Insulin resistance is not due to persistently elevated serum tumor necrosis-alpha levels in small for gestational age, premature, or twin children

Abstract: Background: In pregnancies with small for gestational age (SGA) fetuses, elevated amniotic fluid tumor necrosis factor‐α (TNF‐α) levels have been reported. TNF‐α has been shown to induce insulin resistance in rodents and humans. We hypothesized that an adverse fetal or early neonatal environment for SGA, twin, and premature children leads to persistently elevated TNF‐α levels that induce insulin resistance in each of these groups. Methods: The study group consisted of 16 SGA, 14 premature, 53 twin subjects, and the control group of 40 normal subjects (10 short‐stature and 30 normal‐stature). All subjects were prepubertal and non‐obese. Insulin sensitivity (S_I) was measured in all but the normal‐statured control subjects. Fasting plasma TNF‐α and cortisol levels were measured in all subjects. Results: The study group had reduced S_I[SGA 18.5 ± 3, premature 17.8 ± 2, twin 12.7 ± 0.7 (×10⁻⁴/min/µU/mL)] compared to the short normal control subjects (43 ± 8 × 10⁻⁴/min/µU/mL, p < 0.001). Plasma TNF‐α levels were lower in the insulin‐resistant study group when compared to the control group (2.9 ± 0.1 vs. 5.0 ± 0.2 pg/mL, p < 0.001). An association was present between reduced S_I and low plasma TNF‐α levels in the study group (p = 0.01, r = 0.4). Fasting plasma cortisol was lower in the study compared to the control group (266 ± 16 vs. 341 ± 28 nmol/L, p < 0.01) due to the influence of the twin study subgroup. There was no relationship between plasma cortisol and TNF‐α levels (p = 0.3). Conclusion: SGA, premature, and twin children are insulin resistant and have low plasma TNF‐α and cortisol levels. We speculate that the mechanism leading to insulin resistance in these subjects is also suppressing plasma TNF‐α and cortisol concentrations.     

Impact of small‐quantity lipid‐based nutrient supplement on hemoglobin,iron status and biomarkers of inflammation in pregnant Ghanaian women

We examined hemoglobin (Hb, g/L), iron status (zinc protoporphyrin, ZPP, µmol/mol heme, and transferrin receptor, TfR, mg/L) and inflammation (C‐reactive protein, CRP and alpha‐1 glycoprotein, AGP) in pregnant Ghanaian women who participated in a randomized controlled trial. Women (n = 1320) received either 60 mg Fe + 400‐µg folic acid (IFA); 18 micronutrients including 20‐mg Fe (MMN) or small‐quantity lipid‐based nutrient supplements (SQ‐LNS, 118 kcal/d) with the same micronutrient levels as in MMN, plus four additional minerals (LNS) daily during pregnancy. Intention‐to‐treat analysis included 349, 354 and 354 women in the IFA, MMN and LNS groups, respectively, with overall baseline mean Hb and anemia (Hb <100) prevalence of 112 and 13.3%, respectively. At 36 gestational weeks, overall Hb was 117, and anemia prevalence was 5.3%. Compared with the IFA group, the LNS and MMN groups had lower mean Hb (120 ± 11 vs. 115 ± 12 and 117 ± 12, respectively; P < 0.001), higher mean ZPP (42 ± 30 vs. 50 ± 29 and 49 ± 30; P = 0.010) and TfR (4.0 ± 1.3 vs. 4.9 ± 1.8 and 4.6 ± 1.7; P < 0.001), and greater prevalence of anemia (2.2% vs. 7.9% and 5.8%; P = 0.019), elevated ZPP (>60) [9.4% vs. 18.6% and 19.2%; P = 0.003] and elevated TfR (>6.0) [9.0% vs. 19.2% and 15.1%; P = 0.004]. CRP and AGP concentrations did not differ among groups. We conclude that among pregnant women in a semi‐urban setting in Ghana, supplementation with SQ‐LNS or MMN containing 20 mg iron resulted in lower Hb and iron status but had no impact on inflammation, when compared with iron (60 mg) plus folic acid (400 µg). The amount of iron in such supplements that is most effective for improving both maternal Hb/iron status and birth outcomes requires further evaluation. This trial was registered at ClinicalTrials.gov as: NCT00970866.     

