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Italian Journal of Pediatrics 2014, Volume 40 Suppl 2
http://www.ijponline.net/supplements/40/S2
MEETING ABSTRACTS
Open Access
Proceedings of the XX National Congress of the
Italian Society of Neonatology
Rome, Italy. 9-11 October 2014
Published: 9 October 2014
These abstracts are available online at http://www.ijponline.net/supplements/40/S2
MEETING ABSTRACTS
A1
Delivery and late preterm birth
Antonio Lanzone*, Sergio Ferrazzani, Angela Botta
Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del S. Cuore.,
Rome, Italy
Italian Journal of Pediatrics 2014, 40(Suppl 2):A1
Delivery of infants who are physiologically mature and capable of successful
transition to the extrauterine environment is an important priority for
obstetric practitioners. During the past 15 years in the United States the
percentage of infants born before 40 weeks’ gestation has dramatically
increased and the percentage of infants born after 40 weeks’ gestation has
decreased. In this shift several factors have been implicated: increased
medical surveillance and interventions, increased multifetal pregnancies,
maternal obesity (risk for preeclampsia, diabetes and other complications),
maternal autonomy, route and timing of delivery.
Birth before fetal maturity contributes to short-term and long-term
morbidity and mortality in late preterm (34+0 to 36+6 weeks’ gestation). Age
stratified cohort studies confirms that adverse neonatal outcome decrease
with increasing gestational age independent of delivery mode.
Because of the known morbidity and mortality associated with late preterm
birth, iatrogenic delivery in this period has become a major concern.
Preterm birth has been characterized as either “spontaneous” or “indicated.”
For the most part, spontaneous late preterm births are difficult to avoid,
whereas the term “indicated” implies that the delivery was necessary for
maternal or fetal benefit. Gyamfi-Bannerman and colleagues found that
56.7% of late preterm non spontaneous deliveries were non-evidence
based, concluding that more data were needed to justify many indications.
A recent workshop by the Society for Maternal-Fetal Medicine developed
consensus recommendations regarding the gestational age for delivery.
These recommendations and those of the American College of Obstetricians
and Gynecologists (ACOG) are based on the balance between maternal and
newborn risks of early delivery with the risk of further continuation of
pregnancy.
To decrease the mortality and morbidity associated with late preterm births,
prevention is one of the key components. The ACOG does not recommend
induced vaginal or planned cesarean delivery prior to 39 weeks gestation
unless medically indicate. If elective induction is undertaken for nonmedical
reasons, it should only take place if the preinduction assessment ensures the
gestational age is at least 39 weeks.
In addition, further research is needed to refine the management of late
preterm gestation (such as better identification of pregnancies that
require early delivery for medical conditions):
• Assess the risk/benefit ratio for indications for late preterm delivery,
such as more accurate estimation of fetal outcome in presence of
maternal diseases.
• Identify management strategies to improve outcomes in late
preterm infant (antenatal steroids)
• Improve the precision of determining gestational age.
A2
The transition of late preterm
Maria Pia De Carolis1*, Carmen Cocca1, Serena Antonia Rubortone1,
Giovanni Pinna1, Sara De Carolis2, Silvia Salvi2, Costantino Romagnoli1
1
Division of Neonatology, Department of Obstetrics, Gynecology and
Pediatrics, Catholic University of Sacred Heart, Rome, 00168, Italy; 2Division of
Maternal Medicine, Department of Obstetrics, Gynecology and Pediatrics,
Catholic University of Sacred Heart, Rome, 00168, Italy
Background: The transition from the intra- to the extra-uterine life is
characterized by major physiological changes in respiratory and
hemodynamic functions [1]; moreover, the intrauterine thermostability has to
been replaced by the neonatal termoregulation [2]. Many of the antepartum
and intrapartum risk factors associated with the need of resuscitation may be
present in late-preterm neonates (340/7-366/7 weeks) [3]. It is also reported a
double risk of Caesarean Section (CS) in case of late-preterm compared to
term deliveries [4]. Our objective was to evaluate the transition period in latepreterm infants in particular considering the need for resuscitation and the
incidence of hypothermia.
Materials and methods: This was a retrospective study of all late preterm
neonates during a 1-year period from January 2013. Gestational Age (GA)
was calculated as a function of the date of last menstrual period and/or
biometrics assigned from the ultrasound measurement of the first trimester.
Type of pregnancy (singleton or multiple), use of antepartum steroid
therapy, maternal medical disorders, obstetric and/or fetal complications,
intrapartum fetal distress, birth weight (BW), gender, Apgar score, need for
resuscitation were collected from medical records Rectal temperature was
measured in all neonates at birth and at admission to nursery.
Results: During the study period there were a total of 3354 births. The
number of preterm neonates was 478 (14.2%), of these 279 (58%) were latepreterm (249 singleton pregnancy and 30 multiple pregnancy). Three
neonates were excluded due to in utero fetal death. Table 1 summarizes the
characteristics of the population according to GA: 34 weeks of gestation
(Group I), 35 weeks (Group II) and 36 weeks (Group III). The twins rate was
significantly higher (p<0.001) in Group I than the others. The CS rate was
similar among the groups and increased in comparison to that reported in
our Department for term deliveries (44%). A higher number of neonates with
Apgar score <71 was present in Group I in comparison to the others, as well
as a higher number of neonates requiring resuscitation, independently of the
mode of delivery. In Group II and III, all neonates requiring resuscitation were
born by CS. Higher number of neonates with mild hypothermia at admission
was detected in Group I. Considerable variations occur in the temperature
values in all infants in DR as well as during the transport to the nursery.
© 2014 various authors, licensee BioMed Central Ltd All articles published in this supplement are distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Page 2 of 28
Table 1(abstract A1) Neonatal characteristics by
gestational age group
Gestational age (weeks+days of gestation)
34+0-34+6
35+0-35+6
36+0-36+6
Number (%)
62 (22.5)
77 (27.9)
137(49.6)
Singletons, n (%)
Multiples, n (%)
40 (64.5)
22 (35.4)
65 (84.4)
12 (15.6)
117 (85.4)
20 (14.6)
Vaginal Delivery, n (%)
14 (22.5)
23 (29.8)
51 (37.2)
Caesarean-section, n (%)
48 (77.5)
54 (70.2)
86 (62.8)
1 min Apgar , mean (DS)
7±2
8±1
9±1
1 min Apgar <7, n (%)
15 (24.2)
4 (5.2)
4 (2.9)
9±1
5-min Apgar, mean (DS)
9±1
9±1
5-min Apgar <7, n (%)
2 (3,2%)
2 (2,5%)
0
Positive Pressure Ventilation, n (%)
Endotracheal Intubation, n (%)
15
6 (9.7)
4
3 (3.9)
4
1 (0.7)
Conclusion: Late-preterm birth by CS is associated with significant GAdependent neonatal depression. Additional close monitoring and timely
intervention are necessary in the management of these infants in DR.
References
1. van Vonderen JJ, Roest AA, Siew ML, Walther FJ, Hooper SB, te Pas AB:
Measuring physiological changes during the transition to life after birth.
Neonatology 2014, 105(3):230-242.
2. Laptook A, Jackson GL: Cold stress and hypoglycemia in the late preterm
(“near-term”) infant: impact on nursery of admission. Semin Perinatol
2006, 30(1):24-27.
3. Khashu M, Narayanan M, Bhargava S, Osiovich H: Perinatal outcomes
associated with preterm birth at 33 to 36 weeks’ gestation: a
population-based cohort study. Pediatrics 2009, 123(1):109-113.
4. Guasch XD, Torrent FR, Martínez-Nadal S, Cerén CV, Saco MJ, Castellví PS:
Late preterm infants: A population at underestimated risk. An Pediatr
(Barc) 2009, 71(4):291-298.
A3
The late preterm IUGR and/or SGA
Enrico Bertino*, Luciana Occhi, Paola Di Nicola
Neonatal Unit, University of Turin, 10126 Turin, Italy
E-mail: [email protected]
It is well known that in late preterm infants the mortality and the morbidity
are higher than in term neonates. The rate of complications decreases with
the progression of gestational age through the late preterm period [1].
Intrauterine growth restriction (IUGR) is one of the cause for late preterm
delivery and it occurs more often in late preterm infants than terms ones.
Itself constitutes a risk factor for morbidity and mortality [2,3]. IUGR, as well
as associated peri-natal morbidities, contributes to increase the risk, in these
infants, of postnatal growth impairment, metabolic diseases and poor
neuro-developmental outcome [1,4]. Late preterm small for gestational age
(SGA) infants were 44 times more likely to die in the first month and
22 times more likely to die in their first year than term adequate for
gestational age (AGA) newborns. This increased risk cannot be fully
explained by an increasing prevalence of lethal congenital conditions
among SGA late preterm newborns [5].
The ability to recognize abnormal growth at birth and or a intrauterine
malnutrition is of great importance for the care and the prognosis of
these neonates. Neonatal anthropometric charts are commonly used for
the diagnosis at birth of SGA newborns [6]. The terms SGA and IUGR are
often used as synonyms, however they reflect two different concepts.
SGA refers to a statistical definition, based on an auxological crosssectional evaluation (prenatal or neonatal), and denotes a fetus or a
neonate whose anthropometric variables (usually weight) are lower than
a given threshold value computed on a set of infants having the same
gestational age. IUGR instead refers to a clinical and functional condition
and denotes fetuses unable to achieve their own growth potential. Such
a condition can be assessed by ultrasonography during pregnancy by a
longitudinal evaluation of fetal growth rate. The current gold standard in
neonatal auxological evaluation is based on informations obtained from
both neonatal anthropometric charts and intrauterine growth charts [7].
At present specific growth charts to monitor postnatal growth of late
preterm infants are not available. In the next future the late preterm
postnatal longitudinal growth standards will be available as a result of
“Intergrowth21st Project”.
References
1. Kugelman A, Colin AA: Late preterm infants: near term but still in a
critical developmental time period. Pediatrics 2013, 132:741-751.
2. Dimitriou G, Fouzas S, Georgakis V, Vervenioti A, Papadopoulos VG,
Decavalas G, Mantagos S: Determinants of morbidity in late preterm
infants. Early Hum Dev 2010, 86(9):587-91.
3. Ortigosa Rocha C, Bittar RE, Zugaib M: Neonatal outcomes of late-preterm
birth associated or not with intrauterine growth restriction. Obstet
Gynecol Int 2010.
4. Goyal NK, Fiks AG, Lorch SA: Persistence of underweight status among
late preterm infants. Arch Pediatr Adolesc Med 2012, 166(5):424-30.
5. Pulver LS, Guest-Warnick G, Stoddard GJ, Byington CL, Young PC: Weight
for gestational age affects the mortality of late preterm infants. Pediatrics
2009, 123(6):e1072-1077.
6. Bertino E, Spada E, Occhi L, Coscia A, Giuliani F, Gagliardi L, Gilli G, Bona G,
Fabris C, De Curtis M, Milani S: Neonatal anthropometric charts: the Italian
neonatal study compared with other European studies. J Pediatr
Gastroenterol Nutr 2010, 51(3):353-61.
7. Bertino E, Milani S, Fabris C, De Curtis M: Neonatal anthropometric charts: what
they are, what they are not. Arch Dis Child Fetal Neonatal Ed 2007, 92:7-10.
A4
Rooming-in organization to prevent neonatal mortality and
morbidity in late preterm infants
Mariano Manzionna1*, Antonio Di Mauro2
1
Pediatric Unit, Maternal and Child Health Department, S. Giacomo Hospital,
ASL BA, Monopoli (Bari), Italy; 2Neonatology and Neonatal Intensive Care
Unit, Department of Biomedical Science and Human Oncology, University of
Bari “Aldo Moro”, Bari, Italy
Despite most infants born at 34+0 through 36+7 weeks’ gestation are
thought to be at low risk during the birth hospitalization and have a
neonatal course with no significant complications, they are physiologically
and metabolically immature with an higher rates of morbidity and
mortality than term infants [1].
Most common medical condition associated with late-preterm births are
respiratory distress, apnea, temperature instability, hypoglycemia,
hypocalcemia, jaundice, poor feeding, sepsis and finally an higher rates of
Table 1(abstract A4) Assessment and care of the late
preterm infant [3]
Assess gestational age of neonate
Assess and monitor respiratory status
Appropriate respiratory interventions
Assess for risk factors and symptoms of heat loss and/or cold stress
Interventions to maintain a neutral thermal environment
Interventions and assessment of hypoglycemia including transfer to
higher acuity unit or facility if indicated
Assess for maternal and neonatal risk factors for sepsis
Antibiotic therapy and diagnostic evaluation if sepsis is suspected
Assess for presence of jaundice and hyperbilirubinemia
Phototherapy as indicated
Parent education regarding signs and symptoms of jaundice and
hyperbilirubinemia
Breastfeeding, and support for breastfeeding mothers including
observation, education and validation
Discharge planning including parent education, counseling, and
validation of knowledge about recognizing and acting on risk factors
the hospital readmissions during the neonatal period. These morbidities
result in workup for sepsis evaluations, antibiotic therapy, intravenous
fluid administration, ventilatory support and increased length of stay with
higher hospital costs [2].
Rooming-in organization of late preterms births aims to assess and
identify risk factors, prevent and manage potential medical complications
during hospitalization. Interventions and practices reccomended are
illustred in table 1.
Evidence of physiologic maturity, feeding competency, thermoregulation
and absence of medical of medical illness are minimum discharge criteria
for late-preterm newborns. Furthermore it’s of great importance to assess
educational programs with special instruction and guidance to parents,
engaging families in providing appropriate home care after hospital
discharge. A long term follow-up arrangements is also recommended to
assess and plan early interventions in case of neurodevelopment delay [4].
We conclude that, based on the significant morbidity and mortality of
late preterm births, the health care focus on prematurity should be
expanded to include the late preterm period.
References
1. Engle WA, Tomashek KM, Wallman C: “Late-Preterm” Infants: A Population
at Risk. Pediatrics 2007, 120(6):1390-1401.
2. Engle WA: Infants Born Late Preterm: Definition, Physiologic and
Metabolic Immaturity, and Outcomes. Neoreviews 2009, 10(6):280-286.
3. Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN):
Assessment and Care of the Late Preterm Infant Evidence-Based Clinical
Practice Guidelines. Washington, DC: AWHONN 2010.
4. Kugelman A, Colin AA: Late preterm infants: Near Term But Still in a
Critical Developmental Time Period. Pediatrics 2013, 132(4):741-751.
A5
Preventing sudden unexpected postnatal collapse in term and late
preterm newborn infants: a surveillance protocol
Riccardo Davanzo*, Laura Travan, Giuseppina Verardi, Elisa Corubolo,
Angela De Cunto, Giulia Paviotti, Tamara Strajn, Francesca Marrazzo,
Pierpeolo Brovedani, Jaquelyn Kennedy, Enrica Causin, Sergio Demarini
Perinatal Medicine, Institute for Maternal and Child Health IRCCS “Burlo
Garofolo”, Trieste, Italy
Early and prolonged skin-to-skin contact (SSC) after birth between a mother
and her newborn has been shown to generate beneficial effects on motherinfant relationship and breastfeeding. SSC may ease the infant’s transition to
extra uterine life and helps to regulate the infant’s body temperature and
nursing behavior.
However, reports of sudden unexpected postnatal collapse (SUPC) soon after
birth, in healthy term and late preterm neonates, in association with skin-toskin contact, have raised concerns about the safety of this practice.
Based on the available evidence, the working group on breastfeeding of
the Maternal and Child Health Institute of Trieste (Italy) developed a
surveillance protocol to be implemented in the Delivery Room and
Postnatal Ward. The aim of our protocol is: 1) promoting safe motherinfant
bonding 2) establishing successful early breastfeeding and 3) correcting the
risk factors for sudden unexpected postnatal collapse (SUPC). This protocol
is especially focused on the first 2 hours of life, when about 1/3 of SUPC
occur, but extends to the whole duration of the infant stay in the maternity
ward.
The following interventions will be undertaken: 1. antenatal and early
postnatal oral and written information to parents about: a) the risk of bedsharing b) avoidance potentially suffocating infant positions (i.e. mouth/nose
obstruction) c) the need of an adequate supervision of the infant in the first
hours/days after birth 2. periodical assessment (position, colour, breathing)
of the infant (at 10, 30, 60, 90 and 120 minutes of life) by midwives in the
delivery room 3. discouragement of bed-sharing 4. encouragement of skinto-skin contact only when mothers are fully awake 5. avoidance of mothers
left alone with the baby in the first hours after birth particularly during skinto-skin contact and first breastfeeding attempts.
As there is no evidence of effective interventions to prevent SUPC, our
protocol has been written as a potential best practice. Evidence of its
clinical effectiveness is obviously needed.
Page 3 of 28
A6
Psychological distress in postpartum: influence of late preterm
delivery
Zanardo Vincenzo*, Francesca Volpe, Rita Maione, Arturo Giustardi,
Gianluca Straface
Policlinico Abano Terme, Piazza Colombo 1, 35031 Abano Terme, Italy
Background: Psychological distress in women during the postpartum
period has been for a while an issue of great concern. There is substantial
evidence that maternal psychological distress after pregnancy is associated
with an adverse cognitive and behavioural consequence in the offspring
[1]. There are also severe implications during the perinatal period for the
mother’s long term mental health [2,3], her partner’s mental health [4,5],
and for the parental relationship [6]. The growing trend in late preterm
deliveries suggests research on postpartum psychological distress risk in
this group of vulnerable women.
Materials and methods: This prospective case control study was
performed with the approval of the ethics committee, in accordance with
the Declaration of Helsinki. Women who gave birth from 34/0 to 36/6
weeks and the next women who gave birth from 37g to 40/6 weeks able
to give informed consent were eligible.Three days after childbirth, mothers
of late preterm infants (n=42) and the next mother of at term infant,
matched for parity and delivery route (n=42) completed medical history
that covered key demographic and social information and the following
questionnaires: State-Trait Anxiety Inventory questionnaire (STAI-Y) [7],
Edinburgh Postnatal Depression Scale (EPDS) [8], and Psychological Stress
Measure (PSM [9]).
Results: Findings show that mothers of late preterm infants, presenting
with comparable key demographic and social antenatal risk factors, have
more stress, anxiety, and depression than mothers of at term infants (State
Anxiety-state 42.6±5.3 vs 49.5±9, p<0.0002; Anxiety-trait 39±6.1 vs
45.8±10.1, p<0.02; EPDS 6.3±3.9 vs 9.5±4.5, p<0.008; PSM 38.9±4.5 vs
46±5.9, p<0,001). In addition, Anxiety-state levels were associated with
longer time to stay in hospital (days 6.1±1.8 vs 4.7±1.2: p<0.01).
Conclusions: These data indicate that late preterm delivered mothers are at
increased psychological risk in a critical phase for establish a correct mother
infant relationship. This can happen in two ways: first of all perhaps, by
averting preterms’ delivery and secondly by working through the distress.
Moreover, what should be consider of great importance during the
postpartum period is the presence of an entourage that can help relieve the
mother from psychological distress and to support her and her child in case
of acute symptoms [10]. Taking into account all these consideration it would
be great to be able to arrange a psychological treatment for these mothers
n terms of their immediate and future well-being. and must therefore be
targeted for intervention.
References
1. Younger JB, Kendell MJ, Pickler RH: Mastery of stress in mothers of
preterm Infants. J Spec Pediatr Nurs 2007, 2(1):29-35.
2. Hammen C: Risk and protective factors for children of depressed
parents. Resilience and vulnerability New York: Cambridge University Press:
S. Luthar 2003, 34-41.
3. Philipps LHC, O´Hara MW: Prospective study of postpartum depression:
4½-year follow-up of women and children. J Abnorm Psychol 1991,
100:151-155.
4. Harvey I, McGrath G: Psychiatric morbidity in spouses of women
admitted to a mother and baby unit. Brit J Psychiat 1988, 152:506-510.
5. Lovestone S, Kumar R: Postnatal psychiatric illness: the impact on
partners. Brit J Psychiat 1993, 163:210-216.
6. Boyce P: Personality dysfunction, marital problems and postnatal
depression. Perinatal psychiatry: use and misuse of the Edinburgh Postnatal
Depression Scale London, England: Gaskell: Cox J, Holden J 1994, 82-102.
7. Spielberger CD, Gorsuch RL, Lushene RE: Manual for the State-Trait
Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press 1980.
8. Cox JL, Holden JM, Sagovsky R: Detection of postnatal depression:
Development of the 10-item Edinburgh Postnatal Depression Scale. B J
Psychiat 1987, 150:782-786.
9. Lemyre L, Tessie R: Measuring psychological stress: Concept, model, and
measurement instrument in primary care research. Can Fam Physician
2003, 49:1159-1560.
10. Raju TN, Higgins RD, Stark AR, Leveno KJ: Optimizing care and outcome
for late-reterm(near-term) infants: a summary of the workshop
sponsored by the national 188 institute of child health and human
development. Pediatrics 2006, 118:1207-1214.
A7
Discharge of late preterm newborn: appropriated, controlled…namely
safe
A Coscia*, A Soldi, C Perathoner, L Occhi, E Bertino
SC Neonatology, University of Turin, AOA Città della Salute e della Scienza,
Turin, Italy
Late-preterm newborns accounted for 8.7% of all US births in 2009, while
in Italy, according to Euro-Peristat Report 2010, rate of preterm live births
between 32 and 36 weeks accounts for 6.4%: therefore late-preterm
incidence is around 5% [1]. In the literature is reported that late preterm
infants are at increased risk of neonatal mortality and morbidity,
including feeding problems, hyperbilirubinemia, hypoglycemia, and
respiratory problems. So, in recent years, research has focused on hospital
care, with little known about the real needs of care after discharge and in
the home setting. However, it’s known that early discharge places these
infants at greater risk of complications such as rehospitalizazion,
particularly in breastfed infants [2].
Therefore in this population it’s fundamental to plan an “appropriate”
discharge. What does “appropriateness” mean? In health care the
appropriateness has two aspects: 1) the “clinical” appropriateness that refers
to the criteria of efficacy and safety ; 2) the so-called “administrative”
appropriateness that indicates the extent of provision of health according to
the criterion of efficiency, that is the best use of available resources, with
respect to the clinical case to be treated. Because the resources available
vary by context, administrative appropriateness is a very dynamic concept.
In the discharge of late-preterm baby, clinical appropriateness requires
individualization and involvement of family. Discharge criteria are
substantially similar to those of full-term [3] but include longer observation
times, more attention to the real understanding and involvement of the
family in the scheme of nutrition and follow-up, and an increased need for
planning follow-up and integration with local services.
Although discharge criteria for late preterm infants are quite precise,
however there is a large inter-center heterogeneity regarding the timing of
discharge. It’s clear that the choices on the discharge of late preterm
newborns are strongly influenced by the organizational context. It should be
essential to have accurate population-based surveillance data and
organizational data, as well as clinical ones. Only in this way it is possible to
evaluate the efficacy (and on which outcomes) of programs of protected
discharge, and their compatibility with the available resources. For example,
some studies suggest that home visiting promotes improved parent-infant
interaction; however further studies are needed to demonstrate whether
such interventions in at-risk populations may strengthen their impact and
cost benefits [4].
References
1. EURO-PERISTAT Project with SCPE and EUROCAT: European Perinatal
Health Report. The health and care of pregnant women and babies in
Europe in 2010. 2013.
2. Tomashek KM, Shapiro-Mendoza CK, Weiss J, et al: Early discharge among
late preterm and term newborns and risk of neonatal morbidity. Semin
Perinatol 2006, 30(2):61-68.
3. Engle WA, Tomashek KM, Wallman C, Committee on Fetus and Newborn,
American Academy of Pediatrics: “Late-preterm” infants: a population at
risk. Pediatrics 2007, 120(6):1390-1401.
4. Goyal NK, Teeters A, Ammerman RT: Home Visiting and Outcomes of
Preterm Infants: A Systematic Review. Pediatrics 2013, 132:502-516.
