Adherence to International Follow-Up Guidelines in Type 2 Diabetes: A Longitudinal Cohort Study in Luxembourg

Introduction

Type 2 diabetes is associated with severe micro- and macro-vascular complications. Physicians’ and patients’ adherence to follow-up guidelines permits postponing or reducing these complications. The objectives were to assess the level of adherence to fundamental follow-up guidelines and determine patients’ characteristics associated with this level of adherence in the context of Luxembourg, where no guidelines were implemented.

Study population

The exhaustive residing population treated for type 2 diabetes in Luxembourg during the 2000-2006 period (N = 21,068).

Methods

Seven fundamental criteria were extracted from international guidelines (consultation with the treating physician, HbA1c tests, electrocardiogram, retinal, dental, lipid and renal check-ups). The factors associated with the level of adherence to those criteria were identified using a partial proportional odds model.

Results

In 2006, despite 90% of the patients consulted at least 4 times their treating physician, only 0.6% completed all criteria; 55.0% had no HbA1c test (−8.6 points since 2000) and 31.1% had a renal check-up (+21.6 points). The sex (OR_male: 0.87 [95%CI, 0.83−0.92]), the nationality (OR_NonEU: 0.64 [0.52−0.78]), the type of antidiabetic treatment (OR_oral: 1.48 [1.35−1.63], OR_mixed: 1.35 [1.20−1.52]) and the type of treating physician (OR_G-ID: 0.47 [0.42−0.53]) were the main factors associated with the level of adherence in 2006 (3 or more criteria).

Conclusion

A large percentage of patients were not provided with a systematic annual follow-up between 2000 and 2006. This study highlighted the necessity to promote guidelines in Luxembourg, education for physicians and to launch a national discussion on a disease management program for diabetic patients.     

Longitudinal Intergenerational Birth Cohort Designs: A Systematic Review of Australian and New Zealand Studies

Background

The longitudinal birth cohort design has yielded a substantial contribution to knowledge of child health and development. The last full review in New Zealand and Australia in 2004 identified 13 studies. Since then, birth cohort designs continue to be an important tool in understanding how intrauterine, infant and childhood development affect long-term health and well-being. This updated review in a defined geographical area was conducted to better understand the factors associated with successful quality and productivity, and greater scientific and policy contribution and scope.

Methods

We adopted the preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach, searching PubMed, Scopus, Cinahl, Medline, Science Direct and ProQuest between 1963 and 2013. Experts were consulted regarding further studies. Five inclusion criteria were used: (1) have longitudinally tracked a birth cohort, (2) have collected data on the child and at least one parent or caregiver (3) be based in Australia or New Zealand, (4) be empirical in design, and (5) have been published in English.

Results

10665 records were initially retrieved from which 23 birth cohort studies met the selection criteria. Together these studies recruited 91,196 participants, with 38,600 mothers, 14,206 fathers and 38,390 live births. Seventeen studies were located in Australia and six in New Zealand. Research questions initially focused on the perinatal period, but as studies matured, longer-term effects and outcomes were examined.

Conclusions

This review demonstrates the significant yield from this effort both in terms of scientific discovery and social policy impact. Further opportunities have been recognised with cross-study collaboration and pooling of data between established and newer studies and international studies to investigate global health determinants.     

Breastfeeding Progression in Preterm Infants Is Influenced by Factors in Infants,Mothers and Clinical Practice: The Results of a National Cohort Study with High Breastfeeding Initiation Rates

Background and Aim

Many preterm infants are not capable of exclusive breastfeeding from birth. To guide mothers in breastfeeding, it is important to know when preterm infants can initiate breastfeeding and progress. The aim was to analyse postmenstrual age (PMA) at breastfeeding milestones in different preterm gestational age (GA) groups, to describe rates of breastfeeding duration at pre-defined times, as well as analyse factors associated with PMA at the establishment of exclusive breastfeeding.

Methods

The study was part of a prospective survey of a national Danish cohort of preterm infants based on questionnaires and structured telephone interviews, including 1,221 mothers and their 1,488 preterm infants with GA of 24–36 weeks.

