Breastfeeding Mothers Of Infants Research Articles

Adherence to and early adverse events of COVID-19 vaccine in a cohort of 600 Italian breastfeeding and pregnant physicians

ABSTRACT Pregnant and breastfeeding women (PBW) have been excluded from COVID-19 vaccine registry and the majority of post-marketing trials, despite the recognized increased risk of severe infections and complications. The lack of efficacy and safety data prevented the formulation of specific indications/guidelines for vaccination and could have also contributed to increased vaccine hesitancy (VH) in PBW. The aim of this cross-sectional study is to assess the rate and predictors of VH, and early adverse events (AEFI) following COVID-19 vaccine in PBW with a cross-sectional study. In January 2021, a purposely designed questionnaire was administered to 600 PBW part of a Facebook group of physicians, immunized with two doses of Comirnaty®. Thirty-eight (29%) pregnant women and 13 (2.8%) breastfeeders were hesitant. The only statistically significant negative predictor of COVID-19 VH appeared to be having had the flu shot in 2020/2021 (OR: 0.35; 95% CI: 0.13–0.97; p = .044). Approximately 27% of PBW reported hesitancy toward the 2020/2021 season influenza vaccine. Among the vaccinated subjects, 51.6% of pregnant and 75.2% of breastfeeding women reported at least one symptom after the first, and 82.4% and 81.6%, respectively, after the second dose. Nausea/vomiting, fatigue, headache and arthralgia/myalgia were the most common symptoms; dizziness, shivering, syncope and limb paresthesia were rarely reported. Among infants of breastfeeding mothers, six experienced fever, five rash and four moderate and self-limiting diarrhea. Preliminary data on mRNA COVID-19 vaccine in PBW and in their infants are reassuring since AEFI, although frequent, are typically mild and similar to those occurring in the general population, and in PBW after other vaccines. Larger studies with longer follow-up after vaccination are strongly recommended to develop recommendations in these patients.

Feasibility of the automatic ingestion monitor (AIM-2) for infant feeding assessment: a pilot study among breast-feeding mothers from Ghana.

Passive, wearable sensors can be used to obtain objective information in infant feeding, but their use has not been tested. Our objective was to compare assessment of infant feeding (frequency, duration and cues) by self-report and that of the Automatic Ingestion Monitor-2 (AIM-2). A cross-sectional pilot study was conducted in Ghana. Mothers wore the AIM-2 on eyeglasses for 1 d during waking hours to assess infant feeding using images automatically captured by the device every 15 s. Feasibility was assessed using compliance with wearing the device. Infant feeding practices collected by the AIM-2 images were annotated by a trained evaluator and compared with maternal self-report via interviewer-administered questionnaire. Rural and urban communities in Ghana. Participants were thirty eight (eighteen rural and twenty urban) breast-feeding mothers of infants (child age ≤7 months). Twenty-five mothers reported exclusive breast-feeding, which was common among those < 30 years of age (n 15, 60 %) and those residing in urban communities (n 14, 70 %). Compliance with wearing the AIM-2 was high (83 % of wake-time), suggesting low user burden. Maternal report differed from the AIM-2 data, such that mothers reported higher mean breast-feeding frequency (eleven v. eight times, P = 0·041) and duration (18·5 v. 10 min, P = 0·007) during waking hours. The AIM-2 was a feasible tool for the assessment of infant feeding among mothers in Ghana as a passive, objective method and identified overestimation of self-reported breast-feeding frequency and duration. Future studies using the AIM-2 are warranted to determine validity on a larger scale.

Maternal Medication Transmission through Human Milk

Maternal Medication Transmission through Human Milk

The relationship between dietary elimination and maternal psychopathology in breastfeeding mothers of infants with food allergy.

