Asunto(s)
Protección a la Infancia , Mortalidad Infantil , Pobreza , Niño , Países en Desarrollo , Salud Global , Humanos , Lactante , Servicios de Salud Materna , Mortalidad MaternaRESUMEN
OBJECTIVE: Ballard scores are commonly used to estimate gestational age (GA). The purpose of this study was to determine the accuracy of the New Ballard Score (NBS) for infants <28 weeks GA by accurate menstrual history and to evaluate NBS as an outcome predictor. METHODS: Infants weighing 401 to 1500 g in 12 National Institute of Child Health and Human Development Neonatal Research Network centers had NBS performed before age 48 hours. Accuracy of NBS estimates of GA was assessed for infants with GA determined by accurate menstrual history. In a larger cohort of infants, NBS was included in regression models of the association of NBS and death, poor outcome, and duration of hospital stay. RESULTS: At each week from 22 to 28 weeks GA by accurate menstrual history, NBS estimates exceeded GA by dates by 1.3 to 3.3 weeks, and estimates varied widely (range of widths of 95% CIs for the observations, 6.8 to 11.9 weeks). NBS did not contribute significantly to regression models of death, poor outcome, or duration of hospital stay. CONCLUSIONS: Inaccuracies in GA determined by the NBS should be considered when treating extremely premature infants, particularly in decisions to forego or administer intensive care. Refinement of GA scoring systems is needed to optimize clinical benefit.
Asunto(s)
Edad Gestacional , Recien Nacido Prematuro/crecimiento & desarrollo , Recién Nacido de muy Bajo Peso/crecimiento & desarrollo , Examen Neurológico/métodos , Examen Físico/métodos , Femenino , Humanos , Recién Nacido , Cuidado Intensivo Neonatal , Modelos Lineales , Modelos Logísticos , Menstruación , Oportunidad Relativa , Embarazo , Reproducibilidad de los ResultadosRESUMEN
OBJECTIVE: Late-onset sepsis (occurring after 3 days of age) is an important problem in very low birth weight (VLBW) infants. To determine the current incidence of late-onset sepsis, risk factors for disease, and the impact of late-onset sepsis on subsequent hospital course, we evaluated a cohort of 7861 VLBW (401 to 1500 gm) neonates admitted to the 12 National Institute of Child Health and Human Development (NICHD) Neonatal Research Network centers during a 32-month period (1991 to 1993). METHODS: The NICHD Neonatal Research Network maintains a prospectively collected registry of all VLBW neonates cared for at participating centers. Data from this registry were analyzed retrospectively. RESULTS: Of 6911 infants who survived beyond 3 days, 1696 (25%) had one or more episodes of blood culture-proven sepsis. The vast majority of infection (73%) were caused by gram-positive organisms, with coagulase-negative staphylococci accounting for 55% of all infections. Rate of infection was inversely related to birth weight and gestational age. Complications of prematurity associated with an increased rate of infection included intubation, respiratory distress syndrome, prolonged ventilation, bronchopulmonary dysplasia, patent ductus arteriosus, severe intraventricular hemorrhage, and necrotizing enterocolitis. Among infants with bronchopulmonary dysplasia, those with late-onset sepsis had a significantly longer duration of mechanical ventilation (45 vs 33 days; p <0.01). Late-onset sepsis prolonged hospital stay: the mean number of days in the hospital for VLBW neonates with and without late-onset sepsis was 86 and 61 days, respectively (p <0.001). Even after adjustment for other complications of prematurity, including intraventricular hemorrhage, necrotizing enterocolitis, and bronchopulmonary dysplasia, infants with late-onset sepsis had a significantly longer hospitalization (p <0.001). Moreover, neonates in whom late-onset sepsis developed were significantly more likely to die than those who were uninfected (17% vs 7%; p <0.000 1), especially if they were infected with gram-negative organisms (40%) or fungi (28%). Deaths attributed to infection increased with increasing chronologic age. Whereas only 4% of deaths in the first 3 days of life were attributed to infection, 45% of deaths after 2 weeks were related to infection. CONCLUSIONS: Late-onset sepsis is a frequent and important problem among VLBW preterm infants. Successful strategies to decrease late-onset sepsis should decrease VLBW mortality rates, shorten hospital stay, and reduce costs.
