Reflexiones éticas y recomendaciones para la toma de decisiones clínicas en la atención al recién nacido sano / Ethical reflections and recommendations for making clinical decisions in the care of the healthy newborn

La atención al recién nacido (RN) sano durante su estancia en los centros sanitarios no suele plantear problemas y la relación con la familia transcurre sin que se presenten situaciones de conflicto. Solamente en algunas ocasiones puede haber momentos conflictivos debido a que los padres no aceptan los cuidados o rutinas asistenciales que le proporcionan los profesionales sanitarios. Consideran que el RN no precisa la realización de pruebas o medidas profilácticas, como la administración de vitamina K o punción para la obtención de una muestra de sangre para el cribado neonatal. Esto se debe a que la información que poseen no es la adecuada o porque rechazan algunas medidas, ya que son invasivas y que, a su entender, no se corresponden con el cuidado de un RN sano. Este documento pretende conciliar los valores de la familia y su participación en el cuidado de su hijo, los derechos del RN y los valores de los profesionales sanitarios. Está basado en la información adecuada, la buena relación clínica y la deliberación en caso de discrepancia que puede conducir a modificar algunos procedimientos que no son esenciales en el cuidado del RN(AU)

The care of healthy newborn during their stay in health centres is not usually a problem and there are few conflicts in the relationship with the family. Conflicts may arise because the parents do not accept the care or care routines that health professionals provide. They believe that the newborn does not require testing or prophylactic measures, such as administration of vitamin K, or puncture to obtain a blood sample for newborn screening. This is because the information they have is not adequate, or because they reject some measures as they are invasive and that from their point of view, do not correspond to the care of a healthy newborn. This document seeks to reconcile the values of family and participation in the care of their child, the rights of the newborn, and the values of health professionals. It is based on adequate information, a good clinical relationship, and discussion in case of discrepancies that can lead to changes in some procedures that are not essential in the care of the newborn(AU)

[Ethical reflections and recommendations for making clinical decisions in the care of the healthy newborn]. / Reflexiones éticas y recomendaciones para la toma de decisiones clínicas en la atención al recién nacido sano.

The care of healthy newborn during their stay in health centres is not usually a problem and there are few conflicts in the relationship with the family. Conflicts may arise because the parents do not accept the care or care routines that health professionals provide. They believe that the newborn does not require testing or prophylactic measures, such as administration of vitamin K, or puncture to obtain a blood sample for newborn screening. This is because the information they have is not adequate, or because they reject some measures as they are invasive and that from their point of view, do not correspond to the care of a healthy newborn. This document seeks to reconcile the values of family and participation in the care of their child, the rights of the newborn, and the values of health professionals. It is based on adequate information, a good clinical relationship, and discussion in case of discrepancies that can lead to changes in some procedures that are not essential in the care of the newborn.

Estimulación precoz en los recién nacidos con peso al nacer entre 1.000 y 1.500 g. ¿Es siempre necesaria? / Early stimulation in newborns with birth weight between 1, 000 and 1, 500 g: is it always necessary?

Objetivo: Determinar si la práctica actualmente generalizada de envío de todos los prematuros nacidos entre 1.000 y 1.500 g al nacer a centros de atención temprana es necesaria desde el punto de vista neurológico o si es posible establecer unos criterios de selección. Material y métodos: Estudio retrospectivo de los recién nacidos (RN) en nuestro hospital entre enero de 1998 y diciembre de 2004 con peso al nacer comprendido entre 1.000 y 1.500 g, y seguidos al menos 2 años en la consulta de neuropediatría. Se analiza la significación pronóstica neurológica de las diferentes variables existentes en el periodo neonatal y con las de mayor significado se estableció un score para decidir el inicio de tratamiento de estimulación precozal alta de neonatología. Resultados: 194 recién nacidos cumplieron los criterios mencionados. Las variables de mayor significación fueron: edad gestacional (EG) < 28 semanas, sexo varón, hemorragia intraventricular de grado > I, antecedentes de embarazo de riesgo, sepsis, anemia con repercusión hemodinámica y fundamentalmente exploración neurológica anormal al alta (odds ratio de 16).Se elaboró un score pronóstico cuyo punto de corte fue 4, con área bajo la curva del 88,3%. El valor predictivo positivo y el valor predictivo negativo fueron del 43,75 y el 96,2% respectivamente, con sensibilidad del 84,8% y especificidad del 78,9%.Conclusiones: Los RN con peso al nacer entre 1.000 y 1.500 g, con exploración neurológicanormal al alta y score pronóstico menor de 4 puntos no precisan estimulación precoz desde el punto de vista neurológico dada su previsible buena evolución (AU)

