El prematuro tardío, ¿qué sabemos desde el punto de vista perinatal? / The late premature, what do we know from the perinatal point of view?

Resumen El parto prematuro es la principal causa de morbimortalidad neonatal en Chile. Los prematuros tardíos, definidos como nacimientos entre 34 semanas con 0 días (34+0) y 36 semanas con 6 días (36+6) de gestación, representan el 70-80% de los prematuros y se asocian a baja morbilidad y excepcional mortalidad si se comparan con partos bajo 34 semanas, pero significativamente mayor al compararlos con partos de término. Los prematuros tardíos son el resultado de diversas condiciones obstétricas, tales como síndromes hipertensivos del embarazo, rotura prematura de membranas, colestasia intrahepática del embarazo y comorbilidad médica. El propósito de esta revisión es actualizar la información asociada a los prematuros tardíos y dar una visión de las tendencias en el uso de corticoides y el manejo expectante de la rotura prematura de membranas con el objetivo de disminuir las complicaciones en este grupo de prematuros.

Abstract Preterm delivery is the most important cause of neonatal morbidity and mortality in Chile. Late preterm, defined as deliveries between 34 +0 and 36+6-weeks accounts for 70-80% of preterm and is associated with non-severe morbidity and extremely low mortality when compared with deliveries below 34 weeks but significantly high when compared with full term babies. Late preterm deliveries are a result of several obstetric conditions, such a hypertensive disorder, premature rupture of membranes, intrahepatic cholestasis, and maternal medical comorbidities. The purpose of this review is to update the information associated with the risks of late preterm and to guide in the new trends in the application of steroid and expectant management for premature rupture of membranes in order to reduce the frequency of late preterm.

Implicações da deficiência materna de vitamina D: uma revisão sistemática / Implication of maternal vitamin D deficiency: a systematic review

O estudo objetiva avaliar a relação dos níveis de vitamina D em gestantes com as principais complicações gestacionais. A pesquisa foi realizada nas bases de dados PubMed, LILACS e BIREME, sendo selecionados artigos relevantes publicados de 2013 a 2018, usando os descritores: "vitamin D" AND "maternity" OR "pregnancy". Foram revisados 14 estudos observacionais incluindo casos-controles e coortes que investigaram a relação dos níveis de vitamina D maternos com pré-eclâmpsia, diabetes mellitus gestacional e prematuridade, sendo excluídos os estudos que utilizaram suplementação de vitamina D. Os dados foram extraídos por meio de uma tabulação com as seguintes informações: autor, ano da publicação, país do estudo, score obtido no downs and black, ano da coleta da amostra, tipo do estudo, número de participantes, método de obtenção da amostra de 25(OH)D, tempo da gestação na obtenção da amostra, complicação obstétrica, fatores de confusão ajustados e os principais desfechos. Foi obtido um total de 32.505 pacientes após a soma das amostras de todos os artigos analisados. O principal resultado encontrado, abrangendo as três comorbidades analisadas, relaciona níveis menores que 30 nmol/L de vitamina D como potencial fator de risco para pré-eclâmpsia, diabetes mellitus gestacional e prematuridade.(AU)

The study aims to assess the relationship between vitamin D levels in pregnant women and the main gestational complications. The research was carried out in the PubMed, LILACS and BIREME databases, with the selection of relevant articles published from 2013 to 2018, using the descriptors: "vitamin D" AND "maternity" OR "pregnancy". 14 observational studies were reviewed including control cases and cohorts that investigated the relationship between maternal vitamin D levels and pre-eclampsia, gestational diabetes mellitus and prematurity, and studies that used vitamin D supplementation were excluded. Data were extracted using a tabulation with the following information: author, year of publication, country of study, score obtained in downs and black, year of sample collection, type of study, number of participants, method of obtaining the sample of 25(OH)D, time of pregnancy in obtaining the sample, obstetric complication, adjusted confounding factors and the main outcomes. A total of 32,505 patients were obtained after adding the samples of all analyzed articles. The main result found, covering the three comorbidities analyzed, lists levels below 30 nmol/L of vitamin D as a potential risk factor for pre-eclampsia, gestational diabetes mellitus and prematurity.(AU)

