Improving infant sleep and maternal mental health: a cluster randomised trial

Objectives

To determine whether a community‐delivered intervention targeting infant sleep problems improves infant sleep and maternal well‐being and to report the costs of this approach to the healthcare system.

Design

Cluster randomised trial.

Setting

49 Maternal and Child Health (MCH) centres (clusters) in Melbourne, Australia.

Participants

328 mothers reporting an infant sleep problem at 7 months recruited during October–November 2003.

Intervention

Behavioural strategies delivered over individual structured MCH consultations versus usual care.

Main outcome measures

Maternal report of infant sleep problem, depression symptoms (Edinburgh Postnatal Depression Scale (EPDS)), and SF‐12 mental and physical health scores when infants were 10 and 12 months old. Costs included MCH sleep consultations, other healthcare services and intervention costs.

Results

Prevalence of infant sleep problems was lower in the intervention than control group at 10 months (56% vs 68%; adjusted OR 0.58 (95% CI: 0.36 to 0.94)) and 12 months (39% vs 55%; adjusted OR 0.50 (0.31 to 0.80)). EPDS scores indicated less depression at 10 months (adjusted mean difference −1.4 (−2.3 to −0.4) and 12 months (−1.7 (−2.6 to −0.7)). SF‐12 mental health scores indicated better health at 10 months (adjusted mean difference 3.7 (1.5 to 5.8)) and 12 months (3.9 (1.8 to 6.1)). Total mean costs including intervention design, delivery and use of non‐MCH nurse services were £96.93 and £116.79 per intervention and control family, respectively.

Conclusions

Implementing this sleep intervention may lead to health gains for infants and mothers and resource savings for the healthcare system.

Trial registration

Current Controlled Trial Registry, number ISRCTN48752250 (registered November 2004).Maternal depression impacts adversely on maternal quality of life, mother–child relationships and child development.^1,2 Despite a prevalence of 15% in the first year postpartum,³ depression often remains undiagnosed and, even if detected, many mothers reject the diagnosis, the treatment or both.⁴Maternal depression is linked to poor infant sleep. Problems with frequent night waking and difficulties settling to sleep are reported by over a third of parents in the second 6 months of life^5,6 and are consistently associated with poor maternal health.^7,8,9In a previous efficacy trial, we demonstrated that treating infant sleep problems (simple behavioural techniques delivered in local well‐child centres over two to three sessions) significantly reduced maternal reports of depression symptoms as well as infant sleep problems.¹⁰ However, efficacy and generalisability may be limited by the predominantly middle‐class status of participating families and the fact that the intervention was delivered by a single paediatrician (HH). In another randomised trial,¹¹ a single, nurse‐led consultation emphasising ways to help very young infants settle to sleep independently resulted in intervention infants sleeping more than controls at age 12 weeks but in no change in maternal depression. All other sleep intervention trials have been limited by selection bias, small sample sizes, short follow‐up and/or lack of randomisation.¹²The trial reported here was conducted within an existing universally available, state‐wide primary health care service, training the well‐child care providers themselves to manage infant sleep problems in families from a broad sociodemographic sample. We hypothesised that a brief behavioural intervention designed to reduce infant sleep problems would result in improved infant sleep and maternal well‐being. We also documented the costs of the intervention and costs to the healthcare system.     

Role of home visiting in improving parenting and health in families at risk of abuse and neglect: results of a multicentre randomised controlled trial and economic evaluation

Objectives

To evaluate the effectiveness and cost effectiveness of an intensive home visiting programme in improving outcomes for vulnerable families.

Design

Multicentre randomised controlled trial in which eligible women were allocated to receive home visiting (n = 67) or standard services (n = 64). Incremental cost analysis.

Setting

40 general practitioner practices across 2 counties in the UK.

Participants

131 vulnerable pregnant women.

Intervention

Selected health visitors were trained in the Family Partnership Model to provide a weekly home visiting service from 6 months antenatally to 12 months postnatally.

Main outcome measures

Mother–child interaction, maternal psychological health attitudes and behaviour, infant functioning and development, and risk of neglect or abuse.

Results

At 12 months, differences favouring the home‐visited group were observed on an independent assessment of maternal sensitivity (p<0.04) and infant cooperativeness (p<0.02). No differences were identified on any other measures. A non‐significant increase in the likelihood of intervention group infants being the subject of child protection proceedings, or being removed from the home, and one death in the control group were found. The mean incremental cost per infant of the home visiting intervention was £3246 (bootstrapped 95% CI for the difference £1645–4803).

Conclusion

This intervention may have the potential to improve parenting and increase the identification of infants at risk of abuse and neglect in vulnerable families. Further investigation is needed, along with long‐term follow‐up to assess possible sleeper effects.Multiple studies undertaken over many years attest to the effect of parenting on the development of children and young people,^1,2 and on their mental^3,4,5 and physical health in adult life.^6,7 Good quality, timely support for parents has now been identified in national and international policy documents as important for reducing social inequalities in health,⁸ preventing mental illness,^9,10,11 and enhancing social and educational development.¹²Questions remain, however, about how best to enable improvements in parenting in vulnerable families where parenting skills are poor, social and environmental risk factors are high, and a considerable risk of abuse or neglect exists. Children growing up in such families have a high incidence of emotional and behavioural problems, school failure, delinquency in childhood and adolescence, and psychological and social difficulties as adults.¹³Home visiting programmes have been posited as one approach to supporting parenting in vulnerable families, and such programmes are now being used in countries such as the USA, Australia and New Zealand. Although the evidence base suggests that these programmes are not uniformly effective, recent reviews of reviews conclude that they can support parents, change parenting practices and improve infant outcomes.¹⁴ A small number of studies in the UK^15,16,17,18 have compared the effectiveness of different types of home visiting programmes with standard health visiting, but none has dealt with the effectiveness of such programmes with parents who have been identified prenatally as being at high risk of poor parenting.     

Postnatal factors associated with failure to thrive in term infants in the Avon Longitudinal Study of Parents and Children

Objective

To assess the contribution of postnatal factors to failure to thrive in infancy.

