Eduardo Carlos Tavares

EMLA versus glucose for PICC insertion: a randomised triple-masked controlled study

Preterm neonates experience a large number of painful procedures during their stay in the neonatal intensive care units (NICUs) and these procedures are often not accompanied by satisfactory analgesia.1 2 Peripherally inserted central catheter (PICC) insertion is a painful intervention employed recurrently to provide a secure venous access.3,–,7 The aim of this study was to determine whether 25% oral glucose or EMLA cream was a better strategy for controlling pain in preterm neonates undergoing PICC insertion. A randomised, triple-masked controlled trial was conducted at two tertiary NICUs in the city of Belo Horizonte, Brazil. Participants included 30 preterm neonates (≥28 and <37 weeks of gestational age) during the first week of life with a clinical indication …

Benefícios e limitações da utilização da glicose no tratamento da dor em neonatos: revisão da literatura

This article aims to review the main studies evaluating glucose as a therapeutic alternative during mildly to moderately painful procedures in neonatology, highlighting its benefits and limitations. During their stay in neonatal intensive care units, neonates are constantly subjected to a number of painful procedures without proper therapeutic management, although the medical literature emphatically recommends this type of management, highlighting the deleterious neurological consequences of pain. Most of these interventions are frequently necessary in neonatal intensive care units to maintain clinical stability in these children; the use of systemic analgesia, however, is not considered to be a good option. The administration of oral glucose solution is apparently effective and safe for pain control during procedures causing mild-to-moderate pain in neonate intensive care units, with rare adverse effects; however, its mode of action has not yet been described clearly in the literature. The administration of oral glucose solution is well described for use in venous punctures; it is apparently effective also for heel punctures, especially when associated with nonnutritive sucking, with most studies showing favorable results.

Active and passive immunization in the extremely preterm infant.

OBJECTIVE: A review of the indications, contraindications, ideal timing, immunogenic efficacy and reactogenicity (adverse events) of active and passive immunization for extremely preterm infants. SOURCES OF DATA: Research in classic textbooks on pediatric infectology and in the electronic databases MEDLINE, Lilacs, PubMed and Akwanmed, using the following health sciences descriptors: premature, very low weight newborn, immunization, active immunization, passive immunization, vaccines, immunoglobulin. SUMMARY OF THE FINDINGS: The immunization of extremely premature very low birth weight infants is a huge challenge for pediatricians because there is insufficient knowledge about the efficacy of immune responses and undesirable reactions. Possibly for this reason, it is common that such children are found to be behind schedule with their immunizations or to have been incompletely immunized. Notwithstanding the scarcity of publications on the theme, in principal young gestational age and low birth weight should not be considered limiting factors to clinically stable premature newborns being immunized at the same chronological age indicated for full term children. CONCLUSIONS: Based on the available evidence it not possible to propose vaccine and immunoglobulin administration practice for extremely premature or very low weight newborn babies that is definitive. With rare exceptions however, such as the BCG vaccine, the tendency is to maintain the same active immunization program as for babies born full term, irrespective of weight or gestational age at birth. Passive immunization merits special attention, having more liberal indications in this group of newborn babies.

O uso da fontanela posterior no diagnóstico ultra-sonográfico das hemorragias periintraventriculares

OBJECTIVE: To evaluate the use of the posterior fontanelle in premature neonates (< 37 weeks) with a birth weight < 1,500 g in the ultrasound diagnosis of intraventricular/periventricular hemorrhage and to assess whether the use of the anterior fontanelle associated with the posterior fontanelle changes the interrater agreement. METHODS: Eighty-five premature neonates were evaluated in this prospective study. Ultrasound was performed using the anterior fontanelle, and later, the posterior fontanelle. A consensus diagnosis between two raters was used to analyze the agreement between the anterior fontanelle alone and in association with the posterior fontanelle. If there was no consensus, a third observer was involved to decide. RESULTS: Agreement between the first two raters had a kappa of 0.80 (95%CI 0.76-0.84). However, when the anterior fontanelle was evaluated alone, kappa was 0.74 (95%CI 0.70-0.78). Thirty-seven hemispheres had grade II hemorrhage, of which 17 (45.9%) had their diagnosis performed using the anterior fontanelle; in 10 (27%), diagnosis was suspected by the anterior fontanelle and confirmed by the posterior fontanelle; and in 10 (27%), diagnosis was exclusively performed using the posterior fontanelle. Of the 454 hemispheres, in 20 (4.4%) the diagnosis of intraventricular hemorrhage was performed exclusively by the posterior fontanelle (p < 0.001). CONCLUSIONS: In this study, the anterior fontanelle associated with the posterior fontanelle was better than the use of the anterior fontanelle alone in the identification of intraventricular/periventricular hemorrhage. Ultrasound using the posterior fontanelle allowed diagnosis of unsuspected grade II hemorrhage by the anterior fontanelle. Use of the posterior fontanelle was also useful to clarify presence of hemorrhage in inconclusive examinations by the anterior fontanelle.

