Moderate Soy Consumption OK for Breast Cancer Survivors

From Medscape Medical News > Oncology Sandra Yin November 7, 2011 (Washington, DC) — It is all right for breast cancer survivors to consume moderate amounts of soy foods, Bette Caan, PhD, a senior research scientist who specializes in nutritional epidemiology at the Division of Research at Kaiser Permanente Northern California in Oakland told attendees here at the American Institute for Cancer Research (AICR) Annual Research Conference 2011 on Food, Nutrition, Physical Activity and Cancer in a session on cancer treatment and survivorship. Dr. Caan sought to clarify the highly charged topic of whether soy is safe for breast cancer survivors by reviewing the epidemiologic literature. Soy has been touted in the mainstream media as "the miracle bean" and laypeople read about everything from the "joy of soy" to the "dark side of soy." It is not surprising that the public and experts are confused, Dr. Caan acknowledged. Part of the problem is conflicting data. Soy foods can either increase the risk for breast cancer progression or decrease the risk, she observed. Evidence suggests that lifetime endogenous estrogen exposure increases the risk for breast cancer. So people were afraid to tell breast cancer survivors that it was okay to eat soy. Clinicians have several options based on the epidemiologic literature, and some routinely advise against soy in the diet of patients with breast cancer, Dr. Caan noted, "and I don't think the current science supports that at all." No Evidence of Harm After reviewing the 7 epidemiologic studies, Dr. Caan said there was no evidence that soy is harmful for women with breast cancer, and pointed out that 6 of the 7 studies demonstrate some type of benefit. On the basis of the lack of harm and the benefits reported in the studies she cited, clinicians might want to recommend that patients with breast cancer begin eating whole soy foods to treat breast cancer, but she cautioned that she doesn't think existing data were strong enough to justify that. "What I do think is that they could adopt a stance of permitting use in patients who want to begin eating reasonable amounts of soy foods or for whom soy foods already represent a normal part of their diet," Dr. Caan said. The data support this option, and she said they were consistent with the American Cancer Society (ACS) position. The ACS is in the process of rewording its guidelines. The old ones said that up to 3 servings of traditional soy foods per day are unlikely to be harmful. According to Dr. Caan, those guidelines may be revised to state that women with breast cancer can eat moderate amounts of soy foods. She added 1 caveat: to avoid concentrated sources of soy, such as pills, powders, or supplements containing high amounts of isoflavones, because data are lacking on the risks and benefits. "We still need to proceed with caution," she said. The discussion heated up during the session's Q&A when another presenter, Leena Hilakivi-Clarke, PhD, professor of oncology at Georgetown School of Medicine, Washington, DC, whose talk focused primarily on animal research, shared her advice on soy consumption. If a woman had been consuming soy before diagnosis, it would be perfectly safe to eat the same amount or maybe increase it a little bit, she said. But her recommendation was more cautious for another subgroup. "If she had not eaten any soy beforehand, my opinion is that she shouldn't start before we know whether it's safe or not," she said. A member of the audience took issue with the latter advice. "First, when human data exists, it should surpass animal data," said Mary L. Hardy, MD, medical director at the Simms/Mann University of California at Los Angeles Center for Integrative Oncology. Nor was she convinced that models using a vectorized mouse or rat were an appropriate model for humans. "Third, If we're moving people toward a plant-based diet, and we take out a really good source of plant-based nutrition, how are we taking with one hand and giving with another?" Because her patients have heard from the media or uninformed physicians that soy is bad, Dr. Hardy said they "freak out" because they see soy in everything, as it is used as an emulsifier and a flow agent. "They'll think they can't eat anything, which can be confusing and demoralizing," she said. "I'm very hesitant for that advice to be promulgated, when I think it's going to cause at many levels more harm than good." Later Dr. Hardy told Medscape Medical News that she agreed with Dr. Caan's recommendations. But she had another concern about Dr. Hilakivi-Clarke's advice. In her practice, she actively encourages people to eat a plant-based diet and reduce their dependence on red meats. Taking away meat and then soy would confuse patients who want to identify a good-quality protein source, she said. What's more, the average breast cancer patient whose tumor was caught early and is responsive is probably many times more likely to face risk for heart disease than breast cancer, so it wouldn't make sense to take away a heart-healthy food that lowers cholesterol, she said. "I think inappropriately discouraging soy use is going to cause problems." Dr. Caan told Medscape Medical News that either you eat soy or you don't. If you enjoy soy as part of your diet, you can continue to eat it because more evidence suggests that it's beneficial. Referring to the other speaker's advice that patients with breast cancer who have never eaten soy should not start to eat it to treat their cancer, she said, "Who are those people? You're giving a warning to people who don't exist." Dr. Caan and Dr. Hilakivi-Clarke have disclosed no relevant financial relationships. Dr. Hardy serves on the scientific advisory board of Dean Foods, which makes soy milk. American Institute for Cancer Research (AICR) 2011Annual Research Conference on Food, Nutrition, Physical Activity and Cancer. Presented November 3, 2011.

Prenatal health and your baby

Did you know that having a healthy pregnancy and baby actually starts before you get pregnant? Taking care of yourself when you’re thinking about becoming pregnant is important. This includes: Eating healthy foods and getting regular exercise. Canada’s Food Guide offers tips and advice for healthy eating at all stages of life. Aiming for at least 30 minutes of moderate exercise, 5 days a week. Making sure your vaccines are up-to-date. Check with your doctor to ensure you are properly protected against illnesses like rubella, chickenpox and influenza. Getting these vaccines will help protect your baby. Talking to your doctor about any prescription drugs you are taking to find out whether they are safe during pregnancy. Vitamins before pregnancy: If you are planning to get pregnant, you should be taking folic acid. Folic acid (also called folate or folacin) is a vitamin that helps a baby’s neural tube develop properly during pregnancy. The neural tube becomes your baby’s brain and spinal cord. Neural tube defects (NTD) result from openings in the spinal cord that do not close properly during early pregnancy, causing spina bifida and anencephaly. Folic acid protects against NTDs and can also lessen the risk of other problems at birth, such as cleft palates or heart, genital and urinary defects. Although certain foods (fortified grains, spinach, lentils, chick peas, asparagus, broccoli, peas, Brussels sprouts, corn, and oranges) have folic acid, it can be hard to get enough from diet alone. Most healthy women should take a daily multivitamin with 0.4-1.0 mg of folic acid, for at least 2 to 3 months before getting pregnant, throughout pregnancy, and then after birth for as long as they breastfeed. Women who have diabetes or epilepsy, and women with a family history of NTDs (a sibling, parent or cousin with the condition), or who have already had a baby with an NTD need a higher dosage, and should supplement their diet with between 0.8 and 4 mg of folic acid daily. Talk to your health care professional if you aren’t sure how much you should take. Vitamins during pregnancy: You should take a multivitamin during pregnancy that includes between 16 and 20 mg of iron. You should also take vitamin D. Your doctor may recommend up to 2000 IU/day. Not getting enough vitamin D during pregnancy will affect how much vitamin D your baby has at birth. A baby born to a mother who is vitamin D deficient is more likely to have vitamin D deficiency rickets. Cow’s milk, margarine and some soy beverages produced in Canada are fortified with vitamin D. If you don't use these products, if you do not have much exposure to sunlight or your skin is covered much of the time outside—especially if you do not take vitamin D supplements—then you are more likely to be vitamin D deficient. How much weight should I gain during my pregnancy? Weight gain is an important part of supporting your growing baby and placenta, which provides your baby with the nutrients he needs. Women who gain the recommended amount of weight during pregnancy have fewer complications that can lead to things like caesarean section, high blood pressure, and low or high birth weight for your baby. How much should I eat during pregnancy? Your baby is counting on you to provide all the nutrients she needs to grow healthy and strong. Making smart choices about food will help you both stay healthy during and after pregnancy. Also, be sure to prepare food carefully so that you avoid illnesses such as listeriosis or salmonella infection. Canada’s Food Guide suggests how much you should eat from each food group: Vegetables and fruit are a source of vitamins, minerals and fibre. 7-8 servings/day Choose at least one dark green and one orange vegetable or fruit every day. Grain products are an important source of energy from carbohydrates. 6-7 servings/day Make at least half of the grain products whole grain. Milk and alternatives are nutritious sources of calories, as well as calcium and vitamin D. Some alternatives (such as fortified soy beverage) have vitamin D added. Check labels for calcium and vitamin D content. 2 servings/day Drink skim, 1% or 2% cow’s milk or fortified soy beverage each day. Meat and alternatives are important sources of iron and protein. 2 servings/day Choose a variety of lean meat, poultry, and de-boned fish, eggs, tofu, dried peas, beans and lentils. At least 2 servings of fish /week are recommended. Oils and fats 2-3 tbsp a day Canada’s Food Guide also recommends an extra 2-3 servings from any one of the 4 food groups every day. Be sure to drink plenty of water throughout the day. Is there anything I should avoid consuming while pregnant? Fish with higher levels of mercury (such as shark, swordfish and fresh tuna) should be avoided, because mercury can harm a developing baby. Canned, chunk light tuna generally has a lower amount of mercury than other tuna, but should still be eaten in moderation, with no more than 150 g a month. Avoid raw fish, which may contain bacteria or parasites that can make you sick. Limit caffeine, and consider cutting it out of your diet completely while pregnant. Certain medications can also be dangerous to your baby during pregnancy. If you are on any medications, talk to your doctor about whether you should keep taking them when pregnant. How can I stay active during pregnancy? Staying active during your pregnancy will help ease your aches and pains and may help with your mood. It’s also a good way to ensure you have the energy you need for your pregnancy and delivery. Some suggestions for physical activity include: regular walking, swimming, low-impact aerobics, prenatal exercise classes, and yoga. If you weren’t already active before your pregnancy, start slowly and speak to your health care provider before starting a new exercise routine. Can I drink alcohol while I am pregnant? If you drink alcohol during your pregnancy, the alcohol goes to the baby through your bloodstream. Drinking alcohol during pregnancy can cause fetal alcohol spectrum disorder (FASD, a serious condition that can affect a child for life. If you are thinking about getting pregnant, it’s best to stop drinking alcohol now. Then you’ll know for sure that your baby will be safe from FASD. Women who find it hard to stop drinking, or who already have a child with FASD, should get help before getting pregnant. Can I smoke or take recreational drugs while I am pregnant? Avoid smoking and drug use during pregnancy. These can be dangerous to your growing baby and increase the risk of Sudden Infant Death Syndrome. If you are thinking about getting pregnant, it’s best to stop drinking alcohol, smoking or doing recreational drugs now. Then you’ll know for sure that your baby will be safe. If you are already pregnant, you should stop drinking alcohol, smoking or doing recreational drugs completely. For more information: Fetal alcohol spectrum disorder: What you should know about drinking during pregnancy Depression in pregnant women and mothers: How it affects your child Prenatal nutrition, a resource by Health Canada Healthy pregnancy, a resource by Health Canada Healthy Beginnings, a book on pregnancy from the Society of Obstetricians and Gynaecologists of Canada (SOGC). Healthy eating, exercise and weight gain: Before and during pregnancy, from SOGC. Pregnancy and breastfeeding resources, Motherisk Reviewed by the CPS Public Education Advisory Committee Posted: August 2011 This information should not be used as a substitute for the medical care and advice of your physician. There may be variations in treatment that your physician may recommend based on individual facts and circumstances. Canadian Paediatric Society 2305 St. Laurent Blvd., Ottawa, Ont. K1G 4J8 Phone: 613-526-9397, fax: 613-526-3332

