lunedì 10 novembre 2008
mercoledì 5 novembre 2008
Obama President of America
Obama has won!!!!
President of America.
The world is changing, eventually!!!!!!!!
martedì 4 novembre 2008
Vaccinazione contro il papillomavirus umano
***Dalle ultime news del NIV La vaccinazione contro il papillomavirus umano - Ragioni per essere cauti Nonostante le grandi aspettative ed i promettenti risultati dei trials clinici, non vi sono ancora sufficienti evidence di un vaccino efficace contro carcinoma cervicale. Diversi ceppi di papillomavirus umano (HPV) possono causare il tumore al collo dell'utero e due vaccini sono disponibili contro i più importanti ceppi oncogenici, i sierotipi HPV-16 e HPV-18 Questa è la buona notizia. La cattiva notizia è che l'effetto complessivo dei vaccini sul tumore cervicale rimane sconosciuto. Come Kim e Goldie1 sottolineano in questo numero del Journal l'impatto reale della vaccinazione antiHPV sul tumore cervicale non sarà osservabile ancora per decenni.Sebbene negli Stati Uniti ne sia stato autorizzato dal giugno 2006, i risultati della prima fase 3 della sperimentazione del vaccino antiHPV con end point finali clinicamente rilevanti - neoplasia intraepiteliale cervicaledi grado 2 e 3 (CIN 2 e 3)- non sono stati disponibili fino al maggio 2007, prima nel Journal e il mese successivo sul Lancet. Il vaccino ha avuto un grande successo nel ridurre l'incidenza delle lesioni cervicali precancerose causate da HPV-16 e HPV-18, ma una serie di domande critiche sono rimaste senza risposta. Per esempio, il vaccino può prevenire non solo le lesioni cervicali, ma anche i tumori del collo dell'utero e l'eventuale morte della donna? Quanto tempo dura la protezione conferita? Considerando che la maggior parte delle infezioni HPV sono risolte spontaneamente dal sistema immunitario, la vaccinazione come influenza l'immunità naturale contro l’HPV e con quali conseguenze? Come inciderà il vaccino sulle ragazzepreadolescenti, dato che i soli esperimenti effettuati in questa coorte sono stati sulla risposta immunitaria? Gli studi clinici con end points (quali ad es. CIN 2/3) hanno coinvolto donne nella fascia di 16-24 anni. Come influenzerà la vaccinazione i programmi di screening? Poiché i vaccini proteggono solo da 2 dei ceppi oncogenici di HPV, le donne devono continuare ad essere screenate per le lesioni cervicali? Le donne vaccinate possono sentirsi protette dal tumore del collo dell'utero e potrebbe esserci un probabile minor ricorso allo screening rispetto alle non vaccinate. Come inciderà il vaccino sugli altri ceppi oncogenici di HPV? Se i sierotipi HPV-16 e HPV-18 saranno eliminati in modo efficace, ci sarà una pressione selettiva sui restanti ceppi di HPV? Altri ceppi inoltre potrebbero emergere come sierotipi oncogenici significativi.Risolvere la prima essenziale questione richiederà decenni di osservazione di un gran numero di donne. L'ultima questione può essere risolta prima: i risultati pubblicati di trials mostrano un trend in aumento per le lesioni precancerose causate da sierotipi di HPV diversi dal 16 e dal 18. I risultati non sono stati statisticamente significativi, forse perché gli end point finali sono ancora poco numerosi nel periodo considerato. Se gli studi clinici randomizzati controllati che coinvolgono donne vaccinate e non vaccinate continueranno ancora per qualche anno, si sarà probabilmente in grado di confermare questo trend. Se così fosse, vi sarebbe motivo di seria preoccupazione. Dall'estate del 2007 vi sono stati sicuramente risultati promettenti per quanto riguarda l'efficacia pratica del vaccino HPV nella prevenzione delle lesioni precancerose (es.CIN 2e3) causate dai sierotipi HPV-16 e HPV-18. Tuttavia, rimangono seri interrogativi ai quali occorre dare risposta per quanto concerne l'efficacia del vaccino per la protezione contro il tumore al collo dell'utero , e pertanto si dovrebbero condurre un numero maggiore di studi a lungo termine prima di raccomandare programmi di vaccinazione su larga scala. Purtroppo fino ad ora non sono stati pubblicati risultati di studi a lungo termine. Nel frattempo, ci sono state pressioni sui responsabili politici di tutto il mondo per introdurre il vaccino