RESUMEN
OBJECTIVE: The objective of this study was to assess the frequency of early deaths associated with birth asphyxia of very low birth weight infants between 2005 and 2010, in Brazil. STUDY DESIGN: This population study enrolled all live births with birth weight from 400 to 1499 g, gestational age ⩾ 22 weeks, without malformations that died up to 6 days after birth with perinatal asphyxia. Asphyxia was defined if intrauterine hypoxia, asphyxia at birth or meconium aspiration syndrome were written in any line of the death certificate. Active search was carried out in 27 Brazilian federative units. RESULT: For every 1000 live births of very low birth weight infants without congenital malformations, 40.25 and 32.38 died with birth asphyxia in the first week after birth, respectively, in 2005 and 2010 (P<0.001). The contribution of birth asphyxia to early neonatal death of these infants was approximately 10 to 12% all study years. CONCLUSION: Reduction of birth asphyxia in very low birth weight infants is essential to reducing neonatal mortality in Brazil.
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Asfixia Neonatal/mortalidad , Causas de Muerte , Recién Nacido de muy Bajo Peso , Mortalidad Perinatal/tendencias , Brasil/epidemiología , Estudios de Cohortes , Femenino , Edad Gestacional , Humanos , Incidencia , Recién Nacido , Masculino , Embarazo , Estudios Retrospectivos , Medición de RiesgoRESUMEN
OBJECTIVE: To verify, in extremely preterm infants, if disagreement between obstetricians and neonatologists regarding proactive management is associated with early death. STUDY DESIGN: Prospective cohort of 484 infants with 23(0/7) to 26(6/7) weeks, without malformations, born from January 2006 to December 2009 in eight Brazilian hospitals. Pro-active management was defined as indication of ≥1 dose of antenatal steroid or cesarean section (obstetrician) and resuscitation at birth according to the international guidelines (neonatologist). Main outcome was neonatal death in the first 24 h of life. RESULT: Obstetricians and neonatologists disagreed in 115 (24%) patients: only neonatologists were proactive in 107 of them. Disagreement between professionals increased 2.39 times the chance of death in the first day (95% confidence interval 1.40 to 4.09), adjusted for center and maternal/neonatal clinical conditions. CONCLUSION: In infants with 23 to 26 weeks of gestation, disagreement between obstetricians and neonatologists, translated as lack of antenatal steroids and/or vaginal delivery, despite resuscitation procedures, increases the odds of death in the first day.
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Mortalidad Infantil/tendencias , Recien Nacido Prematuro , Recién Nacido de muy Bajo Peso , Neonatología/normas , Obstetricia/normas , Corticoesteroides/uso terapéutico , Análisis de Varianza , Brasil , Reanimación Cardiopulmonar/normas , Reanimación Cardiopulmonar/tendencias , Cesárea , Estudios de Cohortes , Intervalos de Confianza , Parto Obstétrico/métodos , Femenino , Viabilidad Fetal , Edad Gestacional , Humanos , Recién Nacido , Unidades de Cuidado Intensivo Neonatal , Relaciones Interprofesionales , Cuidados para Prolongación de la Vida/métodos , Modelos Logísticos , Masculino , Neonatología/tendencias , Obstetricia/tendencias , Oportunidad Relativa , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/tendencias , Embarazo , Pronóstico , Estudios Prospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: Evaluate the need for resuscitative procedures at birth, in late prematures. STUDY DESIGN: This prospective cohort study enrolled all liveborn infants from 1 to 30 September 2003, with 34 to 41 weeks of gestation without congenital anomalies, born in 35 public hospitals of 20 Brazilian state capitals. Logistic regression analyzed variables associated with the need for bag and mask ventilation. RESULT: Of the 10 774 infants studied, 1054 were late preterms and 485 required resuscitative measures. Of the 1054, 338 (32%) received only free-flow oxygen, 143 (14%) were bag and mask ventilated, 27 (3%) were intubated and 10/27 received chest compressions and/or medications. Bag and mask ventilation in late preterms was associated with twin gestation, maternal hypertension, nonvertex presentation, cesarean delivery and lower gestational age. CONCLUSION: Improving control of maternal hypertension, prolonging gestation for 1 to 2 weeks and restricting operative deliveries could decrease the need of resuscitation of late preterms at birth.
