Impact of resuscitation training program on neonatal outcomes in a region of high socioeconomic vulnerability in Brazil: an interventional study

Abstract Objectives: This pre/post-intervention study aimed to evaluate neonatal outcomes after the implementation of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics. Method: This interventional study was conducted across five secondary healthcare regions that supported 62 cities in the southwestern mesoregion of Piauí. It included 431 healthcare professionals responsible for neonatal care in the study region. The participants were trained in neonatal resuscitation through the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics. Delivery room structuring, healthcare professionals' knowledge, and neonatal care outcomes were analyzed immediately before and after intervention and after 12 months between February 2018 and March 2019, and healthcare professionals were evaluated. Results: Training was conducted for over 106 courses. As a participant could take multiple courses, 700 training sessions were conducted. Regarding delivery room structuring, the acquisition of materials required for resuscitation increased from 28.4 to 80.6% immediately after the intervention and to 83.3% after 12 months. Knowledge retention was significant in the post-training period, with a 95.5% approval rate, and knowledge acquisition was satisfactory after 12 months. The number of newborns transferred during the study period increased significantly. A 72.6% reduction in mortality at birth was recorded, and 479 newborns were resuscitated. Conclusion: Following the implementation of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics, structural improvements in delivery rooms, adequate knowledge retention regarding neonatal resuscitation, and a consequent reduction in neonatal mortality were observed.

Comparison of mortality and survival without major morbidities of very preterm infants with very low birth weight from Japan and Brazil / Comparação entre mortalidade e sobrevida sem morbidades importantes dos recém-nascidos prematuros de muito baixo peso entre o Japão e o Brasil

Abstract Objective: This study was carried out to understand the disparities in mortality and survival without major morbidities among very premature and very low birth weight infants between participating Neonatal Intensive Care Units (NICUs) from the Brazilian Network on Neonatal Research (RBPN) and the Neonatal Research Network of Japan (NRNJ). Methods: Secondary data analysis of surveys by the RBPN and NRNJ was performed. The surveys were conducted in 2014 and 2015 and included 187 NICUs. Primary outcome was mortality or survival without any major morbidity. Logistic regression analysis adjustment for confounding factors was used. Results: The study population consisted of 6,406 infants from the NRNJ and 2,319 from the RBPN. Controlling for various confounders, infants from RBPN had 9.06 times higher adjusted odds of mortality (95%CI 7.30-11.29), and lower odds of survival without major morbidities (AOR 0.36; 95%CI 0.32-0.41) compared with those from the NRNJ. Factors associated with higher odds of mortality among Brazilian NICUs included: Air Leak Syndrome (AOR 4.73; 95%CI 1.26-15.27), Necrotizing Enterocolitis (AOR 3.25; 95%CI 1.38-7.26), and Late Onset Sepsis (LOS) (AOR 4.86; 95%CI 2.25-10.97). Conclusions: Very premature and very low birth weight infants from Brazil had significantly higher odds for mortality and lower odds for survival without major morbidities in comparison to those from Japan. Additionally, we identified the factors that increased the odds of in-hospital neonatal death in Brazil, most of which was related to LOS.

RESUMO Objetivo: Este estudo foi realizado para compreender as disparidades na mortalidade e sobrevivência sem as principais morbidades entre recém-nascidos muito prematuros e de muito baixo peso entre Unidades de Terapia Intensiva Neonatal (UTINs) participantes da Rede Brasileira de Pesquisas Neonatais (RBPN) e Rede de Pesquisa Neonatal do Japão (NRNJ). Métodos: Foi realizada uma análise dos dados secundários dos bancos de dados da RBPN e da NRNJ. As pesquisas foram realizadas em 2014 e 2015 e incluíram 187 UTINs. O desfecho primário foi mortalidade ou sobrevida sem qualquer morbidade importante. Utilizou-se a análise de regressão logística com ajuste para os fatores de confusão. Resultados: A população do estudo foi composta por 6.406 recém-nascidos do NRNJ e 2.319 do RBPN. Ajustando para diversos fatores de confusão, os prematuros da RBPN tiveram 9,06 vezes maiores chances de mortalidade (IC95% 7,30-11,29) e menores chances de sobrevivência sem morbidades importantes (AOR 0,36; IC95% 0,32-0,41) em comparação com os da NRNJ. Fatores associados a maiores chances de mortalidade entre as UTINs brasileiras incluíram: síndrome de escape de ar (AOR 4,73; IC95% 1,26-15,27), enterocolite necrosante (AOR 3,25; IC95% 1,38-7,26) e sepse de início tardio (AOR 4,86; IC95% 2,25-10,97). Conclusões: Os recém-nascidos muito prematuros e de muito baixo peso do Brasil apresentaram chances significativamente maiores de mortalidade e menores chances de sobrevivência sem as principais morbidades em comparação aos do Japão. Além disso, identificamos os fatores que aumentam as chances da morte neonatal no Brasil, sendo a maioria relacionada à sepse tardia.

