Current Pediatric Reviews (v.8, #4)

Editorial(Hot Topic: Breastfeeding Through the Ages) by Colin W. Binns, Andy H. Lee (277-278).

The Iron Requirement of Breastfeeding Infants by Frank R. Greer (279-284).
The recent report from the American Academy of Pediatrics on the prevention of iron deficiency and iron deficiency anemia recommended increased iron intake for breast fed infants beginning at 4 months of age. This recommendation has not been without controversy. This paper will review the reasoning behind these new recommendations and include a physiologic review of iron metabolism as well as its physiologic importance including its role in neurodevelopment. It will review the diagnosis of both iron deficiency and iron deficiency anemia and how to prevent them in the breastfed infant. This includes introducing medicinal iron at 4 months of age and introducing foods that are rich in heme iron (red meat) when complementary feedings are introduced.

Pacifier Use, Breastfeeding and Sudden Infant Death Syndrome by Katie Hewitt, Colin Binns, Jane Scott, David Forbes (285-291).
Objective: To review the effect of pacifier use in healthy term infants on breastfeeding duration and the risk of Sudden Infant Death Syndrome (SIDS). Design: Two systematic reviews were conducted of published studies (meta-analysis, Systematic Literature Reviews (SLRs), Randomised Controlled Trials (RCTs), cohort, case-control or cross-sectional studies). Electronic databases were searched for articles that assessed the effect of infant pacifier use on the risk of SIDS and/or on breastfeeding outcomes. Retrieved articles were assessed for validity and quality using the Dietitians Association of Australia (DAA) Quality Criteria Checklist and the NHMRC Evidence Hierarchy before being included in the review. Results: The initial search of the databases resulted in 68 references on the use of pacifiers and SIDS; three articles (1 meta-analysis, 1 SLR, 1 narrative review) received a positive rating according to the DAA checklist. The three publications consistently found pacifier use at last sleep was associated with a significant reduction in the risk of SIDS and to a lesser extent, routine pacifier use also provided a significant reduction in the risk. Searching the electronic databases for use of pacifiers and breastfeeding duration resulted in 188 publications and four of these publications were retrieved for analysis (1 Cochrane review, 1 SLR, 1 meta-analysis, 1 cohort study). The epidemiological evidence found pacifier use reduced the duration of any, full and exclusive breastfeeding, but this effect was not significant in four out of the five RCTs analysed in the Cochrane review and the SLR. Conclusion: The present review provides evidence of the association between pacifier use during the postnatal period and a decreased risk of SIDS whilst also drawing attention to the negative association between early pacifier use and reduced duration of breastfeeding (any, full and exclusive). This is the first review to emphasise the U-shaped effect of pacifiers on infant health. When assessing the totality of the evidence the results indicate that pacifiers should be advised against in the first month of life, but after the first month pacifier use may reduce the probability of SIDS.

Nutritional Supplements During Breastfeeding by Mi Kyung Lee, Colin Binns, Yun Zhao, Jane Scott, Wendy Oddy (292-298).
Women who are breastfeeding have increased requirements for energy and nutrients. Nutritional requirements for lactation have been the subject of several international reports and are included in general nutrient requirements documents, including those of the USA, Australia, European Union and WHO. Recommendations are made for all pregnant women to take folic acid prior to becoming pregnant and during the first trimester of the pregnancy and iodine supplementation is recommended in Australia and many other countries during pregnancy and lactation. The current WHO/ICCIDD/UNICEF recommendation for daily iodine intake (250 μg for lactating mothers) has been selected to ensure that iodine deficiency does not occur in the postpartum period and that the iodine content of the milk is sufficient for the infant's iodine requirement. While recommendations for nutritional supplements during pregnancy are specific, recommendations are usually less specific for lactation. The aim of this study was to review the use of supplements during lactation and to document the use of nutritional supplements in a cohort of mothers who are breastfeeding in Perth, Western Australia. A literature search was undertaken of reviews published between January 2000 and May 2011 and further analysis was undertaken of supplement usage in the Perth Infant Feeding Survey. In the USA the limited data that is available suggest that supplement use during lactation is dependent on demographic, sociologic, and economic factors and that more women take supplements during pregnancy than during lactation. Data from the NHANES III study show that ethnicity and income predicted iron supplementation during lactation, with 77% of non-Hispanic white women reporting supplement use compared with 41% of non-Hispanic black or Mexican American women. Multivitamin-multimineral use was the most frequently reported dietary supplement (33%). In a cohort study of postpartum mothers in Australia the use of supplements fluctuated between 40% to 30%, with 35% still taking supplements a year after birth. During their pregnancy 78% of mothers took a folic acid supplement and 21% took an iron supplement. Mothers who took supplements were more likely to continue breastfeeding. More studies are needed to document supplement use by lactating mothers in different cultures and countries.

