Update of adjustable fortification regimen for preterm infants: a new protocol.

Preterm infants fed fortified human milk in standard fashion receive less protein than they need due to customary assumptions. Protein is limiting for growth and neurocognitive development,and shortfalls of protein are not acceptable. Adjustable fortification regimen has been proven as an effective way to provide adequate protein intakes and appropriate growth in this group of infants. Italian Association of Human Milk Banks (AIBLUD) has promoted and implemented this Adjustable fortification regimen in neonatal intensive care units (NICUs) with success. This paper presents an update of Adjustable fortification regimen; a new protocol already utilized in several italian NICUs.

Communication in NICUs.

In a Neonatal Intensive Care Unit (NICU) counseling should be a shared culture for all the care givers: it should be developed by all the professionals, to face up to parents' needs of information, explanations, facility of decisions, finding of resources, agreement, help, reassurance, attention. The first essential aspect is the training in counseling skills, by periodic courses for all professionals of the department (physicians, nurses, and physiotherapists). In our department, a professional counselor is present, assisting the medical staff in direct counseling. The counselor's intervention allows a better parent orientation in the situation. A more effective sharing of these rules also facilitates the communication among parents and medical staff. Periodic meetings are established among the medical staff, in which the professional counselor discusses difficult situations to share possible communicative strategies. We wanted to have not only a common communicative style, but also common subjects, independent from the characteristics of each of us. Individuals are often faced with different situations. For every setting that we more frequently face in communication (for example the first interview with a parent of a very preterm infant) we have built an 'algorithm' that follows a pattern: (1) information always given; (2) frequent questions from parents; and (3) frequent difficulties in the communication. Counselling is also a tool to face some critical issue, such as the decision to open the department to parents 24 h on 24, or the promotion of mother's milk use in Very Low Birth Weight Infants (VLBWI).

Hyperbilirubinemia and management of breastfeeding.

Hyperbilirubinemia and jaundice are natural, physiological phenomena which are only to be expected in the neonatal period, within certain limits. The highest percentage of jaundice in breastfed newborns should be evaluated in connection with inadequate management of breastfeeding rather than a direct effect of breast milk. Breastfeeding is also linked to visible jaundice persisting beyond the first two weeks of life (“breast milk jaundice”), but the appearance of skin jaundice is not a reason for interrupting breastfeeding which can and should continue without any interruption in most cases. There have been numerous contributions to the literature which have rescaled the direct role of breast milk both in early jaundice and in the more severe cases of late jaundice. The reviewed guidelines for detection and management of hyperbilirubinemia underline how prevention of badly managed breastfeeding and early support for the couple mother-child are effective prevention measures against severe early-onset jaundice; furthermore, the breastfeeding interruption is no longer recommended as a diagnostic procedure to identify breast milk jaundice because of its low specificity and the risk to disregarding the detection of a potentially dangerous disease.

Amendment to 2010 Italian guidelines for the establishment and operation of a donor human milk bank.

The present paper is an amendment to the recent Italian Guidelines of human milk banking published in 2010. Working Group on Guidelines (Panel) of the Italian Association of Human Milk Banks (AIBLUD) states, in accordance with the European Union Comission's Amending Directive of January 2011, that the hard plastic feeding bottles used in the collection, storage and pasteurization of the human milk should be Bisphenol A (BPA) free. Until new evidence are available polycarbonate feeding bottles should not be used for collection, storage and pasteurization of human milk. The paper summarizes the former and current European Commission Directives and shows the related amending changes to the 2010 Italian Human Milk Banking Guidelines.

[A multidisciplinary diagnostic and therapeutic approach to atopic eczema in the nursing infant: the 1-year follow-up]. / Approccio diagnostico e terapeutico multidisciplinare all'eczema atopico del lattante: follow-up a un anno.

This study presents the outcome of a multidisciplinary approach to the infants with atopic dermatitis. Forty six patients, 40 males and 6 females, afflicted with atopic dermatitis, aged 3 months-2 years, were examined. A careful history was taken for each case to identify possible allergic disease and particular attention was placed on the relation between food assumption and appearance of lesions. The association of diet, dermatological therapy, elimination of environmental stimulus where possible, treatment of lesions and pruritus and good psychological support enable the Authors to obtain 57% of complete remission of atopic dermatitis. In 43% improvement was observed.

Counselling in neonatal intensive care unit.