Use of posterior fontanelle in the ultrasound diagnosis of intraventricular/periventricular hemorrhage

OBJECTIVE To evaluate the use of the posterior fontanelle in premature neonates (< 37 weeks) with a birth weight < 1,500 g in the ultrasound diagnosis of intraventricular/periventricular hemorrhage and to assess whether the use of the anterior fontanelle associated with the posterior fontanelle changes the interrater agreement. METHODS Eighty-five premature neonates were evaluated in this prospective study. Ultrasound was performed using the anterior fontanelle, and later, the posterior fontanelle. A consensus diagnosis between two raters was used to analyze the agreement between the anterior fontanelle alone and in association with the posterior fontanelle. If there was no consensus, a third observer was involved to decide. RESULTS Agreement between the first two raters had a kappa of 0.80 (95%CI 0.76-0.84). However, when the anterior fontanelle was evaluated alone, kappa was 0.74 (95%CI 0.70-0.78). Thirty-seven hemispheres had grade II hemorrhage, of which 17 (45.9%) had their diagnosis performed using the anterior fontanelle; in 10 (27%), diagnosis was suspected by the anterior fontanelle and confirmed by the posterior fontanelle; and in 10 (27%), diagnosis was exclusively performed using the posterior fontanelle. Of the 454 hemispheres, in 20 (4.4%) the diagnosis of intraventricular hemorrhage was performed exclusively by the posterior fontanelle (p < 0.001). CONCLUSIONS In this study, the anterior fontanelle associated with the posterior fontanelle was better than the use of the anterior fontanelle alone in the identification of intraventricular/periventricular hemorrhage. Ultrasound using the posterior fontanelle allowed diagnosis of unsuspected grade II hemorrhage by the anterior fontanelle. Use of the posterior fontanelle was also useful to clarify presence of hemorrhage in inconclusive examinations by the anterior fontanelle.

Anestesia tópica em recém nascidos prematuros: uma reflexão acerca da subutilização deste recurso na prática clínica

Premature neonates are customarily submitted to invasive painful procedures during their stay in NICUs that are necessary to maintain their clinically stability. Topical anesthesia is a good option to be considered in the treatment of interventions that lead to mild to moderate pain and has the advantage of no systemic effects. In Brazil the most known topical anesthetic available for use is the eutectic mixture of local anesthetics (EMLA® cream). Its efficacy in the treatment of cutaneous painful procedures is well established for children and adults. Its utilization in neonates has been investigated also due to the risk to develop methemoglobinemia. The procedures in which topical anesthesia would be well indicated are those related to mild to moderate pain like: arterial and venous punction, hell lance puncture, lumbar puncture and percutaneous central catheter installation. The studies in the literature have so far lead to different conclusions, mainly depending on the type of the procedure and also due to the use of very different methodologies. The possibility of a direct pain evaluation may decrease the methodological bias leading to a more accurate evaluation of the efficacy of the topical anesthesia and also allowing comparisons among the indirect pain measures used so far.

Risk factors to periventricular-intraventricular hemorrhage

OBJECTIVE: To study the incidence and analyze risk factors to neonatal periventricular-intraventricular hemorrhage; to suggest a working protocol for diagnosis in newborns at risk.METHODS: This is a cohort prospective study including 120 out of 129 children weighing less than 2000g born from May 18 th, 1994 to May 17 th,1995 at the Hospital das Clinicas da UFMG. The study group comprised 39 newborns with the ultrasound diagnosis of periventricular-intraventricular hemorrhage; the control group comprised 81 newborns who although submitted to the same evaluation protocol did not show any echographic signs of hemorrhage. The ultrasound examinations were all done by the same researcher who was not aware of the clinical history or the neurologic and laboratory examinations. The hemorrhage was classified according to Papiles criteria: grade I (13%); grade II (7%); grade III (9%) and grade IV (3%).RESULTS: Low gestational age, low birth weight, masculine sex, vaginal delivery, and neonatal sepsis were significantly associated (p < 0.05) with periventricular-intraventricular hemorrhage in univariate analysis. Apgar score in the first or fifth minute and Battaglias and Lubchenkos classification for the weight in relation to gestational age were not predisposing factors to the hemorrhage. Low gestational age (p = 0.002), vaginal delivery (p = 0.037), and masculine sex (p = 0.016) kept statistical significance after multivariate adjustment. Birth weight may substitute for gestational age in the multivariate model because they are highly associated. The best cutoff point to screen for periventricular-intraventricular hemorrhage was 1750 g instead of the traditionally adopted point of 1500 g. CONCLUSIONS: The incidence of neonatal periventricular-intraventricular hemorrhage was similar to those reported by other studies. Low gestational age or low birth weight, vaginal delivery and masculine sex were the most important risk factors to the hemorrhage. The screening cutoff point of 1750 g seems to be more adequate than the commonly used birth weight of 1500 g.

The unreliability of neurologic examination in the diagnosis

OBJECTIVE: To evaluate the efficacy of the clinical neurologic examination, hematocrit and glycemia in the diagnosis of periventricular-intraventricular hemorrhage in the newborn weighing less than 2000g considering the neurosonography as the gold standard.METHODS: This is a cohort prospective study from May 18th, 1994 to May 17th, 1995 carried out at the Hospital das Clinicas da UFMG. The study group comprised 38 newborns with the ultrasound diagnosis of periventricular-intraventricular hemorrhage; the control group comprised 81 newborns who although submitted to the same evaluation protocol did not show any echographic signs of hemorrhage. The ultrasound examinations were all done by the same researcher who was not aware of the clinical history or the neurologic and laboratory examinations.RESULTS: Clinical neurologic alterations, mainly generalized hypotonia, were found to be associated with hemorrhage (p = 0.009), but there was a confounding effect due to the gestational age of the newborn. The predictive values of a positive or negative test were only 45% and 79%, respectively, which is clearly unreliable for the diagnosis of the hemorrhage. Hematocrit and glycemia were not clinically relevant either.CONCLUSIONS: The clinical neurologic examination is not reliable to indicate periventricular-intraventricular hemorrhage in the newborn. Newborns at risk should be routinely screened by neurosonography.