El Servicio de neonatología en el Hospital Universitario La Paz en el año 2012 / Neonatology Department in the Hospital Universitario La Paz in the year 2012

En relación con el estado actual del Servicio de neonatología (SN), tras señalar la misión y visión del mismo, se concreta la información estructural y cartera de servicios. A continuación se describen la actividad asistencial en el paciente ingresado y en consulta de seguimiento, la actividad docente de pregrado, médicos residentes y formación continuada y las estrategias de mejora de la calidad del SN en el seno de redes nacionales e internacionales. Por último, se destacan objetivos asistenciales y de investigación actuales del SN. Repetidas veces se hace alusión a participación de la familia en todas las actividades del SN del H. Materno Infantil La Paz (AU)

The current situation, objectives and level of care provided by the Neonatal Unit of La Paz Children´s Hospital are specified. Data ate reported of clinical activity in inpatient care and follow-up programs for high risk patients. Undergraduate teaching, pediatrics residency programs, continued quality improvement and education strategies with participation in specific national and global neonatal databases are described. Future clinical and research objectives are highlighted. Family centered and parental involvement in care is considered a major aim in all activities in the neonatal unit (AU)

Consideraciones actuales sobre la prevención de la transmisión vertical del estreptococo β - hemolítico del grupo B / Current considerations on the prevention of vertical transmission of group B beta´hemolytic streptococcus

La sepsis bacteriana del neonato es un síndrome clínico caracterizado por signos de infección sistémica acompañados de bacteriemia. Denominamos infección neonatal de transmisión vertical aquella que es transmitida por la madre al feto o al recién nacido (RN) durante el embarazo, el parto el período neonatal. Las bacterias implicadas son las que se encuentran en el canal del parto que en su mayoría son de baja virulencia, pero ocasionalmente pueden infectar a la madre o al RN. Actualmente el principal agente de infección bacteriana de transmisión vertical es el Streptococcus agalactiae (estreptococo β – hemolítico del grupo B) (EGB), siendo menos frecuente la infección por Escherichia coli y otros bacilos gran negativos y se suele observar, sobre todo, en RN prematuros y de muy bajo peso (AU)

Neonatal bacterial sepsis is a clinical syndrome characterized by signs of systemic infection accompanied by bacteriemia. Neonatal infection due to vertical transmission refers to that which is transmitted by the mother to the fetus or to the newborn (NB) during the pregnancy, delivery and neonatal period. The bacterias involved are those found in the delivery canal, which mostly have low virulence, but they may sometimes infect the mother or NB. Currently the primary agent of vertical transmission bacterial infection is the Streptococcus agalactiae (group B β-hemolytic streptococcus) (EGB) infection by Escherichia coli and other gram negative bacilli being less frequent and it is generally observed, above all, in premature very low weight NB (AU)

[Late onset group B Streptococcus infection: 7 year experience in a tertiary hospital (2000-2006)]. / Infección tardía por estreptococo del grupo B: experiencia en un hospital de tercer nivel (2000-2006).

INTRODUCTION: Group B Streptococcus (GBS) is a major cause of neonatal infection. Two forms of the disease have been described according to the age of presentation: early, beginning in the first 6 days of life, and late, occurring from day 7 up to 3 months of age. OBJECTIVES: To analyze the epidemiology of the late onset form of GBS disease in a tertiary hospital after implementing preventive strategies aimed to reduce the rate of vertical transmission. METHODS: We retrospectively reviewed the medical records of children diagnosed with late GBS infection between January 2000 and December 2006. Diagnostic criteria included a positive blood culture and/or a positive cerebrospinal fluid (CSF) culture for GBS in any patient aged between 7 and 89 days. RESULTS: 24 patients were identified, most of them presenting after January 2005. Median age was 36.2 days (range 9 to 81). GBS isolates in blood were found in 20 patients, 1 in CSF and 3 in both. Most frequently children presented with fever (70.8 %) and irritability (54.1 %). Five patients (20.8 %) had a cellulitis-adenitis syndrome. Cefotaxime and ampicillin were the most often used antibiotic combination. No ampicillin resistances were found. CONCLUSIONS: The number of children with late GBS disease has increased in our center. Accordingly, the recent recommendations for the prevention of perinatal GBS vertical transmission were not effective for reducing late GBS infection. This may be due to horizontal infections from maternal sources, community or cross infections. It is important to maintain clinical suspicion of late GBS infection and start early antibiotic treatment.

