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Reznikov EA, Comstock SS, Hoeflinger JL, Wang M, Miller MJ, Donovan SM. Dietary Bovine Lactoferrin Reduces Staphylococcus aureus in the Tissues and Modulates the Immune Response in Piglets Systemically Infected with S. aureus. Curr Dev Nutr 2018; 2:nzy001. [PMID: 30019029 PMCID: PMC6041752 DOI: 10.1093/cdn/nzy001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/12/2017] [Accepted: 12/21/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Bovine lactoferrin (bLf) reduces Staphylococcus aureus infection in premature infants and promotes the growth of Bifidobacterium infantis, a predominant infant gut species. We hypothesized that bLf in combination with B. infantis would reduce the severity of systemic S. aureus infection. OBJECTIVE The aim was to determine the effects of oral administration of bLf and B. infantis on the course of systemic S. aureus infection. METHODS Colostrum-deprived piglets were fed formulas containing 4 g whey/L (CON group) or bLf (LF group). One-half of the piglets in each group were gavaged with B. infantis (109 colony-forming units/d), resulting in 2 additional groups (BI or COMB, respectively). On day 7, piglets were intravenously injected with S. aureus. Blood samples were collected preinfection and every 12 h postinfection for immune analyses. Tissue samples were collected on day 12 for analysis of bacterial abundance and gene expression. RESULTS Preinfection, LF piglets had lower serum interleukin 10 (IL-10), a higher percentage of lymphocytes, and a lower percentage of neutrophils than BI or COMB piglets. After infection, dietary bLf increased piglet weight gain, reduced staphylococcal counts in the kidneys, and tended to lower staphylococcal counts in the lungs and heart. Dietary bLf also decreased kidney IL-10 and increased lung interferon γ (IFN-γ) mRNA. B. infantis increased splenic IFN-γ expression. Renal Toll-like receptor 2 was upregulated in BI piglets but not in COMB piglets. Postinfection, BI piglets had increased serum IL-10 and decreased memory T cell populations. LF and COMB piglets had fewer circulating monocytes and B cells than CON or BI piglets. CONCLUSIONS Dietary bLf and B. infantis produced independent and tissue-specific effects. Piglets fed bLf alone or in combination with B. infantis mounted a more effective immune response and exhibited lower bacterial abundance. This study provides biological underpinnings to the clinical benefits of bLf observed in preterm infants but does not support B. infantis administration during S. aureus infection.
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Affiliation(s)
| | - Sarah S Comstock
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI
| | | | - Mei Wang
- Department of Food Science and Human Nutrition, University of Illinois, Urbana, IL
| | - Michael J Miller
- Division of Nutritional Sciences
- Department of Food Science and Human Nutrition, University of Illinois, Urbana, IL
| | - Sharon M Donovan
- Division of Nutritional Sciences
- Department of Food Science and Human Nutrition, University of Illinois, Urbana, IL
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52
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Aly E, López-Nicolás R, Darwish AA, Ros-Berruezo G, Frontela-Saseta C. In vitro effectiveness of recombinant human lactoferrin and its hydrolysate in alleviating LPS-induced inflammatory response. Food Res Int 2017; 118:101-107. [PMID: 30898345 DOI: 10.1016/j.foodres.2017.12.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 12/08/2017] [Accepted: 12/12/2017] [Indexed: 12/27/2022]
Abstract
This study aimed to evaluate the potential anti-inflammatory role of the most produced form of lactoferrin expressed in various expression systems (Fe-saturated recombinant human Lf, rhLf) and its hydrolysate in concentrations resembles that found in mature human milk. Co-culture model consisted of CaCo-2 and RAW 246.7 cell lines was used to evaluate the potential anti-inflammatory activity of rhLf and its hydrolysate. During this experiment, CaCo-2 monolayer permeability and integrity was assayed through the measurement of transepithelial electrical resistance (TEER values). Also, the production of reactive oxygen species (ROS), nitric oxide (NO) and different cytokines (IL-8, IL-1β, IL-6, IL-10, IL-12p70, and TNF-α) were measured. The treatment with rhLf and its hydrolysate protected the monolayer integrity against LPS effect and reduced IL-8 and ROS production. This effect was dependent on the dose and 2mgmL-1 of rhLf hydrolysate was more effective. The addition of rhLf and its hydrolysate to infant formula is a prominent step towards improving both infant formula functionality and newborn health. Thus, these functional ingredients could be incorporated in infant foods. In this context, ongoing researches are conducted to clarify this effect whether by using synthetic peptides or by using LPS-sepsis animal.
