Effect of Automated Real-Time Feedback on Early-Sepsis Care: A Pragmatic Clinical Trial.

OBJECTIVES: To determine if a real-time monitoring system with automated clinician alerts improves 3-hour sepsis bundle adherence. DESIGN: Prospective, pragmatic clinical trial. Allocation alternated every 7 days. SETTING: Quaternary hospital from December 1, 2020 to November 30, 2021. PATIENTS: Adult emergency department or inpatients meeting objective sepsis criteria triggered an electronic medical record (EMR)-embedded best practice advisory. Enrollment occurred when clinicians acknowledged the advisory indicating they felt sepsis was likely. INTERVENTION: Real-time automated EMR monitoring identified suspected sepsis patients with incomplete bundle measures within 1-hour of completion deadlines and generated reminder pages. Clinicians responsible for intervention group patients received reminder pages; no pages were sent for controls. The primary analysis cohort was the subset of enrolled patients at risk of bundle nonadherent care that had reminder pages generated. MEASUREMENTS AND MAIN RESULTS: The primary outcome was orders for all 3-hour bundle elements within guideline time limits. Secondary outcomes included guideline-adherent delivery of all 3-hour bundle elements, 28-day mortality, antibiotic discontinuation within 48-hours, and pathogen recovery from any culture within 7 days of time-zero. Among 3,269 enrolled patients, 1,377 had reminder pages generated and were included in the primary analysis. There were 670 (48.7%) at-risk patients randomized to paging alerts and 707 (51.3%) to control. Bundle-adherent orders were placed for 198 intervention patients (29.6%) versus 149 (21.1%) controls (difference: 8.5%; 95% CI, 3.9-13.1%; p = 0.0003). Bundle-adherent care was delivered for 152 (22.7%) intervention versus 121 (17.1%) control patients (difference: 5.6%; 95% CI, 1.4-9.8%; p = 0.0095). Mortality was similar between groups (8.4% vs 8.3%), as were early antibiotic discontinuation (35.1% vs 33.4%) and pan-culture negativity (69.0% vs 68.2%). CONCLUSIONS: Real-time monitoring and paging alerts significantly increased orders for and delivery of guideline-adherent care for suspected sepsis patients at risk of 3-hour bundle nonadherence. The trial was underpowered to determine whether adherence affected mortality. Despite enrolling patients with clinically suspected sepsis, early antibiotic discontinuation and pan-culture negativity were common, highlighting challenges in identifying appropriate patients for sepsis bundle application.

Dissecting antenatal care inequalities in western Nepal: insights from a community-based cohort study.

BACKGROUND: Antenatal care (ANC) ensures continuity of care in maternal and foetal health. Understanding the quality and timing of antenatal care (ANC) is important to further progress maternal health in Nepal. This study aimed to investigate the proportion of and factors associated with, key ANC services in western Nepal. METHODS: Data from a community-based cohort study were utilized to evaluate the major ANC service outcomes: (i) three or less ANC visits (underutilization) (ii) late initiation (≥ 4 months) and (iii) suboptimal ANC (< 8 quality indicators). Mothers were recruited and interviewed within 30 days of childbirth. The outcomes and the factors associated with them were reported using frequency distribution and multiple logistic regressions, respectively. RESULTS: Only 7.5% of 735 mothers reported not attending any ANC visits. While only a quarter (23.77%) of mothers reported under-utilizing ANC, more than half of the women (55.21%) initiated ANC visits late, and one-third (33.8%) received suboptimal ANC quality. A total of seven factors were associated with the suboptimal ANC. Mothers with lower education attainment, residing in rural areas, and those who received service at home, were more likely to attain three or less ANC visits, late initiation of ANC, and report receiving suboptimal ANC. Furthermore, mothers from poor family backgrounds appeared to initiate ANC late. Mothers from disadvantaged Madhesi communities tended to receive suboptimal ANC. CONCLUSIONS: Despite a high ANC attendance, a significant proportion of mothers had initiated ANC late and received suboptimal care. There is a need to tailor ANC services to better support women from Madhesi ethnic community, as well as those with poor and less educated backgrounds to reduce the inequalities in maternal health care.

Implementation of an Electronic Alert to Improve Timeliness of Second Dose Antibiotics for Patients With Suspected Serious Infections in the Emergency Department: A Quasi-Randomized Controlled Trial.

