Maria Albertina Santiago Rego

Death or survival with major morbidity in VLBW infants born at Brazilian neonatal research network centers

Abstract Objective: To analyze unfavorable outcomes at hospital discharge of preterm infants born at Brazilian public university centers. Methods: Prospective cohort of 2646 inborn infants with gestational age 23–33 weeks and birth weight 400–1499 g, without malformations, born at 20 centers in 2012–2013. Unfavorable outcome was defined as in-hospital death or survival at hospital discharge with ≥1 major morbidities: bronchopulmonary dysplasia (BPD) at 36 corrected weeks, intraventricular hemorrhage (IVH) grades 3–4, periventricular leukomalacia (PVL) or surgically treated retinopathy of prematurity (ROP). Results: Among 2646 infants, 1390 (53%) either died or survived with major morbidities: 793 (30%) died; 497 (19%) had BPD; 358 (13%) had IVH 3–4 or PVL; and 84 (3%) had ROP. Logistic regression adjusted by center showed association of unfavorable outcome with: antenatal steroids (OR 0.70; 95%CI 0.55–0.88), C-section (0.72; 0.58–0.90), gestational age <30 (4.00; 3.16–5.07), being male (1.44; 1.19–1.75), small for gestational age (2.19; 1.72–2.78), 5th-min Apgar <7 (3.89; 2.88–5.26), temperature at NICU admission <36.0 °C (1.42; 1.15–1.76), respiratory distress syndrome (3.87; 2.99–5.01), proven late sepsis (1.33; 1.05–1.69), necrotizing enterocolitis (3.10; 2.09–4.60) and patent ductus arteriosus (1.69; 1.37–2.09). Conclusions: More than half of the VLBW infants born at public university level 3 Brazilian hospitals either die or survive with major morbidities.

Posição prona e diminuição da assincronia toracoabdominal em recém-nascidos prematuros

OBJECTIVE: To assess the effect of prone and supine positions on breathing pattern variables, thoracoabdominal motion and peripheral oxygen saturation of hemoglobin of premature newborn infants recovering from respiratory distress syndrome, while breathing spontaneously and in rapid eye movement sleep. METHODS: This was a quasi-experimental study. Twelve preterms weighing > 1,000 g at enrollment were studied in both positions, in random order. Respiratory inductive plethysmography was used to analyze breathing pattern (tidal volume, respiratory rate, minute ventilation, mean inspiratory flow) and thoracoabdominal motion (labored breathing index, phase relation in inspiration, phase relation in expiration, phase relation in total breath and phase angle). Pulse oximetry was used to evaluate peripheral oxygen saturation. Students t test for paired samples or the Wilcoxon test were used for statistical analysis. Significance was set at p < 0.05. RESULTS: A total of 9,167 respiratory cycles were analyzed. The prone position was associated with significant reductions in labored breathing index (-0.84±0.69; p = 0.001; 95%CI -1.29 to -0.40), phase relation in inspiration (-27.36±17.55; p = 0.000; 95%CI -38.51 to -16.20), phase relation in expiration (-32.36±16.20; p = 0.000; 95%CI -42.65 to -22.06) and phase relation in total breath (-30.20±14.76; p = 0.000; 95%CI -39.59 to -20.82). There were no significant differences between the two positions in any of the other variables analyzed. CONCLUSION: The prone position resulted in a significant reduction in thoracoabdominal asynchrony, without affecting breathing pattern or peripheral oxygen saturation.

Monitoring the postnatal growth of preterm infants: A paradigm change

There is no evidence that preterm postnatal growth should mimic that of healthy fetuses. It is seldom achieved and creates extrauterine growth–restricted or overfat infants. There is no consensus regarding how the growth of preterm infants should be monitored or what constitutes their ideal pattern of growth, especially after term-corrected age. The concept that the growth of preterm infants should match that of healthy fetuses is not substantiated by data and, in practice, is seldom attained, particularly for very preterm infants. Hence, by hospital discharge, many preterm infants are classified as postnatal growth–restricted. In a recent systematic review, 61 longitudinal reference charts were identified, most with considerable limitations in the quality of gestational age estimation, anthropometric measures, feeding regimens, and how morbidities were described. We suggest that the correct comparator for assessing the growth of preterm infants, especially those who are moderately or late preterm, is a cohort of preterm newborns (not fetuses or term infants) with an uncomplicated intrauterine life and low neonatal and infant morbidity. Such growth monitoring should be comprehensive, as recommended for term infants, and should include assessments of postnatal length, head circumference, weight/length ratio, and, if possible, fat and fat-free mass. Preterm postnatal growth standards meeting these criteria are now available and may be used to assess preterm infants until 64 weeks’ postmenstrual age (6 months’ corrected age), the time at which they overlap, without the need for any adjustment, with the World Health Organization Child Growth Standards for term newborns. Despite remaining nutritional gaps, 90% of preterm newborns (ie, moderate to late preterm infants) can be monitored by using the International Fetal and Newborn Growth Consortium for the 21st Century Preterm Postnatal Growth Standards from birth until life at home.

