The validity and reliability of weight and height measurements and body mass index calculations in early pregnancy.

BACKGROUND: Obesity is increasing in the UK and this is having an impact on the health of pregnant women and their infants. It is recommended that all pregnant women have their height and weight measured and their body mass index (BMI, kg m(-) ²) calculated and recorded in the midwifery notes. The aim of the present audit was to determine the extent of compliance with this recommendation. METHODS: An audit was undertaken in a large district general hospital in the South West of England. A convenience sample of the midwifery notes was accessed retrospectively on the post-natal wards. Data collected from the notes included weight, height, BMI and gestational age when first recorded. RESULTS: A total of 486 maternal notes were audited; of these, 9% did not have the BMI recorded. In total, 53.8% of the sample had either height or weight not recorded; however, 90.9% of the sample had a BMI recorded. In addition, 39.7% (n = 126) of heights and 16.0% (n = 63) of weights were recorded in imperial format. There was a high prevalence overweight (26.2%) and obesity (21.3%) amongst the sample. CONCLUSIONS: Recommendations for measurement of height, weight and calculation of BMI were not always followed. Where BMI was recorded, many notes had either height or weight missing or had measurements recorded in imperial units. This raises the question of how BMI was calculated and its accuracy. Inaccuracies in BMI could lead to individuals being overlooked as high risk and may not be referred for appropriate care including dietetic care. Accurate anthropometric measurements are important for dietary management and monitoring of weight gain.

Type 2 diabetes and cardiovascular disease in polycystic ovary syndrome: what are the risks and can they be reduced?

Polycystic ovary syndrome (PCOS) is a risk factor for Type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD), but these risks are poorly defined. This study aimed to evaluate the evidence for these risks and whether screening and risk reduction are feasible. Medline reviews and data quality analysis were used using standard tools. Results showed that (i) polycystic ovary syndrome is a risk factor forT2DM but the magnitude of risk is uncertain, (ii) fasting plasma glucose is an inadequate screening test forT2DM in this population and the oral glucose tolerance test is superior, (iii) the identification of women with PCOS for diabetes screening is constrained by current diagnostic criteria for PCOS; however, women with oligomenorrhoea and those with diagnosed PCOS and obesity or a family history of T2DM are at highest risk, (iv) risk factors for T2DM are improved by weight loss interventions and by metformin. However, no studies have determined whether T2DM incidence is reduced, (v) polycystic ovary syndrome is associated with cardiovascular disease (CVD) risk factors but data on CVD incidence are weak, (vi) risk factors for CVD are improved by the same interventions and statins and (vi) no studies have evaluated whether CVD incidence is reduced. While PCOS has important metabolic associations, and short-term interventions reduce risk factors for T2DM and CVD, data on prevalence and incidence of T2DM and particularly CVD are poor. There is a need for a clear definition of PCOS, for diabetes screening protocols and for long-term studies to determine whether risks can be reduced.

Breastfeeding promotion for infants in neonatal units: a systematic review.

BACKGROUND: Breastfeeding/breastmilk feeding of infants in neonatal units is vital to the preservation of short- and long-term health, but rates are very low in many neonatal units internationally. The aim of this review was to evaluate the effectiveness of clinical, public health and health promotion interventions that may promote or inhibit breastfeeding/breastmilk feeding for infants admitted to neonatal units. METHODS: Systematic review with narrative synthesis. Studies were identified from structured searches of 19 electronic databases from inception to February 2008; hand searching of bibliographies; Advisory Group members helped identify additional sources. INCLUSION CRITERIA: controlled studies of interventions intended to increase breastfeeding/feeding with breastmilk that reported breastmilk feeding outcomes and included infants admitted to neonatal units, their mothers, families and caregivers. Data were extracted and appraised for quality using standard processes. Study selection, data extraction and quality assessment were independently checked. Study heterogeneity prevented meta-analysis. RESULTS: Forty-eight studies were identified, mainly measuring short-term outcomes of single interventions in stable infants. We report here a sub-set of 21 studies addressing interventions tested in at least one good-quality or more than one moderate-quality study. Effective interventions identified included kangaroo skin-to-skin contact, simultaneous milk expression, peer support in hospital and community, multidisciplinary staff training, and Unicef Baby Friendly accreditation of the associated maternity hospital. CONCLUSIONS: Breastfeeding/breastmilk feeding is promoted by close, continuing skin-to-skin contact between mother and infant, effective breastmilk expression, peer support in hospital and community, and staff training. Evidence gaps include health outcomes and costs of intervening with less clinically stable infants, and maternal health and well-being. Effects of public health and policy interventions and the organization of neonatal services remain unclear. Infant feeding in neonatal units should be included in public health surveillance and policy development; relevant definitions are proposed.

Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis.

OBJECTIVES: To evaluate the effectiveness and cost-effectiveness of interventions that promote or inhibit breastfeeding or feeding with breastmilk for infants admitted to neonatal units, and to identify an agenda for future research. DATA SOURCES: Electronic databases were searched (including MEDLINE and MEDLINE In-Process Citations, EMBASE, CINAHL, Maternity and Infant Care, PsycINFO, British Nursing Index and Archive, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Science Citation Index, Pascal, Latin American and Caribbean Health Sciences, MetaRegister of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Health Technology Assessment Database, National Research Register) from inception to February 2008. Advisors identified further published or unpublished material. REVIEW METHODS: All papers fulfilled eligibility criteria covering participants, interventions, study design and outcomes. Results from primary studies were assessed and summarised in a qualitative synthesis for each type of intervention and across types of intervention. To estimate long-term cost utility, a decision tree was developed to synthesise data on enhanced staff contact, breastmilk effectiveness, incidence of necrotising enterocolitis (NEC) and sepsis, resource use, survival and utilities. RESULTS: Forty-eight studies met the selection criteria for the effectiveness review, of which 65% (31/48) were RCTs, and 17% (8/48) were conducted in the UK. Seven were rated as good quality and 28 as moderate quality. No studies met the selection criteria for the health economics review. There is strong evidence that short periods of kangaroo skin-to-skin contact increased the duration of any breastfeeding for 1 month after discharge [risk ratio (RR) 4.76, 95% confidence interval (CI) 1.19 to 19.10] and for more than 6 weeks (RR 1.95, 95% CI 1.03 to 3.70) among clinically stable infants in industrialised settings. There is strong evidence for the effectiveness of peer support at home (in Manila) for mothers of term, low birthweight infants on any breastfeeding up to 24 weeks (RR 2.18, 95% CI 1.45 to 3.29) and exclusive breastfeeding from birth to 6 months (RR 65.94, 95% CI 4.12 to 1055.70), and for the effectiveness of peer support in hospital and at home for mothers of infants in Special Care Baby Units on providing any breastmilk at 12 weeks [odds ratio (OR) 2.81, 95% CI 1.11 to 7.14; p = 0.01]. There is more limited evidence for the effectiveness of skilled professional support in a US Neonatal Intensive Care Unit on infants receiving any breastmilk at discharge (OR 2.0, 95% CI 1.2 to 3.2, p = 0.004). Multidisciplinary staff training may increase knowledge and can increase initiation rates and duration of breastfeeding, although evidence is limited. Lack of staff training is an important barrier to implementation of effective interventions. Baby Friendly accreditation of the associated maternity hospital results in improvements in several breastfeeding-related outcomes for infants in neonatal units. Limited evidence suggests that cup feeding (versus bottle feeding) may increase breastfeeding at discharge and reduce the frequency of oxygen desaturation. Breastmilk expression using simultaneous pumping with an electric pump has advantages in the first 2 weeks. Pharmaceutical galactagogues have little benefit among mothers who have recently given birth. Our economic analysis found that additional skilled professional support in hospital was more effective and less costly (due to reduced neonatal illness) than normal staff contact. Additional support ranged from 0.009 quality-adjusted life-years (QALYs) to 0.251 QALYs more beneficial per infant and ranged from 66 pounds to 586 pounds cheaper per infant across the birthweight subpopulations. Donor milk would become cost-effective given improved mechanisms for its provision. CONCLUSIONS: Despite the limitations of the evidence base, kangaroo skin-to-skin contact, peer support, simultaneous breastmilk pumping, multidisciplinary staff training and the Baby Friendly accreditation of the associated maternity hospital have been shown to be effective, and skilled support from trained staff in hospital has been shown to be potentially cost-effective. All these point to future research priorities. Many of these interventions inter-relate: it is unlikely that specific clinical interventions will be effective if used alone. There is a need for national surveillance of feeding, health and cost outcomes for infants and mothers in neonatal units; to assist this goal, we propose consensus definitions of the initiation and duration of breastfeeding/breastmilk feeding with specific reference to infants admitted to neonatal units and their mothers.

