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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
February 24, 2018

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Prenatal Ultrasound Exposure and Autism Risk.
How Well Informed Are OBGYNs About Opioids?
Reassured by a Patient's Prescription Drug Monitoring Program Results? Not So Fast!
Preoperative Exercise for Patients with Lung Cancer
Diaphragmatic Breathing for Refractory GERD: A New Treatment Paradigm?
What is the Optimal Gestational Age for Obese Women to Give Birth?
Natalizumab Washout Prior to Pregnancy Associated with Increased Relapses
Fetal Risks with Exposure to Natalizumab for Multiple Sclerosis
Preterm Birth as a Potential Consequence of Cervical Cancer Screening
Does a Healthy Diet Protect Against Depression in Adolescence?
Helicobacter pylori Eradication and Gastric Cancer in Sweden
Linking Limited Lactation to Risk for Diabetes

JAMA Pediatr 2018 Feb 12
Prenatal Ultrasound Exposure and Autism Risk
In a case-control study, first and second trimester ultrasound tissue penetration was deeper in children with autism spectrum disorder than in controls.
Prevalence of autism spectrum disorder (ASD) has increased to 1 in 68 children in the U.S. The increase can be explained partially by shifts in case identification, however, environmental exposures may also play a role. Researchers examined whether prenatal ultrasound exposure might increase ASD risk — the study was driven by concern that modern ultrasound machines are more powerful than those tested in fetal safety studies, and animal research showing links between prenatal ultrasound exposure, potential thermal effects on neuronal migration, and deficits in offspring behavior.
The researchers reviewed medical records for children who had received prenatal ultrasound exams at a single center in Boston from 2006 to 2014. Number, duration, type (e.g., Doppler, 3D, 4D), and tissue depth penetration of prenatal ultrasound was assessed in three groups: 107 children diagnosed with ASD by a developmental-behavioral pediatrician; 104 children with developmental delay; and 209 age- and sex-matched typically developing children. Analyses controlled for sex, gestational age, and maternal age.
Children with ASD had no differences in ultrasound exposure from those with developmental delay, except for greater tissue penetration depth in the first trimester. Children with ASD had greater tissue penetration depth in the first and second trimesters than typical controls but a shorter duration of ultrasound studies. There were no differences in ultrasound scan frequency or type between groups.
COMMENT: These results may seem alarming given the frequency of prenatal ultrasound examinations (which averaged 6 per pregnancy in this sample). However, editorialists note that tissue penetration depth has not been studied previously, and deeper penetration could actually be interpreted as causing lower, rather than higher, exposure because ultrasound waves attenuate as they propagate through tissue. It is reassuring that number and duration of ultrasonography were not associated with ASD, although is possible that environmental “hits” such as ultrasound may be more important in genetically vulnerable fetuses. These findings emphasize the American College of Obstetricians and Gynecologists recommendation for ultrasound exposure “as low as reasonably achievable,” particularly in low-risk pregnancies.
CITATION(S): Rosman NP et al. Association of prenatal ultrasonography and autism spectrum disorder. JAMA Pediatr 2018 Feb 12; [e-pub].
Webb SJ and Mourad PD. Prenatal ultrasonography and the incidence of autism spectrum disorder. JAMA Pediatr 2018 Feb 12; [e-pub].
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Obstet Gynecol 2017 Dec 42
How Well Informed Are OBGYNs About Opioids?
National survey identifies substantial gaps in knowledge.
Over half of the >2 million Americans with prescription opioid use disorders report accessing these drugs through diversion of prescribed medications. Government agencies and professional societies such as the American College of Obstetricians and Gynecologists (ACOG) have disseminated guidance on measures to minimize opioid misuse. In 2016, investigators conducted a survey of ACOG fellows regarding their knowledge of and adherence to four recommended approaches to outpatient opioid prescribing (including at hospital discharge): Screen patients for opioid dependence, provide the smallest appropriate number of pills, tailor opioid prescriptions, and counsel patients regarding proper use, storage, and disposal of opioids.
Among 179 respondents, 98% indicated they normally prescribed opioids for outpatient postoperative pain management following laparotomy for hysterectomy or cesarean birth, and 22% reported typically prescribing opioids after vaginal delivery. Respondents reported prescribing more pills after laparotomies (median, 30; range, 0–8) than after minimally invasive hysterectomy (25; 6–60). The most variation occurred for treatment of chronic pelvic pain with unknown cause. While 75% of respondents said they provided a standard number of pills, fewer than 20% reported adherence to ≥3 of the 4 recommendations. Fewer than 25% were aware that most individuals who misuse opioids obtain them from family or friends.
