Translating Neonatal Resuscitation Guidelines Into Practice in Brazil.

BACKGROUND AND OBJECTIVES: The Brazilian Neonatal Resuscitation Program releases guidelines based on local interpretation of international consensus on science and treatment recommendations. We aimed to analyze whether guidelines for preterm newborns were applied to practice in the 20 Brazilian Network on Neonatal Research centers of this middle-income country. METHODS: Prospectively collected data from 2014 to 2020 were analyzed for 8514 infants born at 230/7 to 316/7 weeks' gestation. The frequency of procedures was evaluated by gestational age (GA) category, including use of a thermal care bundle, positive pressure ventilation (PPV), PPV with a T-piece resuscitator, maximum fraction of inspired oxygen (Fio2) concentration during PPV, tracheal intubation, chest compressions and medications, and use of continuous positive airway pressure in the delivery room. Logistic regression, adjusted by center and year, was used to estimate the probability of receiving recommended treatment. RESULTS: For 3644 infants 23 to 27 weeks' GA and 4870 infants 28 to 31 weeks' GA, respectively, the probability of receiving care consistent with guidelines per year increased, including thermal care (odds ratio [OR], 1.52 [95% confidence interval (CI) 1.44-1.61] and 1.45 [1.38-1.52]) and PPV with a T-piece (OR, 1.45 [95% CI 1.37-1.55] and 1.41 [1.32-1.51]). The probability of receiving PPV with Fio2 1.00 decreased equally in both GA groups (OR, 0.89; 95% CI, 0.86-0.93). CONCLUSIONS: Between 2014 and 2020, the resuscitation guidelines for newborns <32 weeks' GA on thermal care, PPV with a T-piece resuscitator, and decreased use of Fio2 1.00 were translated into clinical practice.

Developmental Enamel Defects and Dental Caries in the Primary Dentition of Preterm Children.

Purpose: To assess developmental enamel defects (DED) and dental caries of preterm (PT) and/or low birth weight (LBW) children compared to full term (FT) and/or normal birth weight (NBW) infants, and to evaluate the association of DED with socioeconomic factors, gestational health, and postnatal factors.
Methods: This study included 84 two- to five-year-old children. The PT/LBW group included 42 children who received medical care at a university hospital, while FT/ NBW group included 42 subjects. Children were matched by sex and age (1:1 ratio). Descriptive statistics, bivariate analysis, and Poisson regression were used to analyse the data.
Results: Children in the PT/LBW group had a significantly higher number of teeth with DED than subjects in the FT/NBW group. No difference was observed between the groups regarding dental caries (P >0.05). Admission to the neonatal intensive care was significantly associated with DED unit (prevalence ratio = 0.21 [95 percent confidence interval = 0.1 to 0.5]).
Conclusion: PT/LBW children presented more DED than FT/NBW children. No differences were observed between the groups for dental caries. Admission to the neonatal intensive care unit was associated with DED.

Prevalence and Outcomes of Congenital Heart Disease in Very Low Birth Weight Preterm Infants: An Observational Study From the Brazilian Neonatal Network Database.

OBJECTIVES: To evaluate the prevalence of congenital heart disease and their outcomes in a Brazilian cohort of very low birth weight preterm infants. DESIGN: Post hoc analysis of data from the Brazilian Neonatal Network database, complemented by retrospective data from medical charts and a cross-sectional survey. SETTING: Twenty public tertiary-care university hospitals. PATIENTS: A total of 13,955 newborns weighing from 401 to 1,499 g and between 22 and 36 weeks of gestational age, born from 2010 to 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The prevalence of congenital heart disease was 2.45% (95% CI, 2.20-2.72%). In a multivariate regression analysis, risk factors associated with congenital heart disease were maternal diabetes (relative risk, 1.55; 95% CI, 1.11-2.20) and maternal age above 35 years (relative risk, 2.09; 95% CI, 1.73-2.51), whereas the protection factors were maternal hypertension (relative risk, 0.54; 95% CI, 0.43-0.69), congenital infection (relative risk, 0.45; 95% CI, 0.21-0.94), and multiple gestation (relative risk, 0.73; 95% CI, 0.55-0.97). The pooled standardized mortality ratio in patients with congenital heart disease was 2.48 (95% CI, 2.22-2.80), which was significantly higher than in patients without congenital heart disease (2.08; 95% CI, 2.03-2.13). However, in multiple log-binomial regression analyses, only the presence of major congenital anomaly, gestational age (< 29 wk; relative risk, 2.32; 95% CI, 2.13-2.52), and Score for Neonatal Acute Physiology and Perinatal Extension II (> 20; relative risk, 3.76; 95% CI, 3.41-4.14) were independently associated with death, whereas the effect of congenital heart disease was spotted only when a conditional inference tree approach was used. CONCLUSIONS: The overall prevalence of congenital heart disease in this cohort of very low birth weight infants was higher and with higher mortality than in the general population of live births. The occurrence of a major congenital anomaly, gestational age (< 29 wk), and Score for Neonatal Acute Physiology and Perinatal Extension II (> 20) were significantly and independently associated with death, whereas the association of congenital heart disease and death was only evident when a major congenital anomaly was present.

