Maria Elisabeth Lopes Moreira

Retinopathy of Prematurity in 7 Neonatal Units in Rio de Janeiro: Screening Criteria and Workload Implications

OBJECTIVES: The goals were to determine optimal screening criteria for retinopathy of prematurity (ROP) in 7 neonatal units in Rio de Janeiro, Brazil, and to explore the workload implications of applying different criteria. METHODS: Infants with birth weights of ≤2000 g or gestational age of <37 weeks were examined by 3 ophthalmologists in 7 of the largest units in Rio de Janeiro, during a 34-month period. ROP was classified by using the international classification, and laser treatment was given to infants developing type 1 ROP. RESULTS: A total of 3437 (87%) of 3953 eligible infants were examined, of whom 124 (3.6% [range: 2.1%–7.8%]) were treated. Eleven infants were treated for aggressive posterior ROP. Appropriate screening criteria for the 2 NICUs with high survival rates (ie, ≥80% among infants with birth weights of <1500 g) would be ≤1500 g or <32 weeks. For NICUs with low survival rates (ie, <80%), appropriate criteria would be ≤1500 g or ≤35 weeks. UK, US, and previous Brazilian criteria would all miss infants needing treatment. CONCLUSIONS: ROP programs in Brazil should use the wider criteria of ≤1500 g or ≤35 weeks until further evidence-based criteria become available, although this would mean a slight increase in workload across the city, compared with use of the narrower criteria in the better units. Whether survival rates can be used as a proxy to indicate screening criteria requires further investigation.

Desafios para a humanização do cuidado em uma unidade de terapia intensiva neonatal cirúrgica

Este estudo analisa cuidados ambientais e relacoes de atendimento em Unidade de Terapia Intensiva Neonatal Cirurgica, refletindo sobre potencialidades e obstaculos para promocao de cuidado humanizado. A pesquisa, realizada em uma instituicao de nivel terciario, utilizou o metodo da observacao participante enfocando, por cinco meses, relacoes profissional-bebe, profissional-responsavel e mae-bebe. Foram observadas rotinas contemplando condicoes ambientais e necessidades de bebes e familias, e estrategias para reducao de ruido e luminosidade, com diferentes niveis de efetividade. O consolo e bem-estar dos bebes eram proporcionados por suporte do corpo e uso da succao nao-nutritiva. Tais condutas nao eram sistematizadas e revelaram contradicoes e ambiguidades. O acesso dos pais era incentivado, porem sinais de dificuldades como medo, inseguranca e estresse na relacao pais-bebes, indicaram necessidade de ampliacao dos cuidados dirigidos a familia. Posturas e praticas em UTIs Neonatais sao permeadas por conflitos, negociacoes e adaptacoes ao trabalho, constituindo um desafio a construcao de um modelo assistencial humanizado, que alie diferentes tecnologias, respeito e acolhimento as necessidades intersubjetivas de pacientes e profissionais e reconhecimento das logicas culturais das familias.

A criança é o pai do homem: novos desafios para a área de saúde da criança

This paper offers an analysis of current demographic and epidemiological context in which the child falls and addresses the need to the reformulation of the health services intended for child care, pointing also to the question of the need to produce new knowledge that help them in a new pediatrics care. The knowledge that child care needs to be expanded to take into account acute problems and disease prevention in the long run, even in adulthood, introduces a new field for pediatrics that also demands the formation of new researchers who can give the children opportunities to be included in research on drugs and other therapeutic proposals addressed to them. In conclusion, health care strategies concentrated particularly on children with all their specificity, a growing and developing human being, need to be implemented in the health services so that they can grow well and become healthy adults.This paper offers an analysis of current demographic and epidemiological context in which the child falls and addresses the need to the reformulation of the health services intended for child care, pointing also to the question of the need to produce new knowledge that help them in a new pediatrics care. The knowledge that child care needs to be expanded to take into account acute problems and disease prevention in the long run, even in adulthood, introduces a new field for pediatrics that also demands the formation of new researchers who can give the children opportunities to be included in research on drugs and other therapeutic proposals addressed to them. In conclusion, health care strategies concentrated particularly on children with all their specificity, a growing and developing human being, need to be implemented in the health services so that they can grow well and become healthy adults.