STUDY OBJECTIVE: Delays in the second dose of antibiotics in the emergency department (ED) are associated with increased morbidity and mortality in patients with serious infections. We analyzed the influence of clinical decision support to prevent delays in second doses of broad-spectrum antibiotics in the ED. METHODS: We allocated adult patients who received cefepime or piperacillin/tazobactam in 9 EDs within an integrated health care system to an electronic alert that reminded ED clinicians to reorder antibiotics at the appropriate interval vs usual care. The primary outcome was a median delay in antibiotic administration. Secondary outcomes were rates of intensive care unit (ICU) admission, hospital mortality, and hospital length of stay. We included a post hoc secondary outcome of frequency of major delay (>25% of expected interval for second antibiotic dose). RESULTS: A total of 1,113 ED patients treated with cefepime or piperacillin/tazobactam were enrolled in the study, of whom 420 remained under ED care when their second dose was due and were included in the final analysis. The clinical decision support tool was associated with reduced antibiotic delays (median difference 35 minutes, 95% confidence interval [CI], 5 to 65). There were no differences in ICU transfers, inpatient mortality, or hospital length of stay. The clinical decision support tool was associated with decreased probability of major delay (absolute risk reduction 13%, 95% CI, 6 to 20). CONCLUSIONS: The implementation of a clinical decision support alert reminding clinicians to reorder second doses of antibiotics was associated with a reduction in the length and frequency of antibiotic delays in the ED. There was no effect on the rates of ICU transfers, inpatient mortality, or hospital length of stay.

CT utilization in evaluation of skin and soft tissue extremity infections in the ED: Retrospective cohort study.

OBJECTIVE: Skin and soft tissue infections (SSTI) are commonly diagnosed in the emergency department (ED). While most SSTI are diagnosed with patient history and physical exam alone, ED clinicians may order CT imaging when they suspect more serious or complicated infections. Patients who inject drugs are thought to be at higher risk for complications from SSTI and may undergo CT imaging more frequently. The objective of this study is to characterize CT utilization when evaluating for SSTI in ED patients particularly in patients with intravenous drug use (IVDU), the frequency of significant and actionable findings from CT imaging, and its impact on subsequent management and ED operations. METHODS: We performed a retrospective analysis of encounters involving a diagnosis of SSTI in seven EDs across an integrated health system between October 2019 and October 2021. Descriptive statistics were used to assess overall trends, compare CT utilization frequencies, actionable imaging findings, and surgical intervention between patients who inject drugs and those who do not. Multivariable logistic regression was used to analyze patient factors associated with higher likelihood of CT imaging. RESULTS: There were 4833 ED encounters with an ICD-10 diagnosis of SSTI during the study period, of which 6% involved a documented history of IVDU and 30% resulted in admission. 7% (315/4833) of patients received CT imaging, and 22% (70/315) of CTs demonstrated evidence of possible deep space or necrotizing infections. Patients with history of IVDU were more likely than patients without IVDU to receive a CT scan (18% vs 6%), have a CT scan with findings suspicious for deep-space or necrotizing infection (4% vs 1%), and undergo surgical drainage in the operating room within 48 h of arrival (5% vs 2%). Male sex, abnormal vital signs, and history of IVDU were each associated with higher likelihood of CT utilization. Encounters involving CT scans had longer median times to ED disposition than those without CT scans, regardless of whether these encounters resulted in admission (9.0 vs 5.5 h), ED observation (5.5 vs 4.1 h), or discharge (6.8 vs 2.9 h). DISCUSSION: ED clinicians ordered CT scans in 7% of encounters when evaluating for SSTI, most frequently in patients with abnormal vital signs or a history of IV drug use. Patients with a history of IVDU had higher rates of CT findings suspicious for deep space infections or necrotizing infections and higher rates of incision and drainage procedures in the OR. While CT scans significantly extended time spent in the ED for patients, this appeared justified by the high rate of actionable findings found on imaging, particularly for patients with a history of IVDU.

Exposure to dust and respiratory health among Australian miners.

