Sudden Unexpected Death in Infancy [SUDI]: What the clinician, pathologist, coroner and researchers want to know.

The loss of an apparently healthy infant is confronting for any family, puzzling for a clinician and challenging for the pathologist charged with the task of demonstrating a cause for death. The term "cot death" evolved to "sudden infant death syndrome" [SIDS] and now "sudden unexpected death in infancy [SUDI]" as the epidemiology and pathology of infant death changed. Community interventions were successful in changing sleep practices for young babies. The current research focus is on understanding genetic predispositions to unexpected death in early childhood. Whilst much has been achieved in reducing the infant mortality rate from SUDI by between 50%, and 80% in some countries, over the last 30 years, there remain challenges for improving rates of accurate diagnosis and reaching out to more vulnerable families with clearly modifiable risk factors for SUDI. These challenges directly involve the clinician through taking a systematic and detailed history and better standardised death scene evaluations with specifically accredited assessors. Better knowledge regarding circumstances of SUDI cases will help Coroners and researchers provide answers for grieving families now, and in the future contribute to further reductions in the rate of SUDI in communities across the world.

Genetic dissection of a Leishmania flagellar proteome demonstrates requirement for directional motility in sand fly infections.

The protozoan parasite Leishmania possesses a single flagellum, which is remodelled during the parasite's life cycle from a long motile flagellum in promastigote forms in the sand fly to a short immotile flagellum in amastigotes residing in mammalian phagocytes. This study examined the protein composition and in vivo function of the promastigote flagellum. Protein mass spectrometry and label free protein enrichment testing of isolated flagella and deflagellated cell bodies defined a flagellar proteome for L. mexicana promastigote forms (available via ProteomeXchange with identifier PXD011057). This information was used to generate a CRISPR-Cas9 knockout library of 100 mutants to screen for flagellar defects. This first large-scale knockout screen in a Leishmania sp. identified 56 mutants with altered swimming speed (52 reduced and 4 increased) and defined distinct mutant categories (faster swimmers, slower swimmers, slow uncoordinated swimmers and paralysed cells, including aflagellate promastigotes and cells with curled flagella and disruptions of the paraflagellar rod). Each mutant was tagged with a unique 17-nt barcode, providing a simple barcode sequencing (bar-seq) method for measuring the relative fitness of L. mexicana mutants in vivo. In mixed infections of the permissive sand fly vector Lutzomyia longipalpis, paralysed promastigotes and uncoordinated swimmers were severely diminished in the fly after defecation of the bloodmeal. Subsequent examination of flies infected with a single paralysed mutant lacking the central pair protein PF16 or an uncoordinated swimmer lacking the axonemal protein MBO2 showed that these promastigotes did not reach anterior regions of the fly alimentary tract. These data show that L. mexicana need directional motility for successful colonisation of sand flies.

Model Development for Fat Mass Assessment Using Near-Infrared Reflectance in South African Infants and Young Children Aged 3-24 Months.

Undernutrition in infants and young children is a major problem leading to millions of deaths every year. The objective of this study was to provide a new model for body composition assessment using near-infrared reflectance (NIR) to help correctly identify low body fat in infants and young children. Eligibility included infants and young children from 3-24 months of age. Fat mass values were collected from dual-energy x-ray absorptiometry (DXA), deuterium dilution (DD) and skin fold thickness (SFT) measurements, which were then compared to NIR predicted values. Anthropometric measures were also obtained. We developed a model using NIR to predict fat mass and validated it against a multi compartment model. One hundred and sixty-four infants and young children were included. The evaluation of the NIR model against the multi compartment reference method achieved an r value of 0.885, 0.904, and 0.818 for age groups 3-24 months (all subjects), 0-6 months, and 7-24 months, respectively. Compared with conventional methods such as SFT, body mass index and anthropometry, performance was best with NIR. NIR offers an affordable and portable way to measure fat mass in South African infants for growth monitoring in low-middle income settings.

Early-Onset Neonatal Sepsis and Antibiotic Use in Northeast Thailand.

