Infant mortality and stillbirth in the UK

Parliamentary Office of Science and Technology

This document reviews recent UK data relating to infant mortality and stillbirths and examines the factors contributing to increased risk. It then looks at the policy options that may help to improve health outcomes for infants and their families.

Effects of maternal smoking continue long after birth

ScienceDaily. Published online: 30 May 2016.

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Image source: chris vaughan // CC BY 2.0

Early exposure to nicotine can trigger widespread genetic changes that affect formation of connections between brain cells long after birth, a new Yale-led study has found. The finding helps explains why maternal smoking has been linked to behavioral changes such as attention deficit and hyperactivity disorder, addiction and conduct disorder.

Nicotine does this by affecting a master regulator of DNA packaging, which in turn influences activity of genes crucial to the formation and stabilization of synapses between brain cells, according to the study published online May 30 in the journal Nature Neuroscience.

An inability to focus is the hallmark of attention deficit hyperactivity disorder and other behavioral disorders, which have been linked to maternal smoking and exposure to second-hand smoke. However, scientists did not understand how early environmental exposure to smoking could create behavioral problems years later.

Picciotto’s lab found that mice exposed to nicotine during early development did indeed develop behavioral problems that mimic symptoms of attention deficit disorder in humans. They then did extensive genomic screening of mice exposed to nicotine and found higher levels of activity in a key regulator of histone methylation — a process that controls gene expression by changing the DNA wrapping around chromosomes. The researchers found that genes essential to the creation of brain synapses were heavily effected.

Furthermore, the scientists found that these genetic changes were maintained even in adult mice. However, when researchers inhibited the master regulator of histone methylation, these adult mice were calmer and no longer reacted to a stimulus they should ignore. In a final test, they triggered expression of this regulator in mice never exposed to nicotine, and the mice exhibited behavior that mimicked attention deficit disorder.

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Epidemiology of children with head injury: a national overview

Trefan, L. et al. Archives of Disease in Childhood. 2016. 101:527-532

Background The National Confidential Enquiry describes the epidemiology of children admitted to hospital with head injury.

Method Children (<15 years old) who died or were admitted for >4 h with head injury were identified from 216 UK hospitals (1 September 2009 to 28 February 2010). Data were collected using standard proformas and entered on to a database. A descriptive analysis of the causal mechanisms, child demographics, neurological impairment, CT findings, and outcome at 72 h are provided.

Results Details of 5700 children, median age 4 years (range 0–14.9 years), were analysed; 1093 (19.2%) were <1 year old, 3500 (61.4%) were boys. There was a significant association of head injury with social deprivation 39.7/100 000 (95% CI 37.0 to 42.6) in the least deprived first quintile vs. 55.1 (95% CI 52.1 to 58.2) in the most deprived fifth quintile (p<0.01). Twenty-four children died (0.4%). Most children were admitted for one night or less; 4522 (79%) had a Glasgow Coma Scale score of 15 or were Alert (on AVPU (Alert, Voice, Pain, Unresponsive)). The most common causes of head injury were falls (3537 (62.1%); children <5 years), sports-related incidents (783 (13.7%); median age 12.4 years), or motor vehicle accidents (MVAs) (401 (7.1%); primary-school-aged children). CT scans were performed in 1734 (30.4%) children; 536 (30.9%) were abnormal (skull fracture and/or intracranial injury or abnormality): 269 (7.6%) were falls, 82 (10.5%) sports related and 100 (25%). A total of 357 (6.2%) children were referred to social care because of child protection concerns (median age 9 months (range 0–14.9 years)).

Conclusions The data described highlight priorities for targeted age-specific head injury prevention and have the potential to provide a baseline to evaluate the effects of regional trauma networks (2012) and National Institute of Health and Care Excellence (NICE) head injury guidelines (2014), which were revised after the study was completed.

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Psychotropic medication in pregnancy

Wallace, J. The Mental Elf Blog. Published online 17 May 2016

Postpartum psychosis is more common in women with bipolar disorder and even more so in those who were medication free during pregnancy (Wesseloo et al, 2016). Patients who suffer from schizophrenia also report worsening mental health following pregnancy (Jones et al, 2014).