Methods

11 900 infants from the Avon Longitudinal Study of Parents and Children (ALSPAC), born at 37–41 weeks'' gestation, without major malformations and with a complete set of weight measurements in infancy (83% of the original ALSPAC birth cohort) were studied. Conditional weight gain was calculated for the periods from birth to 8 weeks and 8 weeks to 9 months. Cases of growth faltering were defined as those infants with a conditional weight gain below the 5th centile.

Results

Analysis yielded 528 cases of growth faltering from birth to 8 weeks and 495 cases from 8 weeks to 9 months. In multivariable analysis, maternal factors predicting poor infant growth were height <160 cm and age >32 years. Growth faltering between birth and 8 weeks was associated with infant sucking problems regardless of the type of milk, and with infant illness. After 8 weeks of age, the most important postnatal influences on growth were the efficiency of feeding, the ability to successfully take solids and the duration of breast feeding.

Conclusions

The most important postnatal factors associated with growth faltering are the type and efficiency of feeding: no associations were found with social class or parental education. In the first 8 weeks of life, weak sucking is the most important symptom for both breastfed and bottle‐fed babies. After 8 weeks, the duration of breast feeding, the quantity of milk taken and difficulties in weaning are the most important influences.Failure to thrive (FTT) is a term used to describe children whose growth is relatively poor in infancy,¹ and is associated with deficits in development and social interaction. As the most objective clinical finding associated with the condition of FTT is poor weight gain,² the term “growth faltering” is preferable for these infants as it avoids the pejorative use of the word “failure”.In the complex literature on FTT, many factors have been reported to be associated with the condition,³ including biological factors such as parental size,⁴ social factors including deprivation, maternal educational level and family size,⁵ and a wide range of physical conditions.⁶ In most cases, the final pathway is nutritional intake inadequate for the metabolic and growth needs of the child. However, although there is a large literature on the factors associated with FTT,³ many of the studies are limited as a result of small sample size, being hospital or clinic based, or using retrospective data—and the research field is plagued by diagnostic inconsistency between studies.¹ The Avon Longitudinal Study of Parents and Children (ALSPAC; http//www.alspac.bristol.ac.uk) provides a unique opportunity to investigate FTT in a whole population of infants, using prospectively collected information. We have already described the familial, social and prenatal factors associated with FTT in this cohort,⁴ and now report on the postnatal factors associated with poor infant growth.     

Perceptions of parents on the participation of their infants in clinical research

Objective

To analyse the motivations and perceptions of parents on the participation of their infants and young children in a comprehensive and invasive clinical research study.

Methods

Semistructured qualitative interviews were conducted with 23 mothers with asthma whose infants and young children were participating in the Copenhagen Prospective Study on Asthma in Childhood. The interviews were audiotaped, transcribed and analysed using the template analysis method.

Results

Parents were motivated by altruism and by the opportunity to get their child checked regularly by medical experts to prevent the possible development of asthma. Parents found it very important that their children enjoyed their visits to the research clinic, and that they could withdraw from the study if their child started responding negatively to those visits. No apparent difference was seen in the attitude between the parents of children with lung or skin symptoms and those of healthy children.

Conclusions

It is possible to design and accomplish invasive clinical research on infants and young children in a manner that parents find ethically sound.In recent years, various initiatives have aimed at furthering paediatric research, as the absence of adequate studies in the paediatric population has hampered progress in the care of children.^1,2 In the US, several laws have been enacted to make drug manufacturers test their products on children,^3,4,5 and in Europe, the European Research Commission has proposed granting companies testing their medicinal products on children an extended period of patent and data protection.⁶There is a growing body of literature discussing specific ethical dilemmas in relation to paediatric research, such as the inclusion of healthy children in non‐therapeutic research^2,7 and the role of children''s assent and dissent in decision making.^8,9 Considering the ethical debate about children as research subjects, it is relevant to investigate how parents and children perceive their participation in research.In this study, we report the perceptions of parents on the participation of their children in a birth cohort study associated with both therapeutic and non‐therapeutic invasive procedures, such as sedation and lung‐function testing at the age of 1 month, repeated skin tests and venepunctures. To our knowledge, this particular birth cohort study is the most comprehensive and invasive study on healthy infants and young children in recent years.     

Sudden infant death syndrome in infants born to HIV-infected and opiate-using mothers

Objective

This study was undertaken to determine the role of opiate use during pregnancy as a predisposing factor for sudden infant death syndrome (SIDS) in infants born to HIV‐infected mothers.

Methods

In order to identify all infant deaths and their cause and association with maternal opiate use, the data of a nationwide prospective cohort study of HIV‐infected mothers and their children were extracted and analysed for a 13‐year period.

Results

24 (5.1%) infant deaths were observed out of 466 infants followed up until death or at least 12 months of life. 3 (0.6%) of them were due to non‐accidental trauma and were not associated with maternal opiate use. 7 (1.5%) died due to SIDS, which was confirmed by autopsy. All SIDS cases occurred in infants born to mothers reporting use of opiates during pregnancy (n = 124). The relative risk of SIDS compared to the general population was 18 (95% CI 9 to 38) for all infants of HIV‐infected mothers, and 69 (95% CI 33 to 141) for those with intrauterine opiate exposure (p<0.001).

Conclusions

Compared to the Swiss general population, the risk for SIDS in this cohort of infants born to HIV‐infected mothers was greatly increased, but only for mothers reporting opiate use during pregnancy. This effect appeared not to be mediated by prematurity, low birth weight, perinatal HIV infection or antiretroviral drug exposure.The evidence for a link between opiate use and sudden infant death syndrome (SIDS) in the general infant population is inconsistent.^1,2,3,4 In infants of HIV‐infected mothers, an increased rate of verified SIDS possibly related to maternal opiate use was noted in several cohorts, namely 5/1000 live births in the European Collaborative Study,⁵ 6/1000 in France⁶ and 14/1000 in Switzerland.⁷ Thus, a detailed analysis of this link in the Swiss cohort was thought to be worthwhile.This study was undertaken to determine the frequency and causes of non‐HIV‐related infant deaths in the Swiss Mother & Child HIV Cohort (MoCHiV), with special attention given to SIDS and the role of maternal heroin and/or methadone consumption during pregnancy. In addition, the role of non‐accidental trauma and of potential risk factors such as prematurity, low birth weight, maternal HIV infection and antiretroviral medication, were explored.     

