Adequacy of antenatal care and its relationship with low birth weight in Botucatu, Sao Paulo, Brazil: a case-control study

Background: Birth weight reflects gestational conditions and development during the fetal period. Low birth weight (LBW) may be associated with antenatal care (ANC) adequacy and quality. The purpose of this study was to analyze ANC adequacy and its relationship with LBW in the Unified Health System in Brazil.Methods: A case-control study was conducted in Botucatu, Sao Paulo, Brazil, 2004 to 2008. Data were collected from secondary sources (the Live Birth Certificate), and primary sources (the official medical records of pregnant women). The study population consisted of two groups, each with 860 newborns. The case group comprised newborns weighing less than 2,500 grams, while the control group comprised live newborns weighing greater than or equal to 2,500 grams. Adequacy of ANC was evaluated according to three measurements: 1. Adequacy of the number of ANC visits adjusted to gestational age; 2. Modified Kessner Index; and 3. Adequacy of ANC laboratory studies and exams summary measure according to parameters defined by the Ministry of Health in the Program for Prenatal and Birth Care Humanization.Results: Analyses revealed that LBW was associated with the number of ANC visits adjusted to gestational age (OR = 1.78, 95% CI 1.32-2.34) and the ANC laboratory studies and exams summary measure (OR = 4.13, 95% CI 1.36-12.51). According to the modified Kessner Index, 64.4% of antenatal visits in the LBW group were adequate, with no differences between groups.Conclusions: Our data corroborate the association between inadequate number of ANC visits, laboratory studies and exams, and increased risk of LBW newborns. No association was found between the modified Kessner Index as a measure of adequacy of ANC and LBW. This finding reveals the low indices of coverage for basic actions already well regulated in the Health System in Brazil. Despite the association found in the study, we cannot conclude that LBW would be prevented only by an adequate ANC, as LBW is associated with factors of complex and multifactorial etiology. The results could be used to plan monitoring measures and evaluate programs of health care assistance during pregnancy, at delivery and to newborns, focusing on reduced LBW rates.

Salt sensitivity of children with low birth weight

Compromised intrauterine fetal growth leading to low birth weight (<2500 g) is associated with adulthood renal and cardiovascular disease. The aim of this study was to assess the effect of salt intake on blood pressure (salt sensitivity) in children with low birth weight. White children (n=50; mean age: 11.3+/-2.1 years) born with low (n=35) or normal (n=15) birth weight and being either small or appropriate for gestational age (n=25 in each group) were investigated. The glomerular filtration rate was calculated using the Schwartz formula, and renal size was measured by ultrasound. Salt sensitivity was assigned if mean 24-hour blood pressure increased by >or=3 mm Hg on a high-salt diet as compared with a controlled-salt diet. Baseline office blood pressure was higher and glomerular filtration rate lower in children born with low birth weight as compared with children born at term with appropriate weight (P<0.05). Salt sensitivity was present in 37% and 47% of all of the low birth weight and small for gestational age children, respectively, higher even than healthy young adults from the same region. Kidney length and volume (both P<0.0001) were reduced in low birth weight children. Salt sensitivity inversely correlated with kidney length (r(2)=0.31; P=0.005) but not with glomerular filtration rate. We conclude that a reduced renal mass in growth-restricted children poses a risk for a lower renal function and for increased salt sensitivity. Whether the changes in renal growth are causative or are the consequence of the same abnormal "fetal programming" awaits clarification.

Ethnic/racial diversity, maternal stress, lactation and very low birthweight infants.

OBJECTIVE: (1) To compare maternal characteristics and psychological stress profile among African-American, Caucasian and Hispanic mothers who delivered very low birthweight infants. (2) To investigate associations between psychosocial factors, frequency of milk expression, skin-to-skin holding (STS), and lactation performance, defined as maternal drive to express milk and milk volume. STUDY DESIGN: Self-reported psychological questionnaires were given every 2 weeks after delivery over 10 weeks. Milk expression frequency, STS, and socioeconomic variables were collected. RESULT: Infant birthweight, education, and milk expression frequency differed between groups. Trait anxiety, depression and parental stress in a neonatal intensive care unit (PSS:NICU) were similar. African-American and Caucasian mothers reported the lowest scores in state anxiety and social desirability, respectively. Maternal drive to express milk, measured by maintenance of milk expression, correlated negatively with parental role alteration (subset of PSS:NICU) and positively with infant birthweight and STS. Milk volume correlated negatively with depression and positively with milk expression frequency and STS. CONCLUSION: Differences between groups were observed for certain psychosocial factors. The response bias to self-reported questionnaires between groups may not provide an accurate profile of maternal psychosocial profile. With different factors correlating with maintenance of milk expression and milk volume, lactation performance can be best enhanced with a multi-faceted intervention program, incorporating parental involvement in infant care, close awareness and management of maternal mental health, and encouragement for frequent milk expression and STS.

