Abstract. Renal parenchymal disease after urinary tract infection (UTI) has been associated with the development of hypertension and renal functional impairment. A systematic literature review and meta-analysis was performed to determine how effectively the finding of primary vesicoureteric reflux (VUR) on micturating cystography (MCU) in children hospitalized with UTI predicted renal parenchymal disease on 99m Technetium-dimercaptosuccinic acid ( 99m Tc-DMSA) scintigraphy. Medline, Embase, and PubMed were use to find reports with original data for children hospitalized with bacteriologically-proven UTI who had undergone both MCU and 99m Tc-DMSA scintigraphy, and which also reported both positive and negative results of these tests. A meta-analysis of likelihood ratios positive and negative for MCU was then performed, including tests for heterogeneity. Twelve valid studies were found, seven with data for 537 children, with a positive 99m Tc-DMSA scan prevalence of 59% overall, and seven studies with data for 1062 kidneys, with a positive 99m Tc-DMSA scan prevalence of 36%. The likelihood ratio positive for MCU was 1.96 (95% CI, 1.51 to 2.54) for children, and 2.34 (1.53 to 3.57) for kidneys. The likelihood ratio negative was 0.71 (0.58 to 0.85) for children and 0.72 (0.61 to 0.86) for kidneys. There was evidence of heterogeneity. The meta-analysis showed that a positive MCU increases the risk of renal damage in hospitalized UTI patients by about 20%, whereas a negative MCU increases the chance of no renal involvement by just 8%. VUR is hence a weak predictor of renal damage in pediatric patients hospitalized with UTI. Physicians should be aware of the limitations of using MCU-detected primary VUR as an effective screening test for renal damage in this population. Furthermore, the pathogenesis of renal damage in such patients is probably complex because it is often detected without demonstrable VUR.

Although the benefits of breastfeeding are widely accepted, the effectiveness of different strategies to promote the continuation of breastfeeding once initiated are less clear. The objective of this systematic review was to describe studies comparing standard care with the provision of extra breastfeeding support and to measure its effectiveness. Outcome measures used were rates of cessation of any breastfeeding or exclusive breastfeeding at chosen points in time. Measures of child morbidity and maternal satisfaction were also used when these were reported. Twenty eligible randomised or quasi-randomised controlled trials were identified, involving 23 712 mother-infant pairs. Extra support had a beneficial effect on the duration of any breastfeeding (RR [95% confidence intervals] for stopping any breastfeeding before the last study assessment up to 6 months 0.88 [0.81, 0.95]; 15 trials, 21 910 women). The effect was greater for exclusive breastfeeding (RR for stopping exclusive breastfeeding before the last study assessment 0.78 [0.69, 0.89]; 11 trials, 20 788 women). Although the point estimates of relative risk were very similar, benefit derived from professional support achieved statistical significance for any breastfeeding (RR 0.89 [0.81, 0.97]; 10 trials, 19 696 women) but not for exclusive breastfeeding (RR 0.90 [0.81, 1.01]; six trials, 18 258 women). Lay support was effective in reducing the cessation of exclusive breastfeeding (RR 0.66 [0.49, 0.89]; five trials, 2530 women) while the strength of its effect on any breastfeeding was less clear (RR 0.84 [0.69, 1.02]; five trials, 2224 women). Professional support in the largest trial to assess health outcomes produced a significant reduction in the risk of gastrointestinal infections and atopic eczema. In two trials with children suffering from diarrhoeal illness, extra support was highly effective in increasing short-term exclusive breastfeeding rates and reducing recurrence of diarrhoea. This review supports the conclusion that supplementary breastfeeding support should be provided as part of routine health service provision. There is clear evidence for the effectiveness of professional support on the duration of any breastfeeding although the strength of its effect on the rate of exclusive breastfeeding is uncertain. Lay support is effective in promoting exclusive breastfeeding although the strength of its effect on the duration of any breastfeeding is uncertain. Evidence supports the promotion of exclusive breastfeeding as central to the management of diarrhoeal illness in partially breast-fed infants.

The provision of extra support by professionals with special skills in breastfeeding appears to result in more mothers breastfeeding their babies until two months of age, and more mothers breastfeeding their babies exclusively to two months of age.

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