Size for gestational age at birth: impact on risk for sudden infant death and other causes of death, USA 2002

Background

Small for gestational age (SGA) infants have been reported to be at higher risk for sudden infant death syndrome (SIDS).

Objective

To compare the risk of SIDS among SGA and large for gestational age (LGA) infants with that of death from other causes of sudden unexpected deaths in infancy (SUDI) and the residual “other” causes of infant death.

Methods

The 2002 US period infant birth and death certificate linked file was used to identify infant deaths classified as SIDS (ICD‐10 code R95), SUDI (ICD‐10 codes R00‐Y84 excluding R95) or all other residual codes. The 2002 race and sex‐specific birth cohorts were used to generate the 10th and 90th percentiles of birth weight for each gestational age week from 24 to 42 weeks'' gestation. Demographic variables previously identified as associated with SIDS were used in multiple logistic regression equations to determine the risk for death among SGA and LGA infants (birth weight <10th percentile and >90th percentile, respectively) independent of other potentially confounding variables.

Results

Complete data on 1956 SIDS deaths, 2012 SUDI, and 11 592 other deaths were available. The adjusted OR for SIDS, SUDI and “other” causes for SGA infants was 1.65 (95% CI 1.47 to 1.85), 1.78 (1.59 to 2.00) and 4.68 (4.49 to 4.88), respectively. The adjusted OR for LGA infants was reduced for SIDS (0.73 (0.60 to 0.89)), SUDI (0.81 (0.68 to 0.98)) and “other” (0.42 (0.38 to 0.46)).

Conclusion

Although SGA infants seem to be at slightly increased risk for SIDS or SUDI their risk for “other” residual causes is about 2.5 times higher. LGA infants seem to be at reduced risk of mortality for all causes. The mechanisms by which restricted intrauterine growth increases risk of mortality and excessive intrauterine growth offers protective effects are uncertain.Small for gestational age (SGA) infants have been reported to be at 1.4 to 2.0 times greater risk for sudden infant death syndrome (SIDS).1,2,3,4,5 Other causes of death have also been reported to be associated with being SGA by some authors,6,7 in particular, preterm SGA infants are reported to have an increased risk of death ranging from 2.4 to 3.6 times that of appropriate for gestational age (AGA) preterm infants.8,9 Other authors, however, have observed no increase in risk for other causes of death among term SGA infants after adjusting for racial disparities in birth weight.10 The mechanisms associated with the increased risk for SIDS among SGA infants remain unclear, but some investigators have suggested that the risk may be secondary to the hypoxia these infants are suspected of being exposed to in utero.11,12 Why in utero hypoxia may make an infant more vulnerable to SIDS has been hypothesised to be related to a reduction of serotonergic receptors in multiple brainstem nuclei.13,14Despite the biological plausibility of the hypoxic‐related vulnerability of SGA infants for SIDS, comparative studies of just how much greater risk such an infant has for SIDS compared with other causes of death are not replete in the literature. Thus, the purpose of this analysis was to determine whether SGA infants were at greater risk for SIDS compared with other causes of death. The risk of large for gestational age (LGA) infants for SIDS has not been closely examined and an examination of this relationship was thus included in the analysis. Because of a trend towards the reclassification of SIDS deaths to other causes of sudden unexpected causes of death (SUDI),15 the risk of SUDI excluding SIDS for SGA infants as well as the risk of the remaining residual “other” causes of death among these infants was examined for the USA for the year 2002.     

Randomised trial of infant sleep location on the postnatal ward

Objective

To determine whether postnatal mother–infant sleep proximity affects breastfeeding initiation and infant safety.

Design

Randomised non‐blinded trial analysed by intention to treat.

Setting

Postnatal wards of the Royal Victoria Hospital (RVI), Newcastle upon Tyne, UK.

Participants

64 newly delivered mother–infant dyads with a prenatal intention to breastfeed (vaginal deliveries, no intramuscular or intravenous opiate analgesics taken in the preceding 24 h).

Intervention

Infants were randomly allocated to one of three sleep conditions: baby in mother''s bed with cot‐side; baby in side‐car crib attached to mother''s bed; and baby in stand‐alone cot adjacent to mother''s bed.

Main outcome measures

Breastfeeding frequency and infant safety observed via night‐time video recordings.

Results

During standardised 4‐h observation periods, bed and side‐car crib infants breastfed more frequently than stand‐alone cot infants (mean difference (95% confidence interval (CI)): bed v stand‐alone cot = 2.56 (0.72 to 4.41); side‐car crib v stand‐alone cot = 2.52 (0.87 to 4.17); bed v side‐car crib = 0.04 (−2.10 to 2.18)). No infant experienced adverse events; however, bed infants were more frequently considered to be in potentially adverse situations (mean difference (95% CI): bed v stand‐alone cot = 0.13 (0.03 to 0.23); side‐car crib v stand‐alone cot = 0.04 (−0.03 to 0.12); bed v side‐car crib = 0.09 (−0.03–0.21)). No differences were observed in duration of maternal or infant sleep, frequency or duration of assistance provided by staff, or maternal rating of postnatal satisfaction.