COMMENT: Although clinicians may prescribe a standard number of pills to ensure adequate pain control, recent studies (NEJM JW Womens Health Aug 2017 and Obstet Gynecol 2017 Jul, multiple citations) showed that only half of the opioids prescribed after cesarean birth were consumed, leaving the door open to misuse and diversion. I would have been interested to know how these survey findings compare with other surgical specialties. Nonetheless, this report points out the need for more education of OBGYNs about prescribing opioids.
CITATION(S): Madsen AM et al. Opioid knowledge and prescribing practices among obstetrician–gynecologists. Obstet Gynecol 2017 Dec 4; [e-pub]. (http://dx.doi.org/10.1097/AOG.0000000000002407)
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Acad Emerg Med 2017 Nov 22
Reassured by a Patient's Prescription Drug Monitoring Program Results?
Not So Fast!

Nearly two thirds of patients with opioid dependence had no opioid prescriptions logged over the prior 12 months.
Prescription drug monitoring programs (PDMPs) are available in every state. Designed to collect and display prescriptions for controlled substances, they are becoming an indispensable part of prescribing practice for providers. The data they contain can help inform decisions about whether or not to prescribe controlled substances, including opioids for pain. However, the proportion of patients with opioid dependence who are captured by PDMPs remains unknown. Using data previously collected for an emergency department–based treatment trial in Connecticut, researchers determined the correlation between self-reported nonmedical prescription opioid use and opioid prescriptions recorded in the state's PDMP.
Of 329 patients with opioid dependence enrolled, only 118 (36%) had one or more opioid prescriptions recorded in the PDMP during the past year. Among the remaining 211 patients, 60 (28%) reported 15 or more days of nonmedical prescription opioid use during the prior 30 days, despite having no recorded opioid prescriptions.
COMMENT; Most states in the U.S., including mine, have mandated the use of PDMPs in certain cases. However, this paper's findings are a sobering reminder that most patients with opioid use disorder don't get their opioids from prescribers. Don't be falsely assured by a PDMP search that comes up blank — your history-taking abilities and gestalt are still very important when deciding whether to prescribe opioids.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S): Hawk K et al. Past-year prescription drug monitoring program opioid prescriptions and self-reported opioid use in an emergency department population with opioid use disorder. Acad Emerg Med 2017 Nov 22; [e-pub].
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Br J Sports Med 2018 Feb 1
Preoperative Exercise for Patients with Lung Cancer
Preoperative exercise reduced postoperative complication rates and length of hospital stay.
Preoperative exercise has been evaluated in several clinical trials, but its effectiveness in reducing postoperative complications remains unknown.
To examine this issue, investigators performed a meta-analysis of data from 13 randomized controlled trials (RCTs) or quasi-randomized controlled trials (qRCTs) involving 806 patients (median age, 63.3 years) with six different primary tumor types and surgeries. The duration of most preoperative exercise interventions was 2 weeks (range, 1 to 4 weeks). Of note, approximately half the trials had at least one feature with a high risk of bias.
For patients undergoing liver resection for colorectal cancer or surgery for colon, esophageal, lung, oral, and prostate cancer, the effectiveness of preoperative exercise was uncertain owing to the low quality of evidence and a limited number of trials. However, moderate-quality evidence showed that among 432 lung cancer patients from five RCTs and one qRCT, preoperative exercise reduced both postoperative complication rates (relative risk, 0.52; 95% confidence interval, 0.36–0.74) and length of hospital stay (median reduction, 2.86 days; 95% CI, 0.33–5.40 days). Most of the trials analyzed in the lung cohort included aerobic and respiratory muscle training exercises for 1 to 2 weeks prior to surgery, with a frequency that ranged from three times a week to three daily sessions. Studies with more sessions showed a greater benefit.
