RESUMO
OBJECTIVES: This study reviewed evidence on the effect of maternal smoking on early weaning. METHODS: The following databases and journals were searched: Medline, Scientific Citation Index, Pediatrics, Journal of Pediatrics, New England Journal of Medicine, and Lancet. Analysis was restricted to studies in which infants who had never been breastfed were excluded or the prevalence of breastfeeding initiation was more than 90%. RESULTS: In smoking vs nonsmoking mothers, the random effects odds ratio for weaning before 3 months was 1.93 (95% confidence interval [CI] = 1.55, 2.40). An adjusted odds ratio of 1.50 (95% CI = 1.34, 1.68) was shown in studies that had lost-to-follow-up rates below 15% and included adequate adjustment for confounding. CONCLUSIONS: Maternal smoking increases the risk of early weaning.
Assuntos
Atitude Frente a Saúde , Aleitamento Materno/psicologia , Aleitamento Materno/estatística & dados numéricos , Mães/psicologia , Transtornos Puerperais/psicologia , Fumar/psicologia , Desmame , Adulto , Análise de Variância , Viés , Estudos de Casos e Controles , Fatores de Confusão Epidemiológicos , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Lactente , Recém-Nascido , Razão de Chances , Análise de Regressão , Projetos de Pesquisa , Fatores de Risco , Fatores de TempoRESUMO
OBJECTIVE: To compare the risks of contaminated culture results and consequent adverse clinical outcomes in urine specimens obtained by "clean-voided" bag method versus catheterization. STUDY DESIGN: Hospital-based cohort study of all children
Assuntos
Contaminação de Equipamentos , Manejo de Espécimes , Urinálise/métodos , Infecções Urinárias/diagnóstico , Técnicas de Cultura de Células , Estudos de Coortes , Erros de Diagnóstico/prevenção & controle , Feminino , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Razão de Chances , Cateterismo UrinárioRESUMO
BACKGROUND: Earlier studies suggesting an increased recurrence risk of respiratory distress syndrome (RDS) among the subsequent infants of women with a previously affected infant were based on low birth weight inclusion criteria that did not differentiate between preterm and growth-retarded infants. METHODS: We therefore carried out two cohort studies of women who delivered two singleton preterm (gestational age < 37 completed weeks) infants: 1978 to 1989 at the Royal Victoria Hospital (RVH) in Montreal and 1959 to 1966 in the United States Collaborative Perinatal Project (CPP). We compared the relative risk (RR) of the development of RDS in the second infant according to the RDS status of the first. The diagnosis of RDS was based on respiratory distress of more than 24 hours' duration and a reticulogranular pattern on a chest radiograph. RESULTS: The RVH study sample comprised 284 infants born to 142 women, and the CPP sample 642 infants born to 321 mothers. In the RVH cohort the crude RR of RDS in the second sibling was 3.3 (95% confidence interval = 1.0 to 15.1) in women whose first preterm infant had RDS versus those whose first preterm infant did not have RDS. In the CPP cohort the corresponding RR was 2.5 (95% confidence interval = 0.8 to 7.9). These elevated risks were not altered substantially when multiple logistic regression was used to control for potentially confounding factors known to influence the risk of RDS (gestational age, sex, route of delivery, antenatal corticosteroids, and respiratory depression of birth). CONCLUSIONS: We conclude that preterm infants born to women with a previous preterm infant affected by RDS are at an increased risk of RDS, which suggests an important genetic (or other familial) tendency in its origin.
