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.

Objetivo: Avaliar os fatores perinatais associados ao óbito neonatal precoce em prematuros com peso ao nascer entre 400 e 1.500 g. Métodos:Coorte prospectiva e multicêntrica dos nascidos vivos com idade gestacional de 23 a 33 semanas e peso de 400-1.500 g, sem malformações em oito maternidades públicas terciárias universitárias entre junho de 2004 e maio de 2005. As características maternas e neonatais e a morbidade nas primeiras 72 horas de vida foram comparadas entre os prematuros que morreram ou sobreviveram até o sexto dia de vida. As variáveis perinatais associadas ao óbito neonatal precoce foram determinadas por regressão logística.Resultados: No período, 579 recém-nascidos preencheram os critérios de inclusão. O óbito precoce ocorreu em 92 (16%) neonatos, variando entre as unidades de 5 a 31%, e tal diferença persistiu controlando-se por um escore de gravidade clínica (SNAPPE-II). A análise multivariada para o desfecho óbito neonatal intra-hospitalar precoce mostrou associação com: idade gestacional de 23-27 semanas (odds ratio -OR = 5,0; IC95% 2,7-9,4), ausência de hipertensão materna (OR = 1,9; IC95% 1,0-3,7), Apgar 0-6 no 5º minuto (OR = 2,8; IC95% 1,4-5,4), presença de síndrome do desconforto respiratório (OR = 3,1; IC95% 1,4-6,6) e centro em que o paciente nasceu.Conclusão: Importantes fatores associados ao óbito neonatal precoce em prematuros de muito baixo peso são passíveis de intervenção, como a melhora da vitalidade fetal ao nascer e a diminuição da incidência e gravidade da síndrome do desconforto respiratório. As diferenças de mortalidade encontradas entre os centros apontam para a necessidade de identificar as melhores práticas e adotá-las de maneira uniforme em nosso meio.

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 X1 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. Keywords: fetal viability; steroids; cesarean section; cardiopulmonary resuscitation; infant newborn; neonatal mortality Introduction According to the International Liaison Group on Resuscitation, in 2010, 1 for neonates at the margins of viability or those with conditions that predict a high risk of mortality or morbidity, attitudes and practice vary according to region and availability of resources. 2 A systematic review 3 shows that at p22 weeks, no scientific society recommends active treatment for the mother to protect the fetus beyond offering compassionate care. A general agreement is also evident for week 25 0/7 to 25 6/7 : antenatal steroid administration are recommended, prenatal transport and Cesarean section are indicated to protect the fetus and resuscitation is offered to all infants without fatal anomalies. However, there exists a gray area for infants between 23 and 24 weeks, which, in some countries, extends through 25 weeks. 3 The active management of gestations at the limit of viability involves three important clinical decisions: the use of antenatal steroids, delivery method and resuscitation at birth. One prospective cohort study between 1993 and 2007 followed 5476 infants with 23 to 29 weeks gestation admitted for neonatal care. The overall mortality among infants exposed to maternal steroids was lower than in infants not exposed: 19% vs 35% at 24 to 29 weeks and 79% vs 89% at 23 weeks. 4 23, 24, 25 and 26 weeks, respectively. 5 In the same study, 8% of the 125 542 live births with 22 to 31 weeks of gestation had Apgar scores <4 at 5 min, which indicates that resuscitation procedures were frequently needed among preterm infants. However, extensive cardiopulmonary resuscitation at birth

This study is the first that highlights the effectiveness of T-piece resuscitator ventilation in improving relevant outcomes in preterm neonates.

The need of RBC transfusions in very-low-birth-weight preterm infants was associated with clinical conditions and birth center. The distribution of the number of transfusions during hospital stay may be used as a measure of neonatal care quality.

BackgroundPreterm infants in neonatal intensive care units frequently receive red blood cells (RBC) transfusions due to the anemia of prematurity. A number of variables related to gestational age, severity of illness and transfusion practices adopted in the neonatal unit where the neonate was born may contribute to the prescription of RBC transfusions. This study aimed to analyse the frequency and factors associated with RBC transfusions in very-low-birth-weight preterm infants.MethodsA prospective cohort of 4283 preterm infants (gestational age: 29.9 ± 2.9 weeks; birth weight: 1084 ± 275 g) carried out at 16 university hospitals in Brazil between January 2009 and December 2011 was analysed. Factors associated with RBC transfusions were evaluated using univariate and multiple logistic regression analysis.ResultsA total of 2208 (51.6 %) infants received RBC transfusions (variation per neonatal unit: 34.1 % to 66.4 %). RBC transfusions were significantly associated with gestational age (OR: -1.098; 95%CI: -1.12 to -1.04), SNAPPE II score (1.01; 1.00-1.02), apnea (1.69; 1.34-2.14), pulmonary hemorrhage (2.65; 1.74-4.031), need for oxygen at 28 days of life (1.56; 1.17-2.08), clinical sepsis (3.22; 2.55-4.05), necrotising enterocolitis (3.80; 2.26-6.41), grades III/IV intraventricular hemorrhage (1.64; 1.05-2.58), mechanical ventilation (2.27; 1.74-2.97), use of umbilical catheter (1.86; 1.35-2.57), parenteral nutrition (2.06; 1.27-3.33), >60 days of hospitalization (5.29; 4.02-6.95) and the neonatal unit where the neonate was born.ConclusionsThe frequency of RBC transfusions varied among neonatal intensive care units. Even after adjusting for adverse health conditions and therapeutic interventions, the neonatal unit continued to influence transfusion practices in very-low birth-weight infants.

Introduction: Meconium aspiration produces airway obstruction and surfactant inhibition. Bronchoalveolar lavage (BAL) and surfactant replacement have been proposed as treatments for the syndrome. Objective: To evaluate the effect of BAL with normal saline followed by a supplementary dose of surfactant in a piglet model of meconium aspiration syndrome. Methods: 15 newborn piglets were used in the study. The animals were ventilated with fixed settings. After inhalation of 4 ml/kg of diluted meconium, the piglets were randomized into three groups: group I (n = 5) – tracheal aspiration without BAL; group II (n = 5) – BAL with normal saline (15 ml/kg), and group III (n = 5) – BAL with normal saline (15 ml/kg) followed by a supplementary dose of surfactant (Curosurf® 100 mg/kg). Arterial blood gas samples were obtained 30 min and 6 h after the inhalation of meconium. Results: A significant increase of PaO₂ values at 6 h after treatment was only observed in group III (from 51 ± 13 to 189 ± 115 mm Hg; p = 0.04). At this time, PaO₂ in group III was significantly higher compared to group II (189 ± 115 and 37 ± 11 mm Hg, respectively; p = 0.023) and showed a borderline significance when compared to group I (p = 0.066). Conclusion: BAL with normal saline followed by a supplementary dose of surfactant may improve oxygenation in an experimental piglet model of meconium aspiration syndrome.

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