The impact of the Covid-19 pandemic on postnatal anxiety and posttraumatic stress: Analysis of two population-based national maternity surveys in England.

BACKGROUND: Few studies have evaluated postnatal anxiety and posttraumatic stress (PTS) before and during the Covid-19 pandemic using comparable data across time. We used data from two national maternity surveys in England to explore the impact of the pandemic on prevalence and risk factors for postnatal anxiety and PTS. METHODS: Analysis was conducted using population-based surveys carried out in 2018 (n = 4509) and 2020 (n = 4611). Weighted prevalence estimates for postnatal anxiety and PTS were compared across surveys. Adjusted risk ratios (aRR) were estimated for the association between risk factors and postnatal anxiety and PTS. FINDINGS: Prevalence of postnatal anxiety increased from 13.7 % in 2018 to 15.1 % in 2020 (+1.4 %(95%CI:-0.4-3.1)). Prevalence of postnatal PTS increased from 9.7 % in 2018 to 11.5 % in 2020 (+1.8 %(95%CI:0.3-3.4)), due to an increase in PTS related to birth trauma from 2.5 % to 4.3 % (+1.8 %(95%CI:0.9-2.6); there was no increase in PTS related to non-birth trauma. Younger age (aRR = 1.31-1.51), being born in the UK (aRR = 1.29-1.59), long-term physical or mental health problem(s) (aRR = 1.27-1.94), and antenatal anxiety (aRR = 1.97-2.22) were associated with increased risk of postnatal anxiety and PTS before and during the pandemic, whereas higher satisfaction with birth (aRR = 0.92-0.94) and social support (aRR = 0.81-0.82) were associated with decreased risk. INTERPRETATION: Prevalence of postnatal PTS was significantly higher during the pandemic, compared to before the pandemic, due to an increase in PTS related to birth trauma. Prevalence of postnatal anxiety was not significantly higher during the pandemic. Risk factors for postnatal anxiety and PTS were similar before and during the pandemic.

Planned mode of birth after previous caesarean section and special educational needs in childhood: a population-based record linkage cohort study.

OBJECTIVE: To investigate the association between planned mode of birth after previous caesarean section and a child's risk of having a record of special educational needs (SENs). DESIGN: Population-based cohort study. SETTING: Scotland. POPULATION: A cohort of 44 892 singleton children born at term in Scotland between 2002 and 2011 to women with one or more previous caesarean sections. METHODS: Linkage of Scottish national health and education data sets. MAIN OUTCOME MEASURES: Any SENs and specific types of SEN recorded when a child was aged 4-11 years and attending a Scottish primary or special school. RESULTS: Children born following planned vaginal birth after previous caesarean (VBAC) compared with elective repeat caesarean section (ERCS) had a similar risk of having a record of any SENs (19.24 versus 17.63%, adjusted risk ratio aRR 1.04, 95% CI 0.99-1.09) or specific types of SEN. There was also little evidence that planned VBAC with or without labour induction compared with ERCS was associated with a child's risk of having a record of any SENs (21.42 versus 17.63%, aRR 1.09, 95% CI 1.01-1.17 and 18.78 versus 17.63%, aRR 1.03, 95% CI 0.98-1.08, respectively) or most types of SEN. However, an increased risk of sensory impairment was seen for planned VBAC with labour induction compared with ERCS (1.18 versus 0.78%, risk difference 0.4%, adjusted odds ratio aOR 1.60, 95% CI 1.09-2.34). CONCLUSIONS: This study provides little evidence of an association between planned mode of birth after previous caesarean and SENs in childhood beyond a small absolute increased risk of sensory impairment seen for planned VBAC with labour induction. This finding may be the result of performing multiple comparisons or residual confounding. The findings provide valuable information to manage and counsel women with previous caesarean section concerning their future birth choices. TWEETABLE ABSTRACT: There is little evidence planned mode of birth after previous caesarean section is associated with special educational needs in childhood.

Prevalence and factors associated with postpartum posttraumatic stress in a population-based maternity survey in England.