Asunto(s)
Recién Nacido de muy Bajo Peso , Sepsis/epidemiología , Edad de Inicio , Infecciones Bacterianas/epidemiología , Infecciones Bacterianas/microbiología , Infecciones Bacterianas/mortalidad , Candidiasis/epidemiología , Candidiasis/microbiología , Candidiasis/mortalidad , Causas de Muerte , Estudios de Cohortes , Femenino , Humanos , Incidencia , Recién Nacido , Tiempo de Internación , Masculino , Análisis Multivariante , Estudios Prospectivos , Sistema de Registros , Factores de Riesgo , Sepsis/microbiología , Sepsis/mortalidadRESUMEN
OBJECTIVE: Early-onset sepsis (occurring within 72 hours of birth) is included in the differential diagnosis of most very low birth weight (VLBW) neonates. To determine the current incidence of early-onset sepsis, risk factors for disease, and the impact of early-onset sepsis on subsequent hospital course, we studied a cohort of 7861 VLBW neonates (401 to 1500 gm) admitted to the 12 National Institute of Child Health and Human Development (NICHD) Neonatal Research Network centers during a 32-month period (1991-1993). METHODS: The NICHD Neonatal Research Network maintains a prospectively collected registry on all VLBW neonates born or cared for at participating centers. Data from this registry were analyzed retrospectively. RESULTS: Blood culture-proven early-onset sepsis was uncommon, occurring in only 1.9% of VLBW neonates. Group B streptococcus was the most frequent pathogen associated with early-onset sepsis (31%), followed by Escherichia coli (16%) and Haemophilus influenzae (12%). Decreasing gestational age was associated with increased rates of infection. Antibiotic therapy for suspected sepsis is frequently initiated at birth in VLBW neonates. Almost half of the infants in this cohort were considered to have clinical sepsis and continued to receive antibiotics for 5 or more days, despite a negative blood culture result in 98% of cases. These findings underscore the difficulty of ruling out sepsis in the symptomatic immature neonate and the special concern for culture-negative clinical sepsis in the face of maternal antibiotic use. Neonates with early-onset sepsis were significantly more likely to have subsequent comorbidities, including severe intraventricular hemorrhage, patent ductus arteriosus, and prolonged assisted ventilation. Although 26% of VLBW neonates with early-onset sepsis died, only 4% of the 950 deaths that occurred in the first 72 hours of life were attributed to infection. For those infants discharged alive, early-onset sepsis was associated with a significantly prolonged hospital stay (86 vs 69 days; p <0.02). CONCLUSIONS: Early-onset sepsis remains an important but uncommon problem among VLBW preterm infants. Improved diagnostic strategies are needed to enable the clinician to distinguish between the infected and the uninfected VLBW neonate with symptoms and to target continued antibiotic therapy to those who are truly infected.
Asunto(s)
Recién Nacido de muy Bajo Peso , Sepsis/epidemiología , Edad de Inicio , Infecciones Bacterianas/epidemiología , Infecciones Bacterianas/microbiología , Infecciones Bacterianas/mortalidad , Estudios de Cohortes , Femenino , Humanos , Incidencia , Recién Nacido , Masculino , Factores de Riesgo , Sepsis/microbiología , Sepsis/mortalidadRESUMEN
To determine whether a single dose of intravenously administered immune globulin (IVIG) decreases late-onset sepsis in premature infants, we prospectively entered 753 neonates with birth weight 500 to 2000 gm, gestation < or = 34 weeks, and age < or = 12 hours into a multicenter, double-blind, controlled trial. Infants were randomly selected to receive a single intravenous infusion, 10 ml/kg, of either IVIG (500 mg/kg) or albumin (5 mg/kg) and were observed for 8 weeks for infection. Maternal and neonatal risk factors for infection did not differ between groups. Although serum IgG values before infusion were related to gestation (R = 0.62), the change in serum IgG or half-life of IgG after IVIG infusion was not (R < or = 0.09). The serum IgG concentration was increased (p < 0.05) in IVIG-treated patients for 8 weeks. There were 88 episodes of late-onset sepsis in 79 neonates (10.5%). Causative organisms included the following: Staphylococcus epidermidis (37 episodes), Enterococcus (9), Staphylococcus aureus (7), Candida (6), Escherichia coli (6), and multiple organisms (11). Sepsis, death, and death as a result of infection were unaffected by treatment. We conclude that a single infusion of IVIG, 500 mg/kg, shortly after birth was not effective prophylaxis for late-onset infection in premature neonates. Future studies of late-onset sepsis prophylaxis should consider IVIG with known pathogen-specific antibody concentrations against organisms causing these infections, in particular S. epidermidis.