PURPOSE: Occupational exposure to dust has been recognised as a significant health hazard to mine workers. This study aimed to investigate the association between exposure to inhalable (INH) and respirable (RES) dust and respiratory health among mine workers in Western Australia using an industry-wide exposure database. METHODS: The database comprised cross-sectional surveys conducted by mining companies for the period 2001-2012. The study population consisted of 12,797 workers who were monitored for exposure to INH and RES dust and undertook health assessments including a respiratory questionnaire and spirometry test. RESULTS: Despite the general trend of declining exposure to both INH and RES dust observed over the 12 years period, mine workers reported a higher prevalence of phlegm and cough when exposed to elevated concentrations of INH and RES dust. Logistic regression analysis further confirmed the positive association between INH dust exposure and the prevalence of phlegm with an adjusted odds ratio of 1.033 (95% CI 1.012-1.052). Overall, 6.3% of miners might have potential airway obstruction, and exposure to INH dust was associated with impaired lung function parameters. CONCLUSION: Exposure levels of INH and RES dust particles among mine workers have reduced considerably and were well below currently legislated occupational exposure limits. However, given the reported higher prevalence of phlegm and cough among those with elevated dust concentrations, there is a continued need for effective dust exposure monitoring and control in the mineral mining industry.

Level-loading a health system by transferring emergency department patients to a community hospital: Prospective cohort study.

BACKGROUND: Emergency department boarding and crowding lead to worse patient outcomes and patient satisfaction. OBJECTIVE: We describe the implementation of a program to transfer patients requiring medical admission from an academic emergency department to a community hospital's medical floor and analyze its effects on patient outcomes. METHODS: A prospective cohort study was performed. Data was collected on patient flow through the transfer program. Patient characteristics, boarding time in the emergency department, and hospital-based outcome measures were compared between patients in the transfer program who were successfully transferred to the community hospital and patients who were admitted to the academic medical center. RESULTS: 79 patients were successfully transferred to the community hospital between November 23, 2020 and August 5, 2021, resulting in 279 bed days in the community hospital. Successfully transferred patients experienced a statistically shorter ED boarding time (5.7 vs. 10.9 h, p < 0.0001), ED length of stay (10.5 vs 16.1 h, p < 0.0001), and hospital length of stay (3.5 vs 5.7 days, p < 0.0001) compared to patients initially referred to the transfer program who were admitted to the academic medical center. There were no reported adverse events during transfer, upgrades to the ICU within 24 h of admission, or inpatient deaths for patients who were transferred. CONCLUSION: We implemented an academic emergency department to partner community hospital transfer program that safely level-loads medical patients in a healthcare system.

COVID-19 Level-Loading: Transferring Emergency Department Patients to a Partner Academic Medical Center Within a Healthcare System.

COVID-19 continues to challenge bed capacity and the ability of hospitals to provide quality care for patients around the country. However, the COVID-19 pandemic at a given point in time does not impact all hospitals equally-even within a single healthcare system, one hospital may be caring for patients in the hallways, while another has available inpatient beds. Here, we demonstrate a program to level-load COVID-19 patients between 2 academic medical centers in a healthcare system by transferring patients at the time of admission from the emergency department of one institution directly to an inpatient bed of the other institution. Over 42 days, 50 patients were transferred which saved 432 bed-days at the home academic medical center without any adverse events during transfer or upgrades to the ICU within the first 24 hours of admission. Programs like this can expand a healthcare system's ability to allocate personnel and resources efficiently for patients and maximize the quality of care delivered even during a pandemic.

Effectiveness of a Singaporean Community-Based Physical Activity and Nutrition Intervention: A Cluster Randomized Controlled Trial.

This study examined the effectiveness of a 6-month intervention to improve the health behaviors and outcomes among women aged 50 years and older. A sample of 580 (intervention n = 295; control n = 285) women was recruited from 26 recreational centers. Only the intervention group participated in the Singapore Physical Activity (PA) and Nutrition Study (SPANS), received health resources (calendar, recipe, and booklets) and motivational support from program ambassadors. The intervention group showed significant improvements in moderate-intensity PA, vigorous-intensity PA, and total PA (P < .001), increased intake frequency of fruit and vegetables (P = .049), a reduction in salt and sugary beverage intake (P ≤ .042), and reductions in systolic blood pressure (BP; -3.68 mm Hg), diastolic BP (-3.54 mm Hg), and percentage body fat (-2.13%; P ≤ .020) when compared with the control group. The SPANS appeared to be efficacious in improving PA and dietary behaviors, reducing BP and percentage body fat among Singaporean women.

