Farmacocinetica. Utilità nella pratica quotidiana (Metodi) (Italian Edition)

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De Blasio Benevento arbitro: G. Savoia Napoli 4. Lorini Bergamo 8. Oppizzi Milano 9. Sarti Firenze 9. Cattaneo Bergamo Guarracino Pisa 1. Sisillo Milano 2. Lorini Bergamo 2. Colella Roma , M. Ranucci S. Donato Milanese, MI 3. Cattaneo Bergamo , F. Lorini Bergamo 4. Oppizzi Milano 8. Tritapepe Roma 9. Oppizzi Milano Locatelli Cuneo Lorini Bergamo 3.

Sarti Firenze 4. Rossetto Bergamo 4. Salandin Treviso , C. Sorbara Treviso 6. Besso Venezuela Lecture: A life through critical care M. Weil USA 9. Braschi Italia , J. Heuer Germany E. Jaber France Airway fibrescope competencies in critically ill patients R. Sorbello Italy Sunday 30th August Castagneto F. Plani Australia Italy , Penetrating chest trauma D.

Demetriades D. Demetriades USA , G. Hedenstierna Sweden , J. Marshall Canada , F. Plani Australia , G. Sganga Italy , M. Sugrue Australia De La Cal G. Dobb Australia Spain , Initiative to reduce infection L. Silvestri Italy M. Pea Italy Public awareness and perception of sepsis F. Faist Germany Maciel Brazil 9. Maciel G. Citerio Italy Brasil , Multimodal monitoring of cerebral function G. Offenstadt K. Manyalich Spain Lumb USA , R. Abbate Italy J. Vincent Consumption coagulopathy in the critically ill Belgium M. Vincent Belgium Pinsky USA 9.

Parrillo USA , M. Levy USA M. Poelaert Belgium Tuesday 1st September Bhagwanjee D. Cook Canada Braschi Italy , L. Gattinoni Italy E. Conti Italy The open lung concept: clinical relevance G. Lucangelo Italy 1. Demetriades G. Sganga Italy D. Stefano Italy 1. Dellinger USA , P. Dellinger USA J.

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Artigas Spain , P. Dellinger USA , J. Palizas Argentina , K. Reinhart Germany , F. Rubulotta Italy , G. Tulli Italy , J. Vincent Belgium , X. Xi China Tuesday 1st September 1. Lumb USA , F. Cavaliere Italy N. Carli Canada 1. The role of the medical Emergency Team J.

Takala Switzerland Discussion Lecture: Simulation-based education improves the quality of care in critical care M. DeVita USA 1. Weil USA G. Gensini Italy Sudden cardiac death G. Gensini Italy Heart failure: clinical assessment and early pharmacological management J. Weil USA 1. Gullo Italy A. Gullo Italy E. Bhagwanjee South Africa 1.

Marx Germany , M. Pinsky USA J. De Gaudio Effects of acute, severe hypertension on target organ damage Italy A. De Gaudio Italy Strategies for acute blood pressure management in the critical care setting: current and new therapies Monday 31st August J. Levy USA The perioperative setting — unique considerations in the surgical setting: what do the trials teach us? Hedenstierna M. Ranieri Italy Sweden , Evaluating recent clinical trials L. Pistolesi Italy M. Slutsky Canada Discussion Lecture: Computerised selection of ventilatory pattern during mechanical ventilation G.

Iotti Italy 6. Berlot Italy , Pre-hospital trauma care Moderators: Z. Farina South Africa D. Plani Australia Trauma scoring system G. Demetriades USA Room 3 3. Cook Canada Monday 31st August 4. Antonelli Italy , H. Cook Canada Carriage, colonisation and infection L. Silvestri Italy Classification of micro-organism according to their pathogenicity M. Lumb USA , J. Takala Switzerland N. Volpe UK Sedation and analgesia in mechanical ventilation F. Nishimura Japan Analgesia, sedation and awareness in intensive care M. Capuzzo Italy Discussion Room 5 3. Luzzani Italy , G. Sganga Italy G. Sganga Italy New model of scoring M.

Sugrue Australia Enteral nutrition in acute pancreatitis R. Pozzi Mucelli Italy Room 6 3. Scolletta Italy Cardiovascular anti-inflammatory modulation by statin therapy P. Vincent Belgium Room 7 3. Besso G. Offenstadt Y. Garland USA , A. Gullo Italy , G. Offenstadt France , A. Pasetto Italy Y. Putensen Germany 9. Nishimura Grading severity of respiratory dysfunction Japan , A. Artigas Spain C. Putensen Recruitment, oxygenation and overinflation Germany J. Rouby France Dead space and clinical significance G.

Hedenstierna Sweden Discussion Lecture: Is the acute respiratory distress syndrome a systemic disease? Slutsky Canada Friedman USA M. Fisher Australia Trauma in pregnancy D. Plani Australia Monday 31st August Marshall M. Palomar Spain Canada , Systemic antibiotics T. Mazzei Italy C. Adembri Italy Systemic antifungals G. Silvestri Italy Bhagwanjee M. Fanelli Italy G. Park UK De Gasperi L. De Gasperi Italy Albahrani Oman 9. Auler E. Knobel Brazil Brazil , Dangerous arrhythmias P.

Lemaire A. Gallesio Argentina France , Informed consent for critical care research J.

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Ann Ig. Braschi Italy , L. We congratulate our medical and nursing colleagues in Italy and throughout the world for giving generously of their time and resources in the developing of this exciting program. After two hours, at am, dilation was 5 cm and high-dosage oxytocin augmentation was administered. S market in following a fast-track approval procedure before later being withdrawn as according to the National Cancer Institute, it was unable to improve the life expectancy of patients; in fact, subsequent investigations revealed that not only did the drug not help patients suffering from lung cancer, but it could actually be counterproductive. Dobb G. Jaber France Airway fibrescope competencies in critically ill patients R.

Takala Saturday 29th August J. Boles France Switzerland The burn out syndrome: cause and prevention J. Lemaire France Antonelli Italy Critical Care J. Chiumello Italy Ranieri Italy , D. Talmor USA R. Gattinoni Italy 1. Demetriades R. Pozzi Mucelli Italy U. Fisher D. Friedman USA 1. Palomar D. Zandstra J. Zin Brazil Saturday 29th August 1. Weil USA Quintard S. Gruttadauria Italy France Decision-making and strategy in perioperative liver transplant S.

Faenza Italy Discussion Sunday 30th August 1. Fiore Italy , J. Poelaert Belgium H. Metzler Austria Pharmacological manipulation of microcirculation during shock states D. De Backer Belgium Management of cardiogenic shock J. Russell Canada 1. Lemaire P. Lumb USA A. Vincent Belgium 1. Plani Australia Simulation-based training for complex and unusual clinical situations C.

Gullo Italy , C. Ori Italy , F. Plani Australia 1. With an unrestricted L. Bertolini Italy Sunday 30th August Room 3 1. Results from an Austrian study T. Staudinger Austria Monday 31st August Access limited to participants. Artigas Spain , M. Nishimura Japan M. Gorini Italy Ventilatory asynchrony: insight from the physiology of dyspnoea R.

