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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.

Use of intravenous fluids before cesarean section: effects on perinatal glucose, insulin, and sodium homeostasis.

Perinatal glucose, insulin, and sodium homeostasis were assessed in relation to antepartum intravenous infusions administered to 59 normal mothers undergoing cesarean section at term without labor under epidural anesthesia. Group A (N = 20) received 1 L of Ringer's lactate without dextrose during one hour; group B (N = 20), 1 L of 5% dextrose in water during one hour; and group C (N = 19), 1 L of 5% dextrose in water during two and one half hours. Mean maternal and fetal serum glucose and insulin and sodium concentrations at delivery differed among all groups in direct relationship to the rate of glucose infusion. Neonatal hypoglycemia (30 mg/dL or less) correlated with the presence of a glucose infusion, a maternal glucose concentration of 117 mg/dL or greater, and an umbilical venous insulin concentration of 26 microU/mL or greater. Among group A patients who received sodium, and group B and C patients who did not, fetal hyponatremia (umbilical venous sodium 130 mEq/L or less) correlated with the absence of sodium in the prepartum infusion. The results suggest that the antepartum administration of a balanced electrolyte solution without excess glucose infusion can minimize the incidence of fetal hyperglycemia and hyponatremia and neonatal hypoglycemia.
Obstet Gynecol. 1984 May;63(5):654-8.

Warning over rising C-section rates Story

          Caesarean section is one of the most common surgeries in the world, with rates continuing to rise, particularly in high- and middle-income countries.

          Although it can save lives, Caesarean section is often performed without medical need, putting women and their babies at-risk of short- and long-term health problems. A new statement from the World Health Organisation (WHO) underscores the importance of focusing on the needs of the patient, on a case by case basis, and discourages the practice of aiming for “target rates”.

           Caesarean section may be necessary when vaginal delivery might pose a risk to the mother or baby—for example due to prolonged labour, foetal distress, or because the baby is presenting in an abnormal position. However, Caesarean sections can cause significant complications, disability or death, particularly in settings that lack the facilities to conduct safe surgeries or treat potential complications.

           Since 1985, the international healthcare community has considered the “ideal rate” for Caesarean sections to be between ten per cent and 15 per cent. New studies reveal that when Caesarean section rates rise towards ten per cent across a population, the number of maternal and newborn deaths decreases. But when the rate goes above ten per cent, there is no evidence that mortality rates improve.

           It is estimated that globally, the rate of Caesarean section is higher than the ideal. In the Americas, the average is 38.9 per cent, according to the most recent data from 25 countries. However, this figure could be higher given that in many cases it does not include Caesarean sections done by private sector health services.

             “It’s very worrisome that almost four out of every ten births in the region are by C-section,” said Suzanne Serruya, director of the Latin American Centre for Perinatology, Women, and Reproductive Health (CLAP) of the Pan American Health Organisation (PAHO), regional office for the Americas of WHO. “Doctors, midwives, obstetric nurses, those responsible for health policies, mothers and fathers, and society as a whole should work together to reduce this number and use Caesarean sections only when it’s needed for medical reasons.”

             Across a population, the effects of Caesarean section rates on maternal and newborn outcomes such as stillbirths or morbidities like birth asphyxia are still unknown. More research on the impact of Caesarean section on women’s psychological and social well-being is still needed.

            “Having too many Caesarean sections is exposing more women to new health problems, like abnormal placentation, which in the case of a second Caesarean section can occur in 40 per cent of cases, and in the case of a third Caesarean, can occur all the way up to 60 per cent of cases. This represents a risk for maternal death by haemorrhage,” warned Bremen de Mucio, regional adviser on Sexual and Reproductive Health in PAHO/WHO´s CLAP.

              Due to their increased cost, high rates of unnecessary Caesarean sections can pull resources away from other services in overloaded and weak health systems.

             The lack of a standardised internationally accepted classification system to monitor and compare Caesarean section rates in a consistent and action-oriented manner is one of the factors that has hindered a better understanding of this trend. WHO proposes adopting the Robson classification as an internationally applicable Caesarean section classification system.

              The Robson system classifies all women admitted for delivery into one of ten groups based on characteristics that are easily identifiable, such as number of previous pregnancies, whether the baby comes head first, gestational age, previous uterine scars, number of babies and how labour started. Using this system would facilitate comparison and analysis of Caesarean rates within and between different facilities and across countries and regions.

Heart Disease and Height: Do Shorter People Need to Worry?

(Health Day News) — Shorter people may be more likely to have coronary artery disease (CAD), and that increased risk could be linked to the genetics that also determine height, a British-led research team suggests. The study was published online April 8 in the New England Journal of Medicine.

To better understand the cardiovascular risks associated with short stature, researchers pooled data from two recent international research efforts into the human genome, one of which explored the genetics of height and the other the genetics of CAD, study coauthor Christopher O'Donnell, M.D., M.P.H., associate director of the Framing-ham Heart Study for the U.S. National Heart, Lung, and Blood Institute, told Health Day.

The research team first tested the association between a change in height and risk of CAD by examining 180 different height-associated genetic variants in 193,449 people, and concluded that there's a relative 13.5 percent increase in CAD risk for every 2.5 inches shaved off a person's height. They then drilled down to very specific individual genetic data from a smaller pool of 18,249 people. They identified a number of pathways by which genes related to height could also influence CAD risk.

A person's risk of CAD increases about 13.5 percent for every 2.5 inches of difference in height, the scientists said. That means a 5-foot-tall person has an average 32 percent higher risk of CAD than a person who's 5-foot 6-inches tall, according to the researchers. Interestingly, the effect of height on CAD risk may be gender-specific. "We found a clear-cut effect in men, but we didn't see a clear-cut effect in women," study coauthor Nilesh Samani, M.D., of the University of Leicester in the United Kingdom, told HealthDay, adding that significantly fewer women in the study could have affected the statistics.