A8
The Portuguese experience on regionalisation of perinatal care
Hercilia Guimarães
Faculty of Medicine of Porto University, Serviço de Neonatologia, Hospital de
São João, Porto, Portugal
Page 4 of 28
Table 1(abstract A8)
Mortalities
1980
1990
2000
2010
2012
Maternal /100000
19.0
10.3
2.5
7.9
4.5
Late Foetal
11.8
8.6
3.7
2.4
2.8
Neonatal
15.5
7.0
3.4
1.7
2.2
Early neonatal
12.3
4.7
2.5
1.1
1.5
Infant
24.3
10.9
5.5
2.5
2.9 (2013)
In order to improve perinatal outcomes, national guidelines proposed by
the National Committee for Mother and Child Health, were promulgated
by the Ministry of Health in 1990. A Child and Maternal Hospital
Healthecare Referral Network was created. This document advised for
some innovating and frontal aspects: 1. Maternities with less than 1500
deliveries per year should be closed; 2. Hospitals were classified as
Perinatal Care Hospitals (Level II- able to provide care to pregnant women
and normal newborns, and should include a Neonatal Internediate Care
Unit) and Differentiated Perinatal Care Hospitals (Level III-to provide care
to high risk pregnant womenand newborn infants, and should include a
Neonatal Intensive Care Unit); 3. Functional Coordinang Units were created
to connect the Hospitals to the Primary Healcare Centres; 4. Cycles of
Special Studies on Neonatology were created to graduate Paediatricians in
Neonatology; 5. The recognition that the best transport for the newborn is
the mother´s womb; however, in 1987, a Neonatal Transport was created
to unavailable situations.
Both pregnant women and newborns are transferred according to the
following priority: pathology, geographical referral and available vacancy.
Another importante aspect was the organization of paediatricians and
neonatologists (1985) as scientific societies and the publication of
national protocols as an attempt to standardize methodologies.
The National Registry of VLBWinfants, inspired on Vermont-Oxford
Network, was an initiative started in 1994 with a voluntary participation
of the NICU´s.
All these aspects had clinical implications, namely in decreasing mortality
rates, as shown in table 1.
In conclusion, the reform of perinatal care in Portugal is an exemple of
how a good diagnosis and adequate proposals combined with a strong
political will are crucial for changing.
A9
Are all Italian newborns equal?
Stefano Semplici
University of Rome “Tor Vergata”, Rome, 00173, Italy
The debate on the restructuring of Chapter Five (Titolo Quinto) of the Italian
Constitution has brought once again the issue of the allocation of powers
between the State and its regions under the spotlight. According to Article
117 of the Italian Constitution, as reformed in 2001, the State and its regions
share normative competences in regulating certain matters. In the field of
core civil and social rights, including health care, it is the responsibility of
the State to identify fundamental levels of services and assistance that have
to be guaranteed to everyone across the nation. The aim of this provision
was to prevent unacceptable disparities in the enjoyment of the right to
health. In practice, however, this has not been the case. On the one hand,
Italian regions have disciplined certain matters in fairly different ways,
forcing the Ministry of Health to exercise its role of warrantor of fairness
more than expected. On the other hand, the quality of services has been
greatly affected by a “geographical” factor, depending on availability of
resources, different organization of health system and bureaucracy at
regional level.
Health care services for newborns are a case in point. Two examples –
among others – are worth exploring further. The neonatal screening
programmes for cystic fibrosis and inherited metabolic diseases are a lot
different among different regions and sometimes even among different
towns or hospitals in the same town. Some legislative measures have been
taken to overcome this situation, but the implementation of the national
regulation remains difficult to attain. Should the responsibilities and
decisions involved depend on the place a baby is born? As a matter of fact,
this observation keeps playing an important role as to the possibility of
addressing the most critical situations in a successful way. Even though the
neonatal mortality rate in Italy is nowadays among the lowest in the world,
infants born in Southern Italy still run a higher risk of dying in the neonatal
period. Against this background, the situation of neonatal intensive care
units points to inequalities that are not new for the country and yet hard
to reconcile with the idea of sharing the same fundamental constitutional
rights. Starting with everyone’s birth.
A10
Neonatal hyperbilirubinemia
Matteo Dal Ben, Silvia Gazzin, Claudio Tiribelli*
Centro Studi Fegato, Fondazione Italiana Fegato, AREA Science Park,
Campus Basovizza, 34149 Trieste, Italy
Unconjugated hyperbilirubinemia is a common condition in the first week
of postnatal life. Low levels of bilirubin exert antioxidant effects, but
some neonates may develop very high levels of unconjugated bilirubin
(UCB), with an increase of the unbound free fraction (Bf), able to diffuse
through the blood brain barrier.
Amount and duration of hyperbilirubinemia and the neurodevelopmental
age (preterm neonates) at the time of insult exposition is supposed to
influence the location of selective brain damage, as well as the severity of
consequences [1]. The clinical manifestations range from the less severe
Bilirubin-Induced Neurological Damage (BIND) to a more severe chronic
kernicterus, while the regional selectivity of damage may elicit to motor
disorders and athetosis (basal ganglia and cerebellum), auditory dysfunction
(inferior colliculus), memory and learning impairment (hippocampus) [2].
To avoid neurological consequences, the Clinical Practice Guideline of the
American Academy of Pediatrics recommend total bilirubin determination
(TSB) on every jaundice infant, both during hospital stay and post discharge
follow-up. To this goal, Bilistik [3], a new minimally invasive method for
measuring TSB, may improve substantially the triage of jaundice newborns
with potential risk of brain damage and kernicterus to be addressed to
phototherapy. Moreover, recent studies have raised concerns about the
potential toxicity of intensive phototherapy in preterm neonates, and no
information about its effectiveness in quickly reducing brain bilirubin
concentration are yet available [4].
Early neuronal accumulation of bilirubin in damaged regions and its brain
metabolism may have a role in the marked regional differences observed
in kernicterus impairment. This hypothesis is supported by the role of
brain cytochrome P-450 (Cyp), known to oxidize UCB. In the brain of Gunn
rats, an early upregulation of Cyp mRNAs was observed in the unaffected
brain regions, cortex and superior colliculus, in contrast to the delayed and
slight upregulation observed in the affected regions, inferior colliculus and
cerebellum [6], where UCB alters the cell cycle inducing apoptosis [7].
Clarification of pathophysiology of UCB neurotoxicity, that continues to be
an important risk among newborns worldwide, may open new perspectives
for therapeutic approaches, focused in protecting directly the brain, the final
target of bilirubin toxicity. To this aim the development of new research
models, appear of particular relevance. Among them the organotypic brain
cultures, living slices of the CSN that can be cultured in vitro and challenged
with bilirubin in controlled (concentration/timing) manner, strictly modelling
different histopathological aspects of neurological conditions.
References
1. Conlee JW, Shapiro SM: Development of cerebellar hypoplasia in
jaundiced Gunn rats: a quantitative light microscopic analysis. Acta
Neuropathol 1997, 93(5):450-60.
2. Shapiro SM: Chronic bilirubin encephalopathy: diagnosis and outcome.
Semin Fetal Neonatal Med 2010, 15(3):157-63, doi: 10.1016/j.siny.2009.12.004.
Epub 2010 Jan 29.
3. Coda Zabetta CD, Iskander IF, Greco C, Bellarosa C, Demarini S, Tiribelli C,
Wennberg RP: Bilistick: a low-cost point-of-care system to measure total
plasma bilirubin. Neonatology 2013, 103(3):177-81, doi: 10.1159/000345425.
Epub 2012 Dec 22.
4. Morris BH, Oh W, Tyson JE, et al: Aggressive vs. conservative
phototherapy for infants with extremely low birth weight. N Engl J Med
2008, 359:1885-96.
Page 5 of 28
5.
6.
7.
Watchko JF, Tiribelli C: Bilirubin-induced neurologic damage–mechanisms
and management approaches. N Engl J Med 2013, 369(21):2021-30, doi:
10.1056/NEJMra1308124.
Gazzin S, Zelenka J, Zdrahalova L, Konickova R, Zabetta CC, Giraudi PJ,
Berengeno AL, Raseni A, Robert MC, Vitek L, Tiribelli C: Bilirubin
accumulation and Cyp mRNA expression in selected brain regions of
jaundiced Gunn rat pups. Pediatr Res 2012, 71(6):653-60, doi: 10.1038/
pr.2012.23. Epub 2012 Feb 15.
Robert MC, Furlan G, Rosso N, Gambaro SE, Apitsionak F, Vianello E,
Tiribelli C, Gazzin S: Alterations in the cell cycle in the cerebellum of
hyperbilirubinemic gunn rat: a possible link with apoptosis? PLoS One
2013, 8(11):e79073, doi: 10.1371/journal.pone.0079073. eCollection 2013.
A11
Risk of BIND and kernicterus in late preterm
Carlo Dani
Department of Neurosciences, Psychology, Drug Research and Children’s
Health, University of Florence, Italy
Severe hyperbilirubinemia can induce devastating and permanent neurodevelopmental handicaps in infants. The occurrence of hyperbilirubinemia is
higher in late preterm than in term infants, ranging from 8 to 40% of the
formers according to different definitions of hyperbilirubinemia. The
mechanisms by which this occurs is not completely understood, however an
increased bilirubin load on hepatocyte, as result of decreased erythrocyte
survival and increased erythrocyte volume, increased enterohepatic
circulation of bilirubin, decreased hepatic uptake of bilirubin from plasma,
defective bilirubin conjugation, and diminished serum bilirubin binding
capacity play a relevant role.
Hyperbilirubinemia in late preterm infants is not only more prevalent than in
term neonates, but also it occurs later and is more severe and protracted. In
fact, Maisels et al. (Pediatrics 2006;117:1169) demonstrated that at 72 hours of
life the value of 50° percentile of trans-cutaneous bilirubin (TcB) is 9 mg/dl in
35-37 wks infants, while is <6 mg/dl in ≥40 wks infants. Moreover, they found
that the decrease of TcB is slower in 35-37 wks infants than in ≥40 wks
infants, since at 96 hours of life the value of 50° percentile of TcB is 9 mg/dl
in 35-37 wks infants, while is <3 mg/dl in >40 wks infants.
Late preterm infants are at higher risk of bilirubin induced neurological
dysfunction (BIND) and kernicterus than term infants. The mechanisms that
potentially could explain the high susceptibility of central nervous system to
bilirubin-induced damage in late preterm neonates have not been well
defined. However, some of the factors that can potentially contribute are the
diminished serum bilirubin binding capacity due to the lower serum albumin
levels, an enhanced permeability of the blood–brain barrier to unconjugated
bilirubin influx, and an immaturity of neuronal protective mechanisms. This is
probably the reason why late preterm neonates are at an increased risk to
develop acute bilirubin encephalopathy and or kernicterus as demonstrated
in the USA pilot kernicterus registry (Semin Perinatol 2006;30:89) in which
this category of infants is over-represented compared to term neonates.
Thus, clinicians need to be more concerned and conscientious to identify
late preterm’s risk for severe hyperbilirubinemia in view of their increased
susceptibility to BIND. This can allow of planning a prevention program
including nursing and parental education, screening for jaundice in the
nursery, the provision of lactation support, timely post discharge follow-up,
and appropriate treatment when clinically indicated.
A12
Cholestasis in preterm infants: when is a yellow alert?
Silvia Nastasio, Giuseppe Maggiore*
Department of Clinical and Experimental Medicine, Pediatric
Gastroenterology and Hepatology, University Hospital of Pisa, 56127 Pisa,
Italy
Besides the transient bilirubin transport immaturity, preterm infants are
particularly at risk for different forms and degrees of bile formation
impairment because of metabolic demands that are not matched by
functional maturation in the first weeks of life.
Cholestasis, affecting approximately 1 of 2 500 infants, is more commonly
reported in preterm infants with an incidence varying between 10 and
20%, and it is mainly due to a combination of factors including delayed
enteral nutrition, low birth weight, prolonged parenteral nutrition,
hypoxia, infection, liver ischemia, immaturity of bile acid metabolism,
surgical procedures and multiple drug treatments [1]. This reality of the
setting is defined as transient or multifactorial cholestasis [2], which is the
most frequent form of cholestasis in neonatal intensive care unit, usually
transient and followed by a gradual full recovery [3].
Cholestasis in preterm infants may however also be indicative of a severe
liver disease such as biliary atresia (BA) or other biliary tract disorders.
The development of a persistent cholestatic jaundice, even in presence of
colored stools, incentives to conduct a thorough investigation [4].
Abdominal ultrasonography may support the diagnosis of BA showing:
absence of gallbladder, the “triangular cord” sign or a cyst located at
porta hepatis. Transient multifactorial cholestasis is a diagnosis of
exclusion and a definitive diagnosis can be made only after the complete
resolution of the clinical picture. Moreover, diagnosis of biliary atresia in
preterm jaundiced neonates is difficult since discoloration of stools can
occur several weeks after birth [4].
Besides specific cholestatic disorders for which specific medical and surgical
treatment are available, there is no unequivocal evidence that any medical
treatment alters the natural history of multifactorial cholestasis. Treatment
with ursodeoxycholic acid may indeed be useful, although there is no
evidence of effectiveness. Every effort must be made to remove all risk
factors for liver injury. Consequences of cholestasis also need to be
managed by administering fat -soluble vitamins, especially vitamin K and
nutritional formulas containing medium-chain fatty acids.
Although multifactorial transient cholestasis is the most common cause
of prolonged jaundice in preterm infants, neonatologists need to be
aware that premature infants can also present with signs of severe liver
disease. To avoid any diagnostic delay it is mandatory to promptly
identify all the conditions suitable for an early and specific treatment
with a structured approach to the investigation of cholestasis tailored to
the preterm infant [5].
References
1. Champion V, Carbajal R, Lozar J, Girard I, Mitanchez D: Risk factors for
developing transient neonatal cholestasis. J Pediatr Gastroenterol Nutr
2012, 55:592-8.
2. Jacquemin E, Lykavieris P, Chaoui N, Hadchouel M, Bernard O: Transient
neonatal cholestasis: origin and outcome. J Pediatr 1998, 133:563-7.
3. Tufano M, Nicastro E, Giliberti P, Vegnente A, Raimondi F, Iorio R:
Cholestasis in neonatal intensive care unit: incidence, aetiology and
management. Acta Paediatr 2009, 98:1756-61.
4. Mourier O, Franchi-Abella S, Ackermann O, Brancherau S, Gonzales E,
Bernard O, Jacquemin E: Delayed postnatal presentation of Biliary Atresia
in 2 premature neonates. J Pediatr Gastroenterol Nutr 2011, 52:489-91.
5. Tyler W, McKiernan PJ: Prolonged jaundice in the preterm infant- What to
do, when and why. Curr Paediatr 2006, 16:43-50.
Page 6 of 28
The spectrum of cerebral injury associated with hypoglycaemia is wide and
includes: white matter injury including parenchymal haemorrhage and
ischaemic stroke, cortical neuronal injury, and sometimes signal change in
the basal ganglia (mainly the globus pallidus) and thalami. Vulnerability of
the white matter and cortex of the posterior parietal and occipital lobes
has been well reported in human imaging studies, but the site of injury is
more widespread in pathological and experimental studies of neonatal
hypoglycaemia. In the largest series of infants with isolated neonatal
hypoglycaemia and acute neurological dysfunction, there was an association
with a predominantly posterior pattern of injury in one third of the cohort,
and a more extensive distribution of lesions was common.
Safe clinical management relies on the identification of infants at risk of
neurological sequelae from hypoglycaemia, adequate energy provision
after birth, monitoring of blood glucose, and prompt intervention to raise
the BG at specified thresholds, with the caveat that acute neurological
dysfunction in association with low BG at any level should prompt urgent
investigation and treatment. The optimal target blood glucose level for
ensuring adequate energy provision in health and in HIE remains
unknown. However, recent data support guidance to maintain blood
glucose concentration ≥2.5mmol/L in neonates with signs of acute
neurological dysfunction, which includes those with HIE, and is higher
than the accepted threshold of ≥2mmol/L in infants without abnormal
signs or hyperinsulinism.
A14
The kidney of late preterm infants
Vassilios Fanos1*, Clara Gerosa2, Claudia Fanni1, Cristina Loddo1,
Melania Puddu1, Giovanni Ottonello1, Gavino Faa2
1
NICU, Neonatal Pathology, Puericulture Institute and Neonatal Section,
AOU and University of Cagliari, Italy; 2Institute of Pathology, AOU and
University of Cagliari, Italy
Introduction: The risk of morbidity in late preterm neonates varies
greatly depending on gestational age: it is 1 out of 2 at 34 weeks, 1 out
of 4 at 35 weeks and 1 out of 10 at 36 weeks. Very little is known about
the renal pathology of these infants.
Nephrogenesis in the late preterm: The process of nephron formation
ceases between 34 and 36 weeks of gestation [1], the limit within which
the term late preterm is applied.
A13
Hypoglycaemia and neonatal brain injury
James P Boardman
MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh
EH16 4TJ, UK
The transition from fetal to neonatal life requires metabolic adaptation to
ensure energy supply to vital organs and systems after separation from
the placental circulation. Under normal conditions this is achieved
through the mobilisation and use of alternative cerebral fuels (fatty acids,
ketone bodies and lactate) when blood glucose concentration falls.
The level of blood glucose (BG) concentration that leads to cerebral injury
in newborns and adverse neurodevelopmental outcome is unknown: low
BG is often observed during postnatal adaptation of healthy term infants
without apparent adverse consequence, and the capacity to mobilise and
use alternative cerebral fuels when BG is low varies between patient
groups. Severe hypoxic-ischaemic encephalopathy (HIE) is associated with
impaired metabolic adaptation, and animal and human data suggest that
levels of hypoglycaemia that are tolerated under normal conditions may
be harmful in association with hypoxia-ischaemia.
Figure 1(abstract A14) Zones where stem cells were found in the
kidney of the late preterm infant (from Faa G et al. JPNIM 2014 in press,
with permission)
In 1943, Potter and Thierstein examined the autopsies of 1000 fetuses
and neonates and found the presence of the nephrogenic zone in 100%
of 30-week fetuses, in about 80% of 34-week cases and in 30% of
36-week cases. They stated that in most of these neonates nephrogenesis
had ceased at 35 weeks [2].
In 2008, Ferraz et al., on applying immunohistochemistry to the kidneys of
86 fetuses of different gestational ages, observed the disappearance of the
nephrogenic zone in all fetuses above 35 weeks of gestational age [3].
On the contrary, Faa et al. found the presence of active nephrogenesis up to
the 38th week [4]. It appears that in agreement with the data of Rodriguez
et al. [5], the nephrogenetic process continues after preterm birth for a
period of about 6 weeks; this window decreases further if the neonate
develops acute renal injury or if he/she presents a intrauterine growth
retardation. Stem cells are present in different parts of the neonatal kidney
(Figure 1) [6]. A marked interindividual variability in the number of nephrons
has been observed: 6 to 8 glomerular columns were present in late preterm
infants (8 columns in Rodriguez’ cases), but also in a large number of those
up to 23 weeks.
Renal function and pathology in the late preterm: Cuzzolin et al.
studied 246 preterms divided into 4 groups based on gestational age (one
of late preterms): the creatinemia values at birth were similar in the
groups, with differences appearing from the 3rd and up to the 21st day of
postnatal life [7,8].
No correlation between late preterm birth and the onset of renal
pathologies was found shortly after or some time after delivery. This was
confirmed by Picone’s wide ranging study on 417 late-preterm infants [9].
References
1. Faa G, Gerosa C, Fanni D, Monga G, Zaffanello M, Van Eyken P, Fanos V:
Morphogenesis and molecular mechanisms involved in human kidney
development. J Cell Physiol 2012, 227(3):1257-68.
2. Potter EL, Thierstein ST: Glomerular development in the kidney as an
index of fetal maturity. J Pediatr 1943, 22:695-706.
3. Ferraz MLF, dos Santos AM, Cavellani CL, Rossi RC, Correa RRM, dos
Reis MA, Teixeira VPA, Castro ECC: Histochemical and immunoistochemical
study of the glomerular development in human fetuses. Pediatr Nephrol
2008, 23:257-62.
4. Faa G, Gerosa C, Fanni D, Puddu M, Marinelli V, Zaffanello M, Fanos V:
Marked interindividual variability in renal maturation of preterm infants:
lessons from autopsy. J Matern Fetal Neonatal Med 2010, 23:129-133.
5. Rodriguez M, Gomez A, Abitbol C, Chandar J, Duara S, Zilleruelo G:
Histomorphometric analysis of postnatal glomerulogenesis in extremely
preterm infants. Pediatr Dev Pathol 2004, 7:17-25.
6. Fanni D, Gerosa C, Nemolato S, Mocci C, Pichiri G, Coni P, et al: “Physiological”
renal regenerating medicine in VLBW preterm infants: could a dream come
true? J Matern Fetal Neonatal Med 2012, 25(Suppl 3):41-48.
7. Cuzzolin L, Fanos V, Pinna B, di Marzio M, Perin M, Tramontozzi P,
Tonetto P, Cataldi L: Postnatal renal function in preterm newborns: a role
of diseases, drugs and therapeutic interventions. Ped Nephrol 2006,
21(7):931-938.
8. Puddu M, Cataldi L, Faa G, Yurdakok M, Maringhini S, Fanos V: Perinatal
programming: Long-term consequences for the kidney. Developmental
Nephrology: From Embryology to Metabolomics Elena: Hygeia Press: Fanos V.,
Chevalier R., Faa G., & Cataldi L. Quartu S 2011, 57-74, Chapter 3.
9. Picone S, Paolillo P: Neonatal outcomes in a population of late-preterm
infants. J Matern Fetal Neonatal Med 2010, 23(Suppl 3):116-20.
A15
Mineral homeostasis in late preterm infants
Paolo Ghirri1*, Sara Lunardi1, Livia Leuzzi1, Giampiero I Baroncelli2,
Francesca Moscuzza1, Antonio Boldrini1
1
Division of Neonatology and Neonatal Intensive Care Unit, Hospital Santa
Chiara, Pisa, Italy; 2Pediatric Clinic, University Hospital of Pisa, Italy
80% of mineral accretion take place in the third trimester of gestation
with a fetal accretion rates of 100-150 mg/kg/day for calcium, 50-70 mg/kg/
day for phosphate and 3 mg/kg/day for magnesium. During the third
trimester of gestation fetal weight triples but Ca content quadruples with a
faster increase in fetal body Ca accretion from 32 to 40 weeks of gestation
[1]. As a result, late preterm infants will be deprived of the intrauterine
supply of calcium and phosphorus during a period of rapid skeletal growth
Page 7 of 28
affecting bone mineral mass. Late preterm infants have a higher incidence of
hypocalcemia [2] and represent an intermediate risk category as compared
with term and very preterm infants. AGA late-preterm infants have a higher
bone turn-over than term infants, but smaller than very pre-term newborns
[3]. During the third trimester of gestation, bone mineral density (BMD)
increases at a faster rate in utero (term infants) than ex utero (preterm infant)
according to gestational age. At term newborns have a physiological
reduction in BMD in the first 2-3 months of life with a recovery during the
first year of life. Preterm newborns present a similar event with a higher
reduction of mineral retention from birth to term in the presence of high
skeletal growth. Inadequate supply of calcium and phosphate to newborns
requiring parental nutrition and several drugs (steroids, methylxanthines,
diuretics) may increase the risk of osteopenia. Drugs affect bone metabolism
decreasing calcium absorption and osteoblasts proliferation and increasing
calcium renal excretion and osteoclasts activation. How do we best support
the rapid skeletal growth of late preterm infants? Have early nutrition during
the first weeks of life been adequate? Enriched formulas for preterm
newborns have a positive and probably long-term effect on bone
mineralization [4,5]. In late preterm infants the goal should be to provide
nutrients based on gestational age instead of relying on birthweight.
However there are no specific recommendation and further studies are
warranted to determine the best care for late preterm infants.
References
1. Bass JK, et al: 2006.
2. Dani C, et al: 2009.
3. bou Samra H, et al: 2009.
4. Bishop N, et al: 1993.
5. Bozzetti V, et al: 2009.
A16
The role of probiotics in nosocomial infections
Gian Vincenzo Zuccotti*, Fabio Meneghin
Department of Pediatrics, University of Milan, Luigi Sacco Hospital, Milan
20157, Italy
Background: Nosocomial infections are among the leading causes of
mortality and morbidity especially in neonatal intensive care unit (NICU)
[1]. The intestinal microbiota of the gut is nowadays considered to play
an important functional role in the host’s health through nutritional,
physiological and immunological processes. For these reasons, probiotics
may exert actions of prevention and therapy of infectious diseases.
