Impacto en la práctica clínica de la apertura de un banco de leche en una unidad neonatal / Clinical impact of opening a human milk bank in a neonatal unit

INTRODUCCIÓN: Los beneficios de la leche donada frente a la fórmula artificial están demostrados, sin embargo no se conoce la influencia de la apertura de un banco de leche en la práctica clínica habitual. El objetivo de este estudio fue medir el impacto en la práctica clínica de la disponibilidad de leche donada para la nutrición de los prematuros ≤32 semanas de edad gestacional. MÉTODOS: Estudio antes-después de la apertura de un banco de leche. Se incluyeron los ≤32 semanas nacidos en el Hospital 12 de Octubre de julio-diciembre de 2005 y de enero-junio de 2008 (6 primeros meses tras la apertura del banco de leche). RESULTADOS: La apertura del banco de leche permitió empezar 31h antes (p < 0,001) la alimentación enteral, se alcanzaron 59,5h antes los 100ml/kg/día (p < 0,001) y 52h antes los 150ml/kg/día (p = 0,002), permitiendo retirar 72h antes la nutrición parenteral. En ningún prematuro se inició la alimentación enteral con fórmula artificial, la exposición a la misma en los primeros 15días de vida bajó del 50 al 16,6% y su consumo durante los primeros 28 días fue significativamente menor. La cantidad consumida de leche de la propia madre fue mayor, al igual que la tasa de lactancia materna exclusiva al alta (54 vs. 40%). CONCLUSIONES: Disponer de leche donada ha permitido avanzar más rápidamente con la nutrición enteral y retirar antes la nutrición parenteral. La exposición a fórmula artificial ha sido menor y mayor el consumo de leche de madre propia y la lactancia materna al alta

INTRODUCTION: The benefits of donor human milk compared with artificial formulas have been well demonstrated; nevertheless the impact in the clinical practice of opening a human milk bank within a neonatal unit has not yet been studied. The main aim of this study was to analyze the impact on the clinical practice of opening a human milk bank in a neonatal unit to provide donor human milk for preterm infants ≤32 weeks of gestational age. METHODS: A before and after study was designed, with the intervention being the opening a human milk bank. Preterm infants ≤32 weeks of gestational age born in the Hospital 12 Octubre from July to December 2005 and January to June 2008 (firsts 6 months after opening the human milk bank) were included. RESULTS: After opening the human milk bank, enteral feedings were started 31h before (P<0.001), 100ml/kg/day were achieved 59.5h before (P<0.001) and 150ml/kg/day 52h before (P=0.002). Enteral feedings were never started LM with artificial formula, the exposure to formula in the first 15 days of life was reduced from 50% to 16.6%, and it's consumption during the first 28 days of life was significantly reduced. There was a higher consumption of own mother's milk during the hospital stay, and a higher rate of exclusive breastfeeding at hospital discharge (54% vs 40%). CONCLUSIONS: The availability of donor human milk has led to quicker progression with enteral feedings and earlier withdrawal of parenteral nutrition. It has reduced the exposure to artificial formulas, and has also increased the intake of own mother's milk during the hospital stay and the rate of exclusive breastfeeding at hospital discharge

[Clinical impact of opening a human milk bank in a neonatal unit]. / Impacto en la práctica clínica de la apertura de un banco de leche en una unidad neonatal.

INTRODUCTION: The benefits of donor human milk compared with artificial formulas have been well demonstrated; nevertheless the impact in the clinical practice of opening a human milk bank within a neonatal unit has not yet been studied. The main aim of this study was to analyze the impact on the clinical practice of opening a human milk bank in a neonatal unit to provide donor human milk for preterm infants ≤ 32 weeks of gestational age. METHODS: A before and after study was designed, with the intervention being the opening a human milk bank. Preterm infants ≤ 32 weeks of gestational age born in the Hospital 12 Octubre from July to December 2005 and January to June 2008 (firsts 6 months after opening the human milk bank) were included. RESULTS: After opening the human milk bank, enteral feedings were started 31h before (P<.001), 100ml/kg/day were achieved 59.5h before (P<.001) and 150 ml/kg/day 52 h before (P=.002). Enteral feedings were never started LM with artificial formula, the exposure to formula in the first 15 days of life was reduced from 50% to 16.6%, and it's consumption during the first 28 days of life was significantly reduced. There was a higher consumption of own mother's milk during the hospital stay, and a higher rate of exclusive breastfeeding at hospital discharge (54% vs 40%). CONCLUSIONS: The availability of donor human milk has led to quicker progression with enteral feedings and earlier withdrawal of parenteral nutrition. It has reduced the exposure to artificial formulas, and has also increased the intake of own mother's milk during the hospital stay and the rate of exclusive breastfeeding at hospital discharge.

