Is early use of pacifier a risk factor for diarrhea?

AIM

Non nutritive suckling has been always used by mothers for calming and comforting infants and young children. Previous studies have suggested that pacifiers may get contaminated but only three studies have shown a possible association between the use of pacifiers and diarrhea or enteric infections. The goal of this study was to investigate whether the early start of pacifier within the first month of life is a risk factor for diarrhea in early childhood.

METHODS

Case-control study. Subjects 12 to 36 month old were recruited. Cases were children with at least 1 episode of diarrhea per year of life.

RESULTS

Among cases (N.=63), those who had started using pacifier in the first month of life were 61.9%, while among controls (N.=78) they were 29.4%, OR 3.89, CI95% 1.92-7.85. Type and frequency of pacifier hygiene practices were not associated with diarrhea.

CONCLUSION

Our results suggest that the recommendation to postpone pacifier use after the first month of life not to interfere with the duration of breastfeeding, may have also the effect to reduce the risk of episodes of diarrhea in the first three years of life.

["The grandest hero who has ever lived": an unpublished letter written by Florence Nightingale about Garibaldi]

In the year of the 150th anniversary of the Unity of Italy, Italian nurses cannot forget that Florence Nightingale herself, founder of modern Nursing , was a fervid support of the Risorgimento and of Italian unity. An unpublished letter, signed by her and conserved in the State archives of Pistoia, illustrates her feelings about the process of unity under way in the country where she was born.

Nosocomial Rotavirus Gastroenteritis in pediatric patients: a multi-center prospective cohort study

Background

Few data are available on the incidence of nosocomial Rotavirus infections (NRVI) in pediatric hospitals and on their economic impact. The goals of this study were: to evaluate the incidence of NRVI in various Italian pediatric wards during the course of two peak RV seasons; to investigate possible risk factors for NRVI; to estimate the costs caused by NRVI.

Methods

prospective cohort study. Population: all the children under 30 months of age who were admitted without any symptom or diagnosis of gastroenteritis in the pediatric hospitals of Florence, Naples, Brescia and Ancona, Italy, during the winter-spring periods 2006-2007 and 2007-2008. Serial RV rapid tests and clinical monitoring were carried out on the cohort. Telephone interviews were performed from 3 to 5 days after discharge.

Results

520 out of 608 children completed the study (85.6%). The overall incidence of NRVI was 5.3% (CI95% 3.6-7.5), (7.9 per 1,000 days of hospital stay, CI 95% 5.3-11.3). The average duration of hospital stay was significantly longer for children who had NRVI (8.1 days, SD 5.4) than for non-infected children (6.4 days, SD 5.8, difference 1.7 days, p = 0.004). The risk of contracting NRVI increased significantly if the child stayed in hospital more than 5 days, RR = 2.8 (CI95% 1.3-6), p = 0.006. In Italy the costs caused by NRVI can be estimated at 8,019,155.44 Euro per year. 2.7% of the children hospitalized with no gastroenteritis symptoms tested positive for RV.

Conclusions

Our study showed a relevant incidence of NRVI, which can increase the length of the children's stay in hospital. Limiting the number of nosocomial RV infections is important to improve patients' safety as well as to avoid additional health costs.

Birth weight for gestational age centiles for Italian neonates

OBJECTIVE

To provide centiles for birth weight (BW) according to gestational age (GA) and sex for infants born in Italy.

METHODS

We used records of the whole neonatal population of Tuscany, a region in Italy, from July 1991 to June 2002 as resulting from the database of the cystic fibrosis neonatal screening program (n=290129). We excluded as unlikely for GA those BW that were more than two interquartile ranges above the 75th centile or below the 25th centile for each GA and gender group.

RESULTS

We present the 3rd, 10th, 25th, 50th, 75th, 90th and 97th centiles of BW for GA from the 24th to 43rd week of gestation for male and female Italian neonates, as both tables and smoothed curves.

