Hirschsprung's Disease: a Clinical and Pathologic Study in Iranian Constipated Children

Objective

Hirschsprung''s disease (HD) is a complex disorder resulting from absence of ganglion cells in the bowel wall leading to functional obstruction and bowel dilatation proximal to the affected segment. The aim of our study was to evaluate rectal biopsies from constipated children in different age groups to see in which age it is more likely to encounter HD to avoid unnecessary rectal biopsy.

Methods

Records of all children with chronic constipation undergoing a rectal biopsy to exclude HD were obtained from the files of Children''s Medical Center in Tehran, Iran. A detailed retrospective demographic review, including age of beginning of signs and symptoms was made of all cases.

Findings

Totally, 172 biopsies were taken from 168 children in a five year period, of which 127 cases (75%) had HD. The mean age of constipated patients at biopsy was 39 months and the mean age of patients with proven HD was 18 months. Males were affected more than females. Congenital anomalies associated with HD were found in 9.6%. In 85 (91%) cases constipation had begun in neonatal period.

Conclusion

Our data supports previous studies that if constipation begins after the neonatal period, the child is unlikely to have HD. In neonates delay in meconium passage is the most important clinical sign of HD.     

The Role of Cow's Milk Allergy in Pediatric Chronic Constipation: A Randomized Clinical Trial

Objective

Cow''s milk allergy has different presentations in children and can cause functional bowel symptoms such as chronic constipation. The aims of this study were to investigate the role of cow''s milk allergy as a cause of chronic constipation and effect of cow''s milk free diet (CMFD) on its treatment in children.

Methods

We performed a randomized clinical study comparing CMFD with cow''s milk diet (CMD) in two groups each consisting of 70 patients (age range, 1-13 years) with chronic functional constipation (defined as Rome III criteria). All subjects had been referred to a pediatric gastroenterology clinic and had previously been treated with laxatives for at least 3 months without success; also all 140 patients performed skin prick test. The case group received CMFD for 4 weeks. After that they received CMD for 2 extra weeks. The control group received CMD for whole 6 weeks. A response was defined as decreased in signs and symptoms that not fulfilled Rome III criteria after 4 weeks of CMFD and came back to Rome III criteria after 2 weeks of CMD challenge.

Findings

After 4 weeks 56 (80%) patients of the case group responded in comparison to 33 (47.1%) patients in the control group (P=0.0001). In the case group after 2 weeks challenge 24 out of 56 (42.8%) responders developed constipation according to Rome III criteria. With other words, the frequency of cow''s milk allergy among constipated patients was 80%. Only one patient had positive skin prick test.

Conclusion

In children, chronic constipation can be a manifestation of cow''s milk allergy. At present, although several aspects must be further investigated, a therapeutic attempt with elimination diet is advisable in all children with constipation unresponsive to correct laxative treatment.     

Can We Rely on Frozen Sections of a Rectal Biopsy for One-stage Trans-anal Pull-through Operation in Hirschsprung's Disease?

Objective

Successful results after one-stage trans-anal pull-through (OSTAPT) operation for Hirschsprung''s disease (HD) depend on accurate identification of the aganglionic segment in intra-operative frozen section (FS). Misinterpretation of the findings of the rectal biopsy is an anxiety-evoking pitfall for the surgeon. This study aims to describe our experiences in comparing results of FS and permanent Section (PS) rectal biopsies in children with HD who were candidates for OSTAPT in a single-step operation.

Methods

Subjects under the age of 14 years, admitted from March 2000 to July 2008 in a university-affiliated children''s hospital for open rectal biopsy to diagnose HD were included in the study. All biopsies were taken 2–3 cm above the dentate line. 210 specimens of full-thickness rectal biopsy were obtained for both frozen section and permanent biopsy from all patients, examined by two well experienced pediatric pathologists for ascertaining the presence of ganglion cells, and the results were compared. Analysis was performed by SPSS Software version 11.5.

