Randomised controlled trial of home based motivational interviewing by midwives to help pregnant smokers quit or cut down.

OBJECTIVE: To determine whether motivational interviewing--a behavioural therapy for addictions-provided at home by specially trained midwives helps pregnant smokers to quit. DESIGN: Randomised controlled non-blinded trial analysed by intention to treat. SETTING: Clinics attached to two maternity hospitals in Glasgow. PARTICIPANTS: 762/1684 pregnant women who were regular smokers at antenatal booking: 351 in intervention group and 411 in control group. INTERVENTIONS: All women received standard health promotion information. Women in the intervention group were offered motivational interviewing at home. All interviews were recorded. MAIN OUTCOME MEASURES: Self reported smoking cessation verified by plasma or salivary cotinine concentration. RESULTS: 17/351 (4.8%) women in the intervention group stopped smoking (according to self report and serum cotinine concentration < 13.7 ng/ml) compared with 19/411(4.6%) in the control group. Fifteen (4.2%) women in the intervention group cut down (self report and cotinine concentration less than half that at booking) compared with 26 (6.3%) in the control group. Fewer women in the intervention group reported smoking more (18 (5.1%) v 44 (10.7%); relative risk 0.48, 95% confidence interval 0.28 to 0.81). Birth weight did not differ significantly (mean 3078 g v 3048 g). CONCLUSION: Good quality motivational interviewing did not significantly increase smoking cessation among pregnant women.

The Baby Friendly Hospital Initiative and breast feeding rates in Scotland.

OBJECTIVE: To examine the effect of the Baby Friendly Hospital Initiative on breast feeding rates in Scotland. DESIGN: Observational study using an annual survey of progress towards the WHO/UNICEF Baby Friendly Hospital Initiative and routinely collected breast feeding rates gathered on the Guthrie Inborn Errors Screening card at 7 days of postnatal age. SETTING: Scotland, UK, population 5.1 million, with about 53 000 births a year. PARTICIPANTS: All 33 maternity units with over 50 births per annum and 464,246 infants born in Scotland between 1995 and 2002. MAIN OUTCOME MEASURES: Baby Friendly status of each maternity unit at the time of an infant's birth: certificate of commitment, UK standard award, and breast feeding at 7 days postnatal age. RESULTS: Babies born in a hospital with the UK Baby Friendly Hospital Initiative standard award were 28% (p<0.001) more likely to be exclusively breast fed at 7 days of postnatal age than those born in other maternity units after adjustment for mother's age, deprivation, hospital size, and year of birth. From 1995, breast feeding rates had increased significantly faster in hospitals with Baby Friendly status by 2002: 11.39% (95% confidence interval 10.35 to 12.43) v 7.97% (95% confidence interval 7.21 to 8.73). CONCLUSION: Being born in a hospital that held the award increased the chance of being breast fed. All maternity units should be encouraged to undertake the significant strategic and practical changes required to achieve UK Baby Friendly Hospital Initiative standard status.

Constipation and soiling--outcome of treatment at one year.

AIM: To assess the outcome at one year of a cohort of patients referred to outpatient clinics with soiling. METHOD: Retrospective case note audit of 34 children referred to hospital outpatients over a four month period with soiling stated as the main problem in the referral letter. RESULTS: After one year, 29% of the 34 children studied were discharged to patient satisfaction, 38% defaulted from follow up, 24% were still attending outpatient clinics and 9% had been referred back to source. Coexisting pathologies, in particular enuresis and family stress, were found in several of the children. At the time of referral, 44% of new patients and 89% of re-referrals bad symptoms present for longer than 12 months. Only 18% of the children were receiving treatment at the time referral was made. CONCLUSION: Constipation is often undiagnosed until the problem is well established with soiling present, which makes treatment a long and often difficult process. It is necessary to consider the wider social and family issues when managing a child with constipation and soiling. Hospital based general medical and surgical outpatient clinics may not be the ideal setting in which to deal with these problems.

Overnight central and peripheral temperature changes in normal infants.

