From Medscape Medical News
Laurie Barclay, MD
Charles P. Vega, MD, FAAFP
July 10, 2009 — Paternal depressive symptoms during pregnancy may predict excessive infant crying, according to the results of a prospective, population-based study reported in the July issue of Pediatrics.
"Excessive infant crying, or infantile colic, is a common and often stress-inducing problem for parents that can ultimately result in child abuse," write Mijke P. van den Berg, MD, PhD, MA, from Erasmus Medical Center in Rotterdam, the Netherlands, and colleagues. "From previous research it is known that maternal depression is related to excessive crying, but so far little is known about the influence of paternal depression."
The Brief Symptom Inventory was used to collect data regarding maternal and paternal depressive symptoms at 20 weeks of pregnancy, and associations between these symptoms and excessive crying were evaluated in 4426 infants at age 2 months. Excessive crying was defined with Wessel's criteria of crying more than 3 hours per day for more than 3 days in the previous week.
The risk of excessive infant crying was 1.29 higher per SD of paternal depressive symptoms (95% confidence interval, 1.09 -1.52) after adjusting for maternal depressive symptoms and other pertinent confounding factors.
"Our findings indicate that paternal depressive symptoms during pregnancy might be a risk factor for excessive infant crying," the study authors write. "This finding could be related to genetic transmission, interaction of a father with lasting depressive symptoms with the infant, or related indirectly through contextual stressors such as marital, familial, or economic distress."
Limitations of this study include possible false paternity, reliance on a questionnaire for collecting data on crying behavior, embedding of this study within a larger prospective study, and the possibility that parents with depressive symptoms might report differently on crying behavior.
"Although our findings are subject to some limitations and need to be replicated, they emphasize the importance of taking paternal factors into account when studying early infant behavior such as excessive crying," the study authors conclude.
The Netherlands Organization for Health Research and Development supported this study. The study authors have disclosed no relevant financial relationships.
Pediatrics. 2009;124:e96-e103.
Saturday, August 8, 2009
Low Oxygen Best for Resuscitation of Preterm Neonates
From Reuters Health Information
NEW YORK (Reuters Health) Aug 03 - Using 30% rather than 90% oxygen to resuscitate extremely low gestational age neonates results in less oxidative stress, inflammation, and chronic lung disease, new research shows.
Because the body's antioxidant system does not develop until late in gestation, preterm infants are at risk for adverse effects from hyperoxia. Prior research had established that preterm neonates could achieve target oxygen saturation values when resuscitated with 30% oxygen, but whether this approach offered any advantages over standard protocols involving higher oxygen levels was unclear.
Dr. Maximo Vento, from University Hospital La Fe, Valencia, Spain, and colleagues took up this topic by assessing the outcomes of 78 preterm neonates who were randomized to resuscitation with 30% or 90% oxygen. The target oxygen saturation values were 75% at 5 minutes and 85% at 10 minutes.
All of the subjects were extremely low gestational age neonates, defined as a gestational age at birth of no more than 28 weeks, according to the report in the September issue of Pediatrics.
Oxidative stress was evaluated by measuring the oxidized glutathione/reduced glutathione ratio in the blood and by measuring various urinary markers of stress. Inflammation was assessed by measuring plasma levels of interleukin-8 and tumor necrosis factor-alpha.
With use of 30% instead of 90% oxygen, the number of required days of supplemental oxygen fell from 22 to 6 and the number of days of mechanical ventilation dropped from 27 to 13. The rate of bronchopulmonary dysplasia at discharge was also lower in the 30% oxygen group: 15.4% vs. 31.7%.
Both the glutathione ratios and the levels of urinary markers indicated less oxidative stress in the 30% oxygen group. Similarly, the 30% oxygen group had less inflammation, as indicated by lower levels of interleukin-8 and tumor necrosis factor-alpha.
Based on the findings, the authors conclude that extremely low gestational age neonates should be resuscitated with oxygen levels not exceeding 30%.
Further studies, however, are needed with adequate statistical power to determine if use of lower oxygen levels really helps prevent bronchopulmonary dysplasia, they add.
Pediatrics 2009;124:e1-e10.
NEW YORK (Reuters Health) Aug 03 - Using 30% rather than 90% oxygen to resuscitate extremely low gestational age neonates results in less oxidative stress, inflammation, and chronic lung disease, new research shows.
Because the body's antioxidant system does not develop until late in gestation, preterm infants are at risk for adverse effects from hyperoxia. Prior research had established that preterm neonates could achieve target oxygen saturation values when resuscitated with 30% oxygen, but whether this approach offered any advantages over standard protocols involving higher oxygen levels was unclear.
Dr. Maximo Vento, from University Hospital La Fe, Valencia, Spain, and colleagues took up this topic by assessing the outcomes of 78 preterm neonates who were randomized to resuscitation with 30% or 90% oxygen. The target oxygen saturation values were 75% at 5 minutes and 85% at 10 minutes.
All of the subjects were extremely low gestational age neonates, defined as a gestational age at birth of no more than 28 weeks, according to the report in the September issue of Pediatrics.
