Abstracts of the XXVI Congresso Nazionale - Società Italiana di Neonatologia

s of the XXVI Congresso Nazionale Società Italiana di Neonatologia Venezia, Italy. 7-10 October 2020 Published: 29 April 2021 A1: The COVID National Neonatal Registry of the Italian Society of Neonatology (SIN) Camilla Gizzi, Lorenza Pugni, Elena Spada, Claudio Bellù Department of Pediatrics, Ospedale Sandro Pertini, Rome, Italy; NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; Geos Consult S.r.l., Milan, Italy Correspondence: Camilla Gizzi (camillagizzi@gmail.com) Italian Journal of Pediatrics 2021, 47(Suppl 1):A1: Background: The COVID National Neonatal Registry aims to collect clinical data of infants born from mothers with SARS-CoV-2 virus infection diagnosed at any time during pregnancy and data from infants with acquired SARS-CoV-2 virus infection within the first month of life. Methods: After obtaining the approval by the Ethics Committee of the Coordinating Center (IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan), on March 2020 all the Italian birth centres were invited to participate. The database, designed by LP and CG and constructed on a REDCAP platform by CB, is composed of 5 sessions, asking for: birth hospital; mothers; infants born from a positive mother at the time of delivery; infants admitted for COVID infection acquired within the first month of life; infants born from a negative mother at delivery but positive during pregnancy. ES was responsible for data analysis. Results: As of September 2020, 305 records were entered. Data analysis was performed on 291 infants, 238 of which born from a positive mother, 13 with an infection acquired after birth and 40 born from a mother with previous positivity. Most of the records were inserted by Lombardia (70.7%), Emilia Romagna (13%) and Piemonte (8.2%). Among the 278 infants born from a positive mother, 63% were delivered vaginally, 23% by elective and 14% by emergency CS. Of the 238 positive mothers at birth, 208 had a known positivity, 19 were under diagnostic assessment, and 11 showed symptoms and tested positive following delivery. At delivery, 23.5% of women were symptomatic, in most cases with mild to moderate flu-like symptoms. Fourteen% of infants had a GA<37wks showing a prematurity rate double than before the pandemic and in line with the literature data; 12.5% of infants had a BW<2500g. Seventy three% of infants born from positive mothers were isolated with her in rooming-in, 19.7% were isolated in the NICU, 2.9% in the Nursery, 2.5% with their mother and subsequently separated and 10.5% were transferred. Seventy nine% of infants were fed exclusively with breast milk. Overall, 2.8% of infants (n. 6) isolated in rooming-in with their mothers tested positive for SARS-CoV-2 during hospitalization. Of these, 1 was positive on day 1 and subsequently confirmed. Two were negative at birth and became positive during hospitalization, on day 7 and 9. Three were born to a mother not tested at delivery, but positive during hospitalization. In all cases, newborns were asymptomatic or paucisymptomatic. Thirteen infants were admitted for home-acquired SARS-CoV-2 infection; they were all symptomatic (mostly fever and feeding difficulties), requiring a ventilatory support only in 2 cases. The infection was contracted between 5 30 days of life and in 5 cases a contact with a positive family member was reported. Conclusion: The COVID National Neonatal Registry improved epidemiological and scientific knowledge in this field and helped in creating a network which improves uniformity of management and high quality of care to infants and their mothers. None of the authors have competing interest. A2: Feeding difficulties in the very preterm infant in the first year of life Eleonora Pontello , Federica De Osti , Nadia Battajon , Gianluca Visintin , Silvia Vendramin , Marika Buffo , Paola Lago 1 Neonatal Intensive Care Unit, Ca’ Foncello Hospital, Treviso, Italy; Department of Woman’s and Child’s Health, University of Padova, Padova, Italy Correspondence: Eleonora Pontello (eleonora.pontello1@gmail.com) Italian Journal of Pediatrics 2021, 47(Suppl 1):A2: Background: Feeding disorders affect about 25-45% of preschool children; they are especially common in children with developmental disorders, including premature babies. They are one of the most common causes of delayed discharge, increased maternal stress and health care costs. During extrauterine life, the premature baby's nervous system is exposed to sensory overstimulation, resulting in an alteration of sensory processing and the highest risk of developing oro-buccal dyspraxia, hypersensitivity, and food aversion even after discharge . Several studies support an early intervention in NICU, in order to improve the maturation of infants’ proper oral feeding skills . Our primary outcome was to evaluate the incidence of feeding disorders on a VLBWI cohort during the 1st year of life. Secondary outcome was to identify any relationship between extreme prematurity, prolonged passive tube feeding and future feeding disorders. Materials and methods: During NICU stay, we evaluated potential factors that could be correlated with the development of feeding difficulties, such as the duration of tube feeding, the transition time from tube to oral feeding, and the start of independent oral feeding. Italian Journal of Pediatrics 2021, 47(Suppl 1):96 https://doi.org/10.1186/s13052-021-01039-y © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. We examined also feeding difficulties in the first year of life and the incidence of GER, following in the weaning phase and at 12 months of life. We compare infant born GA≤28 with those ≥29 to understand the role of extreme prematurity in the development of feeding disorders. The demographic characteristics and clinical data were collected from electronic medical records by investigators. Prism 8 (GraphPad Software, San Diego, CA, USA) was used for statistical processing. Results: We included 85 VLBW infants born in 2017-2018. The incidence of eating disorders in the first year of life was 29.4%. A statistically significant increase in feeding difficulties was found in VLBWIs with extreme prematurity (44.7% vs 17.0%, p <0.05), but there was no statistically significant difference in specific disorders (difficulty in weaning phase, difficulties at 12 months and GER). Conclusions: Feeding disorders affect about one third of preterm babies in the first year of life. Poor feeding skills in infancy can continue to be problematic later on, for months or even years and become a serious concern for caregiver. This work helps to raise awareness among NICU staff, to reduce as much as possible the exposure to invasive procedures and to rehab these subjects early.