Maternal glucose levels influence birthweight and 'catch-up' and 'catch-down' growth in a large contemporary cohort.

AIM: To explore the effects of maternal glucose on birthweight, infant and childhood growth in non-diabetic pregnant women using routinely collected data. METHODS: Routinely collected data were extracted retrospectively from two clinical databases. These data comprised measurements of maternal random plasma glucose, infant birthweight, infant and child weight and height at 6-8 weeks, 24-36 weeks and 96-120 weeks in 6263 cases. After data cleaning, 4681 were analysed. RESULTS: When the data were analysed in thirds, a positive association between birthweight standard deviation scores (SDS), weight SDS and height SDS with maternal random plasma glucose (RPG) was observed. Regression analysis of birthweight SDS and RPG was significant (P < 0.001). Babies were approximately 48 g heavier at birth for each 1 mmol/l increase of mother's RPG. Infants who showed 'catch-up' growth (as shown by change in weight SDS) at 2 years were born to mothers with lower glucose levels than infants who showed 'catch-down' growth (P < 0.001). CONCLUSIONS: Random maternal glucose concentrations (taken at 28 weeks' gestation) in the normal range are positively related to birthweight. Glucose concentrations also predict greater weight and length in infancy. Despite this, babies born to mothers with higher glucose concentrations within the normal range show significant 'catch-down' growth in infancy as shown by a fall in weight SDS.

Is neighbourhood deprivation a risk factor for gestational diabetes mellitus?

AIMS: To assess the relationship between neighbourhood deprivation and the rate of gestational diabetes mellitus (GDM) using routinely collected data from a clinical information system, in Plymouth, UK. METHODS: Between 1 January 1996 and 31 December 1997, 3933 women residing within the Plymouth Primary Care Trust (PCT) were screened for GDM using indices of neighbourhood deprivation and prevalence of GDM. Areas (n = 43) were classified according to the Townsend index, measuring material deprivation. Pregnant women with and without GDM were compared. RESULTS: The prevalence of GDM was 1.7%[95%, confidence interval (CI) 1.20, 2.11]. The prevalence of GDM ranged from 1.05% (95% CI 0.60, 1.70) in the most deprived to 2.10% (95%, CI 1.34, 3.13), in the least deprived neighbourhood. Crude rates decreased by 50%[relative prevalence (RP) (95% CI) 0.50 (0.27, 0.94); P = 0.06] amongst those living in the most-deprived compared with those living in the least-deprived areas. Using a stepwise binary logistic regression model, older age at delivery significantly increased the risk of developing GDM. [RP (95%, CI) 1.09, (1.04, 1.13)]. Townsend deprivation score had no significant independent association with GDM when other covariates were considered. CONCLUSION: These data suggest that the neighbourhood context in which women live has no impact on the risk of GDM. Diabet.

First-trimester combined ultrasound and biochemical screening for Down syndrome in routine clinical practice.

