Use of cannabis in severe childhood epilepsy and child protection considerations.

The use of medical cannabis in chronic illness is increasingly investigated, yet little is known about its use in paediatric populations. As child protection clinicians are often asked to provide advice around whether parents' actions to give medical cannabis to their chronically ill child constitutes harm or risk of harm, a review of the evidence base is required. This systematic review explores the use of cannabis-derived products in children with seizure disorders. While a reduction in seizure activity was observed in some children, included studies were poorly designed and too small to extrapolate reliable conclusions about clinical use. Due to the lack of high-quality evidence, the use of cannabis-derived products is currently not recommended in children with seizure disorders. However, in assessing risk and harm to subject children by child protection physicians in Australia with existing State and Territory legislation, evaluation must occur on a case-to-case basis with each instance considered on its individual merits. Clinical trials addressing drug efficacy and long-term safety of cannabis-derived products are required.

Support for mothers, fathers and families after perinatal death.

BACKGROUND: Provision of an empathetic, sensitive, caring environment and strategies to support mothers, fathers and their families experiencing perinatal death are now an accepted part of maternity services in many countries. Interventions such as psychological support or counselling, or both, have been suggested to improve outcomes for parents and families after perinatal death. OBJECTIVES: To assess the effect of any form of intervention (i.e. medical, nursing, midwifery, social work, psychology, counselling or community-based) on parents and families who experience perinatal death. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2013) and article bibliographies. SELECTION CRITERIA: Randomised trials of any form of support aimed at encouraging acceptance of loss, bereavement counselling, or specialised psychotherapy or counselling for mothers, fathers and families experiencing perinatal death. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed eligibility of trials. MAIN RESULTS: No trials were included. AUTHORS' CONCLUSIONS: Primary healthcare interventions and a strong family and social support network are invaluable to parents and families around the time a baby dies. However, due to the lack of high-quality randomised trials conducted in this area, the true benefits of currently existing interventions aimed at providing support for mothers, fathers and families experiencing perinatal death is unclear. Further, the currently available evidence around the potential detrimental effects of some interventions (e.g. seeing and holding a deceased baby) remains inconclusive at this point in time. However, some well-designed descriptive studies have shown that, under the right circumstances and guided by compassionate, sensitive, experienced staff, parents' experiences of seeing and holding their deceased baby is often very positive. The sensitive nature of this topic and small sample sizes, make it difficult to develop rigorous clinical trials. Hence, other research designs may further inform practice in this area. Where justified, methodologically rigorous trials are needed. However, methodologically rigorous trials should be considered comparing different approaches to support.

Stillbirths: the way forward in high-income countries.

Stillbirth rates in high-income countries declined dramatically from about 1940, but this decline has slowed or stalled over recent times. The present variation in stillbirth rates across and within high-income countries indicates that further reduction in stillbirth is possible. Large disparities (linked to disadvantage such as poverty) in stillbirth rates need to be addressed by providing more educational opportunities and improving living conditions for women. Placental pathologies and infection associated with preterm birth are linked to a substantial proportion of stillbirths. The proportion of unexplained stillbirths associated with under investigation continues to impede efforts in stillbirth prevention. Overweight, obesity, and smoking are important modifiable risk factors for stillbirth, and advanced maternal age is also an increasingly prevalent risk factor. Intensified efforts are needed to ameliorate the effects of these factors on stillbirth rates. Culturally appropriate preconception care and quality antenatal care that is accessible to all women has the potential to reduce stillbirth rates in high-income countries. Implementation of national perinatal mortality audit programmes aimed at improving the quality of care could substantially reduce stillbirths. Better data on numbers and causes of stillbirth are needed, and international consensus on definition and classification related to stillbirth is a priority. All parents should be offered a thorough investigation including a high-quality autopsy and placental histopathology. Parent organisations are powerful change agents and could have an important role in raising awareness to prevent stillbirth. Future research must focus on screening and interventions to reduce antepartum stillbirth as a result of placental dysfunction. Identification of ways to reduce maternal overweight and obesity is a high priority for high-income countries.

Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis.

BACKGROUND: Stillbirth rates in high-income countries have shown little or no improvement over the past two decades. Prevention strategies that target risk factors could be important in rate reduction. This systematic review and meta-analysis was done to identify priority areas for stillbirth prevention relevant to those countries. METHODS: Population-based studies addressing risk factors for stillbirth were identified through database searches. The factors most frequently reported were identified and selected according to whether they could potentially be reduced through lifestyle or medical intervention. The numbers attributable to modifiable risk factors were calculated from data relating to the five high-income countries with the highest numbers of stillbirths and where all the data required for analysis were available. Odds ratios were calculated for selected risk factors, from which population-attributable risk (PAR) values were calculated. FINDINGS: Of 6963 studies initially identified, 96 population-based studies were included. Maternal overweight and obesity (body-mass index >25 kg/m(2)) was the highest ranking modifiable risk factor, with PARs of 8-18% across the five countries and contributing to around 8000 stillbirths (≥22 weeks' gestation) annually across all high-income countries. Advanced maternal age (>35 years) and maternal smoking yielded PARs of 7-11% and 4-7%, respectively, and each year contribute to more than 4200 and 2800 stillbirths, respectively, across all high-income countries. In disadvantaged populations maternal smoking could contribute to 20% of stillbirths. Primiparity contributes to around 15% of stillbirths. Of the pregnancy disorders, small size for gestational age and abruption are the highest PARs (23% and 15%, respectively), which highlights the notable role of placental pathology in stillbirth. Pre-existing diabetes and hypertension remain important contributors to stillbirth in such countries. INTERPRETATION: The raising of awareness and implementation of effective interventions for modifiable risk factors, such as overweight, obesity, maternal age, and smoking, are priorities for stillbirth prevention in high-income countries. FUNDING: The Stillbirth Foundation Australia, the Department of Health and Ageing, Canberra, Australia, and the Mater Foundation, Brisbane, Australia.