Late-Onset Sepsis in Very Low Birth Weight Premature Infants: A 10-Year Review of a Brazilian Tertiary University Hospital-the Challenge Remains.

OBJECTIVES: This study aimed to assess the incidence of late-onset sepsis (LOS), associated risk factors, and short-term prognosis in very low birth weight (VLBW) infants in a 10-year period. STUDY DESIGN: A cohort study was conducted with 752 VLBW preterm infants-23 to 33 gestational weeks and 400 to 1,500 g birth weight-admitted to a neonatal intensive care unit from 2008 to 2017 and who survived over 72 hours. LOS was defined as clinical and laboratory signs of infection, whether or not confirmed by blood culture. VLBW infants were divided into groups and compared: no LOS versus proven LOS versus clinical LOS. Study variables included maternal, birth, and neonatal data, morbidities, procedures, etiological agents, and outcome-death, bronchopulmonary dysplasia (BPD), severe intraventricular hemorrhage, and retinopathy of prematurity (ROP). Analysis of variance with multiple Tukey's or Wald's comparison with gamma distribution, and stepwise multiple logistic regression model, adjusted for year, and gestational age, were used for statistical analysis. RESULTS: LOS incidence was 39% (proven LOS: 29%; clinical LOS: 10%). Septic VLBW infants showed higher mortality (proven LOS: 23.2%; clinical LOS: 41.9%) compared with no LOS (8.9%). Coagulase-negative staphylococci (56%), Gram-negative (26%), and fungi (8%) were the most frequent etiological agents. In comparing the groups, septic VLBW infants had lower gestational age and birth weight, presented more morbidities, and underwent more invasive procedures. The risk factors for proven and clinical LOS were days of mechanical ventilation and parenteral nutrition. LOS was associated with increased risk of death, BPD, and ROP. CONCLUSION: LOS showed high incidence and mortality, often caused by Gram-positive bacteria. Care interventions were the main risk factors associated. LOS had a major negative impact on short-term prognosis in VLBW infants. LOS reduction strategies are necessary and urgent. KEY POINTS: · LOS is associated with clinically significant neonatal morbidities and death in VLBW premature infants.. · There is association between LOS and duration of intensive care interventions.. · Quality improvement initiatives can be a pathway for LOS reduction..

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.

Growth of preterm low birth weight infants until 24 months corrected age: effect of maternal hypertension / Crescimento de prematuros de baixo peso até a idade de 24 meses corrigidos: efeito da hipertensão materna

OBJECTIVE: To evaluate the growth pattern of low birth weight preterm infants born to hypertensive mothers, the occurrence of growth disorders, and risk factors for inadequate growth at 24 months of corrected age (CA). METHODS: Cohort study of preterm low birth weight infants followed until 24 months CA, in a university hospital between January 2009 and December 2010. Inclusion criteria: gestational age < 37 weeks and birth weight of 1,500-2,499 g. Exclusion criteria: multiple pregnancies, major congenital anomalies, and loss to follow up in the 2nd year of life. The following were evaluated: weight, length, and BMI. Outcomes: growth failure and risk of overweight at 0, 12, and 24 months CA. Student's t-test, Repeated measures ANOVA (RM-ANOVA), and multiple logistic regression were used. RESULTS: A total of 80 preterm low birth weight infants born to hypertensive mothers and 101 born to normotensive mothers were studied. There was a higher risk of overweight in children of hypertensive mothers at 24 months; however, maternal hypertension was not a risk factor for inadequate growth. Logistic regression showed that being born small for gestational age and inadequate growth in the first 12 months of life were associated with poorer growth at 24 months. CONCLUSION: Preterm low birth weight born infants to hypertensive mothers have an increased risk of overweight at 24 months CA. Being born small for gestational age and inadequate growth in the 1st year of life are risk factors for growth disorders at 24 months CA. .

OBJETIVO: Avaliar o padrão de crescimento de prematuros de baixo peso nascidos de mães hipertensas, a ocorrência de distúrbios de crescimento e os fatores de risco para inadequado crescimento aos 24 meses de idade corrigida (IC). MÉTODOS: Estudo de coorte de prematuros de baixo peso acompanhados até 24 meses IC, em um hospital universitário, entre janeiro de 2009 e dezembro de 2010. Critérios de inclusão: idade gestacional < 37 semanas e peso de nascimento de 1500-2499 g. Excluídas: gestações múltiplas, anomalias congênitas maiores e perda de seguimento no segundo ano de vida. Foram avaliados: peso, comprimento e IMC. Desfechos: falha de crescimento e risco de sobrepeso com 0, 12 e 24 meses de IC. Teste t de Student, X2, Anova-RM e regressão logística múltipla foram usados. RESULTADOS: Foram estudados 80 prematuros de baixo peso nascidos de mães hipertensas e 101 de mães normotensas. Houve maior risco de sobrepeso em crianças de mães hipertensas aos 24 meses, entretanto a hipertensão materna não foi fator de risco para inadequado crescimento. A regressão logística mostrou que nascer pequeno para idade gestacional e ter inadequado crescimento nos primeiros 12 meses de vida associaram-se com pior crescimento aos 24 meses. CONCLUSÃO: Prematuros de baixo peso nascidos de mães hipertensas têm risco aumentado de sobrepeso aos 24 meses de IC. Ser pequeno para idade gestacional e ter inadequado crescimento no primeiro ano são fatores de risco para distúrbios no crescimento aos 24 meses de IC. .

