Alan Rothberg

Maternal-infant vitamin D relationships during breast-feeding

To evaluate the effect of maternal dietary vitamin D intake on infant vitamin D status in a country with a temperate climate, but where the commercial milk supply is not vitamin D fortified, this randomized, double-blind study was conducted on term mother-infant pairs during the winter months. Well-nourished, white nursing mothers were given a placebo, 500 IU vitamin D/day or 1,000 IU vitamin D/day; their infants were not given supplemental vitamin D. After six weeks, mothers receiving supplemental vitamin D had higher levels of 25-hydroxyvitamin D than had mothers receiving placebo. A direct relationship was observed between maternal and infant levels of 25-hydroxyvitamin D at six weeks, implying that maternal vitamin D intake directly affects the vitamin D concentration in breast milk. A control group of infants who had received 400 IU vitamin D/day had even higher concentrations of 25-hydroxyvitamin D, suggesting that infant supplementation with vitamin D is more efficacious than maternal supplementation. Despite the favorable climate in South Africa, during winter breast-fed infants have low serum vitamin D values if maternal dietary vitamin D intake is low.

Psychosocial support for maternal stress during pregnancy : effect on birth weight

In a previous study we showed that moderate to severe stress during pregnancy was inversely related to infant birth weight. Using the same criteria for stress (according to the Social Readjustment Rating Scale of Holmes and Rahe), we studied 86 white mothers with singleton pregnancies and with no known medical or obstetric risk factors for reduced birth weight. After strict randomization, data were analyzed for 43 mothers who received psychosocial support between enrollment at +/- 20 weeks and delivery at +/- 38 weeks and for 43 control mothers who received standard care at the antenatal clinic. In the supported group seven infants weighed less than 3000 gm at birth versus 18 control infants (p = 0.008), and analysis revealed that this effect was more the result of improved intrauterine growth than of prolongation of pregnancy. These findings are of little clinical relevance as far as the neonate is concerned, but they do indicate that psychosocial support has a significant effect on birth weight. It is possible that previous studies that have looked only for an effect on low- or very-low-birth-weight rates might have missed this clinically measurable benefit of counseling.

Outcome for survivors of mechanical ventilation weighing less than 1,250 gm at birth

We investigated the outcome in 28 survivors of mechanical ventilation weighing less than 1,250 gm at birth. Fifteen infants (54%) had neurodevelopmental sequelae, of whom eight had major handicaps. These eight infants differed significantly from the rest of the infants studied in the following manner: lower mean birth weight and gestational age, delay in transportation to our Neonatal Intensive Care Unit, and high incidence of bacterial sepsis. The remaining seven infants with NDS were functionally normal or minimally impaired at the time of the study, although significant problems may yet emerge with continued follow-up. Retrolental fibroplasia was diagnosed in 11 infants (39%) and resolved in two. The development of RLF was associated with prolonged oxygen exposure and the presence of bacterial sepsis. However, since major handicap, RLF, and sepsis were all problems observed in the smallest infants, a cause-and-effect relationship between sepsis and these sequelae remains speculative.

Growth and biochemical response of premature infants fed pooled preterm milk or special formula.

This study compared growth of a group of very low birth weight infants fed a formula specifically developed for such infants (Formula) with another group fed expressed breast milk (EBM). The Formula contained 2.4 g/dl of protein (lactalbumin:casein ratio, 60:40); 4.1 g/dl of fat (40% medium-chain triglycerides); 8.8 g/dl of carbohydrates; and 81 kcal/dl, with more calcium, phosphorus, and electrolytes than are in human milk. Premature babies with birth weights between 1,200 and 1,500 g and gestational age less than 36 weeks were eligible for the study and were fed either pooled EBM or Formula until they reached a weight of 1,800 g. Twenty infants fed EBM and 19 infants fed Formula completed the trial. Weight gain was faster in the Formula-fed infants after a caloric intake of 100 kcal/kg/day was achieved (Formula 27.7 g/day vs. EBM 17.2 g/day; p less than 0.001). Time to reach 1,800 g was 27 days for the Formula group and 39 days for those on EBM (p less than 0.001). Increments in head circumference and skinfold thickness were also greater in the Formula-fed group. Laboratory studies in the two groups of infants showed higher alkaline phosphatase levels, which were not due to vitamin D deficiency, in the EBM-fed infants.

Hypertension as the major problem of idiopathic arterial calcification of infancy

We describe two infants with severe hypertension associated with idiopathic arterial calcification of infancy. In both children, blood pressure control was refractory to aggressive antihypertensive therapy. There was radiologic and laboratory evidence of renovascular disease requiring the use of specific renin antagonists and later nephrectomy, resulting in moderate improvement of hypertension. Although on occasion there is a familial incidence, in the vast majority of cases the diagnosis hinges on a high index of suspicion.

Comparative growth and biochemical response of very low birthweight infants fed own mother's milk, a premature infant formula, or one of two standard formulas.