AIM: To explore the relationship between central and peripheral temperature in normal infants after being put down to sleep. METHODS: Overnight shin and rectal temperatures of 21 normal infants were continuously recorded at home for three nights at 2 wk, 6 wk, 3 mo and 5 mo of age. Parents documented the start and end of feed/nappy changes during the night. RESULTS: An initial fall in rectal temperature was recorded on 149 out of 161 nights. This was linearly correlated with a rise in shin temperature for 106/149 (71%) nights (median R2 = 0.95, lower quartile 0.92, upper quartile 0.97). It was not possible to rule out a change in thermal insulation over the shins as a confounding variable in this strong association. However, a similar inverse relationship was seen between shin and rectal temperature during 111 of 121 (92%) feed/nappy changes. CONCLUSION: The fall in rectal temperature after being put down to sleep may be due to redistribution of heat rather than decreased production or heat loss. If causal, the development in early infancy of an inverse relationship between shin and rectal temperature may be important for cardiovascular homeostasis. Further sleep laboratory work is required to distinguish peripheral temperature changes on falling asleep from those associated with changes in thermal insulation.

A nocturnal enuresis service for a deprived inner city.

AIM: Glasgow is a city where 80% of the most deprived children in Scotland live within 20% of the overall population. Of 168,000 children in Glasgow, an estimated 5000 aged 5-15 y have primary nocturnal enuresis. The aim of this study was to establish a nocturnal enuresis service for Glasgow. METHODS: Needs assessment was performed and the incident cases were documented at school entry healthcare appraisal, at the age of 5 y. A cohort of these children was followed up at 8 y of age and symptom resolution was no better than natural remission. Parents, general practitioners, clinical medical officers and a hospital paediatrician were interviewed face-to-face about their need for a service. RESULTS: Ten of 11 general practitioners expressed a need for a specialist service. Ten school nurse-led local nocturnal enuresis clinics were established. Accommodation, funding, default and managing alarms were major problems. School nurses enjoyed extra training and quickly became skilled therapists. Two research projects highlighted that most children at first attendance did not believe they could ever be dry, which predicted outcome. Deprived families, once motivated, could successfully undertake complex behavioural therapies. CONCLUSION: A comprehensive nocturnal enuresis service begins when children stop using night nappies at the age of 3-4 y. Appropriate waterproof mattress, duvet and pillow coverings should be advocated until 5 y, when desmopressin may be helpful. For continued wetting at the age of 7 y, a local service should be led by a team of well-trained nurses using enuretic alarms.

Central and peripheral temperature change in normal infants.

The purpose was to explore the relationship between the fall in rectal temperature seen in normal infants after being put down to sleep and the concomitant rise in peripheral shin temperature. In this observational study 21 normal infants had continuous overnight peripheral shin and central rectal temperature recorded, for three nights at 2 weeks, 6 weeks, 3 months and 5 months of age. Parents documented the start and end of feed/nappy changing episodes during the night. All recordings were made in the infants' own home. A strong inverse linear correlation (median r2 = 0.95, lower quartile 0.92, upper quartile 0.97) was seen between rectal temperature and shin temperature on falling to sleep when put down on 106 (65%) of 161 nights. On many other nights a significant nonlinear association was present. It was not possible to exclude the process of being put down to sleep as a confounding variable in this strong association. However, a similar inverse relationship between shin and rectal temperature was seen overnight during 111 of 121 (92%) feed/nappy changing episodes. If causal, the development in early infancy of an inverse relationship between shin and rectal temperature may be important for cardiovascular homeostasis. Further sleep laboratory work including video recording is required to separate the peripheral and central temperature changes that take place on falling to sleep from those associated with removal of clothing during a nappy change.

Breastfeeding rates are increasing in Scotland.

