Orientadores: Antonio de Azevedo Barros Filho, Gladys Gripp Bicalho / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-07T03:27:15Z (GMT). No. of bitstreams: 1 Baldin_ElizangelaMariadeSouza_M.pdf: 1441616 bytes, checksum: 03cf071757ed3f3c1a0ce8282ecb4996 (MD5) Previous issue date: 2006 / Resumo: O presente estudo teve por objetivo estudar as crianças nascidas pré-termo em cidade de médio porte que precisaram de atendimento em Unidade de Terapia Intensiva e Cuidados Intermediários Neonatal, descrever sua morbimortalidade hospitalar e no primeiro ano de vida, e analisar a sua relação com o crescimento e desenvolvimento. Foi realizada uma pesquisa transversal entre 174 recém-nascidos pré-termos, com peso inferior a 1.750 gramas, atendidos na Unidade Neonatal da Irmandade da Santa Casa de Misericórdia de Mogi-Guaçu, Estado de São Paulo, no período de janeiro de 1999 a dezembro de 2003. As informações foram coletadas da ficha médica e por entrevista com os responsáveis pela criança, após o primeiro ano de vida. As crianças foram divididas em três grupos: óbitos e sobreviventes, com e sem alteração do desenvolvimento neuropsicomotor. Aplicou-se os testes de Qui-quadrado, Exato de Fisher e de Mann-Whitney para as análises entre os grupos. As medidas antropométricas após o primeiro ano foram comparadas com as referências do CDC, em percentis e escore z. Os resultados mostraram que dos 174 recém-nascidos pré-termos com peso inferior a 1750 g, 48 (27,6%) foram a óbito no período de internação e 126 (72,4%) tiveram alta hospitalar. As afecções mais freqüentes foram: doenças respiratórias 121(78%), infecção ovular 38 (24,5%), asfixia perinatal 34 (21,9%), distúrbio metabólico 18 (11,6%), icterícia 66 (42,6%), sepse 47 (30,3%) e anemia 35 (22,5%). A ocorrência de óbito durante a internação acometeu 33 (77,1%) os recém-nascidos com idade gestacional inferior a 30 semanas e 27 (56,3%) com peso menor que 1000g. As principais causas de óbito foram: prematuridade extrema 22 (53,7%), insuficiência respiratória 19 (39,5%) e sepse 10 (21,7%). Para a avaliação do crescimento e do desenvolvimento neuropsicomotor foram encontrados 104 (82,5%) das crianças sobreviventes com idade corrigida de 12 a 70 meses e constatou-se que 3 (2,3%) morreram no primeiro ano de vida. Em relação ao crescimento observou-se que 23 (22,1%) apresentaram-se abaixo do percentil 10 para altura, 68 (65,4%) entre o percentil 10-90 para altura e 13 (12,5 %) acima do percentil 90 para altura. Na avaliação do desenvolvimento neuropsicomotor 64 (61,5%) crianças apresentaram o desenvolvimento adequado e 40 (38,5%) com alterações a longo prazo, tais como: distúrbio de fala, atraso do desenvolvimento neuropsicomotor, paralisia cerebral e deficiência auditiva. Conclui-se que os recém-nascidos pré-termos assistidos em cidades de médio porte sobreviveram na sua maioria (72,4%) e apresentaram um crescimento e desenvolvimento adequados. Assim, os resultados sugerem que estas cidades de médio porte, uma vez preparadas e equipadas para o atendimento neonatal especializado, oferecem uma assistência que anteriormente seria disponível apenas em grandes centros e com resultados satisfatórios / Abstract: The present paper had the aim to study preterm infants born in a medium size town, describe their morbidity during their days of hospitalization and within their first year of age, and analyze its relationship with their growth and development. A cross-sectional research was carried out among 174 newborn preterm infants, with birth weight lower than 1.750 grams, cared for in the Neonatal Unity of Irmandade da Santa Casa de Misoricórdia in Mogi Guaçu, Sao Paulo, from January 1999 to December 2003. The information were collected from medical reports and by interviewing the people responsible for these children, after their first year of life. The children were divided into three groups: deaths and survivors; and the group of survivors was divided into two other groups with and without neurodevelopmental alterations. The tests of Chi-square, Fisher Exact and Mann-Whitney were applied for statistical analysis among the groups. The anthropometric measures after the first year were compared with the CDC references and Z score. The outcomes showed that of 174 newborn preterms with birth weight lower than 1.750 grams, 48 (27,6%) died during hospitalization and 126 (72,4%) were discharged. The more frequent impairments were: 121 (78%) with respiratory, 38 (24,5%) ovular infection, 34 (21,9%) perinatal asphyxia, 18 (11,6%) metabolic disturbance, 66 (42,6%) jaundice, 47 (30,3%) sepsis and 35 (22,5%) with anemia. The occurrence of deaths during hospitalization of newborn infants was 33 (77,1%) with gestational age lower than thirty weeks and 27 (56,3%) with birth weight lower than 1.000grams. The main causes were: 22 (53,7%) of extreme premature infants, 19 (39,5%) of respiratory insufficiency, and 10 (21,7%) of Sepsis. For the growth and neurodevelopmental evaluations were found that 104 (82,5%) of these children that survived with corrected age from 12 to 70 months and it was found that 3 (2,3%) died within their first year of age. Regarding growth it was observed that 23 (22,1%) were below the 10th percentile for height, 68 (65,4%) between 10th-90th percentile for height and 13 (12,5%) above the 90th percentile for height. In the neurodevelopmental evaluation 64 (61,5%) of these infants showed satisfactory development and 40 (38,5%) alterations in DNPM, such as: speech disorders, sensorial deficit, cognitive deficit, visual impairment and brain paralysis. We conclude that the majority of newborn preterm infants (72,4%), cared for in a medium size town, survived and showed satisfactory growth and development. From this point of view, the outcomes suggest that town with this characteristic, once prepared and equipped to assist newborn who need specialized assistance, provide conditions that would previously be available only in big cities and satisfactory outcomes. Key-Words: Preterm, Growth, Development / Mestrado / Saude da Criança e do Adolescente / Mestre em Saude da Criança e do Adolescente