There has been no study evaluating the psychopathology in breastfeeding mothers of infants with food allergy (FA). The aim of the study was to investigate the relationship between dietary elimination and maternal psychopathology, specifically anxiety, depression, and mother-to-infant bonding, in breastfeeding mothers of infants with food allergy. Breastfeeding mothers following an elimination diet due to FA in their children aged 1-to-12months were compared with the healthy controls. The physician-diagnosed FA group was divided into IgE-, non-IgE-mediated, and infants with some minor symptoms which were not enough to make the diagnosis of FA were classified as Indecisive symptoms for FA group. Mothers completed standardized questionnaires including Symptom Checklist 90R, Beck Depression/Anxiety Inventories (BDI/BAI), Postpartum Bonding Questionnaire (Bonding). Of 179mother and infants, 64 were healthy, 89 were FA, 16 were indecisive symptoms for FA. The mean age of the mothers and infants were 31.1±4.7years and 6.3±3.6months, respectively. The physician-diagnosed FA groups had higher scores for anxiety (p=.008), anger (p=.042), depression (p<.001), obsession (p=.002), phobia (p=.008), somatization (p=.002), general symptom index (GSI) (p=.001), BDI (p<.001), BAI (p=.008), and Bonding (attachment [p=.001], anger [p=.019], and total [p=.036]) than the healthy ones. The indecisive symptoms for FA group had a similar score pattern to physician-diagnosed FA, except interpersonal sensitivity, BDI, and attachment. Breastfeeding mothers of infants with FA were more anxious, with higher depression scores than controls, and had many psychopathologies which affected bonding. Interventions targeting negativity in caregivers' social relationships are urgently needed.

Nipple shield use does not impact sucking dynamics in breastfeeding infants of mothers with nipple pain.

Nipple shields (shield) may reduce pain during breastfeeding, but the impact on infant sucking dynamics is not known. We examined the effects of shield use on sucking dynamics, milk removal and nipple pain in two groups of breastfeeding dyads: pain group (PG): shield used for nipple pain; comparison group (CG): no breastfeeding difficulties. Twenty PG (6 ± 4 weeks postnatal) and 28 CG dyads (8 ± 6 weeks postnatal) attended 2 monitored breastfeeding sessions with shield use randomised. Within-subject outcomes were compared. PG: shield use did not affect intra-oral vacuum (peak p = 0.17, baseline p = 0.59), sucking frequency (p = 0.20) or milk transfer (40 mL vs 48 mL, p = 0.80; percentage of available milk removed (PAMR) 55% vs 57%, p = 0.88), and reduced McGill pain scores (p = 0.012). CG: shield use increased non-nutritive sucking (10% more, p = 0.049), and reduced nutritive sucking (18% less, p = 0.017) and milk transfer (63 mL vs 31 mL p < 0.001, PAMR 65% vs 36% p < 0.001). For both groups, feeding duration increased by 2 min (p < 0.0001) and non-nutritive portions of the feed increased with shield use.Conclusion: Nipple shield use improved maternal comfort and did not impact milk removal or sucking strength in PG, but significantly reduced milk transfer and nutritive sucking in CG. What is Known: • Mothers report that nipple shields reduce nipple pain and enable continued breastfeeding. • Concerns that nipple shield use may reduce milk transfer and alter infant sucking patterns are based on limited published evidence. What is New: • Nipple shield use is associated with a 25% reduction in pain scores in breastfeeding mothers with chronic nipple pain. • Milk transfer is not reduced in dyads that regularly use a shield for chronic nipple pain. • Intra-oral vacuums are not impacted by nipple shield use in mothers experiencing pain.

PENGARUH PEMBERIAN BOLU KUKUS DAUN KATUK TERHADAP PRODUKSI ASI DI WILAYAH KERJA RUMAH SAKIT GRANDMED LUBUK PAKAM

Katuk leaves can increase breast milk production because it’s have polyhenols and steroids were instrumental in prolactin reflex to produce breast milk, and can stimulate the hormone oxytocin to stimulate spending and flow of breast milk. Breast milk production and expenditure is influenced by two hormones, prolactin and oxytocin.This studi aims to determine the effect of giving katuk leaves steamed sponge cake for breast milk production in Grandmed Hospital Lubuk Pakam. This research method is quasi experiment with pre and posttest design. The population in this study is breastfeeding mothers of infants 0-6 months in Grandmed Hospital Lubuk Pakam. The sample is 30 people consisting of 15 control and 15 treatment group. In the treatment group was given intervention katuk leaves steamed sponge cake as much as 100 grams (2pieces) every day for 30 days. From the result of this research average frequency of breastfeeding in the control group as 8.07 time and the treatment group times as much as 10.40. While the average duration of breastfeeding in the control group as much as 6.80 minutes and 9.74 minutes in the treatment group. The result of the analysis with T-test was obtained p Value 0,000, it can concluded that there is the effect of giving katuk leaves steamed sponge cake katuk for breast milk production.

