Anthony F Williams

Randomised controlled trial of support from volunteer counsellors for mothers considering breast feeding

Abstract Objective To investigate whether offering volunteer support from counsellors in breast feeding would result in more women breast feeding. Design Randomised controlled trial. Setting 32 general practices in London and south Essex. Participants 720 women considering breast feeding. Main outcome measures Primary outcome was prevalence of any breast feeding at six weeks. Secondary outcomes were the proportion of women giving any breast feeds, or bottle feeds at four months, duration of any breast feeding, time to introduction of bottle feeds, and satisfaction with breast feeding. Results Offering support in breast feeding did not significantly increase the prevalence of any breast feeding to six weeks (65% (218/336) in the intervention group and 63% (213/336) in the control group; relative risk 1.02, 95% confidence interval 0.84 to 1.24). Survival analysis up to four months confirmed that neither duration of breast feeding nor time to introduction of formula feeds differed significantly between control and intervention groups. Not all women in the intervention group contacted counsellors postnatally, but 73% (123/179) of those who did rated them as very helpful. More women in the intervention group than in the control group said that their most helpful advice came from counsellors rather than from other sources. Conclusions Women valued the support of a counsellor in breast feeding, but the intervention did not significantly increase breastfeeding rates, perhaps because some women did not ask for help.

The Child-Friendly Healthcare Initiative (CFHI): Healthcare Provision in Accordance With the UN Convention on the Rights of the Child

Objective. Although modern medical technology and treatment regimens in well-resourced countries have improved the survival of sick or injured children, most of the worlds families do not have access to adequate health care. Many hospitals in poorly resourced countries do not have basic water and sanitation, a reliable electricity supply, or even minimal security. The staff, both clinical and nonclinical, are often underpaid and sometimes undervalued by their communities. In many countries there continues to be minimal, if any, pain control, and the indiscriminate use of powerful antibiotics leads to a proliferation of multiresistant pathogens. Even in well-resourced countries, advances in health care have not always been accompanied by commensurate attention to the childs wider well-being and sufficient concerns about their anxieties, fears, and suffering. In accordance with the United Nations Convention on the Rights of the Child,1 the proposals set out in this article aim to develop a system of care that will focus on the physical, psychological, and emotional well-being of children attending health care facilities, particularly as inpatients. Design of the Program. To develop in consultation with local health care professionals and international organizations, globally applicable standards that will help to ensure that practices in hospitals and health centers everywhere respect childrens rights, not only to survival and avoidance of morbidity, but also to their protection from unnecessary suffering and their informed participation in treatment. Child Advocacy International will liase closely with the Department of Child and Adolescent Health and Development of the World Health Organization (WHO) and the United Nations Childrens Fund (UNICEF) in the implementation of the pilot scheme in 6 countries. In hospitals providing maternity and newborn infant care, the program will be closely linked with the Baby Friendly Hospital Initiative of WHO/UNICEF that aims to strengthen support for breastfeeding. United Nations Childrens Fund, United Nations Convention on the Rights of the Child, child protection, breastfeeding, pain control, palliative care, child abuse.

Revised birth centiles for weight, length and head circumference in the UK-WHO growth charts

Background: The adoption in May 2009 by the UK of the WHO 2006 standard necessitated the provision of UK-based birth centiles for pre-term infants. The pre-existing British 1990 reference birth centiles, used in the UK since 1995, had been biased by the inclusion of post-natal data. Aim: To describe the construction of new UK birth centiles for weight, length and head circumference, based on British 1990 reference data, but excluding post-natal data. Subjects and methods: Birth data from the five original studies, collected between 1983–1993, were pooled and analysed by the LMS method, for the sexes separately. In addition, sex-specific composite centiles were constructed for infants born at term (37–42 completed weeks). Results: The birth data included 9443 weights, 985 lengths and 1841 head circumferences, covering 23–44 weeks gestation. The analysis provided LMS tables defining reference centiles for weight and head circumference from 23–42 weeks and for length from 26–42 weeks. The term centiles are for use at age 0 on the post-natal 0–1 year chart. Conclusion: These new centiles, replacing those of the British 1990 reference, are more accurate than their predecessors which were biased due to the inclusion of post-natal data.

Using the new UK-WHO growth charts

The Royal College of Paediatrics and Child Health has now published a complete set of growth charts for preterm infants up to adolescents for the purpose of surveillance and the assessment of individual children with health and growth problems. This paper describes the various new charts and advises on how they should be used. Novel features of the charts include look-up charts for Body Mass Index (BMI) centile, predicted adult height and mid parental centile. The charts now include detailed evidence based instructions on topics such as how to plot the growth of preterm infants and a simplified classification of the phases of puberty.

Early enteral feeding of the preterm infant

Questions about when, how, and what to feed the preterm baby elicit many different answers. Balancing the risks of enteral feeding with those of parenteral nutrition is not easy. In contrast with the sophistication of clinical cardiorespiratory monitoring, the day to day assessment of gastrointestinal function is still largely dependent on clinical observation. Moreover the population at risk is extremely heterogeneous with respect to both the prevalence of comorbidity and developmental stage, particularly, in this context, the maturation of intestinal motility. Enteral feeding involves many potentially confounding interventions: route chosen, postnatal or postconceptional age at initiation, frequency of administration, amount given, rate of advancement, and, not least, choice between human milk and formula. Given the complexity of the problem, the small size of most controlled studies, problems with blinding, and the difficulties of defining and measuring outcome, it is hardly surprising that confusion exists. The spectre of necrotising enterocolitis (NEC) is the dominant argument for postponing enteral feeding, yet NEC can occur in babies fed parenterally. The risk of sepsis and other complications during total parenteral nutrition (TPN) is high and may more than offset any reduction in the risk of NEC.1 TPN also provides certain important nutrients less effectively, notably vitamin A, glutamine, calcium, and phosphorus. On the other hand, enteral feeding (with milk, not water2) in the first five days of life promotes endocrine adaptation and the maturation of motility patterns,3 provides luminal nutrient, and probably benefits immune function.4Potential clinical benefits are therefore earlier tolerance of enteral feeds, reduced risk of infection, and earlier discharge. Trophic feeding describes the provision of milk feeds in subnutritional quantities for a predetermined period. It has also been termed “minimal enteral nutrition” and “gut priming”. A systematic review of studies published to 1997 concluded that it reduced …