Association between maternal depressive symptoms in the early post‐natal period and responsiveness in feeding at child age 2 years

Maternal depression is a known risk factor for poor outcomes for children. Pathways to these poor outcomes relate to reduced maternal responsiveness or sensitivity to the child. Impaired responsiveness potentially impacts the feeding relationship and thus may be a risk factor for inappropriate feeding practices. The aim of this study was to examine the longitudinal relationships between self‐reported maternal post‐natal depressive symptoms at child age 4 months and feeding practices at child age 2 years in a community sample. Participants were Australian first‐time mothers allocated to the control group of the NOURISH randomized controlled trial when infants were 4 months old. Complete data from 211 mothers (of 346 allocated) followed up when their children were 2 years of age (51% girls) were available for analysis. The relationship between Edinburgh Postnatal Depression Scale (EPDS) score (child age 4 months) and child feeding practices (child age 2 years) was tested using hierarchical linear regression analysis adjusted for maternal and child characteristics. Higher EPDS score was associated with less responsive feeding practices at child age 2 years: greater pressure [β = 0.18, 95% confidence interval (CI): 0.04–0.32, P = 0.01], restriction (β = 0.14, 95% CI: 0.001–0.28, P = 0.05), instrumental (β = 0.14, 95% CI: 0.005–0.27, P = 0.04) and emotional (β = 0.15, 95% CI: 0.01–0.29, P = 0.03) feeding practices (ΔR² values: 0.02–0.03, P < 0.05). This study provides evidence for the proposed link between maternal post‐natal depressive symptoms and lower responsiveness in child feeding. These findings suggest that the provision of support to mothers experiencing some levels of depressive symptomatology in the early post‐natal period may improve responsiveness in the child feeding relationship.     

Cytokines in human milk and late‐onset breast milk jaundice

Background: Maternal milk plays an important role in the development of late‐onset breast milk jaundice (BMJ), possibly due to the unique characteristics of breast milk. The aim of this study was to investigate whether there is a relation between cytokine concentrations in the milk of nursing mothers and BMJ. Methods: Breast milk samples were collected from breast‐feeding mothers of healthy full‐term neonates, 40 with BMJ and 40 without jaundice. Milk samples were taken between the second and the fourth postpartum week. The concentrations of interleukin (IL)‐1 β, IL‐6, IL‐8, IL‐10, and tumor necrosis factor‐α were measured by flow cytometric bead array. Results: There were significant differences between the study groups in terms of IL‐1 β concentrations (P= 0.013). Not statistically significant but similar trends were also seen for IL‐10 (P= 0.067) and tumor necrosis factor‐α (P= 0.053) concentrations. However, no significant differences were noted in IL‐6 (P= 0.174) and IL‐8 (P= 0.285) concentrations. Conclusions: IL‐1 β concentration seems to be increased in milk of mothers whose infants had BMJ. Although the effect of these cytokines on BMJ is unknown, it may cause prolonged jaundice via hepatic uptake, hepatic excretion, conjugation and intestinal absorption.     

Omega‐3 LCPUFA supplement: a nutritional strategy to prevent maternal and neonatal oxidative stress

There is controversy about fish‐oil supplementation and oxidative damage. This ambiguity should be explored to elucidate its role as modulator of oxidative stress, especially during gestation and postnatal life. This is the objective of this study. One hundred ten pregnant women were divided in two groups: control group CT (400 mL/day of the control dairy drink); supplemented group FO (400 mL/day of the fish oil‐enriched dairy drink (±400‐mg EPA‐DHA/day)). Different biomarkers of oxidative damage were determined in the mother's at enrolment, at delivery and at 2.5 and 4 months postpartum and newborns at delivery and at 2.5 months postpartum. Omega‐3 LC‐PUFA supplementation during pregnancy and lactation decreased plasma hydroperoxides especially in newborn at delivery (P = 0.001) and 2.5 months (P = 0.006), increased superoxide dismutase (SOD) and catalase (CAT) in mothers at delivery (P = 0.024 (SOD)) and after 2.5 months (P = 0.040 (CAT)) and in newborns at 2.5 months (P = 0.035 (SOD); P = 0.021 (CAT)). Also, supplementation increased α‐tocoferol in mothers at 2.5 months (P = 0.030) and in umbilical cord artery (P = 0.039). Higher levels of CoQ10 were found in mothers at delivery (P = 0.039) as well as in umbilical cord vein (P = 0.024) and artery (P = 0.036). Our supplementation prevents the oxidative stress in the mother and neonate during the first months of postnatal life, being a potential preventive nutritional strategy to prevent functional alterations associated with oxidative stress that have an important repercussion for the neonate development in the early postnatal life.     

