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          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Nuevas curvas de peso espec&#237;ficas para la edad gestacional &#40;l&#237;neas continuas&#41; para varones &#40;izquierda&#41; y mujeres &#40;derecha&#41;&#44; comparadas con las curvas de Olsen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> &#40;l&#237;neas discontinuas&#59; comenzando a las 23 semanas&#41;&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Desde hace m&#225;s de medio siglo&#44; diversos estudios somatom&#233;tricos en reci&#233;n nacidos &#40;RN&#41; han establecido datos de referencia para el peso &#40;PRN&#41;&#44; longitud y per&#237;metro craneal &#40;PC&#41;&#46; Los primeros estudios procedentes de Norteam&#233;rica datan de los a&#241;os sesenta<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> y han sido y a&#250;n son utilizados en numerosas unidades neonatales de todo el mundo&#46; Sin embargo&#44; muchos de estos trabajos no son poblacionales&#44; est&#225;n basados en datos de un &#250;nico o de pocos centros&#44; la metodolog&#237;a en la recogida de datos es heterog&#233;nea&#44; algunos ofrecen datos obtenidos de distintos grupos de pacientes y&#44; en ocasiones&#44; no se tiene en cuenta el sexo de los RN&#44; ofreci&#233;ndose los datos agrupados&#46; Adem&#225;s&#44; algunos estudios excluyen las gestaciones de alto riesgo y en muchos el c&#225;lculo de la EG se realiza sobre la base &#250;nicamente de la fecha de la &#250;ltima regla &#40;FUR&#41;&#46; Esto que sol&#237;a ser habitual en los primeros trabajos&#44; puede conllevar un error en la estimaci&#243;n&#44; m&#225;s acusado cuanto mayor es la prematuridad y tambi&#233;n en las gestaciones post&#233;rmino<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; Otro problema metodol&#243;gico es si la EG se establece sobre la base de semanas completas o bien la semana m&#225;s pr&#243;xima<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; En funci&#243;n del criterio elegido un mismo ni&#241;o puede incluirse en una categor&#237;a o en la inmediata superior&#46; Finalmente&#44; pero no menos importante&#44; la mejor&#237;a de los cuidados sanitarios en general y de las madres en particular hace que muchos de los datos normativos obtenidos hace m&#225;s de 50 a&#241;os pudieran no ser apropiados para los RN actuales&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Una carencia&#44; tanto de los estudios pasados como de la mayor&#237;a de los contempor&#225;neos&#44; es el escaso n&#250;mero de RN extremadamente inmaduros incluidos&#44; sobre todo por debajo de las 26 semanas de EG<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; Esta carencia dificulta conocer lo adecuado del crecimiento trofog&#233;nico intra&#250;tero en este grupo de RN prematuros y adem&#225;s de limitar el desarrollo de estudios epidemiol&#243;gicos sobre tendencias temporales&#44; impide la evaluaci&#243;n de la repercusi&#243;n de intervenciones cl&#237;nicas o de salud p&#250;blica orientadas a la optimizaci&#243;n del crecimiento fetal&#46; Por tanto&#44; el objetivo de este estudio fue desarrollar tablas y gr&#225;ficas de referencia poblacional en nuestro pa&#237;s para el peso&#44; la longitud y el per&#237;metro cef&#225;lico&#44; por EG y sexo&#44; en RN extremadamente prematuros &#40;22 a 28 semanas de EG&#41;&#44; de raza blanca&#44; procedentes de gestaciones &#250;nicas y sin anomal&#237;as cong&#233;nitas mayores&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pacientes y m&#233;todos</span><p id="par0015" class="elsevierStylePara elsevierViewall">A partir de la Base de Datos de la Red Nacional Espa&#241;ola SEN1500<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#44; se realiz&#243; un estudio transversal de todos los RN vivos&#44; incluyendo los que fallecieron en sala de partos&#44; de raza blanca y procedentes de gestaci&#243;n con un solo feto y sin malformaciones&#44; nacidos en los hospitales participantes&#44; desde el 1 de enero de 2002 hasta el 31 de diciembre del 2011&#46; El n&#250;mero de centros participantes vari&#243; a lo largo del periodo de estudio entre 49 y 63&#44; con representaci&#243;n de pr&#225;cticamente todas las comunidades y estim&#225;ndose una inclusi&#243;n del 60-65&#37; de todos los RN de muy bajo peso de nuestro pa&#237;s&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Las mediciones se llevaron a cabo de acuerdo con las pr&#225;cticas habituales en cada centro participante&#46; Los datos recogidos se registraron en el formulario de morbimortalidad de la Red&#44; aprobado previamente por los comit&#233;s de Investigaci&#243;n y &#201;tica de los hospitales participantes&#46; En este se registran el PRN&#44; la longitud y el PC&#46; La EG registrada se establece sobre la base de la mejor estimaci&#243;n disponible teniendo en cuenta la FUR&#44; los par&#225;metros obst&#233;tricos y la ecograf&#237;a prenatal reflejados en la historia materna&#46; Cuando fue necesario&#44; se estim&#243; por el neonat&#243;logo&#44; bas&#225;ndose en criterios f&#237;sicos&#44; el examen neurol&#243;gico&#44; una combinaci&#243;n del examen f&#237;sico y de la EG &#40;Ballard o Dubowitz&#41;&#46; Para la clasificaci&#243;n &#233;tnica o racial se tuvo en cuenta la de la madre&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Se excluy&#243; a los pacientes con sexo desconocido y los procedentes de gestaciones m&#250;ltiples o con anomal&#237;as cong&#233;nitas mayores o cromosomopat&#237;as&#46; Asimismo&#44; se excluy&#243; a los pacientes con medidas fisiol&#243;gicamente improbables definidas como valores superiores a 3 veces el rango intercuart&#237;lico por encima de tercer cuartil &#40;p75&#41; o por debajo del primero &#40;p25&#41;&#44; para cada EG y sexo&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lisis estad&#237;stico</span><p id="par0030" class="elsevierStylePara elsevierViewall">Los datos se analizaron con el paquete estad&#237;stico SPSS 20&#46; Las medidas de centralizaci&#243;n se expresan como media<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>DE&#46; La comparaci&#243;n de medias entre varones y mujeres se llev&#243; a cabo mediante la prueba de la t de Student&#44; consider&#225;ndose significativa una p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#46; En cada uno de los subgrupos de varones y mujeres se estimaron las curvas de percentiles &#40;3&#44; 10&#44; 25&#44; 50&#44; 75&#44; 90 y 97&#41; de pesos&#44; longitudes y PC&#46; Para tal fin&#44; se asumi&#243; que los datos siguen el modelo LMS de Cole y Green<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Este supone la existencia de las