Peter W. Howie

Protective effect of breast feeding against infection.

OBJECTIVE--To assess the relations between breast feeding and infant illness in the first two years of life with particular reference to gastrointestinal disease. DESIGN--Prospective observational study of mothers and babies followed up for 24 months after birth. SETTING--Community setting in Dundee. PATIENTS--750 pairs of mothers and infants, 76 of whom were excluded because the babies were preterm (less than 38 weeks), low birth weight (less than 2500 g), or treated in special care for more than 48 hours. Of the remaining cohort of 674, 618 were followed up for two years. INTERVENTIONS--Detailed observations of infant feeding and illness were made at two weeks, and one, two, three, four, five, six, nine, 12, 15, 18, 21, and 24 months by health visitors. MAIN OUTCOME MEASURE--The prevalence of gastrointestinal disease in infants during follow up. RESULTS--After confounding variables were corrected for babies who were breast fed for 13 weeks or more (227) had significantly less gastrointestinal illness than those who were bottle fed from birth (267) at ages 0-13 weeks (p less than 0.01; 95% confidence interval for reduction in incidence 6.6% to 16.8%), 14-26 weeks (p less than 0.01), 27-39 weeks (p less than 0.05), and 40-52 weeks (p less than 0.05). This reduction in illness was found whether or not supplements were introduced before 13 weeks, was maintained beyond the period of breast feeding itself, and was accompanied by a reduction in the rate of hospital admission. By contrast, babies who were breast fed for less than 13 weeks (180) had rates of gastrointestinal illness similar to those observed in bottle fed babies. Smaller reductions in the rates of respiratory illness were observed at ages 0-13 and 40-52 weeks (p less than 0.05) in babies who were breast fed for more than 13 weeks. There was no consistent protective effect of breast feeding against ear, eye, mouth, or skin infections, infantile colic, eczema, or nappy rash. CONCLUSION--Breast feeding during the first 13 weeks of life confers protection against gastrointestinal illness that persists beyond the period of breast feeding itself.

Standards for ultrasound fetal growth velocity

Objective An ultrasound study to establish the nature and limits of fetal growth in a low risk population from 22 weeks of gestation until term.

Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians.

Abstract Objective: To compare routine antenatal care provided by general practitioners and midwives with obstetrician led shared care. Design: Multicentre randomised controlled trial. Setting: 51 general practices linked to nine Scottish maternity hospitals. Subjects: 1765 women at low risk of antenatal complications. Intervention: Routine antenatal care by general practitioners and midwives according to a care plan and protocols for managing complications. Main outcome measures: Comparisons of health service use, indicators of quality of care, and womens satisfaction. Results: Continuity of carer was improved for the general practitioner and midwife group as the number of carers was less (median 5 carers v 7 for shared care group, P<0.0001) and the number of routine visits reduced (10.9 v 11.7, P<0.0001). Fewer women in the general practitioner and midwife group had antenatal admissions (27% (222/834) v 32% (266/840), P<0.05), non-attendances (7% (57) v 11% (89), P<0.01) and daycare (12% (102) v 7% (139), P<0.05) but more were referred (49% (406) v 36% (305), P<0.0001). Rates of antenatal diagnoses did not differ except that fewer women in the general practitioner and midwife group had hypertensive disorders (pregnancy induced hypertension, 5% (37) v 8% (70), P<0.01) and fewer had labour induced (18% (149) v 24% (201), P<0.01). Few failures to comply with the care protocol occurred, but more Rhesus negative women in the general practitioner and midwife group did not have an appropriate antibody check (2.5% (20) v 0.4% (3), P<0.0001). Both groups expressed high satisfaction with care (68% (453/663) v 65% (430/656), P=0.5) and acceptability of allocated style of care (93% (618) v 94% (624), P=0.6). Access to hospital support before labour was similar (45% (302) v 48% (312) visited labour rooms before giving birth, P=0.6). Conclusion: Routine specialist visits for women initially at low risk of pregnancy complications offer little or no clinical or consumer benefit. Key messages Key messages Care by general practitioners and midwives improved continuity of care: there were fewer carers, non-attendances, and hospital admissions, and marginally fewer routine visits than with specialist led shared care; incidences of hypertension, proteinuria, pre-eclampsia, and induction of labour were also lower Overall there were few deviations from the care protocol, but a greater proportion of Rhesus negative women in the general practitioner and midwife group did not have an appropriate check for antibodies The women in both trial groups were equally highly satisfied with all aspects of their care; only a small minority of women in the general practitioner and midwife group said they would have liked to have seen a hospital doctor but did not Although there was no net benefit from routine specialist antenatal visits, over half of women developed some complication during their pregnancy; in the general practitioner and midwife model of care, low risk women see a specialist when required and not at predefined routine visits

Randomised controlled trial of cardiotocography versus Doppler auscultation of fetal heart at admission in labour in low risk obstetric population