Practices related to late-onset sepsis in very low-birth weight preterm infants / Práticas relacionadas à sepse tardia em prematuros de muito baixo peso

OBJECTIVE: To understand the practices related to late-onset sepsis (LOS) in the centers of the Brazilian Neonatal Research Network, and to propose strategies to reduce the incidence of LOS. METHODS: This was a cross-sectional descriptive multicenter study approved by the Ethics Committee. Three questionnaires regarding hand hygiene, vascular catheters, and diagnosis/treatment of LOS were sent to the coordinator of each center. The center with the lowest incidence of LOS was compared with the others. RESULTS: All 16 centers answered the questionnaires. Regarding hand hygiene, 87% use chlorhexidine or 70% alcohol; alcohol gel is used in 100%; 80% use bedside dispensers (50% had one dispenser for every two beds); practical training occurs in 100% and theoretical training in 70% of the centers, and 37% train once a year. Catheters: 94% have a protocol, and 75% have a line insertion team. Diagnosis/treatment: complete blood count and blood culture are used in 100%, PCR in 87%, hematological scores in 75%; oxacillin and aminoglycosides is the empirical therapy in 50% of centers. Characteristics of the center with lowest incidence of LOS: stricter hand hygiene; catheter insertion and maintenance groups; use of blood culture, PCR, and hematological score for diagnosis; empirical therapy with oxacillin and aminoglycoside. CONCLUSION: The knowledge of the practices of each center allowed for the identification of aspects to be improved as a strategy to reduce LOS, including: alcohol gel use, hand hygiene training, implementation of catheter teams, and wise use of antibiotic therapy. .

OBJETIVO: Conhecer as práticas relacionadas a sepse tardia (ST) nos centros da Rede Brasileira de Pesquisas Neonatais (RBPN) e propor estratégias para redução da ST. MÉTODOS: Estudo transversal, multicêntrico da RBPN, aprovado pelo CEP. Três questionários sobre higienização das mãos, cateteres vasculares e diagnóstico/tratamento da ST foram elaborados e enviados aos coordenadores de cada centro. O centro com a menor incidência de ST foi comparado aos demais. RESULTADOS: Todos os 16 centros responderam aos questionários. Quanto à higienização das mãos: 87% usam chlorhexidine ou álcool 70%; 100% álcool gel; almotolia/leito em 80% (50% dispõem de um dispensador para cada dois leitos); Treinamento prático ocorre em 100%, teórico em 70% dos centros e 37% treinam uma vez/ano. Cateteres: 94% têm protocolo para passagem, 75% grupo de inserção. Diagnóstico/tratamento: hemograma e hemocultura são usados em 100% dos centros; PCR em 87%; 75% usam escores hematológicos; oxacilina e aminoglicosídeo são usados como terapia empírica em 50% dos centros. Características do centro com menor incidência de ST: rigorosa higienização das mãos; grupos de inserção e manutenção de cateteres; uso de hemocultura, PCR e escores hematológicos para diagnóstico da ST; tratamento empírico com oxacilina e aminoglicosídeo. CONCLUSÕES: O conhecimento das práticas de cada centro permitiu identificar aspectos a serem aprimorados como estratégia para a redução da ST incluindo: uso de álcool gel, treinamento em higienização das mãos, implantação de grupos de cateteres e uso racional de antibióticos. .

Practices related to late-onset sepsis in very low-birth weight preterm infants.

OBJECTIVE: To understand the practices related to late-onset sepsis (LOS) in the centers of the Brazilian Neonatal Research Network, and to propose strategies to reduce the incidence of LOS. METHODS: This was a cross-sectional descriptive multicenter study approved by the Ethics Committee. Three questionnaires regarding hand hygiene, vascular catheters, and diagnosis/treatment of LOS were sent to the coordinator of each center. The center with the lowest incidence of LOS was compared with the others. RESULTS: All 16 centers answered the questionnaires. Regarding hand hygiene, 87% use chlorhexidine or 70% alcohol; alcohol gel is used in 100%; 80% use bedside dispensers (50% had one dispenser for every two beds); practical training occurs in 100% and theoretical training in 70% of the centers, and 37% train once a year. Catheters: 94% have a protocol, and 75% have a line insertion team. Diagnosis/treatment: complete blood count and blood culture are used in 100%, PCR in 87%, hematological scores in 75%; oxacillin and aminoglycosides is the empirical therapy in 50% of centers. Characteristics of the center with lowest incidence of LOS: stricter hand hygiene; catheter insertion and maintenance groups; use of blood culture, PCR, and hematological score for diagnosis; empirical therapy with oxacillin and aminoglycoside. CONCLUSION: The knowledge of the practices of each center allowed for the identification of aspects to be improved as a strategy to reduce LOS, including: alcohol gel use, hand hygiene training, implementation of catheter teams, and wise use of antibiotic therapy.

Growth of preterm low birth weight infants until 24 months corrected age: effect of maternal hypertension.