Rossi Italy Discussion Room 2 3. Stocchetti Italy Sunday 30th August P. Reinstrup Sweden Indications, timing and clinical evidence C. Reinstrup Sweden , N. Stocchetti Italy Room 3 3. Antonelli Italy 4. Parrillo USA , J. Russell Canada J. Sprung Israel Highlights on cardiovascular dysfunction in sepsis and septic shock J.

Parrillo USA State of the art on early goal directed therapy in sepsis eight years after the study E. Payen France , E. Hoste France P. Piccinni Italy Renal repair and recovery S. Payen France Room 6 3. McBride UK R. Rhodes UK Room 7 3. Pesenti Italy , K. Shukri Saudi A matter of facts or values? Discussants: M. Albahrani Oman , J. Curtis USA , B. Du China , M. Fisher Australia , N. Latronico Italy , F. Gattinoni Italy Saturday 29th August 9. Esteban Spain , M.

Ranieri Italy L. Gattinoni Italy Mechanical ventilation: the past and the future A. Slutsky Canada Non-invasive ventilation M. Hedenstierna Sweden Ban USA , F. Plani Australia B. Du China Disaster medicine preparedness E. Gomersall USA Rivers USA , H. Gerlach Germany J. Russell Canada Sepsis and organ dysfunction: What is the evidence?

Romand Switzerland The component of fluid challenges J. Annane France Gristina Italy , M. Levy USA F. Tufano Italy Lecture: End-of-life care around the world C. Celis Rodriguez Colombia , J. Curtis USA , M. Levy USA , A. Montanez Mendoza Peru , K. Shukri Saudi Arabia , C. Sprung Israel , R. Tufano Italy Bagshaw J. Besso Venezuela Canada , Vascular access and management of anticoagulation J. Besso O. Hoste Belgium Nolan UK , R. White USA G. Raimondi Italy Discussion Lecture: How is the volume given transformed in flow? Payen France Tuesday 1st September Lichtenstein L.

Neri Italy France , Ultrasound-enhanced airway management G. Via Italy E. Storti Italy Saturday 29th August Ultrasound-enhanced respiratory failure assessment and respiratory monitoring D. Breitkreutz Germany Ultrasound-enhanced haemodynamic monitoring G. Via Italy Discussion Hedenstierna E. Koh Korea U. Lucangelo Italy Optimisation of artificial ventilation in prone position P. Jimenez USA , U. Lucangelo Italy , P. Pelosi Italy 1. Donchin Israel , F. Baud France C. Gomersall Natural disasters Hong Kong B.

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Du China Poisoning and antidotes F. Kole India 1. Reinhart J. Russell Canada Germany , Clinical implication of mannose binding protein in sepsis J. Vincent Y. Koh Korea Belgium Sepsis predisposition J. Marshall Canada Discussion Lecture: Sepsis — decades of challenges: where are the evidence-based manoeuvres? Vincent Belgium Tuesday 1st September 1. Fisher M. Fisher Australia Australia , How communication can facilitate the end-of-life decisions N. Zamperetti F. Fisher Australia 1. Sahuquillo W. Stocchetti Italy F. Della Corte Italy Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury J.

Stocchetti Italy 1. Gazmuri USA , J. Nolan UK J. Nolan UK Key points for improving the out-hospital cardiac arrest R. Fries Germany Discussion 1. Neri Italy , D. Lichtenstein France T. Barozzi Italy Ultrasound-guided vascular access and nerve blockage B. Nicholls UK Prehospital emergency ultrasound T. Storti Italy Discussion 1. Gattinoni Italy , A. Pesenti Italy E.

Koh Korea Oxygen delivery in the critically ill patient J. Russell Canada Weaning from artificial ventilation A. Esteban Spain New system of weaning J. Mancebo Spain Discussion Lecture: Targeting trans-pulmonary pressure to prevent ventilatory induced lung injury D. Prayag India K. Koh Korea Is Africa different? Gopalan South Africa Discussion 4. Bhagwanjee C. Koh Korea M. Bhagwanjee South Africa Discussion 5. Gopalan M. Shukri S. Levy USA , E. Rivers USA J. Li Volti Italy Biomarkers for diagnosis and risk assessment K. Reinhart Germany Lactate level and lactate clearance E.

Levy USA Room 4 — 5. De Gaudio Welcome and introduction Italy A. De Gaudio Italy , J. Chastre France The use of procalcitonin for the diagnosis of early sepsis and infection Sunday 30th August E. Polati Italy With an unrestricted Procalcitonin as a prognostic marker educational grant T. Stolz Switzerland Room 5 3. Sahuquillo J. Stocchetti Italy D. Harvey USA Room 6 3. Donnino USA , G. Ristagno USA R.

Berlot Italy , G. Iapichino Italy A. Maciel Brazil Sepsis and multiple organ failure: from microvascular to mithocondrial dysfunction F. Hurtado Uruguay Immunoglobulin in sepsis G. Berlot Italy Organisational issues in hospital sepsis management. What can I do? Girardis Italy Discussion Demetriades USA M. Sugrue The importance of relaparatomy Australia M. Sugrue Australia Gastric tonometry revisited J. Dobb G. Pinto Italy G. Van den Berghe G. Biolo Italy Belgium , Energetic target and caloric supply J. Wernerman Saturday 29th August P. Singer Israel Sweden Metabolic changes from onset to recovery of critical illness M.

Van den Berghe Belgium Kern USA L. Wik Norway G. Polderman The Netherlands Discussion Potter Forbes R. Thomas UK A. Piacevoli Italy Discussion Tuesday 1st September Berlot Italy P. Razek Egypt Human error in critical care Y. Donchin Israel Discussion Room 3 Marshall A. Artigas Spain Canada , Does protocol help? Rubulotta Italy J. Levy USA Room 4 Fischer France Belgium , Neurophysiological monitoring in severely brain injured patients G.

Park UK A. Iapichino Italy , J. Wernerman Sweden G. Van den Berghe Enteral nutrition Belgium D. Ceraso Argentina Parenteral nutrition in critical Illness G. Braschi Italy , S. Romagnoli Italy G. Sunde Norway Future advances in resuscitation science M. Gazmuri USA Room 7 Moreno K. Takala M. Aitken Australia L. Aitken Australia Strategies to prevent sepsis S.

Blot Belgium The role of monitoring in the identification and treatment of the septic patient R. Pang Singapore The controversies in sepsis — what care should we provide?

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Aitken Australia , S. Blot Belgium , R. Kleinpell USA , N. Pang Singapore , G. Speed New Zealand Chao Taiwan C. Shelton Revisiting positioning techniques Canada K. Alberto Argentina 1. Marinelli Italy E. Drigo Italy , Resuscitation survivors views on family witnessed resuscitation S. Schmollgruber J. Pedreira Brazil W. Badir Turkey J. Scribante South Sedation assessment and management Africa Y.

