Article: Fetal Movement Counting and Perinatal Mortality

Citation: Bellussi, Federica, et al. “Fetal Movement Counting and Perinatal Mortality.” Obstetrics & Gynecology, vol. 135, no. 2, Feb. 2020, pp. 453–462., https://doi.org/10.1097/aog.0000000000003645.

• Currently, there is no accepted qualitative or quantitative definition of decreased fetal movement. Some of the most commonly used are:
  
  Less than 10 movements within 2 hours
  No movement over 24 hours
  
  
• Decreased fetal movement is associated with many complications including but not limited to stillbirth, growth restrictions, placental insufficiency, congenital anomalies, and neonatal mortality
  
  
• This systematic review studied whether maternal fetal movement counting could prevent poor pregnancy outcomes.
  
  
• 468,000 fetuses were included across 5 studies in which mothers were broken up into standard care or instruction for fetal movement counting.
  
  
• They found no statistically significant difference in neonatal death, five-minute APGAR scores, or NICU admissions.
  
  
• There was a small but significant increase in preterm birth and induction of labor in the intervention group.

Identifying Data

November 28^th, 2022 – 19:45
KJ, 27F, Black, Married, Brooklyn, NY
Informant: Patient, reliable
Referral Source: Self

Chief Complaint: Decreased fetal movement x 2 days

History of Present Illness:

KJ is a 27-year-old G2P0010 Female at 33w3d gestation, no significant PMHx, uncomplicated pregnancy, presenting for reports of decreased fetal movement x 2 days. Patient reports that over the past 2 days she has noticed a significant decrease in the amount of movement she feels compared to baseline. She denies any preceding trauma or injury. She has not tried any methods at home to try to illicit fetal movement, such as drinking cold water or eating a sugar-filled snack. Last fetal movement was felt 1 hour prior to arrival to L&D triage (approximately 19:15). Of note, patient states that she had an US performed at her regularly scheduled OB appointment this morning and was told by the provider that they could see the baby moving during the sonogram, but she was unable to feel the movement at that time. Denies any contractions, vaginal bleeding, loss of fluids, vaginal discharge, dysuria, urinary frequency/urgency, vomiting, or diarrhea. Denies any toxic symptoms of preeclampsia including headache, vision changes, SOB, or RUQ pain. No recent travel, sick contacts, or known exposures to COVID-19.

Past Medical History:

• Childhood illnesses: Denies.
• Adult illness: Denies history of migraines, asthma, DM, HTN, thyroid disease, bleeding disorders, or CA.

Past Surgical History:

• B/L femoral hernia repair, 1996, no complications.
• Cosmetic B/L labial reduction, 2017, no complications.

Medications: Prenatal vitamins daily. Denies other daily medications.

Allergies: Latex (rash, denies difficulty breathing or anaphylaxis), NKDA, NKFA.

Immunizations: Childhood vaccines UTD. Tetanus up to date as of 2021. COVID-19 vaccine & 2022 flu vaccine up to date.

GYN history: Denies history of ovarian cysts, uterine fibroids, abnormal PAP results, or STIs. Last PAP 2021, normal as per patient.

OB history: G2P0010.

• G1 – medical VTP at 6 weeks gestation, 2020, no complications.
• G2 – current pregnancy, regular prenatal care throughout pregnancy, passed GCT at 28 weeks, no history of elevated BP during pregnancy, NIPT WNL, anatomy scan WNL, GBS swab not yet performed, last EFW (as of 11/5/22) 1800g.

Social History:

• Substance Abuse: Endorses social ETOH consumption & social marijuana smoking prior to pregnancy. Denies cigarette smoking, ETOH consumption, or illicit drug use during this pregnancy.
• Diet/Exercise/Sleep: Endorses well-balanced diet, regular exercise 3-4 days/week, & 7-8 hours sleep/night.
• Living conditions: Lives at home with mother & partner in apartment in Brooklyn.
• Occupation/Education: Works as hair stylist.

Review of Systems:

• General: Denies fever, chills, or body aches.
• Skin: Denies rashes, dryness, lesions, or color changes.
• Head: Denies headache, recent head trauma/injury.
• Eyes: Denies visual changes, redness, discharge, pruritis, or photophobia.
• Ears: Denies pain, fullness, change in hearing, discharge, or tinnitus.
• Nose/sinuses: Denies nasal discharge, congestion, epistaxis, or trauma.
• Mouth/throat: Denies sores, bleeding gums, hoarseness, or difficulty swallowing.
• Neck: Denies pain, limitation of movement, or lumps.
• Respiratory: Denies cough, wheezing, or SOB.
• Cardiac: Denies chest pain or palpitations.
• GI:  Denies abdominal pain, nausea, vomiting, diarrhea, or constipation.
• GU: Denies dysuria, hematuria, frequency, hesitancy, or vaginal bleeding/discharge.
• PV: Denies cyanosis or temperature changes of extremities.
• MS: Denies joint pain, stiffness, or deformities.
• Hematologic: Denies easy bleeding or bruising.
• Endocrine: Denies heat/cold intolerance, flushing, sweating, or unintentional weight loss.
• Neurologic: Denies dizziness, lightheadedness, numbness, tingling, weakness, syncope, LOC, or seizures.
• Psychiatric: Denies insomnia, anxiety, depression, hallucinations, or SI/HI.

Physical Exam:

General: 27F, A&Ox3, sitting in triage, dressed, well groomed, not in acute distress. She is not ill-appearing or diaphoretic.

Vital Signs:

• BP (Seated) 124/72
• P: 85bpm, regular
• R: 14 breaths/minute, unlabored
• T: 98.6F (37.0C), oral
• O2 Sat: 99% room air
• Height: 63in – Weight: 138lbs – BMI 24

Skin: Warm, dry. No rashes or lesions. No nail cyanosis or clubbing.

HEENT: Normocephalic, atraumatic. PERRL, EOMI. No external nasal deformity. B/L nares patent without obvious discharge. Lips pink and moist without obvious lesions. Mucosa pink and moist. No tonsillar enlargement, erythema, or exudates.

Neck: Supple. FROM intact without pain. No lymphadenopathy. Trachea midline. Thyroid smooth without enlargement or nodules.

