Made available in DSpace on 2017-07-10T14:17:11Z (GMT). No. of bitstreams: 1 DISSERTAcaoO MILENE ROVER.pdf: 5749062 bytes, checksum: 18f8d6f313597b7afe33896aa5a3c610 (MD5) Previous issue date: 2015-03-13 / The increasing survival of preterm infants with birth weight below 1500 grams (VLBW) determines the need for a focus on care and follow-up of this group after discharge from the Neonatal Intensive Care Unit (NICU). Based on the high morbidity rate and changes in the growth of these children, the growth follow-up of the VLBW preterm is turned into an essential tool for monitoring its health. Thus, this study aims to: evaluate the growth of the VLBW preterm from birth to 12 months of Corrected Age (CA) after the NICU s discharge; describe the Z score profile of the anthropometric variables from birth to 12 months of CA; identify events that have influenced the Extra Uterine Growth Restriction (EUGR) during hospitalization and in the 12 month period of follow-up; identify the morbidities that have influenced the growth of the VLBW preterm. It is a quantitative, observational, longitudinal, retrospective and cross sectional study, which was realized in High Risk Follow up Ambulatory. The study enrolled 71 children who were attended between 2006-2013, with birth weight below 1500 g; admitted to the NICU at birth and had at least three outpatient visits in the following periods: period I up to 3 months of CA; period II between 4-6 months of CA and period III between 7-12 months of CA. In order to classify the relation Weight/Gestational Age (GA) the Fenton and Kim s curve was used. Besides, to calculate the Z score, the Research Bulk Calculator and the Anthro calculators were used. The variables were analyzed by logistic regression with XLSTAT program. The GA average was 29.4 weeks; 36 (51%) PT male, 50 (70%) PT babies the weight was Appropriate for GA (AGA). During hospitalization, 43 (61%) babies used Parenteral Nutrition. The weight score Z average at birth was -0.95; at the hospital discharge -3.05; in period I -2.4; period II -1.8; period III -1.2. The height at birth was -1.21, at discharge -2.23; -2.5, -1.8 and -1.1 for the periods I, II and III, respectively. Regarding the Head Circumference (HC): Z score at birth was -0.71; at discharge -1.5; and monitoring -1.1, -0.8 and -0.5, respectively in the periods I, II and III. Presenting AGA birth weight, shorter hospitalization and percentage of lost weight during the hospitalization, reduce the chance for EUGR. In the follow up period, the occurrence of metabolic bone disease, retinopathy of prematurity, gastro esophageal reflux and hospitalization, increase the EUGR chance. Despite of the substantial reduction in the Z score during hospitalization, there was a progressive improvement during follow up in this score in the three anthropometric variables, especially in the HC. At 12 months of CA 86% of infants were with Z score above -2 in relation to HC. Thus, it was possible to verify the importance of nutrition in the neonatal period, as well as, the proper and systematic follow-up in order to minimize the consequences and changes in the growth caused by prematurity, focusing on the full potential of preterm. / A crescente sobrevida de Prematuros (PT) com peso ao nascimento abaixo de 1.500 gramas (PTMBP) determina a necessidade do enfoque no atendimento e acompanhamento desse grupo após alta da Unidade de Terapia Intensiva Neonatal (UTIN). Frente ao elevado índice de morbidades e alterações no crescimento dessas crianças, o acompanhamento do crescimento infantil do PTMBP se traduz em ferramenta essencial à vigilância à sua saúde. Nesse contexto, têm-se como objetivos: avaliar o crescimento do PTMBP do nascimento aos doze meses de Idade Corrigida (IC) após a alta da UTIN; descrever o perfil do escore Z das variáveis antropométricas do nascimento até aos 12 meses de IC; identificar intercorrências que influenciaram o Retardo de Crescimento Extrauterino (RCEU) durante a internação e no período de 12 meses de seguimento ambulatorial; identificar as morbidades que influenciaram o crescimento dos PTMBP. Estudo quantitativo, observacional, longitudinal, retrospectivo e de corte transversal, realizado em Ambulatório de Seguimento de Alto Risco. Participaram do estudo 71 crianças atendidas entre 2006 a 2013, nascidas com peso menor de 1.500 g; que ficaram internadas na UTIN ao nascimento e realizaram pelo menos três consultas ambulatoriais, nos seguintes períodos: período I - até 3 meses de IC; período II - entre 4 a 6 meses de IC e período III - entre 7 a 12 meses de IC. Para relação Peso/Idade Gestacional (IG) foi utilizada a curva de Fenton e Kim. O escore Z obteve-se na Calculadora de Pesquisa em Massa disponível em: http://www.ucalgary.ca/fenton/ e calculadora Anthro. As variáveis foram analisadas por meio da regressão logística com o programa XLStat 2014. A IG média foi de 29,4 semanas, 36 (51%) masculinos, 50 (70%) PT eram Adequados para a IG (AIG). Na internação, 43 (61%) PT fizeram uso de Nutrição Parenteral (NP). Média do escore Z do peso ao nascimento: -0,95; na alta hospitalar: -3,05; no período I: -2,4; no período II: -1,8; no período III: -1,2. A média da estatura foi: -1,21 ao nascimento; -2,23 na alta; -2,5, -1,8 e -1,1 nos períodos I, II e III, respectivamente. Em relação ao Perímetro Cefálico (PC): escore Z ao nascimento foi -0,71; na alta: -1,5; e seguimento: -1,1, -0,8 e -0,5, respectivamente nos períodos I, II e III. Apresentar o peso AIG, menor tempo de internação na UTIN e porcentagem de peso perdido na hospitalização, reduz a chance de RCEU. No seguimento ambulatorial, a ocorrência de doença metabólica óssea, retinopatia da prematuridade, refluxo gastroesofágico e reinternação, aumentam a chance de RCEU. Apesar da importante queda do escore Z durante a internação, houve melhora progressiva durante o seguimento ambulatorial nos índices de escore Z das três variáveis antropométricas, principalmente do PC. Sendo que com 12 meses de IC, 86% das crianças acompanhadas estavam com escore Z acima de -2 em relação ao PC. Verifica-se a importância da nutrição no período neonatal, assim como, do seguimento ambulatorial adequado e sistematizado, visando minimizar as sequelas e alterações no crescimento advindas da prematuridade, na busca de alcançar todo o potencial do RNPT.