BACKGROUND: Studies on prevalence and factors associated with postpartum posttraumatic stress (PTS) typically do not distinguish between PTS related to childbirth (PTS-C) and PTS related to other stressors (PTS-O). This study aimed to describe the prevalence, clinical characteristics, and factors associated with PTS-C and PTS-O in postpartum women. METHODS: The study was a cross-sectional population-based survey of 16,000 postpartum women, selected at random from birth registrations in England to receive a postal questionnaire, including the Primary Care Posttraumatic Stress Disorder Screen. RESULTS: Questionnaires were returned by 4,509 women. The median age was 32 years (IQR=29-36), 64% were married, 77% were UK-born, and 76% were White-British. Prevalence of PTS-C was 2.5% (95%CI:2.0-3.0) and prevalence of PTS-O was 6.8% (95%CI:6.0-7.8). Women with PTS-C were significantly more likely to report re-experiencing symptoms (Chi-Square=7.69,p<0.01). Factors associated with PTS-C were: higher level of deprivation, not having a health professional to talk to about sensitive issues during pregnancy, and the baby being admitted for neonatal intensive care. Factors associated with PTS-O were: age ≤24 years, depression during pregnancy, and having a pregnancy affected by long-term health problems. Factors associated with both were: living without a partner, anxiety during pregnancy, pregnancy-specific health problems, and lower birth satisfaction. CONCLUSIONS: PTS during the postpartum period is relatively common and, for many women, unrelated to childbirth. Increased awareness among health professionals of prevalence, clinical characteristics and factors associated with postpartum PTS-C and PTS-O will aid the development of appropriate management protocols to identify and support women during the perinatal period. Posttraumatic stress, posttraumatic stress disorder, postpartum PTSD/PTS, birth-related PTSD/PTS, birth trauma, perinatal mental health.

Exclusive breastfeeding duration and infant infection.

BACKGROUND/OBJECTIVES: We estimated the risk of infection associated with the duration of exclusive breastfeeding (EBF). SUBJECT/METHODS: We analysed the data on 15 809 term, singleton infants from the UK Millennium Cohort Study. Infants were grouped according to months of EBF: never, <2, 2-4, 4-6 and 6 (the latter being World Health Organisation (WHO) policy since 2001: 'post-2001 WHO policy'). Among those EBF for 4-6 months, we separated those who started solids, but not formula, before 6 months, and were still breastfeeding at 6 months (that is, WHO policy before 2001: 'pre-2001 WHO policy'), from other patterns. Outcomes were infection in infancy (chest, diarrhoeal and ear). RESULTS: EBF was not associated with the ear infection, but was associated with chest infection and diarrhoea. EBF for <4 months was associated with a significantly increased risk of chest infection (adjusted risk ratios (RR) 1.24-1.28) and diarrhoea (adjusted RRs 1.42-1.66) compared with the pre-2001 WHO policy. There was an excess risk of the chest infection (adjusted RR 1.19, 95% confidence interval (CI): 0.97-1.46) and diarrhoea (adjusted RR 1.66, 95% CI: 1.11, 2.47) among infants EBF for 4-6 months, but who stopped breastfeeding by 6 months, compared with the pre-2001 WHO policy. There was no significant difference in the risk of chest infection or diarrhoea in those fed according to the pre-2001 versus post-2001 WHO policy. CONCLUSIONS: There is an increased risk of infection in infants EBF for <4 months or EBF for 4-6 months who stop breastfeeding by 6 months. These results support current guidelines of EBF for either 4-6 or 6 months, with continued breastfeeding thereafter.

Long-term cognitive and school outcomes of late-preterm and early-term births: a systematic review.

BACKGROUND: Children born before full term (39-41 weeks' gestation) are at increased risk of adverse cognitive outcomes. Risk quantification is important as late-preterm (LPT; 34-36 weeks) and early-term (ET; 37-38 weeks) births are common. METHOD: This review analyses the effect of LPT and ET births on long-term cognitive and educational outcomes. The primary outcome was general cognitive ability. Secondary outcomes included verbal/non-verbal intelligence quotient, subject-specific school performance and special educational needs. The search strategy included Medline and Embase from January 1975 to June 2013. Eligible studies investigated specified outcomes and included suitable gestational age participants assessed at 2 years and older. Outcome measures and socio-demographic descriptors were extracted, and data meta-analysed where possible. RESULTS: Eight studies compared ET birth with full-term birth. Fourteen studies compared LPT birth with either term birth (>37 weeks, n = 12 studies) or full-term birth (39-41 weeks, n = 2 studies). Substantial between-study heterogeneity existed. LPT and ET children underperformed in most outcomes compared with their term/full-term counterparts, respectively. For example, LPT children had an increased risk of lower general cognitive ability (adjusted risk ratio 1.38 [95% confidence interval 1.06-1.79]), and full-term children performed 5% of a standard deviation higher (z-score 0.05 [0.02, 0.08]) than ET children. Poorer outcomes persist into adulthood; term cohorts performed 5% of a standard deviation higher than LPT cohorts (z-score 0.05 [0.04, 0.07]), and full-term cohorts performed 3% of a standard deviation higher than ET cohorts (z-score 0.03 [0.02, 0.04]). CONCLUSION: This review critically examines the knowledge around long-term cognitive outcomes of LPT and ET births, demonstrating multiple, small, adverse differences between LPT/ET and term/full-term births.

