Impact of bundle implementation on the incidence of peri/intraventricular hemorrhage among preterm infants: a pre-post interventional study

ABSTRACT BACKGROUND: Peri/intraventricular hemorrhage (PIVH) is a frequent cause of death and morbidity among preterm infants. Few studies have addressed the use of bundles for preventing PIVH. OBJECTIVE: To evaluate the efficacy of a bundle of interventions designed to decrease the incidence of intraventricular hemorrhage at hospital discharge among preterm infants. DESIGN AND SETTING: Pre-post interventional study with retrospective and prospective data collection performed before and after bundle implementation in the neonatal intensive care unit of a university hospital. METHODS: Infants with gestational age < 32 weeks without malformations, who survived > 6 days were included. The bundle consisted of the following actions during the first 72 hours of life: maintenance of head in neutral position with the body in supine position, minimal handling, including delay of lumbar puncture until after 72 hours and absence of respiratory therapy maneuvers. Cranial ultrasound was performed on days 3, 7 and 28, or later if needed. The effect of the bundle was analyzed through logistic regression and results were adjusted for confounding variables. RESULTS: 167 infants met the inclusion criteria; 146 (87%) were analyzed. Bundle implementation was associated with decreased chances of PIVH at hospital discharge (odds ratio 0.29; 95% confidence interval 0.13-0.65). Cerebrospinal fluid collection within the first 72 hours increased the odds of PIVH of any grade during the hospital stay fourfold, after adjustment for all variables included in the model. CONCLUSION: Implementation of a bundle of interventions to avoid intraventricular hemorrhage was effective for decreasing the incidence of all grades of PIVH in preterm infants.

Percepción del equipo de salud sobre los beneficios del calostro como factor protector de enterocolitis necrotizante en recién nacidos prematuros / Health professionals perception about the use of human colostrum, as preventive measure for necrotizing enterocolitis in preterm newborns

INTRODUCCIÓN: La incidencia de enterocolitis necrotizante (ECN), en Chile es de 0,3 a 2,4 por mil recién nacidos vi vos, siendo principalmente afectados los neonatos prematuros, y de 8 a 12 por ciento en prematuros menores a 1.500 gramos. OBJETIVO: Describir la percepción de profesionales de salud sobre el uso de calostro en recién nacidos prematuros, como factor protector de enterocolitis necrotizante. SUJETOS Y MÉTODO: Estudio cualitativo, mediante entrevista semiestructurada a 18 profesionales de la salud en tres hospitales públicos de la región de Valparaíso. La pauta de entrevista incluyó 3 temas: Conocimientos, percepción del suministro temprano de calostro y opinión acerca de la extensión de la medida, y 6 subtemas, 2 para cada tema respectivamente: Autopercepción del nivel de conocimiento y fuentes de información; Experiencia: aspectos positivos/eventos adversos y opinión del calostro como factor protector de enterocolitis; aspectos facilitadores u obstaculizadores y opinión acerca de la medida como política nacional. Procesamiento de datos mediante análisis de contenido cualitativo, temático. RESULTADOS: El uso de calostro en prematuros se da de modo protocolizado en dos de las tres unidades de alta complejidad neonatal de la región de Valparaíso. Los participantes opinan positivamente acerca de los resultados preventivos de esta medida. Aun cuando en un tercer estable cimiento no se aplique, hay una percepción favorable acerca de su potencial beneficio y su bajo costo de implementación. Se señala, no obstante, que ésta requiere de mayor evidencia y de un protocolo de aplicación. Otras limitantes serían la insuficiente dotación y formación del personal, y la necesidad de adquirir equipamiento e insumos. CONCLUSIONES: Profesionales que han aplicado un protocolo de administración de calostro en neonatos prematuros en la Región de Valparaíso, reportan buenos resultados de salud, y promueven la motivación del equipo hacia esta praxis. Sin embargo, se considera relevante la difusión y discusión de protocolos nacionales e internacionales, así como el desarrollo de investigación local. Dadas las experiencias en curso en Chile, y el debate internacional, se considera oportuno que el tema sea abordado y discutido en la comunidad sanitaria nacional.

