Association of hypermagnesemia at birth and admission hypothermia in pre-term infants: A secondary analysis of a prospective cohort study.

BACKGROUND: Hypothermia on admission is associated with increased mortality in preterm infants. Drugs administered to pregnant women is implicated in its occurrence. Since magnesium sulfate has a myorelaxant effect, we aimed evaluating the association of hypermagnesemia at birth and admission hypothermia (axillary temperature <36.5°C) in preterm infants. METHODS: We performed a secondary analysis of a prospective cohort study database including inborn infants <34 weeks, without congenital malformations. Hypermagnesemia was considered if the umbilical magnesium level > 2.5 mEq/L. Maternal and neonatal variables were used to adjust the model, submitted to the multivariate hierarchical modelling process. RESULTS: We evaluated 249 newborns with median birth weight and gestational age of 1375 (IQR 1020-1375) g and 31 (IQR 28-32) weeks, respectively. Hypermagnesemia occurred in 28.5% and admission hypothermia occurred in 28.9%. In the univariate analysis, the following variables were identified as being associated with admission hypothermia: hypermagnesemia (OR 3.71; CI 2.06-6.68), resuscitation (OR 2.39; CI 1.37-4.19), small to gestational age (OR 1.91; CI1.03-3.53), general anesthesia (OR 3.34; CI 1.37-8.13), birth weight (OR 0.998; CI 0.998-0.999) and gestational age (OR 0.806; CI 0.725-0.895). In the hierarchical regression model, hypermagnesemia remained independent associated with admission hypothermia (OR 3.20; CI 1.66-6.15), as well as birth weight (OR 0.999; CI 0.998-0.999) and tracheal intubation (3.83; CI 1.88-7.80). CONCLUSION: Hypermagnesemia was associated with an increased risk of admission hypothermia, as did tracheal intubation and lower birth weight.

Application of continuous positive airway pressure in the delivery room: a multicenter randomized clinical trial

This study evaluated whether the use of continuous positive airway pressure (CPAP) in the delivery room alters the need for mechanical ventilation and surfactant during the first 5 days of life and modifies the incidence of respiratory morbidity and mortality during the hospital stay. The study was a multicenter randomized clinical trial conducted in five public university hospitals in Brazil, from June 2008 to December 2009. Participants were 197 infants with birth weight of 1000-1500 g and without major birth defects. They were treated according to the guidelines of the American Academy of Pediatrics (APP). Infants not intubated or extubated less than 15 min after birth were randomized for two treatments, routine or CPAP, and were followed until hospital discharge. The routine (n=99) and CPAP (n=98) infants studied presented no statistically significant differences regarding birth characteristics, complications during the prenatal period, the need for mechanical ventilation during the first 5 days of life (19.2 vs 23.4%, P=0.50), use of surfactant (18.2 vs 17.3% P=0.92), or respiratory morbidity and mortality until discharge. The CPAP group required a greater number of doses of surfactant (1.5 vs 1.0, P=0.02). When CPAP was applied to the routine group, it was installed within a median time of 30 min. We found that CPAP applied less than 15 min after birth was not able to reduce the need for ventilator support and was associated with a higher number of doses of surfactant when compared to CPAP applied as clinically indicated within a median time of 30 min.

Application of continuous positive airway pressure in the delivery room: a multicenter randomized clinical trial.

This study evaluated whether the use of continuous positive airway pressure (CPAP) in the delivery room alters the need for mechanical ventilation and surfactant during the first 5 days of life and modifies the incidence of respiratory morbidity and mortality during the hospital stay. The study was a multicenter randomized clinical trial conducted in five public university hospitals in Brazil, from June 2008 to December 2009. Participants were 197 infants with birth weight of 1000-1500 g and without major birth defects. They were treated according to the guidelines of the American Academy of Pediatrics (APP). Infants not intubated or extubated less than 15 min after birth were randomized for two treatments, routine or CPAP, and were followed until hospital discharge. The routine (n=99) and CPAP (n=98) infants studied presented no statistically significant differences regarding birth characteristics, complications during the prenatal period, the need for mechanical ventilation during the first 5 days of life (19.2 vs 23.4%, P=0.50), use of surfactant (18.2 vs 17.3% P=0.92), or respiratory morbidity and mortality until discharge. The CPAP group required a greater number of doses of surfactant (1.5 vs 1.0, P=0.02). When CPAP was applied to the routine group, it was installed within a median time of 30 min. We found that CPAP applied less than 15 min after birth was not able to reduce the need for ventilator support and was associated with a higher number of doses of surfactant when compared to CPAP applied as clinically indicated within a median time of 30 min.

Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists.

