significantly associated with unfavorable outcomes in pediatric patients with sepsis.

Lamellar body count and stable microbubble test on tracheal aspirates from infants for the diagnosis of respiratory distress syndrome.

OBJECTIVES: To evaluate the performance of lamellar body count in tracheal aspirates from intubated preterm babies to predict respiratory distress syndrome. DESIGN: Case-control study. SETTING: Three neonatal intensive care units. PATIENTS: Seventy-two patients not older than 3 days were included in the study, 38 preterm infants with respiratory distress syndrome, 16 preterms without respiratory distress syndrome, and 18 term infants. All required mechanical ventilation. INTERVENTIONS: Lamellar body count was performed in an automated cell counter. Tracheal samples were diluted in dithiothreitol without centrifugation and kept frozen at -20°C until use. Samples were placed in a dithiothreitol-containing test tube at a ratio of one part tracheal aspirate to six parts dithiothreitol solution, vortexed for 10 secs, and aspirated by the cell counter. Lamellar body count was performed using the platelet channel. All results were multiplied by seven. The stable microbubble test was done for comparison. MEASUREMENTS: Lamellar body count and stable microbubble test. MAIN RESULTS: Lamellar body count was significantly lower in the respiratory distress syndrome group compared with the non respiratory distress syndrome preterm group and also with the term group. The median and interquartile range obtained for lamellar body count were 38,500/µL (14,000-112,000) for the respiratory distress syndrome group, 822,500/µL (442,000-962,500) for the non respiratory distress syndrome preterm group, and 633,000/µL (322,000-1,608,000) for the term group (p < .001). The sensitivity and specificity of lamellar body count and stable microbubble test for the diagnosis of respiratory distress syndrome were calculated, taking into consideration the respiratory distress syndrome and the non respiratory distress syndrome preterm groups. Considering a cutoff point of 200,000 lamellar bodies/µL, lamellar body count sensitivity was 92.1% (95% confidence interval 78.6-98.3) and lamellar body count specificity was 93.8% (95% confidence interval 69.8-99.8). The area under the curve was 0.94 (95% confidence interval 0.84-1.00). CONCLUSIONS: Lamellar body count and stable microbubble test can be rapidly and easily performed on tracheal aspirates and they seem to have very good performance for diagnosing respiratory distress syndrome in intubated patients.

Comparação de técnicas não invasivas para medir a pressão arterial em recém-nascidos / Comparison of noninvasive techniques to measure blood pressure in newborns

OBJETIVO: Comparar a pressão arterial pelos métodos do flush, da oximetria de pulso e da oscilometria utilizando o Doppler em neonatos. MÉTODOS: Foram realizadas medidas de pressão arterial não invasiva utilizando três métodos distintos (flush, oximetria de pulso e oscilometria automática) em três grupos de recém-nascidos selecionados por sorteio: 15 a termo e normais, 16 prematuros estáveis e 14 doentes. Todas as medidas foram filmadas, editadas separadamente, codificadas e analisadas independentemente por três neonatologistas. RESULTADOS: Realizaram-se 57 medidas por cada método. Os métodos do flush e da oximetria de pulso mostraram melhor correlação com o Doppler do que a oscilometria (coeficiente de correlação 0,89, 0,85 e 0,71, respectivamente, p < 0,01). A diferença entre as médias das medidas, seus respectivos desvios padrão e o intervalo de confiança de 95 por cento quando comparados com Doppler foram: -5,2±7,9 (-21,1:10,7) mmHg com o método do flush; 0,4±8,9 (-17,5:18,2) mmHg com a oximetria de pulso; e 6,4±16,1 (-25,8:8,6) mmHg com a oscilometria. O método do flush mostrou melhor concordância com o Doppler para diagnóstico de hipotensão do que os métodos da oximetria e da oscilometria. CONCLUSÕES: Os métodos do flush e da oximetria de pulso mostraram-se úteis para medir a pressão arterial sistólica de recém-nascidos, sendo que o método oscilométrico mostrou-se o menos concordante com o Doppler para detectar hipotensão.

