31.8.11
Identification of developmental-behavioral problems in primary care: a systematic review.
Composite measures quantify households' obesogenic potential and adolescents' risk behaviors.
The Association of BMI Status With Adolescent Preventive Screening
29.8.11
Non-pharmacologic management of procedure-related pain in the breastfeeding infant.
Major Recommendations
Soothing the Newborn
There are several techniques that have been shown to provide pain relief for newborns (0–28 days of age) undergoing painful procedures. In breastfed newborns, breastfeeding itself is the preferred method to alleviate procedural pain. In addition to being safe, effective, natural, and without added cost, it provides an additional opportunity to promote and support breastfeeding. The individual components of breastfeeding (sucking, sweet taste, and warm contact) may be used separately or, preferably, in combinations when breastfeeding itself is not possible.
Breastfeeding or Human Milk
When available, breastfeeding should be the first choice to alleviate procedural pain in neonates undergoing a single painful procedure, such as venipuncture or heel lance (Codipietro, Ceccarelli, & Ponzone, 2008; Carbajal et al., 2003; Gray et al., 2002). Breastfeeding should not be discontinued prior to the procedure. Studies show that when breastfeeding was stopped shortly before a painful procedure, no significant differences were found (compared to control groups) in outcomes in terms of the orogustatory, emotional, tactile, or thermal experience (Gradin, Finnstrom, & Schollin, 2004). When breastfeeding is not possible, whether because of the unavailability of the mother or difficulties with breastfeeding, consider the use of expressed human milk by dropper, syringe, or bottle, which has been shown to soothe newborns experiencing procedural pain (Mathew & Mathew, 2003; Upadhyay et al., 2004; Taddio et al., 2008; Shah, Aliwalas, & Shah, 2006). Administration of human milk can also be combined with sucking, by dipping a pacifier (dummy) in the milk, as described below for sucrose.
Although some studies have demonstrated the efficacy of human milk alone (Upadhyay et al., 2004; Shah, Aliwalas, & Shah, 2007), human milk may not be equivalent to breastfeeding because of breastfeeding's multicomponent experience. Breastfeeding throughout the painful procedure is likely to be superior to human milk alone on the basis of synergism between the components of breastfeeding (Gradin, Finnstrom, & Schollin, 2004; Shah, Aliwalas, & Shah, 2007).
Skin-to-Skin Contact
Coordinating a breastfeeding session with the timing of the procedure is best, but, if this is not possible, skin-to-skin contact can comfort infants undergoing a procedure such as a heel lance. Skin-to-skin contact also gives the mother a caretaking role during the procedure that is unobtrusive, and by diminishing infant stress, it can increase maternal confidence as to her value to the infant (Gray, Watt, & Blass, 2000).
Parental contact and sucrose may act synergistically to reduce pain in neonates. Therefore if feasible, this combination can be employed (Schechter et al., 2007). Sucrose taste—first studied 20 years ago—is readily available for increasing the efficacy of other non-pharmacologic techniques (Gradin, Finnstrom, & Schollin, 2004). Sucrose administration is covered in more detail in the section below. Sucrose and pacifier can both be combined with the skin-to-skin component of parental contact.
Sucrose and Sucking (in Combination or Separately)
Sucrose taste has been shown to be effective analgesia for newborns and young infants for minor procedures, but not for more painful experiences like bladder catheterizations:
Sucrose and pacifier. The combination of oral sucrose and pacifier or non-nutritive sucking is remarkably soothing (Blass & Watt, 1999). This technique offers pain reduction to infants undergoing a wide variety of painful procedures, including heel lance, umbilical or percutaneous venous or arterial catheter insertion, central venous line placement, subcutaneous or intramuscular injection, lumbar puncture, circumcision, and endotracheal suction (Anand, 2001; Stevens, Yamada, & Ohlsson, 2004; Stevens et al., 2005). Because pain reduction achieved when using both sucrose and non-nutritive sucking is similar to that with breastfeeding, using a pacifier (dummy) dipped in 24% sucrose (by weight) solution whenever breastfeeding is not possible is an effective option (Blass & Watt, 1999; Akman et al., 2002). Sucrose administration should begin 2 minutes prior to the procedure. If use of a pacifier is not an available or acceptable option, sucrose can also be combined with sucking by dipping a clean, gloved (or non-gloved parental) finger in the sucrose solution. If sucking a pacifier or finger is not an option, administer a sucrose solution orally before the procedure (Anand, 2001). When parents are present, they should be educated that sweet substances other than breast milk and pacifiers both are recommended in the newborn period only for procedural pain.