Oxidative stress was evaluated by measuring the oxidized glutathione/reduced glutathione ratio in the blood and by measuring various urinary markers of stress. Inflammation was assessed by measuring plasma levels of interleukin-8 and tumor necrosis factor-alpha.
With use of 30% instead of 90% oxygen, the number of required days of supplemental oxygen fell from 22 to 6 and the number of days of mechanical ventilation dropped from 27 to 13. The rate of bronchopulmonary dysplasia at discharge was also lower in the 30% oxygen group: 15.4% vs. 31.7%.
Both the glutathione ratios and the levels of urinary markers indicated less oxidative stress in the 30% oxygen group. Similarly, the 30% oxygen group had less inflammation, as indicated by lower levels of interleukin-8 and tumor necrosis factor-alpha.
Based on the findings, the authors conclude that extremely low gestational age neonates should be resuscitated with oxygen levels not exceeding 30%.
Further studies, however, are needed with adequate statistical power to determine if use of lower oxygen levels really helps prevent bronchopulmonary dysplasia, they add.
Pediatrics 2009;124:e1-e10.
Prebiotic Use Beneficial in Formula-Fed Newborns
From Reuters Health Information
NEW YORK (Reuters Health) Aug 05 - Supplementation with prebiotic oligosaccharides is well tolerated and produces short-term beneficial effects in full-term, formula-fed neonates, according to a new study.
"Prebiotic oligosaccharides are short-chain carbohydrates with a degree of polymerization between 2 and 60 and are nondigestible by human or animal digestive systems," Dr. Shripada Rao, of the University of Western Australia, Perth, and colleagues explain in the August issue of the Archives of Pediatric and Adolescent Medicine. The carbohydrates' key feature is their ability to selectively promote the growth of bifidobacteria and lactobacilli in the colon.
Human milk contains prebiotics and, therefore, breastfed infants typically receive adequate amounts to stimulate gut flora. Formula-fed infants, by contrast, may be deficient in prebiotics and might benefit from supplementation.
The researchers searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and CINAHL databases and proceedings of relevant conferences. Trials comparing formula milk supplementation, with or without prebiotics, that commenced no later than age 28 days and continued for at least 2 weeks were eligible for inclusion.
Main outcome measures included stool colony counts of bifidobacteria, lactobacilli, and pathogens; pH; consistency; frequency; anthropometry; and symptoms of intolerance.
Of 24 identified trials, 11 were eligible for inclusion (n = 1459). Six trials showed significant increases in bifidobacteria after prebiotic supplementation. Two studies demonstrated a trend toward increases in bifidobacteria counts.
Meta-analysis results show a significant reduction in stool pH in the prebiotic-supplemented group. Infants who received the prebiotic supplementation also had softer and more frequent stools, similar to those of breastfed infants. Lastly, the supplementation group had slightly better weight gain than controls.
Of eight trials that reported on tolerance, all but one reported that prebiotic supplementation was well tolerated. One study found that infants who received prebiotic supplementation had more frequent diarrhea (18% vs. 4%), irritability (16% vs. 4%), and eczema (18% vs. 7%) compared to control subjects.
"Colonization of intestines with healthy bacteria early in the newborn period has the theoretical potential to confer long-term health benefits; but it is too early to recommend their supplementation routinely for formula fed infants," Dr. Rao told Reuters Health by email. "Rigorously conducted randomized controlled trials focusing on long-term outcome are necessary to find out if this improved colonization results in long-term health benefits."
Arch Pediatr Adolesc Med 2009;163:755-764.
NEW YORK (Reuters Health) Aug 05 - Supplementation with prebiotic oligosaccharides is well tolerated and produces short-term beneficial effects in full-term, formula-fed neonates, according to a new study.
"Prebiotic oligosaccharides are short-chain carbohydrates with a degree of polymerization between 2 and 60 and are nondigestible by human or animal digestive systems," Dr. Shripada Rao, of the University of Western Australia, Perth, and colleagues explain in the August issue of the Archives of Pediatric and Adolescent Medicine. The carbohydrates' key feature is their ability to selectively promote the growth of bifidobacteria and lactobacilli in the colon.
Human milk contains prebiotics and, therefore, breastfed infants typically receive adequate amounts to stimulate gut flora. Formula-fed infants, by contrast, may be deficient in prebiotics and might benefit from supplementation.
The researchers searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and CINAHL databases and proceedings of relevant conferences. Trials comparing formula milk supplementation, with or without prebiotics, that commenced no later than age 28 days and continued for at least 2 weeks were eligible for inclusion.
Main outcome measures included stool colony counts of bifidobacteria, lactobacilli, and pathogens; pH; consistency; frequency; anthropometry; and symptoms of intolerance.
Of 24 identified trials, 11 were eligible for inclusion (n = 1459). Six trials showed significant increases in bifidobacteria after prebiotic supplementation. Two studies demonstrated a trend toward increases in bifidobacteria counts.