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Affiliation(s)
- Esmat Aly
- Food Science and Nutrition Dept., Faculty of Veterinary Sciences, Regional Campus of International Excellence "Campus Mare Nostrum", University of Murcia, 30100 Espinardo, Spain; Special Food and Nutrition Dept., Food Technology Research Institute (FTRI), Agricultural Research Center (ARC), 12619 Giza, Egypt
| | - Rubén López-Nicolás
- Food Science and Nutrition Dept., Faculty of Veterinary Sciences, Regional Campus of International Excellence "Campus Mare Nostrum", University of Murcia, 30100 Espinardo, Spain
| | - Aliaa Ali Darwish
- Dairy Technology Research Dept., Food Technology Research Institute (FTRI), Agricultural Research Center (ARC), 12619 Giza, Egypt
| | - Gaspar Ros-Berruezo
- Food Science and Nutrition Dept., Faculty of Veterinary Sciences, Regional Campus of International Excellence "Campus Mare Nostrum", University of Murcia, 30100 Espinardo, Spain
| | - Carmen Frontela-Saseta
- Food Science and Nutrition Dept., Faculty of Veterinary Sciences, Regional Campus of International Excellence "Campus Mare Nostrum", University of Murcia, 30100 Espinardo, Spain.
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53
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Selection of possible signature peptides for the detection of bovine lactoferrin in infant formulas by LC-MS/MS. PLoS One 2017; 12:e0184152. [PMID: 28926582 PMCID: PMC5604936 DOI: 10.1371/journal.pone.0184152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 08/18/2017] [Indexed: 12/12/2022] Open
Abstract
An LC-MS/MS assay based on a signature peptide was developed and fully validated for the quantitation of bovine lactoferrin in infant formulas. Three unreported signature peptides were derived and identified from the tryptic peptides of bovine lactoferrin. The peptide ETTVFENLPEK was used for quantification based on assay performance. The blank matrix camel milk powder and bovine lactoferrin protein standards were mixed and spiked with stable isotope-labeled internal standard to establish a calibration curve. The established method was extensively validated by determining the linearity (R2 > 0.999), sensitivity (limit of quantitation, 0.16 mg/100 g), recovery (83.1–91.6%), precision (RSD < 5.4%) and repeatability (RSD < 7.7%). To validate the applicability of the method, four different brands of infant formulas in China were analysed. The acquired contents of bovine lactoferrin were 52.60–150.56 mg/100 g.
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54
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Oropharyngeal Colostrum Administration in Very Low Birth Weight Infants: A Randomized Controlled Trial. Pediatr Crit Care Med 2017; 18:869-875. [PMID: 28617764 DOI: 10.1097/pcc.0000000000001221] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Studies have confirmed the safety of oropharyngeal administration of colostrum in very low birth weight infants. However, the effect of oropharyngeal administration of colostrum on immune system is inconclusive. This study aims to evaluate the effect of oropharyngeal administration of colostrum on secretory immunoglobulin A and lactoferrin in very low birth weight infants. DESIGN Randomized controlled trial. SETTING Forty-bedded neonatal ICU in a university children's hospital in the People's Republic of China. PATIENTS Very low birth weight infants were allocated to the study group (n = 32) and control group (n = 32). INTERVENTION The intervention was oropharyngeal administration of 0.2 mL of their mother's colostrum every 4 hours for 7 days. The control group received saline solution. MEASUREMENTS AND MAIN RESULTS Secretory immunoglobulin A and lactoferrin in urine and saliva were measured within 24 hours of life (baseline) and at 7 and 21 days. Primary outcomes were changes of secretory immunoglobulin A and lactoferrin in urine and saliva between baseline and at 7 and 21 days. Infant's clinical data were also collected during hospitalization. Change from baseline in lactoferrin in saliva at 7 days (5.18 ± 7.07 vs -1.74 ± 4.67 µg/mL; p < 0.001) and 21 days (5.31 ± 9.74 vs -1.17 ± 10.38 µg/mL; p = 0.02) shows statistic difference. No differences were found of lactoferrin in urine and also no differences of secretory immunoglobulin A in urine and saliva. There were also no differences between days to full enteral feeding, occurrence rate of clinical sepsis, proven sepsis, and necrotizing enterocolitis. CONCLUSIONS Oropharyngeal administration of colostrum can increases the level of lactoferrin in saliva in very low birth weight infants. No effect could be documented of secretory immunoglobulin A and lactoferrin in urine. Larger trials are needed to better describe the benefit of oropharyngeal administration of colostrum, if any, in very low birth weight infants.