Assuntos
Síndrome do Desconforto Respiratório do Recém-Nascido/etiologia , Estudos de Coortes , Fatores de Confusão Epidemiológicos , Feminino , Humanos , Recém-Nascido de Baixo Peso , Recém-Nascido , Masculino , Análise de Regressão , Síndrome do Desconforto Respiratório do Recém-Nascido/genética , Fatores de RiscoRESUMO
OBJECTIVE: To assess the relative risks and benefits of 10 potential urine testing strategies (compared with no testing) involving urinalysis and urine culture for children aged 3 to 24 months with fever but no focus of bacterial infection. DESIGN: Decision analysis based on the literature. The 10 testing strategies consist of five pairs; within each pair of strategies, one calls for urinalysis and urine culture of a clean-voided (bag) specimen, and urine culture, and in the other, the urine specimen is sent for culture only if the result of the urinalysis is abnormal. The five pairs differ in selectivity for testing: all children, girls only, temperature > or = 39 degrees C only, fever only (no respiratory or gastrointestinal symptoms), or temperature > or = 40 degrees C only. The results of the decision analysis are expressed as the preventive fraction (the proportion of cases prevented) for end-stage renal disease (ESRD) and hypertension, and as two risk/benefit (RB) ratios: the number of children tested per case of ESRD prevented (RB1), and the number of children with false-positive diagnosis and treatment of urinary tract infection per case of ESRD prevented (RB2). RESULTS: On the basis of the available evidence, none of the testing strategies succeeds in preventing the majority of cases of ESRD and hypertension (preventive fraction = 0.10 to 0.50), and all are associated with high ratios of children tested (RB1 = 4167 to 12,500) and false-positive diagnosis and treatment (RB2 = 563 to 1800) per case of ESRD prevented. A strategy of combined urinalysis and urine culture in children with temperature > or = 39 degrees C is associated with the most favorable RB profile: preventive fraction = 0.45, RB1 = 5556; RB2 = 776. Sensitivity analyses indicate that the relative ranking of the strategies is relatively robust in regard to alterations in the estimates of the sensitivity or specificity of the urinalysis, the relative risk of renal scarring associated with delayed diagnosis and treatment, and the risk of scarring-induced hypertension or ESRD. CONCLUSIONS: Up to 50% of the long-term sequelae of occult urinary tract infections in young febrile children appear preventable by urine testing, but even the most favorable strategies require testing of thousands of children, and unnecessarily treating hundreds, for every case prevented. Our analysis reveals those strategies with more favorable RB profiles and emphasizes the need for rapid and convenient urine tests with much higher sensitivity and specificity or the need for less aggressive management strategies for febrile infants and young children with urinary tract infection.
Assuntos
Técnicas de Apoio para a Decisão , Febre de Causa Desconhecida/urina , Hipertensão/prevenção & controle , Falência Renal Crônica/prevenção & controle , Urinálise , Infecções Urinárias/diagnóstico , Antibacterianos/uso terapêutico , Árvores de Decisões , Reações Falso-Positivas , Feminino , Febre de Causa Desconhecida/etiologia , Febre de Causa Desconhecida/microbiologia , Humanos , Hipertensão/etiologia , Lactente , Falência Renal Crônica/etiologia , Masculino , Valor Preditivo dos Testes , Risco , Sensibilidade e Especificidade , Urinálise/efeitos adversos , Urinálise/métodos , Infecções Urinárias/complicações , Infecções Urinárias/tratamento farmacológico , Urina/microbiologiaRESUMO
Fifty-eight actively psychotic inpatients who initially met criteria for long-standing schizophrenia and subsequently met Research Diagnostic Criteria for a current episode of schizoaffective disorder (mainly schizophrenic) with a depressive syndrome, and who scored at least 30 (mean = 55, SEM = 1.6) on the Brief Psychiatric Rating Scale and 17 (mean = 23, SEM = 0.7) on the Hamilton Rating Scale for Depression, were treated for 5 weeks with haloperidol hydrochloride and benztropine. Haloperidol and benztropine treatment was continued, while those patients who consistently scored greater than 17 on the Hamilton Rating Scale for Depression were randomly assigned to the following double-blind treatment groups for 4 weeks: adjunctive amitriptyline hydrochloride, desipramine hydrochloride, or placebo. Adjunctive desipramine or amitriptyline showed no significant therapeutic advantage, when compared with haloperidol and placebo, on the Brief Psychiatric Rating Scale or the Hamilton Rating Scale for Depression. After 4 weeks of combine therapy, patients receiving adjunctive amitriptyline or desipramine, as compared with those receiving adjunctive placebo, tended to score higher on the Brief Psychiatric Rating Scale hallucinatory behavior item and on the thinking disturbance factor than patients receiving placebo. These results suggest that adjunctive antidepressants are not indicated for the treatment of depressive symptoms in actively psychotic schizophrenic inpatients. Adjunctive antidepressants may retard the rate of resolution of psychosis in this population.
