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The objective of this article is to assess the adherence of pregnant women to the national recommendations for influenza and pertussis vaccination and the reasons behind their non-adherence. This was a retrospective observational study conducted in a well-defined puerperant population of adequate healthcare standards from December 2018 to December 2019. The study was carried out with 1006 puerperants and 66 health care practitioners. Data were collected, including demographic-obstetric features of pregnant women, whether they received antenatal vaccination, the reasons for having been vaccinated or not as well as health professional's opinion regarding antenatal immunization. The uptake of influenza and pertussis vaccine during pregnancy was suboptimal with lack of recommendation of the vaccine by the healthcare providers being the main barrier. Factors positively associated with antenatal vaccination against influenza were higher level of maternal education and advanced maternal age while antenatal vaccination against pertussis was positively associated with higher level of maternal education. This large-scale retrospective study reveals the inadequacy of antenatal vaccination rates against pertussis and influenza in Crete, Greece. Results suggest that obstetricians' confidence in vaccination is of outmost importance for implementing immunization in pregnancy and any doubts on vaccine effectiveness and safety should be resolved. Routine antenatal vaccination counseling and pregnancy immunization campaigns are essential to improve vaccine uptake during pregnancy.

Hypogonadism in adolescent females presents as delayed puberty or primary amenorrhea. Constitutional delay of growth and puberty, hypogonadotropic hypogonadism and hypergonadotropic hypogonadism represent the principal differential diagnosis of delayed puberty. Girls with hypogonadism require hormone replacement therapy to initiate and sustain puberty. We aimed to provide a brief review concerning treatment for female adolescents with hypogonadism and further to focus on current data regarding long-term effects of therapy.The published studies and articles of the international literature were used regarding the approach to adolescent girls with hypogonadism.The aim of therapy is the development of secondary sexual characteristics and achievement of target height, body composition and bone mass, to promote psychosexual health and, finally, to maximize the potential for fertility. Hypogonadal females need long-term HRT, so it is of great importance to fully define risks and benefits of therapy.The optimal pubertal induction in women contains both estrogens and progesterone regimens. Different therapeutic options have been described over the years in the literature, but larger randomized trials are required in order to define the ideal approach. The latest acquisitions in the field seem to propose that transdermal 17β-estradiol and micronized progesterone present the most physiological formulations available for this purpose. Further studies and follow up are needed concerning the long-term effects of HRT in adolescents.

Invasive meningococcal disease (IMD) remains a major cause of mortality and morbidity in children worldwide. A systemic review in PubMed and Cochrane Controlled Trials Register was performed for articles on risk factors for IMD in children and adolescents published during a 20-year period (19/09/1998 to 19/09/2018). Inclusion and exclusion criteria were established and applied. The data were meta-analyzed using random-effect model and the results were presented on forest plots separately for each risk factor. We identified 12,559 studies (duplicates removed). Titles, abstracts, and full texts were screened and finally, six studies (five case-control and one cohort study) were included in qualitative synthesis, five in meta-analysis. The median age of meningococcal disease (MD) cases was 72.2 months (0-19 years). Household crowding, smoking exposure, close relationships, and recent respiratory tract infections conferred a more than twofold risk for IMD in exposed individuals compared to controls [overcrowded living OR 2.52 (95% CI 1.75-3.63), exposure to smoke OR 2.10 (95% CI 1.00-4.39), kissing OR 2.00 (95% CI: 1.13-3.51), and recent respiratory tract infection OR 3.13 (95% CI 2.02-4.86)]. Attendance of religious events was associated with a decreased risk [0.47 (95% CI, 0.28-0.79)].Conclusion: Our review highlights the importance of individual characteristics as risk factors for IMD in childhood and adolescence. Preventive policies may consider individual as well as social-environmental factors to target individuals at risk.What is Known:• Close relationships, household crowding, and recent respiratory tract infections are major risk factors for IMD.• Passive smoking is a major risk factor for IMD.What is New:• Intimate kissing, household crowding, and passive smoking were found to double the risk of IMD.• Recent respiratory tract infections almost tripled the risk for IMD.

