DiversityNursing Blog

Delayed Umbilical Cord Clamping May Benefit Children Years Later

Posted by Erica Bettencourt

Wed, May 27, 2015 @ 12:22 PM

TARA HAELLE

www.npr.org 

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A couple of extra minutes attached to the umbilical cord at birth may translate into a small boost in neurodevelopment several years later, a study suggests.

Children whose cords were cut more than three minutes after birth had slightly higher social skills and fine motor skills than those whose cords were cut within 10 seconds. The results showed no differences in IQ.

"There is growing evidence from a number of studies that all infants, those born at term and those born early, benefit from receiving extra blood from the placenta at birth," said Dr. Heike Rabe, a neonatologist at Brighton & Sussex Medical School in the United Kingdom. Rabe's editorial accompanied the study published Tuesday in the journal JAMA Pediatrics.

Delaying the clamping of the cord allows more blood to transfer from the placenta to the infant, sometimes increasing the infant's blood volume by up to a third. The iron in the blood increases infants' iron storage, and iron is essential for healthy brain development.

"The extra blood at birth helps the baby to cope better with the transition from life in the womb, where everything is provided for them by the placenta and the mother, to the outside world," Rabe said. "Their lungs get more blood so that the exchange of oxygen into the blood can take place smoothly."

Past studies have shown higher levels of iron and other positive effects later in infancy among babies whose cords were clamped after several minutes, but few studies have looked at results past infancy.

In this study, researchers randomly assigned half of 263 healthy Swedish full-term newborns to have their cords clamped more than three minutes after birth. The other half were clamped less than 10 seconds after birth.

Four years later, the children underwent a series of assessments for IQ, motor skills, social skills, problem-solving, communication skills and behavior. Those with delayed cord clamping showed modestly higher scores in social skills and fine motor skills. When separated by sex, only the boys showed statistically significant improvement.

"We don't know exactly why, but speculate that girls receive extra protection through higher estrogen levels whilst being in the womb," Rabe said. "The results in term infants are consistent with those of follow-up in preterm infants."

Delayed cord clamping has garnered more attention in the past few years for its potential benefits to the newborn. Until recently, clinicians believed early clamping reduced the risk of hemorrhaging in the mother, but research hasn't borne that out.

Much of the research has focused on preterm infants, who appear to benefit most from delayed cord clamping, Rabe said. Preemies who have delayed cord clamping tend to have better blood pressure in the days immediately after birth, need fewer drugs to support blood pressure, need fewer blood transfusions, have less bleeding into the brain and have a lower risk of necrotizing enterocolitis, a life-threatening bowel injury, she said.

This study is among the few looking at healthy, full-term infants in a country high in resources, as opposed to developing countries where iron deficiency may be more likely.

The American Congress of Obstetricians and Gynecologists has not yet endorsed the practice, citing insufficient evidence for full-term infants. The World Health Organization recommends delayed cord clamping of not less than one minute.

It is unclear whether the practice could harm infants' health. Some studies have found a higher risk of jaundice, a buildup of bilirubin in the blood from the breakdown of red blood cells. Jaundice is treated with blue light therapy and rarely has serious complications.

Another potential risk is a condition called polycythemia, a very high red blood cell count, said Dr. Scott Lorch, an associate professor of pediatrics at the University of Pennsylvania Perelman School of Medicine and director of the Center for Perinatal and Pediatric Health Disparities Research at Children's Hospital of Philadelphia.

"Polycythemia can have medical consequences for the infant, including blood clots, respiratory distress and even strokes in the worst-case scenario," Lorch said. Some studies have found higher levels of red blood cells in babies with delayed cord clamping, but there were no complications.

Lorch also pointed out that this study involved a mostly homogenous population in a country outside the U.S.

"We should see whether similar effects are seen in higher-risk populations, such as the low socioeconomic population, racial and ethnic minorities and those at higher risk for neurodevelopmental delay," Lorch said.

So far, studies on delayed cord clamping have excluded infants born in distress, such as those with breathing difficulties or other problems. But Rabe said these infants may actually benefit most from the practice.

These babies often need more blood volume to help with blood pressure, breathing and circulation problems, Rabe said. "Also, the placental blood is rich with stem cells, which could help to repair any brain damage the baby might have suffered during a difficult birth," she added. "Milking of the cord would be the easiest way to get the extra blood into the baby quickly in an emergency situation."