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Recien Nacido Prematuro , Nacimiento Prematuro , Resucitación/métodos , Adolescente , Adulto , Femenino , Edad Gestacional , Humanos , Recién Nacido , Embarazo , Estudios ProspectivosRESUMEN
OBJECTIVE: To assess potential discrepancies in reproductive patterns of women living in areas at different levels of human development by analyzing their total fertility rates and age-specific rates. METHODS: Ninety-six districts of the city of São Paulo (Brazil) were grouped in 5 areas according to their human development index (HDI). Women aged 15 to 49 years were included in the study and data was obtained from live birth certificates during the year of 1997. Data was collected from live birth certificates and population census for the year 1996. The following variables were analyzed: HDI; district of mother's residence and mother's age. RESULTS: The total fertility rate (TFR) for women living in the lowest HDI area was 2.62, and the highest specific fertility rate (SFR of 151/1,000) was found for the age group 20-24 years. For the area of highest HDI, the TFR was 1.67, and the age group of 25-29 showed the highest SFR (93/1,000). CONCLUSIONS: Women living in higher HDI areas showed a lower TFR and they tended to begin their reproductive life later in life, which suggests the coexistence of different reproductive patterns in the city of São Paulo.
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Tasa de Natalidad , Desarrollo Humano , Condiciones Sociales , Población Urbana , Adolescente , Adulto , Distribución por Edad , Brasil , Escolaridad , Femenino , Fertilidad , Humanos , Persona de Mediana Edad , Paridad , Embarazo , Índice de Embarazo , Características de la Residencia , Factores SocioeconómicosRESUMEN
BACKGROUND: Bloodstream infection represents a major threat among neonates under intensive care with considerable impact on morbidity and mortality. This study evaluated extra stay, attributable mortality and the risk factors associated with late-onset bloodstream infection (LO-BSI) among neonates admitted to a neonatal intensive care unit during a 4-year period. METHODS: A retrospective matched cohort study was conducted. For each case, there was one control patient without LO-BSI matched for sex, birth weight, gestational age, duration of hospitalization prior to the date of LO-BSI in the respective cases, underlying illness and birth date. A novel test, sequential plan, was employed for attributable mortality analysis in addition to standard tests. Multiple logistic regression was employed for risk factor analysis. RESULTS: Fifty pairs of cases and controls were compared. LO-BSI prolonged hospital stay of 25.1 days in pairs where both subjects survived. Overall attributable mortality was 24% (95% CI: 9-39% p < 0.01) and specific attributable mortality due to Staphylococcus epidermidis was 26.7% (95% CI: 23-30.4%; p = 0.01). Blood and/or blood components transfusion was independently associated with neonatal LO-BSI (OR: 21.2; 95% CI: 1.1-423). CONCLUSIONS: LO-BSI infection prolongs hospital stay and is associated with increased mortality among neonates. In the present series, blood transfusion was a significant risk factor for LO-BSI.
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Tiempo de Internación/estadística & datos numéricos , Sepsis/mortalidad , Brasil/epidemiología , Estudios de Casos y Controles , Femenino , Humanos , Recién Nacido , Unidades de Cuidado Intensivo Neonatal , Modelos Logísticos , Masculino , Estudios Retrospectivos , Factores de Riesgo , Sepsis/microbiología , Staphylococcus epidermidis/aislamiento & purificación , Estadísticas no ParamétricasRESUMEN
OBJECTIVE: To determine whether adults can recognize neonatal facial expression of pain. DESIGN: A cross-sectional study. SETTING: Neonatal intensive care unit, nursery, and outpatient clinic of one university hospital and one private hospital in São Paulo, Brazil. PATIENTS: Four hundred five adults divided into 2 groups: health and nonhealth professionals. INTERVENTION: The faces of 3 healthy full-term newborns who needed glucose screening were photographed at rest and during light exposure, heel rubbing, and heel puncture. A series of adults answered a questionnaire on personal and professional data and then they analyzed for 1 minute each of the 3 sets of pictures to answer the following question: "In which picture of this set do you think that the baby is feeling pain?" MAIN OUTCOME MEASURE: Number of correct answers for the 3 sets of photographs shown to the adults. RESULTS: Seventy-four percent of the health professionals and 86% of the nonhealth professionals indicated correctly the picture with facial expressions of pain in at least 2 of the 3 sets. Regarding which picture was picked out by the interviewee, 94% of the health professionals and 92% of the nonhealth professionals indicated the picture taken during the heel puncture in set 1. The same observation was made by 53% and 54% of the health professional and by 68% and 66% of the nonhealth professional interviewees for sets 2 and 3, respectively. CONCLUSIONS: Facial expression of pain represents an effective neonatal communication tool. However, the health professional group achieved a lower level of recognition of neonatal facial expressions of pain. Factors related to the personal and professional characteristics of the adults interviewed probably contributed to this result.