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

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

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

Opinions of Brazilian resuscitation instructors regarding resuscitation in the delivery room of extremely preterm newborns / Opiniões dos instrutores de reanimação brasileiros quanto à reanimação em sala de parto de em recém-nascidos pré-termo extremos

Abstract Objective: To describe the opinions of pediatricians who teach resuscitation in Brazil on initiating and limiting the delivery room resuscitation of extremely preterm infants. Method: Cross-sectional study with electronic questionnaire (Dec/2011-Sep/2013) sent to pediatricians who are instructors of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics, containing three hypothetical clinical cases: (1) decision to start the delivery room resuscitation; (2) limitation of neonatal intensive care after delivery room resuscitation; (3) limitation of advanced resuscitation in the delivery room. For each case, it was requested that the instructor indicate the best management for each gestational age between 23 and 26 weeks. A descriptive analysis was performed. Results: 560 (82%) instructors agreed to participate. Only 9% of the instructors reported the existence of written guidelines at their hospital regarding limitations of delivery room resuscitation. At 23 weeks, 50% of the instructors would initiate delivery room resuscitation procedures. At 26 weeks, 2% would decide based on birth weight and/or presence of fused eyelids. Among the participants, 38% would re-evaluate their delivery room decision and limit the care for 23-week neonates in the neonatal intensive care unit. As for advanced resuscitation, 45% and 4% of the respondents, at 23 and 26 weeks, respectively, would not apply chest compressions and/or medications. Conclusion: Difficulty can be observed regarding the decision to not resuscitate a preterm infant with 23 weeks of gestational age. At the same time, a small percentage of pediatricians would not resuscitate neonates of unquestionable viability at 26 weeks of gestational age in the delivery room.

Resumo Objetivo: Descrever opiniões dos pediatras que ensinam reanimação no Brasil a respeito de iniciar e limitar a reanimação em sala de parto de neonatos pré-termo extremos. Método: Estudo transversal com questionário eletrônico (dez/11-set/13) enviado aos instrutores do Programa de Reanimação Neonatal da Sociedade Brasileira de Pediatria com três casos clínicos hipotéticos: 1) decisão de iniciar ou não a reanimação; 2) limitação ou não dos cuidados intensivos após a reanimação em sala de parto; 3) limitação ou não da reanimação avançada em sala de parto. Para cada caso foi solicitada a indicação da conduta para cada idade gestacional entre 23-26 semanas. A análise foi descritiva por meio da frequência das respostas. Resultados: Consentiram em participar 560 (82%) instrutores. Apenas 9% afirmaram existir em seu hospital norma escrita sobre quando não iniciar a reanimação em sala de parto. Com 23 semanas, 50% dos instrutores fariam a reanimação em sala de parto e com 26 semanas 2% baseariam sua decisão no peso ao nascer e/ou na abertura da fenda palpebral. Dos entrevistados, 38% reavaliariam sua decisão e limitariam o cuidado na UTI a medidas de conforto para nascidos de 23 semanas reanimados na sala de parto. Quanto aos procedimentos de reanimação avançada, 45% e 4% com 23 e 26 semanas, respectivamente, não indicariam tais manobras. Conclusão: Observa-se dificuldade na opção de não reanimar neonatos com 23 semanas de gestação e, ao mesmo tempo, um pequeno percentual de pediatras não reanima, na sala de parto, neonatos cuja viabilidade não é questionada (26 semanas).

