Effects of exclusive formula or breast milk feeding on oxidative stress in healthy preterm infants

Background

Compared to formula, breast milk is considered to have superior antioxidant properties and consequently may reduce the occurrence of a number of diseases of prematurity associated with oxidative stress.

Aims

To test whether the antioxidant properties of breast milk in healthy premature infants are different to those of formula milk by comparing vitamin E levels in milk and determining the excretion of malondialdehyde (MDA) in urine.

Methods

Vitamin E was measured in the breast milk of 20 mothers who had given birth prematurely. Urinary MDA was measured in 10 exclusively breast milk fed and 10 exclusively formula fed healthy preterm infants receiving no vitamin supplements. MDA was measured after derivatisation with 2,4‐dinitrophenylhydrazine and consecutive HPLC with UV detection.

Results

Urinary MDA concentrations were consistently very low (0.074±0.033 μM/mM Cr and 0.078±0.026 μM/mM Cr in breast and formula fed infants respectively) and not significantly different between healthy breast milk and formula fed infants. Both breast and formula milk contained satisfactory levels (0.3–3.0 mg/100 ml) of vitamin E.

Conclusion

Antioxidant properties of both breast milk and formulae are sufficient to prevent significant lipid peroxidation in healthy premature infants.     

An 8 year study of risk factors for SIDS: bed-sharing versus non-bed-sharing

Background

It is unclear if it is safe for babies to bed share with adults. In Ireland 49% of sudden infant death syndrome (SIDS) cases occur when the infant is bed‐sharing with an adult.

Objective

To evaluate the effect of bed‐sharing during the last sleep period on risk factors for SIDS in Irish infants.

Design

An 8 year (1994–2001) population based case control study of 287 SIDS cases and 831 controls matched for date, place of birth, and sleep period. Odds ratios and 95% confidence intervals were calculated by conditional logistic regression.

Results

The risk associated with bed‐sharing was three times greater for infants with low birth weight for gestation (UOR 16.28 v 4.90) and increased fourfold if the combined tog value of clothing and bedding was ⩾10 (UOR 9.68 v 2.34). The unadjusted odds ratio for bed‐sharing was 13.87 (95% CI 9.58 to 20.09) for infants whose mothers smoked and 2.09 (95% CI 0.98 to 4.39) for non‐smokers. Age of death for bed‐sharing and sofa‐sharing infants (12.8 and 8.3 weeks, respectively) was less than for infants not sharing a sleep surface (21.0 weeks, p<0.001) and fewer bed‐sharing cases were found prone (5% v 32%; p = 0.001).

Conclusion

Risk factors for SIDS vary according to the infant''s sleeping environment. The increased risk associated with maternal smoking, high tog value of clothing and bedding, and low z scores of weight for gestation at birth is augmented further by bed‐sharing. These factors should be taken into account when considering sleeping arrangements for young infants.     

The influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive): data from a prospective birth cohort

Aims

To study the influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive) in the first year of life.

Methods

The Gateshead Millennium Baby Study is a population birth cohort in northeast England studied prospectively from birth, via parental questionnaires and a health check aged 13 months. Data were collected on maternal education, deprivation, eating attitudes, and depression, using the Edinburgh Post Natal Depression Scale (EPDS) at 3 months. Weight gain was assessed using change in weight SD score, conditional on birth weight (Thrive Index); weight faltering was defined as conditional weight gain below the 5th centile.

Results

Of 923 eligible infants born at term, 774 (84%) had both weight and questionnaire data. Replicating a previous finding, both the highest and the lowest levels of deprivation were associated with weight faltering; this was independent of the type of milk feeding. No relation was found with maternal educational status. Maternal eating restraint was unrelated to weight gain. Infants of mothers with high depression symptom scores (EPDS >12) had significantly slower weight gain and increased rates of weight faltering up to 4 months (relative risk 2.5), especially if they came from deprived families, but by 12 months they were no different from the remainder of the cohort.

