Carlos Grandi

Bronchopulmonary dysplasia: incidence, risk factors and resource utilization in a population of South-American very low birth weight infants

OBJECTIVE To determine the incidence of bronchopulmonary dysplasia, its risk factors and resource utilization in a large South American population of very low birth weight infants. METHODS Prospectively collected data in infants weighing 500 to 1,500 g born at 16 NEOCOSUR Network centers from 10/2000 through 12/2003. Multivariate relative risk and 95% confidence intervals were estimated by Poisson regression with robust error variance to find factors that affected the risk of bronchopulmonary dysplasia. RESULTS 1,825 very low birth weight infants survivors were analyzed. Mean birth weight and gestational age were 1085+/-279 g and 29+/-3 weeks respectively. Bronchopulmonary dysplasia incidence averaged 24.4% and survival without bronchopulmonary dysplasia augmented with increasing gestational age. A higher birth weight and gestational age and a female gender all decreased the risk for bronchopulmonary dysplasia. Factors that independently increased that risk were surfactant requirement, mechanical ventilation, airleak, patent ductus arteriosus, late onset sepsis and necrotizing enterocolitis. Bronchopulmonary dysplasia infants had more days of hospitalization (91+/-27 vs. 51+/-19), of mechanical ventilation (19+/-20 vs. 4+/-7) and oxygen therapy (72+/-30 vs. 8+/-14) in comparison with non BPD infants. CONCLUSIONS Bronchopulmonary dysplasia incidence was 24.4% in a large South American population and is related to greater resource utilization. Risk factors for bronchopulmonary dysplasia in this study were: surfactant requirement, mechanical ventilation, airleak, patent ductus arteriosus, late onset sepsis and necrotizing enterocolitis. These studies may provide useful information in the design of effective preventive perinatal strategies.

Displasia broncopulmonar: incidência, fatores de risco e utilização de recursos em uma população sul-americana de recém-nascidos de muito baixo peso

OBJETIVO: Determinar a incidencia de displasia broncopulmonar, os fatores de risco e a utilizacao de recursos em uma ampla populacao sul-americana de recem-nascidos de muito baixo peso ao nascer METODOS: Dados prospectivamente registrados de criancas com peso ao nascer entre 500 a 1.500 g, nascidas em 16 centros neonatais pertencendo a rede NEOCOSUR entre 10/2000 a 12/2003. A analise multivariada de Poisson com variância robusta foi utilizada para determinar os fatores de risco relativo e intervalo de confianca de 95% que afetam o risco de apresentacao de displasia broncopulmonar RESULTADOS: Foram analisados 1.825 recem-nascidos de muito baixo peso ao nascer. As medias de peso ao nascer e a idade gestacional foram de 1.085±279g e 29±3 semanas, respectivamente. A incidencia de displasia broncopulmonar foi de 24,4%, e a sobrevida sem displasia broncopulmonar aumentou quanto maior foi a idade gestacional. Maior peso ao nascer, maior idade gestacional e sexo feminino estiveram associados a um menor risco de displasia broncopulmonar. Aumentaram o risco de displasia broncopulmonar: ventilacao mecânica, necessidade de surfactante, escape aereo, persistencia do canal arterial, sepse tardia e enterocolite necrotizante. As criancas com displasia broncopulmonar requerem um maior tempo hospitalizacao (91±27 versus 51±19), de ventilacao mecânica (19±20 versus 4±7) e de oxigenioterapia (72±30 versus 8±14). CONCLUSOES: A incidencia de displasia broncopulmonar foi de 24,4% em uma ampla populacao sul-americana e se relaciona com uma maior utilizacao de recursos. Os fatores de risco associados a displasia broncopulmonar encontrados nesse estudo foram: ventilacao mecânica, necessidade de surfactante, escape aereo, persistencia do canal arterial, sepse tardia e enterocolite necrotizante. As informacoes contidas neste estudo podem ser uteis para o delineamento de estrategias perinatais de prevencao da morbidade.