Findings

Two-hundred one infants and children underwent FS rectal biopsy to exclude HD. Positive results were seen in 63.8% of the specimens examined as PS and in 58.3% of FS samples. 93.9% of positive results in FS studies were confirmed by PS studies. 6.1% of FS reports were false positive and 21.7% were false negative (P<0.001). The sensitivity of FS was 85.8% and specificity 90.2%. Positive predictive value (PPV) was 93.9% and negative predictive value (NPV) was 78.3% in FS studies (P<0.001). The accuracy of FS was 80.4%.

Conclusion

Although FS of the rectal biopsy is useful in defining the aganglionic segment during operation, according to this study, it cannot be used as the sole base for performing primary pull-through operation before the results of the permanent section are on hand.     

Perforation of Meckel's Diverticulum by a Peanut Presenting as a Mesentery Abscess

Background

Perforation of Meckel''s diverticulum by a foreign body in children is rarely reported and is usually associated with localized or generalized fibropurulent peritonitis.

Case Presentation

The authors encountered such a case in a 4-year-old boy with perforation of Meckel''s diverticulum by a piece of peanut presenting as a mesentery abscess. The diverticulum was wide-based and histology showed a transmural perforation at the tip of the diverticulum.

Conclusion

Local inflammation due to irritation of the foreign body and progressive pressure necrosis at the tip of the diverticulum may be the pathogenesis of mesentery abscess. A search of the English literature did not reveal any similar case.     

Value of Gluten Patch Test in Diagnosis of Celiac Disease

Objective

Celiac disease is an intestinal disorder identified by mucus inflammation, villous atrophy and crypt hyperplasia. This disorder can be controlled by elimination of gluten from daily diet. Patients with celiac disease are at greater risk of gastrointestinal malignancy and non-Hodgkin lymphoma than are the general population. This study tries to present the value of gluten patch test for diagnosis of celiac disease.

Methods

In this investigation, the study population was divided into case and control groups. The case group consisted of patients with celiac disease. The control group were patients involved in celiac disease but suffering from other gastrointestinal disorders. Both gluten patch and placebo patch were attached to the skin between the scapulas. The results were read twice: 48 hours and 96 hours after the patch was applied. Patients who showed irritation reactions were withdrawn from this study. The results were analysed by SPSS software, Spearman''s test, chi square, and Mann–Whitney tests.

Findings

The value obtained from the gluten patch test after 96 hours are as follows: specification at 95%, sensitivity at 8%, positive prediction value at 67%, and negative prediction value at 43%.

Conclusion

It can be concluded that the gluten patch test is not an efficient test for screening of celiac disease, however, it can be useful for diagnosis of celiac disease if employed and studied with clinical symptoms and serologic and biopsy tests. Furthermore, we should doubt our judgment if the result of gluten patch test for the patient with celiac disease is positive.     

First Genetic Screening for Maternal Uniparental Disomy of Chromosome 7 in Turkish Silver-Russell Syndrome Patients

Objective

Silver–Russell syndrome (SRS) is a clinically and genetically heterogeneous syndrome which is characterized by severe intrauterine and postnatal growth retardation, and typical characteristic facial dysmorphisms. It has been associated with maternal uniparental disomy (UPD) for chromosome 7 and hypomethylation of imprinting control region 1 (IGF2/H19) in 11p15. UPD refers to the situation in which both copies of a chromosome pair have originated from one parent. UPD can be presented both as partial heterodisomy and isodisomy. The aim of this study was to determine the maternal UPD7 (matUPD7) in 13 Turkish SRS patients.

Methods

Genotyping for matUPD7 was performed with microsatellite markers by polymerase chain reaction.

Findings

The maternal UPD7 including the entire chromosome was identified in 1/13 (7.6%) of individuals within SRS patients. There were no significant differences between clinical features of matUPD7 case and other SRS cases except congenital heart defects.

Conclusion

It is often difficult to establish diagnosis of a child with intrauterine growth retardation (IUGR), growth failure and dysmorphic features. Thus, screening for matUPD7 in IUGR children with growth failure and mild SRS features might be a valuable diagnostic tool.     

