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Neurobehavior of Full-Term Small for Gestational Age Newborn Infants Of 0021-7557/08/84-03/217 Jornal de Pediatria Copyright © 2008 by Sociedade Brasileira de Pediatria ARTIGO ORIGINAL Neurobehavior of full-term small for gestational age newborn infants of adolescent mothers Neurocomportamento de recém-nascidos a termo, pequenos para a idade gestacional, filhos de mães adolescentes Marina C. de Moraes Barros1, Ruth Guinsburg2, Sandro S. Mitsuhiro3, Elisa Chalem4, Ronaldo R. Laranjeira5 Resumo Abstract Objetivo: Comparar o neurocomportamento de recém-nascidos Objective: To compare the neurobehavior of small (SGA) and a termo pequenos (PIG) e adequados (AIG) para a idade gestacional, adequate (AGA) for gestational age full-term neonates born to filhos de mães adolescentes. adolescent mothers. Métodos: Estudo transversal prospectivo de nascidos a termo Methods: This prospective cross-sectional study included AIG e PIG, com 24-72 horas de vida, sem afecções do sistema nervoso full-term newborn infants aged 24-72 hours, free from central central. Os neonatos foram avaliados por meio da Neonatal Intensive nervous system malformations and born to adolescent mothers at a Care Unit Network Neurobehavioral Scale (NNNS) para: habituação, single center in Brazil. Infants were assessed with the Neonatal atenção, despertar,controle, manobras para a orientação, qualidade Intensive Care Unit Network Neurobehavioral Scale (NNNS) for: dos movimentos, excitabilidade, letargia, reflexos não ótimos, habituation, attention, arousal, regulation, handling, quality of assimetria, hipertonia, hipotonia e sinais de estresse e abstinência. movement, excitability, lethargy, nonoptimal reflexes, asymmetry, A comparação dos grupos AIG e PIG foi feita por análise de variância hypertonia, hypotonia, and stress/abstinence signals. The chi-square e teste do qui-quadrado. Aplicou-se a regressão multivariada para test and analysis of variance were used to compare SGA and AGA analisar os fatores associados ao escore de cada variável do NNNS. infants. Multivariate regression was used to analyze factors Resultados: Dos 3.685 nascidos no local do estudo, 928 (25%) associated with the score of each NNNS variable. eram de mães adolescentes. Desses, 477 satisfizeram os critérios Results: Of 3,685 infants born in the study hospital, 928 (25%) de inclusão, sendo 419 (88%) AIG e 58 (12%) PIG. A análise had adolescent mothers. Of these, 477 infants met the inclusion univariada não mostrou diferença em nenhuma das variáveis da criteria: 419 (88%) were AGA and 58 (12%) were SGA. Univariate NNNS entre os PIG e os AIG. Na análise multivariada, os PIG nascidos analysis did not show any differences between AGA and SGA neonates de parto vaginal apresentaram menor escore na variável qualidade in terms of NNNS variables. Multivariate analysis showed that SGA de movimentos do que os nascidos por cesárea. Os PIG nascidos com neonates born by vaginal delivery had lower scores for quality of anestesia local ou sem anestesia apresentaram maior escore na movements than those born by caesarean section. The SGA neonates variável excitabilidade do que os nascidos sob anestesia born with local or without anesthesia had higher scores for excitability loco-regional. Os PIG femininos tiveram menor escore na variável than those born with spinal anesthesia. Additionally, female SGA sinais de estresse/abstinência que os masculinos. neonates had lower scores for stress/abstinence signals than males. Conclusão: Os recém-nascidos PIG de mães adolescentes Conclusion: SGA neonates born to adolescent mothers showed mostraram menor qualidade de movimento, mais excitabilidade e poorer quality of movements, more excitability and more signals of mais sinais de estresse, em associação com o sexo do neonato e com stress in association with sex of infant and variables related to variáveis relacionadas ao parto. delivery. J Pediatr (Rio J). 2008;84(3):217-223: Comportamento, gravidez J Pediatr (Rio J). 2008;84(3):217-223: Behavior, pregnancy in na adolescência, recém-nascido. adolescence, infant, newborn. 1. Doutora, Universidade Federal de São Paulo - Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP. 2. Professora titular, Departamento de Pediatria, UNIFESP-EPM, São Paulo, SP. 3. Doutor, UNIFESP-EPM, São Paulo, SP. 4. Psicóloga pesquisadora, Unidade de Pesquisa em Álcool e Drogas, UNIFESP-EPM, São Paulo, SP. 5. Professor livre-docente, Departamento de Psiquiatria, UNIFESP-EPM, São Paulo, SP.Chefe, Unidade de Pesquisa em Álcool e Drogas, UNIFESP-EPM, São Paulo, SP. Apoio financeiro: FAPESP, projeto nº 00/10.293-5. Não foram declarados conflitos de interesse associados à publicação deste artigo. Como citar este artigo: Barros MC, Guinsburg R, Mitsuhiro SS, Chalem E, Laranjeira RR. Neurobehavior of full-term small for gestational age newborn infants of adolescent mothers. J Pediatr (Rio J). 