Conclusions

In this setting, social and maternal characteristics had little influence on infants'' weight gain, apart from a strong, but transient effect of postnatal depression.     

A low cost, colour coded, hand held spring scale accurately categorises birth weight in low resource settings

Aims

To determine the accuracy of a low cost, spring calibrated, hand held scale in classifying newborns into three weight categories (⩾2500 g, 2000–2499 g, <2000 g).

Methods

The test device was compared to a gold standard digital baby scale with precision to 2 g. In Sarlahi district, Nepal, 1890 newborns were eligible for the study. Measurements were collected for both the test device and the digital scale from 1820 (96.3%) newborns.

Results

The overall low birth weight (LBW) prevalence rate for the gold standard digital scale was 28.1% (511/1820). Sensitivity (93.7%) and specificity (97.6%) of the test device was high compared to LBW classifications based on digital weight measurements. Classification of infants into the <2000 g category was 5.0% and 4.7% for the gold standard and test device, respectively. Sensitivity and specificity of the test device in identifying infants <2000 g was 87.8% and 99.6%, respectively. Positive predictive values were high (>91%) for both weight categories

Conclusions

This low cost, simple‐to‐use device classified infants into weight categories with a high degree of consistency and accuracy that exceeds that of surrogate measures. This new device is useful for identifying and targeting life saving interventions for LBW, high risk infants in settings where infants are born in the home and conventional weighing scales are unavailable.     

Sudden infant death syndrome and sleeping position in pre-term and low birth weight infants: an opportunity for targeted intervention

Aims

To determine the combined effects of sudden infant death syndrome (SIDS) risk factors in the sleeping environment for infants who were “small at birth” (pre‐term (<37 weeks), low birth weight (<2500 g), or both).

Methods

A three year population based, case‐control study in five former health regions in England (population 17.7 million) with 325 cases and 1300 controls. Parental interviews were carried out after each death and reference sleep of age matched controls.

Results

Of the SIDS infants, 26% were “small at birth” compared to 8% of the controls. The most common sleeping position was supine, for both controls (69%) and those SIDS infants (48%) born at term or ⩾2500 g, but for “small at birth” SIDS infants the commonest sleeping position was side (48%). The combined effect of the risk associated with being “small at birth” and factors in the infant sleeping environment remained multiplicative despite controlling for possible confounding in the multivariate model. This effect was more than multiplicative for those infants placed to sleep on their side or who shared the bed with parents who habitually smoked, while for those “small at birth” SIDS who slept in a room separate from the parents, the large combined effect showed evidence of a significant interaction. No excess risk was identified from bed sharing with non‐smoking parents for infants born at term or birth weight ⩾2500 g.

Conclusion

The combined effects of SIDS risk factors in the sleeping environment and being pre‐term or low birth weight generate high risks for these infants. Their longer postnatal stay allows an opportunity to target parents and staff with risk reduction messages.     

Vaccine-related pain: randomised controlled trial of two injection techniques

Objective

To compare acute pain response during immunisation in infants using a slow standard of care injection technique versus a rapid pragmatic technique.

Design

Randomised controlled trial.

Setting

Single‐centre, urban paediatric primary care practice.

Subjects

Healthy infants 4–6 months of age receiving their routine DPTaP‐Hib immunisation.

Interventions

Standard of care group: slow aspiration prior to injection, slow injection and slow withdrawal. Pragmatic group: no aspiration, rapid injection and rapid withdrawal.

Main outcome measures

Immediate infant pain measured by the Modified Behavior Pain Scale (MBPS), crying and parent/paediatrician visual analogue scale (VAS).

