Physical health, breastfeeding problems and maternal mood in the early postpartum: a prospective cohort study.

This study aimed to investigate prospectively the contribution of maternal physical health and/or breastfeeding problems to maternal mood (depression, anxiety, fatigue, irritability, confusion, vigor) at 8-weeks postpartum. A prospective study was conducted. Participants were recruited antenatally from a public and a private maternity hospital in Melbourne, Australia. Nulliparous pregnant women (N = 229), ≥ 18 years of age, ≥ 36-week gestation, singleton pregnancy and with sufficient English were eligible. Data were collected by self-report questionnaire (pregnancy, weeks 1-4 postpartum) and telephone interview (week 8 postpartum). A high burden of physical problems was classified as ≥ 3 problems (caesarean/perineal pain; back pain; constipation; haemorrhoids; urinary and bowel incontinence) for ≥ 2 time points. A high burden of breastfeeding problems was having ≥ 2 problems (mastitis; nipple pain; frequent expressing; over- or under-supply of milk) for ≥ 2 time points. Multivariate linear regression was used to investigate the relationship between maternal mood, assessed using Profile of Mood States (8-week postpartum), and a high burden of breastfeeding and/or physical health problems. Forty-six women (20.1%) had a high burden of physical symptoms, 44 (19.2%) a high burden of breastfeeding problems only and 25 women (11.0%) had both. A high burden of breastfeeding problems alone (ß = 10.6, p = 0.01) or with co-morbid physical problems (ß = 15.35, p = 0.002) was significantly associated with poorer maternal mood at 8 weeks. Early, effective postnatal treatment of maternal health and breastfeeding problems could reduce women's risk for poor mental health.

The effect of skin-to-skin care on cerebral oxygenation during nasogastric feeding of preterm infants.

AIM: To describe cerebral oxygenation during gavage feeding of preterm infants during incubator and skin-to-skin care. METHODS: Further analysis of data from two crossover studies comparing cerebral oxygenation, heart rate and oxygen saturation during skin-to-skin care with incubator care. Data were analysed in three epochs; 10 minutes prefeed, during-feed and 10 minutes postfeed. Measurements from infants fed during incubator care were compared with those obtained during skin-to-skin care. RESULTS: In 39 infants [median (IQR) 27.8 (26.1-30.0) weeks' gestation], there was no difference in cerebral oxygenation between pre-, during- and postfeed. Heart rate increased by three beats per minute postfeed compared with during-feed. Twenty infants received two gavage feeds, one feed in the incubator and another during skin-to-skin care. There was no difference in cerebral oxygenation and heart rate; peripheral oxygen saturation decreased by 3% during feeding whilst skin-to-skin care compared with feeding in the incubator. CONCLUSION: Cerebral oxygenation remained stable before, during and after gavage feeding in an incubator and during skin-to-skin care. The small decrease in oxygen saturation whilst receiving gavage feeding during skin-to-skin care is unlikely to be clinically important, providing reassurance that preterm infants maintain physiological stability during skin-to-skin care.

Assessing the tongue colour of newly born infants may help to predict the need for supplemental oxygen in the delivery room.

AIM: It takes several minutes for infants to become pink after birth. Preductal oxygen saturation (SpO2) measurements are used to guide the delivery of supplemental oxygen to newly born infants, but pulse oximetry is not available in many parts of the world. We explored whether the pinkness of an infant's tongue provided a useful indication that supplemental oxygen was required. METHODS: This was a prospective observational study of infants delivered by Caesarean section. Simultaneous recording of SpO2 and visual assessment of whether the tongue was pink or not was made at 1-7 and 10 min after birth. RESULTS: The 38 midwives and seven paediatric trainees carried out 271 paired assessments on 68 infants with a mean (SD) birthweight of 3214 (545) grams and gestational age of 38 (2) weeks. When the infant did not have a pink tongue, this predicted SpO2 of <70% with a sensitivity of 26% and a specificity of 96%. CONCLUSION: Tongue colour was a specific but insensitive sign that indicated when SpO2 was <70%. When the tongue is pink, it is likely that an infant has an SpO2 of more than 70% and does not require supplemental oxygen.