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Pammi M, Suresh G. Enteral lactoferrin supplementation for prevention of sepsis and necrotizing enterocolitis in preterm infants. Cochrane Database Syst Rev 2017; 6:CD007137. [PMID: 28658720 PMCID: PMC6481465 DOI: 10.1002/14651858.cd007137.pub5] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Lactoferrin, a normal component of human colostrum and milk, can enhance host defenses and may be effective for prevention of sepsis and necrotizing enterocolitis (NEC) in preterm neonates. OBJECTIVES Primary objective 1. To assess the safety and effectiveness of lactoferrin supplementation to enteral feeds for prevention of sepsis and NEC in preterm neonates Secondary objectives 1. To determine the effects of lactoferrin supplementation to enteral feeds to prevent neonatal sepsis and/or NEC on duration of positive-pressure ventilation, development of chronic lung disease (CLD) or periventricular leukomalacia (PVL), length of hospital stay to discharge among survivors, and adverse neurological outcomes at two years of age or later2. To determine the adverse effects of lactoferrin supplementation for prophylaxis of neonatal sepsis and/or NECWhen data were available, we analyzed the following subgroups.1. Gestational age < 32 weeks and 32 to 36 weeks2. Birth weight < 1000 g (extremely low birth weight (ELBW) infants) and birth weight < 1500 g (very low birth weight (VLBW) infants)3. Type of feeding: breast milk versus formula milk SEARCH METHODS: We used the search strategy of the Cochrane Neonatal Review Group (CNRG) to update our search in December 2016. We searched the databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PREMEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), as well as trial registries and conference proceedings. SELECTION CRITERIA Randomized controlled trials (RCTs) evaluating oral lactoferrin at any dose or duration to prevent sepsis or NEC in preterm neonates. DATA COLLECTION AND ANALYSIS Review authors used standard methods of the CNRG. MAIN RESULTS This review includes six RCTs. Trial results show that lactoferrin supplementation to enteral feeds decreased late-onset sepsis (typical risk ratio (RR) 0.59, 95% confidence interval (CI) 0.40 to 0.87; typical risk difference (RD) -0.06, 95% CI -0.10 to -0.02; number needed to treat for an additional beneficial outcome (NNTB) 17, 95% CI 10 to 50; six trials, 886 participants; low-quality evidence) and NEC stage II or III (typical RR 0.40, 95% CI 0.18 to 0.86; typical RD -0.04, 95% CI -0.06 to -0.01; NNTB 25, 95% CI 17 to 100; four studies, 750 participants; low-quality evidence). Lactoferrin supplementation did not have an effect on "all-cause mortality" (typical RR 0.65, 95% CI 0.37 to 1.11; typical RD -0.02, 95% CI -0.05 to 0; six studies, 1041 participants; low-quality evidence).Lactoferrin supplementation to enteral feeds with probiotics decreased late-onset sepsis (RR 0.27, 95% CI 0.12 to 0.60; RD -0.13, 95% CI -0.19 to -0.06; NNTB 8, 95% CI 5 to 17; one study, 321 participants; low-quality evidence) and NEC stage II or III (RR 0.04, 95% CI 0.00 to 0.62; RD -0.05, 95% CI -0.08 to -0.03; NNTB 20, 95% CI 12.5 to 33.3; one study, 496 participants; low-quality evidence), but not "all-cause mortality" (low-quality evidence).Lactoferrin supplementation to enteral feeds with or without probiotics decreased bacterial and fungal sepsis but not CLD or length of hospital stay (low-quality evidence). Investigators reported no adverse effects and did not evaluate long-term neurological outcomes and PVL. AUTHORS' CONCLUSIONS Evidence of low quality suggests that lactoferrin supplementation to enteral feeds with or without probiotics decreases late-onset sepsis and NEC stage II or III in preterm infants without adverse effects. Completed ongoing trials will provide data from more than 6000 preterm neonates, which may enhance the quality of the evidence. Clarification regarding optimal dosing regimens, types of lactoferrin (human or bovine), and long-term outcomes is needed.