INTRODUCTION: In Chile, necrotizing enterocolitis (NEC) mainly affects preterm infants, with an incidence of 0.3 to 2.4 per 1,000 live births, and 8 to 12% in preterm infants weighing less than 1,500 grams. OBJECTIVE: To describe health professionals perceptions on the use of human colostrum as a preventive measu re against necrotizing enterocolitis in preterm newborns. SUBJECTS AND METHOD: Qualitative study, using 18 semi-structured individual interviews of health professionals in three public hospitals of the Valparaíso Region. The interview included 3 topics: Knowledge, Perception of early colostrum supply and Opinion about the extent of the measure, and 6 subtopics, 2 for each topic respectively: Self-perception of knowledge level and Sources of information; Experience: positive aspects/adverse events and Opinion of colostrum as a protective factor for enterocolitis; Facilitating or hindering aspects and Opinion about the measure as national policy. Data were processed through qualitative content analysis. RESULTS: Two of the three high-complexity neonatal units of the Valparaíso Re gion have a protocol for administrating colostrum in premature infants. Participants have a positive opinion about the preventive results of this measure. Even in the third hospital where there is no protocol, they have a favorable perception of its potential benefit and its low cost of implementa tion. However, we observed that this procedure requires more evidence and an application protocol. Other limitations would be the lack of staffing and training and the need for equipment and supplies. CONCLUSIONS: Professionals who have applied a colostrum administration protocol in preterm infants in the Valparaíso Region report good health outcomes and promote team motivation towards this practice. However, it is relevant to the dissemination and discussion of national and international protocols, as well as the development of local research. Given the ongoing experiences in Chile and the international debate, we considered appropriate to address and discuss the topic within the na tional health community.

Fluconazole prophylaxis in preterm infants: a systematic review

ABSTRACT Objective: This article aims to review the use of antifungal prophylaxis with intravenous fluconazole in premature newborns and the occurrence of Invasive Candidiasis. Methods: This is a systematic review with search at databases: PubMed, Capes Portal, Virtual Health Library (BVS - Biblioteca Virtual em Saúde)/Lilacs, Scopus and Cochrane. The keywords used were: "Antifungal", "Candida" "Fluconazole prophylaxis" and "Preterm infants". Results: Invasive Candidiasis was evaluated in all the twelve items. In eleven of them, there was a statistically significant difference between the groups receiving prophylactic fluconazole, with lower frequency of Invasive Candidiasis, compared to placebo or no prophylaxis group. Colonization by Candida species was also evaluated in five studies; four of them presented statistically lower proportion of colonization in patients with Fluconazole prophylaxis, compared to placebo or no drugs. In one study, there was a significant difference, favoring the use of fluconazole, and reduction of death. Conclusion: Studies indicate the effectiveness of prophylaxis with fluconazole, with reduction in the incidence of colonization and invasive fungal disease. The benefits of prophylaxis should be evaluated considering the incidence of candidiasis in the unit, the mortality associated with candidiasis, the safety and toxicity of short and long-term medication, and the potential for development of resistant pathogens.

Estudio prospectivo y randomizado de suplementación de hierro temprana versus tardía en niños con peso al nacer menor de 1.301 g / Prospective randomized study of early versus late enteral iron supplementation in children who weighed < 1, 301 grams at birth

Objetivo: Determinar si la suplementación temprana de hierro disminuye la necesidad, el número y volúmen de glóbulos rojos transfundidos, en relación a la suplementación tardía de hierro en niños con peso de nacimiento menor a 1.301 g. Pacientes y Método: Recién nacidos de muy bajo peso (RNMPN) fueron randomi-zados a recibir suplementación temprana de hierro de 3 mg/kg/día, tan pronto estaban tolerando alimentación enteral de 100 ml/kg/día, o a los 61 días de vida como suplementación tardía. Se midió niveles de hemoglobina al inicio de la suplementación temprana de hierro y a los 2 meses de vida. La transfusión de glóbulos rojos fue restringida de acuerdo a las guías de transfusión y no se administró eritropoyetina. Resultados: No hay diferencias en el número de transfusiones de glóbulos rojos entre los grupos y en relación a las morbilidades asociadas con la prematuridad no habría diferencias significativas. Conclusiones: La suplementación temprana de hierro cuando el niño este tolerando 100 ml/kg/día de leche, no disminuiría la incidencia de las transfusiones de glóbulos rojos en relación al inicio tardío de hierro a los 61 días de vida y probablemente sea segura en los niños menores de 1.301 g.