Risk factors for small-for-gestational-age babies: The Auckland Birthweight Collaborative Study

OBJECTIVE: This case-control study determined whether internationally recognized risk factors for small-for-gestational-age (SGA) term babies were applicable in New Zealand. METHODOLOGY: All babies were born at 37 or more completed weeks of gestation in one of three hospitals in Auckland. Cases weighed less than the sex specific 10th percentile for gestational age at birth, and controls (appropriate-for-gestational-age (AGA)) were a random selection of heavier babies. Information was collected by maternal interview and from obstetric databases. RESULTS: Information from 1714 completed interviews (844 SGA and 870 AGA) was available for analysis. Computerized obstetric records were available for 1691 of the 1701 women who consented to such access. In a multivariate analysis allowing for sex, gestational age at birth, social class and other potential confounders, mothers who smoked had a significantly increased risk of an SGA baby (adjusted OR 2.41; 95% CI 1.78-3.28), as did primiparous mothers (adjusted OR 1.34; 95% CI 1.03-1.73), mothers of Indian ethnicity (adjusted OR 3.22; 95% CI 1.95-5.30), women with pre-eclamptic toxaemia (adjusted OR 2.42; 95% CI 1.08-5.40) and those with pre-existing hypertension toxaemia (adjusted OR 5.49; 95% CI 1.81-16.71). Mothers of SGA infants were shorter (P < 0.001) and reported lower prepregnancy body weights (P < 0.001) than mothers of AGA infants. The population attributable fraction for smoking suggests that up to 18% of SGA infants born in the ABC Study could be related to maternal smoking. CONCLUSIONS: Risk factors associated with SGA births in other countries are also important in New Zealand. Smoking in pregnancy is an important and potentially modifiable behaviour, and efforts to decrease the number of women who smoke during pregnancy should be encouraged.     

Periconceptional folic acid fortification for the risk of gestational hypertension and pre‐eclampsia: a meta‐analysis of prospective studies

Published literatures report controversial results about the association of folic acid–containing multivitamins with gestational hypertension and pre‐eclampsia. A comprehensive search was performed to identify related prospective studies to assess the effect of folic acid fortification on gestational hypertension and pre‐eclampsia. The Q test and I² statistic were used to examine between‐study heterogeneity. Fixed or random effects models were selected based on study heterogeneity. A funnel plot and modified Egger linear regression test were used to estimate publication bias. Eleven studies conformed to the criteria. Pooled results indicated that folic acid fortification alone was not associated with the occurrence of gestational hypertension [relative risk (RR) = 1.03, 95% confidence interval (CI): 0.98–1.09, P = 0.267] and pre‐eclampsia (RR = 0.99, 95% CI: 0.90–1.08, P = 0.738). However, supplementation of multivitamins containing folic acid could prevent gestational hypertension (RR = 0.57, 95% CI: 0.43–0.76, P < 0.001) and pre‐eclampsia (RR = 0.64, 95% CI: 0.48–0.84, P = 0.001). The difference between folic acid fortification alone and multivitamins containing folic acid was significant. This meta‐analysis suggests that periconceptional multivitamin supplementation with appropriate dose, not folic acid alone, is an appropriate recommendation for pregnant women. The effect should be further confirmed by conducting large‐scale randomised controlled trials.     

