Pierpaolo Brovedani

Breast feeding very-low-birthweight infants at discharge: a multicentre study using WHO definitions.

Human milk has several advantages in the nutrition of very-low-birthweight (VLBW) infants. However, there are limited data on breast feeding (BF) in neonatal intensive care units (NICU). The aim of this study was to identify a practical definition of BF rate in VLBW infants and to test its applicability and reproducibility in Italian NICUs. The study population included all VLBW infants discharged from 12 level 3 NICUs, over a 12-month period. Type of feeding was recorded according to the World Health Organisation (WHO) definition, with a 72-h recall period. We enrolled 594 VLBW infants. Mean birthweight was 1105 g (SD: 267), mean gestational age was 29.2 weeks (SD: 2.7) and mean length of stay in NICUs was 62.5 days (SD: 56.5). At discharge, 30.5% of VLBW infants were exclusively breast fed, 0.2% were predominantly breast fed, 23.8% were on complementary feeding and 45.5% were exclusively formula fed. A wide variability in BF rates was seen between centres. Among exclusively breast-fed VLBW infants, only 10% sucked directly and exclusively at the breast. WHO definitions can be used to assess type of feeding at discharge from NICUs. We speculate that common feeding definitions may allow both comparisons among different NICUs and ratings of quality improvement programmes.

Breastfeeding at NICU Discharge: A Multicenter Italian Study

Background: Human milk is the optimal form of nutrition for infants, especially sick or compromised infants, yet international data suggest that breastfeeding (feeding at the breast) and the use of expressed human milk (mother’s and donor’s milk) are limited in patients cared for in the neonatal intensive care unit (NICU). Objective: The goal of this study was to examine feeding status at hospital discharge among high risk infants. Methods: We used the 1991 World Health Organization infant feeding definitions, applied to the 72 hour period preceding discharge from the NICU. The study sample consisted of all high risk infants discharged from July 1, 2005, to June 30, 2006 from 13 Italian NICUs. Data on infant feeding in the last 72 hours were collected at discharge from the medical records. Results: We recorded data from 2948 subjects with a median gestational age of 35 weeks (IQR, 32-38), a median birth weight of 2200 g (IQR, 1630-2920) and a median length of stay of 16 days (IQR, 8-33). At discharge, 28% of all infants were fed exclusively with human milk: 31%, 25%, 22% and 33% respectively in the <1500 g, 1500-2000 g, 2000-2499 g and ≥ 2500 g birth weight categories. The proportion of infants not fed with human milk varied from 6 to 82% across different centers. Conclusion: Our study found limited breastfeeding and use of human milk among the NICU infants at discharge. At discharge, infants with a birth weight 1500-2499 g were fed exclusively with human milk less than those in higher or lower birth weight categories.

Making the First Days of Life Safer Preventing Sudden Unexpected Postnatal Collapse while Promoting Breastfeeding

Early and prolonged skin-to-skin contact (SSC) after birth between a mother and her newborn has been shown to generate beneficial effects on the mother-infant relationship and breastfeeding. Close mother-infant body contact immediately after birth positively enhances exclusive breastfeeding during the hospital stay, with a dose-response relationship. Skin-to-skin contact may ease the infant’s transition to extra-uterine life and helps regulate the infant’s body temperature and nursing behavior. However, reports of sudden unexpected postnatal collapse (SUPC) soon after birth, in healthy term neonates, in association with SSC, have raised concerns about the safety of this practice. Based on available evidence, we developed a surveillance protocol in the delivery room and postnatal ward of the Institute for Maternal and Child Health of Trieste (Italy). The aim of our protocol is (a) to promote safe mother and infant bonding and (b) to establish successful breastfeeding, without increasing the risk of SUPC. As there is no known effective intervention to prevent SUPC, our protocol has been conceived as a potential best practice.