OBJECTIVE: To evaluate the growth pattern of low birth weight preterm infants born to hypertensive mothers, the occurrence of growth disorders, and risk factors for inadequate growth at 24 months of corrected age (CA). METHODS: Cohort study of preterm low birth weight infants followed until 24 months CA, in a university hospital between January 2009 and December 2010. INCLUSION CRITERIA: gestational age < 37 weeks and birth weight of 1,500-2,499 g. EXCLUSION CRITERIA: multiple pregnancies, major congenital anomalies, and loss to follow up in the 2nd year of life. The following were evaluated: weight, length, and BMI. OUTCOMES: growth failure and risk of overweight at 0, 12, and 24 months CA. Student's t-test, Repeated measures ANOVA (RM-ANOVA), and multiple logistic regression were used. RESULTS: A total of 80 preterm low birth weight infants born to hypertensive mothers and 101 born to normotensive mothers were studied. There was a higher risk of overweight in children of hypertensive mothers at 24 months; however, maternal hypertension was not a risk factor for inadequate growth. Logistic regression showed that being born small for gestational age and inadequate growth in the first 12 months of life were associated with poorer growth at 24 months. CONCLUSION: Preterm low birth weight born infants to hypertensive mothers have an increased risk of overweight at 24 months CA. Being born small for gestational age and inadequate growth in the 1st year of life are risk factors for growth disorders at 24 months CA.

Effects of therapeutic approach on the neonatal evolution of very low birth weight infants with patent ductus arteriosus / Efeitos da abordagem terapêutica da persistência de canal arterial sobre a evolução neonatal de recém-nascidos de extremo baixo peso

OBJECTIVE: To analyze the effects of treatment approach on the outcomes of newborns (birth weight [BW] < 1,000 g) with patent ductus arteriosus (PDA), from the Brazilian Neonatal Research Network (BNRN) on: death, bronchopulmonary dysplasia (BPD), severe intraventricular hemorrhage (IVH III/IV), retinopathy of prematurity requiring surgical (ROPsur), necrotizing enterocolitis requiring surgery (NECsur), and death/BPD. METHODS: This was a multicentric cohort study, retrospective data collection, including newborns (BW < 1000 g) with gestational age (GA) < 33 weeks and echocardiographic diagnosis of PDA, from 16 neonatal units of the BNRN from January 1, 2010 to Dec 31, 2011. Newborns who died or were transferred until the third day of life, and those with presence of congenital malformation or infection were excluded. Groups: G1 - conservative approach (without treatment), G2 - pharmacologic (indomethacin or ibuprofen), G3 - surgical ligation (independent of previous treatment). Factors analyzed: antenatal corticosteroid, cesarean section, BW, GA, 5 min. Apgar score < 4, male gender, Score for Neonatal Acute Physiology Perinatal Extension (SNAPPE II), respiratory distress syndrome (RDS), late sepsis (LS), mechanical ventilation (MV), surfactant (< 2 h of life), and time of MV. Outcomes: death, O2 dependence at 36 weeks (BPD36wks), IVH III/IV, ROPsur, NECsur, and death/BPD36wks. Statistics: Student's t-test, chi-squared test, or Fisher's exact test; Odds ratio (95% CI); logistic binary regression and backward stepwise multiple regression. Software: MedCalc (Medical Calculator) software, version 12.1.4.0. p-values < 0.05 were considered statistically significant. RESULTS: 1,097 newborns were selected and 494 newborns were included: G1 - 187 (37.8%), G2 - 205 (41.5%), and G3 - 102 (20.6%). The highest mortality was observed in G1 (51.3%) and the lowest in G3 (14.7%). The highest frequencies of BPD36wks (70.6%) ...

OBJETIVO: Analisar os efeitos da terapêutica adotada para o canal arterial (CA) em recém-nascidos (RN) < 1.000gadmitidos em unidades neonatais (UN) da Rede Brasileira de Pesquisas Neonatais (RBPN), sobre os desfechos: óbito, displasia broncopulmonar (DBP), hemorragia intraventricular grave (HIVIII/IV), retinopatia da prematuridade cirúrgica (ROPcir), enterocolite necrosante cirúrgica (ECNcir) e o desfecho combinado óbito e DBP. MÉTODOS: Estudo multicêntrico, de coorte, coleta de dados retrospectiva, incluindo RN de 16 UN da RBPN de 01/01/2010 a 31/12/2011, PN < 1.000 g, idade gestacional (IG) < 33 semanas e diagnóstico ecocardiográfico de PCA. Excluídos: óbitos ou transferências até o terceiro dia de vida, infecções congênitas ou malformações. Grupos:G1 - conservadora (sem intervenção medicamentosa ou cirúrgica), G2 - farmacológica (indometacina ou ibuprofeno) e G3 - cirúrgico (com ou sem tratamento farmacológico anterior). Analisou-se: uso de esteroide antenatal, parto cesárea, PN, IG, Apgar5' < 4, sexo masculino, SNAPPE II, síndrome do dDesconforto respiratório (SDR), sepse tardia, ventilação mecânica (VM), surfactante < 2 horas de vida, tempo de VM e os desfechos: óbito, dependência de oxigênio com 36 semanas (DBP36s), HIV III/IV, ROPcir, ECNcir e óbito/DBP36s. Estatística: Teste t-Student, Qui-Quadrado ou teste Exato de Fisher. Testes de Regressão Binária Logística e Regressão Múltipla Stepwise Backward. MedCalc (Medical Calculator) software, versão 12.1.4.0.p < 0,05. RESULTADOS: Foram selecionados 1.097 RN e 494 foram incluídos: G1-187 (37,8%), G2-205 (41,5%) e G3-102 (20,6%). Verificou-se: maior mortalidade (51,3%) no G1 e menor no G3(14,7%); maior frequência DBP36s (70,6%) e ROPcir (23,5%) ...

