Maria Elizabeth Lopes Moreira

Birth in Brazil: national survey into labour and birth

BackgroundCaesarean section rates in Brazil have been steadily increasing. In 2009, for the first time, the number of children born by this type of procedure was greater than the number of vaginal births. Caesarean section is associated with a series of adverse effects on the women and newborn, and recent evidence suggests that the increasing rates of prematurity and low birth weight in Brazil are associated to the increasing rates of Caesarean section and labour induction.MethodsNationwide hospital-based cohort study of postnatal women and their offspring with follow-up at 45 to 60 days after birth. The sample was stratified by geographic macro-region, type of the municipality and by type of hospital governance. The number of postnatal women sampled was 23,940, distributed in 191 municipalities throughout Brazil. Two electronic questionnaires were applied to the postnatal women, one baseline face-to-face and one follow-up telephone interview. Two other questionnaires were filled with information on patients’ medical records and to assess hospital facilities. The primary outcome was the percentage of Caesarean sections (total, elective and according to Robson’s groups). Secondary outcomes were: post-partum pain; breastfeeding initiation; severe/near miss maternal morbidity; reasons for maternal mortality; prematurity; low birth weight; use of oxygen use after birth and mechanical ventilation; admission to neonatal ICU; stillbirths; neonatal mortality; readmission in hospital; use of surfactant; asphyxia; severe/near miss neonatal morbidity. The association between variables were investigated using bivariate, stratified and multivariate model analyses. Statistical tests were applied according to data distribution and homogeneity of variances of groups to be compared. All analyses were taken into consideration for the complex sample design.DiscussionThis study, for the first time, depicts a national panorama of labour and birth outcomes in Brazil. Regardless of the socioeconomic level, demand for Caesarean section appears to be based on the belief that the quality of obstetric care is closely associated to the technology used in labour and birth. Within this context, it was justified to conduct a nationwide study to understand the reasons that lead pregnant women to submit to Caesarean sections and to verify any association between this type of birth and it’s consequences on postnatal health.

Effects of non-nutritive sucking and oral stimulation on breastfeeding rates for preterm, low birth weight infants: a randomized clinical trial

OBJECTIVE To determine the influence of non-nutritive sucking and oral stimulation programs on breastfeeding rates at discharge, at 3 and at 6 months of corrected age in preterm infants with very low birth weight. METHODS Preterm infants were randomized into experimental and control groups. Ninety-eight preterm infants were randomized and 96 remained in the study until reaching the corrected age of 6 months. The experimental group received sensory-motor-oral stimulation and non-nutritive sucking, while infants in the control group received a sham stimulation program. Both were administered from reaching enteral feeding (100 kcal/kg/day) until the beginning of oral feeding. RESULTS Fifty-nine infants (61.5%) were breastfeeding at the time of hospital discharge, 31 (36.9%) at 3 months, and only 18 (20.5%) at 6 months of corrected age. At discharge, 46.9% of the control group and 76.5% of the experimental group were breastfeeding. There were statistically significant differences between rates of breastfeeding at discharge (47 vs. 76%), 3 months (18 vs. 47%) and 6 months after discharge (10 vs. 27%). The experimental group showed significantly higher rates of breastfeeding (p < 0.05). CONCLUSION Non-nutritive sucking, associated with oral stimulation programs, can contribute to the improvement of breastfeeding rates among preterm infants with very low birth weight.

