Escherichia coli Is Overtaking Group B Streptococcus in Early-Onset Neonatal Sepsis

The widespread use of intrapartum antibiotic prophylaxis (IAP) to prevent group B streptococcus (GBS) early-onset sepsis (EOS) is changing the epidemiology of EOS. Italian prospective area-based surveillance data (from 1 January 2016 to 31 December 2020) were used, from which we identified 64 cases of culture-proven EOS (E. coli, n = 39; GBS, n = 25) among 159,898 live births (annual incidence rates of 0.24 and 0.16 per 1000, respectively). Approximately 10% of E. coli isolates were resistant to both gentamicin and ampicillin. Five neonates died; among them, four were born very pre-term (E. coli, n = 3; GBS, n = 1) and one was born full-term (E. coli, n = 1). After adjustment for gestational age, IAP-exposed neonates had ≥95% lower risk of death, as compared to IAP-unexposed neonates, both in the whole cohort (OR 0.04, 95% CI 0.00-0.70; p = 0.03) and in the E. coli EOS cohort (OR 0.05, 95% CI 0.00-0.88; p = 0.04). In multi-variable logistic regression analysis, IAP was inversely associated with severe disease (OR = 0.12, 95% CI 0.02-0.76; p = 0.03). E. coli is now the leading pathogen in neonatal EOS, and its incidence is close to that of GBS in full-term neonates. IAP reduces the risk of severe disease and death. Importantly, approximately 10% of E. coli isolates causing EOS were found to be resistant to typical first-line antibiotics

Feeding intolerance in the preterm infant.

Feeding intolerance (FI), defined as the inability to digest enteral feedings associated to increased gastric residuals, abdominal distension and/or emesis, is frequently encountered in the very preterm infant and often leads to a disruption of the feeding plan. In most cases FI represents a benign condition related to the immaturity of gastrointestinal function, however its presentation may largely overlap with that of an impending necrotizing enterocolitis. As a consequence, individual interpretation of signs of FI represents one of the most uncontrollable variables in the early nutritional management of these infants, and may lead to suboptimal nutrition, delayed attainment of full enteral feeding and prolonged intravenous nutrition supply. Strategies aimed at preventing and/or treating FI are diverse, although very few have been validated in large RCT and systematic reviews. The purpose of this paper is to summarize the existing information on this topic, spanning from patho-physiological and clinical aspects to the prevention and treatment strategies tested in clinical studies, with specific attention to practical issues

