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Development of posttraumatic stress disorder (PTSD) in parents of premature neonates has been recently described. Several source of stress have been hypothesized, however causes of PTDS and emotional reaction of the parents of premature birth hospitalized in a neonatal intensive care unit (NICU) remain largely undefined. We demonstrated that alteration of parental role and a history of anxiety have a crucial role in the development of PTSD in the parents of premature neonates. Familiarization with neonatal intensive care unit environment and increasing participation of the parents in the care of neonates during the first weeks of life improves parental role perception. Early involvement of the parents and especially of the mothers in the neonatal care, in particular if the risk of anxiety is consistent, should be considered a primary objective to prevent a PTSD.

Cranial Ultrasound (cUS) may not be sensitive enough to detect subtle white matter (WM) injuries. Our study compared serial cUS with MRI at term equivalent age (TEA) to determine if it is possible to identify an ultrasound representation of subtle diffuse WM injuries such as punctate lesions (PWMLs) and diffuse excessive high signal intensity (DEHSI). Fifty-six very preterm infants were scanned sequentially from birth to TEA, an MRI was performed at TEA. Each echodensity found on cUS was classified as absent, transient (=7 days), or prolonged (>7 days). A transient periventricular echodensity was detected in seven infants (12.5%), and a prolonged echodensity in 15 (26.8%). MRI examinations were performed in all 56 infants. No altered signal intensity was found in 18 infants (32.1%). DEHSI was detected in 14 infants (25%), and PWMLs were detected in eight babies (14.3%). Both abnormalities were found in 16 infants (28.6%). The positive predictive values of the prolonged echodensity for DEHSI and PWMLs were 86.7% and 46.7% respectively. However, a significant statistical correspondence (p=0.002, Odds Ratio 11.9) was found comparing DEHSI with cUS abnormal echodensities. Serial cUS during the neonatal period in preterm infants is essential and cannot be replaced with MRI at TEA. MRI seems to be more reliable in detecting mild or moderate WM abnormalities. However, serial cUS performed by an experienced neonatologist can provide valuable information on early WM changes such as prolonged echodensities that could potentially lead to a diffuse injury.

The number of surviving children born prematurely has increased substantially during the last 2 decades. The major goal of enteral nutrient supply to these infants is to achieve growth similar to foetal growth coupled with satisfactory functional development. The accumulation of knowledge since the previous guideline on nutrition of preterm infants from the Committee on Nutrition of the European Society of Paediatric Gastroenterology and Nutrition in 1987 has made a new guideline necessary. Thus, an ad hoc expert panel was convened by the Committee on Nutrition of the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition in 2007 to make appropriate recommendations. The present guideline, of which the major recommendations are summarised here (for the full report, see http://links.lww.com/A1480), is consistent with, but not identical to, recent guidelines from the Life Sciences Research Office of the American Society for Nutritional Sciences published in 2002 and recommendations from the handbook Nutrition of the Preterm Infant. Scientific Basis and Practical Guidelines, 2nd ed, edited by Tsang et al, and published in 2005. The preferred food for premature infants is fortified human milk from the infant's own mother, or, alternatively, formula designed for premature infants. This guideline aims to provide proposed advisable ranges for nutrient intakes for stable-growing preterm infants up to a weight of approximately 1800 g, because most data are available for these infants. These recommendations are based on a considered review of available scientific reports on the subject, and on expert consensus for which the available scientific data are considered inadequate.