[Congenital anatomic gastrointestinal obstruction: prenatal diagnosis, morbidity and mortality]. / Obstrucción gastrointestinal anatómica congénita: diagnóstico prenatal, morbilidad y mortalidad.

OBJECTIVES: To describe the morbidity and mortality associated with congenital gastrointestinal obstruction, assess the usefulness of prenatal diagnosis, and analyze the results in relation to the site of obstruction. PATIENTS AND METHODS: We performed a retrospective case series study of 148 patients in a 13-year period (1990-2003). Sites of obstruction was classified into three groups: I) gastric, duodenal or jejunal; II) ileal or colonic; III) anorectal. RESULTS: There were 65 patients in group I, 38 in group II and 45 in group III. Surgery was performed in 137 patients. Trisomy was diagnosed in 15 patients, polymalformation syndrome in 16 patients, and cystic fibrosis in seven patients. More than one site of intestinal obstruction was found in 22 patients (15 %). Morbidity consisted of nosocomial sepsis in 32 %, necrotizing enterocolitis in 7 %, and short gut in 3.4 %. Prematurity (48 %) was associated with higher morbidity and mortality. Overall mortality was 14.2 %, mainly associated with other malformations and extraintestinal problems. When patients with other extraintestinal malformations were excluded, the highest mortality was found in group II (OR: 12.19; CI: 2.4-76.2). The overall sensitivity of prenatal diagnosis was 0.44 and the mean gestational age at diagnosis was 31.6 weeks (SD 5.2). According to the site of obstruction, sensitivity was 0.77 in group I, 0.39 in group II and 0.04 in group III. Prenatal diagnosis did not alter prognosis. CONCLUSIONS: Morbidity and mortality were strongly influenced by extraintestinal problems. The most severe intestinal complications were midgut volvulus and necrotizing enterocolitis. Prenatal diagnosis was late and showed good sensitivity only in group I.

Obstrucción gastrointestinal anatómica congénita: diagnóstico prenatal, morbilidad y mortalidad / Congenital anatomic gastrointestinal obstruction: prenatal diagnosis, morbidity and mortality

Objetivos Describir la morbimortalidad de la obstrucción gastrointestinal congénita, valorar la utilidad del diagnóstico prenatal y analizar los resultados según el nivel de obstrucción. Pacientes y métodos Estudio descriptivo retrospectivo de 148 pacientes en el período 1990-2003. Los niveles de obstrucción se clasificaron en tres grupos: I) gástrica, duodenal o yeyunal; II) ileocólica; III) anorrectal. Resultados La distribución por grupos fue: 65 en el grupo I, 38 en el grupo II y 45 en el grupo III. Se intervinieron 137 pacientes. Se diagnosticaron 15 trisomías, 16 síndromes polimalformativos y siete fibrosis quísticas. En 22 casos (15 %) se encontró más de una zona de obstrucción intestinal. La morbilidad fue la siguiente: sepsis nosocomial 32 %, enterocolitis necrosante 7 %, intestino corto 3,4 %. La prematuridad (48 %) se asoció con mayor morbimortalidad. La mortalidad global fue de 14,2 %, asociada fundamentalmente a otras malformaciones y a problemas extraintestinales. Excluyendo los pacientes con otras malformaciones, el grupo II presentó mayor mortalidad (OR: 12,19; IC: 2,4-76,2). La sensibilidad global del diagnóstico prenatal fue 0,44 y la edad gestacional media del diagnóstico 31,6 semanas (DE: 5,2). Según el nivel de la obstrucción, la sensibilidad fue 0,77 en el grupo I; 0,39 en el grupo II y 0,04 en el grupo III. El diagnóstico prenatal no modificó el pronóstico. Conclusiones La morbimortalidad estuvo muy condicionada por problemas extraintestinales. El vólvulo de intestino medio y la enterocolitis necrosante fueron las complicaciones intestinales más graves. El diagnóstico prenatal fue tardío y sólo tuvo buena sensibilidad en el grupo I