Breastfeeding and Helicobacter Pylori Infection in Children with Digestive Symptoms

Objective

This study aims to evaluate the role of breastfeeding in the acquisition of Helicobacter pylori (H. pylori) infection in Iran and to compare the histopathologic changes occurring in children feeding on breast milk with those in infants feeding on formula.

Methods

In a case-control study parents of children with and without H. pylori infection who had undergone endoscopic survey and gastric biopsy in the Children''s Medical Center, Tehran, were asked about their feeding practices during the first 6 months after birth, the duration of breastfeeding period, the symptoms, and the duration of symptoms and concomitant diseases.

Findings

A total of 154 children were included in this study. From this sample, 77 children formed the case group and 77 children formed the control group. A significant difference was found between H. pylori infection and feeding with formula (P=0.045). In case group, a significant difference was found between breastfeeding and age of the infected child (P=0.034), shorter duration of symptoms (P=0.016), and finally degree of H. pylori colonization (P=0.021).

Conclusion

It appears that breastfeeding in the first 6 months after birth can decrease the degree of H. pylori colonization, postpone infection until older age, shorten the duration of symptoms, and be concomitant with milder gastritis.     

Alpha 1 Antitrypsin Deficiency in Infants with Neonatal Cholestasis

Objective

Alpha1-antitrypsin deficiency (A1ATD) is the most important indication for liver transplantation in children. The gene frequencies vary in different ethnic groups. In the present study, we attempt to determine the frequencies of the most common defective alleles, Z and S, in Iranian children suffering from idiopathic neonatal cholestasis. Eighty-seven infants were typed for Z and S alleles.

Methods

In a single center study, 87 consecutive liver biopsies from infants with cholestasis were reviewed and patients with neonatal cholestasis enrolled in the study and cases with confirmed biliary tract atresia excluded. Formalin fixed paraffin embedded blocks were used for DNA extraction. AAT genotype was determined by polymerase chain reaction (PCR) assay and amplification of the two most common deficiency variants, S and Z alleles, and then sequencing of PCR products.

Findings

There were 48 (55.2%) males and 39 (44.8%) females, with a median age of 60 days. Out of 87 of the study subject, 2 (2.2%) were heterozygous for the S allele, and no ZZ, SS or MZ individual was found in the patients. No other polymorphism was found in the sequencing results.

Conclusion

In comparison to other populations, AAT deficiency seems not to be an important etiologic factor for neonatal cholestatic liver disease in Iran; however, further studies are recommended to estimate the true mutant gene frequencies.     

Thyroid Nodules in Childhood: a Single Institute Experience

Objective

Thyroid nodules are rare in children. Multiple diagnostic modalities are used to evaluate the thyroid mass. The aim of this study was to determine results of management of thyroid nodules in children with special attention to the role of fine needle aspiration biopsy (FNAB) in diagnosis.

Methods

Thirty-two children who underwent surgery for thyroid nodules in Mofid Children''s Hospital within 10 years (1996 to 2005) were retrospectively studied. From clinical records we obtained data about demographic characteristics, clinical manifestations, ultrasonography (USG) findings, and FNAB results, pathological reports, surgical therapy and complications. Data was analyzed statistically for association with thyroid cancer.

Findings

Twenty-five patients (78.1%) were girls, and 7 (21.9%) boys. Mean age was 10.9 (range 8 to 14) years. 24 (75%) patients had benign and 8 (25%) malignant tumors. 18 (56.25%) nodules were located in the right lobe. Statistical analysis revealed sensitivity, specificity, accuracy, and positive and negative predictive values as follows: 80%, 65%, 63%, 25%, and 86% for USG; 35%, 41%, 40%, 18%, and 66% for RNS; 91%, 94%, 90%, 74%, and 96% for FNAB respectively.

Conclusion

Clinical judgment as determined by serial physical findings with USG continues to be the most important factor in the management of thyroid nodules in children. FNAB is the most accurate method of investigation and its accuracy is improved by USG guidance.     