curvas <span class="elsevierStyleItalic">L</span>&#40;<span class="elsevierStyleItalic">t</span>&#41;&#44; <span class="elsevierStyleItalic">M</span>&#40;<span class="elsevierStyleItalic">t</span>&#41; y <span class="elsevierStyleItalic">S</span>&#40;<span class="elsevierStyleItalic">t</span>&#41; &#40;potencias de Box-Cox&#44; medianas y coeficientes de variaci&#243;n&#41;&#44; a partir de las cuales la curva de los 100&#945; percentiles &#40;0<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#945;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#41; se obtiene como&#58; <span class="elsevierStyleItalic">C&#945; &#40;t&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>M&#40;t&#41; &#40;1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>z</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">&#945;</span></span> &#183; <span class="elsevierStyleItalic">S &#91;t&#93;</span> &#183; <span class="elsevierStyleItalic">L&#91;t&#93;&#41;</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">1&#47;L&#40;t&#41;</span></span>&#44; cuando <span class="elsevierStyleItalic">L&#40;t&#41;</span> &#8800; 0&#59; o <span class="elsevierStyleItalic">C&#945; &#40;t&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>M&#40;t&#41; exp &#40;z</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">&#945;</span></span><span class="elsevierStyleItalic">S&#91;t&#93;&#41;</span>&#44; cuando <span class="elsevierStyleItalic">L&#40;t&#41;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44; siendo <span class="elsevierStyleItalic">z</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">&#945;</span></span> el &#945;-&#233;simo cuantil de la distribuci&#243;n normal est&#225;ndar&#46; Las curvas <span class="elsevierStyleItalic">L</span>&#44; <span class="elsevierStyleItalic">M</span> y <span class="elsevierStyleItalic">S</span> se estimaron mediante <span class="elsevierStyleItalic">splines</span> c&#250;bicos en el contexto de los modelos aditivos generalizados para localizaci&#243;n&#44; escala y forma &#40;GAMLSS&#41;&#46; Los scores z resultantes siguen una distribuci&#243;n normal y fueron suavizados y convertidos en percentiles para uso cl&#237;nico&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">El estudio fue aprobado por el Comit&#233; de Investigaci&#243;n&#44; Docencia y Formaci&#243;n continuada del centro del investigador principal &#40;FG-MR&#41;&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><p id="par0040" class="elsevierStylePara elsevierViewall">Durante el periodo de estudio &#40;2002-2011&#41; se registraron en la base de datos un total de 27&#46;205 pacientes &#8804; 1&#46;500 g de peso al nacimiento&#46; La distribuci&#243;n &#233;tnica y&#47;o racial fue&#58; raza blanca&#58; 17&#46;708 &#40;65&#44;1&#37;&#41;&#44; latinoamericana&#58; 943 &#40;3&#44;5&#37;&#41;&#44; gitana&#58; 457 &#40;1&#44;7&#37;&#41;&#44; negra&#58; 398 &#40;1&#44;5&#37;&#41;&#44; asi&#225;tica&#58; 172 &#40;0&#44;6&#37;&#41; y perdida o no adecuadamente registrada&#58; 7&#46;527 &#40;27&#44;7&#37;&#41;&#46; Dado el objetivo del presente trabajo&#44; nos centraremos en los RN &#8804; 28 semanas de EG y de raza blanca&#44; que fueron un total de 7&#46;001 pacientes&#46; De estos&#44; 2&#46;233 &#40;31&#44;9&#37;&#41; proced&#237;an de gestaciones m&#250;ltiples y fueron excluidos&#46; Del total de los 4&#46;768 &#40;68&#44;1&#37;&#41; RN procedentes de gestaciones &#250;nicas&#44; se excluy&#243; a 230 por presentar anomal&#237;as cong&#233;nitas graves y&#47;o cromosomopat&#237;as&#46; De los 4&#46;538 pacientes restantes&#44; 16 fueron excluidos por mediciones fisiol&#243;gicamente improbables&#58; valores en cualquiera de los 3 par&#225;metros estudiados &#40;peso&#44; longitud o PC&#41; 3 veces superior o inferior al rango intercuart&#237;lico &#40;extreme outliers&#41;&#46; Finalmente&#44; 4&#46;522 pacientes fueron incluidos&#44; de los que 2&#46;489 &#40;55&#37;&#41; eran varones y 2&#46;033 &#40;45&#37;&#41; mujeres&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se muestran los datos somatom&#233;tricos &#40;peso&#44; longitud y PC&#41; seg&#250;n la EG &#40;22-28 semanas&#41; y se comparan las diferencias entre varones y mujeres&#46; Dichas diferencias fueron estad&#237;sticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; desde la semana 23 para los 3 par&#225;metros estudiados&#44; excepto para el PC a las 23 semanas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;056&#41;&#46; Las <a class="elsevierStyleCrossRefs" href="#tbl0010">tablas 2 y 3</a> muestran los percentiles 3&#44; 10&#44; 25&#44; 50 &#40;mediana&#41;&#44; 75&#44; 90 y 97 del peso&#44; la longitud y del PC seg&#250;n la EG para cada sexo&#44; respectivamente&#46; Finalmente&#44; las <a class="elsevierStyleCrossRefs" href="#fig0005">figuras 1 y 2</a> muestran de forma gr&#225;fica los datos anteriormente referidos&#44; para varones y mujeres por separado&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discusi&#243;n</span><p id="par0050" class="elsevierStylePara elsevierViewall">El conjunto de pacientes estudiados y los datos representados en las tablas y figuras del presente trabajo constituyen el volumen m&#225;s importante y reciente de datos somatom&#233;tricos en RN prematuros extremos&#44; con base poblacional&#44; publicados hasta la fecha en nuestro pa&#237;s&#46; Estas nuevas gr&#225;ficas pueden tener una gran utilidad para el cl&#237;nico&#44; permiti&#233;ndole una m&#225;s precisa clasificaci&#243;n del prematuro extremo en peque&#241;o&#44; apropiado o grande para su EG en funci&#243;n del sexo&#46; Un hallazgo relevante de este trabajo es&#44; precisamente&#44; la presencia de dimorfismo sexual desde edades gestacionales tempranas&#46; Nuestro estudio ha demostrado diferencias significativas en peso&#44; longitud y PC entre ni&#241;os y ni&#241;as desde las 23 semanas de EG&#46; Estudios previos<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> solo hab&#237;an podido objetivar este dimorfismo sexual a partir de la semana 30 de gestaci&#243;n&#44; probablemente debido a la inclusi&#243;n de un n&#250;mero mucho menor de RN en cada grupo de EG&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Repetidamente se ha llamado la atenci&#243;n en la literatura especializada acerca de la inconveniencia de extrapolar datos obtenidos en otras poblaciones y sobre la necesidad de que cada comunidad disponga de sus propios valores de referencia&#46; En este sentido&#44; m&#250;ltiples han sido los esfuerzos en nuestro pa&#237;s para establecer los patrones normales de crecimiento en algunas &#225;reas<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10-16</span></a>&#44; y mantenerlos