OBJECTIVE: To compare blood pressure measurements in newborn infants using the flush method, pulse oximetry and oscillometry according to Doppler findings. METHODS: Noninvasive blood pressure measurements were made using three techniques (flush method, pulse oximetry and oscillometry) in three groups of newborns: 15 normal term infants, 16 stable preterm infants, and 14 critically ill infants. All measurements were video recorded, edited separately, coded and analyzed independently by three neonatologists. RESULTS: Fifty-seven measurements were made using each method. The flush method and pulse oximetry had a better correlation with Doppler findings than oscillometry (correlation coefficients: 0.89, 0.85, 0.71; p < 0.01). The difference between measurement means, their standard deviations and the 95 percent confidence intervals when compared with Doppler findings were: -5.2±7.9 (-21.1:10.7) mmHg for the flush method; 0.4±8.9 (-17.5:18.2) mmHg for pulse oximetry; and 6.4±16.1 (-25.8:8.6) mmHg for oscillometry. The flush method had a better agreement with Doppler findings for the diagnosis of hypotension than oximetry and oscillometry. CONCLUSIONS: The flush method and pulse oximetry seem to be useful techniques to measure systolic blood pressure in newborn infants; oscillometry had the poorest agreement with Doppler findings to detect hypotension.

Comparison of noninvasive techniques to measure blood pressure in newborns.

OBJECTIVE: To compare blood pressure measurements in newborn infants using the flush method, pulse oximetry and oscillometry according to Doppler findings. METHODS: Noninvasive blood pressure measurements were made using three techniques (flush method, pulse oximetry and oscillometry) in three groups of newborns: 15 normal term infants, 16 stable preterm infants, and 14 critically ill infants. All measurements were video recorded, edited separately, coded and analyzed independently by three neonatologists. RESULTS: Fifty-seven measurements were made using each method. The flush method and pulse oximetry had a better correlation with Doppler findings than oscillometry (correlation coefficients: 0.89, 0.85, 0.71; p < 0.01). The difference between measurement means, their standard deviations and the 95% confidence intervals when compared with Doppler findings were: -5.2 ± 7.9 (-21.1:10.7) mmHg for the flush method; 0.4 ± 8.9 (-17.5:18.2) mmHg for pulse oximetry; and 6.4 ± 16.1 (-25.8:8.6) mmHg for oscillometry. The flush method had a better agreement with Doppler findings for the diagnosis of hypotension than oximetry and oscillometry. CONCLUSIONS: The flush method and pulse oximetry seem to be useful techniques to measure systolic blood pressure in newborn infants; oscillometry had the poorest agreement with Doppler findings to detect hypotension.

Selective surfactant prophylaxis in preterm infants born at < or =31 weeks' gestation using the stable microbubble test in gastric aspirates.

OBJECTIVE: To evaluate the stable microbubble test (SMT) ability to select candidates for surfactant prophylaxis for respiratory distress syndrome (RDS). STUDY DESIGN: We followed patients treated according to a new routine for surfactant prophylaxis based on the SMT to determine timing of the initial dose of surfactant, proportion of infants using surfactant, and the predictive value of the SMT. Gastric secretions were collected after birth. Newborns with < 25 microbubbles (MB)/mm(2) received prophylactic surfactant. Surfactant was given only after confirmation of RDS (rescue therapy) to newborns with > or =25 MB/mm(2). RESULTS: Fifty-four (55%) had a low MB count and received prophylactic surfactant. Three out of 44 infants with a high MB count required rescue therapy (negative predictive value 93%; CI:81.3-98.6%). The median interval and interquartile range between surfactant administration and birth in the prophylaxis group was 20 (17-27) minutes. Surfactant was used in 23 of 28 (82%) infants born at < 28 weeks of gestation and in 34 of 70 (49%) infants between 28 and 31 weeks. CONCLUSIONS: The SMT may be useful to determine surfactant prophylaxis (< 30 min after birth). This approach may reduce costs and the number of unnecessary interventions.