Aggressive vs. conservative phototherapy for infants with extremely low birth weight.

BACKGROUND: It is unclear whether aggressive phototherapy to prevent neurotoxic effects of bilirubin benefits or harms infants with extremely low birth weight (1000 g or less). METHODS: We randomly assigned 1974 infants with extremely low birth weight at 12 to 36 hours of age to undergo either aggressive or conservative phototherapy. The primary outcome was a composite of death or neurodevelopmental impairment determined for 91% of the infants by investigators who were unaware of the treatment assignments. RESULTS: Aggressive phototherapy, as compared with conservative phototherapy, significantly reduced the mean peak serum bilirubin level (7.0 vs. 9.8 mg per deciliter [120 vs. 168 micromol per liter], P<0.01) but not the rate of the primary outcome (52% vs. 55%; relative risk, 0.94; 95% confidence interval [CI], 0.87 to 1.02; P=0.15). Aggressive phototherapy did reduce rates of neurodevelopmental impairment (26%, vs. 30% for conservative phototherapy; relative risk, 0.86; 95% CI, 0.74 to 0.99). Rates of death in the aggressive-phototherapy and conservative-phototherapy groups were 24% and 23%, respectively (relative risk, 1.05; 95% CI, 0.90 to 1.22). In preplanned subgroup analyses, the rates of death were 13% with aggressive phototherapy and 14% with conservative phototherapy for infants with a birth weight of 751 to 1000 g and 39% and 34%, respectively (relative risk, 1.13; 95% CI, 0.96 to 1.34), for infants with a birth weight of 501 to 750 g. CONCLUSIONS: Aggressive phototherapy did not significantly reduce the rate of death or neurodevelopmental impairment. The rate of neurodevelopmental impairment alone was significantly reduced with aggressive phototherapy. This reduction may be offset by an increase in mortality among infants weighing 501 to 750 g at birth. (ClinicalTrials.gov number, NCT00114543.)

Less invasive ventilation in extremely low birth weight infants from 1997 to 2011: survey versus evidence.

UNLABELLED Evidence for target values of arterial oxygen saturation (SaO2), CO2, and pH has changed substantially over the last 20 years. A representative survey concerning treatment strategies in extremely low-birth-weight infants (ELBW) was sent to all German neonatal intensive care units (NICUs) treating ELBW infants in 1997. A follow-up survey was conducted in 2011 and sent to all NICUs in Germany, Austria, and Switzerland. During the observation period, NICUs targeting SaO2 of 80, 85, and 90 % have increased, while units aiming for 94 and 96 % decreased (all p < 0.001). Similarly, NICUs aiming for pH 7.25 or lower increased, while 7.35 or higher decreased (both p < 0.001). Furthermore, more units targeted a CO2 of 50 mmHg (7.3 kPa) or higher (p < 0.001), while fewer targeted 40 or 35 mmHg (p < 0.001). Non-invasive ventilation (NIV) was used in 80.2 % of NICUs in 2011. The most frequently used ventilation modes were synchronized intermittent mandatory ventilation (SIMV) (67.5 %) and intermittent positive pressure ventilation (IPPV) (59.7 %) in 1997 and SIMV (77.2 %) and synchronized intermittent positive pressure ventilation (SIPPV) (26.8 %) in 2011. NICUs reporting frequent or always use of IPPV decreased to 11.0 % (p < 0.001). SIMV (77.2 %) and SIPPV (26.8 %) did not change from 1997 to 2011, while high-frequency oscillation (HFO) increased from 9.1 to 19.7 % (p = 0.018). Differences between countries, level of care, and size of the NICU were minimal. CONCLUSIONS Target values for SaO2 decreased, while CO2 and pH increased significantly during the observation period. Current values largely reflect available evidence at time of the surveys. WHAT IS KNOWN • Evidence concerning target values of oxygen saturation, CO 2 , and pH in extremely low-birth-weight infants has grown substantially. • It is not known to which extent this knowledge is transferred into clinical practice and if treatment strategies have changed. WHAT IS NEW • Target values for oxygen saturation in ELBW infants decreased between 1997 and 2011 while target values for CO 2 and pH increased. • Similar treatment strategies existed in different countries, hospitals of different size, or university versus nonuniversity hospitals in 2011.

