Delayed Umbilical Cord Clamping Linked to Better Fine-Motor Scores, Social Skills at Age 4

 

May 26, 2015

CHICAGO -- May 26, 2015 -- Delayed clamping of the umbilical cord to help prevent iron deficiency in infancy was associated with improved scores in fine-motor and social skills in children at age 4, particularly in boys, although it was not associated with any effect on overall IQ or behaviour compared with children whose cords were clamped seconds after delivery.
The findings are published online by JAMA Pediatrics.
Ola Andersson, MD, Uppsala University, Uppsala, Sweden, and colleagues conducted a follow-up of a randomised clinical trial at a Swedish hospital to assess the long-term effects of delayed cord clamping on neurodevelopment in children at age 4.
The researchers assessed 263 children (about 69% of the original study population) based on IQ tests, as well as development and behaviour using other assessments and questionnaires. Delayed cord clamping (141 children in follow-up) was ≥3 minutes after delivery and early cord clamping (122 children in follow-up) was ≤10 seconds after delivery.
The authors found no difference between the 2 groups for full-scale IQ. However, the proportion of children with an immature pencil grip was lower in the delayed cord clamping group and that group had higher scores in personal-social and fine-motor skill assessments.
There were no differences between the groups for girls in any of the assessments. However, boys who had delayed cord clamping had higher average scores in several tasks involving fine-motor function and personal-social domains.
“Delaying cord clamping for 3 minutes after delivery resulted in similar overall neurodevelopment and behaviour among 4-year-old children compared with early cord clamping,” the authors wrote. “However, we did find higher scores for parent-reported prosocial behaviour, as well as personal-social and fine-motor development at 4 years, particularly in boys.”
“The included children constitute a group of low-risk children born in a high-income country with a low prevalence of iron deficiency,” they added. “Still, differences between the groups were found, indicating that there are positive, and in no instance harmful, effects from delayed cord clamping. Future research should involve large groups to secure enough power to draw clear conclusions regarding development.”
In an accompanying editorial, Heike Rabe, MD, Brighton and Sussex Medical School and University Hospitals, Brighton, United Kingdom, wrote: “Until now, data on long-term follow-up of preterm and full-term infants who have been randomised to early versus delayed cord clamping have been limited. Awareness of the benefits for all newborns continues to increase as more studies are published. While many physicians have incorporated delayed cord clamping into practice, there remains a hesitation to implement delayed cord clamping, particularly with full-term infants. As evidence of the safety and benefits of delayed cord clamping are demonstrated, this hesitation should disappear. We applaud Andersson and colleagues for their persistence because their study closes the knowledge gap regarding the long-term safety of delayed cord clamping in healthy full-term newborns. Their important findings suggest that there is an absence of harm that lasts until 4 years of age.”
SOURCE: JAMA Pediatrics

Patient with Elevated HbA1c But No Symptoms of Diabetes

Patient with Elevated HbA1c But No Symptoms of Diabetes

Appearing in the Journal of Medical Cases, a case study outlines what is only the fourth reported case worldwide of a rare hemoglobin (Hb) variant, Hb South Florida (Hb-SF) that can cause falsely elevated HbA1c results during standard laboratory testing in the range of poorly controlled diabetes mellitus.
During routine lab work using the ion-exchange high performance liquid chromatography (HPLC) method, a 42-year-old female patient with a history of sclerosing bone dysplasia (treated with acetaminophen/codeine) was found to have an elevated HbA1c of 13.8%. The patient denied any family history of diabetes but repeat testing showed HbA1c of 12.8% with fasting blood sugar of 98mg/dL. Over the course of several months, her HbA1c was persistently elevated at 12–14% with mildly elevated blood sugar readings. Finally, Hb electrophoresis was performed at an endocrinology clinic and the results indicated that the patients was heterozygous for Hb-SF that leads to falsely elevated HbA1c levels. When evaluated by affinity column HPLC, her HbA1c levels were in the normoglycemic range.
 http://www.empr.com/case-studies/elevated-hba1c-no-diabetes-symptoms/article/415869/?DCMP=EMC-MPR_DailyDose_cp&CPN=epcom,tymd,mprvee,tiv,flecmpr,glidehiv,acuv&hmSubId=&hmEmail=M_hcC57b0-gro8ggC-yQzh7-wZu_ebv40&dl=0&spMailingID=11445158&spUserID=MzEwNzk3NzEzMTMS1&spJobID=541406143&spReportId=NTQxNDA2MTQzS0#