OBJECTIVE: Antibiotics are commonly prescribed in neonatal intensive care units (NICUs) for suspected sepsis because of the nonspecific clinical symptoms of sepsis. The overuse of antibiotic is associated with adverse outcomes. This study aimed to determine the rate of early-onset sepsis (EOS) and antibiotic use in neonates admitted to three NICUs in Northeast Thailand STUDY DESIGN: This is a descriptive study using the data collected in the South East Asia-Using Research for Change in Hospital-acquired Infection in Neonates project. Neonates admitted within 3 days of life were included. EOS was defined as neonates who presented with three or more clinical signs or laboratory results suggested sepsis and received antibiotics for at least 5 days. Those with positive blood culture were culture-proven EOS. Antibiotic use within 3 days of life and up to 28 days was described. RESULTS: Among 1,897 neonates, 160 cases were classified as EOS (8.4%) with culture-proven EOS in 4 cases (0.2%). The median durations of antibiotic use in culture-proven and culture-negative EOSs were 15 and 8 days, respectively. CONCLUSION: The rate of culture-proven EOS was low, but there was a high rate of antibiotic use. Antibiotic stewardship should be emphasized.

Infant pacifiers for reduction in risk of sudden infant death syndrome.

BACKGROUND: Sudden infant death syndrome (SIDS) has been most recently defined as the sudden unexpected death of an infant less than one year of age, with onset of the fatal episode apparently occurring during sleep, that remains unexplained after a thorough investigation, including the performance of a complete autopsy and a review of the circumstances of death and clinical history. Despite the success of several prevention campaigns, SIDS remains a leading cause of infant mortality. In 1994, a 'triple risk model' for SIDS was proposed that described SIDS as an event that results from the intersection of three factors: a vulnerable infant; a critical development period in homeostatic control (age related); and an exogenous stressor. The association between pacifier (dummy) use and reduced incidence of SIDS has been shown in epidemiological studies since the early 1990s. Pacifier use, given its low cost, might be a cost-effective intervention for SIDS prevention if it is confirmed effective in randomised controlled trials. OBJECTIVES: To determine whether the use of pacifiers during sleep versus no pacifier during sleep reduces the risk of SIDS. SEARCH METHODS: We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 2), MEDLINE via PubMed, Embase, and CINAHL to 16 March 2016. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA: Published and unpublished controlled trials using random and quasi-random allocations of infants born at term and at preterm (less than 37 weeks' gestation) or with low birth weight (< 2500 g). Infants must have been randomised by one month' postmenstrual age. We planned to include studies reported only by abstracts, and cluster and cross-over randomised trials. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed studies from searches. We found no eligible studies. MAIN RESULTS: We identified no randomised controlled trials examining infant pacifiers for reduction in risk of SIDS. AUTHORS' CONCLUSIONS: We found no randomised control trial evidence on which to support or refute the use of pacifiers for the prevention of SIDS.

Pediatric hospital admissions in Indigenous children: a population-based study in remote Australia.

BACKGROUND: We analysed hospital admissions of a predominantly Aboriginal cohort of children in the remote Fitzroy Valley in Western Australia during the first 7 years of life. METHODS: All children born between January 1, 2002 and December 31, 2003 and living in the Fitzroy Valley in 2009-2010 were eligible to participate in the Lililwan Project. Of 134 eligible children, 127 (95%) completed Stage 1 (interviews of caregivers and medical record review) in 2011 and comprised our cohort. Lifetime (0-7 years) hospital admission data were available and included the dates, and reasons for admission, and comorbidities. Conditions were coded using ICD-10-AM discharge codes. RESULTS: Of the 127 children, 95.3% were Indigenous and 52.8% male. There were 314 admissions for 424 conditions in 89 (70.0%) of 127 children. The 89 children admitted had a median of five admissions (range 1-12). Hospitalization rates were similar for both genders (p = 0.4). Of the admissions, 108 (38.6%) were for 56 infants aged <12 months (median = 2.5, range = 1-8). Twelve of these admissions were in neonates (aged 0-28 days). Primary reasons for admission (0-7 years) were infections of the lower respiratory tract (27.4%), gastrointestinal system (22.7%), and upper respiratory tract (11.4%), injury (7.0%), and failure to thrive (5.4%). Comorbidities, particularly upper respiratory tract infections (18.1%), failure to thrive (13.6%), and anaemia (12.7%), were common. In infancy, primary cause for admission were infections of the lower respiratory tract (40.8%), gastrointestinal (25.9%) and upper respiratory tract (9.3%). Comorbidities included upper respiratory tract infections (33.3%), failure to thrive (18.5%) and anaemia (18.5%). CONCLUSION: In the Fitzroy Valley 70.0% of children were hospitalised at least once before age 7 years and over one third of admissions were in infants. Infections were the most common reason for admission in all age groups but comorbidities were common and may contribute to need for admission. Many hospitalizations were feasibly preventable. High admission rates reflect disadvantage, remote location and limited access to primary healthcare and outpatient services. Ongoing public health prevention initiatives including breast feeding, vaccination, healthy diet, hygiene and housing improvements are crucial, as is training of Aboriginal Health Workers to increase services in remote communities.