HPV nei programmi di vaccinazione. Come possono i responsabili politici fare scelte razionali circa l'introduzione di interventi medici che potrebbero fare bene in futuro, ma per i quali le evidenze sono ancora insufficienti, in particolare perchè noi non sapremo per molti anni se l'intervento funziona o se - nella peggiore delle ipotesi - sia dannoso? Un modo per fornire un supporto alle decisioni è quello di sviluppare modelli matematici della storia naturale della malattia in questione, introdurre le diverse strategie di intervento e utilizzare analisi costo-efficacia per stimare costi e benefici per la salute associati a ciascun intervento. I risultati si esprimono solitamente in termini di importo che si dovrà pagare per in saluto legato al trattamento specifico, vale a dire i dollari spesi per ogni anno di vita salvato o la qualità di vita adeguata-anno (QALY). In condizioni di incertezza queste analisi del rapporto costo-efficacia possono essere strumenti per il processo decisionale, ma in sè non forniscono la prova che gli interventi medici valutati siano efficaci. In questo numero del Journal Kim e Goldie presentano un modello di vaccinazione antiHPV e si avvalgono di una analisi costo-efficacia per fare proiezioni sui possibili effetti di salute ed economici relativi all'uso del vaccino. Per valutare la qualità dell'analisi del rapporto costo-efficacia, è essenziale considerare le variabili inserite nel modello, le incertezze e le possibili scelte, come i ricercatori hanno fatto. Preparare l’analisi di un intervento sanitario preventivo - in questo caso il vaccino somministrato a ragazze di 12 anni- che potrebbe avere un effetto dopo decenni sull’incidenza del carcinoma della cervice è estremamente complesso. L’ analisi deve considerare la storia naturale di infezione da HPV in questa coorte di ragazze nel corso della loro vita, l’effetto del vaccino su tutti quegli anni, l’effetto sugli altri ceppi di HPV, l’effetto del vaccino sulla immunità naturale contro le infezioni da HPV, il comportamento sessuale delle ragazze e delle donne nonché dei loro partner e infine i programmi di screening. Il modello presentato da Kim e Goldie è ben fatto e ambizioso e comprende la maggior parte di questi fattori. I ricercatori concludono che, in alcune ipotesi, la vaccinazione delle ragazze di 12 anni si associato ad un incrementale rapporto costo-efficacia di $ 43.600 per QALY guadagnato, mentre l’aggiunta di un programma catch-up per in ragazze più grandi o donne non è cost-effective. Tuttavia, le assunzioni di partenza dei ricercatori sono piuttosto ottimistiche in quanto si presume che:-il vaccino protegga per tutta la vita (senza necessità di richiami)-si abbia lo stesso effetto sia sulle ragazze preadolescenti che su donne anziane-non si verifichi sostituzione con altri ceppi oncogenici di HPV-le donne vaccinate continuino a partecipare ai programmi di screening-l’immunità naturale contro HPV non venga influenzata.Quanto queste ipotesi siano ragionevoli o meno, è esattamente ciò che dovrà essere testato nei trials e negli studi di follow-up. Se le ipotesi di partenza degli autori non sono corrette, la vaccinazione diventa meno favorevole e anche meno efficace del solo screening. Ad esempio se la protezione del vaccino venisse meno dopo i 10 anni, la vaccinazione diventa molto meno costo-efficace e i programmi di screening sono più efficace dei programmi di catch-up. Con così tante domande essenziali ancora senza risposta, vi sono buoni motivi per essere cauti circa l’introduzione su larga scala dei programmi di vaccinazione. Ci si dovrebbe invece concentrare su come trovare risposte più solide attraverso la ricerca, piuttosto che su decisioni costose conseguenti ad ipotesi ancora da provare.Segnalato e riassunto da Nicoletta Bertozzi, Dipartimento di sanità Pubblica, AUSL Cesena Fonte :Charlotte J. HaugHuman Papillomavirus Vaccination — Reasons for CautionN ew England Journal of Medicine Volume 359;8, 21 agosto 2008 Riferimento :Leggi l'articolo sul NEJM
mercoledì 29 ottobre 2008
A glass of milk
GRATITUDE AND UNCONDITIONAL LOVE IS ONE OF THE MOST MOST IMPARTANT VALUES'.ONE NEED TO SPREAD AND INCULCATE THIS VALUS UNTO ONE'S LIFE.