The protein content of the only human milk fortifier available in South Africa was increased in 2017. The Original fortifier (OF) and the Reformulated fortifier (RF) provided similar energy. This study aimed to prospectively compare in-hospital growth during the intermediate stage of nutrition support of very low birth weight (VLBW) preterm infants receiving human milk fortified with these two formulations in a tertiary South African hospital. Intake of VLBW infants receiving exclusively human milk plus one of two fortifiers (OF 0.2gprotein/g powder; RF 0.4gprotein/g powder) was calculated. Change in Z-scores (Fenton, 2013) from start to end of fortification of weight, length and head circumference (HC) for age was calculated as primary outcomes. Additionally, weight gain velocity (g/kg/d) and gain in length and HC (cm/wk) were calculated. Fifty eight infants (52% female; gestational age: 30±2wk; birth weight: 1215±187g) received OF (2016 to 2017) and 59 infants (56% female; gestational age: 29±2wk; birth weight 1202±167g) received RF (2017 to 2018) for 15 days. Protein intake of RF (3.7±0.4g/kg/d) was significantly higher (p<0.001) than of OF (3.4±0.2g/kg/d). Protein-to-energy ratio of RF (2.6±0.2) was significantly higher (p<0.001) than of OF (2.3±0.1g/100kcal). No adverse effects were noted. In both groups Z-scores of weight and length dropped; Z-scores for HC showed slight improvements. There were no significant differences between the two groups in terms of Z-scores, weight gain velocity, length gain or HC gain. Analysed human milk from preterm infants’ mothers’ protein levels was higher than published values. In-hospital growth was not statistically different between groups, even though calculated protein intake and protein-to-energy ratio were significantly higher in RF group. / Thesis (PhD (Dietetics))--University of Pretoria, 2019. / Human Nutrition / PhD (Dietetics) / Unrestricted

Obesity is one of the major risk factors for neonate low birthweight among reproductive women. The purpose of this quantitative study was to examine the association between 3 categories of obese status (moderate, severe, and very severe) and low neonate birthweight and preterm birth among women ages 18 to 39 years at all socioeconomic levels. Secondary data were obtained from 141,859 women ages 18-39 years living in the United States who had participated in the 2012-2015 Pregnancy Risk Assessment Monitoring System. Social-ecological theory was used to guide the study, and binary logistic regression was used for the analyses adjusting for age, education, ethnicity, income, marital status, and race confounders. Without accounting for the confounders, moderate, severe, and very severe obesity were associated with preterm birth. However, after adjusting for confounders, the obese categories were no longer associated with preterm birth. The estimated prevalence of preterm birth was higher among moderate, severe, and very severe obesity categories combined (56 preterm births per 1,000 live births) than among normal weight women (43 preterm births per 1,000 live births). Women of moderate obesity had a 10% statistically significant higher odds (p = .046, OR = 1.095) of neonate low birthweight when compared with very severely obese women. Severely obese women were not associated with neonate low birthweight when compared to women with very severe obese status (p = 0.159, OR = 1.056). Findings may be used to promote healthy lifestyle changes that could reduce the prevalence of preterm birth among obese women.