Results

113 infants participated; there were no observed differences in age, birth order or prior analgesic use. Mean MBPS scores (95% confidence interval (CI)) were higher (p<0.001) for the standard group compared to the pragmatic group, 5.6 (5 to 6.3) vs 3.3 (2.6 to 3.9). The standard group was more likely to cry, 47/57 (82%) vs 24/56 (43%), to cry longer, median (interquartile range (IQR)) 14.7 s (8.7–35.6) vs 0 s (0–11.30), and to take longer to have the vaccine injected, median (IQR) 8.8 s (7.9–10.3) vs 0.9 s (0.8–1.1), p<0.001 for all comparisons. The median (IQR) VAS scores by parents and paediatricians were higher for the standard group: VAS parent, 3.5 (1.6–5.5) vs 1.9 (0.1–3.1) and VAS paediatrician, 2.8 (2.0–5.1) vs 1.4 (0.2–2.4). There were no adverse events.

Conclusion

Immunisation using a pragmatic rapid injection technique is less painful than a slow standard of care technique and should be recommended for routine intramuscular immunisations.     

Improvement in screening performance and diagnosis of congenital hypothyroidism in Scotland 1979-2003

Aim

To assess the Scottish newborn screening programme for congenital hypothyroidism from 1994 to 2003 (period 2) for performance and compare with an initial audit covering 1979 to 1993 (period 1).

Design

Performance data—age at blood spot sampling, notification by screening laboratory, start of treatment, and the prevalence of late testing, notification or treatment—were compared, together with the incidence of congenital hypothyroidism.

Results

Comparing data for period 2 with period 1, the mean annual incidence of true congenital hypothyroidism was 1:3655 live births v 1:4363. Median age for Guthrie sampling (all referrals) was 6 v 7 days (p<0.0001). Late sampling (>10 days) had fallen from 10.7% to 7%. For infants requiring repeat sampling before notification, the median (range) interval between initial and final repeat samples was 11 (1 to 52) compared with 14 (3 to 73) days. Median age at notification for true congenital hypothyroidism was 10 v 12 days (p <0.0001). Late notification (>15 days) was justifiable (mild TSH elevation) in 10 of 13 patients in period 2. Median age at start of treatment for true congenital hypothyroidism had improved to 11 days from 13.5 days. For true congenital hypothyroidism, late treatment (>16 days) occurred in 7% of patients compared with 19% (p<0.0001).

Conclusions

There has been an improvement in performance measures for the congenital hypothyroidism screening programme in Scotland. However, late sampling, occurring primarily in inpatients and which is never justified, remains a problem, while the interval between initial and recall sampling is a further source of delay.     

Randomised trial of a parenting intervention during neonatal intensive care

Objective

To evaluate the influence of parenting intervention on maternal responsiveness and infant neurobehavioural development following a very premature birth.

Design

Cluster‐randomised controlled trial, with a crossover design and three‐month washout period.

Setting

Six neonatal intensive care units.

Patients

Infants born <32 weeks'' gestation.

Intervention

The Parent Baby Interaction Programme (PBIP) is a supportive, educational intervention delivered by research nurses in the neonatal intensive care unit, with optional home follow‐up for up to six weeks after discharge.

Main outcome measures

Parenting stress at 3 months adjusted age, as measured by the Parenting Stress Index (PSI). Other outcomes included the Neurobehavioural Assessment of the Preterm Infant (NAPI) and maternal interaction as assessed by the Nursing Child Assessment Teaching Scale (NCATS) and the responsivity subscale for Home Observation for Measurement of the Environment (HOME).

Results

112 infants were recruited in the intervention phases and 121 in the control phases. Mean standardised NAPI scores at 35 weeks did not differ between the PBIP and control groups. Both groups had low but similar NCATS caregiver scores before discharge (36.6 in the PBIP group and 37.4 in control, adjusted mean difference −0.7, 95% CI −2.7 to 1.4). At three months, adjusted age mean PSI scores for the PBIP group were 71.9 compared with 67.1 for controls (adjusted mean difference 3.8, 95% CI −4.7 to 12.4). NCATS scores and HOME responsivity scores were similarly distributed between the groups.

Conclusion

This early, nurse‐delivered, parent‐focused interaction programme intervention had no measurable effects on short‐term infant neurobehavioural function, mother–child interaction or parenting stresses.     