COMMENT: Despite the limitations intrinsic to meta-analyses, this study supports the hypothesis that preoperative exercise benefits patients undergoing lung cancer surgery. In addition to benefiting the patients' quality of life, there is a potential cost savings with the reduction in length of stay and reduced need for management of postoperative complications. Based on this and other studies, standard practice should incorporate 1 to 2 weeks of aerobic and respiratory muscle exercise prior to lung resections. Additional future trials should focus on defining the optimal preoperative program, evaluating measures to improve compliance, and analyzing the cost savings.
CITATION(S): Steffens D et al. Preoperative exercise halves the postoperative complication rate in patients with lung cancer: A systematic review of the effect of exercise on complications, length of stay and quality of life in patients with cancer. Br J Sports Med 2018 Feb 1; [e-pub].
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Clin Gastroenterol Hepatol 2017 Nov 2
Diaphragmatic Breathing for Refractory GERD: A New Treatment Paradigm?
A four-week guided therapy in “belly breathing” was effective in reducing excessive belching and overall GERD symptoms.
Belching is a frequent if not predominant symptom in many patients with gastroesophageal reflux disease (GERD). Typically this is supragastric belching (SGB), which proton-pump inhibitors (PPIs) do not treat.
To determine whether diaphragmatic breathing therapy (DBT) might improve excessive GERD-related belching, researchers in Singapore evaluated 36 consecutive patients with PPI-refractory GERD and severe belching, as determined by a visual analogue score. All patients had well-established GERD and no primary esophageal motility disorder. Fifteen patients underwent standardized DBT, consisting of 4 weekly one-on-one sessions with a speech therapist for 4 weeks, and 21 controls were placed on a waiting list for DBT.
After the 4-week treatment, reduction in belching severity by ≥50% (primary outcome) was evident in 60% of the DBT group and none of the controls. DBT was also associated with improvements in overall GERD symptom score and quality of life. These outcomes were sustained 4 months after treatment ended.
COMMENT: Diaphragmatic breathing (“belly breathing”) may be familiar to your patients who do yoga. Details of DBT and a video are provided in the supplementary material for the original article. In DBT, one hand is placed on the upper chest and one hand on the abdomen just below the rib cage at the bottom of the sternum. Patients are initially instructed to take a deep inspiratory breath to demonstrate chest wall movement, but then to take breaths by only moving the abdomen, while keeping the chest motionless. The goal is to keep the hand on the chest almost still, while the hand on the abdomen rises and falls with the diaphragmatic breath. This technique is also very effective for rumination syndrome and in some with refractory singultus.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S): Ong AM et al. Diaphragmatic breathing reduces belching and proton pump inhibitor refractory gastroesophageal reflux symptoms. Clin Gastroenterol Hepatol 2017 Nov 2; [e-pub].
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Obstet Gynecol d 2017 Dec 4
What is the Optimal Gestational Age for Obese Women to Give Birth?
For women with prepregnancy BMI >30 kg/m2, elective induction of labor at 39 weeks resulted in the best maternal and newborn outcomes.
To explore the optimal timing of birth among obese women, investigators in California conducted a retrospective cohort study of some 166,000 deliveries in women with body-mass index (BMI) >30 kg/m2. Elective induction at ≥39 weeks' gestation was compared with expectant management beginning at 39 weeks (with delivery later in pregnancy). Pregnancy outcomes were analyzed at gestational weeks 39, 40, and 41.
Among nulliparous women, elective induction compared with expectant management at 39 weeks was associated with lower rates of cesarean delivery (36% vs. 41%; adjusted odds ratio (aOR), 0.82), severe maternal morbidity (6% vs. 8%; aOR, 0.75), and newborn admission to the neonatal intensive care unit (NICU; 8% vs. 10%; aOR, 0.79). Among parous women, elective induction compared to expectant management at 39 weeks also was associated with lower rates of cesarean delivery (7% vs. 9%; aOR, 0.79), severe maternal morbidity (3% vs. 4%; aOR, 0.83), and newborn admission to the NICU (5% vs. 7%; aOR, 0.75). Similar distinctions were observed for elective induction at 40 weeks versus expectant management.
COMMENT: Although humans arose >200,000 years ago, we still don't know the best gestational age for delivery to optimize maternal and newborn outcomes. Giving birth before 39 weeks' gestation can threaten neonatal outcomes; hence, the strong recommendation to avoid nonmedically indicated deliveries before that gestational age. This observational study indicates that, in obese women, elective induction at 39 weeks is associated with better maternal and newborn outcomes than expectant management; moreover, it's becoming clearer that the optimal time for humans to give birth is 39 weeks' gestation. A randomized, NIH-funded trial including nonobese women is currently under way. If the results confirm the superiority of induced delivery at 39 weeks over expectant management, a major change in birth practices could result.