As the COVID-19 pandemic evolves, the medical community continues to report a variety of clinical manifestations of SARS-CoV-2 in the pediatric population. Although younger age groups experience less severe disease, attention is given to the immunologic manifestations of the disease. Pericarditis is a rare cardiac complication of COVID-19 infection. We discuss the first case of delayed presentation of pericarditis following recovery from COVID-19 infection in the pediatric population. A 15-year-old male adolescent presented to the emergency department (ED) with a two-day history of left-sided, sub-sternal chest pain that worsened during inspiration and a low-grade fever. Twenty days prior to this presentation, the patient experienced fever and was tested positive for SARS-CoV-2. His family history was remarkable for Hashimoto thyroiditis and rheumatoid arthritis, with his mother having experienced 18 episodes of pericarditis during the exacerbations of her disease. RT-PCR for SARS-CoV-2 was negative on this occasion and the serology assay identified positive IgG antibodies against the virus. The ECG was suggestive for pericarditis and the diagnosis was confirmed by the presence of pericardial effusion on ECHO. The rest of the aetiological investigations for pericarditis were negative. In view of the strong family history of autoimmunity, questions were raised in the medical team of our hospital regarding the etiology of his pericarditis and on whether it represented a postinflammatory immune-mediated presentation of SARS-CoV-2 or a new-onset autoimmune disease.

Aim Co-infections with viral and bacterial enteropathogens often augment severity of diarrhoea, however, there is limited evidence on the clinical importance of bacterial enteric co-infections. We investigated the rate, type and impact of bacterial enteropathogens and their associations in children with gastroenteritis. Methods Retrospective cohort study that included children 0-18 years old with acute bacterial diarrhoea during a 27-year period (1993-2019), in Crete, Greece. Differences in clinical characteristics and pathogen associations were investigated between single and multiple infections. Results Two or more bacteria were isolated in stool culture in 53 out of 1932 children (2.74%). Patients with co-infections were younger (p 0.0001) and had higher hospitalisation rates (p 0.03). Escherichia coli (E. coli) was the most prevalent pathogen associated with co-infections, in particular the E. coli enteropathogenic strains O127 and O111 (p 0.001), and Salmonella spp the least (p 0.001). Co-occurrence analysis revealed two positively associated pathogen pairs, E. coli with Campylobacter spp and E. coli (p 0.001) with Salmonella spp (p 0.04). Conclusion Bacterial enteropathogen co-infection was most common with E. coli strains and related to higher hospitalisation rates and younger age.

Acute diarrhea is one of the most frequent causes of doctor visits and hospital admissions for children. Our objective was to evaluate the association between probiotics administration and reduction of acute infectious diarrhea duration in children dwelling in developed countries. Bibliographic databases, gray literature, and reference lists were searched up to September 29, 2019. Double-blind, randomized controlled trials that examined probiotics efficacy in children with acute infectious diarrhea residing in developed countries were included. Data were synthesized by generic inverse variance method using fixed- and random-effects model. Twenty trials met the eligibility criteria (n = 3469 patients) and were included in the qualitative synthesis, and 19 studies in meta-analysis. Twelve trials (n = 840) were assessed as high/unclear risk of bias and eight (n = 2629) as low risk of bias. Comparisons revealed a moderate effectiveness of probiotics in low risk of bias studies (MD = - 13.45 h; 95% CI - 24.26, - 2.62; p = 0.02, Bayesian meta-analysis pooled effect MD = - 0.38, 95% CrI - 2.3, 1.58) and a notable effect in studies with high/unclear risk for bias (MD = - 19.70 h; 95% CI - 28.09, - 11.31; p = 0.0004). In trials of optimal methodological quality (n = 1989), probiotics effect was absent (MD = - 3.32 h; 95% CI - 8.78, 2.13, p = 0.23).Conclusion: Outcomes suggest that probiotics do not demonstrate sufficient clinical impact in reducing diarrhea duration in children in the developed countries.Systematic Review Registration: This review is registered at PROSPERO (ID: CRD42020152966). What is Known: • Probiotics, due to the conflicting study results, are administered without adequate evidence as an adjuvant therapeutic agent for eliminating duration of acute infectious diarrhea in pediatric patients. What is New: • In developed countries, probiotics are demonstrated as ineffective in reducing the duration of acute infectious diarrhea in children.