Neural tube defects (NTD) are among the most common birth defects and the leading cause of infant mortality. NTDs occur when the neural tube fails to close during early fetal development. The two most common types of NTD are spina bifida and anencephaly. NTDs result in lifelong complications like musculoskeletal deformities and loss of strength. The etiology of NTDs is complex and involves still unclear environmental and genetic factors. However, one of the well-established risk factors of NTDs is folic acid deficiency. The prevalence of NTDs can be lowered by an adequate intake of folic acid in the periconceptual period. In 1996, the Food and Drug Administration mandated that 140 micrograms of folic acid be added to 100 grams of bleached grain products with the goal of reducing the prevalence of NTDs. In the years following this fortification mandate, studies have shown that blood folate levels have more than doubled on average, that there are demographic and socioeconomic disparities in blood folate gains and that NTD rates have declined. However, no studies after the mandate have examined changes in blood folate distribution and differences in NTD prevalence by a wide range of theoretically and biologically relevant risk factors after the mandate. Using a nationally representative sample of non-institutionalized women of reproductive age, I investigated the relationship between the fortification mandate and blood folate levels. I also examined changes in the range/spread of blood folate distribution after the mandate. Using data on US live births from 45 states and the District of Colombia, the second study examined whether (1) the disparities in blood folate changes translate into differences in NTD prevalence and (2) NTD risk factors moderate the association between the mandate and NTD prevalence,. The final study explored potential unintended impacts of the mandate on birth weight, low birth weight, very low birth weight, high birth weight, and physician-diagnosed developmental delay, asthma and allergies. For this study, I employed samples from the Natality files and the National Survey for Children's Health. The cumulative results of my research suggested that the mandate was associated with increases in blood folate concentration, with greater increases in higher quantiles of the blood folate distribution and that the spread of blood folate distribution after the mandate widened. Additionally, the mandate was associated with a decrease in the prevalence of NTDs in the entire US population although the impact of the mandate was moderated by race/ethnicity, maternal educational attainment, acute illness during pregnancy and infant region of birth. Furthermore, the mandate was associated with other unintended infant and child health outcomes such as average birth weight increases in the population and increased risks of developmental delay among six year olds. This research is the first of its kind to examine changes in the spread of blood folate distribution after the mandate and whether NTD risk factors moderate the association between the mandate and NTD prevalence. It is also the first study to explore potential impacts of the actual mandate (not prenatal folic acid supplementation) on other unintended infant and child health outcomes. The results add significantly to our understanding of the effects of the mandate and have important implications for health care providers, women of reproductive age and policy makers because of the potentially increased risk of developmental delay among children and the increasing disparity in blood folate concentrations after the mandate.