Sudden unexplained early neonatal death or collapse: a national surveillance study.

BACKGROUND: The incidence of sudden unexpected early neonatal death (SUEND) or acute life-threatening events (ALTEs) is reported as 0.05/1,000 to 0.38/1,000 live births. There is currently no national system in Australia for reporting and investigating such cases. METHODS: A 3-y prospective, national surveillance study, run in collaboration with the Australian Pediatric Surveillance Unit (APSU). Data were provided by pediatricians reporting to APSU; and independently ascertained by the Coroner in two states (NSW and QLD) and the Newborn Early Transport Network in NSW. A detailed deidentified questionnaire was created. RESULTS: In NSW and QLD, the incidence was 0.1 and 0.08/1,000 live births, respectively. Forty-eight definitive cases were identified. Common causes included accidental asphyxia, cardiac disease, persistent pulmonary hypertension of the newborn, and sudden infant death syndrome. Twenty-six babies collapsed on day 1 and 19 were found on the carer's chest. CONCLUSION: The incidence in NSW and QLD is higher than previously published. The first postnatal day is a vulnerable period for newborns, who require close observation particularly during skin-to-skin contact. Development and implementation of guidelines for safe sleeping in hospital are needed. Collaboration between obstetricians, midwives, and pediatricians is essential to ensure safety of the newborn.

Placental inflammation is associated with rural and remote residence in the Northern Territory, Australia: a cross-sectional study.

BACKGROUND: The Northern Territory has the highest rates of perinatal morbidity and mortality in Australia. Placental histopathology has not been studied in this high-risk group of women. METHODS: This is the first study to detail the placental pathology in Indigenous women and to compare the findings with non-Indigenous women in the Northern Territory. There were a total of 269 deliveries during a three-month period from the 27(th) of June to the 27(th) of August 2009. Seventy-one (71%) percent of all placentas were examined macroscopically, sectioned then reviewed by a Perinatal Pathologist, blinded to the maternal history and outcomes. RESULTS: Indigenous women were found to have higher rates of histologically confirmed chorioamnionitis and or a fetal inflammatory response compared with non-Indigenous women (46% versus 26%; OR 2.4, 95% CI 1.3-4.5). In contrast, non-Indigenous women were twice as likely to show vascular related pathology (31% versus 14%; OR 2.77, 95% CI 1.3-5.9). Indigenous women had significantly higher rates of potentially modifiable risk factors for placental inflammation including genitourinary infections, anaemia and smoking. After adjusting for confounders, histological chorioamnionitis and fetal inflammatory response was significantly associated with rural or remote residence (Adjusted OR 2.5, 95% CI 1.08 - 5.8). CONCLUSION: This study has revealed a complex aetiology underlying a high prevalence of placental inflammation in the Northern Territory. Placental inflammation is associated with rural and remote residence, which may represent greater impact of systemic disadvantage, particularly affecting Indigenous women in the Northern Territory.

Non-nutritive sucking for gastro-oesophageal reflux disease in preterm and low birth weight infants.

