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Female physicians can face breastfeeding challenges at work
CHICAGO – Physician mothers who breastfeed and wish to pump milk during work hours can face many of the same challenges as other working mothers, as well as some issues unique to the profession, a new survey revealed.
“Although physician mothers have high rates of intention to breastfeed while they are pregnant, and initiation of breastfeeding at birth, we unfortunately have low rates of continuing to breastfeed and even meeting the [6 month] recommendations for exclusive breastfeeding,” Rebecca Cantu, MD, MPH said at the annual meeting of the American Academy of Pediatrics.
Dr. Cantu and her colleagues surveyed providers affiliated with the University of Arkansas for Medical Sciences in Little Rock in 2016. The 3-item, Web-based survey was anonymous and assessed role [trainee (medical student, resident physician, fellow) or faculty physician], breastfeeding experience, and perceived barriers to successful breastfeeding.
Common barriers identified
Of the 223 responses, 38% were from medical students, 31% from faculty, 24% from residents, and 7% from fellows. Of the 97 physicians who had breastfed at some point, 97% identified at least one barrier they felt inhibited their breastfeeding goals, said Dr. Cantu, a pediatric hospitalist at Arkansas Children’s Hospital in Little Rock. The survey revealed a total 397 barriers, for an average of 3.7 per person. Being faced with barriers could lead to early unintentional weaning and other consequences like mastitis, decreased milk supply, or anxiety, she added.
“We did find trainees identified a significantly higher median number of barriers, five, versus three for faculty [P less than .01],” Dr. Cantu said. Only one respondent said she faced no barriers.
Lack of time and place to pump breast milk, an unpredictable schedule, short maternity leave, and long working hours were among the most common barriers cited.
“For physicians, we don’t have time. I don’t have a protected lunch break. I’m a hospitalist rounding for hours in the morning,” Dr. Cantu said. “Also, residents don’t always feel comfortable asking for time to leave, and we don’t have people identified to cover our patients. So, depending on the institution, there can be many areas that need to be addressed.”
“The last place I worked had many lactation rooms scattered throughout the hospital, some for physicians only,” she said. “Where I work now we have one room for breastfeeding with two chairs for the entire medical center. So space is a problem.”
A little over half (56%) of respondents had never breastfed. Another 30% had previously breastfed and weaned and 14% were currently breastfeeding at the time of the survey. Of those who had never breastfed, 87% indicated that they planned to at some point in the future. “This emphasizes that the current problem is something we need to continue to work on. We need to address these barriers, and find ways to decrease the impact these barriers have on breastfeeding physicians.”
Future research will investigate association between these barriers and breastfeeding duration and other outcomes, Dr. Cantu said.
Potential solutions
“Policy can play a role here. Plenty of studies have shown that supporting physicians who breastfeed is associated with better patient outcomes, and institutions that support breastfeeding can have a financial benefit,” she said, adding, “If the hospitals cannot even support breastfeeding mothers, how do we expect other places to?”
During the Q&A after Dr. Cantu’s presentation, a meeting attendee suggested using a Freemie pump.* It’s a smaller and more discreet pump that can be used “at an airport, restaurant or while charting in the emergency department.” Dr. Cantu agreed that Freemie pumps could help.
Dr. Cantu also recommended the Dr. Milk support group website and Facebook pages. “I refer a lot of trainees there because you can post a question and get tons of peer advice and support, and find out what’s worked for other people.:
Dr. Cantu had no relevant financial disclosures.
* This article was updated on 1/11/18.
CHICAGO – Physician mothers who breastfeed and wish to pump milk during work hours can face many of the same challenges as other working mothers, as well as some issues unique to the profession, a new survey revealed.
“Although physician mothers have high rates of intention to breastfeed while they are pregnant, and initiation of breastfeeding at birth, we unfortunately have low rates of continuing to breastfeed and even meeting the [6 month] recommendations for exclusive breastfeeding,” Rebecca Cantu, MD, MPH said at the annual meeting of the American Academy of Pediatrics.
Dr. Cantu and her colleagues surveyed providers affiliated with the University of Arkansas for Medical Sciences in Little Rock in 2016. The 3-item, Web-based survey was anonymous and assessed role [trainee (medical student, resident physician, fellow) or faculty physician], breastfeeding experience, and perceived barriers to successful breastfeeding.
Common barriers identified
Of the 223 responses, 38% were from medical students, 31% from faculty, 24% from residents, and 7% from fellows. Of the 97 physicians who had breastfed at some point, 97% identified at least one barrier they felt inhibited their breastfeeding goals, said Dr. Cantu, a pediatric hospitalist at Arkansas Children’s Hospital in Little Rock. The survey revealed a total 397 barriers, for an average of 3.7 per person. Being faced with barriers could lead to early unintentional weaning and other consequences like mastitis, decreased milk supply, or anxiety, she added.
“We did find trainees identified a significantly higher median number of barriers, five, versus three for faculty [P less than .01],” Dr. Cantu said. Only one respondent said she faced no barriers.
Lack of time and place to pump breast milk, an unpredictable schedule, short maternity leave, and long working hours were among the most common barriers cited.
“For physicians, we don’t have time. I don’t have a protected lunch break. I’m a hospitalist rounding for hours in the morning,” Dr. Cantu said. “Also, residents don’t always feel comfortable asking for time to leave, and we don’t have people identified to cover our patients. So, depending on the institution, there can be many areas that need to be addressed.”
“The last place I worked had many lactation rooms scattered throughout the hospital, some for physicians only,” she said. “Where I work now we have one room for breastfeeding with two chairs for the entire medical center. So space is a problem.”
A little over half (56%) of respondents had never breastfed. Another 30% had previously breastfed and weaned and 14% were currently breastfeeding at the time of the survey. Of those who had never breastfed, 87% indicated that they planned to at some point in the future. “This emphasizes that the current problem is something we need to continue to work on. We need to address these barriers, and find ways to decrease the impact these barriers have on breastfeeding physicians.”
Future research will investigate association between these barriers and breastfeeding duration and other outcomes, Dr. Cantu said.
Potential solutions
“Policy can play a role here. Plenty of studies have shown that supporting physicians who breastfeed is associated with better patient outcomes, and institutions that support breastfeeding can have a financial benefit,” she said, adding, “If the hospitals cannot even support breastfeeding mothers, how do we expect other places to?”
During the Q&A after Dr. Cantu’s presentation, a meeting attendee suggested using a Freemie pump.* It’s a smaller and more discreet pump that can be used “at an airport, restaurant or while charting in the emergency department.” Dr. Cantu agreed that Freemie pumps could help.
Dr. Cantu also recommended the Dr. Milk support group website and Facebook pages. “I refer a lot of trainees there because you can post a question and get tons of peer advice and support, and find out what’s worked for other people.:
Dr. Cantu had no relevant financial disclosures.
* This article was updated on 1/11/18.
CHICAGO – Physician mothers who breastfeed and wish to pump milk during work hours can face many of the same challenges as other working mothers, as well as some issues unique to the profession, a new survey revealed.
“Although physician mothers have high rates of intention to breastfeed while they are pregnant, and initiation of breastfeeding at birth, we unfortunately have low rates of continuing to breastfeed and even meeting the [6 month] recommendations for exclusive breastfeeding,” Rebecca Cantu, MD, MPH said at the annual meeting of the American Academy of Pediatrics.
Dr. Cantu and her colleagues surveyed providers affiliated with the University of Arkansas for Medical Sciences in Little Rock in 2016. The 3-item, Web-based survey was anonymous and assessed role [trainee (medical student, resident physician, fellow) or faculty physician], breastfeeding experience, and perceived barriers to successful breastfeeding.
Common barriers identified
Of the 223 responses, 38% were from medical students, 31% from faculty, 24% from residents, and 7% from fellows. Of the 97 physicians who had breastfed at some point, 97% identified at least one barrier they felt inhibited their breastfeeding goals, said Dr. Cantu, a pediatric hospitalist at Arkansas Children’s Hospital in Little Rock. The survey revealed a total 397 barriers, for an average of 3.7 per person. Being faced with barriers could lead to early unintentional weaning and other consequences like mastitis, decreased milk supply, or anxiety, she added.
“We did find trainees identified a significantly higher median number of barriers, five, versus three for faculty [P less than .01],” Dr. Cantu said. Only one respondent said she faced no barriers.
Lack of time and place to pump breast milk, an unpredictable schedule, short maternity leave, and long working hours were among the most common barriers cited.
“For physicians, we don’t have time. I don’t have a protected lunch break. I’m a hospitalist rounding for hours in the morning,” Dr. Cantu said. “Also, residents don’t always feel comfortable asking for time to leave, and we don’t have people identified to cover our patients. So, depending on the institution, there can be many areas that need to be addressed.”
“The last place I worked had many lactation rooms scattered throughout the hospital, some for physicians only,” she said. “Where I work now we have one room for breastfeeding with two chairs for the entire medical center. So space is a problem.”
A little over half (56%) of respondents had never breastfed. Another 30% had previously breastfed and weaned and 14% were currently breastfeeding at the time of the survey. Of those who had never breastfed, 87% indicated that they planned to at some point in the future. “This emphasizes that the current problem is something we need to continue to work on. We need to address these barriers, and find ways to decrease the impact these barriers have on breastfeeding physicians.”
Future research will investigate association between these barriers and breastfeeding duration and other outcomes, Dr. Cantu said.
Potential solutions
“Policy can play a role here. Plenty of studies have shown that supporting physicians who breastfeed is associated with better patient outcomes, and institutions that support breastfeeding can have a financial benefit,” she said, adding, “If the hospitals cannot even support breastfeeding mothers, how do we expect other places to?”
During the Q&A after Dr. Cantu’s presentation, a meeting attendee suggested using a Freemie pump.* It’s a smaller and more discreet pump that can be used “at an airport, restaurant or while charting in the emergency department.” Dr. Cantu agreed that Freemie pumps could help.
Dr. Cantu also recommended the Dr. Milk support group website and Facebook pages. “I refer a lot of trainees there because you can post a question and get tons of peer advice and support, and find out what’s worked for other people.:
Dr. Cantu had no relevant financial disclosures.
* This article was updated on 1/11/18.
AT AAP 2017
Key clinical point: .