Conclusion

Suckling frequency in the early postpartum period is a well‐known predictor of successful breastfeeding initiation. Newborn babies sleeping in close proximity to their mothers (bedding‐in) facilitates frequent feeding in comparison with rooming‐in. None of the three sleep conditions was associated with adverse events, although infrequent, potential risks may have occurred in the bed group. Side‐car cribs are effective in enhancing breastfeeding initiation and preserving infant safety in the postnatal ward.Although the beneficial effects of early and frequent suckling and skin‐to‐skin contact on breastfeeding initiation are well known,^1,2,3,4,5,6 there has been little work on the effect of subsequent mother–infant contact in the initial postnatal days. Night‐time rooming‐in has been shown to enhance breastfeeding on demand in comparison with night‐time nursery care^7,8; however, “rooming‐in” involves babies sleeping in stand‐alone cots that do not allow continuous contact or spontaneous feeding between mothers and infants. Yet, such contact may be of importance for mothers to understand their babies'' signals and to respond effectively.Unhindered contact can only be provided for mother and baby at night in the postnatal ward through some arrangement whereby both of them can maintain continuous contact to allow spontaneous breastfeeding. Two forms of bedding‐in currently practised in UK hospitals include either the baby sleeping in the mother''s bed, usually with the provision of removable cot‐sides to prevent falls, or the baby sleeping in a side‐car crib that is attached to the frame of the mother''s bed and is enclosed on three sides, allowing the baby a separate sleep surface, but one that is contiguous with the mother''s bed. We also recognised that breastfeeding mothers commonly take their babies into their own beds for feeding, and that both parties often fall asleep in this situation, whether or not this was planned, or advised against by midwives, or whether appropriate cot‐sides were provided.We therefore designed a trial to determine the way in which different degrees of mother–infant contact in the immediate postnatal period affects infant care, including breastfeeding, and to ascertain whether infant safety is compromised when babies and mothers are in close proximity.     

Objective measurement of levels and patterns of physical activity

Objective

To measure the levels and patterns of physical activity, using accelerometers, of 11‐year‐old children participating in the Avon Longitudinal Study of Parents and Children (ALSPAC).

Design

Cross‐sectional analysis.

Setting

ALSPAC is a birth cohort study located in the former county of Avon, in the southwest of England. This study used data collected when the children were 11 years old.

Participants

5595 children (2662 boys, 2933 girls). The children are the offspring of women recruited to a birth cohort study during 1991–2. The median age (95% CI) of the children is now 11.8 (11.6 to 11.9) years.

Methods

Physical activity was measured over a maximum of 7 consecutive days using the MTI Actigraph accelerometer.

Main outcome measures

Level and pattern of physical activity.

Results

The median physical activity level was 580 counts/min. Boys were more active than girls (median (IQR) 644 (528–772) counts/min vs 529 (444–638) counts/min, respectively). Only 2.5% (95% CI 2.1% to 2.9%) of children (boys 5.1% (95% CI 4.3% to 6.0%), girls 0.4% (95% CI 0.2% to 0.7%) met current internationally recognised recommendations for physical activity. Children were most active in summer and least active in winter (difference = 108 counts/min). Both the mother and partner''s education level were inversely associated with activity level (p for trend <0.001 (both mother and partner)). The association was lost for mother''s education (p for trend = 0.07) and attenuated for partner''s education (p for trend = 0.02), after adjustment for age, sex, season, maternal age and social class.

Conclusions

A large majority of children are insufficiently active, according to current recommended levels for health.Regular physical activity in children is associated with improved health.^1,2,3 A recent systematic review of the evidence relating physical activity to health concluded that children should spend at least 60 min in moderate to vigorous physical activity (MVPA) each day, in order to promote a broad range of health improvements.³ Few studies^4,5,6 worldwide have collected objective physical activity data in large samples of children and we lack population‐based objective data describing levels and patterns of children''s activity. Nevertheless, physical activity is frequently implicated in the escalating levels of type 2 diabetes⁷ and obesity^8,9,10,11,12 in children. We report here on objectively measured physical activity levels and patterns in a large contemporary cohort of 11‐year‐old children—the Avon Longitudinal Study of Parents and Children (ALSPAC).     

MMR: marginalised,misrepresented and rejected? Autism: a focus group study

Objective

To explore how the measles, mumps, and rubella (MMR) vaccine controversy impacted on the lives of parents caring for children with autism.

Design

Qualitative focus group study.

Setting

United Kingdom.

Patients

A purposively selected sample of 38 parents took part in 10 focus group discussions between March 2003 and May 2005.

Results

Many parents felt that the MMR vaccine could be too potent for children who are susceptible to developing autism. Of the parents whose children received the MMR vaccine, many felt guilty that they may have caused or contributed to their child''s autism. Some parents felt frustrated by health professionals'' lack of understanding of the negative impact the MMR controversy has had on them. Some parents were anxious about subsequent MMR decision‐making for their children.

Conclusions

The controversy has had a negative impact on some parents of children with autism. This has implications for health professionals, who need to be particularly aware of the issues these parents face in future MMR decision‐making for their affected child and younger siblings. It is anticipated that these findings will raise awareness among health professionals of the difficulties faced by such parents. More generally, there is a need to promote a greater awareness of the important role health visitors can play in parental decision‐making and for research examining whether health professionals feel they receive sufficient training in communication skills. It is also essential that the latest scientific research findings are disseminated quickly to these parents and to those health professionals advising parents on matters of vaccine safety.The combined measles, mumps, and rubella (MMR) vaccine was introduced in the United Kingdom (UK) into the routine childhood immunisation programme in 1988, replacing the monocomponent measles vaccine, in order to eliminate measles, mumps and rubella and its associated congenital rubella syndrome.^1,2,3 By the early 1990s, MMR coverage for 2 year old children exceeded 90% nationally.⁴ However, just as rates of measles notification were reaching an all time low, speculation about the safety of the vaccine began to emerge. In February 1998, a paper was published postulating a link between the MMR vaccine, bowel disease and autism.⁵ Wakefield and colleagues hypothesised that the vaccine caused inflammation of the gut making it more permeable, permitting peptides to leak out, which in turn were said to act as toxins on the brain causing serious developmental disorders (including autism). The paper sparked immediate criticism and concern,^6,7,8,9 and researchers were quick to test Wakefield''s hypothesis. However, subsequent scientific support has been absent,^10,11 and further experiments designed to identify the measles virus in intestinal tissue¹² or blood¹³ have failed to find vaccine viruses. Furthermore, researchers have been unable to identify significant intestinal inflammation post‐vaccination¹⁴; large epidemiological studies have found no evidence of a new form of autism associated with MMR^15,16; there is no evidence of an increased incidence of autism related to the uptake of the MMR or measles vaccines^17,18; studies investigating severe adverse reactions to the MMR vaccine conducted in Finland^19,20 have failed to identify bowel problems or autism following vaccination; and a recent Cochrane review concluded that exposure to MMR was unlikely to be associated with autism.²¹