Bronchopulmonary dysplasia prediction model for 7-day-old infants

Objective: To develop a predictive model capable of identifying which premature infants have the greatest probability of presenting bronchopulmonary dysplasia (BPD), based on assessment at the end of their first week of life. Methods: Data were collected retrospectively from January 1998 to July 2001, and prospectively from August 2001 to July 2003. All children born at the institution with gestational age < 34 weeks and birth weight < 1,500 gwere included. The principal risk factors for BPD were subjected to univariate analysis followed by logistic regression. Significant variables were used to construct a formula to calculate the probability of BPD. The model was calibrated and its discriminative power assessed using receiver operating characteristic (ROC) curves. Between August 2003 and July 2005 the model was then applied to a different population for validation. Results: The sample comprised 247 children, of whom 68 developed BPD, classified as follows: mild = 35 (51.4%), moderate = 20 (29.4%) and severe = 8 (11.7 %). Four variables maintained significance with relation to BPD: gestational age .. 30 weeks, persistent ductus arteriosus, mechanical ventilation > 2 days and loss of > 15% of birth weight on the 7th day of life. Where patients exhibited all of these variables, the model had a 93.7% probability of being correct. Themodelwas further validated when using another sample of 61 newborns; similar figures were obtained. Conclusions: At the end of the first week of life, the predictive model developed from our populationwas capable of identifying newborn infants at increased risk of developing BPD with a high degree of sensitivity.

Assistência e mortalidade neonatal no setor público do Município do Rio de Janeiro, Brasil: uma análise do período 1994/2000

This article analyzes an intervention by the Rio de Janeiro Municipal Health Department (SMS-RJ), Brazil, to reduce the neonatal mortality rate (strategies for organizing and upgrading neonatal care in the municipal system, including an increase in the number of neonatal high-risk beds). We studied the trends in neonatal mortality rate (1995/2000), neonatal care provided in different public hospitals (1994/2000), and admissions profile and mortality in four neonatal intensive care units (NICUs) under the SMS-RJ (2000). There was a concentration of high-risk neonatal care in the municipal hospitals (an increase from 28.0% of the care provided for live premature neonates in 1994 to 67.0% in 2000) and a reduction in the neonatal mortality rate in units under the Unified National Health System (from 19.9 deaths per thousand live births in 1996 to 15.5 in 2000). There was no reduction in the prematurity and low birth weight rates among mothers residing in the municipality of Rio de Janeiro. Analysis of admissions to the NICUs showed a high proportion of neonates born to mothers from municipalities outside Rio de Janeiro, while 14.0% of the mothers had not received prenatal care, and the mortality rate among newborns with birth weight < 1.500g was 32.0%.

Early postnatal growth in preterm infants and cord blood leptin

Although circulating leptin and insulin concentration is linked to intrauterine growth, fetal development and birth weight in full-term infants, there has been no enquiry into the influence of cord blood insulin and leptin for catch-up growth in preterm infants. The study evaluated the association of cord blood leptin with growth and weight gain of 96 premature babies during 6 months (corrected age). The temporal changes of anthropometric indexes over this period were calculated by repeated random regression (PROC MIXED) using SAS. Cord blood leptin was negatively associated with the rate of change in BMI (p=0.01) and length (p<0.001), from birth until 64 postnatal weeks. Insulin was positively associated with the change rate in BMI (p=0.03); however, this disappeared when adjusted for birth weight. For the first time, the association between lower leptin levels with greater catch up growth is shown for both BMI and length among preterm children. In conclusion, leptin levels at birth, but not insulin levels, predict growth rates.

Efficacy of new microprocessed phototherapy system with five high intensity light emitting diodes (Super LED)

Objectives: To evaluate the efficacy of a microprocessed phototherapy (PT) system with five high intensity light emitting diodes (Super LED) for the treatment of neonatal hyperbilirubinemia of premature infants.

Avaliação da eficácia clínica de uma nova modalidade de fototerapia utilizando diodos emissores de luz

OBJECTIVES: To evaluate the efficacy of a microprocessed phototherapy (PT) system with five high intensity light emitting diodes (Super LED) for the treatment of neonatal hyperbilirubinemia of premature infants. METHODS: Randomized clinical trial using Super LED phototherapy in the study group and twin halogen spotlight phototherapy in the control group. A stratified blocked randomization, based on birth weight, was performed. The duration of phototherapy and the rate of decrease of total serum bilirubin (TSB) concentration in the first 24 hours of treatment were the main outcome measures. RESULTS: We studied 88 infants, 44 in the Super LED group and 44 in the halogen spotlight PT group. The demographic characteristics of the patients in both groups were similar. Infants in the Super LED group had a similar mean initial serum bilirubin level (10.1±2.4 mg%) to those receiving halogen spotlight treatment (10.9±2.0 mg%). After 24 hours of treatment, the decrease in total serum bilirubin levels was significantly greater in the Super LED group (27.9 vs. 10.7%, p< 0.01) and duration of phototherapy was significantly shorter in this group (36.8 h vs. 63.8 h, p < 0.01). After 24 hours of treatment, a significantly greater number of patients receiving Super LED phototherapy had reached serum bilirubin concentrations low enough to allow withdrawal of treatment (23 vs. 10, p < 0.01). CONCLUSIONS: Our results demonstrate that the efficacy of Super LED phototherapy for treating hyperbilirubinemia in premature infants was significantly better than halogen phototherapy.