In many cultures and countries alcohol is an integral part of the social lifestyle and cultural celebrations. Once the legitimate age for alcohol consumption is reached there are few reasons for the complete abstinence of alcohol consumption, with the exception of pregnancy. The detrimental effects of alcohol consumption during this time are well documented and policy recommendations are clear in their abstinence message. Based on these directives it is apparent that education campaigns to reduce alcohol consumption antenatally have been effective. Internationally policy direction for alcohol consumption in the postnatal period is unclear and often non-existent despite that postnatal alcohol consumption in lactating women also has the potential to cause harmful effects in the new born infant. Alcohol enters the breastmilk within 30 – 60 minutes after maternal ingestion and if transferred to the infant through the breastmilk can result in immediate changes in sleep-wake patterning behaviours. Research surrounding recommendations for lactating women is limited due to ethical reasons, however with correct timing alcohol consumption during the period of lactation is a possibility. There have been recommendations for caution in consuming alcohol while breastfeeding for some years however these have often not been discreet from the recommendations for pregnancy. Currently alcohol policy differs considerably both internationally and within the same country. Unlike the universal adoption of public health policy for abstinence during pregnancy the implementation of policy for breastfeeding women has been less progressive. It is anticipated that the universal adoption of congruent alcohol policy will help support the safe consumption of alcohol and promote the extended duration of breastfeeding.

Prelacteal Feeds in China by Li Tang, Katie Hewitt, Chuan Yu (304-312).
The custom of providing prelacteal feeds is a long-held tradition throughout many parts of China. Prelacteal feeds are not recommended because they can interfere with the establishment of breastfeeding, increase the risk of infection and change the composition of the human microbiome. The objective of this paper is to review the rate of offering prelacteal feeds in different areas in China and the influence this custom has on breastfeeding outcomes. Electronic databases were systematically searched to identify studies reporting on prelacteal feeds in China. In total eight papers (three retrospective cohort studies, one prospective cohort study, one case-control study and three cross-sectional studies) published in the Chinese language and six papers (one Systematic Literature Review (SLR), four prospective cohort studies and one cross-sectional study) published in the English language were retrieved. The prevalence of prelacteal feeding varies widely in China. The highest rates are seen in Shandong Province in Eastern China, with as many as 72.4% of infants receiving a prelacteal feed before the initiation of breastfeeding. Xinjiang- Province in the west of China reported alower prevalence of prelacteal feeding; with 23%, 2% and 6% of infants receiving water, cow's milk and solid food, respectively, before discharge from hospital. In comparison to western developed countries prelacteal feeding rates in China were found to be substantially higher. Five out of the seven studies that measured the effect of prelacteal feeds on breastfeeding outcomes found that prelacteal feeding was associated with reduced breastfeeding duration. Due to the potentially deleterious effect of prelacteal feeding on breastfeeding, every effort should be made to reduce prelacteal feeding throughout China.