Are high flow nasal cannulae noisier than bubble CPAP for preterm infants?

BACKGROUND: Noise exposure in the neonatal intensive care unit is believed to be a risk factor for hearing loss in preterm neonates. Continuous positive airway pressure (CPAP) devices exceed recommended noise levels. High flow nasal cannulae (HFNC) are an increasingly popular alternative to CPAP for treating preterm infants, but there are no in vivo studies assessing noise production by HFNC. OBJECTIVE: To study whether HFNC are noisier than bubble CPAP (BCPAP) for preterm infants. METHODS: An observational study of preterm infants receiving HFNC or BCPAP. Noise levels within the external auditory meatus (EAM) were measured using a microphone probe tube connected to a calibrated digital dosimeter. Noise was measured across a range of frequencies and reported as decibels A-weighted (dBA). RESULTS: A total of 21 HFNC and 13 BCPAP noise measurements were performed in 21 infants. HFNC gas flows were 2-5 L/min, and BCPAP gas flows were 6-10 L/min with set pressures of 5-7 cm of water. There was no evidence of a difference in average noise levels measured at the EAM: mean difference (95% CI) of -1.6 (-4.0 to 0.9) dBA for HFNC compared to BCPAP. At low frequency (500 Hz), HFNC was mean (95% CI) 3.0 (0.3 to 5.7) dBA quieter than BCPAP. Noise increased with increasing BCPAP gas flow (p=0.007), but not with increasing set pressure. There was a trend to noise increasing with increasing HFNC gas flows. CONCLUSIONS: At the gas flows studied, HFNC are not noisier than BCPAP for preterm infants.

Is bedtime supper necessary for older children with diabetes using glargine insulin in multiple daily injection regimens?

AIMS: Current guidelines for dietary management of Type 1 diabetes in children recommend a carbohydrate supper before bed. However, with the introduction of insulin analogues such as glargine (with a basal insulin profile), supper may be unnecessary. The purpose of this study was to investigate whether supper is required to prevent nocturnal hypoglycaemia when using multiple daily injections, with glargine as the basal insulin and rapid-acting insulin pre-meals, in older children with Type 1 diabetes. METHODS: Thirty-five children aged 10-18 years with Type 1 diabetes were recruited to a randomized cross-over trial (supper vs. no supper). Each phase consisted of three consecutive days of wearing a continuous glucose-monitoring system (CGMS) to record nocturnal blood glucose levels in the home setting. The supper phase included one 15-g carbohydrate dairy snack consumed before bed. The evening meals were standardized. Activity was restricted. RESULTS: Valid CGMS data were obtained for 163 nights (85 supper, 78 no supper). Nocturnal hypoglycaemia rates were similar in the supper and no-supper groups (32.9% vs. 33.3% of nights; P = 0.96). CONCLUSIONS: This study suggests that supper is not necessary for all children to prevent nocturnal hypoglycaemia when using glargine insulin. The recommendation for inclusion of supper should be individually tailored and not mandatory.

Changes in heart rate in the first minutes after birth.

The normal range of heart rate (HR) in the first minutes after birth has not been defined. Objective To describe the HR changes of healthy newborn infants in the delivery room (DR) detected by pulse oximetry. Study Design All inborn infants were eligible and included if a member of the research team attended the birth. Infants were excluded if they received any form of medical intervention in the DR including supplemental oxygen, or respiratory support. HR was measured using a pulse oximeter (PO) with the sensor applied to the right hand or wrist immediately after birth. PO data (oxygen saturation, HR and signal quality) were downloaded every 2 sec and analysed only when the signal had no alarm messages (low IQ signal, low perfusion, sensor off, ambient light). Results Data from 468 infants with 61 650 data points were included. Infants had a mean (range) gestational age of 38 (25-42) weeks and birth weight 2970 (625-5135) g. At 1 min the median (IQR) HR was 96 (65-127) beats per min (bpm) rising at 2 min and 5 min to 139 (110-166) bpm and 163 (146-175) bpm respectively. In preterm infants, the HR rose more slowly than term infants. Conclusions The median HR was <100 bpm at 1 min after birth. After 2 min it was uncommon to have a HR <100 bpm. In preterm infants and those born by caesarean section the HR rose more slowly than term vaginal births.