CONCLUSIONS

The large size of the examined population allows us to provide up-to-date, reliable BW for GA centiles for Italian newborns, especially for lower GAs.

A 1-m distance is not safe for children with cystic fibrosis at risk for cross-infection with Pseudomonas aeruginosa

Although maintaining a distance of 1 m between persons with cystic fibrosis (CF) is a universal recommendation to prevent respiratory cross-infections such as Pseudomonas aeruginosa, evidence supporting this preventive measure is scarce. Examining 336 samples from 42 patients with CF collected experimentally from sterile surfaces after speaking and coughing, we found that transmission of P aeruginosa beyond 1 m is possible during both talking and coughing, although the probability is low (1.7%).

Management of fever in children: summary of the Italian Pediatric Society guidelines

OBJECTIVE

This article summarizes the Italian Pediatric Society guideline on the management of the signs and symptoms of fever in children, prepared as part of the National Guideline Program (NGLP).

METHODS

Relevant publications in English and Italian were identified through searches of MEDLINE and the Cochrane Database of Systematic Reviews from their inception through December 31, 2007. Based on the consensus of a multidisciplinary expert panel, the strength of the recommendations was categorized into 5 grades (A-E) according to NGLP methodology.

SUMMARY

In the health care setting, axillary measurement of body temperature using a digital thermometer is recommended in children aged <4 weeks; for children aged > or =4 weeks, axillary measurement using a digital thermometer or tympanic measurement using an infrared thermometer is recommended. When body temperature is measured at home by parents or care-givers, axillary measurement using a digital thermometer is recommended for all children. Children who are afebrile when seen by the clinician but are reported to have had fever by their caregivers should be considered febrile. In special circumstances, high fever may be a predictive factor for severe bacterial infection. Use of physical methods of reducing fever is discouraged, except in the case of hyperthermia. Use of antipyretics-paracetamol (acetaminophen) or ibuprofen-is recommended only when fever is associated with discomfort. Combined or alternating use of antipyretics is discouraged. The dose of antipyretic should be based on the child's weight rather than age. Whenever possible, oral administration of paracetamol is preferable to rectal administration. Use of ibuprofen is not recommended in febrile children with chickenpox or dehydration. Use of ibuprofen or paracetamol is not contraindicated in febrile children with asthma. There is insufficient evidence to form any recommendations concerning fever in children with other chronic conditions, but caution is advised in cases of severe hepatic/renal failure or severe malnutrition. Newborns with fever should always be hospitalized because of the elevated risk of severe disease; paracetamol may be used, with the dose adjusted to gestational age. Use of paracetamol or ibuprofen is not effective in preventing febrile convulsion or the adverse effects of vaccines.

Management of totally implantable vascular access devices in patients with cystic fibrosis

Cystic fibrosis (CF) is a genetic disease associated with recurrent lung infections, that represent a major cause of mortality and morbidity. Cystic fibrosis requires frequent antibiotic treatments, sometimes by mouth or via aerosol but often via the intravenous route. Totally implanted venous access devices (ports) allow an easy and safe vascular access for unlimited periods of time, and they can be used in CF to administer antibiotics and other i.v. infusions; if compared to external central venous catheters, ports are better tolerated, since they permit almost unlimited physical activity and do not interfere with patient's self-image. Though ports require a minimal level of care, they may be sometimes associated with relevant complications, which can be insertion-related (pneumothorax, arterial puncture, local hematoma), or management-related (infection, occlusion of the lumen, venous thrombosis). This article summarizes some recommendations on the management of ports in CF, considering the existing literature. Still, some issues remain unsolved and will need further research and studies.

Breast-feeding in a woman with cystic fibrosis undergoing antibiotic intravenous treatment

We report the case of a 30-year-old woman with cystic fibrosis (CF) chronically infected with Pseudomonas aeruginosa who delivered and breast-fed a healthy boy. While breast-feeding the woman had to undergo an i.v. antibiotic course with tobramycin, due to pulmonary exacerbation. Tobramycin was not detected in her milk and lactation could be continued. This is the first time that the presence of tobramycin in the milk of a CF woman during i.v. administration has been investigated.

