22.4.13

Effect of behavioural-educational intervention on sleep for primiparous women and their infants in early postpartum: multisite randomised controlled trial


Stremler R, Hodnett E, Kenton L, Lee K, Weiss S, Weston J, et al.
(Published 20 March 2013) Cite this as: BMJ 2013;346:f1164
Objective To evaluate the effectiveness of a behavioural-educational sleep intervention delivered in the early postpartum in improving maternal and infant sleep.
Design Randomised controlled trial.
Setting Postpartum units of two university affiliated hospitals.
Participants 246 primiparous women and their infants randomised while in hospital with an internet based randomisation service to intervention (n=123) or usual care (n=123) groups.
Interventions The behavioural-educational sleep intervention included a 45-60 minute meeting with a nurse to discuss sleep information and strategies to promote maternal and infant sleep, a 20 page booklet with the content discussed, and phone contacts at one, two, and four weeks postpartum to reinforce information, provide support, and problem solve. The usual care group received calls at weeks one, two, and four to maintain contact without provision of advice.
Main outcome measures Primary outcome was maternal nocturnal (9 pm to 9 am) sleep (minutes) and secondary outcome was longest stretch of infant nocturnal sleep (minutes) measured at six and 12 weeks postpartum by actigraphy. Other outcomes measured at six and 12 weeks were number of maternal and infant night time awakenings by actigraphy, fatigue visual analogue scale, general sleep disturbance scale, and Edinburgh postnatal depression scale. Rates of exclusive breast feeding were measured at 12 weeks postpartum only.
Results All women who completed any outcome measures at six or 12 weeks were included in analysis. Sleep outcomes were completed at one or both of six and 12 weeks postpartum for 215 of 246 (87%) women (110/123 intervention and 105/123 usual care). Longitudinal mixed effects model analyses indicated no significant differences between the groups on any of the outcomes. The estimated mean difference in maternal nocturnal sleep between the intervention and usual care groups was 5.97 minutes (95% confidence interval −7.55 to 19.5 minutes, P=0.39). No differences in any outcomes were noted based on the specific nurse delivering the intervention or the number of phone contacts received.
Conclusion A behavioural-educational intervention delivered in the early postpartum, in hospital, and in the first weeks at home, was ineffective in improving maternal and infant sleep or other health outcomes in the first months postpartum.

Evidence-based clinical recommendations regarding fluoride intake from reconstituted infant formula and enamel fluorosis: a report of the American Dental Association Council on Scientific Affairs.

The Journal of the American Dental Associationvol. 142 no. 1 79-87

  1. for the American Dental Association Council on Scientific Affairs Expert Panel on Fluoride Intake From Infant Formula and Fluorosis

Background. This article presents evidence-based clinical recommendations regarding the intake of fluoride from reconstituted infant formula and its potential association with enamel fluorosis. The recommendations were developed by an expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs (CSA). The panel addressed the following question: Is consumption of infant formula reconstituted with water that contains various concentrations of fluoride by infants from birth to age 12 months associated with an increased risk of developing enamel fluorosis in the permanent dentition?
Types of Studies Reviewed. A panel of experts convened by the ADA CSA, in collaboration with staff of the ADA Center for Evidence-based Dentistry (CEBD), conducted a MEDLINE search to identify systematic reviews and clinical studies published since the systematic reviews were conducted that addressed the review question.
Results. CEBD staff identified one systematic review and two clinical studies. The panel reviewed this evidence to develop recommendations.
Clinical Implications. The panel suggested that when dentists advise parents and caregivers of infants who consume powdered or liquid concentrate infant formula as the main source of nutrition, they can suggest the continued use of powdered or liquid concentrate infant formulas reconstituted with optimally fluoridated drinking water while being cognizant of the potential risks of enamel fluorosis development. These recommendations are presented as a resource to be considered in the clinical decision-making process. As part of the evidence-based approach to care, these clinical recommendations should be integrated with the practitioner’s professional judgment and the patient’s needs and preferences.

16.4.13

Communication and Dissemination Strategies To Facilitate the Use of Health and Health Care Evidence




The Agency for Healthcare Research and Quality (AHRQ) Effective Healthcare (EHC) Program funds individual researchers, research centers, and academic organizations to work with AHRQ to produce effectiveness and comparative effectiveness research for clinicians and consumers.1 Comparative effectiveness research (CER) compares the benefits, harms, and effectiveness of health interventions for the prevention, diagnosis, treatment, and management of clinical conditions and the improvement of health care delivery. The purpose of CER is to assist patients and consumers, clinicians and other providers, and purchasers and payers to make informed decisions that will improve health care at both the individual and population levels.1

One EHC goal is to make CER accessible to these decisionmakers. The Institute of Medicine’s list of 100 priority topics for CER highlights the importance of translating and disseminating this research.2 The specific topic (“compare the effectiveness of dissemination and translation techniques to facilitate the use of CER by patients, clinicians, payers, and others”) was listed among the first quartile of topics recommended for initial focus. Many hope that better communication and dissemination of CER will result in more widespread use of such information.
Coupled with these mandates is the fact that the ad hoc Uncertainty Committee of the EHC Stakeholder Group is interested in promoting effective ways to communicate uncertainty about health and health care evidence to end-users. The committee would like to know what approaches to conveying uncertainty increase the likelihood that audiences receiving such information will understand it and be able to factor it into their decisionmaking.

This systematic review has three related components; all focus on promoting informed health and health care decisions among patients and providers. First, it addresses the comparative effectiveness of communicating the evidence in various contents and formats that increases the likelihood that it will be understood and used by the target audience. Second, it examines the comparative effectiveness of a variety of approaches for disseminating the evidence from those who develop it to its potential users. Third, it examines the comparative effectiveness of various ways of communicating uncertainty associated with health and health care evidence to different target audiences.