Correlation of thromboelastography with standard tests of anticoagulation in paediatric patients receiving extracorporeal life support.

UNLABELLED: Children requiring extracorporeal life support (ECLS) are at significant risk for thrombotic and haemorrhagic complications. Thromboelastography (TEG) is increasingly being used to assist in monitoring the coagulation status of critically ill patients. Its role in heparinised children receiving ECLS is unknown. METHODS: A retrospective review of TEG in 27 children (mean age 2 years and 8 months) receiving ECLS in a tertiary paediatric intensive care unit between December 2006 and April 2008. Paired TEG (kaolin and heparinase) analysis was performed on 171 occasions. On all occasions activated partial thromboplastin time (APTT) and platelet count were performed within 4 hours of the TEG (mean 6.5 minutes after TEG). On 158 occasions, the activated clotting time (ACT) was measured simultaneously with TEG. RESULTS: The TEG (kaolin) sample was not interpretable due to the heparin effect in 89 (52%) samples. There was a weak correlation between TEG (heparinase) variables and APTT, and between TEG and ACT with a stronger correlation between TEG (Maximum amplitude) and platelet count. CONCLUSION: TEG monitoring should always include paired samples in heparinised children on ECLS. In this heterogeneous population, weak, and moderate correlations exist between TEG and standard haematological tests. Prospective studies, with simultaneous sampling for TEG and conventional laboratory tests, must be performed in order to establish its absolute utility as a clinical tool in this population.

Oxygen saturation and heart rate during delivery room resuscitation of infants <30 weeks' gestation with air or 100% oxygen.

BACKGROUND: Because of concerns about harmful effects of 100% oxygen on newborn infants, air has started to be used for resuscitation in the delivery room. OBJECTIVE: To describe changes in preductal oxygen saturation (Spo(2)) and heart rate (HR) in the first 10 min after birth in very preterm infants initially resuscitated with 100% oxygen (OX(100)) or air (OX(21)). PATIENTS AND METHODS: In July 2006, policy changed from using 100% oxygen to air. Observations of Spo(2) and HR before and after the change were recorded whenever a member of the research team was available to attend the birth. RESULTS: There were 20 infants in the OX(100) group and 106 in the OX(21) group. In the OX(100) group, Spo(2) had risen to a median of 84% after 2 min and 94% by 5 min. In the OX(21) group, median Spo(2) was 31% at 2 min and 54% at 5 min. In the OX(21) group, 92% received supplemental oxygen at a median of 5 min; the Spo(2) rose to a median of 81% by 6 min. In the first 10 min after birth, 80% and 55% of infants in the OX(100) and OX(21) groups, respectively, had an Spo(2) > or =95%. Increases in HR over the first 10 min were very similar in the two groups. CONCLUSIONS: Most very preterm infants received supplemental oxygen if air was used for the initial resuscitation. In these infants, the use of backup 100% oxygen and titration against Spo(2) resulted in a similar course to "normal" term and preterm infants. Of the infants resuscitated with 100% oxygen, 80% had Spo(2) > or =95% during the first 10 min. The HR changes in the two groups were very similar.

Effect of gestation on initiation and duration of breastfeeding.