Incidence of cystic fibrosis in the Albanian population

BACKGROUND

Cystic fibrosis (CF) is the most common life-threatening genetic disease in the Western world. Its incidence varies between 1:4,000 and 1:2,500 among Europeans. No data are available on the incidence of CF among Albanians, mainly due to difficulties of the local health system.

GOALS

To estimate the incidence of CF and the prevalence of healthy carrier status among Albanian ethnic people; to evaluate the incidence of hypertrypsinaemia at birth among Albanian newborns.

METHODS

We used the database of the newborn screening of Tuscany, Italy for the period 1991-2005. Children born to both Albanian parents in Tuscany were identified and incidences were calculated.

RESULTS

The incidence of CF among Albanians (1/555, 99% CI: 1/2,980-1/306) was significantly higher than the rest of the Tuscan population (1/4,101, 99% CI: 1/5,564-1/3,248). The prevalence of CF carrier status among Albanians living in Tuscany is estimated to be 1/12 (99%CI 1/27-1/9) while in the rest of the Tuscan population it is 1/32 (99%CI 1/37-1/28). The incidence of hypertrypsinaemia at birth among Albanian newborns (1/55 99%CI: 1/74-1/44) was significantly higher than in the rest of the population (1/84, 99%CI 1/88-1/82).

CONCLUSION

The incidence of CF among Albanians is considerably higher than expected. Albanian people have a risk to give birth to children with CF higher than the rest of Europeans. The implementation of a newborn screening program in Albania, together with a CF follow up program is highly advisable.

[Control of postoperative pain in children undergoing hypospadias surgery: quasi-experimental controlled trial]

BACKGROUND

Hypospadias is one of the most common congenital anomalies occurring in approximately (1/300) male births. If it is not surgically corrected the consequences may negatively impact on quality of life in adolescents. The surgery is very invasive and the post-operative phase very painful. To improve the control of post-operative pain, continuous analgesia via epidural catheter was implemented.

AIMS

To compare the effectiveness in controlling pain of two different regimens: continuous epidural catheter infusion vs oral and rectal non-steroidal pain-killers.

MATERIALS AND METHODS

Comparative study on children undergoing hypospadias surgery. Group A (catheter) was treated with continuous postoperative analgesia via epidural catheter and Group B (scheduled times) with rectal and oral analgesics at scheduled times and on demand, after caudal block. In both groups nurses measured pain with VAS and FLACC scales (score from 0 to 10) for 72 hours after surgery.

RESULTS

41 children were studied (average age 64.1 months, SD 47.3), with 332 post-operative pain recordings (Group A n = 161, Group B n = 171). Mean pain score of Group A was 0.13 (SD 0.3) and 0.45 (SD 0.8) in group B, p = 0.006. The median duration of the epidural catheter was 65 hours, mean 51.8 hours (SD 24.3). During the 1st post-operative medication, the mean pain score in Group A was 1.2 (SD 1.4), and 3.2 (SD 1.8) in group B, p = 0.003. In group A the number of pain scores indicating pain (> 0) where 3.1% while in group B were 10.5%, p = 0.0007.

CONCLUSIONS

In children undergoing hypospadias surgery, post-operative analgesia with continuous epidural catheter infusion seems to offer a better analgesic coverage than the traditional oral/rectal analgesic treatment at scheduled times and on demand.