Objectives To describe the morbidity and mortality associated with congenital gastrointestinal obstruction, assess the usefulness of prenatal diagnosis, and analyze the results in relation to the site of obstruction. Patients and methods We performed a retrospective case series study of 148 patients in a 13-year period (1990-2003). Sites of obstruction was classified into three groups: I) gastric, duodenal or jejunal; II) ileal or colonic; III) anorectal. Results There were 65 patients in group I, 38 in group II and 45 in group III. Surgery was performed in 137 patients. Trisomy was diagnosed in 15 patients, polymalformation syndrome in 16 patients, and cystic fibrosis in seven patients. More than one site of intestinal obstruction was found in 22 patients (15 %). Morbidity consisted of nosocomial sepsis in 32 %, necrotizing enterocolitis in 7 %, and short gut in 3.4 %.Prematurity (48 %) was associated with higher morbidity and mortality. Overall mortality was 14.2 %, mainly associated with other malformations and extraintestinal problems. When patients with other extraintestinal malformations were excluded, the highest mortality was found in group II (OR: 12.19; CI: 2.4-76.2). The overall sensitivity of prenatal diagnosis was 0.44 and the mean gestational age at diagnosis was 31.6 weeks (SD 5.2). According to the site of obstruction, sensitivity was 0.77 in group I, 0.39 in group II and 0.04 in group III. Prenatal diagnosis did not alter prognosis. Conclusions Morbidity and mortality were strongly influenced by extraintestinal problems. The most severe intestinal complications were midgut volvulus and necrotizing enterocolitis. Prenatal diagnosis was late and showed good sensitivity only in group I

Factores determinantes de la elevación de la uremia en los primeros días de vida en recién nacidos con menos de 30 semanas de gestación / Determinants of uremia elevation in the first days of life in premature infants born at less than 30 weeks of gestation

Objetivo: Encontrar los determinantes asociados con elevación de la uremia en los primeros días de vida en prematuros muy inmaduros. Métodos: Estudio prospectivo de una cohorte de recién nacidos con menos de 30 semanas de gestación. Resultados: Se incluyeron 48 prematuros nacidos vivos, de los que 10 fallecieron. Los aportes medios de líquidos fueron 55, 72, 88 y 124 ml/kg en el primer, segundo, tercer y séptimo días de vida. El aporte de aminoácidos en los primeros 2 días fue escaso y no se relacionó con la uremia. El 31 por ciento presentaron hipernatremia. En 31 prematuros se obtuvo la uremia entre el quinto y el décimo día de vida. Se encontraron 12 (38,7 por ciento) con valores de 100 mg/dl o superiores, sin elevación de la creatininemia. Todos ellos tuvieron menos de 27 semanas de gestación, menos de 850 g al nacer, mayor pérdida de peso (19,2 por ciento frente a 13,8 por ciento; p = 0,037) y mayor natremia máxima (150,2 mEq/l frente a 146,6 mEq/l; p = 0,023). El uso de furosemida aumentó el riesgo de uremia elevada (riesgo relativo [RR], 2,54; intervalo de confianza del 95 por ciento [IC 95 por ciento], 1,05-6,14).Conclusiones La uremia total de 100 mg/dl o superior se relacionó con determinantes asociados con excesiva pérdida precoz de agua libre, como mayor pérdida de peso, mayor natremia máxima, uso de furosemida, menor gestación y menor peso al nacer (AU)

[Determinants of uremia elevation in the first days of life in premature infants born before 30 weeks of gestation]. / Factores determinantes de la elevación de la uremia en los primeros días de vida en recién nacidos con menos de 30 semanas de gestación.