Meta-analysis results show a significant reduction in stool pH in the prebiotic-supplemented group. Infants who received the prebiotic supplementation also had softer and more frequent stools, similar to those of breastfed infants. Lastly, the supplementation group had slightly better weight gain than controls.
Of eight trials that reported on tolerance, all but one reported that prebiotic supplementation was well tolerated. One study found that infants who received prebiotic supplementation had more frequent diarrhea (18% vs. 4%), irritability (16% vs. 4%), and eczema (18% vs. 7%) compared to control subjects.
"Colonization of intestines with healthy bacteria early in the newborn period has the theoretical potential to confer long-term health benefits; but it is too early to recommend their supplementation routinely for formula fed infants," Dr. Rao told Reuters Health by email. "Rigorously conducted randomized controlled trials focusing on long-term outcome are necessary to find out if this improved colonization results in long-term health benefits."
Arch Pediatr Adolesc Med 2009;163:755-764.
Friday, July 31, 2009
Swine Flu Striking Pregnant Women Hard: CDC Study
by Julie Steenhuysen
From Reuters Health Information
CHICAGO (Reuters) Jul 29 - Pregnant women infected with the new H1N1 swine flu have a much higher risk of severe illness and death, U.S. government researchers said on Wednesday, confirming a trend that has worried global health experts.
While pregnant women have always had a higher risk of severe disease from influenza in general, the new H1N1 virus is taking an exceptionally heavy toll, the researchers said.
"We do see a fourfold increase in hospitalization rates among ill pregnant women compared to the general population," Dr. Denise Jamieson of the U.S. Centers for Disease Control and Prevention said in a telephone interview.
"We're also seeing a relatively large proportion of deaths among pregnant women. We report 13% in the paper, but that is a very unstable number based on a small number of deaths reported," said Jamieson, whose study appears in The Lancet medical journal.
The study was based on the deaths of six pregnant women out of 45 deaths related to H1N1 reported to the CDC between April 15 and June 16.
All of the women were healthy prior to infection, and all developed pneumonia and needed to be put on a ventilator.
Dr. Jamieson said 302 deaths have been officially reported to the CDC from the new H1N1 virus.
"Among those, we have relatively complete information on 266 deaths. And of those, 15 have been among pregnant women, which is about 6%," Dr. Jamieson said.
Given that at any point, about 1% of the U.S. population is pregnant, she said, pregnant women "are definitely over-represented in terms of the proportion of deaths."
However, Dr. Jamieson said: "There is no reason to delay pregnancy or to be overly concerned. We do not have evidence that pregnant women have increased susceptibility or are more likely to acquire influenza."
"It's just that when they have influenza they are at increased risk of having severe disease," she said.
Dr. Keiji Fukuda of the World Health Organization said WHO has not yet decided on its policy on the use of antivirals for pregnant women with H1N1.
"Given the overall situation in many countries where the supplies of antivirals can be limited at times, to concentrate them on treating people who are sick makes a lot of sense," he said on Britain's Sky television.
Dr. Fukuda said researchers are debating whether it is best to use antivirals to prevent disease or to treat sick people.
Dr. Jamieson said physicians need to provide a separate waiting area for pregnant women who suspect they are ill, to protect healthy pregnant women from infection.
She also said pregnant women with influenza should be given antiviral drugs as soon as possible, within the first 48 hours to be most effective.
Despite recommendations from the Advisory Committee on Immunization Practices (ACIP) and the American College of Obstetricians and Gynecologists that all pregnant women get a seasonal flu shot, less than 14% do, according to the CDC.
The ACIP, which advises the CDC, is meeting later on Wednesday to decide who should be first to get the new H1N1 vaccine.
The full article is available at: http://press.thelancet.com/h1n1pregart.pdf
From Reuters Health Information
CHICAGO (Reuters) Jul 29 - Pregnant women infected with the new H1N1 swine flu have a much higher risk of severe illness and death, U.S. government researchers said on Wednesday, confirming a trend that has worried global health experts.
While pregnant women have always had a higher risk of severe disease from influenza in general, the new H1N1 virus is taking an exceptionally heavy toll, the researchers said.
"We do see a fourfold increase in hospitalization rates among ill pregnant women compared to the general population," Dr. Denise Jamieson of the U.S. Centers for Disease Control and Prevention said in a telephone interview.
"We're also seeing a relatively large proportion of deaths among pregnant women. We report 13% in the paper, but that is a very unstable number based on a small number of deaths reported," said Jamieson, whose study appears in The Lancet medical journal.
The study was based on the deaths of six pregnant women out of 45 deaths related to H1N1 reported to the CDC between April 15 and June 16.
All of the women were healthy prior to infection, and all developed pneumonia and needed to be put on a ventilator.
Dr. Jamieson said 302 deaths have been officially reported to the CDC from the new H1N1 virus.
"Among those, we have relatively complete information on 266 deaths. And of those, 15 have been among pregnant women, which is about 6%," Dr. Jamieson said.
Given that at any point, about 1% of the U.S. population is pregnant, she said, pregnant women "are definitely over-represented in terms of the proportion of deaths."