Chao Taiwan Medication error and prevention G. Kleinpell USA Alexandrov USA M. Rogado Trauma surveillance, monitoring and improvement Philippines L. Aitken Australia Mass casualty surge — critical care response G. Shelton Canada 1. Lucchini Italy M. Leslie Australia H. Kabara Nigeria Measuring haemodynamic pressure vs.

Why flow is better A. Curley USA H. Speed Recruitment and retention methods in critical care New Zealand J. Scribante South Africa Developing intensive care nursing workforce standards G. Williams Australia International recruitment — ethics and practicalities M. Rogado Philippines Discussion Ikematsu Japan S. Sebastiani European survey of intensive care nurses knowledge Italy , P. Fulbrook Australia R. Gonzales De la Cruz Peru 1. Williams Australia L. Alberto Critical care in India — contrasting private and public sector care Argentina , M.

Rogado Philippines F. Moggia Critical care in Nigeria — making do with limited resources Italy H. Giusti Italy J. Albarran UK P. Fulbrook Writing phase Australia G. Leslie Australia Reviewing draft of paper and quality assurance P. Fulbrook Australia Discussion Supported by an independent educational grant from The Medicines Company. Argent South Africa J. Gillis The optimal organisation of paediatric intensive care services Australia , A. Goh Malaysia P. Busoni The optimal organisation of paediatric emergency services Italy N.

Discussants: A. Argent South Africa , A. Goh Malaysia , N. Kissoon Canada , J. Latour The Netherlands , M. Pedreira Brazil Singhi India P. Singhi India , R. Tasker UK 1. Kissoon Canada K. Singhi India K. Ban USA What imaging systems are really useful to the paediatric emergency medicine practitioner in less resourced countries and how should they be utilised? Argent South Africa , N. Kissoon Canada , M. Madden USA , E. Molyneux Malawi , S. Tasker UK 4. Bohn Canada N.

Pirozzi Mechanical cardiac support — where are we going Italy , D. Macrae UK D. Schell Ventilating the post-operative cardiac patient — what are the priorities Australia B. Discussants: D. Bohn Canada , B. Kavanagh Canada , D. Carcillo USA I. Tibboel The K. Maitland Kenya Netherlands Managing the child with severe dengue or dengue haemorrhagic shock S. Brierley UK , J. Carcillo USA , T. Kissoon Canada , K. Maitland Kenya , S.

Ranjit India Wolfler Italy Sunday 30th August A. Bhutta Is there a role for tight glucose control in the management of paediatric septic shock? USA , R. Branco Brazil A. USA S. Discussants: R. Branco Brazil , J. Brierley UK , S. Goldstein USA , N. Kissoon Canada , A. Wolfler Italy 1. Randolph USA J. Pettenazzo A. Bhutta USA Italy Where do the bundles fit in regarding management of nosocomial infections in neonatal and paediatric intensive care M. Bhutta USA , T. Kendrick Australia , M. Pedreira Brazil , A. Randolph USA 4. Lacroix Canada G. Marraro Italy S.

Discussants: Jonathan Gillis Australia , J. Lacroix Canada , D. Steinhorn USA F. Argent South Africa 4. Conti Preventing lung damage in the neonate and child Italy , G. Marraro Italy A. Goh Acute respiratory failure: What is the current best practice for children Malaysia P. Discussants: W. Marraro Italy , P. Rimensberger Switzerland NO, heliox, surfactants, etc. Moderators: B. Kavanagh Canada E. Ottonello Italy P. Kavanagh Canada , G. Ottonello Italy , P.

Rimensberger Switzerland , S. Singhi India , C. Singhi India A. Messeri End-of-life decision making Italy , D. Devictor France E. Molyneux Should we embark on this therapy? Malawi H. Devictor France , J. Gillis Australia , T. Kendrick Australia , S. Singhi India , H. Sakai Japan 4. Carcillo USA D. Biban Italy L. Mirabile Tuberculosis management for critically ill children Italy S. Variability in drug use among newborns admitted to NICUs: a proposal for a European multicentre study.

The use of drugs in newborns admitted to Neonatal Intensive Care Units NICUs is characterized by a great variability in the management of the most common diseases and is a widespread phenomenon observed both within and between different countries. An interesting paper published some months ago [1] reported data on a preliminary part of the Treat Infections in Neonates TINN project set up under the 7th Framework Programme [2], describing the use of ciprofloxacin and fluconazole in NICUs of 25 different European countries.

From this paper emerged a heterogeneous situation as regards the treatment of bacterial and fungal neonatal sepsis within and between European countries. From the analysis of questionnaires emerged concerns expressed by respondents about antibiotic resistance and lack of safety data in neonates. This aspect of variability in drug use does not regard only the treatment of neonatal infections, but also other medicines commonly used in the neonate in the first period of life. In fact, the same scenario emerged as regards the treatment of PDA in preterm newborns.

To treat remains an unresolved issue, due to a lack of data that could clearly give a universal recommendation. In presence of a hemodynamically significant PDA, a consensus of the Iberian Society of Neonatology recommends to start the treatment between day 2 and 5 of life to increase the probability of success [9]. Undoubtedly, given the unique characteristics of the neonatal population, it could be justified in some situations to apply a treatment on individual basis. However, other factors could contribute to this variability in drug use. First of all, it is common the absence of evidence-based guidelines defining the better treatment for the most common diseases diagnosed in the newborn such as PDA and sepsis.

Moreover, it is widespread the use of drugs in an offlabel manner, given the difficulty to perform clinical studies in the neonatal population. Some years ago, a review by Cuzzolin et al. Despite an improvement in rational prescribing for pediatric population, including more than labelling changes [11], off-label drug use remains an important health issue for neonates, as confirmed more recently by other authors [].

This kind of use of medications makes the neonatal population highly vulnerable to adverse drug reactions ADRs [17] and medication errors [18]. In fact, the potential ADRs rate calculated in pediatric wards is 3 times higher compared to the other patient populations and even more significantly higher in NICUs, with most of ADRs involving uncorrected doses or unapproved formulations [17, 19, 20]. In a review published by Chedoe et al. Therefore, a multicentre study involving different NICUs of European countries could be useful to harmonize drug use in the neonate. The collection and recording of data regarding medicines given to newborns admitted to NICUs is an instrument of knowledge useful to evaluate the efficacy and safety of drugs used in this vulnerable patient population, with the purpose to give to all newborns identical health care opportunities [22].

First SIBEN clinical consensus: diagnostic and therapeutic approach to patent ductus arteriosus in premature newborns. An Pediatr Barc. Expert Opin Drug Saf. American Academy of Pediatrics Committee on Drugs. Off-label use of drugs in children. Pharm World Sci. Unlicensed and off-label drug use. Jacqz-Aigrain E. Drug policy in Europe Research and funding in neonates: current challenges, future perspectives, new.

Int J Clin Pharm. Acta Paediatr. Drug Saf. Unlicensed and off-label uses. Roberto Burgio: the scientist at the service of every new life born into the world [Roberto Burgio: lo scienziato al servizio di ogni nuova vita nata al mondo] Italo Farnetani1, Francesca Farnetani2 1. Roberto Burgio, pediatrics, research, memory. Farnetani I, Farnetani F. Roberto Burgio: the scientist at the service of every new life born into the world. Roberto Burgio: lo scienziato al servizio di ogni nuova vita nata al mondo.