Response to Zhao and Zhou: Diagnosis of HIV infection in breastfed infants of mothers on antiretroviral therapy.

We thank Zhao and Zhou [1] for their thoughtful comments on our report of two infants born to women with HIV who had unusual trajectories of diagnostic tests. The two HIV-exposed infants were initially positive on nucleic acid amplification tests in the first month of life but had multiple negative tests during breastfeeding and presented with definitive evidence of HIV infection around the time of breastfeeding cessation. We hypothesize that constituents of breast milk, or processes induced by breastfeeding, most likely in combination with antiviral effects of maternal antiretroviral therapy, led to the undetectable test results that we observed in already infected infants until breastfeeding ended. We considered the alternative explanation of postnatal transmission proposed by Zhao and Zhou [1], but this explanation requires dismissing the initial positive test results on the early samples as transient infections or false-positive results. A rigorous investigation of 42 cases of suspected transient infection, failed to confirm a single one, despite the plausibility of this concept [2]. In one of the infants in our report, virus was detected in peripheral blood mononuclear cells (PBMCs) from three separate blood samples collected over the first month of life making laboratory errors an unlikely explanation. In this same case, CD4+ T cells from one of these early age time points were found to be positive for 2-LTR episomal HIV-1 DNA. Detection of 2-LTR episomal DNA in CD4+ T cells, although at low levels, provides evidence of viral replication as these episomal circles are a by-product thereof [3]. We acknowledge that early samples were not available for the second case making the alternative explanation of an initial false-positive result followed by postnatal infection a possible explanation of this second case. It should be noted that current birth testing and early treatment guidelines in South Africa would provide indefinite treatment to transient infections should they occur [4]. We would like to clarify the implications of our observations in the context of current guidance around antiretroviral use for women and their children to prevent vertical transmission of HIV. Maintenance of maternal therapeutic antiretroviral drug regimens over the full duration of breastfeeding and beyond is now considered standard of care for prevention of HIV transmission to children. This recommendation is consistent with clinical trials demonstrating exceptionally low rates of postnatal transmission if effective maternal antiretroviral drug treatment is in place [5]. Longer term infant prophylaxis is recommended only for infants whose mothers initiated treatment late and/or who are nonadherent with treatment. In both cases, maternal viral loads through the breastfeeding period were less than 1000 RNA copies/ml and in-country treatment guidelines were followed in terms of prophylactic regimens [6]. Because of concerns that infant prophylaxis may mask underlying HIV infections, some have encouraged repeat testing after prophylaxis has ended [7]. What distinguishes our cases is that the pattern of negative results was observed after discontinuation of antiretrovirals given to the infants but during continuation of maternal antiretroviral treatment and breastfeeding. Although the profile of the results that we observed is rare, we support repeat testing of HIV-exposed breastfed infants after complete cessation of all breastfeeding. The profile of HIV antibodies is of great interest, but it is unlikely that changes in standard anti-HIV IgG antibody titres over time in these infants will be helpful to resolve the timing of transmission. Infant antiretroviral prophylaxis. and on-going antiretroviral exposure via breast milk, like early treatment, may lead to undetectable antibodies [8]. The ability to detect HIV antibody would probably be at the time when these factors are no longer in place and viral levels rise and drive antibody production. Thus, a rise in antibodies, only once breastfeeding has stopped, might not necessarily mean the children were infected later. More sensitive assays differentiating antibody isotypes and antigen specificity may be more informative but will need comparison with the usual profile of antibodies in HIV-exposed uninfected children. The utility of HIV antibodies as markers of viral processes is well appreciated and this is likely to be a productive, albeit complex, line of research. Acknowledgements Conflicts of interest There are no conflicts of interest.

Diagnosis of HIV infection in breastfed infants of mothers on antiretroviral therapy.