Prone position and reduced thoracoabdominal asynchrony in preterm newborns

OBJECTIVE To assess the effect of prone and supine positions on breathing pattern variables, thoracoabdominal motion and peripheral oxygen saturation of hemoglobin of premature newborn infants recovering from respiratory distress syndrome, while breathing spontaneously and in rapid eye movement sleep. METHODS This was a quasi-experimental study. Twelve preterms weighing > 1,000 g at enrollment were studied in both positions, in random order. Respiratory inductive plethysmography was used to analyze breathing pattern (tidal volume, respiratory rate, minute ventilation, mean inspiratory flow) and thoracoabdominal motion (labored breathing index, phase relation in inspiration, phase relation in expiration, phase relation in total breath and phase angle). Pulse oximetry was used to evaluate peripheral oxygen saturation. Students t test for paired samples or the Wilcoxon test were used for statistical analysis. Significance was set at p < 0.05. RESULTS A total of 9,167 respiratory cycles were analyzed. The prone position was associated with significant reductions in labored breathing index (-0.84+/-0.69; p = 0.001; 95%CI -1.29 to -0.40), phase relation in inspiration (-27.36+/-17.55; p = 0.000; 95%CI -38.51 to -16.20), phase relation in expiration (-32.36+/-16.20; p = 0.000; 95%CI -42.65 to -22.06) and phase relation in total breath (-30.20+/-14.76; p = 0.000; 95%CI -39.59 to -20.82). There were no significant differences between the two positions in any of the other variables analyzed. CONCLUSION The prone position resulted in a significant reduction in thoracoabdominal asynchrony, without affecting breathing pattern or peripheral oxygen saturation.

Assessment of the profile of births and deaths in a referral hospital.

OBJECTIVE To compare perinatal health indicators in a referral hospital in Belo Horizonte, Brazil. METHODS Perinatal results and indicators of single live births in Hospital das Clínicas of Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil, were compared for two periods, 1995-1998 and 2003-2006. The chi-square test and Students t test were applied with 5% significance level and 95% confidence interval. Data were obtained from the Perinatal Information System (Sistema Informático Perinatal, SIP), Latin American Center for Perinatology (Centro Latinoamericano de Perinatología, CLAP), Pan American Health Organization (PAHO), Hospital das Clínicas, and from medical records. RESULTS Mothers were approximately 26 years old on average. The number of prenatal appointments had an average increase of one appointment, regardless of birth weight, and there was a significant decrease in the number of caesarean deliveries in the second period. The average gestational age was 38 weeks in both periods, with a high rate of premature births (17.0 and 16.7%, respectively). The rate of newborns < 2,500 g was high in both periods (17.6 and 16.6%, respectively) with a decrease in the rate of newborns considered small for their gestational age. When congenital malformations were excluded, early neonatal mortality risk decreased from 12.4 per 1,000 live births in the first period to 8.0 per 1,000 live births in the second period, with considerable decrease for newborns with gestational age < 34 weeks. CONCLUSIONS Important differences were verified concerning health care assistance procedures and perinatal results, and they are compatible with the global improvement in neonatal health observed in the 2003-2006 period. However, the persistence of unfortunate neonatal incidents that can be reduced with the use of available perinatal technologies reveals the need for constant monitoring of perinatal hospital care for all groups of newborns.

Avaliação do perfil de nascimentos e óbitos em hospital de referência

OBJECTIVE: To compare perinatal health indicators in a referral hospital in Belo Horizonte, Brazil. METHODS: Perinatal results and indicators of single live births in Hospital das Clinicas of Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil, were compared for two periods, 1995-1998 and 2003-2006. The chi-square test and Students t test were applied with 5% significance level and 95% confidence interval. Data were obtained from the Perinatal Information System (Sistema Informatico Perinatal, SIP), Latin American Center for Perinatology (Centro Latinoamericano de Perinatologia, CLAP), Pan American Health Organization (PAHO), Hospital das Clinicas, and from medical records. RESULTS: Mothers were approximately 26 years old on average. The number of prenatal appointments had an average increase of one appointment, regardless of birth weight, and there was a significant decrease in the number of caesarean deliveries in the second period. The average gestational age was 38 weeks in both periods, with a high rate of premature births (17.0 and 16.7%, respectively). The rate of newborns < 2,500 g was high in both periods (17.6 and 16.6%, respectively) with a decrease in the rate of newborns considered small for their gestational age. When congenital malformations were excluded, early neonatal mortality risk decreased from 12.4 per 1,000 live births in the first period to 8.0 per 1,000 live births in the second period, with considerable decrease for newborns with gestational age < 34 weeks. CONCLUSIONS: Important differences were verified concerning health care assistance procedures and perinatal results, and they are compatible with the global improvement in neonatal health observed in the 2003-2006 period. However, the persistence of unfortunate neonatal incidents that can be reduced with the use of available perinatal technologies reveals the need for constant monitoring of perinatal hospital care for all groups of newborns.