He reviewed and verified every page in contact with the authors to whom he sent questions and requests for extensions. It is thus a work that will remain in the annals of pediatrics. By chance, which we do not want to consider fortuitous, Roberto Burgio concluded his life exactly one year after the presentation of the book in his Pavia at the Libreria Feltrinelli Fig.

On that occasion he brought together his co-workers, colleagues, friends and also simple citizens. It was a tribute and homage to the master, but also to the man who had even become identified with his city: suffice it to say that he directed the pediatric clinic for twenty-four years starting from , giving stability to a chair which in the previous half a century had been occupied by twelve different professors.

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He had brought Pavia to a level of international excellence and had refused the chairs in Florence and Rome. Burgio was a descendent of the greatest Italian school of pediatrics, the Scuola di Rocco Jemma, of which he represented the third generation. He received his degree on 8 July at the University of Palermo and immediately entered the pediatric clinic, where he studied under Michele Gerbasi [4].

The period of his training coincided with the time at which the Allies landed in Sicily on 9 July He interpreted the disease as caused by feeding exclusively with the milk of wet nurses who, because of their poverty, ate vegetables only. Figure 1. Pavia, 8 March , presentation of the treatise. Italo Farnetani on the left interviews Roberto Burgio. Italo Farnetani a sinistra intervista Roberto Burgio]. In he won the chair of pediatrics in Perugia, where he remained until , when he moved to Pavia where he spent the rest of his life. After the s, at the time of great progress in the field of immunology and immunopathology, he worked in this sector, performing sophisticated studies.

In particular, he devoted himself to transplantology, but even in this his main interest emerged as that of the child. In conclusion, Burgio was a great master of pediatrics; he surely contributed to the progress of medicine and science in general. Parents first of all, but obviously pediatricians at their sides.

This is. Italian text. Ha riguardato e verificato ogni pagina, confrontandosi con gli autori, ai quali ha spedito quesiti e richieste di ampliamento. Per un caso, che non vogliamo considerare fortuito, Roberto Burgio ha concluso la sua esistenza terrena nello stesso giorno, a un anno di distanza, in cui il libro fu presentato nella sua Pavia alla Libreria Feltrinelli Fig. In questa occasione si riunirono collaboratori, colleghi, amici, ma anche semplici cittadini.

Aveva portato Pavia ad un livello di eccellenza internazionale, rifiutando le cattedre di Firenze e Roma. Per capire il percorso professionale di Burgio, bisogna osservare alcune date. In questo periodo tradusse, con la supervisione di Gerbasi, il Trattato di pediatria di Fanconi e Wallgren [8]. Genitori in primo luogo, ma pediatri ovviamente con essi. Pediatria Essenziale. Milano: Edi-Ermes, Burgio GR. Caronia: lo scienziato-rettore visto da un maestro. In: Farnetani I Ed. Pediatri e medici alla Costituente. Un pezzo sconosciuto di storia della Repubblica. Cento FE : Editeam, , p. Michele Gerbasi: un caposcuola.

Pediatria e Neonatologia. Gerbasi M. Anemia perniciosiforme osservata in bambini ad allattamento materno esclusivo e protratto. La Pediatria. Gerbasi M, Burgio GR, Le dimensioni dei granuloblasti e dei granulociti neutrofili nella ariboflavinosi. In: Scritti medici in onore di Giuseppe Caronia. Roma: Tip. Pliniana Ed.

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Faro, , pp. Napoli: Stabilimento Tipografico G. Genovese, , pp. Fanconi G, Wallgren A. Trattato di pediatria. Milano: Casa Editrice Dr. Francesco Vallardi, Farnetani I. Synthetic oxytocin synOT is a commonly used drug in labor and it can be applied in all stages of labor.

SynOT has been increasingly used over the years, and is currently one of the most common drugs employed in obstetrics. The goal of synOT administration is to cause the augmentation of labor; unfortunately, guidelines for the administration of this drug are often non-specific, although synOT is the drug most commonly associated with preventable adverse perinatal outcomes.

Approximately half of all paid obstetric litigation claims in the United States involve allegations of injudicious use of oxytocin, and the association between oxytocin use, hyperstimulation, fetal distress and adverse neonatal outcome are well know. Furthermore, synOT and oxytocin have some extragenital effects that should be known by obstetricians. This review will present the viewpoint of the authors on this topic. Synthetic oxytocin, labor, litigation, side effects, newborn, augmentation, dystocia.

How to cite Ragusa A, Svelato A. Oxytocin and customization of assistance in labor. Oxytocin was isolated and synthesized for the first time in by Vincent du Vigneaud who was awarded the Nobel Prize for Chemistry for this discovery two years later. SynOT has been increasingly used over the years, and is currently one of the most common drugs employed in obstetrics [1]. Its use in delivery rooms in the Western world has reached epidemic levels, with percentages of use of between SynOT is often used to treat dystocia, which is characterized by abnormal slow progress of labor, and is among the most common challenges in birth care, especially for primiparous women [].

The goal of synOT administration is to cause the augmentation of labor that is, uterine activity sufficient to produce cervical change and fetal descent while avoiding uterine hyperstimulation and fetal compromise. A wide variety of synOT regimens may be used for labor augmentation provided that proper precautions are met, as clear guidelines and continuous cardiotocography CTG.

Unfortunately, guidelines for the administration of this drug are often non-specific [11], although synOT is the drug most commonly associated with preventable adverse perinatal outcomes [12]. Approximately half of all paid obstetric litigation claims in the United States involve allegations of injudicious use of oxytocin [13]. The association between oxytocin use, hyperstimulation, fetal distress and adverse neonatal outcome are well know [].

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Indeed, adverse perinatal outcome, related to fetal hypoxia due to impairment of gas exchange between contractions, may occur in the presence of uterine hyperactivity [18, 19]. Nevertheless, few obstetricians are also informed about the developmental consequences that synOT has on the fetus. It is known that, in addition to the classic endocrine functions in female animals during parturition and lactation, oxytocin acts as a potent modulator of social behavior in a diverse range of species from worms and voles to humans [20]. In experiments on animals, the administration of oxytocin during labor was seen to have long term effects with regard to bonding, social.

Evidence coming from studies on humans show that the use of synOT in labor has effect on the maternal hormone balance. In a study [23], a significant negative correlation was noted in mothers who had received oxytocin infusion during labor: the higher the dose of synOT received during labor, the lower their endogenous oxytocin levels two days later.

In consideration of the above, it is very important to assess and analyze methods to manage dystocia that reduce the use and the amounts of synOT given during labor. Checklists and standardized protocols for the use of oxytocin have been tested and recommended by several authors in order to reduce adverse neonatal outcomes [11, 25]. In this paper, with the aim of clarifying the meaning of a new type of obstetric management, we briefly describe two particularly exemplary clinical cases. Case 1. At am, the patient was admitted in active labor.