CITATION(S): Gibbs Pickens CM et al. Term elective induction of labor and pregnancy outcomes among obese women and their offspring. Obstet Gynecol 2017 Dec 4; [e-pub].
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Neurology 2018 Feb 7
Natalizumab Washout Prior to Pregnancy Associated with Increased Relapses
Robert T. Naismith, MD reviewing Portaccio E et al. Neurology 2018 Feb 7.
Women with a washout interval longer than 2 weeks had more relapses during pregnancy than those with no preconception washout.
Natalizumab is often used for severe multiple sclerosis (MS). Because this treatment blocks lymphocyte entry into the central nervous system (CNS), its withdrawal (e.g., before attempting pregnancy) has been associated with return of disease activity. Investigators used a multicenter registry to track 74 pregnancies in 70 women with relapsing-remitting MS taking natalizumab and compared relapses with those in 350 pregnancies in 345 women (control patients) who were either untreated or taking injectable MS therapies.
For control patients, the relapse profile was consistent with prior studies: stable prior to conception, reduced during pregnancy, and increased after delivery. For those on natalizumab, relapse rate was stable prior to conception, increased in the first trimester, increased again after delivery, and remained high until natalizumab was reinstated in the postpartum period. Washout period was evaluated for 34 pregnancies in women who received natalizumab before their last menstrual period and 40 who received natalizumab after their last menstrual period. The 34 with the longer washout period demonstrated a sixfold increased odds of relapse in the first trimester compared with controls and had a higher rate of relapses in the postpartum period; those with no washout were similar to the control group in relapse rates. In the postpartum period, women with relapses during pregnancy had a significantly increased risk for a relapse (odds ratio, 2.14; 95% confidence interval, 1.12–4.08), and those who did not resume natalizumab within 4 weeks after delivery likewise had increased relapse risk (OR, 4.40; 95% CI, 1.28–15.16). Disability worsening occurred in 16%, almost exclusively as a result of their relapse(s).
COMMENT: Women wishing to conceive while on natalizumab need special counseling due to the risk for relapse upon cessation of treatment. Treatment during pregnancy is not recommended (NEJM JW Neurol Apr 2018 and Neurology 2018 Feb 7; [e-pub]). Those with concerning disease activity prior to natalizumab might consider continuing natalizumab until conception, while accepting potential exposure during the first trimester, or switching to another highly effective therapy with a biologic effect much longer than its plasma half-life, with plans to conceive after the medication is out of the system.
Dr. Naismith reports consulting for Biogen, the manufacturer of natalizumab.
CITATION(S): Portaccio E et al. Pregnancy decision-making in women with multiple sclerosis treated with natalizumab: II: Maternal risks. Neurology 2018 Feb 7; [e-pub].
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Neurology 2018 Feb 7
Fetal Risks with Exposure to Natalizumab for Multiple Sclerosis
Robert T. Naismith, MD reviewing Portaccio E et al. Neurology 2018 Feb 7.
An increased rate of spontaneous abortions compared with other MS patients was suggested in an observational study.
Women taking natalizumab for multiple sclerosis (MS) who plan to become pregnant require counseling on options to discontinue therapy safely (NEJM JW Neurol Apr 2018 and Neurology 2018 Feb 7; [e-pub]). The decision should be based on potential risks for the woman, along with risks for the baby. This multicenter study tracked 92 pregnancies in 83 women taking natalizumab, compared with 406 pregnancies in 398 women with MS who were either untreated or taking interferon.
Spontaneous abortions (SA) occurred in 17.4% on natalizumab, 8.0% on interferon, and 6.5% for those untreated. Natalizumab exposure was associated with a significantly higher risk for SA (odds ratio, 3.9), compared with exposure to interferon or nothing. However, the rate of SA with natalizumab was not statistically different from the background rate of SA in the general population. Rates of congenital anomalies were 3.7% with natalizumab, 1.3% with interferon, and 0.9% with no treatment. Exposure to natalizumab or interferon was associated with a mild reduction in birthweight (−169 g) and length (−1 cm) compared with no treatment. Natalizumab was not associated with preterm delivery or caesarean delivery.