Uso antenatal de corticosteróide e evolução clínica de recém-nascidos pré-termo / Antenatal corticosteroid use and clinical evolution of preterm newborn infants

OBJETIVO: Descrever a freqüência de utilização de corticosteróide antenatal e a evolução clínica dos recém-nascidos pré-termo. MÉTODOS: Estudo observacional prospectivo tipo coorte de todos os neonatos com idade gestacional entre 23 e 34 semanas nascidos na Rede Brasileira de Pesquisas Neonatais entre agosto e dezembro de 2001. Os prontuários médicos foram revistos, as mães entrevistadas e os pré-termos acompanhados. A análise dos dados foi realizada com o teste do qui-quadrado, t de Student, Mann-Whitney, ANOVA e regressão logística múltipla, com nível de significância de 5 por cento. RESULTADOS: Avaliaram-se 463 gestantes e seus 514 recém-nascidos. As gestantes tratadas tiveram mais gestações prévias, consultas de pré-natal, hipertensão arterial e maior uso de tocolíticos. Suas crianças apresentaram melhores escores de Apgar no 1º e 5º minutos, menor necessidade de intervenção na sala de parto e menor SNAPPE II. Nasceram com maior peso e idade gestacional, receberam menos surfatante exógeno, ventilação mecânica e oxigenoterapia. Após regressão logística, o uso pré-natal de corticosteróides manteve de forma independente o efeito protetor para as condições de nascimento e para a diminuição do tempo de ventilação mecânica e esteve associado com aumento na ocorrência de sepse neonatal. CONCLUSAO: O uso do corticosteróide antenatal foi associado a melhor atendimento pré-natal. As crianças nasceram em melhores condições e tiveram melhor evolução, porém com maior risco de infecção.

Evaluation of surfactant function at birth determined by the stable microbubble test in term and near term infants with respiratory distress.

UNLABELLED: Surfactant function using the stable microbubble test (SMT) was investigated in term or near term infants with respiratory distress. Newborn infants > or = 34 weeks gestation with an initial clinical hypothesis of transient tachypnoea of the newborn (TTN) needing supplemental oxygen and controls were included. Gastric aspirates were collected immediately after birth for SMT. The first chest X-ray films were examined by three independent radiologists and according to their interpretation the babies were divided into a TTN, a respiratory distress syndrome of the newborn (RDS), or a poorly-defined X-ray group. A total of 32 infants with respiratory distress and 32 controls with similar gestational age and birth weight were studied. The median and interquartile range (IQR) of the stable microbubble (SMB) count was significantly lower (P < 0.001) for the respiratory distress group than for the control group (17; range 6-33 versus 120; range 79-275). The proportion of babies with less than 35 stable microbubbles/mm2 (SMB/mm2) was significantly different for the whole respiratory distress group (24/32-75%) and for the TTN (9/13-69%), the RDS (5/5-100%), and the poorly-defined (10/12-83%) groups as compared with the controls (2/32-6%; P < 0.05). A total of 24/26 babies (92%) who needed oxygen for > or = 24 h but only 1/6 (17%) of them who needed < 24 h had a bubble count of less than 35 SMB/mm2 (P < 0.05). CONCLUSION: the results suggest that deficiency or dysfunction of the surfactant system is involved in the majority of cases of respiratory distress in near term and possibly term babies. The stable microbubble test can enable clinicians to take an earlier decision to give surfactant to term or near term infants with more severe and progressive respiratory distress.

[Exogenous surfactant therapy in pediatrics]. / Terapia com surfactante pulmonar exógeno em pediatria.

OBJECTIVE: To review current knowledge about the use of exogenous surfactants in the treatment of different lung diseases causing acute respiratory failure in children. SOURCE OF DATA: This review is based on the author's experience and on recent data retrieved from ONIA, Mdconsult, Medline and the Cochrane Database Library. SUMMARY OF THE FINDINGS: In spite of the success of the use of exogenous surfactants in Respiratory Distress Syndrome (RDS) of the newborn, some questions remain unanswered, such as the optimal administration timing - either very early (prophylactic), based on gestational age or on quick tests of lung maturity, or later, when the clinical picture becomes unequivocal. In other severe diseases requiring ventilatory support, the use of surfactants is still controversial, and data in the literature are limited and conflicting. However, successful use in several other diseases has been reported. Recent studies have focused on surfactant inactivation by substances that can be found in the airways. New surfactants with the addition of substances to control inhibition, such as polyethyleneglycol, are being tested for diseases in which inactivation seems to be a significant factor. CONCLUSIONS: Therapy with exogenous surfactants, even as a treatment for RDS, has not been thoroughly investigated. Further studies should be conducted to improve surfactants - mainly their resistance to inhibition - and the treatment of diseases other than RDS.