Obstetrical examination reported an effaced, central cervix dilated: 4 cm, membranes intact. The presenting part was cephalic, station: -3, posterior left position. At am, after two hours of regular active labor with four contractions in 10 minutes, position and cervical dilatation were unchanged. The doctor on duty prescribed and performed amniotomy. After two hours, at am, dilation was 5 cm and high-dosage oxytocin augmentation was administered. Two hours later, at pm, dilation was 8 cm.

Fetal position was right posterior and the head was still deflexed with a palpable presenting brow at the centre of the pelvic canal, station was -2, the contractions. An emergency caesarean section was performed. At pm, a male fetus weighing 3, g was delivered surrounded by thick meconium, Apgar score was 1 and 5 at one and five minutes respectively. Umbilical artery pH was 7.

The overall duration of labor was 6 hours and 30 minutes. The newborn was discharged in good clinical health. Case 2. At pm, the patient was admitted in active labor. The contractions were two in 10 minutes. FHR was normal. At pm, cervical dilatation were unchanged, position of the fetal head was right anterior occiput markedly deflected with palpable brow at the centre of the pelvic cavity. This condition was explained to the patient. Pain control was achieved by epidural analgesia. Active postures were explained to the patient in order to favor fetal head rotation and flexion.

FHR showed slight typical variable decelerations, which reduced in intensity and frequency. At am position of the fetal head was right anterior occiput well flexed, without palpable brow, and dilation was complete. At am, a female newborn of 3, g was delivered.

Apgar score was 10 at one and five minutes, umbilical cord pH 7. The total duration of first stage of labor was 7 hours and 30 minutes, the active second stage lasted 1 hour and 40 minutes. Commonly the cervimetric curve and the progression of the fetal presented part during second stage of labor have been used to diagnose labor dystocia. Using them as a screening test to looking for causes of dystocia together with a standardized protocol, which introduce the need. Screening and, therefore, the presumptive diagnosis made before administration of synOT enabled to use the drug in patients who needed it most.

This, together with the lower dosages used, led to speed reduction of labor in augmented patients while reducing, however, the number of uterine hyperstimulations. In short, excluding fetal malposition or problems regarding maternal tolerance to pain led to a reduced, more targeted and appropriate use of synOT.

The analysis of the two above clinical cases is paradigmatic: in most delivery rooms in the Western world, these two cases would have been treated in the same way, with amniotomy and oxytocin, as for the first case with not so encouraging results. The association between oxytocin use and acidaemia at birth has not been thoroughly investigated.

In prospective studies of induced or augmented labor in which high- versus low-dose protocols for oxytocin administration have been compared, no increased risk of acidaemia has been found []. Higher doses resulted in increased rates of hyperstimulation in some studies, although none demonstrated any significant difference in neonatal outcomes [35, 37, 38]. A recent systematic review [27] showed that the system of administration of high dosage of oxytocin was associated to a reduction in the number of caesarean sections and in the duration of labor compared to an increase in episodes of uterine hypertonus.

We have written we were against this uncritical and depersonalized use of meta-analysis [39]. In studies, strict protocols limited the use of oxytocin, and discontinuation or decrease of the infusion were applied in situations of hyperstimulation, resulting in improvement of the fetal status [40]. Consequently, results in studies regarding the association between oxytocin use and acidaemia are conflicting. An explanation for this may be that if strict guidelines are followed for oxytocin administration, as for controlled clinical studies, with regard to supervision of contraction frequency and FHR patterns, the risk of fetal acidosis at birth could be avoided [40].

However, this focus is not always present in real-life daily clinical situations. There is a need of studies based on practical or pragmatic trials, which should register daily clinical practice, and provide answers to different types of questions compared to randomized controlled trials. The need to integrate these two types of knowledge in evidence-based medicine has been recently stigmatized; fundamentally, there is no clear line that separates efficacy studies from those which assess effectiveness [41].

It is well known that there is a linear relationship between the amount of synOT administered during labor and acid base equilibrium at birth, and that hyperactive uterine contraction pattern and synOT use are the most important risk factors for acidaemia at birth [40]. In addition, various studies show that the shortterm behavior of human newborns is influenced by the use of synOT during labor.

Fewer prefeeding cues were observed in infants exposed to synOT versus those unexposed and differences were significant for brief and sustained hand to mouth cues [21]. Additionally, three months after birth, there was less exclusive breastfeeding in women exposed to higher versus lower intrapartum synOT dosage [43]. After adjusting for covariates, exposed infants had High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error.

The common mistakes regarding synOT use in clinical practice need to be emphasized, not least in view of the fact that the use of synOT is liberal, widespread and is on the increase. Violation of. It is unlikely that there is a lack of awareness of their existence and their contents. A possible reason is that non-adherence only uncommonly results in an adverse neonatal outcome experienced by the individual midwife or physician, since many fetuses have the ability to tolerate hyperstimulation without becoming seriously affected [46], with the consequence that staff members lose their awareness of adverse side effects, such as hyperstimulation of contractions [43].

This mechanism, really important in obstetrics and in all contexts with low prevalence of side effects, is known as the normalization of deviance [12]. In our opinion, the epidemic level of use that synOT has reached in Western countries is in part due to the fact that, in delivery rooms, a diagnosis is not usually carried out, and we tend to observe events that take place and to give them a name slow down of cervimetric curve, secondary arrest of dilation, prolonged latent phase, arrest of progression of the presenting part, etc.

These names do not correspond to the search for an etiology and, therefore, etiological therapies are not applied. As already said, synOT is often used to treat dystocia, but one of the real problem is that there is no universal consensus on the definition of dystocia. One way to define labor abnormalities is to divide them into protraction disorder slower than normal and arrest disorder complete cessation of progress. To diagnose either of these disorders, the woman must be in the active phase of labor. The cause of this abnormality might be searched both in maternal and fetal conditions.

Causes of dystocia can be cephalo-pelvic disproportion, deflection attitude, occiput posterior position and inefficient uterine contractions [48]. Other aspects may also be taken into consideration when discussing causes of dystocia, such as psychological factor, and risk factors.

It should therefore be clear that therapy for dystocia cannot be the same and monotonic for all these causes. In addition, advanced maternal age, nulliparity, maternal anxiety, multiple gestation, and intrauterine infections have been reported to be associated with longer active labors. Once labor has been diagnosed [52, 53], we must understand the correct speed with which to proceed, considering that any cervimetric curve that we choose from the many suggested by literature is, once again, the macroscopic description of a biological phenomenon, and not the absolute benchmark for that particular woman, at that particular time of her labor [54].

In other word the speed at which cervical dilation continues during labor for each woman is characteristic for that particular woman and not for others as demonstrated by the elegant work of Incerti et al. Obstetricians and midwives must know and respect the individuality of each woman; deviation for the percentage is not a diagnosis, but only an alarm signal that needs a diagnosis.

This is the result of what we could define as a minimalistic approach to the management of labor where cervical dilatation becomes a diagnostic test on top of which medical action is taken in a cascade of interventions, amniotomy, oxytocin infusion and caesarean section, without any attempt to understand the reason of this type of delay in dilatation Fig. A more open approach should be applied during labor towards the different causes of dystocia, not confusing the causes of the dystocia, both maternal and fetal, with the consequences of the same, that are lack of progress in dilation and descent of the presenting part.