Objective: Determine whether early iron supplementation would decrease the need, the number and volume of transfused red blood cells in relation to late iron supplementation in children with birth weight less than 1,301 g. Patients and Methods: Very low birth weight (VLBW) infants were randomly assigned to receive early iron supplementation of 3 mg/kg/day as soon as they could tolerate enteral feeding of 100 ml/kg/day, or at 61 days of life as late supplementation. Hemoglobin levels were measured at the beginning of early iron supplementation and at 2 months of age. The red blood cell transfusion was performed according to transfusion guidelines and erythropoietin was not administered. Results: No differences were observed regarding the number of red cell transfusions between the groups. Morbidities associated with prematurity presented no significant differences. Conclusions: Early iron supplementation to a child that is tolerating 100 mL/kg/day of milk, does not decrease the incidence of red blood cell transfusions compared to late start iron at 61 days of life, and it is probably safe in infants with birth weight < 1,301 g.

Sulfato de magnesio y protección neuronal prenatal / Magnesium sulfate for prenatal neuroprotection

Antecedentes: la prematuridad es importante factor de riesgo para el desarrollo de parálisis cerebral (PC). El Sulfato de Magnesio (MgSO4) se ha planteado como una estrategia para reducir el riesgo de PC en recién nacidos por debajo de las 34 semanas de gestación. Objetivo: precisar con la evidencia disponible, la validez del uso del MgSO4 para protección neuronal prenatal en embarazadas en riesgo de parto pretér-mino (PP) inminente. Método: se revisaron las bases de datos PubMed, ScienceDirect, EBSCOhost, Scielo y OvidSP en búsqueda de estudios clínicos y epidemiológicos, revisiones sistemáticas, consensos y meta análisis. Se realizó revisión temática de los artículos que cumplieron los criterios de selección. Resultados: experimentos en modelos animales mostraron la posibilidad que el MgSO4 fuese protector neuronal. Estudios observacionales señalaron la posible asociación entre la exposición fetal al MgS04 y reducción en morbilidad neurológica en nacidos pretérmino (NP). Cinco ensayos clínicos entre 2002-2008, individualmente no mostraron datos concluyentes. En el 2009 se publicaron tres metaanálisis, basados en esos mismos ensayos y mostraron significativa reducción de PC en NP expuestos prenatalmente al MgSO4. Conclusión: existe evidencia para recomendar MgSO4 para protección neuronal prenatal antes de las 34 semanas de embarazo y con riesgo inminente de PP, aunque no está definida la dosis óptima. Se recomienda aplicar hasta el parto o por 12-24 horas.

Background: prematurity is a leading risk factor for development of cerebral palsy (CP). The use of Magnesium sulphate (MgSO4) has been proposed as a strategy to reduce the risk of cerebral palsy in preterm infants less than 34 weeks of gestation. Aims: to assess the best available evidence in order to validate the use of MgSO4 for prenatal neuroprotection in pregnant women at risk of imminent preterm delivery. Methods: we searched the PubMed, ScienceDirect, EBSCOhost, Scielo and OvidSP databases for clinical and epidemiological studies, systematic reviews, consensus and meta-analysis about the use of Magnesium sulphate to prevent cerebral palsy. Thematic review was conducted of articles that met the selection criteria. Results: experiments in animal models showed properties of MgSO4 for neuroprotection. Observational studies indicated the possible association between fetal exposures to MgS04 and reduced neurological morbidity in PP. Five clinical trials between 2002 and 2008 showed no conclusive data individually. In 2009, three meta-analysis showed significant reduction of cerebral palsy in MgSO4 exposed preterm infants. Conclusion: there is evidence to recommend the use of MgSO4 for prenatal neuroprotection before 34 weeks of pregnancy and imminent risk of preterm birth. It is unclear the optimal dose of MgSO4; is recommended until delivery or by 12-24 hours.

Cost-effectiveness analysis of the use of palivizumab in the prophylaxis of preterm patients in Mexico / Análisis de costo-efectividad del uso de palivizumab en la profilaxis de pacientes prematuros en México

OBJECTIVE: The study evaluated the incremental cost-effectiveness ratio (ICER) of the prophylaxis of palivizumab, for the reduction of complications associated to the respiratory syncytial virus in preterm patients in Mexico. MATERIAL AND METHODS: A decision tree was developed in preterm groups [<29 and 29-32 weeks of gestational age (wGA)], by using epidemiological and cost local data; the effectiveness was obtained with a systematic review. Patients were evaluated according to their life expectancy. Mexican Health System perspective was used. Effectiveness measures employed were LYG and QALYs. The costs are reported in USD 2009. RESULTS: ICERs per LYG resulted on values of USD $25,029 and USD $29,637 for <29 wGA and 29-32 wGA respectively, whereas ICERs per QALYs obtained in the model accounted for USD $17,532 and USD $20,760. CONCLUSIONS: Palivizumab prophylaxis for preterm newborn patients ≤32 weeks of age resulted in a cost-effective alternative.

