Long-term outcomes for large for gestational age infants born at term.

AIM: Large for gestational age (LGA) babies have increased risks for short-term outcomes such as shoulder dystocia, neonatal hypoglycaemia and longer hospital stay. Little is known of long-term health, development and educational outcomes of LGA babies. The aim of this study was to determine the long-term health, mortality, development and educational outcomes for infants born LGA at term. METHODS: A population-based record linkage study of live singletons born at term (37-41 weeks of gestation) in New South Wales, Australia, from 2001 to 2006. RESULTS: This study compared 49 439 LGA (>90th percentile for birthweight, gestational age and sex) and 400 418 appropriate size for gestational age (AGA; 10th-90th percentile) infants. LGA infants had increased risk of birth and neonatal outcomes and hospitalisations, for brachial plexus injury after the neonatal period, and for all causes from 1 to 5 years of age. There were no differences in mortality up to 5 years of age or hospitalisations for type 1 diabetes in childhood. LGA infants had lower rates of developmental vulnerability (in kindergarten) and showed a significant trend (χ2 for trend <0.0001) to fewer low scores and more high scores in reading and numeracy (in Year 3) compared with AGA. After adjusting for potential confounders, only the relative risk for higher reading scores was statistically significant. CONCLUSIONS: LGA infants show positive long-term health, development and educational outcomes. Concerns for LGA infants still remain in the perinatal period as a result of birth trauma; however, these complications usually do not persist in postnatal and early childhood.

Dietary vitamin, mineral and herbal supplement use: a cross-sectional survey of before and during pregnancy use in Sydney, Australia.

AIM: To describe the use of dietary vitamin, mineral and herbal supplements before and during pregnancy. MATERIALS AND METHODS: Pregnant women attending for antenatal care at two tertiary Sydney hospitals between January and March 2014 completed an anonymous survey. Information on general maternal and pregnancy characteristics and the use of dietary and herbal supplements, including type, duration and sources of information, was collected. Frequency and contingency tabulations were performed. RESULTS: A total of 612 women agreed to participate (91% response rate). Of 589 women included in the analysis, mean gestational age at the time of survey was 28.5 weeks (SD 8.3), 55% had no children, and 67% were tertiary-educated. Overall, 62.9% of women reported taking a multivitamin (MV) and/or folic acid (FA) supplement in the 3 months prepregnancy, and 97.5% took a MV and/or FA in the first trimester. At the time of the survey, 93.8% of women were taking at least one supplement (median 2, range 1-13). During pregnancy, 79.1% of women were taking MVs, including 59.2% taking MV only and 19.9% taking MV and FA. The five most common supplements outside of a MV were FA (31%), iron (30%), vitamin D (23%), calcium (13%) and fish oil (12%). Reported herbal supplement rates were low. CONCLUSION: Folic acid, MVs and other supplements use during and prepregnancy is relatively high, although prepregnancy FA supplementation rates could still be improved. Further research on the actual dosages and dietary intakes consumed is needed to examine whether pregnant women have adequate intake of nutrients, regardless of supplement use.

High maternal serum ferritin in early pregnancy and risk of spontaneous preterm birth.

Previous studies have reported inconsistent associations between maternal serum ferritin concentrations and the risk of spontaneous preterm birth (sPTB). The aim of the present study was to examine the association between Fe biomarkers, including serum ferritin concentrations, and the risk of total ( 75th percentile ( ≥ 43 µg/l) (OR 1.49, 95% CI 1.06, 2.10) and >90th percentile ( ≥ 68 µg/l) (OR 1.92, 95% CI 1.25, 2.96). Increased odds of early and moderate-to-late sPTB were associated with ferritin levels >90th percentile (OR 2.50, 95% CI 1.32, 4.73) and >75th percentile (OR 1.56, 95% CI 1.03, 2.37), respectively. No association was found between the risk of sPTB and elevated sTfR levels or Fe deficiency. In conclusion, elevated maternal serum ferritin levels in early pregnancy are associated with an increased risk of sPTB from 34 weeks of gestation. The usefulness of early pregnancy ferritin levels in identifying women at risk of sPTB warrants further investigation.

Maternal body weight and first trimester screening for chromosomal anomalies.

Prenatal risk ratios for Down syndrome adjust for maternal weight because maternal serum biomarker levels decrease with increasing maternal weight. This is accomplished by converting serum biomarker values into a multiple of the expected median (MoM) for women of the same gestational age. Weight is frequently not recorded, and the impact of using MoMs not adjusted for weight for calculating risk ratios is unknown. The aim of this study is to examine the effect of missing weight on first trimester Down syndrome risk ratios by comparing risk ratios calculated using weight-unadjusted-and-adjusted MoMs. Findings at the population level indicate that the impact of not adjusting for maternal weight on first trimester screening results for chromosomal anomalies would lead to under-identification of 84 per 10,000 pregnancies.