'Safe Sleep'

From Medscape Medical News Updated AAP Policy Statement Stresses 'Safe Sleep' Fran Lowry October 21, 2011 (Boston, Massachusetts) — The American Academy of Pediatrics (AAP) has expanded its recommendations to ensure a safe sleeping environment for infants and to further reduce the risk for sudden infant death syndrome (SIDS) in a new policy statement. The recommendations were announced here at the AAP 2011 National Conference and Exhibition by pediatrician and SIDS researcher Rachel Moon, MD, from the Children's National Medical Center, Washington, DC, who led the task force that updated the policy statement. Since 1992, when the AAP recommended that all babies be placed on their backs to sleep, deaths from SIDS have declined dramatically; however, sleep-related deaths from other causes, including suffocation, entrapment, and asphyxia, have increased, Dr. Moon said. She told Medscape Medical News that the new policy statement has 3 important changes. First and foremost is the recognition that breastfeeding protects against SIDS. "In 2005, there was a lot of evidence that breastfeeding was great for preventing infant mortality in general, but not SIDS specifically. But since 2005, there has been a lot of research that has shown that breastfeeding is protective against SIDS, and we wanted to emphasize that and make that change," Dr. Moon said. The second change is an emphasis on immunization. "There's been a lot of press out there about how immunizations may cause SIDS. Again, there's been research to show that this is absolutely not the case. In fact, if you are immunized, your risk of SIDS drops by 50%. We wanted to make that clear; we wanted to put that out there," she said. The third big change, Dr. Moon said, is the recommendation against using bumper pads in cribs to reduce accidental smothering. "We have expanded the recommendations in the policy statement to focus not only on SIDS, but on other deaths that can occur. That is why we are recommending against the cushions that go along the sides of the crib," she said. "Children can be suffocated by them." Other key recommendations are: Always use a firm sleep surface. Car seats and other sitting devices are not recommended for routine sleep. The baby should sleep in the same room as the parents, but not in the same bed (room sharing without bed sharing). Keep soft objects or loose bedding out of the crib. Wedges and positioners should not be used. Offer a pacifier at nap time and bedtime. Avoid covering the infant's head or overheating. Do not use home monitors or commercial devices marketed to reduce the risk for SIDS. Supervised, awake tummy time is recommended daily to facilitate development and minimize the occurrence of positional plagiocephaly (flat heads). Eve R. Colson, MD, from the Yale University School of Medicine, New Haven, Connecticut, told Medscape Medical News that she is very happy to see this focus on preventing accidental deaths. "As a director of our nursery and somebody who is really into medical education of families and of staff, I am glad to see this because we have seen lots of accidental deaths," Dr. Colson, who was not a member of the policy statement task force, said. "We, at Yale, have been so upset by the increased number of deaths in beds happening in New Haven and surrounding areas. In my opinion, the adult bed is not a safe place and I'm glad they've come out with this recommendation." Dr. Colson said she understands "totally" that parents like to be close to their babies, and she encourages this. She said she takes a very sensitive approach when explaining to parents why the adult bed is not safe for babies. "We get SIDS deaths in our emergency room, but we also get babies who have suffocated because somebody rolled on them or they have ended up underneath a pillow or got trapped between the mattress and the wall. This is what we have seen and we want to prevent that." Dr. Moon and Dr. Colson have disclosed no relevant financial relationships. American Academy of Pediatrics (AAP) 2011 National Conference and Exhibition. Presented October 17, 2011.

Infants Should Sleep on Their Backs, in Parents' Room

From Reuters Health Information BOSTON (Reuters) Oct 18 - Putting babies to sleep on their backs on a firm crib mattress in the same room as the parents is among recommendations on a list of safe sleep guidelines for infants released on Tuesday. The American Academy of Pediatrics first said in 1992 that infants should be placed in a non-prone position for sleeping to curb sudden infant deaths. The latest report, published October 17 in Pediatrics, recommends infants sleep wholly on their backs for every sleep, noting that side sleeping is unsafe. Some supervised awake-time spent on the tummy is recommended. A series of 18 recommendations from the academy are intended to help guide parents, health care providers and others who care for infants following an increase in sleep-related deaths over the last few years. The expanded recommendations focus broadly on creating a safe sleep environment that can reduce the risk of sudden infant death syndrome, suffocation, entrapment and asphyxia, the report said. The guidelines also recommend soft objects and loose bedding like quilts, pillows and even bumper pads not be kept in cribs. Infants should not have routine sleep time in sitting devices like car seats and strollers and should not sleep in a bed where they might suffocate, according to the guidelines. The recommendations, geared to infants up to one year old, also emphasize the importance of regular prenatal care for pregnant women and encourage smoke-free environments for pregnant women and children. SOURCE: http://bit.ly/ofygWN Pediatrics 2011.

