Costs and savings of parenting interventions: results of a systematic review.

BACKGROUND: This systematic review of economic evaluations of universal preventative or targeted treatment parenting interventions that aim to enhance parent-infant interaction is primarily intended to inform decision makers who have to make difficult spending decisions, especially at a time of reduced spending allocations. A synthesis of available costs and savings about parenting interventions that set out to enhance parent-infant interaction is presented. This topic is important specifically in view of the UK Governments' emphasis on the equalities agenda and the early years. The benefits of positive early life experiences, which include good parent-infant interaction, are far reaching and may be positively correlated with improved educational, health and well-being outcomes and reduced criminality. METHODS: A literature search was undertaken using on-line indexing databases between 2004 and 2014 that included the search terms 'parent', 'infant', 'interaction', 'cost benefit analysis' and their synonyms. RESULTS: Despite existing economic studies generally focusing upon targeted short-run outcomes, significant savings were observed in the included studies. Parenting interventions could save the health service around £2.5k per family over 25 years and could save the criminal justice system over £145k per person over the life course. In light of the escalating costs of remedial services, these potential savings may provide the UK and other governments with a robust incentive to invest in early years parenting interventions. CONCLUSIONS: Parenting interventions can be economically efficient and return savings on investment. Moreover, and one might argue as a moral imperative of democratic societies, population health can be improved and health inequalities reduced. An important debate is needed about early years policy, to include acknowledgement of the differences between UK and international healthcare systems and the potential savings from the synergistic and spin-off effects of early years interventions to inform decision-making to fund and implement appropriate action.

Potential economic impacts from improving breastfeeding rates in the UK.

RATIONALE: Studies suggest that increased breastfeeding rates can provide substantial financial savings, but the scale of such savings in the UK is not known. OBJECTIVE: To calculate potential cost savings attributable to increases in breastfeeding rates from the National Health Service perspective. DESIGN AND SETTINGS: Cost savings focussed on where evidence of health benefit is strongest: reductions in gastrointestinal and lower respiratory tract infections, acute otitis media in infants, necrotising enterocolitis in preterm babies and breast cancer (BC) in women. Savings were estimated using a seven-step framework in which an incidence-based disease model determined the number of cases that could have been avoided if breastfeeding rates were increased. Point estimates of cost savings were subject to a deterministic sensitivity analysis. RESULTS: Treating the four acute diseases in children costs the UK at least £89 million annually. The 2009-2010 value of lifetime costs of treating maternal BC is estimated at £959 million. Supporting mothers who are exclusively breast feeding at 1 week to continue breast feeding until 4 months can be expected to reduce the incidence of three childhood infectious diseases and save at least £11 million annually. Doubling the proportion of mothers currently breast feeding for 7-18 months in their lifetime is likely to reduce the incidence of maternal BC and save at least £31 million at 2009-2010 value. CONCLUSIONS: The economic impact of low breastfeeding rates is substantial. Investing in services that support women who want to breast feed for longer is potentially cost saving.

Being baby friendly: evidence-based breastfeeding support.

Breast feeding improves important outcomes for mothers and infants. In the UK, breastfeeding rates have historically been low, particularly among socially disadvantaged young women. Although there have been gradual increases in breastfeeding initiation rates since 2000, rates of exclusive breast feeding and continuation until 6 months remain lower than those in similar countries. This review summarises the evidence for effective and cost-effective strategies to help women, particularly those in low income groups, make informed choices, overcome barriers and establish and maintain breast feeding. We describe the development and impact of the Unicef Baby Friendly Initiative, and the roles and responsibilities, and challenges and opportunities that clinicians have in promoting breast feeding and maintaining a baby-friendly culture and environment.

Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis.