Infección tardía por estreptococo del grupo B: experiencia en un hospital de tercer nivel (2000-2006) / Late onset group B Streptococcus infection: 7 year experience in a tertiary hospital (2000-2006)

Introducción: El estreptococo del grupo B (SGB) es una causa importante de infección neonatal. Se han descrito dos formas de enfermedad en función de la edad de presentación: precoz, en los primeros 6 días de vida, y tardía, entre el séptimo día y a los 3 meses de edad. Objetivos: Analizar la epidemiología de la enfermedad tardía por SGB en un hospital de tercer nivel después de la implementación de las medidas de prevención de la transmisión vertical de la infección. Métodos: Se revisaron de forma retrospectiva las historias clínicas de los niños diagnosticados de enfermedad tardía por SGB desde enero del año 2000 hasta diciembre de 2006. Se consideraron como criterios diagnósticos un hemocultivo y/o un cultivo de líquido cefalorraquídeo (LCR) positivo para SGB en cualquier paciente entre 7 y 89 días de vida. Resultados: 24 pacientes fueron identificados, la mayor parte de ellos a partir de enero de 2005. La edad media fue de 36,2 días (rango: 9-81). En 20 pacientes el SGB se aisló en el hemocultivo; en 1 paciente, en el LCR y en 3 de ellos, en ambos. Los signos clínicos más frecuentes fueron fiebre (70,8 %) e irritabilidad (54,1 %). El síndrome de celulitis-adenitis se observó en 5 pacientes (20,8 %). El tratamiento antibiótico empírico más empleado fue la asociación de cefotaxima y ampicilina. No se observaron resistencias a la ampicilina. Los 4 casos de meningitis (16,6 %) desarrollaron secuelas neurológicas importantes. Conclusiones: El número de niños con infección tardía por SGB está aumentado en los últimos años. A pesar de la eficacia de las recomendaciones para la prevención de la transmisión vertical de la infección perinatal por SGB en la infección precoz, estas recomendaciones no han sido muy efectivas para reducir la infección tardía por SGB, posiblemente debido a infecciones horizontales desde la madre, la comunidad o fuentes nosocomiales. Es importante mantener la sospecha clínica de infección tardía por SGB e iniciar tratamiento antibiótico precoz (AU)

Introduction: Group B Streptococcus (GBS) is a major cause of neonatal infection. Two forms of the disease have been described according to the age of presentation: early, beginning in the first 6 days of life, and late, occurring from day 7 up to 3 months of age. Objectives: To analyze the epidemiology of the late onset form of GBS disease in a tertiary hospital after implementing preventive strategies aimed to reduce the rate of vertical transmission. Methods: We retrospectively reviewed the medical records of children diagnosed with late GBS infection between January 2000 and December 2006. Diagnostic criteria included a positive blood culture and/or a positive cerebrospinal fluid (CSF) culture for GBS in any patient aged between 7 and 89 days. Results: 24 patients were identified, most of them presenting after January 2005. Median age was 36.2 days (range 9 to 81). GBS isolates in blood were found in 20 patients, 1 in CSF and 3 in both. Most frequently children presented with fever (70.8 %) and irritability (54.1 %). Five patients (20.8 %) had a cellulitis-adenitis syndrome. Cefotaxime and ampicillin were the most often used antibiotic combination. No ampicillin resistances were found. Conclusions: The number of children with late GBS disease has increased in our center. Accordingly, the recent recommendations for the prevention of perinatal GBS vertical transmission were not effective for reducing late GBS infection. This may be due to horizontal infections from maternal sources, community or cross infections. It is important to maintain clinical suspicion of late GBS infection and start early antibiotic treatment (AU)

Sepsis neonatal por Eikenella corrodens / Neonatal sepsis due to Eikenella corrodens

No disponible

Hematología perinatal / Perinatal hematology

No disponible

No disponible

[Morbidity at 2 years in infants with a birth weight of < 1,500 g]. / Morbilidad a los dos años de edad en niños con un peso al nacimiento menor de 1.500 g.

