Perinatal Factors Associated With Early Deaths Of Preterm Infants Born In Brazilian Network On Neonatal Research Centers [fatores Perinatais Associados Ao óbito Precoce Em Prematuros Nascidos Nos Centros Da Rede Brasileira De Pesquisas Neonatais]

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. Copyright © 2008 by Sociedade Brasileira de Pediatria.844300307Joseph, K.S., Liston, R.M., Dodds, L., Dahlgren, L., Allen, A.C., Socioeconomic status and perinatal outcomes in a setting with universal access to essential health care services (2007) CMAJ, 177, pp. 583-590Mathews, T.J., MacDorman, M.F., Infant mortality statistics from the 2004 period linked birth/infant death data set (2007) Natl Vital Stat Rep, 55, pp. 1-32Kramer, M.S., Demissie, K., Yang, H., Platt, R.W., Sauve, R., Liston, R., The contribution of mild and moderate preterm birth to infant mortality. Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System (2000) JAMA, 284, pp. 843-849Ananth, C.V., Vintzileos, A.M., Epidemiology of preterm birth and its clinical subtypes (2006) J Matern Fetal Neonatal Med, 19, pp. 773-782Brasil. Ministério da Saúde. DATASUS. Informaç ões de Saúde-Estatísticas Vitais- Mortalidade e Nascidos Vivos: nascidos vivos desde 1994. http://tabnet.datasus.gov.br/cgi/deftohtm.exe? sinasc/cnv/nvuf.def. Acesso: 29.10.2007Brasil. Ministério da Saúde. DATASUS. Informaç ões de Saúde-Estatísticas Vitais- Mortalidade e Nascidos Vivos: óbitos infantis - desde 1979. http://tabnet.datasus.gov.br/cgi/ deftohtm.exe?sim/cnv/infuf.def. Acesso: 29.10.2007Barros, F.C., Diaz-Rossello, J.L., The quality of care of very low birth weight babies in Brazil (2007) J Pediatr (Rio J), 83, pp. 5-6Horbar, J.D., Badger, G.J., Carpenter, J.H., Fanaroff, A.A., Kilpatrick, S., LaCorte, M., Trends in mortality and morbidity for very low birth weight infants, 1991-1999 (2002) Pediatrics, 110, pp. 143-151Fanaroff AA, Stoll BJ, Wright LL, Carlo WA, Ehrenkranz RA, Stark AR, et al. Trends in neonatal morbidity and mortality for very low birth weight infants. Am J Obstet Gynecol. 2007;196:147.e1-8(2004) Infra-estrutura para atendimento integral ao recém-nascido, , http://www.sbp.com.br/show_item2.cfm?id_categoria=21&id_detalhe=1636&tipo_detalhe=s.Access:02.11.2007, Departamento de Neonatologia da Sociedade Brasileira de PediatriaBallard, J.L., Khoury, J.C., Wedig, K., Wang, L., Eilers-Walsman, B.L., Lipp, R., New Ballard Score, expanded to include extremely premature infants (1991) J Pediatr, 119, pp. 417-423Alexander, G.R., Himes, J.H., Kaufman, R.B., Mor, J., Kogan, M., A United States national reference for fetal growth (1996) Obstet Gynecol, 87, pp. 163-168Kattwinkel, J., (2000) Textbook of Neonatal Resuscitation, , 4th ed. Chicago, IL: American Academy of Pediatrics/American Heart Association;Richardson, D.K., Corcoran, J.D., Escobar, G.J., Lee, S.K., SNAP-II and SNAPPE-II: Simplified newborn illness severity and mortality risk scores (2001) J Pediatr, 138, pp. 92-100El-Metwally D, Vohr B, Tucker R. Survival and neonatal morbidity at the limits of viability in the mid 1990s: 22 to 25 weeks. J Pediatr. 2000;137:616-22Costeloe, K., Hennessy, E., Gibson, A.T., Marlow, N., Wilkinson, A.R., The EPICure study: Outcomes to discharge from hospital for infants born at the threshold of viability (2000) Pediatrics, 106, pp. 659-671MacDonald, H., American Academy of Pediatrics. Committee on Fetus and Newborn. Perinatal care at the threshold of viability (2002) Pediatrics, 110, pp. 1024-1027Jain, L., Raju, T.N., editors. Late preterm pregnancy and the newborn (2006) Clin Perinatol, 33, pp. 751-972de Kleine, M.J., den Ouden, A.L., Kollee, L.A., Ilsen, A., van Wassenaer, A.G., Brand, R., Lower mortality but higher neonatal morbidity over a decade in very preterm infants (2007) Paediatr Perinat Epidemiol, 21, pp. 15-25Moro, M., Figueras-Aloy, J., Fernández, C., Doménech, E., Jiménez, R., Pérez-Rodríguez, J., Mortality for newborns of birthweight less than 1,500 g in Spanish neonatal units (2002-2005) (2007) Am J Perinatol, 24, pp. 593-601Drumond Ede, F., Machado, C.J., Franca, E., Early neonatal mortality: An analysis of multiple causes of death by the Grade of Membership method (2007) Cad Saude Publica, 23, pp. 157-166Richardson, D.K., Shah, B.L., Frantz 3rd, I.D., Bednarek, F., Rubin, L.P., McCormick, M.C., Perinatal risk and severity of illness in newborns at 6 neonatal intensive care units (1999) Am J Public Health, 89, pp. 511-516Horbar, J.D., Rogowski, J., Plsek, P.E., Delmore, P., Edwards, W.H., Hocker, J., Collaborative quality improvement for neonatal intensive care. NIC/Q Project Investigators of the Vermont Oxford Network (2001) Pediatrics, 107, pp. 14-22Vohr, B.R., Wright, L.L., Dusick, A.M., Perritt, R., Poole, W.K., Tyson, J.E., Center differences and outcomes of extremely low birth weight infants (2004) Pediatrics, 113, pp. 781-789Horbar JD, Plsek PE, Leahy KNIC/Q 2000. NIC/Q 2000: establishing habits for improvement in neonatal intensive care units. Pediatrics. 2003;111:e397-410Evans, N., Hutchinson, J., Simpson, J.M., Donoghue, D., Darlow, B., Henderson-Smart, D., Prenatal predictors of mortality in very preterm infants cared for in the Australian and New Zealand Neonatal Network (2007) Arch Dis Child Fetal Neonatal Ed, 92, pp. F34-F40Walther, F.J., Withholding treatment, withdrawing treatment, and palliative care in the neonatal intensive care unit (2005) EarlyHumDev, 81, pp. 965-972von Dadelszen, P., Magee, L.A., Taylor, E.L., Muir, J.C., Stewart, S.D., Sherman, P., Maternal hypertension and neonatal outcome among small for gestational age infants (2005) Obstet Gynecol, 106, pp. 335-339Casey, B.M., McIntire, D.D., Leveno, K.J., The continuing value of the Apgar score for the assessment of newborn infants (2001) N Engl J Med, 344, pp. 467-471,308-31