OBJECTIVE: To measure the change in prevalence of breastfeeding between 1990/1991 and 1997/1998 in Scotland, using information collected on Guthrie cards when newborn infants are about seven days old. DESIGN: Analysis, by geographic postcode area, health board and maternity unit, for babies born in 1990/1991 and 1997/1998. For 1997, maternity unit and health board breastfeeding rates were also compared after standardisation for maternal age, deprivation and age of infant. SETTING: Scotland. SUBJECTS: 131,759 babies born in 1990/1991 and 118,055 in 1997/1998. RESULTS: In 1990/1991, 46,949 (35.6%) were breastfed as were 49,615 (42.0%) in 1997/1998, an increase of 6.4% (95% CI 6.0, 6.8) over eight years. A 3.8% increase remained after adjustment for change in maternal age. Maternity units with the Baby Friendly award improved 8.1% (95% CI 7.0, 9.2) compared with those with a certificate of commitment 6.1% (95% CI 5.2, 7.0). Other units improved 2.2% (95% C1 1.6, 2.8) no more than estimates due to increase in maternal age. Standardised rates were higher on the East Coast of Scotland 111 (109, 112) than the West or Central Regions 97 (96, 99). CONCLUSION: Breastfeeding has increased over eight years in Scotland. Less than half can be explained by demographic change in maternal age. However present breastfeeding targets are unlikely to be met. Maternity units should be urged to participate fully in the UNICEF U.K. Baby Friendly Initiative. Effective interventions prior to pregnancy are required so that more young men and women want their babies to be breastfed.

Monitoring breastfeeding rates and setting local targets: the Glasgow experience.

OBJECTIVE: The objective was to provide baseline data on infant feeding intention and practice in Glasgow. DESIGN: Information was collected from a prospective cohort of women who booked for maternity care in Glasgow during the months November 1995 and May 1996. Figures on feeding intention and practice were collected at five points from maternity booking until six weeks postnatal age. SETTING: Women were recruited at the four maternity units in Glasgow. Follow-up information was collected at birth, discharge from the maternity hospital at four days, and then at 12 days at home by the community midwife, and finally at six weeks by the health visitor. SUBJECTS: One thousand seven hundred and ninety two women were recruited at maternity booking. Breastfeeding information was available at birth for 1723, at discharge for 1743, at 12 days for 1513, and at six weeks for 1394. Multiple logistic regression determined maternal and infant factors predicting feeding intention and duration. RESULTS: At booking 50% planned to breastfeed. Fifty percent breastfed at birth; by four days the rate had dropped to 42%, by 12 days to 36% and by six weeks to 27%. Five factors: deprivation score, maternal age, parity, maternal smoking and previous breastfeeding experience independently predicted feeding intention. Maternal factors explained differences in breastfeeding rates between the four hospitals. CONCLUSION: Original breastfeeding targets for Glasgow have been revised to take account of local circumstances. An alternative method using routinely collected data is needed to monitor progress.

A pilot study to establish a randomized trial methodology to test the efficacy of a behavioural intervention.

How can pregnant women be helped to stop smoking? This was a pilot study of midwife home-based motivational interviewing. Clients were 100 consecutive self-reported smokers booking at clinics in Glasgow from March to May 1997. Smoking guidance is routinely given at booking. In addition, intervention clients received a median of four home-based motivational interviewing sessions from one specially trained midwife. All sessions (n = 171) were audio-taped and interviews (n = 49) from 13 randomly selected clients were transcribed for content analysis. Three 'experts' assessed intervention quality using a recognized rating scale. Cotinine measurement on routine blood samples confirmed self-reported smoking change from late pregnancy telephone interview. Postnatal telephone questionnaire measured client satisfaction. Focus groups of routine midwives explored acceptability, problems and disruption of normal care. Fisher exact, chi 2 and Mann-Whitney tests compared enrolment characteristics. Two-sample t-tests assessed outcome between groups. Motivational interviewing was satisfactory in more than 75% of transcribed interviews. In this pilot study, self-reported smoking at booking (100 of 100 available) corroborated by cotinine (93 of 100) compared with late pregnancy self-reports (intervention 47 of 48; control 49 of 49) and cotinine (intervention 46 of 48; control 47 of 49) showed no significant difference between groups. Tools have been developed to answer the question: 'Can proactive opportunistic home-based motivational interviewing help pregnant smokers reduce their habit?'.

