Nas últimas semanas gestacionais ocorrem importantes alterações na atividade cerebral, tornando-se relevante monitorar o desenvolvimento neurológico de recém-nascidos pré-termos tardios (RNPT-T). Além disso, com os avanços nas unidades de terapia intensiva neonatais (UTIN) os profissionais de reabilitação, fisioterapeutas (FT), terapeutas ocupacionais (TO) e fonoaudiólogos (FG), são considerados integrantes fundamentais na equipe multidisciplinar. Objetivo: (1) avaliar o estado neurocomportamental de recém-nascidos (RNs) de 36 a 36 semanas e 6 dias de idade gestacional (IG) e de 37 a 37 semanas e 6 dias de IG; (2) examinar o papel atual dos profissionais de reabilitação (FT, TO e FG) nas UTINs canadenses e comparar com os dados de um survey de 15 anos atrás. Método: (1) Trata-se de um estudo de corte transversal. A amostra foi definida por conveniência e constitui-se de 20 RNs, sendo 8 RNPT-Ts e 12 recém-nascidos a termo (RNT), de ambos os sexos, internados no Alojamento Conjunto do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, São Paulo, Brasil. Foi realizada uma avaliação do desenvolvimento neurocomportamental através da Neurobehavioral Assessment Preterm Infant (NAPI), em que os bebês foram avaliados em uma sequência invariável nos sete domínios da escala: sinal do cachecol, desenvolvimento motor/vigor, ângulo poplíteo, alerta e orientação, irritabilidade, qualidade do choro e percentual adormecido. Foi realizada uma análise descritiva dos dados. O teste de Mann-Whitney foi utilizado para a comparação dos escores entre os RNPT-T e RNT e comparação entre o gênero e o teste-t de Student para duas amostras independentes foi utilizado para a comparação do grupo de RNPT-T com três estudos nacionais envolvendo o NAPI. (2) Trata-se de um survey do tipo entrevista, via telefone no qual foi conduzido em todas as UTINs canadenses que integram a Canadian Neonatal Network. Um total de 42 questionários foi completado proveniente de 31 instituições de saúde canadenses. Foram realizadas uma análise descritiva das variáveis e a comparação dos dados com o survey realizado há 15 anos.O teste Exato de Fisher foi utilizado para investigar a relação entre a disponibilidade do profissional de reabilitação e o tipo de intervenção por ele conduzida. Em ambos os estudos foi adotado o valor de p 0,05. Resultados: (1) Não houve diferença significativa entre os escores do NAPI comparados entre os grupos RNPT-T e RNT. Houve diferença significativa entre o grupo de RNPT-T com os outros três estudos, em todos os domínios da escala NAPI. (2) Pelo menos um profissional de reabilitação oferece serviço em hospitais pediátrico, adulto e geral. Os profissionais participam de grupos para promover a educação do processo do cuidado, principalmente para os membros da equipe multidisciplinar das unidades e para os pais e familiares dos RNs. Além disso, estão envolvidos com discussão de caso, processo de tomada de decisão, planejamento da alta hospitalar e referenciam RNs para outros serviços. Em relação às intervenções, splinting e amamentação, foram identificadas como sendo atividades realizadas mais por TO, sendo que fisioterapia respiratória e exercícios que englobam amplitude de movimento são realizados mais por FT. Conclusão: (1) Não há diferenças entre o grupo RNPT-T e RNT em relação ao desenvolvimento neurocomportamental na amostra estudada. Os RNPT-Ts demonstram-se mais acordados e ativos durante a avaliação, entretanto, com baixo estado de alerta e orientação, sugerindo que atenção em fatores ambientais e ações no cuidado do RNPT-T na unidade de alojamento conjunto devem ser investigadas. (2) Ao longo da última década, as mudanças no papel dos profissionais de reabilitação evidenciaram maior participação com a equipe multidisciplinar, colaboração nas discussões e planejamento das atividades nas unidades, educação continuada e maior tempo despendido no cuidado com os RNs nas UTINs. / Neonatal neurobehavioral examinations describe newborns behavioral repertoire and observable responses to environmental stimulus and in the neonatal intensive care unit (NICU), rehabilitation specialists are considered an integral part of the multidisciplinary team. New approaches to rehabilitation practice have evolved to promote child health and developmental outcomes. Aim: This study aimed (1) to evaluate the neurobehavioral of healthy late preterm (LP) and full-term infants (FTI) using Neonatal Neurobehavioral Assessment Preterm Infant (NAPI). (2) To describe the current roles in the NICU of the occupational therapist (OT), physical therapist (PT) and speech language pathologist (SLP) in