1. Neurones of the nucleus reticularis thalami of the rat were studied by intracellular recordings from in vitro slices. The resting membrane potential was ‐56.28 +/‐ 5.86 mV (mean value +/‐ S.D.); input resistance was 43.09 +/‐ 9.74 M omega; the time constant tau was 16.51 +/‐ 3.99 ms. At the resting membrane potential tonic firing is present, while at membrane potentials more negative than ‐60 mV a burst firing mode gradually prevails. 2. Prolonged depolarizing current pulses superimposed on a steady hyperpolarization consistently activated sequences of burst‐after‐hyperpolarization complexes. The all‐or‐none burst response consisted of Na+‐mediated, TTX‐sensitive fast action potentials superimposed on a low threshold spike (LTS). The burst was followed by a stereotyped after‐hyperpolarization lasting 100‐120 ms (BAHP), with a maxima ‐85 mV. The BAHP was blocked by Cd2+ and apamine but not by 8‐Br cyclic AMP. The early component of BAHP was significantly attenuated by TEA. The oscillatory rhythmic discharges were abolished by agents which blocked the BAHP. 3. The presence of strong after‐hyperpolarizing potentials (SAHP and BAHP) in RTN neurones plays a significant role in determining two different functional states, defined as tonic and oscillatory burst firing modes, respectively.

1. We investigated the development of epileptic activity in the limbic lobe of the in vitro isolated brain preparation after induction of a restricted epileptic focus in the rostral portion of the anterior piriform cortex (APC) by means of local bicuculline ejection. 2. The modifications of the local responses evoked by stimulation of the lateral olfactory tract were consistent with an increase in excitability of layer II pyramidal neurons. The abnormal discharge output of the epileptic focus propagated throughout the piriform cortex (PC) and generated late synaptic stimulus-evoked epileptiform potentials in layer Ib, where corticocortical associative fibers contact the distal dendrites of pyramidal cells. 3. Spontaneous epileptiform potentials (SEPs) originated in the primary focus at the bicuculline ejection site 10-15 min after drug application and propagated via associative fibers to the posterior PC (PPC). 4. Autonomous secondary foci generating SEPs independently from the primary anterior focus developed in the PPC within 2 h after the bicuculline application. 5. Ictal events seldom occurred spontaneously in PC but could be induced by tetanic afferent stimulation. Evoked ictal events in PC had the characteristics of afterdischarges, being short in duration and localized in space and showing a progressively decreasing firing rate. 6. Self-sustained spontaneous ictal discharges were observed in the entorhinal cortex and hippocampus but not in PC after activation of the APC focus. 7. We conclude that in an acute pharmacological model of focal epilepsy, associative corticocortical connections hold a primary role 1) in the propagation of interictal epileptiform activity throughout the limbic lobe and 2) in the generation of secondary epileptic foci. We also demonstrate that self-sustained ictal events are not spontaneously generated in PC, although paroxysmal seizure-like discharges occur in hippocampus. We discuss the relevance of the rostral-to-caudal-directed associative fiber system in generation of limbic seizures.

Long-term potentiation (LTP) was investigated in the mammalian entorhinal cortex by using two in vitro preparations, the isolated brain and the entorhinal cortex slice. Hebbian and non-Hebbian types of LTP appear to be present in layer II entorhinal cortex cells as demonstrated using two protocols: (i) tetanic stimulation of the piriform-entorhinal cortex afferent pathway to generate homosynaptic potentiation and (ii) postsynaptic subthreshold rhythmic membrane potential manipulation not paired to presynaptic activation, which gives rise to non-Hebbian LTP. The induction and the expression of both types of LTP were found to be dependent on activation of N-methyl-D-aspartate receptors as shown by their sensitivity to the receptor agonist D-2-amino-5-phosphonovalerate. This is in contrast to LTP in the hippocampus [Zalutsky, R. A. & Nicoll, R. A. (1990) Science 248, 1619-1624], where LTP is expressed by quisqualate receptors. Since, in the entorhinal cortex, LTP is linked to a selective increase of the N-methyl-D-aspartate-receptor-mediated synaptic responses, this enhancement is most likely due to postsynaptic factors.