However, Dr. Jamieson said: "There is no reason to delay pregnancy or to be overly concerned. We do not have evidence that pregnant women have increased susceptibility or are more likely to acquire influenza."
"It's just that when they have influenza they are at increased risk of having severe disease," she said.
Dr. Keiji Fukuda of the World Health Organization said WHO has not yet decided on its policy on the use of antivirals for pregnant women with H1N1.
"Given the overall situation in many countries where the supplies of antivirals can be limited at times, to concentrate them on treating people who are sick makes a lot of sense," he said on Britain's Sky television.
Dr. Fukuda said researchers are debating whether it is best to use antivirals to prevent disease or to treat sick people.
Dr. Jamieson said physicians need to provide a separate waiting area for pregnant women who suspect they are ill, to protect healthy pregnant women from infection.
She also said pregnant women with influenza should be given antiviral drugs as soon as possible, within the first 48 hours to be most effective.
Despite recommendations from the Advisory Committee on Immunization Practices (ACIP) and the American College of Obstetricians and Gynecologists that all pregnant women get a seasonal flu shot, less than 14% do, according to the CDC.
The ACIP, which advises the CDC, is meeting later on Wednesday to decide who should be first to get the new H1N1 vaccine.
The full article is available at: http://press.thelancet.com/h1n1pregart.pdf
Monday, July 27, 2009
Ibuprofen Use Linked to Hyperbilirubinemia in Preterm Infants
From Reuters Health Information
Jul 20 - Preterm infants who receive ibuprofen to prevent patent ductus arteriosus have more severe hyperbilirubinemia than their counterparts not given the drug, according to study findings in the August issue of Pediatrics.
Hyperbilirubinemia is thought to adversely affect neurodevelopmental outcomes in preterm infants, and in vitro evidence indicates that ibuprofen can displace bilirubin from albumin, the study authors note. The resulting rise in unbound bilirubin might increase the odds of kernicterus and encephalopathy.
In the current study, Dr. Enrico Zecca, from Universita Cattolica del Sacro Cuore, Rome, and colleagues assessed bilirubin levels and related outcomes in 418 infants who were treated with ibuprofen and in 288 infants not exposed to the drug.
Total serum bilirubin levels were higher in the ibuprofen group than in controls, the researchers found. Moreover, ibuprofen-treated infants were more likely to require phototherapy and did so for longer durations.
No significant differences were noted between the groups in gestational age, birthweight, gender ratio, the incidence of glucose-6-phosphate dehydrogenase deficiency, or hypoalbuminemia, the report shows. Hemolytic isoimmunization also occurred with similar frequency in each group. Lastly, the exchange-transfusion rates in each group were similar, hovering around 4.7%.
The authors believe that in addition to displacing bilirubin from albumin, ibuprofen may promote hyperbilirubinemia by competing with the enzyme responsible for bilirubin conjugation.
"This was a pragmatic study to advise clinicians to balance the benefits of ibuprofen against its possible side effects, among which more-pronounced hyperbilirubinemia, with a subsequent impact on global newborn care, should be considered carefully," the team writes.
Pediatrics 2009;124:480-484.
Jul 20 - Preterm infants who receive ibuprofen to prevent patent ductus arteriosus have more severe hyperbilirubinemia than their counterparts not given the drug, according to study findings in the August issue of Pediatrics.
Hyperbilirubinemia is thought to adversely affect neurodevelopmental outcomes in preterm infants, and in vitro evidence indicates that ibuprofen can displace bilirubin from albumin, the study authors note. The resulting rise in unbound bilirubin might increase the odds of kernicterus and encephalopathy.
In the current study, Dr. Enrico Zecca, from Universita Cattolica del Sacro Cuore, Rome, and colleagues assessed bilirubin levels and related outcomes in 418 infants who were treated with ibuprofen and in 288 infants not exposed to the drug.
Total serum bilirubin levels were higher in the ibuprofen group than in controls, the researchers found. Moreover, ibuprofen-treated infants were more likely to require phototherapy and did so for longer durations.
No significant differences were noted between the groups in gestational age, birthweight, gender ratio, the incidence of glucose-6-phosphate dehydrogenase deficiency, or hypoalbuminemia, the report shows. Hemolytic isoimmunization also occurred with similar frequency in each group. Lastly, the exchange-transfusion rates in each group were similar, hovering around 4.7%.
The authors believe that in addition to displacing bilirubin from albumin, ibuprofen may promote hyperbilirubinemia by competing with the enzyme responsible for bilirubin conjugation.
"This was a pragmatic study to advise clinicians to balance the benefits of ibuprofen against its possible side effects, among which more-pronounced hyperbilirubinemia, with a subsequent impact on global newborn care, should be considered carefully," the team writes.
Pediatrics 2009;124:480-484.
Breast Milk Production - how to increase?
Mix of Hand Techniques, Electric Pumping May Increase Milk Production in Mothers of Preterm Infants
Deborah Brauser
From Medscape Medical News
July 23, 2009 — Mothers of preterm infants can avoid insufficient breast milk production by combining hand techniques with electric pumping, according to results of an observational study reported online July 2 in the Journal of Perinatology.