We examined also feeding difficulties in the first year of life and the incidence of GER, following in the weaning phase and at 12 months of life. We compare infant born GA≤28 with those ≥29 to understand the role of extreme prematurity in the development of feeding disorders. The demographic characteristics and clinical data were collected from electronic medical records by investigators. Prism 8 (GraphPad Software, San Diego, CA, USA) was used for statistical processing. Results: We included 85 VLBW infants born in 2017-2018. The incidence of eating disorders in the first year of life was 29.4%. A statistically significant increase in feeding difficulties was found in VLBWIs with extreme prematurity (44.7% vs 17.0%, p <0.05), but there was no statistically significant difference in specific disorders (difficulty in weaning phase, difficulties at 12 months and GER). Conclusions: Feeding disorders affect about one third of preterm babies in the first year of life. Poor feeding skills in infancy can continue to be problematic later on, for months or even years and become a serious concern for caregiver. This work helps to raise awareness among NICU staff, to reduce as much as possible the exposure to invasive procedures and to rehab these subjects early. KEYWORDS: Feeding disorders; food aversion; sensory overstimulation; preterm; newborns. Patient permission Authors didn't obtain written informed consent from parents for publication, since only anonymous unrecognizable patient data was used to fulfill the database.
Abstract (word count 388) Background: A reappraisal of the guidelines for management of infants with early onset sepsis (EOS) advocates for close observation of well-appearing newborn infants ≥35 weeks' gestation with maternal risk factors, rather than empiric antibiotic treatment [1][2][3][4][5][6][7][8] . EOS calculator represents a useful and safe tool to guide an individualized management of EOS, without any significant increases in adverse outcomes [9][10][11][12][13][14][15][16] . Data on its clinical application is still limited. Our primary outcome was the rate of empiric antibiotics for suspected EOS in the first 72 hours. Secondary outcomes included the frequency of close or intensive monitoring of vital parameters, the rate of blood withdraw, the number of antibiotic use days per 100 live births. Methods: We included newborn infants born at ≥35 weeks' gestation at Treviso hospital in 2018 and 2019, with maternal EOS risk factors or EOS clinical signs. We compared 3 periods, before and after the introduction of EOS calculator, including a learning period and a fully application period. We described the effect of this calculator on clinical practice. The demographic characteristics and clinical data were collected from electronic medical records by investigators. Prism 8 (GraphPad Software, San Diego, CA, USA) was used for statistical processing. Results: The study cohort included 4354 newborn infants with GA ≥35 weeks, respectively 826 in baseline period, 1426 in the learning period and 2102 in the EOS calculator period. Among them 1040 (23,8%) infants presented maternal risk factors for neonatal sepsis, including 216 (26,15%) in baseline period, 164 (11,5%) in learning period and 660 (31,3%) in EOS calculator period. Characteristics of the infants born in these 3 periods were similar for sex, gestational age, birth weight and delivery method. The incidence of cultureconfirmed EOS was very low across 3 periods. Empirical antibiotic administration in the first 72 hours decreased respectively from 13,4% to 6,4% (p< 0,05). Blood culture and laboratory evaluations had fallen from 30,6% to 12,9% (p< 0,05). Close monitoring of vital parameters decreased from 99,1% to 13,8% (p< 0,05). The number of antibiotic days per 100 live births decreased from 17,07 to 8,94 days (p<0,05). We had no readmissions for EOS. Conclusions: Application of EOS calculator is useful to standardize clinical practice as well as to reduce the use of antibiotics without compromising safety in a population with a relatively low incidence of culture-proven EOS and good access to follow-up care. Keywords: Antibiotics; early onset sepsis; infection; newborns; sepsis calculator Patient permission Authors didn't obtain written informed consent from parents for publication, since only anonymous unrecognizable patient data was used to fulfill the database. 15 Since its establishment, the Meyer's HMB has processed more than 80,000 litres of milk, donated by more than 12,000 women, and supplied to more than 16,500 children [1]. The HMBs, functionally linked to paediatric departments, collect, store and distributes donor breast milk on medical prescriptions.