Results: The mechanisms of action of probiotics are strain specific but can be
summarized mainly in three areas: changes of gut ecology, modulation of gut
mucosal barrier and regulation of the immune response through interaction
with gut-associated immune system [2]. Several studies regarding the
supplementation of probiotics in nosocomial infections have been conducted
mainly in adult population. Among pediatric studies major findings have
been observed in treatment of acute gastroenteritis, primarily caused by
Rotavirus [3,4], and in the prevention of antibiotic associated diarrhea (AAD)
[5]. Supplementation with probiotics has proven useful even in the treatment
of Clostridium difficile disease (CDD), the most common pathogen involved in
AAD [6]. Data from meta-analysis and cochrane review on the prevention of
necrotizing enterocolitis (NEC) show an overall benefit of probiotic
supplementation [7]. The limitations of the above cited studies are mainly
related to heterogeneity in terms of strain, dosage and duration of treatment
and the lack of studies on extremely low birth weight preterm infants. Data
on nosocomial pneumonia and ventilator-associated pneumonia in neonatal
and pediatric age is scanty. In a large randomized, double-blind placebo
controlled study, Hojsak et al demonstrated that supplementation with
Lactobacillus GG significantly decreased the risk of nosocomial respiratory
tract infections [8]. On the other hand, the data from adult studies have been
conflicting, with a tendency towards the demonstration of probiotic efficacy
in reducing the incidence of ventilator-associated pneumonia [9]. Meticillinresistant Staphylococcus aureus is a multidrug-resistant nosocomial pathogen;
a recent review of literature [10] showed that many probiotic strains inhibit
MRSA growth in vitro. Furthermore, this review describes that there is little
published clinical data on the use of probiotics in prophylaxis or treatment of
MRSA-mediated infections.
Conclusions: Due to the significant heterogeneity between the studies in
literature it is not possible to draw consistent conclusions on extensive
use of probiotics in prevention and treatment of nosocomial infections,
except for acute gastroenteritis, AAD, CDD and NEC.
References
1. Polin RA, Denson S, Brady MT, et al: Epidemiology and Diagnosis of
Health Care–Associated Infections in the NICU. Pediatrics 2012, 129:
e1104-e1109.
2. Kotzampassi K, Giamarellos-Bourboulis EJ: Probiotics for infectious
diseases: more drugs, less dietary supplementation. International Journal
of Antimicrobial Agents 2012, 40:288-296.
3. Allen SJ, Martinez EG, Gregorio GV: Probiotics for treating acute infectious
diarrhoea (Review). Cochrane Database of Systematic Reviews 2010, 11:
CD003048.
4. Guarino A, Ashkenazi S, Gendrel D, Vecchio AL, Shamir R, Szajewska H:
European Society for Pediatric Gastroenterology, Hepatology, and
Nutrition/European Society for Pediatric Infectious Diseases EvidenceBased Guidelines for the Management of Acute Gastroenteritis in
Children in Europe: Update 2014. JPGN 2014, 59:132-152.
5. McFarland LV: Meta-Analysis of Probiotics for the Prevention of Antibiotic
Associated Diarrhea and the Treatment of Clostridium difficile Disease
Meta-Analysis of Probiotics for the Prevention of Antibiotic Associated
Diarrhea and the Treatment of Clostridium difficile Disease. Am J
Gastroenterol 2006, 101:812-822.
6. Goldenberg JZ, Ma SSY, Saxton JD, Martzen MR, Vandvik PO, Thorlund K,
Guyatt GH, Johnston BC: Probiotics for the prevention of Clostridium
difficile associated diarrhea in adults and children. Cochrane Database of
Systematic Reviews 2013, 5: CD006095.
7. AlFaleh K, Anabrees J, Bassler D, et al: Probiotics for prevention of
necrotizing enterocolitis in preterm infants . Cochrane Database of
Systematic Reviews 2011, 3: CD005496.
8. Hojsak I, Abdovic S, Szajewska H, Milosevic M, Krznaric Z, Kolacek S:
Lactobacillus GG in the Prevention of Nosocomial Gastrointestinal and
Respiratory Tract Infections. Pediatrics 2010, 125:e1171-e1177.
9. Siempos II, Ntaidou TK, Falagas ME: Impact of the administration of
probiotics on the incidence of ventilator-associated pneumonia: A metaanalysis of randomized controlled trials. Crit Care Med 2010, 38:954-962.
10. Sikorska H, Smoragiewicz W: Role
ofprobioticsinthepreventionandtreatmentof meticillin-resistant
Staphylococcus aureus infections. International Journal of Antimicrobial
Agents 2013, 42:475-481.
A17
Mode of delivery and gut microbiota
Vito Leonardo Miniello*, Angela Colasanto, Lucia Diaferio, Laura Ficele,
Maria Serena Leggi, Valentina Santoiemma
Department of Paediatrics, Aldo Moro University of Bari, Bari, Italy
In 1985 the World Health Organization (WHO) stated: “There is no justification
for any region to have Caesarean Section (CS) rates higher than 10-15%” [1].
During the last decades the percentage of births managed by CS has
increased beyond the recommended level, especially in high income areas
such as Italy, Germany, France, United Kingdom, and North America [2,3].
Emerging evidences indicate that the early composition of neonatal gut
microbiota is responsible for shaping of immune response since there is a
complex interaction between the intestinal microbiome and the immune
system (Gut-Associated Lymphoid Tissue) and this cross-talk is involved in
maintaining normal immune homeostasis [4]. The microbiome promotes
human health, but can also drive disease. The potential disadvantages of
caesarean delivery include altered bacterial profile known as dysbiosis of the
gut microbiota which in turn leads to immune dysfunction and increased
tendency for immune-mediated diseases such as allergies [5,6] and
autoimmunity [7].
Upon delivery, the neonate is exposed to a wide variety of microbes, many
of which are provided by the mother during and after the passage through
the birth canal, a heavily colonized ecosystem. The neonatal colonization
pattern is further influenced by several post-natal environmental factors
such as the place and mode of delivery, the level of affluence, the number
of siblings, the use of antibiotics and infant feeding.
The reduced microbial exposure and delayed colonization occurring in
caesarean born infants have been associated with the development of
Page 8 of 28
allergic disease. CS delivered infants, deprived of contact with the maternal
vaginal microbiota, experience a deficiency of strict anaerobes such as
Bacteroides, E. coli, and bifidobacteria and a higher presence of facultative
anaerobes such as Clostridium species, compared with vaginally born
infants [8].
It is debated whether a low total diversity of the gut microbiota during
infancy is more important than an altered prevalence of particular bacterial
species (Clostridia) for the increasing incidence of allergic disease [5,6].
Recently Bisgaard et al. demonstrated that reduced diversity of intestinal
microbiota during infancy is associated with increased risk of allergic disease
during childhood [9].
The concept of probiotics has attracted increasing attention in recent years
since several clinical studies have been published suggesting that probiotics
may convert a dysbiosis to a symbiosis in infants with inadequate intestinal
colonization (premature delivery, delivery by CS and excessive use of
perinatal antibiotics) [10-15]. Clinical evidences suggest that probiotics could
substantially affect metabolic and immunomodulatory functions [16].
References
1. World Health Organization: Appropriate technology for birth. Lancet 1985,
2:436-7.
2. MacDorman MF, Menacker F, Declercq E: Cesarean birth in the United States:
epidemiology, trends, and outcomes. Clin Perinatol 2008, 35:293-307.
3. Zizza A, Tinelli A, Malvasi A, Barbone E, Stark M, De Donno A, Guido M:
Caesarean section in the world: a new ecological approach. J Prev Med
Hyg 2011, 52:161-73.
4. Chung H, Kasper DL: Microbiota-stimulated immune mechanisms to
maintain gut homeostasis. Curr Opin Immunol 2010, 22:455-460.
5. van Nimwegen FA, Penders J, Stobberingh EE, Postma DS, Koppelman GH,
et al: Mode and place of delivery, gastrointestinal microbiota, and their
influence on asthma and atopy. J Allergy Clin Immunol 2011, 128:948-955.
6. Penders J, Thijs C, van den Brandt PA, Kummeling I, Snijders B, Stelma F,
Adams H, van Ree R, Stobberingh EE: Gut microbiota composition and
development of atopic manifestations in infancy: the KOALA Birth
Cohort Study. Gut 2007, 56:661-667.
7. Cardwell CR, Stene LC, Joner G, Cinek O, Svensson J, Goldacre MJ:
Caesarean section is associated with an increased risk of childhoodonset type 1 diabetes mellitus: a meta-analysis of observational studies.
Diabetologia 2008, 51:726-735.
8. Adlerberth I, Wold AE: Establishment of the gut microbiota in Western
infants. Acta Paediatrica 2009, 98:229-238.
9. Bisgaard H, Li N, Bonnelykke K, Chawes BL, Skov T, Paludan-Müller G,
Stokholm J, Smith B, Krogfelt KA: Reduced diversity of the intestinal
microbiota during infancy is associated with increased risk of allergic
disease at school age. J Allergy Clin Immunol 2011, 128:646-652.
10. Prescott SL, Björkstén B: Probiotics for the prevention or treatment of
allergic diseases. J Allergy Clin Immunol 2007, 120:255-62.
11. Pfefferle PI, Prescott SL, Kopp M: Microbial influence on tolerance and
opportunities for intervention with prebiotics/probiotics and bacterial
lysates. J Allergy Clin Immunol 2013, 131:1453-63.
12. Hardy H, Harris J, Lyon E, Beal J, Foey AD: Probiotics, prebiotics and
immunomodulation of gut mucosal defences: homeostasis and
immunopathology. Nutrients 2013, 29:1869-1912.
13. Weng M, Walker WA: The role of gut microbiota in programming the
immune phenotype. J Dev Orig Health Dis 2013, 4:203-214.
14. Bezirtzoglou E, Stavropoulou E: Immunology and probiotic impact of the
newborn and young children intestinal microflora. Anaerobe 2011,
17:369-374.
15. Kuitunen M, Kukkonen K, Juntunen-Backman K, Korpela R, Poussa T,
Tuure T, Haahtela T, Savilahti E: Probiotics prevent IgE-associated allergy
until age 5 years in cesarean-delivered children but not in the total
cohort. J Allergy Clin Immunol 2009, 123:335-341.
16. Walker WA: Initial intestinal colonization in the human infant and
immune homeostasis. Ann Nutr Metab 2013, 63(Suppl 2):8-15.
A18
New trends on childhood nutrition
Luigi Memo1*, Sonia Viale2
1
Paediatric Department, San Martino Hospital, Belluno, Italy; 2Department of
Woman and Child Health, Padua University, Padua, Italy
Background: An optimal growth is the first objective of feeding during
infancy. Recent trials demonstrated that environmental and nutritional
influences during critical periods in development, can have permanent
effects on an individual’s predisposition to diseases in adulthood.
Materials and methods: This review summarises the studies on the
associations between nutrition during pregnancy and infancy with
illnesses later in life.
Results: Maternal nutrition during gestation is important for metabolic
programming. Individuals born small for gestational age or prematurely have
higher rates of insulin resistance, confirming an association between birth
weight and later diabetes, heart disease and obesity [1-3]. High-protein intake
during early childhood is associated with obesity, while breastfeeding and
timely introduction of complementary foods were shown to protect against
obesity in adulthood. Direct benefits of exclusive breastfeeding to the infant’s
nutrition, gastrointestinal function, host defence and psychological well-being
are known in literature. Although evidence is often inconclusive, breastfeeding
may be associated with long term benefits such as lower risk of acute illnesses,
obesity, cancer, adult coronary heart disease, allergic conditions, type 1
diabetes and inflammatory bowel disease [4]. The ESPGHAN recommends
complementary foods introduction between 17 and 26 weeks of age [5,6].
Early introduction has been associated with an increased risk of obesity [7,8];
feeding cereals to infants at high risk for type 1 diabetes or celiac disease
before 3 months of age may increase the risk of autoimmunity. Later
introduction of complementary foods may be associated with adverse effects:
decreased growth, iron deficiency, development of atopy and celiac disease
or type 1 diabetes. Primary prevention of allergic disease through nutritional
interventions has changed [9]. Avoidance diets during pregnancy and
lactation are not recommended. Exclusive breast-feeding for at least 4 and up
to 6 months is endorsed. Hydrolyzed formula prevents allergic disease and
cow’s milk allergy in high-risk infants who cannot be exclusively breast-fed.
Complementary foods can be introduced between 4 and 6 months of age
even for high risk infants. The important role of Vitamin D during pregnancy
and infancy is still supported by literature [10,11]. Several recent clinical trials
have been conducted to evaluate the effect of supplementation of
Docosahexaenoic acid (DHA):it may improve neurodevelopmental outcome in
very preterm infants and visual acuity for all infants [12].
Conclusions: Controlled trials of early nutritional interventions with longterm outcomes are still lacking. Nonetheless, there is ample circumstantial
evidence to support clinical efforts to optimize nutrition during gestation,
infancy, and early childhood.
References
1. Fraser A, Tilling K, Macdonald-Wallis C, Sattar N, Brion MJ, Benfield L, Ness A,
Deanfield J, Hingorani A, Nelson SM, Smith GD, Lawlor DA: Association of
maternal weight gain in pregnancy with offspring obesity and
metabolic and vascular traits in childhood. Circulation 2010,
121(23):2557-2567.
2. Taveras EM, Rifas-Shiman SL, Sherry B, Oken E, Haines J, Kleinman K, RichEdwards JW, Gillman MW: Crossing growth percentiles in infancy and risk
of obesity in childhood. Arch Pediatr Adolesc Med 2011, 165:993.
3. Baird J, Fisher D, Lucas P, Kleijnen J, Roberts H, Law C: Being big or
growing fast: systematic review of size and growth in infancy and later
obesity. BMJ 2005, 331(7522):929.
4. Kramer MS, Kakuma R: Optimal duration of exclusive breastfeeding.
Cochrane Database Syst Rev 2012, 8: CD003517.
5. Agostoni C, Decsi T, Fewtrell M, Goulet O, Koletzko B, Michaelsen KF,
Moreno L, Puntis J, Rigo J, Shamir R, Szajewska H, Turck D, van
Goudoever J: Complementary feeding: a commentary by the ESPGHAN
Committee on Nutrition. J Pediatr Gastroenterol Nutr 2008, 46(1):99-110.
6. Jonsdottir OH, Thorsdottir I, Hibberd PL, Fewtrell MS, Wells JC, Palsson GI,
Lucas A, Gunnlaugsson G, Kleinman RE: Timing of the introduction of
complementary foods in infancy: a randomized controlled trial. Pediatrics
2012, 130:1038.
7. Lin SL, Leung GM, Lam TH, Schooling CM: Timing of solid food
introduction and obesity: Hong Kong’s “children of 1997” birth cohort.
Pediatrics 2013, 131:e1459.
8. Huh SY, Rifas-Shiman SL, Taveras EM, Oken E, Gillman MW: Timing of solid
food introduction and risk of obesity in preschool-aged children.
Pediatrics 2011, 127:e544.
9. Fleischer DM, Spergel JM, Assa’ad AH, Pongracic JA: Primary prevention of
allergic disease through nutritional intervention. J Allergy Clin Immunol
Pact 2013, 1(1):29-36.
Page 9 of 28
10. Misra M, Pacaud D, Petryk A, Collett-Solberg PF, Kappy M: Vitamin D
deficiency in children and its management: review of current
knowledge and recommendations. Pediatrics 2008, 122(2):398-417.
11. Mansbach JM, Ginde AA, Camargo CA Jr: Serum 25-hydroxyvitamin D
levels among US children aged 1 to 11 years: do children need more
vitamin D? Pediatrics 2009, 124:1404.
12. Schulzke SM, Patole SK, Simmer K: Long-chain polyunsaturated fatty acid
supplementation in preterm infants. Cochrane Database Syst Rev 2011, 2:
CD000375.
A19
Fluoride therapy in the prevention of dental caries
Laura Strohmenger
Department Health’s Science, H.San Paolo, Milan, Italy
The document “National Guidelines for the prevention and oral health
promotion in childhood”, 2013, is an act of address for those involved in the
management of oral health and in particular to the pediatrician, because the
figure of the pediatrician in the prevention of oral health is absolutely
critical, as confirmed by the entire international literature in recent years.
Correct attitudes and behaviors adopted since childhood that will allow
the child to protect his health.
The fluoride is the cornerstone of prevention of tooth decay and is
required for all individuals.
Over the years, have been developed different means of administration of
fluorine, each with different strengths, dosages and frequency of use.
Fluoride supplements should be prescribed by the pediatrician in cases of
real difficulty for topical administration of fluoride through toothpaste or
fluoride added as a method of in subjects at risk of tooth decay.
The decline of caries in our country it is highly likely also due to the
pediatrician who, using the national guidelines, can inform parents and
families induce the acquisition of preventive behaviors currently defined
by scientific research.
To this end, again, the ministerial guidelines on the subject that were
reviewed by a team of experts representative of the Italian research in
this area.
References
1. Marinho VC, Higgins JP, Logan S, Sheiham A: Fluoride gels for preventing
dental caries in children and adolescents (Review). Cochrane Database
Syst Rev 2009, 1: CD002280, pub2.
2. Marinho VC, Higgins JP, Logan S, Sheiham A: Fluoride mouthrinses for
preventing dental caries in children and adolescents (Review). Cochrane
Database Syst Rev 2009, 3: CD002284, pub2.
3. Marinho VC, Higgins JP, Logan S, Sheiham A: Fluoride varnishes for
preventing dental caries in children and adolescents (Review). Cochrane
Database Syst Rev 2009, 1: CD002279, pub2.
4. Marinho VC, Higgins JP, Sheiham A, Logan S: Combinations of topical
fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical
fluoride for preventing dental caries in children and adolescents.
Cochrane Database Syst Rev 2009, 1: CD002781, pub2.
5. Marinho VC: Cochrane reviews of randomized trials of fluoride therapies
for preventing dental caries. Eur Arch Paediatr Dent 2009, 10:183-91.
6. Twetman S: Caries prevention with fluoride toothpaste in children: an
update. Eur Arch Paediatr Dent 2009, 10(3):162-7.
7. Twetman S: Prevention of early childhood caries (ECC)–review of
literature published 1998-2007. Eur Arch Paediatr Dent 2008, 9:12-8.
8. [http://www.ministerosalute.gov].
A20
Cranial ultrasound screening in late preterm infants
M Fumagalli1*, LA Ramenghi2, A De Carli1, L Bassi1, F Dessimone1, S Pisoni1,
M Groppo1, A Ometto1, I Sirgiovanni1, F Mosca1
1
NICU, Department of Clinical Sciences and Community Health, Fondazione
IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di
Milano, Milan, Italy; 2Neonatal Intensive Care Unit, Istituto Giannina Gaslini,
Genoa, Italy
Late preterm births have enormously increased in the last decades and
there is mounting evidence showing that infants born late preterm are
less healthy than infants born at term [1] and they are more likely to
develop neonatal morbidities (temperature instability, respiratory
distress syndrome, excessive weight loss and dehydration requiring
intravenous infusion, sepsis, hypoglycemia and jaundice requiring
phototherapy) [2].
More recently, an increased neuromorbidity has been documented and
long-term neurodevelopmental impairments (poor school performance,
early intervention services, special education needs) have been reported in
this population [3,4]. The neuromorbidity of the late preterm infants has
been attributed to both the potential detrimental neurological effects
(extrinsic vulnerability) of the morbidities these babies experience in the
neonatal period, and to the intrinsic brain vulnerability. Advances in
neuroimaging techniques have highlighted a higher intrinsic vulnerability
of the late preterm brain due to the structural and molecular immaturity of
the developing brain at specific gestational ages [5,6].
Therefore, late preterm infants have a risk to develop brain lesions which is
lower than more premature babies but higher than term newborns and
they can be affected by brain lesions common to both preterm and term
infants [7]. However, the incidence of brain abnormalities in this specific
population has never been investigated as late preterm infants have long
been considered a large and low-risk population.
Considering that most of the brain lesions are clinically subtle or silent
during the neonatal period, a cranial ultrasound screening may play a
role in: 1. detecting babies at risk of impaired neurodevelopment later in
childhood and who may benefit from early intervention programs;
2. identifying the most significant perinatal risk factors associated with
brain abnormalities in such a large low-risk population in order to target
the potential need for cranial ultrasound at birth. Based on these
assumptions we performed a cranial ultrasound screening project on late
preterm infants. Our preliminary data (unpublished data) suggest that
lower gestational age, within the late preterm period, and early neonatal
morbidities, can provide an indication at birth to undergo a cranial
ultrasound scan as they are associated with a higher risk to develop brain
abnormalities. Late preterm infants represent a vulnerable population and
investigation and follow-up program should be modulated according to
the prenatal, perinatal and postnatal characteristics.
Follow-up studies are needed to correlate neonatal ultrasound findings
with long-term neurobehavioral outcomes in late preterm infants.
References
1. Shapiro-Mendoza CK, Lackritz EM: Epidemiology of late and moderate
preterm birth. Semin Fetal Neonatal Med 2012, 17(3):120-5.
2. Wang ML, Dorer DJ, Fleming MP, et al: Clinical outcomes of near-term
infants. 2004, 114(2):372-6.
3. Shah PE, Robbins N, Coelho RB, et al: The paradox of prematurity: The
behavioral vulnerability of late preterm infants and the cognitive
susceptibility of very preterm infants at 36 months post-term. Infant
Behav Dev 2013, 36(1):50-62.
4. Talge NM, Holzman C, Wang J, et al: Late-preterm birth and its
association with cognitive and socioemotional outcomes at 6 years of
age. Pediatrics 2010, 126(6):1124-31.
5. Childs AM, Ramenghi LA, Evans DJ, et al: MR features of developing
periventricular white matter in preterm infants: evidence of glial cell
migration. AJNR 1998, 19(5):971-6.
6. Judaš M, Sedmak G, Kostović I: The significance of the subplate for
evolution and developmental plasticity of the human brain. Front Hum
Neurosci 2013, 7:423.
7. Sannia A, Natalizia AR, Parodi A, et al: Different gestational ages and
changing vulnerability of the premature brain. J Matern Fetal Neonatal
Med 2013, [Epub ahead of print].
A21
Vulnerability and “minor” developmental disorders in late preterm
infants
Giovanni Cioni1,2*, Francesca Tinelli1
1
Department of Developmental Neuroscience, Stella Maris Scientific Institute,
Calambrone, 56128-Pisa, Italy; 2Department of Clinical and Experimental
Medicine, University of Pisa, Pisa, Italy
Page 10 of 28
The National Institute of Child Health and Human Development panel
reviewed the evidence of increased risk of infants with a gestational age of
34-36 weeks and, in 2006, changed the earlier definition of “near term” to
“late preterm (LPT)”. LPT infants represent 70% of all the whole population
of preterm but while it is known that they are at major risk of mortality and
morbidity than term infants, less is known about their development
outcome. Samra et al. [1] in 2011 published a review about this topic based
on 817 articles but their conclusion was that, due to paucity and
heterogeneity of the existing data, there was no clear characterization of the
long-term risks. Since then some other interesting papers have been
published, quite all in the direction that LPT children have some “minor”
problems. In 2013, for example, Vohr B. [2] suggested that LPT infants are at
increased risk of neurologic impairments, developmental disabilities, school
failure, and behavior and psychiatric problems suggesting also that for each
1 week decrease in gestational age below 39 weeks, there are stepwise
increases in adverse outcomes after adjusting for confounders. In 2014,
Chan et al. [3] described the negative impact of LPT birth on academic
outcomes at 7 years and Brumbaugh et al. [4] the negative impact on
executive function at preschool age.
A possible explanation of these results is i) the demonstrated major
vulnerability to the brain injury in the late preterm infant respect to the term
infant, particularly involving the white matter [5] since that at 34 weeks the
late preterm brain weights only 65% of the term brain and ii) the possible
role of the extrauterine life compared with the intrauterine life during
the last weeks of gestation.
References
1. Samra HA, McGrath JM, Wehbe M: An integrated review of
developmental outcomes and late-preterm birth. J Obstet Gynecol
Neonatal Nurs 2011, 40(4):399-411.