OBJETIVO: El estudio evaluó la razón costo-efectividad incremental (RCEI) de profilaxis con palivizumab para reducción de complicaciones asociadas al virus sincicial respiratorio en prematuros en México. MATERIAL Y MÉTODOS: Se empleó un árbol de decisiones en los grupos pretérmino [<29 y 29-32 semanas de edad gestacional (SEG)], empleando datos epidemiológicos y costos locales; la eficacia se obtuvo con una revisión sistemática, evaluando a los pacientes de acuerdo con su esperanza de vida. Se empleó la perspectiva del Sistema Nacional de Salud. Las medidas de eficacia fueron AVG y AVAC. Los costos son reportados en dólares de 2009. RESULTADOS: Las RCEI por AVG resultaron de USD $25 029 y USD $29 637 para <29 y 29-32 SEG, mientras que las RCEI por AVAC fueron de USD $17 532 y USD $20 760. CONCLUSIONES: La profilaxis con palivizumab en pacientes recién nacidos pretérmino ≤32 semanas de edad resultó ser una alternativa costo-efectiva.

Factores obstétricos claves en los resultados neonatales y a los dos años de seguimiento en la prematuridad extrema / Influence of obstetrical factors in the neonatal outcome and after two-year follow-up in extreme preterm

Objetivo: Analizar la morbimortalidad en pretérminos extremos evaluando la influencia de factores obstétricos. Método: Estudio retrospectivo de 132 casos nacidos entre las semanas 23 y 27 en el Hospital La Paz, desde 2003 a 2005. Se establecieron tres grupos obstétricos: Amenaza de Parto Pretérmino, Rotura Prematura de Membranas y la asociación de ambas. Se evaluaron como variables obstétricas: tocolisis, corticoterapia, motivo de finalización de la gestación y vía de parto, y como variables en niños: mortalidad y morbilidad respiratoria, neurológica, visual y auditiva en neonatos y a los dos años. Resultados: Los casos con amenaza de parto pretérmino presentaron mayor displasia broncopulmonar y ductus arterioso persistente que los otros dos grupos obstétricos (p=0,03). Las pacientes con amenaza de parto pretérmino y tocolisis desarrollaron menos hemorragia intraventricular [36,4 por ciento (12/33)] e infarto periventricular (0 por ciento) que los casos sin tocolisis, en los que aparecieron en el 68,4 por ciento (13/19) y 31,6 por ciento(6/19), respectivamente (p=0,03 y p=0,001). Además en este subgrupo, los casos que recibieron corticoterapia desarrollaron menos infarto periventricular (0 por ciento) y parálisis cerebral a los 2 años [6,7 por ciento (2/30)], que los que no la recibieron, en los que apareció un 40 por ciento (6/15) de infarto y un 40 por ciento (4/10) de parálisis cerebral, respectivamente (p=0,0001 y p=0,02). La hemorragia intraventricular y la parálisis cerebral fueron más frecuentes en partos vaginales de casos con amenaza de parto pretérmino que en cesáreas [63,3 por ciento (19/30) y 26,1 por ciento (6/23) frente a 27,3 por ciento (6/22) y 0 por ciento; p=0,01 y 0,03]. Conclusión: La conducta obstétrica puede modificar el pronóstico neonatal y a los 2 años de seguimiento.