OBJECTIVES: To assess the effectiveness of combined ultrasound and biochemical (CUB) screening for chromosome abnormalities in singleton pregnancies in a routine antenatal clinic and laboratory setting. METHODS: Women whose pregnancies fell within the gestational age range of 11 to 14 weeks by ultrasound assessment were offered CUB screening on the basis of measurement of nuchal translucency (NT), maternal serum free beta-human chorionic gonadotrophin (FbetahCG) and pregnancy-associated plasma protein A (PAPP-A). NT measurements were obtained using a standardised method defined by the Fetal Medicine Foundation and FbetahCG, and PAPP-A were measured using the DELFIA immunoassay system. Each screening marker measurement was converted to a multiple of the appropriate gestational median and a risk was derived using previously published parameters for each marker in chromosomally abnormal and unaffected pregnancies. A combined risk of Down syndrome and of trisomy 18/13, incorporating the maternal age risk, was calculated for all women. Invasive diagnostic testing was offered to women whose combined risk exceeded the cut-off risk of 1 in 250 (term). RESULTS: Five thousand and eighty-four women accepted a first-trimester screening test for Down syndrome, representing 75% of the eligible booking population. Out of the population eligible for CUB screening at the time of booking, NT measurements were obtained from 93% at the first clinic visit and 7% had to return for a second attempt. After excluding women who defaulted on a return visit, satisfactory NT measurements were obtained in 99.5% of pregnancies. Fifteen cases of Down syndrome and eleven pregnancies with other chromosome abnormalities were ascertained. The detection rate for Down syndrome was 93% (14/15) at a false-positive rate of 5.9% and for all chromosome abnormalities it was 96% (25/26) at an overall false-positive rate of 6.3%. CONCLUSIONS: CUB screening offers a significant improvement in sensitivity over second-trimester biochemical screening and is deliverable within a routine prenatal clinical setting.

Weight differences in Plymouth toddlers compared to the British Growth Reference Population.

Routinely collected weight measurements from 4665 Plymouth children born 1996-97 were compared with the British Growth Reference Charts (BGRC). The children were 0.33 SDS heavier on average than the reference population at 24-30 months, an actual excess of 460 g.

Space-time clustering of childhood Type 1 diabetes in Devon and Cornwall, England.

AIMS: Several studies on space-time clustering have been reported in childhood diabetes, but the findings are conflicting. The present study was undertaken to examine whether such clustering could be detected at either birth or the time of diagnosis in the far South-west of England. METHODS: A cohort of 518 children aged 0-15 years and diagnosed with Type 1 diabetes from 1975 to 1996 contained in the population-based Cornwall and Plymouth Children's Diabetes Register (CPCDR) were included in the analyses. The case ascertainment for this register is estimated to be 94.4% complete. Mantel's modification of Knox's method was employed. A method based on K-function was also used, for the first time, to investigate the space-time clustering of diabetes. RESULTS: Significant space-time clustering at diagnosis was found by the Knox's test in the following combinations of critical cut-off thresholds: 25, 35 and 50 km and 90, 270 and 360 days (all P < 0.05), with the highest significance found at 35 km and 360 days (P = 0.0011). K-function analysis also confirmed the overall clustering (P = 0.013). CONCLUSIONS: There is strong evidence of space-time clustering in the onset of childhood Type 1 diabetes in Devon and Cornwall, England. These results lend some support to the hypothesis that viral infections and some unknown localized environmental factors play a role in the development of childhood Type 1 diabetes.

Chorionicity determination in twin pregnancies: how accurate are we?

OBJECTIVES: To determine the accuracy of antenatal prediction of chorionicity in twin pregnancies in our institution. METHODS: Antenatal chorionicity was determined using the number of placental masses, the presence or absence of a twin peak sign and the fetal sex. The gestational age at assessment was documented. Postnatal diagnosis of chorionicity was determined by neonatal sex and placental pathology. RESULTS: Chorionicity was correctly determined in 95% of cases (n = 131); 91% of the monochorionic and 96% of the dichorionic pregnancies were correctly determined. If chorionicity was assessed prior to 14 weeks' gestation (n = 96) the correct diagnosis was made in all except one case. CONCLUSIONS: Ultrasound assessment of chorionicity has a high sensitivity and specificity. This is further improved if the assessment is performed prior to 14 weeks' gestation.

Drinking water composition and childhood-onset Type 1 diabetes mellitus in Devon and Cornwall, England.