OBJECTIVES: To evaluate the effectiveness and cost-effectiveness of interventions that promote or inhibit breastfeeding or feeding with breastmilk for infants admitted to neonatal units, and to identify an agenda for future research. DATA SOURCES: Electronic databases were searched (including MEDLINE and MEDLINE In-Process Citations, EMBASE, CINAHL, Maternity and Infant Care, PsycINFO, British Nursing Index and Archive, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Science Citation Index, Pascal, Latin American and Caribbean Health Sciences, MetaRegister of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Health Technology Assessment Database, National Research Register) from inception to February 2008. Advisors identified further published or unpublished material. REVIEW METHODS: All papers fulfilled eligibility criteria covering participants, interventions, study design and outcomes. Results from primary studies were assessed and summarised in a qualitative synthesis for each type of intervention and across types of intervention. To estimate long-term cost utility, a decision tree was developed to synthesise data on enhanced staff contact, breastmilk effectiveness, incidence of necrotising enterocolitis (NEC) and sepsis, resource use, survival and utilities. RESULTS: Forty-eight studies met the selection criteria for the effectiveness review, of which 65% (31/48) were RCTs, and 17% (8/48) were conducted in the UK. Seven were rated as good quality and 28 as moderate quality. No studies met the selection criteria for the health economics review. There is strong evidence that short periods of kangaroo skin-to-skin contact increased the duration of any breastfeeding for 1 month after discharge [risk ratio (RR) 4.76, 95% confidence interval (CI) 1.19 to 19.10] and for more than 6 weeks (RR 1.95, 95% CI 1.03 to 3.70) among clinically stable infants in industrialised settings. There is strong evidence for the effectiveness of peer support at home (in Manila) for mothers of term, low birthweight infants on any breastfeeding up to 24 weeks (RR 2.18, 95% CI 1.45 to 3.29) and exclusive breastfeeding from birth to 6 months (RR 65.94, 95% CI 4.12 to 1055.70), and for the effectiveness of peer support in hospital and at home for mothers of infants in Special Care Baby Units on providing any breastmilk at 12 weeks [odds ratio (OR) 2.81, 95% CI 1.11 to 7.14; p = 0.01]. There is more limited evidence for the effectiveness of skilled professional support in a US Neonatal Intensive Care Unit on infants receiving any breastmilk at discharge (OR 2.0, 95% CI 1.2 to 3.2, p = 0.004). Multidisciplinary staff training may increase knowledge and can increase initiation rates and duration of breastfeeding, although evidence is limited. Lack of staff training is an important barrier to implementation of effective interventions. Baby Friendly accreditation of the associated maternity hospital results in improvements in several breastfeeding-related outcomes for infants in neonatal units. Limited evidence suggests that cup feeding (versus bottle feeding) may increase breastfeeding at discharge and reduce the frequency of oxygen desaturation. Breastmilk expression using simultaneous pumping with an electric pump has advantages in the first 2 weeks. Pharmaceutical galactagogues have little benefit among mothers who have recently given birth. Our economic analysis found that additional skilled professional support in hospital was more effective and less costly (due to reduced neonatal illness) than normal staff contact. Additional support ranged from 0.009 quality-adjusted life-years (QALYs) to 0.251 QALYs more beneficial per infant and ranged from 66 pounds to 586 pounds cheaper per infant across the birthweight subpopulations. Donor milk would become cost-effective given improved mechanisms for its provision. CONCLUSIONS: Despite the limitations of the evidence base, kangaroo skin-to-skin contact, peer support, simultaneous breastmilk pumping, multidisciplinary staff training and the Baby Friendly accreditation of the associated maternity hospital have been shown to be effective, and skilled support from trained staff in hospital has been shown to be potentially cost-effective. All these point to future research priorities. Many of these interventions inter-relate: it is unlikely that specific clinical interventions will be effective if used alone. There is a need for national surveillance of feeding, health and cost outcomes for infants and mothers in neonatal units; to assist this goal, we propose consensus definitions of the initiation and duration of breastfeeding/breastmilk feeding with specific reference to infants admitted to neonatal units and their mothers.

WITHDRAWN: Commercial hospital discharge packs for breastfeeding women.

