Lactobacillus paracasei subsp. paracasei F19 in Bell's stage 2 of necrotizing enterocolitis.

AIM: The aim of this trial is to evaluate the role Lactobacillus paracasei in Bell's stage 2 in order to prevent the clinical progression to stage 3. METHODS: A prospective study was approved and started in December 2008. Patients were infants with birth weight 600 to 1500 g. One group received probiotic supplementation (L. paracasei susp.paracasei F-19) and the control group received only standard medical treatment. The primary outcome was the progression to stage 3 as defined by Bell's modified criteria. Inclusion and exclusion criteria were created and discussed with parents before treatment. RESULTS: Thirty-two patients (stage 2 NEC) were considered eligible for the study. Group A: 18 patients and Group B: 14 patients. Three patients in group A and six patients in group B had a clinical history of Bell's stage 3 NEC (P<0.05); oral supplementation of L. paracasei reduced the clinical progression of NEC. It was considered that an improvement in intestinal motility might have contributed to this result. CONCLUSION: The use of Lactobacillus paracasei subsp. paracasei F-19 is safe; the low progression rate to stage 3 NEC suggests that the use of this probiotic in stage 2 NEC could be a valuable therapeutic option.

[Correlations between pediatric emergency department and legal medicine in the field of child abuse: the usefulness of flow-charts]. / Correlazione tra il dipartimento d'urgenza pediatrico e la medicina legale in tema di abuso sui minori: utilità di linee-guida.

According to the World Health Organization, child abuse is one of the major and unrecognised problems affecting the well-being and impairing the harmonic development of children and adolescents. Official statistics, provided by Police and Courts are not useful for quantifying abuse because these numbers refer to cases actually brought to trial, a small part of the amount. In Europe and North America more effective measures and intervention programs were set up in order to get with a reliable description of this crucial social problem; for example, a "dedicated" team performing careful screenings on suspicious cases (Suspected Child Abuse and Neglect Teams, SCAN). A legal medical expert joins the team bringing his specific experience on lesions from the perspective of criminological interpretation, thereby giving a substantial contribution for an objective evaluation of available evidence. The multidisciplinary approach can give the greatest contribution especially in the initial steps of the evaluation of the child. Intervention protocols and guidelines are useful tools to achieve this goal, as shown by medical literature. We propose to introduce a flow-chart for the initial evaluation of cases, derived from that used in the Canadian Paediatric Emergency Departments. This is supposed to be experimentally used by health care workers in an Emergency Department setting and to be subsequently evaluated both as a diagnostic and a statistic instrument.

Antibiotics in neonatal infections: a review.

The bacteria most commonly responsible for early-onset (materno-fetal) infections in neonates are group B streptococci, enterococci, Enterobacteriaceae and Listeria monocytogenes. Coagulase-negative staphylococci, particularly Staphylococcus epidermidis, are the main pathogens in late-onset (nosocomial) infections, especially in high-risk patients such as those with very low birthweight, umbilical or central venous catheters or undergoing prolonged ventilation. The primary objective of the paediatrician is to identity all potential cases of bacterial disease quickly and begin antibacterial treatment immediately after the appropriate cultures have been obtained. Combination therapy is recommended for initial empirical treatment in the neonate. In early-onset infections, an effective first-line empirical therapy is ampicillin plus an aminoglycoside (duration of treatment 10 days). An alternative is ampicillin plus a third-generation cephalosporin such as cefotaxime, a combination particularly useful in neonatal meningitis (mean duration of treatment 14 to 21 days), in patients at risk of nephrotoxicity and/or when therapeutic monitoring of aminoglycosides is not possible. Another potential substitute for the aminoglycoside is aztreonam. Triple combination therapy (such as amoxicillin plus cefotaxime and an aminoglycoside) could also be used for the first 2 to 3 days of life, followed by dual therapy after the microbiological results. In late-onset infections the combination oxacillin plus an aminoglycoside is widely recommended. However, vancomycin plus ceftazidime (+/- an aminoglycoside for the first 2 to 3 days) may be a better choice. Teicoplanin may be a substitute for vancomycin. However, the initial approach should always be modified by knowledge of the local bacterial epidemiology. After the microbiological results, treatment should be switched to narrower spectrum agents if a specific organism has been identified, and should be discontinued if cultures are negative and the neonate is in good clinical condition. Penicillins and third-generation cephalosporins are generally well tolerated in neonates. There is controversy regarding whether therapeutic drug monitoring of aminoglycosides will decrease toxicity (particularly renal damage) in neonates, and on the efficacy and safety of a single daily dose versus multiple daily doses of these drugs. Toxic effects caused by vancomycin are uncommon, but debate still exists over the need for therapeutic drug monitoring of this agent. When antibacterials are used in neonates, accurate determination of dosage is required, particularly for compounds with a low therapeutic index and in patients with renal failure. Very low birthweight infants are also particularly prone to antibacterial-induced toxicity.

