Fluid and Electrolyte Balance During the First Week of Life and Risk of Bronchopulmonary Dysplasia in the Preterm Neonate

BACKGROUND: Early fluid and electrolyte imbalances may be associated with an increased risk of bronchopulmonary dysplasia. OBJECTIVE: We sought to establish an association between fluid and electrolyte balance in the first week of life and the risk of bronchopulmonary dysplasia. METHODS: Clinical charts of 205 neonates <32 weeks gestational age and/or <1,250 g birth weight (admitted to our NICU between 1997 and 2008) were analyzed. Clinical features, fluid and electrolyte balance were analyzed for the first 7 days of life using multivariate models of generalized estimation equations. A p value <0.05 was considered significant in all of the hypothesis tests. RESULTS: The prevalence of bronchopulmonary dysplasia was 22%. Lower gestational age and birth weight, male gender, less frequent use of antenatal steroids, respiratory distress syndrome, use of surfactant, patent ductus arteriosus, duration of invasive ventilation and NICU stay were significantly associated with bronchopulmonary dysplasia. The variation in serum values of potassium, phosphorus and creatinine during the first week of life also revealed an association with bronchopulmonary dysplasia. Higher mean plasma calcium values were associated with spontaneous closure of the patent ductus arteriosus. The use of indomethacin to induce patent ductus arteriosus closure was significantly higher in bronchopulmonary dysplasia patients. CONCLUSIONS: Differences in renal function and tubular handling of potassium and phosphorus are present during the first week of life among preterm neonates who will develop bronchopulmonary dysplasia. The higher rate of patent ductus arteriosus and indomethacin use may influence these differences. Serum levels of calcium also appear to play a role in spontaneous ductus arteriosus closure

Persistent Pulmonary Hypertension of Non Cardiac Cause in a Neonatal Intensive Care Unit

Parenchymal lung diseases are the main cause of persistent pulmonary hypertension of the newborn (PPHN). We aimed to assess the non cardiac conditions associated to PPHN in the newborn and the survival rate over the last 15 years, at our center. A retrospective chart review of the neonates admitted for PPHN from 1996 to 2010 was performed. New therapies were introduced in 2003, and the survival rates between two periods (1996–2002 and 2003–2010) were compared. Out of 6750 newborns, 78 (1.1%) had the diagnosis of PPHN of non cardiac cause. The most prevalent causes were associated to pulmonary hypoplasia (30.7%), infection (24.3%), and aspiration syndromes (15.3%). Many other causes were identified in 33.3%. The overall survival rate was 68%. There was a significant difference on survival rates between the two periods (1996–2002 = 63.8% and 2003–2010 = 71.4%, P = 0.04). Our study showed a myriad of non cardiac aetiologies for PPHN of the newborn, most of them related to lung disease or lung hypoplasia. We observed an improvement in survival rate since 2003, which was associated to the use of new therapies

A literature review and clinical approach

Bronchopulmonary dysplasia (BPD) remains the most common severe complication of preterm birth, and nutrition plays a crucial role in lung growth and repair. A practical nutritional approach for infants at risk of BPD or with established BPD is provided based on a comprehensive literature review. Ideally, infants with BPD should receive a fluid intake of not more than 135‒150 mL/kg/day and an energy intake of 120‒150 kcal/kg/day. Providing high energy in low volume remains a challenge and is the main cause of growth restriction in these infants. They need a nutritional strategy that encompasses early aggressive parenteral nutrition and the initiation of concentrated feedings of energy and nutrients. The order of priority is fortified mother’s own milk, followed by fortified donor milk and preterm enriched formulas. Functional nutrient supplements with a potential protective role against BPD are revisited, despite the limited evidence of their efficacy. Specialized nutritional strategies may be necessary to overcome difficulties common in BPD infants, such as gastroesophageal reflux and poorly coordinated feeding. Planning nutrition support after discharge requires a multidisciplinary approach to deal with multiple potential problems. Regular monitoring based on anthropometry and biochemical markers is needed to guide the nutritional intervention.publishersversionpublishe

Follow-up of the survivors of congenital diaphragmatic hernia

INTRODUCTION: Survivors of congenital diaphragmatic hernia have increased with the introduction of new treatment modalities and have been reported to experience ongoing medical morbidity until adulthood. AIM: To describe the long-term functional impact of congenital diaphragmatic repair on the survivors of a single institution cohort of newborns over a 14-year period. METHODS: The follow up medical charts of 39 congenital diaphragmatic hernia survivors treated at a tertiary neonatal intensive care unit, from January 1997 to December 2010, were analyzed. RESULTS: The median age at follow up was 70 (4-162) months. Gastrointestinal sequelae were the most common with 12 (30.7%) patients affected by failure to thrive. Chronic lung disease occurred in 5 (12.8%) patients, neurodevelopmental delay in 5 (12.8%), musculoskeletal sequelae in 6 (15.3%), recurrence of hernia in 4 (10.2%) and 2 (7.6%) were deceased. CONCLUSION: Congenital diaphragmatic hernia survivors are a group of patients that requires long term periodic follow up in a multidisciplinary setting to provide adequate support and improve their quality of life

Avaliação de novas terapêuticas por via inalatória na prevenção da displasia broncopulmonar

Dissertação de Doutoramento em Medicina, área de especialização em Pediatria, apresentada à Faculdade de Medicina da Universidade do Port