Initiation of resuscitation in the delivery room for extremely preterm infants: a profile of neonatal resuscitation instructors

OBJECTIVE: The goal of the present study was to examine the decisions of pediatricians who teach neonatal resuscitation in Brazil, particularly those who start resuscitation in the delivery room for newborns born at 23-26 gestational weeks. METHODS: The present study was a cross-sectional study that used electronic questionnaires (Dec/11-Sep/13) sent to instructors of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics. The primary outcome was the gestational age at which the respondent said that he/she would initiate positive pressure ventilation in the delivery room. Latent class analysis was used to identify the major profiles of these instructors, and logistic regression was used to identify variables associated with belonging to one of the derived classes. RESULTS: Of 685 instructors, 82% agreed to participate. Two latent classes were identified: ‘pro-resuscitation’ (instructors with a high probability of performing ventilation on infants born at 23-26 weeks) and ‘pro-limitation’ (instructors with a high probability of starting ventilation only for infants born at 25-26 weeks). In the multivariate model, compared with the ‘pro-limitation’ class, ‘pro-resuscitation’ pediatricians were more likely to be board-certified neonatologists and less likely to base their decision on the probability of the infant’s death or on moral/religious considerations. CONCLUSION: The pediatricians in the most aggressive group were more likely to be specialists in neonatology and to use less subjective criteria to make delivery room decisions.

Costs of hospitalization in preterm infants: impact of antenatal steroid therapy / Custos da hospitalização de recém-nascidos pré-termo: impacto da corticoterapia antenatal

ABSTRACT 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.

RESUMO OBJETIVO: Estimar os custos da internação hospitalar de prematuros cujas mães receberam ou não corticoide antenatal (CEA). MÉTODO: Coorte retrospectiva de prematuros sem malformações congênitas com idade gestacional de 26 a 32 semanas, nascidos entre janeiro/2006 e dezembro/2009, em hospital público, terciário e universitário brasileiro. Coletaram-se dados demográficos maternos e dos recém-nascidos (RN), a morbidade neonatal e o uso de recursos de saúde durante a internação hospitalar. Os custos foram analisados pela técnica de microcosting. RESULTADOS: Dos 220 nascidos que obedeciam a critérios de inclusão, 211 (96%) prontuários foram revisados: 170 receberam CEA e 41 não receberam a medicação. Analisando-se toda a população, houve redução de 14-37% entre os diferentes componentes do custo nos pacientes expostos ao CEA, sem significância estatística. Na análise de prematuros que receberam alta hospitalar vivos, o grupo com CEA teve redução de 24-47% nos vários componentes dos custos hospitalares, com diminuição significativa dos dias de internação em terapia intensiva. Os nascidos com peso < 1.500 g, considerando-se somente os sobreviventes, são aqueles que mais se beneficiaram da administração do CEA, com redução significativa de todos os componentes dos custos em 30-50%, diminuição de 36% no custo total (p = 0,008). Para o grupo com idade gestacional < 30 semanas, também sobreviventes, houve diminuição do custo total de 38% (p = 0,008) e redução de 49% dos dias de internação em UTI neonatal (p = 0,011). CONCLUSÕES: O CEA reduz o custo hospitalar de prematuros que sobrevivem à internação após o parto, principalmente naqueles abaixo de 1.500 g e 30 semanas de idade gestacional.

Predictive score for clinical complications during intra-hospital transports of infants treated in a neonatal unit

OBJECTIVE: To develop and validate a predictive score for clinical complications during intra-hospital transport of infants treated in neonatal units. METHODS: This was a cross-sectional study nested in a prospective cohort of infants transported within a public university hospital from January 2001 to December 2008. Transports during even (n=301) and odd (n = 394) years were compared to develop and validate a predictive score. The points attributed to each score variable were derived from multiple logistic regression analysis. The predictive performance and the score calibration were analyzed by a receiver operating characteristic (ROC) curve and Hosmer-Lemeshow test, respectively. RESULTS: Infants with a mean gestational age of 35 + 4 weeks and a birth weight of 2457 + 841 g were studied. In the derivation cohort, clinical complications occurred in 74 (24.6 percent) transports. Logistic regression analysis identified five variables associated with these complications and assigned corresponding point values: gestation at birth [<28 weeks (6 pts); 28-34 weeks (3 pts); >34 weeks (2 pts)]; pre-transport temperature [<36.3°Cor >37°C(3pts); 36.3-37.0°C (2 pts)]; underlying pathological condition [CNS malformation (4 pts); other (2 pts)]; transport destination [surgery (5 pts); magnetic resonance or computed tomography imaging (3 pts); other (2 pts)]; and pre-transport respiratory support [mechanical ventilation (8 pts); supplemental oxygen (7 pts); no oxygen (2 pts)]. For the derivation and validation cohorts, the areas under the ROC curve were 0.770 and 0.712, respectively. Expected and observed frequencies of complications were similar between the two cohorts. CONCLUSION: The predictive score developed and validated in this study presented adequate discriminative power and calibration. This score can help identify infants at risk of clinical complications during intra-hospital transports.

