Cynthia R. Howard

Full Breastfeeding Duration and Associated Decrease in Respiratory Tract Infection in US Children

OBJECTIVE. The American Academy of Pediatrics recommends exclusive breastfeeding for an infants first 6 months of life. When compared with exclusive breastfeeding for 4 months, greater protection against gastrointestinal infection, but not respiratory tract infection, has been demonstrated for the 6-month duration. The objective of this study was to ascertain if full breastfeeding of ≥6 months compared with 4 to <6 months in the United States provides greater protection against respiratory tract infection. METHODS. Secondary analysis of data from the National Health and Nutrition Examination Survey III, a nationally representative cross-sectional home survey conducted from 1988 to 1994, was performed. Data from 2277 children aged 6 to <24 months, who were divided into 5 groups according to breastfeeding status, were compared. Children who required neonatal intensive care were excluded. SUDAAN software was used to account for the complex sampling design. Logistic regression adjusted for confounding factors. Outcome measures included adjusted odds of acquiring pneumonia, ≥3 episodes of cold/influenza, ≥3 episodes of otitis media (OM), or wheezing in the past year or acquiring first OM at <12 months of age. RESULTS. In unadjusted analyses, infants who were fully breastfed for 4 to <6 months (n = 223) were at greater risk for pneumonia than those who were fully breastfed for ≥6 months (n = 136) (6.5% vs 1.6%). There were not statistically significant differences in ≥3 episodes of cold/influenza (45% vs 41%), wheezing (23% vs 24%), ≥3 episodes of OM (27% vs 20%), or first OM at <12 months of age (49% vs 47%). Adjusting for demographic variables, childcare, and smoke exposure revealed statistically significant increased risk for both pneumonia (odds ratio [OR]: 4.27; 95% confidence interval [CI]: 1.27–14.35) and ≥3 episodes of OM (OR: 1.95; 95% CI: 1.06–3.59) in those who were fully breastfed for 4 to <6 months compared with ≥6 months. CONCLUSIONS. This nationally representative study documents increased risk of respiratory tract infection including pneumonia and recurrent OM in children who were fully breastfed for 4 vs 6 months. These findings support current recommendations that infants receive only breast milk for the first 6 months of life.

Office prenatal formula advertising and its effect on breast-feeding patterns

Objective To compare the effect of formula company–produced materials about infant feeding to breast-feeding promotion materials without formula advertising on breast-feeding initiation and duration. Methods Five hundred forty-seven pregnant women were randomized to receive either formula company (commercial; n = 277) or specially designed (research; n = 270) educational packs about infant feeding at their first prenatal visit. Feeding method was determined at delivery. Breast-feeding duration of the 294 women who chose to breast-feed was ascertained at 2, 6, 12, and 24 weeks. Survival analyses were used to evaluate continuous outcomes, and χ2 and logistic regression analyses were used to evaluate discrete outcomes. Results Breast-feeding initiation (relative risk [RR] 0.93, 95% confidence interval [CI] 0.61, 1.43) and duration after 2 weeks (hazard ratio 1.19, 95% CI 0.86, 1.64) were not affected. Women in the commercial group were more likely to cease breast-feeding before hospital discharge (RR 5.80, 95% CI 1.25, 54.01) and before 2 weeks (adjusted odds ratio [OR] 1.91, 95% CI 1.02, 3.55). In subgroup analyses, women with uncertain goals for breast-feeding or goals of 12 weeks or less experienced shortened exclusive (hazard ratio 1.53, 95% CI 1.06, 2.21), full (hazard ratio 1.70, 95% CI 1.18, 2.48), and overall (hazard ratio 1.75, 95% CI 1.16, 2.64) breast-feeding duration when exposed to the commercial intervention. Conclusion Although breast-feeding initiation and long-term duration were not affected, exposure to formula promotion materials increased significantly breast-feeding cessation in the first 2 weeks. Additionally, among women with uncertain goals or breast-feeding goals of 12 weeks or less, exclusive, full, and overall breast-feeding duration were shortened. Educational materials about infant feeding should support unequivocally breast-feeding as optimal nutrition for infants; formula promotion products should be eliminated from prenatal settings.

ABM clinical protocol #3: hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Primary prevention of childhood lead exposure: A randomized trial of dust control.