Topics: WHO, birth, newborn, childhood, health, nurses, doctors, hospital, patient, umbilical cord, children's health, childbirth, cognitive development

New, Aggressive Strain Of HIV Discovered In Cuba

Posted by Erica Bettencourt

Wed, Feb 18, 2015 @ 11:58 AM

JESSICA FIRGER

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Scientists have discovered a highly aggressive new strain of HIV in Cuba that develops into full-blown AIDS three times faster than more common strains of the virus. This finding could have serious public health implications for efforts to contain and reduce incidences of the virus worldwide.

Researchers at the University of Leuven in Belgium say the HIV strain CRF19 can progress to full blown AIDS within two to three years of exposure to virus. Typically, HIV takes approximately 10 years to develop into AIDS. Patients with CRF19 may start getting sick before they even know they've been infected, which ultimately means there's a significantly shorter time span to stop the disease's progression. 

The scientists began studying the cases in Cuba when reports began coming in that a growing number of HIV-infected patients were developing AIDS just three years after diagnosis with the virus. The findings of their study were published in the journal EBioMedicine.

Having unprotected sex with multiple partners can expose a person to numerous strains of the HIV virus. Research has found that when this occurs, the different strains can combine and form a new variant of the virus.

When HIV first enters the human body it latches on to anchor points of a certain protein, known as CCR5 on the cell membranes, which then allows it to enter human cells. Eventually the virus then latches onto another protein of the cell membrane, known as CXCR4. This marks the point when asymptomatic HIV becomes AIDS. In CRF19, the virus makes this move much sooner. 

For the study, the researchers analyzed blood samples of 73 recently infected patients. Among the group, 52 already had full-blown AIDS, while the remaining 21 were HIV-positive but the virus had not yet progressed. The researchers compared their findings to blood samples of 22 AIDS patients who had more common strains of the virus. 

The researchers found that patients with CRF19 had higher levels of the virus in their blood compared with those who had more common strains. 

They also had higher levels of the immune response molecules known as RANTES, which bond to CCR5 proteins in early stages of the virus. The abnormally high level of RANTES in patients infected with the new strain indicates that the virus runs out of CCR5 anchor points much earlier and moves directly to CXCR4 anchor points.

Thanks to advances in medical treatment and the development of highly effective antiretroviral drugs, HIV/AIDS is no longer a death sentence. But the researchers caution that patients with the new strain of the virus are more likely to be diagnosed when they already have full-blown AIDS and when damage from the disease has taken a toll.

The researchers suspect that this aggressive form of HIV occurs when fragments of other subsets of the virus cling to each other through an enzyme that makes the virus more powerful and easily replicated in the body.

There are currently 35 million people worldwide living with HIV/AIDS, according to the most recent data from the World Health Organization. Scientists have identified more than 60 different strains of the HIV 1 virus, with each type typically found predominantly in a specific region of the world.

Source: www.cbsnews.com

Topics: AIDS, science, WHO, health, nurses, doctors, disease, health care, patients, medicine, treatment, HIV, Cuba

Delayed cord clamping results in better immediate newborn outcomes

Posted by Erica Bettencourt

Wed, Dec 17, 2014 @ 11:35 AM

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At birth, a newborn baby is still attached to its mother through the umbilical cord, which is either cut very early - within the first 60 seconds - or later, with some women opting to wait until after the cord has stopped pulsating. Though the right timing for cutting the cord - also referred to as clamping - is widely debated, a new study suggests delaying cord clamping by 2 minutes results in better development for the newborn during the first days of life.

What do you think about it? Do you think the 2 minutes makes a difference? Perhaps you can share a personal and/or professional experience about this.

The research, carried out by scientists from the University of Granada and the San Cecilio Clinical Hospital in Spain, is published in the journal Pediatrics, the official journal of the American Academy of Pediatrics (AAP).

According to the American Congress of Obstetricians and Gynecologists (ACOG), the reason that cord clamping timing is so controversial is that a previous series of studies into blood volume changes after birth concluded that in healthy term infants, more than 90% of blood volume was attained within the first few breaths he or she took after birth.

As a result of these findings, as well as a lack of other recommendations regarding optimal timing, the amount of time between birth and umbilical cord clamping was widely shortened; in most cases, cord clamping occurs within 15-20 seconds after birth.

However, before these studies, in the mid-1950s, cord clamping within 1 minute of birth was defined as "early clamping," and "late clamping" was defined as more than 5 minutes after birth. And the ACOG have stated that "the ideal timing for umbilical cord clamping has yet to be established."

Meanwhile, the World Health Organization (WHO) advocate for late cord clamping (between 1-3 minutes after birth), as it "allows blood flow between the placenta and neonate to continue, which may improve iron status in the infant for up to 6 months after birth."