There is a severe lack of evidence on the risks and benefits of psychotropic medication in pregnancy. No randomised controlled trials have been conducted that establish whether the benefits of taking antipsychotic drugs outweigh the risks for pregnant or postpartum women (Webb et al 2004, 2009). Some psychotropic medications are known to have teratogenic and adverse neurodevelopmental effects (Epstein et al, 2015; Tomson et al 2012) and currently no psychotropic medication is licensed for use in pregnancy. This creates a dilemma for healthcare professionals and patients; protect the woman’s mental health or protect the unborn child from the potentially damaging effects of psychotropic medication?

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Image source: Tatiana Vdb // CC BY 2.0

The National Institute for Health Research has commissioned research to address the question: What are the risks and benefits of psychotropic drugs in women treated for psychosis who become pregnant? (Peterson et al, 2016). The results show that the majority of women discontinue psychotropic medication either before or early in pregnancy. In this cohort, women prescribed anticonvulsant mood stabilisers, in particular valproate, were at increased risk of giving birth to a child with major congenital malformation, neurodevelopmental and behavioural disorders.

This is in contrast to those prescribed antipsychotics where, after controlling for confounding factors such as obesity, alcohol problems, smoking, concomitant medications and illegal drug use, there was no increased risk of major congenital malformations, confirming previous research (Tomson et al 2012; Coughlin et al, 2015; Wide et al, 2004) and Guidelines (NICE, 2014).

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Fathers’ age, lifestyle associated with birth defects

ScienceDaily. Published online:  15 May 2016.

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A growing body of research is revealing associations between birth defects and a father’s age, alcohol use and environmental factors, say researchers at Georgetown University Medical Center. They say these defects result from epigenetic alterations that can potentially affect multiple generations.

The study, published in the American Journal of Stem Cells, suggest both parents contribute to the health status of their offspring — a common sense conclusion which science is only now beginning to demonstrate, says the study’s senior investigator, Joanna Kitlinska, PhD, an associate professor in biochemistry, and molecular and cellular biology.

The report is a review of evidence, human and animal, published to date on the link between fathers and heritable epigenetic programming.

Among the studies reviewed are ones that find:

  • Advanced age of a father is correlated with elevated rates of schizophrenia, autism, and birth defects in his children;
  • A limited diet during a father’s pre-adolescence has been linked to reduced risk of cardiovascular death in his children and grandchildren;
  • Paternal obesity is linked to enlarged fat cells, changes in metabolic regulation, diabetes, obesity and development of brain cancer;
  • Psychosocial stress on the father is linked to defective behavioral traits in his offspring; and
  • Paternal alcohol use leads to decreased newborn birth weight, marked reduction in overall brain size and impaired cognitive function.

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GPs and paediatricians call for joint training to improve child healthcare

O’Dowd, A. BMJ. 2016. 353:i2715

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Image source: RCPCH

Two royal colleges have urged GPs and paediatricians to train together to boost their skills and help improve standards of care for children.

Interprofessional training will help clinicians, increase the quality of child care, and reduce strain on services, claimed the Royal College of Paediatrics and Child Health and the Royal College of General Practitioners in a joint position paper, published on 13 May.1

The colleges cited the success of a pilot scheme that brought together trainee GPs and paediatricians, which showed a reduction in parents taking their children to the emergency department, fewer referrals to specialist children’s services, and better adherence to national guidance.

The new report, Learning Together to Improve Child Health, detailed the Learning Together2 scheme in London, which involved GP and paediatric registrars in their final years of training working in child health training clinics together.

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Tooth decay among 5 year olds continues significant decline

The number of 5 year olds with tooth decay has dropped to its lowest level in almost a decade, according to a PHE oral health survey.

The oral health survey published  10 May 2016 by Public Health England (PHE) reveals that less than 25% of the cohort suffers from tooth decay, a 20% drop since 2008.

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image source: Anthea Sieveking wellcome images//CC BY-NC-ND 4.0

This continues the downward trend seen since 2008, in the first oral health survey of 5 year olds asking parents to opt-in. In 2008, 31% of 5 year olds suffered tooth decay; in 2012 it was 27%. The pattern of dental health improvement among the age group shows the impact parents and carers can have in establishing good dental care habits from an early age.

While there has been a significant decline in tooth decay at a national level, there is still a great deal of regional variation. In the North West, a third (33.4%) of 5 year olds suffer from tooth decay, whereas only a fifth (20.1%) do in the in the South East. As with the 2 previous surveys, areas with higher levels of deprivation tend to have higher levels of tooth decay.

Full survey: Oral health survey of 5-year-old children: 2014 to 2015