Tuesday, January 18, 2011

Location of Placenta and risks associated with

Whilst on my latest search for calcification of the placenta, I came across an article. It outlined the risks that could be associated with the location of the placenta.

Now we all know that have a low-lying placenta is never such a great thing and we all freak out about placenta previa and early bleeding, and in SA, another out-right reason to do a c-section. But did you know:

According to http://www.ncbi.nlm.nih.gov/pubmed/20608801, Cooley SM et al.,

  • An anterior placenta was statistically associated with intrauterine growth restriction (IUGR) and preterm birth.
  • A placenta located in the upper part or the uterus (fundus), was associated with a significant increase in incidence of pregnancy-induced hypertension and infants with a birthweight less than the 9th centile.
I just thought that was interesting...

Calcified Placenta?

I had a patient who was asking me what a calcified placenta actually was and whether it was a danger to her child? It seems, here in South Africa, that the 'calcified placenta' is another reason to give to the mother that 'we need to get this child out through c-section before its time' excuse.

I agree that this is something to monitor, but, it turns out, that it depends on when the calcification is noted, how much and whether the child is growing are the all important factors to consider.

When searching google it seems to be something of a thing that is only really discussed in forums - of which usually poor quality, anecdotal evidence is given. Here I try to tell the truth and explain the medical evidence in lay terms:

A blog post with a very pretty ultrasound display explains a portion of the inside info on calcified placenta:
http://cochinblogs.blogspot.com/2009/08/placental-calcification.html
Turns out that calcification of the placenta, when in the third trimester is a normal part of the aging of the placenta. At this time of presentation it is not part of a pathology. If, however, the calcification is found to be in the second trimester, then further, closer, monitoring of the foetus is required.

On looking the medical journals, PubMed and the like, I found two current articles that seemed to explain further, the issue between whether this is a normal pregnancy occurence or something to worry about:

The first, http://www.ncbi.nlm.nih.gov/pubmed/20586039 an article by Chen, KH et al., in June 2010, showed that calcification found in the 'late pre-term' (32 weeks onwards) was to show no significance, and women at this stage are not at any greater risk for adverse pregnancy outcome. However, if the calcification was found prior to this time, classed as 'early pre-term' (28 weeks +), then these women were found to be in a higher risk category for postpartum hemorrhage, placental abruption, and in adverse foetal outcomes: pre-term birth, low birth weight and lower APGAR scores.

The second article, http://www.ncbi.nlm.nih.gov/pubmed/20608801, by Cooley, SM et al., in July 2010, also backed this up. They went further to say that they found that placental calcification, if found early (seemingly even from 22 weeks in ultrasound), showed a 40-fold increase in the likelihood of the foetus have intrauterine growth retardation (IUGR).

One other article to note, that seemed to just add a note of caution to all this, was http://www.ncbi.nlm.nih.gov/pubmed/11440548, by Poggi SH, et al., in July 2001. They found that the proteins that were responsible to causing calcification of the placenta, were not related to the age of the pregnancy/placenta. Therefore they suggested that this mechanism was not one of a normal physiological mechanism, but one more of a pathological.

So, I guess that the jury is still out and the debate will continue - behind doors.
Thanks Leigh-Anne :)

Tuesday, November 23, 2010

Best position for baby to sleep

I have had an influx of parents asking what I recommend to be the best position for their child to sleep in.

Now, of course, when you search this on google, anyone would find the advice on the 'back to sleep' campaign that was created in 1994 to help avoid Sudden Infant Death Syndrome (SIDS). But what about best for the back, spine and skull?

In adults, we see a lot of back and neck pain that can easily be related to sleeping in the prone (on the front) position. This is because of the lower back having to arch, and the neck being turned to one side. So, naturally, it makes sense that this is the same case in children. Sleeping on the front is not advised, with the back in mind. Consequently, sleeping on the back or side can be seen as a good position for the developing spine.

Lying on the side?
Interestingly lying on the side position has shown in a few studies to increase the likelihood of SIDS, but the research is still divided. The main understanding is that the risk of SIDS is significantly reduced by lying on either the side or back. The American Academy of Paediatrics has advised that if the child is sleeping on the side, the arm on the 'dependent' downside arm should be put in front of the child and out at a 90 degree angle. This aims to decrease the likelihood of the infant rolling onto the front - which is what the research seems to show is the risk to sleeping on the side - rolling onto the front and creating breathing problems.

