Donation barriers, enablers, patterns and predictors of milk bank donors in the United States and United Kingdom

Pasteurised donor human milk is recommended for very low birthweight infants who do not have access to their mother's milk. Although the use of donor milk continues to increase, little is known about the donation experiences of milk bank donors. We aimed to describe and compare enablers, barriers and patterns of human milk donation and identify factors predicting donation volume in a convenience sample of approved milk bank donors in the United Kingdom and the United States. A cross-sectional online survey was conducted from August 2022 to December 2022. Approved milk bank donors (n = 556) from three milk banks in the United States (n = 369, Mothers' Milk Bank of Florida, Mother's Milk Bank of North Texas and Northwest Mothers Milk Bank) and one milk bank in the United Kingdom (n = 187, Hearts Milk Bank) completed the survey. A substantial portion of donors in both settings reported participating in other forms of milk exchange (51% of U.S. donors vs. 39% of UK donors, p = 0.009). Top donation barriers reported in both settings were completing the serological screening and having enough space to store collected milk. Most donors started donating when their infant was 3 months old or older and reported donating mature milk. The most common source of information related to milk banking in each setting was the internet (United Kingdom-70% vs. United States - 63%, p = 0.112). Variables that predicted lifetime donation volume differed between the United States and the United Kingdom, highlighting the importance of setting-specific milk banking research.

Comparison between the for-profit human milk industry and nonprofit human milk banking: Time for regulation?

Human milk (HM) is a highly evolutionary selected, complex biofluid, which provides tailored nutrition, immune system support and developmental cues that are unique to each maternal-infant dyad. In the absence of maternal milk, the World Health Organisation recommends vulnerable infants should be fed with screened donor HM (DHM) from a HM bank (HMB) ideally embedded in local or regional lactation support services. However, demand for HM products has arisen from an increasing awareness of the developmental and health impacts of the early introduction of formula and a lack of prioritisation into government-funded and nonprofit milk banking and innovation. This survey of global nonprofit milk bank leaders aimed to outline the trends, commonalities and differences between nonprofit and for-profit HM banking, examine strategies regarding the marketing and placement of products to hospital and public customers and outline the key social, ethical and human rights concerns. The survey captured information from 59 milk bank leaders in 30 countries from every populated continent. In total, five companies are currently trading HM products with several early-stage private milk companies (PMCs). Products tended to be more expensive from PMC than HMB, milk providers were financially remunerated and lactation support for milk providers and recipients was not a core function of PMCs. Current regulatory frameworks for HM vary widely, with the majority of countries lacking any framework, and most others placing HM within food legislation, which does not include the support and care of milk donors and recipient prioritisation. Regulation as a Medical Product of Human Origin was only in place to prevent the sale of HM in four countries; export and import of HM was banned in two countries. This paper discusses the safety and ethical concerns raised by the commodification of HM and the opportunities policymakers have globally and country-level to limit the potential for exploitation and the undermining of breastfeeding.

Comparison of Breastfeeding and Pumping Experiences of Milk Bank Donors in the United States and United Kingdom

Background/Objective: As human milk banking services expand, information about lifestyle characteristics and infant feeding experiences of milk bank donors is relatively limited. Our goal was to describe and compare milk bank donors' demographic, clinical, and lifestyle characteristics, and breastfeeding experiences in a variety of geographic settings. Methods: A cross-sectional online survey was conducted from August 2022 to December 2022 with approved donors from three milk banks in the United States (n = 369), and one milk bank in United Kingdom (n = 187). Results: Donors in all settings were predominantly in their early 30s, White, married, educated, and identified as female. U.K. donors reported more frequently being on maternity leave (33% versus 5%, p < 0.001), predominantly feeding directly at the breast in the first 3 months postpartum (51% versus 28%, p < 0.001), and breastfeeding a single child longer (21.2 versus 13.3 months, p < 0.001) than U.S. donors. Significantly more U.S. donors reported pumping due to work (34% versus 11%, p < 0.001) and pumping multiple times per day (57% versus 36%, p < 0.001). Most donors reported receiving information about breastfeeding from a health care provider (94% United States and 88% United Kingdom, p = 0.022), while the internet was the most popular source of information about pumping (65% United States and 64% United Kingdom, p = 0.751). Conclusion: Factors not directly related to milk banking (e.g., maternity leave, sources of breastfeeding/pumping assistance) may have an impact on how donors feed their children and ultimately on their milk donation pattern. The impact of donor characteristics and feeding practices on donation patterns warrants further investigation.