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Key Words
- humans
- infant, newborn
- enteral nutrition
- administration, oral
- bacterial infections
- bacterial infections/epidemiology
- bacterial infections/prevention & control
- cause of death
- chronic disease
- enterocolitis, necrotizing
- enterocolitis, necrotizing/epidemiology
- enterocolitis, necrotizing/prevention & control
- infant, premature
- infant, premature, diseases
- infant, premature, diseases/prevention & control
- lactobacillus rhamnosus
- lactoferrin
- lactoferrin/administration & dosage
- lung diseases
- lung diseases/epidemiology
- mycoses
- mycoses/epidemiology
- mycoses/prevention & control
- numbers needed to treat
- probiotics
- probiotics/administration & dosage
- randomized controlled trials as topic
- retinopathy of prematurity
- retinopathy of prematurity/epidemiology
- sepsis
- sepsis/prevention & control
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Affiliation(s)
- Mohan Pammi
- Baylor College of MedicineSection of Neonatology, Department of Pediatrics6621, Fannin, MC.WT 6‐104HoustonUSA77030
| | - Gautham Suresh
- Baylor College of MedicineSection of Neonatology, Department of Pediatrics6621, Fannin, MC.WT 6‐104HoustonUSA77030
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Embleton ND, Berrington JE, Dorling J, Ewer AK, Juszczak E, Kirby JA, Lamb CA, Lanyon CV, McGuire W, Probert CS, Rushton SP, Shirley MD, Stewart CJ, Cummings SP. Mechanisms Affecting the Gut of Preterm Infants in Enteral Feeding Trials. Front Nutr 2017; 4:14. [PMID: 28534028 PMCID: PMC5420562 DOI: 10.3389/fnut.2017.00014] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 04/18/2017] [Indexed: 12/20/2022] Open
Abstract
Large randomized controlled trials (RCTs) in preterm infants offer unique opportunities for mechanistic evaluation of the risk factors leading to serious diseases, as well as the actions of interventions designed to prevent them. Necrotizing enterocolitis (NEC) a serious inflammatory gut condition and late-onset sepsis (LOS) are common feeding and nutrition-related problems that may cause death or serious long-term morbidity and are key outcomes in two current UK National Institutes for Health Research (NIHR) trials. Speed of increasing milk feeds trial (SIFT) randomized preterm infants to different rates of increases in milk feeds with a primary outcome of survival without disability at 2 years corrected age. Enteral lactoferrin in neonates (ELFIN) randomizes infants to supplemental enteral lactoferrin or placebo with a primary outcome of LOS. This is a protocol for the mechanisms affecting the gut of preterm infants in enteral feeding trials (MAGPIE) study and is funded by the UK NIHR Efficacy and Mechanistic Evaluation programme. MAGPIE will recruit ~480 preterm infants who were enrolled in SIFT or ELFIN. Participation in MAGPIE does not change the main trial protocols and uses non-invasive sampling of stool and urine, along with any residual resected gut tissue if infants required surgery. Trial interventions may involve effects on gut microbes, metabolites (e.g., short-chain fatty acids), and aspects of host immune function. Current hypotheses suggest that NEC and/or LOS are due to a dysregulated immune system in the context of gut dysbiosis, but mechanisms have not been systematically studied within large RCTs. Microbiomic analysis will use next-generation sequencing, and metabolites will be assessed by mass spectrometry to detect volatile organic and other compounds produced by microbes or the host. We will explore differences between disease cases and controls, as well as exploring the actions of trial interventions. Impacts of this research are multiple: translation of knowledge of mechanisms promoting gut health may explain outcomes or suggest alternate strategies to improve health. Results may identify new non-invasive diagnostic or monitoring techniques, preventative or treatment strategies for NEC or LOS, or provide data useful for risk stratification in future studies. Mechanistic evaluation might be especially informative where there are not clear effects on the primary outcome (ISRCTN 12554594).