A New Score for Predicting Neonatal Very Low Birth Weight Mortality Risk in the NEOCOSUR South American Network

OBJECTIVE:To develop and validate a model for very low birth weight (VLBW) neonatal mortality prediction, based on commonly available data at birth, in 16 neonatal intensive care units (NICUs) from five South American countries.STUDY DESIGN:Prospectively collected biodemographic data from the Neonatal del Cono Sur (NEOCOSUR) Network between October 2000 and May 2003 in infants with birth weight 500 to 1500 g were employed. A testing sample and crossvalidation techniques were used to validate a statistical model for risk of in-hospital mortality. The new risk score was compared with two existing scores by using area under the receiver operating characteristic curve (AUC).RESULTS:The new NEOCOSUR score was highly predictive for in-hospital mortality (AUC=0.85) and performed better than the Clinical Risk Index for Babies (CRIB) and the NICHD risk models when used in the NEOCOSUR Network. The new score is also well calibrated — it had good predictive capability for in-hospital mortality at all levels of risk (HL test=11.9, p=0.85). The new score also performed well when used to predict in hospital neurological and respiratory complications.CONCLUSIONS:A new and relatively simple VLBW mortality risk score had a good prediction performance in a South American network population. This is an important tool for comparison purposes among NICUs. This score may prove to be a better model for application in developing countries.

Impacto del síndrome de dificultad respiratoria en recién nacidos de muy bajo peso de nacimiento: estudio multicéntrico sudamericano

OBJECTIVE To analyze the incidence, risk factors, major morbidity, mortality and resource employment in very low birth weight infants (< 1500 g) with respiratory distress syndrome (RDS). METHODS Descriptive study using prospectively obtained on-line information from a data base of 20 units belonging to the South American Neocosur Network. A total of 5991 VLBW infants were registered during years 2002-2007. RESULTS The mean gestacional age was 29.1 weeks (95% CI 29.06-29.21) and the mean of birth weight was 1100.5 g (95% CI 1093.79-1107.37). The global incidence of RDS was 74% (95% CI 73-75). Antenatal steroids were administered to 73% of this population. The main risk factor was lower gestational age (p< 0.001); where as prenatal steroids (OR: 0.59; 95% CI 0.49-0.72), female gender (OR: 0.77; 95% CI 0.67-0.89) and premature rupture of membranes (OR: 0.81; 95% CI 0.68-0.96) were protective factors. Antenatal steroids was also associated with a decrease in mortality in those infants that presented with RDS (OR: 0.40; 95% CI 0.34-0.47). Use of resources was higher in the group with RDS, with a greater use of surfactant (74.3% vs. 7.3%, p< 0.001), mechanical ventilation (82.1% vs. 23.8%, p< 0.001), and more days of oxygen (median of 8 vs. 1 day, p< 0.001) and hospitalization (median of 61 vs. 45 days, p< 0.001). RDS was associated to an increase risk in the incidence of ROP, PDA, late onset sepsis, severe IVH and oxygen requirement at 36 weeks of corrected gestational age. CONCLUSIONS RDS had a high incidence in very low birth weight infants, despite the frequent use of antenatal steroids. VLBW Infants with RDS had a higher mortality and an increase risk of relevant morbidity. RDS also increased use of resources.

Riesgo de morbimortalidad neonatal de recién nacidos < 1500 g asociado al volumen de pacientes, personal médico y de enfermería: una investigación multicéntrica latinoamericana

INTRODUCTION Few studies have attempted to evaluate the relationship between medical and nursing staffing and neonatal outcomes providing inconclusive evidence. The purpose was to assess whether morbidity and mortality of VLBW infants are associated with levels of patient volume, provision and training of medical and nursing, and if exist differences between public and private centers. MATERIAL AND METHODS Neonatal outcomes of all VLBW inborn infants consecutively admitted to 15 South-American NICUs between 2005 and 2007 were retrospectively studied. Data of patient volume and provision of medical & nursing resources were obtained from questionnaires. OUTCOME MEASURES death before discharge, incidence of severe IVH, BPD, ROP and late onset sepsis, adjusted for initial risk (Neocosur score). Units were categorized using total annual number of newborns < 1500 g (low < 50, medium 50-100, and high >100) and in public and private centers. RESULTS 2019 preterms were admitted. Mean (SD) gestational age, birth weight and initial risk were 28.9 (0.7) weeks, 1088 (53) g and 0.24 (0.04) respectively. Mortality varied among units and ranged between 6 to 38% (mean 23.2%), as well as other outcomes (median, intercuartil range [ICR]): severe IVH 7.3% (6-14); BPD 20.8% (15-43); ROP ≥ III 5.6% (2.7-8.5); late sepsis 23% (15-29). Staff provision were: daily medical hours (median, ICR) 2.6 (1.4-4.0), full-time (> 40 h/week) equivalent physicians (mean, SD) 15(8), daily nurse hours 6.1 (4.3-7.9), full-time (> 40 h/week) equivalent nurses 32 (22-56) and nurses-to-infant ratio 0.78 (0.52-0.92). Median daily NICU census was 9.8 (8.9-12). A low medical hours provision was significantly associated with increased mortality (OR 1.30 [95% CI: 1.04-1.76], p= 0.020); on the other hand low nurse provision was significantly associated with increased risk of mortality, adjusted by mother age and initial risk (trained NIC 1.52 [1.16 -1.99], nurses-to-infant ratio 1.81 [1.40-2.33]). Although public centers showed higher risk of morbidity and mortality compared with private centers, differences were statistically not significant. CONCLUSIONS In this population neonatal outcomes were associated with levels of patient volume and training of medical and nursing staff. No differences were observed between public and private centers.

