Susana Pissarra

Gastroschisis: preterm or term delivery?

AIM The main objective of this study was to evaluate the association between prematurity and the time to achieve full enteral feeding in newborns with gastroschisis. The second objective was to analyze the associations between length of hospital stay and time to achieve full enteral feeding with mode of delivery, birth weight and surgical procedure. METHODS The medical records of newborns with gastroschisis treated between 1997 and 2007 were reviewed. Two groups were considered: those delivered before 37 weeks (group A) and those delivered after 37 weeks (group B). The variables of gestational age, mode of delivery, birth weight, time to achieve full enteral feeding, length of hospital stay and surgical approach were analyzed and compared between groups. RESULTS Forty-one patients were studied. In Group A, there were 14 patients with a mean birth weight (BW) of 2300 g (range=1680–3000) and a mean gestational age (GA) of 36 weeks (range=34–36). In group B, there were 24 patients with a mean BW of 2700 g (range=1500–3550) and a mean GA of 38 weeks (range=37–39). The mean time to achieve full enteral feeding was 30.1±6.7 days in group A and 17.0±2.5 days in group B (p=0.09) with an OR of 0.82 and a 95% CI of 0.20–3.23 after adjustment for sepsis and BW. No statistical difference was found between low BW (<2500 g), mode of delivery and number of days to achieve full enteral feeding (p=0.34 and p=0.13, respectively). Patients with BW over 2500 g had fewer days in the hospital (22.9±3.1 vs. 35.7±5.7 days; p=0.06). CONCLUSION The results of this study do not support the idea of anticipating the delivery of fetuses with gastroschisis in order to achieve full enteral feeding earlier.

Respiratory outcomes and atopy in school-age children who were preterm at birth, with and without bronchopulmonary dysplasia

OBJECTIVE: To assess pulmonary function and the prevalence of atopy in school-age children who were very low birth weight as infants and to compare those who had bronchopulmonary dysplasia to those who did not. METHOD: We studied 85 (39 male and 46 female) at a mean age of 84 (range, 62 to 107) months who were very low birth weight infants. Bronchopulmonary dysplasia was defined as oxygen dependency at 36 weeks gestational age. We excluded 8 patients (4 for cerebral palsy and 4 for no collaboration). Detailed perinatal and clinical data were collected. Lung function was evaluated using conventional spirometry. Atopy (assessed by the allergy skin-prick test) was considered when at least one positive skin test occurred in a panel of the most common environmental allergens in the local region. Comparisons between the bronchopulmonary dysplasia and no bronchopulmonary dysplasia groups were performed using the Mann-Whitney, χ2 and Fishers exact tests. RESULTS: We compared the bronchopulmonary dysplasia (n = 13) and no bronchopulmonary dysplasia (n = 64) groups. Atopy was observed in 4 (30.8%) of the bronchopulmonary dysplasia patients and in 17 (26.6%) of the no bronchopulmonary dysplasia patients (p = 0.742). Two (15.4%) patients with bronchopulmonary dysplasia had a family history of atopy vs. 17 (26.6%) in the no bronchopulmonary dysplasia group (p = 0.5). Lung function tests showed airway obstruction in 2 (15.4%) of the bronchopulmonary dysplasia patients and in 10 (15.6%) of the no bronchopulmonary dysplasia patients (p = 1.0). Four (33.3%) of the bronchopulmonary dysplasia patients had small airway obstruction vs. 14 (22.2%) of the no bronchopulmonary dysplasia patients (p = 0.466). CONCLUSION: Our data showed no significant differences in lung function between bronchopulmonary dysplasia and no bronchopulmonary dysplasia patients at school age and no evidence of an association between atopy and bronchopulmonary dysplasia.

Severe pertussis in newborns and young vulnerable infants.

A retrospective chart review of 18 nonvaccinated newborns and infants admitted to 6 intensive care units in the north of Portugal between 2007 and 2012 revealed a high rate of admissions in 2012 along with significant rates of severe pulmonary hypertension and mortality. Hyperleukocytosis was significantly associated with a more severe clinical picture and mortality.