Serum diamine oxidase (DAO) activities were measured in 9 pregnant women and in 33 neonates during the 1st week of life. The radiometric method was used. Very high values were found in the mothers (mean ± SE: 720 ± 143 pmol ml-1 h-1) Neonates showed significantly elevated values (mean ± SE: 178 ± 54 pmol ml-1 h-1) on the 1st postnatal day when compared to the 7th day values (mean ± SE: 27 ± 5.7 pmol ml-1 h-1)·Serial determinations showed a progressive decline from day 1 to day 7 after birth. We suggest the high serum DAO levels in neonates during the first days of life are due to leakage of placental enzyme into the circulation either at birth or during fetal life. Consequently, serum DAO cannot be used as a marker of small bowel functional integrity in the 1 st postnatal week.

Selective immunostaining for calcium-binding proteins identifies subpopulations of neurons with hypothetical distinct functional roles. The neuronal localization of calcium-binding proteins calretinin, parvalbumin and calbindin is here correlated to GABA and glutamate immunoreactivity in the guinea-pig piriform cortex. In the external border of the molecular layer, neurons positive for calretinin with morphological features of Cajal-Retzius cells were found. Rare GABA immunoreactive cells were observed in the same subpial region, whereas neurons containing GABA were abundant within layers la and Ib. Aspartate- and glutamate-immunoreactive cells were also found in the outer la layer. A distinct band of calretinin-immunoreactive fibres and terminals localized in layer Ia, where the afferent fibres originating from the olfactory bulb are segregated. In layer II the number of cells containing calretinin exceeded the number of neurons positive for the anti-GABA antibody. Part of the layer II calretinin-positive neurons with pyramidal shape and large apical dendrites directed toward the surface were found to be immunoreactive for the anti-glutamate antibody on adjacent sections. Neurons in layer II immunoreactive for either parvalbumin or calbindin showed morphological features of interneurons, and their number matched the count of GABA containing cells. Calretinin-positive neurons with the general morphological features of interneurons were scarcely represented in the deep piriform cortical layers, where large multipolar and small bipolar calbindin-positive cells prevailed.

The aim of the study was the evaluation of the relationship between chemical fat analysis and some more rapid tests proposed to estimate steatorrhoea. Stool collections (72 h) were obtained on 32 occasions in 22 patients with cystic fibrosis and in seven healthy children. A very close relationship was found between faecal fat, as measured by standard chemical methods, and faecal energy (r=0.95,P<0.001). We conclude that the determination of faecal energy, easier to measure than faecal fat, can provide reliable information about the extent of steatorrhoea in cystic fibrosis.

Introduction: An increased risk of infectious and allergic disease has been suggested for neonates born from caesarean delivery. The innate immunity play a crucial role in the host defence in neonatal age. The aim of this study is to evaluate the effects of delivery mode on innate immunity in newborn.Methods: Prospective, multicentre study involving newborns with birth weight (BW) > 2000 g and gestational age (GA) > 37 weeks. Serum levels of alpha- (HNP 1-3) and beta-defensins (hBD-2) were adopted as a markers of innate immune response. At birth, blood samples from neonatal cord vessels and from their mother peripheral vein were collected, and HPN 1-3 and hBD-2 were measured by commercially available ELISA kits. Data regarding pregnancy and perinatal period were also recorded.Results: Data from 66 newborns and their mother's were available. Levels of hBD2 were higher in newborn by spontaneous delivery (122.7 ± 4.6 pg/ml) than in those born by caesarian section (107.5 ± 5.5 pg/ml, p= 0.038). In the absence of labor maternal HNP 1-3 resulted significantly lower (245.3 ± 25.7 ng/ml) than in the presence of labor (594.6 ± 36.3 ng/ml, p=0.007).Conclusions: Caesarian delivery and absence of labor impair innate immunity in newborns. This may have important implications in the prevention of infectious and allergic disease early in the life.