Contribution of parental blood pressures to association between low birth weight and adult high blood pressure: cross sectional study

Objective: To examine the possibility that low birth weight is a feature of the inherited predisposition to high blood pressure.

Investigation of H19/RsaI Polymorphism in Children With Low Birth Weight in Pernambuco, Brazil

Background: H19 is a strong candidate gene for influencing birth weight variation and is exclusively imprinted maternally. In an attempt to understand the relationship of this gene polymorphism with low birth weight children, we investigated association of H19/RsaI polymorphism with low birth weight and normal birth weight in children and their mothers. Objectives: The aim of our study was to establish the association between H19 gene polymorphism and LW in children born in Pernambuco, state of Brazil. Patients and Methods: It were selected 89 children, 40 low birth weight (LW) and 49 normal birth weight (NW) and 71 mothers (40 mothers of newborns NW and 31 mothers of newborns LW) attended at Dom Malan Hospital, Petrolina, Pernambuco - Brazil. Peripheral blood samples were collected from patients and genomic DNA was extracted and detected by electrophoresis agarose gel, stained by Blue Green Loading Dye. DNA PCR amplification was done using the primers H1 (sense) and H3 (antisense). PCR products were digested with RsaI and electrophoresed on agarose gel stained by ethidium bromide. Statistical analyses were performed using the program BioEstat version 5.0. Results: The RsaI polymorphism in the H19 gene showed that genotype frequencies did not differ statistically between low birth weight (AA = 12.5%, AB = 45%, BB = 42.5%) and control (AA = 8.6% AB = 36.73%, BB= 55.10% groups) and the allele frequencies were not significantly different (P = 0.2897). We also did not observe any association between maternal H19 allele polymorphism and low birth weight newborns (P =0.7799) or normal birth weight children (P = 0.8976). Conclusions: The small size of sample may be the explanation for these results; future studies with more patients are needed to confirm the effect of H19/RsaI polymorphism on birth weight of LW newborns.

Antibiotic Therapy for Very Low BirthWeigh Newborns in NICU

Background: Prolonged empiric antibiotics therapy in neonates results in several adverse consequences including widespread antibiotic resistance, late onset sepsis (LOS), necrotizing enterocolitis (NEC), prolonged hospital course (HC) and increase in mortality rates. Objectives: To assess the risk factors and the outcome of prolonged empiric antibiotic therapy in very low birth weight (VLBW) newborns. Materials and Methods: Prospective study in VLBW neonates admitted to NICU and survived > 2 W, from July 2011 - June 2012. All relevant perinatal and postnatal data including duration of antibiotics therapy (Group I < 2W vs Group II > 2W) and outcome up to the time of discharge or death were documented and compared. Results: Out of 145 newborns included in the study, 62 were in group I, and 83 in Group II. Average duration of antibiotic therapy was 14 days (range 3 - 62 days); duration in Group I and Group II was 102.3 vs 25.510.5 days. Hospital stay was 22.311.5 vs 44.3 14.7 days, respectively. Multiple regression analysis revealed following risk factors as significant for prolonged empiric antibiotic therapy: VLBW especially < 1000 g, (P < 0.001), maternal Illness (P = 0.003), chorioamnionitis (P = 0.048), multiple pregnancy (P = 0.03), non-invasive ventilation (P < 0.001) and mechanical ventilation (P < 0.001). Seventy (48.3%) infants developed LOS; 5 with NEC > stage II, 12 (8.3%) newborns died. Infant mortality alone and with LOS/NEC was higher in group II as compared to group I (P < 0.002 and < 0.001 respectively). Conclusions: Prolonged empiric antibiotic therapy caused increasing rates of LOS, NEC, HC and infant mortality