OBJECTIVE: To verify, in extremely preterm infants, if disagreement between obstetricians and neonatologists regarding proactive management is associated with early death. STUDY DESIGN: Prospective cohort of 484 infants with 23(0/7) to 26(6/7) weeks, without malformations, born from January 2006 to December 2009 in eight Brazilian hospitals. Pro-active management was defined as indication of ≥1 dose of antenatal steroid or cesarean section (obstetrician) and resuscitation at birth according to the international guidelines (neonatologist). Main outcome was neonatal death in the first 24 h of life. RESULT: Obstetricians and neonatologists disagreed in 115 (24%) patients: only neonatologists were proactive in 107 of them. Disagreement between professionals increased 2.39 times the chance of death in the first day (95% confidence interval 1.40 to 4.09), adjusted for center and maternal/neonatal clinical conditions. CONCLUSION: In infants with 23 to 26 weeks of gestation, disagreement between obstetricians and neonatologists, translated as lack of antenatal steroids and/or vaginal delivery, despite resuscitation procedures, increases the odds of death in the first day.

Peri-intraventricular hemorrhage in newborns weighing less than 1500 grams: comparative analysis between 2 institutions.

PURPOSE: This study aims to characterize the peri-intraventricular hemorrhages in the neonatal period in very low birth weight newborns in 2 institutions that provide neonatal tertiary assistance. METHOD: This was a comparative and observational study in 2 neonatal intensive care units, the Maternity Hospital of Campinas and the "Centro de Aten o Integrada Sa de da Mulher" of the State University of Campinas, from December 01, 1998 to November 30, 1999. We examined 187 newborns for peri-intraventricular hemorrhages, using transfontanel ultrasound (76 and 11 respectively at the first and second unit), and classified them into 4 grades. We observed their gender, intrauterine growth, weight, and gestational age at birth. RESULTS: We diagnosed 34 cases of peri-intraventricular hemorrhages (13 and 21, respectively), and both groups differed as to the birth weight and the adequacy of weight to the gestational age at birth. There was no difference in the prevalence or extent of peri-intraventricular hemorrhages among cases. There was a statistically significant occurrence of lower birth weight at gestational ages of less than 30 weeks. CONCLUSIONS: The prevalence of peri-intraventricular hemorrhages in our study was compared to that reported in the world literature. Although the cases of the second institution had a smaller mean birth weight, the prevalence of peri-intraventricular hemorrhages was similar to that at the first institution, probably because in the first one, 69% of the gestational ages of the neonates with hemorrhage were less than 30 weeks as compared to 48% in the second one. We stress the importance of the ultrasonographic method for diagnosing peri-intraventricular hemorrhages in very low birth weight newborns.

Reduction in colonization and nosocomial infection by multiresistant bacteria in a neonatal unit after institution of educational measures and restriction in the use of cephalosporins.

INTRODUCTION: Previous administration of third-generation cephalosporins predisposes to colonization and infections by multiresistant Enterobacter sp. The emergence of multiresistant bacteria infections in a neonatal unit during 1995, especially Enterobacter cloacae, stimulated this study. OBJECTIVE: To evaluate the efficacy of measures to control colonization and nosocomial infection by multiresistant bacteria in a neonatal unit. SETTING: A tertiary care university hospital. PATIENTS AND METHODS: This study was conducted from October 1995 through December 1999 in 4 phases: a cross-sectional study, a longitudinal study with intervention measures, monthly cross-sectional studies, and determination of nosocomial infections caused by multiresistant bacteria (oxacillin-resistant Staphylococcus aureus and gram-negative bacteria resistant to either aminoglycosides or third-generation cephalosporins). Specimens for surveillance culture were obtained through umbilical and rectal swabs, and tracheal aspirates from intubated babies. The intervention measures were as follows: (1) appropriated training of the whole health care team, emphasizing measures to reduce cross-colonization, and the importance of rational usage of antibiotics and (2) suppression of usage of third-generation cephalosporins. Risk factors were analyzed through univariate and multivariate logistic regression. RESULTS: In the first phase, 32% (10/31) of the patients were colonized by multiresistant bacteria (29% by multiresistant E cloacae ). In the second phase, 342 patients were evaluated; 33% of them were colonized by E cloacae, and a multiresistant strain was isolated in 10.8% (37/342) of the babies. A logistic regression model indicated parenteral nutrition and antibiotic usage as risk factors for colonization by multiresistant E cloacae. In the third phase, for 6 months, only 2 patients were colonized by multiresistant E cloacae. In the fourth phase, the analysis of bacterial resistance profile indicated a reduction of nosocomial infections due to multiresistant bacteria from 18 cases in 1995 to 2 cases per year until 1999. CONCLUSION: These results have shown that the measures adopted were effective.

Enterobacter cloacae sepsis outbreak in a newborn unit caused by contaminated total parenteral nutrition solution.