OBJECTIVES: To determine morbidity at 2 years' corrected age in a cohort of neonates with a birth weight of less than 1,500 g born in 1999-2000 in a tertiary hospital in the Autonomous Community of Madrid. PATIENTS AND METHODS: An observational longitudinal follow-up study was performed in a cohort of 213 infants with a birth weight of < 1,500 g. Of these, 188 (87%) completed the 2-year follow-up. Various types of neurosensorial disability were studied, paying special attention to the main impairments: vision, hearing and motor impairment, and low development quotient. RESULTS: Among the patients initially included in the study, 87% completed the follow-up; 17.1% had one or more major sequela. We found one case (0.4%) of bilateral neurosensorial deafness and one case of bilateral blindness. At the age of 2 years, 5.8 % (11/188) had cerebral palsy, 14.9% had a development quotient below 85 and 18% had not reached the 3rd percentile for weight. Factors of poor neurological prognosis were subnormal head size at the age of 2 years and white matter disease (including persistent intraparenchymal periventricular echodensity and ventriculomegaly or irregular shape) as ultrasound findings. CONCLUSIONS: Less than a fifth of the very low birth weight infants presented severe sequelae at 2 years of follow-up. Factors of poor neurological prognosis were subnormal head size at 2 years and the presence of white matter disease on ultrasonography. The findings on growth and development were worrying, since 18 % of the patients had not reached the 3rd percentile for weight at 2 years' corrected age.

Morbilidad a los dos años de edad en niños con un peso al nacimiento menor de 1.500 g / Morbidity at 2 years in infants with a birth weight of < 1.500 g

Objetivos: Conocer la morbilidad a los 2 años de edad corregida de una cohorte de recién nacidos con un peso inferior a1.500 g durante los años 1999-2000 en un hospital terciario de la Comunidad de Madrid. Pacientes y métodos: Estudio observacional de seguimiento longitudinal de una cohorte de 213 pacientes con peso inferior a 1.500 g al nacimiento. De éstos, 188 (87 %) finalizaron el seguimiento completo a los 2 años. Se estudiaron de forma prospectiva las diferentes morbilidades neurosensoriales, prestando especial atención a las morbilidades mayores: oftalmológicas, auditivas, motoras y bajo cociente de desarrollo (CD). Resultados: Completaron el seguimiento el 87 % de los pacientes incluidos inicialmente en el estudio; el 17,1 % presentaron una o más secuelas mayores. Encontramos un caso (0,4%) de sordera neurosensorial bilateral y un caso de ceguera bilateral; el 5,8 % (11/188) de los niños presentaron alguna forma de parálisis cerebral y un 14,9 % tuvieron un CD < 85 a los 2 años de edad. El 18 % no había alcanzado el percentil 3 (P3) de peso a los 2 años de seguimiento. Hallamos, como factores de mal pronóstico neurológico la microcefalia a los 2 años de edad y la aparición de lesiones de sustancia blanca (incluyendo la hiperecogenicidad periventricular persistente y ventriculomegalia de bordes irregulares) como alteraciones ecográficas. Conclusiones: Menos de una quinta parte de los recién nacidos de muy bajo peso (RNMBP) presentan alguna secuela grave a los 2 años de seguimiento. Encontramos como factores de mal pronóstico neurológico la microcefalia a los 2 años de edad corregida y la presencia de alteración de la sustancia blanca en los hallazgos ecográficos. Nos preocupan los datos de crecimiento y desarrollo, puesto que el 18 % de los pacientes no han alcanzado el P3 de peso a los 2 años de edad corregida (AU)

Objectives: To determine morbidity at 2 years’ corrected age in a cohort of neonates with a birth weight of less than 1,500 g born in 1999-2000 in a tertiary hospital in the Autonomous Community of Madrid. Patients and methods: An observational longitudinal follow-up study was performed in a cohort of 213 infants with a birth weight of < 1,500 g. Of these, 188 (87 %) completed the 2-year follow-up. Various types of neurosensorial disability were studied, paying special attention to the main impairments: vision, hearing and motor impairment, and low development quotient. Results: Among the patients initially included in the study, 87%completed the follow-up; 17.1 % had one or more major sequela. We found one case (0.4 %) of bilateral neurosensorial deafness and one case of bilateral blindness. At the age of 2 years, 5.8 % (11/188) had cerebral palsy, 14.9%had a development quotient below 85 and 18 % had not reached the 3rd percentile for weight. Factors of poor neurological prognosis were subnormal head size at the age of2 years and white matter disease (including persistent intraparenchymal periventricular echodensity and ventriculomegaly or irregular shape) as ultrasound findings. Conclusions: Less than a fifth of the very low birth weight infants presented severe sequelae at 2 years of follow-up. Factors of poor neurological prognosis were subnormal head size at 2 years and the presence of white matter disease on ultrasonography. The findings on growth and development were worrying, since 18 % of the patients had not reached the 3rd percentile for weight at 2 years’ corrected age (AU)