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Affiliation(s)
- Nicholas D Embleton
- Newcastle Neonatal Service, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Janet E Berrington
- Newcastle Neonatal Service, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Jon Dorling
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Andrew K Ewer
- College of Medical and Dental Sciences, Institute of Metabolism and Systems Research, Birmingham University, Birmingham, UK
| | | | - John A Kirby
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher A Lamb
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Clare V Lanyon
- Department for Biomedical Sciences, School of Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Christopher S Probert
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | | | - Mark D Shirley
- School of Biology, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher J Stewart
- Department for Biomedical Sciences, School of Life Sciences, Northumbria University, Newcastle upon Tyne, UK.,Alkek Center for Metagenomics and Microbiome Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, USA
| | - Stephen P Cummings
- School of Science and Engineering, Teesside University, Middlesbrough, UK
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57
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Alqahtani MS, Islam MS, Podaralla S, Kaushik RS, Reineke J, Woyengo T, Perumal O. Food Protein Based Core–Shell Nanocarriers for Oral Drug Delivery: Effect of Shell Composition on in Vitro and in Vivo Functional Performance of Zein Nanocarriers. Mol Pharm 2017; 14:757-769. [DOI: 10.1021/acs.molpharmaceut.6b01017] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Mohammed S. Alqahtani
- Department
of Pharmaceutical Sciences, ∥Department of Biology and Microbiology/Veterinary
and Biomedical Sciences, and ⊥Department of Animal Science, South Dakota State University, Brookings, South Dakota 57007, United States
| | - M. Saiful Islam
- Department
of Pharmaceutical Sciences, ∥Department of Biology and Microbiology/Veterinary
and Biomedical Sciences, and ⊥Department of Animal Science, South Dakota State University, Brookings, South Dakota 57007, United States
| | - Satheesh Podaralla
- Department
of Pharmaceutical Sciences, ∥Department of Biology and Microbiology/Veterinary
and Biomedical Sciences, and ⊥Department of Animal Science, South Dakota State University, Brookings, South Dakota 57007, United States
| | - Radhey S. Kaushik
- Department
of Pharmaceutical Sciences, ∥Department of Biology and Microbiology/Veterinary
and Biomedical Sciences, and ⊥Department of Animal Science, South Dakota State University, Brookings, South Dakota 57007, United States
| | - Joshua Reineke
- Department
of Pharmaceutical Sciences, ∥Department of Biology and Microbiology/Veterinary
and Biomedical Sciences, and ⊥Department of Animal Science, South Dakota State University, Brookings, South Dakota 57007, United States
| | - Tofuko Woyengo
- Department
of Pharmaceutical Sciences, ∥Department of Biology and Microbiology/Veterinary
and Biomedical Sciences, and ⊥Department of Animal Science, South Dakota State University, Brookings, South Dakota 57007, United States
| | - Omathanu Perumal
- Department
of Pharmaceutical Sciences, ∥Department of Biology and Microbiology/Veterinary
and Biomedical Sciences, and ⊥Department of Animal Science, South Dakota State University, Brookings, South Dakota 57007, United States
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58
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Donor Human Milk Update: Evidence, Mechanisms, and Priorities for Research and Practice. J Pediatr 2017; 180:15-21. [PMID: 27773337 PMCID: PMC5183469 DOI: 10.1016/j.jpeds.2016.09.027] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/29/2016] [Accepted: 09/09/2016] [Indexed: 12/19/2022]
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Decembrino L, DeAmici M, De Silvestri A, Manzoni P, Paolillo P, Stronati M. Plasma lactoferrin levels in newborn preterm infants with sepsis. J Matern Fetal Neonatal Med 2016; 30:2890-2893. [DOI: 10.1080/14767058.2016.1266479] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Lidia Decembrino
- Fondazione IRCCS Policlinico San Matteo, Neonatal Intesive Care Unit, Pavia, Italy
| | - Mara DeAmici
- Fondazione IRCCS Policlinico San Matteo, Pediatric Clinic, IRCCS San Matteo Foundation, Pavia, Italy
| | | | - Paolo Manzoni
- Neonatology and Neonatal Intensive Care Unit, S. Anna Hospital, Torino, Italy
| | | | - Mauro Stronati
- Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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60
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Manzoni P, Dall'Agnola A. Reducing unnecessary antibiotic exposure in preterm neonates: an achievable goal. THE LANCET. INFECTIOUS DISEASES 2016; 16:1094-1096. [PMID: 27452783 DOI: 10.1016/s1473-3099(16)30222-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Paolo Manzoni
- Neonatology and NICU, S Anna Hospital, Torino 10126, Italy.
| | - Alberto Dall'Agnola
- Paediatrics and Neonatology, "Silvio Orlandi" Hospital, Bussolengo, Verona, Italy
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