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Press releases Saturday 2 December 2006

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(1) BMJ RAISES CONCERNS OVER SUDDEN INFANT DEATH STUDY

(2) FLU JABS FOR CARE HOME STAFF PREVENTS DEATHS

(3) WHAT IS THE ROLE OF DONOR BREAST MILK?

(4) RECORDING NEO-NATAL CONSULTATIONS IS HELPFUL TO PARENTS

(1) BMJ RAISES CONCERNS OVER SUDDEN INFANT DEATH STUDY

(Was message of sudden infant death study misleading?)
http://bmj.com/cgi/content/full/333/7579/1165

This week, the BMJ reveals serious concerns about a study on sudden infant deaths which was used as evidence in several high profile murder appeals.

In a special report, freelance journalist Jonathan Gornall raises questions about the paper’s findings and asks was the message of this study misleading?

In January 2005 the Lancet published an analysis of sudden infant deaths which suggested that almost 90% of second deaths in the same family are natural. The paper was sponsored by the Foundation for the Study of Infant Death.

The paper was written at the height of public debate on child protection issues. It formed part of the evidence that led to Professor Meadow being struck off the General Medical Council Register in July 2005, and led to a change of policy by the American Academy of Pediatrics.

Its findings were also seized on by the media. The study, reported one newspaper, showed that: “The vast majority of second infant deaths in families who have already suffered the sudden loss of a baby are down to natural causes.” Another said the study proved Professor Meadow’s “murder theory” was wrong.

But the BMJ investigation shows that classification of deaths in the study was changed after a senior author, Professor John Emery, died in May 2000. Deaths that he had classed as unnatural or of indeterminate cause were counted as natural. The BMJ has also learnt that before its publication, the interpretation of the data was questioned internally at the foundation.

Furthermore, evidence of Professor Emery’s views shortly before his death suggests that his name has been used to support a conclusion with which he would not have agreed.

The three authors interviewed by the BMJ accepted that they could not be certain that Professor Emery would have agreed with what they had done. However, they thought that their approach had been within the spirit of Professor Emery’s attitude towards parents.

But evidence shows that Professor Emery’s lowest estimate for the proportion of second sudden infant deaths that were unnatural was 34.5% - a striking contrast with the 13% in the 2005 paper.

Gornall also reveals that serious concerns about the paper were expressed by Professor David Hall, then immediate past president of the Royal College of Paediatrics and Child Health. In a letter to the Lancet in November 2005, he concluded that he and others regarded the paper’s findings as “seriously misleading” and thought they could have “serious consequences” for child protection.

Contact:

Jonathan Gornall, freelance journalist, London, UK
Email: Jgornall@mac.com

(2) FLU JABS FOR CARE HOME STAFF PREVENTS DEATHS

Online First
(Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.39010.581354.55

Vaccinating care home staff against influenza can prevent illness, deaths and health service use during periods of moderate influenza activity, concludes a study published online by the BMJ today.

Weak immune systems mean that many care home residents are vulnerable to influenza outbreaks even when they have been vaccinated. Many countries offer influenza vaccine to healthcare workers every year, but in the UK most care homes do not vaccinate their staff.

So, researchers set out to determine whether vaccinating care home staff against influenza indirectly protects residents.

The study took place in 44 UK care homes during the winters of 2003-4 and 2004-5. Vaccination was promoted and offered to full time staff in some homes (intervention homes) but not in others (control homes).

Vaccine coverage among full time staff in intervention homes was 48.2% in 2003-4 and 43.2% in 2004-5 compared with 5.9% and 3.5% in control homes.

During the 2003-4 influenza season, levels of illness and death were significantly lower in intervention homes compared with control homes. Consultations with general practitioners and admissions to hospital were also substantially lower in the intervention homes.

These effects were seen despite high levels of vaccination of residents and are equivalent to preventing five deaths, two admissions to hospital, seven general practitioner consultations, and nine cases of influenza-like illness per 100 residents during the period of influenza activity, say the authors.

However, no significant differences were found in 2004-5, when national influenza rates were substantially below average, or during periods of no influenza activity.

This study provides strong evidence to support influenza vaccination of care home staff even when vaccine uptake by residents is high, write the authors. Results are likely to apply to other care homes in the UK and abroad and may also be relevant to acute hospital settings, in particular elderly care and rehabilitation wards.

Campaigns to promote influenza vaccination among healthcare workers or staff of long term care facilities should emphasise the protection of vulnerable patients and residents as well as the benefits to the individual, they conclude.