Abstract Objective: To compare the effect of admission cardiotocography and Doppler auscultation of the fetal heart on neonatal outcome and levels of obstetric intervention in a low risk obstetric population. Design: Randomised controlled trial. Setting: Obstetric unit of teaching hospital Participants: Pregnant women who had no obstetric complications that warranted continuous monitoring of fetal heart rate in labour. Intervention: Women were randomised to receive either cardiotocography or Doppler auscultation of the fetal heart when they were admitted in spontaneous uncomplicated labour. Main outcome measures: The primary outcome measure was umbilical arterial metabolic acidosis. Secondary outcome measures included other measures of condition at birth and obstetric intervention. Results: There were no significant differences in the incidence of metabolic acidosis or any other measure of neonatal outcome among women who remained at low risk when they were admitted in labour. However, compared with women who received Doppler auscultation, women who had admission cardiotocography were significantly more likely to have continuous fetal heart rate monitoring in labour (odds ratio 1.49, 95% confidence interval 1.26 to 1.76), augmentation of labour (1.26, 1.02 to 1.56), epidural analgesia (1.33, 1.10 to 1.61), and operative delivery (1.36, 1.12 to 1.65). Conclusions: Compared with Doppler auscultation of the fetal heart, admission cardiotocography does not benefit neonatal outcome in low risk women. Its use results in increased obstetric intervention, including operative delivery. What is already known on this topic The admission cardiotocogram is a short recording of the fetal heart rate immediately after admission to the labour ward Opinion varies about its value in identifying a potentially compromised fetus In low risk women, the incidence of intrapartum fetal compromise is low What this study adds Compared with Doppler auscultation of the fetal heart, admission cardiotocography has no benefit on neonatal outcome in low risk women Admission cardiotocography results in increased obstetric intervention, including operative delivery

Breast Milk and the Risk of Opportunistic Infection in Infancy in Industrialized and Non-Industrialized Settings

The purpose of this systematic review is to examine the relationship between infant feeding mode (i.e., breast-feedingversusothers) and infective illnesses in industrialized and non-industrialized countries.

Risk of preterm delivery in pregnant women with group B streptococcal urinary infections or urinary antibodies to group B streptococcal and E. coli antigens

Objective To establish whether there is an association between preterm delivery and either group B streptococcal urinary infection or the presence of urinary antibodies to group B streptococcal or E. coli antigens.

Protective effect of breastfeeding against infection in the first and second six months of life.

The American Academy of Pediatrics (1997) has recommended that babies be exclusively breastfed for the first six months of life, partially breastfed for the second six months and thereafter for as long as is mutually desired. This corresponds closely to the recommendations from the Department of Health in the United Kingdom (1994) of full breastfeeding for 4 months, the introduction of weaning foods between 4 and 6 months and the continuing use of breast milk as an important part of the diet for up to a year or more. Several factors, especially nutritional considerations, contribute to these recommendations but the beneficial health effects for the baby also play an important part.

The progestogen-only pill

This commentary reviews the indications for and side effects of the progestogen-only oral contraceptive (OC) pill, which accounts for under 3% of hormonal contraceptive sales in the UK. The progestogen-only pill has the advantage of fewer metabolic changes, a lower dose of progestogen, and avoidance of the use of estrogen. It is the hormonal method of choice for breast feeding women, older women, and women who are unable to tolerate an estrogen-containing preparation. Its failure rate ranges from 0.9 to 3.0/100 woman-years, which is comparable to that for other reversible methods. The failure rate tends to be lower in older age groups, perhaps reflecting advancing sensitivity with age to the contraceptive effects of progestogen. The major problem associated with use of progestogen-only contraceptives is irregular vaginal bleeding, experienced by 20-30% of users. Progestogen has been reported to induce a variety of effects on the endometrium as well as in ovarian steroid secretion. A high prevalence of functional ovarian cysts has been noted in users. It is now believed that the contraceptive efficacy of the progestogen-only pill depends more upon its effects on ovarian function than was previously realized. A new approach to overcoming some of the problems associated with progestogen-only contraception has involved combining progestogen with sulpiride. This combination appears to be more effective than either component alone in suppressing ovarian activity. There is a need to make progestogen-only OCs more widely available to women in developing countries, where 30-40% of women of reproductive age may be breast feeding at a given time. Numerous studies have demonstrated either no effect or a beneficial effect on lactation.

Undergraduate obstetrics and gynaecology in the United Kingdom and the Republic of Ireland, 1989.

Summary. Undergraduate obstetrics and gynaecology has given rise to concern at a time when the community has become increasingly sensitive about genital structure and function and human reproduction. A survey of clinical schools in the United Kingdom and the Republic of Ireland shows that an average of 11 weeks is available for undergraduate learning in the discipline. Nearly all schools provide written aims and objectives for clinical students. Pelvic examination is taught in what is concluded to be a sensible and responsible manner; students are expected to conduct an average minimum of eight deliveries. Family planning instruction is seen as generally inadequate. Comparison of clinical courses with those in Australia and New Zealand shows striking similarities. Undergraduate courses need to be under constant review and revision so that the best students are encouraged to see obstetrics and gynaecology as a desirable career path.

Breastfeeding : a natural method for child spacing

Lactational amenorrhea plays an important role in child spacing. Recent research has led to a consensus regarding the status of lactational amenorrhea as a method of family planning. This is currently referred to as the lactational amenorrhea method. Research priorities were to field test the lactational amenorrhea method and define the factors that influence lactational amenorrhea and the interface between the lactational amenorrhea method and other family planning methods.