BACKGROUND: Exclusive breastfeeding until around six months of age, followed by the introduction of solids with continued breastfeeding, is considered to be the optimal nutritional start for newborn infants. OBJECTIVES: To determine whether the exclusivity and duration of breastfeeding is affected by giving mothers commercial discharge packs in hospital which contain artificial formula or promotional material for artificial formula. These packs are those which are commonly given to mothers on leaving hospital after giving birth (thus discharge packs). SEARCH STRATEGY: Comprehensive electronic search of the register of clinical trials maintained and updated by the Cochrane Pregnancy and Childbirth Group and CINAHL and MEDLINE. SELECTION CRITERIA: All randomised controlled trials with or without blinding to examine the effects of commercial discharge packs on breastfeeding. PARTICIPANTS: Consenting postpartum women who initiate breastfeeding while in hospital or immediately upon discharge. INTERVENTIONS: Commercial discharge packs which contain free samples of infant formula or promotional material versus non commercial discharge packs (specifically those from which free samples of infant formula have been removed or have been replaced with e.g. breast pads) or no pack. MAIN OUTCOME MEASURES: The proportion of women breastfeeding at six weeks and 3 months (13 weeks) postpartum.Other outcomes: Rates of breastfeeding at other fixed time points between 0 and 6 months postpartum. DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer and checked by a second reviewer. MAIN RESULTS: Nine randomised controlled trials involving a total of 3730 women were analysed. The studies only included women from North America. The meta-analysis showed that when comparing commercial discharge packs with any of the controls (no intervention, non-commercial pack and combinations of these), exclusive breastfeeding was reduced at all time points in the presence of commercial hospital discharge packs. There was no evidence to support the conjecture that use of hospital discharge packs causes the early termination of non-exclusive breastfeeding. Where the introduction of solid food was measured, giving a commercial pack (with or without formula) reduced the time before solid food was introduced. AUTHORS' CONCLUSIONS: The giving of commercial hospital discharge packs (with or without formula) appears to reduce the number of women exclusively breastfeeding at all times but has no significant effect upon the earlier termination of non-exclusive breastfeeding.

WITHDRAWN: Treatments for breast engorgement during lactation.

BACKGROUND: National surveys have shown that painful breasts are the second most common reason for giving up breastfeeding in the first two weeks after birth in the UK. One factor contributing to such pain can be breast engorgement. Views differ as to how engorgement arises, although restrictive feeding patterns in hospital are likely to have contributed in the past. These differing views are reflected in the range of solutions offered to treat engorgement in breastfeeding mothers and these treatments are assessed in this review. OBJECTIVES: To determine the effects of any proposed intervention to relieve symptoms of breast engorgement among breastfeeding women. SEARCH STRATEGY: The register of clinical trials maintained and updated by the Cochrane Pregnancy and Childbirth Group. CINAHL and MEDLINE were also searched. Date of last search: December 2000. SELECTION CRITERIA: All randomised and 'quasi-randomised' controlled trials, with or without blinding, that assess the effectiveness of treatments for the alleviation of symptoms in breastfeeding women experiencing engorgement . DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer and verified by a second reviewer. MAIN RESULTS: Eight trials, involving 424 women, were included. Three different studies were identified which used cabbage leaves or cabbage leaf extracts;. no overall benefit was found. Ultrasound treatment and placebo were equally effective. Use of Danzen (an anti-inflammatory agent) significantly improved the total symptoms of engorgement when compared to placebo (odds ratio (OR) 3.6, 95% confidence interval (CI) 1.3 - 10.3) as did bromelain/trypsin complex (OR 8.02, 95% CI 2.8-23.3). Oxytocin and cold packs had no demonstrable effect on engorgement symptoms. AUTHORS' CONCLUSIONS: Cabbage leaves and gel packs were equally effective in the treatment of engorgement. Since both cabbage extract and placebo cream were equally effective, the alleviation in symptoms may be brought about by other factors, such as breast massage. Ultrasound treatment is equally effective with or without the ultra-wave emitting crystal, therefore its effectiveness is more likely to be due to the effect of radiant heat or massage. Pharmacologically, oxytocin was not an effective engorgement treatment while Danzen and bromelain/trypsin complex significantly improved the symptoms of engorgement. Initial prevention of breast engorgement should remain the key priority.