End of life in the neonatal intensive care unit

PURPOSE: Death at the beginning of life is tragic but not uncommon in neonatal intensive care units. In Portugal, few studies have examined the circumstances surrounding the final moments of neonates. We evaluated the care given to neonates and their families in terminal situations and the changes that had occurred one decade later. DESIGN AND METHODS: We analyzed 256 charts in a retrospective chart review of neonatal deaths between two periods (1992-1995 and 2002-2005) in a level III neonatal intensive care unit. RESULTS: Our results show differences in the care of dying infants between the two periods. The analysis of the 2002-2005 cohort four years revealed more withholding and withdrawing of therapeutic activities and more effective pain and distress relief; however, on the final day of life, 95.7% of the infants received invasive ventilatory support, 76.3% received antibiotics, 58.1% received inotropics, and 25.8% received no opioid or sedative administration. The 2002-2005 cohort had more spiritual advisor solicitation, a higher number of relatives with permission to freely visit and more clinical meetings with neonatologists. Interventions by parents, healthcare providers and ethics committees during decision-making were not documented in any of the charts. Only eight written orders regarding therapeutic limitations and the adoption of palliative care were documented; seven (87.5%) were from the 2002-2005 cohort. Parental presence during death was more frequent in the latter four years (2002-2005 cohort), but only 21.5% of the parents wanted to be present at that moment. CONCLUSION: Despite an increase in the withholding and withdrawing of therapeutic activities and improvements in pain management and family support, many neonates still receive curative and aggressive practices at the end of life

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, x2 and Fisher's 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

Saúde Oral em Pediatria

Introdução. A saúde oral é parte integrante da saúde geral emantê-la é uma prioridade. O conhecimento da prevalênciadas patologias orais que atingem a população desde a infânciaà juventude, e a falta de medidas de prevenção simples, acessíveise eficazes, têm conduzido ao reforço da importânciadada à saúde oral nomeadamente à cárie dentária e às anomaliasde oclusão. Cuidados específicos e diferenciados no tratamentoe na prevenção na assistência à criança obrigam àestreita colaboração entre o pediatra e o odontopediatra, bemcomo à educação dos pais.Objectivo. Neste artigo os autores abordam os problemasdentários mais frequentes em Odontopediatria, com especialdestaque para os aspectos de interesse para o pediatra, obstetrae médico de medicina geral e familiar.Material e Métodos. Pesquisa bibliográfica baseada em artigospublicados e livros de texto de odontopediatria e pediatriados últimos anos, na tentativa de reunir o máximo de informaçãocientífica actual. Foram seleccionados todos os trabalhosque incluíssem como palavras-chave os termos: pediatria,criança, saúde oral, doenças orais, prevenção. Destes escolhemosos mais representativos.Conclusão.A Medicina Dentária para a criança pode resumir-seem: "Educar para manter sempre saúde oral em todos os gruposetários, pois as crianças de hoje serão os adultos saudáveisde amanhã". A prevenção é a filosofia da boa saúde no futuro.Palavras-chave: pediatria, criança, saúde oral, doenças orais,prevençãoIntroduction. The oral health is integrant part of the generalhealth and to keep it is a priority. The knowledge of the pre -valence of the oral pathologies that reach the population sinceinfancy to youth, and the lack of measures, accessible and efficientprevention, has lead to the reinforcement of the importancegiven to the oral health nominated to the dental cariesand the anomalies of occlusion. Specific and differentiatedcare in the treatment and the prevention in the assistance thechild compel to the narrow contribution between pae diatricand odontopaediatric, as well as the education of the parents.Aim. In this article the authors approach the more frequentdental problems in Odontopaediatrics, with special prominen -ce for the aspects of interest for paediatric, obstetrician andgeneral and familiar practitioner.Material and Methods. Bibliographic research based inpublis hed articles and books of odontopaediatric text and paediatricsin the last years, in the attempt to congregate the ma -xi mum of current scientific information. The works had beenselected all that included as word-key the terms: paediatrics,child, oral health, verbal illnesses and prevention. Of these wechoose the most representative.Conclusion. The Dental Medicine for the child can be summarizedin: "To educate to always keep oral health in allgroups, therefore the children of today will be the healthfuladults of tomorrow". The prevention is the philosophy of thegood health in the future

Car Seat Challenge Test in the Neonatal Intensive Care Unit

Background: In Portugal, there is a Guideline of the Directorate General of Health that requires that newborns with hospital discharge should be transported home in a proper and safe restraint system, aligned with AAP policy statements. In the Neonatal Intensive Care Unit (NICU) of Centro Hospitalar Universitário de S. João (Porto, Portugal), the Car Seat Challenge Test has been carried out since 2005, and there is not any study about its safety. Objective: This study aims to report the responses of preterm infants discharged home in 2015 and to develop a standardized procedure for its performance. Methods: This is a descriptive, retrospective, observational, non-experimental study. Data was collected from the NICU nursing records with a form designed for this purpose. Study variables were: gender, gestational age, birth weight, and comorbidities. Saturation of oxygen in arterial blood (SpO2) and heart rate (HR) values were measured at rest (in the crib), in the car seat chair at time 0, 5, 15, 30, 45 and 60 minutes. Results: During the year 2015, 86 preterm infants were discharged home, and all had values of SpO2 and HR within the reference range for this age group, during the Car Seat Challenge Test. The values decrease slightly from the measurement at 15 minutes for both SpO2 and HR. Infants with and without comorbidities had similar values of SpO2 (97-99.5%) and HR (135-155 beats per minute [bpm]), with a small decrease at 15 minutes. Infants with comorbidities did not regain saturation values after 30 minutes. Conclusion: The Car Seat Challenge Test has been performed systematically in the NICU since 2005. Data analyzed demonstrated it is safe. A standardized procedure was developed to provide harmonization of criteria