We read with interest the article by Strehlau et al. [1] on the diagnosis of two children infected with HIV in a recent issue of AIDS. On the basis of the findings that two breastfed children who showed positive results of nucleic acid amplification tests (NAAT) of HIV within 1 month after birth, became negative NAAT and had no detectable viral load for several months, and finally turned out to be infected with HIV with definite evidence after weaning around 1 year of age, the authors hypothesized that breast milk from the mothers of these two children had HIV-specific or HIV-nonspecific factors that caused the undetectability of HIV in these two children until cessation of breastfeeding. However, we consider that the results should be cautiously interpreted, and that the persistent negativity of repeated HIV tests was possibly true and these two children were likely infected postnatally, because of the two following reasons. First, it has been demonstrated that strong uterine contractions during delivery can cause mother-to-fetus transfusion, leading to transfer of maternal circulation cells and other constituents into fetus [2]. The initial positive results of HIV in the first month of life in these two children [1] were probably caused by the exposure to maternal HIV. In other words, the virus detected in the first month of life was derived from their mothers, but not produced by the babies themselves. The fact that neonatal use of antiretroviral agents, such as zidovudine or nevirapine can prevent mother-to-child transmission indicate that infants have been exposed to, but not yet infected with HIV. Virtually all infants born to HIV-infected mothers are exposed to the maternal virus during birth process, regardless of detectable HIV in newborns; detectability means exposure to a relatively large amount of virions, and undetectability means, a relatively small amount of virions below the detection limits. Second, these two children received breastfeeding, which can increase mother-to-child transmission of HIV [3]. Although HIV was not detectable in the breast milk supernatant of one child's mother, HIV exposure by breastfeeding was highly possible. Breastfeeding requires at least several times per day for a period of several months, during which bloody milk and nipple bleeding are not uncommon. Undetectability of HIV in one milk sample cannot reflect the actual scenarios. Additionally, as the authors mentioned, cell-associated HIV in breast milk is known to be strongly correlated with postnatal transmission [1]. Thus, although the maternal postpartum antiretroviral therapy probably delayed the transmission, the HIV infection in these two children was highly associated with breastfeeding. WHO recommends that breastfed infants should continue antiretroviral prophylaxis for 1 week after complete cessation of breastfeeding [4]. However, these two children did not continue to receive antiretroviral agent while they were breastfed. To differentiate whether these two children had been infected with HIV from early life or around 1 year of age, we consider that determination of anti-HIV titers in the longitudinal serum or plasma samples from the children can provide valuable information. As maternal IgG antibodies can transplacentally transfer to fetus and the maternal antibodies in infants can persist for as long as 18 months, anti-HIV is not tested in children less than 18 months age to define HIV infection. However, based on the half-life of maternal IgG antibodies being 21–24 days, anti-HIV titers in an infant who has not been infected with HIV will progressively decline to an expected level after a known period of time, whereas anti-HIV titers in an infant who has been infected will be relatively constant, or will initially decrease and then increase, or will present an increasing trend, depending upon the time of HIV infection. Thus, observation of dynamic changes of anti-HIV levels in these two children can differentiate the time of HIV infection, if serial serum samples collected at different times are available. Acknowledgements Conflicts of interest There are no conflicts of interest.

Breastfeeding practices among mothers of infants in Peringara Panchayat in Pathanamthitta District

The study was aimed to assess the breastfeeding practices among mothers of infants in Peringara Gramapanchayat in Kerala. Study was a community based cross-sectional study among mothers of infants in Peringara gramapanchayat using a pretested questionnaire. 142 breastfeeding mothers of infants in Peringara gramapanchayat were studied and mothers who were not present at home during the study were excluded from the study. Study period consisted of 18 days between December 2015 and January 2016. Study variables includes type of delivery, initiation of breastfeeding, breastfeeding practices and role of ASHAs in promoting good breastfeeding practices. Statistical analysis was done using Pearson’s Chi-square test and T test. The study found that exclusive breastfeeding has been done by 68.3% of mothers. There is no practice of giving pre-lacteal feed, 95.8% of mothers have given colostrum to the new born. Statistically significant association was found between the type of delivery and time of initiation of breastfeeding (p less than 0.05). Time of initiation of breastfeeding was prolonged in case of Caesarean section. 49.3% of mothers have breastfed the baby within one hour. 55.6% of mothers were informed about importance of breastfeeding by ASHAs and only 20.4% of mothers were informed about period of exclusive breastfeeding and period of complimentary feeding by ASHAs.

Plasma and breast milk pharmacokinetics of emtricitabine, tenofovir and lamivudine using dried blood and breast milk spots in nursing African mother-infant pairs.