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Expresión Facial , Recién Nacido/fisiología , Dimensión del Dolor/métodos , Dolor/diagnóstico , Dolor/fisiopatología , Padres/psicología , Personal de Hospital/psicología , Adulto , Estudios Transversales , Señales (Psicología) , Femenino , Humanos , Recién Nacido/psicología , Modelos Lineales , Masculino , Variaciones Dependientes del Observador , Dolor/psicología , Fotograbar , Encuestas y CuestionariosRESUMEN
The study of neonatal gender differences in pain expression is important since neonatal pain behavior occurs prior to any learned reaction pattern. The objective of this study was to verify the presence of gender differences in pain expression in preterm and term newborn infants. Sixty-five consecutive neonates (37 female and 28 male infants) with gestational age between 28 and 42 weeks and with 25-120 h of life were studied. Healthy term neonates required a capillary puncture for PKU screening and clinically stable premature infants needed a capillary puncture for glucose dosage. The Neonatal Facial Coding System (NFCS) and the Neonatal Infant Pain Scale (NIPS) were evaluated at bedside prior to the puncture, when patients were at rest, during foot heating; during capillary puncture; and at 1, 3, and 5 min after heel lancing. Results were analyzed by repeated-measures ANOVA followed by the Multiple Comparison Method of Bonferroni. A significant difference among the mean NFCS scores during the six study periods was noted for the whole group of neonates (P<0.000001). Also, a significant interaction between the NFCS score profile in female and male neonates at the different study periods was observed (P=0.025). Regarding NIPS, ANOVA showed only a significant difference among the mean NIPS scores during the six study periods for the whole group of neonates (P<0.000001). No significant interactions between gestational age and time, nor between gestational age and gender were noted, for both NFCS and NIPS. In conclusion, recently born female neonates of all gestational ages expressed more facial features of pain than male infants, during the capillary puncture and 1 min afterwards. Maybe differences in pain processing and/or pain expression among genders may explain this finding.
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Conducta del Lactante/psicología , Recién Nacido/psicología , Dolor/psicología , Expresión Facial , Femenino , Humanos , Recien Nacido Prematuro/psicología , Masculino , Dimensión del Dolor , Caracteres SexualesRESUMEN
CONTEXT: The subjectivity of pain causes enormous difficulties in evaluating neonatal pain with a single, practical and easy-to-apply tool. Pain evaluation in the neonatal period should be performed by valid, safe, useful and feasible methods. OBJECTIVE: To evaluate the validity of the Neonatal Facial Coding System (NFCS), Neonatal Infant Pain Scale (NIPS), heart rate (HR) and O2 saturation (O2 sat) for neonatal pain assessment. DESIGN: Prospective, double-blind randomized trial. SETTING: A secondary level maternity hospital. PARTICIPANTS: 70 healthy neonates requiring bilirubin dosage were randomly assigned to receive a venous puncture (P: n = 33, BW 3.2 kg, SD 0.6; GA 39 wk, SD 1; 59 h of life, SD 25) or an alcohol swab friction (F: n = 37; BW 3.1 kg, SD 0.5; GA 39 wk, SD 1; 52 h of life, SD 17). INTERVENTION: All measurements were taken prior to (PRE), during (TO), and 1 (T1), 3(T3), 5(T5) and 10(T10) minutes after the procedure. MEASUREMENTS: A neonatologist evaluated NFCS, NIPS, HR and O2 sat by pulse oxymetry. RESULTS: Median NFCS and NIPS results at T0, T1 and T3 were higher in P group, compared to F. More P neonates presented NFCS > 2 and/or NIPS > 3 at T0, T1 and T3. HR was lower in P group at T1. Average O2 sat was above 90% during the whole study period in both groups. CONCLUSION: NFCS and NIPS are suitable instruments for neonatal pain evaluation. Heart rate and O2 saturation can be used only as auxiliary methods.
