Evolução neurocomportamental de recém-nascidos pré-termo e associação com lesões cerebrais na idade pós-conceptual de 40 semanas

• Autor(a) principal: Souza, Vivien Valente de [UNIFESP]
• Data de Publicação: 2017
• Tipo de documento: Dissertação
• Idioma: por
• Título da fonte: Repositório Institucional da UNIFESP
• Texto Completo: https://sucupira.capes.gov.br/sucupira/public/consultas/coleta/trabalhoConclusao/viewTrabalhoConclusao.jsf?popup=true&id_trabalho=5199644; http://repositorio.unifesp.br/handle/11600/50396
• topic: Premature; Neurological examination; Behavior; Brain lesions; Periventricular leukomalacia; Prematuro; Exame neurológico; Comportamento; Hemorragia cerebral; Leucomalácia periventricular

Introduction: Studies show an association between neurobehavioral performance of preterm infants (PT) and developmental delays in childhood. However, little is known about the evolution of neurobehavior in PT. PT are at risk for brain lesions, which is also associated with developmental delay. The association between brain lesions and behavioral changes in PT in the age of the term is also little known. Objective: To evaluate the evolution of neurobehavioral responses in PT with gestational age (GA) less than 32 weeks, up to 48 weeks of postconceptual age (PCA). To verify if the neurobehavioral responses of PT evaluated in the different PCA equals those of full-term newborns (FT), evaluated in the first days of life, and in which PCA this occurs. To verify the association between brain lesions and the neurobehavioral performance of PT in the PCA of term. Method: Prospective unicentric observational study of PT (GA <32 weeks). Excluded PT with genetic syndromes, congenital malformations or infections, those who died and those with severe brain lesions: severe peri-intraventricular hemorrhage (IVHD) (degrees III and IV) or lesions of white and/or gray matter. IVHD was diagnosed by ultrasonographic (US) examinations of skull performed during hospitalization and gray and white matter lesions, by magnetic resonance (MRI) of the skull in the term PCA. The PT were evaluated in the PCA of 32±1, 34±1, 36±1, 38±1, 40±1, 44±2 and 48±2 weeks by the Neonatal Neurobehavior Network Scale (NNNS) and to evaluate the evolution of the domains of the NNNS, along the PCA, the ANOVA with repeated measures was used. The behavioral performance of PT in the different PCA was compared to that of the FT, evaluated in the first days of life, by student t test. The comparison of the NNNS domain scores between PT with and without severe brain lesions was performed by the Mann Whitney test. For each NNNS domain, a linear regression model was constructed, considering as independent variables, besides the brain lesion, clinical variables that could interfere in the neurobehavior, with p<0.150 in the univariate analysis. Results: A total of 46 PT were studied, of which 7 had severe brain lesions. The neurobehavioral evolution was evaluated in 39 PT (GA 29.2 weeks, birth weight (BW) 1100g). PT, as the PCA progressed, showed increased scores of habituation, attention, arousal, control, maneuvers for orientation, quality of movements and hypertonia and decreased scores of excitability, lethargy, non-optimal reflexes, asymmetry, hypotonia and signs of stress and abstinence. The neurobehavior of PT in the different PCA was compared to that of 39 FT (GA 39.0 weeks; BW 3110g). The PT matched their neurobehavioral performance between the PCA of 36 and 48 weeks for habituation, attention, arousal, control, quality of movements, lethargy, non-optimal reflexes, asymmetry and signs of stress and abstinence. Lower scores for excitability and higher scores on hypotonia compared to FT were presented by PT in all PCA. For the domain maneuvers for orientation, the PT presented higher scores than the FT from 34 weeks and for the hypertonia domain, the scores were similar at all ages. The lesion of white and/or gray matter was identified in 7 (15.6%) and severe IVHD in 5 (11.1%) PT, of the 45 PT submitted to US and MRI, and all patients with severe IVHD also presented lesion of white and/or gray matter. PT with severe brain lesions (GA 27.3 weeks, BW 930g), compared to those without or mild lesions (GA 30.0 weeks, BW 1130g) presented higher SNAPPE-II severity score (44.0 vs 16.0; p=0.011), frequency of bronchopulmonary dysplasia (100.0% vs 36.1%; p=0.002), sepsis (85.7% vs 36.1%; p=0.033), meningitis (71.4% vs 5.6%; p<0.001), necrotizing enterocolitis (42.9% vs 8.3%; p=0.045) and convulsive syndrome (100.0% vs. 13.9%; p<0.001). Controlling for confounding variables, PT with severe brain lesions, compared to those with mild or no lesion presented lower scores on attention, control and quality of movements domains, and higher scores on lethargy and non-optimal reflexes. Conclusion: PT with GA less than 32 weeks presents evolution of neurobehavioral responses with the progression of PCA and at term age, they reach the performance of FT, evaluated in the first days of life, in most domains of the NNNS. PT with severe HPIV and/or severe lesion of white and/or gray matter, compared to those with mil or no cerebral lesions present worse neurobehavioral performance in the age of term, on attention, control, quality of movements, lethargy and non-optimal reflexes.