Results

Of the preterm infants, 99% initiated breastfeeding and 68% were discharged exclusively breastfed. Breastfeeding milestones were generally reached at different PMAs for different GA groups, but preterm infants were able to initiate breastfeeding at early times, with some delay in infants less than GA 32 weeks. Very preterm infants had lowest mean PMA (35.5 weeks) at first complete breastfeed, and moderate preterm infants had lowest mean PMA at the establishment of exclusive breastfeeding (36.4 weeks). Admitting mothers to the NICU together with the infant and minimising the use of a pacifier during breastfeeding transition were associated with 1.6 (95% CI 0.4–2.8) and 1.2 days (95% CI 0.1–2.3) earlier establishment of exclusive breastfeeding respectively. Infants that were small for gestational age were associated with 5.6 days (95% CI 4.1–7.0) later establishment of exclusive breastfeeding.

Conclusion

Breastfeeding competence is not developed at a fixed PMA, but is influenced by multiple factors in infants, mothers and clinical practice. Admitting mothers together with their infants to the NICU and minimising the use of pacifiers may contribute to earlier establishment of exclusive breastfeeding.     

Lactation Support and Breastfeeding Duration in Jaundiced Infants: A Randomized Controlled Trial

Objectives

Neonatal jaundice is the most common problem in full-term infants during the immediate post-natal period. We examined the effect of a lactation support intervention on breastfeeding duration in hospitalized jaundiced infants.

Study Design

We conducted a randomized controlled trial with a qualitative component involving mothers of hospitalized jaundiced breastfed infants <4 weeks of age. Mothers receiving the intervention met with an International Board-Certified Lactation Consultant in hospital and 1–3 times post discharge. Both groups received the standard care for jaundice. The primary outcome was exclusive breastfeeding at 3 months. To the exception of research assistants enrolling participants and completing qualitative interviews, all research staff, investigators and statisticians were blinded to group assignment. Qualitative interviews elicited feedback on breastfeeding experiences for both groups.

Results

99 participants were recruited, and 86 analyzed for primary outcome. There was no difference in exclusive breastfeeding at 3 months between groups (RR 0.84, 95% CI 0.56–1.24, p = 0.40) or in the secondary outcomes. 31 participants were included in the qualitative analysis. Participants in the intervention group described an increase in comfort and confidence levels with breastfeeding. Participants in the control group reported limited lactation support.

Conclusions

Our hospital-based lactation support program did not result in a higher proportion of mothers exclusively breastfeeding at 3 months compared to current hospital standard care. Qualitative feedback from the intervention group suggests that mothers’ confidence was increased, which is linked to breastfeeding duration. The decision to breastfeed is multifactorial and hospital-based lactation support may be only a small piece of the puzzle in hospitalized jaundiced infants. Further studies may be needed to fully elucidate the impact of an in-hospital lactation support program on successful breastfeeding for these infants.

Trial Registration

ClinicalTrials.gov NCT00966719 https://www.clinicaltrials.gov/ct2/show/NCT00966719?term=Lactation+Support+and+Breastfeeding+Duration+in+Jaundiced+Infants%3A+a+Randomized+Controlled+Trial&rank=1     

Perinatal Outcomes by Mode of Assisted Conception and Sub-Fertility in an Australian Data Linkage Cohort

Background

Fertility treatment is associated with increased risk of major birth defects, which varies between in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI), and is significantly reduced by embryo freezing. We therefore examined a range of additional perinatal outcomes for these exposures.

Methods

All patients in South Australia receiving assisted conception between Jan 1986–Dec 2002 were linked to the state-wide perinatal collection (all births/stillbirths ≥20 weeks gestation or 400 g birth weight, n = 306 995). We examined stillbirth, mean birth weight, low birth weight (<2500 g, <1500 g), small size for gestational age (<10th percentile, <3rd percentile), large size for gestational age (>90th percentile), preterm birth (32–<37 weeks, <32 weeks gestation), postterm birth (≥41 weeks gestation), Apgar <7 at 5 minutes and neonatal death.