Background. Dust control is recommended as one of the primary strategies to prevent or control childrens exposure to residential lead hazards, but the effect of dust control on childrens blood lead levels is poorly understood. Objective. To determine the effectiveness of dust control in preventing childrens exposure to lead, as measured by blood lead levels, during their peak age of susceptibility. Design. A randomized, controlled trial. Setting. Rochester, NY. Participants. A total of 275 urban children were randomized at 6 months of age, of whom 246 (90%) were available for the 24-month-old follow-up visit. Interventions. Children and their families were randomly assigned to an intervention group (n = 140), which received cleaning equipment and up to eight visits by a dust control advisor, or a control group (n = 135). Outcome Measures. Geometric mean blood lead levels and prevalence of elevated blood lead levels (ie, >10 μg/dL, 15 μg/dL, and 20 μg/dL). Results. At baseline, childrens geometric mean blood lead levels were 2.9 μg/dL (95% confidence interval [CI] = 2.7, 3.1); there were no significant differences in characteristics or lead exposure by group assignment, with the exception of water lead levels. For children in the intervention group, the mean number of visits by a dust control advisor during the 18-month study period was 6.2; 51 (36%) had 4 to 7 visits, and 69 (49%) had 8 visits. At 24 months of age, the geometric mean blood lead was 7.3 μg/dL (95% CI = 6.6, 8.2) for the intervention group and 7.8 μg/dL (95% CI = 6.9, 8.7) for the control group. The percentage of children with a 24-month blood lead ≥10 μg/dL, ≥15 μg/dL, and ≥20 μg/dL was 31% versus 36%, 12% versus 14%, and 5% versus 7% in the intervention and control groups, respectively. Conclusions. We conclude that dust control, as performed by families and in the absence of lead hazard controls to reduce ongoing contamination from lead-based paint, is not effective in the primary prevention of childhood lead exposure. blood lead, lead-contaminated house dust, randomized trial, children, environmental exposure, lead poisoning, primary prevention, prevention.

Maternal Versus Infant Vitamin D Supplementation During Lactation: A Randomized Controlled Trial

OBJECTIVE: Compare effectiveness of maternal vitamin D3 supplementation with 6400 IU per day alone to maternal and infant supplementation with 400 IU per day. METHODS: Exclusively lactating women living in Charleston, SC, or Rochester, NY, at 4 to 6 weeks postpartum were randomized to either 400, 2400, or 6400 IU vitamin D3/day for 6 months. Breastfeeding infants in 400 IU group received oral 400 IU vitamin D3/day; infants in 2400 and 6400 IU groups received 0 IU/day (placebo). Vitamin D deficiency was defined as 25-hydroxy-vitamin D (25(OH)D) <50 nmol/L. 2400 IU group ended in 2009 as greater infant deficiency occurred. Maternal serum vitamin D, 25(OH)D, calcium, and phosphorus concentrations and urinary calcium/creatinine ratios were measured at baseline then monthly, and infant blood parameters were measured at baseline and months 4 and 7. RESULTS: Of the 334 mother-infant pairs in 400 IU and 6400 IU groups at enrollment, 216 (64.7%) were still breastfeeding at visit 1; 148 (44.3%) continued full breastfeeding to 4 months and 95 (28.4%) to 7 months. Vitamin D deficiency in breastfeeding infants was greatly affected by race. Compared with 400 IU vitamin D3 per day, 6400 IU/day safely and significantly increased maternal vitamin D and 25(OH)D from baseline (P < .0001). Compared with breastfeeding infant 25(OH)D in the 400 IU group receiving supplement, infants in the 6400 IU group whose mothers only received supplement did not differ. CONCLUSIONS: Maternal vitamin D supplementation with 6400 IU/day safely supplies breast milk with adequate vitamin D to satisfy her nursing infant’s requirement and offers an alternate strategy to direct infant supplementation.

Combination Feeding of Breast Milk and Formula: Evidence for Shorter Breast-Feeding Duration from the National Health and Nutrition Examination Survey

OBJECTIVE To examine combination breast milk and formula-feeding (CBFF), defined as daily breast-feeding and formula-feeding begun in the first week of life and to examine associations between CBFF and overall breast-feeding duration. STUDY DESIGN We used the National Health and Nutrition Examination Survey, 1999-2006, to determine the prevalence of CBFF in both univariable and multivariable analyses. We examined breast-feeding duration using Kaplan-Meier and Cox proportional hazards analyses. RESULTS Among 6788 children ages 0-71 months, 8% were CBFF and 55% were exclusively breast-fed during the first week of life. Factors independently associated with CBFF were Hispanic ethnicity (adjusted OR, 3.81) and black race (adjusted OR, 2.59). CBFF was associated with decreased overall breast-feeding duration in the full cohort (P < .001) but not in the Hispanic or black subgroups. CBFF and formula-feeding, when compared with 4 months of exclusive breast-feeding, were associated with an increased risk for overweight/obesity between ages 2 and 6 years. CONCLUSIONS In a nationally representative sample, CBFF is associated with shorter overall breast-feeding duration in white but not Hispanic or black mother-baby dyads. A significant number of US infants, though breast-fed, do not receive the health benefits of exclusive breast-feeding.