Maternal antibody to hepatitis B core antigen detected in dried neonatal blood spot samples.

Despite Department of Health recommendations, universal antenatal testing for hepatitis B virus (HBV) is not performed throughout Scotland. We describe the evaluation of an assay to document past or present infection with HBV, by identifying maternal antibody in routine Guthrie dried neonatal blood spot samples taken when infants are 7 days old. A modified haemagglutination assay to detect antibody to hepatitis B core antigen (CORECELL, Green Cross) was validated and found to be 79% sensitive (44/56) and 100% (105/105) specific when used with dried blood spot samples made from panels of serum of known reactivity. Ninety-three percent (13/14) of HBV carriers were CORECELL positive. Sixty-six (0.5%) of 14044 routine Guthrie samples taken from babies born in Scotland from June August 1992 were CORECELL positive indicating past or present maternal infection with HBV. A cross-sectional survey would document the maternity hospitals where universal antenatal hepatitis B screening should be urgently established.

Vision testing in schools: an evaluation of personnel, tests, and premises.

This study compared the results of vision screening of 5 year olds in schools by school nurses and an orthoptist, compared two tests, and examined testing conditions. The specificity of nurse testing was 95% and the sensitivity 83%. No conclusions about the tests could be made owing to the small numbers in this part of the study, but some children, after nearly one year at school, could not match a line of four letters required for the more accurate test. Only 13 of 22 schools had suitable testing conditions.

Changes in cotinine levels during pregnancy.

We measured maternal cotinine levels on residual sera of antenatal blood samples to biochemically document changes in smoking between early and late pregnancy. It was a random sample of 404 mothers who had both an early and late sample. Cotinine levels were used to categorize maternal smoking into nonsmoker (<15 ng/mL) and smoker (> or = 15 ng/mL) groups. Designated smokers were further partitioned into lighter (15-100 ng/mL) and heavier (>100 ng/mL) semiquantitative groupings. There was a positive cotinine result in 113 (28%) mothers in early pregnancy; of these smoking women, 35 (31%) had quit smoking by the time of their late pregnancy blood test and 28 (25%) had reduced their cotinine level by at least 25%. Many more lighter smokers had quit (59%) compared to heavier smokers (17%) (X2 = 20.9, df=1, p<0.001). By late pregnancy, 86 (21%) mothers were still defined as smokers. Almost 30% of pregnant women in this sample were smoking during early pregnancy declining to 21% in late pregnancy.

The febrile stress of routine vaccination does not increase central apnoea in normal infants.

We tested the hypothesis that the febrile stress of routine vaccination would increase central apnoea in normal infants. Twenty-one normal infants had continuous overnight breathing and temperature recorded at home, before and after 58 routine vaccination episodes. Central apnoea, of at least 5 sec duration, was detected by computer algorithm and confirmed by human inspection. The longest recorded apnoea was 16 sec (n = 1) during 3629 h of sleep. Overnight rectal temperature increased after vaccination (median 0.52 degrees C, 95% CI 0.40, 0.65). Apnoea density reduced on 46/53 vaccination nights (median -29%, 95% CI -20, -37) followed by an increase on subsequent nights (median +10%, 95% CI +1%,+21%). Overall, apnoea density was similar during the 3 nights preceding and 4 nights following vaccination (median +1%, 95% CI +9,-6). The febrile stress of routine vaccination did not increase central apnoea in normal infants.

Smoking during pregnancy measured by population cotinine testing.