Keep your baby safe

Injury is the leading cause of death among children in Canada. Some of the biggest dangers to babies are falls, burns or scalds, drowning, choking, suffocation or strangulation, and car crashes. The good news is that these injuries are almost always entirely preventable. Parents can take steps to protect their new baby by: Recognizing everyday risks early, and taking precautions. Anticipating a baby’s new skills, and being prepared. Paying special attention at extra busy times of day. Actively supervising. The best way to prevent injury is to watch, listen and stay nearby. When you have to move away from your baby, put him in a safe place, like his crib. Remember: Your infant can’t lift her head until she is about 4 months old, when her neck muscles are stronger, and then only for a short time. She can’t avoid conditions or objects that make it hard for her to breathe. Your infant can squirm and move along a surface long before she can turn over by herself. Even a newborn can wriggle enough to fall off the change table, bed or sofa. Your infant can grasp and shake things, reach for dangling objects, wave a fist and push down firmly with his legs—and fast enough to knock hot or sharp things from your hand. Before you bring your baby home Make sure your crib has a permanent label with detailed manufacturing information, instructions and a warning statement about mattress size and proper use. Never use a crib that is missing this label, or one made before 1987. Check that all the crib bars are present and secure. The mattress should be firm, flat and fit tight within the crib frame. Sheets are smooth and tight-fitting as well. Corner posts shouldn’t be higher than 3 mm (1/8 inch) above the end panels. The frame must be solid, with no cut-out designs or openings where a baby could catch her head. Crib sides should lock securely in place when raised. Mattress support hangers must be secured by bolts and closed hooks. Don’t use a crib where these hooks are “Z” or “S”-shaped. Be sure to check for loose fittings regularly, especially whenever the crib is moved. Place the crib away from windows, window coverings and blind cords. Do not use bumper pads, pillows, lambskins, quilts, stuffed toys or comforters in the crib. Hang mobiles out of reach of your infant’s hands and fasten them securely to both sides of the crib. Don’t use a bassinet or cradle. Even an infant’s weight and movement can make them tip or collapse. Make sure that shelving or any heavy furniture is anchored securely to the wall. Install a smoke alarm in your baby’s room and check all the household smoke alarms to be sure they are working. Install a carbon monoxide detector in your home. Once baby is home, your precautions and behaviour will help protect her against the most common types of injury. Falls Never leave your infant unattended, or in a carrier on any raised surface, such as a bed, sofa or change table. Make sure your change table has a guard rail and safety strap, and always use them. If the phone rings while you are changing a diaper, take your baby with you to answer it or just let it ring. Store everything you need to change a baby within easy reach, so you don’t have to turn away. Make sure your baby sling or front carrier is appropriate for your baby’s age and size. It should support her head and shoulders and have small leg openings, so she can’t slip out. If you bend over, hold your baby against you with one hand so she won’t fall. Burns or scalds Smoke alarms should be installed on every level of the home and in every sleeping area. Check alarms once monthly to be sure they are working, and change the batteries twice each year, when you change the clocks in the spring and fall. Do not allow smoking in your home. Many house fires are caused by careless smoking or children playing with smoking materials such as lighters and matches. Also, cigarettes and butts are poisonous to young children. Set your hot water heater temperature to 49°C (120°F), or put an anti-scald device on your faucets. A baby’s skin burns very easily. Before bathing, check the water temperature with your elbow or wrist. It should feel warm, not hot. Bathe your baby away from the faucets, and remove him from the tub before running the hot water again. Never carry a baby and a hot drink at the same time. Use plastic mats instead of a table cloth that your baby might pull on and cause a spill of hot liquid. Don’t heat breast milk or formula in a microwave. Dangerous “hot spots” can burn an infant’s mouth. Warm a bottle in a pot of hot water instead, and test the milk on your wrist before feeding. Drowning An infant can drown—very quickly and quietly—in as little as 5 cm (2 inches) of water. Always watch and have at least one hand on your baby when she’s in the bathtub, wading pool or near any standing water. Have everything you need for bathing at hand, so that you never have to turn away. Don’t use a bath seat or ring. They are not safe. Never leave your baby alone in the bath with a brother or sister, even for a few seconds. Do not use a cell phone during bath time. If you must answer the telephone, take baby with you. Choking, suffocation or strangulation Vacuum often, and never leave small objects within a baby’s reach. He will put anything and everything in his mouth. Remove crib mobiles as soon as your baby is 4 months old or pushing up on hand and knees. Use a one-piece soother small enough for infants, with a shield to prevent him from sucking the nipple too far into his mouth. Discard any soother that shows any sign of wear or is more than 2 months old. Get rid of toys with pull strings longer than 20 cm (8 inches) or small, loose or breakable parts that a baby could swallow or inhale. Any object that is small enough to fit inside a toilet paper roll is a choking hazard. Don’t use bibs with ties, or hang pacifiers, a necklace or anything else around an infant’s neck that might catch and strangle her. Keep all plastic bags or wrapping out of reach and out of sight. Car safety All infants need a rear-facing car seat for their first ride home from the hospital. Your baby will use this seat whenever you travel-- even the shortest distance-- for one year or longer. Infants may use a forward-facing car seat once they are at least one year old and at least 10 kg, however it is best to rear-face as long as possible, so look for a car seat with the highest rear-facing weight and length limits once your child has outgrown their first car seat. Install the car seat in the middle of the rear seat—never in the front or near an airbag. Read the manufacturer’s instructions for the car seat and follow all age, height and weight specifications. Secure the car seat using the Universal Anchorage System (UAS or LATCH), which is now mandatory in all car models. Follow both the car seat and car manual instructions. If the UAS system does not secure the seat adequately, then use the seat belt, as indicated in the car seat instructions. Check that the car seat does not move more than 2.5 cm (1 inch) forward or from side to side once it is installed. Harness straps should be threaded just at or below your baby’s shoulders. The chest clip should be at armpit level and the harness should fit snugly. Tuck a blanket around your baby if needed instead of using a bunting bag. Don’t use a car seat that has been in a car crash, even a minor one. It is not safe. Never leave your baby unattended in a car, even to run a quick errand. For more information: Car seat safety Water safety for young children Transportation of infants and children in motor vehicles, a statement of the Canadian Paediatric Society Transport Canada: Safety in the car Reviewed by the CPS Injury Prevention Committee Updated: March 2009 This information should not be used as a substitute for the medical care and advice of your physician. There may be variations in treatment that your physician may recommend based on individual facts and circumstances. Canadian Paediatric Society 2305 St. Laurent Blvd., Ottawa, Ont. K1G 4J8 Phone: 613-526-9397, fax: 613-526-3332

Moms May Think Softer Is Safer for Sleeping Babies

From Reuters Health Information By Genevra Pittman NEW YORK (Reuters Health) Aug 23 - Lots of African American moms put soft bedding such as pillows and blankets where babies sleep, despite warnings that the cushioning increases the risk of infant death, according to a new study. That's because many parents are under the impression that a soft sleeping environment means the baby will be more comfortable or will be protected from injuries, said Dr. Rachel Moon. "There's this impression that soft is safe," said Dr. Moon, one of the authors of the new study from Children's National Medical Center in Washington, D.C. "But when it comes to babies' sleep environment, soft is not safe, it's actually dangerous." Researchers know that black babies are at least twice as likely as white, Latino, and Asian babies to die of accidental suffocation, strangulation or sudden infant death syndrome (SIDS). While some of that higher incidence may be related to genetics, much of it is probably due to parents unknowingly putting infants in a dangerous sleeping place or position, Dr. Moon said. To find out whether black families know about the risks, Dr. Moon and her colleagues conducted one-on-one interviews and small group discussions with 83 black mothers in D.C. and Maryland with a new baby at home. The researchers asked women if they used soft bedding and bumper pads in their baby's crib or other sleeping location -- and why or why not. More than of half of the moms reported using soft bedding for their baby, according to findings published August 22nd in Pediatrics. They told researchers they wanted to make sure the babies were comfortable and warm, or that they used pillows as a barricade on beds and sofas, or to prop babies up. "We were surprised that people use (soft bedding) because they think it's going to make their baby safer," Dr. Moon told Reuters Health. "We weren't that surprised that people use it to make the babies comfortable." Some mothers thought doctors' recommendations to use a "firm sleep surface" included a bed where a sheet was tucked tightly over pillows -- but that's still a dangerous sleep situation, the researchers warned. Moms also used bumper pads on cribs if they worried that a baby would hit its head on the railings or get an arm or leg stuck. Some, the researchers found, also thought the bumper pads were cute. But just like with pillows and blankets, bumper pads pose a suffocation risk to babies, Dr. Moon said. "There really isn't any need for bumper pads," especially for very young babies, she added. Dr. Fern Hauck, a SIDS researcher at the University of Virginia in Charlottesville, said she understood the desire to make babies comfortable with soft bedding in hopes that they'll sleep better and longer. But, "babies can pretty much sleep anywhere," she told Reuters Health. "If you get them used to a firm crib mattress, they're going to sleep fine on a firm crib mattress." She said that pediatricians have to talk to new parents about all SIDS and suffocation risks, and "really get a little more of a dialogue going" about the safest way for a baby to sleep. Grandparents, friends, and anyone else who would be taking care of the baby also need to have that conversation, Dr. Hauck added. And it's important to know that although the interviews were only done with black mothers, parents of all races may misinterpret a pediatrician's recommendations or what constitutes a safe sleeping environment, said Dr. Debra Weese-Mayer, a pediatrician at Northwestern University Feinberg School of Medicine in Chicago. The study "is a very humbling lesson that even though we think we're giving a very clear message (about sleep surfaces), if the parent and the caretaker are interpreting it in a way different from what we intended, we're not doing a very good job," Dr. Weese-Mayer said. "If it can save some babies because we do a better job of translating our recommendations, that's wonderfully important." SOURCE: http://bit.ly/oqyquw Pediatrics 2011.

Women May Not Need to Delay Pregnancy After an Initial Miscarriage

From Medscape Medical News

Laurie Barclay, MD

August 11, 2010 — Women may not need to delay pregnancy after an initial miscarriage, according to the results of a retrospective, Scottish population–based cohort study reported Online First August 5 in the BMJ.
"How long a couple should wait before trying for another pregnancy after a miscarriage is controversial," write Eleanor R. Love, from the University of Aberdeen in Aberdeen, Scotland, and colleagues.
"Some clinicians believe that there is little justification for delaying the next pregnancy, as an increased interpregnancy interval is unlikely to improve perinatal outcomes, whereas a new viable pregnancy and the birth of a child could enhance the women's chances of recovery....

Current guidelines from the World Health Organization recommend that women should wait for at least six months before trying again, whereas others suggest a delay of up to 18 months, based on reports that interpregnancy intervals of 18-23 months after a live birth can enhance maternal and perinatal outcomes in the next pregnancy."

The goal of this study was to evaluate the optimal interval to subsequent pregnancy after miscarriage in a first recorded pregnancy. At Scottish hospitals between 1981 and 2000, a total of 30,937 women who had a miscarriage in their first recorded pregnancy and subsequently became pregnant were followed up during the second pregnancy. The main study outcome was miscarriage, live birth, termination, stillbirth, or ectopic pregnancy in the second pregnancy, and secondary endpoints were rates of cesarean and preterm delivery, low birth weight infants, preeclampsia, placenta previa, placental abruption, and induced labor in the second pregnancy.