In our experience, we utilized the same paradigm of Western medicine to human labor that is applied to any deviation from normal physiology: diagnosis before therapy. We have known, for some time now, that the therapeutic use of change of maternal posture [30, 56] or digital rotation from occipito-posterior to occipito-anterior decreases the need for caesarean sections [32, 57, 58].

There are many open questions that need to be studied further. In addition to fetal position and behavior, there are further important questions that the therapist must consider when faced with an arrest disorder in labor, such as the psychological state of the woman or the type of relationship the woman has with those assisting her during labor and birth or with her partner.

The psychological state of the mother is closely connected to the duration of labor [59, 60]. In effect, taking into consideration and diagnosing the psychological state of the parturient in the case of dystocia, we can also carry out a diagnosis that includes not only the therapeutic possibility of augmentation, but also alternative possibilities such as, for example, the presence of a midwife specifically trained or the use of pain control techniques [61].

A further aspect not well studied regarding labor is the quality of the relationship that the mother has with those assisting her during labor and birth; which is closely connected with the perception of pain [63]. The relationship with the midwife can and must therefore be therapeutic [64, 65]. Some interesting explanations have been given about relationship between length of labor and stress [66]. In a study [68] — in which the authors compare, one month postpartum, the childbirth experiences of primiparous women with slow labor progress who.

The vicious circle of the minimalistic approach to the management of labor. Cervical dilatation becomes a diagnostic test on top of which medical action is taken in a cascade of interventions: amniotomy, oxytocin administration and caesarean section, without any attempt to understand and treat the reason of delay in dilatation.

Figure 3. The spheres of life illustrate numerous areas at which oxytocin may affect behavior and physiology to facilitate the propagation of the species in different periods of life. Modified from Lee et al. We must change our clinical habits and behavior, motivating them with therapeutic actions supported by etiological diagnosis. The administration of oxytocin must be reserved for the category of parturients who have, objectively, a reduction in the effectiveness and frequency of uterine contractility, after the exclusion of all other possible causes.

These changes have led to a significant reduction in. Personalized labor. It is crucial to consider labor as a unique process involving not only the length of cervical dilatation and descent of the fetal presented part but also and primarily the woman with her obstetric and personal history, her feelings and behaviors. In probability theory, the normal or Gaussian distribution is a continuous probability distribution, defined by the formula:. Gaussian distribution is said to be normally distributed and is called a normal deviate.

In conclusion, the mean and median indicators of central tendency are abstract measures that are not suitable for each single case, they describe a biological phenomenon but do not, alone, enable us to carry out a diagnosis. Normality and cervimetric curves must be used as a guide to highlight the need to carry out a diagnosis and not be used as the diagnosis itself. Personalized medicine must take the place of percentile medicine in traditional clinical approach diagnosis and treatment.

The impact of this approach is evident not only on the quality of life of the patient, but also on the optimization of the management of health care resources. In the Western world, more than half the women who give birth are administered oxytocin during labor [33]. From an evolutionary or phylogenetic point of view, it is unlikely that this is really needed, and is therefore a biological need. The fact that more than half of Western women need pharmaceutical help to give birth is unreasonable and, in fact, the reasons behind the widespread and strong administration of oxytocin in the Western world are not only biological, but also cultural.

Nevertheless, it can be easily seen that reducing the use of oxytocin and amniotomy enables to respect longer augmented labor times and probable lead an improvement in all the other index of maternal and newborn outcomes spontaneous or operative labor, caesarean delivery, rate of episiotomy, acid-base balance at birth.

Nevertheless, we trust that personalized therapy will improve patient outcomes, finally entering in the era of personalized medicine. Declaration of interest The Authors declare that there is no conflict of interest. Oxytocin augmentation during labor: how to implement medical guidelines into clinical practice. Sex Reprod Healthc.

Birth outcomes associated with interventions in labour amongst low risk women: a population-based study. Women Birth. Use of oxytocin augmentation after spontaneous onset of labor. Tidsskr Nor Laegeforen. Use and abuse of oxytocin for augmentation of labor. Acta Obstet Gynecol Scand. Gynecol Reprod Biol. Incidence and. Biol Psychiatry. Hayes EJ, Weinstein L. Improving patient safety and uniformity of care by a standardized regimen for the use of oxytocin.

Am J Obstet Gynecol. Common Physiological and Psychological Effects. Doctoral Obstetric centre cohort study. BMC Pregnancy Childbirth. Primiparas with or without oxytocin augmentation: a prospective descriptive study. J Clin Nurs. Obstet Gynecol. The pharmacokinetics of oxytocin as they apply to labor induction. American College of Obstetricians Gynecologists. Oxytocin: new perspectives on an old drug. Reducing obstetric litigation through alterations in practice patterns.

Risk factors for acidemia at birth. Dangers of oxytocin-induced labour to fetuses. Br Med J. Racinet C. Maternal posture during parturition. Gynecol Obstet Fertil. What are the facilitators, inhibitors, and implications of birth positioning? A review of the literature. Digital rotation from occipito-posterior to occipito-anterior decreases the need for cesarean section. Dystocia in nulliparous women. Am Fam Physician. Vanner T, Gardosi J. Intrapartum assessment of uterine activity.

Baillieres Clin Obstet Gynaecol. The effect of oxytocin-induced hyperstimulation on fetal oxygen. Br J Obstet Gynaecol. Effects of oxytocin-induced uterine hyperstimulation during labor on fetal oxygen status and fetal heart rate patterns. Randomized, double-masked comparison of oxytocin dosage in induction and augmentation of labor.

A randomised controlled trial and metaanalysis of active management of labour. Oxytocin for induction of labor. Clin Obstet Gynecol. Seitchik J, Castillo M. Oxytocin augmentation of dysfunctional. Fetal exposure to synthetic oxytocin and the relationship with prefeeding cues within one hour postbirth. Early Hum Dev. Carter CS. Developmental consequences of oxytocin. Physiol Behav. Acidemia at birth, related to obstetric characteristics and to oxytocin use, during the last two hours of labor.

Institute for Safe Medical Practices. High-alert medications. Available at: www. Lowe NK. A review of factors associated with dystocia and cesarean section in nulliparous women. J Midwifery Womens. Analysis of malpractice claims with a focus on oxytocin use in labour. An investigation into the feasibility of comparing three management options augmentation,. World Health Organization partograph in management of labour. Active Management of Labour. Mosby Ireland, Maternal trait personality and childbirth: The role of extraversion and neuroticism.

Birth outcomes in primiparous women who were raped as adults: a matched controlled study. World Health Organization. Diagnosis of Labour. Diagnosis of labor: a prospective study. Med Gen Med.

Greulich B, Tarrant B. The latent phase of labor: diagnosis and management. J Midwifery Womens Health. Proposed biological linkages between obesity, stress, and inefficient uterine contractility during labor in humans. Med Hypotheses. Oxytocin: the great facilitator of life. Prog Neurobiol ;88 2 : Variability in rate of cervical dilation in nulliparous women at term. Pearson K. Notes on the History of Correlation. Brain death BD , as the irreversible and permanent loss of cerebral and brainstem function, is relatively uncommon among newborns who need life support.

