Feeling Guilty about Stopping Breastfeeding?

Posted on by

From NY Times, Link: http://t.co/rBXCORx3mM

Excerpt:

Many women who are unable to breast-feed feel guilty about it and worry they may be depriving their children of a range of benefits. Groups like the American Academy of Pediatrics and the World Health Organization recommend six months of exclusive breast-feeding for all infants, citing studies that show breast milk is easily digestible and has nutrients that are superior to or absent from infant formulas, including immunological substances that reduce rates of infection and fatty acids important in brain development.

But now a new study suggests that many of the long-term benefits attributed to breast-feeding may be an effect not of breast-feeding or breast milk itself but of the general good health and prosperity of women who choose to breast-feed.

Researchers at Ohio State University compared 1,773 sibling pairs, one of whom had been breast-fed and one bottle-fed, on 11 measures of health and intellectual competency. The children ranged in age from 4 to 14 years.

The researchers recorded various health and behavioral outcomes in the sibling pairs, including body mass index, obesity, asthma, hyperactivity, reading comprehension, math ability and memory-based intelligence. The study, published online in Social Science & Medicine, found no statistically significant differences between the breast-fed and bottle-fed siblings on any of these measures.

By studying “discordant” siblings — one of whom had been breast-fed and the other not — the authors sought to minimize the possibility that racial, socioeconomic, educational or other differences between families could affect the results. Many earlier studies on breast-feeding failed to control for such factors, they say.

… researchers have consistently found large socioeconomic and racial disparities in breast-feeding rates. A C.D.C. survey in 2008 found that 75 percent of white infants and 59 percent of black infants were ever breast-fed, and in 2013, the agency reported that 47 percent of white babies but only 30 percent of black babies were still being breast-fed at 6 months. Compared with bottle-fed infants, breast-fed babies are more likely to be born into families with higher incomes, have parents with higher educational attainments, and live in safer neighborhoods with easier access to health care services.

Still, sibling studies such as this latest one do not solve all the problems of bias…

Geoff Der, a statistician at the University of Glasgow who has worked with the same data in previous studies, said that the findings in the present study were robust and the authors’ method for eliminating selection bias was powerful…“In a society with a clean water supply and modern formulas,” he said, “a woman who isn’t able to breast-feed shouldn’t be feeling guilty, and the likelihood that there’s any harm to the baby is pretty slim.”

Related blog posts:

Active Video Games –Part of Weight Loss Program?

Posted on by

From JAMAPediatrics (full article): http://t.co/CmwQjCyhdJ

An excerpt:

Design, Setting, and Participants      Group-randomized clinical trial conducted during a 16-week period in YMCAs and schools .. Seventy-five overweight or obese children (41 girls [55%], 34 whites [45%], 20 Hispanics [27%], and 17 blacks [23%]) enrolled in a community-based pediatric weight management program. Mean (SD) age of the participants was 10.0 (1.7) years; body mass index (BMI) z score, 2.15 (0.40); and percentage overweight from the median BMI for age and sex, 64.3% (19.9%).

Interventions      All participants received a comprehensive family-based pediatric weight management program (JOIN for ME). Participants in the program and active gaming group received hardware consisting of a game console and motion capture device and 1 active game at their second treatment session and a second game in week 9 of the program. Participants in the program-only group were given the hardware and 2 games at the completion of the 16-week program…

Results      Participants in the program and active gaming group exhibited significant increases in moderate-to-vigorous (mean [SD], 7.4 [2.7] min/d) and vigorous (2.8 [0.9] min/d) physical activity at week 16 (P < .05). In the program-only group, a decline or no change was observed in the moderate-to-vigorous (mean [SD] net difference, 8.0 [3.8] min/d; P = .04) and vigorous (3.1 [1.3] min/d; P = .02) physical activity. Participants in both groups exhibited significant reductions in percentage overweight and BMI z scores at week 16. However, the program and active gaming group exhibited significantly greater reductions in percentage overweight (mean [SD], −10.9% [1.6%] vs −5.5% [1.5%]; P = .02) and BMI z score (−0.25 [0.03] vs −0.11 [0.03]; P < .001).

Conclusions and Relevance      Incorporating active video gaming into an evidence-based pediatric weight management program has positive effects on physical activity and relative weight.

Comment: The costs of the games and game consoles were about $350 according to the authors.  Since this was a short study (16-weeks), it is not clear that this will be cost-effective.  However, any tools that may help kids become more active are certainly welcome.

