Sérgio Tadeu Martins Marba

Perinatal factors associated with early deaths of preterm infants born in Brazilian Network on Neonatal Research centers

OBJECTIVE To evaluate perinatal factors associated with early neonatal death in preterm infants with birth weights (BW) of 400-1,500 g. METHODS A multicenter prospective cohort study of all infants with BW of 400-1,500 g and 23-33 weeks of gestational age (GA), without malformations, who were born alive at eight public university tertiary hospitals in Brazil between June of 2004 and May of 2005. Infants who died within their first 6 days of life were compared with those who did not regarding maternal and neonatal characteristics and morbidity during the first 72 hours of life. Variables associated with the early deaths were identified by stepwise logistic regression. RESULTS A total of 579 live births met the inclusion criteria. Early deaths occurred in 92 (16%) cases, varying between centers from 5 to 31%, and these differences persisted after controlling for newborn illness severity and mortality risk score (SNAPPE-II). According to the multivariate analysis, the following factors were associated with early intrahospital neonatal deaths: gestational age of 23-27 weeks (odds ratio - OR = 5.0; 95%CI 2.7-9.4), absence of maternal hypertension (OR = 1.9; 95%CI 1.0-3.7), 5th minute Apgar 0-6 (OR = 2.8; 95%CI 1.4-5.4), presence of respiratory distress syndrome (OR = 3.1; 95%CI 1.4-6.6), and network center of birth. CONCLUSION Important perinatal factors that are associated with early neonatal deaths in very low birth weight preterm infants can be modified by interventions such as improving fetal vitality at birth and reducing the incidence and severity of respiratory distress syndrome. The heterogeneity of early neonatal rates across the different centers studied indicates that best clinical practices should be identified and disseminated throughout the country.

Red Blood Cell Transfusions are Independently Associated with Intra-Hospital Mortality in Very Low Birth Weight Preterm Infants

OBJECTIVE To test the hypothesis that red blood cell (RBC) transfusions in preterm infants are associated with increased intra-hospital mortality. STUDY DESIGN Variables associated with death were studied with Cox regression analysis in a prospective cohort of preterm infants with birth weight <1500 g in the Brazilian Network on Neonatal Research. Intra-hospital death and death after 28 days of life were analyzed as dependent variables. Independent variables were infant demographic and clinical characteristics and RBC transfusions. RESULTS Of 1077 infants, 574 (53.3%) received at least one RBC transfusion during the hospital stay. The mean number of transfusions per infant was 3.3 ± 3.4, with 2.1 ± 2.1 in the first 28 days of life. Intra-hospital death occurred in 299 neonates (27.8%), and 60 infants (5.6%) died after 28 days of life. After adjusting for confounders, the relative risk of death during hospital stay was 1.49 in infants who received at least one RBC transfusion in the first 28 days of life, compared with infants who did not receive a transfusion. The risk of death after 28 days of life was 1.89 times higher in infants who received more than two RBC transfusions during their hospital stay, compared with infants who received one or two transfusions. CONCLUSION Transfusion was associated with increased death, and transfusion guidelines should consider risks and benefits of transfusion.

The frequency of pharmacological pain relief in university neonatal intensive care units

OBJECTIVE To evaluate the use of drugs to relieve procedural pain of newborn infants hospitalized in Neonatal Intensive Care Units (NICU) of university hospitals. METHODS A prospective cohort study of all newborn infants hospitalized in four NICU during October 2001. The following data were collected: demographic data of patients; clinical morbidity; number of potentially painful procedures and frequency of analgesic administration. Multiple linear regression analysis was performed to study the factors associated with the use of analgesia in this cohort of patients with SPSS 8.0. RESULTS Ninety-one newborn infants were admitted to the NICU during the study period (1,025 patient-days). Only 25% of the 1,025 patient-days received any systemic analgesia. No specific drug was administered to relieve acute pain during any of the following painful procedures: arterial, venous, capillary and lumbar punctures and tracheal intubation. For chest tube insertion, 100% of newborn infants received specific analgesia. For the insertion of central catheters, 8% of the newborn infants received analgesia. Only nine of the 17 newborn infants that underwent surgical procedures received any dose of analgesics during the postoperative period. Regarding patients who received analgesia, the drug of choice was fentanyl in 93%. The presence of mechanical ventilation increased 6.9 times the chance of the newborn receiving analgesia and the presence of a chest tube increased this chance by 5.0 times. CONCLUSION It is necessary to train health professionals in order to shorten the lag between scientific knowledge regarding newborn pain and clinical practice.