Compared with an interval of 6 to 12 months between the miscarriage and second conception, an interval less than 6 months was associated with lower risks for repeated miscarriage (adjusted odds ratio [OR], 0.66; 95% confidence interval [CI], 0.57 - 0.77), termination (OR, 0.43; 95% CI, 0.33 - 0.57), and ectopic pregnancy (OR, 0.48; 95% CI, 0.34 - 0.69). The risk for an ectopic second pregnancy was greater with an interpregnancy interval exceeding 24 months (OR, 1.97; 95% CI, 1.42 - 2.72), as was the risk for termination (OR, 2.40; 95% CI, 1.91 - 3.01).

Compared with women who had an interpregnancy interval of 6 to 12 months, those who conceived again within 6 months and had a live birth in the second pregnancy were less likely to have a cesarean delivery (OR, 0.90; 95% CI, 0.83 - 0.98), preterm delivery (OR, 0.89; 95% CI, 0.81 - 0.98), or low-birth-weight infant (OR, 0.84; 95% CI, 0.71 - 0.89). However, they were more likely to have labor induced (OR, 1.08; 95% CI, 1.02 - 1.23).

"Women who conceive within six months of an initial miscarriage have the best reproductive outcomes and lowest complication rates in a subsequent pregnancy," the study authors write.

Limitations of this study include potential lack of uniformity in documenting gestational age and outcomes of interest as well as possible misclassification. This study also evaluated only miscarriages that led to hospital contact, and the findings therefore cannot be generalized to all women with a miscarriage.
"Our research shows that it is unnecessary for women to delay conception after a miscarriage," the study authors conclude. "As such the current WHO [World Health Organization] guidelines may need to be reconsidered. In accordance with our results, women wanting to become pregnant soon after a miscarriage should not be discouraged."

In an accompanying editorial, Julia Shelley, associate professor of health and social development at Deakin University in Melbourne, Australia, discusses some of the methodologic issues regarding this study and earlier studies.
"[A]ll of the studies have selection and measurement biases that cast doubt on the value and generalisability of their findings," Dr. Shelley writes. "Of greatest concern is that women with short interpregnancy intervals are more fertile than those whose subsequent pregnancy occurs later because these women seem to have better pregnancy outcomes and fewer complications. Further research into this question may need to wait for data from more sophisticated linked primary care and hospital datasets or specifically designed research studies that can measure and account for such differences, even if they will not be able to control for them."


BMJ. 2010;341:c3967. Abstract

CDC Issues Revised Guidelines for Postpartum Contraceptive Use

From Medscape Education Clinical Briefs

News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD

Released: 07/12/2011

Clinical Context

Planning for contraception after delivery is a critical element of family planning, and the US Centers for Disease Control and Prevention (CDC) provides a review of all available contraceptive methods in its current recommendations.
Progestin-only hormonal contraceptives are safe to initiate immediately after delivery, and they can be used among women who are breast-feeding.
Intrauterine devices (IUDs) can be placed immediately after delivery. Although there is a higher risk for expulsion immediately after delivery, continuation rates of IUDs at 6 months postpartum is similar regardless of when the device is placed.
Women should not initiate contraception with a diaphragm or cervical cap until 6 weeks postpartum.
The use of combined hormonal contraception during the postpartum period is a complicated issue, and the current recommendations revise previous guidelines issued by the CDC in 2010.

Study Synopsis and Perspective

The CDC has updated its guidelines for postpartum contraceptive use, according to revised recommendations reported in the July 8 issue of MMWR. Morbidity and Mortality Weekly Report.
The new statement, which updates the CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010, advises postpartum women not to use combined hormonal contraceptives during the first 21 days after delivery because of a high risk for venous thromboembolism (VTE).
"The postpartum period is an important time to initiate contraception because women are accessing the health-care system and might have increased motivation to avoid another pregnancy," write Naomi K. Tepper, MD, from the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, and colleagues.
"Ovulation can occur as early as 25 days postpartum among nonbreastfeeding women, underscoring the importance of initiating contraception in the very early postpartum period."
The revised guidelines affirm the importance of starting contraception during the postpartum period to prevent unintended pregnancy and short birth intervals, which are associated with adverse health outcomes for the mother as well as for the infant. These include greater risks for low birth weight and preterm birth.
The 2010 CDC recommendations offered evidence-based guidance for choosing a contraceptive method, considering patient-specific characteristics or medical conditions, such as the postpartum period.
 
New Guidelines More Stringent
On the basis of subsequent evidence, the World Health Organization (WHO) updated its recommendations regarding the safety of combined hormonal contraceptives among postpartum non–breast-feeding women. Compared with control participants, women in the first 42 days of the postpartum period have a 22-fold to 84-fold increased risk for VTE.
The new WHO guidelines were therefore more restrictive concerning use of combined hormonal contraceptives during the first 42 days after delivery, especially in women who had other risk factors for VTE.
To review the WHO recommendations and underlying evidence base, the CDC therefore convened a group of 13 ad hoc reviewers. On the basis of available evidence concerning the safety of combined hormonal contraceptive use in postpartum women, the CDC has now concluded that the high risk for VTE during the first 21 days after delivery should preclude use of combined hormonal contraceptives in this time frame.

Although the risk for pregnancy is very low during the first 21 days postpartum, it increases thereafter, and ovulation before first menses is common.

From 21 to 42 days after delivery, women with risk factors for VTE generally should not use combined hormonal contraceptives, but these are thought to be safe during this period for women without risk factors for VTE. Risk factors for VTE include age 35 years or older, previous VTE, thrombophilia, known thrombogenic mutations, immobility, transfusion at delivery, body mass index of at least 30 kg/m², postpartum hemorrhage, peripartum cardiomyopathy, post cesarean delivery, preeclampsia, or smoking.
The CDC has issued no restrictions on the use of combined hormonal contraceptives in women who delivered more than 42 days previously.
"Health-care providers assessing a woman's individual risk also should consider any other characteristics or medical conditions that might impact the classification," the guidelines authors write.
"For postpartum women, this might include examining the recommendations for other risk factors for VTE, such as known thrombogenic mutations (category 4) or history of VTE with risk factors for recurrence (category 4), both of which pose an unacceptable health risk for combined hormonal contraceptive use, whether or not women are postpartum."
 
Recommendations on Other Contraceptive Methods
The CDC recommendations are unchanged regarding progestin-only contraceptives (progestin-only pills, depot medroxyprogesterone acetate injections, and implants), IUDs, and contraceptive methods other than combined hormonal contraceptives.
These methods can be started immediately after delivery and are safe for postpartum women, including those who are breast-feeding.
However, clinicians should consider that combined hormone contraceptives may hinder successful breast-feeding.
Insertion of IUDs, including the levonorgestrel-releasing IUD and copper-bearing IUD, immediately after delivery, is not associated with an increase in complications. Rates of IUD expulsion are somewhat higher when they are inserted within 28 days of delivery, but continuation rates at 6 months are similar regardless of whether IUD insertion takes place immediately postpartum or is delayed.
Condoms can be safely used at any time, but use of the diaphragm and cervical cap should be delayed to 6 weeks postpartum. Another option in women who have completed their childbearing is to consider postpartum sterilization.
The CDC guidelines authors expressed concern regarding access to contraceptive methods.
Unlike progestin implants, IUDs, and other methods requiring a follow-up visit to a provider, combined hormonal contraceptives could be started by the woman herself at the appropriate time if she is issued a prescription or is given a sample in advance, either before hospital discharge or at a postpartum visit.
"Postpartum contraception is important for the health of mother and infant, and education for both health-care providers and women should focus on the range of contraception options and the safety of most of these methods during the postpartum period," the guidelines authors conclude.
 
MMWR Morb Mortal Wkly Rep. 2011;60:878-883.

Fetal Exposure to Environmental Contaminants May Underlie CHD

From Medscape Medical News

Environmental Link to Congenital Heart Disease Strengthened

Brian Hoyle

May 2, 2011(Denver, Colorado) — Maternal exposure to compounds present in crude oil, cleaning agents, and stain removers has been linked to an increased risk for congenital heart disease (CHD) in a study presented here at the Pediatric Academic Societies and Asian Society for Pediatric Research 2011 Annual Meeting.

CHD "is a major cause of childhood death and life-long health problems, so identifying risk factors contributing to CHD is important to public health. Environmental causes of CHD have been suspected, and animal studies have linked certain chemicals to CHD as potential teratogens, but the link has remained unproven," Gail McCarver, MD, professor of pediatrics at the Medical College of Wisconsin and Children's Research Institute, Milwaukee, told Medscape Medical News.

To probe whether human exposure to a battery of volatile organic compounds and halogens increased the risk for CHD, Dr. McCarver and her colleagues tested meconium as a means of assessing fetal exposure to the solvents.

"Meconium monitoring is an established and valid means of assessment of fetal exposure," Dr. McCarver noted in an interview with Medscape Medical News.

Meconium from 135 newborns diagnosed with CHD and 432 newborns without CHD, as determined by echocardiography, was examined for 17 compounds using gas chromatography–mass spectrometry for volatile organic compounds and gas chromatography–electron capture detector for halogens.

Both techniques were exquisitely sensitive, with detection limits in the parts-per-trillion range.