2. Vohr B: Long-term outcomes of moderately preterm, late preterm, and
early term infants. Clin Perinatol 2013, 40(4):739-51.
3. Chan E, Quigley MA: School performance at age 7 years in late preterm
and early term birth: a cohort study. Arch Dis Child Fetal Neonatal Ed
2014.
4. Brumbaugh JE, Hodel AS, Thomas KM: The impact of late preterm birth
on executive function at preschool age. Am J Perinatol 2014, 31(4):305-14.
5. Kinney HC: The near-term (late preterm) human brain and risk for
periventricular leukomalacia: a review. Semin Perinatol 2006, 30(2):81-8.
A22
Chorioamnionitis and neonatal outcome: early vs late preterm infants
Lidia Decembrino*, Margherita Pozzi, Rossana Falcone, Mauro Stronati
Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo,
Pavia, Italy
Chorioamnionitis (CA) describes an intrauterine status of inflammation and/
or infection of placental membranes, refering to both histological and
clinical CA [1]. It is considered the major risk of spontaneous preterm
delivery, especially at earlier gestational age. The intrauterine exposure to
infection/inflammation leads to the fetal inflammatory syndrome (FIRS) that
together with CA is responsible for multiple organ injury, neonatal morbidity
and mortality [2]. Strong evidences support that neonates exposed to CA
are sicker at birth, have a higher rates of early-onset sepsis, respiratory
distress syndrome (RDS), bronchopulmonary dysplasia (BPD), intraventricular
hemorrhage (IVH), retinopathy of prematurity (ROP), patent ductus
arteriousus (PDA) and surgical necrotizing enterocolitis (NEC) as compared
with unexposed neonates [3-6]. Neonates with ≤ 28 weeks of gestational
age (GA) have a significantly higher mortality than neonates with a longer
gestation period [7]. Recently Pappas et al reported an increased odds of
cognitive impairment and death/neurodevelopmental impairment in
extremely low birth weight (ELBW) exposed to CA [8]. In infants born at
36 weeks or later in gestation CA has been indentified as an independent
risk factor of CP [9]. Lee et al highlighted that acute histologic CA is a risk
factor for adverse neonatal outcome in late preterm birth after preterm
premature rupture of membranes (PPROM) [10]. Neverthless, the effects of
CA on the neonatal outcome remain under debate, because gestationindependent effects of CA on neonatal outcomes are difficult to assess. Thus
in some studies at adjusted analyses for GA, the adverse impact of CA on
neonatal outcome is not confirmed [11]. Additionally in many study groups
discrimination between ELBW and late preterm infants is not considered. In
the future, sufficiently powered cohort studies and well-matched casecontrol studies will be able to provide useful informations regarding the
different outcome between extremely and late preterms infants. An dequate
antenatal screening and treatment for CA will improve the prognosis for
infants at risk of multiple organ disease as a result of exposure to infection/
inflammation before birth [12-14].
References
1. Hagberg H, Wennerholm UB, Savman K: Sequelae of chorioamnionitis.
Curr Opin Infect Dis 2002, 15:301-306.
2. Gotsch F, Romero R, Kusanovic JP, Mazaki-Tovi S, Pineles BL, Erez O,
Espinoza J, Hassan SS: The Fetal Inflammatory Response Syndrome.
Clinical Obstetrics and Gynecol 2007, 50(3):652-683.
3. Galinsky R, Polglase GR, Hooper SB, Back MJ, Moss TJ: The Consequences
of Chorioamnionitis: Preterm Birth and Effects on Development.
J Pregnancy 2013, 2013(2013):412831.
4. Bersani I, Thomas W, Speer CP: Chorioamnionitis – the good or the evil
for neonatal outcome? The Journal of Maternal-Fetal and Neonatal Medicine
2012, 25(Suppl 1):12-16.
5. Seliga-Siwecka JP, Kornacka MK: Neonatal outcome of preterm infants
born to mothers with abnormal genital tract colonisation and
chorioamnionitis: A cohort study. Early Human Development 2013,
89:271-275.
6. Been JV, Lievense S, Zimmermann LJI, Kramer BW, Wolf TG:
Chorioamnionitis as a risk factor for Necrotizing Enterocolitis: A
Systematic Review and Meta-Analysis. J Pediatr 2013, 162:236-42.
7. Stimac M, Vukelic V, Perusko Matasic NP, Kos M, Babic D: Effect of
chorioamnionitis on mortality, early onset neonatal sepsis and
bronchopulmonary dysplasia in preterm neonates with birth weight of
≤1,500 grams. Coll. Antropol 2014, 38(1):167-171.
8. Pappas A, Kendrick DE, Shankaran S, Stoll BJ, Bell EF, Laptook AR, Walsh MC,
Das A, Hale EC, Newman NS, Higgins RD, Eunice Kennedy Shriver National
Institute of Child Health and Human Development Neonatal Research
Network: Chorioamnionitis and Early Childhood Outcomes Among
Extremely Low-Gestational-Age Neonates. JAMA Pediatr 2014,
168(2):137-147.
9. Wu YW, Escobar GJ, Grether JK: Chorioamnionitis and cerebral palsy in
term and near-term infants. JAMA 2003, 290:2677-2684.
10. Lee SM, Park JW, Kim BJ, Park CW, Park JS, Jun JK, Yoon BH: Acute
Histologic Chorioamnionitis Is a Risk Factor for Adverse Neonatal
Outcome in Late Preterm Birth after Preterm Premature Rupture of
Membranes. PloS One 2013, 8(12):e79941.
11. Mitra S, Aune D, Speer CP, Saugstad OD: Chorioamnionitis as a Risk Factor
for Retinopathy of Prematurity: A Systematic Review and Meta-Analysis.
Neonatology 2014, 105:189-199.
12. Popowski T, Goffinet F, Maillard F, Schmitz T, Leroy S, Kayem G: Maternal
markers for detecting early-onset neonatal infection and
chorioamnionitis in cases of premature rupture of membranes at or
after 34 weeks of gestation: a two-center prospective Study. BMC
Pregnancy and Childbirth 2011, 11:26.
13. Tita ATN, Andrews WW: Diagnosis and Management of Clinical
Chorioamnionitis. Clin Perinatol 2010, 37(2):339-354.
14. Been JV, Degraeuwe PL, Kramer BW, Zimmermann LJ: Antenatal steroids
and neonatal outcome after chorioamnionitis: a meta-analysis. BJOG
2011, 118:113-122.
A23
Early and late onset sepsis in late preterm infants
Fabio Natale*, Bianca Bizzarri, Veronica Cardi, Mario De Curtis
Department of Pediatrics and Child Neuropsychiatry, “Sapienza” University of
Rome, Rome, Italy
Preterm birth is increasing worldwide. Late preterm infants (from 34+0 to
36+6 weeks of gestation) comprise more than 70% of premature infants and
this percentage has been increasing in recent years. These infants, though
resembling normal term infants, due to an incomplete maturational process,
suffers higher percentage of mortality (from 0,5 to 1,5/1000 vs 0,2/1000 live
births) and morbidity (from 17% to 34% vs 14%) if compared to term
ones [1].
Page 11 of 28
Late preterm infants are inherently prone to develop sepsis: 1) Preterm
labor and preterm premature rupture of membranes, together accounting
for the 80% of the causes of preterm delivery [2], are well known risk
factor for early onset sepsis (EOS); in fact, intrapartum antibiotic
prophylaxis is widely recommended to prevent group B streptococcal
EOS in women undergoing preterm delivery (risk factors approach), and
sepsis work-up is frequently performed in late preterm infants [1].
2) Some degree of immaturity of both innate and adaptive immunity
makes late preterm infants at increased risk to develop sepsis [3]. 3)
Increase rate of morbidity (respiratory problems, needs for reanimation in
delivery room, hyperbilirubinemia, hypoglicemia, and feeding problems)
exposes these infants to prolonged hospitalization and invasive
procedures favouring nosocomial infections to occur [1].
Mc Intire et al. reported an incidence of culture proven sepsis from 2 to
5 times higher in late preterm infants (the incidence was inversely related
to the gestational age) when compared with 39 weeks gestation infants
[1]. Neonatal infections in late preterm infants (including culture-proven
and suspected sepsis) were 5,2 times more common in a populationbased study lead by Khashu et al [4]. Cohen-Wolkowiez et al. [5], were
the only to specifically address the issue of the incidence of EOS and late
onset sepsis (LOS) in late preterm infants. An observational cohort study
comprising more than 100,000 late preterm infants admitted to 248
neonatal intensive care units from 1996 to 2007 revealed a cumulative
incidence of 4,42/1000 admissions for EOS and 6,3/1000 admissions for
LOS. Gram-positive organisms accounted for the majority (66,4%) of EOS
but mortality (1,3% of all EOS episodes) was mainly due to Gram-negative
sepsis (19,1% vs 1,1%). Of the neonates suffering LOS, 7% died. Infants
with LOS were three times more likely to die than infants without sepsis.
Prevention of sepsis in late preterm infants may be best accomplished
through maternal antibiotic prophylaxis (when indicated), and avoiding
non-indicated late preterm deliveries (17%-25% of all cases) [2,6].
References
1. McIntire DD, Leveno KJ: Neonatal mortality and morbidity rates in late
preterm births compared with births at term. Obstet Gynecol 2008,
111:35-41.
2. Holland MG, Refuerzo JS, Ramin SM, Saade GR, Blackwell SC: Late preterm
birth: how often is it avoidable? Am J Obstet Gynecol 2009, 201(4):404.
e1-404.e4.
3. Sahni R, Polin RA: Physiologic underpinnings for clinical problems in
moderately preterm and late preterm infants. Clin Perinatol 2013,
40:645-63.
4. Khashu M, Narayanan M, Bhargava S, et al: Perinatal outcomes associated
with preterm birth at 33 to 36 weeks’ gestation: a population-based
cohort study. Pediatrics 2009, 123:109-13.
5. Cohen-Wolkowiez M, Moran C, Benjamin DK, et al: Early and late onset
sepsis in late preterm infants. Pediatr Infect Dis J 2009, 28:1052-6.
6. Morais M, Mehta C, Murphy K, et al: How often are late preterm births the
result of non-evidence based practices: analysis from a retrospective
cohort study at two tertiary referral centres in a nationalised healthcare
system. BJOG 2013, 120:1508-14.
A24
Lung development in the late preterm
Maurizio Gente1*, Paola Papoff2, Stefano Luciani2, Rosanna Grossi2,
Elena Caresta2, Corrado Moretti2
1
Department of Paediatrics, Neonatal Emergency Transport Service, Sapienza
University of Rome, Rome, Italy; 2Department of Paediatrics, Paediatric
Emergency and Intensive Care, Sapienza University of Rome, Rome, Italy
An increasing incidence of moderate-to-late prematurity is observed
worldwide (6-7% of all births). Moderate-to-late prematurity is a cause of
important mortality and morbidity, even when it is just a few weeks before
term gestation [1]. Respiratory issues related to moderate prematurity
include delayed neonatal transition to air breathing, respiratory distress
resulting from delayed fluid clearance, surfactant deficiency, and
pulmonary hypertension. There is increasing evidence to support the
hypothesis that preterm delivery, even in the absence of any neonatal
respiratory disease, may have adverse effects on subsequent lung growth
and development, and that these alterations may persist during the early
years of life. Premature birth interrupts normal in utero lung development
and results in an early transition from the hypoxic intrauterine
environment to a comparatively hyperoxic atmospheric environment [2].
Alveolar walls may be thicker, impairing optimal gas exchange. Colin et al.
proposed that preterm birth leads to decreased parenchyma elasticity and
subsequent airway tethering, a mechanism by which airway wall
compliance keeps surrounding alveoli well opened [3]. The long-term
significance of reduced airway function early in life has been emphasized
in a longitudinal study involving a large group of non-selected infants who
had participated in the Tucson Children’s Respiratory study [4]. In this
study Stern et al. showed that infants whose pulmonary function was in
the lowest quartile also had pulmonary function in the lowest quartile
through the years of follow-up until early adulthood. These findings in a
normal unselected population, suggest that the level of pulmonary
function in early life tracks and changes little with growth. Several authors
suggest that deficits in lung function during early life, especially if
associated with lower respiratory illnesses, increase the risk of chronic
obstructive pulmonary disease in late adult life [5-7]. Of particular
importance in this context may be the role played by RSV, which affects
most children during their first year of life. The risk of life-threatening RSV
infection appears relevant up to a post-conceptional age of 44 weeks.
Stein et al. reported that RSV lower respiratory tract illness during the first
3 years of life in a healthy birth cohort was associated with recurrent
wheeze up to age 11 [8].
In conclusion altered lung development is a characteristic feature of the
late preterm infants and its impact on neonatal and postnatal morbidity
needs to be considered.
References
1. Engle WA, Tomashek KM, Wallman C, Committee on Fetus and Newborn,
American Academy of Pediatrics: “Late preterm” infants: a population at
risk. Pediatrics 2007, 120:1390-1401.
2. Hartman WR, Smelter DF, Sathish V, Karass M, Kim S, Aravamudan B,
Thompson MA, Amrani Y, Pandya HC, Martin RJ, Prakash YS, Pabelick CM:
Oxygen dose responsiveness of human fetal airway smooth muscle
cells. Am J Physiol Lung Cell Mol Physiol 2012, 303(8):711-719.
3. Colin AA, McEvoy C, Castile RG: Respiratory morbidity and lung function
in preterm infants of 32 to 36 weeks’ gestational age. Pediatrics 2010,
126(1):115-128.
4. Stern DA, Morgan WJ, Wright AL, Guerra S, Martinez FD: Poor airway
function in early infancy and lung function by age 22 years: a nonselective longitudinal cohort study. Lancet 2007, 370(9589):758-764.
5. Abe K, Shapiro-Mendoza CK, Hall LR, Satten GA, Weiss ST, Ware JH: Late
preterm birth and risk of developing asthma. J Pediatr 2010, 157(1):74-78.
6. Kotecha SJ, Dunstan FD, Kotecha S: Long term respiratory outcomes of
late preterm-born infants. Semin Fetal Neonatal Med 2012, 17(2):77-81.
7. McEvoy C, Venigalla S, Schilling D, Clay N, Spitale P, Nguyen T: Respiratory
function in healthy late preterm infants delivered at 33–36 weeks of
gestation. J Pediatr 2013, 162(3):464-469.
8. Stein RT, Sherrill D, Morgan WJ, Holberg CJ, Halonen M, Taussig LM,
Wright AL, Martinez FD: Respiratory syncytial virus in early life and risk of
wheeze and allergy by age 13 years. Lancet 1999, 354(9178):541-545.
Page 12 of 28
A25
Point-of care lung ultrasound in the NICU: uses and limitations of a
new tool
Francesco Raimondi1*, Fiorella Migliaro1, Angela Sodano1,
Claudio Veropalumbo1, Angela Carla Borrelli1, Silvia Lama1,
Gianfranco Vallone2, Letizia Capasso1
1
Division of Neonatology, Section of Pediatrics, Department of Medical
Translational Sciences, Università “Federico II” , Naples, Italy; 2Section of
Radiology, Department of Advanced Biomedical Science, Università “Federico II”,
Naples, Italy
Pulmonary imaging in the neonatal intensive care unit (NICU) relies
traditionally on the conventional chest radiogram. Translating evidences
from adult emergency medicine, pediatricians and neonatologists have
recently started to apply lung ultrasonography to the critical infant and child
with respiratory problems [1].
Because of the high impedance of a normally aerated lung, an ultrasound
scan does not render an anatomical image of the organ. However,
ultrasounds clearly define the pleural surface with the normal sliding
movement. Pleural effusions and lung consolidations can also be reliably
diagnosed with ultrasonography. However, ultrasounds penetrating the lung
will also generate artifacts (i.e. structures not naturally present in the living
that appear as authentic images). These imagery anomalies come from the
machine acquisition of the ultrasound beam path through means with
markedly different acoustic impedance in close proximity. The horizontal
reverberations of the pleural line (aka the A lines - see Figure 1A) and the
vertical hyperecoic image departing from the pleura (aka the B lines- see
Figure 1B) are commonly seen artifacts.
Real and artefactual images have been combined in disease specific
ultrasound profiles. Using these profiles, adult emergency physicians
have shown that lung ultrasound outperforms conventional radiology
in relevant diagnoses such as pleural effusion, pneumonia or
pneumothorax.
Pediatricians have started to use lung ultrasound with success to their
patients affected by pneumonia but also by bronchiolitis [2]. In the
NICU, lung ultrasound has found its specific applications, not without
controversies [3]. Transient Tachypnea of the Newborn and Respiratory
Distress Syndrome have been described with ultrasound profiles that
are both highly sensitive and specific [4]. A relevant limitation of chest
ultrasound is that surfactant administration gives a persistent white
lung image rendering any follow-up essentially unfeasible. Ultrasounds
can, however, accurately describe the fluid to air transition after birth
and identify those neonates who will fail to adapt to extrauterine life
needing respiratory support [5]. In a series of preterm neonates with
moderate respiratory distress, recent work by our group shows that
chest ultrasound is significantly more accurate than conventional
radiograph in predicting the failure of non invasive ventilation [6].
Lung ultrasound is a very promising clinical tool in the NICU whose
potential applications are well worth future multicenter trials.
Figure 1(abstract A25) 1A: reverberations of the pleural image (aka A-lines) in the normally aerated lung. 1B: the prevalence of vertical B-lines
(in between arrows) has been linked to the interstitial syndrome in the adult and to a progressive aeration of the neonatal lung after birth.
References
1. Raimondi F, Cattarossi L, Copetti R: International Perspectives: Point-ofCare Chest Ultrasound in the Neonatal Intensive Care Unit: An Italian
Perspective. NeoReviews 2014, 15:e2-e6.
2. Caiulo VA, Gargani L, Caiulo S, Fisicaro A, Moramarco F, Latini G, Picano E:
Lung ultrasound in bronchiolitis: comparison with chest X-ray. Eur J
Pediatr 2011, 170(11):1427-33.
3. Raimondi F, Cattarossi L, Copetti R: Pediatric chest ultrasound versus
conventional radiology: experimental evidence first. Pediatr Radiol 2014,
44(7):900.
4. Vergine M, Copetti R, Brusa G, Cattarossi L: Lung Ultrasound Accuracy in
Respiratory Distress Syndrome and Transient Tachypnea of the
Newborn. Neonatology 2014, 106(2):87-93.
5. Raimondi F, Migliaro F, Sodano A, Umbaldo A, Romano A, Vallone G,
Capasso L: Can neonatal lung ultrasound monitor fluid clearance and
predict the need of respiratory support? Crit Care 2012, 16(6):R220.
6. Raimondi F, Migliaro F, Sodano A, Ferrara T, Lama S, Vallone G, Capasso L:
Can neonatal chest ultrasound predict the failure of non-invasive
ventilation? Pediatrics 2014 in press.
A26
Follow-up of late preterm infants: why, what and who?
F Gallini*, R Arena, V Romano, S Frezza, C Romagnoli
Neonatal Intensive Care and Follow-up Unit, Department of Pediatrics,
UCSC- Rome, Italy
Late preterm infants (LPI) represent a growing population with own
peculiar vulnerabilities; only recently attention has been focused on the
impact of late preterm birth on child health, in order to define short and
long-term outcomes [1,2].
LPI are physiologically and metabolically immature; they are at higher risk
than term infants of developing medical complications, resulting in greater
rate of mortality and morbidity not only in the neonatal period, but also
during infancy, childhood, adolescence, and through adulthood [2,3].
Increasing evidence shows the association between late-preterm birth
and various long-term medical and behavioral morbidities, including
cerebral palsy, attention problems and antisocial behavior, as well as
lower IQ, impaired cognitive and academic performance at school age.
Fetal brain undergoes a dramatic growth and maturation during last
four weeks of gestation, and this is probably the most important reason
of LPI worse neurodevelopmental outcomes compared to full-term
infants [3-5].
Physical development is an other important outcome for LPI; in addition to
intrauterine growth restriction, LPI may be susceptible to feeding difficulty
resulting in poor weight gain and underweight. Since failure to thrive in early
infancy may be also associated with adverse cognitive and developmental
outcomes, close monitoring of LPI growth pattern is needed [6].
Moreover, late-preterm birth has a negative effect also on maturation of
the lungs, interrupting evolution from alveolar saccules to mature alveoli.
LPI have been shown to develop early respiratory morbidities more
frequently than infants born at term. However, the risk for long-term
respiratory problems, such as asthma, has not yet been established in this
group of patients [3,7].
Therefore LPI need a multidisciplinary, personalized and effective follow–up
care that begins at birth and continues, with varying degrees of surveillance
and reflecting individual needs, throughout the lifespan. Pediatricians must
play a crucial role by ensuring that appropriate screening and assessments
are completed, referrals are made and continuity of care is coordinated.
They have to be aware of the major problems that LPI may encounter,
providing anticipatory guidance when needed. Pediatricians together with
parents, child development specialists, and education professionals need to
know the possible school underachievement and behavioral problems so
that prompt referrals to early intervention services are made [8,9].
Up to now, standardized short and long term follow-up schedule for LPI
has not been developed yet; therefore, further research should focus on
systematic evaluation of outcomes of LPI, in order to optimize follow-up
monitoring of this population of children.
References
1. Egle WA, Tomashek KM, Wallman C: ’’Late-Preterm’’ Infants: A Population
at Risk. Pediatrics 2007, 120:1390-1401.
Page 13 of 28
2.
3.
4.
5.
6.
7.
8.
9.
Kugelman A, Colin AA: Late Preterm Infants: Near Term But Still in a
Critical Developmental Period. Pediatrics 2013, 132:741-751.
McGowan JE, Alderdice FA, Holmes VA, Johnston L: Early Childhood
Development of Late-Preterm Infants: A Systematic Review. Pediatrics
2011, 127:1111-1122.
Petrini JR, Dias T, McCormick MC, et al: Increased Risk of Adverse Neurological
Development for Late Preterm Infants. J Pediatr 2009, 154:169-76.
Talge NM, Holzman C, Wang J, et al: Late-Preterm Birth and Its
Association With Cognitive and Socioemotional Outcomes at 6 Years of
Age. Pediatrics 2010, 126:1124-1131.
Goyal NK, Fiks AG, Lorch SA: Persistence of Underweight Status Among
Late Preterm Infants. Arch Pediatr Adolesc Med 2012, 166:424-430.
Abe K, Shapiro-Mendoza CK, Hall LR, et al: Late Preterm Birth and Risk of
Developing Asthma,. J Pediatr 2010, 157:74-78.
Phillips RM, Goldstein M, Hougland K, et al: Multidisciplinary guidelines
for the care of e preterm infants. Journal of Perinatology 2013, 33:
S5-S22.
Morse SB, Zheng H, Tang Y, Roth J: Early School-Age Outcomes of Late
Preterm Infants. Pediatrics 2009, 123:e622-e629.
A27
Late preterm infants’ growth and body composition after discharge
Paola Roggero*, Maria Lorella Giannì, Nadia Liotto, Pasqua Piemontese,
Fabio Mosca
NICU, Department of Clinical Sciences and Community Health, Fondazione
IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di
Milano, Milano, Italy
Background: The proportion of late preterm births has markedly
increased during the past two decades, accounting for 70% of preterm
births [1]. There is evidence that monitoring not only the quantity but
also the quality of growth, in terms of body composition changes, may
play an important role in gaining further insight into the relationship
between birth weight and time in utero on early growth pattern and
future health [2]. To our knowledge, data regarding the early dynamic
features of growth and body composition changes of late preterm infants
are scarce [3-5]. The aim of this study was to compare growth and body
composition of late preterm infants to that of very preterm and full term
infants.
Materials and methods: Observational longitudinal study. Forty-nine late
preterm infants and 63 adequate for gestational age very preterm infants
were included in the study. Forty healthy, full-term, breast-fed infants were
enrolled as a reference group. Anthropometric parameters and body
composition by an air displacement plethysmography system were assessed
at term, at 1 and 3 months of corrected age in all groups.
Results: Basal characteristics of the study population are shown in table 1.
