Echocardiography performed by the neonatologist: the impact on the clinical management.

BACKGROUND: The aim of this study was to assess whether neonatologist-performed echocardiography (NPE) changed the previously planned hemodynamic approach in critically ill newborn infants. METHODS: This prospective cross-sectional study included the first NPE of 199 neonates. Before the exam, the clinical team was asked about the planned hemodynamic approach and the answer was classified as an intention to change or not to change the therapy. After being informed about the NPE results, the clinical management was grouped as performed as previously planned (maintained) or modified. RESULTS: NPE modified the planned pre-exam approach in 80 cases (40.2%; 95% CI: 33.3-47.4%), and variables associated with an increased chance of this modification were exams to assess pulmonary hemodynamics (prevalent ratio (PR): 1.75; 95% CI: 1.02-3.00) and to assess systemic flow (PR: 1.68; 95% CI: 1.06-2.68) in relation to those requested for patent ductus arteriosus, pre-exam intention of changing the prescribed management (PR: 2.16; 95% CI: 1.50-3.11), use of catecholamines (PR: 1.68; 95% CI: 1.24-2.28) and birthweight (per kg) (PR: 0.81; 95% CI: 0.68-0.98). CONCLUSION: The NPE was an important tool to direct hemodynamic management in a different approach from the previous intention of the clinical team, mainly for critically ill neonates. IMPACT: This study shows that neonatologist-performed echocardiography guides the therapeutic planning in the NICU, mainly in the more unstable newborns, with lower birthweight and receiving catecholamines. Exams requested with the intention of modifying the current approach were more likely to change the management in a different way than planned pre-exam.

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..

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.

Bronchopulmonary dysplasia: temporal trend from 2010 to 2019 in the Brazilian Network on Neonatal Research.

OBJECTIVE: To evaluate the temporal trend of bronchopulmonary dysplasia (BPD) in preterm infants who survived to at least 36 weeks' post-menstrual age (PMA) and BPD or death at 36 weeks' PMA, and to analyse variables associated with both outcomes. DESIGN: Retrospective cohort with data retrieved from an ongoing national registry. SETTING: 19 Brazilian university public hospitals. PATIENTS: Infants born between 2010 and 2019 with 23-31 weeks and birth weight 400-1499 g. MAIN OUTCOME MEASURES: Temporal trend was evaluated by Prais-Winsten model and variables associated with BPD in survivors or BPD or death were analysed by logistic regression. RESULTS: Of the 11 128 included infants, BPD in survivors occurred in 22%, being constant over time (annual per cent change (APC): -0.80%; 95% CI: -2.59%; 1.03%) and BPD or death in 45%, decreasing over time (APC: -1.05%; 95% CI: -1.67%; -0.43%). Being male, small for gestational age, presenting with respiratory distress syndrome, air leaks, needing longer duration of mechanical ventilation, presenting with treated patent ductus arteriosus and late-onset sepsis were associated with an increase in the chance of BPD. For the outcome BPD or death, maternal bleeding, multiple gestation, 5-minute Apgar <7, late-onset sepsis, necrotising enterocolitis and intraventricular haemorrhage were added to the variables reported above as increasing the chance of the outcome. CONCLUSION: The frequency of BPD in survivors was constant and BPD or death decreased by 1.05% at each study year. These results show some improvement in perinatal care in Brazilian units which resulted in a reduction of BPD or death, but further improvements are still needed to reduce BPD in survivors.

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.

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.

Factors associated with clinical complications during intra-hospital transports in a neonatal unit in Brazil.

OBJECTIVE: Analyze factors associated with clinical complications during intra-hospital transport of neonatal intensive care unit (NICU) patients. METHODS: Prospective study of 641 infants submitted to 1197 intra-hospital transports at a public university NICU. Factors associated with clinical complications during intra-hospital transports were studied by multiple logistic regression analysis. RESULTS: Included infants had a mean gestational age of 35.1 ± 3.8 weeks and a birth weight of 2328 ± 906 g. Underline diseases were: malformations (71.9%), infections (7.6%), respiratory distress (4.1%) and others (16.4%). Patients were transported for surgical procedures (22.6%), magnetic resonance (10.6%), tomography imaging (20.9%), contrasted exams (18.2%), ultrasound (10.4%) and others (17.3%). Clinical complications occurred in 327 (27.3%) transports and were associated (odds ratio; 95% CI) with: central nervous system malformations (1.6; 95% CI 1.0-2.0); use of supplemental oxygen (4.0; 95% CI 2.8-5.6); mechanical ventilation (5.0; 95% CI 3.5-7.5); transport for surgeries (4.0; 95% CI 1.1-14.0) and duration of the transport longer than 120 min (1.6; 95% CI 1.1-2.4). CONCLUSIONS: Intra-hospital transports are associated with increased risk of clinical complications.

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.

Bundle to reduce unplanned extubation in a neonatal intensive care unit.