Fatores perinatais associados ao óbito precoce em prematuros nascidos nos centros da Rede Brasileira de Pesquisas Neonatais / Perinatal factors associated with early deaths of preterm infants born in Brazilian Network on Neonatal Research centers

OBJETIVO: Avaliar os fatores perinatais associados ao óbito neonatal precoce em prematuros com peso ao nascer entre 400 e 1.500 g. MÉTODOS: Coorte prospectiva e multicêntrica dos nascidos vivos com idade gestacional de 23 a 33 semanas e peso de 400-1.500 g, sem malformações em oito maternidades públicas terciárias universitárias entre junho de 2004 e maio de 2005. As características maternas e neonatais e a morbidade nas primeiras 72 horas de vida foram comparadas entre os prematuros que morreram ou sobreviveram até o sexto dia de vida. As variáveis perinatais associadas ao óbito neonatal precoce foram determinadas por regressão logística. RESULTADOS: No período, 579 recém-nascidos preencheram os critérios de inclusão. O óbito precoce ocorreu em 92 (16 por cento) neonatos, variando entre as unidades de 5 a 31 por cento, e tal diferença persistiu controlando-se por um escore de gravidade clínica (SNAPPE-II). A análise multivariada para o desfecho óbito neonatal intra-hospitalar precoce mostrou associação com: idade gestacional de 23-27 semanas (odds ratio - OR = 5,0; IC95 por cento 2,7-9,4), ausência de hipertensão materna (OR = 1,9; IC95 por cento 1,0-3,7), Apgar 0-6 no 5º minuto (OR = 2,8; IC95 por cento 1,4-5,4), presença de síndrome do desconforto respiratório (OR = 3,1; IC95 por cento 1,4-6,6) e centro em que o paciente nasceu. CONCLUSÃO: Importantes fatores associados ao óbito neonatal precoce em prematuros de muito baixo peso são passíveis de intervenção, como a melhora da vitalidade fetal ao nascer e a diminuição da incidência e gravidade da síndrome do desconforto respiratório. As diferenças de mortalidade encontradas entre os centros apontam para a necessidade de identificar as melhores práticas e adotá-las de maneira uniforme em nosso meio.

OBJECTIVE:To evaluate perinatal factors associated with early neonatal death in preterm infants with birth weights (BW) of 400-1,500 g. METHODS: A multicenter prospective cohort study of all infants with BW of 400-1,500 g and 23-33 weeks of gestational age (GA), without malformations, who were born alive at eight public university tertiary hospitals in Brazil between June of 2004 and May of 2005. Infants who died within their first 6 days of life were compared with those who did not regarding maternal and neonatal characteristics and morbidity during the first 72 hours of life. Variables associated with the early deaths were identified by stepwise logistic regression. RESULTS: A total of 579 live births met the inclusion criteria. Early deaths occurred in 92 (16 percent) cases, varying between centers from 5 to 31 percent, and these differences persisted after controlling for newborn illness severity and mortality risk score (SNAPPE-II). According to the multivariate analysis, the following factors were associated with early intrahospital neonatal deaths: gestational age of 23-27 weeks (odds ratio - OR = 5.0; 95 percentCI 2.7-9.4), absence of maternal hypertension (OR = 1.9; 95 percentCI 1.0-3.7), 5th minute Apgar 0-6 (OR = 2.8; 95 percentCI 1.4-5.4), presence of respiratory distress syndrome (OR = 3.1; 95 percentCI 1.4-6.6), and network center of birth. CONCLUSION: Important perinatal factors that are associated with early neonatal deaths in very low birth weight preterm infants can be modified by interventions such as improving fetal vitality at birth and reducing the incidence and severity of respiratory distress syndrome. The heterogeneity of early neonatal rates across the different centers studied indicates that best clinical practices should be identified and disseminated throughout the country.