"Many immediate and long-term benefits of breastfeeding for the preterm infant and mother depend on exclusivity and duration, with the strongest determinant of both being milk production," write Jane Morton, MD, from the Department of Pediatrics at Stanford University School of Medicine, California, and colleagues. "Insufficient production in the first 6 weeks postpartum is the most common reason for discontinuing lactation, 2.8 times more frequent in mothers of preterm than those of term infants."
The authors write that if nutrition from breast-feeding is inadequate for the preterm infant, mothers must "triple feed" — meaning breast-feed, bottle-feed, and pump — to maintain production, a regimen likely to cause the high breast-feeding attrition rates seen in mothers with low production.
In addition, the study authors add that volumes lower than 500 mL/day by postpartum week 6 predict early weaning, whereas higher volumes facilitate the transition from bottle (or tube) feeding to breast-feeding by reducing the effort required for milk transfer. "Thus, maximizing milk production is essential for prolonged breastfeeding."
Past efforts to improve production have primarily focused on pumping schedules and pump design, such as electric vs manual. However, few studies have looked at the use of manual techniques to increase milk yield.
Pump Suction Alone Often Not Enough
"We have observed that pump suction alone often fails to remove a significant fraction of milk as more can be expressed using manual techniques," write the authors. They explain that it may be more effective to use hand expression to remove colostrum before mature milk "comes in," followed by hands-on-pumping (HOP) — a combination of pump suction, breast compression, and hand expression — once volume increases.
The investigators' objective "was to use a prospective observational cohort study to determine whether the use of 2 manual techniques, hand expression of colostrum and HOP of mature milk, could promote establishment and sustainability of a sufficient milk supply." They also examined variables that may affect lactation.
From 2004 to 2006, a convenience sample of eligible mothers of preterm infants (those weighing <1500 g, <31 weeks' gestation) were invited to participate in this observational study. A total of 67 patients were enrolled and instructed on pumping, hand expression of colostrum, and HOP. All were given a Symphony pump (Medela Inc) for the duration of the study or the hospitalization of the infant, whichever was longer.
The investigators collected maternal perinatal information and histories through chart review, questionnaires, and interviews. The mothers recorded their own milk expression information, including date, time, duration, and volume removed from each breast for 8 weeks. Predetermined and modifiable variables were examined at both 2 and 8 weeks postpartum, with only those patients who completed 6 or more days of records for both weeks included in this study.
Hand Expression and Electrical Pumping
The participants were told to begin using the electric pump within the first 6 hours postpartum. Before the onset of copious milk production, they were instructed to "double pump" (pump both breasts simultaneously) 8 times per day for 15 minutes and to hand express colostrums as frequently as possible in the first 3 postpartum days. Once mature milk "came in," they were advised to pump 8 or more times per day until they could express only drops.
After being discharged, mothers were invited to return to the hospital for monitored, instructional HOP sessions. During this time, milk was collected via 2 tubes connecting the breast shields to bottles placed on 2 electric scales, which were linked to a computer that recorded milk removal during the expression period. Each session began by double pumping with the electric pump while simultaneously compressing the breasts and massaging firmer areas.
Once milk flow stopped, double pumping was stopped, breasts were massaged briefly, and the mothers then attempted removal of remaining available milk using whatever technique they chose: double pumping, single pumping, or hand expression only.
Of the 67 enrolled mothers, 52 (78%) stayed in the study for the entire 8 weeks, with 48 completing 6 or more days of records for both weeks 2 and 8. The mothers with complete records were significantly older (P < .001), had more formal education (P < .02), and were more likely to have undergone in vitro fertilization (P < .03).
Results showed that mean daily volumes rose to 820 mL/day by week 8 for all participants (with 75% having >500 mL) and 955 mL/day in mothers who hand expressed more than 5 times per day during the first 3 days.
HOP Increased Milk Production
To determine whether pump-dependent mothers could achieve sustained sufficient milk production using HOP during the 8-week study, mean daily volumes during the 3 days before HOP instruction were compared with week 8 mean daily volumes for each mother with complete pre- and postrecords. A total of 92.9% of the mothers taught HOP had increased milk production; and mean daily volumes of milk increased by 48% (from 583 ± 383 mL/day to 863 ± 506 mL/day; P < .003).
Predetermined variables related to week 2 and/or week 8 mean daily volumes were maternal age and gestational age, with modifiable variables being pumping frequency, duration, and longest interval between pumping.
The authors write that the most intriguing study findings were "the unfaltering and impressive breastmilk volume of preterm infant mothers, who are considered to be at high risk for impaired milk production;...the finding that 2 practices not routinely prescribed, hand expression of colostrum and HOP expression of mature milk, may influence volume; and finally, the lack of correlation between volume and variables believed to influence production in breastfeeding mothers (type of delivery, maternal [body mass index], history of previous breastfeeding, multiples, [in vitro fertilization]) suggests that these factors may be mitigated by techniques supporting effective and frequent milk removal."