Maternal and infant characteristics by mode of vitamin K prophylaxis administration.

AIM: The aim of this study was to compare maternal and infant characteristics by mode of VK administration. METHODS: De-identified computerised birth files of all babies born in New South Wales (NSW), Australia between January 2007 and December 2009 (when VK prophylaxis was measured) were included in the present study. The outcome variable, mode of VK prophylaxis, was recorded by checkbox as oral, IM injection, none or not stated. RESULTS: We analysed population-based birth data from 2007 to 2009 in NSW, Australia and found that IM injection was the most prevalent mode of administration (96.3%, n = 263, 555), followed by oral (2.6%, n = 7023) and none (1.2%, n = 3136). Compared to neonates receiving IM VK, those with oral or none were more likely to have vaginal births without medical interventions at birth centres or planned home births and were less likely to receive hepatitis B vaccination. Among neonates administered oral VK, a larger proportion were preterm births and breastfed at discharge compared to neonates administered VK as an IM injection. Neonates with no VK recorded were more likely to be admitted to neonatal intensive care, but may have received VK later in the birth admission. CONCLUSIONS: A small proportion of the Australian neonates may be at risk of inadequate protection from VKBD due to parental concerns about the safety of IM injection of VK to neonates.

Prevalence and sociodemographic factors of malnutrition among children in Malaysia.

BACKGROUND: For many developing countries undergoing rapid economic growth and urbanization, trends in nutritional status indicate a decrease in malnutrition with an associated rise in the prevalence of obesity. An understanding of the situation among children in Malaysia is lacking. OBJECTIVE: To examine the prevalence, trends and sociodemographic factors described for underweight and overweight children in Malaysia. METHODS: The literature from January 1996 to November 2010 on the prevalence of underweight and overweight among children in Malaysia was reviewed. RESULTS: Twelve studies were identified that reported on both underweight and overweight among children in Malaysia, of which only one was a nationally representative survey. Based on the National Health and Morbidity Survey in 2006, 13.2% (95% CI, 12.6 to 13.9) of children aged 0 to 18 years were underweight (weight-for-age < -2SD), and 8.0% (95% CI, 7.5 to 8.6) of those aged 0 to 13 years were overweight (weight-for-height > +2SD). Both underweight and overweight were more prevalent in males than females. Children in rural areas were more likely to be underweight and less likely to be overweight than urban children. Ethnic differences between Malays, Chinese, and Indians were inconsistent across studies and less clear. Aborigines were more likely to be underweight and less likely to be overweight than the general population. The available evidence, although limited and sparse, suggests that over the past decade the prevalence of both underweight and overweight among children in Malaysia has been stable or has shown an increasing trend. CONCLUSIONS: Long-term national monitoring and longitudinal cohort studies will be critical for understanding, preventing, and managing the double burden of malnutrition among children in Malaysia.

Corticosteroid exposure not associated with long-term bone mineral density in pediatric liver transplantation.

OBJECTIVES: The aim of the study was to examine the association of corticosteroid exposure and other skeletal risk factors with bone mineral density (BMD) and fractures following pediatric liver transplantation (LT) at a large single center. PATIENTS AND METHODS: Lumbar spine BMD, measured using dual-energy x-ray absorptiometry (DXA), was corrected for bone age in 52 ambulatory children ages 4 to 18 years, at least 1 year post-LT. Potential risk factors for skeletal health such as corticosteroid exposure, dietary and lifestyle factors, and growth and fracture occurrence, were related to BMD using univariate and multivariate regression analyses. RESULTS: The prevalence of low BMD (z score <-2) and post-LT fractures was 3 of 52 (5.8%) and 11 of 52 (21%), respectively. Univariate analysis revealed age >10 years at LT and body mass index (BMI) < 85th percentile at time of DXA were significantly associated with BMD (both P = 0.02). BMD did not correlate with corticosteroid dosage in the first year post-LT, the year before DXA or cumulative lifetime exposure. A cholestatic primary LT indication, acute rejection episodes, and fractures post-LT were not associated with BMD. Extracurricular physical activity, vitamin D, and calcium intake were not associated with BMD or fractures. Multivariate linear regression revealed increased time post-LT (P = 0.04) and higher BMI z score at time of DXA (P = 0.02) as the strongest independent variables associated with greater BMD. CONCLUSIONS: Neither corticosteroid exposure nor a cholestatic primary indication for LT influenced BMD, which was largely normal in this ambulatory group. Children and adolescents undergoing LT after the age of 10 years and those with low BMI post-LT may be at greatest risk of poor skeletal health later in life, and thus a potential target patient population to benefit from preventive interventions.