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.

Light drinking versus abstinence in pregnancy - behavioural and cognitive outcomes in 7-year-old children: a longitudinal cohort study.

OBJECTIVE: To assess whether light drinking in pregnancy is linked to unfavourable developmental outcomes in children. DESIGN: Prospective population-based cohort. SETTING: UK. POPULATION: Ten thousand five hundred and thirty-four 7-year-olds. METHODS: Quasi-experimental using propensity score matching (PSM) to compare children born to light (up to 2 units per week) and non-drinkers. MAIN OUTCOME MEASURES: Behavioural difficulties rated by parents and teachers; cognitive test scores for reading, maths and spatial skills. RESULTS: Ordinary least squares (OLS) regression and PSM analyses are presented. For behavioural difficulties, unadjusted estimates for percentage standard deviation (SD) score differences ranged from 2 to 14%. On adjustment for potential confounders, differences were attenuated, with a loss of statistical significance, except for teacher-rated boys' difficulties. For boys, parent-rated behavioural difficulties: unadjusted, -11.5; OLS, -4.3; PSM, -6.8; teacher-rated behavioural difficulties: unadjusted, -13.9; OLS, -9.6; PSM, -10.8. For girls, parent-rated behavioural difficulties: unadjusted, -9.6; OLS, -2.9; PSM, -4.5; teacher-rated behavioural difficulties: unadjusted, -2.4; OLS, 4.9; PSM, 3.9. For cognitive test scores, unadjusted estimates for differences ranged between 12 and 21% of an SD score for reading, maths and spatial skills. After adjustment for potential confounders, estimates were reduced, but remained statistically significantly different for reading and for spatial skills in boys. For boys, reading: unadjusted, 20.9; OLS, 8.3; PSM, 7.3; maths: unadjusted, 14.7; OLS, 5.0; PSM, 6.5; spatial skills: unadjusted, 16.2; OLS, 7.6; PSM, 8.1. For girls, reading: unadjusted, 11.6; OLS, -0.3; PSM, -0.5; maths: unadjusted, 12.9; OLS, 4.3; PSM, 3.9; spatial skills: unadjusted, 16.2; OLS, 7.7; PSM, 6.4. CONCLUSION: The findings suggest that light drinking during pregnancy is not linked to developmental problems in mid-childhood. These findings support current UK Department of Health guidelines on drinking during pregnancy.

Persistent effects of women's parity and breastfeeding patterns on their body mass index: results from the Million Women Study.

OBJECTIVE: To explore the long-term effects of women's childbearing patterns on their body mass index. DESIGN: Cross-sectional analysis. SETTING: Population-based study of UK women. PARTICIPANTS: 740 628 postmenopausal participants in the Million Women Study who reported their height, weight, reproductive histories and other relevant factors. MAIN OUTCOME MEASURES: Standardized mean BMI (kg m(-2)) in groups defined by their parity and breastfeeding history. RESULTS: Women were aged 57.5 (s.d. 4) years on average, and had a mean BMI of 26.2 kg m(-2) (s.d. 5); 88% were parous, with 2.1 (s.d. 1.2) children on average. The standardised mean BMI increased progressively with the number of births from 25.6 kg m(-2) (95% confidence interval (CI): 25.5-25.6) in nulliparous women up to 27.2 kg m(-2) (CI: 27.2-27.3) for women with four or more births, a difference of 1.7 kg m(-2) (CI: 1.6-1.7). Among the parous women 70% had ever breastfed and their average total duration of breastfeeding was 7.7 (s.d. 8.8) months. At every parity level the standardised mean BMI was significantly lower among women who had breastfed than those who had not, decreasing by 0.22 kg m(-2) (CI: 0.21-0.22) for every 6 months of breastfeeding, that is, women's mean BMI was 1% lower for every 6 months that they had breastfed. These associations were highly statistically significant (P<0.0001) and independent of the effects of socioeconomic group, region of residence, smoking and physical activity. CONCLUSIONS: Childbearing patterns have a persistent effect on adiposity in this population. The reduction in BMI associated with just 6 months breastfeeding in UK women could importantly reduce their risk of obesity-related disease as they age.