Major finding: Of 97 physicians who had ever breastfed, 97% perceived at least one barrier at work that inhibited meeting their breastfeeding goals.
Data source: Survey responses from 223 physicians and medical students affiliated with the University of Arkansas.
Disclosures: Dr. Cantu had no relevant financial disclosures.
Breastfeeding practices have improved, but some attitudes are concerning
Pediatricians’ recommendations and practices for breastfeeding have become more closely aligned with American Academy of Pediatrics policy since 1995, but attitudes toward breastfeeding show cause for concern, according to a study.
The percentage of surveyed pediatricians who advise exclusive breastfeeding during the first month rose from 66% in 1995 to 75% in 2014 (P less than .05), reported Lori Feldman-Winter, MD, MPH, of Rowan University, Camden, N.J., and her coauthors (Pediatrics. 2017. doi: 10.1542/peds.2017-1229).
Physicians also were less likely to recommend formula supplementation (12% in 1995; 4.5% in 2014; P less than .05).
In addition, pediatricians in 2014 were significantly more likely to report that their affiliated hospitals had applied to be a baby-friendly hospital (56%), compared with results for 1995 (12%) and 2004 (22%) (P less than .05), the investigators said. The physicians also were more likely to report that their practices were more in line with the “Ten Steps to Successful Breastfeeding” policy.
Despite this general trend toward AAP recommendation–compliant practices, many pediatricians doubt the likelihood of breastfeeding success. Although in 1995, 70% of pediatricians reported that almost any mother can be successful at breastfeeding if she keeps trying, only 56% reported the same in 2014 (P less than .05), Dr. Feldman-Winter and her coauthors said. Similarly, only 50% reported that the benefits of breastfeeding outweigh the difficulties in 2014, compared with 70% in 1995 (P less than .05). This may be in part because younger pediatricians reported less confidence in managing common breastfeeding problems and being able to adequately address parents’ questions about breastfeeding; there was a statistically significant difference between pediatricians younger than 45 years and those 45 years and older (P less than .01).
“Pediatricians have demonstrated a modest decline in attitudes about the potential for breastfeeding success,” the investigators wrote. “Lack of resident support for breastfeeding is apparent among many programs and may set the stage for attitudes about breastfeeding for years to come. There are continued opportunities to enhance training in breastfeeding and participate in breastfeeding management and support.”
The study was funded by the American Academy of Pediatrics and the Maternal and Child Health Bureau, Health Resources and Services Administration, and Department of Health and Human Services. None of the authors reported any financial disclosures.
Despite changes in breastfeeding recommendations and practices as well as numerous initiatives from organizations such as the Centers for Disease Control and Prevention and the Department of Health and Human Services, residency training for breastfeeding is not universal.
The study by Feldman et al. shows some concerning trends toward a lack of belief among pediatricians that the benefits of breastfeeding outweigh the difficulties or inconveniences and toward less confidence in managing breastfeeding. They also indicate that baby-friendly hospitals are providing the required breastfeeding education, but this is only a start.
As the trend toward staffing hospitals with pediatric hospitalists increases, it is essential to remember that ambulatory pediatricians also need breastfeeding education because they are responsible for ongoing follow-up care. Maintenance of certification should include breastfeeding as a “core competency” for general pediatricians as well.
Although this analysis shows progress, “the importance of routine integration of breastfeeding into all aspects of medical education cannot be overstated. Breastfeeding education should be as routine in the curriculum as other preventive health strategies, such as immunization.” Hopefully, future studies will show that pediatricians have the skills, attitudes, and confidence necessary to provide competent support to their patients.
Joan Younger Meek, MD, is the associate dean for graduate medical education and a professor at Florida State University in Tallahassee. Her comments were with the Feldman-Winter et al. article in Pediatrics (2017. doi: 10.1542/peds.2017-2509). She reported no relevant financial disclosures or external funding.
Despite changes in breastfeeding recommendations and practices as well as numerous initiatives from organizations such as the Centers for Disease Control and Prevention and the Department of Health and Human Services, residency training for breastfeeding is not universal.
The study by Feldman et al. shows some concerning trends toward a lack of belief among pediatricians that the benefits of breastfeeding outweigh the difficulties or inconveniences and toward less confidence in managing breastfeeding. They also indicate that baby-friendly hospitals are providing the required breastfeeding education, but this is only a start.
As the trend toward staffing hospitals with pediatric hospitalists increases, it is essential to remember that ambulatory pediatricians also need breastfeeding education because they are responsible for ongoing follow-up care. Maintenance of certification should include breastfeeding as a “core competency” for general pediatricians as well.
Although this analysis shows progress, “the importance of routine integration of breastfeeding into all aspects of medical education cannot be overstated. Breastfeeding education should be as routine in the curriculum as other preventive health strategies, such as immunization.” Hopefully, future studies will show that pediatricians have the skills, attitudes, and confidence necessary to provide competent support to their patients.
Joan Younger Meek, MD, is the associate dean for graduate medical education and a professor at Florida State University in Tallahassee. Her comments were with the Feldman-Winter et al. article in Pediatrics (2017. doi: 10.1542/peds.2017-2509). She reported no relevant financial disclosures or external funding.
Despite changes in breastfeeding recommendations and practices as well as numerous initiatives from organizations such as the Centers for Disease Control and Prevention and the Department of Health and Human Services, residency training for breastfeeding is not universal.
The study by Feldman et al. shows some concerning trends toward a lack of belief among pediatricians that the benefits of breastfeeding outweigh the difficulties or inconveniences and toward less confidence in managing breastfeeding. They also indicate that baby-friendly hospitals are providing the required breastfeeding education, but this is only a start.
As the trend toward staffing hospitals with pediatric hospitalists increases, it is essential to remember that ambulatory pediatricians also need breastfeeding education because they are responsible for ongoing follow-up care. Maintenance of certification should include breastfeeding as a “core competency” for general pediatricians as well.
Although this analysis shows progress, “the importance of routine integration of breastfeeding into all aspects of medical education cannot be overstated. Breastfeeding education should be as routine in the curriculum as other preventive health strategies, such as immunization.” Hopefully, future studies will show that pediatricians have the skills, attitudes, and confidence necessary to provide competent support to their patients.
Joan Younger Meek, MD, is the associate dean for graduate medical education and a professor at Florida State University in Tallahassee. Her comments were with the Feldman-Winter et al. article in Pediatrics (2017. doi: 10.1542/peds.2017-2509). She reported no relevant financial disclosures or external funding.
Pediatricians’ recommendations and practices for breastfeeding have become more closely aligned with American Academy of Pediatrics policy since 1995, but attitudes toward breastfeeding show cause for concern, according to a study.
The percentage of surveyed pediatricians who advise exclusive breastfeeding during the first month rose from 66% in 1995 to 75% in 2014 (P less than .05), reported Lori Feldman-Winter, MD, MPH, of Rowan University, Camden, N.J., and her coauthors (Pediatrics. 2017. doi: 10.1542/peds.2017-1229).
Physicians also were less likely to recommend formula supplementation (12% in 1995; 4.5% in 2014; P less than .05).
In addition, pediatricians in 2014 were significantly more likely to report that their affiliated hospitals had applied to be a baby-friendly hospital (56%), compared with results for 1995 (12%) and 2004 (22%) (P less than .05), the investigators said. The physicians also were more likely to report that their practices were more in line with the “Ten Steps to Successful Breastfeeding” policy.
Despite this general trend toward AAP recommendation–compliant practices, many pediatricians doubt the likelihood of breastfeeding success. Although in 1995, 70% of pediatricians reported that almost any mother can be successful at breastfeeding if she keeps trying, only 56% reported the same in 2014 (P less than .05), Dr. Feldman-Winter and her coauthors said. Similarly, only 50% reported that the benefits of breastfeeding outweigh the difficulties in 2014, compared with 70% in 1995 (P less than .05). This may be in part because younger pediatricians reported less confidence in managing common breastfeeding problems and being able to adequately address parents’ questions about breastfeeding; there was a statistically significant difference between pediatricians younger than 45 years and those 45 years and older (P less than .01).
“Pediatricians have demonstrated a modest decline in attitudes about the potential for breastfeeding success,” the investigators wrote. “Lack of resident support for breastfeeding is apparent among many programs and may set the stage for attitudes about breastfeeding for years to come. There are continued opportunities to enhance training in breastfeeding and participate in breastfeeding management and support.”
The study was funded by the American Academy of Pediatrics and the Maternal and Child Health Bureau, Health Resources and Services Administration, and Department of Health and Human Services. None of the authors reported any financial disclosures.
Pediatricians’ recommendations and practices for breastfeeding have become more closely aligned with American Academy of Pediatrics policy since 1995, but attitudes toward breastfeeding show cause for concern, according to a study.
The percentage of surveyed pediatricians who advise exclusive breastfeeding during the first month rose from 66% in 1995 to 75% in 2014 (P less than .05), reported Lori Feldman-Winter, MD, MPH, of Rowan University, Camden, N.J., and her coauthors (Pediatrics. 2017. doi: 10.1542/peds.2017-1229).
Physicians also were less likely to recommend formula supplementation (12% in 1995; 4.5% in 2014; P less than .05).
In addition, pediatricians in 2014 were significantly more likely to report that their affiliated hospitals had applied to be a baby-friendly hospital (56%), compared with results for 1995 (12%) and 2004 (22%) (P less than .05), the investigators said. The physicians also were more likely to report that their practices were more in line with the “Ten Steps to Successful Breastfeeding” policy.
Despite this general trend toward AAP recommendation–compliant practices, many pediatricians doubt the likelihood of breastfeeding success. Although in 1995, 70% of pediatricians reported that almost any mother can be successful at breastfeeding if she keeps trying, only 56% reported the same in 2014 (P less than .05), Dr. Feldman-Winter and her coauthors said. Similarly, only 50% reported that the benefits of breastfeeding outweigh the difficulties in 2014, compared with 70% in 1995 (P less than .05). This may be in part because younger pediatricians reported less confidence in managing common breastfeeding problems and being able to adequately address parents’ questions about breastfeeding; there was a statistically significant difference between pediatricians younger than 45 years and those 45 years and older (P less than .01).