Bronchopulmonary dysplasia (BPD) is diagnosed in approximately 40% of extremely preterm infants, those born before 28 weeks’ gestational age, and affects roughly 10,000 to 15,000 infants annually in the United States alone. Current treatment of BPD aims to not only aid in the survival of the infant but to also minimize further lung damage and promote physiologic growth to enhance lung development and repair. As the pathogenesis of the disease is multifactorial, including pre-, peri-, and postnatal factors, treatment and prevention approaches to BPD are diverse and include both medical treatment and ventilation strategies. Late postnatal steroids (> 7 days of life) have been proven to facilitate extubation and reduce the incidence of BPD in preterm infants. However, there is evidence that the use of steroids may contribute to increased rates of neurological impairment, including increased incidence of cerebral palsy. Given these findings, the American Academy of Pediatrics (AAP) guidelines recommend against the routine use of systemic steroids in the prevention of BPD and instead argues its use should be limited to infants who are considered extremely high-risk. The aim of this study is to determine whether the use of postnatal dexamethasone decreases the risk of developing BPD in a subset of high-risk infants, those with a concomitant diagnosis of necrotizing enterocolitis or late onset sepsis. A sample size of 200 extremely preterm infants with either necrotizing enterocolitis (NEC) and/or sepsis will be enrolled in a multi-center double-blinded randomized controlled trial comparing a low-dose dexamethasone taper and saline placebo. Infants will be evaluated for the development of BPD based on respiratory support and supplemental oxygen requirement at 36 weeks’ post-menstrual age (PMA). Infants will also be evaluated for presence of neurodevelopmental outcomes at 18- to 22-months follow-up. The results of this proposed study will build the evidence base for the safety and efficacy of postnatal steroids in the prevention of BPD in a subset of high risk, extremely preterm infants. This will help to establish a more detailed characterization of infants for which the benefits of steroids outweigh the risks. The results will enable clinicians to make more informed decisions regarding the medical care of extremely preterm infants and more accurately counsel parents on the incidence of subsequent BPD development, as well as long-term morbidities.

Background: Environmental chemicals may interrupt physiological adaptations necessary in pregnancy, contributing to pregnancy complications with health implications for the mother and child. Nutrients may modify the impact of chemical exposures by blocking their absorption or facilitating their excretion. However, the nature, directionality, and implications of these relationships remain unclear. Objectives: We sought to understand: 1) the potential bidirectional nature of the relationship between vitamin D (25-hydroxyvitamin D, 25OHD) and the toxic metals cadmium (Cd) and lead (Pb) in pregnancy; 2) the association between metals (Cd, Pb, arsenic (As), mercury) and preterm birth and the potential modification of that association by 25OHD; and 3) the long-term association of pregnancy complications with maternal cardiometabolic health. Methods: We used data from the Maternal-Infant Research on Environmental Chemicals Study (n=1983) pregnancy cohort, including long-term follow-up approximately 9 years post-pregnancy. We used cross-lagged panel models to determine the direction of the relationship of 25OHD with Cd and Pb in pregnancy, discrete-time survival analysis to examine the association between metals in pregnancy and preterm birth, and multivariable linear regression to investigate the association of pregnancy complications with long-term maternal outcomes. Results: Each doubling in first trimester 25OHD concentrations was associated with 9% (95% CI: -15%, -3%) lower 3rd trimester Cd and 3% (-7, 0.1%) lower Pb. One-unit increases in Pb (μg/dL) and arsenic (μg/L) concentrations in pregnancy were associated with an increased relative risk (RR) of preterm birth (RR_Pb: 1.48, 95% CI: 1.00, 2.20; RR_As: 1.10, 95% CI 1.02, 1.19); the association with Pb was stronger among those with lower 25OHD. Finally, relative to uncomplicated pregnancy, experiencing a pregnancy complication was positively associated with body fat percentage (β=2.6, 95% CI: 0.3, 4.8) and systolic (average increase of 9.0 mm Hg, 95% CI 5.1, 12.8) and diastolic (average increase of 5.5 mm Hg, 95% CI: 2.6, 8.4) blood pressure 9 years later. Conclusions: Nutrient status during pregnancy may affect and interact with environmental chemicals to impact pregnancy outcomes. Future studies should continue to use methods that elucidate the causal direction of associations and evaluate interactions. Chemicals associated with pregnancy complications could have lasting impacts on maternal health.