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Albúminas/uso terapéutico , Bacteriemia/prevención & control , Inmunoglobulinas Intravenosas/uso terapéutico , Enfermedades del Prematuro/prevención & control , Bacteriemia/epidemiología , Bacteriemia/microbiología , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Femenino , Estudios de Seguimiento , Humanos , Inmunoglobulina G/sangre , Inmunoglobulina G/efectos de los fármacos , Recién Nacido , Enfermedades del Prematuro/epidemiología , Enfermedades del Prematuro/microbiología , Infusiones Intravenosas , Masculino , Factores de Riesgo , Factores de TiempoRESUMEN
The development of quantitative single-cell immunoassays has provided a novel opportunity to demonstrate the isotype-specific immunoglobulin responses in normal and infected neonates. The reverse enzyme-linked immunospot assay was used to determine the number of immunoglobulin-secreting cells (IgSCs) in peripheral blood. Baseline numbers of IgSCs were established in 69 uninfected term and preterm infants within 5 days of birth; values above the 99th percentile were considered elevated. The IgSCs were also measured in 266 infants with proved or suspected infections or congenital anomalies. A subset of newborn infants was retested weekly. Few IgSCs (mostly IgMSCs) were detected within 5 days of birth in uninfected neonates, but by 1 month 77% had increased numbers of IgSCs, primarily IgASCs. Sixty-three (24%) of 266 study infants had increased IgSCs on initial sampling (predominantly IgMSCs); these included infants as immature as 25 to 27 weeks of gestational age; elevations in IgSCs were most frequent in infants with intrauterine infections. Increased numbers of IgSCs were uncommon in infants with early-onset sepsis in the first 5 days but were frequent by the second week, consistent with acquisition of infection near the time of delivery. We conclude that the presence of elevated numbers of IgSCs soon after birth may be a useful surrogate marker of untreated intrauterine infection. The development of predominantly IgASCs in the first month of life suggests postnatal exposure to common mucosal antigens.
Asunto(s)
Inmunoglobulinas/biosíntesis , Enfermedades del Recién Nacido/inmunología , Recién Nacido/inmunología , Infecciones/inmunología , Células Productoras de Anticuerpos , Femenino , Humanos , Recien Nacido Prematuro/inmunología , MasculinoRESUMEN
Group B streptococcus (GBS) is a common cause of early-onset sepsis in neonates. The most recent reviews describing incidence, diagnosis, treatment, and outcome evaluated data on patients from the early 1980s. To obtain current information about this disease, we retrospectively evaluated data on neonates with GBS early-onset sepsis from nine hospitals in the United States between Jan. 1, 1987, and Dec. 31, 1989. There were 245 infants with GBS bacteremia identified among 61,809 live births, resulting in an incidence of 0.32%. Ninety-six infants (39%) were preterm (less than 38 weeks of gestational age). Maternal risk factors for infected preterm and term infants were similar. Antibiotics were administered during parturition in 10% of infants with bacteremia. Mothers of preterm infants received antibiotics up to 48 hours before delivery; mothers of term infants received antibiotics less than 4 hours before delivery. All preterm infants with bacteremia had symptoms; 22% of term infants with bacteremia had no symptoms. Group B streptococcal meningitis was confirmed in 6.3% of infants. Although 86% survived, GBS sepsis increased the birth weight-specific mortality rate up to eightfold in preterm infants and more than 40-fold in term infants. Although the incidence of GBS early-onset sepsis is not changing, we speculate that the improved birth weight-specific survival rate and the changing clinical presentation are due to improved intrapartum and neonatal management.
