José Lauro Araújo Ramos

Early weaning: implications to oral motor development

OBJECTIVE This article aims at reviewing the relationship between early weaning and its consequences to oral motor development, focusing on the consequences to occlusion, breathing, and childrens oral motor aspects. SOURCES A literature review based on Medline database from the early 60s up to 2001 was performed taking into consideration the following topics: pediatrics, dentistry and speech language pathology. SUMMARY OF THE FINDINGS Based on this review of literature, we could verify that early weaning may lead to a proper oral motor development rupture, which may cause negative consequences to swallowing, breathing and speaking activities as well as malocclusion, oral breathing and oral motor disorders. CONCLUSIONS In addition to several benefits of breastfeeding, it contributes to a proper oral motor development and also avoids speech-language disorders, regarding oral motor system.

Prediction of Length of Hospital Stay in Neonatal Units for Very Low Birth Weight Infants

OBJECTIVE:To develop models for estimating the length of hospital stay (LOS) of very low birth weight infants (VLBW), based on perinatal risk factors present during the first week of life and during the entire hospitalization period.STUDY DESIGN:The files of 155 VLBW were analyzed, and the influence of individual risk factors were initially evaluated by univariate analysis, using multiple-regression. Two mathematical models were built to estimate the LOS.RESULTS:The first model, using risk factors present during the first 3 days of life, is as follows: LOS = −0.074A + 22.06B + 22.85C − 16.78D − 2.07E + 10.51F + 203.12 (R2 = 0.63). (The letters are added to show what each number represents: A: birth weight; B: occurrence of respiratory distress syndrome; C: endotracheal intubation during resuscitation; D: 1-minute Apgar score; E: gestational age; F: presence of complications during delivery.) The second model, using factors present during the entire hospitalization period, is: LOS = 0.61G + 29.19H + 24.68I + 14.21J + 23.56K + 9.54L + 7.41M + 20.43 (R2 = 0.82). (G: age receiving nutritional support of ≥120 kcal/kg per day; H: occurrence of systemic candidiasis; I: birth weight < 1000 gm; J: presence of delivery complication; K: occurrence of bronchopulmonary dysplasia; L: birth weight ≥ 1000 gm and ≤ 1249 gm; M: occurrence of anemia).CONCLUSION: Both models are applicable for estimating the hospitalization period, and the addition of variables present during the entire hospitalization period improved the accuracy of the model.

Immune response of preterm infants to hepatitis B vaccine administered within 24 hours after birth

OBJECTIVE To investigate the immune response of preterm infants to hepatitis B vaccination. METHODS Three doses of recombinant hepatitis B vaccine (5 micro g dose) were administered to 35 preterm and 21 full-term infants within 24 hours after birth and at one and six months of postnatal age. RESULTS A protective antibody response (anti-HB > 10 mUI/mL) was observed three months after the last dose in 92.6% and 100% of preterm and full-term infants (p > 0.05), respectively. Newborns with gestational age below 34 weeks presented lower antibody responses in all three periods. However, gestational age was not important to determine the antibody response in the three periods analyzed. When antibody response was analyzed in terms of birth weight, it was observed that a protective response was present in 75 and 100% of newborns with birth weight < or = 1,500 g and > 1,500 g, respectively. Birth weight was shown to be a relevant factor in determining a protective antibody response at six months of postnatal age. Nonresponders received a fourth vaccine dose and an adequate antibody response was obtained in 100%. CONCLUSION The antibody response of preterm infants was similar to that of term newborns. Hepatitis B vaccination can be initiated on the first day of life in preterm newborns, following the same scheme recommended for term newborns. However, in preterm infants with birth weight less than or equal to 1,500 g, whose antibody response is lower, anti-HB titers should be monitored at nine months of age, or a four-dose vaccination scheme should be provided, with doses on the first day of postnatal life and one, six and nine months later.