Effects of therapeutic approach on the neonatal evolution of very low birth weight infants with patent ductus arteriosus.

OBJECTIVE: To analyze the effects of treatment approach on the outcomes of newborns (birth weight [BW] < 1,000 g) with patent ductus arteriosus (PDA), from the Brazilian Neonatal Research Network (BNRN) on: death, bronchopulmonary dysplasia (BPD), severe intraventricular hemorrhage (IVH III/IV), retinopathy of prematurity requiring surgical (ROPsur), necrotizing enterocolitis requiring surgery (NECsur), and death/BPD. METHODS: This was a multicentric, cohort study, retrospective data collection, including newborns (BW < 1000 g) with gestational age (GA) < 33 weeks and echocardiographic diagnosis of PDA, from 16 neonatal units of the BNRN from January 1, 2010 to Dec 31, 2011. Newborns who died or were transferred until the third day of life, and those with presence of congenital malformation or infection were excluded. Groups: G1 - conservative approach (without treatment), G2 - pharmacologic (indomethacin or ibuprofen), G3 - surgical ligation (independent of previous treatment). Factors analyzed: antenatal corticosteroid, cesarean section, BW, GA, 5 min. Apgar score < 4, male gender, Score for Neonatal Acute Physiology Perinatal Extension (SNAPPE II), respiratory distress syndrome (RDS), late sepsis (LS), mechanical ventilation (MV), surfactant (< 2 h of life), and time of MV. OUTCOMES: death, O2 dependence at 36 weeks (BPD36wks), IVH III/IV, ROPsur, NECsur, and death/BPD36wks. STATISTICS: Student's t-test, chi-squared test, or Fisher's exact test; Odds ratio (95% CI); logistic binary regression and backward stepwise multiple regression. Software: MedCalc (Medical Calculator) software, version 12.1.4.0. p-values < 0.05 were considered statistically significant. RESULTS: 1,097 newborns were selected and 494 newborns were included: G1 - 187 (37.8%), G2 - 205 (41.5%), and G3 - 102 (20.6%). The highest mortality was observed in G1 (51.3%) and the lowest in G3 (14.7%). The highest frequencies of BPD36wks (70.6%) and ROPsur were observed in G3 (23.5%). The lowest occurrence of death/BPD36wks occurred in G2 (58.0%). Pharmacological (OR 0.29; 95% CI: 0.14-0.62) and conservative (OR 0.34; 95% CI: 0.14-0.79) treatments were protective for the outcome death/BPD36wks. CONCLUSION: The conservative approach of PDA was associated to high mortality, the surgical approach to the occurrence of BPD36wks and ROPsur, and the pharmacological treatment was protective for the outcome death/BPD36wks.

Risk factors for infection with coagulase-negative staphylococci in newborns from the neonatal unit of a brazilian university hospital.

BACKGROUND: Coagulase-negative staphylococci (CoNS) are one of the most frequent causative agents of neonatal nosocomial infections, especially in premature and low-weight newborns. Risk factors for infection include extracellular polysaccharide production and consequent biofilm formation that permit adhesion to the smooth surface of catheters and other medical devices. The objective of this study was to identify CoNS strains isolated from 105 newborns admitted to the Neonatal Unit of our hospital, and to evaluate the association of biofilm production and host risk factors with the occurrence of infection. METHODS: CoNS isolates were identified and classified as significant or contaminant based on clinical and laboratory data of the newborn medical records. Perinatal risk factors for infection, neonatal clinical evolution, and antibiotic treatment were analysed. In addition, the presence of genes (icaA, icaC and icaD) responsible for biofilm production in CoNS was investigated. RESULTS: Among the 130 CoNS strains studied, 66 (50.8%) were classified as clinically significant and 64 (49.2%) as contaminant. There was no difference in the detection of biofilm-specific genes between CoNS strains isolated from newborns with (81.8%) and without infection (84.3%), although 11 (91.7%) of the 12 children whose death was related to CoNS were infected with strains that were positive for these genes. Forty-five (83.3%) of the 54 newborns infected with CoNS were premature and 33 (61.1%) had a birth weight ≤ 1,500 g. Most newborns infected with CoNS had been submitted to invasive procedures, including catheter use (85.2%), parenteral nutrition (61.1%), and mechanical ventilation (57.4%). S. epidermidis was the most frequently isolated species (81.5%) and was more related to infection (86.3%) than to contamination (76.5%). CONCLUSION: Most newborns infected with CoNS presented factors that contributed to the colonization and development of infection with these microorganisms, including a birth weight ≤ 1,500 g, catheter complications, use of a drain, and previous antibiotic treatment. The fact that most children who died of CoNS-related infection carried strains positive for biofilm-specific genes indicates the importance of this virulence factor for the outcome of staphylococcal infections.

Acquisition of motor abilities up to independent walking in very low birth weight preterm infants.