Exploring Human Milk, Nutrition, Growth, and Breastfeeding Rates at Discharge(HUMMINGBIRD Study): a protocol for a pilot randomised controlled trial

INTRODUCTION

Mother's own breast milk (MOM) is the optimal nutrition for preterm infants as it reduces the incidence of key neonatal morbidities and improves long-term outcomes. However, MOM shortfall is common and either preterm formula or pasteurised donor human milk (DHM) may be used, although practice varies widely. Limited data suggest that the use of DHM may impact maternal beliefs and behaviours and therefore breastfeeding rates. The aim of this pilot study is to determine if longer duration of DHM exposure increases breastfeeding rates, and if a randomised controlled trial (RCT) design is feasible.

METHODS AND ANALYSIS

The Human Milk, Nutrition, Growth, and Breastfeeding Rates at Discharge (HUMMINGBIRD) Study is a feasibility and pilot, non-blinded RCT with a contemporaneous qualitative evaluation. Babies born less than 33 weeks' gestation or with birth weight <1500 g whose mothers intend to provide MOM are randomly assigned to either control (DHM used to make up shortfall until full feeds and preterm formula thereafter) or intervention (DHM used for shortfall until 36 weeks' corrected age or discharge if sooner). The primary outcome is breast feeding at discharge. Secondary outcomes include growth, neonatal morbidities, length of stay, breastfeeding self-efficacy and postnatal depression using validated questionnaires. Qualitative interviews using a topic guide will explore perceptions around use of DHM and analysed using thematic analysis.

ETHICS APPROVAL AND DISSEMINATION

Nottingham 2 Research Ethics Committee granted approval (IRAS Project ID 281071) and recruitment commenced on 7 June 2021. Results will be disseminated in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN57339063.

Diversity and trends of human milk banking: a scoping review from 1946 to 2021

BACKGROUND

The provision of donor human milk (DHM) through human milk banks is now widely practised globally. The study aimed to describe the current state, identify major topics and map out the emerging trends in human milk banking.

METHODS

PubMed was systematically searched for publications related to DHM, with the last update on 14 May 2021, for papers published between 1946 and 2021. Titles and abstracts were screened and indexed into 8 main and 39 subcategories. A top-up search was done in April 2022, but these results have not been incorporated.

RESULTS

A total of 1083 publications were identified, and more than a third (41%) were either observational or interventional studies. Predominant topics were milk type and milk composition. Almost half (49%) of the publications in the last decade were funded through government/research councils, and industry funding started shortly after links between formula and necrotising enterocolitis were published. Literature from high-income countries was six times more than publications from low-income or middle-income countries (LMICs).

CONCLUSION

The diversity and trends of publications included in this scoping review ranged from descriptive studies comparing biological and compositional differences of mother's own milk, DHM and/or formula. Very few studies have investigated associations of different milk types with infant outcomes. Evidence on breastfeeding and recipient psychological health outcomes is limited. Further research should identify the appropriateness of different funding sources. Future collaborations between academics, clinicians and milk banks in LMICs should be fostered to bridge the gap that exists between DHM and access.

Comparative Profiles of SARS-CoV-2 Spike-Specific Human Milk Antibodies Elicited by mRNA- and Adenovirus-Based COVID-19 Vaccines

