The aim of this review is to discuss the local experience of Tuzla’s hospital staff and the knowledge needed to become a Baby-Friendly Hospital (BFH). We also discuss the risks of formula feeding. While breast milk is the natural modality of infant feeding, in Tuzla Canton, the rate of exclusive breastfeeding in the first 6 months of life is only 12%. During the war of 1992-1995, which was the worst European atrocity since World War II and the worst set of events in the recent history of Bosnia-Herzegovina, we had the opportunity to learn more about the impact of breastfeeding on child health from Chloe Fisher, a renowned clinical specialist on infant feeding. The United Nation Children’s Fund (UNICEF) and the World Health Organisation (WHO) held several seminars, about recommended practices and procedures needed to become a BFH. As a result, the Maternity Hospital was certified as a BFH in 2004 and has been operating with this status since then. While our Maternity Hospital and other related departments provided services and care of infants, many infant formula companies donated milk and organized conferences and other paediatric events to promote infant formula. This and other obstacles resulted in the fact that currently only 3 out of 7 mothers in our neonatology department breastfeed, and only 1 baby out of 7 is exclusively breastfed. Conclusion – Transforming a hospital in Baby-Friendly means, amongst other things, all professionals must provide breastfeeding management to ensure a long-term breastfeeding policy. The current low breastfeeding rate in our hospitals is the result of inconsistent policies in achieving long-term goals in breastfeeding practices.

OBJECTIVE The aim of the study was to evaluate the incidence, mortality, risk factors, aetiology and the susceptibility to antibiotics of the bacteria responsible for sepsis. MATERIAL AND METHODS A single centre, prospective, observational study, involving 200 neonates admitted over 12 months to the NICU of the University Children's Hospital, Tuzla, Bosnia and Herzegovina. RESULTS The crude incidence of all neonatal sepsis was 68.0% (136/200) and that of late-onset sepsis (LOS) was 48.5% (97/200), yelding an incidence density of LOS of 41.6/1000 patient days. LOS represented the most frequent infection and was significantly more frequent than early-onset sepsis (EOS) (71.3% versus 28.7% p<0.001). The overall mortality was 14.0%, and 18.4% among infected neonates. Risk factors associated with LOS were: mechanical ventilation, intravascular catheter, surgical procedures, birth weight ≤1500 g, gestational age ≤ 28 weeks and Apgar score ≤ 3 at 5 minutes. Culture proven sepsis developed in 43.4% of neonates. Klebsiella pneumoniae and Enterococcus faecalis were the predominant bacteria. Gram-negative bacteria were susceptible to amikacin, imipenem and meropenem; gram-positive bacteria to vancomycin and amikacin. CONCLUSION Neonatal sepsis in our NICU showed a high incidence rate, and gram-negative bacteria were predominant. Low gestational age, mechanical ventilation and an intra-vascular catheter were significantly associated with sepsis. It is necessary to develop a multidisciplinary approach for routine surveillance of nosocomial infections, to improve the asepsis of therapeutic procedures, and to implement the more appropriate use of antibiotics.

OBJECTIVE The aim of the study was to determine the epidemiological characteristics of bacterial meningitis observed in neonates born in the Department of Gynaecology and Obstetrics, University Clinical Centre Tuzla, Bosnia and Herzegovina, admitted to Intensive care unit (NICU) or readmitted, because of suspected infection, after discharge from the nursery. SUBJECTS AND METHODS This study was carried out from July 1, 2012 to June 30, 2013. During this period 4136 neonates were born. All neonates admitted to the Intensive care unit with signs and symptoms of systemic infections, and neonates readmitted to the Intensive care unit, after discharge from the nursery for sepsis work up were included in the study. RESULTS Eighteen of 200 neonates (9%) admitted or readmitted to the NICU developed meningitis. 61% cases were late onset meningitis. The overall incidence was 4.4/1000 live births. The mortality rate was 11.1%. The mean age of symptom presentation was 8.7 days. The most common clinical features were: fever, respiratory distress and jaundice. Significant risk factors for acquiring meningitis were: male gender, Caesarean delivery, stained amniotic fluid. Positive CSF finding were detected in 6/18 (33.3%) of cases. Gram-positive bacteria were more frequently responsible for confirmed meningitis. In all neonates with meningitis blood culture was examined and 5 (50%) yielded Gram-negative bacteria. CONCLUSION The high rates of neonatal meningitis with predominant late onset may suggest nosocomial origin. Measures to improve antenatal, intrapartum and delivery care and measures during NICU hospitalisation are necessary to lower the risk of nosocomial infections.

Objective – We present a case of osteoarthritis in a ten day old newborn who underwent aspiration and drainage on the fifth day after admission instead of on the first day . The aim of this case report is to describe the importance of a team approach and clinical management algorithms for the successful treatment of septic arthritis in newborns. Case report – We describe a 3580 g male baby, who underwent aspiration and drainage on the fifth day after admission to our Unit for septic arthritis of the right knee. After the surgical drainage of the joint, local signs of inflammation began to improve. Microbiological analysis did not reveal the causative agent. Conclusion – Septic arthritis requires early diagnosis, prompt administration of antibiotics and rapid removal of pus by surgical treatment, due to the possible development of serious and irreversible damage, and even lethal outcome. A team approach with treatment guidelines of septic arthritis in newborns is mandatory.