Asthma in children born after infertility treatment: findings from the UK Millennium Cohort Study.

STUDY QUESTION: Is asthma more common in children born after subfertility and assisted reproduction technologies (ART)? SUMMARY ANSWER: Yes. Asthma, wheezing in the last year and anti-asthmatic medication were all more common in children born after a prolonged time to conception (TTC). This was driven specifically by an increase in children born after ART. WHAT IS KNOWN ALREADY: Few studies have investigated any association between ART and asthma in subsequent children, and findings to date have been mixed. A large registry-based study found an increase in asthma medication in ART children but suggests underlying infertility is the putative risk factor. Little is known about asthma in children after unplanned or mistimed conceptions. STUDY DESIGN, SIZE, DURATION: The Millennium Cohort Study is a UK-wide, prospective study of 18 818 children recruited at 9 months of age. Follow-up is ongoing. This study analyses data from follow-up surveys at 5 and 7 years of age (response rates of 79 and 70%, respectively). PARTICIPANTS/MATERIALS, SETTING, METHODS: Singleton children whose natural mothers provided follow-up data were included. Mothers reported whether their pregnancy was planned; planners provided TTC and details of any ART. The population was divided into 'unplanned' (unplanned and unhappy), 'mistimed' (unplanned but happy), 'planned' (planned, TTC < 12 months), 'untreated subfertile' (planned, TTC >12 months), 'ovulation induced' (received clomiphene citrate) and 'ART' (IVF or ICSI). The primary analysis used the planned children as the comparison group; secondary analysis compared the treatment groups to the children born to untreated subfertile parents. Outcomes were parent report of asthma and wheezing at 5 and 7 years, derived from validated questions in the International Study of Asthma and Allergies in Childhood, plus use of anti-asthmatic medications. A total of 13 041 (72%) children with full data on asthma and confounders were included at 5 years of age, and 11 585 (64%) at 7 years. MAIN RESULTS AND THE ROLE OF CHANCE: Compared with planned children, those born to subfertile parents were significantly more likely to experience asthma, wheezing and to be taking anti-asthmatics at 5 years of age [adjusted odds ratio (OR): 1.39 (95% confidence interval (CI): 1.07, 1.80), OR: 1.27 (1.00, 1.63) and OR: 1.90 (1.32,2.74), respectively]. This association was mainly related to an increase among children born after ART (adjusted OR: 2.65 (1.48, 4.76), OR: 1.97, (1.10, 3.53) and OR: 4.67 (2.20, 9.94) for asthma, wheezing and taking anti-asthmatics, respectively). The association was also present, though reduced, at the age of 7 years. LIMITATIONS, REASONS FOR CAUTION: The number of singletons born after ART was relatively small (n = 104), and as such the findings should be interpreted with caution. However, data on a wide range of possible confounding and mediating factors were available and analysed. The data were weighted for non-response to minimize selection bias. WIDER IMPLICATIONS OF THE FINDINGS: The findings add to the growing body of evidence suggesting an association between subfertility, ART and asthma in children. Further work is needed to establish causality and elucidate the underlying mechanism. These findings are generalizable to singletons only, and further work on multiples is needed.

Effect of pregnancy planning and fertility treatment on cognitive outcomes in children at ages 3 and 5: longitudinal cohort study.