actualizados<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Sin embargo&#44; una limitaci&#243;n inherente a la metodolog&#237;a de estos estudios es&#44; precisamente&#44; la selecci&#243;n de una poblaci&#243;n exclusivamente local con la consiguiente dificultad para extrapolar los datos a otras comunidades y regiones&#44; adem&#225;s de la imposibilidad de conseguir un n&#250;mero suficiente de pacientes en las edades m&#225;s extremas&#44; lo que impide detectar diferencias potencialmente relevantes&#44; como es el dimorfismo sexual encontrado en nuestro trabajo desde las 23 semanas de gestaci&#243;n&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">En nuestro estudio&#44; comparamos las curvas obtenidas de una amplia muestra de RN con representaci&#243;n de la pr&#225;ctica totalidad de las regiones espa&#241;olas&#44; frente a otras curvas utilizadas com&#250;nmente como valores de referencia&#44; pero que se obtuvieron de una poblaci&#243;n m&#225;s limitada &#40;2 hospitales espa&#241;oles&#41;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; La comparaci&#243;n solo es posible a partir de las 26 semanas debido a la falta de datos correspondientes a edades gestacionales inferiores en el estudio mencionado&#46; Adem&#225;s&#44; el n&#250;mero de pacientes incluido en cada EG fue m&#225;s peque&#241;o que en nuestro trabajo&#44; variando entre 18 y 64 pacientes a las 26 y 28 semanas de EG&#44; respectivamente&#46; Aunque los valores medios para el peso en ambos estudios fueron bastante similares&#44; la principal diferencia la encontramos en los valores del percentil 90&#44; que fueron consistentemente inferiores en el estudio de Carrascosa et al&#46; &#40;entre el 4 y el 8&#37; en los varones&#44; y entre un 0&#44;4 y un 10&#37; para mujeres&#44; en las diferentes edades gestacionales&#46; As&#237; mismo&#44; los valores del percentil 10 fueron sistem&#225;ticamente mayores para las mujeres&#44; aunque no en los varones&#44; en aquel estudio &#40;entre un 4 y un 22&#37;&#41;&#46; Estos datos podr&#237;an dar lugar a una sobreestimaci&#243;n tanto de los pacientes de elevado peso para su EG&#44; como de los peque&#241;os para la EG cuando se utilizan las tablas de Carrascosa en estas edades gestacionales&#44; por debajo de las 28 semanas&#46; En contraste&#44; la <a class="elsevierStyleCrossRef" href="#fig0015">figura 3</a> muestra la similitud de nuestros resultados con los de un trabajo reciente que estudia una muestra norteamericana contempor&#225;nea&#44; amplia y racialmente diversa<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Aunque algunos autores consideran m&#225;s apropiado incluir todas las razas y etnias presentes en la poblaci&#243;n para que los resultados sean m&#225;s representativos de la misma<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#44; suele aceptarse que existen diferencias entre ellas en cuanto a los patrones normales de crecimiento<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; Para evitar potenciales sesgos&#44; en nuestro estudio decidimos incluir &#250;nicamente RN de raza cauc&#225;sica&#46; Sin embargo&#44; no se excluy&#243; a los hijos de madres con enfermedad cr&#243;nica &#40;diabetes&#44; hipertensi&#243;n arterial&#44; etc&#46;&#41;&#44; ni h&#225;bitos t&#243;xicos &#40;uso o abuso de alcohol&#44; tabaco&#44; drogas&#44; etc&#46;&#41;&#44; ya que dichas situaciones son relativamente prevalentes y&#47;o est&#225;n muy extendidas en la poblaci&#243;n&#44; adem&#225;s de constituir un &#171;continuo&#187; en cuanto a la intensidad de la afectaci&#243;n o el grado de control de dichas afecciones&#44; as&#237; como en la frecuencia e intensidad en el uso de sustancias&#44; que hacen muy dif&#237;cil&#44; si no imposible&#44; separar a los sujetos en los que el &#171;marcador&#187; est&#225; presente de aquellos en los que no lo est&#225;&#46; Dichos individuos&#44; en definitiva&#44; forman parte de la poblaci&#243;n &#171;normal&#187; y su exclusi&#243;n&#44; aparte de poder de ser potencialmente imprecisa y&#47;o arbitraria&#44; podr&#237;a conllevar un sesgo en los resultados&#44; sobreestimando los valores reales de crecimiento en la poblaci&#243;n&#46; Por esta raz&#243;n&#44; las referencias &#171;prescriptivas&#187; &#40;en lugar de las &#171;descriptivas&#187;&#41; podr&#237;an no ser aplicables a poblaciones en las que las gestaciones de bajo y alto riesgo est&#225;n entremezcladas<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Una controversia frecuente es la idoneidad o no de desarrollar curvas a partir de datos transversales&#44; ya que estos representan el crecimiento &#171;ideal&#187; del feto&#44; el cual difiere del crecimiento posnatal&#44; sobre todo en el RN prematuro<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20-24</span></a>&#46; Adem&#225;s&#44; la propia prematuridad puede ser desencadenada por un proceso que est&#233; interfiriendo con el crecimiento fetal intra&#250;tero&#44; por lo que el RN prematuro podr&#237;a ser m&#225;s peque&#241;o que un feto de la misma EG que permanezca dentro del seno materno&#46; Por otra parte&#44; aunque el perfeccionamiento de las t&#233;cnicas ultrasonogr&#225;ficas durante los &#250;ltimos 25 a&#241;os ha permitido elaborar mediciones seriadas longitudinales del peso fetal estimado &#40;PFE&#41;&#44; algunos estudios han encontrado en el RN prematuro un peso real al nacimiento menor al predicho por dichas estimaciones<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a>&#46; De aqu&#237; que la utilizaci&#243;n de tablas obtenidas con datos transversales tras el nacimiento puede infraestimar la incidencia real de RN peque&#241;os para la EG con sus potenciales repercusiones en la cl&#237;nica&#46; Con todo&#44; la dataci&#243;n ecogr&#225;fica de la gestaci&#243;n tampoco est&#225; exenta de un cierto grado de imprecisi&#243;n y el c&#225;lculo ecogr&#225;fico del PFE no es una medida directa&#44; habi&#233;ndose observado una variabilidad de hasta<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#37; con respecto al PRN&#46; Por todo ello&#44; y a pesar de sus limitaciones&#44; las tablas obtenidas de estudios transversales con datos de pacientes de diversas edades gestacionales contin&#250;an siendo ampliamente aceptadas y utilizadas para evaluar el tama&#241;o del RN y su evoluci&#243;n posnatal<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27-29</span></a>&#46; De hecho&#44; se acepta que representan el crecimiento real del feto hasta el momento del nacimiento y son recomendadas como objetivo de crecimiento para prematuros por algunas sociedades cient&#237;ficas<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Una