15.4.13

Timing of Solid Food Introduction and Obesity: Hong Kong’s “Children of 1997” Birth Cohort



  1. C. Mary Schooling, PhD

ABSTRACT

BACKGROUND: Some observational studies in Western settings show that early introduction of solid food is associated with subsequent obesity. However, introduction of solid food and obesity share social patterning. We examined the association of the timing of the introduction of solid food with BMI and overweight (including obesity) into adolescence in a developed non-Western setting, in which childhood obesity is less clearly socially patterned.
METHODS: We used generalized estimating equation models to estimate the adjusted associations of the timing of the introduction of solid food (<3 3="" 5="" 7="" and="">8 months) with BMI z score and overweight (including obesity) at different growth phases (infancy, childhood, and puberty) in 7809 children (88% follow-up) from a Chinese birth cohort, “Children of 1997.” We assessed if the associations varied with gender or breastfeeding. We used multiple imputation for missing exposure and confounders.
RESULTS: The introduction of solid food at <3 age="" associated="" bmi="" but="" clearly="" difference="" em="" family="" in="" including="" infancy="" lower="" mean="" months="" nbsp="" not="" obesity="" of="" or="" overweight="" position="" socioeconomic="" style="border: 0px; font-family: inherit; font-size: inherit; line-height: inherit; margin: 0px; outline-style: none; padding: 0px; text-align: inherit; vertical-align: baseline;" was="" with="">z
score: 0.01; 95% confidence interval (CI): −0.14 to 0.17], childhood (0.14; 95% CI: −0.11 to 0.40), or at puberty (0.22; 95% CI: −0.07 to 0.52), adjusted for SEP and infant and maternal characteristics.
CONCLUSIONS: In a non-Western developed setting, there was no clear association of the early introduction of solid food with childhood obesity. Together with the inconsistent evidence from studies in Western settings, this finding suggests that any observed associations might simply be residual confounding by SEP.

12.4.13

Large-Scale Use of the Modified Checklist for Autism in Low-Risk Toddlers



  1. Deborah Fein, PhDc,d

  1. aDepartment of Psychiatry, University of California, San Diego, San Diego, California;
  2. bDepartment of Psychology, Georgia State University, Atlanta, Georgia;
  3. cDepartments of Psychology and
  4. dPediatrics, University of Connecticut, Storrs, Connecticut

ABSTRACT

OBJECTIVE: The purpose of the study was to examine use of the Modified Checklist for Autism in Toddlers (M-CHAT) as an autism-specific screening instrument in a large, geographically diverse pediatrics-based sample.
METHODS: The M-CHAT and the M-CHAT Follow-Up (M-CHAT/F) were used to screen 18 989 toddlers at pediatric well-child visits in 2 US geographic regions. Pediatricians directly referred children to ascertain potential missed screening cases. Screen-positive children received the M-CHAT/F; children who continued to screen positive after the M-CHAT/F received a diagnostic evaluation.
RESULTS: Results indicated that 54% of children who screened positive on the M-CHAT and M-CHAT/F presented with an autism spectrum disorder (ASD), and 98% presented with clinically significant developmental concerns warranting intervention. An M-CHAT total score cutoff of ≥3 identifies nearly all screen-positive cases, and for ease of scoring the use of only the M-CHAT total score cutoff is recommended. An M-CHAT total score of 7 serves as an appropriate clinical cutoff, and providers can bypass the M-CHAT/F and refer immediately to evaluation and intervention if a child obtains a score of ≥7.
CONCLUSIONS: This study provides empirical support for the utility of population screening for ASD with the use of the M-CHAT in a primary care setting. Results suggest that the M-CHAT continues to be an effective screening instrument for ASD when the 2-step screening process is used. The M-CHAT is widely used at pediatric offices, and this study provides updated results to facilitate use and scoring of the M-CHAT by clinical providers.


Pacifier Restriction and Exclusive Breastfeeding.


  1. Carrie A. Phillipi, MD, PhDa
  1. ABSTRACT

    OBJECTIVE: We tested the hypothesis that removing pacifiers from routine distribution in our mother-baby unit (MBU) would be associated with greater breastfeeding initiation or exclusivity during the birth hospitalization.
    METHODS: We retrospectively compared exclusive breastfeeding, breastfeeding plus supplemental formula feeding, and exclusive formula feeding rates for 2249 infants admitted to the MBU at our university teaching hospital during the 5 months before and 8 months after restriction of routine pacifier distribution. Formula supplementation, if not medically indicated, was discouraged per standard practice, but access to formula was not restricted.
    RESULTS: Of the 2249 infants, 79% were exclusively breastfed from July through November 2010, when pacifiers were routinely distributed. During the 8-month period after pacifier restriction, this proportion decreased significantly to 68% (P < .001). A corresponding increase from 18% to 28% was observed in the number of breastfed infants receiving supplemental formula feeds in the same period (P < .001). During the study period, the proportion of exclusively formula-fed infants increased from 1.8% to 3.4% (P < .05).
    CONCLUSIONS: Restricting pacifier distribution during the newborn hospitalization without also restricting access to formula was associated with decreased exclusive breastfeeding, increased supplemental formula feeding, and increased exclusive formula feeding. Because high-quality, prospective medical literature addressing pacifier use and breastfeeding does not conclusively show an adverse relationship in women who are motivated to breastfeed, more studies are needed to help determine what effect, if any, pacifiers have on breastfeeding initiation and exclusivity in the immediate newborn period.