Box 1 Examples of parents comparing the general health of their children with and without autism

“they''re like chalk and cheese, she''s a much stronger child, she, she never had a thing where he was just sickly from day one. He''s always been a sickly child… he was always covered in spots, he was always on antibiotics, he always had tonsillitis, erm… he''s always had bowel problems, em…. He''s always had loads and loads of antibiotics. He''s got asthma and eczema, erm, so he''s always been on creams and lotions and potions and God knows what else. He''s got food allergies.… He''s very, very sensitive to whatever goes in his body. But as for our daughter she''s a much stronger child.” (G3: P9)“… his immune system is shot to pieces…. He, he does seem to be one of these children who follows the, the path for antibiotics and then vaccinations and then autism. When he gets a cough or a cold he seems to have it much, much longer whereas my other son can carry on functioning and going to school. But he just gets really ill… it puts him into hospital…. I actually asked the consultant before he discharged him last time. I said ‘you know, he does seem to be poorly a lot of the time, you know and he does have autism and I think there''s a link between his autism and his immune system'' and the consultant said ‘no, that''s absolutely not true, there''s no correlation between autism and the immune, his immune system''. He dismissed it – so I said ‘well okay'' but I just felt that I had to say something.” (G10: P36)Despite government and public health officials acting quickly to reassure parents that the MMR vaccine was not associated with autism, vaccine uptake dropped following the widespread media coverage of the MMR vaccine controversy (see: http://www.hpa.org.uk/infections/topics_az/vaccination/071102_MMRpreferable.htm). Recent research has investigated parents'' reasons for refusing the MMR vaccine and their perceptions of the MMR controversy. Evans and colleagues suggested that for many parents it is easier to live with the risk of their child naturally contracting one of the diseases than with the risk of causing their child damage through vaccination,²² a finding reminiscent of previous work on omission bias.^23,24 Raithatha et al²⁵ highlighted how parents'' assessment of vaccine risk is influenced by their attitudes to the immunisation process as well as by the degree of trust they have in government and health professionals. They warned that the MMR controversy may have triggered a broader reappraisal of vaccine risk, and proposed that in order to address parents'' fears about a causal link between autism and the MMR vaccine, further research into the aetiology of autism should be conducted. This was echoed in the recommendations from the Medical Research Council''s (MRC) review of autism research.²⁶Despite this growing evidence base on parental views of decision‐making about MMR,^22,23,24 there is a notable absence of scientific research reporting the views of one crucial group of parents, namely those caring for children with autism. To date their stories have been represented by journalists^27,28 or through a few books in which parents offer their personal accounts.^29,30,31,32 Horton³³ asserted that parents of children with autism: “… have become an even more marginalized group in the high‐temperature debate over Wakefield''s work” (p 92).

Box 2 Example of a mother recalling an adverse reaction to MMR vaccination

“He was ill. You know, when they''re really, really poorly and they''ve a temperature and they''ve just got that look of, I''m not here, that''s scary as a parent, you''re scared. And then when he finally kind of awoke, you know, he had the deadest eyes, it was like all the life had gone from his eyes. It was like before he was like a wee boy, twinkly eyes and after it, it was like the same eyeballs but as if, the glare had been taken out of them or something.” (G1: P1)Since the putative link with autism was central to the MMR controversy, it is important to understand the views of parents of children with autism both in terms of the impact of the controversy on them, and in determining whether the controversy has given rise to particular needs for information and support. We undertook a study to elicit the views of this neglected group of parents to develop a better understanding of how the MMR controversy impacted upon their lives, and to discover whether their experience can provide lessons for future immunisation policy and practice.     

Does parental body mass index status modify the associations among birth weight,early growth and childhood adiposity?

OBJECTIVES:

To examine the associations among birth weight, infant growth and childhood adiposity, and to test whether parental weight status modifies these associations.

METHODS:

The sample was comprised of 423 participants born at term who were an appropriate size for their gestational age from the Quebec Adipose and Lifestyle Investigation in Youth (QUALITY) study, a cohort of 630 children with a parental history of obesity. Infant growth velocity from zero to two years of age was estimated using slopes from simple linear regression for weight and body mass index (BMI) Z-scores. Child anthropometrics and body composition, and parental BMI were measured from eight to 10 years of age. Associations were modelled using multiple linear regressions.

RESULTS:

Increased birth weight and growth velocity independently predicted increased childhood adiposity. Effects of infant growth velocity on later adiposity were stronger with higher maternal BMI but not with higher paternal BMI. Similar interactions with birth weight were not found.

CONCLUSIONS:

Early childhood measures of growth and the mother’s BMI score should be included in investigations on obesity risk.     

Car seat test for preterm infants: comparison with polysomnography

Objectives

To monitor preterm infants in a cot and a car seat and compare an observed car seat trial with polysomnography (PSG).

Design

Non‐randomised controlled trial.

Setting

Regional neonatal unit.

Patients

Preterm infants before discharge.

Interventions

Nap PSG respiratory and sleep variables were measured including gastro‐oesophageal pH. Nurse observations included respiratory distress, apnoea measured by apnoea alarm, oxygen saturation and heart rate. Infants were studied supine in a cot and then in a car seat. Nursing observations were compared with PSG during the car seat trial only. Criteria for failure of the PSG and observed tests were predefined.

Main outcome measures

Difference in respiratory instability between cot and car seat. Concurrence regarding failure of the car seat trial between nurse‐observed data and PSG.

Results

20 infants (median gestation 33 weeks (range 28–35 weeks; median postmenstrual age (PMA) at study 36.5 weeks (range 35–38 weeks)) were studied. There were sufficient car seat data on 18 infants for comparison. There were fewer central apnoeas and arousals in the cot than the car seat (p = 0.047 and p = 0.024, respectively). Airway obstruction was not more common in the car seat. Younger PMA at time of study predicted failure in both car seat (p = 0.022) and cot (p = 0.022). The nurse‐observed test had low sensitivity for predicting PSG failure but more accurately predicted airway obstruction on PSG.