Lungs: Lungs CTA B/L. No increased work of breathing or accessory muscle use. No rales, rhonchi, or wheezing.

Cardio: No JVD. Normal S1, S2. No murmurs, rubs, clicks, or gallops.

Abdomen: Abdomen gravid, soft, non-tender. Fundal height appropriate for gestational age. Normoactive bowel sounds x 4 quadrants. No hepatosplenomegaly. No CVA tenderness.

Pelvic exam: Deferred at this time, given recent evaluation at OB clinic this morning.

Rectal exam: Deferred.

Extremities: Full ROM intact x 4 extremities. No warmth, edema, or tenderness to palpation. No calf tenderness B/L. Distal pulses 2+ B/L.

Neuro: AOx3. CN II-XII grossly intact. Strength 5/5 x 4 extremities.

Labs and Imaging:

Transabdominal US: Cephalic position. Anterior placenta. BPP 8/8.

NST: Baseline 130 bpm, moderate variability, + accelerations, – decelerations. Overall reactive & reassuring.

Assessment & Plan:

Decreased fetal movement – likely fetal sleep or anterior placental position preventing maternal ability to detect fetal movement; less likely fetal compromise

Explained to patient reassuring results of NST & BPP performed in triage. Encouraged patient to continue regular OB follow up at OB/GYN clinic. Advised patient to continue monitoring fetal movement at home & to perform “kick counts” over a 2 hour period of rest (normal fetal movement approx. 10 kicks over 2 hours of maternal rest). Strict return precautions given to return to OB/GYN clinic or L&D triage immediately for any decreased fetal movement from baseline, absent fetal movement, regular contractions, vaginal bleeding, or loss of fluids.

Clinical Scenario:
A 31-year-old G1P0 Female, currently 30 weeks pregnant with her first child, presents to the emergency department for GERD-like symptoms. During the encounter, while talking about her pregnancy, she expresses that she is currently considering whether she should breastfeed, or formula-feed the baby. She says that she has been reading articles online that say breastfeeding can help prevent certain health conditions, like asthma and food allergies. She asks for your advice/opinion on the matter.

Search Question:
Does breastfeeding help prevent the development of asthma in comparison to formula feeding?

PICO Table:

Population	Intervention	Comparison	Outcome(s)
Pediatrics	Breastfeeding	Formula feeding	Development of asthma
Newborns	Human milk		Asthma during childhood
Infants

Search Strategy and Databases Used:

PubMed:

• Breastfeeding OR formula AND asthma: 30
• Formula feeding causing asthma in kids: 6

JAMA:

• Linking breastfeeding OR formula with childhood asthma: 6

JAMA Pediatrics:

• Breastfeeding AND childhood asthma: 5
  
  

Google Scholar:

• Linking breastfeeding or formula to asthma: 3,480
• Breastfeeding vs formular feeding and “childhood asthma”: 1,480 (Top results overlap heavily with PubMed)

I put the strength of the evidence first into consideration when selecting my final articles for inclusion. Because of the nature of my search question, when systematic reviews and meta-analyses were no longer available, chose to expand to include both randomized control trials and cohort studies. These types of studies would make it possible to compare breastfeeding directly to alternatives like formula feeding and the prevalence of asthma in children. I then considered how recently the articles had been published. Since they must have taken into account the most recent evidence, I favored articles that were published within the last five years.

Research Used:

Article 1: Breastfeeding and risk of childhood asthma: a systematic review and meta-analysis

Citation	Xue, Mike, et al. “Breastfeeding and Risk of Childhood Asthma: A Systematic Review and Meta-Analysis.” ERJ Open Research, vol. 7, no. 4, 26 Aug. 2021, pp. 00504–2021., https://doi.org/10.1183/23120541.00504-2021.
Abstract	Objective: To investigate the relationship between breastfeeding and the development of paediatric asthma.   Methods: A systematic review and meta-analysis was conducted with MEDLINE, Embase, CINAHL and ProQuest Nursing and Allied Health source databases. Retrospective/prospective cohorts in children aged <18 years with breastfeeding exposure reported were included. The primary outcome was a diagnosis of asthma by a physician or using a guideline-based criterion. A secondary outcome was asthma severity.   Results: 42 studies met inclusion criteria. 37 studies reported the primary outcome of physician-/guideline- diagnosed asthma, and five studies reported effects on asthma severity. Children with longer duration/more breastfeeding compared to shorter duration/less breastfeeding have a lower risk of asthma (OR 0.84, 95% CI 0.75–0.93; I2 = 62.4%). Similarly, a lower risk of asthma was found in children who had more exclusive breastfeeding versus less exclusive breastfeeding (OR 0.81, 95% CI 0.72–0.91; I2=44%). Further stratified analysis of different age groups demonstrated a lower risk of asthma in the 0–2-years age group (OR 0.73, 95% CI 0.63–0.83) and the 3–6-years age group (OR 0.69, 95% CI 0.55–0.87); there was no statistically significant effect on the ⩾7-years age group.   Conclusion: The findings suggest that the duration and exclusivity of breastfeeding are associated with a lower risk of asthma in children aged <7 years.
Link:	https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8666625/

Article 2: Infant milk-feeding practices and food allergies, allergic rhinitis, atopic dermatitis, and asthma throughout the life span: a systematic review

