Use of the Geriatric Depression Scale in dementia of the Alzheimer type.

The Geriatric Depression Scale (GDS) has been shown to be an effective screening test for depression in selected geriatric populations. However, it has not been evaluated as a screening test for depression among elderly adults with dementia of the Alzheimer type. Over a two-year period 283 patients were seen in a geriatric assessment center and were screened for depression using the Geriatric Depression Scale. They also received a clinical psychiatric diagnosis by one of two geropsychiatrists. Patients with a Clinical Dementia Rating (CDR) of 0 (cognitively intact) (n = 70) and those with mild Alzheimer's disease (CDR of 1) (n = 72) were selected for comparison. The data were analyzed using Receiver Operating Characteristic Curves (ROCs) in order to compare the utility of the Geriatric Depression Scale in these two groups. ROC curves, which plot sensitivity against false positives, have come into increasing use as a method of examining the clinical performance of tests. The area lying beneath the curve (AUC) can be estimated and used as a quantitative measure of test performance (equivalent to the Wilcoxon rank sum). In the intact group, the Geriatric Depression Scale produced a ROC curve with an AUC of 0.85 (percent score = 1), which is significant (z = 7.28, P less than .0001). In the group composed of those with Alzheimer's disease, the Geriatric Depression Scale yielded a ROC curve with an AUC of 0.66, which was not significantly different from chance (z = 1.92, P = NS). This study provides empirical evidence that while the Geriatric Depression Scale is an accurate screening test for depression in cognitively intact geriatric populations, it does not maintain its validity in populations that contain large numbers of patients with dementia of the Alzheimer type.

Practices and policies in the initiation of breastfeeding.

Despite increasing knowledge about factors affecting the initiation of breastfeeding, many mothers still encounter problems and discontinue breastfeeding earlier than desired. Many hospitals still have not implemented the practices that are known to be helpful in the establishment of breastfeeding. As a result, a study was conducted to examine the policies and practices affecting breastfeeding in hospitals in Alberta, Canada. A questionnaire-based survey of all Alberta hospitals (including directors of nursing and staff nurses) found that many practices were still relatively inflexible; did not always reflect accurate, research-based information; and were not geared to the needs of mothers and infants. The implications of these findings are discussed.

Breast feeding, fertility and child health: a review of international issues.

Breast feeding is of central importance to child survival, growth and development, especially in non-industrialized countries. It also protects the mother against further pregnancy. In the light of the increase in the world's population, the implications of the decrease in breast feeding worldwide are serious. There is a direct association between child health and survival and breast feeding. In this paper, the contraceptive effect of breast feeding is reviewed. The emphasis is on families in non-industrialized societies. The importance of suckling frequency and duration, and the timing of introduction of supplementary foods to the baby, are discussed. Limitations of the method, and recommendations to maximize its effectiveness, are given. It is noted that protection of breast feeding both as a means of improving child health and of spacing births will require positive action at local and at governmental levels.

Fertility after childbirth: pregnancy associated with breast feeding.

During studies on the resumption of fertility postpartum in 12 breast feeding mothers who were using no contraception, eight pregnancies occurred. In seven cases these pregnancies occurred while the mothers continued to breast feed while in one it occurred within 2 weeks of weaning. In two cases pregnancy occurred prior to first postpartum menstruation but followed an abrupt decline in suckling frequency and duration resulting in resumption of follicular development and ovulation. In the remaining six cases, pregnancy was preceded by between 1 and 7 menstrual cycles, the majority of which (13/19) had deficient luteal phases or were anovular (4/19). In all mothers a significant decrease in the suckling frequency and duration observed during lactational amenorrhoea had occurred prior to the resumption of ovulation and conception. No mother conceived with a suckling frequency of greater than three times per day although some mothers ovulated without conceiving when suckling four times per day. The results suggests that if a breast feeding mother wishes to rely upon the infertility associated with lactational amenorrhoea, she must suckle at least five times per day with a total suckling duration of more than 65 min per day (more than 10 min per feed). Any reduction below either of these limits may result in a return of fertility.