AIM We explored the impact of vaccination on bacterial meningitis in a well-defined population of children on the island of Crete, Greece, over a 27-y period. METHODS This was a retrospective observational study of all mandatory notifications of bacterial meningitis in patients aged 1 mo-14 y from 1991 to 2017. RESULTS There were 245 patients with proven (n = 227) or suspected (n = 18) bacterial meningitis, and eight deaths were recorded, giving a case fatality rate of 3.3%. The mean annual incidence rate (IR) per 100 000 children was 4.9 for Neisseria meningitidis, 2.2 for Streptococcus pneumoniae and 0.4 for Haemophilus influenzae type b (Hib). Cases of meningitis C dropped significantly after the conjugate meningitis C vaccine was licensed for routine vaccination in Greece in 2000 (IR of 1.5 vs 0.3, P

Children are often referred to immunologists for the evaluation of reduced serum immunoglobulins. Knowledge of the immunoglobulin levels in healthy children of different ages is necessary when estimating immunological deficiency states of various kinds. After the measurement of the serum levels of the three major isotypes, examination of the capacity of the child to form antibodies to several antigens is a reasonable next step in the evaluation. We can rely on vaccine responses to make the distinction between significant primary immunodeficiency diseases and transiently low immunoglobulin levels. On the other hand, normal values of IgM, IgG and IgA are not always enough to exclude a more serious condition. Regardless of immunoglobulin concentrations, if a child's history indicates that further evaluation is warranted, a complete humoral immunity study should be carried out, including IgG subclasses, specific antibody responses and identification of B lymphocyte populations.

Aim: We reported a case of Miller Fisher syndrome following a breakthrough varicella zoster virus infection in an otherwise healthy 6-year-old male. The objective of this review was to summarize the infectious etiologic agents known to trigger Miller Fisher syndrome. Methods: Review of the literature on infections associated with Miller Fisher syndrome. Results: We identified 762 studies after duplicates were removed. Titles, abstracts, and full texts were screened. Finally, 37 studies were included in qualitative synthesis after citations and reference list were checked. The age range of cases reported was 0-78 years, and male sex was predominant in studies where these parameters were reported. The most common causative agent was Campylobacter jejuni followed by Haemophilus influenzae. Conclusions: Our review highlights the importance of recognizing the infections triggering Miller Fisher syndrome. We also present a unique case of Miller Fisher syndrome associated with breakthrough varicella zoster virus infection. Preventive policies may consider population immunization for certain causative agents.

DiGeorge syndrome (DGS) is a primary immunodeficiency characterized by various degrees of T-cell deficiency. In partial DGS (pDGS), other risk factors could predispose to recurrent infections, autoimmunity, and allergy. The aim of this study was to assess the effect of different factors in the development of infections, autoimmunity, and/or allergy in patients with pDGS. We studied 467 pDGS patients in follow-up at Great Ormond Street Hospital. Using a multivariate approach, we observed that palatal anomalies represent a risk factor for the development of recurrent otitis media with effusion. Gastroesophageal reflux/dysphagia and asthma/rhinitis represent a risk factor for the development of recurrent upper respiratory tract infections. Allergy and autoimmunity were associated with persistently low immunoglobulin M levels and lymphopenia, respectively. Patients with autoimmunity showed lower levels of CD3+, CD3+CD4+, and naïve CD4+CD45RA+CD27+ T lymphocytes compared with pDGS patients without autoimmunity. We also observed that the physiological age-related decline of the T-cell number was slower in pDGS patients compared with age-matched controls. The age-related recovery of the T-cell number depended on a homeostatic peripheral proliferation of T cells, as suggested by an accelerated decline of the naïve T lymphocytes in pDGS as well as a more skewed T-cell repertoire in older pDGS patients. These evidences suggest that premature CD4+ T-cell aging and lymphopenia induced spontaneous peripheral T-cell proliferation might contribute to the pathogenesis of autoimmunity in patients with pDGS. Infections in these patients represent, in most of the cases, a complication of anatomical or gastroenterological anomalies rather than a feature of the underlying immunodeficiency.