Background: Numerous COVID-19 vaccines are authorized globally. To date, ∼71% of doses comprise the Pfizer/BioNTech vaccine, and ∼17% the Moderna/NIH vaccine, both of which are messenger RNA (mRNA) based. The chimpanzee Ad-based Oxford/AstraZeneca (AZ) vaccine comprises ∼9%, while the Johnson & Johnson/Janssen (J&J) human adenovirus (Ad26) vaccine ranks fourth at ∼2%. No COVID-19 vaccine is yet available for children 0-4. One method to protect this population may be passive immunization through antibodies (Abs) provided in the milk of a lactating vaccinated person. Our early work and other reports have demonstrated that unlike the post-SARS-CoV-2 infection milk Ab profile, which is rich in specific secretory (s)IgA, the vaccine response is highly IgG dominant. Results: In this report, we present a comparative assessment of the milk Ab response elicited by Pfizer, Moderna, J&J, and AZ vaccines. This analysis revealed 86-100% of mRNA vaccine recipient milk exhibited Spike-specific IgG endpoint titers, which were 12- to 28-fold higher than those measured for Ad vaccine recipient milk. Ad-based vaccines elicited Spike-specific milk IgG in only 33-38% of recipients. Specific IgA was measured in 52-71% of mRNA vaccine recipient milk and 17-23% of Ad vaccine recipient milk. J&J recipient milk exhibited significantly lower IgA than Moderna recipients, and AZ recipients exhibited significantly lower IgA titers than Moderna and Pfizer. Less than 50% of milk of any group exhibited specific secretory Ab, with Moderna recipient IgA titers measuring significantly higher than AZ. Moderna appeared to most frequently elicit greater than twofold increases in specific secretory Ab titer relative to prevaccine sample. Conclusion: These data indicate that current Ad-based COVID-19 vaccines poorly elicit Spike-specific Ab in milk compared to mRNA-based vaccines, and that mRNA vaccines are preferred for immunizing the lactating population. This study highlights the need to design vaccines better aimed at eliciting an optimal milk Ab response.

Receiving screened donor human milk for their infant supports parental wellbeing: a mixed-methods study

BACKGROUND

Access to donor human milk (DHM) has primarily been based on the health and development outcomes of premature infants but there has been little examination of the broader impact of an infant receiving it upon parental mental health. Breastfeeding and mental health are closely tied with women who experience breastfeeding difficulties or are unable to meet their own breastfeeding goals often experiencing feelings of guilt, sadness and anger, alongside an increased risk of postnatal depression. The aim of the current study was to explore how experience of receiving DHM for their baby affected the wellbeing of parents.

METHODS

UK parents of infants aged 0 - 12 months who had received screened DHM from a milk bank (typically on the neonatal unit or in some cases in the community) completed an online questionnaire exploring their experiences. The questionnaire included Likert scale items examining perceived impact upon infant health, own wellbeing and family functioning alongside open-ended questions exploring perceptions of how receiving DHM affected wellbeing.

RESULTS

Almost all of the 107 participants (women = 102) agreed that receiving DHM had a positive impact upon infant health and development, their own mental and physical health, and their family's wellbeing. Parents felt relieved that their infant was receiving DHM for health reasons but also due to the experience of being listened to, supported and having their infant feeding decisions facilitated. Receiving DHM helped mothers to process some of their emotions at not being able to breastfeed, in part because knowing their baby was being fed gave them the space to focus on recovery and bonding with their baby. Some parents did experience challenges, feeling guilty at receiving DHM, insecure that another woman was able to feed their baby when they could not, or negative reactions from family. Although the impact of receiving DHM upon breastfeeding was not measured, some women who were working to build their own milk supply noted that it helped motivate them to continue.

CONCLUSIONS

DHM may play an important role not only in protecting infant health and development but in supporting the mental health and wellbeing of mothers for whom their infant receiving human milk is important.

Eosinophilic fasciitis: experience with a patient and review of the potential mimics

Bilateral lower limb swelling is a common clinical scenario with a wide differential diagnosis. We present a young man with gradually worsening bilateral leg swelling, who was diagnosed with eosinophilic fasciitis. A 20 year old Hispanic male presented with a six week history of bilateral lower limb pain and swelling, later involving the upper limbs, but sparing the hands, feet and face. He had initial pitting, followed by non-pitting oedema and had a positive 'groove sign'. With peripheral eosinophilia, a clinical diagnosis of eosinophilic fasciitis was suspected and was later confirmed on histology. He improved with prednisolone initially and is currently maintained on tapering prednisolone alongside methotrexate.

Maintaining human milk bank services throughout the COVID-19 pandemic: A global response

