Breast-feeding
Posted: 18 May 2013, 16:13
.
Breast-feeding has been linked with increased arterial distensibility in later life and thus may predispose to hypertension. From ?Duration of breast feeding and arterial distensibility in early adult life: population based study?. Leeson C, Kattenhorn M. BMJ 2001;322:643-7: It is an unusual occurrence in recent years for the practice of breast-feeding to receive negative press. After years of encouragement for new mothers to choose breast over formula feeding, media coverage of this recent research caused considerable interest. This work follows on from the finding of higher rates of ischaemic heart disease in men breast fed at one year.
This observational study from Cambridge collected data on 331 people aged 20 to 28. The participants were assessed for their brachial artery distensibility ? a measure of arterial stiffness. The link between this parameter and cardiovascular disease is only hypothetical. Further, potential problems arise as mothers of participants are asked to recall whether they breast-fed and if so, for how long. The results showed a statistically significant link between those breast-fed for longer than 4 months and increased arterial stiffness. This difference was not apparent in those breast-fed for shorter periods. No link was found between breast-feeding and cholesterol concentration.
The group postulated that any effect of breast-feeding on cardiovascular risk occurs early in life and may occur through programming of cholesterol metabolism.
The authors concluded the study by playing down the evidence for causality and reiterating the accepted maxim of ?breast is best?, noting that further investigation into the optimal duration of breast-feeding is warranted, as no data presently exists.
Lactobacilli in milk decrease the incidence of childhood infections. From ?Effect of long term consumption of probiotic milk on infections in children attending day care centres: double blind, randomised trial?. Hatakka et al. BMJ 2001;322:1327: There is already a strong evidence base (although any mother could tell you), that children have a higher risk of respiratory and gastrointestinal disorders when they attend day care centres. This Finnish study investigated the use of lactobacillus as a means of reducing the incidence of these infections. Lactobacillus is suspected of stimulating humoral immunity. They designed a double blind randomised controlled study of almost 600 children in 18 Helsinki day care facilities. Children were randomised to milk identical in composition except for inclusion of lactobacillus in one group. Over the 7 months of the study, parents kept diaries of gut and respiratory symptoms. Other outcome measures were absenteeism, diagnosis of infections and prescriptions of antibiotics. Statistical analysis showed that there was a decrease in the number of children suffering from complications of respiratory infection or pneumonia. The prescription of antibiotics and amount of absenteeism were also reduced but this was not statistically significant.
The effect of this probiotic may have been affected by the widespread use of lactobacilli containing products in Finland. The control group were thus possibly also exposed to the intervention. The two groups were also not well matched for age despite the older children generally suffering from fewer infections. This is a possible source of bias. However, despite the lack of strong statistical significance, the lactobacilli did show a reduction in all the observed outcome measured and a more focussed trial is justified.
Erythromycin acts as a prokinetic, which can decrease the time it takes for premature neonates to become fully enterally fed. From ?Randomised controlled study of oral erythromycin for treatment of gastrointestinal dysmotility in preterm infants?. Ng et al. Arch Dis Child Fetal Neonatal Ed 2001;84:F177-82: Erythromycin has long been known to have a prokinetic effect on gut motility via a motilin agonist effect. Given the potentially damaging effects of prolonged parenteral feeding on the premature neonate, a study to investigate the potential role of macrolides into this process has been keenly awaited. This Hong Kong study group randomised babies under 1500g to receive either 12.5mgkg erythromycin qds or a saline placebo. The intervention only began if the baby was less than half enteral fed by day 5 of life. Those babies with congenital gut or cardiac abnormalities were excluded from the study. The main outcome measure was time taken to establish full enteral feeds and there was also observation for side effects of the antibiotic.
56 infants were entered into the study. The average time to full enteral feeding was 10 days shorter in the erythromycin group. This was highly significant (p < 0.0001). Furthermore, there was a decrease in the number of babies developing cholestatic jaundice in the treatment group. Concerns regarding arrythmias and infections with resistant organisms were addressed and none of the group suffered these.
Despite these promising results, the team are keen to promote caution regarding the routine use of erythromycin until its safety profile has been more fully investigated in the preterm. They also point to a new generation of macrolide analogues, free of the major cardiac side effects, as the possible future agents for this valuable indication.
Cisapride was a useful agent in managing difficult gastro-oesophageal reflux before it lost its licence due to concerns about side effects. From ?Cisapride and QTc interval in children?. Ramirez-Mayan et al. Pediatrics 2000;106:1028-30: Controversy remains around Cisapride and it has been withdrawn for use in children due to concern that it may cause arrythmias and a prolonged QT (associated with sudden death). Ramirez-Mayan et al studied electrocardiography and predisposition to arrhythmias in those on cisapride and compared them to a normal population. Prolonged QT interval was found in both groups but disappeared in half of the cisapride group when the drug was stopped. Although the study indicates cisapride does prolong the QT interval, this can occur without the drug and its clinical significance remains unclear.
Infantile colic has NOT been demonstrated to respond to chiropractic spinal manipulation in large randomised controlled trials. From ?Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Olafsdottir E et al. Arch Dis Child 2001;84:138-41: After case control studies have suggested that chiropracty was helpful in the management of infantile colic this study evaluated the efficacy of chiropractic spinal manipulation in a randomised, placebo controlled clinical trial. Babies with colic were assigned to either spinal manipulation or just being held by a nurse. Both clinician and parents were blinded to this. Both groups received advice on feeding and baby care and the colic in both groups improved. However, there was no significantly greater improvement in those treated by the chiropractor. The study emphasises the importance of evaluating anecdotally supported alternative treatments
Breast-feeding has been linked with increased arterial distensibility in later life and thus may predispose to hypertension. From ?Duration of breast feeding and arterial distensibility in early adult life: population based study?. Leeson C, Kattenhorn M. BMJ 2001;322:643-7: It is an unusual occurrence in recent years for the practice of breast-feeding to receive negative press. After years of encouragement for new mothers to choose breast over formula feeding, media coverage of this recent research caused considerable interest. This work follows on from the finding of higher rates of ischaemic heart disease in men breast fed at one year.