Objective: Analyse morbidity and mortality in extreme preterm at birth and at 2 year follow-up evaluating the influence of obstetrical factors. Methods: Retrospective study of 132 cases born between weeks 23 and 27 at La Paz Hospital from 2003 to 2005. Three obstetrical groups were established: Threat of Preterm Birth, Premature Rupture of Membranes and the combination of both. The following were evaluated as obstetrical variables: tocolysis, corticosteroid therapy and type of delivery. As variables in children: mortality and respiratory, neurological, visual and auditive morbidity in neonates and two years of age. Results: In the cases of threat of preterm birth a greater bronchopulmonary dysplasia and persistent ductus arteriosus appeared than in the other two obstetrical groups (p=0.03). Focusing on the threat of birth group, the cases with maternal tocolysis developed fewer neurological complications, intraventricular hemorrhage of 36.4 percent (12/33) and periventricular infarct of 0 percent, whereas the cases without tocolysis showed 68.4 percent (13/19) and 31.6 percent (6/19) respectively (p=0.03, p=0.001). Also in this subgroup, the cases that received corticosteroid therapy developed less periventricular infarct (0 percent) and cerebral palsy at age 2 [6.7 percent (2/30)] than the ones that did not receive it in which the percentages were 40 percent (6/15) and 40 percent (4/10) (p=0.0001 and p=0.02 respectively). Also, intraventricular hemorrhage and cerebral palsy were more frequent in vaginal delivery than in caesarean sections in this subgroup [63.3 percent (19/30) and 26.1 percent (6/23) against 27.3 percent (6/22) and 0 percent; p=0.01 and p=0.03)]. Conclusion: Obstetrical characteristics and behaviour can have a decisive impact in the neonatal outcome and after two-year follow-up.

Should we definitively abandon prophylaxis for patent ductus arteriosus in preterm new-borns?

Although the prophylactic administration of indomethacin in extremely low-birth weight infants reduces the frequency of patent ductus arteriosus and severe intraventricular hemorrhage, it does not appear to provide any long-term benefit in terms of survival without neurosensory and cognitive outcomes. Considering the increased drug-induced reduction in renal, intestinal, and cerebral blood flow, the use of prophylaxis cannot be routinely recommended in preterm neonates. However, a better understanding of the genetic background of each infant may allow for individualized prophylaxis using NSAIDs and metabolomics.

[ effect of intravenous immunoglobulin on admission duration and mortality rate related to sepsis in preterm neonates]

The infection in the neonatal period is a significant cause of mortality in the preterm neonates. The transfer of the immunoglobulin from mother to fetus occurs mainly after 32 to 34 weeks of gestation. Therefore, preterm neonates are relatively immune compromised. The aim of the study was to evaluate the impact of intravenous immunoglobulin on mortality rates reduction in preterm neonates. A randomized clinical trial conducted from Jan2008 to July 2009 in Imam Reza hospital of Kermanshah - Iran. The population was 40 preterm neonates with gestational age less than 34 weeks admitted in the NICU with probable sepsis [clinical sepsis + Lab test]. They have been divided into two case and control groups with 20 subjects in each group. The case group received 500 mg/kg intravenous immunoglobulin during first 24 hours of admission in addition to routine treatments, which were the same in both group. Before and 6 hours after administration of intravenous immunoglobulin serum level of IgG was measured in treatment group. Then data were analyzed with SPSS software and Fisher's exact test and Chi [2] test were analyzed. Mortality rate was higher in control than treatment group, but it was no statistically significant. There were not significant differences in variables including the need for ventilation, exchange transfusion, admission duration and positive blood culture. Serum IgG levels significantly increased after administration of immunoglobulin in treatment group [p=0.001]. Using intravenous immunoglobulin in the treatment of sepsis increased serum level of IgG but did not effect on mortality rate and admission duration in preterm neonates

Predição e prevenção do parto pré-termo / Prediction and prevention of preterm delivery

A prevenção da prematuridade é um dos maiores desafio obstétricos deste século, e as medidas preventivas do parto prematuro se baseiam em três níveis de ação: a prevenção primária (identificação e tratamento dos fatores de risco), secundária (diagnóstico precoce do trabalho de parto prematuro) e terciária (intervenções para minimizar as principais complicações do nascimento prematuro). A maioria dos esforços está concentrada na prevenção terciária (utilização de tocólise e corticoide). Tais medidas reduzem a mortalidade e morbidade perinatal, mas a incidência do nascimento prematuro permanece alta. Avanços na prevenção primária e secundária, seguidos de novas estratégias, são necessários para diminuir a incidência do parto prematuro e para prevenir as doenças associadas à prematuridade. O objetivo desta revisão é descrever os métodos de predição do parto prematuro mais utilizados e as principais medidas preventivas do nascimento prematuro.

The prevention of preterm birth is the most important challenge at present time. The interventions to reduce the morbidity and mortality of preterm birth can be primary (identification and treatment of risk factors), secondary (early diagnosis of preterm labor), or tertiary (intended to improve outcomes for preterm infants). Most efforts so far have been tertiary interventions, such as treatment with tocolytic agents and antenatal corticosteroids. These measures have reduced perinatal morbidity and mortality, but the incidence of preterm birth remains high. Advances in primary and secondary care, following new strategies, are needed to prevent prematurity-related illness in infants and children. The purpose of this review is to describe the useful methods of prediction of preterm delivery and the most important measures to prevent the preterm birth.