If maternal milk is unavailable, the World Health Organization recommends that the first alternative should be pasteurised donor human milk (DHM). Human milk banks (HMBs) screen and recruit milk donors, and DHM principally feeds very low birth weight babies, reducing the risk of complications and supporting maternal breastfeeding where used alongside optimal lactation support. The COVID-19 pandemic has presented a range of challenges to HMBs worldwide. This study aimed to understand the impacts of the pandemic on HMB services and develop initial guidance regarding risk limitation. A Virtual Collaborative Network (VCN) comprising over 80 HMB leaders from 36 countries was formed in March 2020 and included academics and nongovernmental organisations. Individual milk banks, national networks and regional associations submitted data regarding the number of HMBs, volume of DHM produced and number of recipients in each global region. Estimates were calculated in the context of missing or incomplete data. Through open-ended questioning, the experiences of milk banks from each country in the first 2 months of the pandemic were collected and major themes identified. According to data collected from 446 individual HMBs, more than 800,000 infants receive DHM worldwide each year. Seven pandemic-related specific vulnerabilities to service provision were identified, including sufficient donors, prescreening disruption, DHM availability, logistics, communication, safe handling and contingency planning, which were highly context-dependent. The VCN now plans a formal consensus approach to the optimal response of HMBs to new pathogens using crowdsourced data, enabling the benchmarking of future strategies to support DHM access and neonatal health in future emergencies.

POS0018 INVESTIGATING VIRTUAL IMMERSIVE EXPERIENCES IN THE MANAGEMENT OF CHRONIC PAIN – THE VIPA STUDY (PRELIMINARY RESULTS)

Background:

Chronic pain is debilitating and prevalent. Current non-pharmacological management of pain conditions such as Fibromyalgia Syndrome (FMS) are labour intensive to implement and poorly available, especially during the pandemic. There is an urgent need to develop widely adoptable, innovative treatment options for pain cohorts.

Virtual reality (VR) provides an innovative therapeutic tool, immersing users within a three-dimensional, interactive virtual environment with use of a head-mounted display (HMD). Beneficial effects of VR have been demonstrated in acute pain1, with limited studies in chronic pain. Given the variation of available VR technologies, it is vital to investigate the impact of different VR characteristics on acceptability in specific chronic pain cohorts.

Objectives:

This feasibility study aims to establish the acceptability of four different VR technologies in patients with FMS whilst undertaking a single interactive VR experience.

Methods:

Patients with FMS were recruited through outpatient clinics at the Norfolk and Norwich University Hospital. Baseline questionnaires were used including the McGill pain questionnaire (MPQ-SF), pain visual analogue scale (VAS) and Revised Fibromyalgia Impact Questionnaire (FIQR). Subjective experience questionnaires collected acceptability data with 7-point Likert scale rating questions (strongly disagree to strongly agree). The simulation sickness questionnaire (SSQ) gained side-effect data (total severity score: 0-235). Categorical data were described using frequencies; and continuous data using mean and standard deviation. Likert-scale data were dichotomised (rating ≤3: disagree, rating ≥5: agree).

Four VR systems representing the spectrum of commercially available technologies were used (seen in Figure 1). These possess different characteristics including screen resolution, processor speed, weight, strap and controller type. The VR experience used with each headset was co-developed alongside industry partners (Orbital Global). Participants are immersed within a naturalistic environment, situated on a wooden boat travelling slowly along a calm river surrounded by trees and hills. The interactive element involves the user shooting targets that appear using handheld controllers.

Results:

13 patients with FMS were included (mean age 41.8±15.6, 92.3% female). Most had severe disease (mean FIQR 67.8±14.1) with moderate self-reported pain at baseline (mean MPQ 25.5±8.8, VAS 6.0±1.7). Most had no previous VR exposure (69.2%). 100% of participants agreed that they would be open to using VR for future pain management (mean rating 6.5±0.7) and that they would use VR regularly at home (mean rating 6.5±0.7). VR HMD comfort and enjoyment data are presented in Table 1. Mean ratings of comfort were high across the four HMDs (Gear VR: 4.9±1.7, Oculus Go: 4.5±1.8, Oculus Quest 5.3±1.9, Oculus Rift 6.6±0.5). Mean ratings of enjoyment with each HMD were also high (Gear VR: 5.4±1.6, Oculus Go: 5.4±1.8, Oculus Quest: 5.6±1.9, Oculus Rift S: 6.6±0.5). Low levels of side effects were described with mean SSQ total scores ranging from 20.1±16.8 (Oculus Rift S) to 38.0±23.9 (Gear VR).

Conclusion:

Preliminary results indicate that FMS patients find VR acceptable, describing high ratings of comfort and enjoyment across the VR HMD spectrum. Side-effect frequency was low, with most settling after HMD removal. All participants were open to future use of VR for home-based pain management.

References:

[1]Dascal J, Reid M, Ishak WW, Spiegel B, Recacho J, Rosen B, Danovitch I. Virtual reality and medical inpatients: A systematic review of randomized, controlled trials. Innov Clin Neurosci 2017;14(1-2):14-21

Table 1.