Counselling is a professional intervention based on skills to communicate and to build relationships. The project "Not alone", related to counselling at our Neonatal Intensive Care Unit, is aimed to let counselling become a "shared culture" for all the care givers. The first essential aspect is to form the ability of counselling through periodic courses for all professionals of the department (physicians, nurses, physiotherapists). In our department a professional counsellor is present assisting the medical staff in direct counselling. The counsellor's intervention allows a better parent orientation in the situation. A more effective sharing of these rules also facilitates the communication among parents and medical staff. Periodic meetings are established among the medical staff, in which the professional counsellor discusses difficult situations in order to share possible communicative strategies. We wanted to have not only a common communicative style, but also common subjects, independent from the characteristics of each of us. Individuals are often faced with diverse situations. For every setting that we more frequently face in communication (for example the first interview with a parent of a very preterm infant) we have built an "algorithm" that follows a pattern: (1) information always given; (2) frequent questions from parents, (3) frequent difficulties in the communication. We also need to record important moments, for instance the "case history of the communication": in fact it would be desirable to have the case history, a sheet dedicated to important communications that are absolutely to be shared with other professionals.

Communicative strategies in a neonatal intensive care unit.

Counseling is a professional intervention based on skills to communicate and to build relationships. The project 'Not alone', related to counseling at our Neonatal Intensive Care Unit, is aimed to let counseling become a 'shared culture' for all the care givers. The first essential aspect is to form the ability of counseling through periodic courses for all professionals of the department (physicians, nurses, and physiotherapists). In our department, a professional counselor is present assisting the medical staff in direct counseling. The counselor's intervention allows a better parent orientation in the situation. A more effective sharing of these rules also facilitates the communication among parents and medical staff. Periodic meetings are established among the medical staff, in which the professional counselor discusses difficult situations to share possible communicative strategies. We wanted to have not only a common communicative style, but also common subjects, independent from the characteristics of each of us. Individuals are often faced with diverse situations. For every setting that we more frequently face in communication (for example the first interview with a parent of a very preterm infant) we have built an 'algorithm' that follows a pattern: (1) information always given; (2) frequent questions from parents; and (3) frequent difficulties in the communication. We also need to record important moments, for instance the 'case history of the communication': in fact it would be desirable to have the case history, a sheet dedicated to important communications that are absolutely to be shared with other professionals.

Staphylococcus aureus skin colonization in infants with atopic dermatitis.

BACKGROUND: Coagulase-positive Staphylococcus aureus colonizes eczematous lesions in 78-100% of children and adults with atopic dermatitis (AD), whereas it is found on skin of healthy subjects in only 2-25% of cases. On unaffected skin of subjects with AD the bacterium has been isolated in 51-100% of cases. OBJECTIVE AND METHODS: This paper examines rate and density of S. aureus colonization, using the swab technique and the contact plate method, respectively, on affected and unaffected skin in 72 infants with AD (age 3-24 months) and in a control group, to determine if there are significant differences with respect to what is reported for children and adults with AD. RESULTS AND CONCLUSIONS: The main differences is that on unaffected skin of our infants with AD, bacterium colonization rate is significantly lower than on affected skin.

Atopic dermatitis of infancy and urinary tract infections.

BACKGROUND: Infants under evaluation for atopic dermatitis (AD) at our clinic undergo a battery of examinations that include urinalysis and urine culture tests with antibiograms. The prevalence of cases with significant bacteriuria and leukocyturia (SBL) appeared to be unexpectedly high. OBJECTIVE: This study attempts to establish whether infants with AD should be suspected of having a higher prevalence of urinary tract infections (UTI). METHODS: A retrospective analysis of urine and urine culture tests was performed in 131 infants (84 males and 47 females) aged 1-24 months with untreated AD and in 1,327 control subjects (621 male, 706 female) aged 1-24 months. RESULTS: SBL was present in 27.5% of cases versus 3% of controls (p < 10(-5)). After routine treatment for AD and antibiotic treatment on the basis of a urine antibiogram, the recurrence rate of SBL, evaluated monthly over a 6-month period, was only 8.3%. CONCLUSION: Infants with AD might be at a greater risk for developing UTI, and when treated for AD this risk might be reduced.

[Milk feeding of infants in the Turin district. An epidemiological survey]. / L'allattamento nell'area torinese. Un'indagine epidemiologica.

A cross section study was performed on 1342 children living in the Turin district to examine the modalities followed for milk-feeding during the first year of life. Children examined had been admitted to the infants' ward of the Pediatric University Clinic of Turin suffering from common illness of early infancy. Mothers were asked to fill in a questionnaire concerning breast-feeding, formula feeding and cow's milk feeding. Data collected show that 75% of infants were exclusively breast-fed at birth, that a large number of infants are already fed cow's milk after the 3rd month of life, that hypoallergenic formulas are overused (18.5% among adapted formulas), and that follow-up formulas are underused. Most of the mothers (74%) say that their dietary choices were made by their physician. These data indicate that infant dietary trends in our district are often not in accordance with scientific recommendations.