High prevalence of vitamin D deficiency in newborn infants of high-risk mothers

Objective

To determine the prevalence of vitamin D deficiency in newborn infants of mothers at risk of vitamin D deficiency because of dark skin or the wearing of concealing clothes (such as a veil) compared with a group presumed not to be at risk. A second aim was to correlate these newborn infants'' vitamin D concentrations with biochemical parameters of vitamin D metabolism and bone turnover at birth.

Design

A prospective study conducted between April 2004 and February 2006 including women delivering during this period and their newborn infants.

Setting

The outpatient clinic of the obstetrics department, Sint Franciscus Gasthuis, Rotterdam, the Netherlands.

Patients

Eighty seven newborn infants of healthy mothers with either dark skin and/or concealing clothing (risk group) or light skin (control group).

Results

We found a significant difference in the prevalence of vitamin D deficiency (25‐hydroxyvitamin D₃ <25 nmol/l) between newborn infants of mothers at risk and those of mothers in the control group (63.3% vs 15.8%; p<0.001). Mean alkaline phosphatase concentrations were significantly higher in the at risk group.

Conclusions

Newborn infants of mothers with dark skin or wearing concealing clothes are at great risk of vitamin D deficiency at birth. The clinical implications are unknown. Further research is necessary to determine the long‐term consequences of maternal and neonatal vitamin D deficiency so that guidelines on vitamin D supplementation during pregnancy can be issued.     

Prevalence rates for constipation and faecal and urinary incontinence

Objective

To evaluate the prevalence rates for constipation and faecal and urinary incontinence in children attending primary care clinics in the United States.

Methods

Retrospective review of case records of all children, 4–17 years of age, seen for at least one health maintenance visit during a 6 month period and followed from birth or within the first 6 months of age in our clinics. We reviewed all charts for constipation, faecal incontinence and urinary incontinence.

Results

We included 482 children in the study, after excluding 39 children with chronic diseases. The prevalence rate for constipation was 22.6% and was similar in boys and girls. The constipation was functional in 18% and acute in 4.6%. The prevalence rate for faecal incontinence (⩾1/week) was 4.4%. The faecal incontinence was associated with constipation in 95% of our children. The prevalence rate for urinary incontinence was 10.5%; 3.3% for daytime only, 1.8% for daytime with night‐time and 5.4% for night‐time urinary incontinence. Faecal and urinary incontinence were significantly more commonly observed in children with constipation than in children without constipation.

Conclusion

The prevalence rates were 22.6% for constipation, 4.4% for faecal incontinence and 10.5% for urinary incontinence in a US primary care clinic. Children with constipation had higher prevalence rates for faecal and urinary incontinence than children without constipation. Boys with constipation had higher rates of faecal incontinence than girls with constipation.     

Is omitting post urinary‐tract‐infection renal ultrasound safe after normal antenatal ultrasound? An observational study

Background

Guidelines recommend obtaining a renal ultrasonogram (RUS) for young children after a first urinary tract infection (UTI).

Objective

The aim of the current study was to assess the concordance of prenatal and post‐UTI RUS findings in children with a first simple UTI.

Methods

This was a prospective study and included all children aged 5 years or younger who were hospitalised with a first simple UTI (determined as clinical response and normalisation of temperature within 48 h on initiation of antibacterial therapy with no complications). Data were collected from each child regarding the results of prenatal and post‐UTI RUS.

Results

Overall, 250 children were included in the study and the results of late‐pregnancy and post‐UTI RUS were available for 84% (n = 209). Complete concordance between the two RUS was demonstrated in 96% (n = 201). The predictive value of normal antenatal to normal post‐UTI RUS was 96% (95% CI: 93% to 99%). These results include four children with mild transient pelvic dilatation. In eight children in whom renal anomalies were demonstrated only in post‐UTI RUS, the influence of these anomalies on the children''s management was negligible.

Conclusions

Prenatal‐RUS have been performed in most children <5 years old hospitalised with a first simple UTI. Concordance with post‐infection tests is very high. Findings which appear only in post‐infectious RUS usually have negligible effects on children''s management. Thus, in such children with normal antenatal RUS omitting post‐UTI RUS could be considered.     