Contact:

Andrew Hayward, Senior Lecturer, University College London Centre for Infectious Disease Epidemiology, London, UK
Email: a.hayward@pcps.ucl.ac.uk

(3) WHAT IS THE ROLE OF DONOR BREAST MILK?

(Editorial: Donor breast milk banking)
http://bmj.com/cgi/content/full/333/7579/1133

More evidence is needed to determine whether donor breast milk is beneficial for babies in intensive care, argues a senior doctor in this week’s BMJ.

Mother’s milk is recommended for all babies, but mothers of preterm babies and other babies in intensive care are often unable to provide enough milk for their baby’s needs. Donor breast milk and formula milk are options to make up the shortfall.

But the extent to which pasteurised donor breast milk retains the biological properties of mother’s milk is uncertain and its place in present day neonatal intensive care is unclear, says Neena Modi, Professor of Neonatal Medicine at Imperial College London.

What evidence is there to support the use of donor breast milk, she asks?

A recent detailed analysis showed that donor breast milk reduced the risk of necrotising enterocolitis (a serious inflammatory condition of the bowel) when compared with formula, but infant growth was slower, and benefit was seen only when breast milk or formula was the sole source of nutrition. Current practice would be to use donor milk as a supplement to mother’s milk and not as sole diet.

Only two studies have compared donor milk and formula as a supplement to mother’s milk and neither found a significant difference in the rate of necrotising enterocolitis. For other outcomes, justification for using donor milk is largely anecdotal. Thus the role of donor breast milk in current neonatal practice remains to be established, she writes.

Furthermore, in contrast to blood banks that also provide a biological product, human milk banks in the UK conform to a voluntary code of practice but are otherwise unregulated.

So where does this leave us?

Human milk banks around the world have arisen through the voluntary efforts of committed individuals. Their altruism is undeniable, but unregulated expansion of human milk banking requires evidence of benefit, she says. Donor breast milk is also expensive. Although donors are unpaid, the cost of UK human milk banking (£30-150 per litre) is probably an underestimate of the full cost to the National Health Service.

Professor Modi believes that research is needed to determine whether donor milk, when used as a supplement to mother’s milk, has short term or long term benefits (or both). At present there are less than 20 human milk banks in the UK but over 250 neonatal units and access to donor milk is very variable.

If donor breast milk is beneficial, clinical guidelines should reflect objective evidence, access should be equitable, and milk banking procedures should be consistent. If it is not beneficial NHS resources would be better directed towards supporting mothers’ own lactation, she concludes.

Contact:

Neena Modi, Professor of Neonatal Medicine, Imperial College London c/o Laura Gallagher, Imperial College Press Office
Email: l.gallagher@imperial.ac.uk

(4) RECORDING NEO-NATAL CONSULTATIONS IS HELPFUL TO PARENTS

Online First
(Provision of taped conversations with neonatologists to mothers of babies in intensive care: randomised controlled trial)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.39017.675648.BE

Parents with infants needing neo-natal care find recordings of consultations with their consultants helpful, finds a study published on bmj.com today.

The parents of babies requiring care in neo-natal intensive care units (NICU) often do not recall the information given to them. Researchers in Australia set out to assess the usefulness of audio recording the conversations between mothers and their neo-natal consultants. Two hundred mothers with babies in NICU were put into two groups – the first had their consultation recorded and were given a copy of the recording. The second – the control group – did not receive a recording.

After ten days, and again at four months, the researchers interviewed the parents to document their recall of the diagnosis, tests, treatment and outcome of their babies, as explained by their neonatologist. The mothers involved also completed a questionnaire about their own general health.

Those who had received a recording had significantly greater recall of information in the diagnosis and outcome of their baby, and of tests and treatments. Six mothers could not remember any information – all of whom were in the control group.

Whilst the study found that audio recordings did not affect the mothers’ general wellbeing, e.g. levels of anxiety or depression, the majority (96%) of those in the ‘tape’ group listened to the tapes and found them helpful. For babies with poor outcomes, the mothers who received the recordings were significantly more satisfied with the conversation than those in the control group.

The authors say that effective communication underpins family-centred care in NICUs and they suggest that neonatologists develop guidelines for the use of audio recordings.

Audiorecording of medical conversation has immense potential for research and may have implications for doctors working in other specialities, they conclude.

Contact:

Tieh Hee Koh, Clinical Director, Institute of Women’s and Children’s Health, Townsville Hospital, Douglas, Queensland, Australia
Email: guan_koh@health.qld.gov.au

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