Changing Spectrum of Celiac Disease in India

Objective

Celiac disease is an important cause of chronic diarrhea, failure to thrive, and anemia in children. Mode of presentation of celiac disease has changed in last few years. Study was conducted to determine the mode of clinical presentation of a large group of patients with celiac disease and whether there has been a change in the presentation with the time.

Methods

A prospective study was conducted on 134 children diagnosed to be having celiac disease in the Pediatric Gastroenterology, PGIMER, Chandigarh, from July 1st 2006 to December 31^st 2007. Their detailed clinical profile was recorded on a pretested proforma and all patients underwent hemogram, liver function tests, IgA anti-tissue transglutaminase (anti tTG), and upper gastro-intestinal endoscopy.

Findings

Major symptoms at presentation were diarrhea (54.5%), failure to thrive (52.2%), abdominal distension (41%), anemia (40%), pain abdomen (19.4%), vomiting (15.7%) and constipation (2.2% of cases). 60.4% of patients had short stature. Anemia was microcytic hypochromic in 79.1% of patients, and dimorphic in 20.9%. Serum transaminases were raised in 38.8% of cases. The mean serum anti tTG level was 164.24U/ml (Range 0-749 U/ml) and levels correlated with the severity of small intestinal damage on biopsy. 15 patients were negative for the serology but 8 out of them had IgA deficiency and all had histopathology suggestive of celiac disease.

Conclusion

Classical presentation of celiac disease is less commonly encountered these days probably related to the more widespread use of serologic testing and early recognition of atypical manifestations of celiac disease.     

Evaluation of Serum Lead Levels in Children with Constipation and Normal Controls in Northern Iran

Objective

Constipation is a major debilitating problem in children. We aimed to assess the serum lead levels of 2-13 year-old children complaining from constipation who referred to our center in Guilan province, Northern Iran.

Methods

This cross-sectional study was done on ninety 2-13 year-old children referring to 17^th Shahrivar Hospital, complaining from constipation (case group) and 90 healthy children The demographic data as well as the children''s serum lead levels were evaluated and recorded. Data were analyzed using SPSS software. Chi-square test was used as applicable.

Findings

Lead poisoning was significantly more frequent in the case group (37.8%) compared with the control group (8.9%). The frequency of lead poisoning in the case group compared with the control group, was significantly higher in children <7 years old (40.2% vs. 10%), boys (40.9% vs. 9.3%), girls (34.8% vs 8.3%), residents of old houses (43.1% vs. 9.7%), residents of new houses (28.1% vs. 8.5%), residents of low-traffic areas (26.8% vs. 5.3%), urban residents (40.5% vs. 9.9%), children whose fathers had low risk (33.3% vs. 10.9%) and high risk jobs (40.7% vs. 3.8%).

Conclusion

The frequency of lead poisoning was higher in children suffering from constipation.No significant difference was found between the two groups with respect to their sex, age, father''s job, and living in urban or rural areas.     

Association of Serum Soluble Triggering Receptor Expressed on Myeloid Cells Levels in Malignant Febrile Neutropenic Patients with Bacteremia and Fungemia

Objective

Infections are the major cause of morbidity and mortality in febrile neutropenic patients with malignancy. Rapid diagnostic tests are needed for prompt diagnosis and early treatment which is crucial for optimal management. We assessed the utility of soluble triggering receptor expressed on myeloid cells (sTREM-1) in the diagnosis of bacteremia and fungemia in febrile neutropenic patients.

Methods

Sixty-five febrile neutropenic children with malignancy hospitalized in Mofid Children''s Hospital during a period of one year from January 2007 were recruited for this cross sectional study (mean age 66.2± 37 months; 35 females and 30 males). Thirty patients (46.2%) had acute lymphoblastic leukemia, 2 (3.1%) acute myeloid leukemia, one (1.5%) lymphoma and 32 (49.2%) were under treatment for solid tumors. Simultaneous blood samples were collected for measurement of serum sTREM-1 levels and for blood cultures which were grown in BACTEC media. Gold standard for the presence of infection was a positive BACTEC culture as a more sensitive method compared to current blood culture techniques.