Asthma is a heterogeneous chronic respiratory disease characterized by an increased burden of infections. Respiratory tract infections associated with an increased risk for asthma especially when occurring in the first months of life, also represent the most common cause of asthma exacerbations. The association between asthma and the increased frequency of infections and microbiota dysbiosis might be explained by a common mechanism, such as an underlying immune system defect. Apart from the well-established association between primary immunodeficiencies and asthma, several alterations in the immune response following infection have also been observed in asthmatic patients. An impairment in lung epithelial barrier integrity exists and is associated with both an increased susceptibility to infections and the development of asthma. Asthmatic patients are also found to have a deficient interferon (IFN) response upon infection. Additionally, defects in Toll-like receptor (TLR) signaling are observed in asthma and are correlated with both recurrent infections and asthma development. In this review, we summarize the common pathophysiological background of asthma and infections, highlighting the importance of an underlying immune system defect that predispose individuals to recurrent infections and asthma.

The immune system poses one of the greatest challenges for the scientific community. The general pediatrician should be able to screen and identify an immunodeficient patient based on certain clinical indications. Further investigation is crucial for the distinction between primary or secondary immunodeficiency as well as for between cellular and humoral immunity defects. Full blood count is the best initial laboratory test when suspecting a primary immunodeficiency, focusing on the absolute lymphocyte count, while lymphocyte subset count offers the advantage of detecting the cell type that causes the immune defect. The aim of the present review was to guide the general pediatrician in the investigation and diagnosis of an immunodeficient patient. Even though an immunodeficiency may seem a very difficult disease to diagnose, a balanced and rational way of thinking, along with the help of modern technological advances, can easily guide us in the right direction.

Background Urinary tract infection (UTI) is the most common serious bacterial infection in childhood. The aim of the present study was therefore to identify the organisms responsible for community-acquired febrile UTI in children, to investigate their susceptibility to commonly used antibiotics, and to identify possible risk factors for antibiotic resistance. Methods A total of 284 children (male, 38%; female, 62%), who were hospitalized due to a community-acquired UTI over a 5 year period in a general district hospital of southern Greece, were enrolled in the study. Results Escherichia coli was the leading uropathogen followed by Klebsiella spp. (9.15%) and Proteus spp. (5.28%). E. coli isolates were most commonly resistant to ampicillin (41.8%), followed by piperacillin (40.3%), amoxicillin-clavulanic acid (28.6%) and trimethoprim-sulfamethoxazole (17.8%), while 27 strains (12.6%) were multi-drug resistant (MDR). Of the E. coli strains, 4.21% were producing extended-spectrum beta-lactamases. Parenteral second- and third-generation cephalosporins, the most commonly used antibiotic agents (81.3%) in the present cohort, remained highly active against E. coli and other urinary isolates, given that >95% of E. coli strains were susceptible to cefuroxime and cefotaxime. Vesicoureteral reflux was a significant risk factor for MDR (P = 0.04). Conclusion Contrary to current local practice, amoxicillin/clavulanic acid may not be the best option for the empirical treatment of community-acquired UTI in southern Greece.

