A. Varalda

Neonatal growth charts.

The ability to recognize abnormal growth at birth and/or an intrauterine malnutrition is of great importance for neonatal care and prognosis. The current gold standard in neonatal auxological evaluation is based on information obtained from both neonatal anthropometric charts and intrauterine growth charts. Numerous charts have been proposed, but they are hardly comparable with each other, due to numerous methodological problems. The Italian Society of Neonatology, the Italian Society of Pediatric Endocrinology and Diabetology and the Italian Society of Medical Statistics and Clinical Epidemiology promoted a multicenter survey with the aim to produce an Italian neonatal anthropometric reference (Italian Neonatal Study [INeS] charts) fulfilling the set of the criteria that a reliable neonatal chart should possess. In clinical practice neonatal charts have some limitations if they are used to monitor postnatal growth of preterm newborns from birth to term. To overcome the problems related to the construction and use of a reference, an international project has recently started a study aiming to create prescriptive standard for the evaluation of postnatal growth of preterm infants (INTERGROWTH-21st). While an international longitudinal standard for evaluating preterm infant postnatal growth is lacking, in Italy the best compromise is likely to be as follows: new INeS charts up to term; International longitudinal charts WHO 2006 or CDC 2002 from term to 2 years; finally, the Italian Society for Pediatric Endocrinology and Diabetes (SIEDP) growth charts could be suitable for monitoring the growth of these infants from 2 years up to 20 years of age.

Detection of cow's milk proteins and minor components in human milk using proteomics techniques.

Cow’s milk proteins (CMPs) are the best characterized food allergens. The aim of this study was to investigate cow’s milk allergens in human colostrum of term and preterm newborns’ mothers, and other minor protein components by proteomics techniques, more sensitive than other techniques used in the past. Sixty-two term and 11 preterm colostrum samples were collected, subjected to a treatment able to increase the concentration of the most diluted proteins and simultaneously to reduce the concentration of the proteins present at high concentration (Proteominer Treatment), and subsequently subjected to the steps of proteomic techniques. The most relevant finding in this study was the detection of the intact bovine alpha-S1-casein in human colostrum, then bovine alpha-1-casein could be considered the cow’s milk allergen that is readily secreted in human milk and could be a cause of sensitization to cow’s milk in exclusively breastfed predisposed infants. Another interesting result was the detection, at very low concentrations, of proteins previously not described in human milk (galectin-7, the different isoforms of the 14-3-3 protein and the serum amyloid P-component), probably involved in the regulation of the normal cell growth, in the pro-apoptotic function and in the regulation of tissue homeostasis. Further investigations are needed to understand if these families of proteins have specific biological activity in human milk.

Is breastfeeding duration influenced by maternal attitude and knowledge? A longitudinal study during the first year of life

Objective: To discuss the duration and types of breastfeeding and to identify the factors associated with the early introduction of formula milk. Materials and methods: This longitudinal study was conducted in the largest birthing centre of Turin. 562 mother-infant pairs were selected randomly and enrolled from among all the births that occurred in our Hospital from January to December 2009. Data was collected by means of a questionnaire filled out by the researcher during a face-to-face interview at mother’s bed side during her hospital stay. This questionnaire included data regarding maternal socio-demographic, biomedical and hospital-related characteristics and some questions regarding family support, maternal attitude and current knowledge on breastfeeding. Mothers were interviewed by telephone at 1, 3, 6 and 12 months postpartum using the 24-h recall technique and definitions recommended by the WHO to investigate the type of breastfeeding adopted. Results: At the age of 6 months only 8.9% of the infants involved were still exclusively breastfed and 44.3% had discontinued breastfeeding. By the age of 12 months 25.3% of infants were still receiving some breast milk. The main factors that had a negative impact on the duration of breastfeeding included maternal smoking habits, early pacifier introduction and the maternal infant feeding attitude. Conclusions: The rate of initiation and overall duration of breastfeeding reached the WHO objectives, but exclusive breastfeeding duration has still not reached satisfactory levels at 6 months. Given that the maternal infant feeding attitude is the only factor independently related to breastfeeding duration for the whole first year of life, reliable measures of maternal attitude could be used as a first step in targeting and assessing interventions that promote and sustain breastfeeding.