Citation	Güngör, Darcy, et al. “Infant Milk-Feeding Practices and Food Allergies, Allergic Rhinitis, Atopic Dermatitis, and Asthma throughout the Life Span: A Systematic Review.” The American Journal of Clinical Nutrition, vol. 109, no. Supplement_1, 1 Mar. 2019, https://doi.org/10.1093/ajcn/nqy283.
Abstract	Background: During the Pregnancy and Birth to 24 Months Project, the USDA and Department of Health and Human Services initiated a review of evidence on diet and health in these populations.   Objectives: The aim of these systematic reviews was to examine the relation of 1) never versus ever feeding human milk, 2) shorter versus longer durations of any human milk feeding, 3) shorter versus longer durations of exclusive human milk feeding prior to infant formula introduction, 4) feeding a lower versus higher intensity of human milk to mixed-fed infants, and 5) feeding a higher intensity of human milk by bottle versus breast with food allergies, allergic rhinitis, atopic dermatitis, and asthma.   Methods: The Nutrition Evidence Systematic Review team con- ducted systematic reviews with external experts. We searched CINAHL, Cochrane, Embase, and PubMed for articles published between January 1980 and March 2016, dual-screened the results according to predetermined criteria, extracted data from and assessed the risk of bias for each included study, qualitatively synthesized the evidence, developed conclusion statements, and graded the strength of the evidence.   Results: The systematic reviews numbered 1–5 above included 44, 35, 1, 0, and 0 articles, respectively. Moderate, mostly observational, evidence suggests that 1) never versus ever being fed human milk is associated with higher risk of childhood asthma, and 2) among children and adolescents who were fed human milk as infants, shorter versus longer durations of any human milk feeding are associated with higher risk of asthma. Limited evidence does not suggest associations between 1) never versus ever being fed human milk and atopic dermatitis in childhood or 2) the duration of any human milk feeding and allergic rhinitis and atopic dermatitis in childhood.   Conclusions: Moderate evidence suggests that feeding human milk for short durations or not at all is associated with higher childhood asthma risk. Evidence on food allergies, allergic rhinitis, and atopic dermatitis is limited.
Link:	https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500928/

Article 3: Effect of Avoiding Cow’s Milk Formula at Birth on Prevention or Asthma or Recurrent Wheeze Among Young Children: Extended Follow-up from the ABC Randomized Clinical Trial

Citation	Tachimoto, Hiroshi, et al. “Effect of Avoiding Cow’s Milk Formula at Birth on Prevention of Asthma or Recurrent Wheeze among Young Children.” JAMA Network Open, vol. 3, no. 10, 2 Oct. 2020, https://doi.org/10.1001/jamanetworkopen.2020.18534.
Abstract	Importance: Children with food allergies may develop asthma or recurrent wheeze.   Objective: To evaluate whether asthma or recurrent wheeze among children were changed by avoiding supplementing breastfeeding (BF) with cow’s milk formula (CMF) in the first 3 days of life.   Design, Setting, and Participants: This randomized, unmasked, clinical trial was conducted at 1 university hospital in Japan beginning October 2013 with follow-up examinations occurring until January 2020. A total of 312 newborns at risk for atopy were randomized and assigned to either BF with or without amino acid–based elemental formula (EF) or BF with CMF, with follow-up examinations for participants showing signs of atopy conducted at 24 months. Follow-up examinations ran through January 2020.   Interventions: Immediately after birth, newborns were randomly assigned (1:1ratio) to either breastfeeding with or without amino acid–based elemental formula for at least the first 3 days of life (no CMF group) or breastfeeding supplemented with CMF (􏰃5 mL/d) from the first day of life to 5 months of age (CMF group).   Main Outcomes and Measures: Asthma or recurrent wheeze diagnosed by the pediatric allergy specialists of this trial; subgroups were stratified by serum levels of 25-hydroxyvitamin D and IgE.   Results: Of 312 infants (156 [50.0% ] randomized to the no CMF group), 302 (96.8%) were followed up at their second birthday: 77 of 151 (51.0%) in the no CMF group and 81 of 151 (53.6%) in the CMF group underwent extended follow-up because of having atopic conditions. Asthma or recurrent wheeze developed in 15 (9.9%) of the children in the no CMF group, significantly less than the children in the CMF group (27 [17.9%]; risk difference, −0.079; 95% CI, −0.157 to −0.002). In participants with vitamin D levels above the median at 5 months of age, asthma or recurrent wheeze developed in 5 (6.4%) children in the no CMF group, significantly less than in the children in the CMF group (17 [24.6%]; risk difference, −0.182; 95% CI, −0.298 to −0.067; P for interaction = .04). In the highest quartile group of total IgE at age 24 months, asthma or recurrent wheeze developed in 2 children (5.3%) in the no CMF group, significantly less than the children in the CMF group (14 [43.8%]; risk difference, −0.385; 95% CI, −0.571 to −0.199; P for interaction = .004).   Conclusions and Relevance: The findings of this study suggest that avoiding CMF supplementation in the first 3 days of life has the potential to reduce the risk of asthma or recurrent wheeze in young children, especially among those with high vitamin D or high IgE levels.
Link:	https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2771187

Article 4: Prospective Cohort Study of Breastfeeding and the Risk of Childhood Asthma

Citation	Lossius, Anne Kristine, et al. “Prospective Cohort Study of Breastfeeding and the Risk of Childhood Asthma.” The Journal of Pediatrics, vol. 195, Apr. 2018, https://doi.org/10.1016/j.jpeds.2017.11.065.
Abstract	Objectives: To study whether the duration of breastfeeding and time for introduction of complementary foods was associated with the risk of childhood asthma.   Study Design: We used data from the Norwegian Mother and Child Study, a nation-wide prospective cohort study which recruited pregnant women from across Norway between 1999 and 2008. Children with complete data of breastfeeding up to 18 months and current age >7 years were eligible (n=41 020). Asthma as the primary outcome was defined based on ≥2 dispensed asthma medications at age 7 years registered in the Norwegian Prescription Database. We used log- binomial regression models to obtain crude relative risks (RR) in the main analysis, and adjusted for selected confounders in multivariable analyses.   Results: For duration of any breastfeeding, 5.9% of infants breastfed <6 months (adjusted relative risk [aRR] 1.05, 0.93-1.19) and 4.6% breastfed 6-11 months (aRR 0.96, 0.87-1.07) had dispensed asthma medications at 7 years as compared with 4.6% of infants breastfed ≥12 months (Ptrend 0.62). Infants still breastfed at 6 months, but introduced to complementary foods <4 months and 4-6 months, had an aRR of 1.15 (0.98-1.36) and 1.09 (0.94-1.27) respectively, as compared with infants fully breastfed for 6 months (Ptrend 0.09). Age at introduction of solids or formula separately were not significant predictors (Ptrend 0.16 and 0.08, respectively).   Conclusion: We found no association between duration of breastfeeding or age of introduction to complementary foods and asthma at age 7.
Link:	https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5869148/

Article 5: Modes of Infant Feeding and the Risk of Childhood Asthma: A Prospective Birth Cohort Study