Results

Relative to spontaneous conceptions, singletons from assisted conception were more likely to be stillborn (OR = 1.82, 95% Confidence Interval (CI) 1.34–2.48), while survivors as a group were comprehensively disadvantaged at birth, including lower birth weight (−109 g, CI −129–−89), very low birth weight (OR = 2.74, CI 2.19–3.43), very preterm birth (OR = 2.30, CI 1.82–2.90) and neonatal death (OR = 2.04, CI 1.27–3.26). Outcomes varied by type of assisted conception. Very low and low birth weight, very preterm and preterm birth, and neonatal death were markedly more common in singleton births from IVF and to a lesser degree, in births from ICSI. Using frozen-embryos eliminated all significant adverse outcomes associated with ICSI but not with IVF. However, frozen-embryo cycles were also associated with increased risk of macrosomia for IVF and ICSI singletons (OR = 1.36, CI 1.02–1.82; OR = 1.55, CI 1.05–2.28). Infertility status without treatment was also associated with adverse outcomes.

Conclusions

Births after assisted conception show an extensive range of compromised outcomes that vary by treatment modality, that are substantially reduced after embryo freezing, but which co-occur with an increased risk of macrosomia.     

Stable and Unstable Malaria Hotspots in Longitudinal Cohort Studies in Kenya

Background

Infectious diseases often demonstrate heterogeneity of transmission among host populations. This heterogeneity reduces the efficacy of control strategies, but also implies that focusing control strategies on “hotspots” of transmission could be highly effective.

Methods and Findings

In order to identify hotspots of malaria transmission, we analysed longitudinal data on febrile malaria episodes, asymptomatic parasitaemia, and antibody titres over 12 y from 256 homesteads in three study areas in Kilifi District on the Kenyan coast. We examined heterogeneity by homestead, and identified groups of homesteads that formed hotspots using a spatial scan statistic. Two types of statistically significant hotspots were detected; stable hotspots of asymptomatic parasitaemia and unstable hotspots of febrile malaria. The stable hotspots were associated with higher average AMA-1 antibody titres than the unstable clusters (optical density [OD] = 1.24, 95% confidence interval [CI] 1.02–1.47 versus OD = 1.1, 95% CI 0.88–1.33) and lower mean ages of febrile malaria episodes (5.8 y, 95% CI 5.6–6.0 versus 5.91 y, 95% CI 5.7–6.1). A falling gradient of febrile malaria incidence was identified in the penumbrae of both hotspots. Hotspots were associated with AMA-1 titres, but not seroconversion rates. In order to target control measures, homesteads at risk of febrile malaria could be predicted by identifying the 20% of homesteads that experienced an episode of febrile malaria during one month in the dry season. That 20% subsequently experienced 65% of all febrile malaria episodes during the following year. A definition based on remote sensing data was 81% sensitive and 63% specific for the stable hotspots of asymptomatic malaria.

Conclusions

Hotspots of asymptomatic parasitaemia are stable over time, but hotspots of febrile malaria are unstable. This finding may be because immunity offsets the high rate of febrile malaria that might otherwise result in stable hotspots, whereas unstable hotspots necessarily affect a population with less prior exposure to malaria. Please see later in the article for the Editors'' Summary     

Adherence to Chemoprophylaxis and Plasmodium falciparum Anti-Circumsporozoite Seroconversion in a Prospective Cohort Study of Dutch Short-Term Travelers

Background

We conducted a prospective study in a cohort of short-term travelers assessing the incidence rate of anti-circumsporozoite seroconversion, adherence to chemoprophylaxis, symptoms of malaria during travel, and malaria treatment abroad.

Methods

Adults were recruited from the travel clinic of the Public Health Service Amsterdam. They kept a structured daily travel diary and donated blood samples before and after travel. Blood samples were serologically tested for the presence of Plasmodium falciparum anti-circumsporozoite antibodies.

Results

Overall, the incidence rate (IR) of anti-circumsporozoite seroconversion was 0.8 per 100 person-months. Of 945 travelers, 620 (66%) visited high-endemic areas and were advised about both chemoprophylaxis and preventive measures against mosquito bites. Most subjects (520/620 = 84%) took at least 75% of recommended prophylaxis during travel. Travel to Africa, use of mefloquine, travel duration of 14–29 days in endemic areas, and concurrent use of DEET (N,N-diethyl-meta-toluamide) were associated with good adherence practices. Four travelers without fever seroconverted, becoming anti-circumsporozoite antibody-positive. All four had been adherent to chemoprophylaxis; two visited Africa, one Suriname, one India. Ten subjects with fever were tested for malaria while abroad and of these, three received treatment. All three were adherent to chemoprophylaxis and tested negative for anti-circumsporozoite antibodies.