Subjective experience results across VR HMDs

Mean Likert scale ratings (% agreement: rating ≥5)VR HMDOverall, I found the VR experience using this equipment comfortableOverall, I enjoyed using this VR headsetGear VR4.9±1.7 (62%)5.4±1.6 (77%)Oculus Go4.5±1.8 (54%)5.4±1.8 (75%)Oculus Quest5.3±1.9 (77%)5.6±1.9 (100%)Oculus Rift S6.6±0.5 (100%)6.6±0.5 (100%)

Acknowledgements:

I would like to acknowledge the contributions of the staff working within the Rheumatology department at the Norfolk and Norwich University Hospital. I would also like to thank and acknowledge our participants for being involved in the study.

Disclosure of Interests:

Jordan Tsigarides Grant/research support from: Our digital health industry partners (Orbital Global) provided a small financial contribution to support this study., Vanessa Grove: None declared, Dheeraj Sethi: None declared, Jacqueline Chipping: None declared, Susan Miles: None declared, Nicholas Shenker: None declared, Saber Sami: None declared, Alex MacGregor: None declared.

Use of donor human milk in nonhospitalized infants: An infant growth study

When mother's own milk (MOM) is unavailable or insufficient, donor human milk (DHM) is recommended as the next best alternative for low birthweight infants. DHM use for healthy, term infants is increasing, but evidence for growth and tolerability is limited. This retrospective study evaluated growth in term infants in the community who received DHM from a UK milk bank. Mothers of infants receiving DHM between 2017 and 2019 were contacted (n = 49), and 31 (63.2%) agreed to participate. Fourteen infants received DHM as a supplement to other feeds (MOM and/or infant formula) and 17 were exclusively fed DHM where breastfeeding was impossible (range: 3–6 weeks). Growth was assessed by deriving z‐scores using the WHO standard for infant growth and compared with 200 exclusively breastfed infants. Multivariate regression analysis revealed no feeding method‐specific association between z‐score and age, nor between weight and age, suggesting that z‐scores and growth velocity were not affected by feeding exclusive MOM, supplemental DHM or exclusive DHM. DHM was well‐tolerated with no adverse events that led to early cessation. After receiving supplemental DHM group, 63% of infants whose mothers had no physical barrier to breastfeeding (5/8 infants) were exclusively breastfed. This novel study reports adequate growth outcomes of healthy nonhospitalized infants receiving DHM, either as the sole milk source or supplement. Prospective studies are needed to confirm whether DHM is a suitable feeding alternative for term infants in the community, optimal durations, as well as the impact of DHM availability on breastfeeding rates and maternal mental health.

DHM recipients were compared with the who infant growth standard (World Health Organization, 2020) by deriving z‐scores. The WHO Anthro Macro (World Health Organization, 2011 ) was used to calculate weight‐for‐age, length‐for‐age and head circumference‐for‐age z‐scores; z‐scores are the standard deviation of an infant's anthropometric measurements when compared with the WHO standard for infant growth and are gender and age specific.

Experiences of breastfeeding during COVID-19: Lessons for future practical and emotional support

The COVID-19 pandemic and subsequent lockdown and social distancing led to changes to breastfeeding support available to women in the United Kingdom. Face-to-face professional support was reduced, and face-to-face peer support was cancelled. Anecdotal media accounts highlighted practices separating some mothers and babies in hospitals, alongside inaccurate stories of the safety of breastfeeding circulating. Meanwhile, new families were confined to their homes, separated from families and support networks. Given that we know breastfeeding is best supported by practices that keep mother and baby together, high-quality professional and peer-to-peer support, and positive maternal well-being, it is important to understand the impact of the pandemic upon the ability to breastfeed. To explore this, we conducted an online survey with 1219 breastfeeding mothers in the United Kingdom with a baby 0-12 months old to understand the impact of the pandemic upon breastfeeding duration, experiences and support. The results highlighted two very different experiences: 41.8% of mothers felt that breastfeeding was protected due to lockdown, but 27.0% of mothers struggled to get support and had numerous barriers stemming from lockdown with some stopped breastfeeding before they were ready. Mothers with a lower education, with more challenging living circumstances and from Black and minority ethnic backgrounds were more likely to find the impact of lockdown challenging and stop breastfeeding. The findings are vital in understanding how we now support those women who may be grieving their loss of breastfeeding and are affected by their negative experiences and how we can learn from those with a positive experience to make sure all breastfeeding women are better supported if similar future events arise.