Análise situacional do atendimento ambulatorial prestado a recém-nascidos egressos das unidades de terapia intensiva neonatais no Estado do Rio de Janeiro

A diminuicao da mortalidade neonatal contribui para o aumento de criancas que necessitam de maior atencao em relacao a morbidades clinicas e a evolucao do desenvolvimento neuropsicomotor. O objetivo deste estudo foi discutir a situacao da assistencia as criancas egressas das Unidades de Terapia Intensiva Neonatais (UTIN) em cinco unidades em diferentes regioes do Estado do Rio de Janeiro; em nenhuma havia informacoes sobre o perfil dos egressos da UTIN. Evidenciou-se restricao ao acesso e baixa estruturacao da rede em relacao a assistencia prestada a esses bebes. Nao ha uniformidade no atendimento prestado, e ambulatorios especificos para essa populacao concentram-se na cidade do Rio de Janeiro. Constatou-se deficiencia de profissionais nas areas de reabilitacao - fisioterapia motora, terapia ocupacional, fonoaudiologia e psicologia -, e de especialistas para atendimento oftalmologico adequado e para a crianca portadora de deficiencia auditiva. Os autores discutem possiveis explicacoes para essa situacao, propondo a organizacao de um sistema de atendimento em graus de complexidade para poder viabilizar o acesso das criancas de risco a um atendimento diferenciado, importante para deteccao precoce de anormalidades do desenvolvimento.

Assessment of the energy content of human milk administered to very low birth weight infants

OBJECTIVE To evaluate and compare the energy content in fresh and processed human milk administered to very low birth weight infants born in the Institute Fernandes Figueira. METHODS Samples of 0.5 ml of fresh and processed human milk were evaluated as for the fat percentile and energy content, which was calculated by mathematical formulas. Four hundred and sixty two human milk samples were analyzed, 401 of processed human milk and 61 of fresh human milk. RESULTS The median and the standard deviation of the fat percentile checked was 2.9+/-1.2% in the processed samples and 8.9+/-4.6% in the fresh samples (p < 0.001). The median and the standard deviation of the energy content calculated was 53.6+/-7.2 kcal/100 ml in processed samples and 85.9+/-27.9 kcal/100 ml in fresh samples (p < 0.001). CONCLUSION The processed human milk samples had less energy content and less fat than fresh human milk samples suggesting that the complex processes of the human milk manipulation and administration can determine losses in energy content.

Ambiente domiciliar e alterações do desenvolvimento em crianças de comunidade da periferia de São Luís - MA

The main bonds of infants in early childhood are established in the home environment. The home is fundamental for providing stimuli that can influence the development of the child. A cross-sectional study was conducted in a low income community in the outskirts of the city of Sao Luis to analyze the provision of stimuli in the home environment of 2-year-old children and the potential association with retardation in child development. A random sample of 176 2-year-old children registered in community outpatient healthcare departments was assessed. Two validated instruments were used, namely the Home Observation for Measurement of the Environment (HOME) Inventory and the Gesell Measurement of Development Scale. Data were gathered in the homes. Logistic regressions were carried out taking the Home Inventory (low or average/high) and the Gesell Scale (suspicion of delay/normal) as outcome variables. Low family income, low maternal and paternal schooling, number of residents, number of children < 5 years old and small number of rooms in the house were considered risk factors for low Home scores, which were associated with the suspicion of development delay. The quality and quantity of environmental stimuli in the family context proved to be essential for the development of the children evaluated.