Coexisting micronutrient deficiencies among Sri Lankan pre-school children: a community-based study

Assessing micronutrient status in children may also have the benefit of addressing the problems of various micronutrient deficiencies with a unified programmatic approach on a public health scale. A cross‐sectional survey in the Galle district of the micronutrient and anthropometric status of 248 children of ages 3–5 years was performed to determine the prevalence of micronutrient deficiencies [iron, zinc (Zn), folate, calcium, caeruloplasmin, iodine, vitamin A and vitamin D] and the extent to which multiple micronutrient deficiencies coexist. The prevalence of anaemia [haemogbolin (Hb) < 110.0 g L^?1] was 34.0% in males and 33.0% in females (overall 33.5%, gender difference, P = 0.92). In anaemic children, 7.0% of males and 15.0% of females were iron deficient (serum ferritin < 15.0 µg L^?1). Folate deficiency (<3.00 ng mL^?1) was found in 41.0% and 33.0% of male and female, respectively, whereas Zn deficiency (<9.95 µmol L^?1) occurred in 57.0% and 50.0% of male and female, respectively. Serum vitamin D deficiency (<35.0 nmol L^?1) was found in 26% and 25% of male and female, respectively. Anaemic males had a 3.0‐fold (95% confidence interval (CI) 1.1–8.3) and 2.3‐fold (95% CI 0.8–6.6) greater risk of being underweight and thin, whereas the risk among anaemic females was 0.7‐fold (95% CI 0.3–1.8) and 0.9‐fold (95% CI 0.3–2.6) for being underweight and thin. Only 7.3% of the subjects did not have any micronutrient deficiency, 38.3% were deficient in two micronutrients, 17.7% had three micronutrient deficiencies and 6.0% had four or more micronutrient deficiencies. Multiple micronutrient deficiencies are prevalent in Sri Lankan pre‐school children and established baseline data for future studies.     

Effect of combined maternal and infant vitamin D supplementation on vitamin D status of exclusively breastfed infants

Severe vitamin D deficiency in mothers and their breastfed infants is a significant health problem in the Middle East. Supplementation of the breastfed infant alone with the recommended dose of vitamin D may be insufficient in high‐risk population. We investigated the effect of combined maternal and infant vitamin D supplementation on vitamin D status of the breastfed infant. We examined also the effect of supplementation on vitamin D antirachitic activity of breast milk in a subset of mothers. Healthy breastfeeding mothers (n = 90) were randomly assigned to 2000 IU daily (group 1) or 60 000 IU monthly (group 2) of vitamin D₂, and all their infants (n = 92) received 400 IU daily of vitamin D₂ for 3 months. Most infants had vitamin D deficiency – 25‐hydroxyvitamin D [25(OH)D] ≤ 37.5 nmol L^?1– at study entry. Serum 25(OH)D concentrations at 3 months increased significantly from baseline in infants of mothers in group 1 (13.9 ± 8.6 vs. 49.6 ± 18.5 nmol L^?1, P < 0.0001) and group 2 (13.7 ± 12.1 vs. 44.6 ± 15.0 nmol L^?1, P < 0.0001). Maternal and infant serum 25(OH)D concentrations correlated positively at baseline (r = 0.36, P = 0.01) and 3 months (r = 0.46, P = 0.002). Milk antirachitic activity increased from undetectable (<20 IU L^?1) to a median of 50.9 IU L^?1. In conclusion, combined maternal and infant vitamin D supplementation was associated with a threefold increase in infants’ serum 25(OH)D concentrations and a 64% reduction in the prevalence of vitamin D deficiency without causing hypervitaminosis D.     

Meta‐analysis of physiological effects of skin‐to‐skin contact for newborns and mothers

Background: Skin‐to‐skin care has been adopted all over the world, although physiological changes during or after it have not been evaluated very well. The purpose of the present study was therefore to investigate whether skin‐to‐skin contact for newborn babies and their mothers affects body temperature, heart rate and oxygen saturation of the babies. Methods: Studies investigating body temperature, heart rate and oxygen saturation of babies during and/or after skin‐to‐skin contact were systematically searched and reviewed. Meta‐analyses to examine the effects and meta‐regression analyses to investigate correlations between the effects and birthweight, duration of the care, environmental temperature, and resources of the setting, were conducted. Results: A total of 23 studies were included. Meta‐analyses showed evidence of an increase in body temperature (weighted mean difference [WMD] 0.22°C, P < 0.001) and a decrease in saturation of babies (WMD ?0.60%; P= 0.01) during skin‐to‐skin care, compared with those before skin‐to‐skin care. Increase in body temperature was more evident in middle–low‐income settings (WMD, 0.61°C, P < 0.001) than high‐income settings (WMD 0.20°C, P < 0.001). Both the positive effect on body temperature and the negative effect on saturation were more marked in cold environments than where the environmental temperature was higher (WMD 0.18°C, P < 0.001; WMD ?0.82%, P= 0.02). Conclusion: Skin‐to‐skin care is effective in increasing the body temperature of babies, especially where resources are limited and the environment is cold. Decreased oxygen saturation of the babies, however, warrants further prospective studies to confirm the findings.     