“Pediatricians have demonstrated a modest decline in attitudes about the potential for breastfeeding success,” the investigators wrote. “Lack of resident support for breastfeeding is apparent among many programs and may set the stage for attitudes about breastfeeding for years to come. There are continued opportunities to enhance training in breastfeeding and participate in breastfeeding management and support.”
The study was funded by the American Academy of Pediatrics and the Maternal and Child Health Bureau, Health Resources and Services Administration, and Department of Health and Human Services. None of the authors reported any financial disclosures.
FROM PEDIATRICS
Key clinical point:
Major finding: The percentage of surveyed physicians who advise exclusive breastfeeding during the first month rose from 66% in 1995 to 75% in 2014 (P less than .05).
Data source: An analysis of data from three AAP Periodic Surveys of Fellows.
Disclosures: The study was funded by the American Academy of Pediatrics and the Maternal and Child Health Bureau, Health Resources and Services Administration, and Department of Health and Human Services. None of the authors reported any financial disclosures.
CONCEPTT: Continuous glucose monitoring during pregnancy benefits baby
LISBON – , according to the investigators of a prospective, multicenter, randomized, controlled study who found that it improved a number of neonatal outcomes.
In the open-label Continuous Glucose Monitoring in Pregnant Women with Type 1 Diabetes(CONCEPTT) study, infants born to mothers who had used continuous glucose monitoring (CGM) versus those who had not had a 49% lower chance of being large for gestational age (53% vs. 69%, odds ratio [OR] 0.51, P = .0210) and were 52% less likely to need neonatal intensive care lasting for longer than 24 hours (27% vs. 43%, OR 0.48, P = .0157).
Neonates born to mothers who used CGM during their pregnancy were also less likely to experience hypoglycemia (15% vs. 28%, OR 0.45, P = .0250) and were able to leave the hospital with their mother 1 day earlier (P = .0091) than those born to mothers who did not use CGM.However, these were secondary outcomes of the study, which first looked at how CGM affected the glycemic profile of the mother.“To the best of our knowledge, this is the first trial to demonstrate a benefit of CGM on health outcomes beyond glucose control,” Helen Murphy, MD, one of the CONCEPTT trial’s two principal investigators, said at the annual meeting of the European Association for the Study of Diabetes.
“We would suggest, on the back of these data, that CGM should be offered to all pregnant women with type 1 diabetes using intensive insulin therapy during the first trimester,” Dr. Murphy said, adding that results of the study were simultaneously published online in the Lancet (2017 Sept. 15. doi. 10.1016/S0140-6736(17)32400-5).
“The CONCEPTT study will change the future for pregnant women with diabetes,” commented Elisabeth Mathiesen, MD, who was the EASD’s invited discussant for the study, and who congratulated the investigators for “a well performed study” and being “brave,” as “performing a RCT [randomized controlled trial] in pregnancy is not easy”.
Satish Garg, MD, and Sarit Polsky, MD, of the Barbara Davis Center for Diabetes at the University of Colorado, Denver, agreed in an editorial (Lancet 2017; Sept. 12. doi: 10.1016/S0140-6736(17)32449-2) accompanying the published article that the study findings were clinically important.
“We believe that the CONCEPTT results support CGM use during pregnancy for all women with type 1 diabetes,” they wrote, adding that the mother’s “time in [glycated hemoglobin, HbA1C] range might become an important measure in pregnancies with type 1 diabetes.”
Dr. Garg and Dr. Polsky also suggested that endocrine and obstetric medical societies take note and perhaps revise accordingly their guidelines on the use of CGM during pregnancy in diabetic women.
CONCEPTT involved 325 women with type 1 diabetes; 215 were pregnant at the time of enrollment, and 110 were planning on becoming pregnant in the near future.
Co-principal investigator Denice Feig, MD, of Sinai Health System in Toronto, explained that women were eligible for inclusion in the trial if they had type 1 diabetes for at least 1 year, were aged between 18 and 40 years, and had been using daily insulin delivered by either an insulin pump or multiple daily injections (MDI). At enrollment, the participants’ insulin regimen had to been stable for at least 4 weeks before randomization to CGM with capillary glucose monitoring or capillary glucose monitoring alone and their glycemic control had to be suboptimal.
Two groups of women were studied: a “pre-pregnancy group” of women who were planning on pregnancy and wanted to optimize their glycemic control before conception, and a “pregnancy group” of women in their first trimester (less than 14 weeks’ gestation) who were due to have a live, singleton birth as confirmed by ultrasound.
The primary outcome of the trial was the change in HbA1C from baseline to 34 weeks, with pre-specified secondary outcomes of various CGM measures, neoneonatal outcomes, and patient-reported outcomes.
Pregnant women using CGM had lower HbA1C levels during the trial than women who did not have CGM monitoring, although the difference was small (–0.19%, P = .0207).
The use of CGM was associated with more time spent in target HbA1C range (68% of women using CMG vs. 61% of those not using CGM, P = .0034), with less time being hyperglycemic (27% vs. 37%, P = .0279) and comparable rates of hypoglycemia (17 vs. 21 episodes) and time spent being hypoglycemic (2% vs. 4%, P = .10).“The CGM effects were very comparable among insulin pump and MDI users and across 31 international sites,” Dr. Murphy summarized, although she noted that there was no consistent benefit of using CGM seen in women who were planning a pregnancy. Dr. Feig noted that the strengths of the study were the large sample size and that CGM was used continuously from the first trimester until delivery. Women using both pumps and MDI were included at multiple centers and countries, and HbA1C was centrally assessed, with detailed CGM measures used in an exclusively type 1 diabetes population.“Of note, one needed to treat only six women with CGM to prevent one episode of large for gestational age,” Dr. Feig reported. “One needed to treat only eight women to prevent one neonatal hypoglycemia, and six women to prevent one NICU [neonatal intensive care unit] admission over 24 hours.”
There were some limitations, of course, including: around 20% of women had missing data on their HbA1C level; women using CGM also made more unscheduled visits to their health care providers although there are no data on the frequency of self-monitoring of blood glucose or frequency of insulin bolus dosing; and the study was open label.
In her independent précis of the trial, Dr. Mathiesen, professor of endocrinology and chief physician managing pregnant women with diabetes at the Rigshospitalet University Hospital in Copenhagen, noted that there were some other downsides to using CGM in the study.
The CONCEPTT study was funded by the Juvenile Diabetes Research Foundation, the Canadian Clinical Trial Network, the National Institute for Health Research, the Center for Mother, Infant, and Child Research, and the Jaeb Center for Health Research. Medtronic also supported the study by providing the CGM sensors and systems at a reduced cost. Dr. Feig declared she had no competing interests. Dr. Murphy disclosed sitting on an advisory board for Medtronic and receiving personal fees from Novo Nordisk and Roche, unrelated to the current study. Dr. Mathiesen was the invited EASD independent commentator for the trial and did not give any disclosures. Dr. Garg has received advisory board consulting fees and research grants from Medtronic and several other pharmaceutical companies specializing in diabetes care. Dr. Polsky has received research funding from DexCom for diabetes device use in patients with diabetes paid directly to the University of Denver.
LISBON – , according to the investigators of a prospective, multicenter, randomized, controlled study who found that it improved a number of neonatal outcomes.
In the open-label Continuous Glucose Monitoring in Pregnant Women with Type 1 Diabetes(CONCEPTT) study, infants born to mothers who had used continuous glucose monitoring (CGM) versus those who had not had a 49% lower chance of being large for gestational age (53% vs. 69%, odds ratio [OR] 0.51, P = .0210) and were 52% less likely to need neonatal intensive care lasting for longer than 24 hours (27% vs. 43%, OR 0.48, P = .0157).
Neonates born to mothers who used CGM during their pregnancy were also less likely to experience hypoglycemia (15% vs. 28%, OR 0.45, P = .0250) and were able to leave the hospital with their mother 1 day earlier (P = .0091) than those born to mothers who did not use CGM.However, these were secondary outcomes of the study, which first looked at how CGM affected the glycemic profile of the mother.“To the best of our knowledge, this is the first trial to demonstrate a benefit of CGM on health outcomes beyond glucose control,” Helen Murphy, MD, one of the CONCEPTT trial’s two principal investigators, said at the annual meeting of the European Association for the Study of Diabetes.
“We would suggest, on the back of these data, that CGM should be offered to all pregnant women with type 1 diabetes using intensive insulin therapy during the first trimester,” Dr. Murphy said, adding that results of the study were simultaneously published online in the Lancet (2017 Sept. 15. doi. 10.1016/S0140-6736(17)32400-5).
“The CONCEPTT study will change the future for pregnant women with diabetes,” commented Elisabeth Mathiesen, MD, who was the EASD’s invited discussant for the study, and who congratulated the investigators for “a well performed study” and being “brave,” as “performing a RCT [randomized controlled trial] in pregnancy is not easy”.
Satish Garg, MD, and Sarit Polsky, MD, of the Barbara Davis Center for Diabetes at the University of Colorado, Denver, agreed in an editorial (Lancet 2017; Sept. 12. doi: 10.1016/S0140-6736(17)32449-2) accompanying the published article that the study findings were clinically important.
“We believe that the CONCEPTT results support CGM use during pregnancy for all women with type 1 diabetes,” they wrote, adding that the mother’s “time in [glycated hemoglobin, HbA1C] range might become an important measure in pregnancies with type 1 diabetes.”
Dr. Garg and Dr. Polsky also suggested that endocrine and obstetric medical societies take note and perhaps revise accordingly their guidelines on the use of CGM during pregnancy in diabetic women.
CONCEPTT involved 325 women with type 1 diabetes; 215 were pregnant at the time of enrollment, and 110 were planning on becoming pregnant in the near future.
Co-principal investigator Denice Feig, MD, of Sinai Health System in Toronto, explained that women were eligible for inclusion in the trial if they had type 1 diabetes for at least 1 year, were aged between 18 and 40 years, and had been using daily insulin delivered by either an insulin pump or multiple daily injections (MDI). At enrollment, the participants’ insulin regimen had to been stable for at least 4 weeks before randomization to CGM with capillary glucose monitoring or capillary glucose monitoring alone and their glycemic control had to be suboptimal.
Two groups of women were studied: a “pre-pregnancy group” of women who were planning on pregnancy and wanted to optimize their glycemic control before conception, and a “pregnancy group” of women in their first trimester (less than 14 weeks’ gestation) who were due to have a live, singleton birth as confirmed by ultrasound.