Fatores associados à morbidade respiratória entre 12 e 36 meses de vida de crianças nascidas de muito baixo peso oriundas de uma UTI neonatal pública / Risk factors for respiratory morbidity at 12 to 36 months in very low birth weight premature infants previously admitted to a public neonatal intensive care unit

O objetivo do estudo foi estimar a morbidade respiratória entre 12 e 36 meses em crianças prematuras e identificar os fatores associados. A população compreendeu 84 crianças de uma coorte de prematuros de muito baixo peso. O desfecho foi a taxa de incidência de morbidade respiratória. A associação entre as variáveis independentes e morbidade respiratória foi verificada por modelo linear generalizado. Entre 12 e 24 meses, 56,3 por cento das crianças apresentaram morbidade respiratória. Entre 24 e 36 meses, 38,1 por cento das crianças foram acometidas. As variáveis associadas à morbidade respiratória foram: displasia broncopulmonar (RT = 1,9; IC95 por cento: 1,2-2,9), complacência pulmonar alterada (RT = 1,6; IC95 por cento: 1,1-2,2), pneumonia neonatal (RT = 2,8; IC95 por cento: 2,0-4,0), persistência do canal arterial (RT = 1,6; IC95 por cento: 1,1-2,4) e morbidade respiratória no primeiro ano de vida (RT = 1,8; IC95 por cento: 1,3-2,6). A incidência de morbidade respiratória entre 12 e 36 meses se manteve elevada neste grupo de crianças de alto risco, o que reforça a necessidade de acompanhamento e de intervenções efetivas na prevenção do adoecimento e na melhora da qualidade de vida destas crianças e suas famílias.

The aim of this paper was to estimate respiratory morbidity and its determinants for premature infants aged 12 to 36 months. The population comprised 84 infants from a cohort of very low birth weight premature infants. The outcome was the respiratory morbidity incidence rate. The relationship between the independent variables and respiratory morbidity was estimated using a Poisson regression model. From 12 to 24 months of age, 56.3 percent of children had experienced at least one episode of respiratory disease. >From 24 to 36 months, 38.1 percent of children were affected. Variables significantly associated with respiratory morbidity were bronchopulmonary dysplasia (RR = 1.9; 95 percentCI: 1.2-2.9), abnormal lung compliance (RR = 1.6; 95 percentCI: 1.1-2.3), neonatal pneumonia (RR = 2.8; 95 percentCI: 1.9-4.0), patent ductus arteriosus (RR = 1.6; 95 percentCI: 1.1-2.5), and respiratory morbidity in the first year of life (RR = 1.7; 95 percentCI: 1.2-2.5). The incidence of respiratory morbidity remains high in this group of high-risk infants, which calls for regular follow-up and effective interventions to prevent respiratory disease and to improve the quality of life of these children and their families.

El prematuro extremo: un desafío mayor / Extreme premature newborn: a greater challenge

Los niños de peso extremadamente bajo al nacer (PEBN) son aquellos con peso de nacimiento inferior a 1.000 gr. y representan el nuevo desafío de la Neonatología. La mortalidad infantil en Chile presentó una caída significativa en las últimas décadas, por lo que el impacto de la mortalidad del grupo de prematuros aumentó en forma considerable y hoy junto a las malformaciones congénitas son las principales causas de mortalidad infantil. El esfuerzo combinado de obstetras y neonatólogos para mejorar el manejo perinatal y neonatal ha llevado a un aumento en la sobre vida del grupo de prematuros extremos, generando un replanteamiento de los límites de viabilidad hasta márgenes insospechados. Impresionan como puntos destacados en esta mejoría de la sobrevida, el uso de corticoides prenatales (1), la administración de surfactante exógeno (2) y la opción del parto por cesárea en fetos con compromiso vital (3, 4). Debido a las alta tasa de complicaciones y discapacidad, vistos principalmente en las edades gestacionales y pesos más bajos, se mantiene el debate de hasta cuándo se justifica el apoyo intensivo en el grupo de prematuros con PEBN. En cuanto al manejo neonatal, muchos aspectos son aún controversiales, siendo fundamental la uniformidad en las estrategias de cada equipo y el compromiso para la constante evaluación y actualización del grupo. Este artículo tiene por intención mostrar las estrategias terapéuticas del Servicio de Neonatología de Clínica Las Condes para estos pacientes, junto con publicar algunos de nuestros resultados en el período comprendido entre enero 2001 a diciembre 2007.