Cooling for Newborns with Hypoxic Ischemic Encephalopathy

adverse effects of cooling and ‘early’ indicators of neurodevelopmental outcome. Data Collection and Analysis: Four review authors independently selected, assessed the quality of and extracted data from the included studies. Study authors were contacted for further information. Meta-analyses were performed using risk ratios (RR) and risk differences (RD) for dichotomous data, and weighted mean difference for continuous data with 95% confidence intervals (CI). Main Results: We included 11 randomized controlled trials in this updated review, comprising 1,505 term and late preterm infants with moderate/severe encephalopathy and evidence of intrapartum asphyxia. Therapeutic hypothermia resulted in a statistically significant and clinically important reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age (typical RR 0.75 (95% CI 0.68–0.83); typical RD –0.15, 95% CI –0.20 to –0.10); number needed to treat for an additional beneficial outcome (NNTB) 7 (95% CI 5–10) (8 studies, 1,344 infants). Cooling also resulted in statistically significant reductions in mortality (typical RR 0.75 (95% CI 0.64–0.88), typical RD –0.09 (95% CI –0.13 to –0.04); NNTB 11 (95% CI 8–25) (11 studies, 1,468 infants) and in neurodevelopmental disability in survivors (typical RR 0.77 (95% CI 0.63–0.94), typical RD –0.13 (95% CI –0.19 to –0.07); NNTB 8 (95% CI 5–14) (8 studies, 917 infants). Some adverse effects of hypothermia included an increase sinus bradycardia and a significant increase in thrombocytopenia. Cochrane Abstract

Functional Neuroimaging of Breastfeeding Analgesia by Multichannel Near-Infrared Spectroscopy

Background: Newborns perceive pain, and several non-pharmacologic analgesic methods have been used during painful procedures. Activation of the neonatal somatosensory cortex, in association with a painful procedure without analgesia, has been demonstrated by two-channel near-infrared spectroscopy (NIRS). Objectives: To evaluate both cortical and behavioural responses of healthy term newborns to a painful procedure during two non-pharmacologic analgesic interventions, i.e. glucose solution and breastfeeding. Methods: The effects of glucose and breastfeeding on pain-associated neonatal cortical activity were studied in two groups (n = 30) by multichannel NIRS during a heel prick. Cortical activation was identified by variations in oxygenated haemoglobin. Neonatal pain expression was assessed by a validated scale. Results: No significant variations in cortical activity emerged using glucose solution, whereas breastfed newborns showed widespread cortical activation. Breastfed neonates showed significantly less behavioural pain expression. Conclusions: Glucose is associated with no significant cortical activation and may interfere with pain-associated response at the cortical level. Conversely, breastfeeding analgesia is associated with generalized cortical activation and may act by multisensory stimulation, possibly overwhelming pain perception.

Intermittent Kangaroo Mother Care: A NICU Protocol

The practice of kangaroo mother care (KMC) is steadily increasing in high-tech settings due to its proven benefits for both infants and parents. In spite of that, clear guidelines about how to implement this method of care are lacking, and as a consequence, some restrictions are applied in many neonatal intensive care units (NICUs), preventing its practice. Based on recommendations from the Expert Group of the International Network on Kangaroo Mother Care, we developed a hospital protocol in the neonatal unit of the Institute for Maternal and Child Health in Trieste, Italy, a level 3 unit, aimed to facilitate and promote KMC implementation in high-tech settings. Our guideline is therefore proposed, based both on current scientific literature and on practical considerations and experience. Future adjustments and improvements would be considered based on increasing clinical KMC use and further knowledge.