Findings

Blood cultures with BACTEC system were positive in 13(20%) patients (12 bacterial and one fungal culture). The mean serum sTREM-1 level in BACTEC positive patients was 948.2±592.9 pg/ml but in BACTEC negative cases it was 76.3±118.8 pg/ml (P<0.001). The optimal cut-off point of sTREM-1 for detecting patients with positive result of BACTEC was 525 pg/ml with sensitivity and specificity of 84.6% and 100%, respectively.

Conclusion

Our study revealed a significant association between serum sTREM-1 level and bacteremia and fungemia in febrile neutropenic patients suffering malignancy with acceptable sensitivity and specificity.     

The Effect of Traditional Remedies (Camel's Thorn,Flixweed and Sugar Water) on Idiopathic Neonatal Jaundice

Objective

Jaundice is the most common reason of newborn''s admission to neonatal ward. Many Iranian families give traditional remedies like sugar water, camel''s thorn and flixweed extracts to breast-fed babies for reducing jaundice. This study investigated the effect of traditional remedies on idiopathic neonatal jaundice.

Methods

This prospective study has been performed on 336 babies with idiopathic jaundice in a four year period (2005-2009) at Ghaem hospital, Mashhad, Iran. The babies were divided into two groups. In case group (n=234) breast-fed babies received no remedy and in control group (n=102), traditional remedies were given additional to breast milk and the results recorded and compared.

Findings

In the present study significant differences were observed between the two groups in age of admission (6.8±3.2 vs 9.2±3.7 day, P<0.001), serum bilirubin values (17.8 vs 21.3 mg/dl, P<0.001) and percent of weight loss (P<0.01). There were no significant differences between the two groups in birth weight, sex, gestational age and duration of hospitalization, age at jaundice remission, hematocrit value and maternal factors (age, gestational order, pregnancy and labor problems)(P>0.05).

Conclusion

Traditional remedies (camel''s thorn, flixweed and sugar water) cause more weight loss and delayed reexamination of newborns leading to increased hyperbilirubinemia. These remedies may raise pseudo confidence in parents, which postpones reexamination and follow up of the newborns.     

An Estimation of Steroid Responsiveness of Idiopathic Nephrotic Syndrome in Iranian Children

Objective

Idiopathic Nephrotic syndrome (INS) is the most common form of nephrotic syndrome (NS) in children with the potential of progression to end stage renal disease (ESRD). INS is steroid-responsive in most children, but not all patients respond to it. The aim of this study was to determine the rate of steroid responsiveness in children with INS that referred to Children''s Medical Center since 1995 to 2007.

Methods

In as a cross sectional study, the medical records of all children with INS aged 1 to 15 years who were referred to our referral hospital was reviewed. All patients with onset of disease less than 1 year of age, spontaneous remission, secondary forms of NS associated with systemic diseases, and follow up duration of less than 12 months were excluded from the study. Patients were categorized into 6 groups: Group 1 needed biopsy prior to any treatment, group 2 non-relapsing NS, group 3 infrequently relapsing NS, Group 4 frequently relapsing NS, group 5 steroid dependent NS and group 6 steroid resistant NS.

Findings

A total of 238 patients were enrolled in the study. Kidney biopsy was performed in 79 cases. Minimal change lesion (MCL) was the most common (36.7%) pathological diagnosis. Steroid responsiveness was found in 81.5% of all cases including: 96% of MCL (consisting of biopsy proven cases and presumed ones), 32% of focal and segmental glomerulosclerosis, 73% of diffuse mesangial proliferation and 58% of membranoproliferative glomerulonephritis patients. During minimal follow up period of 12 months, there were 194 patients in remission, 32 patients with active NS, and 12 patients in ESRD.

Conclusion

Our study results showed that 81.5% of all patients, 96.2% of MCL and 32% of FSGS patients initially responded to steroid therapy.     

