by Luigi Orfeo
Infants are not yet at the center of our country’s objectives and will continue not to be if we do not change course quickly, with structural policies to support the family and especially young people. The one-off universal check was a big step forward, but on its own it is not enough. The birth rate cannot be considered a problem among others. It is not a merely demographic question but a social, economic and cultural one
03 NOV –
Being born and living in a period characterized by emergencies, between war, pandemic and poverty. Thus began the XXVIII National Congress of the Italian Society of Neonatology (SIN) held in Florence from 26 to 29 October last, chaired by me, with an intense program full of updates on the main topics of neonatological interest, but also a light on major current problems these days, which have further aggravated the living conditions of families and children.
Among these is the birth rate, which continues to be a real social emergency for our country. In fact, births continue to decrease, as does the number of children per woman, which dropped to 1.24 in 2021. In no province of Italy today there are 2 children per woman, even if this is not new. In fact, since 1975 there has been no fertility rate higher than 2 and, even more dramatically, there are no “potential” mothers, that is, those women who in these years would have been between 25 and 44 years old.
Infants are not yet at the center of our country’s objectives and will continue not to be if we do not change course quickly, with structural policies to support the family and especially young people. The one-off universal check was a big step forward, but on its own it is not enough. The birth rate cannot be considered a problem among others. It is not a merely demographic question but a social, economic and cultural one. Italy is not a country for children!
Safe neonatal care, TIN open also to the first pediatric months, Ophtalmia neonatorum, discharge from the TIN, practices facilitating the relationship and breastfeeding, prevention of neonatal infections and antibiotic-resistance, palliative care and bioethics, are just some of the issues addressed in these days of sharing and comparison.
Safer care in Italian neonatologyIn Europe the incidence rate of adverse events and patient deaths due to malpractices in healthcare is still high and the most commonly involved structures are the emergency / urgent departments, long-term wards and intensive care for adults, pediatrics and neonatal. The clinical risk is mainly due to infections, the use of inappropriate drugs and uncoded procedures.
Define the neonatological “risk areas” and the most appropriate prevention tools to give substance to the principles of safety of care and the assisted person, as well as to allow Italian neonatologists greater serenity in the exercise of their professional activity: these are the objectives of the Company Italiana di Neonatologia (SIN), which since 2020 has given priority to the issue of safety in care, which concerns the management of clinical risk and the adoption in Italian Neonatology and Neonatal Intensive Care (NICU) of risk management, unfortunately still not sufficiently widespread .
Safe maternal and neonatal care is an area of health care that needs, today more than ever after the experience of the pandemic, particular attention, in light of the significant impact on the physical and mental state of health they could be exposed women and infants when they receive inappropriate care.
To raise awareness among professionals on the subject, SIN, with its Study Group “Clinical Risk and High Fidelity Simulation”, has implemented actions to promote continuous training of the team in the delivery room, FAD courses relating to the topic of clinical risk and the adoption of risk management in all Italian birth centers. It also identified what good practices can be to ensure safe care in neonatology and NICU wards:
- Newborn identification process
- Evacuation process in case of fire or adverse natural events
- Prevention and monitoring of medication errors
- Prevention of health care related infections
- Accidental fall prevention
- Informed consent
TIN extended to the first pediatric months
The Neonatal Intensive Therapies (NICU) could also guarantee assistance for the pediatric intensive treatments of the first months, in order to make up for the lack of Pediatric Intensive Care (TIP). The proposal comes from the Italian Society of Neonatology (SIN).
In Italy, the Pediatric Intensive Care Departments (TIP) are few and with an uneven geographical distribution, in favor of the Northern regions and for this reason, children are frequently hospitalized in the intensive care units of adults, as reported in a recent article by ‘European Journal of Paediatrics by Nicola Pozzi and the Early Childhood Intensive Care Study Group of the Italian Society of Neonatology.
Still, the TIPs are very important, as are the TINs on the other hand. In recent years, a number of studies have shown that critically ill children admitted to the Pediatric Intensive Care Unit (TIP) receive higher quality of care, have better outcomes and lower mortality than those admitted to the intensive care units of adults.