THIS IS MY DESIRE.
One day, a poor boy who was selling goods from door to door to pay his way through school, found he had only one thin dime left, and he was hungry.
He decided he would ask for a meal at the next house. However, he lost
his nerve when a lovely young woman opened the door.
Instead of a meal he asked for a drink of water. She thought he looked hungry
so brought him a large glass of milk. He drank it slowly, and then asked,
How much do I owe you?
"You don't owe me anything," she replied. "Mother has taught us
never toaccept pay for a kindness.
"He said..... "Then I thank you from my heart.
"As Howard Kelly left that house, he not only felt stronger physically, but his faith in God and man was strong also. He had been ready to give up and quit.
Many year's later that same young woman became critically ill. The local doctors were baffled. They finally sent her to the big city, where they called in
specialists to study her rare disease.
Dr. Howard Kelly was called in for the consultation. When he heard the name of the town she came from, a strange light filled his eyes. Immediately
he rose and went down the hall of the hospital to her room.
Dressed in his doctor's gown he went in to see her.
He recognized her at once.
He went back to the consultation room determined to do his best to save her life. From that day he gave special attention to her case.
After a long struggle, the battle was won.
Dr. Kelly requested the business office to pass the final bill to him for approval.
He looked at it, then wrote something on the edge and the bill was sent to her room. She feared to open it, for she was sure it would take the
rest of her life to pay for it all. Finally she looked,
and something caught her attention on the
side of the bill. She read these words.....
"Paid in full with one glass of milk" ........ (Signed) Dr. Howard Kelly.
Tears of joy flooded her eyes as her happy heart prayed: "Thank You, God, that
Your love has spread broad through human hearts and hands.
"There's a saying which goes something like this: Bread cast on the waters comes back to you. The good deed you do today may benefit you or
someone you love at the least expected time.
If you never see the deed again at least you will have made the
world a better place -And, after all, isn't that what life is all about?
Now you have two choices. You can send this page on and spread a positive message. Or ignore it and pretend it never touched your heart.
The hardest thing to learn in life is which bridge to cross and which to burn...
"If God brings you to it - He will bring you through it " - Denny
THIS IS MY DESIRE.
One day, a poor boy who was selling goods from door to door to pay his way through school, found he had only one thin dime left, and he was hungry.
He decided he would ask for a meal at the next house. However, he lost
his nerve when a lovely young woman opened the door.
Instead of a meal he asked for a drink of water. She thought he looked hungry
so brought him a large glass of milk. He drank it slowly, and then asked,
How much do I owe you?
"You don't owe me anything," she replied. "Mother has taught us
never toaccept pay for a kindness.
"He said..... "Then I thank you from my heart.
"As Howard Kelly left that house, he not only felt stronger physically, but his faith in God and man was strong also. He had been ready to give up and quit.
Many year's later that same young woman became critically ill. The local doctors were baffled. They finally sent her to the big city, where they called in
specialists to study her rare disease.
Dr. Howard Kelly was called in for the consultation. When he heard the name of the town she came from, a strange light filled his eyes. Immediately
he rose and went down the hall of the hospital to her room.
Dressed in his doctor's gown he went in to see her.
He recognized her at once.
He went back to the consultation room determined to do his best to save her life. From that day he gave special attention to her case.
After a long struggle, the battle was won.
Dr. Kelly requested the business office to pass the final bill to him for approval.
He looked at it, then wrote something on the edge and the bill was sent to her room. She feared to open it, for she was sure it would take the
rest of her life to pay for it all. Finally she looked,
and something caught her attention on the
side of the bill. She read these words.....
"Paid in full with one glass of milk" ........ (Signed) Dr. Howard Kelly.
Tears of joy flooded her eyes as her happy heart prayed: "Thank You, God, that
Your love has spread broad through human hearts and hands.
"There's a saying which goes something like this: Bread cast on the waters comes back to you. The good deed you do today may benefit you or
someone you love at the least expected time.
If you never see the deed again at least you will have made the
world a better place -And, after all, isn't that what life is all about?