OBJECTIVE: To identify the determinants associated with uremia elevation in the first days of life in extremely premature infants. METHODS: We performed a prospective cohort study in a cohort of neonates born at less than 30 weeks of gestation. RESULTS: Forty-eight preterm infants were included, of which 10 died. The mean fluid administration was 55, 72, 88 and 124 mL/kg on the first, second, third and seventh days of life. Amino acid doses were low in the first two days of life and were unrelated to uremia elevation. Thirty-one percent of the infants presented hypernatremia. Uremia was measured in 31 infants between the fifth and tenth days of life and 12 infants (38.7 %) had uremia values of 100 mg/dL or higher, without creatinine elevation. All of these infants were born at less than 27 weeks of gestation, weighed less than 850 grams at birth, and showed greater weight loss (19.2 % vs. 13.8 %; p 5 0.037) and higher natremia (150.2 mEq/L vs. 146.6 mEq/L; p 5 0.023). The use of furosemide increased the risk of elevated uremia (relative risk: 2.54; 95 % confidence interval: 1.05 6.14). CONCLUSIONS: Total uremia of 100 mg/dL or higher was associated with dehydration, greater weight loss, higher natremia, furosemide use, lower gestational age, and lower birth weight.

[Survival at discharge of newborn infants weighing less than 1000 g (1991-1997). When are they too small?]. / Supervivencia al alta de los recién nacidos con un peso menor de 1.000 g (1991-1997). Cuándo son demasiado pequeños?

OBJECTIVE: To describe survival rates at discharge in liveborn infants with birth-weight under 1000 g by birth-weight and gestational age categories in a third level spanish hospital in order to improve health care planning and parental counselling about the threshold of viability. STUDY DESIGN: A follow-up study of 178 infants with birth-weight under 1000 g born alive between 1991 at 1997. Six newborns with lethal malformations were not included. RESULTS: Overall survival at discharge was 54%. During the study period survival rate improved in the birth-weight group 750-999 g. In the group below 750 g survival rate was lower and improved more slowly. Survival rate for infants below 750 g and 26 weeks was extremely low. Over 749 g and 25 weeks survival was over 50%. CONCLUSIONS: Survival rate showed an improving trend during the study period. In the last years of the study period survival in infants with birth-weight over 749 g was above 85%. For infants under 750 g and 26 weeks was extremely low. Family and medical decision making about active treatment of these newborns should be an individualized process.

[Cerebral palsy and age of sitting and walking in children weighing less than 1,500 g at birth]. / Parálisis cerebral y edad de sedestación y marcha en niños con peso al nacer menor de 1.500 g.

OBJECTIVE: To describe the corrected age (CA) of acquisition for sitting and walking in very low birth weight infants with cerebral palsy and to estimate the probability of walking as a function of age of acquisition of sitting and type of cerebral palsy. METHODS: Follow up study of very low birth weight infants (under 1500 g) admitted to the Neonatology Department of the Hospital 12 de Octubre in Spain between January 1991 and December 1996. At a corrected age of 2 years, 11.5% (34 children) were diagnosed with cerebral palsy. Ages of attainment of sitting and walking were established by interview with the parents and were confirmed by examination. Age of attainment of sitting and type of cerebral palsy were investigated as possible predictors of ambulatory status. RESULTS: Sitting was attained by 73% of the children. The probability of attainment of sitting at 9 months was 21% and at 18 months it was 68%. Only one child achieved sitting after 18 months. Fifty-three percent of the children became ambulatory. The probability of becoming ambulatory was 24% at 18 months and 47% at 30 months. If sitting was attained before 12 months of age the probability of becoming ambulatory was 47% at 18 months and 76% at 30 months. All children with spastic hemiplegia, 66% of those with diplegia and only 8% of those with quadriplegia became ambulatory. CONCLUSIONS: Sitting by the age of 12 months was directly related to achieving ambulation. Irrespective of the type of cerebral palsy, all children with hemiplegia and more than 60% of those with diplegia ambulated while children with quadriplegia were much less likely to ambulate.