OBJECTIVE: To investigate how pregnancy planning, time to conception, and infertility treatment influence cognitive development at ages 3 and 5. DESIGN: Prospective population based cohort study. SETTING: Millennium Cohort Study in the United Kingdom. PARTICIPANTS: 18,818 children recruited at 9 months and followed up at 3 and 5 years. 11,790 singletons with available data on pregnancy, cognitive outcomes, and confounders were included in analyses at age 3 and 12,136 at age 5. Exposure measures Mothers reported whether the pregnancy was planned, and their feelings when first pregnant; those in whom the pregnancy was planned provided time to conception, and details of any assisted reproductive technologies. The population was divided into "unplanned" (unplanned and unhappy), "mistimed" (unplanned but happy), "planned" (planned, time to conception <12 months), "subfertile" (planned, time to conception ≥ 12 months), "induced ovulation" (received clomiphene citrate), and "assisted reproduction" (in vitro fertilisation or intracytoplasmic sperm injection). The "planned" group was the comparison group in all analyses. OUTCOME MEASURES: Three components of the British Ability Scales (BAS II). Naming vocabulary assessed verbal ability at age 3; this test was repeated at age 5 with the picture similarities and pattern construction subscales, which measure non-verbal and spatial abilities. RESULTS: In unadjusted analyses, the scores on all scales in children from unplanned pregnancies were significantly lower than in those from planned pregnancies-for example, the difference in mean verbal ability score at age 3 was -4.8 (95% confidence interval -6.0 to -3.7; P<0.05), equivalent to an average delay of four months. After adjustment for sociodemographic factors these differences were attenuated: -0.3 (-1.3 to 0.7), equivalent to no delay. Children born after assisted reproduction performed consistently better in verbal ability tests (3.8 (-0.2 to 7.9) at age 3 and 3.5 (0.2 to 6.8) at age 5), which suggests that on average these children are three to four months ahead; this difference did not completely disappear with adjustment for confounders. Children born after infertility treatment had lower mean scores in non-verbal tests (-1.2 (-4.1 to 1.6) after assisted reproduction and -1.5 (-3.5 to 0.4) after induced ovulation) and in spatial ability tests (-2.7 (-6.9 to 1.6) after assisted reproduction), though the differences were not significant. CONCLUSIONS: Pregnancy planning, subfertility, or assisted reproduction do not adversely affect children's cognitive development at age 3 or 5. The differences observed in the unadjusted analyses are almost entirely explained by marked inequalities in socioeconomic circumstances between the groups.

Cognitive development following ART: effect of choice of comparison group, confounding and mediating factors.

BACKGROUND: Epidemiological studies have examined the health of children born after assisted reproductive technology (ART), with contradictory results. In this article, we address the question 'Do singletons born after ART have a poorer cognitive developmental outcome at 3 years of age?' We assess the implications of using different comparison groups, and discuss appropriate analytical approaches for the control of confounding and mediating variables. METHODS: Data were drawn from the Millennium Cohort Study. Interviews captured sociodemographic, behavioural and pregnancy information. Developmental assessments conducted at age three included the British Ability Scales II Naming Vocabulary (BAS-NV) instrument. We compared ART infants (born after IVF or ICSI) to four comparison groups: a 'matched' group; a 'subfertile' group (time to conception >12 months); a 'fertile' group (time to conception <12 months); and an 'any spontaneous conceptions' group. Linear regression provided estimates of the difference in mean BAS-NV scores in the ART and comparison groups; both unadjusted estimates and those adjusted for confounding and mediating factors are presented. RESULTS: In the unadjusted analyses, ART children gained significantly better BAS-NV test results than did the comparison group children. When converted to an estimate of developmental age gap, ART children were 2.5, 2.7, 3.6 and 4.5 months ahead of the 'matched', 'subfertile', 'fertile' and 'spontaneous conception' children, respectively. After adjusting for confounding and mediating factors, the differences were reduced, and were not statistically significant. CONCLUSIONS: ART is not associated with poorer cognitive development at 3 years. We have highlighted methodological considerations for researchers planning to study the effect of infertility and ART on childhood outcomes.

Infant feeding, solid foods and hospitalisation in the first 8 months after birth.

Most infants in the UK start solids before the recommended age of 6 months. We assessed the independent effects of solids and breast feeding on the risk of hospitalisation for infection in term, singleton infants in the Millennium Cohort Study (n = 15,980). For both diarrhoea and lower respiratory tract infection (LRTI), the monthly risk of hospitalisation was significantly lower in those receiving breast milk compared with those receiving formula. The monthly risk of hospitalisation was not significantly higher in those who had received solids compared with those not on solids (for diarrhoea, adjusted odds ratio 1.39, 95% CI 0.75 to 2.59; for LRTI, adjusted odds ratio 1.14, 95% CI 0.76 to 1.70), and the risk did not vary significantly according to the age of starting solids.