Comparisons of mortality and pre-discharge respiratory outcomes in small-for-gestational-age and appropriate-for-gestational-age premature infants

BACKGROUND: There are differences in the literature regarding outcomes of premature small-for-gestational-age (SGA) and appropriate-for gestational-age (AGA) infants, possibly due to failure to take into account gestational age at birth. OBJECTIVE: To compare mortality and respiratory morbidity of SGA and AGA premature newborn infants. DESIGN/METHODS: A retrospective study was done of the 2,487 infants born without congenital anomalies at ≤36 weeks of gestation and admitted to the neonatal intensive care unit (NICU) at John Dempsey Hospital, between Jan. 1992 and Dec. 1999. Recent (1994–96) U.S. birth weight percentiles for gestational age (GA), race and gender were used to classify neonates as SGA (<10th percentile for GA) or AGA (10(th)–90th percentile for GA). Using multivariate logistic regression and survival analyses to control for GA, SGA and AGA infants were compared for mortality and respiratory morbidity. RESULTS: Controlling for GA, premature SGA infants were at a higher risk for mortality (Odds ratio 3.1, P = 0.001) and at lower risk of respiratory distress syndrome (OR = 0.71, p = 0.02) than AGA infants. However multivariate logistic regression modeling found that the odds of having respiratory distress syndrome (RDS) varied between SGA and AGA infants by GA. There was no change in RDS risk in SGA infants at GA ≤ 32 wk (OR = 1.27, 95% CI 0.32 – 1.98) but significantly decreased risk for RDS at GA > 32 wk (OR = 0.41, 95% CI 0.27 – 0.63; p < 0.01). After controlling for GA, SGA infants were observed to be at a significantly higher risk for developing chronic lung disease as compared to AGA infants (OR = 2.2, 95% CI = 1.2 – 3.9, P = 0.01). There was no significant difference between SGA and AGA infants in total days on ventilator. Among infants who survived, mean length of hospital stay was significantly higher in SGA infants born between 26–36 wks GA than AGA infants. CONCLUSIONS: Premature SGA infants have significantly higher mortality, significantly higher risk of developing chronic lung disease and longer hospital stay as compared to premature AGA infants. Even the reduced risk of RDS in infants born at ≥32 wk GA, (conferred possibly by intra-uterine stress leading to accelerated lung maturation) appears to be of transient effect and is counterbalanced by adverse effects of poor intrauterine growth on long term pulmonary outcomes such as chronic lung disease