Infants of diabetic mothers and infants identified with chromosomal abnormalities linked to CHD were excluded from the study. Demographic data, information concerning family history of CHD, and maternal history of the use of tobacco, alcohol, illicit drugs, and vitamins were collected. Mothers and infants were genotyped for 2 genes implicated in CHD: ADH, which encodes alcohol dehydrogenase, and CYP2E1, which encodes cytochrome P450 2E1.

The infants with CHD were significantly more likely to be smaller at birth, born at an earlier gestational age, white, have a family history of CHD, and born to a woman who smoked tobacco (P < .05 for all).

Of the 567 infants, 82% had detectable levels of 1 or more of the examined solvents. Infants with CHD more often displayed fetal exposure to ethylbenzene (P < .001), meta/ortho/para-xylene (P < .001), benzene (P < .01), tetrachloroethylene (P < .05), and dichloroethylene (P < .05).

When the data were examined on the basis of race, fetal exposure to ethyl benzene (a component of crude oil) and the inhaled vapors of vehicle emissions, gasoline, and cigarette smoke increased the risk for CHD 4-fold in white infants, but not in black infants.
Exposure to trichloroethylene (a common degreasing chemical that is a component of a variety of cleaners and spot removers) increased CHD risk 2-fold in white infants and 8-fold in black infants.

Maternal obesity; tobacco smoking; the use of alcohol, illicit drugs, or vitamins; exposure to other solvents; and presence/absence of ADH and CYP2E1 were not significant CHD risk factors.

The association between ethylbenzene and CHD — described by Dr. McCarver as "novel and important for public health" — might explain previous reports linking smoking during pregnancy and CHD, and might heighten public health concerns about events such as the recent oil spill in the Gulf of Mexico.

"This is the first report that exposure to ethyl benzene, a compound present in crude oil, is associated with CHD. This association is troubling, particularly concerning recent oil spills," Dr. McCarver told Medscape Medical News.

The data also implicate tetrachloroethylene as a teratogen and strengthen the validity of the noninvasive examination of meconium as a means of analyzing fetal exposure to environmental compounds.

"This is valuable work. But it could, perhaps, be a whole bunch more insightful if we had more of a history of maternal exposure and its relation to pregnancy. This would allow a more accurate assessment of exposure as a causal factor," Robert Geller, MD, from Emory University School of Medicine, Atlanta, Georgia, told Medscape Medical News.

Data gathered throughout pregnancy are limited at present, Dr. Geller added.
Dr. McCarver and Dr. Geller have disclosed no relevant financial relationships.

Pediatric Academic Societies (PAS) and Asian Society for Pediatric Research 2011 Annual Meeting: Abstract 1150.1. Presented April 30, 2011.

Babies Lose Maternal Measles Antibodies After a Few Months

Reuters Health Information

By Frederik Joelving

NEW YORK (Reuters Health) May 18 - Maternal measles antibodies wane earlier than previously thought, leaving infants susceptible to the virus for several months under current immunization guidelines, Belgian researchers report in a May 18th online paper in BMJ.

While not recommending an overhaul of general vaccination age -- currently 12 months in both Belgium and the US -- they said infants with special exposure to measles may need to be immunized at six months.

"We could recommend to vaccinate earlier, but because of good coverage here in Belgium we do not want to lose people" by adding an extra trip to the doctor, said lead author Dr. Elke Leuridan of the University of Antwerp in Wilrijk, Belgium.

Dr. Leuridan and colleagues studied 207 healthy mother-child infant pairs. Eighty-seven of the mothers had been vaccinated against measles and 120 had natural immunity.

The researchers collected venous blood during pregnancy (week 36, 10 ml), at birth (cord blood, 10 ml) and in infants at 1, 3 and 12 months (2 ml). In addition, they took samples randomly at either 6 or 9 months.

They used an enzyme-linked immunosorbent assay to measure the amount of measles immunoglobulin G (IgG) in the blood, calibrating the assay against the international reference preparation of measles antigen. The samples were considered positive if the corrected optical density was greater than 0.2, and negative if it was less than 0.1.

Overall, vaccinated women had lower IgG titers than naturally immune women (779 vs. 2687 milli-International Units per milliliter, or mIU/mL; p<0.001). The same pattern was seen for the infants at all ages (p<0.001).

Maternal antibodies persisted for a median of 3.8 months in infants of naturally immune mothers and for 1 month in babies of vaccinated women. In a linear mixed model, 99% of babies of vaccinated mothers had lost their maternal antibodies after six months, compared to 95% of babies of naturally immune women. Breast feeding, parity, gestational age, birth weight, educational level, day care attendance and cesarean section were not significant in the model.

The findings are consistent with earlier studies showing that measles susceptibility is growing every year, Dr. Leuridan said. Yet, she added, "it is quite new that it is such a large gap."

Part of the reason for the expanding gap, she said, could be the increasing age of mothers and the general success of immunization in lowering overall exposure to the virus.

Dr. Archana Chatterjee, of Creighton University School of Medicine in Omaha, Nebraska, said current immunization practice is based on the theoretical assumption that maternal antibodies might interfere with the necessary replication of the vaccine virus.

She called the new study "food for thought," noting that larger studies are needed before considering guideline changes. For instance, small amounts of maternal antibodies that went undetected in the study in principle might interfere with the vaccine, she said.

Still, Dr. Chatterjee said, "it certainly is something that gives us pause."

http://www.bmj.com/cgi/content/abstract/340/may18_2/c1626
BMJ 2010.

Periconceptional Fever/Influenza Linked to Specific Congenital Birth Defects

From Reuters Health Information CME

News Author: Megan Brooks
CME Author: Désirée Lie, MD, MSEd

NEW YORK (Reuters Health) February 4, 2011 — New research confirms that women who develop influenza or a fever of 101°F or higher during the periconceptional period are at increased risk of delivering a baby with certain congenital heart defects, most notably right-sided obstructive lesions in all infants and atrioventricular septal defects (AVSD) in infants with Down syndrome.

However, maternal use of antipyretic agents in the setting of fever or influenza may attenuate these associations, the researchers reported in the January 24 online issue of The Journal of Pediatrics.

Dr. Adolfo Correa, Medical Officer in the National Center on Birth Defects and Developmental Disabilities, part of the Centers for Disease Control and Prevention, in Atlanta, Georgia, led the study.

"Although our findings are consistent with a few previous studies, the literature on the associations we found is still somewhat limited for drawing conclusive clinical implications," Dr. Correa noted in an e-mail to Reuters Health.

"Further efforts are needed to corroborate our findings and to elucidate the reasons for the observed associations. From a precautionary perspective, women planning to become pregnant should avoid exposure to influenza or other febrile illnesses and seek preconception care," the researcher added.

Maternal febrile illness and hyperthermia have been linked to a variety of birth defects, especially those involving the central nervous system, Dr. Correa and colleagues note in their report. Associations between maternal fever and hyperthermia with congenital heart defects are "less clear-cut," they say.

Moreover, while associations between congenital heart defects and some viral illnesses, particularly rubella, have been well documented, studies on the role of influenza in risk of congenital heart defects have yielded mixed results.

Dr. Correa and colleagues investigated associations between maternal fever and influenza and congenital heart defects using data from the Baltimore-Washington Infant Study, an epidemiologic study of congenital heart defects conducted between 1981 and 1989 in Maryland, Washington DC, and northern Virginia.

Cases were 2,361 infants with congenital heart defects and controls were 3,435 infants without congenital heart defects.

Participating mothers were asked whether they had a fever of 101°F or higher, had influenza, or used an antipyretic agent (acetaminophen, salicylate, or nonsteroidal anti-inflammatory agent) during the period extending from 3 months prior to pregnancy through the end of the third month of pregnancy.

For congenital heart defects overall, no significant associations were found with fever, influenza, or fever/influenza.

However, for specific defects, significant associations were found for right-sided obstructive defects and maternal fever (OR 2.04), influenza (OR 1.75) and fever/influenza (OR 1.69).

These findings were most notable for tricuspid atresia in the setting of fever (OR 7.54), influenza (OR 6.04), and fever/influenza (OR 5.46) and for pulmonary atresia with intact ventricular septum in the setting of influenza (OR 2.71) and fever/influenza (OR 2.80), the researchers reported.

And in infants with Down syndrome, the authors found significant associations between atrioventricular septal defects and periconceptional fever (OR 1.92), influenza (OR 1.66) and fever/influenza (OR 1.66). No significant associations were evident between other cardiac phenotypes and fever, influenza or both.

Maternal antipyretic use tended to decrease these associations, as mentioned.

Dr. Correa and colleagues say the link between fever and influenza and AVSD only in infants with Down syndrome may be "spurious" or it may represent an "important gene-environment interaction that warrants further investigation."

J Pediatr. Published online January 24, 2011. Abstract
Clinical Context

Congenital heart defects continue to be a leading cause of morbidity and mortality in children, and maternal exposures during pregnancy may contribute to the risk for such defects. Maternal fever has been linked to birth defects, especially those of the central nervous system, and studies have noted an almost 2-fold increase in the risk for aggregate congenital heart defects with maternal fever and influenza.

This is a case-control study of infants in a population-based cohort to examine the association between maternal fever or influenza during the 3 months before and after conception and the risk for congenital heart defects.