Breastfeeding and the origins of health: Interdisciplinary perspectives and priorities

Breastfeeding and human milk (HM) are critically important to maternal, infant and population health. This paper summarizes the proceedings of a workshop that convened a multidisciplinary panel of researchers to identify key priorities and anticipated breakthroughs in breastfeeding and HM research, discuss perceived barriers and challenges to achieving these breakthroughs and propose a constructive action plan to maximize the impact of future research in this field. Priority research areas identified were as follows: (1) addressing low breastfeeding rates and inequities using mixed methods, community partnerships and implementation science approaches; (2) improving awareness of evidence-based benefits, challenges and complexities of breastfeeding and HM among health practitioners and the public; (3) identifying differential impacts of alternative modes of HM feeding including expressed/pumped milk, donor milk and shared milk; and (4) developing a mechanistic understanding of the health effects of breastfeeding and the contributors to HM composition and variability. Key barriers and challenges included (1) overcoming methodological limitations of epidemiological breastfeeding research and mechanistic HM research; (2) counteracting 'breastfeeding denialism' arising from negative personal breastfeeding experiences; (3) distinguishing and aligning research and advocacy efforts; and (4) managing real and perceived conflicts of interest. To advance research on breastfeeding and HM and maximize the reach and impact of this research, larger investments are needed, interdisciplinary collaboration is essential, and the scientific community must engage families and other stakeholders in research planning and knowledge translation.

Using donor human milk to feed vulnerable term infants: a case series in KwaZulu Natal, South Africa

BACKGROUND

Donor human milk is the World Health Organization's recommendation for infant feeding when the mother's own breast milk is unavailable. Breast milk has been shown to reduce morbidity and mortality and in low birthweight infants, donor milk reduces the incidence of necrotising enterocolitis, late onset sepsis and improves outcomes. There is a paucity of literature documenting outcomes of using donor human milk in older children who need additional support for a variety of health issues.

CASE PRESENTATION

A series of seven case studies is presented of orphaned and abandoned children, many of whom were either HIV exposed or positive. All children were fed with pasteurised donor human milk at a transition home and their progress reported.

CONCLUSIONS

Although detailed medical records were not always available, the case studies provide anecdotal evidence of the protective effects of donor human milk against failure to thrive, diarrhoea, atopic dermatitis, and opportunistic infections.

Stickler syndrome in children: a radiological review

AIM

To review the radiological findings of the largest cohort to date of paediatric patients with Stickler syndrome, all with confirmed molecular genetic analysis and sub-typing.

PATIENTS AND METHODS

It is understood that the National Health Service (NHS) commissioned service at Addenbrookes Hospital, Cambridge, UK has the largest cohort of Stickler syndrome patients in the paediatric age group worldwide with 240 registered children. Fifty-nine were assessed radiologically and for their genotypes. These radiographs were reviewed and 74 knee, 45 pelvic, and 47 spinal examinations were evaluated.

RESULTS

Radiological features were noted in 45.9% of knee radiographs, 11.1% of pelvic radiographs, and 42.6% of spinal radiographs. The findings were reviewed in the light of each patient's specific genetic Stickler syndrome subtype.

CONCLUSION

The prevalence of orthopaedic abnormalities overall in the present series is substantially below those published in previous smaller case series. This would support the more recent findings of an array of ocular only phenotypes of Stickler syndrome described in the literature.

Contemporary management and outcomes for infants born with oesophageal atresia

Background

Reports on the management and outcome of rare conditions, such as oesophageal atresia, are frequently limited to case series reporting single-centre experience over many years. The aim of this study was to identify all infants born with oesophageal atresia in the UK and Ireland to describe current clinical practice and outcomes.

Methods

This was a prospective multicentre cohort study of all infants born with oesophageal atresia and/or tracheo-oesophageal fistula in 2008–2009 in the UK and Ireland to record current clinical management and early outcomes.

Results

A total of 151 infants admitted to 28 paediatric surgical units were identified. Some aspects of perioperative management were universal, including oesophageal decompression, operative technique and the use of transanastomotic tubes. However, there were a number of areas where clinical practice varied considerably, including the routine use of perioperative chest drains, postoperative contrast studies and antireflux medication, with each of these being employed in 30–50 per cent of patients. There was a trend towards routine postoperative ventilation.

