[Bronchopulmonary dysplasia epidemic: incidence and associated factors in a cohort of premature infants in Bogotá, Colombia]

INTRODUCTION

There is a perception that bronchopulmonary dysplasia incidence has increased in Bogotá since 2000. This study estimates its incidence, compares it with historical data and describes associated factors.

MATERIALS AND METHODS

We carried out a prospective analytical cohort of preterm newborns =34 weeks of gestational age without major malformations from 12 health facilities from Bogotá in 2004. The main outcomes were incidence and severity of bronchopulmonary dysplasia, which were compared with an historical cohort (1994-1999).

RESULTS

Neonatal mortality was 80/496, and the bronchopulmonary dysplasia incidence was 54.3% (95% CI, 49.4-59.1). When controlling for type of institution (low and high mortality) it appeared that being born in an institution with low mortality decreased the risk for death (OR=0.308; 95% CI, 0.129-0.736) but increased the odds for moderate-severe bronchopulmonary dysplasia (OR=1.797; 95% CI, 1.046-3.088). The risk for bronchopulmonary dysplasia was higher than for the historical control cohort (RR=1.924; 95% CI, 1.686-2.196). Weight and gestational age at birth, mechanical ventilation, intrauterine growth restriction and type of institution (low vs. intermediate-high mortality) were independently associated with bronchopulmonary dysplasia of increasing severity or even death.

CONCLUSIONS

The frequency of bronchopulmonary dysplasia in Bogotá has increased markedly, and this cannot be explained solely by better survival of more fragile infants. Survivors-irrespective from gestational age-- have more frequent and more severe respiratory sequels. Probably suboptimal aggressive respiratory care practices associated with a recent transition from restricted to almost universal access to mechanical ventilation in neonatal intensive care units in Bogota might be compromising the quality of neonatal respiratory care.

Cerebral motor function in very premature-at-birth adolescents: a brain stimulation exploration of kangaroo mother care effects

AIM

  Given that prematurity has deleterious effects on brain networking development beyond childhood, the study explored whether an early intervention such as Kangaroo Mother Care (KMC) in very preterm preemies could have influenced brain motor function up to adolescence.

METHODS

  Transcranial magnetic stimulation (TMS) was applied over the primary motor cortex (M1) of 39 adolescents born very prematurely (<33 weeks' gestational age, 21 having received KMC after birth, 18 Controls with no KMC) and nine adolescents born at term (>37 weeks' gestational age, >2500 g) to assess the functional integrity of motor circuits in each hemisphere (motor planning) and between hemispheres (callosal function).

RESULTS

  All TMS outcomes were similar between KMC and term adolescents, with typical values as in healthy adults, and better than in Controls. KMC adolescents presented faster conduction times revealing more efficient M1 cell synchronization (p < 0.05) and interhemispheric transfer time (p < 0.0001), more frequent inhibitory processes with a better control between hemispheres (p < 0.0001).

CONCLUSION

  The enhanced synchronization, conduction times and connectivity of cerebral motor pathways in the KMC group suggests that the Kangaroo Mother Care positively influenced the premature brain networks and synaptic efficacy up to adolescence.

Kangaroo Mother Care, home environment and father involvement in the first year of life: a randomized controlled study

AIMS

This study tested the hypothesis that Kangaroo Mother Care creates a climate in the family, which enhances infants' performance on the developmental quotient scale.

SETTING

The largest social security hospital in Colombia with a neonatal intensive care unit.

SUBJECTS

At 12 months of corrected age, 194 families in the Kangaroo Mother Care group and 144 families in the Traditional Care group were available for analysis.

INTERVENTIONS

Infants were kept 24 h/day in an upright position, in skin-to-skin contact until it was no longer tolerated by the infants. Babies in the Traditional Care were kept in incubators on the Minimal Care Unit until they satisfied the usual discharge criteria.

OUTCOME MEASURES

The Home Observation for Measurement of the Environment (HOME), Father Involvement and Developmental Quotient (Griffiths) scores.

RESULTS

1) Kangaroo mothers created a more stimulating context and a better caregiving environment than mothers in the Traditional Care group; 2) this environment was positively correlated to father involvement and 3) the family environment of male infants was most improved by Kangaroo Mother Care.