It is considered the result of an acute and irreversible central nervous system insult. Asphyxia, severe intracranial hemorrhage and infection are the most common causes of BD in children. BD diagnosis is usually based on clinical criteria. Dilemmas about life prolonging treatment for severely compromised infants — as brain dead infants are — has become challenging since neonatal intensive care unit NICU care has developed, quality of life and resource issues are nowadays continuously underlined.

Caring for premature babies is expensive and costs have risen especially since an increased number of infants with handicaps survives. Ethics, brain death, newborn. Corresponding author Ilias Chatziioannidis, 3B Ag. Triados Str. How to cite Chatziioannidis I, Mitsiakos G.

Considering ethical dilemmas related to brain death in newborns. Brain death BD is the permanent and irreversible loss of brainstem and cortical function [1]. Terms like brainstem, neocortical and whole brain death are not identical [2]. Loss of brain function arises medical, ethical and philosophical issues [3]. Loss of brain function is also loss of human life, even though heart and spinal cord may still operate [].

Determination of BD in newborns is based mainly on clinically accepted neurological criteria [10]. Age-related observational periods and neurodiagnostic tests are still needed to be evaluated for BD diagnosis in children under 1 year of age [8].

Farmacocinetica utilita nella pratica quotidiana metodi italian edition

These guidelines are based on the definition of coma cause, irreversible cessation of higher brain function in addition to brainstem, exclusion of reversible causes, clinical neurological examination criteria, neurodiagnostic tests and suggestion of specific observational periods according to age. Definition of BD is necessary for two main reasons: 1. In UK organ donation is not implemented for children under 2 yrs of age, whereas in other western commonwealth countries donation and transplantation procedures in this age group are customary [13].

In the following paper, we present a moral and medical framework within which guidelines should be followed regarding quality for end of life care for detrimental CNS damage in newborns as in BD. Organ donation decisions are out of the scope of this article. Moral duty in the NICU environment. During this period, treatment has significantly progressed and nowadays it is possible for many more infants to be safely discharged home. Second, every newborn, regardless of his birth weight, gestational age or clinical situation has the right to his preservation for survival and on the other hand the right to die with dignity.

Regarding newborns, their parents decide on behalf of their child [15, 16]. However, it is worth pointing that doctors and nurses should not act as technical managers and, when it is required to use end-of-life treatments for severely compromised newborns, consequences for the newborn itself and its family should always be considered. Additionally, medical staff should always have in mind that available human and financial resources are limited while demands are not. Recognizing that national, cultural and religious differences do exist, for end of life decisions significant questions must be answered.

In what clinical situations are such decisions appropriate? Who should be responsible for such decisions? When should the prolonging life question be erased? What are the appropriate measures for BD newborns? Clinical situations for end of life treatment. Infants with severe congenital malformations i. Quality of life means capacity for future health, development and well-being, potential ability to communicate to act and interact, to have meaningful relationships with others and at least substantial intellectual function.

It does not have to do with probable physical handicap and generally the conception of considering the infant as a burden as a human being or on financial terms for the society is misleading. Responsibility for decision making. End of life treatment decisions and support to the family becomes a responsibility of the intensive care team.

Doctors and parents must be viewed as partners in the decision-making process with a measure of prudence considerating that legislation for BD diagnosis and handling these infants in most countries remains unclear. The key question here is at what point, if the prognosis is so poor, prolonging life should be morally justified? Since there are no benefits for the infant with BD and death is beyond doubt, interpreting BD diagnosis with extreme accuracy is vital for parents and medical staff to help them decide if a newborn should be supported further or not.

Clearly, when it is determined that prognosis is so poor and the burden of treatment appears to outweigh the benefits, like in brain dead newborns, it is considered ethically appropriate to discontinue aggressive life support and employ comfort measures. Non-treatment and comfort measures for brain death infants. There is a need to be consistent in relation to selective non-treatment. Thus the infant must be made comfortable with sufficient analgesia, appropriate hydration and nursing care. Consequently administration antibiotics, resuscitation and even, on occasion, artificial nutrition should be withheld [20].

Gradually, in countries where there is a tendency to wait for a virtually certain prognosis of impending death, it is becoming evident that, with the ongoing discussion of the ethical issues relating not to prolong life, there has been a swing towards a more deliberated approach to decision-making in intensive care units. We should also remind that. Declaring pediatric brain death: current practice in a Canadian pediatric critical care unit. BD should be based mainly on neurological clinical examination and ancillary testing.

Combination of neurologic examination, ECS and no flow on CBF study in a preterm or term newborn for 24 hours observational period is confirmatory of BD. Judgments about non-treatment to withhold or to withdraw treatment of BD newborns, should only be taken by clinical in charge consultant neonatologists.

It is essential for physicians to develop a greater understanding for BD certification in newborns and also to be familiar with end-of-life care methods. Parental support and decisionmaking progress should be handled sensibly and scientifically based, respectively. Adv Exp Med Biol. Wijdicks EF. The neurologist and Harvard criteria for brain death. Neurology ; Determination of death by neurological criteria. J Intensive Care Med. Ashwal S, Serna-Fonseca T. Brain death in infants and children. Critical Care Nurse.

Banasiak KJ, Lister G. Brain death in children. Curr Opin Pediatr. Variability in brain death determination practices in children. Misguided good intentions. J Perinatol. Brierley J. Neonatal organ donation: has the time come? Doyal L. Needs, rights and the moral duties of clinicians. In: Gillon R Ed. Principles of health care ethics. London: Wiley, Doyal L, Wilsher D. Towards guidelines for withholding and withdrawal of life prolonging treatment in neonatal medicine. Brazier M. Medicine, patients and the law. London: Penguin Books, Dunn PM. Appropriate care of the newborn: ethical dilemmas.

J Med Ethics. Brain death documentation: analysis and issues. Catlin A, Carter B. Creation of a neonatal end-of-life palliative care protocol. Bronchopulmonary dysplasia BPD remains the most common severe complication of preterm birth. In addition to well known risk factors, nutrition plays an important role in normal lung development and maturation. Nutrition has a direct effect on the developing lung because it can modulate lung structure. Our aim is to review the scientific literature on the most relevant aspects of nutrition of BPD patients after hospital discharge. Preterm infants, bronchopulmonary dysplasia, hospital discharge, nutrition, human milk, formula feeding, undernutrition.

Nutrition of preterm infants with bronchopulmonary dysplasia after hospital discharge — Part I. Bronchopulmonary dysplasia BPD is a chronic pulmonary disease that affects mainly preterm infants and remains the most common severe complication of preterm birth. Several factors are considered responsible for altering lung development and may subsequently support the development of BPD. In addition to well known risk factors, nutrition plays an important role in normal lung development and maturation [58].