Comparison of alteplase and heparin in maintaining the patency of paediatric central venous haemodialysis lines: a randomised controlled trial

Objectives

To determine whether the tissue plasminogen activator, alteplase, is more effective than heparin in preventing blood clots developing in children''s haemodialysis central lines between dialysis sessions.

Design

A prospective double‐blind, within‐patient multiperiod cross‐over controlled trial of instilling a “lock” of either heparin 5000 U/ml or alteplase 1 mg/ml into the central lines of two children haemodialysed twice weekly, and seven dialysed thrice weekly, over 10 weeks.

Setting

A UK paediatric nephrology unit.

Main outcome measures

Weight of blood clot aspirated from the line at the start of the next dialysis session.

Results

The odds of a clot forming was 2.4 times greater with heparin than alteplase (95% CI 1.4 to 4.0; p = 0.001), and when present they were 1.9 times heavier (31 vs 15 mg; 95% CI 1.5 to 2.4; p<0.0005). There was no effect of inter‐dialytic interval. One child required an alteplase infusion to clear a blocked line following a heparin lock. We subsequently changed our routine locks from heparin to alteplase. Comparing the year before and after that change, the incidence of blocked lines requiring an alteplase or urokinase infusion fell from 2.7 to 1.2 per child (p<0.03), and the need for surgical replacements from 0.7 to nil (p<0.02).

Conclusion

Alteplase is significantly more effective than heparin in preventing clot formation in central haemodialysis lines. This reduces morbidity and improves preservation of central venous access. It is more expensive, though relatively economic if packaged into syringes and stored frozen until needed, but reduces the costs of unblocking or replacing clotted lines.     

Parental consent in paediatric clinical research

Aims

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

Methods

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

Results

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

Conclusion

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

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.     

Impact of nutrient density of nocturnal enteral feeds on appetite: a prospective, randomised crossover study

Objective

To determine whether the energy density of isocaloric nocturnal enteral feeds (NEF) influences daily nutrient intake in children.

Method

In a 6 week, randomised, crossover trial, the impact on spontaneous nutrient intake of manipulating the energy density of two isocaloric overnight feeds (1.0 kcal/ml and 1.5 kcal/ml) was compared in a group of 32 children aged 1–10 years (or 8–25 kg body weight) on long term, overnight enteral feeding at home. Total daily oral energy, protein, fat and carbohydrate intake were assessed using 3 day food diaries. Anthropometric data were also recorded during the study.

Results

Spontaneous intakes of energy, protein, fat and carbohydrate from food were 20–30% greater when receiving the lower nutrient density feed (1 kcal/ml). This was due to a gender effect; males consumed twice as much protein from food than females and had slightly higher (but not significant) energy and fat intakes when on the larger volume feed. All children increased in weight, height and mid‐upper arm circumference in the 6 week period.

Conclusions

Children appear to tolerate and grow equally well, irrespective of the nutrient density and volume of NEF taken. However, it appears that children will consume a more energy and nutrient dense oral diet when given their NEF as a higher volume/lower nutrient density feed. This is particularly so for boys, while for girls the volume of NEF or feed concentration appeared to have no impact on quantity of oral diet taken. However, further blinded studies with larger subject numbers would be useful to support these findings.     

A mixture of prebiotic oligosaccharides reduces the incidence of atopic dermatitis during the first six months of age

Background

Oligosaccharides may alter postnatal immune development by influencing the constitution of gastrointestinal bacterial flora.

Aims

To investigate the effect of a prebiotic mixture of galacto‐ and long chain fructo‐oligosaccharides on the incidence of atopic dermatitis (AD) during the first six months of life in formula fed infants at high risk of atopy.