Citation	Klopp, Annika, et al. “Modes of Infant Feeding and the Risk of Childhood Asthma: A Prospective Birth Cohort Study.” The Journal of Pediatrics, vol. 190, Nov. 2017, pp. 192–199., https://doi.org/10.1016/j.jpeds.2017.07.012.
Abstract	Objective: To determine whether different modes of infant feeding are associated with childhood asthma, including differentiating between direct breastfeeding and expressed breast milk.   Study Design: We studied 3296 children in the Canadian Healthy Infant Longitudinal Development birth cohort. The primary exposure was infant feeding mode at 3 months, reported by mothers and categorized as direct breastfeeding only, breastfeeding with some expressed breast milk, breast milk and formula, or formula only. The primary outcome was asthma at 3 years of age, diagnosed by trained healthcare professionals.   Results: At 3 months of age, the distribution of feeding modes was 27% direct breastfeeding, 32% breastfeeding with some expressed breast milk, 26% breast milk and formula, and 15% formula only. At 3 years of age, 12% of children were diagnosed with possible or probable asthma. Compared with direct breastfeeding, any other mode of infant feeding was associated with an increased risk of asthma. These associations persisted after adjusting for maternal asthma, ethnicity, method of birth, infant sex, gestational age, and daycare attendance (some expressed breast milk: aOR, 1.64, 95% CI, 1.12-2.39; breast milk and formula, aOR, 1.73, 95% CI, 1.17-2.57; formula only: aOR, 2.14, 95% CI, 1.37-3.35). Results were similar after further adjustment for total breastfeeding duration and respiratory infections.   Conclusions: Modes of infant feeding are associated with asthma development. Direct breastfeeding is most protective compared with formula feeding; indirect breast milk confers intermediate protection. Policies that facilitate and promote direct breastfeeding could have impact on the primary prevention of asthma.
Link:	https://www.thrivediscovery.ca/uploads/8/9/1/2/89121762/klopp_2017_-_bf_modes___asthma__j_pediatrics.pdf

Article 6: Breastfeeding and wheeze-related outcomes in high-risk infants: A systematic review and meta-analysis

Citation	Harvey, Soriah M, et al. “Breastfeeding and Wheeze-Related Outcomes in High-Risk Infants: A Systematic Review and Meta-Analysis.” The American Journal of Clinical Nutrition, vol. 113, no. 6, 7 Apr. 2021, pp. 1609–1618., https://doi.org/10.1093/ajcn/nqaa442.
Abstract	Background: The risk of wheezing is high in infancy and is heightened in infants with a family history of asthma/atopy. The role of breastfeeding in influencing respiratory health for these high-risk infants is unclear.   Objectives: To systematically appraise evidence for the association between breastfeeding and wheeze incidences and severity in high-risk infants.   Methods: Studies identified through electronic databases and reference lists were eligible if they assessed breastfeeding and respiratory outcomes in infants with a family history of asthma/atopy. The primary outcome was wheeze incidences in the first year of life. Secondary outcomes were wheeze incidences in the first 6 months of life, indicators of wheeze severity (recurrent wheeze, health-care utilization, and medication use), and other wheeze-related outcomes [bronchiolitis, pneumonia, croup, and incidence of lower respiratory tract infection (LRTI)] up to 12 months old. Meta-analyses were conducted where possible.   Results: Of 1843 articles screened, 15 observational studies met the inclusion criteria. Breastfeeding was associated with 32% reduced odds of wheezing during the first year of life (ever vs. never: OR, 0.68; 95% CI: 0.53, 0.88; n = 9 studies); this association was even stronger in the first 6 months (OR, 0.45; 95% CI: 0.27, 0.75; n = 5 studies). Breastfeeding for a “longer” versus “shorter” time (approximately longer vs. shorter than 3 months) was associated with 50% reduced odds of wheezing at the age of 6 months (OR, 0.50; 95% CI: 0.39, 0.64; n = 3 studies).   Conclusions: Breastfeeding was associated with reduced odds of wheezing in high-risk infants, with the strongest protection in the first 6 months. More research is needed to understand the impact of breastfeeding intensity on wheezing and to examine additional respiratory outcomes, including wheeze severity.
Link:	https://academic.oup.com/ajcn/article/113/6/1609/6214420