Late preterm infants showed higher weight at term than full term and
very preterm infants (table 1). Length (49.5 vs 47.5 cm; p<0.0001) and
head circumference ( 35.2 vs 34.4 cm; p= 0.004) values were also bigger
in late preterm infants at term than in very preterm infants. At 3 months
of corrected age no significant difference in anthropometric parameters
was found between late preterm and full term infants, whereas weight of
late preterm infants was higher than that of very preterm infants.
With regard to body composition, fat mass at term of late preterm infants
was similar to that of very preterm but significantly higher than that of full
term. Fat free mass at term was not different between late preterm and
full term infants while very preterm infants showed the lowest value.
At 3 months of corrected age, late preterm infants reached a similar body
composition to full term infants, whereas very preterm infants still had
the lowest values of weight, fat free mass and fat mass (table 1).
Conclusions: The present findings demonstrate that late preterm infants
have an altered body composition at term corrected age in terms of high
adiposity. Potential metabolic implications of these results need to be
investigated.
References
1. Dong Y, Yu JL: An overview of morbidity, mortality and long-term
outcome of late preterm birth. World J Pediatr 2011, 7:199-204.
2. Dulloo AG, Jacquet J, Seydoux J, Montani JP: The thrifty “catch-up fat”
phenotype: its impact on insulin sensitivity during growth trajectories to
obesity and metabolic syndrome. Int J Obes (Lond) 2006, 30(Suppl 4):S23-35.
Page 14 of 28
Table 1(abstract A27) Basal characteristics and anthropometric and body composition parameters at term and at
3 months of corrected age of the study population
Full term infants
Late preterm infants
Gestational age (wks)
38.8 ± 1.4
35.3 ± 0.75
Very preterm infants
29.1 ± 2.1
Birth Weight (g)
3074 ± 409
2496 ± 330
1202 ± 238
Birth length (cm)
Birth head circumference (cm)
49.3 ± 2
34.2 ± 1.17
44.8 ± 1.7
31.6 ± 1.2
37.2 ± 3.5
29.07 ± 2.1
Weight 40 wks (g)
3074 ± 409
3396*° ± 390
3015 ± 403
Fat free mass 40 wks (g)
2794 ± 358
2837° ± 255
2459 ± 320
Fat mass 40 wks (g)
280 ± 106
559# ± 196
565 ± 168
Weight 3 mo (g)
5978 ± 722
6197° ± 589
5557 ± 669
Fat free mass 3 mo (g)
4345 ± 484
4500^ ± 390
4157 ± 461
Fat mass 3 mo (g)
1632 ± 355
1672^ ± 348
1405 ± 362
*late preterm vs full term p=0.001
° late preterm vs very preterm p<0.001
# late preterm vs full term p<0.001
^ late preterm vs very preterm p=0.005
3.
4.
5.
Santos IS, Matijasevich A, Domingues MR, Barros AJ, Victora CG, Barros FC:
Late preterm birth is a risk factor for growth faltering in early childhood:
a cohort study. BMC Pediatr 2009, 9:71.
Olhager E, Törnqvist C: Body composition in late preterm infants in the
first 10 days of life and at full term. Acta Paediatr 2014, 103:737-743.
Gianni ML, Roggero P, Liotto N, Amato O, Piemontese P, Morniroli D,
Bracco B, Mosca F: Postnatal catch-up after late preterm birth. Pediatric
Res 2012, 72:637-640.
A28
The late preterm in low income
PE Villani1*, G Vellani2, GP Chiaffoni3, R Magaldi4, E Padovani5, A Ricchini6,
P Stillo7, B Tomasini8, F Uxa9, D Trevisanuto10, M Usuelli11
1
SC Neonatologia e Terapia Intensiva Neonatale, Dipartimento MaternoInfantile, AO “C.Poma”, Mantova, Italy; 2Neonatologia, Dipartimento Integrato
Materno-Infantile, AO Universitaria, Policlinico Modena, Italy; 3SC Pediatria e
Neonatologia, ULSS 7 Conegliano e Vittorio Veneto, Italy; 4SC Neonatologia e
Terapia Intensiva Neonatale, Ospedali Riuniti AOU Foggia, Italy; 5SC Patologia
e Terapia Intensiva Neonatale ,Azienda Ospedaliera e Universitaria Integrata,
Verona, Italy; 6UO Neonatologia e Terapia Intensiva Neonatale, Ospedale dei
Bambini, Brescia, Italy; 7SC Chirurgia Pediatrica, Azienda Ospedaliera
Universitaria Meyer, Firenze, Italy; 8UO di Terapia Intensiva Neonatale,
Azienda Ospedaliera Universitaria “Le Scotte”, Siena, Italy; 9IRCCS Materno
Infantile, Azienda Burlo Garofolo, Trieste, Italy; 10Dipartmento di Salute della
Donna e del Bambino, Scuola di Medicina, Università di Padova, AO Padova,
Italy; 11NICU, Fond. IRCCS Cà Granda Osp. Maggiore Policlinico Milano, Italy
Millennium Development Goals (MDGs) represent the widest commitment
in history to addressing global poverty and health. MDG-4 commits
international community to reducing mortality in under 5 by two-thirds
between 1990 and 2015. According to Lancet Neonatal Survival Series
(LNSS), since 2000, child mortality after the first month (from 29 days to
5 years) fell by a third [1]. Meanwhile, little improvement has been
achieved toward reduction of neonatal mortality (NMR), resulting in
neonatal deaths (ND) constituting an increasing proportion of all under-5
deaths. Estimates from LNSS show that 38% of all deaths in children
younger than age 5 years occur in the neonatal period, 99% in 39 lowincome countries where the average NMR is 33/1,000 [2], 50% occur at
community level and 50% at hospital level. The members of SIN study
group “neonatal care in developing countries (PVS)” experience
cooperation with several PVS maternity hospitals. Preterm birth is a major
health issue and most important clinical problem, especially in PVS [3].
In 2010, preterm birth from 184 countries amount to 14.9 million,
representing 11.1% of livebirths [4] with geographical variations ranging
from 5% in European countries up to 18% in African countries. About 75%
of preterm births are late preterm. Compared with term infants, late
preterm have higher risk of mortality, morbidities including hypothermia,
hypocalcemia, hyperbilirubinemia, sepsis, seizures, respiratory distress,
feeding difficulty, readmission and neurodevelopmental problems [5-8].
Neonatal setting in PVS deeply differs from western: WHO consider newborns
<28 weeks gestational age out of threshold of life with chances of survival,
strengthening the emphasis of late preterm survival. This depends on
department organization, a minimal nurse-patient ratio and defined protocols
and procedures rather than intensive care setting [9]. In addition prematurity
is somehow a difficult diagnosis in PVS: usually women cannot define the first
day of their last menstruation period; even harder is to access ultrasound.
Therefore that many senior neonatologists in PVS prefer to ignore, after birth,
the presumptive gestational age and to manage newborns only according
to birth weight. Standardized protocols do not differentiate procedures,
for example, in 2 newborns of 1700g, 1 AGA and 1 SGA [10]. Achievement of
MDG4 on childhood mortality will remain unattainable in developing
countries unless interventions targeted at reducing NM are instituted; late
preterm babies are the most achievable target [11]. The essential package for
neonatal survival include neonatal resuscitation, hygiene, management of
hypothermia, LBW, neonatal infections, hyperbilirubinaemia, kangaroo mother
care and breastfeeding support, especially for small, LBW newborns [12].
References
1. Lawn EJ, Cousens S, Zupan J: 4 million neonatal deaths: When? Where?
Why? Lancet 2005, 365:891-900.
2. Zupan J, Aahman E: perinatal mortality for the year 2000: estimates
developed by WHO: Geneva: WH Organization. 2005.
3. Morken NH: Pretrm Birth: new data on a global health priority. The Lancet
2012, 379:2128-30.
4. Blencowe H, Cousens S, et al: National, regional and worldwide estimates of
preterm birth rates in the year 2010 with time trends since 1990 for selected
countries: a systematic analisys and implications. Lancet 2012, 379:2162-72.
5. Gouyon JB, Vintejoux A, Sagot P, et al: Neonatal outcome associated with
singleton birth at 34-41 weeks of gestation. Intern J of Epidemiol 2010,
39:769-776.
6. Saigal S, Doyle LW: an overview of mortality and sequelae of preterm
birth from infancy to adulthood. Lancet 2008, 371:261-69.
7. Kramer MS, Demissie K, Yang H, Platt RW, Sauvé R, Liston R: The
contribution of mild and modes rate preterm births to infant mortality.
Fetal and Infant Health Study Group of the Canadian Perinatal
Surveillance System. JAMA 2000, 284:843-849.
8. Melamed N, Klinger G, Tenenbaum-Gavish K, Herscovici T, Linder N, Hod M,
Yogev Y: Short-term neonatal outcome in low-risk, spontaneous,
singleton, late preterm deliveries. Obstet Gynecol 2009, 114(2 Pt 1):253-260.
9. Engle WA, Tomashek KM: Committee on Fetus and Newborn, American
Academy of Pediatrics. Late Preterm infants: a population a risk.
Pediatrics 2007, 120:1390-1401.
10. The Partnership for Maternal, Newborn & Child Health: A Global Review of
the Key Interventions Related to Reproductive, Maternal, Newborn and
Child Health (Rmnch). Geneva, Switzerland: PMNCH 2011.
11. Ahmad OB, Lopez AD: The decline in child mortality: a reappraisal. Bull
World Health Organ 2000, 78:1175-91.
12. Bhutta ZA, Das J, Lawn J: Can available interventions end preventable
deaths in mothers, newborn babies and stillbirth and at whath cost? The
Lancet 2014.
A29
Hospital readmissions in late preterm infants
Marco Pezzati
Neonatology and NICU, Ospedale San Giovanni di Dio, ASL 10 Firenze, Italy
Neonatologists generally recognize that late preterm infants face more
problems in the immediate newborn period compared with their fullterm counterparts. [1,2]. This excess morbidity extends beyond the initial
birth hospitalization [3] and the literature recognizes that readmission
rates of late preterm infants are 1.5 to 3 times that of term infants [4-7].
In this group of infants, the overwhelming reasons for rehospitalisation
are jaundice and feeding problems.
The most widely studied metric of health care utilization in late preterm
infants is short-term readmission (the first two weeks) after birth
hospitalization. Escobar [8] found that late preterm babies with short NICU
stays had the highest rehospitalisation rates and in a follow-up study they
found that rehospitalisation rates within 2 weeks were higher among late
preterm infants who never were admitted to the NICU [4]. Shapiro-Mendoza
[7] found that late preterm babies discharged early were at greater risk of
neonatal morbidity. They also found that risk factors for subsequent
readmissions were birth hospital stays less than 4 days, breastfeeding, Asian/
Pacific Islanders, first born infants, and public payers at the time of delivery.
In the United Kingdom, Oddie [9] also noted that late preterm infants had
the highest rate of readmission but infectious disease and not jaundice was
the leading factor for readmission, which the investigators attributed to a
differing approach to management of jaundice in the United Kingdom.
Escobar [10] examined late rehospitalisation (after the first two weeks) and
found 36 week gestation newborns at higher risk for readmission.
Paradoxically, babies of 34 and 35 weeks were not at higher risk and this
may be explained by more frequently delayed discharge of infants of
shorter gestational age. McLaurin [5] also demonstrated increased late
rehospitalisation rates in late preterm infants and found that the subset
with prolonged birth hospitalizations (≥4 days) had the highest rates of
rehospitalisation. Respiratory disease (bronchiolitis and pneumonia) was
the most common cause of readmission.
The late preterm infant is particularly responsive to the benefits but
vulnerable to the risks of early discharge home. Longer length of stay before
discharge is protective against readmission but it is not reasonable to
prolong the birth hospitalization of newborns who meet criteria for
discharge. More effort needs to be placed to reduce the risk of jaundice and
feeding problems in these patients: to avoid mother and infant separation
during birth hospitalization, to arrange a follow-up appointment within
48 hours of discharge, to promote and support lactation before and after
discharge.
Conflict of interest: The author has no conflict of interest to declare.
References
1. McIntire DD, Leveno KJ: Neonatal mortality and morbidity rates in late
preterm births compared with births at term. Obstet Gynecol 2008,
111(11):35-41.
2. Gouyon JB, Vintejoux A, Sagot P: Neonatal outcome associated with
singleton birth at 34-41 weeks of gestation. Int J Epidemiol 2010,
39:769-76.
3. Kuzniewicz MW, Parker SJ, Schnake-Mahl A, Escobar GJ: Hospital
readmissions and emergency department visits in moderate preterm,
late preter, abd early term infants. Clin Perinatol 2013, 40:753-775.
4. Escobar GJ, Greene JD, Hulac P: Rehospitalization after birth
hospitalization: patterns among infants of all gestations. Arcc Dis Child
2005, 90:125-31.
5. McLaurin KK, Hall CB, Jakson EA: Persistence of morbidity and cost
differences between late-preterm and term infants during the first year
of life. Pediatrics 2009, 123:653-9.
6. Martens PJ, Derksen S, Gupta S: Predictors of hospital readmission of
Manitoba newborns within six weeks postbirth discharge: a populationbased study. Pediatrics 2004, 114:708-13.
Page 15 of 28
7.
Shapiro-Mendoza CK, Tomashek KM, Kotelchuck M: Risk factors for
neonatal morbidity and mortality among “healthy”, late preterm
newborns. Semin Perinatol 2006, 30:54-60.
8. Escobar GJ, Joffe S, Gardner MN: Rehospitalization in the first two weeks after
discharge from the neonatal intensive care unit. Pediatrics 1999, 104:e2.
9. Oddie SJ, Hammal D, Richmond S: Early discharge and readmission to
hospital in the first month of life in the NorthernRegion of th UK during
1998: a case cohort study. Arch Dis Child 2005, 90:119-24.
10. Escobar GJ, Clark RH, Greene JD: Short-term outcomes of infant born at
35 and 36 weeks gestation: we need to ask more questions. Semin
Perinatol 2006, 30:28-33.
A30
Neonatal cardiovascular emergencies after hospital discharge
Nicola Pozzi*, Anna Casani, Francesco Cocca, Concetta Coletta,
Maria Gabriella De Luca, Gaetano Di Manso, Lidia Grappone,
Alessandro Scoppa, Luigi Orfeo
Neonatal Intensive Care Unit, Maternal and Child Health Department,
“G. Rummo” Hospital, via dell’Angelo 1, 82100 Benevento, Italy
Neonates with out-of-hospital cardiovascular emergencies get to Emergency
Department or Neonatal Intensive Care Unit in a state of shock, which is a
complex clinical syndrome characterized by an acute failure of the
circulatory system with inadequate tissue and organ perfusion.
It has been demonstrated that early recognition and time-sensitive
aggressive resuscitation of neonatal shock significantly reduce mortality and
improve outcomes [1].
The update algorithm for goal-directed treatment of neonatal shock
emphasizes early use of therapies directed to restore threshold heart rates,
normalize blood pressure and capillary refill ≤2 seconds and subsequent
intensive hemodynamic support aimed to goals of central venous oxygen
saturation (ScvO2) >70% and cardiac index (CI) >3.3 L/min/m2[ 2].
Rapid attainment of a vascular access is pivotal for fluid resuscitation and
inotrope therapy and an intraosseous needle must be early inserted
especially in the case of cardiac arrest or decompensated shock [3].
Rapid crystalloid boluses of 10-20 ml/kg (over 5-10 minutes) up to 60 ml/kg
in the first hour must be administered paying attention to signs of fluid
overload because overaggressive therapy can be detrimental in case of
cardiogenic shock. An echocardiographic analysis can help clinicians to
assess the inferior vena cava diameter or collapsibility as an index of preload
status [4] and to evaluate the ventricular size and contractility to identify a
cardiogenic shock [5]. Prostaglandin infusion is recommended until a ductaldependent lesion is ruled out by trained echocardiographists.
Empiric antibiotics should be administered within one hour if a sepsis is
suspected [6].
Neonates with fluid refractory shock need to start and titrate a peripheral
inotropic support and progressively to be added vasopressors according
to the hemodynamic state.
Many methods are available for the hemodynamic monitoring after the first
hour of stabilization of the neonate. A safer ultrasound-guided central
venous access can easily be obtained [7] and ScvO2 be measured. The radial
arterial pressure monitoring is recommended and the arterial waveform can
be used to derive additional hemodynamic information. The monitoring of
CI is feasible in neonates only by non-invasive methods such as doppler
echocardiography or impedance cardiography [8].
Many aspects of the intensive hemodynamic support of neonatal shock
resemble those of paediatric critical care medicine (PCCM) usually
provided by anaesthesiologists.
We believe that neonatologists need a specific PCCM training before
dealing with critically ill neonates and for this purpose our team has
devised some courses (Figure 1) to meet these particular educational and
procedural skill needs.
References
1. Han YY, Carcillo JA, Dragotta MA, Bills DM, Watson RS, Westerman ME,
Orr RA: Early reversal of pediatric-neonatal septic shock by community
physicians is associated with improved outcome. Pediatrics 2003,
112:793-799.
2. Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, Doctor A,
Davis A, Duff J, Dugas MA, Duncan A, Evans B, Feldman J, Felmet K,
Page 16 of 28
Figure 1(abstract A30) Simulation-based training of an ultrasound-guided central venous catheterization. The figure illustrates the ultrasoundguided vessel puncture technique by using phantoms. The trainee visualizes the simulated vessel in transverse scans (short axis) and advances the needle
tip (red circle) towards the vessel (green square bracket) during the procedure.
3.
4.
5.
6.
7.
Fisher G, Frankel L, Jeffries H, Greenwald B, Gutierrez J, Hall M, Han YY,
Hanson J, Hazelzet J, Hernan L, Kiff J, Kissoon N, Kon A, Irazuzta J, Lin J,
Lorts A, Mariscalco M, Mehta R, Nadel S, Nguyen T, Nicholson C, Peters M,
Okhuysen-Cawley R, Poulton T, Relves M, Rodriguez A, Rozenfeld R,
Schnitzler E, Shanley T, Kache S, Skippen P, Torres A, von Dessauer B,
Weingarten J, Yeh T, Zaritsky A, Stojadinovic B, Zimmerman J, Zuckerberg A:
Clinical practice parameters for hemodynamic support of pediatric and
neonatal septic shock: 2007 update from the American College of
Critical Care Medicine. Crit Care Med 2009, 37(2):666-688.
Biarent D, Binghamb R, Eichc C, López-Herced J, Maconochiee I, RodríguezNúnezf A, Rajkag T, Zidemanh D: European resuscitation council
guidelines for resuscitation 2010 section 6. Paediatric life support.
Resuscitation 2010, 81:1364-1388.
Mertens L, Seri I, Marek J, Arlettaz R, Barker P, McNamara P, Moon-Grady AJ,
Coon PD, Noori S, Simpson J, Lai WW, Writing Group of the American
Society of Echocardiography (ASE), European Association of
Echocardiography (EAE), Association for European Pediatric Cardiologists
(AEPC): Targeted neonatal echocardiography in the neonatal intensive
care unit: practice guidelines and recommendations for training.
European Journal of Echocardiography 2011, 12:715-736.
Perera P, Mailhot T, Riley D, Mandavia D: The RUSH exam: Rapid
Ultrasound in SHock in the evaluation of the critically ill. Emerg Med Clin
North Am 2010, 28(1):29-56.
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE,
Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR,
Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR,
Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R, Surviving Sepsis
Campaign Guidelines Committee including the Pediatric Subgroup: Surviving
sepsis campaign: international guidelines for management of severe sepsis
and septic shock: 2012. Crit Care Med 2013, 41(2):580-637.
Troianos CA, Hartman GS, Glas KE, Skubas NJ, Eberhardt RT, Walker JD, Reeves ST,
Councils on Intraoperative Echocardiography and Vascular Ultrasound of the
8.
American Society of Echocardiography: Guidelines for performing ultrasound
guided vascular cannulation: recommendations of the American Society of
Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am
Soc Echocardiogr 2011, 24(12):1291-318.
Soleymani S, Borzage M, Noori S, Seri I: Neonatal hemodynamics:
monitoring, data acquisition and analysis. Expert Rev Med Devices 2012,
9(5):501-11.
A31
Immunity and nutrition: from research to clinical practice
Francesco Tandoi*, Francesco Pellegrini, Massimo Agosti
Neonatology & NICU Department, “F. Del Ponte” Hospital, 21100 Varese, Italy
Human immune system is a complex and efficient defence system,
consisting of an integrated set of cells and chemical mediators, which
protects from external insults (chemical, traumatic or infectious), in addition
to a series of defensive “modular” responses to protect and modulate
immune response inside our body.
It is extremely difficult to determine what might be the influence of diet on
this system. This is true not only for adults, but can be extended also to
every phase of life.
To express the correlation between nutrition and immunity in the early
stages of an individual’s life it is absolutely essential the knowledge of both
subjects, immunity and nutrition, to justify any intervention carried out in
this early stage of development. It assumes even a greater value if we talk
about newborn infants –preterms especially- maximum expression of an
immature system, conditioned in all its forms by any external intervention.
Theoretically, the limited opportunities in neonatal nutrition (breast milk
or formula) make easier to report specific nutritional effects on any of its
functions although in reality it is much more complex.
In newborn a nutritional “programming” can already be affected by prenatal
interferences. In order to characterize the correlation between nutritional
interventions and development of immunity some interesting clinical trials
in developing countries are in progress (eg, ENID: Early Nutrition and
Immune Development, The Gambia); this study wants to investigate if some
interventions, conducted in pregnant woman and in the early stages of
childhood, can modify parameters such as anthropometry at birth and
during the first months of life, morbidity, thymus dimension and some
biochemical immune responses [1].
About newborn infants, other defence mechanism must be considered: 1) the
system of maternal IgG antibodies that fetus receives, via the placenta; 2) the
system of breast-milk proteins: secretory IgA antibodies which bind
the microbes on the infant’s mucosal membranes; lactoferrin which destroy
microbes and reduce inflammatory responses, non-absorbed milk
oligosaccharides which block attachment of microbes to the infant’s
mucosae; other numerous additional proteins in the milk as the anti-secretory
factor, which is anti-inflammatory, preventing diarrhoea in infants; 4) the
system of micronutrients as zinc, vitamin A, B, C, iron and cytokines [2,3].
In any case breastfeeding and a good nutritional status are essential to give
a functionally correct amount of these nutrients. Even the development of
adapted formulas is directed to clarify functional actions of nutrients,
including the improvement of immune response [4].
References
1. Moore SE, Fulford AJC, Darboe MK, Jobarteh ML, Jarjou L, Prentice AM: A
randomized trial to investigate the effects of pre-natal and infant
nutritional supplementation on infant immune development in rural
Gambia: the ENID trial: Early Nutrition and Immune Development. BMC
Pregnancy and Childbirth 2012, 12:107.
2. Moore SE, Collinson AC, Tamba N’gom P, Aspinall R, Prentice AM: Early
immunological development and mortality from infectious disease in
later life. Proc Nutr Soc 2006, 65(3):311-318.
3. Haider BA, Bhutta ZA: Multiple-micronutrient supplementation for
women during pregnancy. Cochrane Database Syst Rev 2006, 4:CD004905.
4. Kramer MS, Kakuma R: Energy and protein intake in pregnancy. Cochrane
Database Syst Rev 2003, 4:CD000032.
A32
Probiotics for prevention of necrotizing enterocolitis: a systematic
review of current evidences
Mario De Curtis1*, Lucia Dito1, Francesca Conte1, Gianluca Terrin2
1
Department of Pediatrics and Neuropsychiatry, University of Rome La
Sapienza, Italy; 2Department of Gynecology-Obstetrics and Perinatal
Medicine, University of Rome La Sapienza, Italy
Background: The use of probiotics has been proposed to reduce the
incidence of necrotizing enterocolitis (NEC) in preterm neonates.
Aims: To systematically review the evidences regarding the use of
probiotics in preterm neonates to prevent NEC.
Methods: We revised studies with high level of evidence (randomized
clinical trials and meta-analysis). Database: MEDLINE and Pubmed. Search
term: Probiotic (AND) Very Low Birth Weight (AND) necrotizing enterocolitis.
Limits: Randomized clinical trial (AND) Meta-analysis.