FDA Approves First 3-Dimensional Mammography System

From Medscape Medical News > Alerts, Approvals and Safety Changes > FDA Approvals

Steven Fox

February 14, 2011 — The US Food and Drug Administration (FDA) has approved the first mammography system employing 3-dimensional (3-D) imaging, and preclinical studies show that the new technology is 7% more accurate than traditional 2-D mammography in spotting breast tumors.

The new technology is to be marketed as the Selenia Dimensions System and is being manufactured by Hologic, Inc. The system is an upgrade to Hologic's currently available 2-D system.

The system has already been approved in Latin America, Europe, and in Asia.

In approving the device for use in the United States, the FDA assessed results from 2 studies in which radiologists reviewed 2-D and 3-D images from more than 300 mammography studies.

In both studies, radiologists viewing both 2-D and 3-D images were 7% more likely to accurately distinguish between cancerous and noncancerous lesions compared with viewing 2-D images alone.

"Physicians can now access this unique and innovative 3-D technology that could significantly enhance existing diagnosis and treatment approaches," said Jeffrey Shuren, MD, JD, who directs the FDA's Center for Devices and Radiological Health in a press release.

Previous studies have shown that 2-D imaging techniques do not always provide clear images of breast masses, as overlapping skin and other anatomical features can obscure tumors and sometimes create the appearance of a tumor when there is none.

A caveat is that the combination of 2-D and 3-D images approximately doubled the radiation dose to which women were exposed, but the new technology increases efficacy, which presumably will help cut down on the need for follow-up exams. At this time, about 10% of women who undergo 2-D mammography are called back for follow-up X-rays, only to find out later that masses spotted with the 2-D systems are noncancerous.

Mammography Quality Standards require that healthcare professionals undergo 8 hours of instruction before using the new 3-D technology. The FDA also stipulates that the manufacturer provide each user with a manual that defines tests required to maintain quality control.

Early Introduction of Solid Foods Linked to Risk for Early Childhood Obesity

From Medscape Medical News
Laurie Barclay, MD

February 7, 2011 — Early introduction of solid foods is linked to a risk for early childhood obesity, according to the results of a prospective prebirth cohort study reported online February 7 in Pediatrics.

"Parental feeding practices during early infancy, such as the timing of solid food introduction, may be 1 key modifiable determinant of childhood obesity," write Susanna Y. Huh, MD, MPH, from the Division of Gastroenterology and Nutrition, Children's Hospital Boston in Boston, Massachusetts, and colleagues.
"Data suggest that the introduction of solid foods earlier than 4 months of age is associated with increased body fat or weight in childhood or with greater weight gain during infancy, which itself predicts later adiposity. Other studies have found no association between the timing of solid food introduction and body fat or an association between delayed introduction of solid foods after 6 months and greater adiposity."

The goal of the study was to evaluate the association between timing of introduction of solid foods during infancy and obesity at age 3 years, defined as a body mass index for age and sex at the 95th percentile or above, using a cohort of 847 children enrolled in Project Viva. Timing of introduction of solid foods was categorized as younger than 4 months, ages 4 to 5 months, and 6 months or older. Logistic regression models were applied separately for infants who were breast-fed for at least 4 months ("breast-fed"; n = 568; 67%) and for infants who were never breast-fed or in whom breast-feeding was stopped before age 4 months ("formula-fed"; n = 279; 32%). These models were adjusted for child and maternal factors, including change in weight-for-age z score from 0 to 4 months as a marker of early infant growth.

Obesity was present in 75 children (9%) at age 3 years.
The timing of solid food introduction was not associated with odds of obesity in breast-fed infants, (odds ratio, 1.1; 95% confidence interval [CI], 0.3 - 4.4). However, introducing formula-fed infants to solid foods before age 4 months was associated with a 6-fold increase in odds of obesity at age 3 years, which was not explained by rapid early growth (odds ratio after adjustment, 6.3; 95% CI, 2.3 - 6.9).

"Among infants who were never breastfed or those who stopped breastfeeding before the age of 4 months, the introduction of solids before the age of 4 months was associated with a sixfold increase in the odds of obesity at the age of 3 years," the study authors write.

Limitations of this study include possible residual confounding; some loss of the cohort to follow-up; limited generalizability to more socioeconomically disadvantaged populations; and small numbers in some cells, leading to possible chance results.

"Among infants breastfed for 4 months or longer, the timing of the introduction of solid foods was not associated with the odds of obesity," the study authors conclude. "Increased adherence to guidelines regarding the timing of solid food introduction may reduce the risk of obesity in childhood."

The National Institutes of Health supported this study. The study authors have disclosed no relevant financial relationships.

Pediatrics. Published online February 7, 2011. Abstract

AAP Issues New Guidelines for Management of Iron Deficiency

From Medscape Medical News

Jim Kling

October 14, 2010 — Correction: The original text of this article described the daily iron dose for infants 6 to 12 months as 11 mg/kg. This is incorrect.
The dose should be 11 mg/day.

October 5, 2010 (San Francisco, California) — Iron deficiency is one of the most common, yet undetected, problems among children. Here at the American Academy of Pediatrics (AAP) 2010 National Conference and Exhibition, the American Association of Pediatrics released a clinical report, with guidelines for iron intake in infants and children and to improve screening methods.

The clinical report, entitled Diagnosis and Prevention of Iron Deficiency and Iron Deficiency Anemia in Infants and Young Children (0–3 Years of Age), was published online October 5 in Pediatrics. It is a revision of a 1999 policy statement.

Iron deficiency can have long-term irreversible effects on a child's cognitive and behavioral development. By the time a child develops iron-deficiency anemia, it might be too late to prevent future problems. "The body has a preferential tracking of iron. Red blood cells take precedence over the iron requirements of the brain. By the time you get iron-deficiency anemia, you've been iron-deficient for a long time," said Frank Greer, MD, professor of pediatrics at the University of Wisconsin School of Medicine and Public Health in Madison, and a coauthor of the report.

The 1999 guidelines call for children to have their hemoglobin checked sometime between 9 and 12 months of age, and again between 15 and 18 months of age. However, the existing test misses many children with iron deficiency and iron-deficiency anemia. Even those found to be iron deficient frequently receive no follow-up testing or treatment, according to Dr. Greer.

Although supplementing all children with iron would reduce iron deficiency, such a program does not have widespread support in the medical community at this point. That's partly because toddlers, who are the most widely affected group, have a wide range of diets and it is unclear what foods to fortify.

Liquid iron supplements or vitamins could be used, but there is a risk for iron overload in some populations, according to Michael K. Georgieff, MD, professor of pediatrics and child psychology and director of the Center for Neurobehavioral Development at the University of Minnesota in Minneapolis. Dr. Georgieff was on the AAP's committee on nutrition from 1993 to 1999 and played a key role in the 1999 guidelines.

"Iron supplementation and awareness of iron nutrition has probably been one of the most successful public health programs in the United States. In the 1960s, iron deficiency was probably 30% to 40%. Today, it may be under 10%. But in trying to eliminate that last 10%, you have to consider it in terms of exposing kids to [too much] iron," said Dr. Georgieff.

No single screening test is available that will accurately characterize the iron status of a child, he noted. In the report, the AAP recommends 4 protocols for screening for iron deficiency and iron-deficiency anemia, including combinations of several tests and follow-up protocols. "It's burdensome," Dr. Greer admitted.

"Since we're not going to do universal supplementation, we need to identify kids who are at risk for iron deficiency and start targeting them," said Dr. Georgieff, who studies the neurodevelopmental effects of iron deficiency in children.

The AAP report identified several factors associated with iron deficiency and iron-deficiency anemia, including prematurity or low birth-weight, lead exposure, exclusive breastfeeding past 4 months of age without iron supplements, and weaning to foods that don't include iron-fortified cereals or iron-rich foods. Infants with special healthcare needs might also be at risk. Children of low economic status, particularly those of Mexican American descent, are also of concern, according to the report, which recommends selective screening for these individuals.

The guidelines also address means to prevent iron deficiency through a diet of foods naturally rich in iron, such as meat, shellfish, legumes, iron-rich fruits and vegetables, and iron-fortified cereals. Fruits rich in vitamin C help iron absorption. Some children might require liquid iron supplements or chewable vitamins to get sufficient iron.

The AAP recommends varying amounts of iron based on a child's age:

* Term, healthy infants have sufficient iron for the first 4 months of life. Because human breast milk contains very little iron, breastfed infants should be supplemented with 1 mg/kg per day of oral iron from 4 months of age until iron-rich foods (such as iron-fortified cereals) are introduced.
* Formula-fed infants will receive adequate iron from formula and complementary foods. Whole milk should not be used before 12 months.
* Infants 6 to 12 months of age need 11 mg/day of iron a day. When infants are given complementary foods, red meat and vegetables with high iron content should be introduced early. Liquid iron supplements can be used if iron needs are not met by formula and complementary foods.
* Toddlers 1 to 3 years of age need 7 mg per day of iron. It is best if this comes from foods such as red meats, iron-rich vegetables, and fruits with vitamin C, which enhance iron absorption. Liquid supplements and chewable multivitamins can also be used.
* All preterm infants should have at least 2 mg/kg of iron per day until 12 months of age, which is the amount of iron in iron-fortified formulas. Preterm infants fed human milk should receive an iron supplement of 2 mg/kg per day by 1 month of age; this should be continued until the infant is weaned to iron-fortified formula or begins eating foods that supply the required 2 mg/kg of iron.