Summary of Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcomes Studied	Key Findings	Limitations and Biases
Xue, Mike, et al. (2021)	Systematic review and meta-analysis	42 studies met inclusion criteria.   Exclusive breastfeeding: Based on World Health Organization (WHO) criteria, where infants received only breastmilk with no other liquids or solids.   Only studies with either physician-diagnosed asthma or appropriate strict guidelines for asthma definition were included.   Alternatively, included studies could use secondary outcomes of asthma severity such as hospitalization, medication use and spirometry	Primary outcome: Diagnosis of asthma by a physician or using a guideline-based criterion.   Secondary outcome: Asthma severity.	Children with exclusive breastfeeding for ⩾6 months compared to <6 months had a 30% lower risk of asthma.   There is a reduced risk of asthma development in children with ⩾3 months of exclusive breastfeeding when compared with those <3 months. Additionally, any breastfeeding for ⩾3 months and ⩾6 months showed a significant benefit for asthma prevention.   Babies who do not meet the 6 months of exclusive breastfeeding guidelines may still receive some protection against asthma development with partial or intermittent breastfeeding.	Observational data was restricted to cohort studies, limiting the total number of studies available.   Limited data addressing maternal atopy and its influence on breastfeeding effects. Similarly, we were unable to stratify by sex, which has been highlighted as a risk factor in recent literature with evidence that childhood asthma severity and frequency are differentially affected by the pubertal stage between males and females [67].
Güngör, Darcy, et al. (2019)	Systematic review	For search question 1 in the next column, twenty-one articles presented evidence about never versus ever being fed human milk and asthma in childhood. The evidence differed between the studies that included children only and the studies that included children as well as adolescents   For search question 2, one cluster randomized controlled trial and seventeen prospective cohort studies that looked at asthma in childhood and adolescence.   Search questions 3 through 5 did not yield any results that met inclusion criteria in this study.	Collectively, 5 search questions respectively compared:   Never versus ever feeding human milk…   Shorter versus longer durations of any human milk feeding…   Shorter versus longer durations of exclusive human milk feeding prior to infant formula introduction…   Feeding a lower versus higher intensity of human milk to mixed-fed infants…   Feeding a higher intensity of human milk by bottle versus breast…   …with food allergies, allergic rhinitis, atopic dermatitis, and asthma	These studies provided consistent evidence of an inverse association between the duration of any human milk feeding and asthma risk in children and adolescents.   Findings suggest that longer durations of any human milk feeding are associated with higher relative risk of asthma in childhood and adolescence	Many of the articles used for search question 2  made generalizations of the US population, however they lacked racial and ethnic diversity.   Infant milk feeding research can be prone to detection bias because infant milk-feeding data are often collected through the use of parent-reporting methods that may not be valid and reliable. Confounding can arise because differences between feeding groups are rarely mitigated by randomization (due to ethical issues around allocating infants to be fed less or no human milk) and infant-feeding decisions can be strongly socially patterned.
Tachimoto, Hiroshi, et al. (2020)	Randomized clinical trial	A total of 312 newborns at risk for atopy were randomized and assigned to either breastfeeding (BF) with or without amino acid–based elemental formula (EF) or BF with cow’s milk formula (CMF), with follow-up examinations for participants showing signs of atopy conducted at 24 months.	The primary outcome of this study was the incidence of asthma or recurrent wheeze based on the asthma predictive index.	In the overall study population, asthma or recurrent wheeze developed in 15 of 151 infants (9.9%) in the no CMF group, significantly less than in the CMF group (27 of 151 infants, 9.9%).   The incidence of asthma or recurrent wheeze was not different among the no CMF group and the groups in which mothers switched from no CMF to CMF either within or after 14 days.   In this RCT, by avoiding exposure to CMF for at least the first 3 days of life, the risk of asthma or recurrent wheeze appeared to have been decreased compared with supplementing with CMF from the first day of life.	Only participants with atopic conditions at their second birthdays were followed to the maximum age of 6 years. Asthma or recurrent wheeze could have developed in participants whose follow-up ended at their second birthday   Second, the present study was conducted in a single center in Japan, so that the results may not be relevant for other racial/ethnic groups and countries with different food cultures.   Last, this trial was performed in the central area of Tokyo. Participants tended to be in a high socioeconomic class, and their children may have a high risk of atopic disease such as food allergy.
Lossius, Anne Kristine, et al. (2018)	Prospective cohort study	41,020 children with complete data of breastfeeding up to 18 months and current age >7 years were eligible.   Children who had at least one dispensed prescription for asthma medications in the past year at the age of 7, in addition to a second dispensed prescription within 12 months of the first, were defined as asthma cases.   Children were classified with asthma into 3 groups; early transient (asthma at only 3 years), late-onset (asthma onset after 3 years) and persistent asthma (asthma at both 3 and 7 years).	The primary outcome was current asthma at 7 years as defined based on dispensed prescriptions in the NorPD (Norwegian Prescription Database).   Secondary outcome: Current asthma at 3 years and 7 years based on maternal report through questionnaire	The risk of asthma for children with no or any breastfeeding <6 months compared with ≥12 months was increased before adjustments. However, in the adjusted analysis, we observed no significant differences among categories.   When looking at age for introduction of formula separately, the risk of asthma was increased when formula was introduced between 4-5.9 months as compared with 6 months or later.   For early transient asthma, there was a  significantly increased risk for children breastfed less than 6 months compared with 12 months or longer. There was no significant associations between duration of breastfeeding with late-onset asthma or persistent asthma.	The high prevalence of breastfeeding in the study limits the power to study the subgroup who did not receive breastmilk, but it provides a good opportunity to study duration of breastfeeding and the introduction of complementary foods.   The accuracy of the asthma diagnosis is a limitation as there was no access to individual medical records to verify the diagnosis. The strict diagnostic criteria though should reduce risk of misclassification.
Kloop, Annika, et al. (2017)	Prospective cohort study	3296 children in the Canadian Healthy Infant Longitudinal Development birth cohort. The primary exposure was infant feeding mode at 3 months, reported by mothers and categorized as direct breastfeeding only, breastfeeding with some expressed breast milk, breast milk and formula, or formula only	The primary outcome was asthma at 3 years of age, diagnosed by trained healthcare professionals.	At 3 months of age, the distribution of feeding modes was 27% direct breastfeeding, 32% breastfeeding with some expressed breast milk, 26% breast milk and formula, and 15% formula only.   At 3 years of age, 12% of children were diagnosed with possible or probable asthma.   Compared with direct breastfeeding, any other mode of infant feeding was associated with an increased risk of asthma.	There was an inability to quantify the relative proportion of direct breast milk, expressed breast milk, and formula provided, which precludes evaluation of dose effects.   The frequency and timing of expressed milk feeding within the first 3 months was not reported, leading to potential exposure misclassification for feeding mode “at 3 months of age.”   Although our asthma diagnosis was based on a structured history and physical examination, there can also be diagnostic uncertainty with that age group.
Harvey, Soriah, et al. (2021)	Systematic review and meta-analysis	15 observational studies included a total of 9,164 infants with a family history of asthma/allergic disease.   13 were prospective cohort studies and 2 were retrospective.   In 6 studies, 100% of the population had a family history of asthma/allergic disease.   For the other 9 studies, the proportion of infants with a family history of asthma/allergic disease ranged from 12% to 79% of the study population; only data from the high-risk infants in these studies were used in this review.	The primary outcome was wheeze incidences in the first year of life.   Secondary outcomes were wheeze incidences in the first 6 months of life, indicators of wheeze severity and other wheeze-related outcomes [bronchiolitis, pneumonia, croup, and incidence of lower respiratory tract infection (LRTI)] up to 12 months old.	Breastfeeding was associated with 32% reduced odds of wheezing during the first year of life and even stronger in the first 6 months   Breastfeeding for a “longer” versus “shorter” time (approximately longer vs. shorter than 3 months) was associated with 50% reduced odds of wheezing at the age of 6 months.	Varying methods of data collection and different frequencies of follow-ups (weekly/fortnightly vs once or twice per year) for the outcome(s) of interest between studies.   There were also different categories of breastfeeding duration and intensity examined, with some studies comparing ever breastfeeding with never breastfeeding, others comparing breastfeeding duration groups, and some comparing breastfeeding Exclusivity.