Desmame em recém-nascidos de muito baixo peso ao nascer no primeiro retorno ambulatorial após a alta hospitalar

Investigate intrahospital and neonatal determinants associated to the weaning of very low birth weight (VLBW) infants. Methods: 119 VLBW (<1500g) infants 81 were monitored from July 2005 through August 2006, from birth to the first ambulatory visit after maternity discharge. This maternity unit uses the Kangaroo Method and the Baby Friendly Hospital Initiative. Results: Out of 119 VLBW infants monitored until discharge, 88 (75%) returned to the facility, 22 (25%) were on exclusive breastfeeding (EB) and 66 (75%) were weaned (partial breastfeeding or formula feeding). Univariate analysis found an association between weaning and lower birth weight, longer stays in the NICU and longer hospitalization times, in addition to more prolonged enteral feeding and birth weight recovery period. Logistic regression showed length of NICU stay as being the main determinant of weaning. Conclusion: The negative repercussion on EB of an extended stay in the NICU is a significant challenge for health professionals to provide more adequate nutrition to VLBW infants

Trajetórias e fatores associados a qualidade de vida de mães de recém-nascidos pré-termos de muito baixo peso até três anos após o parto

Preterm birth is a public health problem worldwide. It holds growing global incidence rates, high mortality rates and a risk of the long-term sequelae in the newborn. It is also poses burden on the family and society. Mothers of very low birth weight (VLBW) preterm infants may develop psychological disorders, and impaired quality of life (QoL). Factors related to mothers and children in the postpartum period may be negatively associated with the QoL of these mothers. The aim of this study was to assess factors possibly associated with the QoL of mothers of VLBW preterm newborns during the first three years after birth. Mothers of VLBW preterm answered the World Health Organization Quality of Life (WHOQOL)-bref and the Beck Depression Inventory (BDI) in five time points up to 36 months postpartum, totalizing 260 observations. The WHOQOL–bref scores were compared and correlated with sociodemographic and clinical variables of mothers and children at discharge (T0) and at six (T1), twelve (T2), 24 (T3) and 36 (T4) months after the delivery. We used the Kruskal Wallis test to compared scores across different time points and correlated WHOQOL-bref scores with the sociodemographic and clinical variables of mothers and preterm infants. Multiple linear regression models were used to evaluate the contribution of these variables for the QoL of mothers. The WHOQOL–bref scores at T1 and T2 were higher when compared to scores in T0 in the physical health dimension (p = 0.013). BDI scores were also higher at T1 and T2 than those at T0 (p = 0.027). Among the maternal variables that contributed most to the QoL of mothers, there were: at T0, stable marital union (b= 13.60; p= 0.000) on the social relationships dimension, gestational age (b= 2.38; p= 0.010) in the physical health dimension; post-hemorrhagic hydrocephalus (b= -10.05; p= 0.010; b= -12.18; p= 0.013, respectively) in the psychological dimension; at T1 and T2, Bronchopulmonary dysplasia (b= -7.41; p= 0.005) and female sex (b= 8,094; p= 0.011) in the physical health dimension and environment, respectively. At T3, family income (b= -12.75’ p= 0.001) in the environment dimension, the SNAPPE neonatal severity score (b= -0.23; p= 0.027) on the social relationships dimension; at the T4, evangelical religion (b= 8.11; p= 0.019) and post-hemorrhagic hydrocephalus (b: -18.84 p: 0.001) on the social relationships dimension. The BDI scores were negatively associated with WHOQOL scores in all dimensions and at all times points: (-1.42 ≤ b ≤ -0.36; T0, T1, T2, T3 and T4). We conclude that mothers of preterm infants VLBW tend to have a transient improvement in the physical well-being during the first postpartum year. Their quality of life seems to return to levels at discharge between two and three years after delivery. The presence of maternal depressive symptoms and diagnosis of post-hemorrhagic hydrocephalus or BDP are factors negatively associated with the QoL of mothers. Social, religious and economic variables are positively associated with the QoL of mothers of VLBW preterm.