Designing the new UK–WHO growth charts to enhance assessment of growth around birth

The decision to adopt the new WHO standard in the UK necessitated substantial changes to the neonatal section of the chart, including separation of the preterm UK birth weight reference from the WHO standard. The evidence-based design process has led to several novel features that could be generally applied in other chart designs, and revealed uncertainties leading to inconsistencies in charting. Failing to plot the birth weight of term infants at age 0 can lead to spurious centile crossing in the early weeks of life, particularly among infants at the extreme of gestation. Users will need training to use the charts, but this should improve overall understanding and the use of charts.

Measurement of carbon dioxide production in very low birth weight babies.

BACKGROUND CO2production is most commonly measured by using indirect calorimetry to quantify elimination of CO2 in breath (Vco 2). An alternative is to measure the rate at which CO2 appears in the body pool (Raco 2) by infusing a 13C labelled bicarbonate tracer. Vco 2 and Raco 2 generally differ but are related byc, a factor that adjusts for the incomplete recovery of infused tracer in the breath. The literature relating to human studies cites a wide range of values forc but the only neonatal study to determinec empirically estimated a mean value of 0.77. AIM To estimate fractional recovery rate, c, in very low birthweight babies, and assess the feasibility of using the isotopic technique to measure CO2 production during mechanical ventilation. METHOD Eleven spontaneously breathing, continuously fed, very low birthweight infants (median birth weight 1060 g, median gestational age 29 weeks) were studied. RESULTS Mean (SD) Vco 2 was 9.0 (2.0) ml/min (standard temperature and pressure dry, STPD) and mean (SD) Raco 2 was 9.6 (2.1) ml/min (STPD). The mean (SD) value ofc was estimated as 0.95 (0.13). The 95% confidence intervals of the mean were 0.87–1.03. CONCLUSIONS The results emphasise the importance of measuringc for a given study population rather than assuming a value based on adult studies. The close approximation of Raco 2 and Vco 2 in this group of babies implies that the labelled bicarbonate infusion technique could be used to measure simply CO2 production during mechanical ventilation.

Breast feeding: the baby friendly initiative : Unicef’s baby friendly initiative is making great progress in UK

Editor—We share Malik and Cutting’s enthusiasm for Unicef’s baby friendly initiative in the United Kingdom but were disappointed that they did not acknowledge the great progress made over the past year.1 It is pessimistic to state that hospitals have been slow to work with the initiative. In fact, almost all units are working towards baby friendly accreditation; 11 British maternity units have achieved the required standard and another 40 have a certificate of commitment. Although Malik and Cutting suggest that hospitals might be demoralised by unachievable targets (such as the 75% breastfeeding rate required for the global baby friendly award), we removed this requirement for the United Kingdom’s standard award in order to focus on the support and encouragement of best clinical practice. It is also unfair to suggest that the baby friendly initiative is confined to hospitals. On 15 May we launched best practice standards for community healthcare settings, with the support of the minister for public health. This is the first step in introducing the initiative into the community and provides a framework around which clinical accreditation will be developed. The United Kingdom will probably be unique in having a primary care baby friendly award. As with the existing awards, particular emphasis is placed on support for mothers to make informed decisions about feeding their babies. Malik and Cutting call for better coordination with existing groups that support mothers; in fact, all four national groups are fully involved with the baby friendly initiative. We were also puzzled by the statement that “government and NHS managers should recognise and encourage [the baby friendly initiative’s] development.” The Department of Health has worked in partnership with the initiative since its inception in the United Kingdom,2,3 while an increasing proportion of NHS managers see the initiative as a cost effective quality framework to achieve a high standard of care, which can be independently accredited. We agree that much more could be done to support mothers in their choice to breast feed. Nevertheless, the healthcare system has a crucial role; it was particularly pleasing to note that the 1995 infant feeding statistics4 documented progress on relevant hospital practices.5 We are optimistic that the progress of Unicef’s baby friendly initiative in the United Kingdom can strengthen this trend.

Management of pregnancy complicated by diabetes: Maternal glycaemic control during pregnancy and neonatal management

Pre-existing diabetes is one of the commonest medical conditions complicating pregnancy in the UK, and is associated with increased perinatal and neonatal mortality and morbidity. The prevalence of both type 1 and type 2 diabetes is increasing in the UK and worldwide, and management strategies to optimise health outcomes for mother and baby are of utmost importance. Since 2001, a number of United Kingdom national guidelines have been published which make clear recommendations for optimal maternal glycaemic control before and during pregnancy and for neonatal management. However, there is evidence that these recommendations are not being consistently achieved within the UK and some of the specific challenges are highlighted in this chapter.

How Low Can I Go? The Impact of Hypoglycemia on the Immature Brain

To the Editor .— In a recent commentary in Pediatrics ,1 Inder discussed neonatal hypoglycemia and commented on an article by Burns et al2 that presented a diverse picture of hypoglycemia-related cerebral abnormalities found on neuroimaging in neonates. Dr Inders review and cautions in extrapolation were sensible, but she concluded with a statement with which we strongly disagree: “… the experimental and human clinical data are clear that hypoglycemia (blood glucose level < 45 mg/dL), isolated or combined with …