limitaci&#243;n de nuestro estudio&#44; y universal a los estudios poblacionales&#44; es la relacionada con la precisi&#243;n y la fiabilidad de los resultados en funci&#243;n de los instrumentos de medida y con el amplio n&#250;mero de investigadores que llevan a cabo las mediciones&#46; Aunque en condiciones experimentales la homogeneidad en los instrumentos y el hecho de que sean uno o pocos los investigadores que realizan las mediciones podr&#237;a mejorar la precisi&#243;n de los resultados&#44; los estudios multic&#233;ntricos del tipo aqu&#237; presentado&#44; aparte de ser m&#225;s representativos de la poblaci&#243;n a la que van dirigidos&#44; podr&#237;an ser un mejor reflejo de lo que acontece en la pr&#225;ctica cl&#237;nica asistencial y&#44; por tanto&#44; sus resultados m&#225;s generalizables&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; los datos y las gr&#225;ficas que presentamos&#44; espec&#237;ficas por sexo y de base poblacional&#44; pueden ser datos normativos de referencia &#250;tiles para mejorar la evaluaci&#243;n del crecimiento del prematuro extremo en nuestro pa&#237;s&#44; as&#237; como para el desarrollo de estudios epidemiol&#243;gicos o la evaluaci&#243;n de tendencias temporales y de intervenciones cl&#237;nicas o de salud p&#250;blica orientadas a la optimizaci&#243;n del crecimiento fetal&#46; Algunos estudios han mostrado que la mejora de la salud materna&#44; relacionada sobre todo con aspectos nutricionales y h&#225;bitos de vida m&#225;s saludables&#44; ha incrementado progresivamente el tama&#241;o de los fetos y de los RN a lo largo del tiempo<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&#46; La actualizaci&#243;n peri&#243;dica de los datos para una determinada poblaci&#243;n es considerada altamente recomendable&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicto de intereses</span><p id="par0085" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La mayor&#237;a de los datos antropom&#233;tricos de referencia utilizados en nuestro pa&#237;s proceden de estudios llevados a cabo fuera del mismo hace muchos a&#241;os&#44; o bien est&#225;n basados en datos de un &#250;nico o pocos centros&#46; Adem&#225;s&#44; el n&#250;mero de reci&#233;n nacidos extremadamente prematuros &#40;RNEP&#41; incluidos ha sido muy escaso&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objetivos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Desarrollar unas tablas y gr&#225;ficas de referencia poblacionales en nuestro pa&#237;s para el peso&#44; la longitud y el per&#237;metro craneal &#40;PC&#41;&#44; por edad gestacional y sexo&#44; en RNEP de raza blanca procedentes de gestaciones &#250;nicas&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Pacientes y m&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron de todos los reci&#233;n nacidos &#8804; 28 semanas de EG&#44; registrados sobre la base de los datos SEN1500 durante 10 a&#241;os &#40;2002-2011&#41;&#46; La EG se estim&#243; bas&#225;ndose en la ecograf&#237;a fetal precoz o la fecha de la &#250;ltima regla&#46; Los datos se analizaron mediante el paquete estad&#237;stico SPSS 20 y se crearon tablas percentiladas de referencia independientes para varones y mujeres&#44; utilizando el m&#233;todo LMS de Cole y Green&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se presentan las primeras tablas y gr&#225;ficas percentiladas con base poblacional en nuestro pa&#237;s de peso&#44; longitud y PC en RNEP&#44; incluyendo reci&#233;n nacidos al l&#237;mite de viabilidad&#46; Se objetiva un dimorfismo sexual desde las 23 semanas de gestaci&#243;n&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Estas nuevas referencias&#44; espec&#237;ficas por sexo y de base poblacional&#44; pueden ser &#250;tiles para mejorar la evaluaci&#243;n del crecimiento del prematuro extremo en nuestro pa&#237;s&#44; as&#237; como para el desarrollo de estudios epidemiol&#243;gicos&#44; o evaluaci&#243;n de tendencias temporales y de intervenciones cl&#237;nicas o de salud p&#250;blica dirigidas a la optimizaci&#243;n del crecimiento fetal&#46; Un dimorfismo sexual es evidente desde etapas muy tempranas de la gestaci&#243;n&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Most anthropometric reference data for extremely preterm infants used in Spain are outdated and based on non-Spanish populations&#44; or are derived from small hospital-based samples that failed to include neonates of borderline viability&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Objectives</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To develop gender-specific&#44; population-based curves for birth weight&#44; length&#44; and head circumference in extremely preterm Caucasian infants&#44; using a large contemporary sample size of Spanish singletons&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Patients and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Anthropometric data from neonates &#8804; 28 weeks of gestational age were collected between January 2002 and December 2010 using the Spanish database SEN1500&#46; Gestational age was estimated according to obstetric data &#40;early pregnancy ultrasound&#41;&#46; The data were analyzed with the SPSS&#46;20 package&#44; and centile tables were created for males and females using the Cole and Green LMS method&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">This study presents the first population-based growth curves for extremely preterm infants&#44; including those of borderline viability&#44; in Spain&#46; A sexual dimorphism is evident for all of the studied parameters&#44; starting at early gestation&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">These new gender-specific and population-based data could be useful for the improvement of growth assessments of extremely preterm infants in our country&#44; for the development of epidemiological studies&#44; for the evaluation of temporal trends&#44; and for clinical or public health interventions seeking to optimize fetal growth&#46;</p>"
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                  """
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          "es" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Percentiles de peso &#40;g&#41;&#44; longitud &#40;cm&#41; y per&#237;metro craneal &#40;cm&#41;&#44; en mujeres por semanas de edad gestacional</p>"
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Original
Nuevas curvas poblacionales de crecimiento en recién nacidos extremadamente prematuros españoles
New population curves in spanish extremely preterm neonates
F. García-Muñoz Rodrigoa,
Autor para correspondencia
fgarciamu@gmail.com

Autor para correspondencia.