BACKGROUND: Gastro-oesophageal reflux (GOR) is commonly diagnosed in the neonatal population (DiPietro 1994), and generally causes few or no symptoms (Vandenplas 2009). Conversely, gastro-oesophageal reflux disease (GORD) refers to GOR that causes troublesome symptoms with or without complications such as damage to the oesophagus (Vandenplas 2009). Currently there is no evidence to support the range of measures recommended to help alleviate acid reflux experienced by infants. Non-nutritive sucking (NNS) has been used as an intervention to modulate neonatal state behaviours through its pacifying effects such as decrease infant fussiness and crying during feeds (Boiron 2007; Pickler 2004). OBJECTIVES: To determine if NNS reduces GORD in preterm infants (less than 37 weeks' gestation) and low birth weight (less than 2500 g) infants, three months of age and less, with signs or symptoms suggestive of GORD, or infants with a diagnosis of GORD. SEARCH METHODS: We performed computerised searches of the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 9, 2013), MEDLINE (1966 to September 2013), CINAHL (1982 to September 2013), and EMBASE (1988 to September 2013). We applied no language restrictions. SELECTION CRITERIA: Controlled trials using random or quasi-random allocation of preterm infants (less than 37 weeks' gestation) and low birth weight (less than 2500 g) infants three months of age and less with signs or symptoms suggestive of GORD, or infants with a diagnosis of GORD. We included studies reported only by abstracts, and cluster and cross-over randomised trials. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed and selected trials from searches, assessed and rated study quality and extracted relevant data. We identified two studies from the initial search. After further review, we excluded both studies. MAIN RESULTS: We identified no studies examining the effects of NNS for GORD in preterm and low birth weight infants AUTHORS' CONCLUSIONS: There was insufficient evidence to determine the effectiveness of NNS for GORD. Adequately powered RCTs on the effect of NNS in preterm and low birth weight infants diagnosed with GORD are required.

Customised versus population-based growth charts as a screening tool for detecting small for gestational age infants in low-risk pregnant women.

BACKGROUND: Fetal growth restriction is defined as failure to reach growth potential and considered one of the major complications of pregnancy. These infants are often, although not universally, small for gestational age (SGA). SGA is defined as a weight less than a specified percentile (usually the 10th percentile). Identification of SGA infants is important because these infants are at increased risk of perinatal morbidity and mortality. Screening for SGA is a challenge for all maternity care providers and current methods of clinical assessment fail to detect many infants who are SGA. Large observational studies suggest that customised growth charts may be better able to differentiate between constitutional and pathologic smallness. Customised charts adjust for physiological variables such as maternal weight and height, ethnicity and parity. OBJECTIVES: To assess the benefits and harms of using population-based growth charts compared with customised growth charts as a screening tool for detection of fetal growth in pregnant women. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (12 March 2014), reviewed published guidelines and searched the reference lists of review articles. SELECTION CRITERIA: Randomised, quasi-randomised or cluster-randomised clinical trials comparing customised versus population-based growth charts used as a screening tool for detection of fetal growth in pregnant women. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion. MAIN RESULTS: No randomised trials met the inclusion criteria. AUTHORS' CONCLUSIONS: There is no randomised trial evidence currently available. Further randomised trials are required to accurately assess whether the improvement in detection shown is secondary to customised charts alone or an effect of the policy change. Future research in large trials is needed to investigate the benefits and harms (including perinatal mortality) of using customised growth charts in different settings and for both fundal height and ultrasound measurements.

Customized versus population-based birth weight charts for the detection of neonatal growth and perinatal morbidity in a cross-sectional study of term neonates.

Customized birth weight charts that incorporate maternal characteristics are now being adopted into clinical practice. However, there is controversy surrounding the value of these charts in the prediction of growth and perinatal outcomes. The objective of this study was to assess the use of customized charts in predicting growth, defined by body fat percentage, and perinatal morbidity. A total of 581 term (≥37 weeks' gestation) neonates born in Sydney, Australia, in 2010 were included. Body fat percentage measurements were taken by using air displacement plethysmography. Objective composite measurements of perinatal morbidity were used to identify neonates who had poor outcomes; these data were extracted from medical records. The value of customized charts was assessed by calculating positive predictive values, negative predictive values, and odds ratios with 95% confidence intervals. Customized versus population-based charts did not improve the prediction of either low body fat percentage (59% vs. 66% positive predictive value and 87% vs. 89% negative predictive value, respectively) or high body fat percentage (48% vs. 53% positive predictive value and 90% vs. 89% negative predictive value, respectively). Customized charts were not better than population-based charts at predicting perinatal morbidity (for customized charts, odds ratio = 1.02, 95% confidence interval: 1.01, 1.04; for population-based charts, odds ratio = 1.03, 95% confidence interval: 1.01, 1.05) per percentile decrease in birth weight. Customized birth weight charts do not provide significant improvements over population-based charts in predicting neonatal growth and morbidity.

Is body fat percentage a better measure of undernutrition in newborns than birth weight percentiles?