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Dimensión del Dolor/métodos , Dolor/diagnóstico , Enfermedad Aguda , Método Doble Ciego , Expresión Facial , Frecuencia Cardíaca , Humanos , Recién Nacido , Estudios Prospectivos , Reproducibilidad de los ResultadosRESUMEN
INTRODUCTION: Variables of birth certificates were analysed as risk factors of SGA (Small for Gestational Age) infantis, and with a view to discovering if retarded intra-uterine growth was a risk factor neonatal mortality. MATERIAL AND METHOD: Data were obtained directly from 11 hospital medical records. A cohort of 2.251 hospital live births was obtained. Linkage of the death and birth certificates was undertaken to identify the neonatal deaths. The study was carried out in Santo André county in the S. Paulo Metropolitan area in the period from 1/1 to 30/6/1992. RESULTS: There were 4.3% of SGA live births. A higher statistically significant proportion of SGA was found in pre-term and post-term live births, among live births of mothers with 35 years of age and over and in those whose mothers had less than complete primary education. The SGA live births showed a higher risk of neonatal death, even when allowing for gestational age. CONCLUSIONS: In areas where there is a low proportion of low birthweight, the presence of retarded intra-uterine growth may be an important risk factor to pre-term live births, due to the association between the pre-term and SGA. It would be easier to evaluate signs of retarded intra-uterine growth in the live birth population, if the gestational age data were registered, on the birth certificate in weeks.
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Retardo del Crecimiento Fetal/complicaciones , Mortalidad Infantil , Recién Nacido Pequeño para la Edad Gestacional , Adulto , Certificado de Nacimiento , Estudios de Cohortes , Femenino , Retardo del Crecimiento Fetal/mortalidad , Edad Gestacional , Humanos , Recién Nacido , Recien Nacido Prematuro , Edad Materna , Embarazo , Embarazo de Alto Riesgo , Factores de RiesgoRESUMEN
OBJECTIVE: To study the responses of ventilated preterm neonates to a single dose of opioid. STUDY DESIGN: In a randomized, double-blind, controlled trial, 22 mechanically ventilated preterm infants (< or = 32 weeks) were observed before medication and at 30 and 60 minutes after administration of fentanyl (3 micrograms/kg) or placebo. Heart rate, blood pressure, arterial blood gases, ventilator settings, and behavioral measures (Neonatal Facial Coding System and Modified Postoperative Comfort Score) were recorded during each period. Blood cortisol, growth hormone, glucose, and lactate were measured before and at 60 minutes after analgesia. Behavioral measures were assessed at the bedside and from video films recorded during each observation period. RESULTS: Patients presented high basal levels of cortisol, growth hormone, and lactate. Behavioral scales indicated the presence of pain before any medication. In the fentanyl group, the maximum and minimum heart rate decreased and growth hormone level increased after analgesia. At the video analysis of behavioral measures, postoperative comfort score increased and neonatal facial coding system score decreased in the fentanyl group. CONCLUSION: Single doses of fentanyl analgesia can reduce the physiologic/behavioral measures of pain and stress associated with mechanical ventilation in preterm infants.
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Analgesia , Analgésicos Opioides , Fentanilo , Recien Nacido Prematuro/fisiología , Intubación Intratraqueal , Dolor/fisiopatología , Respiración Artificial , Glucemia/análisis , Cateterismo Venoso Central , Método Doble Ciego , Femenino , Hemodinámica , Hormona de Crecimiento Humana/sangre , Humanos , Hidrocortisona/sangre , Recién Nacido , Ácido Láctico/sangre , Masculino , Dolor/prevención & control , Dimensión del Dolor , Factores de TiempoRESUMEN
OBJECTIVE: To establish the sensitivity and specificity of two behavioral pain scales in different gestational ages (GA). METHODS: 133 clinically stable neonates, <72 h of life, without diseases, analgesic/sedative use or Apgar<7 at 5' were randomly assigned to receive capillary puncture--P or alcohol swab friction--F. Patients were divided according to GA (28-33 wk=A; 34-37 wk=B; 38-41 wk=C ) and procedure: Group A-P (n=17, BW 1.5 +/- .4 kg); A-F (n=18, BW 1.5 +/- .4 kg); B-P (n=25, BW 2.5 +/- .5 kg); B-F (n=25, BW 2.4 +/- 0.6 kg); C-P (n=23, BW 3.3 kg +/- 0.5 kg); C-F (n=25; BW 3.3 +/- 0.4 kg). A neonatologist, blind to P or F, evaluated the Neonatal Facial Action Coding System (NFCS 0-8 pts, pain>3) and the Neonatal Infant Pain Scale (NIPS 0-7 pts, pain>3). All evaluations were performed prior to P or F, without (pr) and with foot heating (h), during (0), 1' and 3' after P or F. Reliability was assessed in 20% of the sample. Agreement rate was NFCS-97% and NIPS-95%. RESULTS: During the procedure, median NFCS and NIPS P score were greater than F (M. Whitney), p< or =0.0001) for A, B and C groups. At 1', NCFS and NIPS P scores were greater than F (MW, p< or =0.04) for A and C groups. For P patients, NFCS and NIPS scores were similar among the 3 GA groups at all study periods (K. Wallis). For F patients only at 0; NIPS scores were different (K. Wallis, p<0.03). During the procedure, NFCS>3 had sensitivity of 88-91% and specificity of 80-84%, NIPS>3 presented sensitivity of 77-87% and specificity of 68-83%. CONCLUSION: Both behavioral scales are sensitive tools for pain assessment in premature infants, although NFCS seems superior to NIPS.