Waiting 2 minutes increased antioxidant capacity

To provide further evidence in the debate of early versus late cord clamping, the researchers from this latest study, led by Prof. Julio José Ochoa Herrera of the University of Granada, assessed newborn outcomes for infants born to 64 healthy pregnant women to determine the impact of clamping timing on oxidative stress and the inflammatory signal produced during delivery.

All of these women had a normal pregnancy and spontaneous vaginal delivery. However, half of the women's newborns had their umbilical cord cut 10 seconds after delivery and half had it cut after 2 minutes.

Results revealed beneficial effects of late cord clamping; there was an increase in antioxidant capacity and moderation of inflammatory effects in the newborns.

Commenting further, Prof. Ochoa says:


"Our study demonstrates that late clamping of the umbilical cord has a beneficial effect upon the antioxidant capacity and reduces the inflammatory signal induced during labor, which could improve the development of the newborn during his or her first days of life."

He adds that umbilical cord clamping is one of the most frequent surgical interventions practiced in humans, with proof of the practice dating back centuries. 

Early clamping 'not advised unless newborn needs resuscitation'

With evidence of benefits for delayed cord clamping, however, why are most newborns separated from the placenta within 15-20 seconds after birth? According to the ACOG, there are concerns over universally adopting delayed clamping because it could "jeopardize timely resuscitation efforts, if needed, especially in preterm infants."

"However," the organization states, "because the placenta continues to perform gas exchange after delivery, sick and preterm infants are likely to benefit most from additional blood volume derived from a delay in umbilical cord clamping."

There are also other concerns regarding delayed cord clamping, including an increased potential for "excessive placental transfusion, which can lead to neonatal polycythemia" - an abnormally high level of red blood cells. This is especially of concern in the presence of risk factors including maternal diabetes, intrauterine grown restriction and high altitude.

Another concern stated by the ACOG is that delayed umbilical cord clamping "may be technically difficult in some circumstances."

Still, the WHO say late cord clamping is recommended for all births, and the improved iron status associated with it "may be particularly relevant for infants living in low-resource settings with reduced access to iron-rich foods."

The organization clearly states that early cord clamping - less than 1 minute after birth - is not advised unless the newborn is asphyxiated and needs to be moved for resuscitation.

Source: www.medicalnewstoday.com

Topics: studies, WHO, birth, health, healthcare, nurses, medicine, physicians, hospitals, newborns, babies, cord clamping, umbilical cord, AAP

The debilitating outbreak sweeping the Americas

Posted by Erica Bettencourt

Wed, Dec 17, 2014 @ 11:04 AM

By Meera Senthilingam

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Its name means "bending over in pain." It has no treatment or vaccine. Its symptoms resemble Dengue fever. And it has infected more than 1 million people -- 155 of them fatally -- since spreading to the Americas one year ago.

The mosquito-borne Chikungunya virus has long been diagnosed in travelers returning from countries in Asia and Africa, where the disease is widespread. But in December 2013, the first people infected by mosquitoes local to the region were reported on the Caribbean island of Saint Martin.

This was the first outbreak of the debilitating disease in the Western hemisphere, health officials said.

All countries in Central America have now reported local transmission of Chikungunya [pronounced chik-un-GOON-ya], and the United States had 11 confirmed cases of local infection this year as of December 12, all in the state of Florida. There also have been 1,900 imported cases across the U.S. in returning travelers.

"It wasn't until 2013 that unfortunately a traveler resulted in local transmission of Chikungunya," said Erin Staples of the U.S. Centers for Disease Control (CDC), referring to the people infected in Saint Martin.

Those infected carry the virus in their bloodstream; it can then be picked up by mosquitoes as they bite, making them carriers. The virus has since spread rapidly and shows no signs of leaving, as ecological conditions are perfect for the disease to flourish.

"We knew it would spread," said Staples, a medical epidemiologist.

The big question perplexing officials: Why now?

Two mosquito species primed to the temperatures of Central and South America carry Chikungunya. The species -- Aedes aegypti and Aedes albopictus -- also carry the virus behind Dengue fever.

"Given the level of Dengue in the region, we knew there could be the same levels of Chikungunya," Staples said. Both diseases can cause joint pain and inflammation, headaches, rashes and fever, and can lead to death in rare cases.

But this tropical disease with an exotic name (which originates from the African Makonde dialect) causes more intense joint pain and inflammation. For some people the pain can last for months or years, resulting in additional psychological strain.