Objective: To evaluate the effectiveness of a bundle to reduce unplanned extubations (UE) in ventilated newborn infants (NB) and to verify the factors associated to UE.Method: Intervention study with a historical control group in a university hospital neonatal intensive care unit (NICU) between June 2014-May 2015 (Period I) and September 2015-August 2016 (Period II). All ventilated NB were included except those with facial malformations. The bundle (new tracheal tube fixation model, team training, identification of NB at risk of UE, and debriefing after UE episodes) was implemented between Periods I and II. Rates of UE/100 NB ventilated-day were compared between periods for the entire sample and according to the cause: accidental or by medical indication. Factors associated to the first UE episode of each NB were studied by logistic regression.Results: A total of 231 intubations were performed in 120 infants in Period I (gestational age 33.6 ± 4.7 W; birth weight: 2020 ± 929 g) and 212 intubations in 131 infants in Period II (34.2 ± 4.7 W; 2080 ± 997 g). UE occurred in 19.9% and 14.6% of the NB, in Periods I and II, respectively. Accidental extubation and change of the tube by medical indication were observed in 58.7% and 41.3% of UE in Period I and in 51.6% and 48.4% in Period II. Higher birth weight, lower SNAPPE-II score, and daytime period were associated with a lower chance of UE in all newborns.Conclusion: The bundle did not reduce the UE in NB ventilated in NICU but continued control of UE rates is crucial for improved care, especially for immature and critically neonates.What is new about the paper? The study presented a strategy for assessing the causes of unplanned extubations in a Neonatal Intensive Care Unit, considering not only the accidental extubations, but aldo the medical ordered extubations, which contributes to the definition of actions for the reduction of unplanned extubations in the NICU setting.

Chest expansion for assessing tidal volume in premature newborn infants on ventilators.

OBJECTIVES: To investigate whether clinical observation of chest expansion predicts tidal volume in neonates on mechanical ventilation and whether observer experience interferes with results. METHODS: An observational study that enrolled less experienced physicians in the first year of pediatric residency, moderately experienced (second year pediatric residency, first year of neonatology or pediatric intensive care specialization) or who were already experienced (second year neonatology specialization, graduate students or primary physician supervisors with minimum experience of 4 years in neonatology). These professionals observed the chest expansion of newborn infants on mechanical ventilation and estimated the tidal volume being supplied to the babies. True tidal volume given was calculated, indexed by the patient's current weight, and considered adequate between 4 and 6 mL/kg, insufficient below 4 mL/kg and excessive over 6 mL/kg. Results were analyzed using chi-square test. RESULTS: One hundred and eleven assessments were carried out with 21 newborn infants and the estimates given were in agreement with measured volume in 23.1, 41.3 and 65.7% for less, moderately and experienced physicians, respectively. These results are evidence that the three groups are not statistically equal (p = 0.013) and that the group of fully-experienced physicians have a better level of agreement than those with little or moderate experience (p = 0.007). CONCLUSIONS: Clinical analysis of chest expansion by physicians with less or moderate experience exhibit a low level of agreement with the tidal volume given to newborn infants on mechanical ventilation. Although increased experience did result in higher levels of agreement, chest expansion must still be interpreted with caution.

Costs of hospitalization in preterm infants: impact of antenatal steroid therapy.

OBJECTIVE: To estimate the costs of hospitalization in premature infants exposed or not to antenatal corticosteroids (ACS). METHOD: Retrospective cohort analysis of premature infants with gestational age of 26-32 weeks without congenital malformations, born between January of 2006 and December of 2009 in a tertiary, public university hospital. Maternal and neonatal demographic data, neonatal morbidities, and hospital inpatient services during the hospitalization were collected. The costs were analyzed using the microcosting technique. RESULTS: Of 220 patients that met the inclusion criteria, 211 (96%) charts were reviewed: 170 newborns received at least one dose of antenatal corticosteroid and 41 did not receive the antenatal medication. There was a 14-37% reduction of the different cost components in infants exposed to ACS when the entire population was analyzed, without statistical significance. Regarding premature infants who were discharged alive, there was a 24-47% reduction of the components of the hospital services costs for the ACS group, with a significant decrease in the length of stay in the neonatal intensive care unit (NICU). In very-low birth weight infants, considering only the survivors, ACS promoted a 30-50% reduction of all elements of the costs, with a 36% decrease in the total cost (p=0.008). The survivors with gestational age <30 weeks showed a decrease in the total cost of 38% (p=0.008) and a 49% reduction of NICU length of stay (p=0.011). CONCLUSION: ACS reduces the costs of hospitalization of premature infants who are discharged alive, especially those with very low birth weight and <30 weeks of gestational age.

[Advances in necrotizing enterocolitis]. / Avanços em enterocolite necrosante.