Objective: To determine whether the currently widespread practice of sending all premature infants with birth weight between 1,000 and 1,500 g to early care centres is necessary from a neurological point of view, or if it is possible to establish selection criteria. Material and methods: A retrospective study of newborns (NB) at our hospital between January 1998 and December 2004 with birth weight between 1,000 and 1,500 g, and followed up for atleast two years in a paediatric neurology clinic. We analysed the prognostic significance of the different neurological variables in the neonatal period, and those of greater significance were set at a score for deciding the start of early stimulation treatment on discharge from neonatology. Results: A total of 194 infants met the above criteria. The most significant neurological prognostic variables were: gestational age < 28 weeks, male sex, intraventricular haemorrhage grade >I, history of high risk pregnancy, sepsis, anaemia with haemodynamic repercussion and fundamentally abnormal neurological examination at discharge (odds ratio of 16). A prognostic score was developed with a cut-off of 4 points, with an area under the curve of 88.3%. The positive predictive value and negative predictive value were 43.75% and 96.2%, respectively, with 84.8%sensitivity and 78.9% specificity. Conclusions: The newborns with birth weight between 1,000 and 1,500 g and normal neurological examination at discharge, with a score of less than 4 points, do not require early stimulation treatment from a neurological standpoint, given its predictable good outcome (AU)

[Early stimulation in newborns with birth weight between 1,000 and 1,500 g: is it always necessary?]. / Estimulación precoz en los recién nacidos con peso al nacer entre 1.000 y 1.500g. ¿Es siempre necesaria?

OBJECTIVE: To determine whether the currently widespread practice of sending all premature infants with birth weight between 1,000 and 1,500 g to early care centres is necessary from a neurological point of view, or if it is possible to establish selection criteria. MATERIAL AND METHODS: A retrospective study of newborns (NB) at our hospital between January 1998 and December 2004 with birth weight between 1,000 and 1,500 g, and followed up for at least two years in a paediatric neurology clinic. We analysed the prognostic significance of the different neurological variables in the neonatal period, and those of greater significance were set at a score for deciding the start of early stimulation treatment on discharge from neonatology. RESULTS: A total of 194 infants met the above criteria. The most significant neurological prognostic variables were: gestational age < 28 weeks, male sex, intraventricular haemorrhage grade > I, history of high risk pregnancy, sepsis, anaemia with haemodynamic repercussion and fundamentally abnormal neurological examination at discharge (odds ratio of 16). A prognostic score was developed with a cut-off of 4 points, with an area under the curve of 88.3%. The positive predictive value and negative predictive value were 43.75% and 96.2%, respectively, with 84.8% sensitivity and 78.9% specificity. CONCLUSIONS: The newborns with birth weight between 1,000 and 1,500 g and normal neurological examination at discharge, with a score of less than 4 points, do not require early stimulation treatment from a neurological standpoint, given its predictable good outcome.

[Aortic and cerebral trombosis caused by hypernatremic dehydration in an exclusively breast-fed infant]. / Trombosis aórtica y cerebral secundarias a deshidratación hipernatrémica en un recién nacido con lactancia materna exclusiva.

Complete aortic thrombosis is rare in neonates. Because it carries high morbidity and mortality, this entity requires aggressive and early treatment. This report describes an 8-day-old healthy and exclusively breast-fed infant, without specific coagulopathy, who developed complete aortic and cerebral venous thrombosis, which was attributed to inadequate breast-feeding and severe hypernatremic dehydration. Early systemic anticoagulation and thrombolytic therapy allowed complete resolution of the problem.

Trombosis aórtica y cerebral secundarias a deshidratación hipernatrémica en un recién nacido con lactancia materna exclusiva / Aortic and cerebral trombosis caused by hypernatremic dehydration in an exclusively breast-fed infant

La trombosis aórtica completa es una entidad rara en el período neonatal, precisando tratamiento agresivo de forma precoz debido a la alta morbimortalidad que asocia. Se presenta el caso de un recién nacido de 8 días de vida, sano y sin antecedentes de interés ni coagulopatía asociada, alimentado con lactancia materna de forma exclusiva, que presentó una trombosis aórtica masiva y venosa cerebral secundaria a una deshidratación hipernatrémica grave. La instauración precoz de tratamiento fibrinolítico y anticoagulante permitió la resolución completa del cuadro

Complete aortic thrombosis is rare in neonates. Because it carries high morbidity and mortality, this entity requires aggressive and early treatment. This report describes an 8-day-old healthy and exclusively breast-fed infant, without specific coagulopathy, who developed complete aortic and cerebral venous thrombosis, which was attributed to inadequate breast-feeding and severe hypernatremic dehydration. Early systemic anticoagulation and thrombolytic therapy allowed complete resolution of the problem

[Recommendations for the care of healthy newborn infants]. / Recomendaciones de mínimos para la asistencia al recién nacido sano.