Canadian NICU and compared to these roles documented 15 years ago. Method: (1) In this cross-sectional study, 20 babies were assessed. Eight infants born with 36 weeks gestational age (GA) and 6 days late preterm group (LPG) 12 infants born with 37 weeks GA and 6 days the full-term infants (FTI) in a tertiary health care institution of São Paulo state, Brazil were assessed 24 hour after birth, using NAPI. The infants were assessed in seven clusters of NAPI: scarf sign, motor development and vigor, popliteal angle, alertness and orientation, irritability, cry quality and percent asleep ratings. A descriptive analysis was conducted and Mann-Whitney test was used for comparison between groups and Students t test for two independent sample was conducted for comparison with three Brazilian studies. (2) In total, 42 questionnaires were completed from rehabilitation departments in 31 Canadian health care institutions. A descriptive analysis was conducted and The Fisher Exact Test was conducted to investigate the relationship between availability of rehabilitation specialist and type of intervention. In both studies the p value was 0,05. Results: (1) There was no statistical difference between LPG and FTI groups. The infants of LPG group were more awake during the NAPI exam, although with lower alertness and orientation score. (2) Results demonstrate that all have some rehabilitation coverage and they provide service in pediatric, general and adult hospitals. All therapists provide education to staff and to families. Typically therapists are involved with case discussion, decision-making, referrals to other services and discharge planning. Splinting and feeding were most often carried out by OT whereas chest physiotherapy and range of motion (ROM) were predominantly accomplished by PT. Conclusion: (1) The comparison between LPG and FTI showed no statistical difference. New strategies in terms of care must be stimulated in the unit of data collect to promote best practice in late preterm infants. (2) Changes to the role of rehabilitation specialists over the last decade were perceived as participation with the NICU team, education and training, collaboration and discussion and modifications/interventions.

Made available in DSpace on 2016-06-02T19:44:17Z (GMT). No. of bitstreams: 1 6036.pdf: 5242612 bytes, checksum: 3cb0e318b6cda04ede7a26d39cfc78d5 (MD5) Previous issue date: 2014-02-25 / Universidade Federal de Sao Carlos / Learning to read is preceded by the acquisition of vocabulary, and premature birth is a risk factor for the delayed development of language. However, few studies have investigated the association between prematurity and delays in expanding vocabulary and learning to read and write. The present study was conducted with 20 students, aged 5 years 8 months to 6 years 6 months, 10 of whom were born late preterm and 10 were born full term. Their receptive and expressive vocabulary was initially assessed. A computerized program was then implemented to expand vocabulary and teach reading and writing. The late preterm students average gestational age was 35 weeks, and their average birth weight was 2,450 g. The full term students gestational age was 39 weeks, and their average birth weight was 3,146 g. The predominant classification of nutritional status among the students was appropriate for their gestational age and weight. The results showed similar performance between late preterm students and full term students in receptive skills, such as expressive vocabulary, which was lower than expected for their ages. In expansive vocabulary, all of the students achieved 100% accuracy in the selection of figures. In the picture-naming task, late learners who were born preterm had higher scores than those born full term (93% vs. 76%). None of the students read or wrote (dictation) any of the words presented in the pretest. In the post-test, we found the partial emergence of reading and speaking repertoires among the students. The two groups read 50% and 40% of the words correctly and wrote 29% and 12% of the words correctly, respectively. Therefore, the performance of late preterm students was higher compared with full term students in both reading and writing. Prematurity is a multifactorial event, and other factors may have potentially interfered with linguistic development in these children. Regardless of the condition of their birth, all of the students scored below the expected range for typical development in word recognition and naming. The correlation that was observed in the post-test confirmed the predictive relationship described in the literature