Methods
Women who choose to become a donor agree to undergo a simple but necessary screening, similar to that carried out at blood transfusion centres. The aim of this practice is to identify any clinical conditions or behaviour of the donor that may be harmful to the children who receive the donated milk [2]. The HMB follows the recommendations of international scientific associations [3,4] and European Union directives on food hygiene (HACCP) in order to provide a product that meets the highest possible safety and integrity requirements for biologically active components. The quality of the product is guaranteed by well-established procedures regarding donor screening, milk collection and storage methods, physical and bacteriological controls, pasteurisation and documentation of medical-administrative acts. Donated, pasteurized milk is mainly provided to children admitted to the Meyer's (about 300 patients per year); 20-25% of the bank milk is required by other public and private healthcare facilities. The use of fresh human milk is temporarily contraindicated for newborns < 32 weeks (completed) of gestational age and/or immunodeficient neonates (T-cell deficiency) in case of women who contracted a CMV infection before pregnancy. Positivity for HIV, HBV, HCV, drug use and alcoholism are conditions that permanently contraindicate the use of donated breast milk. Women with an ongoing syphilis and tuberculosis are temporarily excluded as donors.

Results
The consequent adoption of the method described above ensured the total absence of infectious diseases caused by the use of donor breast milk.

Conclusion
The reason for investing significant resources in a HMB is summarised by the main advantages of using human milk [5]: low incidence of necrotizing enterocolitis reduced incidence of sepsis and other infections reduced incidence of bronchopulmonary dysplasia high food tolerance prevention of hypertension and insulin resistance.

Background
The SARS-CoV-2 pandemic has heavily impacted the Italian public health system, highlighting the urgency of guidelines for the mothernewborn dyad management. Droplets and close contact are known to be a common route of viral transmission [1] , while little is known about other routes, including the transplacental one. Transplacental transmission of SARS-CoV-2 infection is possible during the last weeks of pregnancy, but this remains still controversial [2][3] . Methods Unlike other institutions, the Italian Society of Neonatology (SIN) reviewed the current scientific knowledge and assured that the mother-newborn dyad to the extent possible [4] . Breastfeeding is not considered a transmission vehicle, neither for SARS-CoV-2 nor for other known respiratory viral infections (WHO, 2020). On the contrary, it has been found to be vehicle of specific SARS-CoV-2 antibodies within a few days following the onset of the disease in the mother, possibly modulating the clinical expression of infants' infection.