Impact of maternal diabetes mellitus on mortality and morbidity of very low birth weight infants: a multicenter Latin America study ☆ ☆☆

OBJECTIVES To compare mortality and morbidity in very low birth weight infants (VLBWI) born to women with and without diabetes mellitus (DM). METHODS This was a cohort study with retrospective data collection (2001-2010, n=11.991) from the NEOCOSUR network. Adjusted odds ratios and 95% confidence intervals were calculated for the outcome of neonatal mortality and morbidity as a function of maternal DM. Women with no DM served as the reference group. RESULTS The rate of maternal DM was 2.8% (95% CI: 2.5-3.1), but a significant (p=0.019) increase was observed between 2001-2005 (2.4%, 2.1-2.8) and 2006-2010 (3.2%, 2.8-3.6). Mothers with DM were more likely to have received a complete course of prenatal steroids than those without DM. Infants of diabetic mothers had a slightly higher gestational age and birth weight than infants of born to non-DM mothers. Distribution of mean birth weight Z-scores, small for gestational age status, and Apgar scores were similar. There were no significant differences between the two groups regarding respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, and patent ductus arteriosus. Delivery room mortality, total mortality, need for mechanical ventilation, and early-onset sepsis rates were significantly lower in the diabetic group, whereas necrotizing enterocolitis (NEC) was significantly higher in infants born to DM mothers. In the logistic regression analysis, NEC grades 2-3 was the only condition independently associated with DM (adjusted OR: 1.65 [95% CI: 1.2 -2.27]). CONCLUSIONS VLBWI born to DM mothers do not appear to be at an excess risk of mortality or early morbidity, except for NEC.

Tendencia secular del peso de nacimiento en Argentina (1992-2002): un estudio poblacional

INTRODUCTION Birth weight (BW) is considered an important measure of the health status of a population. Objectives. 1) to assess secular trends in average BW, low birth weight (LBW,<2.500 g), very low birth weight (VLBW, < 1.500 g) and BW > or = 3.000 g of liveborn infants in Argentina; 2) calculate risks of LBW, VLBW and > or = 3.000 g; 3) influence of underreported birth weight. MATERIAL AND METHODS In this national-based study 7.113.931 liveborn infants born in Argentina from 1992 to 2002 were included. BW was assessed from the National Ministry of Public Health. Annuals mean BW and residual distribution (RD) following the Wilcox-Russell approach were calculated, and also LBW, VLBW and > or =3.000 g proportions. RESULTS A decrease of 32 g in average BW (p= 0.577) and 24 g between 2000 and 2002 (p <0.001) was observed. RD reached 4%. The significant increase in LBW (12%, p= 0.034) and VLBW (26%, p= 0.002) proportions was paralleled by a reduction of 3.6% in BW > or =3.000 g (p= 0.011, average 75.2%). Risks of being LBW and VLBW were 1.13 (95% CI 1.12-1.15) and 1.30 (1.25-1.35), respectively; for BW > or =3.000 g was 0.86 (95% CI 0.85-0.87). No significant correlations between underreported BW and proportions of LBW (r= 0.10) or VLBW (r= 0.01) were observed. CONCLUSION A negative secular trends of BW was observed, all categories of LBW and VLBW were increased, BW > 3.000 g was diminished and under-reported BW did not influenced these results.