Predictive value of the "Clinical Risk Index for Babies" for the risk of neonatal death

OBJECTIVE Several indicators, mainly birthweight and gestational age, have been used to predict the mortality risk in neonatal intensive care units. In order to assess the potential value of CRIB in predicting neonatal mortality, the score was used over the first 12 hours of life of the newborns admitted to this unit, during the year of 1996. METHOD The inclusion criteria consisted of all infants without inevitably lethal congenital malformations, birthweight below 1,500 g and/or gestational age less than 31 weeks. Newborn children who died within 12 hours after delivery were excluded. The CRIB score covers birth weight, gestational age, the presence of congenital malformations (not inevitably lethal) and three indexes of physiological status during first 12 hours after birth-maximum and minimum appropriate fraction of inspired oxygen and maximum (most acidotic) base excess. RESULTS In a prospective cohort, seventy one newborn children were studied. The birthweight (average) was 1,119 +/- 275.6 g, gestational age 30 weeks 4/7 +/- 2 weeks 3/7; male (57%); Apgar 1(0) min. score < or = 3 (36.2%) and Apgar 5 degrees min. score < 5 (5.8%). The mortality rate was 29.6% (gold standard). But mortality rate by birthweight less than 1,000 gr. or gestational age lower than 29 weeks was 60.0% and for the CRIB score above 10 was 100%. DISCUSSION The specificity and predictive positive values for CRIB score above 10 were greater than any other two parameters. The area under the receiver operating characteristic (ROC) curve for predicting death was significantly greater for CRIB than for birthweight alone. It was concluded that the CRIB score is a better predictive indicator for mortality than are birthweight and gestational age.

A risk factor for early-onset infection in premature newborns: invasion of chorioamniotic tissues by leukocytes.

The authors report a prospective study of correlation between histopathological alterations of the placenta, risk factors and early-onset bacterial infections in 224 premature newborns. They used a mathematical model for evaluation and prediction of neonatal bacterial infection according to the localization in chorioamniotic tissues (chorioamniotic plate, amniotic membranes and umbilical cord) invaded by leukocytes. Septicemia, pneumonia or omphalitis were documented in 45 (20%) infected premature newborns and inflammatory lesions in the placenta were observed in all of them. In order of statistical significance, the most important variables for early-onset bacterial neonatal infection were invasion of the chorioamniotic plate, amniotic membranes and umbilical cord tissues by PMNL (P < 0.0000), premature rupture of membranes (P < 0.0000), birthweight lower than 1500 g (P < 0.0000), gestational age under 34 weeks (P < 0.0001), foul smell (P < 0.0038), no antibiotics before delivery (P < 0.0066) and intrapartum fever (P < 0.0087). By logistic stepwise multiple regression analysis, invasion of fetal chorioamniotic plate and of amniotic membranes by leukocytes were the only statistically significant variables. The probability of neonatal infection in premature newborns, when polymorphonuclear neutrophils were present in chorioamniotic plate and in amniotic membranes, was 62.5%, while the probability was 0.5% when these tissues were normal. These data suggest that histological chorioamnionitis has to be considered as an important risk factor for early-onset infection in premature newborns.

Meningite bacteriana neonatal: estudo prospectivo da evolução a longo prazo de 55 crianças

Fifty-five infants who presented bacterial neonatal meningitis were prospectively studied to analyze the frequency and the type of sequelae. All the infants were full term newborns. There were 38 boys and 17 girls; the age of disease onset varied from 3 to 28 days. The causative organism was represented mainly by enterobacteriae. The median time of follow-up was 5 years. The frequency of neurologic sequelae was 63.7%, represented mainly by neuropsychomotor development delay (58.2%), hydrocephaly (45.5%) and convulsions (34.5%). Severe motor abnormalities ocurred in 23.6% of children (quadriplegia, diplegia, hemiparesia and ataxia). Convulsions in the acute phase of the disease and the positive cerebrospinal fluid culture were highly associated to sequelae. The school performance, obtained in 25 children, showed presence of disabilities in 48% of cases, which were significantly associated to mental retardation.