Conclusion

Travel to Africa, using mefloquine, travel duration of 14–29 days in endemic areas, and use of DEET were associated with good adherence to chemoprophylaxis. The combination of chemoprophylaxis and other preventive measures were sufficient to protect seroconverting travelers from clinical malaria. Travelers who were treated for malaria abroad did not seroconvert.     

Sleep Duration and Obesity in Middle‐aged Australian Adults

The present study examined the association between sleep duration and obesity in 40,834 middle‐aged Australian adults. Multinomial logistic regression was used to test the relationship between sleep duration and obesity while controlling for important demographic and health covariates; separate models were tested for males and females. Short sleep (i.e., <7 h a night) was found to be independently associated with obesity in males and females. To our knowledge, this is the first study to report an association between short sleep and obesity in Australian adults. Although more research is required, interventions targeting short sleep could aid obesity treatment and prevention.     

Sleep Duration Trajectories and Body Composition in Adolescents: Prospective Birth Cohort Study

We aimed to estimate the association between sleep duration trajectories and body composition in adolescents. We used data from participants of the 1993 Pelotas (Brazil) Birth Cohort Study who were later followed up at age 18 years (response rate of 81.3%). At the time, 3974 adolescents had complete data on body composition, which was assessed by air displacement plethysmography. Sleep duration was self-reported by participants at ages 11 and 18 years. Analyses were sex-stratified. The mean sleep duration at 11 years was 9.7 (SD 1.4) and 8.4 (SD 1.9) at 18 years. Sleep duration was dichotomized as inadequate (<8 hours/day) or adequate (≥8 hours/day). Mean body mass, fat mass, and fat-free mass indices at 18 years were 23.4 kg/m² (SD 4.5), 6.1 kg/m² (SD 3.9) and 17.3 kg/m² (SD 2.5), respectively. Girls who reported inadequate sleep duration at 11 years of age, but adequate sleep duration at 18, on average experienced an increase in body mass index (β = 0.39 z-scores; 95% CI 0.13, 0.65), fat mass index (β = 0.30 z-scores; 95% CI 0.07, 0.53), and fat-free mass index (β = 0.24 z-scores; 95% CI 0.08, 0.39) compared to those who had adequate sleep duration at both time points. The results suggest that changes in sleep duration across adolescence may impact body composition in later adolescence and that this may differ by sex.     

Effect of Breastfeeding Promotion on Early Childhood Caries and Breastfeeding Duration among 5 Year Old Children in Eastern Uganda: A Cluster Randomized Trial

BackgroundAlthough several studies have shown short term health benefits of exclusive breastfeeding (EBF), its long term consequences have not been studied extensively in low-income contexts. This study assessed the impact of an EBF promotion initiative for 6 months on early childhood caries (ECC) and breastfeeding duration in children aged 5 years in Mbale, Eastern Uganda.MethodsParticipants were recruited from the Ugandan site of the PROMISE- EBF cluster randomised trial (ClinicalTrials.gov no: {"type":"clinical-trial","attrs":{"text":"NCT00397150","term_id":"NCT00397150"}}NCT00397150). A total of 765 pregnant women from 24 clusters were included in the ratio 1:1 to receive peer counselled promotion of EBF as the intervention or standard of care. At the 5 year follow-up, ECC was recorded under field conditions using the World Health Organization’s decayed missing filled tooth (dmft) index. Adjusted negative binomial and linear regression were used in the analysis.ResultsMean breastfeeding duration in the intervention and control groups (n=417) were 21.8 (CI 20.7–22.9) and 21.3(CI 20.7–21.9) months, respectively. The mean dmft was 1.5 (standard deviation [SD] 2.9) and 1.7 (SD 2.9) in the intervention and control groups, respectively. Corresponding prevalence estimates of ECC were 38% and 41%. Negative binomial regression analysis adjusted for cluster effects and loss-to-follow-up by inverse probability weights (IPW) showed an incidence-rate ratio (IRR) of 0.91 (95% CI 0.65–1.2). Comparing the effect of the trial arm on breastfeeding duration showed a difference in months of 0.48 (-0.72 to 1.7).ConclusionPROMISE EBF trial did not impact on early childhood caries or breastfeeding duration at 5 years of age. This study contributes to the body of evidence that promotion of exclusive breastfeeding does not raise oral health concerns. However, the high burden of caries calls for efforts to improve the oral health condition in this setting.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00397150","term_id":"NCT00397150"}}NCT00397150     