Rethinking research in breast-feeding: a critique of the evidence base identified in a systematic review of interventions to promote and support breast-feeding.

OBJECTIVE: To appraise critically the relevance and value of the evidence base to promote and support the duration of breast-feeding, with a specific focus on disadvantaged groups. DESIGN: A systematic review was conducted of intervention studies relevant to enhancing the duration of breast-feeding; topics included public health, public policy, clinical issues, and education, training and practice change. A systematic search was conducted. Eighty studies met the inclusion criteria. Data were systematically extracted and analysed. Full results and recommendations are reported elsewhere. Here a critique of the evidence base--topics, quality and gaps--is reported. RESULTS: Many studies were substantially methodologically flawed, with problems including small sample sizes, inconsistent definitions of breast-feeding and lack of appropriate outcomes. Few were based on relevant theory. Only a small number of included studies (10%) were conducted in the UK. Very few targeted disadvantaged subgroups of women. No studies of policy initiatives or of community interventions were identified. There were virtually no robust studies of interventions to prevent and treat common clinical problems, or of strategies related to women's health issues. Studies of health professional education and practice change were limited. Cost-effectiveness studies were rare. CONCLUSIONS: Policy goals both in the UK and internationally support exclusive breast-feeding until 6 months of age. The evidence base to enable women to continue to breast-feed needs to be strengthened to include robust evaluations of policies and practices related to breast-feeding; a step change is needed in the quality and quantity of research funded.

Support for breastfeeding mothers.

BACKGROUND: There is extensive evidence of the benefits of breastfeeding for infants and mothers. In 2003, the World Health Organization (WHO) recommended infants be fed exclusively on breast milk until six months of age. However, breastfeeding rates in many developed countries continue to be resistant to change. OBJECTIVES: To assess the effectiveness of support for breastfeeding mothers. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2006), MEDLINE (1966 to November 2005), EMBASE (1974 to November 2005) and MIDIRS (1991 to September 2005). SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing extra support for breastfeeding mothers with usual maternity care. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. MAIN RESULTS: We have included 34 trials (29,385 mother-infant pairs) from 14 countries. All forms of extra support analysed together showed an increase in duration of 'any breastfeeding' (includes partial and exclusive breastfeeding) (relative risk (RR) for stopping any breastfeeding before six months 0.91, 95% confidence interval (CI) 0.86 to 0.96). All forms of extra support together had a larger effect on duration of exclusive breastfeeding than on any breastfeeding (RR 0.81, 95% CI 0.74 to 0.89). Lay and professional support together extended duration of any breastfeeding significantly (RR before 4-6 weeks 0.65, 95% 0.51 to 0.82; RR before 2 months 0.74, 95% CI 0.66 to 0.83). Exclusive breastfeeding was significantly prolonged with use of WHO/UNICEF training (RR 0.69, 95% CI 0.52 to 0.91). Maternal satisfaction was poorly reported. AUTHORS' CONCLUSIONS: Additional professional support was effective in prolonging any breastfeeding, but its effects on exclusive breastfeeding were less clear. WHO/UNICEF training courses appeared to be effective for professional training. Additional lay support was effective in prolonging exclusive breastfeeding, while its effects on duration of any breastfeeding were uncertain. Effective support offered by professionals and lay people together was specific to breastfeeding and was offered to women who had decided to breastfeed. Further trials are required to assess the effectiveness (including cost-effectiveness) of both lay and professional support in different settings, particularly those with low rates of breastfeeding initiation, and for women who wish to breastfeed for longer than three months. Trials should consider timing and delivery of support interventions and relative effectiveness of intervention components, and should report women's views. Research into appropriate training for supporters (whether lay or professional) of breastfeeding mothers is also needed.

Interventions for promoting the initiation of breastfeeding.