Medication errors in a neonatal intensive care unit

OBJECTIVE To determine the incidence and type of medical errors in a newborn intensive care unit and the relationship between the error and the patients clinical status. METHODS We reviewed the medical charts, during the first 7 days of hospitalization, of all high-risk newborn infants admitted for a period of 3 months. RESULTS Seventy-three patients were admitted during the study period. Their mean birth weight was 2,140 g (640-5,020 g) and mean gestational age was 34 weeks (25-40 weeks). Of 73 medical charts analyzed, 40 (55%) had one or more errors. A total of 365 days of hospitalization was analyzed and 95 medical errors were detected (one error per 3.9 days of hospitalization). The most frequent error was associated with medication use (84.2%). Use of therapeutic procedures (drugs, phototherapy, etc.) without proper prescription in the patients chart (commission error) accounted for 7.4% of the errors, and incidence of omission errors was 8.4%. Incidence of medical errors was significantly higher in newborn infants with lower gestational age. CONCLUSIONS Incidence of errors in the care of high-risk newborn infants is elevated. Strategies to improve education of health professionals involved in the care and development of local culture by disseminating clear, accessible algorithms to guide behavior when errors occur must be encouraged.

Adequacy of human milk viscosity to respond to infants with dysphagia: experimental study

Neonatal nutrition is an important subject in health in the short, medium and long term. In preterm newborns, nutrition assumes a predominant role for the childs overall development. Babies with uncoordinated swallowing or respiration may not have the necessary oral abilities to suck the mothers breast and will need to implement different feeding practices; one of them is changing the consistency of the milk offered. Objectives Determine viscosity variations of untreated human and pasteurized milk without and with thickening to adapt the diet to the needs of dysphagic infants hospitalized in the Neonatal Intensive Cara Unit (NICU). Material and Methods The authors altered the viscosity of natural infant powdered milk and, after thickening, determined and adopted a thickening standard for human milk. Untreated human and pasteurized milk was thickened in concentrations of 2%, 3%, 5% and 7% and the viscosity were determined every 20 minutes for a period of 60 minutes at a temperature of 37ºC. Results The infant lactose formula thickened at concentrations of 2% and 3% produced viscosities of 8.97cP and 27.73 cP, respectively. The increases were significantly different after 1 hour. Inversely, untreated human milk at 2%, 3%, 5% and 7% produced diminished viscosity over time; the changes were more accentuated in the first 20 minutes. In pasteurized human milk, the 2% concentration had no variation in viscosity, but with the 3%, 5% and 7% concentrations, there was a significant decrease in the first 20 minutes with stability observed in the subsequent times. Conclusion In powdered milk, the viscosity increases over time; the viscosity in human milk diminishes. The results point out the importance not only of considering the concentration of the thickener but also the time being administered after its addition to effectively treat dysphagic infants.

Case report: vertical dengue infection

OBJECTIVES To report a case of vertical dengue infection in a newborn from Rio de Janeiro, Brazil, and to review the literature concerning this problem. DESCRIPTION We report a case of vertical dengue infection. Female neonate, birth weight 3,940 g, term, was admitted to a neonatal intensive care unit on the fifth day of life with fever and erythematous rash. Her mother had had dengue fever 3 days before delivery. Her platelet count was 38,000, dropping to 15,000. She did not have any hemorrhagic episodes, including cerebral hemorrhages. Anti-dengue antibodies (IgM) were positive in the mother and infant. Dengue type 2 was detected in the infant using polymerase chain reaction. COMMENTS This report emphasizes that pediatricians should be aware of the possibility of vertical dengue infection so that early management can be instituted.

The efficacy of the use of intravenous human immunoglobulin in Brazilian newborns with rhesus hemolytic disease: a randomized double-blind trial.