Parálisis cerebral y edad de sedestación y marcha en niños con peso al nacer menor de 1.500 g / Cerebral palsy and age of sitting and walking in very low birth weight infants

OBJETIVO: Describir la cronología de adquisición de la sedestación y la marcha en los niños con un peso al nacer menor de 1.500 g con diagnóstico de parálisis cerebral, y estimar la probabilidad de alcanzar la marcha en función de la edad de sedestación y del tipo de parálisis cerebral. MÉTODOS: Estudio observacional de una cohorte de niños con peso al nacer menor de 1.500 g y atendidos entre enero de 1991 y diciembre de 1996 en el Servicio de Neonatología del Hospital 12 de Octubre. A los 2 años de edad corregida un 11,5 por ciento (34 niños) se habían diagnosticado de parálisis cerebral. Las edades de sedestación y marcha se establecieron por entrevista a los padres y se confirmaron en la exploración. Se estudiaron la edad de sedestación y el tipo de parálisis cerebral como predictores de la marcha. RESULTADOS: El 73 por ciento de los niños alcanza lograr la sedestación. A los 9 meses la probabilidad de alcanzar la sedestación fue del 21 por ciento, a los 18 meses de un 68 por ciento. Sólo un niño alcanzó la sedestación después de los 18 meses. El 53 por ciento alcanzó la marcha. La probabilidad de marcha a los 18 meses fue del 24 por ciento, y a los 30 meses del 47 por ciento. Si la sedestación se había conseguido a los 12 meses, la probabilidad de marcha a los 18 meses fue del 47 por ciento y a los 30 meses del 76 por ciento. Todos los niños con hemiplejía alcanzan la marcha, el 66 por ciento de los dipléjicos y sólo el 8 por ciento de los tetrapléjicos. CONCLUSIÓN: El haber alcanzado la sedestación a los 12 meses de edad se relaciona con una mayor probabilidad de alcanzar la marcha. Con respecto al tipo de parálisis cerebral, todos los niños con hemiplejía pueden alcanzar la marcha y más del 60 por ciento de los que presentan formas dipléjicas. Los que presentan formas tetrapléjicas es mucho menos probable que alcancen la marcha (AU)

Supervivencia al alta de los recién nacidos con un peso menor de 1.000 g (1991-1997).¿Cuándo son demasiado pequeños? / Survival at discharge of extremely-low-birth-weight infants under 1000 g (1991-1997)

OBJETIVO: Obtener información sobre la supervivencia al alta de todos los niños nacidos vivos con peso menor de 1.000 g en un hospital español de tercer nivel para conocer la supervivencia en relación con el peso y la edad gestacional e intentar mejorar los cuidados médicos y la información a los padres de los niños en el límite de la viabilidad. DISEÑO DEL ESTUDIO: Se estudió una cohorte de 178 niños con un peso menor de 1.000 g nacidos en el Hospital 12 de Octubre durante los años 1991-1997. No se incluyeron 6 niños por presentar malformaciones letales. RESULTADOS: La supervivencia al alta fue del 54 por ciento, la de los niños con peso entre 750 y 999 g mejoró durante el período de estudio; los menores de 750 g tuvieron una baja supervivencia que fue mejorando lentamente. La supervivencia de los menores de 750 g y menos de 26 semanas fue muy baja. Los niños por encima de 749 g y de 25 semanas presentaron supervivencias mayores del 50 por ciento. CONCLUSIÓN: La supervivencia mejoró durante el período de estudio. Durante los últimos años la supervivencia de los niños con un peso mayor de 750 g fue superior al 85 por ciento. La supervivencia de los niños con menos de 750 g y menos de 26 semanas fue muy baja. La toma de decisiones desde el punto de vista médico y familiar sobre el tratamiento activo de estos niños debe hacerse de forma individualizada (AU)

[Changes in weight, length and head circumference in premature newborn babies weighing less than 1,500 grams at birth]. / Evolución del peso, la longitud--talla y el perímetro craneal en los prematuros de menos de 1.500 gramos al nacimiento.

OBJECTIVE: The objective of this study was to analyze the weight, length and head circumference development in prematurely born babies who weighed less than 1,500 grams and who were included in the follow-up program of our neonatal unit. PATIENTS AND METHODS: Review of data of the cohort included in the follow-up program between May 1990 and September 1995 was carried out. The weight and length were measured from 3 months of corrected age to 4 years of age. The head circumference was measured until 2 years of age. RESULTS: We recruited 259 premature newborns (136 boys and 123 girls). The median gestational age was 30 weeks (23 to 36) and the median weight was 1,150 g (500 to 1,499 g). Twenty-seven percent were underweight for their gestational age (LWGA). The proportion of cases with weight below the 3rd percentile in the follow-up was stable around 25% in the group of adequate weight for gestational age. (AWGA). At 3 months of corrected age this proportion was 70% in the LWGA group, but there was a trend towards catch-up at 2 years of age. The worst results were obtained in the group that weighed less than 750 g at birth. The head circumference was better preserved than longitudinal growth and thus better than weight. All cases of head circumference below the 3rd percentile in the follow-up occurs in the LWGA group. CONCLUSIONS: Weight was the parameter with the worst evolution during follow-up, especially in the group that weighed less than 750 g at birth. The group of LWGA tended to catch-up at 2 years of age.