, A. García-Alix Pérezb, J. Figueras Aloyc, P. Saavedra Santanad, grupo español SEN1500
a Servicio de Neonatología, Hospital Universitario Materno-Infantil, Las Palmas de Gran Canaria, Las Palmas, España
b Servicio de Neonatología, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
c Servicio de Neonatología, Hospital Clínic i Provincial, Barcelona, España
d Departamento de Matemáticas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, España
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en ocasiones&#44; no se tiene en cuenta el sexo de los RN&#44; ofreci&#233;ndose los datos agrupados&#46; Adem&#225;s&#44; algunos estudios excluyen las gestaciones de alto riesgo y en muchos el c&#225;lculo de la EG se realiza sobre la base &#250;nicamente de la fecha de la &#250;ltima regla &#40;FUR&#41;&#46; Esto que sol&#237;a ser habitual en los primeros trabajos&#44; puede conllevar un error en la estimaci&#243;n&#44; m&#225;s acusado cuanto mayor es la prematuridad y tambi&#233;n en las gestaciones post&#233;rmino<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; Otro problema metodol&#243;gico es si la EG se establece sobre la base de semanas completas o bien la semana m&#225;s pr&#243;xima<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; En funci&#243;n del criterio elegido un mismo ni&#241;o puede incluirse en una categor&#237;a o en la inmediata superior&#46; Finalmente&#44; pero no menos importante&#44; la mejor&#237;a de los cuidados sanitarios en general y de las madres en particular hace que muchos de los datos normativos obtenidos hace m&#225;s de 50 a&#241;os pudieran no ser apropiados para los RN actuales&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Una carencia&#44; tanto de los estudios pasados como de la mayor&#237;a de los contempor&#225;neos&#44; es el escaso n&#250;mero de RN extremadamente inmaduros incluidos&#44; sobre todo por debajo de las 26 semanas de EG<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; Esta carencia dificulta conocer lo adecuado del crecimiento trofog&#233;nico intra&#250;tero en este grupo de RN prematuros y adem&#225;s de limitar el desarrollo de estudios epidemiol&#243;gicos sobre tendencias temporales&#44; impide la evaluaci&#243;n de la repercusi&#243;n de intervenciones cl&#237;nicas o de salud p&#250;blica orientadas a la optimizaci&#243;n del crecimiento fetal&#46; Por tanto&#44; el objetivo de este estudio fue desarrollar tablas y gr&#225;ficas de referencia poblacional en nuestro pa&#237;s para el peso&#44; la longitud y el per&#237;metro cef&#225;lico&#44; por EG y sexo&#44; en RN extremadamente prematuros &#40;22 a 28 semanas de EG&#41;&#44; de raza blanca&#44; procedentes de gestaciones &#250;nicas y sin anomal&#237;as cong&#233;nitas mayores&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pacientes y m&#233;todos</span><p id="par0015" class="elsevierStylePara elsevierViewall">A partir de la Base de Datos de la Red Nacional Espa&#241;ola SEN1500<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#44; se realiz&#243; un estudio transversal de todos los RN vivos&#44; incluyendo los que fallecieron en sala de partos&#44; de raza blanca y procedentes de gestaci&#243;n con un solo feto y sin malformaciones&#44; nacidos en los hospitales participantes&#44; desde el 1 de enero de 2002 hasta el 31 de diciembre del 2011&#46; El n&#250;mero de centros participantes vari&#243; a lo largo del periodo de estudio entre 49 y 63&#44; con representaci&#243;n de pr&#225;cticamente todas las comunidades y estim&#225;ndose una inclusi&#243;n del 60-65&#37; de todos los RN de muy bajo peso de nuestro pa&#237;s&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Las mediciones se llevaron a cabo de acuerdo con las pr&#225;cticas habituales en cada centro participante&#46; Los datos recogidos se registraron en el formulario de morbimortalidad de la Red&#44; aprobado previamente por los comit&#233;s de Investigaci&#243;n y &#201;tica de los hospitales participantes&#46; En este se registran el PRN&#44; la longitud y el PC&#46; La EG registrada se establece sobre la base de la mejor estimaci&#243;n disponible teniendo en cuenta la FUR&#44; los par&#225;metros obst&#233;tricos y la ecograf&#237;a prenatal reflejados en la historia materna&#46; Cuando fue necesario&#44; se estim&#243; por el neonat&#243;logo&#44; bas&#225;ndose en criterios f&#237;sicos&#44; el examen neurol&#243;gico&#44; una combinaci&#243;n del examen f&#237;sico y de la EG &#40;Ballard o Dubowitz&#41;&#46; Para la clasificaci&#243;n &#233;tnica o racial se tuvo en cuenta la de la madre&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Se excluy&#243; a los pacientes con sexo desconocido y los procedentes de gestaciones m&#250;ltiples o con anomal&#237;as cong&#233;nitas mayores o cromosomopat&#237;as&#46; Asimismo&#44; se excluy&#243; a los pacientes con medidas fisiol&#243;gicamente improbables definidas como valores superiores a 3 veces el rango intercuart&#237;lico por encima de tercer cuartil &#40;p75&#41; o por debajo del primero &#40;p25&#41;&#44; para cada EG y sexo&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">An&#225;lisis estad&#237;stico</span><p id="par0030" class="elsevierStylePara elsevierViewall">Los datos se analizaron con el paquete estad&#237;stico SPSS 20&#46; 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escala y forma &#40;GAMLSS&#41;&#46; Los scores z resultantes siguen una distribuci&#243;n normal y fueron suavizados y convertidos en percentiles para uso cl&#237;nico&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">El estudio fue aprobado por el Comit&#233; de Investigaci&#243;n&#44; Docencia y Formaci&#243;n continuada del centro del investigador principal &#40;FG-MR&#41;&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><p id="par0040" class="elsevierStylePara elsevierViewall">Durante el periodo de estudio &#40;2002-2011&#41; se registraron en la base de datos un total de 27&#46;205 pacientes &#8804; 1&#46;500 g de peso al nacimiento&#46; La distribuci&#243;n &#233;tnica y&#47;o racial fue&#58; raza blanca&#58; 17&#46;708 &#40;65&#44;1&#37;&#41;&#44; latinoamericana&#58; 943 &#40;3&#44;5&#37;&#41;&#44; gitana&#58; 457 &#40;1&#44;7&#37;&#41;&#44; negra&#58; 