Women's views about the timing of birth.

BACKGROUND: Estimated date of birth (EDB) is used to guide the care provided to women during pregnancy and birth, although its imprecision is recognised. Alternatives to the EDB have been suggested for use with women however their attitudes to timing of birth information have not been examined. AIMS: To explore women's expectations of giving birth on or near their EDB, and their attitudes to alternative estimates for timing of birth. METHODS: A survey of pregnant women attending four public hospitals in Sydney, Australia, between July and December 2012. RESULTS: Among 769 surveyed women, 42% expected to birth before their due date, 16% after the due date, 15% within a day or so of the due date, and 27% had no expectations. Nulliparous women were more likely to expect to give birth before their due date. Women in the earlier stages of pregnancy were more likely to have no expectations or to expect to birth before the EDB while women in later pregnancy were more likely to expect birth after their due date. For timing of birth information, only 30% of women preferred an EDB; the remainder favoured other options. CONCLUSIONS: Most women understood the EDB is imprecise. The majority of women expressed a preference for timing of birth information in a format other than an EDB. In support of woman-centred care, clinicians should consider discussing other options for estimated timing of birth information with the women in their care.

Iron supplement use in pregnancy - Are the right women taking the right amount?

OBJECTIVES: To examine the prevalence and determinants of iron supplement use and the amount of iron consumed from iron-containing supplements. METHODS: A cross-sectional survey was performed in antenatal clinics in two tertiary hospitals in Sydney, Australia between January and March 2014. RESULTS: Of 612 (91% response rate) pregnant women, 589 with complete data were analysed. Overall iron-containing supplement use was 88.0%, of which 70.1% was multivitamin (MV) only, 7.2% was iron-only and 22.2% was both. Use of iron-containing supplements was associated with increased gestational age, a diagnosis of anaemia or iron deficiency (ID) in the current pregnancy and pre-pregnancy use of an iron-containing supplement. Several risk factors for ID or anaemia such as non-red meat eating and previous miscarriage were not associated with current iron supplement use. About 65% of women diagnosed with ID, and 62.3% of women diagnosed with anaemia were taking an iron-only supplement, with or without a MV. The proportion of women consuming low (<30), preventative (30-99) and treatment (≥100) mg/day doses were 36.8%, 45.4%, and 17.8%, respectively. Only 46.7% of women diagnosed with ID were taking ≥100 mg/day iron from supplements, while 23.3% were taking <30 mg/day. CONCLUSION: Women are consuming varying doses of iron and some high-risk women are taking inadequate doses of iron to prevent or treat ID or iron deficiency anaemia. Healthcare professionals are best positioned to advise women on iron supplement use in pregnancy and should educate women individually about the type and dose of supplement best suited to their needs.

Effects of maternal serum 25-hydroxyvitamin D concentrations in the first trimester on subsequent pregnancy outcomes in an Australian population.

BACKGROUND: Low serum 25-hydroxyvitamin D [25(OH)D] concentrations during pregnancy have been associated with adverse pregnancy outcomes in a few studies but not in other studies. OBJECTIVES: We assessed the serum 25(OH)D concentration at 10-14 wk of pregnancy and its association with adverse pregnancy outcomes and examined the predictive accuracy. DESIGN: In this nested case-control study, we measured serum 25(OH)D in 5109 women with singleton pregnancies who were attending first-trimester screening in New South Wales, Australia. Multivariate logistic regression was conducted to examine the association between low 25(OH)D concentrations and adverse pregnancy outcomes (small for gestational age, preterm birth, preeclampsia, gestational diabetes, miscarriage, and stillbirth). The predictive accuracy of models was assessed. RESULTS: The median (IQR) 25(OH)D concentration for the total population was 56.4 nmol/L (43.3-69.8 nmol/L). Serum 25(OH)D concentrations showed significant variation by parity, smoking, weight, season of sampling, country of birth, and socioeconomic status. After adjustment for maternal and clinical risk factors, low 25(OH)D concentrations were not associated with most adverse pregnancy outcomes. The area under the receiver operating characteristic curve (AUC) and likelihood ratio for a composite of severe adverse pregnancy outcomes of 25(OH)D concentrations <25 nmol/L were 0.51 and 1.44, respectively, and, for risk factors alone, were 0.64 and 2.87, respectively. The addition of 25(OH)D information to maternal and clinical risk factors did not improve the ability to predict severe adverse pregnancy outcomes (AUC: 0.64; likelihood ratio: 2.32; P = 0.39). CONCLUSION: Low 25(OH)D serum concentrations in the first trimester of pregnancy are not associated with adverse pregnancy outcomes and do not predict complications any better than routinely assessed clinical and maternal risk-factor information.