VITAMINS AND FLUORIDE: NEW REQUIREMENTS IN A MULTI-ETHNIC WORLD

During the last decades Italy (as Europe in general) has experienced a mass migration from countries afflicted by poverty, civil wars and religious fundamentalism. More than 5 million foreigners of about 200 different nationalities reside in Italy, forming the 8.3% of total population. In central-northern regions the percentage is even higher (10.6% of the resident population) [1]. Over 50% of foreign residents come from other European countries (Romania, Albania, etc.). About 70,000 foreigners are pediatric subjects (0-17 years). In 2014, on a total of 8 million hospitalizations for acute care, more than 520,000 involved foreign patients (6.5%) [1]. However, there are huge variations among our regions, with hospitalization rates ranging from 0.3% in Basilicata region to 10% in Emilia Romagna region, with a highest rate in Prato province (17.5%) (Tuscany region) [1]. In this evolving panorama, pediatricians are required to be able to understand the diverse health needs of these new patients that, for age, ethnic origins, traditional customs, religious practices, level of undernutrition dramatically differ from each other. In particular, a different approach is indicated for newly arrived subjects and for long-term residents. Undernutrition during pregnancy, prolonged exclusive breastfeeding, late weaning, restricted diets, abnormal intake of tannins, and chronic diarrhea or parasitic infections are frequently observed in foreign subjects recently moved from Africa, Middle-East and Far East countries. All these circumstances contribute to a high prevalence of iron deficiency anemia, although other micronutrient deficiency may contribute to the anemic state [2]. In general, this new composite population implies for the health care provider, and in particular for the pediatrician, a specific attention aimed at evaluating different nutritional and cultural habits which may elicit new or forgotten diseases. In particular, in the last few years, great attention has been focused on hypovitaminosis D and its health consequences, especially in the pediatric population and, in particular, in those subjects at higher risk for ethnic and cultural reasons. Rickets and osteomalacia represent short-term latency manifestations of plain vitamin D deficiency. Although florid rickets is a relatively rare condition in western countries, over the past few years several papers have reported that it is resurging in Europe [3] and North America [4], in a variety of ethnic groups. Subclinical or asymptomatic hypovitaminosis D are definitely more common, even in the Caucasian population. Several epidemiological studies have shown in recent years that the prevalence of hypovitaminosis D in Italian pediatric population is very high, up to 89% [5, 6]. As for adults, the main source of vitamin D is the endogenous production in the skin triggered by the ultraviolet B irradiation. However the skin synthesis is influenced by a number of factors, including, latitude, season, time of the day, cloud cover and pollution. In addition, individual factors, such as skin pigmentation, clothing, time spent outdoor, use of sunscreens, can strongly interfere with its natural production [7]. Very few natural foods contains substantial amount of vitamin D, so dietary sources accounts for less than 10% of vitamin status. Only fortified foods, including cereals and infant formulas or some dairy products, may account for some dietary supply. At our latitudes people at risk of developing vitamin D deficiency are all those with darker skin, e.g. people from Africa, Middle-East and Asia living in Europe, but also pregnant women and their infants with reduced sun exposure (religious and cultural reasons), infants < 12 months (especially if breastfed), subjects with restricted diets (e.g. macrobiotic, vegetarian, strict vegan), adolescents and those with a high body mass index. Finally, vitamin D levels are frequently insufficient in subjects affected by liver or kidney diseases and in case of chronic therapy with anticonvulsants, glucocorticoids and antifungal drugs [6]. There is increasing evidence that besides calcium metabolism and bone health, vitamin D has beneficial effects on several extra-skeletal tissues. The vitamin D receptor (VDR) is nearly ubiquitously expressed in a variety of tissues such as brain, heart, skin, stomach, pancreas, lymphocytes, gonads, and prostate tissue. In recent years, an impressive number of studies have been performed, on both children and adults, to investigate the preventative and therapeutic effects of vitamin D supplementation on various diseases, such as respiratory infections and flu, cardiovascular diseases, diabetes, asthma, multiple sclerosis, and cancer [8]. Furthermore, inadequate vitamin D levels during pregnancy may have short- and long-term effects on offspring health [9]. New insights on the individual metabolism are coming from studies on different VDR gene polymorphisms that may influence the vitamin D expression and activity in individuals [10, 11]. Even though specific recommendations on the adequate intake aimed at preventing extra-skeletal diseases have not yet been provided, it is mandatory for all health caregivers to look carefully to vitamin status at any age, particularly in subjects at higher risk [6]. While in industrialized countries other vitamin deficits are rare and limited to chronically ill patients or subjects with inadequate nutritional regimens (e.g. vitamin B12 in vegans), they have to be considered when approaching foreign subjects, especially if they have recently moved from poor countries [12]. For example, vitamin A deficiency is very common in refugee children and supplementation is always indicated [13]. Vitamin B12 is another vitamin that often results insufficient in refugees [14]. Vitamin B12 occurs naturally in animal products (e.g., meat, milk, eggs), and deficiency results from inadequate dietary intake (economic, cultural and religious restrictions) or impaired absorption. Plain vitamin B12 deficiency is associated with macrocytic anemia, and occasionally pancytopenia, but it may also present with subtle nonspecific symptoms, such as fatigue, decreased concentration and memory, irritability, depression, or other neurologic manifestations. Other deficits that may be encountered in foreign children recently settled in western countries pertain to thiamine, niacin, vitamins C and E [14]. Among others, dental health represents at all ages a major health issue in both native and migrant subjects. In western countries oral health has dramatically improved since the 1960s. However, poor oral health still represents a problem in certain migrant groups. Frequently observed dental disorders include dental cavities, missing teeth, malocclusion, periodontal disease, abscesses and oral cancer. As pediatricians are responsible for the primary and often sole medical care for migrant children, they should be particularly alert to the risk of oral health problems [15]. In particular, the pediatrician must include oral examination in the daily clinical routine, educate children and their parents on reducing dietary sugar, maintaining good oral hygiene, and using topical fluoride agents (toothpaste and varnishes). After carefully assessing total daily fluoride intake, mainly via bottled or tap water (which in our country present considerable variations in fluoride concentration), oral supplements may be indicated [16]. With the same accuracy, pediatricians must be aware of the risk of acute and chronic toxicity due to excessive fluoride ingestion. Fluorosis, beyond dental disease, has, in fact, several detrimental health effects on several tissues, such as bone, heart, CNS, liver, thyroid and kidneys [17]. For this purpose pediatricians should appropriately educate parents in using a judicious amount of toothpaste, teaching kids not to swallow it, and keeping fluoride drops/tablets out of the reach of children. In this context, the toughest challenge the pediatrician has to cope with, with no doubts, is to overcome language and cultural barriers. More integrated intercultural services, especially outside the hospital, are needed; cultural and linguistic mediators have a central role in helping the immigrants integrate in our culture and ensuring clear and effective communication between health caregivers and children and their parents

