Letters to the Editor
Merits of Breastfeeding Children Through the Toddler Years
to the editor: Thank you for the informative article on the nutritional needs of toddlers that appeared in the November 1, 2006, issue of American Family Physician.1 I am concerned, however, that there was no mention of nursing toddlers. Many of the women I assist with breastfeeding are nursing their babies into toddlerhood. Some parents do not mention this to their health care professional for fear of chastisement. Some physicians have told mothers that breast milk has no value after one year post-birth.
Several medical organizations recommend that babies continue to be breastfed through the toddler years.2,3 Health professionals should know that the toddler who nurses even a few times a day receives a significant amount of calories, good quality protein, and immune factors from breast milk.4
Also, there is growing evidence that leptin in breast milk helps regulate appetite and future weight.5,6 Children who are nursing self-regulate intake because breast milk changes in composition throughout the nursing. Toddlers are known for occasionally having capricious tastes and appetites. Nursing such a child while offering appropriate complementary foods is a bonus.
Parents may need reassurance that nursing children into the toddler years is an acceptable, normal, and healthy way to nurture and nourish their child and that it carries benefits into adult life.
Author disclosure: Nothing to disclose.
REFERENCES
1. Allen RE, Meyers AL. Nutrition in toddlers. Am Fam Physician 2006;74:1527-32.
2. Gartner LM, Morton J, Lawrence RA, Naylor AJ, O'Hare D, Schanler RJ, et al. Breastfeeding and the use of human milk. Pediatrics 2005;115:496-506.
3. Global strategy for infant and young child feeding. World Health Organization; Geneva, Switzerland:2003. Accessed May 1, 2007 at: http://www.who.int/child-adolescent-health/NUTRITION/global_strategy.htm.
4. Fewtrell MS. The long-term benefits of having been breast-fed. Curr Paedatri 2004;14:97-103.
5. Grummer-Strawn LM, Mei Z; Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Pediatrics 2004;113:e81-6.
6. Miralles O, Sanchez J, Palou A, Pico C. A physiological role of breast milk leptin in body weight control in developing infants. Obesity 2006;14:1371-7.
in reply: I thank Ms. Gubala for pointing out that some women continue to breastfeed babies through the toddler years, and I am personally grateful that my wife breastfed all six of our children beyond their first year. I agree that physicians should not discourage this decision, as there is no evidence that breastfeeding toddler-age children is harmful.
Unfortunately, the evidence for the benefit of breastfeeding beyond 12 months of age is scant and of poor quality. Although the World Health Organization (WHO) recommends breastfeeding through 24 months of age, this guideline is based on expert consensus and lower-quality cohort studies.1-4 WHO also focuses on developing countries, and notes that extended breastfeeding is controversial outside of sub-Saharan Africa and has been associated with malnutrition in some surveys.5
Although the American Academy of Pediatrics allows for breastfeeding beyond the first year of life, this should not be interpreted as a universal recommendation.6 Scientific data on nutritional or other benefits in this age group are lacking. Finally, although I agree that more evidence is supporting decreased obesity as a positive benefit of extended breastfeeding, a careful review of the Grummer-Strawn analysis mentioned by Ms. Gubala reveals that "longer duration" of breastfeeding means six to 12 months, with no measurement beyond 12 months.
Author disclosure: Nothing to disclose.
REFERENCES
1. Global strategy for infant and young child feeding. World Health Organization; Geneva, Switzerland:2003. Accessed May 1, 2007 at: http://www.who.int/child-adolescent-health/NUTRITION/global_strategy.htm.
2. Butte NF. The role of breastfeeding in obesity. Pediatr Clin North Am 2001;48:189-98.
3. Davis MK. Breastfeeding and chronic disease in childhood and adolescence. Pediatr Clin North Am 2001; 48:125-41.
4. Reynolds A. Breastfeeding and brain development. Pediatr Clin North Am 2001;48:159-71.
5. Caulfield LE, Bentley ME, Ahmed S. Is prolonged breastfeeding associated with malnutrition? Evidence from nineteen demographic and health surveys. Int J Epidemiol 1996;25:693-703.
6. Gartner LM, Morton J, Lawrence RA, Naylor AJ, O'Hare D, Schanler RJ, et al. Breastfeeding and the use of human milk. Pediatrics 2005;115:496-506.
Emergency Preparedness Plan Crucial for Physicians and Patients
TO THE EDITOR: I would like to express my appreciation to the authors of "Disaster-Related Physical and Mental Health: A Role for the Family Physician,"1 which appeared in the March 15, 2007, issue of American Family Physician. The authors provided an excellent discussion of this important and increasingly researched area of health. I fully agree with the authors' description of family physicians' suitability to address the physical and mental health needs of disaster victims. In addition, family physicians can help prevent many of these negative health outcomes by educating their patients and staff as a component of a disaster preparation plan.