Conclusions

Immature infants exhibit respiratory instability in cots and car seats. A car seat test does not accurately detect all adverse events during sleep in the seat.Since concerns were first raised about the vulnerability of preterm infants during transportation,1,2 several studies have attempted to quantify the respiratory compromise experienced by these infants while in car seats.3,4,5,6,7,8,9,10,11,12,13 Many of these studies had methodological limitations as not all measured the sleep state, or used a supine position for comparison or airflow measures to detect obstructive apnoea, or allowed for differences in postmenstrual age (PMA) at study.Although car seat trial before discharge has been incorporated into many neonatal discharge practices it has not been universally accepted as the gold standard test for assessing risk of respiratory compromise in a car seat after discharge.14,15,16 Despite many neonatal nurseries implementing variations of the practice,14 criteria defining how premature infants should be monitored, how long to monitor or what constitutes failure of the test are lacking.15,17,18 Neonatal unit car seat testing programmes therefore vary in equipment type, quality, time and outcome data.14The present study aimed to examine respiratory variables during active and quiet sleep in preterm infants ready for discharge and compare variables recorded supine in a cot with those recorded supine in a car seat, in particular, to determine whether more obstructive events occurred after transfer to the car seat. A second aim was to compare car seat testing before discharge with concurrent polysomnography (PSG) recording to determine if a nurse‐observed test was a sensitive enough predictor of respiratory instability, and in particular airway obstruction, found on PSG.     

The significance of isolated elevation of serum aminotransferases in infants and young children

Introduction

The aim of this study was to assess the clinical significance and prognosis of a prolonged isolated elevation of serum aminotransferases without cholestasis (>3 months) in infants and young children, investigated for a variety of conditions, and to determine a protocol for their follow‐up and investigation.

Methods

A combined prospective‐retrospective analysis of apparently healthy babies and young children with isolated elevation of serum aminotransferases of at least 1.5 times above the norm for age which persisted for at least 3 months and whose creatine phosphokinase (CK), gamma glutamyltransferase (GGT), alkaline phosphatase and bilirubin levels remained normal throughout the study duration. The children underwent the following investigations: abdominal ultrasound and infectious, metabolic and/or immunological investigation depending on the duration of the abnormality.

Results

Six children were eliminated following the finding of positive cytomegalovirus (CMV) antigen in the urine. 72 children were investigated (47 males and 25 females). The duration of serum aminotransferases elevation was 3–36 months (average 12.4, median 11.5 months). The initial, maximal and final alanine aminotransferase (ALT) values were 85.5, 140.5 and 39.8 IU/l, respectively. Of seven children who had liver biopsies performed, three (42.8%) were suspected of having a glycogen storage disease which was not confirmed enzymatically. Four biopsies revealed non‐specific histological changes.

Conclusions

Isolated elevation of serum aminotransferases in healthy looking young children is mostly a benign condition that usually resolves within a year. If no pathology is found during routine investigation, these children can be followed conservatively. Liver biopsy does not contribute much to the diagnosis and is probably unnecessary.There is a plethora of literature on the investigation of the infant or child with cholestasis.^1,2,3,4 In the adult literature much attention is devoted to evaluation of the asymptomatic patient with abnormal liver enzymes.^{5,6,7,8,9,10,11,12,13,14} On the other hand, there are few if any studies on the investigation and prognosis of the asymptomatic infant or child with isolated elevation of serum aminotransferases. In most cases increased enzyme levels resolve within a few weeks and need no further evaluation. However, some of these apparently healthy subjects continue to exhibit high enzyme levels for several months.Therefore, the aim of the present study was to assess the clinical significance and prognosis of isolated elevation of serum aminotransferases without cholestasis (>3 months) in infants and young children, and to establish a protocol for their investigation and follow‐up.     

Zinc, copper, selenium and manganese blood levels in preterm infants

Objective

To measure the zinc, copper, selenium and manganese blood levels in a cohort of 68 preterm infants, and to establish any associations with growth and/or dietary intake.

Design

Blood samples were collected at an infant''s expected date of delivery (term) and 6 months later. Serum zinc, plasma copper and whole blood manganese were analysed by atomic absorption spectrometry, plasma and red cell selenium were determined by mass spectrometry. Growth and dietary intake determinations have been previously published.

Setting

Hampshire, England.

Results

Mean (SD) birth weight of the infants was 1.47 (0.434) kg and mean gestation was 31.4 (2.9) weeks. Mean blood levels at term and 6 months were: serum zinc 12.0 (2.6) µmol/l and 13.8 (2.5) µmol/l; plasma copper 10.1 (2.6) µmol/l and 19.2 (3.6) µmol/l; plasma selenium 0.49 (0.15) µmol/l and 0.72 (0.14) µmol/l; red blood cell selenium 1.68 (0.40) µmol/l and 1.33 (0.19) µmol/l; and blood manganese 320 (189) nmol/l and 211 (68) nmol/l, respectively. There were no significant associations between levels of zinc and copper and dietary intakes of those nutrients at either age (dietary intakes of selenium and manganese were not determined). Only copper levels at term were significantly associated (r = 0.31; p = 0.05) with a growth parameter (head circumference).

Conclusion

These results provide new information about trace element status in this vulnerable population.Trace elements are essential nutrients for metabolism, growth, and neurological and immunological function.1,2,3 Zinc is an important micronutrient that supports normal growth.2 Preterm infants are especially vulnerable to zinc deficiency.4,5 Selenium is an essential component of selenoproteins including the antioxidant glutathione peroxidase. At birth, blood levels of selenium are lower in preterm infants than in term infants and continue to fall until weaning is commenced.6,7,8 Copper is a cofactor in several metalloproteins, essential for oxidative metabolism, myelination and the metabolism of several steroid hormones.2 Clinical copper deficiency is a recognised hazard among preterm infants.9 Manganese is an essential micronutrient component of several enzymes including pyruvate carboxylase, mitochondrial superoxide dismutase and enzymatic systems of matrix turnover in skeletal growth.10,11 The measurement of the variation in trace element blood levels in preterm infants throughout infancy, and the range of levels associated with good development are important areas of research.We have previously reported a randomised clinical trial of a specially devised nutritional strategy in preterm infants.12 The trial aimed to analyse blood mineral levels at term (expected date of delivery) and 6 months'' gestation corrected age (GCA), and assess dietary intake and growth at these ages. As we did not find any significant differences in the blood levels of trace elements in the two arms of the trial, in this paper we report on the combined results of all infants enrolled in the trial to provide information on zinc, selenium, copper and manganese blood levels in a healthy population of UK preterm infants. The interaction between growth and dietary intake and blood biochemistry is also explored.     