Predicting date of birth and examining the best time to date a pregnancy.

OBJECTIVE: To compare the estimated date of birth (eDOB) from the last menstrual period (LMP) and ultrasound scans at varying gestations (<7(0), 7(0)-10(6), 11(0)-14(0), 14(1)-19(6), and 20(0)-27(6)weeks) with the actual date of birth (aDOB). METHODS: In a retrospective study, data were analyzed from 18 708 women with spontaneous labor who delivered a single neonate without major anomalies in a local health district in Australia between 2007 and 2011. Data were sourced from a computerized population birth database. The study outcomes were duration of pregnancy expressed as total days, and the difference between aDOB and eDOB by dating method. RESULTS: Only 5% of births occurred on the eDOB, regardless of the dating method or timing of the dating. Approximately 66% of births occurred within 7days of the eDOB, and there was little difference among the ultrasound examinations performed at varying gestational weeks. The ultrasound scans at 11(0)-14(0)weeks of gestation performed as well as ultrasound scans conducted at other gestational ages. CONCLUSION: On a population basis, there were no meaningful differences in the prediction of date of birth by ultrasound scan date. An early dating scan (≤10weeks) is unnecessary if LMP is reliable.

Burden of anemia among indigenous populations.

An international perspective of the magnitude of anemia in indigenous peoples is currently lacking. The present systematic review was performed to characterize the global prevalence, severity, and etiology of anemia in indigenous peoples by conducting a systematic search of original research published in English from 1996 to February 2010 using PubMed, Medline, and Embase. A total of 50 studies, representing the following 13 countries, met the inclusion criteria: Australia, Brazil, Canada, Guatemala, India, Kenya, Malaysia, Mexico, New Zealand, Sri Lanka, Tanzania, the United States, and Venezuela. Results indicate major deficiencies in the coverage and quality of anemia monitoring data for indigenous populations worldwide. The burden of anemia is overwhelmingly higher among indigenous groups compared to the general population and represents a moderate (20-39.9%) to severe (≥40%) public health problem. For the most part, the etiology of anemia is preventable and includes inadequate diet, poor living conditions, and high infection rates (i.e., malaria and intestinal parasites). A concerted global effort is needed to reduce the worldwide burden of anemia in these marginalized populations.

Periconceptional iron supplementation does not reduce anemia or improve iron status among pregnant women in rural Bangladesh.

BACKGROUND: There is a growing interest in periconceptional iron supplementation in developing countries by researchers and policy makers; however, there are no randomized controlled trials that examine the effectiveness of this strategy in decreasing anemia during pregnancy. OBJECTIVE: The aim was to determine whether periconceptional iron supplementation reduces anemia during pregnancy. DESIGN: A randomized, double-blind, controlled trial was conducted in rural Bangladesh. Married, nulliparous women were randomly assigned to receive daily iron and folic acid (IFA; 60 mg ferrous fumarate and 400 microg folic acid) (n = 134) or folic acid (FA; 400 microg) (n = 138) in the form of a powdered supplement added to food. Women were followed until pregnancy or the end of 9 mo. Primary outcomes included hemoglobin, plasma ferritin, and plasma transferrin receptor concentrations. RESULTS: Among 88 pregnant women, periconceptional IFA in comparison with FA did not affect anemia or iron status at 15 wk gestation. However, each 1% increase in adherence was associated with a 10-g/L increase in change in hemoglobin from baseline (P = 0.03), and those who initiated supplementation at a mean (+/-SD) time of 72.9 +/- 57.8 d before conception showed a 7.3-g/L increase in change in hemoglobin from baseline compared with those who initiated supplementation at 26.3 +/- 12.3 d after conception (P = 0.01). Among 146 nonpregnant women, IFA decreased anemia (odds ratio: 0.19; 95% CI: 0.04, 0.95) and improved iron stores (P = 0.001) more than did FA. CONCLUSION: Good adherence and initiation of supplementation before conception are needed to reduce anemia during early pregnancy. This trial was registered at www.clinicaltrials.gov as NCT00953134.