American Academy of Pediatrics (AAP) 2010 National Conference and Exhibition. Presented October 5, 2010.

Recommendation of 6 Months of Breast-Feeding Scrutinized

From Medscape Medical News

Emma Hitt, PhD

January 18, 2011 — The evidence in favor of 6 months of exclusive breast-feeding has come under scrutiny in a new study published by the BMJ.

A review article assessing the evidence was published by researcher Mary Fewtrell, MD, from the Child Nutrition Research Center at the University College London Institute of Child Health, United Kingdom, and colleagues was published online January 13 in the BMJ.

Current World Health Organization guidelines recommend that infants be exclusively breast-fed for 6 months; that is, with a diet that excludes solids or any fluids other than breast milk, including infant formulas. These guidelines, announced in 2001, were adopted by the United Kingdom in 2003.
Exclusive breast-feeding may not adequately meet infants' energy needs for a full 6 months.

"The critical question is whether the United Kingdom should alter its advice on the introduction of complementary foods while new evidence is assembled," the authors note.

The current report maintains that this change in policy occurred without formal consideration of the scientific evidence. Since the announcement of the World Health Organization guidelines, findings from a number of studies suggest that breast milk may not be a reliable single source of nutrition for the first 6 months of life. In addition, the European Food Safety Authority recently concluded that it was safe to introduce complementary foods between 4 and 6 months' of age for infants residing in the European Union.

In the current study, Dr. Fewtrell and colleagues reassessed the evidence in favor of 6 months of exclusive breast-feeding and concluded that exclusive breast-feeding may not adequately meet infants' energy needs for a full 6 months. Higher rates of iron deficiency anemia are an additional concern, having been linked to poorer long-term mental, motor, and social development. Furthermore, existing data suggest an increased risk for reaction to certain allergens (eg, gluten, which has been linked to celiac disease) when their introduction is delayed past 6 months.

Even in the case of protection from infection — considered to be a clear benefit of breast-feeding — a study conducted in Spain showed that these benefits largely accrue to infants breast-fed for 3 months, providing little "extra" benefit thereafter. However, a large study based in the United States did find that infants breast-fed exclusively for more than 6 months had a lower risk for otitis media and pneumonia when compared with infants who were breast-fed exclusively for 4 to 6 months.

Dr. Fewtrell and colleagues conclude that, in light of data that have accumulated during the last 10 years (ie, since the World Health Organization guidelines came out in 2001), the time is ripe for an evidence-based reappraisal of the United Kingdom's stance in this important, yet controversial, area.

According to independent commentator Richard Aubry, MD, MPH, a professor of obstetrics and gynecology at Upstate Medical University in New York, this work does not add any new evidence about the pros and cons regarding adding other foods earlier than 6 months' age.

He told Medscape Medical News that clinicians "need to keep the message clear: Exclusive breast-feeding is the preferred method for feeding the baby until approximately 6 months of age, and then mothers should be encouraged to continue breast-feeding as long as they can. These are the specific terms and overall advice by [the American Congress of Obstetricians and Gynecologists]."

This study was not commercially funded. Three of the 4 authors of the study report having performed consultancy work and/or received research funding in the past 3 years from companies that manufacture infant formulas and baby foods.

BMJ. Published online January 13, 2011.

Frozen Hope: Fertility Preservation for Women with Cancer

From Journal of Midwifery & Women's Health

Gwendolyn P. Quinn, PhD; Susan T. Vadaparampil, PhD, MPH; Paul B. Jacobsen, PhD; Caprice Knapp, PhD; David L. Keefe, MD; Geri E. Bell, BS

Posted: 03/12/2010; J Midwifery Womens Health. 2010;55(2):175-180. © 2010 Elsevier Science, Inc.

Abstract

Young women diagnosed with cancer have the option of preserving their fertility by using assisted reproductive technology (ART) techniques prior to undergoing cancer treatment. This article presents a composite case of a young woman with cancer who had many unanswered emotional and ethical questions about her future as a parent. Fertility preservation techniques, including preimplantation genetic diagnosis (PGD), and related patient education are described.
Current literature regarding reproductive counseling for cancer survivors is reviewed. Resources for providing psychosocial support for decisions about fertility preservation are lagging behind the rapid pace of scientific advancements in cancer treatment and ART.
As more young women are surviving cancer and taking steps to preserve fertility, there is great need for the provision of psychologic support services and the establishment of ethical guidelines to aid them on this path.
Women's health care providers can provide support to cancer survivors facing fertility and parenting issues by becoming knowledgeable about the long-term aspects of decision making and developing educational materials and guidelines for these patients.

Introduction

The number of young women diagnosed with cancer is increasing.[1] Recent data indicate the most common types of cancer occurring among women aged 15 to 29 are cancers of the female genital system, lymphoma, thyroid cancer, melanoma, and breast cancer.[1] Advances in cancer treatment have resulted in an increased number of long-term survivors. Young women who are diagnosed with cancer must make decisions about their reproductive future at a time when they are emotionally fragile. In addition to processing the cancer diagnosis and associated treatment choices, the decisions required concerning preserving future fertility and the time constraints associated with judgments can understandably be emotionally distressing. Women without cancer who are diagnosed with infertility have typically had at least a year in which to process their desire for a child and understand the barriers and benefits for each of the assisted reproductive technologies that may be available to their unique situation. The traditional reproductive counseling and the time frame for decision making offered to a woman or a couple experiencing infertility may not be available to a woman with a cancer diagnosis. This article presents a composite case of a young woman with cancer who faced infertility due to her cancer treatment but hoped to have a biologic child in the future. The case is examined in light of what is known and not yet known about the medical and psychosocial aspects of fertility preservation for women with cancer.
Cancer and Infertility

The best treatment for cancer may lead to impaired fertility or the complete loss of fertility. However, rates of infertility vary depending on a number of factors, including cancer site, type of treatment, and the age of the patient. Infertility in cancer patients can be caused by the cancer or the type of cancer treatment received. Exact infertility rates are not known, because there are no valid measures for women to establish that fertility was present prior to treatment. Women who undergo chemotherapy or radiation for malignancies during reproductive years have a 40% to 80% chance of losing fertility. The treatments that produce the greatest risk for infertility include alkylating agents such as cyclophosphamide, methotrexate, and fluorouracil in chemotherapy; total body radiation; and external beam radiation in a field that includes the ovaries. Both chemotherapy and radiation can cause premature ovarian failure for females, often leading to premature menopause.

Fertility Preservation

Rapidly improving assisted reproductive technologies and therapies offer some opportunities to preserve the fertility of female patients receiving chemotherapy and/or radiation. The emerging field of proteomics is leading the way toward the identification of proteins involved in oocyte maturation, embryo development, and implantation that could improve assisted reproduction techniques. Assisted reproductive technology (ART) consists of clinical treatments and laboratory procedures that include the handling of human oocytes, sperm, or embryos, with the intent of establishing a pregnancy. This includes, but is not limited to, in vitro fertilization (IVF), intracytoplasmic sperm injection, gamete intrafallopian transfer, zygote intrafallopian transfer, embryo biopsy, preimplantation genetic diagnosis (PGD), embryo cryopreservation, oocyte or embryo donation, and gestational surrogacy. Table 1 includes definitions of each type of procedure.

There are currently only two established options for fertility preservation for women with cancer: 1) oophoropexy, moving the ovaries out of the range of radiation, and 2) embryo cryopreservation, the freezing of fertilized eggs via IVF for later use. Additional techniques for fertility preservation, such as oocyte cryopreservation (freezing unfertilized eggs) and ovarian tissue cryopreservation (freezing strips of ovarian tissue, which may be transplanted either orthotopically within the pelvis or heterotopically within subcutaneous tissue), are less established and not widely available. All options must typically be considered and undertaken prior to the initiation of treatment.

There are also ethical, spiritual, and legal issues related to decision making about fertility preservation, such as the disposition of stored embryos. These issues often concern health care professionals as well and may pose barriers to the discussion of or assistance with the use of ART.Some patients and their families choose to consider posthumous parenting, that is, they intend to use the stored embryos whether or not the patient survives. Although this is an ethically charged situation, the American Society for Reproductive Medicine recommends that health care professionals do not deny patients assistance for this form of reproduction and also advises that "precise instructions" be given by the patient in the event of his or her death. The precise instructions for the disposition of DNA are part of the informed consent counseling, and patients are required to outline the procedures for future use of the stored embryos (e.g., willed to a spouse or parent, discarded, donated, etc.) If these procedures are followed, this can reduce the need for legal involvement to determine ownership of the stored embryos in the event of the patient's death or in the case of divorce. The United Kingdom also regulates the disposition of embryos through informed consent. Information about this practice is not readily available from other countries.

Preimplantation Genetic Diagnosis for Hereditary Cancers

The concerns of individuals affected with cancer regarding biologic parenthood are often focused on the health risks for future children. Carriers of genetic mutations, such as women with mutations in the BRCA1/2 genes, may have additional concerns about passing on hereditary cancers to future offspring. For those survivors who are concerned about the possibility of transmitting a serious hereditary cancer to their future children, limited biologic parenting options are available. Preimplantation genetic diagnosis is one option for parents who want to avoid this dilemma.