Results
Consequently, SIN's indications [5] , endorsed by the Union of European Neonatal & Perinatal Societies (UENPS) are: Allow rooming-in and breastfeeding in asymptomatic mothers (Table1) [6][7] ; Separate symptomatic mothers from their baby until they are able to take care of her/him it; Expressed breast milk when possible, unpasteurised, to not reduce its biological and immunological value [8] ; Background. The awareness that hospitalized infants might be at high risk of developing pressure injuries has increased in the last years. This is due to immature skin, compromised perfusion, decreased mobility, altered neurological responsiveness, fluid retention and medical devices. [1,2] Pressure injuries can be classified using the National Pressure Injuries Advisory Panel staging system based on the depth and severity of tissue injury. They can be also divided into conventional (caused by pressure on a bony prominence) or device-related (caused by pressure on the tissues from a medical device). [3] Materials and methods. A systematic review was performed. The aims of the study were: 1) to investigate incidence and risk factors of pressure injuries in neonatal population and 2) to analyze the most frequent neonatal pressure injuries. Secondary, preventive and therapeutic strategies were analyzed.
Results. Studies show that the incidence of pressure injuries is very variable in infants admitted to the Neonatal Intensive Care Units. [4] Infants develop both conventional and device pressure injuries: conventional pressure injuries are often located at the occiput because of the large dimension of this area, while device-pressure injuries are frequently caused by non-invasive ventilation devices on infants' noses, particularly by Nasal Continuous Positive Airway Pressure (Ncpap). [2,4,5] Infants with Ncpap lesions are younger, have a lower weight and a lower gestational age than those with occipital pressure injuries [1,2,5] who are usually intubated, deeply sedated, in the post-surgery period and very edematous. [6,7,8] Proper identification of at-risk infants and the implementation of preventive strategies are crucial to reduce the incidence of pressure injuries. [9] Neonatal nurses should use validate neonatal skin risk assessment scales and develop protocols for the standardization of skin inspection and care, nutritional management and pressure management through specific dressings or special support surfaces. All nursing staff should know the basic rules for pressure injuries prevention, the possible support surfaces and the available options for treatment. [7,9,10] When a pressure injury unfortunately occurs, it is necessary to use the proper dressing. Few products are approved in newborns' care due to the risk of possible adverse reactions using adult treatments. [8] Conclusions. Pressure injuries are a nursing care quality indicator and represent a relatively frequent, potentially preventable and critical event. [9] Implementation of an effective pressure injury prevention and treatment strategies program based on available scientific evidence is needed to reduce the variability of care. The benefits of standardized care include early risk identification and increasing and improving adherence to evidence-based preventive interventions. [11] Conflicts of interest The authors have no conflicts of interest to disclose. The quality of nursing care derives from the development of the knowledge that this discipline 1,2 Research plays e central role. The goal of nursing research is to strengthen and broaden current knowledge regarding nursing in order to contribute to performance improvement. Research is critical to meet the challenging goal of the delivering quality results in collaboration with clients, their families/ their loved ones 1,2,3,4 By analyzing the literature produced in a specific sector, it is possible to have a picture of the cultural evoluttion

YES -SARS-CoV-2 positive or under investigation
Pasteurization is not indicated § Room divider or tent, face mask for the mother when she is breastfeeding or in intimate contact with the newborn, careful hand washing, arrangement of the baby's cradle at a distance of 2 meters from the mother's head, suspension of visits from relatives and friends°I n addition, adequate protection measures by health personnel, according to ministerial indicationŝ The mother's fresh milk must be expressed with a manual or dedicated electric breast pump. The mother should always wash her hands before touching the bottles and all components of the breast pump, following the recommendations for proper washing of the breast pump after each use of a science and its theoretical elaboration. The priorities of nursing research, identified in the study by Wielenga et al. 5 on the European NICUs, confirm identified neonatal intensive care nursing research priority provide a roadmap for future collaborative research efforts. The top nursing research priorities identified in our study relate to prevention and reduction of pain, medication errors, end-of-life care, the needs of parents and family, implementing evidence into nursing practice and pain assessment. The study aims to describe the publications' to nursing care in the neonatal setting, published in Europe in journals indexed in the main database. Methods A bibliometric search was conducted in july 2020 selecting the studies published between 2010 and 2020in international journals were searched on databases biomedical: PUB MED, EMBASE, and CINA HL.Each study has been classified on the base of qualitative and quantitative parameters. Results 97 publications have been included. Results show the studies' focus, the top nursing research priorities identified in the publications relate to: breastfeeding, palliative care /ethics, developmental care, education/ training, organization, pain, procedures. The main destination of the publications were national journals. The quantitative approach is more developed. In Italy and mainly concern single-center studies 6 . Qualitative, experimental and second research studies are still limited 7 .

Conclusions
The results suggest e development of Italian nursing research in the last decade. However, more reading and publications in international scientific journals should be encouraged. Key words: nurse's role, nursing care, neonatal nursing, neonatal, newborn, infant, premature infant . Background Neonatal bonding is that particular bond between mother and her newborn that begins in the mother's womb and is consolidated at birth immediately after childbirth. It is an important practice, which has a significant influence on the psychological component of the newborn. Indeed, it plays an essential role in supporting early neonatal social interactions, which can influence the neuro-behavioral outcomes of late childhood. Bonding consists of different elements that interact with each other: skin to skin contact, early and exclusive breastfeeding, eye contact and rooming-in.

Methods
The aim of this study is to assess glucose stability, breastfeeding rates at discharge and nutritional needs comparing groups of women who gave birth vaginally and by caesarean section. For this purpose, the responses of a group of 224 women were examined. We a randomly selected sample of women who had given birth from September 2019 and February 2020 in maternity and neonatology ward of the San Leonardo Hospital of Castellammare di Stabia, which has about 1000 births a year with a strong prevalence of vaginal births compared to caesarean ones. The sample included mothers of healthy and full-term infants. The women had an average age of 31 years with a range from 16 to 47 years old. In particular, 80,36% of women gave birth vaginally, 14,29% planned caesarean section and 5.35% by emergency caesarean birth. Statistical analysis was conducted by means of the Chi-square tests to estimate, with 95% confidence intervals, differences between categorical variables.