In my opinion, sleeping on the side is fine, but everytime the child is placed back into the cot/bed, then they should be placed on the opposite side. This avoids preference of head position and turning. Keeping stimulus equal from side to side is important for the child's neurological development.

Sleeping on the back is obviously recommended, but this has created an increase in positional plagiocephaly (flattening of the skull) over the years of its recommendation. This is a benign condition and the head will normalise once the child has begun to sit. But this can also be balanced out by giving the child enough tummy time - when awake.

Shall I use the wedge support?
The use of supporting wedges to help the child stay, particularly on the side position, has not been shown to be of any value. The AAP Task Force does not recommend their use. They suggest that for a child to sleep on their side, put the dependent arm out and support the back of the child against the side of the cot.
The child sleeping on their back does not need any support.


Should healthy babies ever be placed on their front?
It is vital for the development of the strength of the neck, shoulder girdle and back for the child to be placed on the front. However, this must be done when the child is awake, and in a happy alert state. The younger the child, the more they will probably complain. This is not that it may be particularly uncomfortable - its just hard work! The head is heavy and its hard to keep it up all the time! 'Tummy time' is very important, but it doesn't have to be for such long periods of time - even a minute at a time if it has to be.

Recommended reading
http://www.nichd.nih.gov/sids/sids_qa.cfm - Questions and Answers on the 'back to sleep' campaign from the Task Force by the American Academy of Pediatrics



Thursday, October 7, 2010

Which Infant Formula?

Of course we all suggest that breastmilk is best when feeding a newborn child, but what happens when you cannot breastfeed or express milk and now you have to look at the infant formula market? Which formula is better for your baby?

The latest information from the American Academy of Paediatrics (2009) suggests that certain formulas should be used for certain types of child. It is important to note any familial allergies, current symptoms of fussiness, reflux, gas and type of stool (soft, hard runny, bubbly) when taking into consideration each type of infant formula. The AAP suggests that all children under 12 months should be breastfed or be fed using an iron-fortified infant formula. They suggest that the child older than 12 months should be given whole milk, not skimmed or semi-skimmed.

The typical infant formula that is suggested to be the routine in all babies is the Standard milk-based formula. These formulas have been derived from cows-milk protein and changed to be similar to breast-milk. Lactose and minerals from the cow's milk, as well as vegetable oils, minerals, and vitamins are also in the formula. The American Academy of Paediatrics suggests that the majority of children will do well on this formula. They advise that fussiness and colic symptoms are typically not related to the infant formula, and it is not necessary to switch to a different formula in such cases.

Commonly, from my experience, it is usually the action of changing the infant formula that tends to be the issue than the actual formula itself. It seems to take the child’s digestive system approximately a week to normalise after the change of a formula, which during this time will commonly entail a shift between loose stools through to hard through to soft again. It is usually 2 or 3 days into the change that the parents see that ‘oh no, the child is constipated now’ with the harder stools and then go and change the formula yet again...creating another cycle of issues. If you are not sure whether this is the right formula for the child, wait for a week. Unless you get frothy, extremely pungent stools, which in this case, it’s probably lactose intolerance and best to ask the advice of your medical practitioner.

If your child has been diagnosed with galactosemia, or congenital lactase deficiency, then the soy based formulas are suggested. These formulas are derived from soy and do not contain lactose. They are also designed for the family who does not want their child to consume animal-derived protein. For the baby who may be allergic to cow’s milk it is not always that they will not be allergic to soy as well. Soy based formulas have not been shown to be helpful for milk allergies or colic. Most of the time soy based formulas are used as an alternative, due to the high expense of the hypoallergenic formulas. Research suggests that the evidence is still out there on the effect of the phyto-oestrogen content of the soy products. These increase the isoflavone serum levels (in the blood) which when administered directly to animals can cause decrease in fertility. However,clinically relevant adverse effects of soy formulas in infants are not reported. 

Hypoallergenic formulas are designed for the true allergy to milk protein baby, or wheezes, or skin rashes from allergies. They contain extensively hydrolysed proteins that are less likely to stimulate antibody production in the child, hence aiming to decrease the allergic reaction to the formula.