Social and ethnic differences in attendance for antenatal care in England.

OBJECTIVES: Evidence about sociodemographic factors associated with late attendance for antenatal care in the UK is of poor quality. This study aimed to identify any social or ethnic differences in access to antenatal care, and to quantify the effect of any such differences using data collected in a survey of women's experiences of antenatal screening. STUDY DESIGN: Cross-sectional survey using a postal questionnaire. METHODS: A stratified clustered random sampling strategy was used. Hospitals in England were stratified according to ethnic mix. In order to ensure inclusion of an adequate number of women from Black and Minority Ethnic (BME) backgrounds, hospitals with >or= 15% of women of BME origin were oversampled. Pregnant women aged >or= 16 years, receiving care in 15 participating hospitals, were sent a postal questionnaire at 27-31 weeks of gestation. Logistic regression was used to estimate odds ratios (ORs) comparing social and ethnic groups for attendance for antenatal care, adjusting for sociodemographic and clinical factors. RESULTS: In total, 839 women (57%) returned completed questionnaires. Compared with all women giving birth in 2005 in England and Wales, the survey sample contained fewer women aged <20 years (5.8% vs 6.9%), more women aged >35 years (24.1% vs 19.6%) and fewer women who were born outside the UK (14.8% vs 20.8%). Five percent of responders were late attenders for their first antenatal appointment. The odds of late initiation of antenatal care were higher for women born outside the UK [OR 4.37, 95% confidence interval (CI) 2.25-8.52; P=0.0004] and for women living without a husband/partner (OR 2.74, 95% CI 1.81-4.16; P=0.0002). In total, 2.5% of women were late attenders for their booking appointment. The odds of late booking were higher for Black women (OR 5.92, 95% CI 2.97-11.83) and women living without a husband/partner (OR 1.95, 95% CI 0.97-3.93; P=0.06). CONCLUSIONS: A small proportion of women initiate and/or book late for antenatal care. This study provides recent, good-quality evidence that women born outside the UK and those living without a husband/partner may be at particular risk of late attendance for antenatal care.

Formula milk versus donor breast milk for feeding preterm or low birth weight infants.

BACKGROUND: When sufficient maternal breast milk is not available, the alternative sources of enteral nutrition for preterm or low birth weight infants are donor breast milk or artificial formula milk. Feeding preterm or low birth weight infants with formula milk might increase nutrient input and growth rates. However, since feeding with formula milk may be associated with a higher incidence of feeding intolerance and necrotising enterocolitis, this may adversely affect growth and development. OBJECTIVES: To determine the effect of formula milk compared with donor human breast milk on growth and development in preterm or low birth weight infants. SEARCH STRATEGY: The standard search strategy of the Cochrane Neonatal Review Group was used. This included electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - May 2007), EMBASE (1980 - May 2007), CINAHL (1982 - May 2007), conference proceedings, and previous reviews. SELECTION CRITERIA: Randomised controlled trials comparing feeding with formula milk versus donor breast milk in preterm or low birth weight infants. DATA COLLECTION AND ANALYSIS: Data were extracted using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two reviewer authors, and synthesis of data using relative risk, risk difference and weighted mean difference. MAIN RESULTS: Eight trials fulfilled the inclusion criteria. Only one trial used nutrient-fortified donor breast milk. Enteral feeding with formula milk compared with donor breast milk resulted in higher rates of growth in the short term. There was no evidence of an effect on long-term growth rates or neurodevelopmental outcomes. Meta-analysis of data from five trials demonstrated a statistically significantly higher incidence of necrotising enterocolitis in the formula fed group: typical relative risk 2.5 (95% confidence interval 1.2, 5.1); typical risk difference: 0.03 (95% confidence interval 0.01, 0.06; number needed to harm: 33 (95% confidence interval 17, 100). AUTHORS' CONCLUSIONS: In preterm and low birth weight infants, feeding with formula milk compared with donor breast milk results in a higher rate of short-term growth but also a higher risk of developing necrotising enterocolitis. There are only limited data on the comparison of feeding with formula milk versus nutrient-fortified donor breast milk. This limits the applicability of the findings as nutrient fortification of breast milk is now a common practice in neonatal care. Future trials may compare growth, development and adverse outcomes in infants who receive formula milk versus nutrient-fortified donor breast milk given as a supplement to maternal expressed breast milk or as a sole diet.