Glucose versus sucrose. Glucose has also been shown to be an acceptable and effective alternative analgesic (Axelin et al., 2009; Idam-Siuriun et al., 2008). Taste difference is not a factor. Studies in rat (Blass & Shide, 1994) and human (Okan et al., 2007) newborns have not shown a preference for sucrose over glucose. The commercial availability of sucrose (table sugar) may have increased its use.
Sucrose by syringe. If use of a pacifier is not possible, administer 0.5–2mL of a 24% sucrose solution orally via syringe 2 minutes before the painful procedure (Anand, 2001; Shann, 2007). Several 24% sucrose solutions are commercially available. Sucrose administered by oro- or nasogastric tube is not analgesic.
Pacifier alone. While pacifiers alone may decrease crying associated with painful procedures, they do not have the same effect on physiological parameters such as heart rate or vagal tone (Taddio, 2001: Porges & Lipsitt, 1993). Moreover, sucking a pacifier has been found to reduce pain only when the suck rate exceeds 30 sucks/minute (Stevens, Yamada, & Ohlsson, 2004). A pacifier (or clean gloved or parental finger) should be used as the sole soothing intervention only if breastfeeding, human milk, sucrose (or glucose), and skin-to-skin contact are unavailable because non-nutritive sucking has consistently been found to be better than no intervention at all (Pinelli, Symington, & Ciliska, 2002).
Sucrose better than human milk? At least one study indicates that sucrose is more effective than human milk, when both are administered orally via syringe, at reducing infants' cry time, recovery time (heart rate peak returns to baseline), and change in heart rate (Ors et al., 1999). The sugar in human milk is lactose, which has been shown to be an ineffective analgesic agent (Blass & Shide, 1994). The analgesic component of human milk may be attributed to its fat content or other constituent
Y SIGUE.../...
23.8.11
Reduced or modified dietary fat for preventing cardiovascular disease
Assessed as up-to-date: 1 DEC 2010 DOI: 10.1002/14651858.CD002137.pub2
Abstract
Background
Reduction and modification of dietary fats have differing effects on cardiovascular risk factors (such as serum cholesterol), but their effects on important health outcomes are less clear.
Objectives
To assess the effect of reduction and/or modification of dietary fats on mortality, cardiovascular mortality, cardiovascular morbidity and individual outcomes including myocardial infarction, stroke and cancer diagnoses in randomised clinical trials of at least 6 months duration.
Search strategy
For this review update, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, were searched through to June 2010. References of Included studies and reviews were also checked.
Selection criteria
Trials fulfilled the following criteria: 1) randomised with appropriate control group, 2) intention to reduce or modify fat or cholesterol intake (excluding exclusively omega-3 fat interventions), 3) not multi factorial, 4) adult humans with or without cardiovascular disease, 5) intervention at least six months, 6) mortality or cardiovascular morbidity data available.
Data collection and analysis
Participant numbers experiencing health outcomes in each arm were extracted independently in duplicate and random effects meta-analyses, meta-regression, sub-grouping, sensitivity analyses and funnel plots were performed.
Main results
This updated review suggested that reducing saturated fat by reducing and/or modifying dietary fat reduced the risk of cardiovascular events by 14% (RR 0.86, 95% CI 0.77 to 0.96, 24 comparisons, 65,508 participants of whom 7% had a cardiovascular event, I2 50%). Subgrouping suggested that this reduction in cardiovascular events was seen in studies of fat modification (not reduction - which related directly to the degree of effect on serum total and LDL cholesterol and triglycerides), of at least two years duration and in studies of men (not of women). There were no clear effects of dietary fat changes on total mortality (RR 0.98, 95% CI 0.93 to 1.04, 71,790 participants) or cardiovascular mortality (RR 0.94, 95% CI 0.85 to 1.04, 65,978 participants). This did not alter with sub-grouping or sensitivity analysis.
Few studies compared reduced with modified fat diets, so direct comparison was not possible.
Authors' conclusions
The findings are suggestive of a small but potentially important reduction in cardiovascular risk on modification of dietary fat, but not reduction of total fat, in longer trials. Lifestyle advice to all those at risk of cardiovascular disease and to lower risk population groups, should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturates. The ideal type of unsaturated fat is unclear.