Hearing screening in a neonatal intensive care unit

OBJECTIVE Investigate the prevalence of hearing impairment in newborns hospitalized at the Intensive and Intermediate Care Unit at the Womens Comprehensive Health Center Neonatology Service (UNICAMP) and associated risk factors. METHODS 979 newborn babies were assessed between January 2000 and January 2003, through automated auditory brainstem response (AABR) (ALGO 2e color screener). The result was considered normal when the newborn showed response to a 35dBNA signal bilaterally. The prevalence of AABR impairment and the odds ratio were analyzed with a 95% confidence interval using bivariate analysis. To identify the independent risk factors for hearing alterations, multivariate analyses were used with logistic regression. RESULTS The prevalence of AABR impairment was 10.2%, of which 5.3% was unilateral and 4.9% bilateral. From the multivariate analyses, the following observations were made: family history of congenital hearing loss (OR = 5.192; p = 0.016), craniofacial deformity (OR = 5.530; p < 0.001), genetic syndromes associated with hearing loss (OR = 4.212; p < 0.001), weight below 1,000 g (OR = 3.230; p < 0.001), asphyxia (OR = 3.532; p < 0.001), hyperbilirubinemia (OR = 4.099; p = 0.002) and use of mechanical ventilation (OR = 1.826; p < 0.031) were the indicators that best characterized the group at risk for hearing impairment. CONCLUSIONS The prevalence of hearing impairment using AABR is high. Therefore, it is essential for all newborns who present isolated or associated risk factors to undergo hearing screening in situations in which it is not possible to have universal hearing screening.

Triagem auditiva em recém-nascidos internados em UTI neonatal

OBJETIVO: Avaliar a prevalencia de alteracoes auditivas em recem-nascidos internados na unidade de terapia intensiva e cuidados intermediarios do servico de neonatologia do Centro de Assistencia Integral a Saude da Mulher, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas, e analisar os fatores de risco associados. METODOS: Foram avaliados 979 recem-nascidos no periodo de janeiro de 2000 a janeiro de 2003, utilizando-se a audiometria automatica de tronco encefalico (AABR), com aparelho ALGO-2e color - Natus. O resultado foi considerado normal quando o recem-nascido apresentou resposta para 35 dBNA bilateralmente. Foi analisada a prevalencia de AABR alterada e odds ratio com intervalo de confianca de 95% em analise bivariada. Para identificar os fatores de risco independentes para AABR alterada, foi feita analise multipla com modelo de regressao logistica. RESULTADOS: A prevalencia de alteracao no AABR foi de 10,2%, sendo 5,3% unilateral e 4,9% bilateral. Pela analise multivariada, observamos que: antecedente familiar (OR = 5,192; p = 0,016), malformacao craniofacial (OR = 5,530; p < 0,001), sindrome genetica (OR = 4,212; p < 0,001), peso menor que 1.000 g (OR = 3,230; p < 0,001), asfixia (OR = 3,532; p < 0,001), hiperbilirrubinemia (OR = 4,099; p = 0,002) e uso de ventilacao mecânica (OR = 1,826; p < 0,031) foram os indicadores que melhor caracterizaram um grupo de risco para perda auditiva. CONCLUSOES: A prevalencia de alteracao auditiva pela AABR e elevada. E essencial que todos os recem-nascidos que apresentam fatores de risco associados ou isolados passem por avaliacao auditiva nas situacoes em que nao seja possivel ter a triagem universal.

Accuracy of white blood cell count, C-reactive protein, interleukin-6 and tumor necrosis factor alpha for diagnosing late neonatal sepsis

OBJECTIVE To evaluate the diagnostic value for late neonatal sepsis of white blood cell count (WBC) and assays for C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha), in isolation and in conjunction. METHODS This was a diagnostic test validation study. Chemiluminescence was used to assay CRP, IL-6 and TNF-alpha at the time of clinical suspicion and again after 24 and 48 hours, whereas the WBC was performed only once, at the time of suspicion. Patients were classified into three groups based on clinical progress and culture results: confirmed sepsis (CS), probable sepsis (PS), and not infected (NI). Statistical analysis was performed using the Wilcoxon and chi-square tests and Friedman analysis of variance; cutoffs were defined by plotting receiver operator characteristic curves. RESULTS The total study sample comprised 82 children, 42 of whom were classed as CS, 16 as PS and 24 as NI. At all three test times, the medians for CRP and IL-6 were significantly more elevated in the CS and PS groups, while the medians for TNF-alpha were abnormal only in the CS group. The CRP test had elevated indices of diagnostic utility at all three test times, better accuracy than the WBC and similar accuracy to the first IL-6 and TNF-alpha assays. There was no statistical difference between the cytokines, nor between them and the WBC. Combining tests did not increase diagnostic power, with the exception of the combination of WBC with CRP2 and when the sequential CRP assays were combined. CONCLUSIONS Both CRP and WBC were useful for the diagnosis of late neonatal sepsis and comparable with IL-6 and TNF-alpha. Accuracy increased when CRP and WBC were combined and when sequential CRP assay results were used.

Detecção de perdas auditivas em neonatos de um hospital público

ABSTRACT Purpose: To analyze the results obtained in a neonatal hearing screening program that included two procedures, Transient Otoacoustic Emissions and Automated Brainstem Evoked Response Audiometry, in healthy neonates, born in a public hospital, regarding the variables gender (male or female) and ear that failed (left, right or bilateral). Methods: Neonates born in a public maternity hospi-eonates born in a public maternity hospi-born in a public maternity hospi-tal, who stayed in shared rooms and attended hearing screening after discharge were included in the study. The screening included the Transient Otoacoustic Emissions with pass/fail criterium , and a retest for neonates who failed the first test with the Automated Brainstem Evoked Response Audiometry. Results: A total of 5106 neonates were screened, 51.3% male and 48.7% female. Among them, 628 (12.3%) neonates failed the test, 368 (58.6%) male and 260 (41.4%) female. They were referred to the Brainstem Evoked Response Audiometry, and 223 (35.3%) came to the test. From these subjects, 199 (89.2%) passed and 24 (10.8%) failed the test: 17 (70.9%) male and seven (29.1%) female. Statistically significant difference was found between gender and fail in the Transient Otoacoustic Emissions. Ten percent of the neonates failed both screening procedures.

