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Study objectiveTo describe sleep duration and quality in the first month postpartum and compare the sleep of women who exclusively breastfed at night to those who used formula.MethodsWe conducted a longitudinal study in a predominantly low-income and ethnically diverse sample of 120 first-time mothers. Both objective and subjective measures of sleep were obtained using actigraphy, diary, and self-report data. Measures were collected in the last month of pregnancy and at one month postpartum. Infant feeding diaries were used to group mothers by nighttime breastfeeding behavior.ResultsMothers who used at least some formula at night (n = 54) and those who breastfed exclusively (n = 66) had similar sleep patterns in late pregnancy. However, there was a significant group difference in nocturnal sleep at one month postpartum as measured by actigraphy. Total nighttime sleep was 386 ± 66 minutes for the exclusive breastfeeding group and 356 ± 67 minutes for the formula group. The groups did not differ with respect to daytime sleep, wake after sleep onset (sleep fragmentation), or subjective sleep disturbance at one month postpartum.ConclusionWomen who breastfed exclusively averaged 30 minutes more nocturnal sleep than women who used formula at night, but measures of sleep fragmentation did not differ. New mothers should be encouraged to breastfeed exclusively since breastfeeding may promote sleep during postpartum recovery. Further research is needed to better understand how infant feeding method affects maternal sleep duration and fragmentation.CitationDoan T; Gay CL; Kennedy HP; Newman J; Lee KA. Nighttime breastfeeding behavior is associated with more nocturnal sleep among first-time mothers at one month postpartum.

Mental stress increases cardiovascular morbidity and mortality. Although laboratory mental stress often causes less myocardial ischemia than exercise stress (ES), it is unclear whether mental stress is intrinsically different or differences are due to less hemodynamic stress with mental stress. We sought to evaluate the hemodynamic and ischemic response to intense realistic mental stress created by modern flight simulators and compare this response to that of exercise treadmill testing and conventional laboratory mental stress (CMS) testing in pilots with coronary disease. Sixteen airline pilots with angiographically documented coronary disease and documented myocardial ischemia during ES were studied using maximal treadmill ES, CMS, and aviation mental stress (AMS) testing. AMS testing was done in a sophisticated simulator using multiple system failures as stressors. Treadmill ES testing resulted in the highest heart rate, but AMS caused a higher blood pressure response than CMS. Maximal rate-pressure product was not significantly different between ES and AMS (25,646 vs 23,347, p = 0.08), although these were higher than CMS (16,336, p

Some of the molecules and cells in human milk actively help protect against infection. Infants who are breastfed therefore contract fewer infections than those who are given formula. UNICEF and the World Health Organization advise breast feeding to two years and beyond since a childs immune response does not reach its full strength until after approximately five years. All babies receive maternal antibodies through the placenta before birth but breastfed infants receive extra protection from antibodies other proteins and immune cells in human milk. Once ingested the molecules and cells help to prevent microorganisms from penetrating the bodys tissues. This assistance is particularly important during the first few months of life when an infant cannot effectively defend itself against foreign organisms. Some of the molecules bind to microbes in the lumen of the gastrointestinal tract blocking microbes from attaching to and crossing through the mucosa which line the digestive tract and other body cavities. Other molecules lessen the supply of particular minerals and vitamins which harmful bacteria need to survive in the digestive tract. Certain immune cells in human milk are phagocytes which attack microbes directly while another set produces chemicals which boost the infants own immune response. The author describes breast milk antibodies and the general immune benefits of breast milk.