PIP: During studies on the resumption of fertility postpartum in 12 breastfeeding mothers who were using no contraception, 8 pregnancies occurred. In 7 cases, these pregnancies occurred while the mothers continued to breastfeed, while in 1 it occurred within 2 weeks of weaning. In 2 cases, pregnancy occurred prior to 1st postpartum menstruation but followed an abrupt decline in suckling frequency and duration resulting in resumption of follicular development and ovulation. In the remaining 6 cases, pregnancy was preceded by between 1 and 7 menstrual cycles, the majority of which (13/19) had deficient luteal phases or were anovular (4/19). In all mothers, a significant decrease in suckling frequency and duration observed during lactational amenorrhea had occurred prior to the resumption of ovulation and conception. No mother conceived with a suckling frequency of greater than 3 times/day although some mothers ovulated without conceiving when suckling 4 times/day. The results suggest that if a breastfeeding mother wishes to rely on the infertility associated with lactational amenorrhea, she must suckle at least 5 times/day with a total suckling duration of more than 65 minutes/day (more than 10 minutes/feed). Any reduction below either of these limits may result in a return of fertility.

Factors affecting the duration of breast feeding: 1. Measurement of breast milk intake in the first week of life.

Test-weigh measurements of 24 h milk intake by babies in the immediate puerperium (days 1-9) were carried out in a group of 18 mothers and babies using an accurate electronic balance. Estimated milk intakes were then calculated on the basis of one, and of two consecutive, breast feeds. These estimates were then compared with the actual total intake to give a measurement of reliability. Significant positive correlations were found between both the one-feed and the two-feed estimated intake, and the measured 24 h intake. Accuracy increased from day 3 onwards. These results show that using an electronic balance an accurate estimate of 24 h milk intake during the first week of life can be obtained by using one or two test-weigh measurements. While this gives a minimally invasive and reliable method for estimating daily milk intake, it is not advocated as a routine procedure in postnatal wards.

Factors affecting the duration of breast feeding: 2. Early feeding practices and social class.

Breast milk intake by babies on the third and the sixth postpartum day was measured by a test-weigh procedure in a group of 47 mothers and babies. Women who gave the largest amount of breast milk to their babies on the third postpartum day continued to breast feed for longer than women who gave smaller amounts. These mothers also suckled most frequently, gave least additional fluid to their babies, and their infants regained their birth weight most rapidly. However, an increased early milk intake and duration of breast feeding were both associated with higher social class. These results suggest that, although practices in the initiation of breast feeding are relevant, factors in the background and environment of the mother are also of fundamental importance. Thus recent emphasis on the importance of breast-feeding practices in the immediate puerperium should not divert attention from the equally important task of establishing the optimum conditions for breast feeding in the home environment of mothers.

Release of oxytocin and prolactin in response to suckling.

The oxytocin and prolactin responses to suckling were measured in 10 women in early (n = 5) and established lactation (n = 5). Oxytocin was released in a pulsatile manner during suckling in all women, but the response was not related to milk volume, prolactin response, or parity of the mother. In all 10 women plasma oxytocin concentrations increased three to 10 minutes before suckling began. In five women this occurred in response to the baby crying, in three it coincided with the baby becoming restless in expectation of the feed, while in two it corresponded with the mother preparing for the feed. There was no prolactin response to stimuli other than stimulation of the nipple associated with suckling. These results clearly indicate that the milk ejection reflex, with release of oxytocin, occurs in most women before the tactile stimulus of suckling. A second release of oxytocin follows in response to the suckling stimulus itself. Thus it is important that care is taken to protect breast feeding mothers from stress not only during suckling but also immediately before nursing, when conditioned releases of oxytocin will occur.

Fertility after childbirth: adequacy of post-partum luteal phases.