Objective – Outbreaks of sepsis caused by multidrug-resistant Acinetobacter baumannii in neonatal intensive care units have been reported, but rarely from our country. We describe such an outbreak in the Department of Paediatrics of the University Clinical Centre Tuzla in 2012 to investigate risk factors, the mode of transmission and to assess control measures. Setting – An 18 bed, level 3 neonatal intensive care unit in a university affiliated teaching hospital. Patients and methods – Seventeen neonates who developed multidrug-resistant Acinetobacter baumannii nosocomial infection were matched to 17 neonates who were admitted to the same unit without infections, during the outbreak period. Cases and controls were compared for possible risk factors (birth weight, gender, intubation, antibiotic use, etc.). Surveillance cultures were collected from health care personnel and the environment. Results – Six out of the 17 neonates (35.3%) died. Surveillance cultures were negative. Seventeen isolates from newborns had the same patterns of resistance. Multidrug-resistant Acinetobacter baumannii was brought into the unit by an infected infant who was transferred from the neurosurgery hospital. Risk factors significantly associated with the infection were: incubator care (OR 6.66; p =0.034), exposure to a central venous catheter (OR 13.75; p=0.004), mechanical ventilation (OR 5.25;p =0.031) and exposure to a patient with Acinetobacter baumannii infection (OR 38.40; p =0.02). Conclusion – Surveillance cultures for all newborns transferred from other hospitals and isolation measures are important to prevent nosocomial infections and outbreak. Negative environmental and health care worker cultures have to be meticulously analyzed. Cohorting of affected newborns and nursing staff, contact isolation, and environmental cleaning are crucial to control the outbreak.

Objective – The aim of this study was to determine the antibiotic resistance in bacteria that colonized neonates with suspected sepsis, born in the Department of Gynecology and Obstetrics, University Clinical Centre Tuzla, Tuzla, Bosnia and Herzegovina from December 1, 2008 to December 31, 2009.  Methods – The study included neonates who were discharged from the Maternity ward, who developed clinical signs of suspected sepsis after forty eight hours of life, and were therefore rehospitalized at the Department of Pediatrics in Tuzla.  Results – The study showed that 55 of 4299 newborns were diagnosed with suspected sepsis. The cumulative incidence of suspected sepsis was 1.3% The bacteria that most often colonized neonates was Klebsiella pneumoniae, that was isolated in 42 (76.4%) newborns. In 14 cases (33.3%) Klebsiella was ESBL–producing. Moreover we found Escherichia coli in 5 neonates (9%), Enterococcus faecalis in 5 neonates (9%) and Enterobacter Cloacae in 3 neonates (5.4%). The bacteria that colonized newborns showed high resistance to ampicillin (91% of cases), slightly lower to cefotaxime (53.3%), gentamicin (43.6%), amikacin 12%, amoxiclav 14.3%, and imipenem and meropenem (2.1%).  Conclusions – The high degree of resistance among the enterobacteriacae that were isolated from our neonates indicates the need to investigate the risk factors for colonization of newborns with antibiotic resistant bacterial strains. The promotion of breastfeeding could be a preventive intervention.

Nosocomial infections are an important cause of morbidity and mortality in pediatric patients.The highest rates being in patients in intensive care units, imunocompromised patients and those undergoing surgical procedures. Risk factors include intrinsic and extrinsic factors. The major intrinsic factors are: age, birth weight, underlying diseases and immune status. The extrinsic risk factors are invasive devices and procedures, transmission of the pathogens via the hands of healthcare workers and using antimicrobials injudiciously, with the emergence of antimicrobials - resistant pathogens. Preventing nosocomial infections requires understanding and fully implementing guideline recommendations for the prevention of infections. Preventing nosocomial infections will reduce the prevalence of antimicrobial – resistant pathogens, improve patient outcomes, and reduce health care costs. Â

OBJECTIVE To investigate the effect of the method of feeding on respiratory and gastrointestinal illnesses during the first six months of life. METHODS Observational study of infants feeding practice and respiratory and gastrointestinal illnesses in first six months who were born in Gynecology-Obstetric department in period from May-September 2004, who weighed 2500 gm or more and at least 37 gestation weeks. In that period was born 1838 babies. Dates were collected by means of answered questionnaires. RESULTS We sent 612 questionnaires and 518 (85%) were answered. From 493 eligible questionnaires 395 (80.1%) infants were breastfed, and 98 (20%) formula fed. A total of 279 episodes of illnesses were observed in 493 infants. These infants had on average 1.76 episodes of illnesses. The crude incidence density ratio (IDR) revealed a protective effect of breastfeeding on respiratory illnesses (IDR = 059; 95% confidence interval (CI), 0.44-0.79), for gastrointestinal illnesses (IDR = 0.50; CI, 0.24-0.86) and on all illnesses (IDR = 0.58; CI 0.45-0.86). The IDR adjusted in turn for infant's age, mother's age, socioeconomic status and cigarette consumption in family were similar to the crude IDR. CONCLUSION the results of this study suggest a protective effect of breastfeeding against respiratory and gastrointestinal illnesses.