between receptive vocabulary and reading acquisition in late preterm and full term infants and expressive vocabulary acquisition and writing in late preterm infants. Differences were found between oral reading among late preterm students and receptive reading (or recognition) among full term students. Similar to writing, speaking was correlated with expressive vocabulary only among late preterm students. These results strongly suggest the need to implement and maintain literacy interventions in the study participants using different classes of verbal operants that feature oral language. / O aprendizado de leitura é precedido pela aquisição de vocabulário e a prematuridade é um fator de risco para o desenvolvimento da linguagem, de forma que alguns estudos têm investigado a associação da prematuridade com atrasos em vocabulário, leitura e escrita. Este estudo, conduzido com vinte alunos na faixa etária de cinco anos e oito meses a seis anos e seis meses, dez pré-termo tardios e dez a termo, avaliou, inicialmente, seu vocabulário receptivo e expressivo. Em seguida, implementou e avaliou efeitos de um programa informatizado para ampliação de vocabulário no ensino de leitura e emergência de escrita dos mesmos alunos. Os valores médios para idade gestacional e peso ao nascimento foram de 35 semanas e 2.450 g entre os alunos prétermo tardios e de 39 semanas e 3.146 g entre os nascidos a termo. Na relação idade gestacional e peso ao nascimento, a classificação predominante entre os alunos foi de peso adequado para idade gestacional. Os resultados evidenciaram desempenhos similares entre os alunos pré-termo tardios e a termo tanto nas habilidades receptivas quanto nas expressivas de vocabulário, ambas avaliadas como inferiores ao esperado para as respectivas faixas etárias. Na ampliação de vocabulário, todos os alunos alcançaram 100% de acertos na seleção de figuras. Na nomeação de figuras os alunos pré-termo tardios acertaram mais que os nascidos a termo (93% versus 76%). Nenhum dos alunos lia ou escrevia (ditado) quaisquer das palavras apresentadas no pré-teste. No pós-teste, verificou-se a emergência parcial de repertórios de leitura e ditado entre os alunos: os dois grupos leram, respectivamente, 50% e 40% das palavras e escreveram corretamente 29% e 12% das palavras. Portanto, o desempenho dos pré-termo tardios foi superior ao dos nascidos a termo tanto em leitura quanto em escrita. Como a prematuridade é um evento multifatorial, potencialmente outros fatores interferiram no desenvolvimento linguístico destas crianças, uma vez que, independente da condição de nascimento, todos os alunos pontuaram abaixo do esperado para o desenvolvimento típico no reconhecimento de palavras e na nomeação de figuras. As correlações verificadas no pós-teste confirmaram a relação preditiva descrita na literatura entre vocabulário receptivo e aquisição de leitura (para pré-termo tardios e nascidos a termo) e vocabulário expressivo e aquisição de escrita (apenas entre pré-termo tardios); porém, indicaram diferenças entre leitura oral entre prétermo tardios e leitura receptiva (ou reconhecimento) entre os alunos nascidos a termo. Quanto à escrita, o ditado foi correlacionado ao vocabulário expressivo apenas entre os pré-termo tardios. Os resultados sugerem fortemente a necessidade de intervenções para instalar e manter, nas crianças dessa amostra, as diferentes classes de operantes verbais que caracterizam a linguagem oral e que serão críticas para a alfabetização.

Die Kaiserschnittrate erhöhte sich in den letzten Jahrzehnten in zahlreichen geburtshilflichen Kliniken. Diese Entwicklung ist problematisch, weil damit eine erhöhte pulmonale Morbidität der Neugeborenen verbunden sein kann. Die vor­ liegende Arbeit untersucht die Anpassung von späten Frühgeborenen (34,0–36,6 SSW) und 2 Gruppen von reifen Neugeborenen (37,0–37,6 und 40,6–40,6 SSW) in einem Level 1 Zentrum in Abhängigkeit vom Geburtsmodus. Eingeschlos­ sen wurden primär gesunde Kinder, die im Verlauf eines Jahres geboren wurden. Ausge­ schlossen wurden Kinder mit nachgewiesener angeborener Anomalie und Kinder mit einer schweren Anpassungsstörung (Apgar 5‘<6). Die Kaiserschnittrate lag bei 22% und war am höch­ sten bei späten Frühgeborenen (39%) im Ver­ gleich zu Kindern der 37. (30 %) und der 40. SSW (11%). Die Rate der Kinder, die mit CPAP behan­ delt werden mussten fiel von 88 % in der 34. SSW auf 17% in der 37. und 8% in der 40. SSW. Kinder nach Kaiserschnitt mussten im Vergleich zur spontan geborenen Kindern signifikant häufiger mit CPAP therapiert werden (50 vs. 12%). Dieser Unterschied war für späte