A study of serum zinc levels in cord blood of neonates and their mothers

Serum zinc was estimated in the cord blood of 60 neonates of different gestational age and birth weight, and their mothers. Mean serum zinc levels in neonates FTGA, PTAGA and term SGA were 128.88±14.37, 94.32±17.79 and 111.8±9.2 ug/dl respectively. The maternal serum zinc levels in corresponding groups was 96.28±19.48, 115.44±15.41 and 93.8±7.62 ug/dl. Thus mean serum zinc level in cord blood of FT AGA newborns was significantly higher than that in PT AGA and FT SGA. Mean serum zinc level in mothers of FT AGA was significantly lower than that in mothers of PT AGA. However, there was no significant difference between the maternal serum zinc levels of FT AGA and FT SGAs. There was positive correlation between gestational age and serum zinc level in cord blood of AGAs while correlation was negative in case of their mothers. There was positive correlation between weight (keeping gestational age constant) and serum zinc level in case of neonates while corresponding maternal zinc levels did not vary. (FT AGA and FT SGA).     

Micronutrient status differs among Maasai and Kamba preschoolers in a supplementary feeding programme in Kenya

Since 2001, ChildFund Kenya has supplied micronutrient fortified school meals to preschoolers from two tribes (Kamba and Maasai) attending early childhood development (ECD) centres in Emali, S.E. Kenya. Lack of information on the micronutrient status of the preschoolers prompted a cross‐sectional assessment of micronutrient (iron, zinc, selenium, vitamin A, vitamin D) status and prevalence of deficiencies among the two tribes. Data on sociodemographic, health, anthropometric status, and micronutrient supply from preschool meals were collected from 287 Kamba and 213 Maasai children aged 3 to 5 years attending 23 ECD centres. Nonfasting blood samples were collected for haemoglobin and plasma biomarkers of iron, zinc, selenium, vitamin A, vitamin D, C‐reactive protein (CRP), α₁‐acid glycoprotein, and immunoglobin G. The prevalence of anaemia was significantly higher in Maasai children than Kamba (38%, 95% CI [31%, 45%], vs. 5%, [3%, 9%]), as well as iron deficiency and its various stages (P < 0.001). No differences were seen in the prevalence of zinc, selenium, vitamin A, or vitamin D deficiencies (all P > 0.05). Body iron, CRP, and age were significant predictors of haemoglobin concentrations for both tribes (all P < 0.006) and plasma 25‐OHD for Maasai children only. The higher prevalence of iron deficiency among Maasai than Kamba children was possibly attributed to the high consumption of cow's milk (low in bioavailable iron) in place of micronutrient fortified meals together with a higher prevalence of chronic inflammation and intestinal damage.     

Effect of a low glycaemic index diet in gestational diabetes mellitus on post‐natal outcomes after 3 months of birth: a pilot follow‐up study

A low glycaemic index (LGI) diet during pregnancy complicated by gestational diabetes mellitus (GDM) may offer benefits to the mother and infant pair beyond those during pregnancy. We aimed to investigate the effect of an LGI diet during pregnancy complicated with GDM on early post‐natal outcomes. Fifty‐eight women (age: 23–41 years; mean ± SD pre‐pregnancy body mass index: 24.5 ± 5.6 kg m^?2) who had GDM and followed either an LGI diet (n = 33) or a conventional high‐fibre diet (HF; n = 25) during pregnancy had a 75‐g oral glucose tolerance test and blood lipid tests at 3 months post‐partum. Anthropometric assessments were conducted for 55 mother–infant pairs. The glycaemic index of the antenatal diets differed modestly (mean ± SD: 46.8 ± 5.4 vs. 52.4 ± 4.4; P < 0.001), but there were no significant differences in any of the post‐natal outcomes. In conclusion, an LGI diet during pregnancy complicated by GDM has outcomes similar to those of a conventional healthy diet. Adequately powered studies should explore the potential beneficial effects of LGI diet on risk factors for chronic disease.     