To the Editor; I recently sent around a mailing to colleagues quoting what one fourth-year resident in paediatrics, having consulted with me by e-mail about certain breastfeeding issues, had to say about her paediatric training on breastfeeding. Here, from her e-mails, in a nugget, is what she said. “Teaching of breastfeeding at University of xxxx and at xxxxx Hospital? Exactly what teaching are you referring to? I do not recall a single lecture or problem-based learning case or anything.” And “I have had whole lectures on the components and makeup of one million different formulas (normal, premie, soy-based, partially or totally hydrolyzed, etc).” I was not surprised by what this resident had to say. After all, my work now consists exclusively of helping breastfeeding mothers breastfeed, and what I have heard mothers say about what paediatricians advised them regarding breastfeeding beggars the imagination. In 21 years of working with breastfeeding mothers, I have asked thousands whether their baby’s doctor ever observed the baby breast-feeding. Only a few said yes. And yet, one can learn a tremendous amount by simple observation. One can see whether a baby is latched on well and whether the baby is getting milk. It is easy. Look at the video clips at to see the distinct pause in the chin of the baby at the breast. This pause says, “I just got a mouthful of milk.” The longer the pause, the more milk the baby got. The pause can be seen even on day 1, though not as dramatically. Once an observer knows this, he or she knows that breastfeeding by numbers is an absurdity. Per cent weight loss is misleading, and leads to undue confidence in some cases and unnecessary interventions in others. “Feed the baby at least eight to 12 times a day” makes no sense. A baby who feeds well will wake up when he’s hungry. A baby who feeds so poorly that we are concerned he will get dehydrated should not be woken up to feed more frequently. What’s the point of the baby getting nothing eight times a day instead of five? The point is to fix the breastfeeding not to wake the baby up more frequently to feed poorly more frequently. Twenty minutes on each side is meaningless. If the baby breast-feeds well, he may have had enough in 20 min on just one side. A baby who ‘nibbles’ for 20 h will not get enough. Are paediatricians aware of how to evaluate a breastfeeding? Do they learn this in their training, something that takes 15 s to see and then understand? Paediatricians lean on these numbers and the scales (which are sometimes inaccurate, and comparing different scales is useless) because they do not know about breastfeeding, and so numbers offer them security – false security. This is part of an e-mail I received recently from a new mother. “She had lost a considerable amount of weight and was admitted into the [a world-class Canadian paediatric] hospital. She was put through a battery of various tests to determine what may have been the cause for such an amount of weight loss (1 lb). After four days of hospitalization, it was determined that I was not producing enough milk.” This is appalling. If someone, someone who knows, had just watched the baby at the breast, they could have told immediately that the baby was not getting enough milk (which is not the same as the mother not producing enough; it is quite possible that her situation represented the usual situation, not that the mother was not producing enough, but that the baby was not getting the milk that was available). Four days of hospitalization at great cost could have been avoided, and the real problem, inadequate breastfeeding, could have been addressed, often without supplementation, in fact. This case is not unique, not by a long shot. Consider this: articles are frequently published on dehydration in breastfed babies. Breastfed babies do not get dehydrated. Babies get dehydrated if they are only pretending to breastfeed. They are not breastfeeding simply because they have the nipple in their mouths anymore than a baby who is sucking a bottle with a clogged nipple hole is feeding, and the fact that so many cases of dehydration occur is a black mark on our hospital system, in which most of the staff have no idea of how to help mothers establish breastfeeding. Consider this: most mothers could produce all the milk the baby needs, but most are failed by our system. They could have produced enough if given good help and information. Consider this: most mothers who have sore nipples do not need to have developed sore nipples. Simply helping the mother latch the baby on well will prevent and treat most sore nipples. Most mothers in Canada succeed in breastfeeding in spite of the ‘help’ they get because most women will produce more than enough milk, and when you produce more than enough milk, you can often overcome any problem. The Canadian Paediatric Society needs to do more to encourage teaching about breastfeeding to paediatric residents and to emphasize breastfeeding support strategies for practising paediatricans. Now is the time to get breastfeeding on the curriculum of medical schools and into the training of paediatricians, not just ‘breastmilk contains x g% protein, y g% fat, just like formula’, but important, practical stuff, so paediatricians can really do what they should be doing to help mothers and their babies maintain good health. Or, they should not advise mothers about breastfeeding at all, and leave it to those who know.

Breastfeeding is a natural physiologic process upon which human survival has depended for uncounted generations. Natural selection over millions of years has ensured that breastmilk contains all the nutritional requirements of the newborn period and beyond. In order to prevent problems for the few, modern management of labour, delivery and the postpartum period has subjected most mothers and infants to routines which are contrary to the physiologic principles underlying successful breastfeeding. The early introduction of bottles may render suckling less effective or may result in breast refusal, thus paving the way for failure to thrive, hyperbilirubinemia, "colic" and crying, prolonged and frequent feedings, sore and cracked nipples for the mother, and it may contribute to the onset of plugged ducts and mastitis. Alternatives to bottles can be used when supplementation is thought to be indicated. They include using a lactation aid, finger feeding, or feeding with a cup, spoon, or eyedropper.