2008;84(3):217-223. Artigo submetido em 13.12.07, aceito em 27.02.08. doi:10.2223/JPED.1796 217 218 Jornal de Pediatria - Vol. 84, Nº 3, 2008 Neurocomportamento de recém-nascidos PIG - Barros MC et al. Introdução O neurocomportamento, em recém-nascidos PIG, além de pouco estudado, não conta com homogeneidade em relação O recém-nascido pequeno para a idade gestacional (PIG) à definição de “pequeno para a idade gestacional” nem quanto resulta da restrição de crescimento intra-uterino, que pode ao método de avaliação neurocomportamental. Neste con- ser desencadeada por uma série de fatores inerentes à saúde texto, o presente estudo tem por objetivo comparar o perfil da mãe e do feto, além daqueles relacionados à situação socio- neurocomportamental de recém-nascidos a termo, filhos de econômica da família. A gravidez na adolescência, a ausência mães adolescentes, PIG e AIG, por meio da Neonatal Inten- de parceiro fixo, a baixa escolaridade, a realização inade- sive Care Unit Neurobehavioral Network Scale (NNNS). quada de pré-natal, o uso de drogas lícitas e ilícitas, a expo- sição a doenças sexualmente transmissíveis, à violência e a Métodos distúrbios psicopatológicos podem, de maneira conjunta ou Trata-se de estudo de transversal, unicêntrico, com coleta isolada, levar ao crescimento inadequado do feto1,2.Noque prospectiva de dados, em um hospital de nível terciário do se refere à gestação na adolescência, esta se acompanha com município de São Paulo (SP), no período de julho de 2001 a certa freqüência de exposição à violência e à presença de novembro de 2002. O estudo foi aprovado pelo Comitê de desordens mentais, sendo a violência durante a gravidez ado- Ética em Pesquisa do hospital onde foi realizada a coleta de lescente associada ao nascimento de PIG, ao passo que as dados e da instituição de ensino dos pesquisadores, sendo doenças mentais se associam à prematuridade3. Por outro financiado pela Fundação de Apoio à Pesquisa do Estado de lado, a gravidez na adolescência não representa fator de risco São Paulo. para baixo peso ao nascer quando a influência de fatores clí- nicos, gestacionais e psicossociais desfavoráveis é afastada4. Para a constituição da casuística, foram considerados os seguintes critérios de inclusão: assinatura do termo de con- Sabe-se que a desnutrição intra-uterina influencia a matu- sentimento livre esclarecido materno, recém-nascido filho de ração anatômica e funcional do sistema nervoso central. A mãe adolescente (idade 10-19 anos), a termo (idade gesta- insuficiência placentária crônica, que resulta em restrição do cional 37-416,7 semanas), sendo a idade gestacional calcu- crescimento fetal, leva a déficits de conexão neural e mielini- lada a partir da data da última menstruação ou, quando este zação e altera a funcionalidade dos sistemas auditivo e visual dado não estava disponível, estimada pelo método de New 5 no período pós-natal . No recém-nascido a termo PIG, estu- Ballard17. dos volumétricos por ressonância magnética indicam redu- ção da substância cinzenta, sendo o hipocampo especialmente Foram excluídos os neonatos que apresentaram uma ou vulnerável aos efeitos da insuficiência placentária6. Além mais das seguintes condições que poderiam interferir nas res- disso, em fetos com restrição grave do crescimento intra- postas neurocomportamentais: mães com sorologia positiva uterino, há comprometimento do crescimento cortical, com na gestação ou parto para infecções congênitas; mães que diminuição do número de células no córtex cerebral7. Tais receberam opióides, sedativos e/ou anticonvulsivantes nas modificações do crescimento e desenvolvimento do sistema 24 horas antes do parto ou anestesia geral para o parto; nervoso central podem desencadear alterações neurocom- recém-nascidos expostos intra-útero ao tabaco, álcool, maco- portamentais perceptíveis já nos primeiros dias de vida8. nha, cocaína ou outra droga; gemelares; pacientes com bole- tim de Apgar<3no1ºminuto ou<7no5ºminuto de vida; A descrição clássica do recém-nascido PIG inclui maior recém-nascidos com malformações congênitas maiores; e habilidade motora, resposta exacerbada à pesquisa dos refle- presença de intercorrências clínicas no dia do estudo. Foram xos, permanência prolongada em estado de alerta e mais ape- incluídos os neonatos ictéricos que não estavam em fototera- tite do que neonatos de mesmo peso, porém menor idade pia à época do exame e aqueles que haviam apresentado des- gestacional9. No entanto, estudos de aspectos específicos do conforto respiratório adaptativo, mas não necessitavam de desempenho neurológico de recém-nascidos PIG, como a pes- oxigenoterapia e estavam em berço comum no momento do quisa de avaliação do tônus muscular por método objetivo, exame. indicam a presença
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