AIM: To establish a baseline cross-sectional prevalence of maternal smoking, measured by antenatal serum cotinine testing, in a population of pregnant women. METHODS: Residual sera from first and second routine antenatal blood samples were collected anonymously over a six-month period for pregnancies within the Canterbury region. Cotinine levels were measured by an ELISA test with a result of > 14 ng/mL indicative of active smoking. Only pregnancies ending in a confirmed live birth were considered in smoking prevalence calculations. There was a total of 1948 eligible residual blood samples. RESULTS: Of the 414 residual blood samples available for the first two months of pregnancy, 146 (35.3%) were found to be positive for cotinine. Smoking prevalence decreased over pregnancy so that by the third trimester 225 (26.8%) of 838 samples were cotinine positive. Infants born from smoking mothers had significantly lower birth weights. CONCLUSIONS: In 1994, a third of women tested in early pregnancy and a quarter of women tested in late pregnancy were identified as being smokers. Repeated objective cross-sectional surveys will allow accurate assessment of the efficacy of smokefree interventions both before and during pregnancy.

Smoking during pregnancy: how reliable are maternal self reports in New Zealand?

OBJECTIVE: To determine the reliability of self reports of smoking during pregnancy. METHODS: Residual sera from early and late antenatal blood samples were tested for cotinine for all pregnancies over a six month period. Over an overlapping 12 month period, a postal questionnaire on smoking was also sent to all new mothers (n = 4857) when their baby was 4-8 weeks old. Smoking status from obstetric booking notes was also obtained. RESULTS: The cotinine-validated smoking prevalence was 31.3% for the first trimester and 27.7% for the third trimester. Questionnaire self reported prevalences were 19.2% and 15.7% for the first and third trimesters respectively, and 18.9% for obstetric booking. Of cotinine-validated smokers, 22% denied smoking-self deceivers. Of mothers who replied to the questionnaire, a half appeared to systematically under report the amount they smoked. CONCLUSIONS: Nearly a quarter of smoking pregnant women did not report smoking. Moreover, of those who did, the amount smoked was often under reported. This tendency to under report may rise as pressures to stop smoking increase. Accurate measures of smoking prevalence in pregnant women will require objective testing.

Breathing, sleep state, and rectal temperature oscillations.

Overheating may cause terminal apnoea and cot death. Rectal temperature and breathing patterns were examined in normal infants at home during the first 6 months of life. Twenty one infants had continuous overnight rectal temperature and breathing recordings for 429 nights (mean 20.4 nights, range 7-30) spaced over the first six months of life. Periods when breathing was 'regular' were directly marked on single night records. Sleep state was determined from respiratory variables. 'Regular' breathing was a reliable marker of 'quiet' sleep (specificity 93%). The duration of 'quiet' sleep increased from 6 to 22 minutes from two weeks to three months of age and then remained static, as did the proportion of sleep spent in the quiet phase (9% to 34%). Rectal temperature fell during 66% of quiet sleep and usually rose during rapid eye movement (REM) sleep. The drop in rectal temperature was maximal at the start of quiet sleep, whereas the maximum rise during REM sleep was reached after 10 to 15 minutes. Oscillations in rectal temperature are associated with changes in sleep and breathing state. The maturation of rectal temperature patterns during the first six months of life are closely related to a maturation of sleep state and breathing patterns.

Prevalence of smoking in early pregnancy by census area: measured by anonymous cotinine testing of residual antenatal blood samples.

AIM: To accurately measure the prevalence of smoking in early pregnancy by census area units (CAU) in Christchurch. METHODS: Smoking status in pregnancy was determined by serum cotinine assay for all antenatal blood samples taken over a 6 month period. CAUs in Christchurch were grouped into quartiles according to the proportion of maternal smokers. Social factors from 1991 census data were used to describe the characteristics of each quartile. RESULTS: The overall rate of smoking in pregnancy was 33.0%. Rates ranged from 10.6% to 56.9% for the census area groups. CAUs in the upper quartile (39-57% of women smoking in pregnancy) were clustered together geographically and were associated with lower socioeconomic indices. The strongest correlation was between average income with smoking rates (Pearson correlation coefficient 0.76). CONCLUSION: Smoking rates in pregnancy have remained at around 30% for at least 20 years, with some areas of the city having rates nearly double this. It would seem logical to promote smoke-free pregnancy activities in localities with the highest rates of smoking. Future evaluation of the efficacy of such programmes should be done using objective measurements.