Now you have two choices. You can send this page on and spread a positive message. Or ignore it and pretend it never touched your heart.
The hardest thing to learn in life is which bridge to cross and which to burn...
"If God brings you to it - He will bring you through it " - Denny
Promotion and support of breastfeeding
MEDLINE
Counseling Interventions Recommended to Promote and Support Breast-Feeding
News Author: Laurie Barclay, MDCME Author: Charles Vega, MD
Release Date: October 23, 2008;
Authors and Disclosures
Laurie Barclay, MDDisclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
Charles Vega, MDDisclosure: Charles Vega, MD, has disclosed an advisor/consultant relationship to Novartis, Inc.
Laurie Scudder, MS, NP-CDisclosure: Laurie Scudder, MS, NP-C, has disclosed no relevant financial information.
Brande Nicole MartinDisclosure: Brande Nicole Martin has disclosed no relevant financial information.
October 23, 2008 — The US Preventive Services Task Force (USPSTF) has issued an updated statement recommending counseling interventions during pregnancy and after birth to promote and support breast-feeding. The updated guidelines and evidence review are published in the October 21 issue of the Annals of Internal Medicine.
"In children, breastfeeding has been associated with a reduction in the risk for acute otitis media, nonspecific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, childhood leukemia, and the sudden infant death syndrome," write Mei Chung, MPH, from Tufts-New England Medical Center Evidence-Based Practice Center in Boston, Massachusetts, and coauthors of the accompanying evidence review. "In mothers, a history of lactation has been associated with a reduced risk for type 2 diabetes and breast and ovarian cancer. According to the American Academy of Pediatrics, some of the obstacles to initiation and continuation of breastfeeding include insufficient prenatal education about breastfeeding, disruptive maternity care practices, and lack of family and broad societal support."
The goal of the evidence review was to evaluate the efficacy of primary care–based interventions to promote breast-feeding in breast-feeding rates and child and maternal health outcomes.
The reviewers performed electronic searches of MEDLINE, the Cochrane Central Register of Controlled Trials, and CINAHL from September 2001 to February 2008 as well as references of selected articles. Inclusion criteria for the review were English-language publications describing randomized controlled trials of interventions initiated in primary care to promote breast-feeding, primarily in developed countries.
Pertinent data reviewed by the authors included characteristics of interventions and comparators, study setting and design, clinical and demographic characteristics of the study sample, the proportion of infants continuing to be breast-fed for various durations, and health outcomes in infant and mother.
Of 38 randomized controlled trials identified that met inclusion criteria, 36 took place in developed countries. Breast-feeding promotion interventions in developed countries were associated with significantly increased rates of short-term (1 - 3 months) and long-term (6 - 8 months) exclusive breast-feeding, based on random-effects meta-analyses. Rate ratios were 1.28 for short-term rates (95% confidence interval [CI], 1.11 - 1.48) and 1.44 for long-term rates (95% CI, 1.13 - 1.84).
Compared with either prenatal or postnatal interventions alone, combining prenatal and postnatal breast-feeding interventions had a greater effect on increasing breast-feeding durations, according to the results of subgroup analyses. In increasing the short-term breast-feeding rate, interventions associated with a component of lay support, such as peer support or peer counseling, were more effective than usual care.
Limitations of this review included clinical and methodologic heterogeneity, precluding extensive meta-analyses; and inability to obtain reliable estimates for the isolated effects of each component of multicomponent interventions.
"Evidence suggests that breastfeeding interventions are more effective than usual care in increasing short- and long-term breastfeeding rates," the review authors write. "Combined pre- and postnatal interventions and inclusion of lay support in a multicomponent intervention may be beneficial."
On the basis of the above-described systematic evidence review, the USPSTF evaluated the efficacy of interventions to promote and support breast-feeding that were initiated in, conducted in, or referred to primary care. The resulting guidelines are an update of the 2003 USPSTF recommendation on counseling to promote breast-feeding.
Because the USPSTF concluded that there was moderate certainty that interventions to promote and support breast-feeding have a moderate net benefit, the updated statement recommends interventions during pregnancy and after birth to promote and support breast-feeding (grade B level recommendation).