Adverse birth outcomes and adverse childhood experiences (ACE) are concerns in the United States, with potential to impact health indices now and in the future. The purpose of this study was to quantitatively examine the association between maternal exposure to ACE, low birth weight, and county of residence in the Appalachian population using the Life Course Approach as the theoretical framework. A cross-sectional study design and clustering strategy was used to randomly select potential respondents from a data set that was provided by Ohio Department of Health. Self-administered questionnaires were sent to potential respondents to collect information about ACE in the maternal population of Appalachia, Ohio with an overall response rate of 29.5% and 212 total participants. A chi-square analysis was completed and no significant association was found between county of residence and risk of low birth weight. However, statistically significant associations were found between the different types of ACE exposure and low birth weight delivery as well as Appalachian county of residence and exposure to ACE. As the sample of low birth weight deliveries was small, it is recommended that the relationship between ACE exposure and low birth weight be further studied to develop more purposeful health interventions to improve maternal health in Appalachia, Ohio specifically, as well as other rural communities. Reducing rates of adverse birth outcomes and chronic disease burden in Appalachia have potential to reduce health disparities between urban and Appalachian communities, allowing for positive social change for many socioeconomically disadvantaged communities and improving population health.

Low birth weight (LBW) is a major public health concern globally. Despite its negative social and economic impact on the family and community at large, it has remained relatively unexplored at population level in Zimbabwe. The purpose of the study was to establish determinants of LBW using data from the 2015 Zimbabwe Demographic and Health Survey. The socioecological model was the conceptual framework for the study. A secondary analysis was conducted on 4,227 mother-infant dyads. Independent variables were duration of pregnancy, number of births within the past 5-year period, exposure to mass media, type of fuel used for cooking in the household, and intimate partner violence. Covariates were maternal age at delivery, place of residence, anemia, marital status, education, wealth index, ever terminated pregnancy, infant sex, and alcohol consumption. For parsimony, statistical significance was set at p < 0.05 at the 95% confidence interval (CI). Multivariable logistic regression analysis showed that mild maternal anemia (adjusted odds ratio [aOR] 1.83 CI 1.17-2.87 p = 0.01), moderate to severe anemia (aOR 1.80 CI 1.01-3.19 p = 0.05), and being a female neonate (aOR 1.48 CI 1.17-2.87 p = 0.008) had higher odds for LBW. Pregnancy duration of 8 months (aOR 0.01 CI 0.003-0.039 p < 0.001) and of 9 months (aOR 0.12 CI 0.04-0.33 p = 0.001) had lower odds for LBW. Birth of 2 infants within a 5-year period (aOR 2.40 CI 1.24-4.66 p = 0.01) was associated with LBW. Implications for positive social change include coming up with a health policy on the management of anemia during pregnancy and health promotion messages to promote optimal birth spacing, including strategies that reduce chances for preterm deliveries.