Vacunaciones en niños prematuros. Muchas preguntas, pocas respuestas / No disponible

Hoy en día los niños prematuros deben vacunarse a los 2 meses del nacimiento, independientemente del peso y edad gestacional, y deben de seguir el calendario como los niños a término. En un próximo futuro es muy probable que el esquema de vacunación cambie al menos para algunos grupos de prematuros. Salvo circunstancias clínicas muy especiales, la administración de las vacunas no debe retrasarse ni en el hospital ni en asistencia primaria, debiéndose continuar con las mismas vacunas con los que se iniciaron. Cuanto más pequeño es el niño más grave puede resultar la tos ferina o la infección invasiva por el Haemophilus influenzae o Streptococcus pneumoniae. Hasta que en España no se universalice el uso de la vacuna de poliomielitis inactivada (VPI) (cosa que ocurrirá pronto pese a la estulticia de algunos), en los niños ingresados en el hospital debe sustituir a la vacuna oral de virus vivos atenuados (VPO). A la luz de los datos revisados y por las complicaciones descritas no debe administrarse la vacuna pertussis de célula completa en los niños prematuros. En general, estos niños responden a las diferentes inmunizaciones con una baja reactogenicidad y con títulos frente a los diferentes antígenos más bajos que los niños a término, aunque las tasas de seroprotección superan el 90 %. Los grandes prematuros (extremadamente prematuros) responden de forma adecuada, influidos por sus condiciones clínicas particulares. En la respuesta a la formación de anticuerpos frente a la vacuna de la hepatitis B probablemente infuye más la edad posnatal que el peso. Aunque resulta un hecho controvertido, la peor respuesta parece obtenerse frente a Haemophilus, actuando como posible factor negativo el uso posnatal de corticoides. En algunos estudios se ha observado una baja respuesta frente al serotipo 3 del virus de la poliomielitis. Son excepcionales los ensayor clínicos con vacunas combinadas en prematuros, quienes por sus especiales características deberían ser uno de los primeros grupos en beneficiarse de ellas. Debe estimularse la investigación clínica en estos niños, los estudios son escasos, la metodología diversa, los resultados en ocasiones contradictorios y el número de niños bajo. Las preguntas son muchas y las respuestas muy pocas (AU)

No disponible

[The Adams-Oliver syndrome in Spain: the epidemiological aspects]. / Síndrome de Adams-Oliver en nuestro medio: aspectos epidemiológicos.

Adams and Oliver (1945) described a family with several affected individuals with terminal transverse limb reduction defects and aplasia cutis congenita of the scalp. The clinical expression was highly variable and the pattern showed a family transmission compatible with an autosomal dominant condition. Since the first description, many cases have been published with this pattern of anomalies being known as Adams-Oliver syndrome. Here we present five affected patients ascertained among the 21,835 malformed infants registered by the Spanish Collaborative Study of Congenital Malformations (ECEMC). Epidemiological aspects and clinical features of the patients are presented and compared with data from the literature.

[High frequency ventilation in the newborn. Study of 27 cases]. / Ventilación de alta frecuencia en el recién nacido. Estudio de 27 casos.