Suckling and sugar for pain reduction in babies

www.thelancet.com Vol 369 April 28, 2007 1429 However, this fi nding comes from only one trial in which breastfeeding was stopped before the procedure. Even if this fi nding was confi rmed by other studies, it might not necessarily be clinically signifi cant. In this regard, we would like to summarise our fi ndings on nonpharma cological analgesia in new born babies. We studied 197 healthy term infants (birthweight 2500–4500 g) at the time of blood sampling by heel prick for metabolic screening. They were randomly assigned to one of four groups: (1) breastfeeding 2 min before and during the procedure; (2) 2·0 mL 20% glucose 2 min before and during the procedure; (3) sensory stimulation by holding, speaking, and fondling; or (4) wrapping. Pain was evaluated with the premature infant pain profi le (PIPP score). As in Carbajal’s study, we found no diff erence between breastfeeding and glucose (table). In both studies, mean PIPP scores were very similar and quite low. It might well be that sucrose plus breastfeeding will further lower the pain score. However, in the average nursery, this can represent an additional burden in an already busy routine. One might wonder whether lowering an already low score is worth the eff ort.

Pain activates a defined area of the somatosensory and motor cortex in newborn infants

Cerebral near-infrared spectroscopy (NIRS) has already been used to detect pain-associated cortical activity in newborn infants. Two-channel NIRS has identified significant responses in cortical areas, such as the somatosensory cortex, in association with painful blood sampling procedures (1–3). However, neuroimaging studies in adults have showed that a painful conscious experience activated additional cortical areas, such as the motor cortex and the secondary somatosensory cortex (4). Moreover, the adult primary somatosensory cortex exhibits a somatotopic organisation in processing noxious stimulations (5), similar to the somatotopic cortical representation of nonpainful stimuli. Using functional magnetic resonance imaging (MRI) in a healthy non-sedated term-born newborn infant showed that a pinprick stimulation on the foot bilaterally activated the primary and secondary somatosensory cortex (6). Cortical activation was localised in a somatosensory area appropriate for foot representation. In this study, we used a multichannel NIRS system, which allowed a higher spatial resolution than two-channel devices (7), to assess pain-associated cortical activity during a heel prick for blood sampling, in healthy full-term infants. The aim of the study was to assess the feasibility of multichannel NIRS for studying pain-associated cortical activation in non-sedated newborn infants. We tested the hypothesis that the cortical representation of pain on the somatosensory cortex in the newborn infant does not topographically differ from that of an adult.

Opitz trigonocephaly syndrome presenting with sudden unexplained death in the operating room: a case report

IntroductionOpitz trigonocephaly C syndrome (OTCS) is a rare malformation syndrome with the following features: synostosis of metopic suture, craniofacial abnormalities, severe mental retardation and a multitude of pathological findings affecting almost every organ system. OTCS is associated with a high mortality rate.Case presentationWe describe the case of a Caucasian male baby who died at five months of age during surgical correction of the craniofacial anomaly.ConclusionAs previously reported, OTCS may have an increased mortality rate during craniofacial surgery. Careful evaluation of surgery risk-benefit ratio is warranted in such patients.

An IBCLC in the Maternity Ward of a Mother and Child Hospital: A Pre- and Post-Intervention Study

Published evidence on the impact of the integration of International Board Certified Lactation Consultants (IBCLCs) for breastfeeding promotion is growing, but still relatively limited. Our study aims at evaluating the effects of adding an IBCLC for breastfeeding support in a mother and child hospital environment. We conducted a prospective study in the maternity ward of our maternal and child health Institute, recruiting 402 mothers of healthy term newborns soon after birth. The 18-month intervention of the IBCLC (Phase II) was preceded (Phase I) by data collection on breastfeeding rates and factors related to breastfeeding, both at hospital discharge and two weeks later. Data collection was replicated just before the end of the intervention (Phase III). In Phase III, a significantly higher percentage of mothers: (a) received help to breastfeed, and also received correct information on breastfeeding and community support, (b) started breastfeeding within two hours from delivery, (c) reported a good experience with the hospital staff. Moreover, the frequency of sore and/or cracked nipples was significantly lower in Phase III. However, no difference was found in exclusive breastfeeding rates at hospital discharge or at two weeks after birth.