Prevalence of nasopharyngeal carriage of pneumococcus in preschool children attending day care in London

Objective

To estimate the prevalence of nasopharyngeal (NP) carriage of pneumococcus (Streptococcus pneumoniae) and describe the antibiotic resistance patterns and serotypes in young children attending group day care in London.

Design and subjects

Cross‐sectional survey of attendees at a sample of registered child day care centres (CDCCs) in a London borough.

Setting

Urban setting with a socially and culturally diverse population.

Methods and outcomes

19 CDCCs (13% of total) participated between March and November 2003. A single NP swab was required from each child, and parents completed a questionnaire about their child''s health and attendance at day care. WHO methodology for pneumococcal carriage studies was followed.

Results

30% of parents consented. 234 swabs were collected from children aged 6 months to 5 years. 53% were boys and 81% were white. 120 children (51%, 95% CI 45% to 58%) carried pneumococci in their nasopharynx. None of the isolates were resistant to penicillin (upper CL 3%). 21 isolates were resistant to erythromycin (17.5%, 95% CI 11% to 25.5%). 68 isolates (57%) were serotypes included in the 7‐valent conjugate vaccine. Non‐white children had a lower prevalence of carriage (27% vs 58%).Conclusion: The prevalence of pneumococcal NP carriage was high. The penicillin resistance rate is lower than in many other countries and may reflect a decrease in community antibiotic prescribing in the UK. Monitoring circulating serotypes is important in the context of recent changes to the vaccination policy. Further study is required to explore the association with ethnicity and risk factors for antibiotic resistance.Out‐of‐home group childcare is associated with an increased risk of infectious illnesses^1,2,3 including invasive pneumococcal disease (IPD).⁴ Carriage studies in child day care centres (CDCCs) have shown increased risk of pneumococcal nasopharyngeal (NP) colonisation⁵ leading to concerns that CDCCs may act as foci for the emergence and transmission of antibiotic resistant organisms.^6,7Universal childhood vaccination against pneumococcal infection has been adopted in the US, and some European countries include attendance at day care as one of the risk factors for pneumococcal disease in their targeted vaccination strategies. The UK vaccination policy has recently changed to include universal vaccination.⁸ Previously only children who fell into certain clinical risk groups were recommended to be vaccinated either with the 7‐valent conjugate pneumococcal vaccine (under 5 years of age) or the 23‐valent polysaccharide vaccine and attendance at group day care was not regarded as a risk factor.Social changes in recent years have already led to many more children under the age of 5 attending group day care⁹ and a huge expansion of pre‐school day care provision is underway in England.¹⁰There are few UK data on pneumococcal carriage in the day care setting and this study was set up to address this gap. The aim was to determine the prevalence of pneumococcal carriage and resistance, and to describe the prevalent serotypes.     

New height, weight and head circumference charts for British children with Williams syndrome

Aim

To produce a growth reference for British children with Williams syndrome.

Methods

The children and adults recruited into the study were all affiliated to the Williams Syndrome Foundation, a parent support group founded in 1979. They have all been shown to have a deletion of chromosome 7q11.23. One growth nurse (WRS) prospectively measured the weight, height and head circumference of individuals from 19 regions in Great Britain including Scotland, England and Wales. 169 children and adults were measured on up to four occasions between 2001 and 2004 (275 measurements). In addition, retrospective data were obtained from the hospital notes of 67 of these individuals (586 measurements). Centile curves were constructed using Cole''s LMS method.

Results

The centile charts differ from charts previously derived in the USA and Germany and provide more appropriate standards for the British population.

Conclusions

We propose that these charts be adopted for routine clinical practice as abnormalities in growth are an important feature of this syndrome.Short stature is a recognised feature of Williams syndrome. This syndrome was first described in 1961 as a triad of supravalvular aortic stenosis, learning difficulties and unusual facial features.¹ It was quickly recognised as being linked with infantile hypercalcaemia and in 1993, Ewart et al demonstrated the presence of a micro deletion on chromosome 7 (del 7q11.23) in all children with this syndrome.^2,3 To date, 28 genes have been detected within this region, including the elastin gene. The genes responsible for the developmental abnormalities and hypercalcaemia remain to be determined. A number of large cohort studies have described the presence of low birth weight, failure to thrive in infancy, short stature and precocious puberty.^4,5,6 In addition to congenital heart disease and infantile hypercalcaemia, children with Williams syndrome have been described as having hypothyroidism,⁷ growth hormone insufficiency^8,9 and coeliac disease.¹⁰ These diverse conditions make accurate assessment of growth an essential requirement of health surveillance.Morris et al produced growth charts for children with Williams syndrome in 1988 from retrospective, cross‐sectional data collected from American children attending either their clinic in Salt Lake City, Utah or a Williams Syndrome National Association meeting in 1986.¹¹ The mean adult heights of males and females were 167 and 157 cm, respectively. Pankau et al published retrospective data from a cohort of German children with Williams syndrome and in this population mean adult heights for males and females were 168 and 154 cm, respectively.¹² Both these studies were published before the gene deletion had been identified. Partsch et al subsequently documented a prospective study of a cohort of the same German children in 1999 but again the diagnosis was only confirmed genetically in 44% of cases.⁶ Mean adult heights for this cohort of males and females were 165 and 152 cm, respectively. The most recent British data were published by Martin et al in 1984 and in that cohort mean adult heights for males and females were 159 and 147 cm, respectively. Therefore, we identified the need for a contemporary British growth reference for children with genetically diagnosed Williams syndrome.⁴     

Accuracy of parents and health care professionals at estimating infant emesis volume

OBJECTIVE

To quantify visual estimation inaccuracies of infant emesis by parents and caregivers (P/Cs) and health care professionals (HCPs).