Birth size effect on pulmonary functions and atopic sensitization in preadolescence

Background: The purpose of the present paper was to examine whether low birth size is associated with reduced pulmonary function and increased atopic sensitization in preadolescence. Methods: A cohort of 25 small‐for‐gestational‐age (SGA) infants and an age‐ and sex‐matched comparison group of 29 appropriate‐for‐gestational‐age (AGA) infants born in 1993/94 were studied in preadolescence. Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and forced expiratory flow when 25–75% of FVC is expired (FEF_25–75%) were measured using a spirometer. Atopic sensitization was assessed on serum total IgE levels and skin prick tests (SPT) to common allergens. Results: There were positive correlations among FEV1 (r = 0.30, P = 0.001), FVC (r = 0.20, P = 0.03), and FEF_25–75% (r = 0.5, P = 0.001) and ponderal index (PI), although the FEV1/FVC ratio was not correlated with birth size. Mean value of serum total IgE was higher in SGA (106.0 ± 73.4 IU/mL) than AGA children (71.4 ± 67.1 IU/mL; P = 0.02). PI under 10th centile was associated with high IgE levels (P = 0.04, odds ratio, 3.2; 95%CI: 1.0–9.8). The overall prevalence of atopy was 14.8% and there was no significant difference between the groups (P > 0.05). Conclusion: Preadolescents who were born SGA with low birth size compared to controls had reduced pulmonary function. In preadolescence the prevalence of atopy is not higher in SGA than AGA children, although low PI at birth is associated with high IgE levels. Further follow up of this cohort is required to establish the pattern of pulmonary functions and atopic sensitizations in relation to birth size.     

Combined renin angiotensin blockade in childhood steroid‐resistant nephrotic syndrome

Background: Reduced proteinuria results in delayed deterioration of renal function and remission of proteinuria predicts a good long‐term prognosis in steroid‐resistant nephrotic syndrome (SRNS). The aim of this study was to analyze the effects of the combined angiotensin‐converting enzyme inhibitor and angiotensin II receptor blocker in reducing proteinuria in SRNS. Methods: A prospective study of eight patients with SRNS was conducted at the Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University from September 2003 to December 2007. Enalapril was given at 0.1 mg/kg/day and was increased by 0.1 mg/kg/day every 4 weeks up to 0.6 mg/kg/day (maximum 40 mg/day) and 1 mg/kg/day of losartan was added for 4 weeks and stepped up to 2 mg/kg/day (maximum 100 mg/day) for another 4 weeks. Results: There were five boys (62.5%) and three girls (37.5%). The mean age at diagnosis was 8.3 ± 4.1 years (range 2.05–13 years) and age at enrollment was 11.7 ± 3.8 years (range 6–16 years). Renal histology revealed seven focal segmental glomerulosclerosis and one immunoglobulin M nephropathy. The results showed significant reduction on mean spot urine protein : creatinine ratio from 9.6 ± 2.3 to 3.6 ± 1.6 (P < 0.05) and 24‐h urine protein from 182.8 ± 59.6 to 28.7 ± 8.2 mg/m²/h (P < 0.05). Urine protein reduction ratio at the end of the study was 50% (P= 0.08). Serum cholesterol, albumin, potassium, blood pressure and renal function had no significant change. No clinical and laboratory side‐effects were reported. Conclusion: Combined high‐dose angiotensin II receptor blocker to high‐dose angiotensin‐converting enzyme inhibitor therapy is safe and effective in reducing proteinuria in childhood SRNS. However a large‐scale study should be conducted to validate this result.     