Dietary Inflammatory Index and Epithelial Ovarian Cancer in Southern Chinese Women: A Case-Control Study.

The association between inflammatory properties of diet and ovarian cancer risk has been investigated in some Western populations. However, little evidence is available from Asian women whose ovarian cancer incidence rates are low and dietary and lifestyle patterns are very different from their Western counterparts. We aimed to examine whether more pro-inflammatory diets, as indicated by higher dietary inflammatory index (DII®) scores, are associated with increased odds of epithelial ovarian cancer in southern China. A case-control study was conducted during 2006-2008 in Guangzhou, Guangdong Province. Energy-adjusted DII (E-DII) scores were calculated based on dietary intake assessed by a validated food frequency questionnaire administered to 500 incident epithelial ovarian cancer patients and 500 hospital-based controls. Logistic regression models were used to assess the relationship between E-DII scores and odds of ovarian cancer. Positive associations were observed between higher E-DII scores and ovarian cancer odds, using both continuous DII scores (odds ratio (OR) 1.87; 95% confidence interval (CI) 1.65, 2.13) and by DII tertiles (ORtertile3vs1 7.04, 95% CI: 4.70, 10.54, p for trend < 0.001). Likewise, a more pro-inflammatory diet was associated with a higher chance of serous and mucinous ovarian tumors. Our results suggest that a pro-inflammatory diet was associated with increased odds of developing epithelial ovarian cancer in southern Chinese women. The findings add to epidemiological evidence for the role of dietary inflammatory potential in ovarian cancer development.

WeChat-based intervention to support breastfeeding for Chinese mothers: protocol of a randomised controlled trial.

BACKGROUND: Exclusive breastfeeding for the first 6 months of life is the optimal way to feed infants. However, recent studies suggest that exclusive breastfeeding rates in China remain low and are well below the recommended target. There has been evidence that a lack of awareness of, or exposure to, breastfeeding information is associated with poor breastfeeding practices. WeChat, the most widely used social networking platform in China, has shown some potential to promote health behaviours. We thus hypothesised that a breastfeeding intervention program delivered via WeChat would achieve at least a 10% increase in exclusive breastfeeding prevalence at 6 months compared to the control group. METHODS: A two-arm, parallel, multicentre randomised controlled trial of 1000 pregnant women will be conducted at four maternity hospitals of Chengdu, China. Eligible women who consent to participate in the trial will be recruited at 28-30 weeks of gestation, and randomly allocated to either the intervention group (participants receive breastfeeding-related information from WeChat) or the control group (participants receive non-breastfeeding information from WeChat) using a central randomisation system on a 1:1 ratio at each participating site. The primary outcomes are exclusive breastfeeding rate and full breastfeeding rate at 6 months postpartum. All randomised participants will be included in the outcome analyses with missing data being imputed based on the best-case and worst-case scenarios. Multilevel mixed regression models will be used in the primary analyses to assess the effectiveness of intervention program on the breastfeeding rates. DISCUSSION: This trial uses the most widely used social media program as a means of delivering messages to mothers to increase exclusive breastfeeding in China. Increasing exclusive breastfeeding will contribute to meeting the health and environmental goals of the Sustainable Development Guidelines. Trial registration ClinicalTrials.gov, NCT04499404. Registered 5 August 2020-Retrospectively registered, https://clinicaltrials.gov/show/NCT04499404.

Prevalence of anemia and iron deficiency anemia in Chinese pregnant women (IRON WOMEN): a national cross-sectional survey.

BACKGROUND: The current evidence about anemia and iron deficiency anemia (IDA) during pregnancy remains elusive in China. The purpose of this study is to investigate the prevalence of anemia and IDA and their risk factors in Chinese pregnant women. METHODS: A nationwide cross-sectional survey of pregnant women was conducted during their antenatal visits. Using a multi-stage sampling method, 24 hospitals from 16 provinces across China were selected. Structured questionnaires were administered to collect information from participants and to extract clinical data from electronic medical records. Mixed-effects logistic regression models were performed to determine the risk factors associated with anemia and IDA. RESULTS: In total, 12,403 pregnant women were enrolled, including 1018 (8.2%) at the first trimester, 3487 (28.1%) at the second, and 7898 (63.7%) at the third. Overall, 19.8% of women were diagnosed with anemia and 13.9% were diagnosed with IDA. The prevalence of anemia and IDA varied among regions and increased by gestational month, peaking at the eighth gestational month (24.0% for anemia and 17.8% for IDA). Pregnant women at advanced stage of gestation, non-local residents, multiple gestations, multiparity, pre-pregnancy underweight, and those experiencing severe nausea or vomiting during pregnancy, were associated with higher risks of anemia and IDA. CONCLUSIONS: The prevalence of anemia and IDA during pregnancy are similar to those from developed countries and vary across regions in China.