398 &#40;1&#44;5&#37;&#41;&#44; asi&#225;tica&#58; 172 &#40;0&#44;6&#37;&#41; y perdida o no adecuadamente registrada&#58; 7&#46;527 &#40;27&#44;7&#37;&#41;&#46; Dado el objetivo del presente trabajo&#44; nos centraremos en los RN &#8804; 28 semanas de EG y de raza blanca&#44; que fueron un total de 7&#46;001 pacientes&#46; De estos&#44; 2&#46;233 &#40;31&#44;9&#37;&#41; proced&#237;an de gestaciones m&#250;ltiples y fueron excluidos&#46; Del total de los 4&#46;768 &#40;68&#44;1&#37;&#41; RN procedentes de gestaciones &#250;nicas&#44; se excluy&#243; a 230 por presentar anomal&#237;as cong&#233;nitas graves y&#47;o cromosomopat&#237;as&#46; De los 4&#46;538 pacientes restantes&#44; 16 fueron excluidos por mediciones fisiol&#243;gicamente improbables&#58; valores en cualquiera de los 3 par&#225;metros estudiados &#40;peso&#44; longitud o PC&#41; 3 veces superior o inferior al rango intercuart&#237;lico &#40;extreme outliers&#41;&#46; Finalmente&#44; 4&#46;522 pacientes fueron incluidos&#44; de los que 2&#46;489 &#40;55&#37;&#41; eran varones y 2&#46;033 &#40;45&#37;&#41; mujeres&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se muestran los datos somatom&#233;tricos &#40;peso&#44; longitud y PC&#41; seg&#250;n la EG &#40;22-28 semanas&#41; y se comparan las diferencias entre varones y mujeres&#46; Dichas diferencias fueron estad&#237;sticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; desde la semana 23 para los 3 par&#225;metros estudiados&#44; excepto para el PC a las 23 semanas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;056&#41;&#46; Las <a class="elsevierStyleCrossRefs" href="#tbl0010">tablas 2 y 3</a> muestran los percentiles 3&#44; 10&#44; 25&#44; 50 &#40;mediana&#41;&#44; 75&#44; 90 y 97 del peso&#44; la longitud y del PC seg&#250;n la EG para cada sexo&#44; respectivamente&#46; Finalmente&#44; las <a class="elsevierStyleCrossRefs" href="#fig0005">figuras 1 y 2</a> muestran de forma gr&#225;fica los datos anteriormente referidos&#44; para varones y mujeres por separado&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discusi&#243;n</span><p id="par0050" class="elsevierStylePara elsevierViewall">El conjunto de pacientes estudiados y los datos representados en las tablas y figuras del presente trabajo constituyen el volumen m&#225;s importante y reciente de datos somatom&#233;tricos en RN prematuros extremos&#44; con base poblacional&#44; publicados hasta la fecha en nuestro pa&#237;s&#46; Estas nuevas gr&#225;ficas pueden tener una gran utilidad para el cl&#237;nico&#44; permiti&#233;ndole una m&#225;s precisa clasificaci&#243;n del prematuro extremo en peque&#241;o&#44; apropiado o grande para su EG en funci&#243;n del sexo&#46; Un hallazgo relevante de este trabajo es&#44; precisamente&#44; la presencia de dimorfismo sexual desde edades gestacionales tempranas&#46; Nuestro estudio ha demostrado diferencias significativas en peso&#44; longitud y PC entre ni&#241;os y ni&#241;as desde las 23 semanas de EG&#46; Estudios previos<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> solo hab&#237;an podido objetivar este dimorfismo sexual a partir de la semana 30 de gestaci&#243;n&#44; probablemente debido a la inclusi&#243;n de un n&#250;mero mucho menor de RN en cada grupo de EG&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Repetidamente se ha llamado la atenci&#243;n en la literatura especializada acerca de la inconveniencia de extrapolar datos obtenidos en otras poblaciones y sobre la necesidad de que cada comunidad disponga de sus propios valores de referencia&#46; En este sentido&#44; m&#250;ltiples han sido los esfuerzos en nuestro pa&#237;s para establecer los patrones normales de crecimiento en algunas &#225;reas<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10-16</span></a>&#44; y mantenerlos actualizados<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; Sin embargo&#44; una limitaci&#243;n inherente a la metodolog&#237;a de estos estudios es&#44; precisamente&#44; la selecci&#243;n de una poblaci&#243;n exclusivamente local con la consiguiente dificultad para extrapolar los datos a otras comunidades y regiones&#44; adem&#225;s de la imposibilidad de conseguir un n&#250;mero suficiente de pacientes en las edades m&#225;s extremas&#44; lo que impide detectar diferencias potencialmente relevantes&#44; como es el dimorfismo sexual encontrado en nuestro trabajo desde las 23 semanas de gestaci&#243;n&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">En nuestro estudio&#44; comparamos las curvas obtenidas de una amplia muestra de RN con representaci&#243;n de la pr&#225;ctica totalidad de las regiones espa&#241;olas&#44; frente a otras curvas utilizadas com&#250;nmente como valores de referencia&#44; pero que se obtuvieron de una poblaci&#243;n m&#225;s limitada &#40;2 hospitales espa&#241;oles&#41;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; La comparaci&#243;n solo es posible a partir de las 26 semanas debido a la falta de datos correspondientes a edades gestacionales inferiores en el estudio mencionado&#46; Adem&#225;s&#44; el n&#250;mero de pacientes incluido en cada EG fue m&#225;s peque&#241;o que en nuestro trabajo&#44; variando entre 18 y 64 pacientes a las 26 y 28 semanas de EG&#44; respectivamente&#46; Aunque los valores medios para el peso en ambos estudios fueron bastante similares&#44; la principal diferencia la encontramos en los valores del percentil 90&#44; que fueron consistentemente inferiores en el estudio de Carrascosa et al&#46; &#40;entre el 4 y el 8&#37; en los varones&#44; y entre un 0&#44;4 y un 10&#37; para mujeres&#44; en las diferentes edades gestacionales&#46; As&#237; mismo&#44; los valores del percentil 10 fueron sistem&#225;ticamente mayores para las mujeres&#44; aunque no en los varones&#44; en aquel estudio &#40;entre un 4 y un 22&#37;&#41;&#46; Estos datos podr&#237;an dar lugar a una sobreestimaci&#243;n tanto de los pacientes de elevado peso para su EG&#44; como de los peque&#241;os para la EG cuando se utilizan las tablas de Carrascosa en estas edades gestacionales&#44; por debajo de las 28 semanas&#46; En contraste&#44; la <a class="elsevierStyleCrossRef" href="#fig0015">figura 3</a> muestra la