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Are Long Hours Killing Doctors, Nurses and Patients?

Doctors and nurses in the United States are pretty used to brutally long work days. But is it the only or best way to practice medicine in a hospital?

First of all, I think we should all ask the question, “How did we get here?” Well, the American practice of having doctors work long hours started with William Halsted, the first chief of surgery at Johns Hopkins in the 1890s and a founder of modern medical training. He required his residents to be on call 362 days a year for long shifts. It was only later revealed that Halsted powered his schedule with a cocaine addiction- a habit which 10%-12% of doctors are following today. (Concerned about continuity of care if your doctor goes to rehab? The state of California allows doctors rehab to continue seeing patients while they are undergoing treatment for substance abuse. Though nurses typically have to stop working until they can prove they are safe to return to work. But I digress…)

In 2011, the Accreditation Council for Graduate Medical Education shortened the shifts of residents for medical residents to a maximum of 16 hours at a time. This year though, the ACGME reversed its policy and put residents back on a maximum shift of 24 hours. One of the biggest reasons they cite is the need to ensure that residents who will need to be on long shifts will have that experience. Of course, most doctors won’t need ridiculously long shifts. (When was the last time you called a dermatologist, urologist, or your kid’s pediatrician at 3:00 AM in the morning? Though doctors in France still make house calls at all hours. )

The question then comes, should a doctor or nurse in an ER, ICU, PICU, NICU, burn unit, etc. really be working a 12, 16 or 24 hour shift?

How Normal Are 80 Hour Weeks For Doctors?

ACGME has placed the maximum a resident can work to be 80 a week. It’s interesting to note that in the European Union, doctors and residents are by law only supposed to work a maximum of 48 hours a week with a minimum daily consecutive rest period of 11 hours.

Long Shifts: Better or Worse for Patients?

If 24 hour shifts sound brutal, consider that up until the mid-1980’s, it was common for doctors and residents at hospitals to work for 36 hours straight. That changed in 1984 when an 18 year old girl named Libby Zion showed up in the emergency room at New York Hospital with a high fever and uncontrollable jerking. She was given Tylenol and some sedatives and restrained in bed. But her fever shot up to 108 degrees and she went into cardiac arrest and died.

Libby’s father was a newspaper columnist who was appalled that the intern on duty when his daughter died had been awake for 24 hours and that many doctors, residents and interns frequently worked 36 hour shifts. He wrote columns about the working conditions of doctors, a series of news stories followed and the work week for residents was capped at 80 hours.

The ACGME cites improving patient care as a reason why residents should be allowed to work 24 hour shifts. But with 97,000 people a year dying from medical errors, it’s certainly worth questioning if the old school method of long shifts is the way to go. And it’s not just doctors but nurses too. One study showed that when nurses worked 8-9 hour shifts as opposed to 10-11 hour shifts or 12-13 hour shifts, the nurses had less burnout and job dissatisfaction and patient satisfaction was actually higher.

And sleep deprived health professionals can make mistakes. One doctor described a time when as a resident he had just fallen asleep in a call room during a 36 hour shift. A nurse notified him of a 9 year old girl who was rapidly deteriorating from an asthma attack. He was so confused that he went into the bathroom, locked the door and started brushing his teeth instead of responding to the call. (Fortunately another doctor got the girl on a ventilator and she survived.)

Another case was the 2006 death of 16 year old Jasmine Gant when a nurse who had been voluntarily working sixteen hours straight failed to check a medication when she was preparing Jasmine for an epidural. She gave Jasmine the wrong medication causing cardiac arrest. Jasmine’s son was delivered by emergency c-section and is being raised by her mother.

Some large scale studies have found that cutting back to 80 hour work weeks for residents didn’t reduce mistakes. Though, I think we have to ask ourselves if 80 hours is enough of a reduction considering that other developed countries allow their doctors to work only half that in a week. Comparing 90-100 hours a week to 80 hours a week isn’t the same as comparing 80 hours a week to 48 hours a week.

But It’s Not Just Long Shifts Either…

It’s true that sleep deprivation can cause a person to be as impaired as being drunk. But in hospitals, it’s rarely so straightforward either. Libby Zion was taking several medications at the time of her death- even the most well-rested doctor would still need to inquire about medications.

In the case of Jasmine Gant, the nurse had failed to follow hospital procedure by scanning a bar code to check the right medication. This was a newer policy at the time for St. Mary’s Hospital in Madison, Wisconsin and it wasn’t well-enforced. The report also mentioned how nurses working in labor and delivery at St. Mary’s typically had many tasks to attend to and emphasized that the nurses needed to be ready for physicians’ needs: “Anesthesia staff in the past had expressed dissatisfaction with patients’ state of readiness for an epidural on their arrival on the unit.   This dissatisfaction had placed considerable pressure on nurses to ensure that the patient was ready for the epidural before anesthesia staff arrived.”

Now, hospital staff always have a fine line to walk in priorities. Doctors do have to be able to provide care and there are so many nurses out there who do their best to ensure the safety of patients in their care. But it is disturbing that in this case, the emphasis on the convenience of the anesthesia staff created an environment that placed the patient’s safety second.