Limitations of this study included the expertise of the investigators in HOP instruction, the lack of a control group, and a single hospital-based population with a high level of education and lack of ethnic diversity.
"Ours is the first report of a steady increase in [milk] production over 8 weeks, which surpasses reference levels for mothers of term infants," conclude the study authors. They add that a larger, prospective, randomized, controlled trial is needed to validate the observed benefits.
J Perinatol. Published online July 2, 2009.
Deborah Brauser
From Medscape Medical News
July 23, 2009 — Mothers of preterm infants can avoid insufficient breast milk production by combining hand techniques with electric pumping, according to results of an observational study reported online July 2 in the Journal of Perinatology.
"Many immediate and long-term benefits of breastfeeding for the preterm infant and mother depend on exclusivity and duration, with the strongest determinant of both being milk production," write Jane Morton, MD, from the Department of Pediatrics at Stanford University School of Medicine, California, and colleagues. "Insufficient production in the first 6 weeks postpartum is the most common reason for discontinuing lactation, 2.8 times more frequent in mothers of preterm than those of term infants."
The authors write that if nutrition from breast-feeding is inadequate for the preterm infant, mothers must "triple feed" — meaning breast-feed, bottle-feed, and pump — to maintain production, a regimen likely to cause the high breast-feeding attrition rates seen in mothers with low production.
In addition, the study authors add that volumes lower than 500 mL/day by postpartum week 6 predict early weaning, whereas higher volumes facilitate the transition from bottle (or tube) feeding to breast-feeding by reducing the effort required for milk transfer. "Thus, maximizing milk production is essential for prolonged breastfeeding."
Past efforts to improve production have primarily focused on pumping schedules and pump design, such as electric vs manual. However, few studies have looked at the use of manual techniques to increase milk yield.
Pump Suction Alone Often Not Enough
"We have observed that pump suction alone often fails to remove a significant fraction of milk as more can be expressed using manual techniques," write the authors. They explain that it may be more effective to use hand expression to remove colostrum before mature milk "comes in," followed by hands-on-pumping (HOP) — a combination of pump suction, breast compression, and hand expression — once volume increases.
The investigators' objective "was to use a prospective observational cohort study to determine whether the use of 2 manual techniques, hand expression of colostrum and HOP of mature milk, could promote establishment and sustainability of a sufficient milk supply." They also examined variables that may affect lactation.
From 2004 to 2006, a convenience sample of eligible mothers of preterm infants (those weighing <1500 g, <31 weeks' gestation) were invited to participate in this observational study. A total of 67 patients were enrolled and instructed on pumping, hand expression of colostrum, and HOP. All were given a Symphony pump (Medela Inc) for the duration of the study or the hospitalization of the infant, whichever was longer.
The investigators collected maternal perinatal information and histories through chart review, questionnaires, and interviews. The mothers recorded their own milk expression information, including date, time, duration, and volume removed from each breast for 8 weeks. Predetermined and modifiable variables were examined at both 2 and 8 weeks postpartum, with only those patients who completed 6 or more days of records for both weeks included in this study.
Hand Expression and Electrical Pumping
The participants were told to begin using the electric pump within the first 6 hours postpartum. Before the onset of copious milk production, they were instructed to "double pump" (pump both breasts simultaneously) 8 times per day for 15 minutes and to hand express colostrums as frequently as possible in the first 3 postpartum days. Once mature milk "came in," they were advised to pump 8 or more times per day until they could express only drops.
After being discharged, mothers were invited to return to the hospital for monitored, instructional HOP sessions. During this time, milk was collected via 2 tubes connecting the breast shields to bottles placed on 2 electric scales, which were linked to a computer that recorded milk removal during the expression period. Each session began by double pumping with the electric pump while simultaneously compressing the breasts and massaging firmer areas.
Once milk flow stopped, double pumping was stopped, breasts were massaged briefly, and the mothers then attempted removal of remaining available milk using whatever technique they chose: double pumping, single pumping, or hand expression only.
Of the 67 enrolled mothers, 52 (78%) stayed in the study for the entire 8 weeks, with 48 completing 6 or more days of records for both weeks 2 and 8. The mothers with complete records were significantly older (P < .001), had more formal education (P < .02), and were more likely to have undergone in vitro fertilization (P < .03).
Results showed that mean daily volumes rose to 820 mL/day by week 8 for all participants (with 75% having >500 mL) and 955 mL/day in mothers who hand expressed more than 5 times per day during the first 3 days.
HOP Increased Milk Production
To determine whether pump-dependent mothers could achieve sustained sufficient milk production using HOP during the 8-week study, mean daily volumes during the 3 days before HOP instruction were compared with week 8 mean daily volumes for each mother with complete pre- and postrecords. A total of 92.9% of the mothers taught HOP had increased milk production; and mean daily volumes of milk increased by 48% (from 583 ± 383 mL/day to 863 ± 506 mL/day; P < .003).
Predetermined variables related to week 2 and/or week 8 mean daily volumes were maternal age and gestational age, with modifiable variables being pumping frequency, duration, and longest interval between pumping.