RESUMEN
The utilization of record linkage of the mortality and birth information systems in studies of neonatal mortality is presented. The record linkage was used to obtain a cohort of live births and neonatal deaths in Santo André county, located within greater S. Paulo, in 1992. The procedures applied in order to avoid selection and effect biases, are discussed. The use of linked data allows the probabilities of neonatal deaths according to the exposure status of the variables which are registered on the birth certificate, and the identification of the live born at risk, to be calculated. Another advantage of the record linkage is the low financial cost of this type of study, because it uses information already registered.
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Redes de Comunicación de Computadores , Mortalidad Infantil , Sistemas de Información , Certificado de Nacimiento , Estudios de Cohortes , Certificado de Defunción , Femenino , Humanos , Recién Nacido , Masculino , Registros Médicos , Estudios RetrospectivosRESUMEN
The purpose of this study was to verify if multidimensional pain assessment, performed through physiologic and behavioral measures, together with this assessment modifications in response to opioid analgesia, could determine the presence of pain in preterm neonates (PT) under mechanical ventilation through endotracheal tube (ETT). The population consisted of 22 PT with gest. age < or = 32 weeks, between 12-48 h of life. All of them had an ETT and an umbilical arterial line in place and were on mechanical ventilation. The infants were admitted at São Paulo Hospital NICU from 11/91 to 11/92. Neonates' observation was performed in three 10 minute periods: prior medication (Pre-Analgesia), 30 min (Analgesia 1) and 60 min (Analgesia 2) after the injection of either fentanyl (3 mcg/kg) or sterile water (0.2 ml). In each period an arterial blood gas was drawn and the following parameters were recorded: ventilator settings, heart rate, non-invasive blood pressure and 02 saturation. Behavioral measures were also observed: ATTIA scale, MCGRATH scale and GRUNAU & CRAIG pain facial features. In Pre-Analgesia and Analgesia 2 periods, blood samples were obtained and serum cortisol, serum GH, plasmatic glucose and lactate were measured. Patients were filmed through the study and behavioral measures applied for each patient film. The research author was blind to the medication until final results. High levels of serum cortisol, serum GH and plasmatic lactate were present in the whole study population prior to medication. They also presented low ATTIA scale scores and pain facial mimic, as per MCGRATH and GRUNAU & CRAIG evaluations. Patients that received fentanyl exhibited decrease in the maximum heart rate, decrease in serum cortisol, increase in serum GH, stability in blood glucose levels, better ATTIA scale comfort scores and less pain facial movements. None of these occurred in neonates that received placebo. Critically ill intubated and ventilated PT do feel pain, as assessed by this multidimensional evaluation. Analgesia should be considered in order to treat these patients' pain.
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The Brazilian Ministry of Health implemented, in 1990, a System of Information of Live Births (SINASC) which introduced a Birth Certificate with a view to obtaining the total number of these events and their distribution according to epidemiological, demographic and clinical characteristics. It was decided to evaluate the System according to its coverage and the quality of information obtained, two years after its initial implementation. The population of this study consists of 15,142 hospital live births which occurred in five cities of the State of São Paulo, Brazil, in 1992. Birth Certificates and the corresponding maternal and child hospital records were examined visually with a view to checking data recorded on the Birth Certificate. It was seen that the system achieved a high degree of completeness (99.5%) and obtained a very accurate report for most of the items, though rather poor reporting for Apgar Score, length of gestation, mother's schooling, parity and father's name. This study allows suggestions to be made for the reformulation of some items and regarding the necessity for retraining the hospital personnel involved in the filling in of the certificates. Overall this study confirms that the Birth Certificate data are adequate for a valid analysis of aspects of maternal and child health research. The data showed high percentages of adolescent mothers (17.5%) and deliveries by cesarian section (48.4%). The percentage of low birth weight was 8.5%.