Breastfeeding Support for Working Mothers: Global and Pakistani Perspectives by Shela Akbar Ali Hirani, Rozina Karmaliani (313-321).
Breastfeeding is an important aspect of parenting, however, working mothers often find it challenging to continue breastfeeding, especially if breastfeeding support is minimal or absent. Pakistan is a developing country with the second highest child mortality rate in South Asia. Recent surveys document a gradual decline in the prevalence of breastfeeding in Pakistan, especially among urban working mothers. The aim of this paper is to identify the sources of breastfeeding support for working mothers, as well as to explore the availability of instruments that can measure their perceptions about breastfeeding support. A literature review documented working mothers who breastfeed require emotional and tangible support to initiate and sustain breastfeeding. Sources of support include the availability and access to information about breastfeeding management (informational support), family and child daycare facilities (social support), anticipatory guidance from health care professionals (health care support), and a workplace environment that provides physical facilities conducive to breastfeeding with accompanying policies and the respect of both the employers and the co-workers (workplace support). The literature also documents the importance of assessing working mothers' perceptions about breastfeeding support. The strengths and limitations of existing instruments that measure working mothers' perceptions of breastfeeding support were evaluated and the feasibility of using these instruments with women in Pakistan was determined. We determined that existing instruments do not comprehensively measure all aspects of breastfeeding support and are applicable to working mothers in the United States. A comprehensive, validated, and reliable tool is needed in the national language of Pakistan to measure Pakistani working mothers' perceptions about breastfeeding support.

Breastfeeding Policy Development and the Prevention of Obesity by Adriano Cattaneo, Laura Cogoy (322-331).
Childhood obesity has been increasing for decades in many countries and represents an important challenge for public health worldwide. Most factors associated with obesity act very early in life, from conception through pregnancy and infancy. Among these factors, breastfeeding has been widely studied. Six systematic reviews have analysed the association between breastfeeding (initiation, exclusivity and duration) and obesity. All these reviews reach similar conclusions: there is a dose-response negative association between breastfeeding and obesity, even after controlling for known confounders. It is difficult, however, to come to firm conclusions; the reviews are based on observational cross-sectional and longitudinal studies using different methods to determine breastfeeding rates and different definitions of obesity with different growth references. In addition, it is impossible to exclude the effect of unknown confounding. Yet, other studies published afterwards confirm the association, including a study in twins. The only study with different results, a cluster randomised controlled trial carried out for other purposes, reported no difference in BMI and adiposity at 6.5 years of age in a sample of children with different duration and exclusivity of breastfeeding; the analysis, however, did not include non breastfed or formula fed children. The negative association between breastfeeding and obesity is biologically plausible; several behavioural and nutritional mechanisms have been proposed to support the hypothesis of a causal link. Overall, and despite the need to fill some knowledge gaps with further research, it is generally accepted that interventions to protect, promote and support breastfeeding will help prevent obesity and contribute to curbing the present epidemic, as reflected in policies and strategies recommended by different agencies and governments worldwide.

It is generally agreed that contraception after childbirth improves the health of mothers and children by lengthening birth intervals. Every year, it is estimated over 100 million women make decision about beginning or resuming contraception after childbirth. The timing of contraception initiation is important since the return of menstruation and ovulation can be unpredictable in breastfeeding women. This review discusses the relationship between breastfeeding, sexuality and contraception during the postpartum period. Evidence shows that many couples resume sexual intercourse before the sixth postpartum week. Yet information on the relationship between sexuality and breastfeeding is limited and conflicting. While some studies reported positive effects of breastfeeding on sexuality, many studies showed a delay in the resumption of sexual activities among breastfeeding compared with bottle-feeding women. Since many women become sexually active earlier than 6 weeks post-partum, they should use a method of contraception before the sixth week, especially if they are not breastfeeding. Evidence confirms the recommendations of Bellagio Consensus Conference in 1988 on Lactational Amenorrhea Method (LAM) that fully breastfeeding women who remain amenorrheic have a very small risk of becoming pregnant in the first 6 months after delivery (less than 2%). As soon as the baby is 6 months old or as soon as supplementary feeding is started or menses is resumed, LAM no longer provides effective contraception, and other family planning methods should be introduced if pregnancy is not desired. Despite its demonstrated efficacy, many women, however, decide not to use LAM due to concerns of its efficacy and uptake of this method is low in many countries. Given the demonstrated efficacy of LAM as a contraceptive in the postpartum period, the method should be more strongly promoted for its effective use in developing countries, in particular where access to or the acceptability of other forms of contraception may be limited.