Evaluation of postnatal growth of preterm infants

The past two decades have seen a progressive improvement in the survival rates of preterm infants, especially in neonates <30 weeks of gestational age. These neonates constitute the large majority of the population in neonatal intensive care units. The correct evaluation of postnatal growth of these babies is nowadays of primary concern, although the definition of their optimal postnatal growth pattern is still controversial. Concerns have also been raised about the strategies to monitor their growth, specifically in relation to the charts used. At present the available charts in clinical practice are fetal growth charts, neonatal anthropometric charts and postnatal growth charts for term infants. None of these, for different reasons, is suitable to correctly evaluate preterm infant growth. An international multicentric project has recently started a study aiming at building a prescriptive standard for the evaluation of postnatal growth of preterm infants and it will be available in the next years providing a population that is conceptually as close as possible to the prescriptive approach used for the construction of the WHO infant and child growth standards. At present, while an international longitudinal standard for evaluating preterm infant postnatal growth is lacking, in Italy the best compromise in clinical practice is likely to be as follows: new Italian INeS (Italian Neonatal Study) charts up to term; International longitudinal charts WHO 2006 or CDC 2002 from term to two years; finally the Italian Society for Pediatric Endocrinology and Diabetes (SIEDP) 2006 growth charts could be suitable for monitoring the growth of these infants from two years up to 20 years of age.

Neonatal jaundice and human milk

Breastfeeding is linked both to a greater jaundice frequency and intensity in the first postnatal days (“breastfeeding jaundice”) and 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. In fact, 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.

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 counselors 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.

Drugs and breastfeeding: instructions for use

It’s universally well known that breastfeeding, due to its numerous beneficial effects on child and maternal health, is the best feeding method for infants. The use of medication by the nursing mother and the physician’s advice to stop nursing are the most common reasons for the cessation of breastfeeding. The physician plays an extremely delicate role and should be able to assess risks and benefits for both mother and child. The issue of which drugs are safe to take during lactation is quite complicated. Three main factors must be taken into account: pharmacokinetics, assessment of the risk to the infant and to the lactation. Excellent sources of reliable information are the reference books. For the most up-to-date information it would be useful to consult the online medical literature. Few drugs have been demonstrated to be absolutely contraindicated during breastfeeding. Clear, safe and reliable information is still lacking for most drugs. It would be desirable to see an improvement in knowledge about mechanisms for transfer of drugs into milk, to analyze the biotransformation process for a given drug and to study the clinical consequences of infant exposure to drugs present in milk.

Esophageal Bolus Transit in Newborn with Gastroesophageal Reflux

Background and aim: Gastroesophageal dismotility due to immaturity is primarily involved in the pathogenesis of gastroesophageal reflux (GER) in newborns. Impaired swallowing patterns could influence refluxes characteristics and esophageal acid exposure. Multichannel Intraluminal Impedance (MII) is a novel technique to evaluate GER, and it has been used to evaluate esophageal bolus transit in adults and children, but data on its use in newborns are scanty.The aim of this study was to investigate the relation between esophageal motor disfunction and GER.Methods: Esophageal bolus transit was evaluated in 16 term newborns aged 15-30 days, who underwent 24h-pH/MII analysis for clinical suspect of GER disease. Eight patients had ≥5% time with esophageal pH< 4 (GER positive) and the other 8 patients had < 5% time with esophageal pH< 4 (GER negative). Bolus Head Advance Time (BHAT) and Total Bolus Transit Time (TBTT) were assessed on 3-hours intervals of MII recording.Results: BHAT and TBTT were calculated on a total of 1056 swallowing events MII detected.Table 1BHAT and TBTT observed during meal were shorter than in the fasting periods in both groups (p< 0.001). During meal, TBTT, but not BHAT, was longer (p=0.03) in the GER positive than in the GER negative group.Conclusions: Our results support that esophageal motor disfunction contributes to the pathogenesis of GER in newborns, impairing esophageal clearance.