Methods

Prospective, double‐blind, randomised, placebo controlled trial; 259 infants at risk for atopy were enrolled. A total of 102 infants in the prebiotic group and 104 infants in the placebo group completed the study. If bottle feeding was started, the infant was randomly assigned to one of two hydrolysed protein formula groups (0.8 g/100 ml prebiotics or maltodextrine as placebo). All infants were examined for clinical evidence of atopic dermatitis. In a subgroup of 98 infants, faecal flora was analysed.

Results

Ten infants (9.8%; 95 CI 5.4–17.1%) in the intervention group and 24 infants (23.1%; 95 CI 16.0–32.1%) in the control group developed AD. The severity of the dermatitis was not affected by diet. Prebiotic supplements were associated with a significantly higher number of faecal bifidobacteria compared with controls but there was no significant difference in lactobacilli counts.

Conclusion

Results show for the first time a beneficial effect of prebiotics on the development of atopic dermatitis in a high risk population of infants. Although the mechanism of this effect requires further investigation, it appears likely that oligosaccharides modulate postnatal immune development by altering bowel flora and have a potential role in primary allergy prevention during infancy.     

Nasopharyngeal aspiration for diagnosis of pulmonary tuberculosis

Background

Confirmation of pulmonary tuberculosis (PTB) in young children is difficult as they seldom expectorate sputum.

Aim

To compare sputa obtained by nasopharyngeal aspiration and by sputum induction for staining and culture of Mycobacterium tuberculosis.

Patients and methods

Patients from Mulago Hospital, Kampala with symptoms suggestive of PTB were considered for inclusion in the study. Those with a positive tuberculin test and/or a chest radiograph compatible with tuberculosis were recruited. Infection with human immunodeficiency virus (HIV) was confirmed by duplicate enzyme‐labelled immunosorbent assay or in children <15 months by polymerase chain reaction (PCR). Direct PCR was undertaken on 82 nasopharyngeal aspirates.

Results

Of 438 patients referred, 94 were recruited over a period of 5 months. Median (range) age was 48 (4–144) months. Of 63 patients tested, 69.8% were infected with HIV. Paired and uncontaminated culture results were available for 88 patients and smear results for 94 patients. Nasopharyngeal aspirates were smear‐positive in 8.5% and culture‐positive in 23.9%. Induced sputa were smear‐positive in 9.6% and culture positive in 21.6%. Overall, 10.6% were smear‐positive, 25.5% were culture‐positive and 26.6% had smear and/or culture confirmed tuberculosis. Direct PCR on nasopharyngeal aspirates had a sensitivity of 62% and specificity of 98% for confirmation of culture‐positive tuberculosis.

Conclusions

Nasopharyngeal aspiration is a useful, safe and low‐technology method for confirmation of PTB and, like sputum induction, can be undertaken in outpatient clinics.     

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.     

How protective is breast feeding against diarrhoeal disease in infants in 1990s England? A case‐control study

Aims

To assess the effect of several measures of infant feeding on diarrhoeal disease, and whether these effects vary according to markers of social deprivation.

Methods

Case‐control study of diarrhoeal disease cases presenting to 34 general practices in England. Controls were stratified on age group, area deprivation index for the practice, and whether or not the practice was in London. Data were available on 304 infants (167 cases and 137 controls).

Results

After adjustment for confounders, breast feeding was associated with significantly less diarrhoeal disease. Associations were striking even in infants aged ⩾ 6 months. They did not vary by social class, but were greater in those living in rented council accommodation and in more crowded households. The effect of receiving no breast milk was stronger in more deprived areas than in less deprived areas. The effect of not receiving exclusive breast milk was stronger in more deprived areas than in less deprived areas. In formula fed infants, there was significantly more diarrhoeal disease in those not sterilising bottles/teats with steam or chemicals. The protective effect of breast feeding did not persist beyond two months after breast feeding had stopped.

Conclusions

Breast feeding protects against diarrhoeal disease in infants in England although the degree of protection may vary across infants and wear off after breast feeding cessation. Education about the benefits of breast feeding and the risks of inadequate sterilisation should be targeted at carers in deprived areas or households.