Asunto(s)
Bacteriemia/epidemiología , Infecciones Estreptocócicas/epidemiología , Streptococcus agalactiae , Peso al Nacer , Humanos , Incidencia , Recién Nacido , Enfermedades del Prematuro/epidemiología , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
Newborn infants may have IgG deficiencies that increase their susceptibility to bacterial infection. To determine whether intravenous immune globulin (IVIG) therapy improves survival rates in early-onset sepsis, we prospectively entered 753 neonates (birth weight 500 to 2000 gm, gestation less than or equal to 34 weeks, age less than or equal to 12 hours) into a multicenter, double-blind, controlled trial. Blood culture specimens were obtained and infants randomly assigned to receive 10 ml (per kilogram) intravenously of a selected IVIG (500 mg/kg) or albumin (5 mg/kg) preparation. Maternal and neonatal risk factors were not different between groups. Thirty-one babies (4.2%) had early-onset sepsis; the causative organisms were group B streptococcus (12 babies), Escherichia coli (6), and others (13). Of these 31 neonates, 7 (23%) died. Total serum IgG was higher for 7 days after IVIG therapy than after albumin treatment (p less than 0.05). During these 7 days, 5 (30%) of 17 albumin-treated and none of 14 IVIG-treated patients died (p less than 0.05). The survival rate at 56 days of age, however, was not significantly improved. Group B streptococcus type-specific IgG antibody was significantly increased after IVIG treatment and appeared to be related to the amount of IVIG specific antibody. Infusion-related adverse reactions were less frequent in patients receiving IVIG therapy (0.5%) than in those receiving albumin. The IVIG therapy in neonates with early-onset sepsis, while reducing the early mortality rate, did not significantly affect the overall survival rate. Further studies are necessary to confirm these findings and to determine more effective therapeutic regimens.
Asunto(s)
Bacteriemia/terapia , Inmunoglobulinas Intravenosas/uso terapéutico , Enfermedades del Prematuro/terapia , Antibacterianos/uso terapéutico , Anticuerpos Antibacterianos/sangre , Bacteriemia/inmunología , Bacteriemia/mortalidad , Terapia Combinada , Método Doble Ciego , Femenino , Humanos , Inmunoglobulina G/sangre , Recién Nacido , Enfermedades del Prematuro/inmunología , Enfermedades del Prematuro/mortalidad , Masculino , Estudios Prospectivos , Streptococcus agalactiae/inmunología , Resultado del TratamientoRESUMEN
Giardia lamblia infection in an endemic area was investigated by following a cohort of 33 lactating mothers and their infants in a semiurban community of Bangladesh for one year. Eighty-two percent of mothers and 42% of infants excreted Giardia at least once during the study period. Infants became infected as early as 3 months of age, and 86% of the infected infants had diarrhea, suggesting that the first exposure to the parasite results in disease. Only one of the infected mothers had diarrhea, indicating that with repeated exposure to Giardia, mothers in an endemic area may develop partial immunity that protects against disease but not infection. An interrelationship between maternal and infant colonization was not found. Local and systemic immune responses to Giardia correlated poorly with infection, but milk antibodies were a better reflection of infection than serum antibodies were. Infection with G. lamblia was significantly lower in infants younger than 6 months (9%), an age when many are totally breast-fed. However, we were unable to establish clear-cut protection related to human milk antibodies, and suggest that the lower infection rate in younger infants results mainly from decreased exposure to Giardia cysts.
Asunto(s)
Anticuerpos/análisis , Giardiasis/inmunología , Adolescente , Adulto , Bangladesh , Femenino , Estudios de Seguimiento , Giardiasis/genética , Giardiasis/parasitología , Humanos , Lactante , Recién Nacido , Masculino , Leche Humana/inmunología , Saliva/inmunologíaRESUMEN
All neonates with necrotizing enterocoltis cared for at Grady Memorial Hospital from July, 1977, through February, 1979, were compared with controls matched for birth weight and time of admission to the nursery, to examine risk factors which have been implicated in the etiology of the disease. Data on maternal history, birth history, and hospital course were uniformly collected and contrasted for 35 cases and 98 controls. Low birth weight was associated with an increased incidence of NEC and an increased case fatality rate. All babies 36 weeks or more at birth were diagnosed by seven days. More immature infants developed the disease later in their hospital course. In addition, preterm babies who developed NEC after 2 weeks of age appear to be smaller and sicker. Factors previously thought to predispose an infant to the development of the disease, such as prolonged rupture of membranes, infectious complications of pregnancy, low Apgar scores, patent ductus arteriosus, and use of umbilical catheters, were found with equal frequency in cases and controls and may simply represent the descriptive characteristics of a population of sick premature infants. Feeding history and antibiotic use were examined in depth and were not correlated with the development of NEC.