Effectiveness of Baby‐friendly community health services on exclusive breastfeeding and maternal satisfaction: a pragmatic trial

The WHO/UNICEF Baby‐friendly Hospital Initiative has been shown to increase breastfeeding rates, but uncertainty remains about effective methods to improve breastfeeding in community health services. The aim of this pragmatic cluster quasi‐randomised controlled trial was to assess the effectiveness of implementing the Baby‐friendly Initiative (BFI) in community health services. The primary outcome was exclusive breastfeeding until 6 months in healthy babies. Secondary outcomes were other breastfeeding indicators, mothers' satisfaction with the breastfeeding experience, and perceived pressure to breastfeed. A total of 54 Norwegian municipalities were allocated by alternation to the BFI in community health service intervention or routine care. All mothers with infants of five completed months were invited to participate (n = 3948), and 1051 mothers in the intervention arm and 981 in the comparison arm returned the questionnaire. Analyses were by intention to treat. Women in the intervention group were more likely to breastfeed exclusively compared with those who received routine care: 17.9% vs. 14.1% until 6 months [cluster adjusted odds ratio (OR) = 1.33; 95% confidence interval (CI): 1.03, 1.72; P = 0.03], 41.4% vs. 35.8% until 5 months [cluster adjusted OR = 1.39; 95% CI: 1.09, 1.77; P = 0.01], and 72.1% vs. 68.2% for any breastfeeding until 6 months [cluster adjusted OR = 1.24; 95% CI: 0.99, 1.54; P = 0.06]. The intervention had no effect on breastfeeding until 12 months. Maternal breastfeeding experience in the two groups did not differ, neither did perceived breastfeeding pressure from staff in the community health services. In conclusion, the BFI in community health services increased rates of exclusive breastfeeding until 6 months. © 2015 Blackwell Publishing Ltd     

Comparison of low‐dose and high‐dose cosyntropin stimulation testing in children

Background: There is no consensus among pediatric endocrinologists in using low‐dose (LD) versus high‐dose (HD) cosyntropin to test for secondary/tertiary adrenal insufficiency. This paper compares LD and HD cosyntropin stimulation testing in children for evaluation of hypothalamic‐pituitary‐adrenal axis (HPAA) and suggests a new peak cortisol cut‐off value for LD stimulation testing to avoid false positivity. Methods: Data of 36 children receiving LD (1 µg) and HD (249 µg) cosyntropin consecutively during growth hormone (GH) stimulation testing were analyzed in two groups. Group A were patients who passed GH stimulation testing and were not on oral, inhaled or intranasal steroids (intact hypothalamic‐pituitary axis, n= 19). Group B were patients who failed GH stimulation testing and/or were on oral, inhaled or intranasal steroids (impaired hypothalamic‐pituitary axis, n= 17). Results: In group A, the mean peak cortisol response in LD cosyntropin was 18.5 ± 2.4 µg/dL and that for the HD cosyntropin was 24.8 ± 3.1 µg/dL (r: 0.76, P≤ 0.05). In group B, the mean peak cortisol response in LD cosyntropin was 15.7 ± 6.1 µg/dL and that for HD cosyntropin was 21.7 ± 7.9 µg/dL (r: 0.98, P≤ 0.05). When a standard cut‐off of 18 µg/dL was used, 37% of the patients with intact HPAA failed LD cosyntropin testing, but a cut‐off of 14 µg/dL eliminated false positive results. Conclusions: LD cosyntropin stimulation testing results should be interpreted cautiously when used alone to prevent unnecessary long‐term treatment. Using a lower cut‐off for LD (≥14 µg/dL) seems to avoid false positive results and still detects most cases of impaired HPAA.     

Gestational weight gain and obesity,adiposity and body size in African–American and Dominican children in the Bronx and Northern Manhattan