Conclusion

The prospective methodology used in this study can help identify practices that all surgeons employ and also those that few surgeons use. Areas of clinical equipoise can be recognized and avenues for further research identified.

Neonatal survival of prenatally diagnosed exomphalos

PURPOSE

Exomphalos is a midline defect, with a viable sac composed of amnion and peritoneum containing herniated abdominal contents with an incidence of about 1 in 4,000 live births. Associated major abnormalities can be karyotypic, syndromic or structural in up to 70% of cases. The aim of this study is to determine the factors that influence survival of antenatally diagnosed exomphalos.

METHODS

All antenatally diagnosed and postnatally confirmed exomphalos registered with our fetal medicine unit, during 2002-2007, were reviewed. Both prenatal and postnatal outcomes were analysed.

RESULTS

Of 88 cases identified with exomphalos, 85 were prenatally diagnosed. Fifty-five of them died in utero (45 terminations, 5 spontaneous abortions and 5 still births). There were 33 live births (37.5%), 7 of which were premature (30-35/40 gestation). Five babies died before coming to surgery (all with major exomphalos as well as abnormal karyotype) while 28 were operated upon. Fourteen cases with minor exomphalos, all isolated, were primarily closed and all survived to discharge. Of 14 babies with major exomphalos, 4 were closed primarily. Nine required silo formation and six successfully underwent secondary closure (one of which had a prenatal diagnosis of giant ruptured exomphalos). Three died before closure, two from sepsis and multi-organ failure, and one from an undiagnosed tracheo-oesophalgeal cleft. All three deaths had antenatally diagnosed giant ruptured exomphalos and were less than 34/40 weeks gestation. One baby was managed conservatively with antiseptic solution applied to the sac and left to heal by secondary intention. There were 17 cases of isolated exomphalos (with no other structural abnormalities), all of which survived.

CONCLUSION

Antenatal diagnosis of exomphalos is 96% sensitive. Severe karyotypic and structural abnormalities were present in all intra-uterine and early postnatal deaths. Overall survival to discharge was 28%. Both minor and isolated exomphalos carried a good prognosis. Isolated exomphalos was a better prognostic factor than severity of the exomphalos itself. Ruptured giant exomphalos were associated with a poorer outcome especially in premature babies.

Hypovitaminosis D among rheumatology outpatients in clinical practice

Objectives. A role for vitamin D in the pathogenesis of autoimmune and inflammatory diseases is emerging. We undertook an audit of 25-hydroxyvitamin D (25OHD) investigation and treatment in rheumatology outpatients.

Methods. Serum 25OHD requests were matched to electronic medical records from rheumatology and metabolic bone clinics (April 2006–March 2007). Data were analysed separately for two groups, ‘Documented osteoporosis/osteopaenia’ (Group 1) and ‘General rheumatology outpatients’ (Group 2, sub-divided by diagnosis). Hypovitaminosis D was defined by 25OHD levels <50 nmol/l. Values were compared with healthy adults to calculate geometric z-scores.

Results. A total of 263 patients were included (Group 1, n = 122; Group 2, n = 141) with an overall median 25OHD of 44 nmol/l.The 25OHD level among general rheumatology patients (median 39 nmol/l, mean z score −1.2, was statistically significantly lower than among osteoporotic/osteopaenic patients (median 49 nmol/l, mean z score of −0.9, p < 0.05 for the difference). 25OHD was lower in inflammatory arthritis and chronic pain/fibromyalgia than in other groups. Prescribing was recorded in 100 in Group 1 (of whom 95% were prescribed calcium/800 IU cholecalciferol) and 83 in Group 2 (91% calcium/800 IU). Only 31% of the patients with 25OHD <50 nmol/l would have been identified using general guidelines for screening patients at ‘high risk’ of hypovitaminosis D.

Conclusions. Improved guidelines for managing hypovitaminosis D in rheumatology patients are needed. We found a high prevalence of hypovitaminosis D among secondary care patients in rheumatology and widespread supplementation with 800 IU cholecalciferol. Substantially reduced levels of serum 25OHD were identified among patients with inflammatory arthritis and chronic pain.