Extremely Low Birth Weight Infant (ELBW), those weighting less than 1000 9 at birth, are neonatology new challenge, since they are the main proportion of infant mortality rate along with congenital malformations. Perinatal efforts have led to progressive improving on ELBW survival rate. Remarkable milestones are widely spread use of prenatal steroids, exogenous surfactant and caesarean section on perinatal high risk births. Because of high rate on disabilities on these patients, limits to treatment are today under discussion. Nevertheless, state of the art on treatments trend to consensus on different approaches and needs of permanent assessments. Our goal at Clinica Las Condes is to show our experience with ELBW patients on period 2001 - 2007 and our therapeutic strategies.

Vinyl bags prevent hypothermia at birth in preterm infants.

OBJECTIVE: To compare the effect of standard care vs. the use of vinyl bags (Vi-Drape (R) isolation bag) on admission temperature in extremely premature infants < or = 28 weeks gestational age at birth. METHODS: Twenty seven premature infants with similar baseline characteristics were assigned and placed in vinyl bags (n=14) immediately following delivery without drying or received standard care (controls, n=13), including drying and placement under a radiant warmer. Axillary temperature was recorded on admission to the neonatal unit. RESULTS: The average temperature in the vinyl bag group was significantly higher (35.9 +/- 0.13 vs 34.9 +/- 0.24 degrees C, p=0.002). Although the cord blood pH was similar between the two groups (7.33+0.02 in the vinyl bag group and 7.33 +/- 0.01 in the control group), the worst pH in the first 6 hours of life was significantly lower in the control group (7.32 +/- 0.02 vs 7.22 +/- 0.04, p=0.03). There was a significant increase in maximal oxygen requirement during the first 24 h in the control group (82.9 vs 43.3% in the vinyl bag group, p=0.0004). CONCLUSION: Vinyl bags prevent heat loss and are a simple and effective intervention in preventing hypothermia in the delivery room and early acidosis in premature infants.

Vacunación del niño prematuro: un tema a veces olvidado / Vaccination in premature infants: an issue many times forgotten

Las infecciones bacterianas o virales pueden adquirir mayor gravedad o incluso ser letales en niños prematuros. El retraso de la vacunación en prematuros es frecuente. Esto se debería a falta de claridad sobre la seguridad y respuesta inmune de las vacunas así como a una subestimación de los riesgos de las infecciones en estos niños. No hay evidencia de que la frecuencia de reacciones adversas a vacunas en prematuros sea mayor que en niños de término. Aunque en prematuros extremos la respuesta inmune a vacunas puede ser menor, generalmente es suficiente para una adecuada protección contra infecciones graves. El esquema de inmunización debe ser similar al del niño de término, según edad cronológica. En prematuros debieran considerarse vacunas especiales como anti-neumocócicas conjugadas, anti-influenza. Otras estrategias para proteger a estos niños serían la adherencia rigurosa de los contactos intra domiciliarios al esquema del Programa Ampliado de Inmunizaciones así como el uso de vacunas especiales como la anti-influenza y pertussis acelular en niños mayores y adultos.

Crianças nascidas pré-termo: comparação entre o diagnóstico do desenvolvimento auditivo com o diagnóstico neurológico / Pre-term mewborn: parallel between the hearing development and neurological diagnisis

Com a finalidade de comparar o diagnóstico das avaliações do desnvolvimento auditivo com diagnóstico neurológico, e identificar a freqüência dos sinais indicativos de alteração do processamneto auditivo central, avaliamos 90 crianças pré-termo de alto risco do Programa de Atendimento Multidiscilplinar de Neonatos da Universidade Federal de São Paulo (UNIFESP) - Escola Paulista de Medicina (EPM). Neste estudo, as crianças passaram no mínimo por quatro avaliações de acompanhamento do desenvolvimento auditivo e neurológico: ao nascimento, aos 6 meses, 12 e/ou aso 18 e 24 meses de idade cronológica. A avaliação auditiva constou de observação das respostas comportamentais a estímulos sonoros e verbais, audiometria com reforço visual, avaliação das condições da orelha média, estudo do desenvolvimento auditivo e pesquisa dos sinais sugestivos de alteração do processamento auditivo central. A avaliação neurológica consistiu de exame neurológico tradicional. Pudemos concluir que houve uma relação entre o disgnóstico neurológico e o diagnóstico do desenvolvimento auditivo: quanto maior o comprometimento neurológico, pior o desempenho auditivo. Os sinais centrais mais freqüentes na avaliação audiológica foram: a incompreensão a ordens verbais, ausência de reflexo cocleopalpebral e inconsistência de resposta para tom puro. houve uma maior ocorrência de sinais centrais no grupo com diagnóstico de distúrbio do desenvolvimento auditivo e no grupo neurológico patológico.