Patients with juvenile idiopathic arthritis (JIA) can experience a severe disease course, with progressive destructive polyarthritis refractory to conventional therapy with disease-modifying antirheumatic drugs including biologics, as well as life-threatening complications including macrophage activation syndrome (MAS). Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a potentially curative immunomodulatory strategy for patients with such refractory disease. We treated 16 patients in 5 transplant centers between 2007 and 2016: 11 children with systemic JIA and 5 with rheumatoid factor-negative polyarticular JIA; all were either refractory to standard therapy, had developed secondary hemophagocytic lymphohistiocytosis/MAS poorly responsive to treatment, or had failed autologous HSCT. All children received reduced toxicity fludarabine-based conditioning regimens and serotherapy with alemtuzumab. Fourteen of 16 patients are alive with a median follow-up of 29 months (range, 2.8-96 months). All patients had hematological recovery. Three patients had grade II-IV acute graft-versus-host disease. The incidence of viral infections after HSCT was high, likely due to the use of alemtuzumab in already heavily immunosuppressed patients. All patients had significant improvement of arthritis, resolution of MAS, and improved quality of life early following allo-HSCT; most importantly, 11 children achieved complete drug-free remission at the last follow-up. Allo-HSCT using alemtuzumab and reduced toxicity conditioning is a promising therapeutic option for patients with JIA refractory to conventional therapy and/or complicated by MAS. Long-term follow-up is required to ascertain whether disease control following HSCT continues indefinitely.

Among the neurological manifestations of systemic lupus erythematosus (SLE), chorea is rare, presenting in less than 7% of the pediatric SLE patients. It can appear early in the onset of SLE, be the first or even the sole clinical feature of the illness and has strongly been associated with the presence of antiphospholipid antibodies. We report on the case of a 13-year old boy, admitted with acute onset chorea and finally diagnosed with SLE. Subsequently, we present a short review of the literature on the epidemiology, suggested pathogenesis, clinical presentation and treatment of this rare presentation of SLE.

Aim Information on the epidemiology of childhood urinary tract infections (UTIs) is scarce and mostly based on retrospective data. This study investigated incidence rates, morbidity and risk factors for UTIs in a prospective cohort of children. Methods We explored UTIs in a representative cohort of 1049 neonates from birth to 6 years of age, using maternal interviews that were verified by hospital records. The majority (88.2%) completed the first-year, and more than half (56.2%) completed the 6-year follow-up. Results By 6 years of age, more than 10% of our sample had been affected by UTIs. The cumulative incidence for the first year of life was 3.77%, without significant differences between genders, and for one to 6 years, it was 6.81% and 5.7 times higher in girls than boys. Clinical information was available for 63 children: 25 were hospitalised, 16 suffered recurrences, 10 received prophylaxis, eight had urinary tract malformations, three required surgery, and two had impaired renal function. Conclusion UTIs affected approximately 4% and 10% of children by the ages of one and 6 years, respectively, and their incidence was related to gender and age. Morbidity was considerable, recurrences were common, and despite advances in management, long-term consequences may still be encountered.

Primary immune deficiencies (PID) in children are a rare but serious group of genetic disorders of the immune system which apart from the host's defenses, can also affect every system of the human body, including the gastrointestinal tract. In their severe form they can lead to increased susceptibility to serious infections during infancy and even death. In the less severe form, they can present later in childhood or adolescence with subtle signs and symptoms. As PID can often mimic gastrointestinal diseases, children presenting with atypical gastrointestinal disease and/or failure to respond to conventional therapy should be evaluated for an underlying primary immune disorder and initiated appropriate treatment. The current review of the literature will summarize the gastrointestinal manifestations of primary immune deficiencies in children.

Rituximab (RTX) is a monoclonal antibody against CD20, commonly used in the treatment of hematological malignancies and autoimmune diseases. The use of RTX is related to the development of hypogammaglobulinemia and infections. Aim of this review is to summarize the evidence supporting the association of specific risk factors with the development of hypogammaglobulinemia and infections post-RTX. Immunological complications are more common in patients with malignant diseases as compared to non-malignant diseases. Moreover, the use of more than one dose of RTX, maintenance regimens, low pre-treatment basal immunoglobulin levels and the association with Mycophenolate and purine analogues represent risk factors for the development of hypogammaglobulinemia. The number of RTX courses, the evidence of low IgG levels for more than 6 months, the use of G-CSF, the occurrence of chronic lung disease, cardiac insufficiency, extra-articular involvement in patients with rheumatoid arthritis, low levels of IgG and older age have been correlated with a higher risk of infections. Even though the heterogeneity of the studies in terms of study population age and underlying disease, RTX schedules as well as differences in pre-treatment or concomitant therapy doesn't allow drawing definitive conclusions, the study of the literature highlight the association of specific risk factors with the occurrence of hypogammaglobulinemia and/or infections. A long term randomized controlled clinical trial could be useful to define a personalized evidence-based risk management plan for patients treated with RTX.