OBJECTIVE: To determine chronological and corrected ages at acquisition of motor abilities up to unaided walking in very low weight preterms and to determine up to what point it is necessary to use corrected age. METHODS: This was a longitudinal study of preterms with birth weight < 1,500 g and gestational age < or = 34 weeks, free from neurosensory sequelae, selected at the high-risk infants follow-up clinic at the Hospital das Clínicas, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP) in Botucatu, Brazil, between 1998 to 2003, and assessed every 2 months until acquisition of unaided walking. RESULTS: Nine percent of the 155 preterms recruited were excluded from the study, leaving a total of 143 patients. The mean gestational age was 30+/-2 weeks, birth weight was 1,130+/-222 g, 59% were female and 44% were small for gestational age. Preterms achieved head control in their second month, could sit unaided at 7 months and walked at 12.8 months' corrected age, corresponding to the 4th, 9th and 15th months of chronological age. There were significant differences between chronological age and corrected age for all motor abilities. Preterms who were small for their gestational age acquired motor abilities later, but still within expected limits. CONCLUSIONS: Very low weight preterms, free from neurosensory disorders, acquired their motor abilities within the ranges expected for their corrected ages. Corrected age should be used until unaided walking is achieved.

Aquisição de habilidades motoras até a marcha independente em prematuros de muito baixo peso / Acquisition of motor abilities up to independent walking in very low birth weight preterm infants

OBJETIVO: Determinar as idades cronológica e corrigida de aquisição das habilidades motoras até a marcha independente em prematuros de muito baixo peso e avaliar até quando é necessário o uso da idade corrigida. MÉTODOS: Estudo longitudinal de prematuros < 1.500 g e com idade gestacional < 34 semanas, sem alterações neurossensoriais, selecionados no ambulatório de seguimento de recém-nascidos de alto risco do Hospital das Clinicas da Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP), Botucatu (SP), no período de 1998 a 2003, e avaliados a cada 2 meses até a aquisição da marcha independente. RESULTADOS: Dos 155 prematuros incluídos, 9 por cento foram excluídos, sendo estudados 143 pacientes. A idade gestacional média foi 30±2 semanas, o peso ao nascimento, 1.130±222 g, 59 por cento foram do sexo feminino e 44 por cento, pequenos para idade gestacional. Os prematuros controlaram a cabeça no 2º mês, sentaram sem apoio aos 7 meses e andaram com 12,8 meses de idade corrigida, correspondendo respectivamente ao 4o, ao 9o e ao 15o mês de idade cronológica. Para todas as habilidades motoras houve diferença significativa entre idade cronológica e corrigida. Prematuros pequenos para idade gestacional adquiriram suas habilidades mais tardiamente, porém dentro do limite esperado. CONCLUSÕES: Prematuros de muito baixo peso, sem alterações neurossensoriais, adquirem as habilidades motoras dentro do prazo previsto para a idade corrigida. A correção da idade deve ser feita até a aquisição da marcha independente.

OBJECTIVE: To determine chronological and corrected ages at acquisition of motor abilities up to unaided walking in very low weight preterms and to determine up to what point it is necessary to use corrected age. METHODS: This was a longitudinal study of preterms with birth weight < 1,500 g and gestational age < 34 weeks, free from neurosensory sequelae, selected at the high-risk infants follow-up clinic at the Hospital das Clínicas, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP) in Botucatu, Brazil, between 1998 to 2003, and assessed every 2 months until acquisition of unaided walking. RESULTS: Nine percent of the 155 preterms recruited were excluded from the study, leaving a total of 143 patients. The mean gestational age was 30±2 weeks, birth weight was 1,130±222 g, 59 percent were female and 44 percent were small for gestational age. Preterms achieved head control in their second month, could sit unaided at 7 months and walked at 12.8 months' corrected age, corresponding to the 4th, 9th and 15th months of chronological age. There were significant differences between chronological age and corrected age for all motor abilities. Preterms who were small for their gestational age acquired motor abilities later, but still within expected limits. CONCLUSIONS: Very low weight preterms, free from neurosensory disorders, acquired their motor abilities within the ranges expected for their corrected ages. Corrected age should be used until unaided walking is achieved.

Utilidade da cultura da ponta de cateter no diagnóstico de infecção neonatal / Usefulness of catheter tip culture in the diagnosis of neonatal infections

OBJETIVO: Determinar o número de unidades formadoras de colônias que melhor correlaciona com a infecção relacionada a cateter em recém-nascidos. MÉTODOS: Este foi um estudo prospectivo de culturas semiquantitativas de pontas de cateteres de recém-nascidos da unidade neonatal da Faculdade de Medicina de Botucatu. Os microrganismos isolados de cateteres e hemoculturas periféricas foram identificados e submetidos ao teste de sensibilidade a drogas. O ponto de corte ótimo foi determinado pela curva receiver operating characteristic (ROC). RESULTADOS: Foram estudados 85 cateteres de 63 recém-nascidos. A espécie Staphylococcus epidermidis foi prevalente (75 por cento) nos cateteres. Dos 11 episódios de infecção diagnosticados, oito (72,7 por cento) foram associados aos estafilococos coagulase-negativa, dos quais seis pertenciam à espécie S. epidermidis. Pela curva ROC, o ponto de corte ótimo para o diagnóstico de infecção relacionada a cateter foi 122 unidades formadoras de colônias. CONCLUSÃO: O ponto de corte 122 unidades formadoras de colônias melhor se correlacionou com o diagnóstico de infecção relacionada a cateter em recém-nascidos.