Communicative performance and vocabulary domain in preschool preterm infants

Abstract Objective The objective of this study was to evaluate and compare the performance of children in preschool age who were born premature and term, without neurological injury, regarding receptive and expressive language skills, and to reflect on the importance of these skills for performance in preschool. Materials and Methods Two groups named Preterm Group and Comparison Group, each composed by 40 children, as well as 80 legal representatives (mothers) and 80 teachers of the participants. To pair the groups, we considered chronological age (months), sex, educational level, type of school (public or private) and socioeconomic status. To assess the groups we used structured and semi-structured Observation of Communicative Behavior and applied the ABFW Child Language Test - Part B-Vocabulary and the Peabody Picture Vocabulary Test. To assess the legal representatives we applied an anamnesis questionnaire and the MacArthur Communicative Development Inventory. The assessment of the teachers consisted of the MacArthur Communicative Development Inventory and a Student Assessment Protocol developed by the authors. Results For the observation of communicative behavior, the categories with the highest losses were: narrative, maintaining dialogic activities and attention difficulties. In the ABFW Child Language Test and Peabody Picture Vocabulary Test there were statistically significant differences. In the MacArthur Communicative Development Inventory there were statistically significant differences in expressive vocabulary, but no differences in receptive vocabulary, for both the mothers and the teachers. Conclusion Children born prematurely with low risk of neurological sequelae in preschool age may have greater difficulties in linguistic performance than their peers born to term.

Growth, lung function, and physical activity in schoolchildren who were very-low-birth-weight preterm infants / Crescimento, função pulmonar e atividade física em escolares nascidos prematuros e com muito baixo peso

ABSTRACT Objective: To compare somatic growth, lung function, and level of physical activity in schoolchildren who had been very-low-birth-weight preterm infants (VLBWPIs) or normal-birth-weight full-term infants. Methods: We recruited two groups of schoolchildren between 8 and 11 years of age residing in the study catchment area: those who had been VLBWPIs (birth weight < 1,500 g); and those who had been normal-birth-weight full-term infants (controls, birth weight ≥ 2,500 g). Anthropometric and spirometric data were collected from the schoolchildren, who also completed a questionnaire regarding their physical activity. In addition, data regarding the perinatal and neonatal period were collected from the medical records of the VLBWPIs. Results: Of the 93 schoolchildren screened, 48 and 45 were in the VLBWPI and control groups, respectively. No significant differences were found between the groups regarding anthropometric characteristics, nutritional status, or pulmonary function. No associations were found between perinatal/neonatal variables and lung function parameters in the VLBWPI group. Although the difference was not significant, the level of physical activity was slightly higher in the VLBWPI group than in the control group. Conclusions: Among the schoolchildren evaluated here, neither growth nor lung function appear to have been affected by prematurity birth weight, or level of physical activity.

RESUMO Objetivo: Comparar o crescimento somático, a função pulmonar e o nível de atividade física entre escolares nascidos prematuros com muito baixo peso e escolares nascidos a termo e com peso adequado. Métodos: Foram recrutados escolares com idade de 8 a 11 anos residentes na mesma área de abrangência do estudo: prematuros e com peso < 1.500 g e controles (nascidos a termo e com peso ≥ 2.500 g). Foram obtidas medidas antropométricas e espirométricas e aplicado um questionário sobre a atividade física. Além disso, foram coletadas informações do período perinatal/neonatal dos recém-nascidos com muito baixo peso (RNMBP) de seus prontuários médicos. Resultados: Dos 93 escolares avaliados, 48 crianças no grupo RNMBP e 45 no grupo controle. Não houve diferenças significativas entre os grupos em relação às características antropométricas e nutricionais ou aos parâmetros de função pulmonar. Não foram encontradas associações entre as variáveis perinatais/neonatais e parâmetros da função pulmonar dos escolares no grupo RNMBP. Embora sem diferença significativa em relação aos níveis de atividade física, o grupo RNMBP apresentou uma tendência de ser mais ativo que o grupo controle. Conclusões: Nos escolares aqui estudados o crescimento e a função pulmonar parecem não ser afetados por prematuridade, peso ao nascimento ou nível de atividade física.

Down syndrome: a risk factor for malocclusion severity?

The aims of the present study were to compare aspects related to malocclusion between individuals with Down syndrome (DS) and a control group, establish malocclusion severity, and identify determinant factors. A total of 120 individuals (60 with DS and 60 with no physical or mental impairment), were included in the study. Data were collected through interviews, analyses of the medical charts, and oral examinations. The criteria of the Dental Aesthetic Index were used for the diagnosis of malocclusion. Chi-square test (p ≤ 0.05) and multivariate logistic regression were used for comparisons between the two groups and to determine the association between the dependent (malocclusion severity) and independent variables. Statistically significant differences were found between the two groups for the following variables: missing teeth, diastema, overjet, mandibular protrusion, anterior open bite, posterior crossbite, facial type, lip incompetence, and Angle classification. DS, a history of premature birth, and long face pattern were found to be associated with malocclusion severity. Individuals with DS exhibited more occlusal problems than those in the control group.