Difference of Socioeconomic Factors among Mothers of Preterm and Full-Term Infant

Abstract Objective: To analyze the difference of socioeconomic factors among mothers of preterm and full-term infants. Material and Methods: A cross-sectional retrospective study was developed with 250 mothers of children aged three to five years. The sample was divided into two groups: 125 mothers of preterm infants from the referral center of a public hospital in the city of Belo Horizonte, Brazil and 125 mothers of children born full-term at a daycare center within the same city. A pre-tested questionnaire was used to collect socioeconomic data and type of breastfeeding. To verify if there was association between the dependent variable gestational age at birth and the independent variables, the chi-square test was used. A final model with multiple Poisson regression estimated prevalence ratio values for each independent variable was developed. Results: The final multiple regression model showed that mothers that have a low monthly income of up to USD 450.28 (PR = 1.979, 95% CI = 1.082-3.620), used drugs, cigarettes, or alcohol during their pregnancy (PR = 4.095, 95% CI = 2.422-6.921), and did not breastfeed (PR = 2.294, 95% CI = 1.205-4.369) were more likely to give birth to preterm infants. Conclusion: Low monthly family income, use of drugs, alcohol, or smoking during pregnancy and absence of breastfeeding were more frequent on mothers of preterm infants.

Clinical application of the Newborn Behavioral Observation (NBO) System to characterize the behavioral pattern of newborns at biological and social risk / Aplicação clínica do Newborn Behavioral Observation (NBO) System para caracterizar o padrão comportamental dos recém-nascidos de risco biológico e social

Abstract Objective To compare the behavior of preterm newborns and full-term newborns using the Newborn Behavioral Observation and to evaluate the mothers' experience when participating in this observation. Method This was a cross-sectional study performed at a referral hospital for high-risk births, involving mothers and neonates before hospital discharge. The mothers answered the sociodemographic questionnaire, participated in the Newborn Behavioral Observation session, and evaluated the experience by answering the parents' questionnaire at the end. The characteristics of the preterm newborn and full-term newborn groups and the autonomic, motor, organization of states, and responsiveness scores were compared. Linear regression was performed to test the association of the characteristics of mothers and neonates with the scores in the autonomic, motor, organization of states, and responsiveness domains. Results The Newborn Behavioral Observation was performed with 170 newborns (eight twins and 77% preterm newborns). Approximately 15% of the mothers were adolescents and had nine years of schooling, on average. The groups differed regarding weight for gestational age, age at observation, APGAR score, feeding, and primiparity. The linear regression adjusted for these variables showed that only prematurity remained associated with differences in the scores of the motor (p = 0.002) and responsiveness (p = 0.02) domains. No statistical difference was observed between the groups in the score attributed to one's own knowledge prior to the session (p = 0.10). After the session, these means increased in both groups. This increase was significantly higher in the preterm newborn group (p = 0.02). Conclusions The Newborn Behavioral Observation increased the mothers' knowledge about the behavior of their children, especially in mothers of preterm newborns, and identified differences in the behavior of preterm newborns and full-term newborns regarding the motor and responsiveness domains.