OBJECTIVE: To determine the number of colony-forming units (CFU) that best correlates with catheter-related infections (CRI) in newborns. METHODS: This was a prospective study of semiquantitative cultures of catheter tips obtained from newborns in the neonatal unit at Faculdade de Medicina de Botucatu, state of São Paulo, Brazil. The microorganisms isolated from catheter and peripheral blood cultures were identified and submitted to a drug susceptibility test. The optimal cutoff point was determined by the receiver operating characteristic (ROC) curve. RESULTS: A total of 85 catheters obtained from 63 newborns were studied. Staphylococcus epidermidis was the predominant species in the catheters (75 percent). Eight of 11 (72.7 percent) CRI episodes were associated with coagulase-negative staphylococci, six of which were of the S. epidermidis type. ROC curve analysis indicated that the optimal cutoff point for the diagnosis of CRI was 122 CFU. CONCLUSION: The cutoff point of 122 CFU correlated best with the diagnosis of CRI in newborns.

Usefulness of catheter tip culture in the diagnosis of neonatal infections.

OBJECTIVE: To determine the number of colony-forming units (CFU) that best correlates with catheter-related infections (CRI) in newborns. METHODS: This was a prospective study of semiquantitative cultures of catheter tips obtained from newborns in the neonatal unit at Faculdade de Medicina de Botucatu, state of São Paulo, Brazil. The microorganisms isolated from catheter and peripheral blood cultures were identified and submitted to a drug susceptibility test. The optimal cutoff point was determined by the receiver operating characteristic (ROC) curve. RESULTS: A total of 85 catheters obtained from 63 newborns were studied. Staphylococcus epidermidis was the predominant species in the catheters (75%). Eight of 11 (72.7%) CRI episodes were associated with coagulase-negative staphylococci, six of which were of the S. epidermidis type. ROC curve analysis indicated that the optimal cutoff point for the diagnosis of CRI was 122 CFU. CONCLUSIONS: The cutoff point of 122 CFU correlated best with the diagnosis of CRI in newborns.

Comparison between qualitative and semiquantitative catheter-tip cultures: laboratory diagnosis of catheter-related infection in newborns / Comparação entre culturas qualitativa e semiquantitativa de ponta de cateter: diagnóstico laboratorial de infecção relacionada a cateter em recém-nascidos

This prospective study evaluated semiquantitative and qualitative catheter-culture methods for diagnosis of catheter-related infection (CRI) in newborns. Catheter tips from newborns admitted to the Neonatal Unit of the University Hospital of the Botucatu Medical School, UNESP were included in the study. Catheter cultures were performed with both semiquantitative and qualitative techniques. For CRI diagnosis, microorganisms isolated from catheter cultures and from peripheral blood cultures were identified and submitted to agent susceptibility test. The gold standard was the certain CRI diagnosis when same microorganism (specie and profile of susceptibility to agents) was isolated from both catheter tips and peripheral blood culture. A total of 85 catheters from 63 newborns were included in the study. The semiquantitative culture method, despite presenting lower sensitivity (90 percent), showed higher specificity (71 percent) when compared to 100 percent of sensitivity and 60 percent of specificity in the qualitative method. The identification of the microorganisms obtained from the catheter cultures showed a prevalence of coagulase-negative staphylococci(CNS) species. The specie Staphylococcus epidermidis (77.5 percent) was the prevalent in the catheters with positive semiquantitative cultures. Among 11 episodes with CRI diagnosis, 8 (72.7 percent) were associated with CNS species, of which 6 were S. epidermidis. Two episodes of CRI by S. aureus and one by Candida parapsilosis were also detected. The semiquantitative catheter-culture method showed advantages for CRI diagnosis in newborns when compared to the conservative qualitative method.

Este estudo prospectivo avaliou os métodos semiquantitativo e qualitativo de cultura de cateter para o diagnóstico de infecção relacionada a cateter (IRC) em recém-nascidos (RN). Foram incluídas pontas de cateteres provenientes de recém-nascidos internados na Unidade Neonatal do Hospital das Clínicas da Faculdade de Medicina de Botucatu, UNESP. Foram utilizadas as técnicas semiquantitativa e qualitativa de cultura de cateter. Para o diagnóstico de IRC, os microrganismos isolados das culturas de cateteres e de hemoculturas periféricas foram identificados e submetidos ao teste de sensibilidade a antimicrobianos. O padrão ouro correspondeu ao diagnóstico de certeza de IRC, com o isolamento do mesmo microrganismo (espécie e perfil de sensibilidade a antimicrobianos) isolado em hemocultura periférica. Foram estudados 85 cateteres provenientes de 63 RN. A cultura semiquantitativa, embora tenha apresentado menor sensibilidade (90 por cento), apresentou uma maior especificidade (71 por cento) em comparação à sensibilidade de 100 por cento e especificidade de 60 por cento encontradas na cultura qualitativa. Através da identificação dos microrganismos obtidos nas culturas de cateteres, observou-se uma predominância de espécies de Estafilococos coagulase-negativa (ECN). A espécie Staphylococcus epidermidis foi a prevalente (77,5 por cento) nos cateteres com culturas semiquantitativas positivas. Dos 11 episódios de IRC diagnosticados, 8 (72,7 por cento) foram associados a espécies de ECN, dos quais 6 eram da espécie S. epidermidis. Também foram detectados dois casos de IRC por S. aureus e um caso por Candida parapsilosis. O método de cultura semiquantitativo cateter apresentou vantagens para o diagnóstico de IRC em RN quando comparado com o método qualitativo tradicional.