BACKGROUND: Undernutrition in neonates increases the risk of serious morbidities. The objective of this study was to describe neonatal morbidity associated with low body fat percentage (BF%) and measure the number of undernourished neonates defined by BF% and compare this with birth weight percentiles (<10th). METHODS: Eligibility included term (≥37 wk) neonates. BF% measurements were undertaken by air displacement plethysmography. Data on neonatal outcomes were extracted from medical records and used to develop a measure of neonatal morbidity. We assessed the association between neonatal morbidity and population-based birth weight percentiles compared with the BF% measurements. RESULTS: Five hundred and eighty-one neonates were included. Low BF% was defined by 1 SD below the mean and identified in 73 per 1,000 live births. Neonatal morbidity was found in 3.4% of neonates. Birth weight percentile was associated with neonatal morbidity (odds ratio (OR): 1.03 (95% confidence interval (CI): 1.01, 1.05); P = <0.001). BF% was associated with a higher risk of neonatal morbidity (OR: 1.30 (95% CI: 1.15, 1.47); P = <0.001). CONCLUSION: In this population, measuring BF% is more closely associated with identification of neonates at risk of neonatal morbidity as compared with birth weight percentiles. BF% measurements could assist with identifying neonates who are appropriately grown yet undernourished and exclude small neonates not at risk.

Risk factors for antepartum stillbirth and the influence of maternal age in New South Wales Australia: a population based study.

BACKGROUND: Maternal age is a known risk factor for stillbirth and delayed childbearing is a societal norm in developed country settings. The timing and reasons for age being a risk factor are less clear. This study aimed to document the gestational specific risk of maternal age throughout pregnancy and whether the underlying causes of stillbirth differ for older women. METHODS: Using linkage of state maternity and perinatal death data collections the authors assessed risk factors for antepartum stillbirth in New South Wales Australia for births between 2002 - 2006 (n = 327,690) using a Cox proportional hazards model. Gestational age specific risk was calculated for different maternal age groups. Deaths were classified according to the Perinatal Mortality Classifications of the Perinatal Society of Australia and New Zealand. RESULTS: Maternal age was a significant independent risk factor for antepartum stillbirth (35 - 39 years HR 1.4 95% CI 1.12 - 1.75; ≥ 40 years HR 2.41 95% CI 1.8 - 3.23). Other significant risk factors were smoking HR 1.82 (95% CI 1.56 -2.12) nulliparity HR 1.23 (95% CI 1.08 - 1.40), pre-existing hypertension HR 2.77 (95% CI 1.94 - 3.97) and pre-existing diabetes HR 2.65 (95% CI 1.63 - 4.32). For women aged 40 or over the risk of antepartum stillbirth beyond 40 weeks was 1 in 455 ongoing pregnancies compared with 1 in 1177 ongoing pregnancies for those under 40. This risk was increased in nulliparous women to 1 in 247 ongoing pregnancies. Unexplained stillbirths were the most common classification for all women, stillbirths classified as perinatal infection were more common in the women aged 40 or above. CONCLUSIONS: Women aged 35 or older in a first pregnancy should be counselled regarding stillbirth risk at the end of pregnancy to assist with informed decision making regarding delivery. For women aged 40 or older in their first pregnancy it would be reasonable to offer induction of labour by 40 weeks gestation.

Neonatal length inaccuracies in clinical practice and related percentile discrepancies detected by a simple length-board.

AIM: The study aims to assess accuracy of standard practice measurement of neonatal length compared with a gold-standard length-board technique. METHODS: Data were obtained from a population-based, cross-sectional study of 602 term babies at Royal Prince Alfred Hospital, Sydney, Australia, in 2010. Neonatal length was measured by standard clinical practice and by a length-board (gold standard) and measurements compared. Standard growth curve percentiles were used to plot length measurements. The Bland and Altman method was used to assess agreement, and acceptable levels of agreement were set at ≤1 cm and ≤0.5 cm. RESULTS: The limits of agreement were between -3.06 cm (95% CI -3.08 to -3.04) and 2.67 cm (95% CI 2.65 to 2.69). Neonates whose standard-practice length fell within 0.5 cm of the gold standard totalled 41% (241 neonates), while 59% (342) were >0.5 cm. The change in length resulted in a change in the percentile range of 53% (309) on a standard growth curve percentile. When examining neonates whose length was plotted at the extremes of percentile regions, the positive predictive value results of the standard practice compared with the gold standard were poor, with positive predictive values of 37.5%, 57.1% and 31.3% for neonates who were measured as <3rd, <10th and ≥90th percentile, respectively. CONCLUSIONS: In current clinical practice, measures of neonatal length are often inaccurate, which has implications for potentially erroneous clinical care. Health-care providers should be educated on the importance of length and trained in how to measure length with the correct technique using a length-board.