COMMENT: Fetal exposure to natalizumab was associated with a trend toward increased risk for spontaneous abortions, in addition to a slightly increased risk for congenital anomalies, and a lower birthweight. Other studies and registries for natalizumab exposure prior to pregnancy have yielded various results: Some have found increased SAs, but congenital anomalies were not consistently observed. Women desiring pregnancy need to be counseled about the risk for disease reactivation along with potential risks for the baby. Switching to another high-efficacy therapy option before conceiving might be an option, although we lack studies on such an approach. Neurologists should educate their patients about the risks and share decision making about MS treatment before and during pregnancy.
Dr. Naismith reports consulting for Biogen, the manufacturer of natalizumab.
CITATION(S): Portaccio E et al. Pregnancy decision-making in women with multiple sclerosis treated with natalizumab: I: Fetal risks. Neurology 2018 Feb 7; [e-pub].
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Obstet Gynecol 2017 Nov 3
Preterm Birth as a Potential Consequence of Cervical Cancer Screening
Modeling analysis reinforces that more-frequent screening identifies a few more malignancies, but ablative treatment also raises risk for preterm birth and associated costs.
Cervical high-grade lesions — precursors to cancer — are removed with techniques such as the loop electrosurgical excision procedure (LEEP); however, these procedures raise risk for preterm birth and associated morbidity (NEJM JW Womens Health Dec 2016 and Obstet Gynecol 2016; 128:1265). Investigators modelled data about several potential cervical cancer screening strategies in the Netherlands to estimate the number of cervical cancers diagnosed, life-years gained, cancer deaths, and costs. Based on the number of LEEPs performed (with associated preterm birth risk ranging from 11% to 67%), they calculated the additional preterm births and associated costs.
Cervical cancer screening programs ranged from cytologic screening every 3 years starting at age 21 to human papillomavirus (HPV) testing every 5 years starting at age 30. Compared with the least intensive screening, the most aggressive program reduced cervical cancer cases by 67% and deaths from 16 to 4 per 100,000 women screened, but was associated with 250% more preterm births (158 vs. 45) and threefold higher costs.
COMMENT: Cervical cancer screening programs are shifting toward HPV testing initiated at an older age, as lesions often spontaneously regress in younger women. This analysis reminds us that excess risk for preterm birth is a potential cost of more-frequent screening while the benefit is small. Moreover, as HPV immunization coverage increases, this risk-benefit profile will continue to evolve. Notably, in the U.S., incidence of preterm birth is more than twice that in the Netherlands, with a relatively lower proportion resulting from cervical ablation.
CITATION(S): Kamphuis EI et al. Effect of cervical cancer screening programs on preterm birth: A decision and cost-effectiveness analysis. Obstet Gynecol 2017 Nov 3; [e-pub].
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Brain Behav Immun 2018 Jan 12
Does a Healthy Diet Protect Against Depression in Adolescence?
More-frequent consumption of healthy nutrients at age 14 was associated with fewer depressive symptoms at age 17.
Building on prior work showing a cross-sectional relationship between diet, body-mass index (BMI), and depressive symptoms at age 14 years, investigators from Australia further analyzed data from a longitudinal study of pregnant women and their offspring (the Raine Study) to determine if diet quality (frequency of consumption of meat, fish, fruits, vegetables, and whole grains) at age 14 predicted similar outcomes at age 17.
A total of 853 offspring (51% female) had BMI recorded and completed the Beck Depression Inventory for Youth and the Youth Self Report of the Child Behavior Checklist at ages 14 and 17. The cohort also had levels of the inflammatory markers serum leptin and high sensitivity C-reactive protein (hs-CRP) measured at age 17.
Analyses controlled for potential confounders (e.g., maternal education, family income, drug use, and physical activity at age 14) yielded the following results:
·  A “Western” diet (consisting of more meat and less fruits, vegetables, and whole grains) at age 14 was positively associated with higher BMI at ages 14 and 17 and with leptin and hs-CRP levels at age 17 (P<0.05 for all).
·  A “healthy” diet (consisting of more fish, fruits, vegetables, whole grains) was not significantly associated with BMI at age 14 but was negatively associated with BMI and hs-CRP at age 17 (P<0.05).
·  BMI at 14 was positively associated with BMI and inflammatory markers at age 17, and both were linked to depressive symptoms at age 17 (P<0.05 for both).