[Steinert's myotonic dystrophy: severe neonatal form with unknown family history]. / Distrofia miotonica di Steinert: grave forma neonatale con famigliarità misconosciuta.

UNLABELLED: A child with severe generalized hypotonia and respiratory insufficiency, with an unknown positive family history for Steinert's disease, is referred. We want to point out the importance of correct anamnesis and of physical examination during pregnancy to suspect and diagnose rare and incurable fetal pathologies. CASE REPORT: The child was born after caesarean section. Polyhydramnios and decreased fetal movements were noticed during pregnancy. At birth, the baby presented asphyxia (Apgar 4/6) and respiratory insufficiency: he was then intubed. He received assisted ventilation for 37 days. At the physical examination, the child appeared hypotonic, hyporeflexic, without sucking reflex, with arthrogryposis and ligament laxity. On first day, chest X-ray showed paralysis of the right hemidiaphragm. His mother presented with hypotonia of the facial muscles, lid drop, light muscular weakness, positivity to neostigmine test: we then assumed that the baby was affected by transient neonatal myasthenia gravis and neostigmine was carried on. Anyway, the general conditions of the baby didn't improve. We were able to establish diagnosis of Steinert's disease (a form of muscular dystrophy with autosomal dominant inheritance with incomplete penetrance) after some other examinations (negativity of acetylcholine receptor antibodies, elevation of creatine kinase level, myopathic pattern on electromyography). Gene DMPK alteration was documented with a molecular genetic test.

[Neonatal pseudohypoaldosteronism: when a denied truth can delay a diagnosis]. / Pseudoipoaldosteronismo neonatale: quando una verità negata può ritardare una diagnosi.

A child with neonatal pseudohypoaldosteronism is referred. The diagnosis was delayed and complicated as her parents didn't tell us that her sister had been affected by the same illness. The child was born after premature rupture of membranes at 34 weeks. At birth, her conditions were satisfactory. The general conditions of the child gradually worsened and, though she regularly ate human pastorized bank milk, she didn't gain any weight. After 13 days she appeared dehydrated with marbled dry skin and haloed eyes, hypotonic and hyporeflexic. Her suction became more and more weaker, with frequent regurgitations and vomiting. Laboratory tests pointed out hyponatremia (110 mEq/l) and hyperkalemia (6.8 mEq/l). We were able to establish diagnosis of primary pseudohypoaldosteronism measuring plasma concentrations of aldosterone (> 5000 pg/ml), 17 hydroxyprogesterone (normal) and corticosteroids (normal). The child was then supplemented with sodium chlorure. A gradual improvement of general conditions took place. We assumed that both childrens and mother were affected by a milder form of primary pseudohypoaldosteronism, characterized by an autosomal dominant way of transmission. We found high levels of aldosterone with normal levels of blood salts also in the sister and mother patient's. After the neonatal period, pseudohypoaldosteronism can be only suspected in case of positive family history.

[Neonatal arteriovenous thrombosis: report of a case]. / Trombosi artero-venosa ad insorgenza prenatale: presentazione di un caso.

UNLABELLED: Limb vascular thrombosis is a severe, rare entity, often needing invasive surgery and sometimes leading to loss of function. An infant with in utero arteiro-venous thrombosis is reported. CASE REPORT: The baby, a female infant, was born at 34 weeks from a mother affected by gestational diabetes. She was referred to Neonatal Care Unit because of mild respiratory distress syndrome. She had no malformations. Spontaneous acute ischemia of right upper limb was noticed soon after admission: the limb appeared pale, cold, atonic and areflexic; no signs were noticed on it. Axillary artery and vein thromboses were soon confirmed by ultrasonography and arteriography. Intravenous administration of recombinant tissue plasminogen activator was carried on for 36 hours and followed by heparin and antithrombin III administration. Partial revascularization was obtained after a few hours: at the beginning of the treatment the limb became cyanotic, then edematous and finally the normal colour appeared everywhere but in the hand, was it became visible after a few days, when edema was reabsorbed. No recurrence of thrombosis occurred with heparin prophylaxis. Pain was treated with analgesic therapy, and motor impairment required physiotherapy. The doppler ultrasonographies which were performed subsequently confirmed a complete revascularization of axillary artery and vein. Coagulation and metabolic parameters (clotting tests, protein C, protein S, prothrombin, aminoacids) were studied but disorders predisposing to thrombosis were not found both in the patient and in her parents. CONCLUSION: Early identification of limb vascular thrombosis through external symptoms is very important, as it can avoid invasive surgical procedures.