"There is convincing evidence that breastfeeding provides substantial health benefits for children and adequate evidence that breastfeeding provides moderate health benefits for women," write Ned Calonge, MD, MPH, from the Colorado Department of Public Health and Environment in Denver, and colleagues. "Adequate evidence indicates that interventions to promote and support breastfeeding increase the rates of initiation, duration, and exclusivity of breastfeeding. No published studies focus on the potential direct harms from interventions to promote and support breastfeeding."
Although the review did not include a search for possible harms associated with breast-feeding itself, the USPSTF concluded that the potential harms of interventions to promote and support breast-feeding were no greater than small.
The task force noted that interventions including both prenatal and postnatal components may be most effective at increasing duration of breast-feeding, and they also recommended considering multiple intervention strategies. These may include formal breast-feeding education for mothers and their families, direct support of mothers during breast-feeding, training primary care staff regarding breast-feeding and various techniques for breast-feeding support, and peer support.
"Although the activities of individual clinicians to promote and support breastfeeding are likely to be positive, additional benefit may result from efforts that are integrated into systems of care," the statement authors conclude. "System-level interventions can incorporate clinician and team member training and policy development, and through senior leadership support and institutionalization, these initiatives may be more likely to be sustained over time. Although outside the scope of this recommendation and evidence review, community-based interventions to promote and support breastfeeding, such as direct peer-to-peer support, social marketing initiatives, workplace initiatives, and public policy actions, may offer additional sizeable benefits."
The Agency for Healthcare Research and Quality, US Department of Health and Human Services, supported this evidence review and statement. The authors of the statement have disclosed no relevant financial relationships.
Ann Intern Med. 2008;149:560-564, 565-582.
Clinical Context
The American Academy of Pediatrics recommends breast milk as the preferred choice for feeding infants, and the goals of the Healthy People 2010 initiative includes a target of 75% of mothers initiating breast-feeding their infants. In the United States, the rate of new mothers initiating breast-feeding was 73% in 2005, and 20% of mothers breast-fed their infants exclusively for 12 months. These rates in 2005 were higher vs 2002.
In its last recommendation in 2003, the USPSTF recommended counseling to promote higher rates of breast-feeding. The current recommendation uses the results of a systematic review of data available from January 2007 to update this recommendation. The results of this review and new recommendation are described in the "Study Highlights."
Study Highlights
Breast-feeding has been associated with numerous health benefits for both mother and infant. Breast-feeding during infancy has been associated with lower rates of otitis media, respiratory tract infection, and gastrointestinal tract infection. Later in childhood, breast-fed children have a lower risk for asthma, obesity, and type 2 diabetes vs children who were not breast-fed. Finally, breast-feeding is associated with lower risks for breast and ovarian cancer in the mother.
The systematic review included 38 randomized controlled trials of primary care–initiated interventions to promote breast-feeding. Study settings included primary care offices, hospital settings, and patient homes. The majority of these studies were located in developed countries.
Overall, breast-feeding promotion increased the odds ratio of breast-feeding during 1 to 3 months by a factor of 1.28. These programs increased the odds ratio of breast-feeding during 6 to 8 months by 1.44.
One study from Belarus, a developing country, demonstrated that a program to promote breast-feeding not only improved rates of breast-feeding but also reduced rates of gastrointestinal tract infection and atopic dermatitis in children.
Many interventions used multiple modalities to promote breast-feeding, so it was difficult to identify the most effective individual tool to increase the rate of breast-feeding. However, interventions built into health systems seemed to be the most effective, and combining prenatal and postnatal interventions was more effective than either type of intervention alone.
Interventions involving lay workers appeared more effective than usual care in promoting higher rates of breast-feeding.
No harms were reported in research studying interventions to support breast-feeding.
Overall, the USPSTF gives a grade B recommendation to interventions to promote and support breast-feeding. This level means that there is a high certainty of a moderate degree of benefit for these interventions or that a moderate certainty that the benefit is moderate to substantial.
The authors of the current recommendation call for further research into the individual components of breast-feeding promotion programs as well as cost-benefit analyses of these programs.
Pearls for Practice
Breast-feeding during infancy has been associated with lower rates of otitis media, respiratory tract infection, and gastrointestinal tract infection. Later in childhood, breast-fed children have a lower risk for asthma, obesity, and type 2 diabetes vs children who were not breast-fed. Finally, breast-feeding is associated with lower risks for breast and ovarian cancer in the mother.
