José M. Ceriani Cernadas

Maternal and Perinatal Factors Influencing the Duration of Exclusive Breastfeeding During the First 6 Months of Life

The aim of this study was to evaluate the influence of certain factors on the duration of exclusive breastfeeding during the first 6 months of life. In 597 mothers, 26 variables were assessed during the postpartum period. The mothers were interviewed monthly by telephone about how they were feeding their babies. In 539 mothers (92.2%), complete data were obtained until the sixth month. At discharge, 1 month, 4 months, and 6 months, the frequency of exclusive breastfeeding was 97%, 83%, 56%, and 19%, respectively. The median duration was 4 months. A longer duration of exclusive breastfeeding was significantly associated with positive maternal attitudes toward breastfeeding, adequate family support, good mother-infant bonding, appropriate suckling technique, and no nipple problems. These associations persisted after controlling for maternal education and other confounding variables. Certain maternal factors related to a longer duration of exclusive breastfeeding can be identified in the maternity ward and might contribute to the development of more effective breastfeeding policies. J Hum Lact. 19(2):136-144.

A Randomized, Double-Blind, Placebo-Controlled Trial of the Effects of Prophylactic Theophylline on Renal Function in Term Neonates With Perinatal Asphyxia

Background. The kidney is the most damaged organ in asphyxiated full-term infants. Experiments in rabbits and rats have shown that renal adenosine acts as a vasoconstrictive metabolite in the kidney after hypoxemia and/or ischemia, contributing to the fall in glomerular filtration rate (GFR) and filtration fraction. Vasoconstriction produced by adenosine can be inhibited by the nonspecific adenosine receptor antagonist, theophylline. Gouyon and Guignard performed studies in newborn and adult rabbits subjected to normocapnic hypoxemia. Their results clearly showed that the hypoxemia-induced drop in GFR could be avoided by the administration of low doses of theophylline. Objective. This study was designed to determine whether theophylline could prevent and/or ameliorate renal dysfunction in term neonates with perinatal asphyxia. Setting. Buenos Aires, Argentina. Study Design. We randomized 51 severe asphyxiated term infants to receive intravenously a single dose of either theophylline (8 mg/kg; study group: n = 24) or placebo (control group: n = 27) during the first 60 minutes of life. The 24-hour fluid intake and the urine volumes formed were recorded during the first 5 days of life. Daily volume balances (water output/input ratio and weights) were determined. Severe renal dysfunction was defined as serum creatinine elevated above 1.50 mg/dL, for at least 2 consecutive days after a fluid challenge, or rising levels of serum creatinine (.3 mg/dL/day). The GFR was estimated during the second to third days of life by endogenous creatinine clearance (mL/minute/1.73 m2) and using Schwartzs formula: GFR (mL/minute/1.73 m2) = .45 × length (cm)/plasma creatinine (mg/100 mL) during the first 5 days of life. Tubular performance was assessed as the concentration of β2-microglobulin (β2M) determined by enzyme immunoassay, on the first voided urine 12 hours after theophylline administration. The statistical analysis for the evaluation of the differences between the groups was performed with Studentst and χ2 tests as appropriate. Results. During the first day of life, the 24-hour fluid balance was significantly more positive in the infants receiving placebo compared with the infants receiving theophyline. Over the next few days, the change in fluid balance favored the theophyline group. Significantly higher mean plasma values were recorded in the placebo group from the second to the fifth days of life. Severe renal dysfunction was present in 4 of 24 (17%) infants of the theophylline group and in 15 of 27 (55%) infants of the control group (relative risk: .30; 95% confidence interval: .12–.78). Mean endogenous creatinine clearance of the theophylline group was significantly increased compared with the creatinine clearance in infants receiving placebo (21.84 ± 7.96 vs 6.42 ± 4.16). The GFR (estimated by Schwartzs formula) was markedly decreased in the placebo group. Urinary β2M concentrations were significantly reduced in the theophylline group (5.01 ± 2.3 mg/L vs 11.5 ± 7.1 mg/L). Moreover, 9 (33%) patients of the theophylline group versus 20 (63%) infants of the control group had urinary β2M above the normal limit (<.018). There was no difference in the severity of the asphyxia between infants belonging to the theophylline and control groups in regards of Portmans score. Except for renal involvement, a similar frequency of multiorganic dysfunction, including neurologic impairment, was observed in both groups. The theophylline group achieved an average serum level of 12.7 μg/mL (range: 7.5–18.9 μg/mL) at 36 to 48 hours of live versus traces (an average serum level of .87 μg/mg) in the placebo group. Conclusions. Our data suggest that prophylactic theophylline, given early after birth, has beneficial effects on reducing the renal dysfunction in asphyxiated full-term infants. A single dose of 8 mg/kg of theophylline within the first postnatal hour in term neonates with severe perinatal asphyxia results in a significant decrease in serum creatine and urinary β2M, together with a significant increase in the creatine clearance. The potential clinical relevance of the data would be the avoidance of the contributory role of hypoxemia in the development of acute renal failure. Additional studies will be necessary before the use of theophylline in asphyxiated newborns can be considered for clinical practice.