Liver Hydatid Cyst in Children (A 14-year Review)

Objective

Hydatid disease is still an important health hazard in the world. This disease is a parasitic infestation which is endemic in many sheep and cattle raising areas such as in Iran. The aim of this study was to evaluate the clinical appearance, diagnosis, and treatment of liver hydatid cyst in children.

Methods

This retrospective study evaluated 100 patients who were referred to Mofid Children''s Hospital with liver hydatid cyst from March 1996 to March 2010. Medical records of 1 to 14 year old patients who had definitive liver hydatid cyst were included and analysis of variables such as age, gender, symptoms, diagnostic investigation, operative technique, hospital stay, mortality, morbidity and outcome of treatment were evaluated.

Findings

The patients consisted of 54 boys (54%) and 46 (46%) girls with an age range of 1-14 years (mean 11.8±4.6). The incidence rate increased by age. The patients had totally 110 cysts, right pulmonary lobe 81 (73%) cysts and left side had 29 (27%). Abdominal mass was the most common (50%) symptom. Abdominal sonography gave correct diagnosis in 94 (94%) patients. Conservative surgical treatment was carried out in 98 children. Two patients were treated medically as the cysts were small and calcified. The most common complication was wound infection in 3 cases. Mean length of hospitalization was 9 days. In 100% of our patients the type of parasite was Echinoccocus granulosus. The morbidity rate was 12% (prolonging external catheter drainage in 12 patients). There was only one (1%) mortality and 2 (2%) recurrences.

Conclusion

Due to the less invasive and high accuracy of liver sonography in diagnosis of hydatid cyst, we recommend it as the method of choice for the diagnosis in endemic regions. Surgery is the method of choice for treatment.     

Attempt to Suicide in Young Ages with Epilepsy

Objective

The suicidal rate among epileptic patients is up to 5 times more than general population and depression is the most common mood disturbance among them while usually under noticed. This study was performed to determine possible symptoms of psychiatric disorders for suicidal behavior in pediatric patients with epilepsy that had attempted suicide.

Methods

Among medical records of 1169 patients under 17 years of age being admitted to the exclusive university hospital for poisoning in Tehran since April 2006 to Feb 2008 due to attempt to suicide, 31 cases (13 male and 18 female) with mean age 15.8±1.3 years had concomitant epilepsy. Mental status and epilepsy data sheet of these patients were analyzed.

Findings

The psychological evaluation of these 31 cases revealed long lasting symptoms of psychological disorder in 21 (91.4%) cases before their attempt to suicide while only 5(16%) cases had been noticed for psychiatric care and merely 3 of them had been under treatment.

Conclusion

Despite strong correlation between affective disorders and epilepsy it is unfortunately under-diagnosed or undertreated. Since overdose of antiepileptic drugs used for treatment of epilepsy may be lethal, dismissing suicidal behavior can be life threatening.     

Zinc and Copper Concentrations in Human Milk and Infant Formulas

Objective

Available accurate data on the concentrations of copper (Cu) and zinc (Zn) in human milk throughout lactation and infant formulas is important both for formulating nutritional requirements for substances and to provide a base line for the understanding the physiology of their secretion. The objective of this study was to analyze the concentrations of zinc and copper in infant formulas and human milk during prolonged lactation. Levels of these metals were examined in relation to selected parameters such as age, weight, height, education and occupation of mothers.

Methods

Thirty mothers referred to the selected clinics in Tehran entered the study. Human milk samples were collected at 2 months postpartum. Zinc and copper concentrations were determined by atomic absorption spectrophotometer.

Findings

The mean values of Zn and Cu in human milk were 2.95±0.77mg/L and 0.36±0.11 mg/L. The mean values of Zn and Cu in infant formulas were 3.98±0.25 mg/L and 0.53±0.17mg/L.

Conclusion

No significant relationship was found between levels of trace elements in human milk and evaluated parameters such as age, weight, height, education and occupation of mothers. The concentrations of zinc and copper in breast milk were lower than those reported in the literature.     