Process evaluation of the 'Singapore Physical Activity and Nutrition Study'.

INTRODUCTION: The Singapore Physical Activity and Nutrition Study (SPANS) aimed to improve the physical activity (PA) and nutrition behaviours of Singaporean women aged 50 years and over. The SPANS program consisted of PA classes, nutrition workshops, telephone dietary counselling, health booklets, a health calendar and program ambassadors. This study aimed to assess and understand the implementation of the program strategies and gain insight into process evaluation components to inform future programs. METHODS: The evaluation was guided by a process evaluation framework and collected data via questionnaires (n = 209), program ambassador documentation and exit interviews with program completers (n = 13) and non-completers (n = 12). RESULTS: In total, 295 participants completed the program (response rate = 84 %). Participants reported high levels of satisfaction with the overall program (99.5 %) and program activities (96.7 %), and also rated program ambassadors highly. Participation rates were highest for telephone dietary counselling sessions. The main reason for not attending program activities was having a 'busy schedule' (n = 158). Participants cited a need for improved recreational centre facilities and increased flexibility around program delivery. CONCLUSIONS: The process evaluation showed that the program strategies were implemented as planned and were deemed suitable for supporting behaviour change among Singaporean women aged 50 years and over. The program reached and involved the majority of participants throughout the six months. The combination of practical educational resources and supportive program ambassadors were key strategies that facilitated positive PA and dietary behaviours. However, there needs to be some flexibility in the delivery of programs. The findings of this research may inform other programs in the region.

Long-term sustainability of a physical activity and nutrition intervention for rural adults with or at risk of metabolic syndrome.

OBJECTIVE: To determine longer-term (18-month) sustainability of a six-month physical activity and nutrition intervention for 50-69-year-olds with or at risk of metabolic syndrome residing in a rural Australian community. METHODS: Participants (n=151) were followed-up at 12 and 18 months post-intervention. Changes in nutrition behaviours (fat and fibre barometer); physical activity behaviours (IPAQ); anthropometry (waist-hip ratio, weight, BMI), blood pressure, blood parameters (triglycerides, glucose, LDL-, HDL-, non-HDL, total-cholesterol) were analysed using t-tests and repeated measures ANOVA. RESULTS: Across three time points (6, 12 and 18 months) marginal decrease was observed for waist circumference (p=0.001), a modest increase was observed for diastolic blood pressure (p=0.010) and other outcome measures remained stable. CONCLUSION: Maintenance and ongoing improvement of health behaviours in the longer-term is challenging. Future studies must look for ways to embed interventions into communities so they are sustainable and investigate new approaches to reduce the risk of chronic disease. Implications for public health: Metabolic syndrome is a major health issue in Australia and worldwide. Early identification and management are required to prevent the progression to chronic disease. This 18-month follow-up showed that outcomes measures remained relatively stable; however, there is a need to investigate opportunities for embedded community interventions to support long-term health behaviour change.

Validity of the International Physical Activity Questionnaire-Short Form for Application in Asian Countries: A Study in Vietnam.

This is the first study in the Asia-Pacific region to examine the criterion validity of the self-reported International Physical Activity Questionnaire-Short form (IPAQ-SF) using accelerometers, in terms of achieving the World Health Organization's (WHO) recommended physical activity guidelines for health benefits. Vietnamese adults aged 40-65 years (n = 240) wore an ActiGraph GT3X+ accelerometer for at least 5 days and completed the Vietnamese version of the IPAQ-SF. Correlations between IPAQ-SF and accelerometer-measured physical activity intensities varied from .087 to .232. Mean difference in moderate-vigorous physical activity was 0.699 min/day (95% limits: [-107, 109]). Agreement on the classification of achieving the WHO's physical activity guidelines was 69.16%. The IPAQ-SF identified 71.86% of adults who met the guidelines, whereas 56.09% of those not meeting the guidelines were classified correctly. The IPAQ-SF was found to have acceptable criterion validity and is a useful instrument to classify Vietnamese adults as achieving or not achieving the WHO's physical activity guidelines for health benefits.