Summary: Very low birthweight (VLBW) infants weighing < 1,600 g at birth were fed their own mothers milk (OMM) or randomly assigned to receive one of three formulas: a “humanized” formula (SF), a partially modified casein-predominant cows milk formula (CF), or a premature formula (PF). All infants were fed at 120 kcal/kg/day where possible, PF infants had significantly greater weight increments (28.0 g/day) than those on OMM (19.4 g/day), SF (18.9 g/day), and CF (18.2 g/day). Those on PF also had greater increments of length, head circumference, and skinfold thickness than those on the other two formulas and greater length increments than those on OMM. Dynamic skinfold measurements suggested that no infants accumulated excessive amounts of interstitial fluid. Infants on the two standard formulas had significantly greater base deficits, whereas those on CF also had higher urea values. Those on OMM had lower phosphate and higher alkaline phosphatase values than the other groups. Thus VLBW infants fed a premature formula had better growth and fewer biochemical problems than those on standard formulas, whereas supplementation of OMM may be necessary to ensure optimal growth and bone mineralization.

Private-sector caesarean sections in perspective

Extracted from text ... SAJOG 66 September 2005, Vol. 11, No. 3 In a recent issue of the Journal, 1 views were expressed that our national private sector caesarean section (CS) rate is too high at over 60%, and government and/or funders are likely to intervene unless doctors begin to self-regulate by developing appropriate protocols and guidelines. This is not a new issue for South Africa or for medically insured populations around the world, and the sheer volume of literature on the subject of high CS rates indicates that it is unlikely one will reach consensus on a national target CS rate simply by ..

Three-year growth and developmental follow-up of very low birth weight infants fed own mother's milk, a premature infant formula, or one of two standard formulas

A cohort of 40 very low birth weight (VLBW) infants was followed until they reached 3 years of age. These infants were originally part of a feeding trial in the early postnatal period whereby they were fed either their own mothers milk, a standard whey-predominant formula, a casein-predominant formula, or a premature formula. Those fed the latter formula grew significantly better while in the hospital and had no biochemical derangements. At 3 years of age, there were no significant intergroup differences with respect to growth or development. There was a positive correlation between head growth in hospital and weight at 3 years, but there were no other significant relationships between early postnatal growth and growth parameters at 3 years. Socioeconomic status was the only predictor of developmental scores at 3 years of age. No adverse effects from early metabolic acidosis or alterations of amino acid profiles during the neonatal period were detectable at 3 years of age. However, the small sample size of this study may have missed true differences in outcome measures at 3 years, and larger studies are required to examine these questions further.

The integration of blended learning into an occupational therapy curriculum: a qualitative reflection

BackgroundThis paper presents a critical reflection of the integration of Blended Learning (BL) into an undergraduate occupational therapy curriculum which was delivered through Problem Based Learning (PBL).MethodThis is a qualitative reflection of a Participatory Action Research (PAR) study using Brookfield’s model for critical reflection of an educator’s practice. The model uses four ‘lenses’ through which to focus enquiry: Lens 1) our autobiography as a learner of practice; Lens 2) our learners’ eyes; Lens 3) our colleagues’ experiences; and Lens 4) the theoretical literature. Grounded theory analysis was applied to the data.ResultsThe factors that contributed to successful integration of technology and e-Learning into an existing curriculum, the hurdles that were navigated along the way, and how these influenced decisions and innovation are explored. The core categories identified in the data were “drivers of change” and “outcomes of BL integration”. Key situations and pivotal events are highlighted for their role in the process that led to the project maturing. Each lens reflects the successes and hurdles experienced during the study.ConclusionBrookfield’s model provides an objective method of reflection which showed that despite the hurdles, e-Learning was successfully integrated into the curriculum.

Application of different measures of skeletal maturity in initiating weaning from a brace for scoliosis: two case reports

IntroductionVarious measures of skeletal maturity are used to initiate weaning from a brace in patients suffering from idiopathic scoliosis, resulting in different outcomes. We present two cases with double major curves, treated with the Rigo System Cheneau brace, and weaned using different criteria.Case presentationCase 1 was a South African, Caucasian girl who was initially treated with a brace at 14.75 years and who began weaning at 16.25 years on the basis of the Greulich and Pyle Index. She was out of her brace in 6 months, at least 11 months before reaching skeletal maturity as shown by the Risser Sign. Case 2 was a South African, Caucasian girl, initially treated with a brace at 14.25 years and who began the weaning process at 17.67 years on the basis of skeletal maturity according to the Risser Sign and static height for a period of 6 months. She was out of the brace 12 months later. In Case 1, the thoracic Cobb angle progressed during weaning and scoliometer readings deteriorated. The iliac apophysis fused 11 months after the wrist. In Case 2, the therapeutic gains made during the period of bracing were maintained during weaning, that is the improvement in the lumbar Cobb angle was maintained until the brace was removed, and scoliometer readings improved. The iliac apophysis fused 8.5 months after the wrist.ConclusionsIn patients with idiopathic scoliosis, it would seem to be more appropriate to base the timing of weaning on the Risser Sign and static height measurements rather than on traditional methods such as the Greulich and Pyle Index.