Conclusion: (Briefly summarize the conclusions of each article then provide an overarching conclusion)

Article 1 (Xue, 2021): Both longer duration of any breastfeeding and exclusive breastfeeding is associated with a decreased likelihood of developing asthma, particularly in children aged <7 years. The results of longer duration of any breastfeeding demonstrated similar protective effects compared to prior reviews; however, this review is the first to clearly demonstrate a pooled protective effect of longer duration of exclusive breastfeeding.

Article 2 (Güngör 2019): Moderate evidence suggests that never, in comparison to ever, being fed human milk is associated with higher risk of childhood asthma.

Article 3 (Tachimoto 2020): In this RCT, by avoiding exposure to CMF for at least the first 3 days of life, the risk of asthma or recurrent wheeze appeared to have been decreased compared with supplementing with CMF from the first day of life.

Article 4 (Lossius 2018): The duration of breastfeeding is not associated with asthma at 7 years. Weaning before 6 months was associated with increased risk of asthma at age 3.

Article 5 (Kloop 2017): Any mode of infant feeding other than direct breastfeeding is associated with an increased likelihood of possible or probable asthma by 3 years of age. Compared with infants who received direct breast milk only, those who received some expressed milk had a 43% increased odds of this diagnosis, and those who received only formula had a 79% increased odds.

Article 6 (Harvery 2021): Breastfeeding ever versus never was shown to be protective against wheezing at 12 months of age in infants with a family history of asthma/allergy, reducing the odds of wheezing by 32%.

Overarching: Up until roughly six years of age, exclusive breastfeeding seems to be linked to a decreased risk of recurrent asthma-related symptoms. However, in the studies included, the protective impact of breastfeeding seems to be the largest in the first two years of life as opposed to later in childhood.

Clinical Bottom Line:

• Weight of the evidence – summarize the weaknesses/strengths of the articles and explain how they factored into your clinical bottom line (this may recap what you discussed in the criteria for choosing the articles)
  
  • Article 1 (Xue, 2021) – The most recent and relevant systematic review and meta-analysis to my search question. Including 43 studies, this tracked incidence of the diagnosis of asthma when compared to the different variations of feeding. Additionally, these numbers were tracked through the first 7 years of life.
    
    Article 2 (Güngör 2019) – Slightly older than the systematic review above, this article posed 5 different scenarios in which articles were included. Additionally, outcomes of asthma and the other diagnoses that were studied were tracked from birth through the first two years of life.
    
    Article 6 (Harvey 2021) – A third systematic review and meta-analysis, though more recent than article 2, this review of 15 observational studies including over 9,000 infants, only tracked incidence and wheezing severity (not of the diagnosis of asthma) through the first year of life.
    
    Article 3 (Tachimoto 2020) – Next highest on the evidence pyramid, a 7-year continuous follow-up of a RCT of 300 newborns. Each group adhered to these conditions until age 5 months and then followed up to their second birthdays. The population studied were newborns that were breastfed with and without supplementation of cow’s milk formula.
    
    Article 4 (Lossius 2018) – While this prospective cohort study looked at over 40,000 children that were breastfed up to 18 months, asthma as a primary outcome was defined as having 2+ dispensed asthma medications at 7 years of age, not of an official diagnosis.
  
  
  • Article 5 (Kloop 2017) – Another prospective cohort study, this was a smaller population than article 4 and only looked at the diagnosis of asthma by 3 years of age.

Magnitude of any effects

Using the evidence from these studies, until roughly six years of age, exclusive breastfeeding seems to be linked to a decreased risk of recurrent asthma-related symptoms. However, the protective impact of breastfeeding seems to be the largest in the first two years of life as opposed to later in childhood. Nevertheless, the benefits of breastfeeding concerning the overall health of the child have been proven to outweigh any potential disadvantages.

Clinical significance (not just statistical significance)

According to the CDC, about 6 million children in the US (1 in 12) have asthma. Due to its high prevalence, vast research has been done to see if there are things that can be done from birth to lower its incidence later in life. For the first six months of an infant’s life, human milk is the best source of nutrients. Governmental and medical professional groups strongly advocate breastfeeding for all infants due to its recognized advantages in terms of nutrition, gastrointestinal function, immediate protection against infectious disease, and psychological well-being. Additionally, research has shown that breastfeeding reduces the number of clinically significant respiratory tract infections in infants and would therefore be expected to reduce wheezing associated with these infections.

Site evaluator: Dr. Manuel Saint Martin, MD JD

In the first site evaluation, all the students doing our Psychiatry rotation all joined the zoom call and each presented a patient we had seen on rotation and shared our experiences. It was very helpful to get feedback from Dr. Saint Martin on our write-ups and what to include in which sections, as well as commentary on the nuances of each of our cases. It was also interesting to see how the psychiatric emergency experience I was getting differed from the inpatient psychiatry experience one of my classmates described. I presented the first write-up about a woman with major depressive disorder, suicidal ideation/attempt, and post-traumatic stress disorder.

For our second visit, we submitted 2 H&Ps (presenting one), 5 drug cards, and a research article. I chose to present my second write-up, a man presenting with delusional thinking, mania, and substance abuse disorder. His official diagnosis was ultimately diagnosed with Bipolar 1 disorder and admitted to the inpatient unit for treatment and stabilization. Relating to this case, I presented an article that analyzed emerging findings of Bipolar Disorder regarding both new drug-target therapy and mechanisms to understand more of the Bipolar Disorder phenotype.

Due to the complexity of psychiatry, it was extremely beneficial to discuss these cases and receive feedback on our written accounts from Dr. Saint Martin, who has so much expertise in this field.

This rotation was particularly instructive because it involved a completely different method of patient care than any of my previous ones. The patient interview and mental state examination took the place of the history and physical examination. In addition, unlike a patient in an urgent care or emergency room where they can express exactly what their complaint is, the patients I assisted in treating in CPEP frequently lacked proper insight and good judgment and could not articulate the issue that caused them to present in the unit. I believe that as a result, my observational abilities have significantly increased, enabling me, for instance, to determine whether a mentally ill patient is internally concerned or if they are acting incoherently and bizarrely.