Principais causas da mortalidade na infância no Brasil, em 1990 e 2015: estimativas do estudo de Carga Global de Doença

Objective: To analyze under-5 mortality rates and leading causes in Brazil and states in 1990 and 2015, using the Global Burden of Disease Study (GBD) 2015 estimates. Methods: The main sources of data for all-causes under-5 mortality and live births estimates were the mortality information system, surveys, and censuses. Proportions and rates per 1,000 live births (LB) were calculated for total deaths and leading causes. Results: Estimates of under-5 deaths in Brazil were 191,505 in 1990, and 51,226 in 2015, 90% of which were infant deaths. The rates per 1,000 LB showed a reduction of 67.6% from 1990 to 2015, achieving the proposed target established by the Millennium Development Goals (MDGs). The reduction generally was more than 60% in states, with a faster reduction in the poorest Northeast region. The ratio of the highest and lowest rates in the states decreased from 4.9 in 1990 to 2.3 in 2015, indicating a reduction in socioeconomic regional disparities. Although prematurity showed a 72% reduction, it still remains as the leading cause of death (COD), followed by diarrheal diseases in 1990, and congenital anomalies, birth asphyxia and septicemia neonatal in 2015. Conclusion: Under-5 mortality has decreased over the past 25 years, with reduction of regional disparities. However, pregnancy and childbirth-related causes remain as major causes of death, together with congenital anomalies. Intersectoral and specific public health policies must be continued to improve living conditions and health care in order to achieve further reduction of under-5 mortality rates in Brazil.RESUMO: Objetivo: Analisar as taxas de mortalidade e as principais causas de morte na infância no Brasil e estados, entre 1990 e 2015, utilizando estimativas do estudo Carga Global de Doenca (Global Burden of Disease - GBD) 2015. Metodos: As fontes de dados foram obitos e nascimentos estimados com base nos dados do Sistema de Informacoes sobre Mortalidade (SIM), censos e pesquisas. Foram calculadas proporcoes e taxas por mil nascidos vivos (NV) para o total de obitos e as principais causas de morte na infância. Resultados: O numero estimado de obitos para menores de 5 anos, no Brasil, foi de 191.505, em 1990, e 51.226, em 2015, sendo cerca de 90% mortes infantis. A taxa de mortalidade na infância no Brasil sofreu reducao de 67,6%, entre 1990 e 2015, cumprindo a meta estabelecida nos Objetivos de Desenvolvimento do Milenio (ODM). A reducao total das taxas foi, em geral, acima de 60% nos estados, sendo maior na regiao Nordeste. A disparidade entre as regioes foi reduzida, sendo que a razao entre o estado com a maior e a menor taxa diminuiu de 4,9, em 1990, para 2,3, em 2015. A prematuridade, apesar de queda de 72% nas taxas, figurou como a principal causa de obito em ambos os anos, seguida da doenca diarreica, em 1990, e das anomalias congenitas, da asfixia no parto e da sepse neonatal, em 2015. Conclusao: A queda nas taxas de mortalidade na infância representa um importante ganho no periodo, com reducao de disparidades geograficas. As causas relacionadas ao cuidado em saude na gestacao, no parto e no nascimento figuram como as principais em 2015, em conjunto com as anomalias congenitas. Politicas publicas intersetoriais e de saude especificas devem ser aprimoradas.

Avaliação da qualidade da informação do Sistema de Informação Perinatal (SIP-CLAP /OPAS) para monitoramento da assistência perinatal hospitalar, Belo Horizonte, 2004

OBJETIVO: avaliar a qualidade da informacao do SIP-CLAP/OPAS em maternidades de Belo Horizonte. METODOS: para avaliacao da completude foi analisada amostra aleatoria sistematica de 562 formularios SIP e prontuarios medicos correspondentes, coletados durante a assistencia em duas maternidades, em 2004. Uma subamostra de 20% foi utilizada para avaliacao da confiabilidade do banco de dados eletronico do programa. Foram calculadas proporcoes de completude antes e apos resgate da informacao disponivel em prontuario, e o indice Kappa e o coeficiente de correlacao intraclasse (ICC), com nivel de significância de 5%, para analise da concordância. RESULTADOS: a completude de variaveis do SIP durante a assistencia foi em media 72% no Hospital 1 e 86% no Hospital 2. O ganho medio percentual apos busca da informacao em prontuarios foi de 18% e 7%, respectivamente. Foram observados indices muito bons de concordância nos dois hospitais. CONCLUSOES: o SIP-CLAP representa uma alternativa para monitoramento da assistencia hospitalar perinatal, mas apresenta problemas para sua utilizacao adequada, pois a completude avaliada durante a assistencia nao foi satisfatoria. Sao necessarios investimentos para o aprimoramento do programa nos hospitais, fundamentais para obtencao de indicadores essenciais para a qualificacao da assistencia hospitalar ao parto e nascimento.