OBJECTIVE: The aim of this study was to investigate the effect of gestation on initiation and duration of breastfeeding in Australian infants. METHODS: The Longitudinal Study of Australian Children recruited a national sample of children born between March 2003 and February 2004 (n = 3600 in this multivariate sample). RESULTS: Breastfeeding initiation was lower for infants of 35-36 weeks' gestation (88.2%) than 37-39 weeks' gestation (92.0%) and > or =40 weeks' gestation (93.9%). At 6 months, 41.2% of infants 35-36 weeks' gestation were breastfeeding compared with 54.5% of 37-39 weeks' gestation infants and 60.5% of infants born > or =40 weeks. Compared with infants born > or =40 weeks, infants born at 35-36 weeks had an adjusted odds ratio (OR) of 0.51 (95% CI 0.34 to 0.76) and infants born at 37-39 weeks had an adjusted OR of 0.80 (95% CI 0.69 to 0.93) of breastfeeding at 6 months. CONCLUSION: Infants born before 40 weeks are at greater risk of being artificially fed than infants born > or =40 weeks.

Twice-daily variable insulin regimens: proportions of insulin types have little impact on glycaemic control in primary school-aged children.

AIM: To ascertain the relationship between glycaemic outcome and proportions and timing of insulin admixture in a cohort of primary school-aged children who were receiving insulin in a twice-daily regimen. METHODS: Children aged 4-10 years with Type 1 diabetes of > 2 years duration and on twice-daily variable insulin regimens were eligible for inclusion in this study, which took place over a 12-month period. Characteristics of insulin regimen [total daily dose (TDD), proportion of total daily dose given in the morning and proportion of the TDD given as intermediate-acting insulin] were compared with parameters of glycaemia including glycated haemoglobin (HbA(1c)) and continuous glucose monitoring measures (mean glucose, per cent time in various glycaemic ranges, and intra- and inter-day glycaemic variation). RESULTS: Forty-nine children completed the study. Participants were all prepubertal at the start of the study and representative of the local diabetes population aged 4-10 years (mean age 8.2 years, mean duration of diabetes 3.5 years, mean HbA(1c) 8.1%). The mean TDD was 0.9 units/kg/day (range 0.6-1.3). The TDD, percentage of TDD given as intermediate-acting insulin and the percentage of TDD given as the morning dose were not associated with HbA(1c), mean continuous glucose monitoring system glucose, per cent time in various glycaemic ranges or intra- and inter-day glycaemic variation. CONCLUSIONS: Insulin proportions in twice-daily, variable insulin regimens are not associated with any short- or medium-term glycaemic outcomes.

Social consumption of alcohol in adolescents with Type 1 diabetes is associated with increased glucose lability, but not hypoglycaemia.

AIM: To determine the effects of social consumption of alcohol by diabetic adolescents on glycaemic control. METHODS: Fourteen (five male) patients aged > 16 years were recruited from the diabetes clinic at the Royal Children's Hospital. The continuous glucose monitoring system (CGMS) was attached at a weekend when alcohol consumption was planned for one night only. For each patient, the 12-h period from 18.00 h to 06.00 h for the night with alcohol consumption (study period) was compared with the same period with non-alcohol consumption (control period) either 24 h before or after the alcohol study night. Thus, each subject was his/her own control. Glycaemic outcomes calculated from continuous glucose monitoring included mean blood glucose (MBG), percentage of time spent at low glucose levels (CGMS < 4.0 mmol/l), normal glucose levels (CGMS 4.0-10.0 mmol/l) and high glucose levels (> 10.0 mmol/l) and continuous overall net glycaemic action (CONGA). RESULTS: The mean number of standard alcohol drinks consumed during the study period was 9.0 for males and 6.3 for females. There was no difference in percentage of time at high and normal glucose levels in the study and control periods. During the control period, there was a higher percentage of time with low glucose levels compared with the study period (P < 0.05). There was an increased level of glycaemic variation during the study time when compared with the control period. CONCLUSIONS: In an uncontrolled, social context, moderately heavy alcohol consumption by adolescents with Type 1 diabetes appears to be associated with increased glycaemic variation, but not with low glucose levels.

A novel approach to continuous glucose analysis utilizing glycemic variation.