This observational study from Cambridge collected data on 331 people aged 20 to 28. The participants were assessed for their brachial artery distensibility ? a measure of arterial stiffness. The link between this parameter and cardiovascular disease is only hypothetical. Further, potential problems arise as mothers of participants are asked to recall whether they breast-fed and if so, for how long. The results showed a statistically significant link between those breast-fed for longer than 4 months and increased arterial stiffness. This difference was not apparent in those breast-fed for shorter periods. No link was found between breast-feeding and cholesterol concentration.
The group postulated that any effect of breast-feeding on cardiovascular risk occurs early in life and may occur through programming of cholesterol metabolism.
The authors concluded the study by playing down the evidence for causality and reiterating the accepted maxim of ?breast is best?, noting that further investigation into the optimal duration of breast-feeding is warranted, as no data presently exists.
Lactobacilli in milk decrease the incidence of childhood infections. From ?Effect of long term consumption of probiotic milk on infections in children attending day care centres: double blind, randomised trial?. Hatakka et al. BMJ 2001;322:1327: There is already a strong evidence base (although any mother could tell you), that children have a higher risk of respiratory and gastrointestinal disorders when they attend day care centres. This Finnish study investigated the use of lactobacillus as a means of reducing the incidence of these infections. Lactobacillus is suspected of stimulating humoral immunity. They designed a double blind randomised controlled study of almost 600 children in 18 Helsinki day care facilities. Children were randomised to milk identical in composition except for inclusion of lactobacillus in one group. Over the 7 months of the study, parents kept diaries of gut and respiratory symptoms. Other outcome measures were absenteeism, diagnosis of infections and prescriptions of antibiotics. Statistical analysis showed that there was a decrease in the number of children suffering from complications of respiratory infection or pneumonia. The prescription of antibiotics and amount of absenteeism were also reduced but this was not statistically significant.
The effect of this probiotic may have been affected by the widespread use of lactobacilli containing products in Finland. The control group were thus possibly also exposed to the intervention. The two groups were also not well matched for age despite the older children generally suffering from fewer infections. This is a possible source of bias. However, despite the lack of strong statistical significance, the lactobacilli did show a reduction in all the observed outcome measured and a more focussed trial is justified.
Erythromycin acts as a prokinetic, which can decrease the time it takes for premature neonates to become fully enterally fed. From ?Randomised controlled study of oral erythromycin for treatment of gastrointestinal dysmotility in preterm infants?. Ng et al. Arch Dis Child Fetal Neonatal Ed 2001;84:F177-82: Erythromycin has long been known to have a prokinetic effect on gut motility via a motilin agonist effect. Given the potentially damaging effects of prolonged parenteral feeding on the premature neonate, a study to investigate the potential role of macrolides into this process has been keenly awaited. This Hong Kong study group randomised babies under 1500g to receive either 12.5mgkg erythromycin qds or a saline placebo. The intervention only began if the baby was less than half enteral fed by day 5 of life. Those babies with congenital gut or cardiac abnormalities were excluded from the study. The main outcome measure was time taken to establish full enteral feeds and there was also observation for side effects of the antibiotic.
56 infants were entered into the study. The average time to full enteral feeding was 10 days shorter in the erythromycin group. This was highly significant (p < 0.0001). Furthermore, there was a decrease in the number of babies developing cholestatic jaundice in the treatment group. Concerns regarding arrythmias and infections with resistant organisms were addressed and none of the group suffered these.
Despite these promising results, the team are keen to promote caution regarding the routine use of erythromycin until its safety profile has been more fully investigated in the preterm. They also point to a new generation of macrolide analogues, free of the major cardiac side effects, as the possible future agents for this valuable indication.
Cisapride was a useful agent in managing difficult gastro-oesophageal reflux before it lost its licence due to concerns about side effects. From ?Cisapride and QTc interval in children?. Ramirez-Mayan et al. Pediatrics 2000;106:1028-30: Controversy remains around Cisapride and it has been withdrawn for use in children due to concern that it may cause arrythmias and a prolonged QT (associated with sudden death). Ramirez-Mayan et al studied electrocardiography and predisposition to arrhythmias in those on cisapride and compared them to a normal population. Prolonged QT interval was found in both groups but disappeared in half of the cisapride group when the drug was stopped. Although the study indicates cisapride does prolong the QT interval, this can occur without the drug and its clinical significance remains unclear.
Infantile colic has NOT been demonstrated to respond to chiropractic spinal manipulation in large randomised controlled trials. From ?Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Olafsdottir E et al. Arch Dis Child 2001;84:138-41: After case control studies have suggested that chiropracty was helpful in the management of infantile colic this study evaluated the efficacy of chiropractic spinal manipulation in a randomised, placebo controlled clinical trial. Babies with colic were assigned to either spinal manipulation or just being held by a nurse. Both clinician and parents were blinded to this. Both groups received advice on feeding and baby care and the colic in both groups improved. However, there was no significantly greater improvement in those treated by the chiropractor. The study emphasises the importance of evaluating anecdotally supported alternative treatments