Blood transfusion in infants: techniques and adverse events

High risk infants, especially preterm ones, often require the administration of blood products. Specific guidelines and recommendations on this topic are continually issued and updated and their clinical application is strongly supported, in order to optimize the transfusion practice in neonatal and pediatric patients. Blood transfusion in infants has, in fact, specific indications, requires special considerations on technical procedures, and deserves particular awareness of possible errors and potential adverse reactions. Read More: http://informahealthcare.com/doi/abs/10.3109/14767058.2011.60758

Alimentazione del neonato pretermine : verso un più ampio consenso

Garantire un apporto nutrizionale ottimale al neonato pretermine costituisce uno dei compiti prioritari del neonatologo. Nutrire in modo ottimale non significa, però, semplicemente garantire apporti capaci di soddisfare il più possibile i fabbisogni nutrizionali di un determinato soggetto in determinate ccondizioni adatte a sviluppare globalmente le potenzialità psico-fisiche dei diversi soggetti, nel pieno rispetto dei limiti immuno-metabolici individuali

Profilassi con la vitamina K nel neonato sano: le strategie adottate

none2La vitamina K è una vitamina liposolubile,indispensabile per la sintesi e l'attività di alcuni fattori della coagulazione (X,IX,VII e II, proteina C ed S) e dell'osteocalcina. La vitamina K può essere somministrata per via parenterale e per via orale, non vi sono dubbi sull'efficacia di entrambe le vie di somministrazione.noneE.Ballardini; S.FanaroBallardini, Elisa; Fanaro, Silvi

Las proteinas en la leches para lactantes: cuáles y en qué cantidad

La calidad y cantidad ideal da la proteína en la leches para lactantes es todavía objeto de discusión. En la mayor parte de las leches de formula que existen en el mercado, la concentración proteica está entre 1,4 y 1,8 g/100 ml. El valor màs bajo del tal intervalo se acerca más a las necesidades del lactante. El empleo de concentraciones proteicas mas bajas todavía, o sea 1,2 g/100 ml (cerca de 1,8 g/100 kcal), necesita de una amplia validación clínica. Además falta datos reales y ventajas concretas para el lactante. De notable interés parecen las intervenciones realizadas sobre el aspecto cualitativo. La eliminación de la fracción seroproteica del glicomacropeptido (GMP), con la conseguiente normalización del aporte de treonina al lactante, pareche un aporte válido en la elaboracion de leche de fórmula siempre muy cercana al modelo de leche de mujer