BACKGROUND: Various methodologies have been proposed for analysis of continuous glucose measurements. These methods have mainly focused on the proportion of low or high glucose readings and have not attempted to analyze other dimensions of the data obtained. This study proposes an algorithm for analysis of continuous glucose data including a novel method of assessing glycemic variability. METHODS: Mean blood glucose and mean of daily differences (MODD) assessed the degree that the Continuous Glucose Monitoring System (CGMS, Medtronic MiniMed, Northridge, CA) trace was representative of the 3-month glycemic pattern. Percentages of times in low, normal, and high glucose ranges were used to assess marked glycemic excursion. Continuous overall net glycemic action (CONGA), a novel method developed by the authors, assessed intra-day glycemic variability. These methods were applied to 10 CGMS traces chosen randomly from those completed by children with type 1 diabetes from the Royal Children's Hospital, Melbourne, Victoria, Australia and 10 traces recorded by healthy volunteer controls. RESULTS: The healthy controls had lower values for mean blood glucose, MODD, and CONGA. Patients with diabetes had higher percentages of time spent in high and low glucose ranges. There was no overlap between the CONGA values for patients with diabetes and for controls, and the difference between controls and patients with diabetes increased markedly as the CONGA time period increased. CONCLUSIONS: We advocate an approach to the analysis of CGMS data based upon a hierarchy of relevant clinical questions alluding to the representative nature of the data, the amount of time spent in glycemic excursions, and the degree of glycemic variation. Integrated use of these algorithms distinguishes between various patterns of glycemic control in those with and without diabetes.

The relationship between maternal smoking and breastfeeding duration after adjustment for maternal infant feeding intention.

AIM: To investigate whether maternal smoking remains associated with decreased breastfeeding duration after adjustment for the mother's infant feeding intention. METHOD: Pregnant women resident within Avon, UK, expected to give birth between 1 April 1991 and 31 December 1992 were recruited in a longitudinal cohort study. Main outcome measures included maternal infant feeding intention at 32 wk of pregnancy: intention for the first week, intention for the rest of the first month and intention in months 2 to 4. Maternal smoking was defined as any smoking reported at any time during pregnancy. Data on initiation and duration of breastfeeding were based on the questionnaire at 6 mo postpartum, supplemented by data from the 15-mo questionnaire if necessary. RESULTS: Women who smoked during pregnancy had an adjusted odds ratio of 1.5 (95% CI: 1.3-1.7) of not breastfeeding at 6 mo compared to non-smokers (adjusting for maternal age, education and intention). Survival analysis of duration of breastfeeding in the first 6 mo postpartum found that women who intended to breastfeed for less than 1 mo were 78% more likely to stop at any given time than women planning to breastfeed for at least 4 mo, while smokers were 17% more likely to stop breastfeeding than non-smokers. CONCLUSION: Although women who smoke are less likely to breastfeed their infants than are non-smoking women, it appears that this is largely due to lower motivation to breastfeed rather than a physiological effect of smoking on their milk supply.

Relationship between prenatal infant feeding intention and initiation and duration of breastfeeding: a cohort study.

AIM: To report the relationship between maternal prenatal intention to breastfeed and the actual initiation and duration of breastfeeding. METHODS: Pregnant women resident within Avon, UK, expected to give birth between 1 April 1991 and 31 December 1992 were recruited in a longitudinal cohort study. Main outcome measures included maternal infant feeding intention (breastfeed, breast and bottle feed, bottle feed, or uncertain) at 32 wk of pregnancy: intention in the first week, intention for the rest of the first month and intention in months 2 to 4; initiation and duration of breastfeeding up to six months. RESULTS: Data were available on 10,548 women. Prenatal intention to breastfeed had an influence on both initiation and duration of breastfeeding. Of the women intending to bottle feed from birth, only 3.4% initiated breastfeeding compared with 96.6% of women planning to breastfeed for at least four months. At six months postpartum, the mean duration of breastfeeding for women intending to breastfeed for at least five months was 4.4 mo (95% CI 4.3, 4.4), compared with 2.5 mo (95% CI 2.4, 2.6) for women with a prenatal intention to breastfeed for only one month. Logistic regression, using intended duration as the only explanatory variable, correctly predicted 91.4% of breastfeeding initiation and 72.2% of infant feeding at six months. CONCLUSIONS: This large population-based study confirms the strength of the relationship between maternal prenatal intention to breastfeed and both breastfeeding initiation and duration. Maternal intention was a stronger predictor than the standard demographic factors combined. This should be taken into account in future research, and trials should be undertaken to establish whether interventions could alter maternal intention and thereby increase rates of breastfeeding initiation and duration.