METHODS:

A single-blinded survey was performed in which P/Cs and HCPs visually estimated predetermined volumes of simulated emesis spilled on receiving blankets or pyjamas.

RESULTS:

HCPs’ estimations of volumes 1 and 3 were 150.4% and 145.1%, respectively, of the actual volumes, and their estimations of volumes 2 and 4 were 81.9% and 85.8%, respectively, of the actual volumes. This was, on average, significantly more accurate than the P/Cs’ estimations (P<0.001 to P=0.002), which ranged from 130.4% to 275.7% of the actual volumes.

CONCLUSION:

P/Cs and HCPs were, on average, highly inaccurate at visually estimating simulated emesis volume, an important consideration when making clinical judgments based on these estimations. In addition, HCPs now have an evidence-based tool to use in their practice when reassuring and counselling anxious parents.     

Selective ambulatory management of Plasmodium falciparum malaria in paediatric refugees

Background

Plasmodium falciparum (Pf) malaria is a leading cause of childhood mortality and morbidity. In developed countries, it is widely recommended that even patients with uncomplicated Pf malaria are hospitalised for at least 24 h, whereas ambulatory treatment is usual for uncomplicated infections in developing countries. This observational study assessed the safety of selective admission of paediatric refugees with Pf malaria in Australia.

Methods

Data were collected on African humanitarian refugee children (<16 years of age) presenting with malaria between February 2005 and April 2006. Children were treated as outpatients if they fulfilled specific criteria devised to maximise the safety of outpatient management of this potentially life‐threatening condition.

Results

Ninety paediatric refugees were infected with P falciparum, of whom 56 were treated as outpatients. Of the 34 children admitted to hospital, four had parasite loads ⩾4%. Most children were treated with oral atovaquone‐proguanil. Eighty eight patients attended follow‐up; all were compliant and none reported side‐effects. One infant failed treatment and was subsequently readmitted; he did not meet criteria for severe malaria on either occasion and had been initially treated as an inpatient.

Conclusions

Using this protocol, outpatient management of refugee children with Pf malaria appears safe, with minimal complication and treatment failure rates. This approach has rationalised management of paediatric malaria in this carefully selected population and substantially reduced utilisation of hospital resources.Malaria is responsible for considerable global mortality and morbidity and accounts for up to 20% of childhood deaths in Africa.¹Plasmodium falciparum (Pf) malaria has a significant case‐fatality rate even when managed appropriately.² Prompt recognition and treatment is essential in the non‐immune patient and in young children, who are at increased risk of rapid deterioration and death.³ In Australia, as in the US⁴ and Canada,⁵ there has been a increase in the incidence of malaria in recently resettled African refugees.^6,7,8Current guidelines generally advocate mandatory admission to hospital of all children with Pf malaria in developed countries,^9,10,11 but there is little evidence to support this recommendation. This study evaluated the safety of selective ambulatory management of African refugee children with Pf malaria in Australia.     

Nosocomial infection in small for gestational age newborns with birth weight <1500 g: a multicentre analysis

Objective

To investigate whether preterm newborns who are small for gestational age are at increased risk of nosocomial infections and necrotising enterocolitis.

Design, setting and subjects

The German national surveillance system for nosocomial infection in very low birthweight infants uses the US Centers for Disease Control and Prevention criteria. 2918 newborns (24–28 weeks), born between 2000 and 2004, were selected after application of predefined inclusion criteria to ensure similar proportions of small and appropriate weight for gestational age newborns across gestational age groups.

Main outcome measures

The outcome criterion was at least one episode of nosocomial sepsis, pneumonia or necrotising enterocolitis. Adjusted odds ratios and corresponding 95% CIs were calculated based on general estimating equation models.

Results

The study population consisted of 13% (n = 392) small and 87% (n = 2526) appropriate weight for gestational age infants. 33% (n = 950) of the infants experienced at least one episode of sepsis: 42% (n = 163) of small and 31% (n = 787) of appropriate weight for gestational age newborns (adjusted OR 1.41, 95% CI 1.05 to 1.89). Pneumonia was diagnosed in 6% (n = 171) of infants: 8.4% (n = 33) of small and 5.5% (n = 138) of appropriate weight for gestational age newborns (adjusted OR 1.57, 95% CI 1.19 to 5.57). Necrotising enterocolitis was documented in 5.2% (n = 152) of infants: 7.1% (n = 28) of small and 4.9% of (n = 124) appropriate weight for gestational age newborns (adjusted OR 1.20, 95% confidence interval 0.75 to 1.94).

Conclusions

Growth‐retarded preterm infants seem to be at increased risk of nosocomial infection, irrespective of the responsible pathogen. Future immunological research should elucidate potential causal associations.Very low birthweight (VLBW, <1500 g) newborns are at increased risk of morbidity and mortality. Besides their immaturity, risk profiles can vary due to a multitude of factors. Growth retardation is one factor conferring additional risk. Recent studies have consistently shown an increased mortality risk for small for gestational age (SGA) infants,1,2,3 but results regarding morbidity are conflicting.4,5,6Nosocomial infection has a large impact on neonatal survival and has important cost implications,7,8 affecting up to 40% of babies in neonatal intensive care units (NICUs).9,10,11,12,13 Immunological immaturity (eg, poor phagocytosis or hypogammaglobinaemia), exposure to invasive procedures and prolonged hospitalisation predispose VLBW newborns to nosocomial infection.7,14,15 However, little is known about nosocomial infection in SGA newborns.4,11,16,17,18,19We addressed this issue in a large, multicentre analysis to investigate the association of being SGA and being at increased risk of nosocomial infection—that is, sepsis and pneumonia. In addition, necrotising enterocolitis (NEC) was considered as an outcome criterion.