[Loss to follow-up and cerebral palsy]

BACKGROUND

The longer follow-up programs last, the greater the loss to follow-up. These losses to follow-up may undermine the completion of health care goals and the validity of study results.

OBJECTIVES

1) To compare neonatal characteristics in children easily followed-up and in those lost to follow-up. 2) To trace and assess children lost to follow-up. 3) To estimate the occurrence of cerebral palsy in children easily followed-up and in those lost to follow-up.

METHODS

From 1991 to 1997, 601 neonates with a birth weight under 1,500 g were admitted to the Neonatology Department. At discharge, 447 infants were included in the follow-up program. Moderate-to-severe cerebral palsy was assessed when the children were aged 2 years. A specific search strategy was implemented to find those children lost to follow-up. Data on the development of those traced were updated through a standardized telephone questionnaire.

RESULTS

Twenty percent of the children were lost to follow-up before the age of 2 years. Fifty-seven percent of those not available at this age were assessed by telephone interview. No differences were found in the neonatal characteristics of infants easily followed-up and those lost to follow-up except in situations of critical social disadvantage: 10 % in followed-up infants, 41 % in infants lost to follow-up. Disabling cerebral palsy was observed in 7 % of children easily followed-up and in 23 % of those lost and traced (relative risk: 3.1, 1.5-5.5).

CONCLUSIONS

The risk of having disabling cerebral palsy is three times higher in children lost to follow-up than in those easily followed-up. Dismissing this source of bias may underestimate disability rates when assessing health care programs or when interpreting study results.

Litter size and vagina-cervix catheter penetration length in gilts

As in other species, the reproductive tract in pigs increases in size with age and body weight, and the development of the reproductive tract depends on a balance between development of the pituitary-ovarian axis and the influence of metabolic hormones. Two experiments were conducted in prepubertal Duroc gilts, 150-180 days of age, to determine whether litter size is related to vaginal-cervix catheter penetration length during insemination. In experiment 1, oestrus was induced in 452 gilts with a combined dose of 400 IU Pregnant Mare Serum Gonadotrophine (PMSG) + 200 IU human chorionic gonadotropin (hCG). The gilts were classified into three catheter penetration length groups: Ih, < or = 21 cm; IIh, > 21 and < 28 cm, IIIh, > 28 cm. The litter size was lowest in group Ih (7.35 +/- 0.15) compared with groups IIh (7.81 +/- 0.12; p < 0.05) and IIIh (10.0 +/- 0.36; p < 0.001). In experiment 2, first oestrus was induced in 162 gilts by boar exposure. The gilts were classified into three catheter penetration length groups at insemination during their second oestrus: In, < or = 24 cm; IIn, > 24 and < 26 cm; IIIn, > 26 cm. As in experiment 1, the litter size was lowest in the group with the shortest catheter penetration length (8.32 +/- 0.19). The litter size was not different among gilts of groups IIn and IIIn (8.84 +/- 0.35 and 9.56 +/- 0.46, respectively), but litter size was lower (p < 0.05) in group In than in group IIn. Based on the combined data from both experiments, the correlation between the catheter penetration length and total number of piglets born was expressed as: y =5.346 +/- 0.104x; r = 0.361 (p < 0.05). Fertility rate was not different among the groups of gilts induced into oestrus by hormone treatment or inseminated in the second oestrus; however, the total fertility rate of boar-exposed gilts was higher (p < 0.0001) than PMSG/hCG treated animals. Thus, it is possible to conclude that litter size at first farrowing is associated with vaginal-cervix catheter penetration length during insemination of the gilt.

[Pneumococci: a new microorganism in the newborn?]

OBJECTIVE

To study the clinical characteristics and susceptibility to antimicrobial agents of Streptococcus pneumoniae invasive infection in our neonatal unit.

METHODS

Data from newborns with Streptococcus pneumoniae invasive infection in the last 12 years were retrospectively collected.

RESULTS

Eight cases of invasive infection were identified. Gestational age ranged from 30 to 38 weeks (median: 34 weeks) and birth weight ranged from 1,680g to 4,460g (median: 2,480g). Risk factors related to infection were identified in 7 patients. Although infection manifested as shock in 4 patients and meningitis in 1, evolution was favorable in all patients. Penicillin resistance was found in 3 patients.

CONCLUSIONS

Streptococcus pneumoniae produces serious disease in neonates. Because of the increasing prevalence of penicillin-resistant pneumococci, the relationship between the percentage of mothers colonized with pneumococci and neonatal infection should be determined to develop new prevention and treatment strategies in newborn infants.

[Age for sitting and walking in children born weighing less than 1,500 g and normal motor development at two years of age]

OBJECTIVE

To estimate the corrected age (CA) of acquisition of sitting and walking in very low birth weight infants with normal motor outcome at 2 years of age and to determine whether transient hypertonia is associated with a delay in the acquisition of sitting and walking.

METHODS

Follow-up study of very low birth weight infants (under 1500 g) admitted to the Neonatology Department of the Hospital 12 de Octubre from January 1991 to December 1996. At 2 years of age, 260 infants had normal motor outcome and 36% of these had been diagnosed with transient hypertonia. The age at which sitting and walking were attained was recorded by interview with the parents and was confirmed by examination.