The USPSTF recommends measures to promote and support breast-feeding in the prenatal and postnatal periods (a grade B recommendation).
Counseling Interventions Recommended to Promote and Support Breast-Feeding
News Author: Laurie Barclay, MDCME Author: Charles Vega, MD
Release Date: October 23, 2008;
Authors and Disclosures
Laurie Barclay, MDDisclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
Charles Vega, MDDisclosure: Charles Vega, MD, has disclosed an advisor/consultant relationship to Novartis, Inc.
Laurie Scudder, MS, NP-CDisclosure: Laurie Scudder, MS, NP-C, has disclosed no relevant financial information.
Brande Nicole MartinDisclosure: Brande Nicole Martin has disclosed no relevant financial information.
October 23, 2008 — The US Preventive Services Task Force (USPSTF) has issued an updated statement recommending counseling interventions during pregnancy and after birth to promote and support breast-feeding. The updated guidelines and evidence review are published in the October 21 issue of the Annals of Internal Medicine.
"In children, breastfeeding has been associated with a reduction in the risk for acute otitis media, nonspecific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, childhood leukemia, and the sudden infant death syndrome," write Mei Chung, MPH, from Tufts-New England Medical Center Evidence-Based Practice Center in Boston, Massachusetts, and coauthors of the accompanying evidence review. "In mothers, a history of lactation has been associated with a reduced risk for type 2 diabetes and breast and ovarian cancer. According to the American Academy of Pediatrics, some of the obstacles to initiation and continuation of breastfeeding include insufficient prenatal education about breastfeeding, disruptive maternity care practices, and lack of family and broad societal support."
The goal of the evidence review was to evaluate the efficacy of primary care–based interventions to promote breast-feeding in breast-feeding rates and child and maternal health outcomes.
The reviewers performed electronic searches of MEDLINE, the Cochrane Central Register of Controlled Trials, and CINAHL from September 2001 to February 2008 as well as references of selected articles. Inclusion criteria for the review were English-language publications describing randomized controlled trials of interventions initiated in primary care to promote breast-feeding, primarily in developed countries.
Pertinent data reviewed by the authors included characteristics of interventions and comparators, study setting and design, clinical and demographic characteristics of the study sample, the proportion of infants continuing to be breast-fed for various durations, and health outcomes in infant and mother.
Of 38 randomized controlled trials identified that met inclusion criteria, 36 took place in developed countries. Breast-feeding promotion interventions in developed countries were associated with significantly increased rates of short-term (1 - 3 months) and long-term (6 - 8 months) exclusive breast-feeding, based on random-effects meta-analyses. Rate ratios were 1.28 for short-term rates (95% confidence interval [CI], 1.11 - 1.48) and 1.44 for long-term rates (95% CI, 1.13 - 1.84).
Compared with either prenatal or postnatal interventions alone, combining prenatal and postnatal breast-feeding interventions had a greater effect on increasing breast-feeding durations, according to the results of subgroup analyses. In increasing the short-term breast-feeding rate, interventions associated with a component of lay support, such as peer support or peer counseling, were more effective than usual care.
Limitations of this review included clinical and methodologic heterogeneity, precluding extensive meta-analyses; and inability to obtain reliable estimates for the isolated effects of each component of multicomponent interventions.
"Evidence suggests that breastfeeding interventions are more effective than usual care in increasing short- and long-term breastfeeding rates," the review authors write. "Combined pre- and postnatal interventions and inclusion of lay support in a multicomponent intervention may be beneficial."
On the basis of the above-described systematic evidence review, the USPSTF evaluated the efficacy of interventions to promote and support breast-feeding that were initiated in, conducted in, or referred to primary care. The resulting guidelines are an update of the 2003 USPSTF recommendation on counseling to promote breast-feeding.
Because the USPSTF concluded that there was moderate certainty that interventions to promote and support breast-feeding have a moderate net benefit, the updated statement recommends interventions during pregnancy and after birth to promote and support breast-feeding (grade B level recommendation).
"There is convincing evidence that breastfeeding provides substantial health benefits for children and adequate evidence that breastfeeding provides moderate health benefits for women," write Ned Calonge, MD, MPH, from the Colorado Department of Public Health and Environment in Denver, and colleagues. "Adequate evidence indicates that interventions to promote and support breastfeeding increase the rates of initiation, duration, and exclusivity of breastfeeding. No published studies focus on the potential direct harms from interventions to promote and support breastfeeding."