CONCLUSION

Kangaroo Mother Care has a positive impact on home environment. The results also suggest, first, that both parents should be involved as direct caregivers in the Kangaroo Mother Care procedure and secondly, that this intervention should be directed more specifically at infants who are more at risk at birth. The Kangaroo Mother Care intervention could be an excellent means to ensure parents' mature involvement in the future of their children.

Influence of feeding patterns and other factors on early somatic growth of healthy, preterm infants in home-based kangaroo mother care: a cohort study

OBJECTIVE

Breast-milk fortifiers recommended for premature infants are seldom available in developing countries. We describe the characteristics of growth in preterm infants under ambulatory Kangaroo Mother Care (KMC) who eventually required supplemental formula because of failure to thrive with exclusive breast feeding. We evaluated the relationship between growth indices at term, nutritional status of the infant at birth, and feeding pattern.

DESIGN

Prospective cohort study conducted in the Neonatal Unit at Clínica San Pedro Claver and the KMC program, an ambulatory clinic from the Clínica del Niño tertiary care clinics in Bogotá, Colombia. Included were 115 mothers and their 129 healthy, preterm infants. One hundred twenty-six (98.4%) infants were available for evaluation at term. Infant weights were monitored daily until they achieved 15 g/kg per day for 2 days and then weekly until term. Formula was offered only to infants who did not gain 15 g per kg per day for 3 consecutive days.

RESULTS

Sixty (47.6%) infants gained weight adequately with exclusive breast feeding. In 14 of those who needed supplements, adequate weight gain was achieved before reaching term and supplements could be stopped. The more immature infants required supplementation more frequently. With or without supplementation, infants with lower weight for gestational age at birth were less likely to achieve adequate weight by term.

CONCLUSIONS

Growth indices at term in premature infants were close to those expected for term infants born in Bogotá (between percentile 10 to percentile 25). Decision on formula supplementation of breast milk should be made not only based on birth weight or gestational age but on a careful monitoring of weight gain while the mother is receiving continuous support to enhance and maintain successful breast-feeding. Small-for-date premature infants thrive less well than other infants even with supplementation.

Accuracy of fecal lactoferrin and other stool tests for diagnosis of invasive diarrhea at a Colombian pediatric hospital

OBJECTIVES

Estimate under "real life" conditions the operating characteristics of several stool tests for determining whether a diarrheal episode is invasive-inflammatory.

DESIGN

Determination of operating characteristics of diagnostic tests against a standard in a prospectively gathered sample.

SETTING

The emergency room of the largest Social Security Pediatric Hospital in Colombia serving referred and nonreferred patients.

PATIENTS

Stool samples from children attending the emergency room because of acute diarrhea (three or more loose stools per day lasting <7 days). Patients receiving antibiotics or antiparasitic medications were excluded.

INTERVENTIONS

Samples were collected in sterile containers and examined immediately for protozoa, fecal leukocytes, occult blood and lactoferrin. Specimens were inoculated onto culture media for common bacterial fecal pathogens except enteroinvasive Escherichia coli and Clostridium difficile.

MAIN OUTCOME MEASURE

Sensitivity, specificity and likelihood ratios of several cutoff levels for fecal lactoferrin, fecal leukocytes and occult blood.

RESULTS

Stool samples from 500 infants and children with diarrhea were collected. Patients' median age was 2.66 years (range, 0.5 to 13 years), and 261 (52.2%) were males. In 155 (31%) cases enteroinvasive bacteria and/or Entamoeba histolytica were documented. Fecal leukocytes >5 had the best sensitivity (63.2%; 95% confidence interval, 55.4 to 70.5) and specificity (84.3%; 95% confidence interval, 80.2 to 87.9), although not statistically or clinically significantly different from lactoferrin.

CONCLUSIONS

No single test or combination had satisfactory operating characteristics. Nevertheless the use of likelihood ratios derived here can help clinicians identify invasive-inflammatory diarrheal episodes in many instances.

Kangaroo mother versus traditional care for newborn infants </=2000 grams: a randomized, controlled trial

BACKGROUND

In 1978, kangaroo mother care (KMC) was proposed as a caring alternative for low birth weight (LBW) infants. We are reporting here early outcomes of a randomized, controlled trial comparing KMC to traditional care.