Related Blog Posts:

Think Like a Doctor –Another Reason for Cyclic Vomiting

Posted on by

When cyclic vomiting pattern starts in young adults, the differential diagnosis is different than in toddlers.  A case in point is a recent think like a doctor column from NY Times.

The initial presentation described a 25-year-old man who gets sweaty and nauseated and starts vomiting uncontrollably every few weeks.

1st the link with the case challenge: challenged Well readers to figure out

A big clue in this case was the fact that hot showers ameliorated his symptoms.

Now the answer, full link: http://nyti.ms/1lcPJKj 

“The correct diagnosis is…

 

 

 

Cannabinoid hyperemesis caused by smoking synthetic marijuana.”

Related blog post: Diet or drugs for cyclic vomiting syndrome | gutsandgrowth

Briefly Noted…Scoliosis, Cystic Fibrosis, Specific Carbohydrate Diet, GGT, Surgeon General

Posted on by

“Net effect of scoliosis surgery on gastric emptying, upper gastrointestinal symptoms, and clinical nutritional status was minimal”  according to this prospective study of 31 children: JPGN 2014; 58: 38-45.

Lactobacillus reuteri ATCC55730 was associated with reduced pulmonary exacerbations (but not improved FEV1) in 61 patients with cystic fibrosis who were enrolled in a prospective randomized, double-blind, placebo-controlled study over 6 months between 2007-2009 (JPGN 2014; 58: 81-86).

A retrospective chart review of seven children with Crohn disease who were treated with the specific carbohydrate diet with an average diet duration of 14.6 months showed that all symptoms resolved and laboratory studies improved or normalized.  (JPGN 2014; 58: 87-91). More studies on this diet are expected to be published soon.

Data from 200 preterm infants and 383 term infants help provide updated GGT (gamma-glutamyl transferase) reference values.  In preterm infants during 1st 7 days: 141 ± 89 U/L, then between days 8-28: 131 ± 85 U/L.  In term infants the values were similar 140 ±86 U/L and 145 ± 87 U/L respectively. (JPGN 2014; 58: 99-101).

And from NEJM twitter feed, Congress may allow the NRA veto power in the selection the next surgeon general: http://nej.md/1nECFlM.

Revising the Textbooks on Isoniazid Hepatotoxicity

Posted on by

Previously, isoniazid (INH) hepatoxicity has generally been described as “idiosyncratic.”  New research shows that INH-induced hepatotoxicity is often associated with anti-INH and anti-cytochrome P450 antibodies (Hepatology 2014; 59: 1084-93, editorial 746-48).

Background: INH is a crucial treatment for tuberculosis.  About 10% of patients receiving monotherapy may develop mild elevations (<3-fold the upper limit of normal) of alanine aminotransferase.  However, 0.5-1% develop overt hepatitis and some develop acute liver failure (ALF).  Risk factors for ALF include female gender, age >35 years, cotreatment with other tuberculosis medications, INH dose >50 mg/kg, ethanol use, and slower metabolic pathways (slow acetylator N-acetyltransferase 2 or cytochrome (CYP) P450 2E1 genotype).

The authors utilized two patient groups: 19 from the ALF study group registry who had >50% likelihood of IHN toxicity and 20 control patients who were receiving INH prophylaxis.  In this control group, 15 had no liver injury and 5 had mild hepatitis. The authors utilized several immunoassays.

Key findings:

  • 15 of 19 cases of INH-associated ALF had detectable antibodies: 8 anti-INH and 11 had antiCYP2E1 Abs.
  • None of these antibodies were detected from INH-treated controls

Bottomline: from the authors of the study “Although the presence of these antibodies only in INH-induced liver failure suggests that INH-induced liver injury is immune mediated, there is no evidence that these Abs are actually responsible for the liver injury.”

In this same issue is a lengthy guideline on the “Evaluation for Liver Transplantation in Adults”: http://t.co/AnnJHHVNh0

Related blog post:

Liver toxicity -where to look online | gutsandgrowth

Training Not Meeting Procedure Thresholds for Fellows

Posted on by

With expanding numbers of pediatric GI trainees, it is even more concerning that training centers have had difficulty providing adequate experience for their trainees.  In a recent study (JPGN 2014; 58: 27-33), not one of 12 centers was able to meet the threshold for all of the procedures.

The authors provide NASPGHAN procedural competency guidelines in Table 2. The 2013 guidelines lowered the threshold for almost all procedures in comparison to the 1999 guidelines.  One notable exception was foreign bodies which was increased to 10. Then, the authors examined the frequency of procedures actually performed between 2009-2011.