Physical activity and sedentary behaviour during pregnancy are associated with gestational weight gain in Vietnamese women.

BACKGROUND AND OBJECTIVES: Gestational weight gain is known to impact maternal and child health outcomes. Energy intake and energy expenditure are major components of clinical nutrition in relation to weight gain during pregnancy. The study was to determine the association of physical activity and sitting time during pregnancy with gestational weight gain in Vietnamese women. METHODS AND STUDY DESIGN: A multicentre prospective cohort study was conducted in Vietnam from 2015 to 2017. A total of 1873 women with a singleton pregnancy were included. Physical activity and sitting exposures during pregnancy were determined using an interviewer-administered validated questionnaire. Multiple regression analysis was performed to assess physical activity and sitting time in relation to gestational weight gain, adjusting for the confounding effects of maternal characteristics and total energy intake during pregnancy. RESULTS: The mean weight gain was 12.9 (Standard deviation 4.1) kg throughout pregnancy. Pregnant women with prolonged sitting time gained an average of 0.6 kg more weight (p=0.016 for highest versus lowest tertiles). Conversely, women who were physically active, in terms of having higher tertiles of total physical activity, moderate-to-vigorous-intensity, household/ caregiving activities, and occupational physical activity, experienced significantly less gestational weight gain (p<0.05 for highest versus lowest tertiles). CONCLUSIONS: Inverse associations were found between gestational weight gain and physical activity (i.e. intensities and several domains), whereas gestational weight gain tended to increase with longer sitting time. Therefore, being physically active and less sedentary is important to regulate weight gain during pregnancy.

Postpartum Physical Activity and Weight Retention within One Year: A Prospective Cohort Study in Vietnam.

After delivery, mothers are encouraged to increase physical activity (PA) gradually to regulate body weight; however, data on PA in relation to postpartum weight retention remains scarce, particularly among Asian women. In a cohort of 1617 Vietnamese mothers, we investigated the prospective association between habitual PA exposures at 3-month postpartum and weight retention at 6-month and 12-month postpartum. Detailed information on PA intensity and domains was collected from participants using a validated instrument specifically for Vietnamese women. Linear regression analyses and a general linear model for the repeated weight retention measures were used to ascertain the apparent relationships. On average, the participants reported 3.6 (SD 3.9) and 2.6 (SD 3.8) kg weight loss at 6- and 12-month postpartum, respectively. Total and light-intensity PA were inversely associated with the postpartum weight retention (p for trend <0.05). Our findings highlight the importance of resuming PA in the early postpartum period as an appropriate weight management strategy.

Prelacteal and early formula feeding increase risk of infant hospitalisation: a prospective cohort study.

OBJECTIVE: To ascertain the relationship between prelacteal feeding, early formula feeding and adverse health outcomes, especially hospitalisation during the first year of life. DESIGN: Multicentre prospective cohort study. SETTING: Six hospitals across three cities in Vietnam. PATIENTS: A total of 2030 pregnant women were recruited at 24-28 weeks of gestation and followed up at hospital discharge, 1, 3, 6 and 12 months post partum. MAIN OUTCOME MEASURES: Rates of infant hospitalisation, diarrhoea and lower respiratory tract infection during the first 12 months. RESULTS: For the final complete sample (n=1709, 84%), about one-quarter of the infants experienced diarrhoea (25.5%) or were admitted to hospital with at least one episode (24.8%), and almost half (47.6%) the cohort contracted lower respiratory tract infection by 12 months. The prevalence of prelacteal feeding was high (56.5%) while formula feeding was common (79.5%) before hospital discharge, both of which increased the risks of adverse health outcomes particularly hospitalisation by approximately 1.5-fold, with adjusted OR (95% CI) 1.43 (1.09 to 1.88) and 1.48 (1.07 to 2.05), respectively for these infants by 12 months, when compared with others who were exclusively breast fed. CONCLUSIONS: Prelacteal feeding and early formula feeding before hospital discharge are associated with higher risks of infection and hospital admission in Vietnamese infants. Support for exclusive breast feeding should be provided to mothers to avoid the adverse consequences of giving formula milk and prelateal foods.