Assuntos
Amitriptilina/uso terapêutico , Transtorno Depressivo/tratamento farmacológico , Desipramina/uso terapêutico , Haloperidol/uso terapêutico , Hospitalização , Esquizofrenia/tratamento farmacológico , Adolescente , Adulto , Benzotropina/uso terapêutico , Ensaios Clínicos como Assunto , Transtorno Depressivo/complicações , Transtorno Depressivo/psicologia , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Placebos , Escalas de Graduação Psiquiátrica , Esquizofrenia/complicações , Esquizofrenia/diagnóstico , Psicologia do EsquizofrênicoRESUMO
Twelve DSM-IIIR diagnosed schizophrenics, with neuroleptic-induced akathisia (NIA), were treated with either propranolol or matched placebo for two days, followed by a treatment crossover phase for five more days. Raters and patients were "blind" to treatment. This study shows that 120 mg of propranolol a day is more effective than placebo in reducing akathisia, and that propranolol's antiakathisic effect may require several days of treatment.
Assuntos
Antipsicóticos/efeitos adversos , Propranolol/administração & dosagem , Agitação Psicomotora/tratamento farmacológico , Esquizofrenia/tratamento farmacológico , Psicologia do Esquizofrênico , Acatisia Induzida por Medicamentos , Antipsicóticos/administração & dosagem , Benzotropina/administração & dosagem , Relação Dose-Resposta a Droga , Método Duplo-Cego , Humanos , Exame NeurológicoRESUMO
To help shed some light on the 50-year-old controversy concerning the possible protective effect of breast feeding on subsequent atopic disease, I developed 12 standards pertaining to both biologic and methodologic aspects of exposure (infant feeding), outcome (atopic conditions), and statistical analysis for studies of atopic eczema, asthma, allergic rhinitis, cow milk allergy, and other food allergy. Among the published studies on atopic eczema, the nine claiming a protective benefit of breast feeding performed less well than the 12 not making such a claim on "methodologic" standards relating to strict diagnostic criteria and blind ascertainment of outcome. The positive studies were somewhat stronger, however, on the "biologic" standards bearing on sufficient duration and exclusivity of breast feeding and on separate analysis of children at high risk. For the other atopic conditions, there were no important differences between positive and negative studies. In few negative or positive studies was there adequate control for confounding variables or examination of potential benefits relating to the severity or age at onset of atopic disease. To avoid another 50 years of unresolved controversy, future studies should improve both the biologic and methodologic aspects of their design and analysis.
PIP: In the last 50 years many studies have been published that purportedly prove or refute the hypothesis that breast feeding protects infants against 6 immediate hypersensitivity-mediated disease states -- atopic eczema, asthma, allergic rhinitis, cow milk allergy, other food allergy, and combinations of these. A MEDLINE search for articles published between 1983 and 1986 and an examination of end references back to 1936 provided a supply of articles on both sides of the debate. These articles were rated against 12 biological and methodological standards to determine whether their conclusions were based on rigorous examination of the facts. The 12 standards were: nonreliance on recall, blind ascertainment of infant feeding history, breast feeding duration of at least 2 months, specifically stated exclusivity of breast feeding, strict diagnostic criteria for the atopic diseases, blind ascertainment of outcome, measured severity of disease outcome, age at onset of disease, control for confounding variables, assessment of dose-response effect, assessment of genetic of risk factors for atopic disease, and rigorous statistical methods. The total retrieval included 22 studies of atopic eczema, 13 studies of asthma, 7 studies of rhinitis, 3 studies of cow milk allergy, 4 studies of other food allergy, and 8 studies of mixtures of 2 or more atopic diseases. These studies were rated against the 12 standards. Serious flaws reduced the value of all studies in greater or lesser degree. Nonblind ascertainment of outcome, failure to control for confounding variables, failure to ascertain disease severity, and failure to record age at onset of disease were the most common drawbacks. It is not possible to determine from these studies whether or not breast feeding has a prophylactic effect on atopic disease. More research is obviously necessary, but a rigorous study design must come first.