AIMS: Previous studies have reported inconsistent results on the association between some compositions (e.g. nitrate) in domestic water and the risk of childhood-onset Type 1 diabetes mellitus. This study aimed to examine the relationship between nitrate, zinc and magnesium in drinking water and the risk of childhood-onset Type 1 diabetes mellitus. METHODS: The study covers the Cornwall and the former Plymouth Health Authority Regions in the far south-west of England. Five hundred and seventeen children, aged 0-15 years, diagnosed with Type 1 diabetes mellitus between 1975 and 1996, were identified for inclusion in the study. Domestic water data (nitrate, Zn, Mg, Cu, Al, Ca, Fe and Mn) between 1993 and 1997 were provided by South-west Water Plc, UK, for each of the 40 Water Supply Zones in which the subjects had been resident at the time of diagnosis. The standardized incidence ratio (SIR) of the disease was calculated for each Water Supply Zone using the UK 1991 census population data. The relationship between the SIR of the disease and the water quality indicators in thirds (three strata of low, medium and high concentrations) was examined by chi2 test for trend and Poisson regression analysis. RESULTS: The initial analyses by chi2 test for trend on the relation of SIRs and drinking water compositions suggested that copper, magnesium and nitrate might have some protective effects, but Poisson regression analyses showed that only zinc and magnesium were significant factors. The data suggest that the incidence rate of childhood diabetes is significantly lower when the concentrations of zinc and magnesium in the domestic drinking water are in the range 22.27-27.00 microg/l (incidence rate ratio (IRR), 0.76; 95% CI, 0.59-0.97) and greater than 2.61 mg/l (IRR, 0.72; 95% CI, 0.58-0.91), respectively. CONCLUSIONS: Our findings suggest evidence of a possible association between zinc and magnesium in the domestic drinking water and childhood diabetes in the far south-west of England. However, these possible protective effects of zinc and magnesium in domestic drinking water warrant further confirmation.

The development and evaluation of a computer-assisted teaching programme for intrapartum fetal monitoring.

OBJECTIVE: The development and evaluation of a computer-assisted teaching programme of cardiotocography and acid-base balance. DESIGN: Randomised controlled trial. PARTICIPANTS: One hundred and seventeen midwifery and obstetric staff at Derriford Hospital, Plymouth. METHODS: The obstetricians and midwives were randomly allocated to use the teaching programme, either early or late. The late group (control) used the teaching programme three months after the early group. To assess the effect of the teaching programme, participants were tested on four occasions over eight months by a multiple choice questionnaire. Two questionnaires on ease of use were also completed. MAIN OUTCOME MEASURES: Multiple choice questionnaire scores and opinion questionnaire results. RESULTS: The mean score in the early group improved from 50-8% (test 1, pre-teaching programme) to 70.2% (test 2, post-teaching programme). The mean score in the control group was 50.3% (test 1) and 54.8% (test 2). Knowledge was retained up to seven months. CONCLUSIONS: The teaching programme was effective in improving knowledge of acid-base balance and cardiotocography and can be used by all staff whilst on duty on the labour ward.

Incidence of childhood-onset Type 1 diabetes mellitus in Devon and Cornwall, England, 1975-1996.

AIMS: To determine the incidence of Type 1 diabetes mellitus (DM) in children aged 0-15 years in the far south-west of England between 1975 and 1996. METHODS: Patient information was collected to set up the Cornwall and Plymouth Children's Diabetes Register (CPCDR) through two main data sources; hospitals and the general practitioners in all surgeries in the study region. All children under 16 years living within Cornwall and the Isles of Scilly, and the former Plymouth Health Authorities and diagnosed as having Type 1 DM during the study period were included. The case ascertainment was estimated by a capture-recapture method. Trends and differences in incidence of sex, age, time period and district of diagnosis were analysed by Poisson regression analysis. Roger's method was used to estimate the seasonal variations. RESULTS: A total of 522 subjects aged between 0 and 15 years were identified from 01/01/1975 to 31/12/1996, giving an overall crude incidence of 14.9/ 100 000 population/year. The case ascertainment was 94.4% (95% confidence interval (CI) 91.4- 97.6%) for the whole register. Poisson regression analysis showed that a significant increase of incidence (2.49% per year) was observed throughout the 22-year study period, which was mainly a result of the significant increase in the 0-4 year age-group (6.29% per year). The incidence significantly differed among the 22-years (P = 0.007), the three age groups (0-4, 5-9 and 10-14 years, P<0.001) and different sexes (P=0.049). The significant seasonal variations were detected with peak incidence appearing in autumn and winter. CONCLUSIONS: The first validated childhood-onset diabetes register has been set up in the far south-west of England. The incidence of childhood Type 1 DM in this region has increased significantly over the past two decades, especially in children under 5 years.