I enjoyed nearly every aspect of this rotation. First, it was nice to see a service that is largely run by PAs, many of whom had previously graduated from the York Program. Additionally, the staff seemed to enjoy having students around and were willing to give mini-lectures on disorders and medication classes and indications, while also bringing students along to see cases and conduct interviews. Moreover, they were all really mindful of our safety and what we were comfortable with. I recall an instance where one of the PAs wanted to take me to see a consult in the medical emergency room for a patient who was brought in for homicidal ideations and they would look for constant reassurance that I was comfortable seeing and speaking with patients that had aggressive and violent histories.

Of course, I want the staff and my preceptor to see that I am eager to learn on every rotation, I believe that was especially true for this rotation because it was one that I was particularly interested in. I would make a point to leave my comfort zone in an area I did not feel academically strong while offering to see as many patients as possible, ask questions as needed, and request to make patient notes whenever practical. The fact that the various doctors asked me to visit patients with them and trusted me to see their designated patients alone suggests that this translated well.

Article: The Emerging Neurobiology of Bipolar Disorder

Citation: Harrison, Paul J., et al. “The Emerging Neurobiology of Bipolar Disorder.” Trends in Neurosciences, vol. 41, no. 1, Jan. 2018, pp. 18–30., https://doi.org/10.1016/j.tins.2017.10.006.

• Our understanding of bipolar disorder remains frustratingly limited. It continues to be a descriptive syndrome since there is a lack of sufficient knowledge to allow its characterization or conceptualization to be based on etiology or mechanism.
  
• The discovery of some of the bipolar disorder risk genes has the potential to revolutionize the understanding of its pathogenesis and neurobiology.
  
• The use of digital technologies and remote sensors, coupled with advanced analyses of the resulting data, is allowing a more-quantitative, longitudinal approach to the bipolar disorder’s phenotype and its corresponding treatment.
  
• The ultimate objective of these modern methods is to enable a more scientifically informed, evidence-based approach to the classification, measurement, and treatment of bipolar disorder. The distinctions between bipolar disorder and other conditions characterized by lability of mood, emotion, and behavior could be redrawn or eliminated. The behavioral and physiological correlation of mood and mood instability could be incorporated into clinical practice, while the emphasis on finding interventions that can stabilize mood independently of the underlying diagnosis, and new, genetically informed therapies, like those that target voltage-gated calcium channels, could be implemented.

Identifying Data:

• Name: GD
• Sex: Female
• Age: 17
• Date and Time: October 12^th, 2022; 2:05 PM
• Location: NYC H+H/Queens Hospital Center – Emergency Extended Length of Stay (EELOS)
• Source of Information: Self, Mother, Mother’s boyfriend
• Source of Referral: Guidance counselor

Chief Complaint: “School sent me here because I said I could kill myself”

History of Present Illness:

GD is a 17-year-old Hispanic female, high school student, domiciled with family, with reported medical history of depressive disorder, OCD, PTSD, who presents to the pediatric ER, brought in by EMS, activated by school guidance counselor, secondary to reported suicidal ideations with plan as well as being found to have a metal fork in her belongings.

Upon psychiatric evaluation in EELOS, patient remains with anxious mood, constricted affect, but is otherwise cooperative with assessment. Patient admits that she told her counselor that she no longer had any reason to live because she has fulfilled all promises and obligations to her friends, family, and therapist, and thusly no longer has any reason to live. Patient reports that every year around her birthday (October 5^th) she feels much more depressed than usual because it reminds her of her deceased father. She reports that her father was an NYPD officer who was a first responder on September 11^th and passed away when she was 14 due to a 9/11 related illness. Patient admits to suicidal ideations but denies active ideation or intent. Patient endorses long history of non-suicidal self-injurious behavior via forearm cutting throughout her teenage years. Patient also reports approximately 5 times, most recently being September 2021, where she overdosed on medication and did not inform her family or seek medical attention.

Patient is known to follow up without outpatient psychiatrics and is compliant with her medication regimen of Zoloft, Lithium, Topamax, and Prazosin. Collateral information is obtained from the patient’s mother and mother’s boyfriend. As per boyfriend, patient was recently discharged from inpatient psychiatric facility in August 2022 after an 8-week admission.

Past Medical History: Asthma

Past Psychiatric History:

• Major depressive disorder
• Obsessive compulsive disorder
• Post-traumatic stress disorder

Past Surgical History: Patient denies

Medications:

• Albuterol pump PRN
• Sertraline (Zoloft) 100mg PO QD
• Prazosin HCL 2mg PO HS – for nightmares

Allergies: Patient denies

Family History:

• Mother: Alive and well
• Father: Deceased, 9/11/01 related illness
• Brother: Older, alive, and well

Social History:

• Employment: Full time high school student.
• Education: High school senior
• Travel: Denies recent travel
• Diet: States that she eats regularly with no dietary restriction.
• Exercise: Denies regular exercise
• Sexual Activity: Not sexually active, denies ever having sex.
• Smoking: Denies current or past use of tobacco products
• Alcohol: Denies any alcohol use
• Drugs: Denies use of any illicit drugs.

Vital Signs:

• BP: 116/72
• Pulse: 81 beats/minute, regular
• Respiratory rate: 16 breaths/minute, unlabored
• Temperature: 98.4F (36.9C), oral
• SpO2: 100% RA
• Height: 64 inches
• Weight: 125 pounds
• BMI: 24.5

Mental Status Exam:

General:

• Appearance – GD is a Hispanic female with a narrow frame and long black hair untied. She is dressed in blue hospital-provided pajamas and is well groomed with good hygiene. She appears her stated age. She has multiple superficial abrasions on her right wrist.
  
  
• Behavior – Upon initial evaluation in Emergency Extended Length of Stay unit, the patient is sitting upright in stretcher with good posture, eating a candy bar, thoughts are clear, logical, and easily understood. She does not appear to have any tics, tremors, or psychomotor agitation or retardation.
  
  
• Attitude Towards Examiner – LW is calm and cooperative and responds to all questions appropriately. She appears guarded during the interview yet maintained good eye contact. She does not display any hostility or aggression towards the examiner or other unit staff.