[Outcome at 3 years of age in a low birth weight cohort]. / Evolución a los 3 años de edad de una cohorte de recién nacidos de muy bajo peso.

OBJECTIVE: The objective of this study was to establish the outcome at 3 years of age for very low birth weight newborns admitted to the Hospital 12 de Octubre from January 1991 to December 1993. PATIENTS AND METHODS: A follow-up study was performed. The pediatric assessment included a neurological, psychological, visual and audiological evaluation. At the end of the follow-up, children were blindly assessed to determine the rate of neurosensory disability. The severity of the neurosensory disability was graded as severe, moderate or mild by a functional classification. The rates of cerebral palsy, blindness and deafness were reported. RESULTS: Two hundred fifty-three infants between 500 and 1,499 g were admitted to the Hospital 12 de Octubre of which 182 survived. Of these, 137 (75% of the survivors) were assessed at 3 years of age. The children who dropped out during the follow-up period had similar characteristics to those with a complete follow-up program except that the drop-out child was more likely to belong to a disadvantaged family. The rate of neurosensory disability was 28.5% (39/137), 16% were mild, 5% moderate and 7% severe. The rate of cerebral palsy was 13% (18/137), blindness 1.4% and deafness 0.7%. CONCLUSIONS: Children from more disadvantaged families are less likely to continue in follow-up programs and this supposes a bias in the follow-up program. At 3 years, neurosensory disability was diagnosed in 1 out of every 4 children and cerebral palsy in 1 out of 8 children.

[Preventive use of antibiotics in neonatal surgery]. / Profilaxis antibiótica en la cirugía neonatal.

OBJECTIVE: The objective of this study was to determine the incidence of surgical wound infection and the impact of this on the implementation of an antibiotic protocol according to the type of surgery and the prevailing endogenous flora in our neonatology unit. PATIENTS AND METHODS: Patients' charts were retrospectively reviewed in order to assess the effectiveness of a protocol of surgical prophylaxis, comparing the incidence of postsurgical wound infection in two periods of time. Surgical interventions were classified according to the period of the study in which they were performed, before (period A) and after (period B) the protocol was undertaken. In addition, if the antibiotics administered fit or not those indicated in the protocol, it was classified as correct or not. RESULTS: A total of 31 (37%) of the interventions were performed in period A, whereas 53 (63%) were carried out in period B. No statistically significant differences were found between periods with regard to the proportion of infections 925.8% vs 15%). When prophylactic antibiotics were administered correctly, infection occurred in 10.2%, as compared to 31.4% when they did not fit the protocol (p < 0.05). The duration of the antibiotics was longer in period A, in infected wounds and when prophylaxis was not correct. CONCLUSIONS: The correct adjustment to the protocol significantly decreases the incidence of wound infections, as well as the duration of antibiotic use. An appropriate policy of antibiotic prophylaxis in surgery is advantageous in terms of economic cost and might prevent antibiotic resistance and avoid unnecessary toxicity.

[Transcutaneous bilirubin measurement in neonates]. / Bilirrubina transcutánea en neonatos.

A study was performed to determine, in our population, the relationship between transcutaneous, visual and serum bilirubin values. This was done in attempts to reduce the number of serum bilirubin determinations to be performed in the future. We did a correlation coefficient between serum bilirubin and five measurements of transcutaneous bilirubin levels in a group of 60 term newborns and 60 preterm newborns, obtaining a value of 0.84 in both groups. The results were also considered from an analytical point of view where the ability of the test to predict an alteration in serum bilirubin levels, for example > or = 12 mg/dl in preterm and > or = 13 mg/dl in term newborns, was assessed. For values of 18 in preterm and 17 in term infants, the transcutaneous method was found to be both sensitive and specific. If Kramer's test is also evaluated the results improve.