BACKGROUND: Despite the widely documented health benefits of breastfeeding, initiation rates remain relatively low in many high-income countries, particularly among women in lower income groups. OBJECTIVES: To evaluate the effectiveness of interventions which aim to encourage women to breastfeed in terms of changes in the number of women who start to breastfeed. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (30 May 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003) and the following databases from inception to October 2002: MEDLINE, CINAHL, ERIC, Applied Social Sciences, PsychLIT, EMBASE, British Nursing Index, BIDS, EPI-centre. We also searched the following in October 2002 for 'grey literature: 'SIGLE, DHSS Data, and Dissertation Abstracts. We handsearched the Journal of Human Lactation, Health Promotion International and Health Education Quarterly from inception to October 1998. We scanned reference lists of all articles obtained. SELECTION CRITERIA: Randomised controlled trials, with or without blinding, of any breastfeeding promotion intervention in any population group except women and infants with a specific health problem. DATA COLLECTION AND ANALYSIS: One review author independently extracted data and assessed trial quality for checking by a second author. We contacted investigators to obtain missing information. MAIN RESULTS: Seven trials involving 1388 women were included. Five trials involving 582 women on low incomes in the USA showed breastfeeding education had a significant effect on increasing initiation rates compared to routine care (relative risk (RR) 1.53, 95% confidence interval (CI) 1.25 to 1.88). AUTHORS' CONCLUSIONS: Evidence from this review shows that the forms of breastfeeding education evaluated were effective at increasing breastfeeding initiation rates among women on low incomes in the USA.

Formula feed preparation: helping reduce the risks; a systematic review.

AIMS: To assess what is known about the risks associated with errors in reconstituting the present generation of infant formula feeds, and to examine which methods are likely to be safest. METHODS: Systematic review, and examination of the range of infant formula products currently on sale in the UK. Studies from developed countries conducted after 1977 were included. All studies investigating the reconstitution of formula feeds for full term, healthy babies were eligible. Parameters studied were: measures of accuracy of feed reconstitution including fat, protein, total solids, energy content, and osmolality of feed; weight of powder in scoop; and reported method of preparing feed and measuring powder. Formula products were collected from one large UK supermarket in 2002. Number of different types of infant formula preparations available for sale were determined, together with scoop sizes for powdered preparations. RESULTS: Only five studies were identified, none of adequate quality or size. All found errors in reconstitution, with a tendency to over-concentrate feeds; under-concentration also occurred. Thirty one different formula preparations were available for sale in one UK supermarket, with a range of scoop sizes. Some preparations had never been tested. CONCLUSIONS: There is a paucity of evidence available to inform the proper use of breast milk substitutes, and a large array of different preparations for sale. Given the impact incorrect reconstitution of formula feeds can have on the health of large numbers of babies, there is an important and urgent need to examine ways of minimising the risks of feed preparation.

Support for breastfeeding mothers.

BACKGROUND: Both observational and recent experimental evidence support the promotion of breastfeeding as the optimal form of infant nutrition. There is, however, uncertainty as to the most effective way of providing support to women who choose to breastfeed their children. A systematic review was performed to describe studies undertaken in this area and to assess the effectiveness of supplementary support. OBJECTIVES: The objective of this review was to assess the effects of breastfeeding support. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register, MEDLINE and EMBASE. These were last searched in March 2001. Secondary references were searched and researchers in the field were contacted. SELECTION CRITERIA: Controlled trials of acceptable quality comparing extra support for breastfeeding mothers with usual maternity care. DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer and checked by a second reviewer. MAIN RESULTS: Twenty eligible randomised or quasi-randomised controlled trials from 10 countries were identified involving 23,712 mother-infant pairs. There was a beneficial effect on the duration of any breastfeeding in the meta-analysis of all forms of extra support (relative risk (RR) for stopping any breastfeeding before six months 0.88 [95% confidence interval (CI) 0.81,0.95]; 15 trials, 21,910 women). The effect was greater for exclusive breastfeeding (RR 0.78 [95% CI 0.69,0.89]; 11 trials, 20,788 women). Extra professional support appeared beneficial for any breastfeeding (RR 0.89 [95% CI 0.81,0.97]; 10 trials, 19,696 women) and for exclusive breastfeeding (RR 0.90 [95% confidence interval 0.81,1.01]; six trials, 18,258 women) although the latter effect did not achieve full statistical significance. Lay support was effective in reducing the cessation of exclusive breastfeeding (RR 0.66 [95% CI 0.49,0.89]; five trials, 2530 women) but its effect on any breastfeeding did not reach statistical significance (RR 0.84 [95% CI 0.69,1.02]; five trials, 2224 women). Professional support in the largest trial to assess health outcomes produced a significant reduction in the risk of gastro-intestinal infections and atopic eczema. In two trials with children suffering from diarrhoeal illness extra support was highly effective in increasing short term exclusive breastfeeding rates and reducing recurrence of diarrhoea. REVIEWER'S CONCLUSIONS: Consideration should be given to providing supplementary breastfeeding support as part of routine health service provision. There is clear evidence for the effectiveness of professional support on the duration of any breastfeeding although the strength of its effect on the rate of exclusive breastfeeding is uncertain. Lay support is effective in promoting exclusive breastfeeding while the strength of its effect on the duration of any breastfeeding is also uncertain. Evidence supports the promotion of exclusive breastfeeding as central to the management of diarrhoeal illness in partially breastfed infants. Further trials are required to assess the effectiveness (including cost-effectiveness) of both lay and professional support in different settings - in particular in those communities with low rates of breastfeeding initiation. Research is also required into the most appropriate training for those, whether lay or professional, who support breastfeeding mothers.