Fatores de risco associados à mortalidade de recém-nascidos de muito baixo peso na cidade de Botucatu, São Paulo, no período 1995-2000 / Risk factors for mortality in very low birth-weight infants in the city of Botucaty, State of São Paulo, during the period 1995-2000

OBJETIVOS: avaliar as práticas assistenciais, a ocorrência de doenças, a mortalidade durante a hospitalização e os fatores associados em recém-nascidos prematuros de muito baixo peso (PT-MBP). MÉTODOS: estudo transversal comparando dois períodos: 1995-1997 e 1998-2000 e envolvendo todos os PT-MBP nascidos vivos (n= 451), em um centro perinatal, em Botucatu, São Paulo, Brasil. Os fatores de risco pré-natal e pós-natal foram submetidos a análise multivariada. RESULTADOS: a mortalidade diminuiu de 36,2 por cento para 29,5 por cento. A sobrevida melhorou e foi superior a 50 por cento a partir de 28 semanas e de 750 g de peso. O uso de corticosteróide antenatal aumentou de 25 por cento para 42 por cento, o surfactante exógeno de 14 por cento para 28 por cento, com redução na incidência e gravidade da síndrome do desconforto respiratório. A regressão logística mostrou que a síndrome do desconforto respiratório grave, Odds ratio=18, e a sepse precoce, Odds ratio=2,8, foram importantes fatores de risco para morte em 1995-1997. No período de 1998-2000, a sepse precoce e tardia, Odds ratio=10,5 e 12, respectivamente, aumentaram o risco de morte. CONCLUSÕES: a melhora na assistência perinatal diminuiu a mortalidade do PT-MBP. O aumento na exposição antenatal ao corticosteróide diminuiu a gravidade da síndrome do desconforto respiratório. Em 1998-2000, a sepse foi o único fator de risco para morte.

OBJECTIVES: to evaluate perinatal care, the incidence of diseases, and mortality during hospitalization and associated risk factors in very low birth-weight infants (VLBW). METHODS: a cross sectional survey comparing two periods: 1995-1997 and 1998-2000, including all live-born VLBW preterm infants (n= 451), delivered at a level III perinatal center in the city of Botucatu, State of São Paulo, Brazil. The antenatal and postnatal risk factors were analyzed using multivariable techniques. RESULTS: mortality decreased from 36.2 percent to 29.5 percent. The survival of infants 750 g, and 28 weeks' gestation improved and was higher than 50 percent. The use of antenatal corticosteroid increased from 25 percent to 42 percent, surfactant therapy from 14 percent to 28 percent, and the incidence and severity of respiratory distress syndrome decreased. Regression analysis showed that severe respiratory distress syndrome (Odds ratio= 18) and early-onset sepsis (Odds ratio=2.8) were important risk factors for death in 1995-1997. During 1998-2000 early- and late-onset sepsis (Odds ratio=10.5 and 12 respectively) increased the risk of death. CONCLUSIONS: the improvement in perinatal care has reduced the mortality of VLBW infants. The increase in antenatal corticosteroid exposure has reduced the severity of respiratory distress syndrome. In 1998-2000, sepsis was the only risk factor associated with death.

The newborn pain cry: descriptive acoustic spectrographic analysis.

INTRODUCTION: Study the characteristics of pain vocal emission of newborns during venepuncture through acoustic analysis and relate it to NIPS pain scale and some variables of the newborns. METHODS: Emissions of 111 healthy term newborns were recorded, whose lifetime varied from 24 to 72 h. The acoustic analysis was realized with GRAM 5.7 software verifying the occurrence of tense strangled voice quality, sounds, concentration of acoustic energy, breaks, double harmonic breaks and frequency instability, type of phonation, vocal attack and cough. The NIPS scale was realized during venepuncture and descriptive statistical analysis and correlation through Spearman test. RESULTS: Hundred percent of the emissions had guttural sounds, vowels, hard vocal attack, frequency, breaks, double harmonic breaks and tense strangled voice quality; 34.2% higher fundamental frequency; 62.2% periods of emission absence and 100% occurrence of tracing instability, concentration of acoustic energy, inspiratory and expiratory phonation. The cough occurred in 14.4%. The signs of vocal tract constriction associated with all the parameters. There was a negative correlation between the higher fundamental frequencies and the weight of newborns and positive correlation between cough and NIPS score. CONCLUSIONS: The newborn pain emission is tense and strident, the modifications of frequency and spectrographic tracing and the presence of sounds show laryngeal and vocal tract participation. The smaller the newborn weight, the bigger the presence of higher fundamental frequency with tense strangled voice quality and the bigger the NIPS score, the more frequent the cough. Such characteristics make pain crying peculiar, helping in the evaluation of pain during a procedure.