CENTRAL DIABETES INSIPIDUS AS A COMPLICATION OF NEONATAL PATHOLOGY : REPORT OF THREE CASES

Abstract Three patients. II. 17 and 41 days old with various degrees of central nervous system (CNS) lesions developed central diabetes insipidus as a complication of hypothalamic damage. Two of the children had congenital CNS malformations including meningomyelocele, hydrocephalus, and prosencephaly, while the third child presented Streptococcus agalactiae meningitis, complicated with CNS hemorrhage and hypertensive dilatation of the lateral ventricles. All of them fulfilled the criteria for central diabetes insipidus, reaching high levels of serum sodium and osmolality, along with hypotonic urine. The responses to intranasal arginine‐vasopressin were prompt, normalizing the serum levels of sodium and increasing urinary osmolality, allowing a better metabolic balance, avoiding continuing damage to the already compromised CNS. The neonatologist must be aware of the possibility of this kind of complication even in a normal child with CNS infection. Imaging studies showing hemorrhage in the region of the posterior hypothalamus must be a sign that this type of complication is able to occur.

Relationship between plasma creatinine concentration and glomerular filtration in preterm newborn infants

Fluid management and dosage regimens of drugs in preterm infants should be based on the glomerular filtration rate. The current methods to determine glomerular filtration rate are invasive, time-consuming, and expensive. In contrast, creatinine clearance can be easy obtained and quickly determined. The purpose of this study was to compare plasma creatinine on the third and seventh day of life in preterm newborn infants, to evaluate the influence of maternal creatinine, and to demonstrate creatinine clearance can be used as a reliable indicator of glomerular filtration rate. We developed a prospective study (1994) including 40 preterm newborns (gestational age < 37 weeks), average = 34 weeks; birth weight (average) = 1840 g, in the first week of life. Inclusion criteria consisted of: absence of renal and urinary tract anomalies; O2 saturation >/= 92%; adequate urine output (>1ml/kg/hr); normal blood pressure; absence of infections and no sympathomimetic amines in use. A blood sample was collected to determine plasma creatinine (enzymatic method) on the third and seventh day of life and creatinine clearance (CrCl) was obtained using the following equation: [formula: see text], k = 0.33 in preterm infant All plasma creatinine determinations showed normal values [third day: 0.78 mg/dl +/- 0.24 (mean +/- SD)and seventh day: 0.67 mg/dl +/- 0.31 - (p>0.05)]. Also all creatinine clearance at third and seventh day of life were normal [third day: 19.5 ml/min +/- 5.2 (mean +/- SD) and seventh day: 23.8 ml/min +/- 7.3 - (p>0,05)]. All preterm infants developed adequate renal function for their respective gestational age. In summary, our results indicate that, for clinical practice, the creatinine clearance, using newborn length, can be used to estimate glomerular filtration rate in preterm newborn infants.

Progress in phototherapy

The purpose of this article is to present a recent advance in phototherapy employed on newborn babies with jaundice. The efficacy of this treatment depends on the intensity of emitted light; it is believed that a dose between 6 -12 nm is necessary. The usefulness of phototherapy in healthy, full-term infants is currently being questioned. Therefore, the adequate use of this therapy should be emphasized until a consensus is reached on its advantages and disadvantages.

Seizure recurrence in infants with neonatal convulsions: a follow-up study

Twenty three infants with neonatal seizures were followed prospectively to a mean age of 11 months. Only 2 were pre-term and birth weight ranged from 1700 to 4230 grams, with 17 male and 6 female infants. Hypoxic-ischemic encephalopathy was the most common etiology (82.6%). Focal clonic convulsions were the predominant seizure type, present in 7/16 infants in which the seizure type could be identified. All infants had a neurological examination and EEG, and 18 had a cranial ultrasonography performed at the follow-up. Anticonvulsant medication was discontinued, if follow-up EEG and neurological examination were normal. At the follow-up, seizure recurrence was observed in 7/23 (30%) infants. Abnormal EEG, neurological examination and cranial ultrasonography were statistically correlated with seizure recurrence. We conclude that infants with neonatal seizures can remain free of anticonvulsant medication provided they have normal neurological examination, EEG and cranial ultrasonography.