The primary outcome of the trial was the change in HbA1C from baseline to 34 weeks, with pre-specified secondary outcomes of various CGM measures, neoneonatal outcomes, and patient-reported outcomes.
Pregnant women using CGM had lower HbA1C levels during the trial than women who did not have CGM monitoring, although the difference was small (–0.19%, P = .0207).
The use of CGM was associated with more time spent in target HbA1C range (68% of women using CMG vs. 61% of those not using CGM, P = .0034), with less time being hyperglycemic (27% vs. 37%, P = .0279) and comparable rates of hypoglycemia (17 vs. 21 episodes) and time spent being hypoglycemic (2% vs. 4%, P = .10).“The CGM effects were very comparable among insulin pump and MDI users and across 31 international sites,” Dr. Murphy summarized, although she noted that there was no consistent benefit of using CGM seen in women who were planning a pregnancy. Dr. Feig noted that the strengths of the study were the large sample size and that CGM was used continuously from the first trimester until delivery. Women using both pumps and MDI were included at multiple centers and countries, and HbA1C was centrally assessed, with detailed CGM measures used in an exclusively type 1 diabetes population.“Of note, one needed to treat only six women with CGM to prevent one episode of large for gestational age,” Dr. Feig reported. “One needed to treat only eight women to prevent one neonatal hypoglycemia, and six women to prevent one NICU [neonatal intensive care unit] admission over 24 hours.”
There were some limitations, of course, including: around 20% of women had missing data on their HbA1C level; women using CGM also made more unscheduled visits to their health care providers although there are no data on the frequency of self-monitoring of blood glucose or frequency of insulin bolus dosing; and the study was open label.
In her independent précis of the trial, Dr. Mathiesen, professor of endocrinology and chief physician managing pregnant women with diabetes at the Rigshospitalet University Hospital in Copenhagen, noted that there were some other downsides to using CGM in the study.
The CONCEPTT study was funded by the Juvenile Diabetes Research Foundation, the Canadian Clinical Trial Network, the National Institute for Health Research, the Center for Mother, Infant, and Child Research, and the Jaeb Center for Health Research. Medtronic also supported the study by providing the CGM sensors and systems at a reduced cost. Dr. Feig declared she had no competing interests. Dr. Murphy disclosed sitting on an advisory board for Medtronic and receiving personal fees from Novo Nordisk and Roche, unrelated to the current study. Dr. Mathiesen was the invited EASD independent commentator for the trial and did not give any disclosures. Dr. Garg has received advisory board consulting fees and research grants from Medtronic and several other pharmaceutical companies specializing in diabetes care. Dr. Polsky has received research funding from DexCom for diabetes device use in patients with diabetes paid directly to the University of Denver.
LISBON – , according to the investigators of a prospective, multicenter, randomized, controlled study who found that it improved a number of neonatal outcomes.
In the open-label Continuous Glucose Monitoring in Pregnant Women with Type 1 Diabetes(CONCEPTT) study, infants born to mothers who had used continuous glucose monitoring (CGM) versus those who had not had a 49% lower chance of being large for gestational age (53% vs. 69%, odds ratio [OR] 0.51, P = .0210) and were 52% less likely to need neonatal intensive care lasting for longer than 24 hours (27% vs. 43%, OR 0.48, P = .0157).
Neonates born to mothers who used CGM during their pregnancy were also less likely to experience hypoglycemia (15% vs. 28%, OR 0.45, P = .0250) and were able to leave the hospital with their mother 1 day earlier (P = .0091) than those born to mothers who did not use CGM.However, these were secondary outcomes of the study, which first looked at how CGM affected the glycemic profile of the mother.“To the best of our knowledge, this is the first trial to demonstrate a benefit of CGM on health outcomes beyond glucose control,” Helen Murphy, MD, one of the CONCEPTT trial’s two principal investigators, said at the annual meeting of the European Association for the Study of Diabetes.
“We would suggest, on the back of these data, that CGM should be offered to all pregnant women with type 1 diabetes using intensive insulin therapy during the first trimester,” Dr. Murphy said, adding that results of the study were simultaneously published online in the Lancet (2017 Sept. 15. doi. 10.1016/S0140-6736(17)32400-5).
“The CONCEPTT study will change the future for pregnant women with diabetes,” commented Elisabeth Mathiesen, MD, who was the EASD’s invited discussant for the study, and who congratulated the investigators for “a well performed study” and being “brave,” as “performing a RCT [randomized controlled trial] in pregnancy is not easy”.
Satish Garg, MD, and Sarit Polsky, MD, of the Barbara Davis Center for Diabetes at the University of Colorado, Denver, agreed in an editorial (Lancet 2017; Sept. 12. doi: 10.1016/S0140-6736(17)32449-2) accompanying the published article that the study findings were clinically important.
“We believe that the CONCEPTT results support CGM use during pregnancy for all women with type 1 diabetes,” they wrote, adding that the mother’s “time in [glycated hemoglobin, HbA1C] range might become an important measure in pregnancies with type 1 diabetes.”
Dr. Garg and Dr. Polsky also suggested that endocrine and obstetric medical societies take note and perhaps revise accordingly their guidelines on the use of CGM during pregnancy in diabetic women.
CONCEPTT involved 325 women with type 1 diabetes; 215 were pregnant at the time of enrollment, and 110 were planning on becoming pregnant in the near future.
Co-principal investigator Denice Feig, MD, of Sinai Health System in Toronto, explained that women were eligible for inclusion in the trial if they had type 1 diabetes for at least 1 year, were aged between 18 and 40 years, and had been using daily insulin delivered by either an insulin pump or multiple daily injections (MDI). At enrollment, the participants’ insulin regimen had to been stable for at least 4 weeks before randomization to CGM with capillary glucose monitoring or capillary glucose monitoring alone and their glycemic control had to be suboptimal.
Two groups of women were studied: a “pre-pregnancy group” of women who were planning on pregnancy and wanted to optimize their glycemic control before conception, and a “pregnancy group” of women in their first trimester (less than 14 weeks’ gestation) who were due to have a live, singleton birth as confirmed by ultrasound.
The primary outcome of the trial was the change in HbA1C from baseline to 34 weeks, with pre-specified secondary outcomes of various CGM measures, neoneonatal outcomes, and patient-reported outcomes.
Pregnant women using CGM had lower HbA1C levels during the trial than women who did not have CGM monitoring, although the difference was small (–0.19%, P = .0207).
The use of CGM was associated with more time spent in target HbA1C range (68% of women using CMG vs. 61% of those not using CGM, P = .0034), with less time being hyperglycemic (27% vs. 37%, P = .0279) and comparable rates of hypoglycemia (17 vs. 21 episodes) and time spent being hypoglycemic (2% vs. 4%, P = .10).“The CGM effects were very comparable among insulin pump and MDI users and across 31 international sites,” Dr. Murphy summarized, although she noted that there was no consistent benefit of using CGM seen in women who were planning a pregnancy. Dr. Feig noted that the strengths of the study were the large sample size and that CGM was used continuously from the first trimester until delivery. Women using both pumps and MDI were included at multiple centers and countries, and HbA1C was centrally assessed, with detailed CGM measures used in an exclusively type 1 diabetes population.“Of note, one needed to treat only six women with CGM to prevent one episode of large for gestational age,” Dr. Feig reported. “One needed to treat only eight women to prevent one neonatal hypoglycemia, and six women to prevent one NICU [neonatal intensive care unit] admission over 24 hours.”
There were some limitations, of course, including: around 20% of women had missing data on their HbA1C level; women using CGM also made more unscheduled visits to their health care providers although there are no data on the frequency of self-monitoring of blood glucose or frequency of insulin bolus dosing; and the study was open label.
In her independent précis of the trial, Dr. Mathiesen, professor of endocrinology and chief physician managing pregnant women with diabetes at the Rigshospitalet University Hospital in Copenhagen, noted that there were some other downsides to using CGM in the study.
The CONCEPTT study was funded by the Juvenile Diabetes Research Foundation, the Canadian Clinical Trial Network, the National Institute for Health Research, the Center for Mother, Infant, and Child Research, and the Jaeb Center for Health Research. Medtronic also supported the study by providing the CGM sensors and systems at a reduced cost. Dr. Feig declared she had no competing interests. Dr. Murphy disclosed sitting on an advisory board for Medtronic and receiving personal fees from Novo Nordisk and Roche, unrelated to the current study. Dr. Mathiesen was the invited EASD independent commentator for the trial and did not give any disclosures. Dr. Garg has received advisory board consulting fees and research grants from Medtronic and several other pharmaceutical companies specializing in diabetes care. Dr. Polsky has received research funding from DexCom for diabetes device use in patients with diabetes paid directly to the University of Denver.
AT EASD 2017
Key clinical point: Continuous glucose monitoring should be offered to women with type 1 diabetes on intensive insulin therapy during their pregnancy.
Major finding: Neonatal outcomes were significantly better if women used CGM while they were pregnant than if they did not. Some maternal outcomes were also improved.
Data source: CONCEPTT: a prospective, multicenter, open-label, randomized controlled trial of 325 women with type 1 diabetes: 215 were pregnant; 110 were planning a pregnancy.
Disclosures: The study was funded by the Juvenile Diabetes Research Foundation, the Canadian Clinical Trial Network, the National Institute for Health Research, the Center for Mother, Infant, and Child Research, and the Jaeb Center for Health Research. Medtronic also supported the study by providing the CGM sensors and systems at a reduced cost. One of the study presenters disclosed sitting on an advisory board for Medtronic.
Buprenorphine linked to less neonatal abstinence syndrome than methadone
CHICAGO – Methadone was associated with a significantly higher incidence of neonatal abstinence syndrome (NAS), compared with babies born to mothers who took buprenorphine for opioid maintenance therapy during pregnancy, a retrospective study of 204 neonates revealed.
Interestingly, among babies who developed the syndrome, the duration of treatment and length of stay did not differ significantly between groups.
“We found buprenorphine decreases [the incidence of] NAS,” said Alla Kushnir, MD, an attending neonatologist at Cooper University Hospital in Camden, N.J. The findings also demonstrate that physicians can expect to see “about the same withdrawal once they withdraw,” regardless of whether the mother took methadone or buprenorphine during pregnancy.