Uncomplicated UTI (urinary tract infection) in pregnancy

• if the women has fever or loin tenderness
  • suspect upper urinary tract infection and admit or seek urgent specialist opinion
• give paracetamol for symptomatic relief
• do not recommend urine alkalinizing agents or cranberry products
• send a urine sample for culture before starting antibiotic treatment
• prescribe antibiotics empirically
  • refer to local guidelines
    
    
  • if local guidelines are uavailable, suitable first-line antibiotics are (in order of preference) (1):
    • however see also notes below about use of trimethoprim and nitrofurantoin in pregnancy
      • nitrofurantoin 50 mg four times daily, or 100 mg (modified-release) twice daily, for 7 days
      • trimethoprim 200 mg twice daily, for 7 days
        • give folic acid 5 mg daily if it is the first trimester of pregnancy. Do not give trimethoprim if the woman is folate deficient, taking a folate antagonist, or has been treated with trimethoprim in the past year
      • cefalexin 500 mg twice daily, or 250 mg 6-hourly, for 7 days
      • amoxicillin 250 mg three times daily, for 7 days may occasionally be used if unable to treat with other suggested antibiotics. However resistance to amoxicillin makes it less effective as an empirical treatment option compared to those stated
        
        
    • if symptoms of UTI persist when sensitivities are known, treatment options are (in order of preference) (1):
      • amoxicillin 250 mg three times daily, for 7 days
      • nitrofurantoin 50 mg four times daily, or 100 mg (modified-release) twice daily, for 7 days
      • trimethoprim 200 mg twice daily, for 7 days (off-label use). Give folic acid 5 mg daily if it is the first trimester of pregnancy. Do not give trimethoprim if the woman is folate deficient, taking a folate antagonist, or has been treated with trimethoprim in the past year
      • cefalexin (500 mg twice daily, or 250 mg 6-hourly, for 7 days) may be used but is less preferred
        
        
• follow-up
  • ensure that there is patient follow up after 48 hours (or according to the clinical situation) to check response to treatment and the urine culture results.

Quinolones and tetracyclines should be avoided as empirical treatments. There are concerns about use of sulphonamides and trimethoprim in pregnancy:

• trimethoprim - theoretical teratogenic risk (folate antagonist); manufacturers advise avoid; BNF states first trimester is the trimester of risk. It is, however, widely used and probably safe in the second and third trimesters (2)
• sulphonamides - neonatal haemolysis and methaemaglobinaemia; BNF states third trimester is trimester of risk
• tetracyclines - avoid use during pregnancy; effects on skeletal development in animal studies if used during first trimester; dental discoloration and maternal hepatoxicity may occur if used during second or third trimesters
• quinolones - should be avoided during pregnancy; arthropathy in animal studies

Nitrofurantoin should not be used at term because of the risk of neonatal haemolysis - during the last few weeks may precipitate haemolytic anaemia due to glucose-6-phosphate dehydrogenase deficiency in the newborn

• BNF states third trimester is the trimester of risk associated with nitrofurantoin use

Consult local microbiology advice and latest edition of BNF for up-to-date guidance before definitive treatment.
Notes:

• about 1-2% of pregnant women suffer an acute lower UTI (cystitis) or upper UTI (pyelonephritis), with the former being more common
  • the most common infecting organisms is Escherichia coli (75-90 per cent); other infecting organisms include Proteus, Klebsiella, coagulase-negative staphylococci and Pseudomonas
• when the pregnant mother is very ill with acute pyelonephritis then there is a risk of preterm labour and even fetal loss. Thus hospital admission is recommended for these patients with intravenous antibiotics, hydration and analgesia. Treatment should be continued for two or three weeks
• about 15 % of women will have a recurrent UTI during pregnancy. Sometimes, a continuous low-dose prophylaxis throughout pregnancy is required in some women with recurrent UTI. These women require renal tract ultrasound scans, and review by a nephrologist or a urologist postnatally

Reference:

1. NHS Clinical Knowledge Summaries (Accessed 28/4/15). Uncomplicated UTI in pregnancy.