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.

Nacimiento por cesárea al término en embarazos de bajo riesgo: efectos sobre la morbilidad neonatal

INTRODUCTION The rate of cesarean delivery (CD) has significantly increased over the last years, even in low risk pregnancies. Our objective was to compare the neonatal morbidity rate in low risk term infants delivered by vaginal or CD. DESIGN Prospective observational and analytical cohort study. Main outcome measures. Incidence of any neonatal morbidity and respiratory morbidity. Population and methods. Infants < or = 37 weeks born at the Hospital Italiano de Buenos Aires between December 2004 and July 2006 were eligible. Exclusion criteria included: any maternal related disorder, acute or chronic fetal distress, breech presentation in primiparous women, multiple pregnancies, intrauterine growth restriction and newborns with major malformations. RESULTS A total of 2021 infants were included, 1120 born vaginally and 901 by CD. Main indications for CD were failure to progress labor (46%) and previous CD (37%). Only 3% of CD was performed by maternal request. Any neonatal morbidity rate was 9% in infants born by CD and 6.6% in infants born vaginally (RR 1.36; 95%CI 1.01-1.8). Respiratory morbidity rate was 5.3% in infants born by CD and 3.1% in those born vaginally (RR 1.7; 95%CI 1.1-2.6). When stratified by gestational age, respiratory morbidity was higher only for infants < or =38 weeks (7.4% in CD vs. 2.1% in vaginal delivery; RR 3.5; 95%CI 1.5-8.1). Also, respiratory morbidity was higher in infants born < or =38 weeks by CD without labor vs. those with labor 10.5% and 3.9%, respectively (RR 1.35; 95%CI: 1.07-1.70). In a logistic regression analysis, CD and male sex were independently associated with higher respiratory morbidity. There were not significant differences in other morbidities. NICU admission was higher in infants born by CD (9.5% vs. 6.1%; RR 1.5; 95% CI: 1.1-2.1). Sixty-eight percent of the mothers from the CD group refereed having moderate to severe pain in the puerperium vs. 36% in the vaginal group (RR 1.9; 95% CI: 1.7-2.1). Exclusive breastfeeding at discharge was significantly lower in infants born by CD (90% vs. 96%; RR 0.94 95%CI 0.92-0.96). CONCLUSIONS Low risk CD at term was associated with a higher neonatal morbidity, NICU admission and maternal pain in the puerperium. It also reduces exclusive breastfeeding rate at discharge.

Aspectos bioéticos en el cuidado de los recién nacidos extremadamente prematuros

The survival rate of extremely preterm infants improved over the last years as a result of a better prenatal and neonatal care mainly due to a greater use of antenatal steroids, appropriate management in the delivery room and in the initial care, surfactant therapy, and better modalities of assisted ventilation. However, this improvement in survival has not been associated with an equal reduction in morbidity. In fact, the frequency of bronchopulmonary displasia, sepsis, poor growth, and neurological disorders in the future may have increased. The purpose of this article is to examine, from a bioethical point of view, different aspects in perinatal care at the threshold of viability.

Medication error in an extremely low birth weight infant: paracetamol overdose

Errors are part of human nature and are usually present in our actions. Medical errors occur quite often and can be serious. Medication errors are among the most frequent, especially in newborn infants because of the multiple steps that occur during the process of prescribing and administering drugs and because most drugs are not licensed for being used in newborn infants (off-label). The aim of this report is to describe a medication error in prescribing paracetamol for closing a patent ductus arteriosus in a preterm infant and to analyze its causes. A preterm female infant born at 27 weeks of gestational age with a birth weight of 750 g received paracetamol at 9 days old at a dose 20 times greater than required. The initial plasma level was 480 µg/mL. N-acetylcysteine was administered and her clinical outcome was satisfactory. Parents were notified of the event, which was recorded in the medical record and in the electronic error reporting system of the Hospital Italiano de Buenos Aires. We consider this report as an example that we are exposed to making mistakes and should maximize precautions to improve patient safety in neonatal units.