This article makes certain recommendations on the care of the healthy newborn. Firstly, we discuss the situations that should be reported to the pediatrician/neonatologist and the reasons why the presence of these specialists is required in the delivery room (urgent or elective cesarean section, preterm labor). Secondly, we discuss the most important guidelines to follow in the delivery room and after birth. Concerning care in the delivery room, we stress the importance of care of the newborn (especially of the umbilical cord), bonding between the mother and child, identification of the newborn, assessment of neonatal adaptation to extrauterine life, prevention of ophthalmia neonatorum and hypoprothrombinemia, placing the baby correctly in the crib and hepatitis B prophylaxis. Concerning the postnatal period, we recommend feeding (promotion of breast feeding), rooming-in with the mother if the newborn is hospitalized in the nursery screening for hypoacousia and metabolic diseases, and discharge with special surveillance in cases of early discharge.

[Recommendations for perinatal transport]. / Recomendaciones para el transporte perinatal.

Perinatal transport should be integrated into a system of perinatal care within a regional health care program and should be planned according to the healthcare map of each community. We describe the various types of transport, their advantages and disadvantages, the resources required, and the protocol that should be followed in perinatal transfer. We highlight the importance of maternal and neonatal transport. The organization of transfers receives special attention, and we discuss the different functions of the coordinating, referral and receiving centers as well as those of the transport assistance team. We also discuss ethical-legal questions.

Asfixia perinatal y parálisis cerebral / Asfixia perinatal y parálisis cerebral

No disponible

[Extracorporeal membrane oxygenation, ECMO. Experience with the first 22 cases]. / Oxigenación por membrana extracorpórea, ECMO. Experiencia de los primeros 22 casos.

OBJECTIVE: Extracorporal membrane oxygenation (ECMO) is an alternative to cases of respiratory or cardiopulmonary insufficiency when conventional therapy has failed. We present the first 22 patients treated with ECMO at the neonatology unit of the "Gregorio Marañon" Hospital. PATIENTS AND METHODS: From October 1997 until September 1999, 22 patients were treated with ECMO. In 8 of them ECMO was necessary because of respiratory insufficiency without response to conventional treatment (r-ECMO) and a veno-venous tidal flow system was used. In 14 patients, cardiac ECMO was necessary in the veno-arterial modality because of ventricular failure after extracorporal circulatory assistance during cardiovascular surgery. RESULTS: The 8 patients of the respiratory ECMO group had a mean previous oxygenation index of 89 +/- 36.6 (50-150). The mean duration of ECMO was 7.8 +/- 6.5 (1-16) days and the age at the beginning of ECMO ranged between 1 and 151 days. The most frequent indications in this group were congenital diaphragmatic hernia in three cases, meconium aspiration syndrome in 2 cases and 1 case each of septic shock, idiopathic pulmonary hypertension and air leak. The cannula was removed in 5/8 patients due to recovery and 5/8 survived. The 14 patients of the cardiac ECMO group needed veno-arterial ECMO because of severe ventricular failure. Eight out of fourteen were decannulated after improvement. In 5/14 there was multiorgan failure or bad neurological prognosis resulting in death while on ECMO. In 1 out of 14 patients removal of the cannula was impossible because of cardiac insufficiency. The mean age at the beginning of ECMO was 54 (3-178) days. The mean weight at ECMO was 3209 +/- 739 (2700-5000) gr and the mean duration of ECMO was 6 (1-15) days. CONCLUSIONS: ECMO is an effective treatment in rescuing critical patients when conventional treatment fails. Meconium aspiration syndrome is the pathology with the best prognosis on ECMO. Cardiac ECMO represents a complex group of patients in which ECMO is the only treatment and which may result in recovery in 40% of the patients.

[Balloon (Rashkind) atrio-septostomy in transposition of great vessels in the neonatal period]. / Atrioseptostomía con balón (Rashkind) en la trasposición de grandes arterias durante el periodo neonatal.