“We can’t make it better, but we can prevent some neonatal abstinence syndrome,” Dr. Kushnir said in an interview at the annual meeting of the American Academy of Pediatrics.
The infants in the study were admitted to the neonatal ICU between July 2010 and June 2016. The mothers self-reported prenatal use of methadone, buprenorphine, other opioids and/or various illicit drugs, or tested positive on a urine screen during pregnancy. In the methadone group, 81% of infants developed NAS, compared with 50% of those in the buprenorphine group. The higher likelihood of developing NAS from methadone-treated mothers was statistically significant (P less than .001).
The study population included some women who reported taking additional drugs. Among 65 infants born to women who combined methadone with other agents, 58 (89%) developed NAS. In addition, all seven infants (100%) born to women who took buprenorphine and other drugs developed the syndrome.
“Methadone was the clear bad guy in terms of incidence” between the two drugs, said Ravi Bhavsar, MBBS, a research assistant at the hospital.
Among the infants who developed NAS symptoms, the hospital length of stay and duration of medical treatment – indicators of syndrome severity – did not differ significantly (P = .015).
“This study also tells us that more research needs to be done,” Dr. Bhavsar said. Methadone is a mainstay of opioid maintenance therapy, he added, and additional evidence is warranted before shifting recommendations toward buprenorphine.
Dr. Kushnir and Dr. Bhavsar reported having no relevant financial disclosures.
CHICAGO – Methadone was associated with a significantly higher incidence of neonatal abstinence syndrome (NAS), compared with babies born to mothers who took buprenorphine for opioid maintenance therapy during pregnancy, a retrospective study of 204 neonates revealed.
Interestingly, among babies who developed the syndrome, the duration of treatment and length of stay did not differ significantly between groups.
“We found buprenorphine decreases [the incidence of] NAS,” said Alla Kushnir, MD, an attending neonatologist at Cooper University Hospital in Camden, N.J. The findings also demonstrate that physicians can expect to see “about the same withdrawal once they withdraw,” regardless of whether the mother took methadone or buprenorphine during pregnancy.
“We can’t make it better, but we can prevent some neonatal abstinence syndrome,” Dr. Kushnir said in an interview at the annual meeting of the American Academy of Pediatrics.
The infants in the study were admitted to the neonatal ICU between July 2010 and June 2016. The mothers self-reported prenatal use of methadone, buprenorphine, other opioids and/or various illicit drugs, or tested positive on a urine screen during pregnancy. In the methadone group, 81% of infants developed NAS, compared with 50% of those in the buprenorphine group. The higher likelihood of developing NAS from methadone-treated mothers was statistically significant (P less than .001).
The study population included some women who reported taking additional drugs. Among 65 infants born to women who combined methadone with other agents, 58 (89%) developed NAS. In addition, all seven infants (100%) born to women who took buprenorphine and other drugs developed the syndrome.
“Methadone was the clear bad guy in terms of incidence” between the two drugs, said Ravi Bhavsar, MBBS, a research assistant at the hospital.
Among the infants who developed NAS symptoms, the hospital length of stay and duration of medical treatment – indicators of syndrome severity – did not differ significantly (P = .015).
“This study also tells us that more research needs to be done,” Dr. Bhavsar said. Methadone is a mainstay of opioid maintenance therapy, he added, and additional evidence is warranted before shifting recommendations toward buprenorphine.
Dr. Kushnir and Dr. Bhavsar reported having no relevant financial disclosures.
CHICAGO – Methadone was associated with a significantly higher incidence of neonatal abstinence syndrome (NAS), compared with babies born to mothers who took buprenorphine for opioid maintenance therapy during pregnancy, a retrospective study of 204 neonates revealed.
Interestingly, among babies who developed the syndrome, the duration of treatment and length of stay did not differ significantly between groups.
“We found buprenorphine decreases [the incidence of] NAS,” said Alla Kushnir, MD, an attending neonatologist at Cooper University Hospital in Camden, N.J. The findings also demonstrate that physicians can expect to see “about the same withdrawal once they withdraw,” regardless of whether the mother took methadone or buprenorphine during pregnancy.
“We can’t make it better, but we can prevent some neonatal abstinence syndrome,” Dr. Kushnir said in an interview at the annual meeting of the American Academy of Pediatrics.
The infants in the study were admitted to the neonatal ICU between July 2010 and June 2016. The mothers self-reported prenatal use of methadone, buprenorphine, other opioids and/or various illicit drugs, or tested positive on a urine screen during pregnancy. In the methadone group, 81% of infants developed NAS, compared with 50% of those in the buprenorphine group. The higher likelihood of developing NAS from methadone-treated mothers was statistically significant (P less than .001).
The study population included some women who reported taking additional drugs. Among 65 infants born to women who combined methadone with other agents, 58 (89%) developed NAS. In addition, all seven infants (100%) born to women who took buprenorphine and other drugs developed the syndrome.
“Methadone was the clear bad guy in terms of incidence” between the two drugs, said Ravi Bhavsar, MBBS, a research assistant at the hospital.
Among the infants who developed NAS symptoms, the hospital length of stay and duration of medical treatment – indicators of syndrome severity – did not differ significantly (P = .015).
“This study also tells us that more research needs to be done,” Dr. Bhavsar said. Methadone is a mainstay of opioid maintenance therapy, he added, and additional evidence is warranted before shifting recommendations toward buprenorphine.
Dr. Kushnir and Dr. Bhavsar reported having no relevant financial disclosures.
AT AAP 2017
Key clinical point: .
Major finding: 81% of infants in the methadone group developed NAS, compared with 50% of the buprenorphine group.
Data source: Retrospective study of 204 babies admitted to a NICU between July 2010 to June 2016 whose mothers admitted or tested positive for opioid maintenance therapy.
Disclosures: Dr. Kushnir and Dr. Bhaysar reported having no relevant financial disclosures.
Postpartum sepsis risk persists after 6 weeks
PARK CITY, UTAH – The risk of sepsis after delivery persists beyond 6 weeks, the traditional point at which women are thought to be in the clear, according to investigators from Stanford (Calif.) University.
The team analyzed 506 sepsis hospitalizations following delivery, culled from almost 2 million live births in California from 2008-2012; 199 (39%) were at or before 6 weeks postpartum, and 310 (61%) were after 6 weeks, out to a year.
“Going into this, our view was that sepsis cases before 6 weeks would be due to obstetrical causes, and cases after 6 weeks would be due to [nonobstetrical causes],” said senior investigator Ronald Gibbs, MD, clinical professor of obstetrics and gynecology at Stanford. But that’s not what the team found. 
In both the early and late admission groups, early preterm delivery was one of the leading risks for postpartum sepsis and other risk factors were largely the same. Pyelonephritis and pneumonia were by far the most common diagnoses in both groups, accounting for more than 70% of cases. The rank order of causative organisms was the same whether women presented before 6 weeks or after: gram-negative bacteria, staphylococcus, and streptococcus.
“In view of this, we think the risk for sepsis goes beyond 6 weeks,” Dr. Gibbs said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. Although women were admitted largely for nonuterine infections, “the reservoir of infection could be in the uterus,” with later seeding to the urinary tract or lungs. “I think there’s a chronic intrauterine infection that sets women up for” both early preterm birth and later sepsis, he added.
“These late admissions would probably go to a nonobstetrical service, but we are thinking that there may be a pelvic origin related to something that went on at delivery. I can’t really say that we ought to change our practice, but it sets the stage for looking at that. Finding that late [admissions for sepsis] have a lot in common with the early admissions and are probably related to the pregnancy really reorders the thinking,” Dr. Gibbs said.
The team found that among women who were delivered at 24-28 weeks, the adjusted odds ratio was 8.6 (95% confidence interval[CI], 4.4-17.1) for early and 4.2 (95% CI, 1.9-9.0) for late postpartum sepsis admission, even after delivery mode, maternal comorbidities, maternal age, “and everything else we could think of” were controlled for, said lead investigator Megan Foeller, MD, a maternal-fetal medicine fellow at Stanford.
A body mass index above 35 kg/m2 also increased the risk for sepsis admission, as did government-provided insurance, primary cesarean delivery, a failed trial of labor after a previous cesarean, and four or more previous deliveries.
Postoperative infection, acute hepatic failure, acute renal failure, acute respiratory failure, and heart failure during the delivery hospitalization greatly increased the risk of subsequent sepsis, as well.
The findings help define a group of women who likely need especially close follow-up after delivery to prevent sepsis, Dr. Foeller said.
Sepsis was defined in the study by ICD-9 codes for septicemia plus acute organ dysfunction.
There was no industry funding for the work and the investigators reported having no relevant financial disclosures.
PARK CITY, UTAH – The risk of sepsis after delivery persists beyond 6 weeks, the traditional point at which women are thought to be in the clear, according to investigators from Stanford (Calif.) University.
The team analyzed 506 sepsis hospitalizations following delivery, culled from almost 2 million live births in California from 2008-2012; 199 (39%) were at or before 6 weeks postpartum, and 310 (61%) were after 6 weeks, out to a year.
“Going into this, our view was that sepsis cases before 6 weeks would be due to obstetrical causes, and cases after 6 weeks would be due to [nonobstetrical causes],” said senior investigator Ronald Gibbs, MD, clinical professor of obstetrics and gynecology at Stanford. But that’s not what the team found.
In both the early and late admission groups, early preterm delivery was one of the leading risks for postpartum sepsis and other risk factors were largely the same. Pyelonephritis and pneumonia were by far the most common diagnoses in both groups, accounting for more than 70% of cases. The rank order of causative organisms was the same whether women presented before 6 weeks or after: gram-negative bacteria, staphylococcus, and streptococcus.
“In view of this, we think the risk for sepsis goes beyond 6 weeks,” Dr. Gibbs said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. Although women were admitted largely for nonuterine infections, “the reservoir of infection could be in the uterus,” with later seeding to the urinary tract or lungs. “I think there’s a chronic intrauterine infection that sets women up for” both early preterm birth and later sepsis, he added.
“These late admissions would probably go to a nonobstetrical service, but we are thinking that there may be a pelvic origin related to something that went on at delivery. I can’t really say that we ought to change our practice, but it sets the stage for looking at that. Finding that late [admissions for sepsis] have a lot in common with the early admissions and are probably related to the pregnancy really reorders the thinking,” Dr. Gibbs said.