John Hilton (1805-78): anatomist and surgeon

John Hilton was the foremost anatomist of his day. From only humble beginnings he became an anatomy demonstrator at Guy's Hospital. When appointed Surgeon to Guy's Hospital, his meticulous clinical skills, arising from his depth of anatomical knowledge, led him to develop many anatomical principles culminating in a series of lectures on 'Rest and Pain'. For the first time the clinical importance of each was highlighted in surgical practice. By public demand the lectures were published as a book, still in print today, which brought a new emphasis to clinical anatomy that would permeate surgery thereafter. He became President of the Royal College of Surgeons and was Surgeon Extraordinary to Queen Victoria. A substantial review of his life has not been published; with the present decline in anatomical teaching, we can learn much from understanding a surgeon who dedicated his life to anatomy.

Extensive intraalveolar pulmonary hemorrhage in infants dying after surfactant therapy

To assess the possible relationship between exogenous surfactant therapy and pulmonary hemorrhage in premature infants, we compared autopsy findings in 15 infants treated with exogenous surfactant and in 29 who died before the introduction of surfactant therapy. Infants who met the following criteria were included: birth weight 501 to 1500 gm, survival 4 hours to 7 days, and no congenital anomalies. Average birth weight, gestational age, and age at death were equivalent for the two groups. High rates of pulmonary hemorrhage were present in both groups (treated 80% vs untreated 83%). The untreated group had higher incidences of interstitial hemorrhage and lung hematomas and significantly more large interstitial hemorrhages: 31% untreated versus 0% treated (p < 0.05). The overall rate of intraalveolar hemorrhage was similar in the two groups, but surfactant-treated infants were more likely to have extensive intraalveolar hemorrhage: 53% versus 14% (p < 0.05). Most surfactant-treated infants who survived more than 24 hours had extensive intraalveolar hemorrhage (8/9). Patients who had extensive intraalveolar hemorrhage, with or without prior surfactant therapy, frequently had clinically significant pulmonary hemorrhage (7/12). These findings indicate that infants who die after surfactant therapy have higher rates of a specific type of pulmonary hemorrhage--extensive intraalveolar hemorrhage.

Pathology of neonatal necrotizing enterocolitis: a ten-year experience

We reviewed pathology specimens from 84 patients seen during a 10-year period with neonatal necrotizing enterocolitis, and these findings were correlated with clinical features. Coagulation (ischemic) necrosis, inflammation, and bacterial overgrowth were all present in the intestine of nearly all patients but with individual variability in the severity of these findings. Overall, coagulation necrosis was more severe than any other finding in most infants, indicating the importance of ischemia in the pathophysiology of necrotizing enterocolitis. Reparative tissue changes such as epithelial regeneration, granulation tissue formation, and fibrosis, found in two thirds of cases, suggested ongoing tissue injury of at least several days' duration. Birth weight, Apgar score, age, feeding status, and the presence of respiratory distress syndrome were not correlated with any particular histologic feature. The pathologic changes of necrotizing enterocolitis suggest that its cause is multifactorial, with ischemia, inflammation, bacterial overgrowth, and reparative tissue changes all playing important roles.

Use of intravenously administered immune globulin to prevent nosocomial sepsis in low birth weight infants: report of a pilot study

To evaluate the use of intravenously administered immune globulin (IVIG) for prevention of sepsis in preterm infants, we administered IVIG in a protocol designed to maintain a therapeutic serum "target level" of 700 mg/dl. The 200 patients who were eligible for the study (600 to 2000 gm birth weight) were monitored throughout their initial hospitalization. Of these, 115 patients were randomly assigned in a double-blind, controlled trial to treatment and placebo groups. The remaining 85 infants were not randomly assigned to a group, by parental request, but were followed and analyzed separately. In one patient who received IVIG, transient tachycardia and a decrease in blood pressure developed during an infusion; resolution occurred promptly after the infusion was discontinued. No persistent hepatic or renal abnormalities were noted in either the IVIG- or the placebo-treated group. There were seven episodes of sepsis in the placebo group and nine in the group whose parents refused consent to the study. No infant who received IVIG acquired nosocomial sepsis (p less than 0.01). All patients in the placebo group in whom sepsis developed had serum IgG levels less than 400 mg/dl at the time sepsis developed. Serum IgG levels were maintained near 700 mg/dl in patients who received IVIG. These data indicate that administration of sufficient IVIG to maintain target serum IgG levels throughout hospitalization may decrease the incidence of nosocomial sepsis in preterm infants.