Results and conclusions
This work showed the correlation between the practice of bonding and the absence of glycemic changes in infants born from vaginal birth compared to those born from caesarean section, for which bonding is not performed. No differences between the two types of birth were found, with a confidence interval of 95%, both in terms of breastfeeding and the nutritional needs of each newborn. Background: Congenital heart disease (CHD) represent an important cause of morbidity and mortality in the neonatal period but also in later ages. [1] Prenatal diagnosis remains a very important tool in the diagnosis of these pathologies. Literature shows that only 50% of CHD is recognized during fetal life, [2] with wide variability from center to center and depending on the type of CHD. Neonatologist therefore plays a fundamental role in the diagnosis and management of these conditions. Discussion: Congenital heart defects can occur with acute clinical onset, immediately after birth or in the first hours or days of life. In these cases the cardiopathies involved are generally those characterized by non-duct dependent mixing circulation (i.e. total pulmonary anomalous venous return or transposition of the great arteries) or by ductus dependencies of the systemic or pulmonary circulation. These heart diseases generally manifest themselves clinically with cyanosis or shock. The neonatologist can use various tools to reach the diagnosis such as: clinical history, physical examination (finding of murmurs, reduction or absence of femoral pulses, etc.), hyperoxia test, etc. However in an emergency setting echocardiography remains essential. The use of this tool by the neonatologist has become widespread in recent years, as shown by recent literature. [3,4] Recently, European scientific societies have also drawn up guidelines in an attempt to standardize the use of this method. [5] Certain types of CHD could manifest themselves later in life, even after months or years from birth. For these conditions, proactive research by the pediatrician who follows the child is essential. Thus oximetry screening has entered in current clinical practice. [6] However, this instrument has some limitations such as the low detection rate for CHD characterized by left ventricle outflow obstructive defects (i.e. aortic coarctation, aortic stenosis, hypoplastic left heart, etc.). [7] In later ages, CHD can manifest with variable symptoms such as growth retardation, poor exercise tolerance, electrocardiographic modifications. Conclusion: It is important for the pediatrician to always remember, at any age, that the child may be suffering from a congenital heart disease. The proactive research of these diseases, using all available tools, will ensure the best possible care for children.
The imbalance between oxygen delivery (D02) and consumption (V02) leads to morbidity, mortality and adverse neurodevelopmental outcomes in premature infants.Central and peripheral factors define the amount of oxygen available to cells. Haemoglobin concentration, arterial oxygen partial pressure and, above all, cardiac index and output (CO) are the central factors, while microcirculation, haemoglobin affinity and CO redistribution are the peripheral factors. In the prematurenewborn, the cardiovascular system is immature and frequently leads to low-systemic blood flow (LSBF) states (35% of <30-week-old and61% of <27-week-old-infants). The low cardiac output syndrome (LCOS) is defined as a condition caused by a transient decrease in the systemic perfusion withVO2/DO2 imbalance at the cellular level. Immature organs are vulnerable to hypoxic damage and a differential diagnosis between LSBF and LCOS is crucial. The transitional circulation makes the CO monitoring particularly difficult. Treating low mean arterial pressure without signs of organ hypoperfusion represents an oversimplification of the physiopathology and can beevena damaging intervention. The neonatologists should adopt all the diagnostic tools (eco-functional, Non-Invasive CO Monitor, Near-infrared spectroscopy) to try to detect inadequate tissue perfusion and oxygenation at an early stage. In the suspicion of LCOS, clinicians should think to the possible contributing factors and the clinical context and should consider adaptation/maladaptation to a dynamic cardiocirculatory change. Contributing factors include reduced preload, reduced contractility, increased afterload and reduced vascular resistances. Moreover, it is important to consider the clinical context, the prenatal conditions and the time of LCOS onset. The management of LCOS include drugs that can be categorized as predominantly vasopressors (dopamine, norepinephrine) or inotropes (dobutamine, milrinone, levosimendan). Epinephrine is an inotropic drug with dose-dependent vasoactive action. The choice of the therapeutic agent should accurately follow the pathophysiology of the disease, considering the action on the heart and the peripheral receptor profile, with specific attention to the effect on systemic/pulmonary flows and resistances.
In conclusion, newborns with hemodynamic compromise require careful approach, due to the peculiarity of their neonatal circulation, the immaturity of the organism and the different responses to stimuli. Further studies are required to improve the monitoring of patients and the understanding of the individual response to inotropic agents.
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