Resumo Objetivo Comparar o comportamento de recém-nascidos pré-termo e a termo utilizando a Newborn Behavioral Observation e avaliar a experiência das mães em participar dessa observação. Método Estudo transversal realizado em hospital de referência para partos de risco, envolvendo mães e neonatos antes da alta hospitalar. As mães responderam ao questionário sociodemográfico, participaram da sessão de Newborn Behavioral Observation e ao final avaliaram a experiência e responderam ao questionário de pais. As características dos grupos de recém-nascidos pré-termo e recém-nascidos termo e os escores dos domínios autonômico, motor, organização dos estados e responsividade foram comparados. Realizou-se regressão linear para testar a associação de características das mães e neonatos com os escores nos domínios autonômico, motor, organização dos estados e responsividade. Resultados A Newborn Behavioral Observation foi realizada com 170 recém-nascidos (oito gemelares e 77% pré-termo). Cerca de 15% das mães eram adolescentes e estudaram em média por 9 anos. Os grupos diferiram quanto ao peso para idade gestacional, idade na observação, APGAR, alimentação e primiparidade. A regressão linear ajustada para essas variáveis mostrou que apenas a prematuridade manteve-se associada a diferenças nos escores dos domínios motor (p = 0,002) e responsividade (p = 0,02). Não houve diferença estatística entre os grupos na pontuação atribuída ao próprio conhecimento antes da sessão (p = 0,10). Após a sessão estas médias subiram em ambos os grupos. Esse aumento foi significativamente maior no grupo de recém-nascidos pré-termo (p = 0,02). Conclusões A Newborn Behavioral Observation aumentou o conhecimento das mães sobre o comportamento dos filhos, principalmente para as mães de recém-nascidos pré-termo, e identificou diferenças no comportamento de recém-nascidos pré-termo e recém-nascidos termo nos domínios motor e responsividade.

Clinical application of the Newborn Behavioral Observation (NBO) System to characterize the behavioral pattern of newborns at biological and social risk.

OBJECTIVE: To compare the behavior of preterm newborns and full-term newborns using the Newborn Behavioral Observation and to evaluate the mothers' experience when participating in this observation. METHOD: This was a cross-sectional study performed at a referral hospital for high-risk births, involving mothers and neonates before hospital discharge. The mothers answered the sociodemographic questionnaire, participated in the Newborn Behavioral Observation session, and evaluated the experience by answering the parents' questionnaire at the end. The characteristics of the preterm newborn and full-term newborn groups and the autonomic, motor, organization of states, and responsiveness scores were compared. Linear regression was performed to test the association of the characteristics of mothers and neonates with the scores in the autonomic, motor, organization of states, and responsiveness domains. RESULTS: The Newborn Behavioral Observation was performed with 170 newborns (eight twins and 77% preterm newborns). Approximately 15% of the mothers were adolescents and had nine years of schooling, on average. The groups differed regarding weight for gestational age, age at observation, APGAR score, feeding, and primiparity. The linear regression adjusted for these variables showed that only prematurity remained associated with differences in the scores of the motor (p=0.002) and responsiveness (p=0.02) domains. No statistical difference was observed between the groups in the score attributed to one's own knowledge prior to the session (p=0.10). After the session, these means increased in both groups. This increase was significantly higher in the preterm newborn group (p=0.02). CONCLUSIONS: The Newborn Behavioral Observation increased the mothers' knowledge about the behavior of their children, especially in mothers of preterm newborns, and identified differences in the behavior of preterm newborns and full-term newborns regarding the motor and responsiveness domains.

T-piece versus self-inflating bag ventilation in preterm neonates at birth.

OBJECTIVE: To verify whether the use of the T-piece resuscitator compared with the self-inflating bag in preterm infants ventilated at birth modifies survival to hospital discharge without major morbidities. DESIGN: Pragmatic prospective cohort study. SETTING: 20 Brazilian university hospitals of Brazilian Network on Neonatal Research. Patients were 1962 inborn infants in 2014-2015 ventilated at birth with 23-33' weeks gestation and birth weight 400-1499 g without malformations. Patients transferred until the 27th day after birth were excluded. INTERVENTIONS: Positive pressure ventilation at birth with T-piece resuscitator or self-inflating bag without positive end expiratory pressure valve. Intervention with ventilation followed the Brazilian Society of Pediatrics guidelines. The choice of the equipment was at the neonatologist's discretion in each delivery. The main outcome measures were survival to hospital discharge without bronchopulmonary dysplasia, severe peri-intraventricular haemorrhage and periventricular leucomalacia. Logistic regression adjusted for confounding variables was applied for main outcome. RESULTS: 1456 (74%) were only ventilated with T-piece resuscitator and 506 (26%) with the self-inflating bag. The characteristics of those ventilated with T-Piece resuscitator versus self-inflating bag were birth weight 969 ± 277 vs 941 ± 279 g, gestational age 28.2±2.5 vs 27.8±2.7 weeks and survival to hospital discharge without major morbidities 47% vs 35%. Logistic regression adjusted for maternal characteristics, obstetric and neonatal morbidities showed that the T-piece resuscitator increased the chance of survival to hospital discharge without major morbidities (OR=1.38; 95% CI 1.06 to 1.80; Hosmer-Lemeshow goodness of fit: 0.695). CONCLUSION: This study is the first that highlights the effectiveness of T-piece resuscitator ventilation in improving relevant outcomes in preterm neonates.