Trisomy 21 (T21), trisomy 18 (T18) and trisomy 13 (T13) represent the most common autosomal trisomies detected in live-born infants. Previous studies have addressed interventions, morbidities and survival in term or near-term infants with T21, T18 or T13, or were limited by a small number of patients. However, the combination of one of these chromosomal anomalies and very low birth weight (VLBW) presents greater challenges. Data from the NICHD Neonatal Research Network (NRN) and from the Vermont Oxford Network (VON) databases were used to examine the frequency, interventions, risk of mortality and neonatal morbidities, including patent ductus arteriosus (PDA), necrotizing enterocolitis (NEC), late onset sepsis (LOS), retinopathy of prematurity (ROP), and bronchopulmonary dysplasia (BPD), among VLBW infants with T21, T18 or T13 compared to VLBW infants without major birth defects (BD) and VLBW infants with non-chromosomal BD. Anthropometric VON charts for the assessment of birth weight for gestational age among 22 week to term infants with T21, T18 or T13 were also developed. In the VON database (n=539,509), the frequency of VLBW infants diagnosed with T21 was 1681 (0.31%), with T18 was 1416 (0.27%), and with T13 was 435 (0.08%). Major surgery was reported for 30.4% of infants with T21, 9.2% with T18, and 6.8% with T13. In-hospital mortality occurred for 33.1% of infants with T21, 89.0% with T18, and 92.4% with T13. Median survival time was 4 days (95% CI: 3-4) among infants with T18 and 3 days (95% CI: 2-4) among infants with T13. Birth weight for gestational age charts were created using VON data with a total of 5147 infants with T21 aged 22-41 weeks, 1053 infants with T18 aged 22-41 weeks, and 613 infants with T13 aged 22-40 weeks. Among the three groups, infants with T18 were the most likely to be growth restricted while infants with T21 were the least likely to be growth restricted. The new anthropometric VON charts for infants with T21 were also compared to the Lubchenco and Fenton charts and both showed frequent misclassification of infants with T21 as small or large for gestational age. In the NICHD NRN database (n=52,259), 133 (0.26%) VLBW infants were diagnosed with T21, 132 (0.25%) with T18 and 40 (0.08%) with T13. The adjusted relative risk, estimated using Poisson regression models with robust variance estimators, showed an increased risk of death, PDA, NEC, LOS, and BPD among infants with T21 relative to infants with no BD. Relative to infants with non-chromosomal BD, infants with T21 were at increased risk of PDA and NEC. A trend toward a lower risk of ROP was observed among infants with T21 compared to infants with non-chromosomal BD and infants without major BD. Infants with T13, but not infants with T18, were less likely to be mechanically ventilated than infants with T21 and infants without BD. Infants with T18 had increased risk of PDA compared to infants with T13, infants with T21 and infants without BD and increased risk of BPD compared to infants with T21 and infants without BD. The current studies evaluated the largest cohorts of VLBW infants with T21, T18 or T13. These data are important to help families and care providers make informed decisions involving the care of their VLBW infants with these chromosomal anomalies.

The purpose of this study is to assess the prevalence of low birth weight among non-Hispanic Blacks and non-Hispanic Whites along the rural/urban continuum, as well as the combined effect of being both non-Hispanic Black and residing in a completely rural county. Degree of social isolation and lack of support are proposed mechanisms for explaining disparities in low birth weight for Blacks in rural counties. Using data from the National Longitudinal Survey of Youth 1979 (NLSY79) and the National Longitudinal Survey of Youth 1979 Child (NLSY79-C) datasets, logistic regression models were used to estimate the odds of low birth weight. Key variables employed in these models include race/ethnicity, a five category measure of counties by degree of rural versus urban residence, interaction terms for race by county categorization, measures of the degree of community level support or isolation, household composition as a measure of the family support structure, access to medical care, maternal SES, birth characteristics, and maternal pregnancy behavior. Results demonstrate that Blacks have much higher odds of low birth weight than Whites and living in a completely rural county exacerbates disadvantage in birth weight outcomes for non-Hispanic Blacks but not for non-Hispanic Whites. The community and household level support measures have little mediating effect on the magnitude of the negative birth weight outcomes found for non-Hispanic Blacks in the most rural counties. However, the first order effect for non-Hispanic Blacks was almost completely explained by the presence of the father in the household when interaction effects for race and place of residence were also included in the model.

The associations of neighborhood level socioeconomic deprivation and low birth weight were investigated among 1,030,443 singleton live births in the State of Florida between the years 1992 and 1997. Census data for per capita income, unemployment, percent of individuals living below the poverty line, vehicle ownership and educational attainment were used as neighborhood level indicators of socioeconomic status. Additionally, these variables were combined into a deprivation index to measure relative deprivation of neighborhoods across Florida. Birth data were linked to census block groups and tracts, which were used as proxies for low birth weight. Multilevel models were used to model the relationship between the deprivation index and each of the indicators and low birth weight, while adjusting for individual level risk factors. After adjusting for individual level factors no consistent relationship between neighborhood socioeconomic measures and low birth weight could be established. The relationship between neighborhood socioeconomic factors and low birth weight varied across ethnic categories. Among White Non-Hispanics and Hispanics measures of socioeconomic deprivation had a small association with low birth weight. However, for Black Non-Hispanics neighborhood measures had little consistency in predicting the occurrence of low birth weight