OBJECTIVE: To evaluate recently reported findings on necrotizing enterocolitis, Paying particular attention to pathogenesis, management and preventative strategies. DATA SOURCES: The articles covered in this report consist of randomized and quasi-randomized trials, case control studies, meta-analyses and reviews published recently. Certain other articles were also included because of their utmost importance to the subject. RESULTS: Necrotizing enterocolitis remains a major cause of morbidity and mortality in preterm infants. Those who are born with intra-uterine-growth retardation are at a several-fold increased risk. Possible pathophysiologic processes beginning in utero and continuing after birth are discussed in this review. Other factors involved in the process are related to the role of arginine and the production of intestinal nitric oxide and the action of epidermal growth factor in the regulation of cell regeneration. Perforated necrotizing enterocolitis is a complex surgical problem; definitive evidence-based guidelines for the best approach are yet to be determined. After surgery, although residual small bowel length and the presence of the ileo-cecal valve remain important predictors of duration of parenteral nutrition in infants, other factors, such as the early use of breast milk or amino acid-based formula, may also play a role in intestinal re-adaptation. Prevention strategies have centered on feeding practices and emerging experiments such as amino acid supplementation, are also discussed. CONCLUSION: Significant results in terms of mortality and morbidity will be achieved through better understanding of necrotizing enterocolitis pathogenesis and clinical and surgical management in addition to the employment of preventative strategies.

[Bronchopulmonary dysplasia]. / Displasia broncopulmonar.

OBJECTIVE: To present a wide-ranging review of the literature on broncopulmonary dysplasia, covering new definitions, pathophysiology, prevention, treatment, prognosis and progression. SOURCES OF DATA: The most relevant articles published on the subject since it was first described in 1967 were selected from MEDLINE search results. SUMMARY OF THE FINDINGS: Bronchopulmonary dysplasia is considered one of the primary causes of chronic lung disease among infants. It is associated with frequent and prolonged hospital admissions, in particular for pulmonary diseases, with high rates of mortality and alterations to neuropsychomotor development and pondero-statural growth. Pathogenesis is complex, being primarily influenced by prematurity, infection, supplementary oxygen and mechanical ventilation. Prevention involves appropriate prenatal care, the prevention of premature delivery, prenatal corticosteroids, surfactant replacement therapy and "protective" ventilatory strategies. Treatment of bronchopulmonary dysplasia patients demands a multidisciplinary team. When indicated, oxygen supplementation is extremely important. Despite increased risk of morbidity and mortality during the first years of life, long term progress is favorable in the majority of cases. CONCLUSIONS: Bronchopulmonary dysplasia has been and continues to be studied in great depth with the objective of identifying its causes and possible prevention and treatment strategies. Controversies remain with respect of these issues and also about the prognosis of these patients, in particular when the subject is long-term progress of "new" bronchopulmonary dysplasia patients.

Antenatal treatment with corticosteroids for preterm neonates: impact on the incidence of respiratory distress syndrome and intra-hospital mortality.

CONTEXT: Although the benefits of antenatal corticosteroids have been widely demonstrated in other countries, there are few studies among Brazilian newborn infants. OBJECTIVE: To evaluate the effectiveness of antenatal corticosteroids on the incidence of respiratory distress syndrome and intra-hospital mortality among neonates with a gestational age of less than 34 weeks. TYPE OF STUDY: Cross-sectional. SETTING: A tertiary-care hospital. PARTICIPANTS: Neonates exposed to any dose of antenatal corticosteroids for fetal maturation up to 7 days before delivery, and newborns paired by sex, birth weight, gestational age and time of birth that were not exposed to antenatal corticosteroids. The sample obtained consisted of 205 exposed newborns, 205 non-exposed and 39 newborns exposed to antenatal corticosteroids for whom it was not possible to find an unexposed pair. PROCEDURES: Analysis of maternal and newborn records. MAIN MEASUREMENTS: The primary clinical outcomes for the two groups were compared: the incidence of respiratory distress syndrome and intra-hospital mortality; as well as secondary outcomes related to neonatal morbidity. RESULTS: Antenatal corticosteroids reduced the occurrence of respiratory distress syndrome (OR: 0.33; 95% CI: 0.21-0.51) and the protective effect persisted when adjusted for weight, gestational age and the presence of asphyxia (adjusted OR: 0.27; 95% CI: 0.17-0.43). The protective effect could also be detected through the reduction in the need for and number of doses of exogenous surfactant utilized and the number of days of mechanical ventilation needed for the newborns exposed to antenatal corticosteroids. Their use also reduced the occurrence of intra-hospital deaths (OR: 0.51: 95% CI: 0.38-0.82). However, when adjusted for weight, gestational age, presence of prenatal asphyxia, respiratory distress syndrome, necrotizing enterocolitis and use of mechanical ventilation, the antenatal corticosteroids did not maintain the protective effect in relation to death. With regard to other outcomes, antenatal corticosteroids reduced the incidence of intraventricular hemorrhage grades III and IV (OR: 0.28; 95% CI: 0.10-0.77). CONCLUSIONS: Antenatal corticosteroids were effective in the reduction of morbidity and mortality among premature newborns in the population studied, and therefore their use should be stimulated within our environment.