Single Umbilical Artery and Associated Malformations in over 5500 Autopsies: Relevance for Perinatal Management:

With a birth prevalence rate of about 1%, single umbilical artery (SUA) is the most frequent of all congenital anomalies. It is recognizably associated with a variety of birth defects, but disagreement exists as to whether a SUA can predict an adverse perinatal outcome; disagreement also exists related to if, when present, other birth defects should be ruled out. The aims of the study were to estimate the association between SUA and other birth defects in a series of perinatal autopsies, to establish if preferential associations between SUA and certain birth defects exist, and to quantify the risks for other birth defects when a SUA is diagnosed. In a series of 5539 perinatal autopsies conducted at the Hospital Materno Infantil Ramón Sardá and the Private Laboratory of Perinatal Pathology, Buenos Aires, Argentina, the rate of each malformation (grouped by organ/system) associated with SUA and the risks of associated malformations were estimated. In this series of autopsies, the rate of SUA showed a 10-fold increase when other malformations were present. The risk for other malformations increased significantly, by a 3-fold to 9-fold measure, when a SUA was present. Urinary and gut anomalies showed a preferential association with SUA. The absence of other birth defects lowered the risk of chromosome anomalies associated with SUA in 56% (odds ratio = 0.44). These results, obtained from a series of perinatal autopsies, are in agreement with most observations found in the literature, namely, high association rates between SUA and urinary and cardiovascular anomalies as well as a low risk for chromosome anomalies in SUA cases without other malformations.

Renal enlargement in the fetus and newborn with Congenital diaphragmatic hernia : A refuted hypothesis

BACKGROUND/PURPOSE Congenital diaphragmatic hernia (CDH) is one of the most frequent causes of neonatal death because of lung hypoplasia (LH). The literature mentions a relationship between renal and pulmonary development, with higher kidney weight in presence of LH. The aims of this study were to evaluate the relationship between lung and kidney weight and to test the hypothesis of renal enlargement in fetuses and newborns with CDH. METHODS Body weight (BW), combined kidney weight (KW), and lung weight (LW) of 52 CDH cases were established; 52 morphologically normal fetuses or newborns, matched by BW, served as a control population. Comparisons were done by covariance analysis, and a P value of less than .05 was considered as significant. RESULTS Excluding renal abnormalities, adjusted mean kidney weights were 22.0 g (+/-1.8 SE) in CDH cases and 20.5 g (+/-1.5 SE) in controls (F = 1.05; P = .308). KW to BW ratio was lower in CDH cases than in controls (P = .023). LW was significantly lower in CDH cases than in controls. CONCLUSIONS No significant difference between KW of CDH cases and controls could be observed. The current study provides enough evidence to reject the hypothesis of renal enlargement in cases of LH and CDH.

Placental Growth Measures in Relation to Birth Weight in a Latin American Population

Introduction The placenta, translates how the fetus experiences the maternal environment and is a principal influence on birth weight (BW). Objective To explore the relationship between placental growth measures (PGMs) and BW in a public maternity hospital. Methods Observational retrospective study of 870 singleton live born infants at Hospital Maternidad Sardá, Universidad de Buenos Aires, Argentina, between January 2011 and August 2012 with complete data of PGMs. Details of history, clinical and obstetrical maternal data, labor and delivery and neonatal outcome data, including placental measures derived from the records, were evaluated. The following manual measurements of the placenta according to standard methods were performed: placental weight (PW, g), larger and smaller diameters (cm), eccentricity, width (cm), shape, area (cm(2)), BW/PW ratio (BPR) and PW/BW ratio (PBR), and efficiency. Associations between BW and PGMs were examined using multiple linear regression. Results Birth weight was correlated with placental weight (R(2) = 0.49, p < 0.001), whereas gestational age was moderately correlated with placental weight (R(2) = 0.64, p < 0.001). By gestational age, there was a positive trend for PW and BPR, but an inverse relationship with PBR (p < 0.001). Placental weight alone accounted for 49% of birth weight variability (p < 0,001), whereas all PGMs accounted for 52% (p < 0,001). Combined, PGMs, maternal characteristics (parity, pre-eclampsia, tobacco use), gestational age and gender explained 77.8% of BW variations (p < 0,001). Among preterm births, 59% of BW variances were accounted for by PGMs, compared with 44% at term. All placental measures except BPR were consistently higher in females than in males, which was also not significant. Indices of placental efficiency showed weakly clinical relevance. Conclusions Reliable measures of placental growth estimate 53.6% of BW variances and project this outcome to a greater degree in preterm births than at term. These findings would contribute to the understanding of the maternal-placental programming of chronic diseases.