Cognition, behavior and social competence of preterm low birth weight children at school age

OBJECTIVE: The aim of this study was to assess the cognitive and behavioral development of preterm and low birth weight newborns living in a disadvantageous socioeconomic environment at school age. METHODS: This cross-sectional study included children aged 6-7 from a historical birth cohort of preterm (gestational age <37 weeks) and low birth weight (<2,500 g) infants. The Wechsler Intelligence Scale for Children III (WISC-III) was administered by a psychologist while the parents completed the Child Behavior Checklist. The results were compared to the test's reference. The perinatal information and follow-up data were collected from the hospital files. The demographic data were collected from the parents. The current performance was compared with the results from the Denver II and Bayley II tests, which were administered during the first years of life. RESULTS: The total intelligence quotient varied from 70 to 140 (mean 98.7±15.8). The borderline intelligence quotient was observed in 9.3% of the children. The Child Behavior Checklist indicated a predominance of social competence problems (27.8%, CI 19.2 to 37.9) compared with behavioral problems (15.5%, CI 8.9 to 24.2). Both the Child Behavior Checklist domains, such as schooling, social and attention problems, and the cognitive scores were significantly associated with maternal education and family income. The results of the Denver and Bayley tests were associated with the cognitive performance (p<0.001) and the Child Behavior Checklist social profile, including aggressive and externalizing behavior (p<0.001). CONCLUSIONS: Our data suggest that even low-risk preterm newborns are at risk for developing disturbances in early school age, such as mild cognitive deficits and behavioral disorders. This risk might increase under unfavorable socioeconomic conditions. .

Efectos de la prematurez sobre el desarrollo cognitivo y la atención en etapa escolar / Effects of prematurity on cognitive development and attention at school age

Gracias a los avances tecnológicos, los niños prematuros con discapacidades físicas mayores han disminuido su prevalencia; actualmente, los defectos cognitivos son la secuela predominante. Se investigó el desarrollo cognitivo y la atención en escolares con antecedentes de haber sido recién nacidos prematuros, a través de un estudio descriptivo, de corte transversal, en que se realizaron evaluaciones neuropsicológicas mediante WISC-R y test de Gordon a niños escolares con antecedentes de prematurez (EG<33s y/o PN<1500g) y niños controles con antecedentes de ser recién nacidos de término. Se evaluó a 77 pacientes: 40 niños prematuros (EG: 30,5 s) y 37 de término, entre 6-7 años. Aunque ambos grupos obtuvieron un CIT dentro del rango normal, se observó diferencias significativas (p<0,03) en desmedro del grupo prematuro en comparación con controles. Las habilidades atencionales también fueron significativamente menores para los prematuros (p< 0,01). Los niños prematuros se encuentran en riesgo de presentar problemas cognitivos y/o de atención en la etapa escolar. Se sugiere incorporar instrumentos de pesquisa de estas dificultades durante el seguimiento, que permitan un reconocimiento precoz e intervención oportuna.

The prevalence of premature children with major physical disabilities has diminished over time mainly due to advances in technology. Cognitive disorders are currently the main sequels. In order to study cognitive and attentional functioning of extremely premature infants at school age, a cross sectional study was designed. Neuropsychological assessments were performed by WISC-R and Gordon test, in prematures and controls at school age. Seventy seven children, 40 preterm (GA: 30.5 w) and 37 term at birth, aged 6-7 years-old were assessed. Although both groups obtained an overall IQ within the normal range, prematures showed significantly lower scores than the control group (p< 0.03). Attentional skills were also significantly lower (p <0.01) in the premature children. Children with a history of extreme prematurity are at risk for cognitive and attention impairment at school age. We suggest to introduce screening tools during follow-up which allow early recognition and appropriate intervention.