Assuntos
Aleitamento Materno , Hipersensibilidade/prevenção & controle , Projetos de Pesquisa/normas , Animais , Asma/fisiopatologia , Asma/prevenção & controle , Pré-Escolar , Humanos , Hipersensibilidade/diagnóstico , Hipersensibilidade/fisiopatologia , Lactente , Recém-Nascido , Leite/imunologia , Estatística como AssuntoAssuntos
Hidróxido de Alumínio/uso terapêutico , Carbonato de Cálcio/uso terapêutico , Fosfatos/sangue , Diálise Renal , Fosfatase Alcalina/sangue , Bicarbonatos/sangue , Cálcio/sangue , Proteínas de Ligação ao Cálcio/sangue , Ensaios Clínicos como Assunto , Eritrócitos/efeitos dos fármacos , Eritrócitos/fisiologia , Feminino , Humanos , Masculino , Osteocalcina , Hormônio Paratireóideo/sangue , Vitamina K/sangueAssuntos
Obesidade/etiologia , Envelhecimento , Peso ao Nascer , Peso Corporal , Seguimentos , Humanos , Lactente , Alimentos Infantis , Fatores Sexuais , Dobras CutâneasRESUMO
We used a recently developed diagnostic adverse drug reaction (ADR) algorithm and an intensive telephone surveillance program to monitor all courses of prescription and nonprescription drug therapy in a general pediatric group practice for 1 year. A total of 3181 different children visited the practice during the year and received 4244 separate courses of drug therapy. Adverse symptoms were noted in 473 (11.1%) of these courses of therapy. Of 534 total adverse symptoms, however, only 24 scored as definite and 176 as probable ADRs. The main ADRs noted were antibiotic-associated gastrointestinal complaints and rashes, and various manifestations of CNS stimulation with bronchodilators. Sociodemographic variables significantly associated with the risk of a definite or probable ADR were socioeconomic status (P less than 0.0001), ethnic origin (P = 0.0015), and age (P less than 0.05). Treatment-related risk factors included treatment by a practitioner outside the study practice (usually during nonoffice hours) (P less than 0.001) and administration of a dosage above the range recommended by the manufacturer (P less than 0.001). Half the ADRs were judged as inconsequential by the children's parents, and most of the remainder resulted in only minor morbidity. Half were judged to be highly or probably preventable. Our results suggest that ADRs do not occur commonly in general pediatric outpatients and that most are mild and self-limited.
Assuntos
Assistência Ambulatorial , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Adolescente , Criança , Pré-Escolar , Prescrições de Medicamentos , Feminino , Humanos , Doença Iatrogênica/prevenção & controle , Lactente , Recém-Nascido , Masculino , Relações Pais-Filho , Cooperação do Paciente , Risco , Fatores Socioeconômicos , Fatores de TempoRESUMO
To overcome methodologic defects (failure to control for confounding factors, univariate statistical analyses) in previous studies of etiologic determinants of childhood adiposity, we carried out a prospective cohort study of 462 healthy, full-term infants observed from birth to 12 months. Postpartum, we obtained sociodemographic data and administered two recently validated scales of maternal attitudes toward feeding and infant body habitus. Parental heights and weights and infant feeding variables were determined by interview, and at 6 and 12 months we measured height and weight and triceps, subscapular, and suprailiac skinfolds. Multiple regression analysis was used to determine independently predictive factors for weight, body mass index (BMI = weight/height), and the sum of the three skinfold measurements. Birth weight, sex, age at introduction of solid, and duration of breast-feeding were all significant predictors of weight at 12 months (r2 = 0.296, P less than 0.0001). Significant determinants for BMI included birth weight, duration of breast-feeding, sex, and IBH (r2 = 0.125, P less than 0.0001); those for total skinfold were age at introduction of solid foods and birth weight (r2 = 0.038, P = 0.002). Similar results were obtained at 6 months, although slightly less of the variance was explained. We conclude that the ability to predict which babies will be heavy or obese during the first year is limited. Breast-feeding and delayed introduction of solid foods do offer some protective effect, however, and thus efforts to encourage these practices may be reaping some benefit.