BackgroundBreast milk transfer of first-line ART from mother to infant is not fully understood.ObjectivesTo determine the concentrations of lamivudine, emtricitabine and tenofovir in maternal blood, breast milk and infant blood from breastfeeding mother–infant pairs.MethodsIntensive pharmacokinetic sampling of maternal dried blood spots (DBS), dried breast milk spots (DBMS) and infant DBS from 30 Ugandan and 29 Nigerian mothers receiving first-line ART and their infants was conducted. DBS and DBMS were collected pre-dose and at 5–6 timepoints up to 12 h following observed dosing. Infant DBS were sampled twice during this period. Lamivudine, emtricitabine and tenofovir were quantified using LC-MS/MS, with non-compartmental analysis to calculate key pharmacokinetic parameters.ResultsPeak concentrations in breast milk from women taking lamivudine and emtricitabine occurred later than in plasma (4–8 h compared with 2 h for lamivudine and 2–4 h for emtricitabine). Consequently, the milk-to-plasma (M:P) ratio of lamivudine taken once daily was 0.95 (0.82–1.15) for AUC0–12, whereas for AUC12–20 this was 3.04 (2.87–4.16). Lamivudine was detectable in 36% (14/39) of infants [median 17.7 (16.3–22.7) ng/mL]. For 200 mg of emtricitabine once daily, the median M:P ratio was 3.01 (2.06–3.38). Three infants (19%) had measurable emtricitabine [median 18.5 (17.6–20.8) ng/mL]. For 300 mg of tenofovir once daily, the median M:P ratio was 0.015 (0–0.03) and no infant had measurable tenofovir concentrations.ConclusionsEmtricitabine and lamivudine accumulate in breast milk and were detected in breastfeeding infants. In contrast, tenofovir penetrates the breast milk to a small degree, but is undetectable in breastfeeding infants.

Pre‐ and probiotics for allergy prevention: time to revisit recommendations?

Reduced intensity and diversity of microbial exposure is considered a major factor driving abnormal postnatal immune maturation and increasing allergy prevalence, particularly in more affluent regions. Quantitatively, the largest important source of early immune-microbial interaction, the gut microbiota, is of particular interest in this context, with variations in composition and diversity in the first months of life associated with subsequent allergy development. Attempting to restore the health consequences of the 'dysbiotic drift' in modern society, interventions modulating gut microbiota for allergy prevention have been evaluated in several randomized placebo-controlled trials. In this review, we provide an overview of these trials and discuss recommendations from international expert bodies regarding prebiotic, probiotic and synbiotic interventions. Recent guidelines from the World Allergy Organization recommend the use of probiotics for the primary prevention of eczema in pregnant and breastfeeding mothers of infants at high risk for developing allergy and in high-risk infants. It is however stressed that these recommendations are conditional, based on very low-quality evidence and great heterogeneity between studies, which also impedes specific and practical advice to consumers on the most effective regimens. We discuss how the choice of probiotic strains, timing and duration of administration can critically influence the outcome due to different effects on immune modulation and gut microbiota composition. Furthermore, we propose strategies to potentially improve allergy-preventive effects and enable future evidence-based implementation.

Persistent Nipple Pain in Breastfeeding Mothers Associated with Abnormal Infant Tongue Movement.

Background: Infants of breastfeeding mothers with persistent nipple pain have been shown to apply stronger vacuums to the breast and transfer less milk during one monitored feed. This may be associated with differences in the movement of the tongue. The aim was to analyse the intra-oral nipple shape and movement of the tongue of infants of mothers with and without nipple pain. Methods: Breastfeeding infants of mothers with or without nipple pain were monitored using ultrasound and intra-oral vacuum during one breastfeed. From cine clips of the ultrasound scans measurements were made of the depth of the intra-oral space between the hard-soft palate junction (HSPJ) and the mid-tongue; the distance of the tip of the nipple to the HSPJ; and nipple diameters from the tip to the base. Results: During nutritive sucking, tongue movements of infants of mothers with nipple pain resulted in a smaller intra-oral space (p = 0.040) and restricted nipple expansion compared to controls (p < 0.012). Stronger baseline and peak vacuums compared to controls were confirmed (p = 0.002). Conclusion: In these mothers, nipple pain was associated with restricted infant tongue movement. Ultrasound may complement measurement of intra-oral vacuum in monitoring treatment strategies in breastfeeding women experiencing nipple pain.