Audit of a clinical guideline for neonatal hypoglycaemia screening.

AIM: This study aims to evaluate adherence to a clinical guideline for screening and prevention of neonatal hypoglycaemia on the post-natal wards. METHODS: Retrospective chart review of 581 healthy term neonates born at a tertiary maternity hospital. Indications for hypoglycaemia screening included small for gestational age (SGA), infants of diabetic mothers (IDM; gestational, Type 1 or 2), symptomatic hypoglycaemia, macrosomia and wasted (undernourished) appearance. Outcomes were protocol entry and adherence with hypoglycaemia prevention strategies including early and frequent feeding and timely blood glucose measurement. RESULTS: Of 115 neonates screened for hypoglycaemia, 67 were IDM, 19 were SGA (including two both IDM and SGA), and two were macrosomic. One IDM and one SGA were not screened. Twenty-two neonates were screened for a reason not identifiable from the medical record, and 13 neonates were SGA by a definition different to the guideline definition, including five who were also IDM. Guideline adherence was variable. Few neonates (41 of 106, 39%) were fed in the first post-natal hour, and blood glucose measurement occurred later than recommended for 41 of 106 (39%) of neonates. CONCLUSIONS: Most IDM and SGA neonates were screened. While guideline adherence overall was comparable with other studies, neonates were fed late. We recommend staff education about benefits of early (within the first hour) frequent breastfeeding for neonates at risk.

Health services for aboriginal and Torres Strait Islander children in remote Australia: A scoping review.

In Australia, there is a significant gap between health outcomes in Indigenous and non-Indigenous children, which may relate to inequity in health service provision, particularly in remote areas. The aim was to conduct a scoping review to identify publications in the academic and grey literature and describe 1) Existing health services for Indigenous children in remote Australia and service use, 2) Workforce challenges in remote settings, 3) Characteristics of an effective health service, and 4) Models of care and solutions. Electronic databases of medical/health literature were searched (Jan 1990 to May 2021). Grey literature was identified through investigation of websites, including of local, state and national health departments. Identified papers (n = 1775) were screened and duplicates removed. Information was extracted and summarised from 116 papers that met review inclusion criteria (70 from electronic medical databases and 45 from the grey literature). This review identified that existing services struggle to meet demand. Barriers to effective child health service delivery in remote Australia include availability of trained staff, limited services, and difficult access. Aboriginal and Community Controlled Health Organisations are effective and should receive increased support including increased training and remuneration for Aboriginal Health Workers. Continuous quality assessment of existing and future programs will improve quality; as will measures that reflect aboriginal ways of knowing and being, that go beyond traditional Key Performance Indicators. Best practice models for service delivery have community leadership and collaboration. Increased resources with a focus on primary prevention and health promotion are essential.

Positional circulatory control in the sleeping infant and toddler: role of the inner ear and arterial pulse pressure.

Heart rate (HR) and arterial blood pressure (BP) are rapidly and reflexively adjusted as body position and the force/direction of gravity alters. Anomalies in these mechanisms may predispose to circulatory failure during sleep. We analysed the development of two key reflexes involved by undertaking a longitudinal (birth­1 year) comparison of instantaneous HR and BP changes evoked by abrupt upright, sideways or horizontal repositioning. Each manoeuvre triggered an identical rise in HR (tachycardia) followed by a slower rise in diastolic blood pressure (DBP)/systolic blood pressure (SBP) and variable pulse pressure (PP) change. We show that tachycardia is triggered by acceleration (vestibular) sensors located in the inner ear and slight changes in the pulsatile component of BP then signal to the arterial baroreceptors to reinforce or oppose these actions as needed. We also identified a PP anomaly in sleeping 1-year-olds of smokers that prematurely slows HR and is associated with mild positional hypotension. We conclude that positional circulatory compensation is initiated pre-emptively in a feed-forward manner and that feedback changes in vago-sympathetic drive to the heart (and perhaps blood vessels) by PP exert a slower but powerful modulating effect. An anomaly in either or both mechanisms may weaken positional compensation in some sleeping infants.