Preimplantation genetic diagnosis is a procedure used in conjunction with IVF to screen for specific genetic or chromosomal abnormalities before transferring the fertilized eggs into the woman. Preimplantation genetic diagnosis involves microsurgical removal of one or two blastomeres (embryos) at the six- to eight-cell stage, usually 3 days after fertilization. At this stage, the cells of the embryo have not differentiated into particular body tissues, and there is not likely to be damage to the resulting embryo. Biopsies of embryos are analyzed to detect genetic abnormalities arising from the maternal or paternal chromosomes. However, since diagnostic tests are performed on a single cell, the possibility of misdiagnosis must be considered. Preimplantation genetic diagnosis results are usually available within 48 hours after biopsy, which corresponds to day 5 after egg retrieval. Depending on their original quality, embryos may or may not reach the blastocyst stage, which is the final stage of in vitro development.[9] Usually on day 5, embryos free of genetic defects are transferred into the patient; however, some women or couples may choose to cryopreserve affected embryos. Currently data are not collected on the health of offspring born through the use of PGD, so it is unknown if there are related long-term health consequences.

Preimplantation genetic diagnosis has been accomplished for both cancer-specific disorders such as adenomatous polyposis coli, BRCA1/2, retinoblastoma, Li-Fraumeni syndrome, and von Hippel-Lindau syndrome, as well as disorders predisposing to neoplasia (Fanconi anemia, Wiskott-Aldrich syndrome).[11–13] The PGD procedure has been performed for a little over a decade and involves the use of IVF so parents can select the embryos that are implanted into the uterus. Embryos are tested for genetic status at the early stages of development. The ability to use PGD testing for all cancer types is not currently possible. The regulations developed for PGD testing and the types of cancers for which embryos can be tested vary by country and availability within each country. For example, the ability to use PGD for BRCA became available in 2006; however, other hereditary cancers, such as familial adenomatous polyposis, have been tested for in the Netherlands since 2004, although BRCA testing of embryos is not allowed there.[13] Thus, although the availability of PGD testing for certain cancer types varies by country and facility, the psychosocial issues women face over certain issues such as embryo selection are quite similar. One option for PGD is to implant only those embryos that are found to be unaffected. Some parents still may choose to implant affected embryos with the knowledge that the potential for hereditary syndromes is high. In the past, options for hereditary cancer mutation carriers included not having children or undergoing amniocentesis or other forms of prenatal diagnosis. Preimplantation genetic diagnosis allows parents to avoid terminating a pregnancy and/or risking the health of the fetus or the mother.

In Europe, guidelines regulate which clinics can perform PGD and for which diseases they can screen. In the United Kingdom, the Human Fertilisation and Embryology Authority (HFEA) governs which procedures are acceptable and provides guidelines as to how these procedures should be performed. It also licenses clinics that wish to use any type of ART. Currently, no such oversight exists in the United States.[14] At present, HFEA has approved PGD to test for 50 disorders, including hereditary breast and ovarian cancers, which can be caused by a mutation in the BRCA1/2 genes. Mutations in BRCA1/2 are passed down in families in an autosomal dominant pattern, and children of individuals with a BRCA1/2 mutation have a 50% chance of inheriting it. Women who carry the BRCA1/2 gene have an 80% lifetime risk of developing breast cancer and approximately a 40% risk of developing ovarian cancer. With such a high risk for developing cancer, the HFEA considers it appropriate to allow PGD for this cancer predisposition gene.

The use of PGD in the United States is predicted to be approximately 20% across all embryos created via IVF; however, it is not known specifically which abnormalities or conditions PGD testing has been used for.[11] Almost 2000 babies have been born after the process of PGD since it was developed in 1989.[15] There are no published reports of increased fetal defects or late effects in babies born using PGD, but it is possible abnormalities may occur later in life as a result of the procedure.[9,10,13] Preimplantation genetic diagnosis cannot detect all genetic irregularities because only a limited number of chromosomes can be tested per procedure, and misdiagnosis may still occur.Prenatal diagnosis (amniocentesis or chorionic villus sampling) may still need to be considered after use of PGD to determine if the fetus carries a genetic abnormality.

Cancer and Parenting

Although cancer presents obstacles to becoming a parent, an experience with a major illness can also make survivors excellent parents, with greater emotional resilience and appreciation for parenthood. However, the decision to become a biologic parent after cancer must be weighed with the obstacles of the time and expense of fertility preservation procedures such as IVF. Adoption remains an option, but cancer survivors may experience difficulty in becoming qualified as adoptive parents. Survivors seeking adoption may encounter discrimination from US adoption agencies because of the survivor's physical health and condition.Some US agencies require an applicant to be at least 5 years post-treatment before he or she can qualify as a potential adoptive parent. Some cancer survivors have had success qualifying for the adoption of foreign-born children through international adoption agencies. Additionally, infertility treatments and adoption procedures may be too costly for some survivors, especially after an expensive battle with cancer.

In addition to concerns about cancer recurrence and parenting, survivors often have psychosocial concerns related to pregnancy and parenting, many of which mirror issues faced by any woman considering the use of ART. These concerns focus primarily on risks of birth defects or cancer in offspring; anxiety about hormonal factors related to pregnancy or infertility treatment increasing a risk of cancer recurrence, leaving the spouse/partner to raise the child if the parent with cancer dies; and conflicts about using ART because of ethical beliefs or religious beliefs, as some religions prohibit the use of donor gametes

Reproductive Counseling for Cancer Survivors

Canada and Schover[22] identified the need for research to promote improved patient education regarding cancer and reproductive health. Although the researchers indicate oncologists would probably be the ideal health care professionals for cancer patients to have in-depth discussions with regarding fertility preservation and future parenting, they further note that time constraints may make this unrealistic. However, their objective is to promote better information about the risks of infertility to the newly diagnosed cancer patient, a communication initiative for which other researchers have made a similar plea. Although this is a crucial first step on the road to improved quality of life in cancer survivors and risk management for infertility, it does not fully address the decision-making issues the patient must consider in rapid time.

There is little research about the psychosocial decision making of newly diagnosed cancer survivors regarding fertility and PGD choices. Unlike infertility in couples without a cancer diagnosis, the impending infertility of a cancer patient and the need for treatment provides a narrow window of time for patient counseling. Although some patients, similar to the woman in this case study, perceive stored embryos and oocytes as "frozen hope," decisions about the future of the stored embryo can be agonizing. Recent studies have begun to examine patient choices for the donation or destruction of stored embryos.

One study conducted in an Australian population among 235 couples with banked embryos found 27% would donate to stem cell research or infertility research, whereas 15% would consider donating to another couple.
However, the disagreement rate among the couples was high, with more than 40% disagreeing over each of the options.Additionally, 90% of the couples indicated they would want to discuss donation with a health care professional rather than make the decision alone. The majority preferred a fertility specialist or scientist as their choice for the discussions. This study highlights the fact that deciding to pursue ART is only the beginning of the decision-making process that may span several years.

Other researchers have begun to examine how patients feel about stored embryos and oocytes in fertility clinics. An emerging trend indicates patients may enter reproductive counseling with one set of ideas about stored embryos and feel differently after a successful pregnancy or failed attempts.[26–28] However, no studies have examined this meaning among women who stored embryos or oocytes due to cancer treatment.

There are currently no guidelines specifically tailored for the reproductive counseling needs of newly diagnosed cancer patients, especially for those who may have concerns about hereditary cancer syndromes. Peshkin et al.suggest strong support for such guidelines and continued collaborations among providers who work in oncology, cancer genetics, and ART.Conclusion

Finishing cancer treatment and transitioning from patient to survivor does not end the psychologic trauma of cancer. There are a plethora of issues that survivors often face after their cancer is in remission that affect quality of life. This case report illustrates the loss of fertility often experienced by a cancer survivor as a result of treatment. Young women with genetic mutations, such as those in the BRCA1/2 genes, may have additional concerns about passing on hereditary cancers to future offspring. Considering PGD to avoid passing the mutation may allow parents to select only healthy embryos, but decisions about the fate of embryos that are mutation carriers remain perplexing.

Decisions about using fertility preservation typically must be made at the same time as other decisions about treatment of a life-threatening diagnosis. Ethical, religious, financial, and other implications of preserving her fertility confront the woman before she begins cancer treatment. This leaves limited time for the patient to consider the implications of her choices and how she may feel about her reproductive options at a later date.

Given that 2.5 million young adults in the United States have survived cancer, more research is needed on the psychosocial aspects of parenthood, particularly to identify the psychosocial needs of survivors regarding cryopreservation and PGD. The resources for providing support for using ART and PGD lag behind the rapid advance of technology. Table 2 provides a list of online sources of information for patients and health care professionals. Communication guidelines should be developed for informing cancer patients of the emotional and psychosocial impact of fertility preservation, with particular regard to future decision making. More research is needed to develop educational resources specific to this population that will aid the women newly diagnosed with cancer in decision making. Although social support is an important aspect of survivorship, the medical community can also provide support by assigning social workers or counselors to survivors and to the newly diagnosed who are facing fertility and parenting issues.