Indometacina profiláctica en el prematuro extremo / Prophylactic indomethacin in the very low birth weight infant

La indometacina es útil en el cierre del ductus arterioso. Durante los últimos años, se ha utilizado de manera profiláctica precoz, en la disminución de la incidencia de hemorragia intraventricular (HIV) y ductus arterioso persistente (DAP). Diferentes esquemas terapéuticos han sido publicados. Nuestro objetivo es reportar la experiencia clínica de dos protocolos profilácticos comparándolos con un grupo sin profilaxis. Se incluyó recién nacidos (RN) menores de 1 500 gramos y/o edad gestacional inferior a 32 semanas. Se utilizó un grupo histórico sin profilaxis, con RN pareados según peso y edad gestacional, nacidos en el período 1994-1996 (n = 74). Se consideró grupo I a 71 RN con estas características, nacidos entre 1997-1999 y grupo II, 83 RN del período 1999-2001. Se excluyeron en todos los grupos, aquellos con cardiopatías congénitas, asfixia severa, trastornos genéticos y malformaciones mayores. Todos los niños fueron evaluados con ecotomografía encefálica, en los días 3, 10 y 30 de vida, y con ecocardiografía el 7° día de acuerdo a normas de tratamiento similares en los tres periodos. Se registró la incidencia de complicaciones. El grupo I, recibió indometacina en dosis de 0,1 mg/kg, a las 6, 30 y 54 horas de vida; mientras que el grupo II, una dosis única a las 6 horas. En todos los pacientes se administró en infusión continua en 30 minutos. Los tres grupos resultaron comparables. En el grupo sin profilaxis, se observó DAP en 14 pacientes (18,9 por ciento) y HIV en 13 casos (17,5 por ciento). En el grupo I, 6 niños presentaron DAP (8,4 por ciento) y 7 HIV (9,8 por ciento). En el grupo II, se registró DAP en 6 RN (8,4 por ciento), mientras que HIV en 13 pacientes (15,7 por ciento). Así, la incidencia de DAP se puede disminuir utilizando una o tres dosis de indometacina (61,9 por ciento y 55,5 por ciento respectivamente, en relación al grupo sin profilaxis, p < 0,01). Sin embargo, se observó disminución significativa de HIV, sólo con el esquema de tres dosis (disminución de 44 por ciento, p < 0,01 vs 10,28 por ciento en el grupo II, NS). Conclusión: El uso precoz de Indometacina profiláctica, puede disminuir la incidencia de DAP. La dosis única puede ser tan efectiva, como el protocolo de tres. Sin embargo, en la reducción de HIV, sólo éste último demostró utilidad. De esta manera, la elección del esquema a usar debe basarse en los objetivos terapéuticos de cada centro...

Uso precoz de la eritropoyetina en la prevención de la anemia del prematuro / Early erythropoietin use for the prevention of anemia in very low birth weight newborns

Background: Anemia is common among very low birth weight newborns and requires frequent blood tranfusions. Erythropoietin was been reported to be useful in the prevention of this anemia. Aim: To asses the benefits of early (before the third week of life) Human recombinant Erythropoietin (r-EPO) administration to reduce the requirement of blood tranfusions in very low birth weight newborns. Patients and methods: sixty newborns under 1500g of birthweight were randomly assigned to recive r-EPO (n=29) or placebo (n=31) three times per week, during four weeks. Packed red cell volume and reticulocyte counts were measured weekly. Serum erythropoietin was measured prior to eigth dose. Transfusion requirements were recorded. Results: r-EPO reduced transfusions from 1.41 ñ 1.1 to 0.69 ñ 1 transfusions/newborns (p<0.001). At the fourth week of treatment, reticulocyte count was 14.8 ñ 7 and 6.4 ñ 4.9 percent in the active treatment group and placebo group respectively (p<0.001). Conclusions: r-EPO reduces the requrement of transfusions in low birth weight infants