Béribéri du nourrisson : à propos d’un cas

Thiamine deficiency is recognized in varied parts of the world. In Asia, it remains an important public health problem where highly polished rice is the major staple food and where other primary dietary sources of thiamine are in short supply. Beriberi, or clinically apparent thiamine deficiency, may present a variety of syndromes including myocardial dysfunction or wet beriberi, dry beriberi with neurological symptoms, and the more severe form Shoshin beriberi with cardiac failure and lactic acidosis. Infantile thiamine deficiency is a very rare condition in developed countries today. It occurs mainly in breastfed infants of mothers who have inadequate intake of thiamine. Clinical symptoms in such infants include gastrointestinal symptoms, cardiac failure, and lactic acidosis. We report the case of a 10-week-old girl, admitted with diarrhea, vomiting, acidosis, and cardiac failure. After excluding other etiologies of cardiomyopathy, biochemical thiamine deficiency confirmed the diagnosis of beriberi in an infant of a thiamine-deficient mother from Reunion Island, a French island where recently, with Mayotte Island, epidemic cases of beriberi have been described. This case is important to highlight the manifestations in young infants and to alert physicians to the possibility of thiamine deficiency in developed countries.

There's Nothing Sweeter Than Mom's Own Milk

Newborn Care Poster Presentation Background The labor and delivery (LD a successful latch was noted. Current hospital guideline requires blood glucose to be performed between 1 and 2 hours of life on LGA and sick infants. Initial blood glucose results were 34, with immediate repeat of 28. Per hospital guideline, blood glucose levels less than 36 require physician notification, infant feeding of 10 ml/kg of formula, and administration of IV glucose. Upon notification, the pediatrician ordered formula supplementation; however, the mother stated her desire to continue giving breast milk to correct the hypoglycemia. I taught the mother how to hand‐express colostrum and spoon feed the infant, and 35 ml of colostrum was successfully expressed and spoon fed to the infant. The repeat blood glucose was 52. The pediatrician was notified of the results using the mother's expressed breast milk. The infant remained on the hypoglycemia management guideline, but did not require formula supplementation or IV glucose. Mother and infant were able to exclusively breastfeed for the duration of their hospital stay. This successful scenario of treating infant hypoglycemia with the mother's expressed milk was well received by my hospital's neonatology and lactation departments, as well as hospital management, thus generating new teaching projects surrounding hand expression and spoon feeding. Conclusion As nurses, we must strive for excellence in the care of the exclusively breastfeeding mother–infant dyad realizing that current practices and hospital guidelines must be updated to align with recent research and Joint Commission recommendations. By utilizing current evidence surrounding a mother's expressed breast milk, we can ensure successful breastfeeding for the long term as well as increase the mother's confidence that she can provide for her infant's needs.

Early, abrupt weaning did not reduce risk of HIV infection or mortality in breast-fed infants of mothers with HIV

Early, abrupt weaning did not reduce risk of HIV infection or mortality in breast-fed infants of mothers with HIV

Immunomodulatory constituents of human milk change in response to infant bronchiolitis

Although epidemiological evidence is generally supportive of a causal association between respiratory syncytial virus (RSV) bronchiolitis during infancy and the development of persistent wheeze/asthma, if not allergy, the mechanism by which this occurs and an explanation for why all children do not succumb remains to be elucidated. Breast feeding has been found to confer a protective effect against respiratory infections such as RSV bronchiolitis and allergy; however, again there is little direct evidence and no clear mechanism. In this study, we examined whether human milk immunomodulatory factors (cells, cytokines) change in response to clinically diagnosed, severe bronchiolitis in the recipient breast-fed infant. We examined milk from 36 breast feeding mothers of infants hospitalized with bronchiolitis and compared them with milk from 63 mothers of postpartum age-matched healthy controls. Milks from mothers of infants hospitalized with bronchiolitis had significantly greater numbers of viable cells when compared with the milks obtained from mothers of healthy infants (1.3 +/- 0.4 vs. 0.3 +/- 0.03 x 10(6) cells/ml, mean +/- s.e.m.; p < or = 0.001). Further, the cells obtained from the mothers of infants hospitalized with bronchiolitis were found to produce a skewed cytokine profile ex vivo in response to stimulation by live RSV but not when cultured with a non-specific mitogen (concanavalin A). This study provides preliminary evidence for an immunological link between mothers and their breast-fed infants during severe respiratory infections as well as a possible contributing factor to the development of persistent wheeze in these infants.