METHOD

An open randomized, controlled trial was conducted in a large tertiary care hospital. All newborn infants </=2000 g, surviving the neonatal period and being eligible for a minimal care unit, were included. A total of 1084 newborns </=2000 g were followed, and 746 were randomized-382 to KMC and 364 to traditional care. KMC infants were discharged after randomization, regardless of weight or gestational age. Infants spent 24 hours per day in an upright position, in skin-to-skin contact, and attached to the mother's chest. After randomization, control infants remained at the minimal care unit until meeting usual discharge criteria. Both groups are being followed up to 12 months of corrected age; 679 (90%) were available for evaluation when they reached term (40 to 41 weeks of postconceptional age). The present paper reports early outcomes (when reaching term) including mortality, infectious episodes, hospital stay after eligibility, and growth and feeding patterns.

RESULTS

Both study groups were similar regarding all baseline variables but weight at eligibility. The risk of dying was similar in both groups (relative risk = 0.59, 95% confidence interval 0.22-1. 6). There were no differences in growth indices. Nosocomial infections were more frequent in control infants. Hospital stay after eligibility was shorter in KMC, primarily for infants </=1800 g.

CONCLUSIONS

These results show that KMC is a safe approach to the care of clinically stable LBW infants. Our findings provide the necessary scientific support to a method that is already incorporated in the care of LBW infants at many hospitals around the world and at different levels of care.

Current knowledge of Kangaroo Mother Intervention

Kangaroo Mother Intervention (KMI) started in 1978 in Colombia as a way of dealing with overcrowding and scarcity of resources in hospitals caring for low birth weight infants. Currently the intervention comprises three components: kangaroo position (skin-to-skin contact), kangaroo nutrition (exclusive or nearly exclusive breast-feeding), and kangaroo discharge policies (early discharge in kangaroo position regardless of weight or gestational age). Different authors have adopted and adapted diverse components of the KMI to suit the particular needs of their parents. We discuss different modalities of kangaroo care reported in developed and in developing countries and also describe in some detail the components of the whole KMI program. In addition, results from a systematic review of kangaroo-related papers published in English between 1991 and 1995 are provided, together with a summary of current knowledge (evidence-based) and research needs.

Rey-Martinez Kangaroo Mother Program: an alternative way of caring for low birth weight infants? One year mortality in a two cohort study

OBJECTIVES

To assess the effectiveness and safety of the Kangaroo mother intervention (KMI).

DESIGN

Observational, analytic, prospective (two cohorts) study.

SETTING

Two large tertiary care obstetric hospitals, one offering "traditional" care and the other KMI.

PATIENTS

Newborn infants with birth weights < or = 2000 g, who survive the neonatal period and are eligible for an in-patient minimal care unit (MCU) (having overcome major adaptation problems to extra uterine life).

INTERVENTIONS

"Kangaroo infants" (KI) were discharged as soon as they were eligible for MCU, regardless of weight or gestational age. Infants were kept 24 hours a day in an upright position, in skin-to-skin contact and firmly attached to the mother's chest until the KMI was not tolerated anymore. Control babies (from the other facility) were kept in incubators at the MCU until they satisfied usual discharge criteria for the control hospital. Both groups were followed periodically up to the age of 1 year.

RESULTS

Three hundred thirty-two eligible infants were recruited, 162 at the Kangaroo hospital and 170 at the control hospital. KI came from a much lower socio-economic class and were more ill before eligibility. Relative risk of death was higher for KI (RR 1.9), although this figure was reversed after adjusting for weight at birth and gestational age (RR 0.5). KI grew less in the first 3 months and had a higher proportion of developmental delay at 1 year, and a multivariate analysis failed to control for the large baseline differences in socioeconomic levels and babies' health status between the two cohorts.

CONCLUSIONS

In spite of major baseline differences between studied cohorts, the survival of LBW infants in Bogotá is similar between the KMI and the "traditional care". Questions remain about quality of life, especially regarding weight gain and neurodevelopment, that may be answered by a Randomized Controlled Trial.