Background and aims: Gastric acidity is a major non-immune defense mechanism against infections. In adults and children treated with gastric acidity inhibitors (GAI) there is evidence of an increased risk of intestinal and extraintestinal infections. These drugs are being increasingly used in the neonatal period. To investigate the possible association between GAI and infections or necrotizing enterocolitis (NEC) in very-low-birthweight (VLBW) newborns.Methods: VLBW consecutively observed in Neonatal Intensive Care Units for at least 8 weeks were evaluated and the effect of GAI exposure on the rate of infections and NEC was analysed.Results: As many as 274 VLBW infants were evaluated 183 not exposed to GAI and 91 received ranitidine. The main clinical and demographic characteristics were not different between the two groups. The rate of infections was significantly higher in neonates receiving ranitidine (34/91) compared to subjects not receiving GAI (18/183, p< 0.001). The number of infants presenting sepsis (23/91 vs 16/183), pneumonia (4/91 vs 1/183), urinary tract infections (7/91 vs 1/183) was significantly higher in the newborns receiving ranitidine than in controls (p< 0.05). The risk of infections (OR 5.47, 95% CI 2.9-10.4) and NEC (OR 6.58, 95% CI 1.7-25.0) were significantly increased in neonates exposed to ranitidine.Conclusions: Ranitidine therapy is associated with an increased risk of infections and NEC in VLBW infants. Neonatologists need to consider that the benefits of treatment outweigh the potential risk.

AIM: To evaluate the effect of fortification on the osmolality of human milk. METHODS: The osmolality of 47 samples of human milk was determined at baseline, just after, and 24 hours after supplementation with five different human milk fortifiers (HMF) at 4 degrees C. RESULTS: Ten minutes after HMF supplementation the osmolality of human milk was significantly higher than the sum of the respective values of HMF dissolved in water and human milk, measured separately at baseline (p<0.0001), with the exception of the HMF containing only proteins. After 24 hours a further increase in osmolality was observed. Linear regression analysis showed that total dextrin content (r=0.84) was the main determinant of the increase. CONCLUSIONS: Human milk and HMF interact to induce a rapid increase in osmolality higher than would be expected from composition alone. This rise could be explained by the amylase activity of human milk, inducing hydrolysis of the dextrin content of HMF, leading to small osmotically active molecules of oligosaccharides. The high osmolality of fortified human milk should be considered in the nutritional management of preterm infants.

23 E and N balances were performed in 12 VLBI. 4 were fed with a preterm formula (P F) and 8 with expressed breast milk (EBM). The two groups were comparable for birthweight (1133±164 vs 1016±235g), gestational age (28.5±1.7vs28.4±2.8 weeks), age and weight at beginning of the study (17±10vs31±29 days and 1258±108vs1243±218g) (M±1SD). The E and N content of PF and EBM was 81vs 64±9kcal/dl and 329±8vs 242±46mgN/dl respectively. The two groups received similar milk intakes (187±17vs 184±15ml/kg/d). The PF group showed a higher E retention (117±17vs 97±21kcal/kg/d p=0.03), a higher N retention (377±62vs 297±64mgN/kg/d p=0.009) and a higher weight gain (17±6vs 14±6g/kg/d p=0.03). We found a positive linear relationship between N retention and E retention (r=0.68, p<0.001). The EBM was highly variable in E and N content so the ratio between them was not constant. Using multiple regression analysis we found no effect of E retention on the relationship between N intake and N retention in EBM group (15 balances).Conclusions: 1) VLBI behave in similar manner than low birth weight infants. 2) The most relevant factor affecting N retention is N intake. The E content of EBM and of modern PF is generally well retained by VLBI and it is probable that E is less often the limiting factor in growth than it was previously thought to be. Protein deficiency seems to be the most likely reason for poor growth in human milk-fed infants.

The incidence of rickets of prematurity was studied over 3 different mineral intake periods. During 1981-83 48 infants were studied, they received 2000 units of Vit D a day but not additional calcium and phosphate. During 1984 31 infants were studied receiving 1000U Vit D daily but in addition 0.83mmols phosphate/kg/day. During 1985 21 infants were studied receiving 1000U Vit D 0.83mmols/kg of phosphate and 1.62mmols/kg of calcium per day. The mineral supplements were only given to infants fed on expressed breast milk. The infants studied were all those of birthweight <1000g who survived at least 28 days. The diagnosis of rickets was radiological and based on the grading system of Koo et al(1) and grade 2 or 3 was defined as frank rickets. The highest alkaline phosphatase(A.P.) during each babies stay in the Unit was also recorded (three babies 1981-84 had A.P. measurements but no x-ray).We conclude that mineral supplementation in extremely low birthweight infants does not eradicate rickets of prematurity. (1) Koo, W.W. et al, Arch Dis Child 1982, 57;447-452.