Preterm birth is the leading cause of neonatal mortality and long-term morbidity. Neonatologists can adjust nutrition to preterm neonates to control their weight gain so that the possibility of long-term morbidity can be minimized. This optimization of growth trajectories of preterm infants can be achieved by studying a cohort of selected healthy preterm infants with weights observed during day 1 to day 21. However, missing values in such a data poses a big challenge in this case. In fact, missing data is a common problem faced by most applied researchers. Most statistical softwares deal with missing data by simply deleting subjects with missing items. Analyses carried out on such incomplete data result in biased estimates of the parameters of interest and consequently lead to misleading or invalid inference. Even though many statistical methods may provide robust analysis, it will be better to handle missing data by imputing them with plausible values and then carry out a suitable analysis on the full data. In this thesis, several imputation methods are first introduced and discussed. Once the data get completed by the use of any of these methods, the growth trajectories for this cohort of preterm infants can be presented in the form of percentile growth curves. These growth trajectories can now serve as references for the population of preterm babies. To find out the explicit growth rate, we are interested in establishing predictive models for weights at days 7, 14 and 21. I have used both univariate and multivariate linear models on the completed data. The resulting predictive models can then be used to calculate the target weight at days 7, 14 and 21 for any other infant given the information at birth. Then, neonatologists can adjust the amount of nutrition given in order to preterm infants to control their growth so that they will not grow too fast or too slow, thus avoiding later-life complications. / Thesis / Master of Science (MSc)

No description available.

The purpose of this review of literature is to understand the current state of the science and to make recommendations for practice and research in regards to the gastrointestinal condition affecting premature infants, necrotizing enterocolitis (NEC). Emphasis is placed on reviewing the literature to identify prevention strategies nurses can use to reduce the incidence, morbidity and mortality of NEC. The introduction will focus on discussing the problem of NEC including its risk factors, pathophysiology, and disease presentation. The findings sections will focus on the most promising and researched areas of intervention. The discussion section will focus on how this knowledge can be translated into practice and what nurses can do about it. The research will be conducted through nursing databases with conceptual primary sources that will further expand upon the selected studies on this topic.

BACKGROUND: Prenatal maternal stress has been implicated in having a role in adverse health outcomes across the life span. Despite its potentially pervasive effects and population health significance, research examining the determinants of prenatal maternal stress is limited and inconclusive. One particularly intractable outcome, preterm birth, has shown inconsistent associations with prenatal maternal stress. In addition, few measures of childhood perceived stress and perceived stress in pregnancy exist. OBJECTIVE: The purpose of these papers is to: present the theoretical foundation, conceptualization, and evidence base for the Life Course Stress and Preterm Birth Model; test and refine the Life Course Stress and Preterm Birth Model by evaluating the fit of the proposed model of stressors related to socioeconomic position (SEP) and family environment during childhood and pregnancy, perceived stress in pregnancy, and preterm birth; and conceptualize and measure perceived stress in pregnancy and childhood perceived stress, and to evaluate the validity and reliability of these two measures. METHOD: We used a prospective cohort design to collect data for structural equation analysis. All women who attended pre-birth clinics at two hospitals in different communities in south-western Ontario were invited to participate; women (N = 421) completed questionnaires following their pre-birth clinic visit. RESULTS: The mean gestational age at the time of questionnaire completion was 28.2 (SD = 5.3) weeks. Questionnaire return rate was 74%. Perceived childhood stress was moderately associated with perceived stress in pregnancy(β= .54). Adult subjective SEP had a moderate effect on stress-reduction in pregnancy (β = -.44). The main influence of childhood subjective SEP on prenatal stress was indirect by increasing adult subjective SEP and reducing childhood stress. Family cohesion in childhood and pregnancy had small, direct effects on prenatal stress, but played a greater role in increasing subjective SEP and adult family cohesion and reducing stress in childhood. Findings related to our stress measurement analysis demonstrated that perceived childhood stress and prenatal maternal stress were each conceptualized as a single, latent variable. The childhood perceived stress measure was comprised of one item related to perceived family stress and three global perceived stress items. The construct of perceived stress in pregnancy differed from childhood. Perceived stress in pregnancy encompassed items of perceived financial and family stress and global measures of recent and more distant past perceived stress, suggesting that it reflected chronic stress. Initial analyses provide evidence of reliability and validity in this sample. CONCLUSIONS: Perceived childhood stress had a persistent effect on stress in pregnancy after adjustment for other child and adult factors. Childhood factors played important direct and indirect roles on stress in pregnancy. Adult subjective SEP constituted the main adult contribution. The childhood and pregnancy measures of perceived stress contribute to our understanding of the construct of perceived childhood and prenatal maternal stress and inform the timing and nature of effective prevention and intervention approaches. The Life Course Model of Stress and Preterm Birth can be used as a framework to (a) direct clinical risk assessment, (b) guide research on preconception psychosocial influences on perinatal health, (c) direct perinatal surveillance approaches, (d) influence policy and program development to include determinants of perinatal health across the life course, and (e) inform population health approaches to preconception and prenatal care. / Thesis / Doctor of Philosophy (PhD)