Normal ranges of urinary pregnanediol and total urinary oestrogen were determined from weekly estimations in twenty-seven cycles from seven normally menstruating control women and compared with the levels in the cycles of twenty-seven breast feeding and ten bottle feeding mothers. During lactation, the luteal phase pregnanediol levels were within normal limits in thirteen of forty-nine (27%) cycles, the remainder of the luteal phases being deficient (31%) or absent (42%). The proportion of normal luteal phases remained low during first cycles after lactation in six of twenty-three (26%) but rose to twenty-four of thirty-one (77%) in subsequent cycles. In bottle feeding mothers, the luteal phases of first post-partum cycles were deficient in two of ten (20%) and absent in eight of ten (80%). In second post-partum cycles, the majority of luteal phases were deficient (eight of ten, 80%) and it was not until third post-partum cycles that seven of eight (88%) had luteal phase pregnanediol levels in the normal range. Cycles during lactation and first cycles after lactation had significantly lower mean urinary pregnanediol and total urinary oestrogen levels than both the control cycles and the later cycles after lactation. Similarly, first post-partum cycles in bottle feeders had lower urinary pregnanediol and total urinary oestrogen levels than controls. This study shows an increased frequency of abnormal luteal phases during the early post-partum menstrual cycles of both breast and bottle feeding mothers which may be associated with defective development of the follicle.

Fertility after childbirth: infant feeding patterns, basal PRL levels and post-partum ovulation.

The infant feeding patterns at the time of first ovulation after childbirth were determined in a longitudinal study of twenty-seven mothers who chose to breast feed their babies. Fourteen mothers suppressed ovulation throughout lactation and thirteen ovulated while still breast feeding. Those who ovulated while breast feeding had all introduced two or more supplementary feeds/day, reduced suckling frequency to less than six times/day and reduced suckling duration to less than 60 min/day at the time of first ovulation. Basal PRL levels had fallen to below 600 microunits/l in all but one of the mothers at first ovulation. Those mothers who suppressed ovulation for more than 40 weeks post-partum (late ovulation group) were compared with those who ovulated between 30 and 40 weeks post-partum (middle group) and with those who ovulated before 30 weeks post-partum (early group). The late ovulation group breast-fed for longest, suckled most intensively, maintained night feeds for longest and introduced supplementary feeds most gradually. This study suggests suckling may be the most important factor inhibiting the return of ovulation during lactation and that policies which encourage increased suckling frequency and duration will maximize the contraceptive effects of breast feeding.

Breast feeding: success or failure.

Awareness of the important role of breast feeding in child health and the reproductive cycle, which is well documented elsewhere, necessitates an examination of the changing practice of breast feeding. This paper reviews these changing practices both in Western and developing societies, examines the problems which lead to lactation failure, and looks at factors related to success in breast feeding. In the light of the need for practical help for successful breast feeding. the present system of support both in hospital and at home is then discussed. An alternative system of structured home support for post-natal women, which has been shown to increase the success rate of breast feeding, is outlined. The way in which this system acts is discussed and the implications for both mothers and health staff are considered.

Effect of supplementary food on suckling patterns and ovarian activity during lactation.

Patterns of infant feeding, basal prolactin concentrations, and ovarian activity were studied longitudinally in 27 breast-feeding mothers from delivery until first ovulation. Suckling frequency (6.1 feeds/day) and suckling duration (122 mins/day) reached peak values four weeks post partum and remained relatively constant until the introduction of supplementary food at a mean of 16 weeks post partum. There were subsequently sharp declines in both the frequency and duration of suckling, both of which correlated closely with basal prolactin concentrations. None of the 27 mothers ovulated during unsupplemented breast-feeding, but within 16 weeks of introducing supplements ovarian follicular development had returned in 20 and ovulation in 14 mothers. The mothers who ovulated within 16 weeks of giving supplements had reduced frequency and duration of suckling more quickly and weaned more abruptly than those who continued to suppress ovulation. These data suggest that the introduction of supplementary food may exert an important and hitherto unrecognised effect on the timing of first ovulation by reducing the frequency and duration of suckling episodes.

Do breast feeding mothers get the home support they need?