The clinical histories of 27 neonates ventilated with high frequency respirators (Volumetric Diffusive Respirator VDR-2) have been analyzed in order to evaluate the efficiency of this type of ventilation in neonatal pathology. The average gestational age of these patients was 32 +/- 4 weeks. Most of them (70%) presented respiratory distress due to hyaline membrane disease. Of the remaining cases, three (11%) presented with congenital diaphragmatic hernia, two with pulmonary hypertension, two with meconium aspiration syndrome, one with Group B Streptococal sepsis/shock and one with case diaphragmatic agenesia. Between two and six hours after initiation of high frequency ventilation (HFV), pH, paCO2 and pO2 improved significantly in relationship to former values (p < 0.05- p < 0.001), reaching values in the normal range at 6.5 +/- 14 hours regarding pH, 30 +/- 50 hours regarding paCO2 and 6.5 +/- 10 hours regarding paO2. No hemodynamic modification could be attributed to this procedure. The principal complications were ectopic air (62%) and necrotizing tracheobronchitis (TBN) (25%). Bronchopulmonary dysplasia (BDP) was diagnosed in 20% of the cases, ductus (DAP) in 33% of the cases and intracraneal hemorrhage in 25% of the cases. Mortality was 70%. High frequency ventilation is an alternative procedure to conventional ventilation in this group of neonates. It produces an important number of favorable responses, but has complications that can not be overlooked.

PIP: Clinical records of 27 newborns treated with high frequency ventilation in a hospital neonatal service in Madrid were retrospectively studied. High frequency ventilation is a technique with specific indications that has recently been applied in some neonatal pathologies as an alternative to conventional ventilation. The respirators, model 2 Volumetric Diffusive Respirators, were used in 24 of the 27 cases because of failure of conventional ventilation. The 27 newborns weighed an average of 1850 +or- 944 g and ranged from 900 to 4000 g. Their average gestational age was 32 +or- 4 weeks, and the range was 26-42 weeks. 19 had respiratory difficulties stemming from hyaline membrane disease, 3 had congenital diaphragmatic hernias, 2 had pulmonary hypertension, and one each had meconium aspiration syndrome, septic shock from group B streptococcus, and diaphragmatic agenesia. 66% were delivered by cesarean. The pH, paCO2, and paO2 improved significantly between 2 and 6 hours after initiation of HFV treatment. Values in the normal range were reached at 6.5 +or- 14 hours for pH, 30 +or- 50 hours for paCO2, and 6.5 +or- 10 hours for paO2. No hemodynamic modifications were attributed to HFV. The most significant complications were ectopic air (62%) and necrotizing tracheobronchitis (25%). Broncopulmonary dysphasia was diagnosed in 20%, ductus in 33%, and intracraneal hemorrhage in 25%. The case fatality rate was 70%. Ten newborns improved definitively with HFV and proceeded to conventional ventilation. Two later succumbed to other causes. The study showed that HFV can lead to serious complications and should be applied with great prudence despite it great potential benefit.

[Prospective immunologic study of mothers of HIV positive children]. / Estudio inmunológico prospectivo en madres e hijos VIH positivos.

From a cohort of 162 children born to 161 mothers belonging to risk groups for human immunodeficiency virus (HIV) infection, we have studied 32 asymptomatic HIV seropositive and 19 HIV seronegative mothers and their offspring seropositive mothers when compared with the seronegative group had lower counts of leukocytes, lymphocytes, CD4+ cells and CD4+/CD8+ ratio as well as higher IgG and IgM serum levels. The offspring from HIV seropositive mothers differed from children born to HIV seronegative mothers in having higher lymphocyte counts, serum IgG level and spontaneous in vitro IgG production. The number of lymphocytes and the IgG serum level correlated in the child HIV seropositive mother pairs. Two children born to HIV seropositive mothers had a CD4+/CD8+ ratio below 0.8. The significance of these abnormalities and its possible relationship with active HIV infection in children is at present unknown.

[Newborn infants of mothers addicted to heroin. Study of 45 cases]. / Recién nacidos de madres adictas a heroína. Estudio de 45 casos.

Authors have studied 45 babies born during past five years to drug-addicted mothers. Increase in number han been remarkable: from 0.095 per thousand live births in 1980 to 1.57 in 1984. There was and 16.3% incidence for preterm infants, 34.8% for low birth weight and 18.6% were small for gestational age. One third (30.2%) suffered infections, mostly sepsis. Morbidity was high in these babies, caused mainly by prematurity. Drug withdrawal syndrome appeared in 26 babies (60.4%) at an age of 13 +/- 10 hours. Fifteen of these babies (57.6%) required pharmacological treatment during 10 +/- 7.3 days, with a good response, and only two cases needed treatment for more than a month. There were no deaths in the neonatal period. In our experience children of heroin addicted mothers form a group difficult to study because their parents give not reliable data, they have high morbidity and true problems begin when they leave hospital.