Peer Support and Exclusive Breastfeeding Duration in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis

Objective

To examine the effect of peer support on duration of exclusive breastfeeding (EBF) in low and middle-income countries (LMICs).

Data Sources

Medline, EMBASE, and Cochrane Central Register for Controlled Trials were searched from inception to April 2012.

Methods

Two authors independently searched, reviewed, and assessed the quality of randomized controlled trials utilizing peer support in LMICs. Meta-analysis and metaregression techniques were used to produce pooled relative risks and investigate sources of heterogeneity in the estimates.

Results

Eleven randomized controlled trials conducted at 13 study sites met the inclusion criteria for systematic review. We noted significant differences in study populations, peer counselor training methods, peer visit schedule, and outcome ascertainment methods. Peer support significantly decreased the risk of discontinuing EBF as compared to control (RR: 0.71; 95% CI: 0.61–0.82; I² = 92%). The effect of peer support was significantly reduced in settings with >10% community prevalence of formula feeding as compared to settings with <10% prevalence (p = 0.048). There was no evidence of effect modification by inclusion of low birth weight infants (p = 0.367) and no difference in the effect of peer support on EBF at 4 versus 6 months postpartum (p = 0.398).

Conclusions

Peer support increases the duration of EBF in LMICs; however, the effect appears to be reduced in formula feeding cultures. Future studies are needed to determine the optimal timing of peer visits, how to best integrate peer support into packaged intervention strategies, and the effectiveness of supplemental interventions to peer support in formula feeding cultures.     

International Influence of an Australian Nongovernment Organization in the Protection of Patagonian Toothfish

Soviet Union fishing fleets found Patagonian toothfish in 1985 off the Kerguelen Islands in the Southern Ocean. In a few short years, toothfish became heavily fished and the viability of the fishery was put in question. This pressure largely arose from illegal, unreported, and unregulated (IUU) fishing that undermined fisheries management by coastal states and the Convention for the Conservation of Antarctic Marine Living Resources (CCAMLR) Commission. The International Southern Oceans Longline Fisheries Information Clearing House (ISOFISH), based in Hobart, Tasmania, Australia, raised awareness about IUU fishing among governments, fishers, and the community. This article presents a case study of ISOFISH and the influence this nongovernment organization coalition exerted on the international community, including the deep-sea fishing industry, governments, and CCAMLR members, in an effort to protect toothfish stocks and reduce the incidental mortality of endangered seabirds and other nontarget marine species from longlining activities.­     

Mycobacterium ulcerans Disease: Experience with Primary Oral Medical Therapy in an Australian Cohort

Background

Mycobacterium ulcerans (MU) is responsible for disfiguring skin lesions and is endemic on the Bellarine peninsula of southeastern Australia. Antibiotics have been shown to be highly effective in sterilizing lesions and preventing disease recurrences when used alone or in combination with surgery. Our practice has evolved to using primarily oral medical therapy.

Methods

From a prospective cohort of MU patients managed at Barwon Health, we describe those treated with primary medical therapy defined as treatment of a M. ulcerans lesion with antimicrobials either alone or in conjunction with limited surgical debridement.

Results

From 1/10/2010 through 31/12/11, 43 patients were treated with exclusive medical therapy, of which 5 (12%) also underwent limited surgical debridement. The median patient age was 50.2 years, and 86% had WHO category 1 and 91% ulcerative lesions. Rifampicin was combined with ciprofloxacin in 30 (70%) and clarithromycin in 12 (28%) patients. The median duration of antibiotic therapy was 56 days, with 7 (16%) receiving less than 56 days. Medication side effects requiring cessation of one or more antibiotics occurred in 7 (16%) patients. Forty-two (98%) patients healed without recurrence within 12 months, and 1 patient (2%) experienced a relapse 4 months after completion of 8 weeks of antimicrobial therapy.