Material and human resources for neonatal resuscitation in public maternity hospitals in Brazilian state capitals / Recursos materiais e humanos para a reanimação neonatal nas maternidades públicas das capitais brasileiras

CONTEXT AND OBJECTIVE: In 2002, the early neonatal mortality rate in Brazil was 12.42 per thousand live births. Perinatal asphyxia was the greatest cause of neonatal death (about 23 percent). This study aimed to evaluate the availability of the resources required for neonatal resuscitation in delivery rooms of public hospitals in Brazilian state capitals. DESIGN AND SETTING: Multicenter cross-sectional study involving 36 hospitals in 20 Brazilian state capitals in June 2003. METHODS: Each Brazilian region was represented by 1-4 percent of its live births. A local coordinator collected data regarding physical infrastructure, supplies and professionals available for neonatal resuscitation in the delivery room. The information was analyzed using the Statistical Package for the Social Sciences, version 10. RESULTS: Among the 36 hospitals, 89 percent were referral centers for high-risk pregnancies. Each institution had a monthly mean of 365 live births (3 percent < 1,500 g and 15 percent < 2,500 g). The 36 hospitals had 125 resuscitation tables (3-4 per hospital), all with overhead radiant heat, oxygen and vacuum sources. Appropriate equipment for pulmonary ventilation was available for more than 90 percent of the 125 resuscitation tables. On average, one pediatrician, three nurses and five nursing assistants per shift worked in the delivery rooms of each institution. Out of the 874 pediatricians and 1,037 nursing personnel that worked in the delivery rooms of the 36 hospitals, 94 percent and 22 percent, respectively, were trained in neonatal resuscitation. CONCLUSIONS: The main public maternity hospitals in Brazilian state capitals have the resources to resuscitate neonates at birth.

CONTEXTO E OBJETIVO: Em 2002, a mortalidade neonatal precoce brasileira foi 12,42 para cada mil nascidos vivos e a asfixia perinatal foi responsável por 23 por cento dessas mortes. Este estudo visa avaliar a disponibilidade dos recursos necessários para a reanimação neonatal nas salas de parto de hospitais públicos brasileiros. TIPO DE ESTUDO E LOCAL: Estudo transversal multicêntrico de 36 maternidades, em 20 capitais brasileiras, em junho de 2003. MÉTODOS: As maternidades selecionadas em cada região brasileira representaram 1-4 por cento dos nascidos vivos da região. O coordenador local da pesquisa respondeu a um questionário estruturado com dados a respeito da estrutura física, os equipamentos e o pessoal disponível para a reanimação neonatal em cada maternidade. A análise descritiva foi feita por meio do programa Statistical Package for Social Science 10.0. RESULTADOS: 89 por cento das 36 maternidades eram referência para gestação de risco. Cada hospital tinha um número médio mensal de 365 nascimentos (3 por cento < 1.500 g e 15 por cento < 2.500 g). Os 36 hospitais tinham 125 mesas de reanimação (3-4/hospital), todas com calor radiante, fonte de oxigênio e vácuo. Equipamento adequado para ventilação pulmonar estava disponível em mais de 90 por cento das 125 mesas. Em média, um pediatra, três enfermeiras e cinco auxiliares de enfermagem trabalhavam por turno nas salas de parto de cada instituição. Dos 874 pediatras e 1.037 profissionais de enfermagem que atuavam nas salas de parto, 94 por cento e 22 por cento haviam recebido treinamento em reanimação neonatal respectivamente. CONCLUSÕES: As maternidades públicas das capitais brasileiras apresentam salas de parto com infra-estrutura adequada para a reanimação neonatal.

A reanimação do prematuro extremo em sala de parto: controvérsias / Controversies about the resuscitation of extremely preterm infants in the delivery room