Assuntos
Peso Corporal , Obesidade/etiologia , Adulto , Atitude , Peso ao Nascer , Aleitamento Materno , Feminino , Humanos , Lactente , Alimentos Infantis , Recém-Nascido , Masculino , Mães/psicologia , Obesidade/genética , Probabilidade , Estudos Prospectivos , Fatores Sexuais , Dobras Cutâneas , Fatores Socioeconômicos , Estatística como Assunto , Fatores de TempoRESUMO
To correct methodologic flaws (Type II error, confounding variables, and nonblinding) in previous studies relating infant feeding to later obesity, we conducted case-control studies of 639 patients 12 to 18 years of age attending our Adolescent Clinic, and 533 similarly aged healthy children attending a Montreal high school. Each subject was classified as either obese, overweight, or nonobese based on measurements of height, weight, and triceps and subscapular skinfolds. Feeding history, family history, and demographic data were later ascertained "blindly" by telephone interview. Analysis of the raw data revealed a significantly elevated estimated relative risk of not breast-feeding and a significant trend for rates of breast-feeding among the three weight groups. The magnitude of the protective effect appeared to rise slightly with increased duration of breast-feeding. Delayed introduction of solid foods provided little if any additional benefit. Several demographic and clinical variables proved to be confounding, but the significant protective effect of breast-feeding persisted even after controlling for confounders. We conclude that breast-feeding does protect against later obesity and attribute the conflicting results of previous studies to insufficient attention to methodologic standards.
Assuntos
Aleitamento Materno , Obesidade/prevenção & controle , Adolescente , Criança , HumanosRESUMO
Previous studies relating infant feeding to subsequent atopic eczema have had methodologic flaws that include insensitive study designs, nonblind observation, and failure to control for confounding variables. To avoid these flaws, we conducted a case-control study of 636 patients attending a dermatology clinic. The dermatologic problem in each patient was classified as atopic eczema (case), dermatologic condition unrelated to atopy (control), or dermatologic condition with questionable relation to atopy (uncertain). The feeding history was ascertained later, along with family history and demographic data, by an assistant blind both to the question under study and to the case vs control status of each subject. Breast-feeding was not associated with any reduction in the estimated relative risk of developing atopic eczema. No significant relationship was found among the cases between severity of disease and breast-feeding nor between age of onset of disease and duration of breast-feeding or age at introduction of solid foods. Even when breast-feeding was redefined as "pure" and exclusive (no nonhuman milk or solids) for greater than or equal to 2 months, no protective effect was uncovered. We conclude that breast-feeding and delayed introduction of solids do not protect against atopic eczema, and that previous claims of protective effects were based on data probably biased by nonblinding and important confounders.
Assuntos
Aleitamento Materno , Eczema/prevenção & controle , Fenômenos Fisiológicos da Nutrição do Lactente , Adolescente , Adulto , Criança , Pré-Escolar , Eczema/diagnóstico , Eczema/etiologia , Métodos Epidemiológicos , Humanos , Lactente , Recém-Nascido , RiscoAssuntos
Anemia Falciforme/fisiopatologia , Desenvolvimento Infantil , Crescimento , Doenças do Recém-Nascido/sangue , Anemia Falciforme/psicologia , Antropometria , Criança , Pré-Escolar , Sangue Fetal/análise , Feto/fisiologia , Hemoglobina Falciforme/análise , Humanos , Lactente , Recém-Nascido , Doenças do Recém-Nascido/fisiopatologia , Estudos ProspectivosRESUMO
In adolescent girls, secondary amenorrhea can result from a variety of physiologic and psychologic disturbances. Previous reports associating amenorrhea and primary hypothyroidism have not distinguished between the alternative etiologic roles of thyroxine deficiency and hyperprolactinemia. We have evaluated two girls with secondary amenorrhea who had clinical and chemical evidence of hypothyroidism. Both had low basal T4 values (0.8 and 3.2 microgram/dl), calculated free T4 (0.1 and 0.7 ng/dl), and T3 (51 and 81 ng/dl). Both had undetectable basal TSH with normal TSH response to TRH. Basal FSH and LH values were normal, as was the response to LHRH. Basal prolactin levels were 6 and 14 ng/ml, respectively, and both girls had growth hormone responses of greater than or equal to 15 ng/ml in response to insulin-induced hypoglycemia. Pituitary-adrenal function and reserve were also normal. In neither patient was there any historical, physical, or laboratory features compatible with anorexia nervosa. After treatment with 1-thyroxine, both girls had a resumption in menses. These two adolescent girls thus appear to have isolated hypothalamic hypothyroidism. The associated secondary amenorrhea demonstrates that thyroid deficiency alone, without hyperprolactinemia, can interfere with normal hypothalamic-pituitary-ovarian function.