However, 72 hours after re-feeding rat lungs are remodeled with normal alveolar numbers and surface areas [10]. A sufficient amount of protein and calories is necessary for organ growth; thus, a low protein or caloric intake will impair lung development, resulting in BPD. However, there is an ongoing debate concerning the required amount of nutrients to prevent the postnatal growth retardation or postnatal growth failure also called extrauterine growth restriction EUGR of very preterm infants with BPD [11, 12].

Undernutrition, growth failure and nutritional needs in BPD patients. Malnutrition is associated with prematurity and is aggravated by BPD although the actual impact of these two factors is difficult to quantify [18]. During NICU hospitalization preterm infants receive enteral and parenteral nutrition, according to usual recommendations [19]. However, due to the clinical status of high risk newborns, in some severe situations babies receive fewer nutrients that they really need.

It has been shown that preterm with BPD received less enteral feeding in the first two weeks of life than those without BPD, suggesting that a minimal amount of enteral nutrition is necessary to prevent BPD [20]. This post discharge feeding desaturation also has a negative association with growth outcome in BPD patients [21]. Anorexia often seen in these patients can further aggravate and difficult the oral intake. The mechanisms of anorexia are probably multiple: exhaustion associated with dyspnoea and respiratory failure increased effort during breast feeding or bottle feeding , eating disorders prolonged hospitalizations, divestment in the oropharyngeal sphere, oral painful stimuli as well as the anorectic effect of pro-inflammatory cytokines.

Anorexia may be responsible for oral feeding failure and precipitate the beginning of supplemental enteral nutrition EN through a nasogastric tube or gastrostomy. The behavioural problems can also contribute to an inadequate oral intake e. Early intervention programs may be helpful in addressing these issues by providing developmental stimulation and physical and occupational therapy as indicated. Referral to a developmental behavioural paediatrician or behavioural psychologist may be helpful for such children.

The inability to meet increased metabolic demands through oral nutrition can be aggravated by the frequent malnutrition and the need for catch up growth. Denne et al. Assuming that inferior growth is undesirable we can improve nutrient intake of a human fed preterm infant in two ways: 1 Fortifying expressed breast milk or 2 Replacing some breast feeds with nutrientenriched formula feeds formula for preterm infants or postdischarge formulae.

In this case the effects of the substitution of one third, half, two thirds of daily energy intake in breast-fed infants by formula for preterm infants or postdischarge formula has been studied [24]. Fortified expressed breast milk. Although human milk HM is the recommended nutritional source for newborn infants for at least the first six months of life, unfortified HM may not meet the recommended nutritional needs of the growing preterm [25, 26]. Fortification is an alternative approach to increase nutrient intake in human milk-fed infants.

The available human milk fortifiers contain varying amounts of protein, carbohydrate, calcium, phosphate, electrolytes, vitamins and other minerals zinc, manganese, copper and magnesium [25]. There are two different forms of fortification of HM: standard and individualized. The standard fortification consists in adding fixed concentrations of fortifier to maternal milk, not always corresponding to the nutritional requirements of individual infants.

This method is commonly used in most NICUs but the results obtained in terms of growth are not always satisfactory. Standard fortification improved short-term growth, increased nitrogen retention, had no long term advantages in terms of either growth or development, had no clear effect on bone mineral content and was not associated with adverse effects [27]. The individualized fortification is now believed to be the best solution to prevent the protein undernutrition of preterm infants.

Two methods have been proposed for individualization: targeted fortification, depending on milk analyses, and adjustable fortification, depending on the metabolic. Using targeted fortification the amount of fortifier is given according to the weekly determinations of milk protein content. It depends on the availability of the milk analyses [28]. In the adjustable fortification the protein intake is adjusted on the basis of blood urea nitrogen.

This method is effective in delivering an adequate protein intake, and growth approximates the one in uterus [29]. In this setting, protein, minerals and trace elements are all increased. The strategy to fortify human milk is considerably more laborious and difficult and dispute exists as to which should be the human milk fortifier formula for term infants, formula for preterm infants or human milk fortifiers used in hospitals.

There is some evidence pointing towards a positive relationship between duration of human milk feeding and the later Bayley Mental Index, particularly in infants with chronic lung disease. There are some concerns regarding safety of fortifying human milk with human milk fortifiers after hospital discharge since the content of some minerals and vitamins may well be excessive, posing these infants at increased risk of trace elements deficiency copper and hypervitaminosis vitamin A and D [24].

Formula feeding. Postdischarge formulae are specifically designed for preterm infants after discharge from hospital. Expert bodies and authorities recommend these formulae for preterm infants for three to twelve months post-discharge [31]. Some experts state that current recommendations to prescribe postdischarge formula for preterm infants following hospital discharge are not supported by enough available evidence. However, they agree that some limited evidence exist that feeding preterm infants following hospital discharge with formula for preterm infants energy enriched [to about Healthy preterm babies can up-regulat their feed volume in such away that energy intake is identical no matter the type of milk ingested human milk, standard, preterm or postdischarge formula [33].

However same upregulating pattern is difficult for the sick preterm infant with BPD due to the high nutritional needs. Infant formulae, designed to be similar to human milk, are typically lower in caloric density, calcium, and phosphorus. We need to be aware that increasing the caloric density of commercial infant formula through concentration or the addition of modular nutrients like glucose polymers and medium chain triglycerides increases the osmolality of the formula, which can cause diarrhoea or malabsorption [34, 35].

Additional increases in the caloric density of formulae should be made gradually e. In this setting, the prescriber should be certain that individual nutrients are not provided in excessive amounts. The addition of carbohydrate or fat to infant formulae alters the nutrient ratio of the formula by providing no protein calories [37, 38]. Care should be taken to avoid providing more than 60 percent of energy from fat, which may induce ketosis. In a study performed by Brunton and co-workers, 60 preterm infants with BPD were randomly assigned to receive, as postdischarge feeding, term or postdischarge formula.

The authors reported that BPD infants fed postdischarge formula had higher nitrogen, mineral and zinc retention and, at 3. Fewtrell and co-workers, however, compared high caloric density formula with standard term formula in infants with BPD and found no difference in growth parameters between groups [39].

If the baby has already introduced complementary food, the most caloric solid foods need to be chosen, like soups and dishes enriched with fat and carbohydrates. How to feed BPD infants to provide nutritional needs in difficult patients? If despite the optimization of oral intake the child is unable to meet nutritional requirements by mouth in order to achieve adequate catchup growth, supplementation of oral feedings with daytime or nighttime enteric feedings must quickly be considered [37].

Enteral nutrition allows increasing caloric intake, reducing the gastric distension that impairs ventilation and ensures better digestion and intestinal absorption of nutrients. Nasal or orogastric access can be used for infants and children who are predicted to have only short-term need for enteral feeds e. In addition, they are often used as an interim measure to feed and assess tolerance of enteral feedings before placement of an ostomy for long-term enteral feeding. A soft, flexible feeding tube e. Tube sizes of 4 French should be used for neonates and infants.

A gastrostomy tube should be rapidly programmed in the more severe cases or if longterm enteral feeding is required. They are usually easily placed laparoscopically or endoscopically. The gastrostomy can be fitted with a device that is easy to cover with clothes and transient and easily removed without sequelae when no longer needed.