OBJETIVO: Relatar as principais controvérsias quanto aos procedimentos atualmente realizados na reanimação de recém-nascidos de extremo baixo peso na sala de parto. FONTES DOS DADOS: Revisão sistemática dos artigos incluídos em MEDLINE, SciELO e Cochrane Library e dos temas livres publicados em congressos internacionais e nacionais, utilizando-se as palavras-chave reanimação, asfixia e recém-nascido. SíNTESE DOS DADOS: As principais controvérsias incluem aspectos relacionados à oxigenação e à ventilação do prematuro de extremo baixo peso ao nascimento. Os efeitos da administração de oxigênio em concentrações entre 21 por cento e 100 por cento precisam ser investigados. Os parâmetros adequados de pressão inspiratória, volume pulmonar e pressão expiratória final positiva necessitam ser estabelecidos com a finalidade de minimizar o barotrauma e o volutrauma. Os benefícios da aplicação da pressão positiva contínua de vias aéreas por via nasal também precisam ser bem determinados através de ensaios clínicos randomizados. Além disso, reanimadores manuais devem ser desenvolvidos para otimizar a administração desses parâmetros e minimizar a lesão pulmonar no início da vida extra-uterina. Estudos clínicos sobre a administração ao nascimento de adrenalina, expansores de volume e bicarbonato de sódio são inexistentes em prematuros de muito baixo peso. Adicionalmente, o principal dilema ético envolve a decisão conjunta entre os profissionais e os pais de não iniciar a reanimação na dependência da idade gestacional. CONCLUSÕES: A conduta atualmente vigente poderá ser modificada a partir dos resultados de ensaios clínicos randomizados e controlados, em conjunto com a avaliação do desenvolvimento, realizados em recém-nascidos de extremo baixo peso submetidos à reanimação na sala de parto.

Reliability of two behavioral tools to assess pain in preterm neonates

CONTEXT: One of the main difficulties in adequately treating the pain of neonatal patients is the scarcity of validated pain evaluation methods for this population. OBJECTIVE: To analyze the reliability of two behavioral pain scales in neonates. TYPE OF STUDY: Cross-sectional. SETTING: University hospital neonatal intensive care unit. PARTICIPANTS: 22 preterm neonates were studied, with gestational age of 34 ± 2 weeks, birth weight of 1804 ± 584 g, 68 percent female, 30 ± 12 hours of life, and 30 percent intubated. PROCEDURES: Two neonatologists (A and B) observed the patients at the bedside and on video films for 10 minutes. The Neonatal Facial Coding System and the Clinical Scoring System were scored at 1, 5, and 10 minutes. The final score was the median of the three values for each observer and scale. A and B were blinded to each other. Video assessments were made three months after bedside evaluations. MAIN MEASUREMENTS: End scores were compared between the observers using the intraclass correlation coefficient and bias analysis (paired t test and signal test). RESULTS: For the Neonatal Facial Coding System, at the bedside and on video, A and B showed a significant correlation of scores (intraclass correlation score: 0.62), without bias between them (t test and signal test: p > 0.05). For the Clinical Scoring System bedside assessment, A and B showed correlation of scores (intraclass correlation score: 0.55), but bias was also detected between them: A scored on average two points higher than B (paired t test and signal test: p < 0.05). For the Clinical Scoring System video assessment, A and B did not show correlation of scores (intraclass correlation score: 0.25), and bias was also detected between them (paired t-test and signal test: p < 0.05). CONCLUSION: The results strengthen the reliability of the Neonatal Facial Coding System for bedside pain assessment in preterm neonates

A survey of the incidence of neonatal sepsis by group B Streptococcus during a decade in a Brazilian maternity hospital

Group B Streptococcus (GBS) is the main etiological agent of neonatal sepsis in developed countries, however there is no detailed information on its incidence in Brazil. We registered the incidence and lethality of GBS infection in a Brazilian private maternity hospital from April 1991 to March 2000. Maternal risk factors contributing to neonatal infections were also scored. The rate of infection was determined by checking for GBS in the blood and liquor of symptomatic neonates within 72 hours of birth. Sepsis and/or early onset meningitis were diagnosed in 43 neonates (32 cases in blood, 1in liquor and 10 in blood and liquor). The overall incidence was 0.39 per thousand neonates and remained quite constant throughout the period, ranging from 0.25-0.63. Septic shock occurred in 33 neonates within 1 to 36 hours of birth (mean 15 hours). Among those patients, 26 (60) died between the 5th and the 85th hour after birth. Maternal risk factors, according to CDC criteria, included: gestational age below 37 weeks in 26 cases (60), amniorrhexis equal or superior to 18 hours in 7 cases (16), and maternal temperature equal or superior to 38(o)C in 4 cases (9). None of the mothers had received prophylactic antibiotics during labor nor were urine, rectal or vaginal swabs screened for GBS. Although the incidence of GBS infection in the population in this study was lower than that found in developed countries, its rate of mortality was higher. The death rate could be reduced through recognition of the risk factors and prophylactic antibiotics during labor.