Antibiotic therapy against Pseudomonas aeruginosa in cystic fibrosis

Antibiotic strategies against Pseudomonas aeruginosa infection in cystic fibrosis (CF) patients should consider the natural history of the P. aeruginosa infection, ranging from the first isolation of the germ in the airways to isolation at every microbiological culture, and the patient's clinical condition. Antibiotic treatment against P. aeruginosa given at the time of first isolation may prevent or delay chronic infection. The period of intermittent colonization can be considered the time before the development of mucoid P. aeruginosa phenotype. The optimal treatment strategy in this stage remains unclear in terms of agents used and duration of treatment. To treat acute exacerbation, the authors suggest using intravenous administration of two different classes of antibiotics. Maintenance antibiotics are administered to slow the decline in pulmonary function for P. aeruginosa chronic infection. The meaning of maintenance therapy has changed over time, beginning from intravenous quarterly anti-Pseudomonas antibiotics, irrespective of symptoms, to other strategies such as oral macrolides, ciprofloxacin or inhaled antibiotics (tobramycin and colistin). Aerosol delivery can provide a high concentration at the desired site with minimal absorption and therefore low risk of toxicity. There is scientific evidence that antibiotics are clinically effective in CF patients. Antibiotic selection should be based on periodic isolation and identification of pathogens and antimicrobial susceptibility.

Bone mineral density in cystic fibrosis patients under the age of 18 years

AIM

The increase in life expectancy of cystic fibrosis (CF) patients has brought about a rise in new clinical problems in these patients, such as a decrease in bone mineral density (BMD). The cause of diminished BMD in CF is multi-factorial.

METHODS

The aim of this cross-sectional study, conducted on 39 CF patients under the age of 18 years, was to evaluate the degree of bone mineralization and the prevalence of low BMD in these patients during a follow-up at the Cystic Fibrosis Regional Center of Tuscany, using a dual energy X-ray absorptiometry (DXA) scan, and to then study the factors correlated with low BMD.

RESULTS

Areas BMD values (g/cm2) and Z-score values were determined. Eighteen patients (46%) out of the our sample had decreased BMD, while 21 patients (54%) had normal values. A statistically significant association was found between BMD Z-score values and pancreatic insufficiency, BMI<5th percentile and DeltaF508 homozygosis. Subjects treated with oral steroid therapy had a 3.9 times greater risk of developing osteoporosis compared to non-treated subjects (95% C.I.: 1.07-22.6; R.R. 4.9). An association was found between BMD Z-score values and FEV1 values (r=0.29; P=0.06), physical activity total score values (r=0.22; P=0.19) and the Chrispin-Norman chest radiographic score (r=-0.31; P=0.06).

CONCLUSION

Early identification of reduced bone mass values would permit early intervention to prevent the development of osteoporosis. Maintaining pulmonary function, guaranteeing optimal nutritional status, following an adequate program of physical activity and controlling steroid intake could maintain BMD over time.

[Voluntary incident reporting by nurses in a pediatric hospital: a pilot study]

In recent years Voluntary Incident Reporting (VIR) has spread as a tool to monitor and prevent adverse events in healthcare (AE). In Italy, experiences of VIR are limited.

AIM

The goals of this pilot study were to test the feasibility of a VIR system in a population of nurses of a Pediatric Hospital and to make a preliminary survey of situations of risk for patients' safety, to plan corrective actions.

METHODS

Nurses of 3 wards were asked to report AEs with or without harm for patient, near misses and unsafe behaviours or situations at risk for generating AEs. Results were cumulatively reported to participating nurses during ward's meetings and possible corrective interventions were discussed.

RESULTS

The study was carried out from April to August 2006. Eighty-seven nurses participated. Forty-eight reports were made (one third signed, two thirds anonymous). Twenty reports (41.6%) regarded unsafe behaviours or situations at risk for AEs, 11 near misses, 15 AEs without patient harm and 2 AEs with harm. Twenty-three reports involved patients. Reports regarded mainly therapy (62.5%), care delivery (14.5%), equipment (8.3%), clinical documentation (6.3%). 40% of all AEs and near misses were reported to happen during the first or the last hour of the shift. AEs most frequently reported were: missing administration of treatments, administration of a wrong drug or of a wrong dose. "Look-alike" drugs and incomplete or illegible prescriptions.

CONCLUSIONS

Our pilot study confirms that nurses are generally willing to get involved in VIR systems. It also suggests that to succeed VIR systems have to ensure that reporters remain anonymous and non-prosecutable.