Although the review did not include a search for possible harms associated with breast-feeding itself, the USPSTF concluded that the potential harms of interventions to promote and support breast-feeding were no greater than small.
The task force noted that interventions including both prenatal and postnatal components may be most effective at increasing duration of breast-feeding, and they also recommended considering multiple intervention strategies. These may include formal breast-feeding education for mothers and their families, direct support of mothers during breast-feeding, training primary care staff regarding breast-feeding and various techniques for breast-feeding support, and peer support.
"Although the activities of individual clinicians to promote and support breastfeeding are likely to be positive, additional benefit may result from efforts that are integrated into systems of care," the statement authors conclude. "System-level interventions can incorporate clinician and team member training and policy development, and through senior leadership support and institutionalization, these initiatives may be more likely to be sustained over time. Although outside the scope of this recommendation and evidence review, community-based interventions to promote and support breastfeeding, such as direct peer-to-peer support, social marketing initiatives, workplace initiatives, and public policy actions, may offer additional sizeable benefits."
The Agency for Healthcare Research and Quality, US Department of Health and Human Services, supported this evidence review and statement. The authors of the statement have disclosed no relevant financial relationships.
Ann Intern Med. 2008;149:560-564, 565-582.
Clinical Context
The American Academy of Pediatrics recommends breast milk as the preferred choice for feeding infants, and the goals of the Healthy People 2010 initiative includes a target of 75% of mothers initiating breast-feeding their infants. In the United States, the rate of new mothers initiating breast-feeding was 73% in 2005, and 20% of mothers breast-fed their infants exclusively for 12 months. These rates in 2005 were higher vs 2002.
In its last recommendation in 2003, the USPSTF recommended counseling to promote higher rates of breast-feeding. The current recommendation uses the results of a systematic review of data available from January 2007 to update this recommendation. The results of this review and new recommendation are described in the "Study Highlights."
Study Highlights
Breast-feeding has been associated with numerous health benefits for both mother and infant. Breast-feeding during infancy has been associated with lower rates of otitis media, respiratory tract infection, and gastrointestinal tract infection. Later in childhood, breast-fed children have a lower risk for asthma, obesity, and type 2 diabetes vs children who were not breast-fed. Finally, breast-feeding is associated with lower risks for breast and ovarian cancer in the mother.
The systematic review included 38 randomized controlled trials of primary care–initiated interventions to promote breast-feeding. Study settings included primary care offices, hospital settings, and patient homes. The majority of these studies were located in developed countries.
Overall, breast-feeding promotion increased the odds ratio of breast-feeding during 1 to 3 months by a factor of 1.28. These programs increased the odds ratio of breast-feeding during 6 to 8 months by 1.44.
One study from Belarus, a developing country, demonstrated that a program to promote breast-feeding not only improved rates of breast-feeding but also reduced rates of gastrointestinal tract infection and atopic dermatitis in children.
Many interventions used multiple modalities to promote breast-feeding, so it was difficult to identify the most effective individual tool to increase the rate of breast-feeding. However, interventions built into health systems seemed to be the most effective, and combining prenatal and postnatal interventions was more effective than either type of intervention alone.
Interventions involving lay workers appeared more effective than usual care in promoting higher rates of breast-feeding.
No harms were reported in research studying interventions to support breast-feeding.
Overall, the USPSTF gives a grade B recommendation to interventions to promote and support breast-feeding. This level means that there is a high certainty of a moderate degree of benefit for these interventions or that a moderate certainty that the benefit is moderate to substantial.
The authors of the current recommendation call for further research into the individual components of breast-feeding promotion programs as well as cost-benefit analyses of these programs.
Pearls for Practice
Breast-feeding during infancy has been associated with lower rates of otitis media, respiratory tract infection, and gastrointestinal tract infection. Later in childhood, breast-fed children have a lower risk for asthma, obesity, and type 2 diabetes vs children who were not breast-fed. Finally, breast-feeding is associated with lower risks for breast and ovarian cancer in the mother.
The USPSTF recommends measures to promote and support breast-feeding in the prenatal and postnatal periods (a grade B recommendation).
mercoledì 22 ottobre 2008
Iscriviti a:
Post (Atom)