RESULTS

The mean CA at which sitting was attained was 7.2 +/- 1.4 months. Ninety percent of the infants had acquired sitting at a CA of 9 months. Mean age at which walking was attained was 13.4 +/- 2.8 months. Ninety percent could walk at 16 months. Infants with and without transient hypertonia acquired sitting and walking at the same age.

CONCLUSIONS

Ninety percent of very low birth weight infants attained sitting at a CA of 9 months and walking at a CA of 16 months. Transient hypertonia did not modify the pattern of sitting and walking and it could be considered a variation of normality within the development of very premature infants.

[Experience with ventriculitis at a neonatology department]

OBJECTIVE

To study the characteristics, treatment and follow-up of patients with ventriculitis in our neonatal unit.

PATIENTS AND METHODS

Retrospective study of patients diagnosed with ventriculitis from January 1990 to December 1997. Diagnostic criteria were the identification of any bacteria in the ventricular fluid and pleocytosis (> or = 100 leukocytes per microl). Personal history, clinical and analytical findings and evolution after diagnosis were studied.

RESULTS

We recorded ten cases of ventriculitis in nine patients. Six of them occurred as a complication of previous meningitis and four occurred after neurosurgical treatment. The mean age at diagnosis was of 38.8 days (range 8-130), and mean gestational age was 29.4 weeks (range 25-38). Clinical and ventricular fluid anomalies were seen in six cases and in four the diagnosis was made at autopsy. Treatment was systemic antibiotics. In two cases intraventricular antibiotics were added. Six patients died, ventriculitis being the direct cause of death in five. Of the three survivors, one had mental retardation and cerebral palsy and the other two had minor disabilities.

CONCLUSIONS

During the neonatal period, a high degree of clinical suspicion and techniques for an early diagnosis and treatment are needed for ventriculitis.

[Outcome at 3 years of age in a low birth weight cohort]

OBJECTIVE

The objective of this study was to establish the outcome at 3 years of age for very low birth weight newborns admitted to the Hospital 12 de Octubre from January 1991 to December 1993.

PATIENTS AND METHODS

A follow-up study was performed. The pediatric assessment included a neurological, psychological, visual and audiological evaluation. At the end of the follow-up, children were blindly assessed to determine the rate of neurosensory disability. The severity of the neurosensory disability was graded as severe, moderate or mild by a functional classification. The rates of cerebral palsy, blindness and deafness were reported.

RESULTS

Two hundred fifty-three infants between 500 and 1,499 g were admitted to the Hospital 12 de Octubre of which 182 survived. Of these, 137 (75% of the survivors) were assessed at 3 years of age. The children who dropped out during the follow-up period had similar characteristics to those with a complete follow-up program except that the drop-out child was more likely to belong to a disadvantaged family. The rate of neurosensory disability was 28.5% (39/137), 16% were mild, 5% moderate and 7% severe. The rate of cerebral palsy was 13% (18/137), blindness 1.4% and deafness 0.7%.

CONCLUSIONS

Children from more disadvantaged families are less likely to continue in follow-up programs and this supposes a bias in the follow-up program. At 3 years, neurosensory disability was diagnosed in 1 out of every 4 children and cerebral palsy in 1 out of 8 children.

[Preventive use of antibiotics in neonatal surgery]

OBJECTIVE

The objective of this study was to determine the incidence of surgical wound infection and the impact of this on the implementation of an antibiotic protocol according to the type of surgery and the prevailing endogenous flora in our neonatology unit.

PATIENTS AND METHODS

Patients' charts were retrospectively reviewed in order to assess the effectiveness of a protocol of surgical prophylaxis, comparing the incidence of postsurgical wound infection in two periods of time. Surgical interventions were classified according to the period of the study in which they were performed, before (period A) and after (period B) the protocol was undertaken. In addition, if the antibiotics administered fit or not those indicated in the protocol, it was classified as correct or not.

RESULTS

A total of 31 (37%) of the interventions were performed in period A, whereas 53 (63%) were carried out in period B. No statistically significant differences were found between periods with regard to the proportion of infections 925.8% vs 15%). When prophylactic antibiotics were administered correctly, infection occurred in 10.2%, as compared to 31.4% when they did not fit the protocol (p < 0.05). The duration of the antibiotics was longer in period A, in infected wounds and when prophylaxis was not correct.

CONCLUSIONS

The correct adjustment to the protocol significantly decreases the incidence of wound infections, as well as the duration of antibiotic use. An appropriate policy of antibiotic prophylaxis in surgery is advantageous in terms of economic cost and might prevent antibiotic resistance and avoid unnecessary toxicity.

[Neonatal systemic candidiasis]

We analysed 7 cases of systemic candida sp. infection diagnosed between 1986 to 1989. Clinical presentation was of sepsis. Evolution was favorable in all, excepting two cases that died due to a candidiasic meningitis and a candidiasic aortic thrombosis, respectively. Almost all patients were treated with amphotericin B only. A newborn had signs of toxicity (thrombocytopenia). We emphasize the importance of a prompt diagnosis and treatment and the effectivity of amphotericin B for systemic candidiasis, besides of its rare toxicity in newborns.