Analysis of the balloon atrial septostomy (BA) for treatment of the transposition of the great arteries (TVG) during the neonatal period will allow the evaluation of some of the changes that have occurred in the diagnosis and therapy of this congenital cardiopathy. We performed a retrospective survey of the management, evolution complications of 24 BA as a palliative technique in TGV cases, admitted to the Neonatal Intensive Care Unit during a 5 1/2 year period. The aim of the study was to evaluate the factors that indicated a bad prognosis by comparing patients that are still alive (21) with those that are dead (3). The mean age at BA performance was 4.5 +/- 5.5 days. The biological constants prior to catheterization were normal, maintaining good oxygenation, administering prostaglandins in 80% of the patients and mechanical ventilation in 25% of the patients. BA outcome was considered as good in 68%, moderate in 12% and bad in 20% of the cases. Intra-catheterization complications, mainly hemorrhages and bradycardia, were suffered by 40% of the patients and one patient died during catheterization. We could see a progressive arterial desaturation due to the lack of efficacy of the BA. As bad post-catheterization outcome factors were found: hypotension, arrhythmia, hemorrhage, greater need of dobutamine, volume expansion and mechanical ventilation. Our principal conclusion is that, although BA has improved the prognosis of newborns with TGV, because of the progressive worsening of the patients during the months following the BA, it is necessary to perform early corrective surgery.

[Perioperative management of systemic pulmonary shunts in the neonatal period]. / Manejo perioperatorio de las fístulas sistémico pulmonares en el periodo neonatal.

We have analyzed 36 newborns (19 males and 17 females), with cyanotic cardiopathies in whom a systemic-pulmonary shunt had been performed. These patients were admitted to the Neonatal Intensive Care Unite between January 1985 and June 1990. We studied the perioperative events with the aim of describing the general features of this palliative surgery in the neonatal period and to determine the factors which indicate a bad prognosis. The age at admission was 10.5 +/- 16.5 days and at surgery was 19.5 +/- 20 days. Cardiopathy types included: 13 pulmonary atresias, 9 pulmonary stenoses, 6 D-transposition of the great arteries and 8 tetralogies of Fallot. Of these patients, 83% required prostaglandin administration before surgery. Cardiac catheterization was performed in 54% (in 1/3 balloon atrioseptostomy was performed). The mean diameter of the pulmonary branches was 3.5 +/- 0.7 mm. In 89%, a modified Blalock-Taussig shunt and in 11% a central aorto-pulmonary shunt were performed. The size of the prosthetic graft used was 4 mm in diameter in 77% of the cases, 5 mm in 20% and 3 mm in 3% of the patients. The mortality rate was 27% (intraoperative = 0%, early postoperative = 16%, late postoperative = 11%) with two critical periods: the initial 48 postoperative hours and the reoperation. Bad prognosis factors related to mortality are; preoperative (shorter gestational age and low newborn weight), operative (performance of a central aortopulmonary shunt, surgical ligation of the ductus during operation) and postoperative (arrhythmias, metabolic acidosis in the immediate postoperative period, lower oxygen saturation at 24 hours after the operation, hemorrhage). Our data are compared with other reports of systemic-pulmonary shunt in the neonatal period.

[The perioperative management of aortic coarctation in the neonatal period]. / Manejo perioperatorio de la coartación de aorta en el período neonatal.

Clinical records of 30 neonates with aortic coarctation admitted to neonate ICU from January 1985 to June 1990 are reviewed. We analyzed perioperative data to search for adverse prognostic signs. Patients weights were 2,970 +/- 500 grams and gestational age 38.5 +/- 1.7 weeks. Mean age at admission was 10.5 +/- 10 and mean age of surgery 13 +/- 11 days. 70% had associated congenital heart defects. Surgical technique was patch angioplasty in 86% and subclavian flap in 14%. Early or late mortality among patients with isolated aortic coarctation was nonexistent, and it was 28.5% in patients with other congenital heart defects. 13% has postoperative hypertension and 3.3% recoarctation. Adverse prognosis signs were preoperative (associated congenital heart defects, especially ventricular septal defect and interrupted aortic arch, greater dose of catecholamines and mechanical ventilation), intraoperative (pulmonary artery banding), and postoperative (hypotension, cardiac failure, arrhythmia, oligoanuria, metabolic acidosis, greater need of mechanical ventilation, bleeding and thrombopenia). Date are compared with other neonatal series.