Derrames pleurais parapneumónicos em pediatria: Experiência num hospital central universitário

Resumo Introducao: Os derrames pleurais podem complicar as pneumonias na populacao pediatrica. Assumem especial importância pelas implicacoes na duracao do internamento, geralmente prolongado, e pela morbilidade associada. Objectivos: Caracterizar uma populacao de doentes com pneumonia complicada de derrame; determinar os possiveis factores de prognostico a partir de dados clinicos, radiologicos e analiticos na admissao; e avaliar a influencia das intervencoes terapeuticas na evolucao da doenca. Metodos: Revisao casuistica dos doentes com idade inferior a 18 anos e derrame pleural parapneu monico, internados de Julho de 1997 a Junho de 2004 (7 anos). Resultados: Foram estudados 118 casos, 60% do sexo masculino, com idade media 7 anos. A incidencia de derrame pleural aumentou ao longo do periodo do estudo. Verificou-se maior incidencia de casos no Outono e no Inverno. Na admissao, 60% dos doentes apresentavam sinais de dificuldade respiratoria e 39% dor toracica. Em 40% dos doentes foram detectados septos pleurais na admissao, o que se associou a maior duracao de internamento e de antibioticoterapia e mais frequente necessidade de cirurgia. Em 72% dos doentes foi efectuada toracocentese (pH medio: 7,24). Em 17% foi possivel isolar o agente: Streptococcus pneumoniae (cinco), Staphylococcus aureus (quatro) e Streptococcus pyogenes (quatro). Foram submetidos a drenagem pleural 52% e necessitaram de cirurgia 18%. A mediana da duracao de internamento foi de 15 dias e a media de 16,4 dias (2 a 51). Discussao : Associam-se a pior prognostico a presenca de: sinais de dificuldade respiratoria; septos; empiema; baixo valor no liquido pleural de pH, glicose ou proteinas; desidrogenase lactica elevada no liquido pleural e proteina C-reactiva sanguinea aumentada. A drenagem pleural e/ou cirurgia mais precoces provavelmente diminuem o tempo de doenca e de internamento. Conclusao : Os derrames parapneumonicos complicados sao tratados com exito em centros de referencia com experiencia nos diferentes tipos de intervencao que poderao ser necessarios. Rev Port Pneumol 2009; XV (2): 241-259

Pediatric parapneumonic pleural effusions: Experience in a university central hospital

INTRODUCTION Pleural effusions can complicate pneumonias in children and adolescents and are usually associated with a long hospital stay and increased morbidity. AIMS To characterise a population of patients with parapneumonic pleural effusion and to establish possible prognostic factors on admission based on clinical, imaging and analytical data. To correlate treatment options with the outcome. METHODS Case review of patients under 18 years old with parapneumonic pleural effusion, admitted between July 1997 - June 2004 (7 years). RESULTS 118 patients were included, 60% male, with mean age 7 years. The incidence of pleural effusion increased throughout the period of the study. The admissions occurred predominantly in autumn and winter. On admission 60% of patients had respiratory distress and 39% chest pain. In 40% loculations were found on admission and were associated with longer hospital stay, longer course of antibiotic therapy and more frequent need for surgery. Thoracentesis was performed in 72% of patients (mean pH pleural fluid 7.24). The aetiologic agent was identified in 17% of cases: Streptococcus pneumoniae (five), Staphylococcus aureus (four) and Streptococcus pyogenes (four). In our study, 52% of patients underwent pleural drainage and 18% surgery. Median length of hospital stay was 15 days with mean 16.4 days (2 - 51). DISCUSSION Factors associated with worse prognosis were respiratory distress, loculations, empyema, low pH in pleural fluid, glucose or proteins in pleural fluid, high lactic dehydrogenase level in pleural fluid and high serum C-reactive protein. Pleural drainage and/or surgery can shorten hospital stay and improve outcome. CONCLUSION Complicated parapneumonic pleural effusions are managed successfully in centres with experience in the different types of procedure that might be necessary.

Pneumonias necrosantes em crianças previamente saudáveis

Background: Necrotizing pneumonia used to be rare in the postantibiotic era. Its incidence appears to be rising in our hospital although there is no clear explanation for that. Patients and Methods: Retrospective analysis of the clinical presentation and evolution of necrotizing pneumonia in previously healthy children admitted at our hospital during two years. Results: Among 392 admissions for pneumonia in the study period, 15 patients (3,4–2, 4 years; 9 boys) had evidence of lung necrosis on thoracic computed tomography. Despite appropriate antibiotic therapy, fever persisted for 13–7 days. Ten patients deve loped pneumatoceles and three lung abscesses. Twelve patients had parapneumonic pleural effusions (4 empyemas), nine of whom need closed chest drainage. An agent was isolated from pleural fluid or blood culture in 3 children (2 S. aureus and 1 Enterobacter cloacae); in two further, bacteria were seen on Gram-stained pleural fluid. Two patients had an immunodefficiency state previously unknown (IgA deficiency and hiper-IgE syndrome). Thoracotomy were performed in 9 patients: 2 pleural debridement, 6 decortication, 1 ressection of a giant pneumatocele, 1 abscess drainage and 2 lobectomies. The mean length of hospital stay was 30–11 days and there were no deaths. During the follow-up period (18–9 months) 3 patients required surgery for recurrent infection or fibrothorax. In the remaining, asymptomatic children, 2 have pleural ticknening, 1 a residual pneumatocele and 1 bronchiectasis. Conclusions: The results of this study do not explain the recent increase of the suppurative complications of community acquired-pneumonia in children. The low rate of infectious agent isolation was probably related with frequent previous antibiotic use. Although the final outcome was generally good, the clinical course was very prolonged and surgery was frequently needed. In order to clarify the reason for the increase of this kind of pneumonia complications a prospective multicenter study is warranted. REV PORT PNEUMOL 2002; VIII (1):