Smoking Hygiene: Reducing Infant Exposure to Tobacco

The American Academy of Pediatrics recently removed nicotine from the list of drugs contraindicated during breastfeeding. The objective of this study was to evaluate the feasibility of determining the effect of a smoking hygiene intervention on infants of breastfeeding mothers who smoke cigarettes. An experimental design with repeated measures was used. A convenience sample of 35 mother-infant dyads from seven sites was recruited and randomly assigned to the intervention or control group. Of the 27 dyads completing the study, 16 were in the experimental group and 11 were in the control group. Smoking hygiene was introduced when infants were 2 weeks old and reinforced when they were 3 and 5 weeks old. At these three data points, infant health and urinary nicotine and cotinine levels were measured, as well as the mothers' breast-milk nicotine and cotinine levels and smoking hygiene behaviors. Recruiting and retaining a sample of breastfeeding mothers who smoke proved difficult. Only 27% of women in the intervention group implemented all aspects of the smoking hygiene intervention behaviors. Repeated-measures ANOVA revealed no difference in a) infant urinary nicotine and cotinine levels or b) breast-milk nicotine and cotinine levels between the two groups. The McNemar test for related samples revealed no difference between frequency of respiratory symptoms in either the control or intervention groups when Week 2 levels were compared with levels at Weeks 3 and 5. Mothers were not successful in adhering to the smoking hygiene intervention. To adequately test interventions, strategies must be developed to help women incorporate health-promoting behaviors into their lives.

Treatment of depression associated with the menstrual cycle: premenstrual dysphoria, postpartum depression, and the perimenopause

Several forms of depression are unique to women because of their apparent association with changes in gonadal hormones, which in turn modulate neuroregulatory systems associated with mood and behavior. This review examines the evaluation and treatment of depression that occurs premenstrually, postpartum, or in the perimenopause on the basis of current literature. The serotonergic antidepressants consistently show efficacy for severe premenstrual syndromes (PMSs) and premenstrual dysphoric disorder (PMDD), and are the first-line treatment for these disorders. The use of antidepressants for postpartum depression is compromised by concerns for effects in the infants of breast-feeding mothers, but increasing evidence suggests the relative safety of the antidepressant medications, and the risk calculation should be made on an individual basis. Estradiol may be effective for postpartum depression and for moderate-to-severe major depression in the perimenopause. In spite of its frequent use, progesterone is not effective for the mood and behavioral symptoms of PMS/PMDD, postpartum depression, or perimenopausal depressive symptoms.

A question that won't go away.