The lack of immunity among people living in the Americas provided a blank canvas for Chikungunya to spread throughout the population this year. As of December 12, more than 1.03 million people have been infected, in addition to the 155 who died, according to the Pan-American Health Organisation (PAHO). Almost all of the fatalities occurred in the Caribbean island countries of Guadaloupe and Martinique.

"Where we saw the biggest jump was after it reached the Spanish-speaking countries in the region," said Staples, referring to the weakened infrastructures and health systems of countries such as the Dominican Republic, which has reported more than 520,000 cases -- more than half of the overall outbreak and 5% of the island country's population.

As South American countries approach their summer, numbers are expected to rise there as the mosquitoes flourish in the heat.

"Brazil, Peru, Paraguay are coming into their summer months and reporting their first local transmission," Staples said. Already, more than 2,000 people have been infected in Brazil.

Is there cause for concern?

Because infection with Chikungunya is rarely fatal, the issue of most concern to officials is the burden on health services and the impact of the debilitating symptoms on the economy.

"The high number of cases can overload health services," says Dr. Pilar Ramon-Pardo, regional adviser for PAHO, the regional office of the World Health Organization. Until recently, monitoring for Chikungunya was not part of routine surveillance in the region.

"Clinicians have to be ready to diagnose," she said

About 20% to 30% of cases are expected to become chronic, with symptoms such as arthritis and other rheumatic manifestations leading to physical disabilities, Ramon-Pardo said. Further long-term effects are psychological as people become more depressed and tired.

All of this can result in missed work and lower school attendance, she said, hurting local economies.

Is it here to stay?

The warm climate of the region offers potential for Chikungunya levels to be maintained for years to come, just like Dengue fever. But areas of most concern are the tropics.

"The areas which have year-round favorable climate for the mosquito are at the greatest risk," says Dr. Laith Yakob of the London School of Hygiene and Tropical Medicine, which is monitoring the spread of the outbreak.

While the climate and mosquitos have long been present, Ramon-Pardo said, "we don't know why this is happening now." She said globalization is likely to blame, with increased population movement from one country to another. This offers more opportunities for local mosquitos to bite infected humans.

The CDC's Staples said she is temporarily at ease regarding numbers in the U.S. "We're moving into fall and winter periods, which should see activity decrease," she said. Cold temperatures reduce mosquito survival rates.

The rapid spread of Chikungunya this year also could help minimize future infections. "Chikungunya will go through a region quite rapidly and create a level of population immunity which helps mitigate large outbreaks of the disease," Staples said. Unlike Dengue, infection with Chikungunya results in lifelong immunity.

Like many other infections, Chikungunya could, however, remain in the background through animals capable of carrying the virus in their bloodstream and acting as so-called reservoirs of the disease.

"In Asia and Africa there is a transmission cycle in small mammals and monkeys," Ramon-Pardo said, meaning these animals keep the virus present within the population. "In the Americas ... we don't know yet."

Those words -- "we don't know" -- resonate throughout the community of scientists and government officials trying to control the outbreak.

The future risk of spread, levels of future immunity, risk from animal reservoirs, why this is only happening now, and the total economic impact are all unknown.

"Mathematical models are under construction by numerous research groups around the world to improve confidence over projections of future spread," said Yakob, whose team is modeling the disease. As they work, control efforts continue.

Getting it under control

When it comes to controlling Chikungunya, there are two main strategies -- reduce the likelihood of bites and remove the ever-biting mosquito. Prevention is the priority.

Unlike the mosquitoes behind malaria, which bite at night, the species behind Chikungunya bite any time, day or night. Those living in affected areas are asked to use repellent, sleep under bed nets and wear long clothing to avoid getting bitten. The air conditioned and indoor environments of people living in the U.S. mean numbers are likely to stay low there.

But mosquito control is at the heart of it all. Mass spraying of insecticides and removal of any sources of shallow water in which mosquitoes can breed are taking place across the continents. According to the CDC's Staples, Florida has been highly aggressive with its approach to control. "We're only at 11 (cases) due to such proactive measures," Staples said. For now, prevention is all they have as officials wait and see how the outbreak pans out.

"There is no vaccine currently and no good antivirals, so we are trying to control the spread of the disease," Staples said. "There are a lot of questions and only time will tell what we'll see for Chikungunya in the future."

Source: www.cnn.com

Topics: symptoms, Chikungunya, DCD, mosquitos, WHO, health, healthcare, nurses, disease, medical, vaccine, medicine, treatment, physicians, hospitals, infection

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