A predictive score for retinopathy of prematurity in very low birth weight preterm infants

Aims This study describes the development of a score based on cumulative risk factors for the prediction of severe retinopathy of prematurity (ROP) comparing the performance of the score against the birth weight (BW) and gestational age (GA) in order to predict the onset of ROP.Methods A prospective cohort of preterm infants with BWp1500 g and/or GAp32 weeks was studied. the score was developed based on BW, GA, proportional weight gain from birth to the 6th week of life, use of oxygen in mechanical ventilation, and need for blood transfusions from birth to the 6th week of life. the score was established after linear regression, considering the impact of each variable on the occurrences of any stage and severe ROP. Receiver operating characteristic (ROC) curves were used to determine the best sensitivity and specificity values for the score. All variables were entered into an Excel spreadsheet (Microsoft) for practical use by ophthalmologists during screening sessions.Results the sample included 474 patients. the area under the ROC curve for the score was 0.77 and 0.88 to predict any stage and severe ROP, respectively. These values were significantly higher for the score than for BW (0.71) and GA (0.69) when measured separately.Conclusions ROPScore is an excellent index of neonatal risk factors for ROP, which is easy to record and more accurate than BW and GA to predict any stage ROP or severe ROP in preterm infants. the scoring system is simple enough to be routinely used by ophthalmologists during screening examination for detection of ROP. Eye (2012) 26, 400-406; doi: 10.1038/eye. 2011.334; published online 23 December 2011Hosp Clin Porto Alegre, Dept Ophthalmol, BR-90035903 Porto Alegre, RS, BrazilUniv Fed Rio Grande do Sul, Dept Ophthalmol, Sch Med, Porto Alegre, RS, BrazilUniversidade Federal de São Paulo, Dept Ophthalmol, Sch Med, São Paulo, BrazilUniv Fed Rio Grande do Sul, Dept Paediat, Newborn Sect, Sch Med, Porto Alegre, RS, BrazilUniversidade Federal de São Paulo, Dept Ophthalmol, Sch Med, São Paulo, BrazilWeb of Scienc

Effects Of Therapeutic Approach On The Neonatal Evolution Of Very Low Birth Weight Infants With Patent Ductus Arteriosus