similitud de nuestros resultados con los de un trabajo reciente que estudia una muestra norteamericana contempor&#225;nea&#44; amplia y racialmente diversa<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Aunque algunos autores consideran m&#225;s apropiado incluir todas las razas y etnias presentes en la poblaci&#243;n para que los resultados sean m&#225;s representativos de la misma<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#44; suele aceptarse que existen diferencias entre ellas en cuanto a los patrones normales de crecimiento<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; Para evitar potenciales sesgos&#44; en nuestro estudio decidimos incluir &#250;nicamente RN de raza cauc&#225;sica&#46; Sin embargo&#44; no se excluy&#243; a los hijos de madres con enfermedad cr&#243;nica &#40;diabetes&#44; hipertensi&#243;n arterial&#44; etc&#46;&#41;&#44; ni h&#225;bitos t&#243;xicos &#40;uso o abuso de alcohol&#44; tabaco&#44; drogas&#44; etc&#46;&#41;&#44; ya que dichas situaciones son relativamente prevalentes y&#47;o est&#225;n muy extendidas en la poblaci&#243;n&#44; adem&#225;s de constituir un &#171;continuo&#187; en cuanto a la intensidad de la afectaci&#243;n o el grado de control de dichas afecciones&#44; as&#237; como en la frecuencia e intensidad en el uso de sustancias&#44; que hacen muy dif&#237;cil&#44; si no imposible&#44; separar a los sujetos en los que el &#171;marcador&#187; est&#225; presente de aquellos en los que no lo est&#225;&#46; Dichos individuos&#44; en definitiva&#44; forman parte de la poblaci&#243;n &#171;normal&#187; y su exclusi&#243;n&#44; aparte de poder de ser potencialmente imprecisa y&#47;o arbitraria&#44; podr&#237;a conllevar un sesgo en los resultados&#44; sobreestimando los valores reales de crecimiento en la poblaci&#243;n&#46; Por esta raz&#243;n&#44; las referencias &#171;prescriptivas&#187; &#40;en lugar de las &#171;descriptivas&#187;&#41; podr&#237;an no ser aplicables a poblaciones en las que las gestaciones de bajo y alto riesgo est&#225;n entremezcladas<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Una controversia frecuente es la idoneidad o no de desarrollar curvas a partir de datos transversales&#44; ya que estos representan el crecimiento &#171;ideal&#187; del feto&#44; el cual difiere del crecimiento posnatal&#44; sobre todo en el RN prematuro<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20-24</span></a>&#46; Adem&#225;s&#44; la propia prematuridad puede ser desencadenada por un proceso que est&#233; interfiriendo con el crecimiento fetal intra&#250;tero&#44; por lo que el RN prematuro podr&#237;a ser m&#225;s peque&#241;o que un feto de la misma EG que permanezca dentro del seno materno&#46; Por otra parte&#44; aunque el perfeccionamiento de las t&#233;cnicas ultrasonogr&#225;ficas durante los &#250;ltimos 25 a&#241;os ha permitido elaborar mediciones seriadas longitudinales del peso fetal estimado &#40;PFE&#41;&#44; algunos estudios han encontrado en el RN prematuro un peso real al nacimiento menor al predicho por dichas estimaciones<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a>&#46; De aqu&#237; que la utilizaci&#243;n de tablas obtenidas con datos transversales tras el nacimiento puede infraestimar la incidencia real de RN peque&#241;os para la EG con sus potenciales repercusiones en la cl&#237;nica&#46; Con todo&#44; la dataci&#243;n ecogr&#225;fica de la gestaci&#243;n tampoco est&#225; exenta de un cierto grado de imprecisi&#243;n y el c&#225;lculo ecogr&#225;fico del PFE no es una medida directa&#44; habi&#233;ndose observado una variabilidad de hasta<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#37; con respecto al PRN&#46; Por todo ello&#44; y a pesar de sus limitaciones&#44; las tablas obtenidas de estudios transversales con datos de pacientes de diversas edades gestacionales contin&#250;an siendo ampliamente aceptadas y utilizadas para evaluar el tama&#241;o del RN y su evoluci&#243;n posnatal<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27-29</span></a>&#46; De hecho&#44; se acepta que representan el crecimiento real del feto hasta el momento del nacimiento y son recomendadas como objetivo de crecimiento para prematuros por algunas sociedades cient&#237;ficas<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Una limitaci&#243;n de nuestro estudio&#44; y universal a los estudios poblacionales&#44; es la relacionada con la precisi&#243;n y la fiabilidad de los resultados en funci&#243;n de los instrumentos de medida y con el amplio n&#250;mero de investigadores que llevan a cabo las mediciones&#46; Aunque en condiciones experimentales la homogeneidad en los instrumentos y el hecho de que sean uno o pocos los investigadores que realizan las mediciones podr&#237;a mejorar la precisi&#243;n de los resultados&#44; los estudios multic&#233;ntricos del tipo aqu&#237; presentado&#44; aparte de ser m&#225;s representativos de la poblaci&#243;n a la que van dirigidos&#44; podr&#237;an ser un mejor reflejo de lo que acontece en la pr&#225;ctica cl&#237;nica asistencial y&#44; por tanto&#44; sus resultados m&#225;s generalizables&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; los datos y las gr&#225;ficas que presentamos&#44; espec&#237;ficas por sexo y de base poblacional&#44; pueden ser datos normativos de referencia &#250;tiles para mejorar la evaluaci&#243;n del crecimiento del prematuro extremo en nuestro pa&#237;s&#44; as&#237; como para el desarrollo de estudios epidemiol&#243;gicos o la evaluaci&#243;n de tendencias temporales y de intervenciones cl&#237;nicas o de salud p&#250;blica orientadas a la optimizaci&#243;n del crecimiento fetal&#46; Algunos estudios han mostrado que la mejora de la salud materna&#44; relacionada sobre todo con aspectos nutricionales y h&#225;bitos de vida m&#225;s saludables&#44; ha incrementado progresivamente el tama&#241;o de los fetos y de los RN a lo largo del tiempo<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&#46; La actualizaci&#243;n peri&#243;dica de los datos para una determinada poblaci&#243;n es considerada altamente recomendable&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicto de intereses</span><p id="par0085" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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    "fechaRecibido" => "2013-05-24"