The primary objective of this study was to evaluate the associations between psychosocial stressors, urine sugar levels, and subsequent birth outcomes, specifically high birth weight babies and Caesarean section births. In a prospective cohort study, 506 Black and White women of childbearing age were followed for the duration of one pregnancy in Tuscaloosa and Mobile counties in Alabama from 1990 to 2001. Participants were interviewed twice throughout pregnancy, during the first and third trimesters, respectively, and birth outcome data were collected via medical chart reviews. Six percent (6.1%) of the women in the sample had a high birth weight baby, and 18.4% received a C-section during childbirth. Adjusted logistic regression results indicate that urine sugar levels are predictive of high-weight births, with women who have higher urine sugar levels were more than three times likely to birth a high weight baby compared with women who have no detectable urine sugar spill (OR 3.25; 95% CI 1.30, 8.10). In addition, the interaction of familial social support throughout pregnancy, physical or verbal abuse during the second and third trimesters, and ethnicity is significantly associated with increased risk of having a high birth weight baby. For C-section, single participants are over two times less likely to receive a C-section during childbirth compared with currently married participants (OR 0.46; 95% CI 0.21-1.00). Examining structural equation modeling results; pathways leading from urine sugar levels, physical or verbal abuse during the latter half of the pregnancy, and a mother's social support among White participants are indicative of high weight births (R² = 0.65). White abused women who receive their mother's social support are more likely to have a high birth weight baby compared with both White and Black women who are not abused and receive the same amount of social support. Recommendations to public health practitioners include primary prevention through promotion of familial support during pregnancy, secondary prevention through urine sugar screening at every prenatal visit, and direct intervention by identifying and inquiring about instances of suspected abuse during pregnancy.

Abstract not available

Intrauterine Growth Restriction (IUGR) is evident in infants born with a reduced weight or length, and/or increased thinness for gestational age. IUGR is associated with altered postnatal growth and regulation, due to unknown mechanisms. Much clinical IUGR results from the reduced delivery of essential substrates (oxygen and nutrients) to the fetus, due to either maternal or placental limitations. Catch-up growth (accelerated rate of growth in absolute or fractional terms) occurs in the majority of IUGR infants, and returns an infant to their predetermined growth curve. IUGR is associated with increased risks of morbidity and mortality in the perinatal period, and with a reduced final adult stature and increased risk of adult onset diseases, particularly diabetes and cardiovascular disease. Catch-up growth after IUGR predicts improved health in terms of reduced hospital visits in infants and children, and an increased final adult stature but also predicts an increased risk of developing obesity, as well as diabetes and cardiovascular disease. The underlying mechanisms for catch-up growth may contribute to this range of outcomes in later life, but are poorly understood. Studies in IUGR infants have demonstrated increased absolute and/or fractional growth rates following birth, termed catch-up growth, in the presence of reduced or normal plasma concentrations of the thyroid hormones and major anabolic hormones (insulin and/or IGF-I). This suggests that increased sensitivity to, rather than increased production of insulin, IGF-I and thyroid hormone, causes catch-up growth following IUGR. We therefore hypothesised that placental restriction of fetal growth would reduce size at birth and increase postnatal growth and adiposity in association with increased metabolic sensitivity to insulin, IGFs and thyroid hormones. This study has shown that the placentally restricted (PR) lamb has a reduced size at birth in terms of soft and skeletal tissues, has increased rates of growth postnatally, and has increased adiposity by six weeks of age. We have also shown that PR of fetal growth in the sheep did not alter gestational age at delivery, but reduced survival rate. PR lambs demonstrated catch-up growth in most parameters by 30 days of age and increased adiposity at six weeks of age compared to the control lambs. Placental restriction increased insulin and IGF sensitivity of circulating free fatty acids, which in turn, predicts increased adiposity. Neonatal catch-up growth after fetal growth restriction was substantially predicted by both abundance of, and metabolic sensitivity to insulin, suggesting increased insulin action as an underlying cause. Catch-up growth occurs in the neonate despite reduced concentrations of fasting plasma IGFs, along with increased IGF sensitivity of free fatty acid metabolism and adiposity. Plasma TH concentrations predicted growth of soft and skeletal tissue in lambs during early postnatal life, particularly in those undergoing catch-up growth following PR. Therefore neonatal catch-up growth after IUGR is associated with increased sensitivity to both insulin and IGFs, particularly of circulating free fatty acids, and appears to occur to the extent allowed by the prevailing abundance of these hormones and of thyroid hormones. If this altered endocrine state persists, increased adiposity and its subsequent amplification may contribute to the development of obesity, and related adverse metabolic and cardiovascular outcomes in adult life. / Thesis (Ph.D.)--School of Molecular and Biomedical Science, 2004.