Key findings (with the lower thresholds)

  • Polypectomy (threshold, n=10) 67% of programs meeting 2013 NASPGHAN guidelines
  • Control of nonvariceal bleeding/Sclerotherpy/Variceal band ligation (threshold, n=15) 17% of programs meeting 2013 NASPGHAN guidelines. Mean number per fellow of nonvariceal bleeding cases was 2 procedures. Mean number per fellow of banding/sclerotherapy was 7 procedures. With the 1999 guidelines, the threshold had been 35 for these procedures combined.
  • Esophageal, pyloric and duodenal stricture dilatation (threshold, n=15) 42% of programs meeting 2013 NASPGHAN guidelines
  • PEG (threshold, n=10) 42% of programs meeting 2013 NASPGHAN guidelines (training not available at 42% of these institutions)
  • Percutaneous liver biopsy (threshold, n=15) 67% of programs meeting 2013 NASPGHAN guidelines
  • Foreign-body removal (threshold, n=10) 58% of programs meeting 2013 NASPGHAN guidelines

It is noted that the 2013 guidelines “reclassified control of variceal and nonvariceal bleeding from a level 2 to a level 1 procedure, stressing that expertise in hemostasis should be achieved during fellowship.” “Without supplemental training, none of these programs, which are likely representative of most programs, were able to provide sufficient opportunities to meet the NASPGHAN guidelines.” Besides spending more time working with adult gastroenterologists, other potential ways to gain more experience includes simulators and hands-on training courses.

Take-home message: Pediatric gastroenterology training centers are not providing enough procedural experience and need to make rotating with adult gastroenterologists mandatory. It is unfair to trainees and vulnerable patients to consider their training complete with these obvious deficiencies.

When families ask the newly trained pediatric gastroenterologist how many cases like this that they have completed, how will they feel if the honest answer is two?

Related blog post:

Training for Tomorrow | gutsandgrowth

The Liver –Front and Center

Posted on by

Before proceeding with today’s post, those who read yesterday’s post may be interested in Atul Gawande’s take on the NEJM checklist publication -here’s the link (from Atul Gawande’s twitter feed): bit.ly/1d6v31z. 

A recent review “Extrahepatic Complications of Nonalcoholic Fatty Liver Disease” (NAFLD)(Hepatology 2014; 59: 1174-97) seems to position the liver as the center of a multitude of problems rather than one of many associated problems.

It is known that NAFLD increases the risk of end-stage liver disease and hepatocellular carcinoma.  However, the majority of deaths among individuals with NAFLD are attributed to cardiovascular disease and malignancy.  This lengthy review describes in great detail the associations between NAFLD and the risk of developing cardiovascular disease (CVD), type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), and colorectal neoplasm.  The presence of NAFLD appears to convey an independent increase in risk for these conditions.

Key points:

  • “The aggregated evidence provides strong evidence that individuals with NAFLD are at increased “independent” risk of developing CVD.  The risk of CVD mortality may be greater in subgroups of subjects with NASH and advanced fibrosis, compared to those with simple steatosis.”
  • “USS-defined NAFLD is associated with a 2- to 5-fold risk of developing T2DM after adjustment of several lifestyle and metabolic confounders.”
  • “NAFLD (in particular, biopsy-proven NASH) is associated with a greater prevalence of CKD (20% to 50% of patients). USS-defined NAFLD carries a 1.5- to 2-fold adjusted risk of incident CKD.”
  • “A true causal relationship between and NASH and colorectal cancer cannot be confirmed.”
  • Other potential extrahepatic manifestations: hypothyroidism, polycystic ovarian syndrome, obstructive sleep apnea syndrome, and osteoporosis.

Take-Home Message: NAFLD has independent associations for greater risk of CVD, hyperglycemia, and malignancy.  Whether these associations are simply an epiphenomenon  of more aggressive metabolic syndrome or whether the liver injury primarily causes these additional risks remains unclear.

Related blog posts:

Checklists -Helpful? Overhyped? Hawthorne Effect?

Posted on by

Over the last few years, adoption of surgical safety checklists has taken hold due to the promise of improving outcomes with a simple intervention.  While the concept of checklists is sound, new data indicate that in practical experience these checklists may not result in any significant reductions in meaningful outcomes (NEJM 2014; 370: 1029-38).

The study of surgical safety checklists in Ontario (13 million people) examined the 3-month periods before and after adoption of a surgical safety checklist (around July 2010) at a total of 101 hospitals.  In the period prior to adoption, there were 109,341 procedures and afterwards 106,370.