A review of the literature on women's views on their maternity care in the community in the UK.

OBJECTIVES: to review the UK literature relating to women's views on community-based maternity care between 1970 and 1998. DESIGN: UK research studies examining community-based maternity care were identified by searching several electronic databases using defined search terms. Data extraction was carried out by two or more independent reviewers using a pro-forma. Findings are summarised in this paper. FINDINGS: a total of 624 papers were retrieved and 241 met inclusion criteria. Only 40 papers included some form of comparison group. Examples from more recent and relevant papers focusing on women's views of their maternity care are described and discussed. Women expressed high levels of satisfaction with care. However, there are serious gaps in the research evidence. CONCLUSION AND POLICY IMPLICATIONS: most of the papers included in the review were descriptive and few studies were of a size and quality to enable findings to be generalised to other groups and settings. More information is needed on the care process. There is a need for research studies to examine consumer views where different groups of women experience different care processes.

A review of the literature on the midwife and community-based maternity care.

OBJECTIVE: to review the UK literature relating to community-based maternity care. DESIGN: all UK research studies published between 1970 and 1998 relating to community-based maternity care were included. Searches were made via a number of electronic databases using defined search terms. All papers included were independently reviewed by a minimum of two researchers. Study findings were tabulated using a pro-forma. Findings are summarised in this paper. FINDINGS: a total of 241 papers were deemed to meet all inclusion criteria. The majority of studies used descriptive methods with only 11 papers reporting findings from randomised controlled trials. Findings are reported relating to clinical outcomes, the care process and the views of women and health professionals. CONCLUSION AND POLICY IMPLICATIONS: the overall quality of the evidence in the papers reviewed was very mixed. What limited evidence there is suggests that, for the majority of women, care in community settings is as safe and as acceptable to women as care provided in hospital. Despite a large volume of literature, the amount that is known about midwives' contribution to care, and what women think about it, is limited. There is a need for controlled studies to compare outcomes for different patterns of care and for well-designed observational studies to provide information on the care process.

Treatments for breast engorgement during lactation.