Recién nacido prematuro tardío: incidencia y morbilidad neonatal precoz / Late preterm infant: incidence and early neonatal morbidity

La incidencia de prematuridad ha aumentado por el auge en el nacimiento de prematuros tardíos. La prematuridad tardía está asociada a un aumento de la morbilidad y mortalidad neonatal. Determinar la incidencia de nacimientos prematuros tardíos y su relación con complicaciones en el período neonatal. En un estudio cohorte prospectivo se analizó la población global de neonatos en un lapso de 9 meses. Se midieron la frecuencia de prematuridad tardía y los riesgos relativos de complicaciones, admisión a cuidados intensivos, enfermedad respiratoria, soporte ventilatorio y muerte, asociados a la prematuridad tardía. La frecuencia general de prematuridad fue 19 por ciento. Los prematuros tardíos conformaron 12 por ciento del total de nacidos y 66 por ciento de todos los prematuros. El 62,5 por ciento de los prematuros tardíos presentó alguna complicación aguda, mientras que esto ocurrió en 17,7 por ciento de los neonatos a término. Las causas primarias de admisión fueron las enfermedades respiratorias y la ictericia. La mortalidad en el grupo de prematuros tardíos fue 4,7 por ciento, mientras que en los niños a término fue 0,3 por ciento. Los prematuros tardíos manifestaron riesgos relativos aumentados en cuanto a complicaciones agudas, admisión a cuidados intensivos, dificultad respiratoria,  necesidad de ventilación  y muerte. Conclusiones: La frecuencia de prematuridad tardía es alta en nuestra población. Los prematuros tardíos representan dos tercios de todos los niños prematuros. Hay un riesgo aumentado de  hospitalización, dificultad respiratoria y muerte en el prematuro tardío, en comparación al niño a término. Los prematuros tardíos precisan una atención más cuidadosa por parte de los profesionales de salud.

The global incidence of prematurity has increased worldwide within the last twenty years, primarily because of a continuous increment in the birth of late preterm (LPT) infants. LPT infants entail a higher risk of morbidity and mortality than their term peers. To know the frequency of LPT births and their association with the risk of acute neonatal complications, as compared with term newborns. A prospective cohort study was undertaken during a nine-month period. Global incidence of LPT infants was estimated, and relative risks of complications, admission to intensive care, respiratory distress, need of ventilatory support and death in LPT infants were measured in comparison to their contemporaneous term neonates. Total frequency of prematurity was 19 percent. LPT infants represented 12 percent of total births and 66 percent of all preterm infants. 62.5 percent of all LPT infants had to be admitted because of complications, in contrast to 17.7 percent of all term infants. The main causes of admission were respiratory distress and jaundice. Overall mortality in LPT newborns was 4.7 percent, whereas in term infants it was 0.3 percent. LPT infants showed higher relative risks than term infants as regard to acute complications, hospitalizations, respiratory distress, need of ventilatory support and death. Conclusions: The frequency of LPT births in our institution is high. Two thirds of all preterm infants are LPT newborns. Late prematurity is associated with a high risk of hospitalizations, respiratory distress and death, as compared to term birth.  Greater attention needs to be paid to the management of LPT infants.

O peso ao nascer influencia o estado nutricional ao final do primeiro ano de vida? / Does birth weight affect nutritional status at the end of first year of life?

OBJETIVO: Analisar a associação entre o baixo peso ao nascer e o estado nutricional ao final do primeiro ano de vida. MÉTODOS: Foi realizado estudo caso-controle aninhado a uma coorte em quatro municípios da Zona da Mata Meridional de Pernambuco. Os recém-nascidos foram recrutados para a coorte nas primeiras 24 horas de vida, sendo o peso aferido ao nascimento e ao final do primeiro ano de vida. Durante o primeiro ano de vida, foram realizadas duas visitas domiciliares semanais para confirmar aleitamento materno predominante e ocorrência de episódios diarréicos. Considerou-se caso (risco nutricional) a criança com índice peso/idade abaixo do percentil 10 (n = 117); e controle aquela com percentil igual ou maior que 10 (n = 411). Realizou-se análise de regressão logística hierarquizada para detectar os fatores determinantes do estado nutricional no primeiro ano de vida. RESULTADOS: Os fatores que explicaram o risco nutricional ao final do primeiro ano de vida foram peso ao nascer e ausência de sanitário no domicílio. As crianças que nasceram com peso entre 1.500 g e 2.499 g tiveram uma chance 29 vezes maior (IC 95 por cento = 9,77-87,49) de apresentar risco nutricional aos 12 meses de idade em relação àquelas com peso de nascimento maior que 3.500 g. Nas que residiam em domicílio sem sanitário, a chance foi três vezes maior (IC 95 por cento = 1,54-6,22) em relação àquelas com sanitário com descarga no domicílio. CONCLUSÃO: O baixo peso ao nascer é um dos principais fatores responsáveis pelo risco nutricional ao final do primeiro ano de vida, sendo imprescindível adotar estratégias para sua redução e prevenção.