The team found that among women who were delivered at 24-28 weeks, the adjusted odds ratio was 8.6 (95% confidence interval[CI], 4.4-17.1) for early and 4.2 (95% CI, 1.9-9.0) for late postpartum sepsis admission, even after delivery mode, maternal comorbidities, maternal age, “and everything else we could think of” were controlled for, said lead investigator Megan Foeller, MD, a maternal-fetal medicine fellow at Stanford.
A body mass index above 35 kg/m2 also increased the risk for sepsis admission, as did government-provided insurance, primary cesarean delivery, a failed trial of labor after a previous cesarean, and four or more previous deliveries.
Postoperative infection, acute hepatic failure, acute renal failure, acute respiratory failure, and heart failure during the delivery hospitalization greatly increased the risk of subsequent sepsis, as well.
The findings help define a group of women who likely need especially close follow-up after delivery to prevent sepsis, Dr. Foeller said.
Sepsis was defined in the study by ICD-9 codes for septicemia plus acute organ dysfunction.
There was no industry funding for the work and the investigators reported having no relevant financial disclosures.
PARK CITY, UTAH – The risk of sepsis after delivery persists beyond 6 weeks, the traditional point at which women are thought to be in the clear, according to investigators from Stanford (Calif.) University.
The team analyzed 506 sepsis hospitalizations following delivery, culled from almost 2 million live births in California from 2008-2012; 199 (39%) were at or before 6 weeks postpartum, and 310 (61%) were after 6 weeks, out to a year.
“Going into this, our view was that sepsis cases before 6 weeks would be due to obstetrical causes, and cases after 6 weeks would be due to [nonobstetrical causes],” said senior investigator Ronald Gibbs, MD, clinical professor of obstetrics and gynecology at Stanford. But that’s not what the team found.
In both the early and late admission groups, early preterm delivery was one of the leading risks for postpartum sepsis and other risk factors were largely the same. Pyelonephritis and pneumonia were by far the most common diagnoses in both groups, accounting for more than 70% of cases. The rank order of causative organisms was the same whether women presented before 6 weeks or after: gram-negative bacteria, staphylococcus, and streptococcus.
“In view of this, we think the risk for sepsis goes beyond 6 weeks,” Dr. Gibbs said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. Although women were admitted largely for nonuterine infections, “the reservoir of infection could be in the uterus,” with later seeding to the urinary tract or lungs. “I think there’s a chronic intrauterine infection that sets women up for” both early preterm birth and later sepsis, he added.
“These late admissions would probably go to a nonobstetrical service, but we are thinking that there may be a pelvic origin related to something that went on at delivery. I can’t really say that we ought to change our practice, but it sets the stage for looking at that. Finding that late [admissions for sepsis] have a lot in common with the early admissions and are probably related to the pregnancy really reorders the thinking,” Dr. Gibbs said.
The team found that among women who were delivered at 24-28 weeks, the adjusted odds ratio was 8.6 (95% confidence interval[CI], 4.4-17.1) for early and 4.2 (95% CI, 1.9-9.0) for late postpartum sepsis admission, even after delivery mode, maternal comorbidities, maternal age, “and everything else we could think of” were controlled for, said lead investigator Megan Foeller, MD, a maternal-fetal medicine fellow at Stanford.
A body mass index above 35 kg/m2 also increased the risk for sepsis admission, as did government-provided insurance, primary cesarean delivery, a failed trial of labor after a previous cesarean, and four or more previous deliveries.
Postoperative infection, acute hepatic failure, acute renal failure, acute respiratory failure, and heart failure during the delivery hospitalization greatly increased the risk of subsequent sepsis, as well.
The findings help define a group of women who likely need especially close follow-up after delivery to prevent sepsis, Dr. Foeller said.
Sepsis was defined in the study by ICD-9 codes for septicemia plus acute organ dysfunction.
There was no industry funding for the work and the investigators reported having no relevant financial disclosures.
AT IDSOG
Key clinical point:
Major finding: Of 506 cases of sepsis hospitalization following delivery, 199 (39%) cases were at or before postpartum week 6, and 310 (61%) were after week 6.
Data source: A database review of 506 sepsis hospitalizations following delivery, culled from almost 2 million live births in California from the period of 2008-2012.
Disclosures: There was no industry funding for the work and the investigators reported having no relevant financial disclosures.
The Importance of Cord Blood and Cord Tissue Stem Cells: Today vs Tomorrow
Click Here to Read Supplement.
Topics include:
- Applications of cord blood stem cells
- Ongoing research with cord blood and cord tissue
- ASCT in autism spectrum disorder
- Patient education and counseling
- Banking options
- Science and education
Faculty/Faculty Disclosure:
Joel Weinthal, MD
Director of Pediatric Stem Cell Transplantation and Attending Physician
Texas Oncology Pediatrics
Medical Director, Apheresis and Stem Cell Laboratory
Medical City Dallas Hospital
Dallas, Texas
Dr. Weinthal reports that he is on the speakers’ bureau and advisory board, and a consultant, for CBR®, Cord Blood Registry®.
Click Here to Read the Supplement.
Click Here to Read Supplement.
Topics include:
- Applications of cord blood stem cells
- Ongoing research with cord blood and cord tissue
- ASCT in autism spectrum disorder
- Patient education and counseling
- Banking options
- Science and education
Faculty/Faculty Disclosure:
Joel Weinthal, MD
Director of Pediatric Stem Cell Transplantation and Attending Physician
Texas Oncology Pediatrics
Medical Director, Apheresis and Stem Cell Laboratory
Medical City Dallas Hospital
Dallas, Texas
Dr. Weinthal reports that he is on the speakers’ bureau and advisory board, and a consultant, for CBR®, Cord Blood Registry®.
Click Here to Read the Supplement.
Click Here to Read Supplement.
Topics include:
- Applications of cord blood stem cells
- Ongoing research with cord blood and cord tissue
- ASCT in autism spectrum disorder
- Patient education and counseling
- Banking options
- Science and education
Faculty/Faculty Disclosure:
Joel Weinthal, MD
Director of Pediatric Stem Cell Transplantation and Attending Physician
Texas Oncology Pediatrics
Medical Director, Apheresis and Stem Cell Laboratory
Medical City Dallas Hospital
Dallas, Texas
Dr. Weinthal reports that he is on the speakers’ bureau and advisory board, and a consultant, for CBR®, Cord Blood Registry®.
Click Here to Read the Supplement.
Postpartum NSAIDs didn’t up hypertension risk in preeclampsia
Women with severe preeclampsia who received nonsteroidal anti-inflammatory drugs during the postpartum period had no greater risk of persistent postpartum hypertension than women who didn’t take them, a study showed.
Additionally, though the numbers of women affected were small, there was no increased risk of severe maternal morbidity. Rates of pulmonary hypertension, renal failure, eclampsia, or intensive care unit admission were similar between women who received NSAIDs during the postpartum period and women who did not.
The single-center retrospective cohort study examined the records of 399 women with severe preeclampsia, 324 of whom (81%) were still hypertensive 24 hours post delivery (Obstet Gynecol. 2017;130:830-5. doi: 10.1097/AOG.0000000000002247). Of this group, three-quarters (n = 243) received NSAIDs, while one-quarter (n = 81) did not.
After multivariable analysis, first author Oscar Viteri, MD, and his colleagues reported that 70% of patients who received NSAIDs had persistent postpartum hypertension, defined as a blood pressure of at least 150 mm Hg or a diastolic BP of at least 100 mm Hg obtained on two occasions at least 4 hours apart. This compared with a rate of 73% for the women who did not receive NSAIDs (adjusted odds ratio, 1.1; 95% confidence interval [CI], 0.6-2.0; P = .57).
Relatively small numbers of women in each group experienced severe morbidity, limiting statistical analysis of these secondary outcome measures. Just six women who received NSAIDs and eight who did not (3% and 10%) developed pulmonary edema (OR, 4.4; 95% CI, 1.5-13.1).
Renal dysfunction occurred in 5% of the NSAIDs users vs. 8% of the nonusers (OR, 1.7; 95% CI, 0.6-4.8), and eclampsia occurred in two patients who took NSAIDs and none of the nonusers. Of those who took NSAIDs, 3% had an intensive care unit admission, compared with 8% of those who did not take these drugs (OR 2.4; 95% CI, 0.8-7.1).
Dr. Viteri and his coauthors at the University of Texas Health Science Center, Houston, noted that a high proportion of women with severe preeclampsia received ibuprofen (40%), ketorolac (6%), or both (54%) during their postpartum hospital stay. This occurred despite a 2013 recommendation from the American College of Obstetricians and Gynecologists Task Force for Hypertension in Pregnancy urging clinicians to avoid NSAIDs in women with hypertension persisting for 24 hours post partum.
In nonpregnant women with hypertension who are taking beta-blockers or angiotensin-converting enzyme inhibitors, NSAIDs use has been associated with increased systolic and diastolic blood pressure, said Dr. Viteri and his colleagues. There are several plausible physiologic mechanisms for this effect, including increased renal sodium retention from inhibition of prostaglandin E2. This potential effect, in particular, may have implications for women in the puerperum, since 6-8 L of fluid are returned to the maternal intravascular space during the early postpartum period.
However, “evidence on the effects of NSAIDs in otherwise healthy puerperal women with preeclampsia before delivery remains conflicting,” the investigators wrote. This study helps to fill the knowledge gap, though there are some limitations, including the fact that the non-NSAIDs arm was small, leaving an unbalanced study that was underpowered to detect differences in “rare but clinically significant” severe maternal morbidity. Also, the study captured only the inpatient period; because the mean duration of hospital stay was 4.5 days, the study missed a portion of the window of fluid volume redistribution, which occurs mostly during postpartum days 3-6.
Still, the findings from this large retrospective study warrant an adequately powered clinical trial to settle the question of the safety of NSAIDs for women with preeclampsia, the investigators said.
Dr. Viteri and his colleagues reported having no relevant conflicts of interest.
Women with severe preeclampsia who received nonsteroidal anti-inflammatory drugs during the postpartum period had no greater risk of persistent postpartum hypertension than women who didn’t take them, a study showed.