    "fechaAceptado" => "2013-06-23"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:9 [
            0 => "Curvas de crecimiento"
            1 => "Prematuridad extrema"
            2 => "Peso"
            3 => "Longitud"
            4 => "Per&#237;metro craneal"
            5 => "Grande para la edad gestacional"
            6 => "Apropiado para la edad gestacional"
            7 => "Peque&#241;o para la edad gestacional"
            8 => "Reci&#233;n nacido de muy bajo peso"
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          "clase" => "keyword"
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          "palabras" => array:8 [
            0 => "Growth curves"
            1 => "Birth weight"
            2 => "Longitude"
            3 => "Head circumference"
            4 => "Large for gestational age"
            5 => "Appropriate for gestational age"
            6 => "Small for gestational age"
            7 => "Very low birth weight"
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    "resumen" => array:2 [
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La mayor&#237;a de los datos antropom&#233;tricos de referencia utilizados en nuestro pa&#237;s proceden de estudios llevados a cabo fuera del mismo hace muchos a&#241;os&#44; o bien est&#225;n basados en datos de un &#250;nico o pocos centros&#46; Adem&#225;s&#44; el n&#250;mero de reci&#233;n nacidos extremadamente prematuros &#40;RNEP&#41; incluidos ha sido muy escaso&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objetivos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Desarrollar unas tablas y gr&#225;ficas de referencia poblacionales en nuestro pa&#237;s para el peso&#44; la longitud y el per&#237;metro craneal &#40;PC&#41;&#44; por edad gestacional y sexo&#44; en RNEP de raza blanca procedentes de gestaciones &#250;nicas&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Pacientes y m&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron de todos los reci&#233;n nacidos &#8804; 28 semanas de EG&#44; registrados sobre la base de los datos SEN1500 durante 10 a&#241;os &#40;2002-2011&#41;&#46; La EG se estim&#243; bas&#225;ndose en la ecograf&#237;a fetal precoz o la fecha de la &#250;ltima regla&#46; Los datos se analizaron mediante el paquete estad&#237;stico SPSS 20 y se crearon tablas percentiladas de referencia independientes para varones y mujeres&#44; utilizando el m&#233;todo LMS de Cole y Green&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se presentan las primeras tablas y gr&#225;ficas percentiladas con base poblacional en nuestro pa&#237;s de peso&#44; longitud y PC en RNEP&#44; incluyendo reci&#233;n nacidos al l&#237;mite de viabilidad&#46; Se objetiva un dimorfismo sexual desde las 23 semanas de gestaci&#243;n&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Estas nuevas referencias&#44; espec&#237;ficas por sexo y de base poblacional&#44; pueden ser &#250;tiles para mejorar la evaluaci&#243;n del crecimiento del prematuro extremo en nuestro pa&#237;s&#44; as&#237; como para el desarrollo de estudios epidemiol&#243;gicos&#44; o evaluaci&#243;n de tendencias temporales y de intervenciones cl&#237;nicas o de salud p&#250;blica dirigidas a la optimizaci&#243;n del crecimiento fetal&#46; Un dimorfismo sexual es evidente desde etapas muy tempranas de la gestaci&#243;n&#46;</p>"
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        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Most anthropometric reference data for extremely preterm infants used in Spain are outdated and based on non-Spanish populations&#44; or are derived from small hospital-based samples that failed to include neonates of borderline viability&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Objectives</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To develop gender-specific&#44; population-based curves for birth weight&#44; length&#44; and head circumference in extremely preterm Caucasian infants&#44; using a large contemporary sample size of Spanish singletons&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Patients and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Anthropometric data from neonates &#8804; 28 weeks of gestational age were collected between January 2002 and December 2010 using the Spanish database SEN1500&#46; Gestational age was estimated according to obstetric data &#40;early pregnancy ultrasound&#41;&#46; The data were analyzed with the SPSS&#46;20 package&#44; and centile tables were created for males and females using the Cole and Green LMS method&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">This study presents the first population-based growth curves for extremely preterm infants&#44; including those of borderline viability&#44; in Spain&#46; A sexual dimorphism is evident for all of the studied parameters&#44; starting at early gestation&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">These new gender-specific and population-based data could be useful for the improvement of growth assessments of extremely preterm infants in our country&#44; for the development of epidemiological studies&#44; for the evaluation of temporal trends&#44; and for clinical or public health interventions seeking to optimize fetal growth&#46;</p>"
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                  """
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ISSN: 16954033
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2017 Noviembre 156 1 157
2017 Octubre 125 1 126
2017 Septiembre 115 0 115
2017 Agosto 121 0 121
2017 Julio 173 7 180
2017 Junio 201 50 251
2017 Mayo 218 62 280
2017 Abril 163 43 206
2017 Marzo 230 40 270
2017 Febrero 348 32 380
2017 Enero 156 23 179
2016 Diciembre 145 35 180
2016 Noviembre 247 35 282
2016 Octubre 271 46 317
2016 Septiembre 318 59 377
2016 Agosto 299 42 341
2016 Julio 123 31 154
2016 Mayo 1 0 1
2015 Diciembre 2 0 2
2015 Abril 2 0 2
2015 Marzo 2 0 2
2015 Febrero 3 0 3
2014 Diciembre 3 0 3
2014 Noviembre 1 1 2
2014 Septiembre 2 0 2
2014 Agosto 4 0 4
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Anales de Pediatría