Elementi per una scelta ragionata di un latte formulato

L'alimentazione infantile costituisce uno dei compiti primari del Pediatra. In assenza del latte materno o in caso di una controindicazione reale, la scelta del latte formulato deve essere eseguita con criterio e responsabilità.Infatti, le formule per lattanti, non sono tutte uguali. In particolare, si evidenziano notevoli differenze nella qualità della componente proteica nella presenza di proteine ad azione biologica, di acidi grassi poliinsaturi a lunga catena ed infine di oligosaccaridi prebiotici. Una scelta ottimale deve prescindere da una valutazione puramente commerciale che potrebbe indurre a lungo andare una progressiva involuzione in termini qualitativi degli alimenti per lattanti

FOREWORD

none2The second International Conference on Preterm Nutrition, held in Rome in September 2008, dealt with several pertinent and emerging aspects of infant nutrition and care, not strictly limited to the problems consequent to pre-term birth. The workshop attracted a group of international scientists and eminent experts in neonatology and infant nutrition, as well as a competent audience of neonatologists and nutritionists. It is now generally accepted that the intestinal ecosystem has an important role in human health, especially because intestinal microbiota may play a non-secondary role in the postnatal development of the immune system. Diet has an important role in the colonisation of the gut, and it is well known that the dominant gut microbiota in breastfed infants are bifidobacteria, which are usually present, but not dominant in bottle-fed infants. Delivery by Caesarean section and pre-term birth have a strong effect on the development and establishment of the intestinal ecosystem. Useful information and new evidence on the complexity of intestinal microflora were presented by several lecturers during the meeting, confirming not only the importance of this topic but also that this important field of research still needs further investigation. Several lectures were dedicated to the much-discussed topic of vitamin K prophylaxis, both for pre-term and term infants. A consistent part of this section of the conference was dedicated to the different and still-controversial policies of vitamin K administration at birth, as well as possible alternative schemes of oral prophylaxis. Vitamin K status and metabolism in pre-term infants after different regimens of prophylaxis and nutrition approaches were also discussed. It was suggested that, given the low body mass and underdeveloped metabolic capacity of the pre-term infant, as well as the consistent intravenous supply with parenteral nutrition, the initial prophylactic dose requires proper tailoring. As usual, attention was given to the specific and relevant issues concerning pre-term nutrition. Topics covered within this section pertained to the composition of pre-term formulas, with particular reference to the elevated protein needs of very low birth weight infants. High protein intakes can be adequately covered only by special pre-term formulas tailored to the special needs of this group of infants, whose number is continuously increasing as a result of improvements in neonatal intensive care. The clear benefits of human milk, with a particular focus on the effects on the nutritional status and body composition of the pre-term infant, were also discussed. Other lectures were concerned with the vast field of neonatal infections, where interesting data were presented on the possible preventive role of lactoferrin, especially in pre-term infants. The highly qualified speakers and critically selected audience created optimal conditions for an animated and detailed discussion of the different issues, as well as other important topics related to the nutrition and care of infants. We sincerely hope that the proceedings of this meeting may offer the reader interesting information and valuable insights into several important aspects of neonatal care. Finally, the highly professional and competent role of “e-meeting and consulting” (Rome, Italy) as the organising secretariat, and the constant, precise and intelligent support of Dicofarm S.p.A. (Rome, Italy) are gratefully acknowledged.PII: S0378-3782(10)00076-9 doi:10.1016/j.earlhumdev.2010.03.005 dx.doi.org/10.1016/j.bbr.2011.03.031noneV. Vigi; S. Fanaro.Vigi, Vittorio; Fanaro, Silvi

VITAMIN K DEFICIENCY BLEEDING

This letter deals with the problem of vitamin k deficiency bleeding, affecting exclusively breast-fed infants, and with the possible prophylactic choices