·  In a reverse-hypothesis model, depressive symptoms were not significantly associated with diet quality at age 14.
COMMENT: Emerging evidence indicates a link between depression and inflammation. By extending their prior work to include a longitudinal prospective analysis, these investigators provide stronger evidence that these relationships are emerging during adolescence. Pediatricians can use this information to counsel adolescents that eating healthily may improve not only physical health but mental health, as well.
CITATION(S): Oddy WH et al. Dietary patterns, body mass index and inflammation: Pathways to depression and mental health problems in adolescents. Brain Behav Immun 2018 Jan 12; [e-pub].
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Gut 2018 Jan 30
Helicobacter pylori Eradication and Gastric Cancer in Sweden
Data from a Western population support evidence showing that the risk for gastric cancer changes based on time since H. pylori eradication.
Helicobacter pylori is a risk factor for gastric cancer. Some studies show that preneoplastic mucosal changes improve with H. pylori eradication. Investigators in Sweden tested this hypothesis by comparing gastric cancer incidence among 95,000 patients (contributing 350,000 person-years at risk) who were treated for H. pylori and the background Swedish population.
During follow-up (maximum, 7.5 years), 75 patients (0.1%) developed gastric adenocarcinoma, mostly noncardia (69). The risk for gastric cancer was initially elevated after H. pylori eradication (standardized incidence ratio [SIR], 8.7, for years 1 to 3 posteradication), then declined during years 3 to 5 (SIR, 2.0), and was eventually lower compared with the general population during years 5 to 7.5 (SIR, 0.3). The same pattern was seen for noncardia cancers (SIR decreased from 10.7 to 2.7 to 0.4). Patients who had multiple courses of therapy for H. pylori had a higher risk for cancer.
COMMENT: This study provides important data on gastric cancer risk in a Western population with a low prevalence of H. pylori infection (15%). Even with a large population at risk, cancer incidence was low (0.1%). Although the observational nature of this study and the lack of data on the success of eradication therapy are limitations, the large number of patients in the initial cohort and follow-up period are strengths. The shift over time from an increased to a decreased SIR is consistent with the known increased gastric cancer risk associated with H. pylori in the short term, which decreases with time from eradication. The observed reduced risk for gastric cancer 5 years after H. pylori eradication could potentially be explained by the relatively higher (though still low) risk for gastric cancer in the background population in which H. pylori is still present.
CITATION(S): Doorakkers E et al. Helicobacter pylori eradication treatment and the risk of gastric adenocarcinoma in a Western population. Gut 2018 Jan 30; [e-pub].
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JAMA Intern Med 2018 Jan 16
Linking Limited Lactation to Risk for Diabetes
In a prospective cohort study, incident diabetes was more common among mothers who never breast-fed than those who did.
Several retrospective studies have shown that, among parous women, risk for diabetes is reduced in association with breast-feeding (e.g., NEJM Journal Watch Womens Health Dec. 2016 and Obstet Gynecol2016 Nov; 128:1095). Building on this work, researchers analyzed prospective community-based data collected from 1238 U.S. women who gave birth at least once.
Median duration of lactation was 1.4 months among mothers who developed diabetes versus 4.4 months among those who did not develop the condition (P<0.001).
Compared with mothers who breast-fed for at least 12 months, those who never breast-fed had 89% higher risk for incident diabetes in models adjusted for race, parity, gestational diabetes, family history of diabetes, diet, physical activity, prepregnancy body-mass index and waist circumference, and weight change during 30 years of follow-up.
COMMENT: These findings support a protective link between lactation and maternal risk for diabetes in later life, beyond the other known maternal benefits of breast-feeding, including lower rates of hypertension, breast cancer, ovarian cancer, endometrial cancer, and endometriosis. Regrettably, the U.S. remains one of just three countries worldwide without paid parental leave, and many mothers are hindered from breast-feeding for as long as they'd like. Given that suboptimal duration of breast-feeding contributes to >3000 U.S. deaths and costs the country billions of dollars each year, we must ensure that all mothers who want to breast-feed receive the support they need to do so.
CITATION(S): Gunderson EP et al. Lactation duration and progression to diabetes in women across the childbearing years: The 30-year CARDIA study.
JAMA Intern Med 2018 Jan 16; [e-pub].

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