Conclusion

Our experience demonstrates the efficacy and safety of primary oral medical management of MU infection with oral rifampicin-based regimens. Further research is required to determine the optimal and minimum durations of antibiotic therapy, and the most effective antibiotic dosages and formulations for young children.     

Relationships between Neonatal Weight,Limb Lengths,Skinfold Thicknesses,Body Breadths and Circumferences in an Australian Cohort

Background

Low birth weight has been consistently associated with adult chronic disease risk. The thrifty phenotype hypothesis assumes that reduced fetal growth impacts some organs more than others. However, it remains unclear how birth weight relates to different body components, such as circumferences, adiposity, body segment lengths and limb proportions. We hypothesized that these components vary in their relationship to birth weight.

Methods

We analysed the relationship between birth weight and detailed anthropometry in 1270 singleton live-born neonates (668 male) from the Mater-University of Queensland Study of Pregnancy (Brisbane, Australia). We tested adjusted anthropometry for correlations with birth weight. We then performed stepwise multiple regression on birth weight of: body lengths, breadths and circumferences; relative limb to neck-rump proportions; or skinfold thicknesses. All analyses were adjusted for sex and gestational age, and used logged data.

Results

Circumferences, especially chest, were most strongly related to birth weight, while segment lengths (neck-rump, thigh, upper arm, and especially lower arm and lower leg) were relatively weakly related to birth weight, and limb lengths relative to neck-rump length showed no relationship. Skinfolds accounted for 36% of birth weight variance, but adjusting for size (neck-rump, thigh and upper arm lengths, and head circumference), this decreased to 10%. There was no evidence that heavier babies had proportionally thicker skinfolds.

Conclusions

Neonatal body measurements vary in their association with birth weight: head and chest circumferences showed the strongest associations while limb segment lengths did not relate strongly to birth weight. After adjusting for body size, subcutaneous fatness accounted for a smaller proportion of birth weight variance than previously reported. While heavier babies had absolutely thicker skinfolds, this was proportional to their size. Relative limb to trunk length was unrelated to birth weight, suggesting that limb proportions at birth do not index factors relevant to prenatal life.     

Longitudinal study of dental arch relationships in Australian aboriginals with reference to alternate intercuspation

The patterns of age change in dental arch breadths and depths were studied longitudinally in Australian Aboriginals, 92 males and 68 females. Three types of change in relative arch dimensions were recognized: a divergent pattern in which the differences between maxillary and mandibular dimensions increased with age, a convergent pattern in which the differences decreased, and a parallel pattern in which the arch differences remained metrically stable. The feature that best distinguished the Aboriginals from Caucasian groups was the high frequency of subjects, 71% of males and 40% of females, who showed a divergent growth pattern. The association between divergent growth in arch breadths and the development of alternate intercuspation, which is characterized by an inability to occlude the teeth on both sides of the arch at the same time, is discussed.     

Poor Growth and Pneumonia Seasonality in Infants in the Philippines: Cohort and Time Series Studies

Children with poor nutrition are at increased risk of pneumonia. In many tropical settings seasonal pneumonia epidemics occur during the rainy season, which is often a period of poor nutrition. We have investigated whether seasonal hunger may be a driver of seasonal pneumonia epidemics in children in the tropical setting of the Philippines. In individual level cohort analysis, infant size and growth were both associated with increased pneumonia admissions, consistent with findings from previous studies. A low weight for age z-score in early infancy was associated with an increased risk of pneumonia admission over the following 12 months (RR for infants in the lowest quartile of weight for age z-scores 1.28 [95% CI 1.08 to 1.51]). Poor growth in smaller than average infants was also associated with an increased risk of pneumonia (RR for those in the lowest quartile of growth in early infancy 1.31 [95%CI 1.02 to 1.68]). At a population level, we found that seasonal undernutrition preceded the seasonal increase in pneumonia and respiratory syncytial virus admissions by approximately 10 weeks (pairwise correlation at this lag was −0.41 [95%CI −0.53 to −0.27] for pneumonia admissions, and −0.63 [95%CI −0.72 to −0.51] for respiratory syncytial virus admissions). This lag appears biologically plausible. These results suggest that in addition to being an individual level risk factor for pneumonia, poor nutrition may act as a population level driver of seasonal pneumonia epidemics in the tropics. Further investigation of the seasonal level association, in particular the estimation of the expected lag between seasonal undernutrition and increased pneumonia incidence, is recommended.     