In this study, we investigated the long-term trends in the epidemiology and susceptibility of bacterial enteropathogens among children in a well-defined area of adequate health standards. The study included all children younger than 14 years of age treated for enteritis at Heraklion University General Hospital on the island of Crete during the 18-year period from January 1993 to December 2010. Stool specimens were tested for Salmonella, Shigella, Campylobacter, enteropathogenic Escherichia coli (EPEC), Yersinia, and Aeromonas species. Of the 33,032 stool samples from patients of any age, 2,912 (8.82%) were positive for bacterial enteropathogens. The 1,597 isolates from children were identified as S. enterica (42.3%), Campylobacter spp. (33.6%), EPEC (17.4%), Y. enterocolitica (5.82%), A. hydrophila (0.44%), and Shigella spp. (0.38%). A decline in prevalence was observed for all bacterial enteropathogens. Taken as a total, enteropathogens were susceptible to gentamicin, ceftriaxone, ciprofloxacin, co-trimoxazole, and amoxicillin in 98.8%, 88.0%, 83.0%, 67.1%, and 59.6%, respectively. During the study period, the susceptibility rates decreased for co-trimoxazole (p

Factors predisposing to acute otitis media (AOM) are not thoroughly understood.In this study we prospectively investigated incidence rates and risk factors of AOM in a systematic sample of infants in a well-defined population.Following interview soon after delivery in a representative sample of 1049 mother-infant pairs, information was collected 1, 3, 6, 9 and 12 months after birth. Episodes of AOM were recorded as by parental reports of diagnosis made by a physician. AOM frequency was further analyzed against 21 social, maternal, paternal, prenatal, perinatal and infantile factors.Successful 12-month follow-up was achieved for 926/1049 infants (88.3%), of whom 265 (28.6%) were reported with episodes of AOM; 153 with a single, 55 with two, and 57 with three to six episodes (16.5%, 5.94%, and 6.16% respectively). Factors founded by multivariate analysis to predispose to AOM included presence of siblings (P0.001), out-of-home daycare (P0.001), ill health in pregnancy (P0.01), and suboptimal breastfeeding (P0.01). Multiple (3 or more) episodes were related to presence of siblings (P0.0001), out-of-home daycare (P0.001), ill health in pregnancy (P0.001), and low parental education (P0.001). 28 infants were hospitalized (10.6% of infants with AOM, 3.02% of the total cohort). Hospitalization was related to young maternal age (P0.05).Our findings confirm the high morbidity of AOM during infancy and point to several infant- and family-related predisposing factors, some of which are liable to intervention.

Background: Human milk is the most suitable food for newborn and young infants and its exclusive supply for at least the first six months of life ought to be universally provided. A wide array of benefits of breastfeeding have been well documented, including financial, psychosocial, developmental and prevention of illnesses, including infections. Although it has long been shown that breastfed infants are less prone to a variety of infections, skeptics have asserted that breastfeeding and formula-feeding mothers differ in ways which might alter infantile risk for infection and that the breastfeeding protective effect may be attributable to confounding factors and may be expressed less in societies with high health standards. Purpose:Σο prospectively investigate the effect of breastfeeding on both the frequency, expressed as number of infectious episodes, and the severity, expressed as need for doctor visits and hospitalization for common infections throughout the first year of life, in a well-defined, well-vaccinated infant population with adequate health standards. Based on existing experience in the field, the study was designed first to verify the hypothesis that breastfeeding protects against common infantile infections, second to explore the impact of exclusive breastfeeding and its duration, and third to investigate this impact during both the first and the second 6 months of infancy (months 1-6 and months 6-12). Study design: The study was conducted as a prospective observational study in a fixed cohort in the island of Crete. From a total of 6,878 births in 2004, a representative cohort of 1,049 (15.2%) mother-infant pairs was formed. Sampling was based on consecutive births in random days from October to December, 2004 and from April to July, 2005. This 2-period sampling facilitated assessment of the effect of breastfeeding on infections as related to season of birth. In 926 infants, successfully followed up for 12 months, feeding mode and all infectious episodes, including acute otitis media (AOM), acute respiratory infection (ARI), gastroenteritis, urinary tract infection, conjunctivitis and thrush, were recorded at 1, 3, 6, 9 and 12 months of life. Severity of infections was estimated by the number of doctor visits and admissions to hospital. Potential confounders evaluated were ethnic origin, average parental age (years), average years of parental education, birth weight, sex, season of birth (autumn/spring), gestation duration, delivery mode and number of siblings. ...........................