Does Disclosure of Terminal Prognosis Mean Losing Hope? Insights from Exploring Patient Perspectives on Their Experience of Palliative Care Consultations.

BACKGROUND: A primary barrier to physician disclosure of terminal prognosis is concern that patients will lose hope. Inpatient palliative care (IPC) teams are especially posed to mediate this barrier, but little is known about patient perceptions and experience of IPC. OBJECTIVE: This study aimed to elicit seriously ill patients' perspective and experience of an IPC consultation, and to explore patient attitudes toward information derived from the consultation. METHODS: An exploratory, qualitative study was conducted at a large nonprofit community hospital in the Los Angeles area. An established IPC team conducted individualized consults with patients and families within 24 hours of referral. Eligible participants were English-speaking adults, aged 18 or over, who had received an IPC consultation within the previous week during their hospitalization. Purposive recruitment of patients was conducted by the IPC social worker. Interviews were conducted at bedside using a semistructured interview protocol employing open-ended questions. RESULTS: Twelve seriously ill patients were interviewed. Four themes were identified from the interview transcripts: (1) holistic care approach, (2) knowledge/information gained, (3) hope and enlightenment, and (4) patient readiness. CONCLUSIONS: Results suggest that disclosure of a terminal prognosis does not mean loss of patient hope. Instead, hope was redefined on a goal other than cure. Presenting patients with information and increasing their knowledge about care options and resources may facilitate patients in identifying meaningful goals that are better aligned with their prognosis.

Family members' perceptions of inpatient palliative care consult services: a qualitative study.

BACKGROUND: Family members are commonly involved in end-of-life decision making and typically involved in inpatient palliative care consultations. Although much research has documented patient outcomes following inpatient palliative care consultation, little is known about family member perceptions of the consultation. AIM: The purpose of this study was to determine how inpatient palliative care consultations impacted family members' understanding of the patient's condition, knowledge of available care options, and decision-making ability. DESIGN: An exploratory, qualitative study was conducted employing individual interviews among family members of seriously ill patients, recruited purposively. Interviews were conducted in person, at the hospital, or via telephone, using a semistructured protocol. SETTING/PARTICIPANTS: Family members of seriously ill patients were recruited from a nonprofit, community hospital. RESULTS: Interviews were conducted among 23 family members. Four themes were identified and included: perceived qualities of the inpatient palliative care consultation, family readiness, impact on decision-making process, and focus on comfort and quality of life. While most comments reflected positive aspects of the inpatient palliative care consult, such as improved pain control and communication, and increased access to medical professionals and time to discuss patient conditions, some themes reflected a lack of adequate preparation for the inpatient palliative care consultation and readiness for discussing prognosis. CONCLUSION: Family members report discussion with the inpatient palliative care team results in improved communication and knowledge, which contributes to decision-making ability. However, palliative care consultation may be improved by developing stronger protocols for introducing palliative care and by including the attending physician in the process to preclude conflicting, inconsistent information and recommendations.

Remifentanil in neonatal intensive care and anaesthesia practice.

UNLABELLED: Remifentanil is a relatively new ultrashort action synthetic opioid. Studies on the use of remifentanil in neonatology have emerged demonstrating its effectiveness and safety in neonates. The present study describes the use of remifentanil in both full-term and premature newborns, highlighting the theoretical benefits for this population in terms of both neonatal intensive care and anaesthesia. A Medline search was undertaken of all reviews and reports about the use of remifentanil in neonates published between 1996 and 2009 using MeSH search terms 'remifentanil', 'analgesia', 'anaesthesia', 'newborn' and 'neonate'. The review points that remifentanil has been used with advantages in newborns including preterm neonates and even for foetal anaesthesia. It proved to be a good option to attenuate the hemodynamic/endocrine markers of stress related to surgery. Owing to its unique pharmacokinetic profile, shorter extubation times can be achieved what makes the drug also a good option for short duration invasive procedures in NICUs (InSurE). A concern on its use is that the hemodynamic response (hypotension) may become significant when the drug is associated to other drugs like sevoflurane. CONCLUSION: Remifentanil seems to be an effective and safely used opioid for neonatal intensive care and anaesthesia practice.