Lactose-free formulas are ones that are specifically for congenital or primary lactase deficiencies, or galactosemia children. Please take note that lactase deficiency can only be diagnosed when the child is over 12 months old using special tests.
A child who has an illness with diarrhoea does not necessarily need a lactose-free formula. Though, a temporary lactase deficiency can arise after an acute bout of gastroenteritis, soy and lactose-free formulas shorten the bout of diarrhoea, but do not change the overall recovery or weight gain in the following 2-week period.

Anti-Reflux formulas are thickened with rice starch and are designed to be used for the reflux child who is not gaining weight or who is very uncomfortable. They are shown to decrease vomiting/regurgitation, but have not been shown to affect growth or development.

There are also special premature and low birth weight formulas that are designed for the premie. These contain extra calories and minerals to aid the child who needs to put on weight.

Interestingly, the formulas designed for Toddlers who are picky eaters, have not been shown to be any better than whole milk and multivitamins.

Reference:

O'Connor NR (2009). Infant formula. Am Fam Physician.79:565-570.

Vandenplas Y (2010). Soy infant formula: is it that bad? Acta Paediatrica. Sept 22.

Thursday, March 11, 2010

Breastfeeding and Maternal Diet



Breastfeeding and mothers nutrition
When looking at the maternal diet whilst breastfeeding I came across little documented evidence that confirms what to and what not to eat whilst breast feeding to avoid any ‘colicky’ symptoms in the child. Surprising given all the ‘old wives tales’ about you can’t eat this or that whilst breast feeding.

So, for the sake of all those rumours and hours of chatting mothers saying the ‘not so evidence-based’ anecdotes, I decided to put it all on my blog so others cannot be soooo confused!

In the early research days in an article by Evans et al., found that a number of foods, particularly chocolate and fruit, did seem to cause an increase in colicky symptoms, but cow’s milk showed no significant change in symptoms.  R. W. Evans, R. A. Allardyce, D. M. Fergusson, Brent Taylor (1981). Maternal diet and infantile colic in breast fed infants. The Lancet  317 (8234): 1340-2
However, another earlier article had written that their evidence showed that it was worthwhile for breast feeding mothers to exclude cow’s milk in their diet to avoid colicky symptoms. But, looking at the ages ranges in the experiment, it was highly likely that the colicky symptoms disappeared as a matter of time anyway. Jakobsson I, Lindberg T. (1978). Cow's milk as a cause of infantile colic in breast-fed infants. The Lancet  312  (8087) 437-439
Two of the most in-depth studies in 1995 and 1996 however, did seem to show a little more promise in identifying the ‘cursed’ foods. The study by Hill et al., (1996) took out all the previously said allergens in a diet and gave mothers a diet that was artificial colour-free, preservative-free, and additive-free and also randomized some to an active low allergen diet (milk-, egg-, wheat-, nut-free). 
For those that would like to know, the diet only allowed:
Rice, buckwheat, apple, pear, water, watery tea, watery coffee, potato, pumpkin, zucchini, marrow, lettuce, carrot, cauliflower, squash, lamb, beef, chicken, veal, turkey, fish, milk-free margarine, safflower oil, honey, sugar, salt and pepper.
Hill et al concluded that “a period of dietary modification with low allergen diet should be considered to avoid colicky symptoms”. Hill D J et al. (1995). A low allergen diet is a significant intervention in infantile colic: Results of a community-based study. J Allergy and Clinical Immunology 96 (6) 886-892
Lust et al. In 1996 came up with the research that colic was significant with the consumption of: Cabbage, cauliflower, broccoli, cow’s milk, onion and chocolate. They said that the occurrence of colicky symptoms may depend less on how often these item are consumed than whether they were consumed at all. Lust K D et al. (1996). Maternal intake of cruciferous vegetables and other food and colic symptoms in exclusively breast-fed infants.  J Am Diet Assoc  96 (1): 46-48

As to the reason why these foodstuffs cause the colicky symptoms the jury is still out. Some have come to say that the cruciferous veggies have a certain chemical that could irritate the intestines and cause gas, and others suggest that cow’s milk intolerance is immunologically mediated. Whether this is just a transient protein intolerance that improves after 6 weeks of age, in regards to the cow’s milk protein, is also still to be argued.

Wednesday, July 22, 2009

The suck spot

So, your child isn't taking the dummy? needing some time off the breast?
Here's some of the tips I have come across in practice to make you understand why it takes time for the child to understand how to take the dummy - and plus how you can help.

Firstly it is important to know how the 'suck cycle' works.