Key findings:

  • Adjusted risk of death during a hospital stay or within 30 days of surgery was 0.71 prior and 0.65 afterwards.  This produced an odds ratio of 0.91 with 95% confidence limits of 0.80 to 1.03.
  • Adjusted risk of surgical complications was 3.86% and 3.82% respectively, yielding an odds ratio of 0.97 with 95% confidence limits of 0.90 to 1.03.
  • Checklists did not reduce emergency room visits or hospital readmissions within 30 days after discharge.

These findings contradict previous WHO estimates that at least 500,000 deaths per year could be prevented through worldwide implementation of checklists.  A previous meta-analysis of three other before-and-after checklist studies determined that the checklists were associated with a pooled relative risk of operative death of 0.57 (confidence intervals 0.42 to 0.76). Yet, this Ontario study had a similar implementation without this reduction.

So, how can this study show no significant reduction in operative mortality or complications?

Possible explanations:

  • Hawthorne effect could explain some of the previous results.  This effect refers to “the tendency for some people to perform better when they perceive that their work is under scrutiny.”
  • Publication bias.  Because these checklists are utilized in thousands of hospitals, “many will have improvements in the outcomes by chance alone.”

The authors note that there has never been a controlled trial with randomization to determine conclusively the effectiveness of checklists.  However, the current study is less susceptible to biases than single center studies and no other confounding variables were identified.

Take-home message: In this study, checklists did not result any striking improvements.  Nevertheless, “there may be value in the use of surgical safety checklists, such as enhanced communication and teamwork and the promotion of a hospital culture in which safety is a high priority.”

On a side note, this study reinforced my view that many quality initiatives are well-meaning but sometimes overhyped with regard to their effectiveness.

Related blog posts:

More on Gut Microbiome and Crohn Disease

Posted on by

Earlier this week on NPR there was a story summarizing the altered microbiome in Crohn disease and a related recent paper; here’s the link: Mix Of Gut Microbes May Play Role In Crohn’s Disease.  Other media outlets covered the story too:

The graphical abstract (Cell Host & Microbe, Volume 15, Issue 3, 382-392, 12 March 2014) is noted below:

Graphical Abstract

The link to the full study is listed below if you want to see the source article.  The amount of data that is presented is impressive but easy to follow with the figures:

Full link to article (from Kipp Ellsworth twitter feed): http://goo.gl/603Rbz 

Related blog posts:

Curing Iron Overload with Liver Transplantation

Posted on by

The role of hepcidin in iron metabolism has been described in detail.  Yet, a new study provides another line of evidence that the liver has a primary role in regulating iron absorption (Hepatology 2014; 59: 839-47, editorial 749-50).

Background: Hereditary hemochomatosis (HH) is mainly due to defects in the gene encoding the human hemochromatosis protein (HFE), particularly the C282Y mutation.  Initially, HH was thought to be related to the role of HFE in regulation iron absorption at the intestinal crypt.  However, the discovery of hepcidin, which is mainly secreted by the liver, was shown to regulate iron absorption through its interaction with ferroportin, the cellular iron exporter. With HH, inappropriately low hepcidin was associated with excessive iron absorption.

Despite this understanding, many questions remain, especially regarding the fact that some C282Y homozygotes have a normal serum ferritin and transferrin saturation.  In addition, whether liver transplantation prevents further iron overload in patients transplanted for HH is not entirely certain.

Methods: This study evaluated 18 liver transplant (LT) patients with HH and who were homozygous for C282Y mutations.  16 of these patients had HCC.  All patients underwent iron evaluations (iron, hepcidin, hepatic iron concentrations) prior to LT and most (n=11) had evaluations following LT with a median followup of 57 months.

Key findings:

  • After LT, no patients received iron depletion therapy (eg. phlebotomy).  9 of 11 had no iron overload based on bloodwork (normal transferrin saturation) and MRI without iron overload.
  • One patient with hereditary spherocytosis continued to have iron overload, and one patient with metabolic syndrome had mild iron overload.
  • Hepcidin was normal (11.12 nmol/L) in 10 patients at the end of followup and low in one patient with iron deficiency anemia; prior to LT, serum hepcidin levels were low in all patients (mean 0.54 nmol/L)

Bottomline: This study shows that LT corrects hepcidin dysregulation caused by the HFE mutation and that post-LT HH patients do not require phlebotomy.  Thus, HH is clearly a liver disease and not an intestinal disease.

Related blog post: Help with hepcidin | gutsandgrowth (with annotated references)