Molar Incisor Hypomineralization: A Study of Prevalence and Etiology in a Group of Iranian Children

Objective

The aim of this study was to investigate the prevalence of molar incisor hypomineralization (MIH) and its relationship with systemic conditions in a group of Iranian children.

Methods

The study population comprised of 433 7-9 year olds, from four schools in Zahedan, Iran. Subjects were evaluated clinically by one examiner, and at a separate session, their mothers completed a coded medical history questionnaire. Hypo-mineralized molars and incisors were recorded based on DDE (developmental defects of enamel) index and DMFT (number of decayed, filled and missing teeth) was determined. Statistical analyses were performed using Chi-square and independent sample t-tests.

Findings

Fifty-five (12.7%) children showed MIH. The overall mean number of affected teeth was 0.2. The mean value of DMFT in MIH children was greater than in normal children. Demarcated opacities were the most frequent (76%) enamel defect. Mother''s and child''s medical problems during prenatal, perinatal and post natal period were significantly remarkable in MIH children.

Conclusion

The prevalence of MIH in a group of Iranian children was 12.7%. Prenatal, perinatal and post natal medical conditions were more prevalent in children affected by MIH.     

Parental consent in paediatric clinical research

Aims

To assess parental understanding and memorisation of the information given when seeking for consent to their child''s participation to clinical research, and to identify the factors of significant influence on parents'' decision making process.

Methods

Sixty eight parents who had been approached for enrolling their child in a clinical oncology or HIV study were asked to complete an interview. Their understanding was measured by a score which included items required to obtain a valid consent according to French legislation.

Results

Items that were best understood by parents were the aims of the study (75%), the risks (70%), the potential benefits to their child (83%), the potential benefits to other children (70%), the right to withdraw (73%), and voluntariness (84%). Items that were least understood were the procedures (44%), the possibility of alternative treatments (53%), and the duration of participation (39%). Less than 10% of the parents had understood all these points. Ten parents (15%) did not remember that they had signed up for a research protocol. Thirty three parents (48%) reported no difficulty in making their decision. Twenty four parents (38%) declared that they made their decision together with the investigator; 26 (41%) let the physician decide. Fifty four parents (78%) felt that the level of information given was satisfactory.

Conclusion

There was an apparent discrepancy between parents'' evaluation of the adequacy of the information delivered and evaluation of their understanding and memorisation. The majority of parents preferred that the physician take as much responsibility as possible in the decision making process.     

Infant feeding in the second 6 months of life related to iron status: an observational study

Objective

To investigate the relationship between iron status in infancy and type of milk and weaning solids consumed.

Design

An observational cohort study.

Setting

928 term infants from the Avon Longitudinal Study of Parents and Children in 1993–94.

Methods

Haemoglobin and ferritin concentrations at 8 and 12 months were assessed in relation to type and quantity of milk intake at 8 months.

Results

By WHO criteria, 22.7% of the infants were anaemic at 8 months and 18.1% at 12 months. More breast‐ than formula‐fed infants were anaemic at 8 and 12 months. Cows'' milk as the main drink was associated with increased anaemia at 12 months and low ferritin at 8 and 12 months. No association was found between any nutrients and haemoglobin concentrations. Protein and non‐haem iron intakes were positively associated with ferritin concentrations and calcium intake negatively. This effect was more marked in infants being fed cows'' milk. More than 25% of infants in the breast milk and cows'' milk groups and 41% of infants having >6 breast feeds per day had iron intakes below the lower reference nutrient intake. Feeding cows'' milk or formula above 600 ml or >6 breast feeds per day was associated with lower intakes of solids.

Conclusions

Both breast and cows'' milk feeding were associated with higher levels of anaemia. Satisfactory iron intake from solids in later infancy is more likely if formula intake is <600 ml per day and breast feeds are limited to <6 feeds per day. Cows'' milk should be strongly discouraged as a main drink before 12 months.