Stable microbubble test and click test to predict respiratory distress syndrome in preterm infants not requiring ventilation at birth.

AIMS: To determine the usefulness of the stable microbubble test (SMT) and of the click test (CT) on gastric aspirates obtained soon after birth to predict respiratory distress syndrome (RDS) in preterm babies not requiring ventilation at birth. PATIENTS AND METHODS: The study was carried out with a cohort between 24 and 34 weeks of gestational age. Gastric secretions were collected before 1 hour of life and frozen for further analysis. RESULTS: 110 neonates were studied. For a cut-off value 10 microbubbles/mm2 (mb/mm2) the sensitivity and specificity to predict RDS were 73.9 % and 92%, respectively, in the SMT. The best SMT cut-off point to predict RDS was < or = 15 mb/mm2 (sensitivity = 82.6% specificity = 85.1%) if equal weight was given to false-positive and false-negative results. CT (104 samples) showed a sensitivity of 100% and a specificity of 45.1% to predict RDS. The overall accuracy of the SMT was better than the overall accuracy of the CT (87.5% vs. 64.4%; p < 0.001) to predict RDS. CONCLUSIONS: The SMT is more accurate than the CT to predict RDS in infants below 35 weeks of gestational age and may be helpful to select patients to receive surfactant.

Doença periodontal na gravidez e baixo peso ao nascer / Periodontal disease in pregnancy and low birth weight

Objetivo: Sabe-se, de longa data que infecções dentogengivais podem ter repercussões orgânicas a distância. Recentemente, foi sugerido que a doença periodontal na gravidez seja uma causa determinante de baixo peso ao nascer. Objetivo: avaliar a influência da doença periodontal na gravidez sobre o peso de nascimento dos recém-nascidos. Pacientes e Métodos: Mães de recém-nascidos (RNs) com peso <2500 gramas selecionadas na forma de amostra de conveniência (Grupo I - GI; n=13). Para cada mãe do GI, era selecionada, como controle, a mãe do próximo recém-nascido (RN) a termo, com peso > ou = a 2500g (Grupo II - GII;n=13). As mães eram examinadas por um periodontistas não informado do peso da criança, o qual utilizou uma sonda milimetrada para medir a perda de inserção do osso alveolar. Os índices de extensão (IE) e severidade (IS) da doença periodontal foram determinados usando-se fórmulas descritas por Carlos et al. Resultados: Ambos os grupos de mães eram similares no que se refere a idade, paridade, raça, estastura, nutrição, tabagismo, uso de álcool, situação socioeconomica, pré-natal, rotura prematura de membranas, corioamnionite, bacteriúria, placenta prévia, descolamento de placenta, hipertenção prévia, pré-eclampsia e cardiopatia. As características dos recém-nascidos eram as seguintes: peso ao nascer - GI=1804ñ675g x GII=3030ñ516g; idade gestacional (DUM) - GI = 33ñ5 sem. x GII=39ñ2 sem.; tempo em UTI - GI = 128 dias x GII=0 dias. O IE médio foi de GI = 89,788ñ18,355 x GII=72,420ñ20,717; P=0,033. O IS médio foi de GI= 1,377ñ0,626 x GII=0,754ñ0,413;("Odds ratio" - OP=18,3; IC95 por cento: 2,5 a 133,3; P=0,006). Após ajuste para diversos fatores de risco para baixo peso incluindo fumo, estatura materna, bacteriúria e hipertensão prévia, o OR do IS caiu para 7,2 (0,4 a 125,4; P=0,176). Conclusões: a análise multivariada mostrou uma forte associação entre doença periodontal, marcada pelo escore IS, e baixo peso ao nascer. Os dados sugerem a possibilidade de que a doença periodontal na gravidez seja um fator de risco para o nascimento com baixo peso