Results: We analyzed 20 manuscripts (13 Randomized clinical trial and
7 Meta-analysis) that were published from 2005 to 2014 and that analyze
3025 neonates. Analysis of the best evidences revealed that probiotics
may have beneficial effects in the prevention of NEC, however current
studies have failed to control for numerous confounding variables such
as breast feeding rates, antibiotic exposure, feeding practices, and
environmental cross-contamination. The incidence of NEC (stage > 2) was
significantly lowered only in infants weighing 1001 to 1500 g. Thus, there
is not enough evidence to support the efficacy of probiotics in extremely
low birth-weight infants, and future well-designed studies are needed.
Trials performed at institutions with high NEC rates have observed
significant benefit from probiotics, while those institutions with low NEC
rates have shown limited effects. Multistrain probiotics may be more
effective than single-strain products. Currently, data from about 3000
neonates indicates that significant adverse effects of probiotics are rare.
Conclusions: Probiotics appear to be effective in preventing NEC only in
specific setting. Although reports of probiotic-related sepsis are limited,
Page 17 of 28
caution should be used when considering probiotic supplementation in
infants at greatest risk for an impaired mucosal barrier. Policies regarding
storage, preparation, distribution, administration and documentation of
probiotics to ensure patient safety should be adopted.
A33
Control of breathing
Corrado Moretti*, Stefano Luciani, Rosanna Grossi, Caterina S Barbàra,
Paola Papoff
Department of Paediatrics, Paediatric Emergency and Intensive Care,
Sapienza University of Rome, Rome, Italy
Late preterm infants have been called “great imposters” [1] because they
often appear to be and are therefore treated as term infants, however their
brainstem development and neural control of respiration are less mature
than in full-term infants. During late gestation there are dramatic
developmental changes in the brainstem and forebrain: at 34 gestational
weeks the total brain weight is 65% of that at term [2]. The control of lung
volume, laryngeal reflexes, upper airways, chemoreceptor activity,
coordination of sucking, swallowing, breathing, the incidence of apnea and
periodic breathing and the control of heart rate are still developing during
late gestation and the degree of maturity of these mechanisms appears to lie
on a continuum that extends from more immature infants to after term. Also,
these reflexes are influenced by sleep-wake states whose neurobiological
development is still evolving. The brainstem is not completely mature even
at term, as confirmed by the fact that its myelination, the marker of
completed neuronal/axonal maturation, is still incomplete at that time. This
protracted maturation is not surprising, considering that the neurodevelopment of the respiratory control and sleep-wake cycle continues into
infancy. The few data on control of breathing in late preterm infants indicate
that ventilatory responses to CO2 and hypoxia as well as autonomic control
of heart rate are not yet mature at 36 weeks PMA. Clinically, late preterm
infants have more apnea and periodic breathing than term infants and
immature coordination of sucking, swallowing and breathing often delay
their ability to feed without episodes of bradycardia, desaturation and
even apnea [3]. The incidence of apparent life-threatening events is more
common in preterm infants (8-10%) than full-term infants (1% or less). In
the Collaborative Home Infant Monitoring Evaluation studies the
frequency of conventional and extreme (clinically relevant) events in near
term infants is intermediate between preterm infants <34 weeks at birth
and full-term infants [4].
Clinical data indicate that late preterm are also predisposed to wheezing
in infancy and early childhood although not exposed to excessive
supplemental oxygen or ventilator support [5]. Exposure to 21% oxygen
could represent premature exposure to hyperoxic environment compared
to that in utero, with long-term effects on the still immature conducting
airways. Recent data demonstrate that immature human airway smooth
muscle are highly sensitive to even short durations of hyperoxia, with
increased proliferation at moderate levels of oxygen (< 60%) but
apoptosis at higher levels [6].
References
1. Buss FM: The great imposter. Adv Neonatal Care 2005, 5:233-236.
2. Darnall RA, Ariagno RL, Kinney HC: The late preterm infant and the
control of breathing, sleep, and brainstem development: a review. Clin
Perinatol 2006, 33:883-914.
3. Hunt CE: Ontogeny of Autonomic Regulation in Late Preterm Infants
Born at 34-37 Weeks Postmenstrual Age. Semin Perinatol 2006, 30:73-76.
4. Ramanathan R, Corwin MJ, Hunt CE, Lister G, Tinsley LR, Baird T, Silvestri JM,
Crowell DH, Hufford D, Martin RJ, Neuman MR, Weese-Mayer DE,
Cupples LA, Peucker M, Willinger M, Keens TG: Cardiorespiratory events
recorded on home monitors: comparison of healthy infants with those
at increased risk for SIDS. JAMA 2001, 17:2199-2207.
5. Goyal NK, Fiks AG, Lorch SA: Association of late-preterm birth with asthma in
young children: practice-based study. Pediatrics 2011, 128:e830-8.
6. Hartman WR, Smelter DF, Sathish V, Karass M, Kim S, Aravamudan B,
Thompson MA, Amrani Y, Pandya HC, Martin RJ, Prakash YS, Pabelick CM:
Oxygen dose-responsiveness of human fetal airway smooth muscle
cells. Am J Physiol Lung Cell Mol Physiol 2012, 303:L711-L719.
Page 18 of 28
A34
Acute respiratory morbidity in late preterm infants
Simonetta Picone*, Roberto Aufieri, Piermichele Paolillo
Division of Neonatology and Neonatal Intensive Care, Department of
Maternal and Child Health, Casilino General Hospital, Roma, Italy
Background: Late preterm (LP) infants [gestational age (GA): 34-36 weeks]
are at increased risk of neonatal acute respiratory morbidity compared with
term infants (GA: 37- 41)[1,2]. The observed rate of acute respiratory
morbidity, in a population of about 20,000 LP infants, was 10-12% vs 1.4%
of term infants [1]. Transient tachypnea of the newborn (TTN) and
respiratory distress syndrome (RDS) are the most common diagnosis, with
RDS rate reaching 10.5% in infants born at 34 weeks of GA [1,2]. Major
causes of respiratory morbidity in LP are: prematurity and birth by Cesarean
Section (CS) [1,3].
Material and methods: We retrospectively studied 830 LP and moderate
preterm (MP) infants (GA: 33-36 weeks) admitted to our unit from June 2009
to December 2013. Infants were classified according to GA: 33 weeks
(n=129), 34 weeks (n=176), 35 weeks (n=225), 36 weeks (n=300). Clinical
charts for each patient were reviewed and main diagnosis recorded.
Results: Twenty-six percent of LP/MP infants (214/830) had an acute
respiratory disorder. The most frequent diagnosis were: TTN (n=75; 9.0%);
respiratory failure (RF) (n=65; 7.8%) and RDS (n=62; 7.5%); pneumothorax /
pneumomediastinum (n=16; 1.9%); pneumonia (n=13; 1.6%); apnea of
prematurity (n=5; 0.6%); persistent pulmonary hypertension (n=2; 0.2%). All
the 62 infants with RDS were intubated, required mechanical ventilation
(1-4 days) and surfactant administration (1-4 doses). The forty-three
percent of infants with RDS also had a concomitant diagnosis of infections.
The infection rate in infants with RDS was significantly higher than that in
other respiratory morbidities (p<0.05). Complete results are reported in
Table 1. Of the 62 cases of RDS reported: 60 resolved and 2 deceased (one
patient with necrotizing enterocolitis, one patient with disseminated
intravascular coagulation).
Conclusions: Acute respiratory morbidity in our unit affects a quarter of LP/
MP infants. An important percentage (7.5%) is represented by RDS, that is
often associated with infection. Infants born at 34 weeks of GA are the
population at higher risk of RDS. Even if rate and severity of acute respiratory
morbidity in LP are already described by a number of epidemiological
studies, further investigation is needed to better clarify the optimal timing
and dose of surfactant administration and to correlate different strategies of
respiratory management with long-term respiratory and neurological
outcomes. The high infection rate found among infants with RDS and acute
respiratory morbidity, emphasizes the importance of a prompt diagnosis and
treatment of chorioamnionitis and perinatal infections.
References
1. Hibbard JU, Wilkins I, Sun L, Consortium of Safe Labor: Respiratory
morbidity in late preterm births. JAMA 2010, 304:419-425.
2. Ashley Darcy M, Lucky J: Respiratory disorders in moderately preterm,
late preterm and early term infants. Clin Perinatol 2013, 40:665-678.
3. Natile M, Ventura ML, Colombo M, Bernasconi D, Locatelli A, Plevani C,
Valsecchi MG, Tagliabue P: Short-term respiratory outcomes in late
preterm infants. Ital J Pediatr 2014, 40:52.
A35
The prevention of respiratory syncytial virus infection
L Bollani*, M Pozzi
Pavia, Italy
Respiratory syncytial virus (RSV) is the most significant cause of acute
respiratory tract infections in infants and young children worldwide. RSV
accounts for approximately 70% of hospitalizations for bronchiolitis and
40% of pneumonia among infants <1 year of life.
RSV infection seems to be associated with recurrent wheezing during the
first decade of life and impaired respiratory health-related quality of life
in adults [1].
Universal prevention of RSV infection is based on environmental
prophylaxis aimed at minimizing the spread of the virus good hand
hygiene in the home, and limiting direct contact of high-risk children
with other children and adults with respiratory tract infections.
Exposure to tobacco smoke should be avoid in family with infants,
breastfeeding should be encouraged.Pharmacological prophylaxis is
based on the administration of palivizumab (Synagis®, MedImmune)
during the epidemic period to the children at risk [2].
Palivizumab is a humanized monoclonal antibody directed to an epitope in
the A antigenic site of F protein of RSV. It is designed to provide passive
immunity against RSV and thereby prevent or reduce the severity of RSV
infection [2].
The aim of this work is to provide Italian neonatologists shared
recommendations regarding palivizumab use in premature and other at-risk
infants in the light of new emerging evidence.
The peak incidence of severe RSV disease occurs between 2 and 3 months
of age. The risk of serious RSV illness is highest among preterm neonates,
children with chronic lung disease, congenital heart disease [3,4].
Table 1(abstract A34) Acute respiratory morbidity in LP/MP infants (n= 830)
GAa
(weeks)
33
34
35
36
TOT
129
176
225
300
830
Respiratory morbidity
60 (46.5)
53 (30.1)
42 (18.7)
59 (19.7)
214 (25.8)
TTNb n (%)
RFc n (%)
14 (10.9)
31(24.0)
15 (8.5)
14 (8.0)
16 (7.1)
12 (5.3)
30 (10.0)
8 (2.7)
75 (9.0)
65 (7.8)
RDSd n (%)
12 (9.3)
24 (13.6)
12 (5.3)
14 (4.7)
62 (7.5)
PNXe n (%)
1 (0.8)
-
8 (3.5)
7 (2.3)
16 (1.9)
Pneumonia n (%)
1 (0.8)
3 (1.7)
1 (0.4)
8 (2.7)
13 (1.6)
AOPf n (%)
3 (2.3)
-
-
2 (0.7)
5 (0.6)
PPHg n (%)
-
1 (0.6)
1 (0.4)
-
2 (0.2)
MASh n (%)
-
-
-
-
-
Infection in infants with RDS n (%)
3 (25.0)
9 (37.5)
6 (50.0)
9* (64.3)
27* (43.5)
Infection in infants with other respiratory morbidity n (%)
8 (16.7)
10 (34.5)
11 (39.7)
14* (31.1)
43* (28.3)
n
* p<0.05
a gestational age. b transient tachypnea of newborn. c respiratory failure. d respiratory distress syndrome. e pneumothorax / pneumomediastinum. f apnea of
prematurity. g persistent pulmonary hypertension. h meconium aspiration syndrome.
The children with the above mentioned clinical conditions, particularly in
cases of hospitalization, are more likely to require admission to an
intensive care unit and need mechanical ventilation. In addition they have
high rates of re-hospitalization for lower respiratory tract infections [5,6].
Therefore, all these categories of infants are likely to benefit from
prophylaxis, and have been included in the recommendations. Specific
recommendations are provided according to gestational age at birth.
RSV infections occur most frequently during the period between
October-March.
According to this observation, prophylaxis with Palivizumab is indicated in
this 5-6 months long seasonal window of RSV infection.
The duration of prophylaxis (up to one year or up to two years of life during
the seasonal period) depends on the underlying condition.
Palivizumab is clinically effective; however, the cost is very high. In our
opinion strict criteria for patient selection and reduced drug costs would
improve the cost-effectiveness of the prophylaxis [7].
References
1. Backman K, Piippo-Savolainen E, Ollikainen H, Koskela H, Korppi M:
Increased asthma risk and impaired quality of life after bronchiolitis or
pneumonia in infancy. Pediatr Pulmonol 2014, 49:318-25.
2. The IMpact-RSV Study Group: Palivizumab, a humanized respiratory
syncytial virus monoclonal antibody, reduces hospitalization from
respiratory syncytial virus infection in high-risk infants. Pediatrics 1998,
102(3 Pt 1):531-7.
3. Committee on Infectious Diseases from the Academy of Pediatrics: policy
statement: Modified Recommendations for use of Palivizumab for
prevention of respiratory syncytial virus infections. Pediatrics American
Academy of Pediatrics 2009, 124(6):1694-1701.
4. Feltes TF, Cabalka AK, Meissner HC, Piazza FM, Carlin DA, Top FH Jr, Cardiac
Study Group, et al: Palivizumab prophylaxis reduces hospitalization due
to respiratory syncytial virus in congenital heart disease. J Pediatr 2003,
143:532-40.
5. Hall CB, Geoffrey A Weinberg, Aaron K Blumkin, et al: Respiratory syncytial
virus associated hospitalization among children less than 24 months of
age. Pediatrics 2013, 132:341-348.
6. Committee on Infectious Diseases and Bronchiolitis Guidelines Committee:
Updated guidance for palivizumab prophylaxis among infants and
young children at increased risk of hospitalization for respiratory
syncytial virus infection. Pediatrics 2014, 134:415-420.
7. Anabaka T, Nickerson JW, Rojas-Reyes MX, Rueda JD, Bacic Vrca V, Barsic B:
Monoclonal antibody for reducing the risk of respiratory syncytial virus
infection in children. Cochrane Database Syst Rev 2013, 4:CD006602.
A36
Management of breastefeeding for late preterm infants
Elisa Civardi1*, Francesca Garofoli2, Margherita Pozzi1, Mauro Stronati1,2
1
Pavia, Italy; 2Neonatal Immunology Laboratory, Fondazione IRCCS Policlinico
San Matteo, Pavia, Italy
Breast milk is the preferred feeding for all infants. Unfortunately, late
preterm infants (LPIs) have a lower rate of feeding at-breast and lower
expressed breast milk intake than other infants [1]. In fact, literature
documents an increased risk of morbidity and even mortality of LPIs, often
related to feeding problems, possibly due to an inadequate support of the
breastfeeding [2].
Born with low energy stores and high energy demands, LPIs may be
sleepier and have more difficulty with latch, suck, and swallow. They are
at risk for hypothermia, hypoglycemia, excessive weight loss, dehydration,
failure to thrive, kernicterus, and breastfeeding failure.
Establishing breastfeeding in LPIs is problematic, due to neonatal
physiological, neurological immaturity and due to maternal risk factors
leading to delayed lactogenesis II. Mothers may be obese, experienced a
cesarean delivery, have pregnancy induced hypertension, diabetes, or been
treated for preterm labor. They easily experience anxiety about milk
insufficiency and about separation from their babies for medical problems.
Sanitary staff has to encourage the immediate and extended skin-to-skin
contact to improve postpartum stabilization of heart rate, respiratory
effort, temperature control, metabolic stability, and early breastfeeding,
Page 19 of 28
possibly within 1 hour after birth. If the infant is healthy, it’s important to
allow rooming in and free access to the breast.
It may be necessary to wake the baby up if he/she does not indicate hunger
cues, which is not unusual in LPIs. The infant should be breastfed (even with
expressed milk) 8 to 12 times/day. It is important observing the baby
feeding at breast and showing the mother techniques to facilitate effective
latch and adequate support of the neonate’s head. A nipple shield could be
recommended. Pre- post-feeding weight may be helpful to assess milk
transfer, because a supplementation with small quantities of maternal
expressed milk, donor human milk, or formula may be necessary. If
supplementing, the mother should pump milk after breastfeeding, 6 to 8
times/day to establish and maintain milk supply [3].
LPIs developing complications are often discharged early, after successful
transition to extra-uterine environment, but before lactogenesis II is fully
established. Before discharge, adequate milk intake should be documented
by feeding volume or by thriving. One/2 days after discharge, a follow up to
check weight, feeding ability and jaundice is recommended.
In conclusion we may say that breastfeeding LPIs is possible, but to
achieve this target, an adequate maternal support and a regular neonatal
monitoring is required [4].
Competing interests: The authors declare that they have no competing
interests.
References
1. Machado Júnior LC, Passini Júnior R, Rodrigues Machado Rosa I: Late
prematurity: a systematic review. J Pediatr (Rio J) 2014, 90:221-231.
2. Radtke JV: The paradox of breastfeeding-associated morbidity among
late preterm infants. J Obstet Gynecol Neonatal Nurs 2011, 40:9-24.
3. Meier P, Patel AL, Wright K, Engstrom JL: Management of breastfeeding
during and after the maternity hospitalization for late preterm infants.
Clin Perinatol 2013, 40:689-705.
4. Academy of Breastfeeding Medicine: ABM clinical protocol #10:
breastfeeding the late preterm infant (34(0/7) to 36(6/7) weeks
gestation) (first revision June 2011). Breastfeed Med 2011, 6:151-156.
A37
Formula feeding for late-preterm infants
Luigi Corvaglia*, Arianna Aceti
Neonatology and Neonatal Intensive Care Unit S.Orsola-Malpighi Hospital,
Department of Medical and Surgical Sciences (DIMEC), University of Bologna,
Italy
Preterm birth interrupts physiological foetal development, leading to
various degrees of immaturity according to the gestational age at which
the infant is born [1].
Since 2005, the imprecise definition of “near-term” infants has been replaced
with “late-preterm”, which includes infants born between 340/7 and 366/7
weeks of gestation [2]. Late-preterm infants are at higher risk than term
infants of developing medical complications that result in higher rates of
mortality and morbidity [3], including thermal instability, respiratory
problems, hypoglycaemia, jaundice, and feeding problems.
Breastfeeding is the first nutritional choice for all infants, especially for those
born preterm. The establishment of successful breastfeeding in late-preterm
infants is usually problematic, as late-preterm infants can be sleepier, have
less muscular strength and more difficulty with latch, suck and swallow than
term infants [4]. For this reason, health-care providers should implement
specific strategies aimed at anticipate, identify promptly, and manage
breastfeeding problems that the late-preterm infant and mother can
experience.
However, when exclusive breastfeeding does not guarantee adequate
nutrition, supplements might be advisable. Nutritional requirements of latepreterm infants are currently derived from speculations on foetal growth and
requirements of preterm and term infants, while specific data on nutritional
needs of this population are scarce. There is currently no consensus on
whether late-preterm infants would benefit most of a high-protein diet, such
as that proposed for “micropreterm” infants [5], or of a low-protein diet, such
as that recommended for full-term infants. Some studies suggest that the
provision of extra protein and energy could reduce weight loss and increase
growth velocity [6], thus decreasing the risk for dehydration and hospital
readmission. However, it is important to note that growth rate during late
gestation decreases dramatically, and it is likely that protein and energy
Page 20 of 28
requirements for infants born during this period wouldn’t be as high as those
of very preterm infants [7].
Current guidelines recommend the supplementation with essential
nutrients also for late-preterm infants. Actually, it has been shown that
supplementation with LC-PUFAs improves visual acuity and cognitive
development in infants 30-37 weeks gestation [8].
The best nutritional approach to late-preterm infants still needs to be
determined. Human milk’s benefits are undoubted; however, caregivers
have to adequately support the establishment of successful breastfeeding
and also identify those cases where some supplementation is needed.
Further studies will have to clarify whether all late-preterm infants, or
only a subgroup such as small-for-gestational-age infants, could benefit
from formulas with high energy and protein content.
References
1. Raju TNK: Developmental physiology of late and moderate prematurity.
Semin Fetal Neonatal Med 2012, 17:126-31.
2. Raju TNK, Higgins RD, Stark AR, Leveno KJ: Optimizing care and outcome
for late-preterm (near-term) infants: a summary of the workshop
sponsored by the National Institute of Child Health and Human
Development. Pediatrics 2006, 118:1207-14.
3. Engle Wa, Tomashek KM, Wallman C: “Late-preterm” infants: a population
at risk. Pediatrics 2007, 120:1390-401.
4. The Academy of Breastfeeding Medicine: ABM clinical protocol #10:
breastfeeding the late preterm infant (34(0/7) to 36(6/7) weeks
gestation) (first revision June 2011). Breastfeed Med 2011, 6:151-6.
5. Tudehope D, Fewtrell M, Kashyap S, Udaeta E: Nutritional needs of the
micropreterm infant. J Pediatr 2013, 162(3 Suppl):S72-80.
6. Blackwell MT, Eichenwald EC, McAlmon K, Petit K, Linton PT,
McCormick MC, Richardson DK: Interneonatal intensive care unit variation
in growth rates and feeding practices in healthy moderately premature
infants. J Perinatol 2005, 25:478-85.
7. Lapillonne A, O’Connor DL, Wang D, Rigo J: Nutritional recommendations
for the late-preterm infant and the preterm infant after hospital
discharge. J Pediatr 2013, 162(3 Suppl):S90-100.
8. Fang P, Kuo H, Huang C, Ko T, Chen C, Chung M: The effect of
supplementation of docosahexaenoic acid and arachidonic acid on
visual acuity and neurodevelopment in larger preterm infants. Chang
Gung Med J 2005, 28:708-715.
A38
Developmental haemostasis in moderate and late preterm infants
Mario Motta*, Fabio Giovanni Russo
Neonatology and Neonatal Intensive Care Unit, Children’s Hospital of Brescia, Italy
Introduction: The term “developmental haemostasis” was first coined by
Maureen Andrews to describe the age-related physiological changes of the
coagulation system during childhood.[1] Given the age-dependent
specificity of haemostasis, the evaluation and the interpretation of
coagulation assays in newborns may present diagnostic difficulties and
appropriate reference ranges for the diagnosis and management of
coagulopathies in moderate and late preterm infants are needed.
Age-related changes in the coagulation plasma proteins: The
haemostatic system is a dynamic evolving process that is age-dependent.
At birth, plasma concentrations of vitamin K-dependent and contact factors
(F) are decreased if compared with adult levels [2]. During the first 6
months of life, they gradually increase to values approaching adult levels.
[2] These changes in protein levels lead to corresponding changes in
global tests of coagulation such as the Prothrombine Time and the
Activated Partial Thromboplastin Time. Plasma concentrations of fibrinogen,
FV, FVIII, FXIII and von Willebrand are not decreased at birth [2]. In
addition, plasma concentrations of antithrombin, protein C and protein S
are low at birth, and they reach adult levels at about 6-12 months of life.
[2] In the fibrinolytic system, plasma concentrations of plasminogen are
decreased at birth, whereas tissue plasminogen activator and plasminogen
activator inhibitor are increased [2]. These postnatal changes in the
coagulation system, observed both in term and preterm neonates, are
functionally balanced, suggesting a normal haemostasis during early
infancy in healthy conditions.
Reference ranges of coagulation tests in moderate and late preterm
infants: Considering the developmental changes of coagulation proteins in
term and preterm neonates, specific age-related reference ranges are
necessary for an accurate diagnosis and management of neonatal
coagulation disorders. In table 1 reference ranges for coagulation assays
obtained in moderate and late preterm neonates are summarized [3]. Since
coagulation assays are analyzer and reagent dependent, laboratories should
develop specific reference ranges to their own testing systems [4].
New diagnostic assays: Thromboelastography and the measurement
of thrombin generation are methods that provide a global assessment of
hemostasis. Recently, the use of these assays has been reported in neonates
and the results suggest that these methods may offer advantages for the
evaluation of developmental hemostasis. Thrombo-elastography, in
particular, may be less sensitive to age-related changes of coagulation
protein.[5,6] However, the introduction of these methods into clinical
practice of neonatal medicine should be based on larger studies confirming
the predictive value of the assays.
References
1. Andrew M: The relevance of developmental hemostasis to hemorrhagic
disorders of newborns. Semin Perinatol 1997, 21:70-85.
2. Monagle P, Massicotte P: Developmental haemostasis: secondary
haemostasis. Semin Fetal Neonatal Med 2011, 16:294-300.