BACKGROUND: National surveys have shown that painful breasts are the second most common reason for giving up breastfeeding in the first two weeks after birth in the UK. One factor contributing to such pain can be breast engorgement. Views differ as to how engorgement arises, although restrictive feeding patterns in hospital are likely to have contributed in the past. These differing views are reflected in the range of solutions offered to treat engorgement in breastfeeding mothers and these treatments are assessed in this review. OBJECTIVES: To determine the effects of any proposed intervention to relieve symptoms of breast engorgement among breastfeeding women. SEARCH STRATEGY: The register of clinical trials maintained and updated by the Cochrane Pregnancy and Childbirth Group. CINAHL and MEDLINE were also searched. Date of last search: December 2000. SELECTION CRITERIA: All randomised and 'quasi-randomised' controlled trials, with or without blinding, that assess the effectiveness of treatments for the alleviation of symptoms in breastfeeding women experiencing engorgement. DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer and verified by a second reviewer. MAIN RESULTS: Eight trials, involving 424 women, were included. Three different studies were identified which used cabbage leaves or cabbage leaf extracts;. no overall benefit was found. Ultrasound treatment and placebo were equally effective. Use of Danzen (an anti-inflammatory agent) significantly improved the total symptoms of engorgement when compared to placebo (odds ratio (OR) 3.6, 95% confidence interval (CI) 1.3 - 10.3) as did bromelain/trypsin complex (OR 8.02, 95% CI 2.8-23.3). Oxytocin and cold packs had no demonstrable effect on engorgement symptoms. REVIEWER'S CONCLUSIONS: Cabbage leaves and gel packs were equally effective in the treatment of engorgement. Since both cabbage extract and placebo cream were equally effective, the alleviation in symptoms may be brought about by other factors, such as breast massage. Ultrasound treatment is equally effective with or without the ultra-wave emitting crystal, therefore its effectiveness is more likely to be due to the effect of radiant heat or massage. Pharmacologically, oxytocin was not an effective engorgement treatment while Danzen and bromelain/trypsin complex significantly improved the symptoms of engorgement. Initial prevention of breast engorgement should remain the key priority.

Vitamin K policies and midwifery practice: questionnaire survey.

OBJECTIVES: To investigate policies on neonatal vitamin K and their implementation. DESIGN: Two phase postal survey. SETTING: United Kingdom. PARTICIPANTS: A 10% random sample of midwives registered with the United Kingdom Central Council for nursing, midwifery, and health visiting. Of 3191 midwives in the sample, 2515 (79%) responded to phase one and 2294 (72%) completed questionnaires on their current jobs (November 1998 to May 1999). In phase two, 853 (62%) of 1383 eligible midwives gave details on 2179 of their earliest jobs (start dates before 1990). RESULTS: All the midwives in clinical practice at the time of the survey (2271, 99%) reported that they were working in areas with official policies on neonatal vitamin K. Seven distinct policies were described: intramuscular vitamin K for all babies (1159, 51.0%); intramuscular vitamin K for babies at "high risk," oral for others (470, 20.7%); oral vitamin K for all babies (323, 14.2%); parental choice for all (124, 5.5%); parental choice for all except babies at high risk, (119, 5.2%); intramuscular vitamin K for babies at high risk only (33, 1.5%); oral vitamin K for babies at high risk only (17, 0.7%); and a disparate group of policies including intravenous vitamin K for some babies (26, 1.1%). Previous policies were (and some may still be) open to individual interpretation and were not always followed. CONCLUSIONS: Hospital policy is not necessarily a good guide to individual practice. The primary purpose of clinical records is to document patient care, and recording practices reflect this. There is considerable variation in vitamin K policies and midwifery practice in the United Kingdom, and there is no clear consensus on which babies should receive vitamin K intramuscularly.

Assessing the risks of pesticide residues to consumers: recent and future developments.

Assessing exposure of consumers to pesticide residues is an area of regulatory science that has rapidly developed over the last decade. From simplistic, deterministic models calculating lifetime exposure for adults only, assessment procedures have diversified so that more realistic estimates of long term exposures for adults, schoolchildren, toddlers and infants and short term exposures for adults and toddlers (who generally bound the more extreme consumer patterns) are now carried out. The final assessment of risk still remains a simplistic numeric comparison against hazard assessment based on a wide range of toxicity studies incorporating the appropriate safety or uncertainty factors. As development of risk assessments continues, the use of probabilistic models is becoming an invaluable information tool for quantitative risk management and aiding assessment of cumulative exposure. This paper examines the recent developments in risk assessment and consumer perception of the risks of pesticide residues, and speculates where the future developments in these areas may lie.