PIP: The effect of 1 pattern of additional home support for breast feeding mothers was compared with the routine care currently offered by health visitors. All patients were mothers who were breast feeding when they were discharged from the Simpson Memorial Maternity Pavilion in Edinburgh, Scotland after delivering mature and normal birth weight infants. None of the mothers were intending to use hormonal contraception. 28 mothers were recruited to the study group and 52 to the control group. Patients in the study group were visited in the postnatal ward by 1 of the 2 midwifery sisters involved in the study. All home visits were then carried out by the same sister and were additional to the routine visits by the health visitors. All mothers were visited once by the sister in the 1st week after discharge and thereafter visits were arranged fortnightly at times which were convenient to the mother. The visits were conducted on a non-directive basis, simply giving the mothers the opportunity to raise problems. Visits were made fortnightly until the cessation of breast feeding. The mothers in the control group received the normal care from the community services, but they did not have the extra visits from the midwifery sisters. 24 weeks after delivery, control mothers were interviewed at home about the progress of breast feeding. All but 2 babies were thriving. No significant differences were found between the 2 groups in regard to age, parity, or social class distribution. The number of routine home visits by health visitors as recalled by the mothers showed a wide range from 1-10 visits per patient, but the average number of 2.7 visits per patient was the same in the 2 groups. The study group received an additional 11.5 plus-minus 0.5 visits per patient during the first 24 weeks from the sisters involved in the study. In the study group, all mothers continued breast feeding until 12 weeks and 24 of 28 (86%) were still feeding at 24 weeks. Compared with the controls, the proportion of mothers breast feeding in the study group was higher throughout the 24 weeks of observation, the differences being significant at 12 weeks and 20 weeks. The effect of social class was shown by a progressive decline in continuation rates down the gradient of social class. Additional food in the form of formula milk or solids was introduced at an earlier stage in the control group. 19% of the mothers in the control gave insufficient milk or an unsettled baby as the major factors in stopping breast feeding. The remaining reasons, not related to the adequacy of the milk supply, were given by 16% of the control and 14% of the study group. It was possible to achieve a very high degree of successful breast feeding with the provision of consistent home support.^ieng

How long should a breast feed last?

Patterns of milk flow were studied in 50 mothers who were breast-feeding normal birth-weight babies on days 5-7 of the puerperium by progressive test weighing at 5-min intervals during two consecutive feeds. Compared with a regime in which mothers attempted to feed for 10 X 10 min on alternate breasts, a regime of 5 X 5 X 5 X 5 min increased the amount of milk taken in the first 10 min did not influence the final milk intake of the suckling-induced prolactin release. The wide variation of breast-feeding patterns between mothers was demonstrated in respect of the duration of the feed (mean 17.3 min; S.D. +/- 3.1; range 7-30 min), the initial rate of milk flow (mean 6 g/min; S.D. +/- 4.2, range 1-14 g/min) and the final milk intake (mean 70.9 g; S.D. +/- 20.5, range 42-125 g). The advice to breast-feed for 20 min was in appropriate for the majority of mothers because the nutritive feeding time was 15 min or less in 75% of the feeding episodes. The milk intake correlated with the initial rate of milk flow but not with the duration of the feed, the infant's birth weight, or the time since the last feed. It is suggested that the duration of a breast feed should be determined by the infant's response and not by an arbitrary time schedule.

The contraceptive effects of lactation. Failure to appreciate these effects resulted in unnecessary stress for a couple.

PIP: Lactational infertility is being investigated in mothers who delivered in the Simpson Memorial Maternity Pavilion in Edinburgh, Scotland. A group of breast feeding and a group of bottle feeding mothers were monitored. Weekly urinary total estrogen, pregnanediol excretion, and fortnightly plasma gonadotropins and prolactin concentrations were measured to determine the relationship between the resumption of menstruation and 1st postpartum ovulation. A research sister visited each mother at home every 2 weeks to collect a 10 ml sample of venous blood and to check on the progress of breast feeding. Although lactation is not a totally reliable contraceptive method, a mother is very unlikely to ovulate when she is fully breast feeding in the early weeks after delivery and particularly if she is giving night-time feeds. When the timing of 1st ovulation was compared in 7 bottle feeding mothers and 10 breast feeding mothers, ovulation was delayed in all lacting women and returned only when the mother started to wean her baby. A case history is reported of 1 patient who highlights the need for a deeper understanding of this natural contraceptive mechanism. The patient was Roman Catholic, mother of 4 children, and she and her husband wanted to practice only natural methods of contraception. She was informed that her weekly urinary steroid levels showed no evidence of ovulation, but she remained unconvinced and requested information and guidance on cervical mucus assessment. By choosing to stop breast feeding to return to a familiar contraceptive method, the patient increased the risk of unwanted conception. A prolonged period of lactation may be an effective method for couples who want to space their children, and this option should be explained to couples.^ieng