Reported Breastfeeding Rates in the Asia-Pacific Region by Colin Binns, Andy Lee, Kay Sauer, Katie Hewitt (339-345).
Breastfeeding should be promoted widely to improve health across Asia. In the Western Pacific Region breastfeeding prevalence is considered suboptimal, however, there is no consensus on the actual level. This review compared breastfeeding rates as reported to the Western Pacific Region of WHO with the rates obtained from other research organizations. There was considerable variability observed between the different methods of data collection. For example, the WHO and UNICEF data from the Western Pacific Region which pools information mainly from national and regional survey that are cross-sectional in nature, reported the exclusive breastfeedingrate in infants less than six months of age to be 56% in China and 41% in Japan. Whereas, studies undertaken by the Curtin School of Public Health which have limited sample sizes but all use cohort methodology, reported the rate of exclusive breastfeeding at six months to be 6% in China and 15% in Japan. The large discrepancies among results indicate that representative, accurate and reproducible datais required. This implies the use of standard WHO definitions of categories of breastfeeding and a combination of routine surveillance and cohort studies in sentinel districts. Obtaining reliable data on infant feeding in the Asia-Pacific will highlight areas of focus, target interventions more appropriately and assist health professionals and parents to continue advocating for improved breastfeeding outcomes.

Molluscum Contagiosum - An Overview by Alexander K. C. Leung, H. Dele Davies (346-349).
Molluscum contagiosum, a common viral cutaneous infection in childhood, is caused by a poxvirus of the molluscipox genus. Molluscum contagiosum occurs worldwide, but is more common in areas with tropical and humid climates. Elementary school-aged children are more commonly affected. The virus is transmitted by close physical contact, autoinoculation, and fomites (e.g., bath sponges, towels), especially if the skin is wet. Typically, molluscum contagiosum presents as discrete, smooth, flesh-colored, dome-shaped papules with central umbilication from which a plug of cheesy material can be expressed. Lesions are usually 1 to 5 mm in diameter and the number is usually less than 20. They often appear in clusters or in a linear pattern. The lesions are often asymptomatic. No single intervention has been convincingly effective in the treatment of molluscum contagiosum. Some authors suggest benign neglect of the lesions and to await spontaneous resolution.Most authors suggest active treatment of lesions for cosmetic reasons or concerns of transmission and autoinoculation. Active treatments may be mechanical (e.g. curettage, cryotherapy with liquid nitrogen, pulsed dye laser therapy, carbon dioxide laser therapy), chemical (e.g. cantharidin, tretinoin, podophyllotoxin, trichloroacetic acid, potassium hydroxide, lactic acid, glycolic acid, salicylic acid), immune-modulating (e.g. imiquimod, cimetidine) and antiviral (cidofovir). The choice of the treatment method should depend on the physician's comfort level with the various treatment options, the patient's age, the number and severity of lesions, and the preference of the child/parents.

The impact on adult disease, of prenatal programming and of the environment during infancy has been widely described. Yet the increased morbidity due to this prenatal and neonatal environment seems to occur ever more early. Indeed, recent studies detected the consequences of prenatal programming in childhood, making it also an immediate concern for paediatricians. This review, focusing on oligonephropathy, aimed to give an up-dated view on when prenatal-programmed morbidity is first detectable, and on possible preventive strategies and treatments. As renal morbidity related to prenatal programming has been diagnosed in early childhood, at only two years old, it is now urgent to evaluate early strategies such as sports, low-protein or iron diets and antiproteinuric drugs, preventing an accentuation of glomerulosclerosis. A yearly follow-up seems appropriate for patients born small for gestation or preterm, including the measure of blood pressure and of albuminuria. A diet preventing protein and salt excess, and a smoking prohibition could delay the onset of glomerulosclerosis. The yearly follow-up would allow to diagnose it early enough to administer angiotensin converting enzyme inhibitors delaying the progression of renal sclerosis.