Complete 24 or 72hour stool collections were performed during metabolic balances on 39 occasions in 9 preterm infants with birthweight and gestation (M±2SD) of 1081 ± 173g&28.4±2.1 weeks, between 9-90 days (33±29d). All infants were growing well and receiving food only by the oral route. Five infants were fed expressed breast milk (EBM) and 4 with a preterm formula (P.F.). Milk intake was 182±18 ml/kg/d. The weight of the wet stool (w.s.) pooled for each balance and the weight after freeze drying were recorded. The difference between freeze-dried and w.s. weight was defined as the water content of stool and expressed as % of the weight of w.s. Fat analyses were performed on the same samples using a gravimetric method and the fat content was expressed also as % of weight. The correlation between % of fat and % of water in the stool was very close considering feeds together (r=-0.95 p< 0.001) or individually (EBMr=-0.96 p< 0.001, P.F.r=-0.89 p< 0.001).By using the regression equation of the line y=79.2-0.87x, the % of stool fat (y) can be calculated simply from a knowledge of the % water of the stool (x) to an accuracy of ± 4% (2SEM) without time consuming and expensive analyses of fat.

NNS by an infant is sucking on a dummy. The effect of NNS on Energy (E), Fat (F) and Nitrogen (N) balances was studied in 10 preterm infants with birthweight and gestation (M±SD) of 1111±189 g, 28.8±2.3 weeks between 7-89 day of life. All infants were well, gaining weight and fed by tube at 2 hourly intervals. Each baby received a 3 day period of conventional feeding (control period: CP) and a 3 day period during which infants were encouraged to suck a dummy for the duration of feed (NNS). Starting allocation to C.P. or NNS was randomized. 6 infants were fed with expressed breast milk (EBM) and 4 with a preterm formula (P.F.). No significant difference was observed in the 10 infants between C.P. and NNS periods in the E intake (131±24 vs 129±20 KcalAg/d), Metabolizable E (110±24 vs 105±19 Kcal/kg/d); N intake (520±112 vs 501±107 mg/kg/d), N Retention (336±68 vs 336±83 mg/kg/d); F intake (6.2± 1.0 vs 6.1±0.9 g/kg/d); F absorption coefficient (80±7 vs 78±11%). No significant difference was observed considering individually EBM and P.P. fed infants. NNS does not improve F absorption or N or E retention.

Hyperbilirubinemic newborns (h.n.) in phototherapy (ph) often develop diarrhea. We have previously presented evidence that this is of secretory type (1), furthermore in an animal model we showed that bilirubin acts as a secretagogue in the proximal jejunum (2) and this can be held responsible for such effect. In order to investigate the involvement of the colon in such secretory state, we studied electrolyte and water transport, using the technique of non equilibrium dialysis of the rectum with an isotonic solution, in 10 h.n. in ph, in 10 h.n. not light treated and in 10 controls. All infants were at term and breast fed. There were no differences in birthweight, gestational age, weight and age at beginning of the study between the three groups. Bilirubin level at the study was 15±0.3 mg% in the light treated group and 13.9±0.2 mg% in the group of h.n. not in ph. Results, expressed as water and electrolyte net fluxes, are reported in the table.CONCLUSIONS: the impaired absorption of water and electrolytes seen in h.n. in ph. and not in the h.n. not light treated demonstrates: 1) the colonic involvement in the pathogenesis of secretory diarrhea and 2) that this effect is caused by the simultaneous action of hyperbilirubinemia and phototherapy.1)M.De Curtis et al.Lancet 1,909,1982; 2)A.Fasano et al.Pediatr.Res.18,1049,1984.