Does maternal obesity adversely affect breastfeeding initiation and duration?

OBJECTIVE: To examine the relationship between maternal obesity and the initiation and duration of breastfeeding. METHODS: Analysis was made of the 1995 National Health Survey, in which personal interviews were conducted on a multistage area sample of private dwellings and a list sample of non-private dwellings in all states and territories of Australia. Mothers between the ages of 17 and 50 years (n = 1991) with children under the age of 4 years in 1995 participated in the study. RESULTS: Of the group of mothers with a body mass index (BMI) of 20-25, 89.2% (95% confidence interval (CI) 87.4-91.0) initiated breastfeeding, compared with 82.3% (95% CI 77.6-87.0) of mothers with a BMI of 30 or more. There was also a significant difference between the mean and median duration of breastfeeding of obese and non-obese mothers (BMI 30 and over, < 25, respectively). These differences remained significant when maternal smoking, age and other sociodemographic factors were taken into consideration. CONCLUSIONS: Health professionals should be aware that obese women may be at increased risk of not breastfeeding or stopping breastfeeding prematurely.

Who's overweight? Comparison of the medical definition and community views.

OBJECTIVE: To investigate the extent to which people who are medically defined as overweight perceive themselves to be overweight. DESIGN: Secondary data analysis of the National Health Survey and the National Nutrition Survey conducted by the Australian Bureau of Statistics in 1995. PARTICIPANTS: 10,652 people aged 18 years and over (5076 men, 5576 women) in a multistage cluster sample of households throughout Australia. MAIN OUTCOME MEASURES: Body mass index (BMI) based on measured height and weight; self-reported perception of body weight (underweight, acceptable weight, or overweight). RESULTS: Among people with a measured BMI > or = 25, 49.3% of men (95% CI, 48.1%-50.5%) and 72.0% of women (95% CI, 70.8%-73.1%) considered themselves overweight. Among those with a measured BMI < 25, 3.4% of men (95% CI, 2.8%-4.1%) and 12.4% of women (95% CI, 11.4%-13.3%) considered themselves overweight. Older women were less likely to perceive themselves as overweight than younger women. The lowest BMI at which at least half the respondents considered themselves overweight was 26 to < 27 for women aged 18-59 years, and 28 to < 29 for older women and men. CONCLUSION: For many people, particularly men and older women, the meaning of "overweight" differs from the medical definition. Clinical and public health weight reduction programs which do not take this into account are unlikely to be successful.

Does maternal obesity adversely affect breastfeeding initiation and duration?

OBJECTIVE: To examine the relationship between maternal obesity and the initiation and duration of breastfeeding. METHODS: Analysis was made of the 1995 National Health Survey, in which personal interviews were conducted on a multistage area sample of private dwellings and a list sample of non-private dwellings in all States and Territories of Australia. Mothers between the ages of 17 and 50 years (n = 1991) with children under the age of four years in 1995 participated in the study. RESULTS: Of the group of mothers with a body mass index (BMI) of 20-25, 89.2% (95% confidence interval (CI) 87.4-91.0) initiated breastfeeding, compared with 82.3% (95% CI 77.6-87.0) of mothers with a BMI of 30 or more. There was also a significant difference between the mean and median duration of breastfeeding of obese and non-obese mothers (BMI 30 and over, < 25, respectively). These differences remained significant when maternal smoking, age and other sociodemographic factors were taken into consideration. CONCLUSIONS: Health professionals should be aware that obese women may be at increased risk of not breastfeeding or stopping breastfeeding prematurely.