Children suffering from mild to moderate (3 to 6%) dehydration likely caused by viral gastroenteritis are often hospitalized because they are unable to tolerate oral fluids. We studied 17 such children, aged one to six years, who were otherwise healthy. All had isonatremic dehydration and were treated with 30 ml/kg of 3.3% dextrose and 0.3% saline over a period of three hours in the emergency department before being discharged. No patient required admission to the hospital. Only one patient required another course of rapid intravenous rehydration and subsequently improved without hospitalization. Although all our patients experienced vomiting before treatment, 65% had no vomiting after treatment. Rapid intravenous rehydration is an effective treatment, for children with mild to moderate dehydration secondary to presumed viral gastroenteritis, that obviates the need for hospitalization.

Dehydration and poor weight gain in breastfed infants are common but potentially preventable problems. Serious consequences are severe hypernatremic dehydration, severe weight loss, and severe hyperbilirubinemia with possible irreversible damage to the baby's brain or other vital organs. The dangers of dehydration have been emphasized by recent media reports of severe cases. These reports have resulted in increased, but often inappropriate, intervention in breastfeeding. On the basis of our experience at the Hospital for Sick Children, and the Doctors Hospital (Toronto), we have developed a decision tree and management protocol to assess breastfeeding, intervene effectively, and prevent such problems. If all breastfeeding mothers and babies are evaluated by qualified staff before discharge using this tool, it is expected that the serious consequences associated with babies leaving hospital appearing to be breastfeeding, but in fact not breastfeeding at all, will be prevented. Application of this approach, however, will require considerable upgrading of nurses' and physicians' skills and knowledge with regard to breastfeeding. A case report is presented.

To the Editor, I would like to comment on the Canadian Paediatric Society statement on the guidelines for jaundice published in the May/June issue of Paediatrics & Child Health. On at least two occasions the statement mentions breastfeeding being a risk factor for hyperbilirubinemia. This is an unfortunate way of putting it, is very misleading and inaccurate, as well as reinforces the prejudices of many health professionals with regard to breastfeeding. Early-onset hyperbilirubinemia is not due to breastfeeding or breastmilk, but to the lack of breastmilk. The study by Bertini et al (1), not referenced in the statement, backs up our clinic’s extensive clinical experience of what is really happening and what the real issue is. Support for breastfeeding in most Canadian hospitals is so poor that many babies are not breastfeeding well until the milk ‘comes in’ and are, in fact, only pretending to breastfeed. There is not a large volume of colostrum available in the first few days, but there is enough, if the baby gets it. Because of poor intake of breastmilk, one cannot say that they are breastfeeding, which leads directly to hyperbilirubinemia due to an increased enterohepatic circulation of bilirubin. I appreciate the paragraph on supporting breastfeeding and it is well stated. But unfortunately, individuals experienced in helping mothers breastfeed well are not always easy to come by and paediatricians rarely figure among them. What is necessary is an upgrading of breastfeeding knowledge and skills of the nursing staff and physicians (particularly paediatricians) who deal with newborn babies

Sir .—I was appalled, but only slightly surprised, that neither in the article by Keating et al, 1 nor in the editorial comment by Finberg, 2 is there the slightest suggestion that water intoxication would have been prevented by the mothers' breast-feeding. After all, water intoxication is a complication of bottle feeding. Despite the suggestion by Keating et al that"... preventive interventions applicable to the population at risk are discussed...," all they can manage is that more formula be supplied by the Supplemental Food Program for Women, Infants, and Children (WIC) of the US Department of Agriculture. This is feeble. Surely they are not suggesting that this population is incapable of breast-feeding? Rather, the provision of free formula by WIC is more likely than not to encourage mothers to use the formula and discourage them from breast-feeding. 3 Surely a good beginning to the resolution of the problem would be