Frühgeborene deutlich (82 vs. 36 %) und lag niedriger bei in der 37. (33 vs. 9 %) und 40. (26 vs. 6 %) SSW geborenen Kindern. Der deutlichste Unterschied fiel bei in der 36. SSW geborenen Kindern auf (66 vs. 9%). Die Ergebnisse der Analyse dokumentieren, dass ein Kaiserschnitt bei primär gesunden Kindern zu einer schlechteren respiratorischen Anpassung führt. Dies gilt besonders, jedoch nicht nur, für späte Frühgeborene und dort besonders für Kinder, die in der 36. SSW geboren werden. Die weltweit wachsende Rate von Kaiserschnittent­ bindungen sollte immer wieder kritisch hinter­ fragt werden. Eine Kaiserschnittentbindung ohne klare Indikation führt zu einer erhöhten Rate an respiratorischen Anpassungsstörungen, zur neo­ natologischen Aufnahme der Kinder und damit verbunden zu einer Störung der Mutter­Kind­Bindung, sowie zu einer unnötigen finanziellen Belastung des Gesundheitssystems. Es ist zu wünschen, dass die Daten der Studie benutzt werden, um in der Diskussion zwischen Eltern, Geburtshelfern und Neo­ natologen immer den besten Geburtsweg für das Kind zu finden. / The rates of delivery by Cesarean section (CS) have been trending upwards in recent decades, perhaps leading to higher rates of dysfunction in respiratory adaptation in newborns. We present epidemiological data for pulmonary adaptation by mode of delivery for healthy late preterm and term infants born at a regional tertiary care center. The overall CS rate was 22 % with the lar­ gest proportion of these in late preterms (39%). This drops to 30% in infants born after 37 weeks gestation and to 11% for those born after 40 weeks. Infants needing respiratory support de­ creased significantly as gestational age increased: 88% at 34 weeks, 67% at 35 weeks, 28% at 36 weeks, 17% at 37 weeks and 8% at 40 weeks. The risk of respiratory morbidity following CS as compared to vaginal delivery (VD) was substan­ tially higher. 50% of infants born by CS needed respiratory support compared to only 12% fol­ lowing VD. 82% of all late preterm infants born by CS developed respiratory morbidity compared to 36 % following VD. Comparable data for infants born after 37 and 40 weeks gestation were 33% compared to 9 % and 26 % compared to 6 % respec­ tively. Late preterm infants born after 36 weeks gestation showed the most marked difference by mode of birth with 66 % needing respiratory sup­ port following CS as compared to only 9 % follow­ ing VD. Our data could be useful in counselling parents about risk associated with delivery by Cesarean section. A critical view should be taken of increasing CS rates worldwide because of a clear correlation in increased morbidity in infants, especially late preterm infants.

Preterm birth (< 37 weeks gestation) is a major health burden for affected children. Although the risk of health problems increases as the gestational age decreases, research in the last decades has revealed that even late preterm infants born at 34-36 weeks gestational age have higher mortality and morbidity than term infants. Because late preterm infants constitute three fourths of preterm infants, they are important from both public health and health policy perspectives. This doctoral thesis sought to answer important knowledge gaps in health service utilization of late preterm infants via three studies. Study A, a systematic review and meta-analysis comparing health service utilizations of late preterm infants with those of term infants, found that late preterm infants had increased hospitalization compared with term infants that persisted from the neonatal period through adolescence. Study B is a cohort study evaluating the re-admissions and emergency department visits by late preterm and term singletons and twins for the first 5 years after birth. Study B demonstrated that late preterm infants had higher re-admission rates than term infants although differences in twins were less pronounced than in singletons. Study C is a population-based cohort study with cost analyses assessing the health care costs and resource utilization related to three different discharge timings of late preterm and term singletons: early (< 48 hours), late (48-71 hours), and very-late (72-95 hours) discharge after birth. Study C found that early discharge was not associated with the reduction of health care cost in late preterm infants, and instead was associated with an increase in the cost in term infants over the first year after birth. These findings are useful for parents, care providers, health policy makers, and guideline developers to provide optimal care for late preterm infants. / Thesis / Doctor of Philosophy (PhD)