Maternal and Infant Use of Erythromycin and Other Macrolide Antibiotics as Risk Factors for Infantile Hypertrophic Pyloric Stenosis Mahon BE, Rosenman MB, Kleiman MB. J Pediatr 2001;139:380–4. Summary: The charts were reviewed of infants born at a large urban hospital between 1993 and 1999 for evidence of macrolide antibiotic use either by their mothers during pregnancy or by the infants themselves during the first 3 months of life and for the incidence of infantile hypertrophic pyloric stenosis (IHPS). Prescriptions from the hospital pharmacy records for erythromycin, azithromycin, or clarithromycin were viewed as proof of medication use. Single-dose prophylaxis and topical use, including erythromycin ophthalmic ointment used at delivery, were recorded. Hospital records were then searched electronically for the diagnosis of IHPS using several key words. The study eventually included 14,876 infants (and their mothers) of whom 469 received prescriptions for oral or intravenous erythromycin. Pyloric stenosis was found in 43 of these infants (0.29%). The risk of pyloric stenosis was increased in only the infants who had prescriptions for oral or intravenous erythromycin (not topical). Pyloric stenosis developed in none of the infants who received erythromycin after the first 2 weeks of life. Pyloric stenosis developed in 3% of the 201 infants with prescriptions for more than 2 weeks of use, whereas IHPS developed in none of 215 with prescriptions for fewer than 14 days. Only six infants in the study received azithromycin, and none received clarithromycin; therefore, no conclusions about the risk of these macrolides could be reached. Erythromycin ophthalmic ointment use did not increase the incidence of IHPS. Findings suggest that from the 3,346 mothers who received macrolide antibiotics during pregnancy, erythromycin use during the last 10 weeks of pregnancy was a possible risk factor for IHPS, but no increase in risk was associated with use earlier in pregnancy. Comment: During the years, studies have suggested that early infant exposure to erythromycin is associated with increased risk of IHPS. Most of the studies have been either brief case reports or have been from institutions in which a modest cohort of newborn infants exposed to pertussis before immunization received the medication as prophylaxis. The oversimplified explanation for the association between IHPS and erythromycin is that erythromycin, a potent motilin agonist, causes muscular hypertrophy in the antrum or pylorus by prolonged overstimulation of the antral musculature. The current study does not speak to cause. Its strength is the large number of patients included and the obvious care expended on the record review. The risk of IHPS in the general population of infants is only 0.25%. Thus, a large number of study infants are needed to statistically support what prior studies have suggested. The risk estimated by this large study is that 2.65% of infants treated with erythromycin in the first 2 weeks of life will develop IHPS, a 10-fold increase over the general population. This study also clarifies the timing of erythromycin administration (before 2 weeks of age seems to be the period of risk), the risk of topical erythromycin ointment (none), and the duration of use (higher risk with use for more than 14 days). The dosages of erythromycin prescribed were appropriate, and no dosage-related effect was detected in the affected infants. Unfortunately, the numbers were not large enough to determine whether maternal use was a risk factor, although use late in pregnancy may prove, in bigger future studies, to be a factor. The authors did not extend their study to look at the incidence of IHPS in the infants of breast-feeding mothers who received erythromycin postnatally. The weakness of this study is obvious. Using prescription records to define actual antibiotic use may be unreliable; however, the large number of neonates involved in this study decreases that concern somewhat. The increase in incidence of IHPS was the same in infants receiving drug therapy in the hospital as for outpatients. This finding supported the use of pharmacy records as being synonymous with drug administration in the outpatients. Ninety-seven percent of the infants treated with erythromycin did not develop IHPS. This suggests that other factors relating to IHPS remain to be identified. It would have been interesting to see whether there were any differences in erythromycin dosage or duration of use in the 97% of treated infants who did not develop IHPS. We congratulate the authors for their effort in extracting so much information in this retrospective study. Their findings will have an impact on several aspects of general pediatric care of the newborn, and will also have an impact on gastrointestinal care. Specifically, in the young infant with blood-streaked stool, we should wait for Campylobacter culture results before starting erythromycin therapy.

Evidence for the sensitivity of the SF-36 health status measure to inequalities in health: results from the Oxford healthy lifestyles survey.

The short form 36 (SF-36) health questionnaire may not be appropriate for population surveys assessing health gain because of the low responsiveness (sensitivity to change) of domains on the measure. An hypothesised health gain of respondents in social class V to that of those in social class I indicated only marginal improvement in self reported health. Subgroup analysis, however, showed that the SF-36 would indicate dramatic changes if the health of social class V could be improved to that of social class I. Postal survey using a questionnaire booklet containing the SF-36 and a number of other items concerned with lifestyles and illness. A letter outlining the purpose of the study was included. The sample was drawn from family health services authority (FHSA) computerised registers for Berkshire, Buckinghamshire, Northamptonshire, and Oxfordshire. The questionnaire was sent to 13,042 randomly selected subjects between the ages of 17-65. Altogether 9332 (72%) responded. Scores for the eight dimensions of the SF-36. The sensitivity of the SF-36 was tested by hypothesising that the scores of those in the bottom quartile of the SF-36 scores in class V could be improved to the level of the scores from the bottom quartile of SF-36 scores in class I using the effect size statistic. SF-36 scores for the population at the 25th, 50th, and 75th centiles were provided. Those who reported worse health on each dimension of the SF-36 (ie in the lowest 25% of scores) differ dramatically between social class I and V. Large effect sizes were gained on all but one dimension of the SF-36 when the health of those in the bottom quartile of the SF-36 scores in class V were hypothesised to have improved to the level of the scores from the bottom quartile of SF-36 scores in class I. Analysis of SF-36 data at a population level is inappropriate; subgroup analysis is more appropriate. The data suggest that if it were possible to improve the functioning and wellbeing of those in worst health in class V to those reporting the worst health in class I the improvement would be dramatic. Furthermore, differences between the classes detected by the SF-36 are substantial and more dramatic than might previously have been imagined.