Experience with oseltamivir in term and preterm newborns

Since April 2009 in Mexico, a novel influenza virus A (H1N1) o f swine origin has emerged as a cause of disease in humans, and has rapidly spread worldwide, declared a pandemic on June 11. Oseltamivir is the only anti-viral agent avail able for influenza virus in young children, with no proven efficacy and safety in infants and newborns. The authors report their experience with oseltamivir use for term and preterm neonates, during an outbreak of influenza virus A (H1N1) in a level II I neonatal intensive care unit, from November 28 to December 7, 2009. Fifteen hospitalized high risk neonates of non-vaccinated mothers, 6 males and 9 females; gestational age 34 weeks (24-40 weeks); birth weight 1873 g (530-3310 g); 12 became infected with influenza virus A (H1N1); two were (17%) symptomatic. In fection control measures were adopted and oseltamivir was administered after parental consent; for prophylactic use in three (3 mg/kg once a day, 10 days); and therapeutic use in 12 (3 mg/kg twice a day, 5 days). No fatal cases occurred. No adverse effects were reported. The outcome was favorable and the outbreak controlled. The majority of patients infected wit h influenza virus A (H1N1) were asymptomatic, and no fatal cas es were documented. Oseltamivir was not associated with evident short-term adverse effects, and it may have helped to control the epidemic and lessened the severity of illness in affected in fants.

Infecção por Bordetella pertussis com hipertensão pulmonar grave num recém-nascido com boa evolução clínica - Caso clínico

Resumo Apesar da ampla cobertura vacinal, a infeccao por Bordetella pertussis esta longe de estar controlada. Os recem-nascidos e lactentes ainda sem imunizacao completa e filhos de maes com baixos titulos de anticorpos para a Bordetella pertussis sao altamente susceptiveis a infeccao e tem maior risco de doenca grave e morte. A infeccao por Bordetella pertussis associada a hipertensao pulmonar no recem-nascido e frequentemente fatal. Os autores descrevem um caso clinico de doenca grave num recem-nascido com insuficiencia respiratoria aguda e hipertensao pulmonar grave, tratado com sucesso com sildenafil e oxido nitrico inalado. Rev Port Pneumol 2008; XIV (5): 687-692

Pertussis with severe pulmonary hypertension in a newborn with good outcome – case report

In spite of the availability and widespread use of vaccines, pertussis is far from controlled. Newborns and infants too young to be fully vaccinated, born from mothers with low antibody titers to Bordetella pertussis, are highly susceptible to infection and at risk of severe disease and death. Pertussis associated with pulmonary hypertension in the newborn is often fatal. The authors report a clinical case of severe pertussis -induced respiratory failure associated to severe pulmonary hypertension in a neonate successfully treated with sildenafil and inhaled nitric oxide.

Complications of central lines in neonates admitted to a level III Neonatal Intensive Care Unit

Abstract Objective: To investigate the incidence and risk factors for central line related complications in neonates. Methods: A retrospective cohort study of infants who underwent central line (CL) placement, from 1 July 2014 to 31 June 2016, was conducted in Neonatal Intensive Care Unit of Centro Hospitalar de São João. Infants hospitalized more than 2 d and CLs placed for more than 24 h were included. Patients’ demographic characteristics, hospital data, and information on CLs were collected. Indwelling complications were compared between infant groups and types of CL inserted. Results: A total of 400 CLs were inserted in 240 infants with a CL utilization ratio of 0.64. Overall CL complication rate was 29.6 per 1000 catheter days. Of all complications, central line-associated bloodstream infection had the highest incidence (12.4 per 1000 catheter days). Infiltration was the most reported mechanical complication. Non-umbilical catheters showed a significantly higher incidence of complications than umbilical ones. Low gestational age, low birth weight, prolonged catheter stay, long duration of total parenteral nutrition, and peripherally inserted central catheter placement were associated with a higher risk of indwelling complication. Conclusions: The implementation of measures to prevent catheter-related complications must be a priority in care of vulnerable neonates.