ABM clinical protocol #9: Use of galactogogues in initiating or augmenting the rate of maternal milk secretion (First revision January 2011)

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. These guidelines are not intended to be all-inclusive, but to provide a basic framework for physician education regarding breastfeeding.

Long-term effect of dust control on blood lead concentrations.

Background. Dust control is recommended to prevent childrens exposure to residential lead hazards, but the long-term effect of dust control on childrens exposure to environmental lead is unknown. Objective. To determine the effect of dust control on childrens exposure to lead, as measured by blood lead concentration at 48 months of age. Design. A randomized, controlled trial. Setting. Rochester, New York. Participants. A total of 275 urban children were randomized at 6 months of age; 189 (69%) were available for the 48-month follow-up blood test. Intervention. Children and their families were randomly assigned to an intervention group that received cleaning equipment and up to 8 visits by a trained lead hazard control advisor or to a control group. The intervention was terminated when the children were 24 months of age. Outcome Measures. Geometric mean blood lead concentration and prevalence of elevated blood lead concentration (ie, ≥10 μg/dL, ≥15 μg/dL, and ≥20 μg/dL), by group assignment. Results. For children with 48-month blood tests, baseline geometric mean blood lead concentrations were 2.8 μg/dL (95% confidence interval [CI]: 2.6,3.0); there were no significant differences in baseline characteristics or lead exposure by group assignment. At 48 months of age, the geometric mean blood lead was 5.9 μg/dL (95% CI: 5.3,6.7) for the intervention group and 6.1 μg/dL (95% CI: 5.5,6.9) for the control group. The percentage of children with a 48-month blood lead ≥10 μg/dL, ≥15 μg/dL, and ≥20 μg/dL was 19% versus 19%, 2% versus 9%, and 1% versus 2% in the intervention and control groups, respectively. Conclusions. We conclude that dust control, as performed by families and in the absence of lead hazard controls to reduce ongoing contamination from lead-based paint, was not effective in preventing childrens exposure to residential lead hazards.

ABM clinical protocol #10: Breastfeeding the late preterm infant (34 0/7 to 366/7 weeks gestation) (first revision june 2011)*

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. These guidelines are not intended to be all-inclusive, but to provide a basic framework for physician education regarding breastfeeding.

Neonatal Circumcision and Pain Relief: Current Training Practices

Objective. We conducted a national survey of pediatric, family practice, and obstetrics and gynecology residency program directors to determine the curriculum content and predominant practices in US training programs with regard to neonatal circumcision and anesthesia/analgesia for the procedure. Methods. Residency directors of accredited programs were surveyed in two mailings of a forced response and short answer survey (response rate: 680/914, 74%; pediatrics 83%; family practice 72%; obstetrics 71%). Results. Pediatric residents were less likely than family practice [odds ratio (OR), 0.04; 95% confidence interval (CI), 0.02–0.08] or obstetrical (OR, 0.14; 95% CI, 0.08–0.23) residents to be taught circumcision. Training and local custom were rated as important determinants of medical responsibility for neonatal circumcision. Pediatric residents training in programs in which community pediatricians perform circumcisions were more likely to learn circumcision (OR, 39.0; 95% CI, 14.3–110.6) as were obstetric residents (OR, 79.0; 95% CI, 22.4–306.4) training in programs in which community obstetricians perform circumcision. In programs that teach circumcision, pediatric (84%; OR, 3.4; 95% CI, 1.7–7.1) and family practice (80%; OR, 2.7; 95% CI, 1.7–4.2) programs were more likely than obstetric programs (60%) to teach analgesia/anesthesia techniques to relieve procedural pain. Overall, 26% of programs that taught circumcision failed to provide instruction in anesthesia/analgesia for the procedure. Significant regional variations in training in circumcision and analgesia/anesthesia techniques were noted within and across medical specialties. Conclusions. Residency training standards are not consistent for pediatric, family practice, and obstetrical residents with regard to neonatal circumcision or instruction in analgesia/anesthesia for the procedure. Training with regard to pain relief is clearly inadequate for what remains a common surgical procedure in the United States. Given the overwhelming evidence that neonatal circumcision is painful and the existence of safe and effective anesthesia/analgesia methods, residency training in neonatal circumcision should include instruction in pain relief techniques.