Plain language summary
Cutting down or changing the fat we eat may reduce our risk of heart disease
Modifying fat in our food (replacing some saturated (animal) fats with plant oils and unsaturated spreads) may reduce risk of heart and vascular disease, but it is not clear whether monounsaturated or polyunsaturated fats are more beneficial. There are no clear health benefits of replacing saturated fats with starchy foods (reducing the total amount of fat we eat). Heart and vascular disease includes heart attacks, angina, strokes, sudden cardiovascular death and the need for heart surgery. Modifying the fat we eat seems to protect us better if we adhere in doing so for at least two years. It is not clear whether people who are currently healthy benefit as much as those at increased risk of cardiovascular disease (people with hypertension, raised serum lipids or diabetes for example) and people who already have heart disease, but the suggestion is that they would all benefit to some extent.
22.8.11
Child passenger safety.
17.8.11
Associations between problems with crying, sleeping and/or feeding in infancy and long-term behavioural outcomes in childhood: a meta-analysis.
12.8.11
Secondhand Smoke Exposure and Neurobehavioral
DMD, MPH,b and Hillel R. Alpert, ScMb.aTobacco Free Research Institute, Dublin, Ireland; and bCenter
for Global Tobacco Control, Harvard School of Public Health,
Boston, Massachusetts
Relación entre el tabaquismo pasivo y los trastornos neuroconductuales en niños
El tabaquismo pasivo en el hogar se asocia a un mayor riesgo de que los niños menores de 12 años padezcan algun trastorno neuroconductual.
En un trabajo publicado en la revista Pediatrics, para examinar los trastornos neuroconductuales pediátricos más comunes, incluyendo el trastorno por déficit de atención/hiperactividad, problemas de aprendizaje y los trastornos de conducta, en niños expuestos al humo del tabaco en el hogar, los investigadores accedieron a la Encuesta Nacional de Salud Infantil realizada entre abril de 2007 y julio de 2008, analizando los datos de un total de 55.358 niños menores de 12 años.
El 6% de los niños menores de 12 años había estado expuestos al humo del tabaco en el hogar. De éstos, el 8,2% presentaba problemas de aprendizaje, el 5,9% trastorno por déficit de atención/hiperactividad y el 3,6% trastornos de comportamiento y conducta. Las probabilidades de que un niño presentase dos o más de estas trastornos era un 50% superior en los hogares donde había personas fumadoras.
4.8.11
Christina N. Lessov-Schlaggar, PhDa, Dennis R. Wahlgren, MAb, Sandy Liles, MPHb, Ming Ji, PhDc, Suzanne C. Hughes, PhD, MPHb, Jonathan P. Winickoff, MD, MPHd, Jennifer A. Jones, MPHb, Gary E. Swan, PhDe, Melbourne F. Hovell, PhD, MPHb Sensitivity to
is a strong predictor of smoking initiation. Identifying mechanisms
that contribute to smoking susceptibility provide information about
early targets for smoking prevention. This study investigated whether
sensitivity to secondhand smoke exposure (SHSe) contributes to smoking
susceptibility.
PARTICIPANTS AND METHODS: Subjects were high-risk, ethnically diverse
8- to 13-year-old subjects who never smoked and who lived with at
least 1 smoker and who participated in a longitudinal SHSe reduction
intervention trial. Reactions (eg, feeling dizzy) to SHSe were
assessed at baseline, and smoking susceptibility was assessed at
baseline and 3 follow-up measurements over 12 months. We examined the
SHSe reaction factor structure, association with demographic
characteristics, and prediction of longitudinal smoking susceptibility
status.
RESULTS: Factor analysis identified "physically unpleasant" and
"pleasant" reaction factors. Reported SHSe reactions did not differ
across gender or family smoking history. More black preteens reported
feeling relaxed and calm, and fewer reported feeling a head rush or
buzz compared with non-Hispanic white and Hispanic white counterparts.
Longitudinally, 8.5% of subjects tracked along the trajectory for high
(versus low) smoking susceptibility. Reporting SHSe as "unpleasant or
gross" predicted a 78% reduction in the probability of being assigned
to the high–smoking susceptibility trajectory (odds ratio: 0.22 [95%
confidence interval: 0.05–0.95]), after covariate adjustment.
CONCLUSIONS: Assessment of SHSe sensitivity is a novel approach to the
study of cigarette initiation etiology and informs prevention
interventions.
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Un Saludo
Jose Galbe