Brazilian multicenter study on prevalence of preterm birth and associated factors

BackgroundThe occurrence of preterm birth remains a complex public health condition. It is considered the main cause of neonatal morbidity and mortality, resulting in a high likelihood of sequelae in surviving children. With variable incidence in several countries, it has grown markedly in the last decades. In Brazil, however, there are still difficulties to estimate its real occurrence. Therefore, it is essential to establish the prevalence and causes of this condition in order to propose prevention actions. This study intend to collect information from hospitals nationwide on the prevalence of preterm births, their associated socioeconomic and environmental factors, diagnostic and treatment methods resulting from causes such as spontaneous preterm labor, prelabor rupture of membranes, and therapeutic preterm birth, as well as neonatal results.Methods/DesignThis proposal is a multicenter cross-sectional study plus a nested case-control study, to be implemented in 27 reference obstetric centers in several regions of Brazil (North: 1; Northeast: 10; Central-west: 1; Southeast: 13; South: 2). For the cross sectional component, the participating centers should perform, during a period of six months, a prospective surveillance of all patients hospitalized to give birth, in order to identify preterm birth cases and their main causes. In the first three months of the study, an analysis of the factors associated with preterm birth will also be carried out, comparing women who have preterm birth with those who deliver at term. For the prevalence study, 37,000 births will be evaluated (at term and preterm), corresponding to approximately half the deliveries of all participating centers in 12 months. For the case-control study component, the estimated sample size is 1,055 women in each group (cases and controls). The total number of preterm births estimated to be followed in both components of the study is around 3,600. Data will be collected through a questionnaire all patients will answer after delivery. The data will then be encoded in an electronic form and sent online by internet to a central database. The data analysis will be carried out by subgroups according to gestational age at preterm birth, its probable causes, therapeutic management, and neonatal outcomes. Then, the respective rates, ratios and relative risks will be estimated for the possible predictors.DiscussionThese findings will provide information on preterm births in Brazil and their main social and biological risk factors, supporting health policies and the implementation of clinical trials on preterm birth prevention and treatment strategies, a condition with many physical and emotional consequences to children and their families.

Acurácia diagnóstica do leucograma, proteína C-reativa, interleucina-6 e fator de necrose tumoral-alfa na sepse neonatal tardia

OBJETIVO: Avaliar o valor do leucograma, proteina C-reativa (PCR), interleucina-6 (IL-6) e do fator de necrose tumoral-alfa (TNF-α), isoladamente e em conjunto, na deteccao da sepse neonatal tardia. METODOS: Estudo de validacao diagnostica. A PCR, IL-6 e TNF-α foram dosados por quimioluminescencia a suspeita clinica, 24 e 48 horas depois, e o leucograma unicamente a suspeita. De acordo com evolucao clinica e resultados de culturas, tres grupos foram definidos: sepse comprovada (SC), sepse provavel (SP) e nao infectados (NI). Os testes estatisticos utilizados foram os de Wilcoxon, qui-quadrado e analise de variância de Friedman e os limites de corte foram obtidos pela construcao da curva ROC. RESULTADOS: Estudaram-se 82 criancas, sendo 42 no grupo SC, 16 no SP e 24 NI. Nos tres momentos, as medianas da PCR e da IL-6 mostraram-se significativamente mais elevadas nos grupos SC e SP, e as do TNF-α alteraram-se apenas no grupo SC. Os indices diagnosticos da PCR foram elevados nos tres momentos e com acuracia superior a do leucograma e semelhante a da IL-6 e a do TNF-α em suas primeiras medidas. Entre as citocinas, nao houve diferenca estatistica entre elas, nem em relacao ao leucograma. A associacao dos testes nao aumentou a capacidade diagnostica, exceto na combinacao entre leucograma e PCR2 e na dosagem seriada de PCR. CONCLUSOES: A PCR e o leucograma mostram-se uteis no diagnostico de sepse neonatal tardia e comparaveis a IL-6 e ao TNF-α. A acuracia aumentou com a associacao PCR-leucograma e a dosagem seriada da PCR.

A prospective study on the prevalence and risk factors for neonatal thrombocytopenia and platelet alloimmunization among 9332 unselected Brazilian newborns

BACKGROUND: Neonatal thrombocytopenia (NT) occurs in 0.5 to 0.9% of unselected Caucasian newborns. However, the prevalence of this complication in other populations is unknown. In this study the prevalence/causes of NT was determined in Brazilian newborns, a population characterized by admixture among Indigenous, Africans, and Caucasians.