Objective To analyze the effects of treatment approach on the outcomes of newborns (birth weight [BW] &lt; 1,000 g) with patent ductus arteriosus (PDA), from the Brazilian Neonatal Research Network (BNRN) on: death, bronchopulmonary dysplasia (BPD), severe intraventricular hemorrhage (IVH III/IV), retinopathy of prematurity requiring surgical (ROPsur), necrotizing enterocolitis requiring surgery (NECsur), and death/BPD.Methods This was a multicentric, cohort study, retrospective data collection, including newborns (BW &lt; 1000 g) with gestational age (GA) &lt; 33 weeks and echocardiographic diagnosis of PDA, from 16 neonatal units of the BNRN from January 1, 2010 to Dec 31, 2011. Newborns who died or were transferred until the third day of life, and those with presence of congenital malformation or infection were excluded. Groups: G1 - conservative approach (without treatment), G2 - pharmacologic (indomethacin or ibuprofen), G3 - surgical ligation (independent of previous treatment). Factors analyzed: antenatal corticosteroid, cesarean section, BW, GA, 5 min. Apgar score &lt; 4, male gender, Score for Neonatal Acute Physiology Perinatal Extension (SNAPPE II), respiratory distress syndrome (RDS), late sepsis (LS), mechanical ventilation (MV), surfactant (&lt; 2 h of life), and time of MV. Outcomes: death, O2 dependence at 36 weeks (BPD36wks), IVH III/IV, ROPsur, NECsur, and death/BPD36wks. Statistics: Student's t-test, chi-squared test, or Fisher's exact test; Odds ratio (95% CI); logistic binary regression and backward stepwise multiple regression. Software: MedCalc (Medical Calculator) software, version 12.1.4.0. p-values &lt; 0.05 were considered statistically significantResults 1,097 newborns were selected and 494 newborns were included: G1 - 187 (37.8%), G2 - 205 (41.5%), and G3 - 102 (20.6%). The highest mortality was observed in G1 (51.3%) and the lowest in G3 (14.7%). The highest frequencies of BPD36wks (70.6%) and ROPsur were observed in G3 (23.5%). The lowest occurrence of death/BPD36wks occurred in G2 (58.0%). Pharmacological (OR 0.29; 95% CI: 0.14-0.62) and conservative (OR 0.34; 95% CI: 0.14-0.79) treatments were protective for the outcome death/BPD36wks. Conclusion The conservative approach of PDA was associated to high mortality, the surgical approach to the occurrence of BPD36wks and ROPsur, and the pharmacological treatment was protective for the outcome death/BPD36wks.906616623Clyman, R.I., Mechanisms regulating the ductus arteriosus (2006) Biol Neonate., 89, pp. 330-335Benitz, W.E., Treatment of persistent patent ductus arteriosus in preterm infants: Time to accept the null hypothesis? (2010) J Perinatol., 30, pp. 241-252Redline, R.W., Wilson-Costello, D., Hack, M., Placental and other perinatal risk factors for chronic lung disease in very low birth weight infants (2002) Pediatr Res., 52, pp. 713-719Evans, N., Kluckow, M., Early ductal shunting and intraventricular haemorrhage in ventilated preterm infants (1996) Arch Dis Child Fetal Neonatal Ed., 75, pp. 183-F186Noerr, B., Current controversies in the understanding of necrotizing enterocolitis Part 1 (2003) Adv Neonatal Care., 3, pp. 107-120Koch, J., Hensley, G., Roy, L., Brown, S., Ramaciotti, C., Rosenfeld, C.R., Prevalence of spontaneous closure of the ductus arteriosus in neonates at a birth weight of 1000 grams or less (2006) Pediatrics., 117, pp. 1113-1121Afiune, J.Y., Singer, J.M., Leone, C.R., Evolução ecocardiográfica de recém-nascidos com persistência do canal arterial (2005) J Pediatr (Rio J)., 81, pp. 454-460Sosenko, I.R., Fajardo, M.F., Claure, N., Bancalari, E., Timing of patent ductus arteriosus treatment and respiratory outcome in premature infants: A double-blind randomized controlled trial (2012) J Pediatr., 160, pp. 929-935. , e1Laughon, M.M., Simmons, M.A., Bose, C.L., Patency of the ductus arteriosus in the premature infant: Is it pathologic? Should it be treated? (2004) Curr Opin Pediatr., 16, pp. 146-151Clyman, R.I., Chorne, N., Patent ductus arteriosus: Evidence for and against treatment (2007) J Pediatr., 150, pp. 216-219Bose, C.L., Laughon, M., Treatment to prevent patency of the ductus arteriosus: Beneficial or harmful? (2006) J Pediatr., 148, pp. 713-714Clyman, R.I., Couto, J., Murphy, G.M., Patent ductus arteriosus: Are current neonatal treatment options better or worse than no treatment at all? (2012) Semin Perinatol., 36, pp. 123-129Alexander, G.R., Himes, J.H., Kaufman, R.B., Mor, J., Kogan, M., A United States national reference for fetal growth (1996) Obstet Gynecol., 87, pp. 163-168Jhaveri, N., Moon-Grady, A., Clyman, R.I., Early surgical ligation versus a conservative approach for management of patent ductus arteriosus that fails to close after indomethacin treatment (2010) J Pediatr., 157. , 381-7, 387.e1Clyman, R., Cassady, G., Kirklin, J.K., Collins, M., Philips, J.B., III, The role of patent ductus arteriosus ligation in bronchopulmonary dysplasia: Reexamining a randomized controlled trial (2009) J Pediatr., 154, pp. 873-876Mirea, L., Sankaran, K., Seshia, M., Ohlsson, A., Allen, A.C., Aziz, K., Treatment of patent ductus arteriosus and neonatal mortality/morbidities: Adjustment for treatment selection bias (2012) J Pediatr., 161, pp. 689-694. , e1Youn, Y., Lee, J.Y., Lee, J.H., Kim, S.Y., Sung, I.K., Lee, J.Y., Impact of patient selection on outcomes of PDA in very low birth weight infants (2013) Early Hum Dev., 89, pp. 175-17