Gestational weight gain (GWG) is potentially modifiable and is associated with infant size and body composition; however, long‐term effects on childhood obesity have not been reported among multi‐ethnic urban populations. We examined the association between GWG and child anthropometric measures and body composition at 7 years [waist circumference (WC), body mass index z‐score (BMIZ), obesity (BMIZ ≥95%ile) and bioelectrical impedance analysis estimates of percentage body fat (%fat)] in African–American and Dominican dyads (n = 323) in the Columbia Center for Children's Environmental Health prospective birth cohort study from 1998 to 2013. Linear and logistic regression evaluated associations between excessive GWG [>Institute of Medicine (IOM) 2009 guidelines] and outcomes, adjusting for pre‐pregnancy BMI and covariates. Pre‐pregnancy BMI (mean ± standard deviation, all such values) and total GWG were 25.8 ± 6.2 kg m^?2 (45% overweight/obese) and 16.4 ± 7.9 kg (64% > IOM guidelines), respectively. Excessive GWG was associated with higher BMIZ {0.44 [95% confidence interval (CI): 0.2, 0.7], P < 0.001}, WC [β: 2.9 cm (95% CI: 1.1, 4.6), P = 0.002], %fat at 7 years [β: 2.2% (95% CI: 1.0, 3.5), P = 0.001)] and obesity [odds ratio: 2.93 (95% CI: 1.5, 5.8), P = 0.002]. Pre‐pregnancy BMI was positively associated with child size, adiposity and obesity (all P < 0.05). Excessive GWG was highly prevalent and was associated with child obesity, greater percentage body fat and abdominal adiposity. Strategies to support healthy GWG are warranted to promote healthy growth and prevent childhood obesity.     

The contribution of preterm birth and intrauterine growth restriction to childhood undernutrition in Tanzania

Objectives were to examine the growth patterns of preterm and growth‐restricted infants and to evaluate the associations of prematurity and intrauterine growth restriction (IUGR) with risk of stunting, wasting and underweight. Data from a cohort of HIV‐negative pregnant women–infant pairs were collected prospectively in Tanzania. Small for gestational age [SGA, birthweight (BW) <10th percentile] was used as proxy for IUGR. Anthropometry was measured monthly until 18 months. Length‐for‐age (LAZ), weight‐for‐length (WLZ), and weight‐for‐age (WAZ) z‐scores were calculated using the 2006 World Health Organization (WHO) Child Growth Standards. Stunting, wasting and underweight were defined as binary outcomes using a cut‐off of z‐scores. Multivariate Cox proportional hazard models were used to assess the associations between preterm and SGA to time to stunting, wasting and underweight. The study included 6664 singletons. Preterm and appropriate for gestational age (AGA) infants had slightly better nutritional status than term‐SGA infants and despite some catch‐up growth, preterm‐SGA infants had the poorest nutritional status. The gap in LAZ and WAZ z‐scores among the groups remained similar throughout the follow‐up. Compared with term‐AGA babies, relative risk (RR) of stunting among preterm‐AGA babies was 2.13 (95% confidence interval (CI) 1.93–2.36), RR among term‐SGA was 2.21 (95% CI 2.02–2.41) and the highest risk was among the babies who were both preterm and SGA (RR = 7.58, 95% CI 5.41–10.64). Similar magnitude of RR of underweight was observed among the three groups. Preterm and SGA infants should be closely monitored for growth failure. Intervention to reduce preterm and SGA birth may lower risk of undernutrition in resource‐limited settings.     

Changes in milk composition associated with pethidine‐PCEA usage after Caesarean section

The effect of pethidine as patient‐controlled epidural analgesia (PCEA) on specific biochemical components in breast milk in relation to the timing of secretory activation is not well investigated. The aim of this study was to compare biochemical timing of secretory activation between women who had a vaginal (V) or Caesarean birth with pethidine‐PCEA (CBP). Several milk samples were collected daily from 36 mothers (17 V, 19 CBP) for the first 265 h post‐partum. Protein and lactose concentrations and Na⁺ and K⁺ ion levels were measured. Samples were assigned to three time periods: 0–72, >72–165 and >165–265 h post‐partum for statistical analyses. Data were analyzed using linear mixed effect models. In the first 72 h post‐partum, the mean difference in lactose concentration was 5 gL^?1 higher in group V (P < 0.05). From >72–165 h post‐partum, protein and Na⁺ concentrations were lower in group V (P = 0.05, P = 0.02), and K⁺ levels were higher in group V (P < 0.001). From >165–265 h post‐partum, there were no significant differences between the groups. Biochemically, secretory activation had occurred by 72 h post‐partum in both groups. There were greater variations in measured biochemical components observed within group CBP initially. However, by 165 h post‐partum, there were no differences in the biochemical components between the groups. This suggests that effects of pethidine‐PCEA are diminished by 72 h post‐partum and undetected by 165 h.