Sensorium and Cognition:

• Alertness and Consciousness – LW was conscious and alert consistently throughout the interview
  
  
• Orientation – Patient was oriented to person, place, time, and situation
  
  
• Concentration and Attention – LW maintained attention and concentration throughout the interview and did not appear distractible or internally preoccupied. She was able to answer all questions appropriately.
  
  
• Visuospatial Ability – The patient displays normal visual perception as suggested by appropriate balance on her feet, normal gait, and purposeful body movements. She did not maintain consistent eye contact but displayed normal gaze when she did make eye contact.
  
  
• Capacity to Read and Write – LW displayed average reading and writing ability as shown by her reviewing legal holding paperwork provided in unit.
  
  
• Abstract Thinking – The patient displays intact abstract thinking by interpretation of commonly used English metaphors
  • The grass is always greener on the other side – “Things aren’t as good as you hoped when you get them.”
  • What makes apples and oranges similar? – “They are fruits.”
    
    
• Memory – The patient’s remote and recent memory appear normal as suggested by her ability to provide her mother’s phone number from memory and recollection of recent events leading up to her presentation to the facility.
  
  
• Fund of Information and Knowledge – LW’s intellectual performance was average and consistent with her education level.
  
  
  
  

Mood and Affect:

• Mood – The patient’s mood appears sad/depressed. She did not smile during the interview. She states that she feels “fine” and wants to go home.
  
  
• Affect – LW appeared guarded and her affect was flat.
  
  
• Appropriateness – LW’s mood and affect were congruent throughout the interview.

Motor:

• Speech – LW’s speech rate was slow, rhythm was monotone, and volume was low. Her speech was coherent and organized. The patient’s answer latency was increased. She did not require redirection to answer questions.
  
  
• Eye Contact – LW maintained good eye contact.
  
  
• Body Movements – Patient appeared fidgety during the exam as shown by rubbing her hands together and shifting on the bed. She does not display any tics or unintentional body movements. All movements were fluid.

Reasoning and Control:

• Impulse Control – LW displays appropriate impulse control. She denies current suicidal or homicidal urges. She is compliant with all requests (urine sample, blood samples, accepting food and drinks etc.)
  
  
• Judgment – LW denies current paranoia, delusions, and auditory/visual hallucinations. Her judgment is appropriate.
  • If you were walking on the street and notices a letter with a stamp and address on the ground next to a mailbox you drop mail in, what would you do? – “I would put the letter in the mailbox.”
    
    
• Insight – LW’s insight is appropriate; she is aware of her current condition and why she was brought to the hospital (“I tried to kill myself earlier.”).

Patient Health Questionnaire – 9:

• In the past 2 weeks have you felt little interest or pleasure in doing things you used to enjoy?
  • Nearly every day: +3
• In the past 2 weeks, have you been feeling down, depressed, or hopeless?
  • More than half the days: +2
• In the past 2 weeks, have you had trouble falling or staying asleep, or sleeping too much?
  • Several days: +1
    
    
• In the past 2 weeks, have you been feeling tired or having little energy?
  • Nearly every day: +3
• In the past 2 weeks, have you had poor appetite or been overeating?
  • Not at all: 0
• In the past 2 weeks, have you been feeling bad about yourself or that you are a failure or have let yourself or your family down?
  • More than half the days: +2
• In the past 2 weeks, have you had trouble concentrating on things, such as reading the newspaper or watching television?
  • Not at all: 0
• In the past 2 weeks, have you been moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
  • Not at all: 0
• In the past 2 weeks, have you thought that you would be better off dead, or thoughts of hurting yourself in some way?
  • Nearly every day: +3

Total Score – 14 – Suggests moderate depression severity; patients should have a treatment plan ranging from counseling, follow-up, and/or pharmacotherapy.

Differential Diagnoses:

MDD: Previously diagnosed. Sadness, anhedonia, decreased energy, decreased concentration, and suicidal ideations are all present. These symptoms cause impairment in social and school settings, are not attributable to effects of a substance or other medical conditions. Patient has never had a manic or hypomanic episode.

PTSD: Previously diagnosed. Experienced the death of her father around the time of her birthday, as he died from a 9/11 related illness. Every year on her birthday she has dissociative reactions of her father in the hospital. Currently has detachment from many of her old friends.

Plan

At this time, patient will benefit from overnight behavioral observation in EELOS.

• Maintain 1:1 behavioral observation at all times
• Continue patient’s home medication regimen
• Prior to discharge, create safety plan that includes goals for the future
• Follow-up with outpatient team
• Continue efforts for combined schooling and therapeutic program

Site Evaluator: Gary Maida, PA-C

During my site evaluations, I presented two cases, ten drug cards, and one article relevant to one of my cases. First, I presented a 10-year-old girl who came in complaining of constipation and UTI symptoms. After taking a thorough history and investigating imaging, the emergency department attending decided it would be best to transfer this patient to another NYC HHC facility for an ultrasound to rule out appendicitis. This case was interesting as it did not present with the typical “exam” presentation that one would expect. Professor Maida was impressed that this child has never had an extensive workup before, after I had mentioned that this child has presented to the emergency department twice in the past for the exact same symptoms. Our discussion emphasized not letting a previous diagnosis give you tunnel vision with your current patient, no matter how simple the diagnosis may seem.

Because the fourth week of the rotation was spent in the neonatal ICU, I presented my second case on a 27-week-old born to a 43-year-old mother with a history of two miscarriages, T2DM, and hypertension throughout her pregnancy. The baby was taken to the NICU where we inserted an umbilical venous catheter and briefly intubated them for surfactant administration. The baby was also seen to have transient episodes of apnea, so we gave a caffeine dose to reduce the incidence of bronchopulmonary dysplasia.

Because I had never heard of this caffeine treatment, my article was an 11-year follow-up study to the Caffeine for Apnea of Prematurity trial published in 2006. The original RCT found that caffeine citrate therapy for apnea of prematurity reduces the rates of bronchopulmonary dysplasia, severe retinopathy, and neurodevelopmental disability at 18 months and may improve motor function at 5 years. This follow-up study was conducted to evaluate whether enrollment in that original therapy is associated with improved functional outcomes 11 years later.