Luigi Cataldi

Febrile urinary tract infections in young children: recommendations for the diagnosis, treatment and follow-up

We report the recommendations for the diagnosis, treatment, imaging evaluation and use of antibiotic prophylaxis in children with the first febrile urinary tract infection, aged 2 months to 3 years. They were prepared by a working group of the Italian Society of Pediatric Nephrology after careful review of the available literature and a consensus decision, when clear evidence was not available.

Cranberry juice for the prevention of recurrent urinary tract infections: a randomized controlled trial in children.

Objective. This study compares the effects of daily cranberry juice to those of Lactobacillus in children with recurrent urinary tract infections (UTIs). Material and methods. Eighty-four girls aged between 3 and 14 years were randomized to cranberry, Lactobacillus or control in three treatment arms: G1, cranberry juice 50 ml daily (n=28); G2, 100 ml of Lactobacillus GG drink on 5 days a month (n=27); and G3, controls (n=29). The study lasted for 6 months. Results. Only four subjects withdrew: 1/28 (3.5%) from G1, 1/27 (3.7%) from G2 and 2/29 (6.8%) from G3, because of poor compliance to the established protocol. There were 34 episodes of UTIs in this cohort: 5/27 (18.5%) in G1, 11/26 (42.3%) in G2 and 18/27 (48.1%) in the G3, with at least one episode of infection (p<0.05). Conclusion. These data suggest that daily consumption of concentrated cranberry juice can significantly prevent the recurrence of symptomatic UTIs in children.

Antibacterial-Induced Nephrotoxicity in the Newborn

Antibacterials are the primary cause of drug-induced kidney disease in all age groups and these agents bring about renal damage by 2 main mechanisms, namely, direct and immunologically mediated.For some antibacterials (aminoglycosides and vancomycin) nephrotoxicity is very frequent but generally reversible upon discontinuation of the drug. However, the development of acute renal failure with these agents is possible and its incidence in the newborn seems to be increasing.Antibacterials are very often used in the neonatal period especially in very low birthweight neonates. The role of neonatal age in developing nephrotoxicity has still to be defined.Since the traditional laboratory parameters of nephrotoxicity are abnormal only in the presence of substantial renal damage, the identification of early non-invasive markers of the renal damage (urinary microglobulins, enzymes and growth factors) is of importance.Aminoglycosides and glycopeptides are still frequently used, either alone or in combination, despite their low therapeutic index. Numerous factors intervene in bringing about the kidney damage induced by these 2 classes of antibacterials, such as factors related to the antibacterial itself and others related to the associated pathology as well as pharmacological factors. Nephrotoxicity can be caused by the β-lactams and related compounds. Their potential to cause nephrotoxicity decreases in the order: carbapenems > cephalosporins > penicillins > monobactams. Third generation cephalosporins are frequently used in neonates. However, they are well tolerated compounds at the renal level.The nephrotoxicity of other classes of antibacterials is not discussed either because they are only used in neonates in exceptional circumstances, for example, chloramphenicol and cotrimoxazole (trimethoprim-sulfamethoxazole) or are not associated with significant nephrotoxicity, for example macrolides, clindamicin, quinolones, rifampicin (rifampin) and metronidazole.Antibacterial-induced nephrotoxicity is an important parameter to be considered when treating the newborn and this is particularly true when use of a combination of different antibacterials and/or drugs with a nephrotoxic potential is being considered. However, other parameters, such as antibacterial spectrum, pharmacokinetics, post-antibacterial effect, clinical efficacy, general adverse effect profile and cost, must also be considered in the choice of antibacterial therapy in the neonate.Knowledge of the renal safety of antibacterials and the correct approach to therapeutic drug monitoring may be useful elements for preventing iatrogenic renal disorders.

Renal function and volume of infants born with a very low birth‐weight: a preliminary cross‐sectional study

Aim:  The aim of our study was to compare the function and volumes of kidneys of very low birth‐weight (VLBW) and of extremely low birth‐weight (ELBW) infants at pre‐school ages.

Hidden high-grade vesicoureteral reflux is the main risk factor for chronic renal damage in children under the age of two years with first urinary tract infection.