Objective To prospectively investigate the effects of breastfeeding on the frequency and severity of infections in a well-defined infant population with adequate vaccination coverage and healthcare standards. Study design In a representative sample of 926 infants, successfully followed up for 12 months, feeding mode and all infectious episodes, including acute otitis media (AOM), acute respiratory infection (ARI), gastroenteritis, urinary tract infection, conjunctivitis and thrush, were recorded at 1, 3, 6, 9 and 12 months of life. Results Infants exclusively breastfed for 6 months, as per WHO recommendations, presented with fewer infectious episodes than their partially breastfed or non-breastfed peers and this protective effect persisted after adjustment for potential confounders for ARI (OR 0.58, 95% CI 0.36 to 0.92), AOM (OR 0.37, 95% CI 0.13 to 1.05) and thrush (OR 0.14, 95% CI 0.02 to 1.02). Prolonged exclusive breastfeeding was associated with fewer infectious episodes (r s =−0.07, p=0.019) and fewer admissions to hospital for infection (r s =−0.06, p=0.037) in the first year of life. Partial breastfeeding was not related to protective effect. Several confounding factors, including parental age and education, ethnicity, presence of other siblings, environmental tobacco smoke exposure and season of birth were demonstrated to have an effect on frequency of infections during infancy. Conclusions Findings from this large-scale prospective study in a well-defined infant population with adequate healthcare standards suggest that exclusive breastfeeding contributes to protection against common infections during infancy regarding and lessens the frequency and severity of infectious episodes. Partial breastfeeding did not seem to provide this protective effect.

Aim: To identify maternal and infantile factors affecting intention to breastfeed, early weaning and duration of breastfeeding. Design/subjects: In a prospective cohort study, 1049 mothers were interviewed after delivery and at 1, 3, 6, 9 and 12 months post-partum. Results: Of 1049 mothers, 942 (89.7%) intended to breastfeed. Negative attitude was associated with lack of breastfeeding previous offspring, multiparity, admission to neonatal ward, tobacco use, prematurity and male gender (OR: 10.1, 2.67, 3.02, 2.63, 2.40 and 1.54, respectively). Six hundred and twenty-three mothers (60.7%) were breastfeeding at month 1. Early weaning was associated with lack of breastfeeding previous offspring, tobacco use, prematurity, admission to neonatal ward, caesarean section (OR: 12.3, 3.39, 2.33, 2.22, 1.34), low education (p < 0.0001) and young age (p = 0.034). Factors negatively affecting total duration of breastfeeding included lack of breastfeeding previous offspring (3.91 vs. 16.2 weeks, p < 0.001), tobacco use (6.78 vs. 15.9 weeks, p < 0.001), low education (p < 0.001), early re-employment (12.5 vs. 15.1 weeks, p < 0.01) and prematurity (p < 0.005). Conclusion: Maternal negative attitude, tobacco use and early re-employment are factors negatively affecting breastfeeding that can be liable to intervention. All health professionals involved in perinatal medicine share a part of responsibility in sustaining breastfeeding, particularly in high-risk groups of mothers.