OBJECTIVE: The study aimed to investigate an outbreak caused by Enterobacter cloacae in a neonate intensive care unit. DESIGN: A descriptive study of an outbreak of sepsis in high-risk neonates was used. SETTING: The study was set in a tertiary care university teaching hospital. PATIENTS: The patients were 11 neonates infected with Enterobacter cloacae whose symptoms and signs of sepsis developed during a 16-hour period. All but one neonate received parenteral nutrition. Isolates from blood cultures, in-use parenteral nutrition solutions, and control aliquots of parenteral nutrition solution were typed by pulsed-field gel electrophoresis. RESULTS: Enterobacter cloacae was found in the refrigerated aliquots of parenteral nutrition solution, in blood cultures from infected newborns, and from in-use parenteral nutrition solutions. All these strains of Enterobacter cloacae had the same antibiotic susceptibility pattern and the same genomic DNA profile. The strain isolated from the one patient who did not receive parenteral nutrition presented a different susceptibility profile and genotype. CONCLUSION: The source of the nosocomial sepsis was the parenteral nutrition solution in 10 neonates. This contamination apparently occurred during preparation of the parenteral solution.

Neurological evaluation of neonates with intraventricular and periventricular hemorrhage.

We studied the clinical aspects of 100 consecutive premature newborns with and without intraventricular and periventricular hemorrhage (IPVH). The diagnosis of IPVH was obtained by ultrasonic scans of the skull during the first week of life and at the age of one month. Forty eight percent of newborns with IPVH had abnormal results, and there was a significant correlation with the neurological evaluation in 85% of the infants. The probability of normality for a child with no associated brain abnormalities was 72%, whereas for a child of the same gestational age with associated brain abnormalities was 48.7%.

Cerebrovascular disease in neonates. Evaluation of four cases.

The clinical and neurological study in four neonates infants with cerebral infarction are reported. The purpose of this study is to call attention for the clinical course, cranial ultrasound, computed tomography and laboratories tests, in order to evaluate the neurological sequelae. A careful evaluation has be taken in order to determine the significance of clinical and laboratory tests for syndromic, topographic and etiologic diagnosis after one year ambulatorial follow-up.

[Risk factors for neonatal asphyxia in neonates weighing more than 1000 grams] / Fatores de risco para asfixia neonatal em recém-nascidos com peso acima de 1000 gramas.

OBJECTIVE: To evaluate some of the risk factors for neonatal asphyxia in neonates weighing more than 1000 grams. METHODS: In a population of 13.385 consecutive deliveries, from January 1991 to December 1994, 135 newborns with neonatal asphyxia were compared with 135 without the disease, in a casecontrol study, matched by birth weight, at the Neonatology Unit of the Pediatric Department of the Universidade Estadual de Campinas (UNICAMP). The statistical analysis employed was bivariate and multiple by logistic regression, and expressed as odds ratio (OR) with 95% confidence intervals. RESULTS: In the bivariate analysis, the factors significantly associated with asphyxia were: abruptio placentae [OR = 8.00 (1.07-353.4)], cesarean section [OR = 2.94 (1.64 -5.55)], breech presentation [OR = 3.33 (1.54 - 7.98)], abnormal fetal heart rates [OR = 4.88 (2.25-12.08)], prolonged rupture of membranes [OR = 4.33 (1.19-23.71)], a meconial hemorrhagic or infected amniotic fluid [OR = 9.00 (3.58 - 29.03)], oligohydramnios or polyhydramnios [OR =5.00 (1.88 - 16.76), use of anesthesia [OR = 2.56 (1.41 - 4.89)] and general anesthesia [OR = 14.00 (2.13 - 598.8)], male sex [OR = 2.06 (1.12 - 3.92)] and a gestational age of less than 37 weeks [OR = 3.29 (1.37 - 9.07). After multiple analysis, abnormal amniotic fluid, oligohydramnios or polyhydramnios, and anesthesia were the only factors associated with neonatal asphyxia, and more than six prenatal visits was a protector factor. CONCLUSIONS: Obstetrical, perinatal and neonatal clinical events are associated with neonatal asphyxia, that concerted efforts to provide adequate prenatal care, optimal assistance during delivery and birth, and appropriate neonatal intensive care should significantly reduce neonatal morbidity and mortality.

Cord IgM levels in placentas with villitis of unknown etiology.

Villitis of unknown etiology (VUE) is the largest category of the placental villitides and its incidence varies in different countries. The possibility that a higher incidence of intrauterine infection could explain the high frequency of VUE in developing countries led us to determine the incidence of raised IgM levels (a non-specific monitor to intrauterine infections) in cord serum of placentas with VUE. Eighty-six placentas were studied. Of these 67 were from infants with adequate weight for their gestational age (AGA) and 19 from infants small for their gestational age (SGA). IgM level in the cord serum was measured on radial immunodiffusion plates. VUE was found in 36 placentas (41.8%) and it predominated in the SGA group. Raised IgM levels were found in only 13.8% of the placentas with VUE. In spite of our frequency of VUE being high, our incidence of raised IgM levels in placentas with VUE was low and similar to that reported by authors who have low incidence of VUE in their series. We conclude that determination of cord IgM did not help significantly in the investigation of the cause of the high frequency of VUE in our series.