Abstract Objective. The aim of the present prospective trial was to investigate, in a cohort of young children with first urinary tract infection (UTI) and negative prenatal history, the role of imaging in screening babies at risk of renal deterioration. Material and methods. Children who had experienced the first febrile UTI at or under the age of 2 years were enrolled. They had had normal foetal routine ultrasound. All the children underwent renal ultrasound after admission; those with sonographic signs of obstruction were excluded. Voiding cystoureterogram (VCUG) and 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy were performed approximately 1 month and 6 months after the UTI, respectively. Finally, 65 babies (47.7% males, 38.6 ± 1.3 weeks of gestational age) were prospectively followed up. Results. In 15.4% and 29.2% of cases, the renal pelvis was ≤7 and >7 mm in diameter, respectively. Vesicoureteral reflux (VUR) was detected in 55.4% of the children and renal scarring in 18.5%. Stepwise binary logistic regression analysis showed that the severity of VUR correlated significantly with renal scarring, excluding all the other variables from the model. In this cohort of babies, the severity of VUR seriously enhanced the risk of renal damage (odds ratio = 6.658, p = 0.004). Conclusion. Follow-up renal scintigraphy 6 months after a UTI can predict severe VUR in very young children showing renal scarring, detecting only those who are at risk of loss of kidney function and who would require further assessment. After the first episode of UTI, the practice of performing VCUG in babies with normal DMSA scintigraphy is of doubtful value.

Biochemical markers for the early assessment of neonatal sepsis: the role of procalcitonin

Summary Procalcitonin (PCT) is the precursor of calcitonin, normally synthesized in the C-cells of the thyroid gland. Systemic inflammation and sepsis induce PCT production by various cell types, including hepatocytes, nephrons, monocytes. PCT begins to rise four hours after exposure to bacterial endotoxins, peaking at six to eight hours, and remaining raised for at least 24 hours with a half-life of 25-30 hours. Serum PCT levels significantly increase in systemic bacterial infection, necrotizing enterocolitis, and during both early and late onset neonatal sepsis. By using a cut-off limit of 0.5 μg/L, the PCT positive likelihood ratio was found of 12.5. PCT has a theoretical advantage as a marker of systemic bacterial infection over other cytokines because of its virtual absence in health, induction in sepsis and its half-life suitable for daily monitoring of disease progress. PCT may be useful in assessing the severity of infection, following the progress of treatment, and predicting outcomes.

Prenatal and perinatal risk factors of schizophrenia

Schizophrenia could be considered the most severe of all psychiatric disorders. It shows a heterogeneous clinical picture and presents an etiopathogenesis that is not cleared sufficiently. Even if the etiopathogenesis remains a puzzle, there is a scientific consensus that it is an expression of interaction between genotype and environmental factors. In the present article, following a study of literature and the accumulated evidence, the role of prenatal and perinatal factors in the development of schizophrenia will be revised and synthesized. We think that better knowledge of the risk factors could be helpful not only for better comprehension of the pathogenesis but especially to optimize interventions for prevention of the disorder.

ABO hemolytic disease of the fetus and newborn: an iatrogenic complication of heterologous assisted reproductive technology-induced pregnancy.

BACKGROUND: ABO hemolytic disease of the fetus and newborn (ABO HDFN) may manifest itself in cases of mothers belonging to blood group O and newborns of groups A or B and more frequently in group A and less so in group B.

Urinary tract infection in the newborn and the infant: state of the art

Urinary tract infection is one of the most common cause of infection in newborns. Obtaining a urinary tract infections (UTIs) diagnosis just on the basis of the clinical findings is frequently difficult, however, being the pediatricians goal to reduce the risk of renal scarring, a prompt diagnosis and treatment is of extreme importance. The key instrument for the diagnosis of UTIs is represented today by urine culture. However, in reality, the caregivers and investigators are increasingly demanding fast and cheap methods for a rapid and effective diagnosis.

Incidental detection of neuroblastoma and “wait and see” strategy

To the Editor: We read with great interest the paper by Peter Fritsch et al. [1] entitled ‘‘Wait and See’’ strategy in localized neuroblastoma in infants: An option not only for cases detected by mass screening. We fully agree with the Authors’ conclusion that a ‘‘Wait and See’’ strategy is beneficial in the management of neuroblastoma (NB) found by urinary mass screening or detected incidentally, as these tumors may spontaneously regress or turn out to be benign lesions. Since 1992, we have been performing a ultrasound mass screening for urinary tract malformations between 2 and 4 months of age (approximately a total of 15,000 infants screened to date). Three clinical cases were incidentally diagnosed with abdominal NB in the course of the screening. Median age at diagnosis was 3 months (range 2–4 months). All patients met the following criteria: localized tumors, tumor size less than 5 cm in diameter, absence of invasive growth, vanillylmandelic acid (VMA) and homovanillic acid (HVA) less than 50 mg/mg creatinine, and informed consent of parents. Monitoring was performed by monthly ultrasound examinations and urine catecholamine analysis. Median follow-up is 21 months (5–38 months). In one patient, the tumor rapidly increased in size and was resected after 5 months of observation displaying unfavorable histology. At 5 years of age, the child is in good health, with no signs of NB recurrence. The two other tumors spontaneously regressed. Our clinical observations indicate the possibility of successfully detecting NB at an early stage as an incidental ultrasonic finding during a mass screening for urinary tract malformations. A ‘‘Wait and See’’ strategy may be successfully applied in incidentally detected cases of localized neuroblastoma.