The authors write that the most intriguing study findings were "the unfaltering and impressive breastmilk volume of preterm infant mothers, who are considered to be at high risk for impaired milk production;...the finding that 2 practices not routinely prescribed, hand expression of colostrum and HOP expression of mature milk, may influence volume; and finally, the lack of correlation between volume and variables believed to influence production in breastfeeding mothers (type of delivery, maternal [body mass index], history of previous breastfeeding, multiples, [in vitro fertilization]) suggests that these factors may be mitigated by techniques supporting effective and frequent milk removal."
Limitations of this study included the expertise of the investigators in HOP instruction, the lack of a control group, and a single hospital-based population with a high level of education and lack of ethnic diversity.
"Ours is the first report of a steady increase in [milk] production over 8 weeks, which surpasses reference levels for mothers of term infants," conclude the study authors. They add that a larger, prospective, randomized, controlled trial is needed to validate the observed benefits.
J Perinatol. Published online July 2, 2009.
Thursday, July 23, 2009
Guidelines on Labor Induction Revised
From Medscape Medical News
Laurie Barclay, MD
July 23, 2009 — On July 21, the American College of Obstetricians and Gynecologists (ACOG) issued revised guidelines on when and how to induce labor in pregnant women. The updated recommendations are published as a Practice Bulletin, "Induction of Labor," in the August issue of Obstetrics & Gynecology. The bulletin aims to guide physicians regarding their choice of induction methods that may be most suitable in specific settings and to elucidate the safety requirements, risks, and benefits of various regimens to induce labor.
Benefits vs Risks of Labor Induction
For the last 2 decades, the rate of labor induction in the United States has more than doubled, with more than 22% of all pregnant women in 2006 having labor induced. This increase in use necessitates a careful review of indications, risks, and benefits.
The goal of labor induction is to stimulate uterine contractions before the spontaneous onset of labor, resulting in vaginal delivery. The benefits of labor induction must be weighed against the potential maternal and fetal risks associated with this procedure. When the benefits of expeditious delivery are greater than the risks of continuing the pregnancy, inducing labor can be justified as a therapeutic intervention.
"There are certain health conditions, in either the woman or the fetus, where the benefit of inducing labor is clear-cut," coauthor Susan Ramin, MD, from the University of Texas Medical School in Houston, said in a news release. "And, there are some nonmedical situations in which induction also may be prudent, for instance, in rural areas where the distance to the hospital is just too great to risk waiting for spontaneous labor to happen at home."
Recommendations Based on Sound Evidence
Based on evidence from methodologically sound outcomes-based research, the bulletin attempts to review current methods for cervical ripening and for inducing labor and to summarize the efficacy of these approaches. Also highlighted are indications for and contraindications to inducting labor, pharmacologic characteristics of various agents used for cervical ripening, regimens used for labor induction, and the requirements for safe clinical use of these techniques.
Indications for Labor Induction
Possible indications for labor induction may include gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth restriction, and postterm pregnancy. However, physicians should decide whether labor induction is warranted on a case-by-case basis, after consideration of maternal and infant conditions, cervical status, gestational age, and other factors.
Contraindications to labor induction include transverse fetal position, umbilical cord prolapse, active genital herpes infection, placenta previa, and a history of previous myomectomy.
When labor induction is deemed necessary, the gestational age of the fetus should be determined to be at least 39 weeks, or there must be evidence of fetal lung maturity.
The first step in labor induction is cervical ripening using drugs or mechanical cervical dilators to dilate the cervix sufficiently before labor is induced. The next step is to induce labor using oxytocin, membrane stripping, rupture of the amniotic membrane, or nipple stimulation.
Misoprostol, which is approved for treatment of peptic ulcers, is often used off-label for cervical ripening as well as for labor induction. In women who have had any previous cesarean delivery, however, inducing labor with misoprostol may increase risk for uterine rupture and should therefore be avoided.
Clinical Recommendations
Specific clinical recommendations and conclusions, all based on good and consistent scientific evidence (level A), are as follows:
•For cervical ripening and labor induction, prostaglandin E (PGE) analogues are effective.
•When labor induction is indicated, low-dose or high-dose oxytocin regimens are appropriate.
•Regardless of Bishop score, the most efficient method of labor induction before 28 weeks of gestation appears to be vaginal misoprostol. However, infusion of high-dose oxytocin is also an acceptable option.
•For cervical ripening and induction of labor, an appropriate initial dose of misoprostol is approximately 25 µg, with frequency of administration not to exceed 1 dose every 3 to 6 hours.
•For induction of labor in women with premature rupture of membranes, intravaginal PGE2 appears to be safe and effective.
•In women with previous cesarean delivery or major uterine surgery, the use of misoprostol should be avoided in the third trimester because it has been linked to a greater risk for uterine rupture.
•The Foley catheter is a reasonable, effective option to promote cervical ripening and labor induction.
An additional clinical recommendation, based on limited or inconsistent evidence (level B), is that misoprostol, 50 µg every 6 hours, to induce labor may be appropriate in some situations. However, higher doses are linked to a greater risk for uterine tachysystole with fetal heart rate (FHR) decelerations and other complications.