Controvérsias em reanimanção do recém-nascido / Controversies in neonatal resuscitation

Objetivo: relatar as principais controvérsias quanto aos procedimentos na reanimação neonatal. Métodos: revisão sistemática dos artigos incluídos em MEDLINE, LILACS e Cochrane Library e temas livres publicados no Pediatric Research, utilizando-se as palavras-chave reanimação, asfixia neonatal e recém-nascido. Resultados: a aplicação da hipotermia e da ventilação com ar ambiente encontra-se em fase de ensaios clínicos para avaliação da sua eficácia. A pressão e o volume adequados para ventilar o prematuro constituem ainda em um desafio para diminuir o baurotrauma e volutrauma. A indicação da intubação traqueal apenas por ser o prematuro de extremo baixo peso também não é aceita de modo uniforme, exceto se existe a necessidade de surfactante exógeno. Muitas dúvidas persistem quanto à dose ideal de adrenalina administrada por via endovenosa ou endotraqueal e quanto à necessidade de de bicarbonato de sódio, principalmente para prematuros. Os dilemas éticos envolvem a decisão de não se iniciar a reanimação em circunstâncias relacionadas à idade gestacional, ao peso ao nascer e às anomalias congênitas graves. Conclusões: somente as respostas obtidas através de experimentos em animais e a realização de ensaios clínicos controlados e randomizados com a evolução do desenvolvimento dos recém-nascidos submetidos a determinados procedimentos de reanimação poderão alterar a conduta atualmente utilizada

Validity of behavioral and physiologic parameters for acute pain assessment of term newborn infants

The subjectivity of pain causes enormous difficultines in evaluating neonatal pain with a single, pratical and easy-to-apply tool. Pain evaluation in the neonatal period should be performed by valid, safe, useful and feasible methods. Objective: To evaluate the validity of the Neonatal Facial Coding System (NFCS), Neonatal Infant Pain Scale (NIPS), heart rate (HR) and O2 saturation (O2 sat) for neonatal pain assessment. Design: Prospective double-blind randomized trial. Setting: A secondary level maternity hospital. Participants: 70 healthy neonates requiring bilirubin dosage were randomly assigned to receive a venous puncture (P: n=33, BW 3.2kg, SD 0.6; GA 39wk, SD 1; 59h of life, SD 25) or an alcohol swab friction (F: n=37; BW 3.1kg, SD 0.5; GA 39wk, SD 1; 52h of life, SD 17). Intervention: All measurements were taken prior to (PRE), during (TO), and 1 (T1), 3(T3), 5(T5) and 10 (T10) minutes after the procedure. Measurements: A neonatologist evaluated NFCS, NIPS, HR and O2 sat by pulse oxymetry. Results: Median NFCS and NIPS results at TO, T1 and T3 were higher in P group, compared to F. More P neonates presented NFCS > 2 and/or NIPS > 3 at T0, T1 and T3. HR was lower in P group at T1. Average O2 sat was above 90 per cent during the whole study period in both groups. Conclusion: NFCS and NIPS are suitable instruments for neonatal pain evaluation. Heart rate and O2 saturation can be used only as auxiliary methods.

Laser de diodo versus crioterapia no tratamento da retinopatia da prematuridade: estudo comparativo / Diodo laser versus cryotherapy for the treatment of the retinopathy of prematurity: a comparative study

Examinamos prospectivamente 1677 recém-nascidos pré-termo com oftalmoscopia binocular indireta e depressäo escleral na quarta, quinta, sétima, nona, 12a. e 24a. semanas de vida, no período de janeiro de 1988 a dezembro de 1995. Todas as crianças obtiveram a regressäo completa da doença e foram acompanhadas por, no mínimo, cinco meses. Como complicaçöes do tratamento com crioterapia encontramos quemose, edema palpebral e truvaçäo vítrea; já com o tratamento a laser, observamos dois casos com rotura da membrana de Bruch, um caso de hemorragia retiniana e um caso de queimadura da íris. As complicaçöes anestésicas incluíram hipoxemia transitória, bradicardia trans-operatória e apnéia pós-operatória. Os resultados sugerem que a laserterapia é täo eficaz quanto a crioterapia no tratamento da retinopatia da prematuridade, apresentando, menos complicaçöes pós-operatórias