This is different in bottle feeding and breastfeeding.
  • Bottle feeding sucking requires the use of the tongue being thrusted up and forward to control the milk flow.
  • Breast feeding requires the use of the lips, tongue, gums, cheeks, and hard and soft palates. This is classed as 'suckling'.
  • Breastfeeding: Typically the initial presentation of the nipple to the child's mouth/side of cheek, stimulates the rooting reflex which allows the child to open the mouth wide and enable the head to arch back.
  • The tongue then thrusts forward to pull the nipple into the mouth (N.B. this stage is important, I'll refer back to it later).
  • The contact of the nipple of the bridge between the hard palate and the soft palate, stimulates the 'suck spot'. This spot then stimulates the child to initiate suckling.
  • The tongue then begins it's rhythmic contractions forcing milk through the nipple and guiding it to the back to mouth to be swallowed. At the same time the cheeks are contracting and creating the negative pressure to bring the milk through.
So, as we know, it is easier for a child to bottle feed, and the technique is completely different to that of breastfeeding. That's why I always say that it is imperative that you firstly get the child used to breastfeeding and get the technique in-grained in the brain, before even trying something else like the dummy. (I usually say about 1-2 weeks after birth).

So you want to know how to get the child to take the dummy?

  1. First rule of thumb, be patient.
If you have a bottle feeding baby on your hands, this should be easier...
If the child is a breast feeder, this make take a little longer. Requiring a few practice rounds.

  1. Begin with stimulating the child's rooting reflex by gently stroking the outside of the cheek, this should initiate the opening of the mouth.
  2. Insert dummy.
  3. Then, hold the dummy in the mouth - if the child is a breastfeeder the initial response is to thrust the tongue forward (which will knock the dummy out), if this happens, push the dummy back in the mouth again. (recognise what i said earlier?: the breastfeeding technique is to bring the tongue forward to pull the nipple in). Of course the nipple (dummy) in this case is already in the mouth, so let the child run through her/his routine anyway.
  4. Eventually, the tongue will no longer be thrust forward and the dummy will stay in the mouth.
  5. Then, hold the dummy gently up in the roof of the palate. This stimulates that 'suck spot'.
  6. This should stimulate the child to begin the suck cycle.

SO the tips are: hold the dummy gently in the mouth, and hold it up onto the roof of the mouth.

If the child is crying, don't make it a horrible experience, try this out when the child is in the relaxed state.

Cradle Cap

Cradle cap (infantile seborrheic dermatitis) what is it all about and how can you treat it without using all the medications?

Cradle cap is prevalent in children usually under the age of 3 months, usually appearing within the first 6 weeks of life.

It is a oily, flaky, usually yellowish, scaley skin condition that is present over the areas of the body that are the most sebum rich. Typically on the top of the scalp, but in more severe cases can be over the face and trunk (this is then named seborrheic dermatitis of infancy).

It is not related to uncleanliness, nor part of an illness and is not related to the child not being cared for.

Whats the cause?
The most recent understanding in medicine is that cradle cap is related to a normal amount of yeast malassezia, but an abnormal immune response of the skin cells. This is typically related to overactivity of sebaceous glands, causing more oil to but put on the skin surface, causing skin cells to stick that would normally have been shed. Some doctors also relate this overactivity to the remaining mother's hormones in the child's circulation after birth.

Treatment
So what can you do at home without having to get to the parmacy and spend a fortune?

In the research, the most common advice is to wash the scalp regularly with a mild baby shampoo and gently comb the scalp with a baby brush to help remove the excess flaky skin.

To aid the removal of the flaky skin, another aid can be applying mineral oil or petroleum jelly to the scalp/skin over night and then gently brush in the morning to remove. Then wash regularly...

It seems that applying olive oil to the area, as I have heard, is actually not a good thing. By applying more oil (typically vegetable oil) to the area, you are allowing yeast to increase its growth and therby creating a possible pathway to secondary infection. This secondary yeast infection typically occurs more in the skin folds than on the top of the scalp. This is something to watch out for, as cradle cap/ seborrheic dermatitis should not be itchy, if it is, then it is likely that there is an underlying infection - which does require medication.

Do not use anti-dandruff shampoo. This is too harsh for a baby's skin and can create further irritation.

Do not use eczema creams (like Elidel) this is also too harsh for a child's skin and has not been tested on the under 2's.