Partially purified (approx. 5000-fold), low molecular weight human antihemophilic factor, free of detectable Von Willebrand factor (ristocetin cofactor activity or Von Willebrand antigen), was prepared from fresh citrated plasma by limited reduction with 1 mM dithiothreitol and chromatography on Sepharose CL-4B, Sephadex G-100, and polyelectrolyte E-5. The ratio of antihemophilic factor activity to Von Willebrand factor activity or antigen was greater than 27 000 : 1. The antihemophilic factor activity could be neutralized with homologous antibody and could be further increased with thrombin. The Mr (approx. 116 000) was determined by calibrated gel permeation chromatography, electrophoresis in 5% polyacrylamide gels with sodium dodecyl sulfate and by electrophoresis in large-pore acrylamide gels without it. Since the low Mr antihemophilic factor could be prepared by treating fresh rather than fresh-frozen plasma with dithiothreitol, it was concluded that partial reduction of the antihemophilic factor with this reagent helped to maintain the antihemophilic factor in a low Mr form. When iodo[l-14C]acetamide was used to alkylate the reduced plasma proteins prior to purification, the molecular weight of the purified antihemophilic factor remained low despite numerous purification steps. By this means, one of four radioactive proteins (Mr 116 000) in the final preparation was bound specifically to homologous antihemophilic factor antibody and attributed to 14C-labeled antihemophilic factor. While the data suggest that antihemophilic factor in fresh plasma contains one or more dithiothreitol-sensitive intramolecular disulfide bonds, the possibility of disulfide linkages with other proteins(s) cannot be excluded.

Lyophilized plasma derivatives are more stable to heat than when they are in the liquid state. Commercial Factor VIII (antihemophilic factor) was seeded with a measured quantity of hepatitis B virus. The contaminated material was then lyophilized and subjected to heat of 60 degrees C for 30 hr. Chimpanzees were inoculated with the heat-treated antihemophilic factor or sham-treated antihemophilic factor that had been held at 4 degrees C. Surprisingly, hepatitis B virus survived the heating procedure with no apparent loss in titer: the incubation period to appearance of HBsAg was that expected for the challenge dose of virus. Even more surprising, one chimpanzee (the recipient of the unheated antihemophilic factor) also developed non-A, non-B hepatitis and two chimpanzees (recipients of the heated antihemophilic factor) also developed delta hepatitis. Neither of these agents was a contaminant of the hepatitis B virus challenge pool, since the purity of this hepatitis B virus pool was established previously in chimpanzees. Thus, both a non-A, non-B agent and the delta agent apparently contaminated the commercial antihemophilic factor. This is the first direct evidence for contamination of antihemophilic factor with the delta agent and confirms previous seroepidemiologic evidence for its presence in pooled plasma derivatives. Subsequent inactivation studies were performed with antihemophilic factor experimentally contaminated with the Hutchinson strain of non-A, non-B hepatitis virus. In these studies, heating at 60 degrees C for 30 hr in the dry state rendered antihemophilic factor free of detectable non-A, non-B hepatitis virus.

1. 1. The isolation of human fibrinogen by differential polyethylene glycol precipitations of the fibrinogen contained in the cryoprecipitate of plasma is described. 2. 2. Purification was performed in the presence of 1 mM diisopropyl fluorophosphate and trasylol. 3. 3. The protein obtained is > 95% clottable. 4. 4. It contains no detectable prothrombim, thrombin, plasminogen or plasmin. 5. 5. It is highly soluble and apparently undegraded.

With more mothers breastfeeding their babies and postpartum stays in hospital becoming shorter, more mothers are presenting to the emergency department with problems that formerly were managed in the newborn nursery. This article deals with an approach to the breastfeeding baby who presents in the emergency department because of jaundice, poor feeding, "colic," gastrointestinal bleeding, and failure to thrive. Although many of these problems also occur in the bottle-feeding baby, only the special considerations which apply to the breastfeeding baby will be considered.

Six instances of subluxation of the radial head ("nursemaid's elbow, pulled elbow") in babies in the first 6 months of life are presented. In four cases, the pulled elbow was produced in a previously unreported fashion.

Infant walkers have been described as a cause of unexpected trauma in the first year of life. We conducted a prospective study to determine the mechanism and pattern of walker injuries presenting to an urban pediatric teaching hospital. We also studied the patterns of walker use. All injuries sustained by infants in baby walkers during a 1-year period were reviewed. The 139 injuries included 29 fractures. The most severe injuries were caused by falls down stairs; these falls accounted for 123 of the injuries. Stair gates were present in one third of all falls. At follow-up 2 months later, two thirds of the children had been in the walker subsequent to the injury. One third were still in the walker at 2 months after their initial injury. Less than half of the homes that had not had stair gates in place had acquired them at the time of follow-up. Baby walkers represent a cause of significant injury in the infant population; studies of warning labels and anticipatory guidance are needed.