Additionally, though the numbers of women affected were small, there was no increased risk of severe maternal morbidity. Rates of pulmonary hypertension, renal failure, eclampsia, or intensive care unit admission were similar between women who received NSAIDs during the postpartum period and women who did not.
The single-center retrospective cohort study examined the records of 399 women with severe preeclampsia, 324 of whom (81%) were still hypertensive 24 hours post delivery (Obstet Gynecol. 2017;130:830-5. doi: 10.1097/AOG.0000000000002247). Of this group, three-quarters (n = 243) received NSAIDs, while one-quarter (n = 81) did not.
After multivariable analysis, first author Oscar Viteri, MD, and his colleagues reported that 70% of patients who received NSAIDs had persistent postpartum hypertension, defined as a blood pressure of at least 150 mm Hg or a diastolic BP of at least 100 mm Hg obtained on two occasions at least 4 hours apart. This compared with a rate of 73% for the women who did not receive NSAIDs (adjusted odds ratio, 1.1; 95% confidence interval [CI], 0.6-2.0; P = .57).
Relatively small numbers of women in each group experienced severe morbidity, limiting statistical analysis of these secondary outcome measures. Just six women who received NSAIDs and eight who did not (3% and 10%) developed pulmonary edema (OR, 4.4; 95% CI, 1.5-13.1).
Renal dysfunction occurred in 5% of the NSAIDs users vs. 8% of the nonusers (OR, 1.7; 95% CI, 0.6-4.8), and eclampsia occurred in two patients who took NSAIDs and none of the nonusers. Of those who took NSAIDs, 3% had an intensive care unit admission, compared with 8% of those who did not take these drugs (OR 2.4; 95% CI, 0.8-7.1).
Dr. Viteri and his coauthors at the University of Texas Health Science Center, Houston, noted that a high proportion of women with severe preeclampsia received ibuprofen (40%), ketorolac (6%), or both (54%) during their postpartum hospital stay. This occurred despite a 2013 recommendation from the American College of Obstetricians and Gynecologists Task Force for Hypertension in Pregnancy urging clinicians to avoid NSAIDs in women with hypertension persisting for 24 hours post partum.
In nonpregnant women with hypertension who are taking beta-blockers or angiotensin-converting enzyme inhibitors, NSAIDs use has been associated with increased systolic and diastolic blood pressure, said Dr. Viteri and his colleagues. There are several plausible physiologic mechanisms for this effect, including increased renal sodium retention from inhibition of prostaglandin E2. This potential effect, in particular, may have implications for women in the puerperum, since 6-8 L of fluid are returned to the maternal intravascular space during the early postpartum period.
However, “evidence on the effects of NSAIDs in otherwise healthy puerperal women with preeclampsia before delivery remains conflicting,” the investigators wrote. This study helps to fill the knowledge gap, though there are some limitations, including the fact that the non-NSAIDs arm was small, leaving an unbalanced study that was underpowered to detect differences in “rare but clinically significant” severe maternal morbidity. Also, the study captured only the inpatient period; because the mean duration of hospital stay was 4.5 days, the study missed a portion of the window of fluid volume redistribution, which occurs mostly during postpartum days 3-6.
Still, the findings from this large retrospective study warrant an adequately powered clinical trial to settle the question of the safety of NSAIDs for women with preeclampsia, the investigators said.
Dr. Viteri and his colleagues reported having no relevant conflicts of interest.
Women with severe preeclampsia who received nonsteroidal anti-inflammatory drugs during the postpartum period had no greater risk of persistent postpartum hypertension than women who didn’t take them, a study showed.
Additionally, though the numbers of women affected were small, there was no increased risk of severe maternal morbidity. Rates of pulmonary hypertension, renal failure, eclampsia, or intensive care unit admission were similar between women who received NSAIDs during the postpartum period and women who did not.
The single-center retrospective cohort study examined the records of 399 women with severe preeclampsia, 324 of whom (81%) were still hypertensive 24 hours post delivery (Obstet Gynecol. 2017;130:830-5. doi: 10.1097/AOG.0000000000002247). Of this group, three-quarters (n = 243) received NSAIDs, while one-quarter (n = 81) did not.
After multivariable analysis, first author Oscar Viteri, MD, and his colleagues reported that 70% of patients who received NSAIDs had persistent postpartum hypertension, defined as a blood pressure of at least 150 mm Hg or a diastolic BP of at least 100 mm Hg obtained on two occasions at least 4 hours apart. This compared with a rate of 73% for the women who did not receive NSAIDs (adjusted odds ratio, 1.1; 95% confidence interval [CI], 0.6-2.0; P = .57).
Relatively small numbers of women in each group experienced severe morbidity, limiting statistical analysis of these secondary outcome measures. Just six women who received NSAIDs and eight who did not (3% and 10%) developed pulmonary edema (OR, 4.4; 95% CI, 1.5-13.1).
Renal dysfunction occurred in 5% of the NSAIDs users vs. 8% of the nonusers (OR, 1.7; 95% CI, 0.6-4.8), and eclampsia occurred in two patients who took NSAIDs and none of the nonusers. Of those who took NSAIDs, 3% had an intensive care unit admission, compared with 8% of those who did not take these drugs (OR 2.4; 95% CI, 0.8-7.1).
Dr. Viteri and his coauthors at the University of Texas Health Science Center, Houston, noted that a high proportion of women with severe preeclampsia received ibuprofen (40%), ketorolac (6%), or both (54%) during their postpartum hospital stay. This occurred despite a 2013 recommendation from the American College of Obstetricians and Gynecologists Task Force for Hypertension in Pregnancy urging clinicians to avoid NSAIDs in women with hypertension persisting for 24 hours post partum.
In nonpregnant women with hypertension who are taking beta-blockers or angiotensin-converting enzyme inhibitors, NSAIDs use has been associated with increased systolic and diastolic blood pressure, said Dr. Viteri and his colleagues. There are several plausible physiologic mechanisms for this effect, including increased renal sodium retention from inhibition of prostaglandin E2. This potential effect, in particular, may have implications for women in the puerperum, since 6-8 L of fluid are returned to the maternal intravascular space during the early postpartum period.
However, “evidence on the effects of NSAIDs in otherwise healthy puerperal women with preeclampsia before delivery remains conflicting,” the investigators wrote. This study helps to fill the knowledge gap, though there are some limitations, including the fact that the non-NSAIDs arm was small, leaving an unbalanced study that was underpowered to detect differences in “rare but clinically significant” severe maternal morbidity. Also, the study captured only the inpatient period; because the mean duration of hospital stay was 4.5 days, the study missed a portion of the window of fluid volume redistribution, which occurs mostly during postpartum days 3-6.
Still, the findings from this large retrospective study warrant an adequately powered clinical trial to settle the question of the safety of NSAIDs for women with preeclampsia, the investigators said.
Dr. Viteri and his colleagues reported having no relevant conflicts of interest.
FROM OBSTETRICS AND GYNECOLOGY
Key clinical point:
Major finding: In total, 70% of women with severe preeclampsia taking NSAIDs, and 73% of those who did not, had persistent postpartum hypertension.
Study details: A retrospective cohort study of 324 women with severe preeclampsia who remained hypertensive for more than 24 hours after delivery.
Disclosures: None of the study authors reported having relevant conflicts of interest.
Capillary leakage predicts hysterectomy in postpartum group A strep
PARK CITY, UTAH – Systemic capillary leakage – which involves acute respiratory distress, ascites, pleural effusion, and abdominal distention – significantly increases the risk of hysterectomy in women with postpartum group A Streptococcus infection, according to findings from a single-site study.
The investigators at the University of Utah in Salt Lake City analyzed 71 cases of culture-proven infection at the university since 1991. They compared the 33 women who had hysterectomies, ICU admissions, pressor support, or mechanical ventilation with the 38 women who did not.
The goal was to identify predictors of poor outcomes and clarify when hysterectomy is the appropriate clinical decision. “These are young women, and it might have been their first pregnancy. You don’t want to remove their uterus if they don’t need it, but we know if women get really sick, they need that source control within 6-12 hours of presentation,” said Jennifer Kaiser, MD, the study’s lead investigator and an ob.gyn. fellow at the University of Utah.
“Capillary leak is an important objective clinical parameter that should be evaluated and considered with due exigency. I think this has not been well recognized,” Dr. Kaiser said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. The finding “should prompt you to mobilize a team for hysterectomy, or if you are at a smaller hospital, to think about transporting the patient to a higher level hospital that can perform hysterectomy and offer ICU care,” she added.
The investigators also found that a traditional marker for severe infection – uterine and cervical motion tenderness – did not predict adverse outcomes among the 71 women. Many patients with severe disease don’t actually have tenderness, Dr. Kaiser said.
It also didn’t matter whether the organism was isolated from the uterus or the blood. It’s sometimes thought uterine positivity predicts “worse prognosis, but that didn’t pan out,” she said.
Capillary leakage was a concern in 27 (82%) of the 33 women who had adverse outcomes, compared with 7 (18%) of the women who fared better, and included acute respiratory distress (30% versus 0%); ascites (73% versus 3%); pleural effusion (58% versus 5%), and abdominal distention (61% versus 18%). In total, 21 of the 33 women with adverse outcomes (64%) had hysterectomies. There were no deaths in the group.
Postpartum group A Streptococcus infections are more common in Utah than in other parts of the country, and it’s not known why. The next step for the investigators is to look at genealogies and genetic factors that may predispose women to severe infections, Dr. Kaiser said.
There was no industry funding for the work and Dr. Kaiser reported having no relevant financial disclosures.
PARK CITY, UTAH – Systemic capillary leakage – which involves acute respiratory distress, ascites, pleural effusion, and abdominal distention – significantly increases the risk of hysterectomy in women with postpartum group A Streptococcus infection, according to findings from a single-site study.
The investigators at the University of Utah in Salt Lake City analyzed 71 cases of culture-proven infection at the university since 1991. They compared the 33 women who had hysterectomies, ICU admissions, pressor support, or mechanical ventilation with the 38 women who did not.
The goal was to identify predictors of poor outcomes and clarify when hysterectomy is the appropriate clinical decision. “These are young women, and it might have been their first pregnancy. You don’t want to remove their uterus if they don’t need it, but we know if women get really sick, they need that source control within 6-12 hours of presentation,” said Jennifer Kaiser, MD, the study’s lead investigator and an ob.gyn. fellow at the University of Utah.