Fração de excreção de sódio, osmolaridade e densidade urinária em recém-nascidos prematuros alimentados com leite humano de banco adicionado de suplemento / Fractional sodium excretion, urinary osmolality and specific gravity in preterm infants fed with fortified donor human milk

OBJETIVO: Esta pesquisa teve como objetivo investigar, em recém-nascidos prematuros, os efeitos renais da adição de suplemento ao leite humano de banco. MÉTODO: Ensaio clínico de intervenção, tipo antes e após, envolvendo 28 recém-nascidos prematuros distribuídos em dois grupos conforme a idade pós-concepção no início do estudo: GI < 34 semanas (n = 14) e GII > 34 semanas (n = 14), avaliados em três momentos: M1 = uso do leite humano de banco sem suplemento; M2 = após 3 dias e; M3 = 10-13 dias de uso do leite com suplemento. Foram comparadas oferta alimentar, evolução ponderal, fração de excreção de sódio, osmolaridade e densidade urinária pela análise estatística two-way ANOVA para medidas repetidas. RESULTADOS: A oferta hídrica, energética e de sódio foi similar nos dois grupos, e a evolução ponderal foi satisfatória. Nos prematuros < 34 semanas de idade pós-concepção, o sódio sérico diminuiu ao final do estudo e a fração de excreção de sódio foi elevada no início e final do estudo (M1 = 2,11±1,05; M2 = 1,25±0,64; M3 = 1,62±0,88), com diferença significante em relação ao GII (M1 = 1,34±0,94; M2 = 0,90±0,54; M3 = 0,91±0,82). Osmolaridade e densidade urinária foram normais, sem diferenças entre grupos e momentos. CONCLUSÃO: Não foi detectado efeito adverso na função renal dos prematuros com o uso de leite humano de banco suplementado.

OBJECTIVE: This research was performed with the objective of investigating the renal effects on premature newborn infants of fortifying banked donor human milk. METHODS: Clinical intervention trial, of the before-and-after type, involving 28 premature newborn infants split into two groups by postconceptional age at the start of the study: GI < 34 weeks (n = 14) and GII > 34 weeks (n = 14), and assessed at three sample points: S1, on unfortified donor human milk, S2, after 3 days, and S3, after 10-13 days on fortified donor human milk. Nutrient intake, weight gain, fractional sodium excretion, urinary osmolality and specific density were compared with two-way ANOVA for repeated measures. RESULTS: Fluids, energy and sodium intakes were similar for both groups, and weight gain was satisfactory. Among the preterms with < 34 weeks postconceptional age, serum sodium was lower at the end of the study and the fractional sodium excretion was elevated at the start and at the end of the study (S1 = 2.11±1.05; S2 = 1.25±0.64; S3 = 1.62±0.88), with a significant difference in relation to GII (S1 = 1.34±0.94; S2 = 0.90±0.54; S3 = 0.91±0.82). Osmolality and urinary specific density were normal, with no differences between groups or collection dates. CONCLUSIONS: No adverse effects on the renal function of these preterms were detected as a result of being fed fortified donor human milk.

Fractional sodium excretion, urinary osmolality and specific gravity in preterm infants fed with fortified donor human milk.

OBJECTIVE: This research was performed with the objective of investigating the renal effects on premature newborn infants of fortifying banked donor human milk. METHODS: Clinical intervention trial, of the before-and-after type, involving 28 premature newborn infants split into two groups by postconceptional age at the start of the study: GI < 34 weeks (n = 14) and GII >or= 34 weeks (n = 14), and assessed at three sample points: S1, on unfortified donor human milk, S2, after 3 days, and S3, after 10-13 days on fortified donor human milk. Nutrient intake, weight gain, fractional sodium excretion, urinary osmolality and specific density were compared with two-way ANOVA for repeated measures. RESULTS: Fluids, energy and sodium intakes were similar for both groups, and weight gain was satisfactory. Among the preterms with < 34 weeks postconceptional age, serum sodium was lower at the end of the study and the fractional sodium excretion was elevated at the start and at the end of the study (S1 = 2.11+/-1.05; S2 = 1.25+/-0.64; S3 = 1.62+/-0.88), with a significant difference in relation to GII (S1 = 1.34+/-0.94; S2 = 0.90+/-0.54; S3 = 0.91+/-0.82). Osmolality and urinary specific density were normal, with no differences between groups or collection dates. CONCLUSIONS: No adverse effects on the renal function of these preterms were detected as a result of being fed fortified donor human milk.

[The frequency of pharmacological pain relief in university neonatal intensive care units]. / Freqüência do emprego de analgésicos em unidades de terapia intensiva neonatal universitárias.

OBJECTIVE: To evaluate the use of drugs to relieve procedural pain of newborn infants hospitalized in Neonatal Intensive Care Units (NICU) of university hospitals. METHODS: A prospective cohort study of all newborn infants hospitalized in four NICU during October 2001. The following data were collected: demographic data of patients; clinical morbidity; number of potentially painful procedures and frequency of analgesic administration. Multiple linear regression analysis was performed to study the factors associated with the use of analgesia in this cohort of patients with SPSS 8.0. RESULTS: Ninety-one newborn infants were admitted to the NICU during the study period (1,025 patient-days). Only 25% of the 1,025 patient-days received any systemic analgesia. No specific drug was administered to relieve acute pain during any of the following painful procedures: arterial, venous, capillary and lumbar punctures and tracheal intubation. For chest tube insertion, 100% of newborn infants received specific analgesia. For the insertion of central catheters, 8% of the newborn infants received analgesia. Only nine of the 17 newborn infants that underwent surgical procedures received any dose of analgesics during the postoperative period. Regarding patients who received analgesia, the drug of choice was fentanyl in 93%. The presence of mechanical ventilation increased 6.9 times the chance of the newborn receiving analgesia and the presence of a chest tube increased this chance by 5.0 times. CONCLUSION: It is necessary to train health professionals in order to shorten the lag between scientific knowledge regarding newborn pain and clinical practice.