3. Andrew M, Paes B, Milner R, Johnston M, Mitchell L, Tollefsen DM, Castle V,
Powers P: Development of the human coagulation system in the healthy
premature infant. Blood 1988, 72:1651-7.
4. Monagle P, Ignjatovic V, Savoia H: Hemostasis in neonates and children:
pitfalls and dilemmas. Blood Rev 2010, 24:63-8.
5. Edwards RM, Naik-Mathuria BJ, Gay AN, Olutoye OO, Teruya J: Parameters of
thromboelastography in healthy newborns. Am J Clin Pathol 2008, 130:99-102.
6. Tripodi A, Ramenghi LA, Chantarangkul V, De Carli A, Clerici M, Groppo M,
Mosca F, Mannucci PM: Normal thrombin generation in neonates in spite
of prolonged conventional coagulation tests. Haematologica 2008,
93:1256-9.
Table 1(abstract A38) Reference values for coagulation tests in healthy moderate and late preterm neonates (30 to
36 weeks of gestation) during the first 6 months of life
Postnatal Age
PT (s)
APTT (s)
Fibrinogen (g/L)
AT-III (U/mL)
Protein C (U/mL)
Protein S (U/mL)
Day 1
13.0
(10.6-16.2)
53.6
(27.5-79.4)
2.43
(1.50-3.73)
0.38
(0.14-0.62)
0.28
(0.12-0.44)
0.26
(0.14-0.38)
Day 5
12.5
(10.0-15.3)
50.5
(29.6-74.1)
2.80
(1.60-4.18)
0.56
(0.30-0.82)
0.31
(0.11-0.51)
0.37
(0.13-0.61)
Day 30
11.8
(10.0-13.6)
44.7
(26.9-62.5)
2.54
(1.50-4.14)
0.59
(0.37-0.81)
0.37
(0.15-0.59)
0.56
(0.22-0.90)
Day 90
12.3
(10.0-14.6)
39.5
(28.3-50.7)
2.46
(1.50-3.52)
0.83
(0.45-1.21)
0.45
(0.23-0.67)
0.76
(0.40-1.12)
Day 180
12.5
(10.0-15.0)
37.5
(21.7-53.3)
2.28
(1.50-3.60)
0.90
(0.52-1.28)
0.57
(0.31-0.83)
0.82
(0.44-1.20)
All values are given as a mean followed by lower and upper limit (95% of confidence interval). From Andrew M at al., modified [3].
A39
Iron and late preterm
Rita Luciano
Neonatology Unit, Gemelli University Hospital, 00169 Rome, Italy
Iron is essential for the Central Nervous System development, i.e. mielinization
process and cellular differentiation as well as correct functioning of
neurotransmitters [1]. Preterm infants show an increased risk of iron
deficiency (ID) since 80% of the iron storage at birth is accumulated during
the third trimester of pregnancy. Rapid child growth and elevated red cell
turn over in the neonatal period may exaust iron storage after two months of
age [2]. ID risk is greater in the breast-fed babies, since maternal milk does
not contain an amount of iron sufficient to demands. However, ID prevalence
equal to 14%, between the fourth and the eighth month of age [3], is also
reported in the preterm infants who are nourished with milk formulas
enriched with iron. Referred long-lasting effects of ID in infancy include
reduced cognitive functions, motor performances and social-emotional
development, as well as persisting neurophysiologic abnormalities [1]. As a
consequence early iron supplementation is recommended for preterm and
very-low-birth-weight infants [3]. Healthy late-preterm infants are often
treated with the same modalities than term neonates. For these infants we
lack strong evidence based recommendations about supplementation of iron,
doses, time of beginning as well as duration of treatment. The RCT evidence
to date does not suggest a definite threshold of birth-weight or gestational
age at which iron supplementation becomes beneficial. Two methodologically sound trials suggest a benefit even for marginally low-birth-weight
infants, whether term or preterm [4]. As recently reported, marginally lowbirth-weight neonates showed a high prevalence of ID and Iron Deficiency
Anemia (IDA) when evaluated at the age of six months, especially in the case
of exclusive breast feeding to age six weeks [5]. Martial supplementation
lowered ID and IDA prevalence without adverse effects. In conclusion, despite
the amount of studies concerning ID in infancy, there is still a paucity of
evidence about the effects of iron deficiency/overload with respect to growth
, morbidity and neurodevelopmental outcomes in the different categories of
neonates ,as well as about the reliability of the presently available iron
methabolism markers.
References
1. Lozoff B, Georgieff MK: Iron Deficiency and Brain Development. Semin
Pediatr Neurol 2006, 3:158-65.
2. Iannotti LL, Tielsch JM, Black MM, Black RE: Iron supplementation in early
childhood: health benefits and risks. Am J Clin Nutr 2006, 84:1261-76.
3. Baker RD, Greer FR, Committee on Nutrition American Academy of
Pediatrics: Diagnosis and prevention of iron deficiency and irondeficiency anemia in infants and young children (0-3 years of age).
Pediatrics 2010, 126:1040-50.
4. Mills RJ, Davies MW: Enteral iron supplementation in preterm and low
birth weight infants. Cochrane Database Syst Rev 2012, 3:CD005095.
5. Berglund S, Westrup B, Domellöf M: Iron supplements reduce the risk of
iron deficiency anemia in marginally low birth weight infants. Pediatrics
2010, 126:874-83.
A40
Immune development in late preterm neonates
Gaetano Chirico
Neonatology and Neonatal Intensive Care Unit, Children Hospital, Spedali
Civili, Brescia, Italy
Several recent studies have underlined that late preterm infants have a
significantly increased risk of infection and sepsis, [1-3] mainly related to
problems of adaptation from intra- to extra-uterine life of the immune
defense mechanisms. Indeed, both the innate (natural, non specific) and the
adaptive (acquired, specific) immune systems are incompletely developed at
birth, the more preterm the neonate, the more severe and prolonged the
immunodeficiency [4,5].
T lymphocytes response to mitogens is poor, and T and B lymphocytes are
immature: higher percentage of CD4+ T lymphocytes and lower of CD8+
Page 21 of 28
cells, with a gradual decline with age of the CD4 + /CD8 + ratio, and
predominant naïve phenotype with elevated percentages of CD4+/CD45RA+
T cells; in addition, cytokine production is reduced and Th1-like response
inadequate. The immaturity of lymphocytes and of antigen presenting cells
are responsible for the marked deficiency of antibody production; also,
levels of IgG are low in late preterm infants because transplacental passage
from the mother mostly occurs during the last trimester of gestation;
therefore, these neonates may lack the protection ensured by maternal
derived pathogen-specific IgG. The inability to produce adequate amounts
of hematopoietic growth factors, particularly G- and GM-CSF, and the
reduced neutrophil, complement and natural killer cell activity, may further
amplify the neonatal impairment of immune defenses.
The combined neonatal deficiency of immunoglobulin, complement and
neutrophil activity results in increased susceptibility to systemic infections
from encapsulated pathogens, such as Group B Streptococcus, Staphylococci
and Klebsiella, that require opsonization for efficient phagocytosis and killing.
The immaturity of pattern recognition receptors (PRR) response to pathogenassociated molecular patterns (PAMP), in particular the impaired TLR4 (Toll
Like Receptor) signaling, [1] may contribute to the late preterm vulnerability
to Gram-negative bacteria [6].
It should be noted, however, that neonatal T cells are capable to raise
type 1 and 2 immune responses upon appropriate stimulus. Neonatal
immunization does not generally lead to rapid antibody responses,
however, it may result in an efficient immunologic priming which can act
as a basis for future responses. It is therefore possible to induce early
protection by immunization at birth [7].
Finally, to mitigate detrimental consequences of immunodeficiency in late
preterm infants, it is of paramount importance to maintain the mothernewborn protective immunological link by ensuring the host of protective
components provided by human milk [8].
References
1. Picone S, Aufieri R, Paolillo P: Infection in late preterm infants. Early Hum
Dev 2014, 90(Suppl 1):S71-4.
2. Chirico G, Cortinovis S, Fonte C, Giudici G: Bacterial sepsis. J Chemother
2007, 19(Suppl 2):28-30.
3. Machado Júnior LC, Passini Júnior R, Rodrigues Machado Rosa I:
Late prematurity: a systematic review. J Pediatr (Rio J) 2014, 90:221-31.
4. Chirico G: Development of the Immune System in Neonates. J. Arab
Neonatal Forum 2005, 2:5-11.
5. Sharma AA, Jen R, Butler A, Lavoie PM: The developing human preterm
neonatal immune system: a case for more research in this area. Clin
Immunol 2012, 145:61-8.
6. Quinello C, Silveira-Lessa AL, Ceccon ME, Cianciarullo MA, Carneiro-Sampaio M,
Palmeira P: Phenotypic Differences in Leucocyte Populations among
Healthy Preterm and Full-Term Newborns. Scand J Immunol 2014, 80:57-70.
7. Sahni R, Polin RA: Physiologic underpinnings for clinical problems in
moderately preterm and late preterm infants. Clin Perinatol 2013, 40:645-63.
8. Belloni C, De Silvestri A, Tinelli C, Avanzini MA, Marconi M, Strano F,
Rondini G, Chirico G: Immunogenicity of a three-component acellular
pertussis vaccine administered at birth. Pediatrics 2003, 111:1042-5.
9. Chirico G, Marzollo R, Cortinovis S, Fonte C, Gasparoni A: Antiinfective
properties of human milk. J Nutr 2008, 138:1801S-1806S.
A41
Erythropoietin use in the newborn
Giuseppe Buonocore
Department of Molecular and Development Medicine, University of Siena,
53100 Siena, Italy
The first descriptions of blood transfusion in neonates date back to the
nineteenth century. Time is past but uncertainties still remain considerable
on optimal red blood cell (RBC) transfusion use in an era of evidence-based
medicine. The need for RBC transfusion in critically ill neonates is differently
judged among clinicians due to a lack of an agreement on measures of the
need for transfusion. However some studies have shown an association
between preterm infant morbidities, such as necrotizing enterocolitis and
significant intracranial hemorrhage, with transfusions. The erythropoietin
(EPO) use might prove clinically important. Physiologically in all newborns
there is a progressive fall in hemoglobin concentrations to the nadir at
about 8–12 weeks of life. The nadir is even lower and sooner in preterm
neonates. This anemia of prematurity is the consequence of multiple factors,
some are physiological processes as vulnerability of red cells to oxidative
damage, reduced red cell lifespan when compared to the adult, lower
erythropoietin (EPO) response to anemia than in older ages, increased
requirements due to the postnatal growth; some are non-physiological
processes as iatrogenic blood sampling, inter-current illnesses and sepsis. All
these factors are responsible for low plasma EPO concentration in preterm
newborns. This provides a rationale for the use of EPO in prophylaxis or
treatment of the anemia. EPO has been used clinically for more than
20 years and many randomized clinical trials demonstrated that EPO
successfully stimulate erythropoiesis and decrease the need of transfusion in
anemic adults and children with end-stage renal disease or cancer.
Differently in preterm newborns, the EPO treatment has demonstrated
varied success in decreasing the total number and volume of transfusions.
There are not clear evidences from high quality trials to define the absolute
requirement and benefit for neonatal RBC transfusion. A recent Cochrane
metanalysis performed by Ohlsson A. and Aher S.M. (1) to assess the
effectiveness and safety of early initiation of EPO or darbepoetin in reducing
RBC transfusions in preterm and/or low birth weight infants, concludes that
the small reductions in RBC transfusion observed after EPO treatment are of
limited clinical importance. In contrast the possibly increased risk of ROP,
does not recommend the administration of EPO. Darbepoetin requires
further study for definitive conclusions.
Reference
1. Ohlsson A, Aher SM: Early erythropoietin for preventing red blood cell
transfusion in preterm and/or low birth weight infants. Cochrane
Database Syst Rev 2014, 4.
A42
“Crack babies” : the management protocol
Fedora del Prato*, Romilda Ferraro, Concetta Pellecchia, Maria Sellitto
Neonatal Intensive Care Unit, Villa Betania Evangelical Hospital, Naples, Italy
Introduction: During the pregnancy maternal drugs use represent an
important socio medical issue for their children. In the USA, 10% of women
takes drugs during pregnancy: 1-2% use heroin, 3-4% cocaine and less than
1% cannabinoids [1]. The phenomenon is increasing and the country and
the neonatal divisions need new management protocols. In Italy children of
a mother drug addict born as late preterm are the 17- 29%. The “crack
babies” are children exposed to drugs during the pregnancy: we can already
define them drug addicts. They may show intrauterine (choking, infection,
malformations), neonatal (withdrawals symptoms, prematurity, respiratory
distress syndrome, growth restriction neonatal hyperbilirubinemia), and
postnatal complications (delay in psychomotor, deficit in language, SIDS,
learning disabilities, difficulties in concentration, instability etc)[2] .
In some countries several projects about essential care have been
elaborated and realized. In Campania people involved in this field are
pediatricians, child psychiatrists, psychologists, teachers judges, social
assistants, without a real defined cooperation.
Network: Protocol provides hospital stay of drug addict woman during the
labour to guarantee assistance and monitoring of the mother and the child
[3]. For this reason it has been created a sociology service to coordinate the
network. System facilities are: the Ser.T (services for drug addicts) to help the
mother, a territorial social office which provides to the child, the Minor’s
court, the hospital for the psychological and physiological children
development (if he was born with Newborn Abstinence Syndrome) and the
obstetrical service.
Conclusion: Our protocol has two main targets:
• Safe the health, the security and the wellness of the child even
after the discharge trough periodical check-up of follow-up (DH);
• Facilitate the development of relationship between mother and
child to reduce the necessity of Minor’s court interventions.
Only in this way it will be possible to realize a real and integrated
takeover of the mother-child entity.
References
1. Bhuvaneswar CG, Chang G, Epstein LA, Stern TA: Cocaine and Opioid Use
During Pregnancy: Prevalence and Management. Prim Care Companion J
Clin Psychiatry 2008, 10:59-65.
Page 22 of 28
2.
3.
Ladewing P, Davidson M: Contemporary Maternal-Newborn Nursing Care.
Pearson Prentice Hall New Jersey 2006.
Regione Veneto - Provaid: Progetto Veneto di Assistenza Integrata alle
Donne Tossicodipendenti con Figli, D. G. R. n. 4019/2002, a valere sul
fondo nazionale per la lotta alla droga.
A43
“A hug of cuddles”
Belvisi Rosaria
Azienda Ospedaliera L. Sacco, Milan, Italy
Venue: 1st level Nursery, LUIGI SACCO HOSPITAL MILAN, 1250 births
per year.
Late Preterm (LP) : 8%
Target: Create procedures cannot break the creation of bonding: the
process that contribute to form the bond between parents and children
necessary to reach a mutual harmony. In the LP this interactive dance where
you learn to recognize, is less rigidly determined and you have to start it
with a well-defined Care program.
Participants: Late preterm infants, parents, and professionals who are
trained with periodic refresher courses.
Project: Smooth approach with new parents that are made immediately
bring to their child.
Presentation of the structure, the incubator and equipment that monitor
the baby.
Support in the first contact between parents and child.
Kangaroo therapy at different times and different way depending on the
clinical condition of the child.
Ad hoc preparation of the room in order to involve all the senses of the
newborn.
Involvement of parents in the care of the newborn LP: postural care, nest,
wrapping, holding, hygiene care, serving meals, breast feeding, even if
the baby is in the incubator.
Course with parents, aimed to autonomy.
Planned Hospital discharge
Massage Course
Results: The impressions collected at discharge and beyond, demonstrate
how this project is hugely important, not only for children but also for the
well-being and balance of the newly couples, who often find themselves
terrified and frightened by their child premature birth and they just need to
be supported and accompanied in this path that leads to the creation of a
unique and indissoluble bond like that with their children.
A44
Clinical care issues between safety and quality of care for the late
preterm: “The Future of Nursing in Neonatology “
Graziella Costamagna
Director of Health Professions SC SITRO AO Mauriziano Turin and
component technical group National Federation of Colleges IPASVI on
‘Pediatric Nursing, Italy
Neonatology and pediatric nursing in the world and in Europe:
Professional standards of the American and Canadian companies stress the
importance of a minimum number of “experts” nurses of neonatology or
pediatrics in the reality where infants and children are assisted.
Also the document about PNAE of Education stresses how training programs
for the general nursing in many countries don’t give the necessary
preparation to nurses in this area.
The professional practice of neonatology and pediatric area in Italy:
The Pediatric Nurse in Italy is the figure that the DM 70/1997 has identified
as the one responsible of the nursing care to individuals in growth.
These are flanked by the generalist nurses with specialized annual
training.
But also the general nurse according to DM 793/1994 can assist babies
and children, as he’s generally enabled to the nursing care of individuals
of all ages.
Even the Midwife is enabled to care babies and also in delivery room.
The reflections within the professional community about the future:
The Federation IPASVI in the past 10 years has activated some strategies to
support and enhance the innovation in this area of neonatology and
pediatric care through the creation of working groups of pediatric nurses at
the national level, the spred of best care practices in this area, the guidelines
for the university training of master’s degree in the pediatric area, the
definition of competence’s profiles of nurse in neonatal area differentiated
by levels of complexity of care, a patnership with a SIN to the building of
the certification’s manual of the path birth of the group GINS/Agenas,
allowing to the pediatric’s area nurses to work on the network throughot
the country.
The neonatology’s and pediatric’s scientific associations and of
universities have allowed evidence of the specificity of this area and the
development of best practices and evidence.
The reflection on the future of the neonatology’s and pediatric’s nurses in
Italy is still open. Crucial points are the definition of uniform standards
training and operating within the national territory, the skills certification,
the paths of professional accreditation and professional skills and advanced
responsibilities.
A45
Nursing surgery in late preterm
Chiara Selmi
U.O. PEDIATRIA , USL 4 PRATO, 59100 Italy
Nursing surgery born for an organizational and strategical choise which
allowed us to create a link whit hospital and territorial children’s doctor,
going to fill the lack of assistance during the period of hospital discharge and
first visit of specialist for children’s. Our aims are essentially two: see to
peaceful back home baby and their family, insure a continuity of care,
continuing the technical educational intervention started during
hospitalization, increasing the confidence in themselves in this new role. This
anamnestic assessment carried out together with the parents enables us to
empathize with the parent to allow itself to expose their doubts and
questions. The cases to which addressed a nurse’s control are: weight loss
>10%, maternal-fetal incompatibility group, deficit of G6PDH (Glucose-6phosphate dehydrogenase), values predischarge of bilirubins in the
intermediate zone of risk such as descript of AAP guidelines, baby with
perinatal risk factors of infection, preterm infants, SGA (Small for Gestational
Age) infants, infants from families at risk (drug addiction, alcoholism, poor
socio-economic conditions, migrant families without residence permits) , red
highlights not executed due to technical problems at birth (eyelids
tightened); doubt audiological screening at birth, any other baby who, for
whatever reason, the physician who performs the discharge decides to
revalue in post discharge. Access to the surgery is by reservation CUP that
takes place directly at the discharge of the baby and is closely related to the
hospital stay and do not in any way replace the first visit to the pediatrician
to be made within 7° to 10° days after discharge.
A46
Planning of the nursing team in the management of multiple births:
from medically assisted reproduction center to neonatal intensive
care unit
Martina Cecconi*, Laura Ligi, Assunta Fabi, Luisa Pieragostini
Neonatal Intensive Care Unit, San Filippo Neri Hospital, Rome, Italy
Background: In the last twenty years the number of multiple births in Italy
growed up to around 25% due to the increase of medically assisted
reproduction. Multiple birth usually occurs between the 34th and the 37th week
of gestational age, that coincides with the “Late-Preterm” newborns. For theirs
peculiarities, late-preterm newborns require more assistance and care [1-3].
Aim: In this study we tried to leave procedures based largely on tradition
and “commonsense”, burdened by wide variability of pediatric team. We
tried to organize a shared and standardized procedural planning,
according to the evidence-based practices criteria and the operative
context, improving the safety level of the newborns and team.
Page 23 of 28
The collaboration between different professionals, from obstetric to
neonatal care area, is necessary in order to ensure an interdisciplinary
and highly specialized standard of care.
Materials and methods: After approbation of the Hospital Committee
we planned a scheduled care process that provides:
a) Early stage of training: acquisition of care pathways encoded for every
professional involved, including participation in training specialized
courses and simulation cases;
b) The establishment of a multidisciplinary study group that defines the
indicators and the standard of result to be achieved, including the emotional
and psychological aspect of the new mother and the identification of the
role of the various members of the team;
c) Strict planning and management of human resources and equipment
available, listed in detail and sequence of use, updated with the latest
national legislative directives;
d) Estimates of possible variables and complications; identification of
properly safety systems and alternative recommendations to be observed,
not covered by the standard procedure;
e) Insertion of a self-assessment system in order to check the feasibility
and the adherence to the protocol.
Results: We performed a procedural planning that ensures the
standardization and uniformity of the nursing of the multiple late preterm
newborn, managing the collaboration between several professionals in
order to minimize adverse and unexpected events.
Conclusions: The quality of the health care level provided depends on the
cooperation of the professionals. The management of the team work allows
to ensure an optimal and personalized care level from the medically assisted
reproduction center to the neonatal intensive care unit, following the
updated scientific evidence and the humanization of birth route.
References
1. Shebl O, Ebner T, Sir A, Sommergruber M, Tews G: The role of mode of
conception in the outcome of twin pregnancies. Minerva Ginecol 2009,
61(2):141-52.
2. Caserta D, Bordi G, Stegagno M, Filippini F, Podagrosi M, Roselli D,
Moscarini M: Maternal and perinatal outcomes in spontaneous versus
assisted conception twin pregnancies. 2013, Epub.
3. Moini A, Shiva M, Arabipoor A, Hosseini R, Chehrazi M, Sadeghi M:
Obstetric and neonatal outcomes of twin pregnancies conceived by
assisted reproductive technology compared with twin pregnancies
conceived spontaneously: a prospective follow-up study. Eur J Obstet
Gynecol Reprod Biol 2012.
A47
Implementing the family-centered care model, parents’ satisfaction
and experiences in neonatology
Immacolata Dall’Oglio1*, Anna Portanova2, Martina Fiori1, Orsola Gawronski1,
Roberta Fida3, Antonello Cocchieri4, Gennaro Rocco5, Emanuela Tiozzo1,
Jos M Latour6, Italian Empathic-N Study Group1
1
Professional Development, Continuing Education and Nursing Research
Service-Medical Direction, Bambino Gesù Children’s Hospital, IRCCS,
Rome, Italy; 2Department of Medical and Surgical Neonatology, Bambino
Gesù Children’s Hospital, IRCCS, Rome, Italy; 3W&O Psychology,
Department of Psychology, Sapienza University of Rome, Italy; 4Catholic
University of Rome, Italy; 5Centre of Excellence for Nursing Scholarship,
Ipasvi Rome Nursing College; 6School of Nursing, Plymouth University,
Plymouth, UK
Background: The quality of family-centered care (FCC) in Neonatal
Intensive Care Unit (NICU) is often assessed through Parental satisfaction
(PS). Empathic-N, a validated questionnaire to evaluate PS in NICU, was
recently developed in the Netherlands [1].To our knowledge similar
instruments have not yet been used in Italy. The aim of this project is to
translate the 57-item Empathic-N questionnaire and to develop and adapted
Italian version for post-NICU (Empathic-SN) taking the Italian cultural
adaptation into account, and to test their psychometric validity.
Materials and methods: The translation process followed a structured
method including forward and backward translation [2].
The psychometric validation of both the Empathic-N and the Empathic-SN
questionnaires is being performed by administering the questionnaires
to parents of newborns discharged from 9 NICUs and post-NICUs
across Italy.
Ethical approval is granted by the Bambino Gesù Children’s Hospital.
Written informed consent forms are collected.
Results: 150 questionnaires from NICU and 150 from post-NICU are being
collected. Preliminary analyses showed a positive correlation between the
questionnaire items and the overall satisfaction indicators. Reached scores
ranged from 4.1 to 5.9 for the Empathic-N and from 4.2 to 5.7 for the
Empathic-SN, on a 1-to-6 Likert scale. Results from Cronbach’s alpha
coefficients attested the reliability of the scale. Thematic analysis of the
open answers identified 385 quotations, coded into seven major themes,
expressing parents’ experiences. Generally, a good overall parents’
satisfaction is showed. Further descriptive statistical analysis will be
performed on the complete sample.