BACKGROUND: The purpose of this study was to evaluate the efficacy of intravenous human immunoglobulin (IVIG) in the presence of high‐intensity phototherapy in decreasing the need for exchange transfusion in newborns with rhesus hemolytic disease.

O uso da fototerapia em recém-nascidos: avaliação da prática clínica

OBJECTIVES: to describe the use of phototherapy in the day to day clinical practice by healthcare professionals of public maternity hospitals in the city of Rio de Janeiro. METHODS: heads of healthcare departments, doctors and nurses of 17 public maternity hospitals were interviewed on issues related to phototherapy management in their services. RESULTS: eighty nine healthcare professionals were interviewed. Seventy four per cent of the doctors noted there was a written guideline for neonatal jaundice management in their departments but with a great variation of responses related to the medical conduct adopted, including among professionals working in the same unit, 74% of doctors prescribed prophylactic phototherapy and 64% said they increased fluid intake during treatment. Distance placed between the newborn and the irradiance source varied from 20 to 70 cms. Half of the respondents noted the lack of guidelines to verify irradiation during phototherapy. A marked variation of bilirubin serum levels were used for phototherapy and exchange blood transfusion indications. CONCLUSIONS: our findings suggest the lack of consensus among healthcare professionals related to the use of phototherapy and that some of the routinely adopted practices could impair treatment efficacy.

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.

Screening Criteria for Ophthalmic Manifestations of Congenital Zika Virus Infection

Importance Current guidelines recommend screening eye examinations for infants with microcephaly or laboratory-confirmed Zika virus infection but not for all infants potentially exposed to Zika virus in utero. Objective To evaluate eye findings in a cohort of infants whose mothers had polymerase chain reaction–confirmed Zika virus infection during pregnancy. Design, Setting, and Participants In this descriptive case series performed from January 2 through October 30, 2016, infants were examined from birth to 1 year of age by a multidisciplinary medical team, including a pediatric ophthalmologist, from Fernandes Figueira Institute, a Ministry of Health referral center for high-risk pregnancies and infectious diseases in children in Rio de Janeiro, Brazil. Participants Mother-infant pairs from Rio de Janeiro, Brazil, who presented with suspected Zika virus infection during pregnancy were referred to our institution and had serum, urine, amniotic fluid, or placenta samples tested by real-time polymerase chain reaction for Zika virus. Main Outcomes and Measures Description of eye findings, presence of microcephaly or other central nervous system abnormalities, and timing of infection in infants with confirmed Zika virus during pregnancy. Eye abnormalities were correlated with central nervous system findings, microcephaly, and the timing of maternal infection. Results Of the 112 with polymerase chain reaction–confirmed Zika virus infection in maternal specimens, 24 infants (21.4%) examined had eye abnormalities (median age at first eye examination, 31 days; range, 0-305 days). Ten infants (41.7%) with eye abnormalities did not have microcephaly, and 8 (33.3%) did not have any central nervous system findings. Fourteen infants with eye abnormalities (58.3%) were born to women infected in the first trimester, 8 (33.3%) in the second trimester, and 2 (8.3%) in the third trimester. Optic nerve and retinal abnormalities were the most frequent findings. Eye abnormalities were statistically associated with microcephaly (odds ratio [OR], 19.1; 95% CI, 6.0-61.0), other central nervous system abnormalities (OR, 4.3; 95% CI, 1.6-11.2), arthrogryposis (OR, 29.0; 95% CI, 3.3-255.8), and maternal trimester of infection (first trimester OR, 5.1; 95% CI, 1.9-13.2; second trimester OR, 0.5; 95% CI, 0.2-1.2; and third trimester OR, 0.3; 95% CI, 0.1-1.2). Conclusions and Relevance Eye abnormalities may be the only initial finding in congenital Zika virus infection. All infants with potential maternal Zika virus exposure at any time during pregnancy should undergo screening eye examinations regardless of the presence or absence of central nervous system abnormalities.