BACKGROUND: The DoHAD hypothesis suggests that preterm infants should achieve similar growth and body composition to healthy term-born infants in order to minimize disease risk. Postnatal growth of preterm infants is not fully understood and requires additional characterization, particularly in terms of differences to and transition from intrauterine growth. The period of postnatal adaptation to extrauterine life has been described in preterm infants by Rochow et al., 2016 and was seen to last 21 days. During these first 21 days of life, preterm infants experience a physiological, one-time, permanent contraction of extracellular water spaces (water loss), which causes a downward shift in the growth trajectories. This period of adaptation/water loss and the transition to extrauterine growth rates to achieve WHOGS target trajectories need to be incorporated into individual reference curves for preterm infants. OBJECTIVES: To develop and evaluate approaches to establish individualized growth trajectories for preterm infants to achieve growth similar to the WHO growth standards (WHOGS) for healthy infants at term, using recently published data about the physiological postnatal adaptation. METHODS: Two approaches were compared: 1) Postnatal-Percentile Approach: growth following the percentile at day of life (DOL) 21 until term; 2) Growth-Velocity Approach: using day-specific Fenton median growth velocities between DOL 21 and term. The impact of these approaches were compared using body compositions of 57 healthy preterm infants obtained before discharge (36+0/7 to 42+6/7 weeks PMA). The main outcome was the weight difference between the predicted trajectory and WHOGS target at 42+0/7 weeks PMA for the infants’ birth weight percentile. RESULTS: Postnatal-Percentile Approach: Trajectories deviated by up to 930g and did not match with WHOGS. Growth-Velocity Approach: Trajectories converged with term WHOGS after adjusting growth velocities with a factor of 1.0017 (approximately 10% increase in daily growth velocities). The validation of the Growth-Velocity Approach in preterm infants with minimal medical interventions revealed little deviation between predicted and actual weights. Infants were symmetrically distributed around zero deviation with a mean deviation of -10±370g and an average of 20% fat mass. In contrast, the Postnatal-Percentile Approach showed large deviations between predicted and actual weights and a skewed distribution around zero deviation with a mean deviation of -310±380g or 70±350g, following the birth or DOL 21 percentile, respectively. CONCLUSIONS: Individualized growth trajectories for preterm infants converged with the WHOGS when Fenton daily median growth velocities were applied and optimized with a single factor. The simplicity of the model and its ability to predict target weights that correspond to an appropriate fat mass suggests a biological principle. These results provide a superior understanding of preterm infant’s growth including the physiological postnatal adaptation and new trajectories to achieve WHOGS target trajectories. Results can be used to develop a bedside tool to aid clinicians in monitoring growth, guiding nutrition and preventing chronic adult diseases as a consequence of unguided, inappropriate growth. / Thesis / Master of Science (MSc) / It has been well established that growth of preterm infants has a long-term impact on health in adulthood. Since the survivability of preterm infants has drastically improved in the last decades, there has been a shift in focus to improving quality of life, including improved growth. Infants that grow too quickly or too slowly may develop inappropriate body compositions, with either too much or too little fat. A sub-optimal body composition can put infants at an increased risk for developing cardiovascular, metabolic or neurodevelopmental diseases later in life. In order to prevent these diseases and optimize growth, it is necessary to have a better understanding of how preterm infants should grow. This thesis aims to improve the characterization of growth for preterm infants by providing individual reference growth trajectories for preterm infants that take into consideration postnatal adaptation and aim to minimize later disease risk.