Conclusion: Validity and reliability of the Italian version of the
questionnaires assessed by psychometric testing is expected. The EmpathicN and Empathic-SN questionnaires, or their further versions, would constitute
important tools to assess the actual quality of FCC in Italian NICUs and postNICUs and to set the baseline for improvement interventions.
Acknowledgements: The Italian Empathic-N Study Group, was as follows:
Luca Di Sarra, Catholic University of Rome; Gina Ancora, Sandra Lazzari,
Hospital of Rimini; Marilena Galeazzo, Elisabetta Lolli, University Hospital of
Padova; Enrica Lupo, Mariella Frongia, Buzzi Children’s Hospital, Milan; Silvia
Prunecchi, Meyer Children’s Hospital of Florence; Angela Ragni, Bambino
Gesù Children’s Hospital IRCCS Rome, Rosanna Bruno, Antonella Raimondi,
San Carlo Hospital, Potenza; Liliana Vagliano, Serena Rovei, Sant’Anna
University Hospital, Turin; Loredana Bonafede, Anna Marotta, San Eugenio
Hospital, Rome.
The contribution of the Centre of Excellence for Nursing Scholarship for
the funding to this project is acknowledged.
References
1. Latour JM, Duivenvoorden HJ, Hazelzet JA, van Goudoever JB:
Development and validation of a neonatal intensive care parent
satisfaction instrument. Pediatr Crit Care Med 2012, 13:554-559.
2. Wild D, Grove A, Martin M, Eremenco S, McElroy S, Verjee-Lorenz A,
Erikson P, ISPOR Task Force for Translation and Cultural Adaptation:
Principles of Good Practice for the Translation and Cultural Adaptation
Process for Patient-Reported Outcomes (PRO) Measures: Report of the
ISPOR Task Force for Translation and Cultural Adaptation. Value Health
2005, 8:94-104.
A48
The primary nursing implementation in late preterm
R Ongaretto1*, F Villardino1, F Faggion1, S Tosatti2, A Croso3
1
Nurse Neonatal Intensive Care Unit ASLBI Hospital Biella, Italy; 2Chief Nurse
Neonatal Intensive Care Unit ASLBI Hospital Biella, Italy; 3Nursing Care
Director ASLBI Hospital Biella, Italy
Background: The Primary Nursing is a nursing care policy based upon an
individualized patient-nurse relationship, with a particular attention to the
communication and the continuity of the health care. This model has been
implemented in all the structures of the ASL of Biella in 2013. The nurse
becomes the coordinator of the patient’s assistance. The Primary Nursing
objective is to develop the principles of self-care and enpowerment through
taking care of the person and the continuity of care. The patient care is
committed to a specific nurse (primary nurse) who is responsible for him
during the hospitalisation.
The primary nurse, planning a personalized and continuative assistance in
cooperation with the patient, the family and the health staff, is the point of
reference, not only for the patient and the family, but also for the health
team.
Objective: The introduction of the Primary Nursing policy in the Neonatal
Intensive Care Unit aimed at:
1) increasing the satisfaction:
- of patients and families who are better informed and
supported by an individualized and qualified assistance
- of nurses because the increase responsibility raises their
competence and the ability to cooperate in the health staff
Page 24 of 28
2) developing the continuity of the health care by increasing the
parent’s self government in the late preterm care and the quality of
nursing management
Material and methods: The method chosen for the care policy trial can
be divided in two parts:
the general area ; the paediatric nurses take part to the different steps of
the hospital health care strategy defined by the guidelines of the
literature (FAD residential practical training)
the specific area with the achievement of nursing plans, tools and
monitoring systems for the application and the evaluation of the policy in
the specific area
Results: We analysed 79 medical records, that is all the newborns
discharged from 1 st September 2013 to 31 st March 2014. Outcomes
highlight that 64.6% of the patients have been taken in care by a PN ; that
39.2% of prescriptions have been planned; the 53% of the latters has been
followed by the associated nurses. Conflicts between nurses have been
observed in only 3.9% of the cases.
Conclusions: in the analysis of data , we notice a constant improvement
of outcomes in the nursing care plan compiling. We intend to propose a
new period of data collection in 2015.
A49
Late preterm: reorganization of Neonatology Unit
Anna Maria Alessi*, Luciana Leva, Elisabetta Villa, Mario Barbarini
Neonatology and Neonatal Intensive Care Unit, Azienda Ospedaliera
Ospedale Sant’Anna, Como, Italy
Our reorganization project arises from the need to assist in Neonatology
newborns with GA (Gestational Age) ≥ 34 weeks and/or birth weight ≥
1800 g in good cardiorespiratory conditions and newborns still partially
fed by nasogatric tube.
Up to June 2010 our Neonatology usually assisted late-preterm newborns
but our new needs require to increase patients’ complexity, maintaning
pre-existent Staff.
In accordance with the informations provided by the legislation in force
about equipment and staff requirement, we made an organization change
that led to the transition from nursing care organized by tasks to a newborn
assistance organized by complexity of care.
This change leads to the identification of a nurse which is the person in
charge of the baby, ensures continuity of care and promotes improvement
of personalization of the assistance.
We also carried out assistance modality which guarantees the respect of
the skills of the individual infant in relation to his neuro-evolutionary
development, resulting in a greater involvement of parents in the process
of care.
We also made a review of nursing documentation because the pre-existent
one was not suitable to record adequately the needs and observations
necessary for this type of patients: we introduced a “Survey of parameters”
for every newborn, defined by a specific protocol, which needs a particular
observation.
After an initial trial of this new tool in Neonatology, we decided to extend its
application even in the delivery room involving midwives and this change
ensures greater safety of the newborn and a continuing process of
documentation, safeguarding a good start bounding.
This experience of sharing a course so far kept strictly separate led to a
marked improvement over the documents relating to the early hours of the
infant’s life and promoted greater collaboration between the different
disciplines involved in the care process.
A50
Considerations on the late-preterm newborn with cardiac problems
S Fiocchi
Terapia Intensiva Neonatale, Ospedale Niguarda Ca’ Granda, Milano, Italy
Focus on the late preterm birth (LPB) and critical congenital heart defects
(CCHD)
Data on outcomes of CCHD specifically in late preterm infants are
exceedingly scarce.
The preterm newborn with associated complex CHD presents many
intricate problems to clinicians who take care (neonatologist, cardiologist,
cardiothoracic surgeon). Therapies used for the preterm neonate without
heart disease frequently need to be altered in the presence of heart
disease and those needed for management of heart disease may need to
be altered because of prematurity.
The population of newborn born preterm is at higher risk for
postoperative death and short and long term complications than term
newborn with the same CHD and the causes of this are multifactorial.
Technical issue related to small cardiac structure, immaturity of other
organ systems, decreased nutritional and cardiac reserve, increased risks
of bleeding, abnormal chest wall mechanics after sternotomy can all
together account for this epidemiologic data. In past years these
findings were related in particular to low-birth weight infants and
conventional management was oriented to await a threshold weight in
order to reduce bypass-related morbidities. From 1990 rates of LPB
have risen and now account for 75% of all preterm births. Whether
late preterm infants with CHD, who may be only marginally more
immature than their term counterparts, remain at risk for adverse
outcome in unclear. Some recent papers do demonstrate the
independent effect of LPB on mortality and morbidity if a CHD is
present and this issue emerge as an important factor for a correct
counseling. Natarajan have observed that the weight at surgical
intervention was significantly lower and age higher in the late preterm
infants compared to those delivered at term. Late preterm infants had
significantly higher rates of NEC and seizures, with a greater risk of
supplemental oxygen and tube feeding at discharge. Costello have
examined mortality and morbidity stratified by gestational age, reporting
for LPB group with CHD an hospital mortality rate of 16.4% compared to
2.6-8% in the term group. The exact mechanism of this vulnerability
remains unclear although functional immaturity of the lung and the brain
are plausible aetiologies. Altered intrinsic cardiac mechanism could play a
role in adverse outcome of late preterm with CHD. Gestational age at
delivery can be a risk factor over which clinicians might have some
control. Before birth the challenge is planning the time and the place
for the delivery of a foetus with CHD. After birth the challenge is not
waiting for obtain an arbitrary correct weight for surgery but working in
a complex team to discuss each case in order to maximize outcome.
Domande inerenti la relazione del Dott. Stefano Fiocchi
Considerations in the late-preterm newborn with cardiac problems:
Una cardiopatia congenita critica è:
a) Quasi sempre mortale
b) se esiste una ostruzione “critica” agli efflussi ventricolari
c) se richiede l’uso delle prostaglandine
d) se richiede intervento chirurgico nel primo mese di vita
Qual’è il peso ottimale per la correzione chirurgica di una cardiopatia
congenita critica?
a) Non esiste un peso “ottimale”
b) > 2000 gr
c) > 2500 gr
d) > 3000 gr
Page 25 of 28
A51
Treatment of pulmonary hypertension
Paolo Tagliabue*, Tiziana Fedeli
Neonatology and Neonatal Intensive Care, MBBM Foundation, Monza, Italy
The therapeutic approach to the management of pulmonary hypertension
(PH) is based on strategies to decrease pulmonary vascular resistance (PVR)
whilst ensuring optimal cardiorespiratory support to improve oxygenation.
The goal is to maintain appropriate systemic blood pressure, ensure oxygen
release to tissues and minimize lesions induced by oxygen and ventilation.
Inhaled nitric oxide (iNO) remains the mainstay of treatment for this
condition. As an inhaled agent it reaches the alveolar space and diffuses
into the vascular smooth muscle of the adjacent pulmonary arteries where it
causes vasodilation by increasing guanosine monophosphate (cGMP) levels
without affecting systemic vascular tone. Although iNO significantly reduces
the need for extracorporeal membrane oxygenation, almost 25-40% of iNOtreated infants are considered iNO non–responders.
A complementary vasodilatory pathway in the lung is mediated by cyclic
adenosine monophosphate (cAMP); prostacyclin stimulates adenylyl
cyclase in vascular smooth muscle cells and causes an increase in
intracellular cAMP and vasodilation of the systemic and pulmonary
circulatory systems. If given as an inhaled drug the vasodilatory effects of
prostacyclin tend to be limited to the pulmonary circulation, making this
strategy appealing when acute pulmonary vasodilation is needed [1].
Inhibition of the cGMP-degrading phosphodiesterase (PDE5) and inhibition
of the cAMP-degrading phosphodiesterase (PDE3) are two other promising
therapies. Sildenafil is a PDE5 inhibitor, the predominant PDE isoform in the
lung responsible for the breakdown of cGMP. It acts by enhancing NOmediated vasodilation and may facilitate iNO discontinuation in infants with
critical illness[2]. Milrinone is a PDE3 inhibitor with inotropic and
vasodilatory effects; it improves the left ventricular cardiac function both
directly and by reducing systemic afterload and exerts also important effects
on the pulmonary vasculature by reducing PVR. It may be a plausible agent
for treating patients with PH and impaired myocardial function [3].
One of the most potent vasoconstrictors described in the pulmonary
vasculature is Endothelin-1 (ET-1). Inhibition of ET-1 mediated vasoconstriction
could be achieved by administration of an endothelin receptor antagonist
(Bosentan). Bosentan lowers pulmonary artery pressure and PVR in children
with diverse causes of PH and may improve oxygenation in neonates with
persistent pulmonary hypertension; it has also been successfully used as an
adjunctive treatment for children receiving long-term prostacyclin therapy.
Conclusion: Although a great deal of progress has been made in recent
decades in PH treatment, it remains a devastating illness that requires
further studies to adapt the therapy to pediatric lung and its peculiar
vasculature.
References
1. Berkelhamer SK, Mestan KK, Steinhorn RH: Pulmonary hypertension in
bronchopulmonary dysplasia. Semin Perinatol 2013, 37:124-31.
2. Steinhorn RH: Pharmacotherapy for Pulmonary Hypertension. Pediatr Clin
N Am 2012, 59:1129-1146.
3. McNamara PJ, Shivananda SP, Sahni M, et al: Pharmacology of Milrinone in
Neonates With Persistent Pulmonary Hypertension of the Newborn and
Suboptimal Response to Inhaled Nitric Oxide. Pediatr Crit Care Med 2013,
14:74-84.
Il rischio di mortalità neonatale nel late preterm affetto da cardiopatia
congenita critica è:
a) 8%
b) < 5%
c) 25-30%
d) 15-20%
La aumentata vulnerabilità del late preterm con cardiopatia congenita si
associa a:
a) Ventilazione prolungata
b) Prolungato uso delle prostaglandine
c) Presenza di altre malformazioni associate
d) Tutte le precedenti
A52
Non-pharmacological intervention for neonatal pain control
Paola Lago1*, Elisabetta Garetti2, Anna Pirelli3, Daniele Merazzi4,
Carlo V Bellieni5, Patrizia Savant Levet6, Luisa Pieragostini7, Gina Ancora8
1
Woman’s and Child’s Health Department, Azienda Ospedaliera-University of
Padova, Padova, Italy; 2Dept of Pediatrics, Azienda Ospedaliero-UniversitariaPoliclinico di Modena, Italy; 3San Gerardo Hospital, Monza, Italy; 4Dept of
Women’s and Children’s Health, Valduce Hospital, Como, Italy; 5Dept of
Pediatrics, University Hospital, Siena, Italy; 6Mother’s and Child’s Health
Department, Maria Vittoria Hospital, Torino, Italy; 7San Filippo Neri Hospital,
Roma, Italy; 8Azienda Ospedaliera Rimini, Italy
Background: Acute pain and distress during medical procedures are
commonplace in newborn admitted to Intensive Care Unit and can have
detrimental effects, if uncontrolled.
Accumulating evidence suggests that neonate, as older children, could
benefice of non pharmacological interventions (NPIs) to relive mild to
moderate pain, anxiety and discomfort from minor invasive procedures [1].
These therapies include nonnutritive sucking (NNS) both with and without
sucrose, swaddling, positioning, facilitated tucking (FT), kangaroo care or
skin to skin contact (KMC), multi-sensorial stimulation (SS) and music
therapy.
Material and methods: To assess efficacy of NPIs for acute procedural pain
in neonate, a literature search covered the period 2000-2014 via Medline
and Cochrane Library database, was undertaken. Inclusion criteria were
preterm and newborn, involved in randomized controlled or crossover trial.
Pain reactivity was described in term of physiological parameters (heart rate,
oxygen saturation) behavioral indicators (duration of first cry and total
crying time) and validated unidimensional, multidimensional and/or
composite pain scores as PIPP, NIPS, DAN, NFCS etc. Two independent
reviewers extracted data and methodological quality was assessed,
according with GRADE system.
Results: Nineteen Randomized Controlled Trials and twelve meta-analysis
and systematic reviews were taken in consideration. The efficacy of NPIs
in reliving pain and distress from skin-breaking procedures has been
demonstrated mostly in heel prick and venipuncture (Table 1).
There are sufficient evidence that supports efficacy in reducing painrelating behaviors for NNS, swaddling and FT in preterm and term
neonates. [1] KMC appears to be effective, as measured by composite pain
score including physiological and behavioral indicators and safe for single
painful procedures, alone or combined with other NPIs [2]. Small volumes
of 24% sucrose with or without NNS reduced efficiently behavioral
Page 26 of 28
expressions of pain and crying time, as well as PIPP scores [3]. Also
expressed human milk or breastfeeding, if available, should be used to
alleviate procedural pain [4], as well as 20-30% glucose [5]. SS is more
effective than glucose and sucking, but there are no studies comparing SS
and standard sucrose 24% and NNS with pacifier, which actually is the
standard of care for heel lance [6].
Limited evidence suggests that Music Therapy may be beneficial primarily
for measures of behavior and pain, however the heterogeneity of the
study preclude definitive conclusions [7].
Conclusions: As the efficacy of the majority of NPIs is clearly demonstrated
in preterm and neonates, they should be considered for inclusion in a
graduated multidisciplinary algorithm for neonatal pain management.
References
1. Pillar Riddell RR, Racine NM, Turcotte K, Uman LS, Horton RE, Din Osmun L,
Ahola Kohut S, Hillgrove Stuart J, Stevens B, Gerwitz-Sten A: Nonpharmacological management of infant and young child procedural
pain. Cochrane Database of Systematic Reviews 2011, 10: CD006275.
2. Johnston C, Campbell-Yeo M, Fernandes A, Inglis D, Streiner D, Zee R: Skinto-skin for procedural pain in neonates. Cochrane Database of Systematic
Reviews 2014, 1: CD008435.
3. Stevens B, Yamada J, Lee GY, Ohlsson A: Sucrose for analgesia in newborn
infants undergoing painful procedures. Cochrane Database of Systematic
Reviews 2013, 1: CD001069.
4. Shah PS, Herbozo C, Aliwalas LL, Shah VS: Breastfeeding or breast milk for
procedural pain in neonates. Cochrane Database of Systematic Reviews
2013, 12: CD004950.
5. Bueno M, Yamada J, Harrison D, Khan S, Ohlsson A, Adams-Webber T,
Beyene J, Stevens B: A systematic review and meta-analysis of
nonsucrose sweet solutions for pain relief in neonates. Pain Res Manag
2013, 18:153-161.
Table 1(abstract A52) Efficacy of environmental, behavioral and non-pharmacological strategies on pain reactivity in
newborn
Behavioral, cognitive and contextual interventions
Level of evidence
Grade of
Recommendation
Heel
Prick
Venipuncture
Other
Non-nutritive sucking (NNS): placing a pacifier or non-lactating nipple in an infant’s mouth
to promote sucking behavior with no breast or formula milk to provide nourishment.
1
1
-
Facilitated tucking: holding the arms and legs in a flexed position
1
1
Strong
3 ET
Strong
Suctioning
Swaddling: wrapping securely the neonate in a sheet/blanket
1
1
-
Strong
Positioning: laying the neonate supine
3
3
-
Weak
Maternal touching and holding: cradling the baby in the mother’s arms
3
3
-
Weak
Environmental care: controlling/ reducing light and noise, clustering care etc.
3
3
-
Weak
Individualized developmental care e.g. limiting environmental stimuli, lateral positioning,
using supportive bedding, monitoring behavioural clues, respecting circadian rhythms
-
-
Skin to skin or Kangaroo Mother Care an infants is placed on their care-giver’s bare chest
during a painful procedure or for soothing after a painful procedure
1
2
2 IM
Strong
Sensorial saturation: multiple sensorial stimulation at gustatory, auditory, olfactory and
tactile level
1
-
-
Strong
Music therapy: music with intrauterine sounds or instrumental music in association with NNS
3
3
-
Weak
Sucrose 24%: in dose of 0.1-0.3 ml orally 2 minutes before the procedure in preterm infants
and 1-2 ml in term infants.
1
1
-
Strong
Breastfeeding or expressed human milk
1
1
-
Strong
Glucose solutions 20-30% in dose of 1-2ml orally 2 minutes before the procedure.
1
1
-
Strong
ET suctioning= endotracheal suctioning, ROP= retinopathy of prematurity IM= intramuscular injection
Legend
1. Sufficient evidence supports efficacy for reducing pain-related behaviors (support of two or more trials)
2. Limited evidence suggests efficacy for reducing pain-related behaviors (e.g. support of 1 trial or heterogeneity among trial)
3. Limited evidence suggests inefficacy for reducing pain-related behaviors (e.g. support of 1 trial or heterogeneity among trial)
4. Sufficient evidence supports inefficacy for reducing pain-related behaviors ( support of two or more trial)
3 ROP
Weak
screening
6.
7.
Bellieni CV, Bagnoli F, Perrone S, Nenci A, Cordelli DM, Fusi M, Ceccarelli s,
Buonocore G: Effect of multisensory stimulation on analgesia in term
neonates: a randomized controlled trial. Pediatr Res 2002, 51:460-3.
Harling L, Shaik MS, Tjosvold L, Leich R, Liang Y, Kumar M: Music for
medical indications in the neonatal period: a systematic review of
randomized controlled trials. Arch Dis Child Fetal Neonatal Ed 2009, 94:
F349-354.
A53
Pharmacological errors in NICU
Silvia Foligno, Virginia Garofalo, Anna Portanova, Andrea Dotta*
Neonatal Intensive Care Unit, Department of Medical and Surgical
Neonatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
Background: Medical errors are particularly frequent in Neonatal Intensive
Care Units (NICUs) [1], increasing morbidity and mortality of newborns [2].
This category of patients requires the application of high technology and
needs individualized medical prescription mainly based on body weight
and gestational age[3]. The most frequent event categories are wrong
medication, dose, schedule, or infusion rate; error in administration or
method of using a specific treatment; patient misidentification; error
or delay in diagnosis and in the performance of an operation, procedure,
or test [2]. The staff inexperience and intensity of workload are indicated
as risk factors [4]. Most vulnerable newborns are those with indwelling
infusion lines and long length of stay [1]. Common errors are due to the
dose because of the lack of reference standards and of awareness of
Page 27 of 28
pharmacokinetics and pharmacodynamics drug [1]. The Joint Commission
for Accreditation of Health Care Organization (JCHAO) estimates as many
as 95% of adverse drug reactions (ADRs) in children remain unreported
each year[5]. Frequent analysis of reporting data, training and meeting of
all participating NICUs, implementation of computerized physician order
entry (CPOE), and improve the staff with supervisor pharmacist might be
help to detect errors and to learn about these [1,4].
Materials and methods: We carried out our study from 2011 and 2012
in Department of Medical and Surgical Neonatology of Bambino Gesù
Children’s Hospital. We recorded throughout retrospective methods
nursing reports to detect an error or incidents. We used voluntary
reporting, non punitive, of medical errors by health care providers.
Results: From 2011 and 2012 we detected 29 adverse events in Neonatal
Department; 15 (58%)of whom were therapeutic errors concerning of drug
process: 2 (13%) order, 1 (7%) preparation, 7 (46%) prescription, 5 (33%)
administration (Figure 1). While in the Bambino Gesù Children’s Hospital
the adverse events related to pharmacological errors were only 20%.
Conclusions: The voluntary reporting system represents the best option to
detect the human errors. In our experienced the introduction of shared
protocols, of the nurse staff training, and the following of the JCHAO
directives have been achieved to identify all procedures performed for
patient care. To reduce the ADRs the Paediatric Investigation Plans should
be required by the Paediatric Committed to guarantee safer and tolerated
drugs, especially for newborns.
References
1. Chedoe I, Molendijk HA, Dittrich ST, Jansman FG, Harting JW, Brouwers JR,
Taxis K: Incidence and nature of medication errors in neonatal intensive
care with strategies to improve safety: a review of the current literature.
Figure 1(abstract A53) Adverse events at the Bambino Gesù Children’s Hospital from 2011 to 2012. Distribution of adverse events at the Bambino
Gesù Children’s Hospital (BGCH), at the Department of Medical and Surgical Neonatology (DMSN) and the percentage of different stages of the drug
within the DMSN.
2.
3.
4.
Drug safety : an international journal of medical toxicology and drug
experience 2007, 30:503-513.
Suresh G, Horbar JD, Plsek P, Gray J, Edwards WH, Shiono PH, Ursprung R,
Nickerson J, Lucey JF, Goldmann D: Voluntary anonymous reporting of
medical errors for neonatal intensive care. Pediatrics 2004, 113:1609-1618.
Lehmann CU, Kim GR: Prevention of medication errors. Clinics in
perinatology 2005, 32:107-123, vii.
Simpson JH, Lynch R, Grant J, Alroomi L: Reducing medication errors in
the neonatal intensive care unit. Archives of disease in childhood Fetal and
neonatal edition 2004, 89:F480-482.
Page 28 of 28
5.
Joint Commission for Accreditation of Health care Organization: Sentinel
event statistics. 2003, Available at: wwwjcahoorg/ accredited
+organizations/laboratory+services/sentinel+events/ sentinel+event
+statisticshtm Accessed April 26, 2003.
Cite abstracts in this supplement using the relevant abstract number,
e.g.: Foligno et al.: Pharmacological errors in NICU. Italian Journal of
Pediatrics 2014, 40(Suppl 2):A53

PDF (all abstracts) - Italian Journal of Pediatrics

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