Candida infections in newborns: a review.

Despite adequate treatment, nosocomial fungal infections have become an increasingly important cause of morbidity, extended hospitalization, and mortality in critically ill newborn babies. Furthermore, the high incidence of central nervous system involvement in septic newborns frequently results in serious neurological damage and psychomotorial sequelae. The prevention of fungal colonization in the population at risk, together with prompt diagnosis and treatment, are an efficient combination which lead to a better outcome of neonatal fungal infections. New drugs characterized by great efficacy and tolerance have recently been employed in clinical practice. This article summarizes certain aspects of Candida spp. infections in the neonatal period with regard to multisystemic presentation and involvement.

[Sepsis caused by Candida in the neonatal period]. / Sepsi da Candida nel periodo neonatale.

Fungal pathogens have become increasingly important as causes of mortality and in newborn infants, especially preterm with very law birth weight, admitted to a neonatal intensive care unit. We report here the cases of 26 neonates (19 VLBW) with systemic fungal infections. Average birth weight and gestational age were 1405 +/- 977 g (range 595-4180 g) and 29 +/- 5 weeks (range 24-41 weeks) respectively. 24 newborn infants required endotracheal intubation and mechanical ventilation and 6 were affected by a severe congenital malformation. An umbilical e/o central intravascular catheter was inserted in all infants and each of them received antibiotics (one or more courses). The Candida species isolated were: C. albicans (n. 23; 88.5%), C. parapsilosis (n. 2; 7.6%) and C. glabrata (n. 1; 3.8%). Frequently encountered symptoms and signs in our neonates included: vasomotor instability with peripheral hypoperfusion (92%), gastro-intestinal disturbances (69%), respiratory distress and increasing ventilatory requirements (65%). Other symptoms were less frequent. 20 newborn infants had leucocytosis, 19 thrombocytopenia, 14 presented both signs. Factors found to be frequently associated with fungal infection included: use of broad-spectrum antibiotic therapy, presence of central venous or umbilical artery catheter, endotracheal intubation and mechanical ventilation, surgical abdominal intervention. After antifungal systemic therapy, clinical cure and microbiological eradication were achieved in 81% of cases, only 1 out of 11 deaths was directly attributed to Candida infection. In our experience the association of amphotericin B+ 5 glucytosine proved to be an effective and well-tolerated therapy for the treatment of severe fungal infections in neonates. A high index of suspicion, especially in premature infants (VLBW), a rapid diagnosis and early initiation of antifungal therapy still remain the essential features in treating neonatal fungal infections.

[Sudden infant death syndrome (SIDS) update: etiopathogenesis, epidemiology, legal medicine aspects, cases]. / Morte improvvisa del lattante (SIDS) update: eziopatogenesi, epidemiologia, aspetti medico legali, casistica.

Sudden infant death syndrome (SIDS) is the most common cause of postneonatal infant death in developed countries. The causes of SIDS remain unknown. The principal hypothesis appears abnormality of cardiorespiratory control, sleep-wake regulation. Also in our personal date the autopsy have not been of sufficient specificity and sensitivity to explain the disease.

[Aminoglycosides, risk factors and neonatal kidney]. / Aminoglicosidi, fattori di rischio e rene neonatale.

Antibiotics are the leading cause of drug-induced kidney disease, and among them the aminoglycosides (AMG) are the main nephrotoxic agents, bringing about kidney damage via a direct dose-dependent mechanism. The combination of an aminoglycoside and a penicillin derivative is still the most commonly recommended and used first-line treatment modality in the empirical therapy of neonatal sepsis, despite the low therapeutic index of AMG. The immaturity of neonatal kidney function, particularly in preterm neonates, makes newborn infants particularly susceptible to AMG-induced kidney damage. Numerous factors intervene in bringing about AMG-induced kidney damage, such as factors related to the antibiotic itself (intrinsic toxicity, administration route, type of monitoring of blood concentrations), those related to the subject treated (neonatal age, constitutional sensitivity), and others related to associated pathology (neonatal anoxia, renal hypoperfusion, respiratory distress/mechanical ventilation, hyperbilirubinaemia/phototherapy, electrolyte disorders, and even the acute sepsis calling for antibiotic therapy), as well as pharmacological factors (concomitant therapies such as diuretics, indomethacin and other antibiotics, particularly glycopeptides and cephalosporins).