Consequences of gestational diabetes in an urban hospital in Viet Nam: a prospective cohort study.

BACKGROUND: Gestational diabetes mellitus (GDM) is increasing and is a risk for type 2 diabetes. Evidence supporting screening comes mostly from high-income countries. We aimed to determine prevalence and outcomes in urban Viet Nam. We compared the proposed International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criterion, requiring one positive value on the 75-g glucose tolerance test, to the 2010 American Diabetes Association (ADA) criterion, requiring two positive values. METHODS AND FINDINGS: We conducted a prospective cohort study in Ho Chi Minh City, Viet Nam. Study participants were 2,772 women undergoing routine prenatal care who underwent a 75-g glucose tolerance test and interview around 28 (range 24-32) wk. GDM diagnosed by the ADA criterion was treated by local protocol. Women with GDM by the IADPSG criterion but not the ADA criterion were termed "borderline" and received standard care. 2,702 women (97.5% of cohort) were followed until discharge after delivery. GDM was diagnosed in 164 participants (6.1%) by the ADA criterion, 550 (20.3%) by the IADPSG criterion. Mean body mass index was 20.45 kg/m(2) in women with out GDM, 21.10 in women with borderline GDM, and 21.81 in women with GDM, p<0.001. Women with GDM and borderline GDM were more likely to deliver preterm, with adjusted odds ratios (aORs) of 1.49 (95% CI 1.16-1.91) and 1.52 (1.03-2.24), respectively. They were more likely to have clinical neonatal hypoglycaemia, aORs of 4.94 (3.41-7.14) and 3.34 (1.41-7.89), respectively. For large for gestational age, the aORs were 1.16 (0.93-1.45) and 1.31 (0.96-1.79), respectively. There was no significant difference in large for gestational age, death, severe birth trauma, or maternal morbidity between the groups. Women with GDM underwent more labour inductions, aOR 1.51 (1.08-2.11). CONCLUSIONS: Choice of criterion greatly affects GDM prevalence in Viet Nam. Women with GDM by the IADPSG criterion were at risk of preterm delivery and neonatal hypoglycaemia, although this criterion resulted in 20% of pregnant women being positive for GDM. The ability to cope with such a large number of cases and prevent associated adverse outcomes needs to be demonstrated before recommending widespread screening. Please see later in the article for the Editors' Summary.

Women with gestational diabetes in Vietnam: a qualitative study to determine attitudes and health behaviours.

BACKGROUND: Diabetes is increasing in prevalence globally, notably amongst populations from low- and middle- income countries. Gestational Diabetes Mellitus(GDM), a precursor for type 2 diabetes, is increasing in line with this trend. Few studies have considered the personal and social effects of GDM on women living in low and middle-income countries. The aim of this study was determine attitudes and health behaviours of pregnant women with GDM in Vietnam. METHODS: This was a qualitative study using focus group methodology conducted in Ho Chi Minh City. Pregnant women, aged over 18 years, with GDM were eligible to participate. Women were purposely sampled to obtain a range of gestational ages and severity of disease. They were invited to attend a 1-hour focus group. Questions were semi structured around six themes. Focus groups were recorded, transcribed, translated and cross-referenced. Non-verbal and group interactions were recorded. Thematic analysis was performed using a theoretical framework approach. RESULTS: From December 2010 to February 2011, four focus groups were conducted involving 34 women. Median age was 31.5 years (range 23 to 44), median BMI 21.8 kg/m(2). Women felt confusion, anxiety and guilt about GDM. Many perceived their baby to be at increased risk of death. Advice to reduce dietary starch was confusing. Women reported being 'hungry' or 'starving' most of the time, unaware of appropriate food substitutions. They were concerned about transmission of GDM through breast milk. Several women planned not to breastfeed. All felt they needed more information. Current sources of information included friends, magazines, a health phone line or the Internet. Women felt small group sessions and information leaflets could benefit them. CONCLUSIONS: This study highlights the need for culturally appropriate clinical education and health promotion activities for women with GDM in Vietnam.