Breastfeeding self-efficacy of women using second-line strategies for healthy term infants in the first week postpartum: an Australian observational study

Background

Breastfeeding self-efficacy (BFSE) supports breastfeeding initiation and duration. Challenges to breastfeeding may undermine BFSE, but second-line strategies including nipple shields, syringe, cup, supply line and bottle feeding may support breastfeeding until challenges are resolved. The primary aim of this study was to examine BFSE in a sample of women using second-line strategies for feeding healthy term infants in the first week postpartum.

Methods

A retrospective self-report study was conducted using the Breastfeeding Self-Efficacy Scale - Short Form (BSES-SF), demographic and infant feeding questionnaires. Breastfeeding women who gave birth to a singleton healthy term infant at one private metropolitan birthing facility in Australia from November 2008 to February 2009 returned anonymous questionnaires by mail.

Results

A total of 128 (73 multiparous, 55 primiparous) women participated in the study. The mean BSES-SF score was 51.18 (Standard deviation, SD: 12.48). The median BSES-SF score was 53. Of women using a second-line strategy, 16 exceeded the median, and 42 were below. Analyses using Kruskal-Wallis tests confirmed this difference was statistically significant (H = 21.569, p = 0.001). The rate of second-line strategy use was 48%. The four most commonly used second-line strategies were: bottles with regular teats (77%); syringe feeding (44%); bottles with wide teats (34%); and nipple shields (27%). Seven key challenges were identified that contributed to the decision to use second-line strategies, including: nipple pain (40%); unsettled infant (40%); insufficient milk supply (37%); fatigue (37%); night nursery care (25%); infant weight loss?>?10% (24%); and maternal birth associated pain (20%). Skin-to-skin contact at birth was commonly reported (93%). At seven days postpartum 124 women (97%) were continuing to breastfeed.

Conclusions

The high rate of use of second-line strategies identified in this study and high rate of breastfeeding at day seven despite lower BFSE indicate that such practices should not be overlooked by health professionals. The design of this study does not enable determination of cause-effect relationships to identify factors which contribute to use of second-line strategies. Nevertheless, the significantly lower BSES-SF score of women using a second-line strategy highlights this group of women have particular needs that require attention.

     

Assessment of the Association of Matrix Metalloproteinases with Myopia,Refractive Error and Ocular Biometric Measures in an Australian Cohort

Extracellular matrix proteins have been implicated in protein remodelling of the sclera in refractive error. The matrix metalloproteinases (MMPs) falling into the collagenase (MMP1, MMP8, MMP13), gelatinase (MMP2, MMP9) and stromelysin (MMP3, MMP10, MMP11) functional groups are particularly important. We wished to assess their association with myopia, refractive error and ocular biometric measures in an Australian cohort. A total of 543 unrelated individuals of Caucasian ethnicity were genotyped including 269 myopes (≤−1.0D) and 274 controls (>−1.0D). Tag single nucleotide polymorphisms (SNPs) (n = 53) were chosen to encompass these eight MMPs. Association tests were performed using linear and logistic regression analysis with age and gender as covariates. Spherical equivalent, myopia, axial length, anterior chamber depth and corneal curvature were the phenotypes of interest. Initial findings indicated that the best p values for each trait were 0.02 for myopia at rs2274755 (MMP9), 0.02 for SE at both rs3740938 (MMP8) and rs131451 (MMP11), 0.01 for axial length at rs11225395 (MMP8), 0.01 for anterior chamber depth at rs498186 (MMP1) and 0.02 at rs10488 (MMP1). However, following correction for multiple testing, none of these SNPs remained statistically significant. Our data suggests that the MMPs in the collagenase, gelatinase and stromelysin categories do not appear to be associated with myopia, refractive error or ocular biometric measures in this cohort.