The SIN proposal of “enlarged” NICs would allow many children to receive more appropriate care. According to the latest data from the Italian Society of Neonatology, there are 118 Neonatal Intensive Therapies, with a homogeneous distribution throughout the national territory. Furthermore, some NICUs have already begun to manage children over the canonical 30 days of life. In fact, from a survey conducted by the Early Childhood Intensive Care Study Group of SIN, referring to the calendar year 2019 and to which 86% of the interviewed TINs replied, it emerges that 79% of the TIN hospitalize or manage children over 30 days of life and / or 44 weeks of post-conception age, although most facilities with very low activity volumes.
Indeed, in geographic areas with limited or absent TIP positions, one or more “enlarged” TINs could be set up in order to manage these infants and children, who would find no place except in the intensive departments of adults, which are not the most suitable and equipped for this type of patient and pathology, considering, moreover, that infants and young children represent about 30% of hospitalizations in TIP.
Conjunctivitis in newborns, it’s time to change prophylaxis
Ophthalmic prophylaxis for the treatment of conjunctivitis, ie the instillation of antibiotic eye drops in the eyes of newborns in the delivery room, is one of the actions performed on all newborns and is now obsolete. The obligation of conjunctival prophylaxis with silver nitrate (subsequently replaced by antibiotic eye drops) dates back, in fact, to a decree-law of 23-01-1940, repealed by subsequent measures and disappeared in the Italian legislation currently in force. Even the guidelines on physiological pregnancy, issued by the Ministry of Health in 2011, make no reference to the obligation of conjunctival prophylaxis in the newborn and, to date, there are no regulatory constraints that require the implementation of this procedure on newborns.
The Italian Society of Neonatology (SIN), with the Italian Society of Gynecology and Obstetrics (SIGO) and the Italian Society of Perinatal Medicine (SIMP), following a survey, has prepared a document that contains recommendations in line with what is in force in international field on the prevention of ophthalmia neonatorum. In fact, over the last two years there has been a comparison between the members of some Study Groups of the Italian Society of Neonatology (Neonatal Infectivology, Sense Organs, Quality of Care and Neonatal Pharmacotherapy) regarding the mandatory nature in Italy and to the methods of carrying out the prophylaxis of ophthalmia neonatorum, to evaluate the appropriateness of modifying this procedure which, in the current method of implementation, seems largely outdated.
To verify the Italian situation in 2021, the SIN Neonatal Infectious Disease Study Group conducted a national survey to find out how many newborns were subjected to ocular prophylaxis, with which drugs, at what times after birth, how many conjunctivitis due to Neisseria gonorrheae and by Chlamydia trachomatis had been observed in the three-year period 2018-2020, in order to have concrete and current data, to think about some changes to be made to this procedure, apparently outdated.
The SIN-Safe multidisciplinary group (Neonatal Infectivology, Pharmacotherapy, Sense Organs, Quality of Care) also supported by the legal advice of SIN-Safe’s lawyer Paolo D’Agostino, is working to modify and make this obsolete procedure more current. The team, coordinated by Dr. Chryssoula Tzialla, is made up of me, the past president prof. Fabio Mosca and by dr. Cinzia Auriti, Salvatore Aversa, Mario Giuffrè, Daniele Merazzi, Vito Mondì, Stefano Martinelli, Luca Massenzi, Giacomo Cavallaro, Luigi Gagliardi, Gabriella Araimo and prof. Vito Troiano and Irene Cetin.
Antibiotic resistance
The phenomenon of antibiotic resistance in newborns is a major concern of neonatologists and pediatricians.
The strategies to be implemented to stem this silent pandemic are no different from those proposed for the general population, but the correct use of antibiotics and the implementation of prevention and control programs for healthcare-related infections certainly play a very important role..
Resignation from the TIN
The discharge of a newborn after the experience in Neonatal Intensive Care (NICU) is always a moment of great happiness, but also of fear, doubts and uncertainties for parents.
For this reason, SIN has thought of a path of “active involvement of parents”, which allows them to acquire skills and technical knowledge, emotional comfort and trust in the care of their child, during hospitalization, up to the time of discharge.
Dr. Luigi Orfeo
President of the Italian Society of Neonatology (SIN)
03 November 2022
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