Caesarean delivery and risk of stillbirth in subsequent pregnancy: a retrospective cohort study in an English population.

OBJECTIVE: Two recent studies indicate an increased risk of stillbirth in the pregnancy that follows a pregnancy delivered by caesarean section. In this study, we report an analysis designed to test the hypothesis that delivery by caesarean section is a risk factor for explained or unexplained stillbirth in any subsequent pregnancy. We also report on the proportion of stillbirths in our study population, which may have been attributable to previous delivery by caesarean section. DESIGN: Retrospective cohort study. POPULATION: Linked statistical data set of 81 784 singleton deliveries registered in Oxfordshire and West Berkshire between 1968 and 1989. METHODS: The crude and adjusted hazard ratios for stillbirth in deliveries following a previous delivery by caesarean section, compared with no previous caesarean, were estimated using Cox regression. MAIN OUTCOME MEASURE: Stillbirth. RESULTS: The unadjusted hazard ratios for all, explained, and unexplained stillbirths were 1.54 (95% CI 1.04-2.29); 2.13 (1.22-3.72); and 1.19 (0.68-2.09), respectively. After adjustment for maternal age, parity, social class, previous adverse outcome of pregnancy, body mass indexand smoking the hazard ratios were 1.58 (0.95-2.63), 2.08 (1.00-4.31) and 1.24 (0.60-2.56). CONCLUSIONS: Pregnancies in women following a pregnancy delivered by caesarean section are at an increased risk of stillbirth. In our study, the risk appears to be mainly concentrated in the subgroup of explained stillbirths. However, there are sufficient inconsistencies in the developing literature about stillbirth risk that further research is needed.

Agreement between hospital records and maternal recall of mode of delivery: evidence from 12 391 deliveries in the UK Millennium Cohort Study.

OBJECTIVE: The objective of this study was to measure the agreement between hospital records and maternal reporting of mode of delivery in a representative UK sample. DESIGN: Population-based survey (Millennium Cohort Study). SETTING: UK. POPULATION: A total of 12,391 singleton infants born in 2000-2002. METHODS: Mothers were interviewed when infants were approximately 9 months old. Information was collected by interview on many obstetric and perinatal factors including mode of delivery. Record linkage to the mother's delivery hospital records was undertaken in those who gave consent (90%). A matching record was found for 83%. Maternal report and hospital records were compared using mode of delivery classified into three (normal, assisted and caesarean) and six groups. Factors associated with disagreement between the two data sources were identified. MAIN OUTCOME MEASURE: Proportion of records in which there was agreement between the two data sources. RESULTS: Agreement between maternal report and hospital records was at least 94% using six mode of delivery groups and 98% using three groups. Much of the disagreement (57-63%, depending on country) was between forceps and ventouse, and between planned and emergency caesarean. Disagreement was more common in women whose babies were first born and in women not born in the UK. CONCLUSION: Our study confirms that maternal reporting of mode of delivery is highly reliable. This is important for clinical staff caring for women and those conducting epidemiological studies. Additional data sources may be necessary to gather reliable data from ethnic minority women, particularly those born outside the UK, or to distinguish forceps from ventouse, or planned from emergency caesarean section.

How protective is breast feeding against diarrhoeal disease in infants in 1990s England? A case-control study.

AIMS: To assess the effect of several measures of infant feeding on diarrhoeal disease, and whether these effects vary according to markers of social deprivation. METHODS: Case-control study of diarrhoeal disease cases presenting to 34 general practices in England. Controls were stratified on age group, area deprivation index for the practice, and whether or not the practice was in London. Data were available on 304 infants (167 cases and 137 controls). RESULTS: After adjustment for confounders, breast feeding was associated with significantly less diarrhoeal disease. Associations were striking even in infants aged > or = 6 months. They did not vary by social class, but were greater in those living in rented council accommodation and in more crowded households. The effect of receiving no breast milk was stronger in more deprived areas than in less deprived areas. The effect of not receiving exclusive breast milk was stronger in more deprived areas than in less deprived areas. In formula fed infants, there was significantly more diarrhoeal disease in those not sterilising bottles/teats with steam or chemicals. The protective effect of breast feeding did not persist beyond two months after breast feeding had stopped. CONCLUSIONS: Breast feeding protects against diarrhoeal disease in infants in England although the degree of protection may vary across infants and wear off after breast feeding cessation. Education about the benefits of breast feeding and the risks of inadequate sterilisation should be targeted at carers in deprived areas or households.

Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace.

BACKGROUND: Lateral ligament ankle sprains are the single most common sports injury. OBJECTIVE: To determine the functional outcome of the ankle joint after a moderate or severe inversion injury, comparing standard treatment with an elastic support bandage against an Aircast ankle brace. DESIGN: Prospective, randomised controlled trial. SETTING: Two accident and emergency departments. METHOD: Fifty patients presenting consecutively were randomised into two equal groups: one group was treated with an elastic support bandage and the other with an Aircast ankle brace. All patients were given a standardised advice sheet referring to rest, ice, compression, and elevation. Patients were reviewed after 48-72 hours, 10 days, and one month. PRIMARY OUTCOME MEASURE: Ankle joint function assessed at 10 days and one month using the modified Karlsson scoring method (maximum score 90). SECONDARY OUTCOME MEASURE: The difference in ankle girth (swelling) and pain score at 10 days. RESULTS: Seventeen patients in the elastic support bandage group (six defaulted, two excluded) and 18 patients in the Aircast ankle brace group (six defaulted, one excluded) completed the study. There were no significant differences between the two groups at presentation in terms of age (mean 35.3 and 32.6 years respectively), sex, dominant leg, left or right ankle injured, previous injury, time to presentation (median three and four hours respectively), difference in ankle girth (mean 14.5 and 14.3 mm respectively), and pain scores (mean 6.2 and 5.8 respectively). The Karlsson score was significantly higher in the Aircast ankle cast group than in the elastic bandage group at 10 days (mean 50 v 35, p = 0.028, 95% confidence interval (CI) 1.7 to 27.7) and one month (mean 68 v 55, p = 0.029, 95% CI 1.4 to 24.8) (Student's t test). There was no difference between the groups in the secondary outcome measures (swelling, p = 0.09; pain, p = 0.07). When hierarchical multiple regression analysis was used to correct for possible baseline confounding factors, the Aircast ankle brace group was significantly associated with higher Karlsson scores at 10 days (p = 0.009) and one month (p = 0.024). CONCLUSION: The use of an Aircast ankle brace for the treatment of lateral ligament ankle sprains produces a significant improvement in ankle joint function at both 10 days and one month compared with standard management with an elastic support bandage.

An audit of sports injuries in children attending an Accident & Emergency department.

OBJECTIVE: To assess the incidence of attendance, type of injury, sport involved and management of sports injuries in children attending an Accident & Emergency (A&E) department. METHOD: Children, aged between 5-16 years, presenting with an injury related to sport, were studied over a period of three months. RESULTS: 1858 children attended the A&E department during the three month period. 238 (12.8%) were classified as sports injuries. Boys (71%) were injured more frequently than girls (29%). Injury rates in boys peaked at 14 years whereas in girls a peak occurred earlier at 12 years. Football was the most common sport implicated in injuries (39%). Rollerblading (14%), Rugby (8%), Basketball (7%) and Physical Education at school (7%) were the next most frequently involved sports. Soft tissue injuries dominated (61%). The upper limb was the most common anatomical area injured (46%). Other injuries involved the lower limb (36%), head and neck (15%) and the trunk (3%). Injuries to the wrist were the most frequent presentation accounting for 30 fractures and 30 soft tissue injuries (25%). The majority of children were discharged from the A&E department after treatment (71%). 26% were reviewed at out-patient clinics and 3% required hospital admission. No children were referred for physiotherapy. CONCLUSION: Children participate in sport and can be injured. The majority of sports injuries presenting to an A&E department appear to be of a minor nature and could be managed with simple first aid techniques by parents, teachers and coaches at the scene or by attending primary care in the first instance. Supervision of children, participation in organised sport and the use of protection devices may help to prevent serious injury.