Influence of dietary taurine on vitamin D absorption.

To evaluate the influence of dietary taurine supplementation on vitamin D absorption, we studied three groups of infants: 21 (11 preterm) were fed a taurine-free formula, 21 (10 preterm) were fed a taurine-supplemented formula (50 mg/100 g of powder) and 20 (9 preterm) were fed human, not heat-treated milk. Taurine, total bile acids, glyco-(GBA) and tauro-(TBA) conjugated bile acids, 25-hydroxyvitamin D3 (25OHD3) and 1,25-dihydroxyvitamin D3 (1,25OH2D3) were determined in all infants at birth in blood cord and at one and three months of life. In preterm infants fed a taurine-free formula, we found lower plasma taurine levels than in infants of other groups at one and three months of life. In these infants, GBA predominated, with a G/T ratio of 1.1 and 1.4 at one and three months of life, whereas in all other infants TBA predominated with a G/T ratio always < 1. Also, 25OHD3 and 1,25OH2D3 levels were significantly lower in preterm infants fed a taurine-free formula than in infants fed a taurine-enriched formula or human milk. Term infants fed a taurine-free formula did not show differences in the parameters studied in comparison to infants of other groups. Low taurine dietary intake appears to compromise vitamin D absorption in preterm infants, and therefore taurine supplementation of preterm infant formulas should be encouraged.

[Specific IgE in the cord blood of infants from allergic parents]. / Le IgE specifiche nel sangue del funicolo di nati da genitori atopici.

We evaluated the cord blood level of specific IgE in newborn having first grade relatives affected by allergic disease. We aimed: a) to look for a significant threshold (if any) of sp. IgE predictive of atopy; b) to verify the clinical reliability of the CAP System by Pharmacia. 9 out of 60 patients with positive family history had sp. IgE > 0.35 KU/L; 7 out of these 9 children were symptomatic to a clinical follow-up at 18 months. Moreover 65% of children with positive history but no sp. IgE and 100% of patients with both a negative history and no sp. IgE were completely free of allergic symptoms in the same period. We conclude that a careful history and cord blood sp. IgE measurement might be of value in early diagnosis of atopy.

[Evaluation of the therapeutic effectiveness of orally administered fenoterol in asthmatic children]. / Valutazione dell'efficacia terapeutica del fenoterolo per os nel bambino asmatico.

In a single blind controlled trial we evaluated the effectiveness of fenoterol, administrated by oral route, in 14 pediatric patients, suffering from allergic asthma. The study was designed through three cycles of therapy: the first with fenoterol (0.25 mg/kg), the second with placebo and the third with the active drug again. The duration of each period was of one month and every two weeks a clinical and spirometric evaluation were performed. Positive data with statistically significant differences for the spirometric parameters were found together with a good safety and tolerability.

[Phagocytic function of PMN granulocytes in a pediatric population with recurrent respiratory infections]. / Studio della funzionalità fagocitaria dei granulociti PMN in una popolazione pediatrica con infezioni respiratorie ricorrenti (IRR).

We have studied the Phagocytosis at 32 children who had recurrent respiratory tract infection (RRI). We used a easy method (Phagolux). The seventy-five percent (24/32) of children had a Phagocytosis and/or Opsonisation Deficit during or following the acute respiratory tract infection. All children (except for one who had a C3-deficit) reached normal parameters after (or al least) fourty-five days.

[Giardiasis: a clinical case with rare symptomatology]. / Giardiasi: un caso clinico con sintomatologia rara.

We reported a clinical case of a child with Giardiasis whose clinical symptoms show some common aspects (acute diarrhea, abdominal pain) with others less known (irido-keratoconjunctivitis) or even rare (acute interstitial nephritis).

[Influence of 2 different milk formulas on renal tubular function in full- and pre-term newborn infants]. / Influenza di due differenti formule sulla funzione tubulare renale nei neonati a termine e pretermine.

74 neonates (39 premature and 35 full term) were fed during first week of life on two available formulas: one was adapted and the other a powdered sweetened half skimmed milk. Urinary osmolarity was higher in neonates fed half skimmed milk. The study of blood parameters of renal function showed an higher urea nitrogen and a lower base excess in neonate fed half skimmed milk and in particular in prematures. Renal tubular function studied by means of volume/minute (V/m') of the clearance of free water (CH2O), of the clearance of osmotically active substances (COsm), and of the maximum tubular reabsorption of water (TcH2O), showed an increased clearance of osmotically active substances in both premature and full term neonates fed half skimmed milk and tubular reabsorption of water (TCH2O) in prematures. Such parameters of renal tubular function seem to be sensible indices for evaluating renal solute load of diet.