Urinary tract anomalies (UTA) are frequent anatomic anomalies in children. They represent approximately 30% of all congenital anomalies. Although in 45% they are the cause of end stage renal disease, they are still diagnosed late. This paper discusses epidemiology, embryology, pathogenesis, and type of UTA, as well as diagnosis and treatment. Prenatal ultrasonografic diagnosis and ultrasound screening in infancy are very important to achieve timely treatment and prevention of complications.

Breastfeeding is superior to infant formula feeding, it has many advantages because it protects neonates against infections when the immune system is immature. Breast milk has special components that provide immunologic protection and a beneficial effect on intestinal flora. Through bioactive factors in human milk breastfeeding strengthens the host defences against: sepsis, respiratory, gastrointestinal and urinary infections. The protective effect of breastfeeding against infections is fundamental for breastfeeding sup­port and promotion as the best food for neonates.

OBJECTIVE To investigate the infants feeding practice in first six months in Tuzla canton. METHODS Observations of feeding practices in first six months of infants life, born in Obstetrics and Gynecology Department in Tuzla in period May-September 2004 who weighted more than 2500 gm and over 37 weeks gestation age. Dates were collected by standardized questionnaire mailed to 493 mothers from 13 regions in Tuzla canton. With questionnaire we mailed the explanatory letter with investigations detail. RESULTS Exclusive breast feeding at first 3 month was very high reaching from 74.4% in 1 month, 62.3% in 2 month and 50.9% in 3 month of life. After third month exclusive breast feeding was decreasing and reached 12% at sixth month. Predominant breast feeding was reaching from 13.2% at first month, 27.6% at fourth month and 20.7% at sixth month. Breast feeding and complementary feeding before six month was very low, 1% in first month reaching 47.7% in sixth month. Bottle feeding rate was 11.4% in first month and 20% in sixth month of infant life. CONCLUSION Infants feeding practice in first 6 months was inadequate according to WHO recommendation, exclusive breast feeding for first six months. Breast feeding initiation rate was high but lack of mothers support after discharge and many barriers discourage exclusive breast feeding of infants in first six months in Tuzla canton.

The aim of this study was to determine the frequency and type of anomalies of the urinary tract (AUT) and their association with anomalies of the other organ systems in infants (age 0 to 12 months) hospitalized at the Tuzla Pediatric Clinic between January 1st 2003 and December 31st 2004. This was a retrospective chart review of 44 infants (26 females and 18 males) who underwent urinary tract evaluation consisting of voiding cystography, intravenous urography and dynamic scintigraphy. Twelve different types of AUT were found in 25 (56.9%) patients. The commonest AUT were vesicoureteral reflux, hydronephrosis, and megaureter secondary to ureteral stenosis found in 29.2%, 19.5% and 12.1% of patients respectively. Six infants (24% of the infants with AUT) had associated anomalies of other organ systems: three of them had anomalies of two organ systems. Early diagnosis of AUT, including prenatal diagnosis, is essential for timely treatment and prevention of complications that may lead to renal insufficiency. Since only 3 out of 25 infants in this study had suspected AUT on prenatal sonography, improvement of prenatal health in Tuzla Canton may contribute to earlier diagnosis. Due to the frequent association of AUT and anomalies of other organ systems, when the diagnosis of AUT is confirmed there should be vigilance in investigating for the presence of other anomalies.

The aim of this study was to assess infants feeding practice in first six months of life between infants in different areas in Tuzla Canton. Results of this investigation are base for breastfeeding assessment under WHO recommendation. It was an observational study of infants feeding practice in first six months of life. The babies were born in Gynecology-Obstetric department in Tuzla in period from May - September 2004, with 2500 gm or more and at least 37 gestational weeks. Infant feeding practice was collected by questionnaire which was sent to mothers at 13 regions in Tuzla Canton. 493 mothers returned a valid questionnaire. The areas of Tuzla’s canton were divided in two groups according to the statistical significant differences (p<0.05) between the number of exclusive breastfeeding months. First group were areas with more than 41% exclusive breastfeeding rate, and the second below 41%. According to predominant breastfeeding and formula feeding rate the areas of Tuzla Canton were divided in two groups with significant differences (p<0.05) between. First group was areas with predominant breastfeeding rate higher than 20%, and second was below. The areas with formula feeding rate higher than 16.6% were in the first group and below 16.6% were second group. Breastfeeding with supplementation was greatest with infants from Doboj Istok region. WHO recomendation-exclussive breastfeeding in first six months was inadequite in infants of Tuzla regions, especially in areas with low exclussive breasfeeding rate and high formula feeding rate. In areas with high exclusive breastfeeding rate every second infat had adequite feeding but in other regions every thirth or forth. There are many barriers for exclussive breastfeeding and we have a long way to go to enable all women to breastfeed exclussively. Team work is essential for success.