As a proposed performance measure, the guidelines authors suggest that the percentage of patients in whom gestational age is established by clinical criteria when labor is induced for logistic or psychosocial indications.
"A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn't successful in producing a vaginal delivery," Dr. Ramin concluded. "These guidelines will help physicians utilize the most appropriate method depending on the unique characteristics of the pregnant woman and her fetus."
Obstet Gynecol. 2009;114:386-397.
Laurie Barclay, MD
July 23, 2009 — On July 21, the American College of Obstetricians and Gynecologists (ACOG) issued revised guidelines on when and how to induce labor in pregnant women. The updated recommendations are published as a Practice Bulletin, "Induction of Labor," in the August issue of Obstetrics & Gynecology. The bulletin aims to guide physicians regarding their choice of induction methods that may be most suitable in specific settings and to elucidate the safety requirements, risks, and benefits of various regimens to induce labor.
Benefits vs Risks of Labor Induction
For the last 2 decades, the rate of labor induction in the United States has more than doubled, with more than 22% of all pregnant women in 2006 having labor induced. This increase in use necessitates a careful review of indications, risks, and benefits.
The goal of labor induction is to stimulate uterine contractions before the spontaneous onset of labor, resulting in vaginal delivery. The benefits of labor induction must be weighed against the potential maternal and fetal risks associated with this procedure. When the benefits of expeditious delivery are greater than the risks of continuing the pregnancy, inducing labor can be justified as a therapeutic intervention.
"There are certain health conditions, in either the woman or the fetus, where the benefit of inducing labor is clear-cut," coauthor Susan Ramin, MD, from the University of Texas Medical School in Houston, said in a news release. "And, there are some nonmedical situations in which induction also may be prudent, for instance, in rural areas where the distance to the hospital is just too great to risk waiting for spontaneous labor to happen at home."
Recommendations Based on Sound Evidence
Based on evidence from methodologically sound outcomes-based research, the bulletin attempts to review current methods for cervical ripening and for inducing labor and to summarize the efficacy of these approaches. Also highlighted are indications for and contraindications to inducting labor, pharmacologic characteristics of various agents used for cervical ripening, regimens used for labor induction, and the requirements for safe clinical use of these techniques.
Indications for Labor Induction
Possible indications for labor induction may include gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth restriction, and postterm pregnancy. However, physicians should decide whether labor induction is warranted on a case-by-case basis, after consideration of maternal and infant conditions, cervical status, gestational age, and other factors.
Contraindications to labor induction include transverse fetal position, umbilical cord prolapse, active genital herpes infection, placenta previa, and a history of previous myomectomy.
When labor induction is deemed necessary, the gestational age of the fetus should be determined to be at least 39 weeks, or there must be evidence of fetal lung maturity.
The first step in labor induction is cervical ripening using drugs or mechanical cervical dilators to dilate the cervix sufficiently before labor is induced. The next step is to induce labor using oxytocin, membrane stripping, rupture of the amniotic membrane, or nipple stimulation.
Misoprostol, which is approved for treatment of peptic ulcers, is often used off-label for cervical ripening as well as for labor induction. In women who have had any previous cesarean delivery, however, inducing labor with misoprostol may increase risk for uterine rupture and should therefore be avoided.
Clinical Recommendations
Specific clinical recommendations and conclusions, all based on good and consistent scientific evidence (level A), are as follows:
•For cervical ripening and labor induction, prostaglandin E (PGE) analogues are effective.
•When labor induction is indicated, low-dose or high-dose oxytocin regimens are appropriate.
•Regardless of Bishop score, the most efficient method of labor induction before 28 weeks of gestation appears to be vaginal misoprostol. However, infusion of high-dose oxytocin is also an acceptable option.
•For cervical ripening and induction of labor, an appropriate initial dose of misoprostol is approximately 25 µg, with frequency of administration not to exceed 1 dose every 3 to 6 hours.
•For induction of labor in women with premature rupture of membranes, intravaginal PGE2 appears to be safe and effective.
•In women with previous cesarean delivery or major uterine surgery, the use of misoprostol should be avoided in the third trimester because it has been linked to a greater risk for uterine rupture.
•The Foley catheter is a reasonable, effective option to promote cervical ripening and labor induction.
An additional clinical recommendation, based on limited or inconsistent evidence (level B), is that misoprostol, 50 µg every 6 hours, to induce labor may be appropriate in some situations. However, higher doses are linked to a greater risk for uterine tachysystole with fetal heart rate (FHR) decelerations and other complications.
As a proposed performance measure, the guidelines authors suggest that the percentage of patients in whom gestational age is established by clinical criteria when labor is induced for logistic or psychosocial indications.
"A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn't successful in producing a vaginal delivery," Dr. Ramin concluded. "These guidelines will help physicians utilize the most appropriate method depending on the unique characteristics of the pregnant woman and her fetus."
Obstet Gynecol. 2009;114:386-397.
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