It is essential that family physicians educate and prepare themselves for disasters; however, in the event of a disaster, it is still likely that practices will be overwhelmed with patients. Physicians should encourage individuals and families to prepare themselves by following recommendations such as those described in the Ready campaign (http://www.ready.gov) created by the U.S. Department of Homeland Security. Despite the availability of these and other resources, fewer than one half of Americans report having an emergency preparedness plan, and only 29 percent report having all or some of the major elements of a plan (including water, batteries, and necessary medications). Those who do have a plan are more likely than those who do not to be familiar with the emergency/evacuation plan at their children's school (71 versus 28 percent, respectively) and feel more prepared for a terrorist attack (62 versus 24 percent, respectively).2
Personal and family preparedness will likely decrease the volume of patients presenting for medical care. Empowering individuals through personal preparation will also reduce the number of psychological casualties, which typically exceed the number of physical casualties to various degrees depending on the nature of the disaster.
In the event of a disaster, family physicians and their practices will be relied on to provide necessary services, support, and leadership. To accomplish these tasks, physicians and staff must be available, educated, and prepared.
The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large.
Author disclosure: Nothing to disclose.
REFERENCES
1. Freedy JR, Simpson WM. Disaster-related physical and mental health: a role for the family physician. Am Fam Physician 2007;75:841-6.
2. Redlener I, Johnson D, Berman DA, Grant R. Snapshot 2005: where the American public stands on terrorism and preparedness four years after September 11. The 2005 Annual Survey of the American Public by the National Center for Disaster Preparedness, Columbia University Mailman School of Public Health. Accessed March 30, 2007, at: http://www.ncdp.mailman.columbia.edu/files/NCDP_2005_Annual_Survey_Overview.pdf#search=%22parents%20attitudes%20terrorism%22.
Case Report:
Patient
Adherence to Drug Regimens Vital to Treatment
TO THE EDITOR: A 57-year-old woman presented to the emergency department with worsening right leg pain over the previous two months. On the day of presentation, the patient was unable to bear any weight on her right leg. Her medical history was significant for hypertension, mental retardation, and a seizure disorder. Physical examination revealed right lower extremity warmth, tenderness to palpation, and 1+ nonpitting edema from her ankle to her knee. Lower extremity Doppler ultrasonography confirmed the diagnosis of acute right femoral-popliteal deep venous thrombosis (DVT).
The patient was started on a therapeutic dose of enoxaparin (Lovenox) and warfarin (Coumadin) and admitted to the hospital. Her International Normalized Ratio (INR) became therapeutic on day four with a value of 2.09. The family was instructed on how to administer enoxaparin at home, given a prescription for enoxaparin, and instructed to continue it until her follow-up appointment the next day. For reasons that are unclear, the enoxaparin prescription was never filled. The prescription for warfarin was filled and continued as an outpatient.
Two days after discharge, the patient returned to the emergency room because of bilateral leg pain. Physical examination revealed bilateral lower extremity tenderness to palpation, trace pitting edema bilaterally, and ecchymosis of her left popliteal fossa. Her INR was 2.24. An ultrasound examination showed propagation of her right DVT and a new left femoral-popliteal DVT. The patient was discharged to subacute rehabilitation with a new INR goal of 2.5 to 3.0.
The American College of Chest Physicians (ACCP) guidelines recommend initial treatment of DVT with low-molecular-weight heparin (LMWH) or unfractionated heparin for a minimum of five days1 and until the INR is stable at 2 or more for at least two days with two measurements 24 hours apart.2 However, a retrospective study of patients with DVT, pulmonary embolism, or both revealed that 49.4 percent of patients had LMWH or unfractionated heparin discontinued before reaching an INR of 2.0 or greater for two consecutive days.3 In a recent survey of physicians, 30 percent stated it was not necessary to have a therapeutic INR for two days before discontinuation of LMWH or unfractionated heparin.4 A recent clinical guideline from the American College of Physicians and the American Academy of Family Physicians recommends outpatient treatment of DVT and possibly pulmonary embolism with LMWH if required support services are in place;5 therefore, it is imperative for family physicians to familiarize themselves with these guidelines.
In this case, the patient had only four days of overlap, and only one day of a therapeutic INR before discontinuation of enoxaparin. Failure to ensure an adequate overlap of LMWH and warfarin may result in apparent warfarin failure and worsening thrombosis.
Author disclosure: Nothing to disclose.
REFERENCES
1. Büller HR, Agnelli G, Hull RD, Hyers TM, Prins MH, Raskob GE. Antithrombotic therapy for venous thromboembolic disease, the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy [Published correction appears in Chest 2005;127:416]. Chest 2004;126(suppl 3):401S-28S.
2. Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy [Published correction appears in Chest 2005;127:415-6]. Chest 2004;126(suppl 3):204S-33S.
3. Tapson VF, Hyers TM, Waldo AL, Ballard DJ, Becker RC, Caprini JA, et al., for the NABOR (National Anticoagulation Benchmark and Outcomes Report) Steering Committee. Antithrombotic therapy practices in US hospitals in an era of practice guidelines. Arch Intern Med 2005;165:1458-64.
4. Caprini JA, Tapson VF, Hyers TM, Waldo AL, Wittkowsky AK, Friedman R, et al. Treatment of venous thromboembolism: adherence to guidelines and impact of physician knowledge, attitudes, and beliefs. J Vasc Surg 2005;42:726-33.
5. Snow V, Qaseem A, Barry P, Hornbake ER, Rodnick JE, Tobolic T, et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2007;146:204-10.
Send letters to Kenny Lin, MD, Assistant Editor, American Family Physician, e-mail: afplet@aafp.org. Letters submitted via regular mail should be sent to: 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-6272.
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