“Capillary leak is an important objective clinical parameter that should be evaluated and considered with due exigency. I think this has not been well recognized,” Dr. Kaiser said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. The finding “should prompt you to mobilize a team for hysterectomy, or if you are at a smaller hospital, to think about transporting the patient to a higher level hospital that can perform hysterectomy and offer ICU care,” she added.
The investigators also found that a traditional marker for severe infection – uterine and cervical motion tenderness – did not predict adverse outcomes among the 71 women. Many patients with severe disease don’t actually have tenderness, Dr. Kaiser said.
It also didn’t matter whether the organism was isolated from the uterus or the blood. It’s sometimes thought uterine positivity predicts “worse prognosis, but that didn’t pan out,” she said.
Capillary leakage was a concern in 27 (82%) of the 33 women who had adverse outcomes, compared with 7 (18%) of the women who fared better, and included acute respiratory distress (30% versus 0%); ascites (73% versus 3%); pleural effusion (58% versus 5%), and abdominal distention (61% versus 18%). In total, 21 of the 33 women with adverse outcomes (64%) had hysterectomies. There were no deaths in the group.
Postpartum group A Streptococcus infections are more common in Utah than in other parts of the country, and it’s not known why. The next step for the investigators is to look at genealogies and genetic factors that may predispose women to severe infections, Dr. Kaiser said.
There was no industry funding for the work and Dr. Kaiser reported having no relevant financial disclosures.
PARK CITY, UTAH – Systemic capillary leakage – which involves acute respiratory distress, ascites, pleural effusion, and abdominal distention – significantly increases the risk of hysterectomy in women with postpartum group A Streptococcus infection, according to findings from a single-site study.
The investigators at the University of Utah in Salt Lake City analyzed 71 cases of culture-proven infection at the university since 1991. They compared the 33 women who had hysterectomies, ICU admissions, pressor support, or mechanical ventilation with the 38 women who did not.
The goal was to identify predictors of poor outcomes and clarify when hysterectomy is the appropriate clinical decision. “These are young women, and it might have been their first pregnancy. You don’t want to remove their uterus if they don’t need it, but we know if women get really sick, they need that source control within 6-12 hours of presentation,” said Jennifer Kaiser, MD, the study’s lead investigator and an ob.gyn. fellow at the University of Utah.
“Capillary leak is an important objective clinical parameter that should be evaluated and considered with due exigency. I think this has not been well recognized,” Dr. Kaiser said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. The finding “should prompt you to mobilize a team for hysterectomy, or if you are at a smaller hospital, to think about transporting the patient to a higher level hospital that can perform hysterectomy and offer ICU care,” she added.
The investigators also found that a traditional marker for severe infection – uterine and cervical motion tenderness – did not predict adverse outcomes among the 71 women. Many patients with severe disease don’t actually have tenderness, Dr. Kaiser said.
It also didn’t matter whether the organism was isolated from the uterus or the blood. It’s sometimes thought uterine positivity predicts “worse prognosis, but that didn’t pan out,” she said.
Capillary leakage was a concern in 27 (82%) of the 33 women who had adverse outcomes, compared with 7 (18%) of the women who fared better, and included acute respiratory distress (30% versus 0%); ascites (73% versus 3%); pleural effusion (58% versus 5%), and abdominal distention (61% versus 18%). In total, 21 of the 33 women with adverse outcomes (64%) had hysterectomies. There were no deaths in the group.
Postpartum group A Streptococcus infections are more common in Utah than in other parts of the country, and it’s not known why. The next step for the investigators is to look at genealogies and genetic factors that may predispose women to severe infections, Dr. Kaiser said.
There was no industry funding for the work and Dr. Kaiser reported having no relevant financial disclosures.
AT IDSOG
Key clinical point:
Major finding: Signs of capillary leakage were predictive of adverse outcomes (OR 19.93, 95% CI 5.96-66.57, P less than .0001), specifically hysterectomy (OR 51.43, 95% CI 6.29-420.41, P less than .002).
Data source: A review of 71 cases of culture-proven infection at the University of Utah.
Disclosures: There was no industry funding for the work and the lead investigator reported having no relevant financial disclosures.
Domperidone appears safe galactagogue for mothers and infants
Denver – Prescribing domperidone to support breastfeeding effectively reduced the use of infant formula without significant adverse effects in mothers and infants in a large retrospective study, Mitko Madjunkov, MD, reported at the annual meeting of the Teratology Society.
His study included 985 mothers who began taking domperidone to initiate and support breastfeeding after a visit to the International Breastfeeding Centre in Toronto. Collectively, the women had 1,005 infants.
The study was undertaken because few data exist on the dosing and safety of domperidone during lactation. Additionally, the Food and Drug Administration issued a warning in 2004 regarding the use of domperidone as a galactagogue in response to reports of cardiac arrhythmias and sudden deaths when the drug was prescribed as an antiemetic, explained Dr. Madjunkov of the Hospital for Sick Children in Toronto.
The FDA has not approved domperidone for any indication in the United States, though it is available in Canada and other countries.
Domperidone was used by the Toronto women for a median of 20 days. The maximum daily dose was 107 mg. The infants were an average of 38 days old at the time of the visit when domperidone was prescribed and 72 days of age at their last follow-up visit related to the study.
The drug was effective as a galactagogue: 63% of women were using infant formula before going on domperidone; after using the drug, 41% were still using formula, for an absolute 22% reduction. The drug was similarly effective in promoting breastfeeding in infants with or without tongue-tie/lip-tie defects.
In total, 18% of mothers reported minor side effects. Headaches were the most common, reported by 9.2% of domperidone users. Dose reduction was employed in just 0.6% of women in the study; 0.4% of participants discontinued treatment. Rapid heart rate and other minor cardiac side effects were reported by 0.7% of women, uniformly in conjunction with trigger factors such as anxiety or caffeine use, but none of these women discontinued treatment. No treatment-associated adverse effects occurred in the infants.
Dr. Madjunkov reported having no financial conflicts related to his study.
Denver – Prescribing domperidone to support breastfeeding effectively reduced the use of infant formula without significant adverse effects in mothers and infants in a large retrospective study, Mitko Madjunkov, MD, reported at the annual meeting of the Teratology Society.
His study included 985 mothers who began taking domperidone to initiate and support breastfeeding after a visit to the International Breastfeeding Centre in Toronto. Collectively, the women had 1,005 infants.
The study was undertaken because few data exist on the dosing and safety of domperidone during lactation. Additionally, the Food and Drug Administration issued a warning in 2004 regarding the use of domperidone as a galactagogue in response to reports of cardiac arrhythmias and sudden deaths when the drug was prescribed as an antiemetic, explained Dr. Madjunkov of the Hospital for Sick Children in Toronto.
The FDA has not approved domperidone for any indication in the United States, though it is available in Canada and other countries.
Domperidone was used by the Toronto women for a median of 20 days. The maximum daily dose was 107 mg. The infants were an average of 38 days old at the time of the visit when domperidone was prescribed and 72 days of age at their last follow-up visit related to the study.
The drug was effective as a galactagogue: 63% of women were using infant formula before going on domperidone; after using the drug, 41% were still using formula, for an absolute 22% reduction. The drug was similarly effective in promoting breastfeeding in infants with or without tongue-tie/lip-tie defects.
In total, 18% of mothers reported minor side effects. Headaches were the most common, reported by 9.2% of domperidone users. Dose reduction was employed in just 0.6% of women in the study; 0.4% of participants discontinued treatment. Rapid heart rate and other minor cardiac side effects were reported by 0.7% of women, uniformly in conjunction with trigger factors such as anxiety or caffeine use, but none of these women discontinued treatment. No treatment-associated adverse effects occurred in the infants.
Dr. Madjunkov reported having no financial conflicts related to his study.
Denver – Prescribing domperidone to support breastfeeding effectively reduced the use of infant formula without significant adverse effects in mothers and infants in a large retrospective study, Mitko Madjunkov, MD, reported at the annual meeting of the Teratology Society.
His study included 985 mothers who began taking domperidone to initiate and support breastfeeding after a visit to the International Breastfeeding Centre in Toronto. Collectively, the women had 1,005 infants.
The study was undertaken because few data exist on the dosing and safety of domperidone during lactation. Additionally, the Food and Drug Administration issued a warning in 2004 regarding the use of domperidone as a galactagogue in response to reports of cardiac arrhythmias and sudden deaths when the drug was prescribed as an antiemetic, explained Dr. Madjunkov of the Hospital for Sick Children in Toronto.
The FDA has not approved domperidone for any indication in the United States, though it is available in Canada and other countries.
Domperidone was used by the Toronto women for a median of 20 days. The maximum daily dose was 107 mg. The infants were an average of 38 days old at the time of the visit when domperidone was prescribed and 72 days of age at their last follow-up visit related to the study.
The drug was effective as a galactagogue: 63% of women were using infant formula before going on domperidone; after using the drug, 41% were still using formula, for an absolute 22% reduction. The drug was similarly effective in promoting breastfeeding in infants with or without tongue-tie/lip-tie defects.
In total, 18% of mothers reported minor side effects. Headaches were the most common, reported by 9.2% of domperidone users. Dose reduction was employed in just 0.6% of women in the study; 0.4% of participants discontinued treatment. Rapid heart rate and other minor cardiac side effects were reported by 0.7% of women, uniformly in conjunction with trigger factors such as anxiety or caffeine use, but none of these women discontinued treatment. No treatment-associated adverse effects occurred in the infants.
Dr. Madjunkov reported having no financial conflicts related to his study.
EXPERT ANALYSIS FROM TERATOLOGY SOCIETY 2017
Key clinical point:
Major finding: The use of the domperidone reduced the proportion of women using infant formula by an absolute 22%.
Data source: A retrospective study of 985 women who were prescribed domperidone as a galactagogue at the International Breastfeeding Centre in Toronto.
Disclosures: Dr. Madjunkov reported having no financial conflicts of interest related to the study.
Study: Don’t separate NAS infants from moms
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
AT PHM 2017
Key clinical point:
Major finding: Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from, in one study, a mean of almost $45,000 per NAS infant stay to just over $10,000.
Data source: A meta-analysis of six studies.
Disclosures: The investigators had no relevant financial disclosures.