An environment in hospitals that emphasizes the safety of patients and respect for the health of doctors and nurses along with better case management and “hand-offs” is going to be necessary if we want to see health care in the United States crawl its way up to meet the standards of the rest of the developed world.

 

 

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Water Birth and Legionnaires’ Disease

Last year, two babies in Arizona developed Legionnaires’ Disease after their mothers labored in birthing pools. Since then, I’ve seen parenting magazines and websites decrying water birth as dangerous and Legionnaires’ Disease as just one more piece of “proof”.

These claims are not informed by current research or by the American Congress of Obstetricians and Gynecologists’ stance on water immersion during labor. 

So, the second video in the “Let Me Level With You” series is dedicated to setting the record straight on Legionnaires’ Disease and water birth.

On YouTube, find it here.

On Vimeo, find it here.

Feel free to share this video any time someone posts misinformation about this subject on social media. Enjoy!

Video: Let Me Level With You About Vitamin D and Breastfeeding

I’ve often felt like much of the public health information parents get is filtered. When I was first advised about vitamin D supplementation for newborns, our son’s doctor at the NICU said that because our baby was exclusively breastfed he would get rickets if he wasn’t supplemented. Well, that was an extremely oversimplified and misleading statement that does not reflect the high degree of variability for vitamin D levels, breastfeeding and sunlight exposure.

This is the first in a new series of videos to help parents get a better idea of the research behind the recommendations. I want to bridge the gap between the research and the information that parents get from medical and public health professionals, thus the title “Let Me Level With You”. All videos in this series will use scholarly references, so the information you get will be the most up-to-date.

So without further ado, here is “Let Me Level With You About Vitamin D and Breastfeeding”…

YouTube

Vimeo

 

Save a Life- Spread the Word About Sickle Cell Disease and Pregnancy

Sickle cell disease made the news earlier this year when rapper Prodigy died from complications related to SCD this past June at the age of 42.  It’s actually very common among African-Americans with 1 in 13 being carriers for the disease and 1 in 365 having sickle cell disease. There are other ethnic groups that are frequently affected as well. In some parts of Central India and eastern Saudi Arabia, as much as 40% of the population carries the sickle cell trait or is affected by sickle cell disease. People with Mediterranean and Central American heritage have higher rates as well. (People with Mediterranean heritage often have a variety of SCD known as thalassemia.) Because of the high number of people with Sub-Saharan African ancestry in the Caribbean and parts of South America, sickle cell trait is more common there as well.

For a long time, sickle cell disease was treated as a fatal children’s disease because children who were born with it frequently died very young. But in the last 3o years, advances in medications and treatment have led to longer lifespans for people with sickle cell disease- resulting in more women of childbearing age with the disease. While there are more specialists going into pediatric care for SCD, there are fewer care providers who are confident or knowledgeable about treating adults.

This gap between pediatric care and adult care is more of a problem as we have more children living to adulthood with birth defects and genetic conditions. I feel a similar frustration with CJ’s care. I feel like specialists are often thinking mostly of the “here and now” instead of the impact on his life as he grows to adulthood. To me, it kind of feels like that part in Dark Knight where the Joker says, “I’m like a dog chasing a car. I wouldn’t know what to do with one if I caught it.” As we have more children with disabling and genetic conditions living longer, our healthcare professionals are going to have to raise the bar beyond “Your child is still alive”. (But I digress…)

Sickle cell disease tsting has only only been widely implemented since 1986 and universal testing only started in the 2000’s. The American Society of Hematology estimates that as many as 30% of infants with SCD may be lost to follow-up. So the current situation is that many women of childbearing age who are at risk may not know that they have SCD or that they are carriers for the disease. We also have a growing population of immigrants from areas where SCT is common who may not have had genetic testing available to them and may not know their sickle cell status.

If you want the whole ten page paper I wrote on this in all it’s APA cited glory with recommendations for public health strategies, you can find it here. (A little light reading before bedtime anyone?)

How SCD causes pregnancy complications

Most of us have red blood cells that are round shaped, but people with sickle cell disease have red blood cells that are shaped like a crescent or sickle. This causes the red blood cells to become stiff and sticky and clump together. When the blood cells clump together, it cuts off oxygen to the body’s tissues and organs causing pain and organ damage. Sickle cell trait (SCT) can cause all kinds of problems, but it also seems to give carriers a level of protection against malaria that other people don’t have. Scientists think it may have evolved as a way to protect people living in malaria prone areas from the disease.

Sickle cell disease impacts many of the body’s systems, it can cause many different types of complications for a pregnant woman and her baby:

  • Infections- UTI’s, but also kidney and lung infections
  • Gallbladder problems

  • Heart enlargement and heart failure from anemia

  • Miscarriage

  • Death

  • Severe anemia for baby
  • Intrauterine growth restriction (IUGR)
  • Preterm birth.

  • Low birth weight (less than 5.5 pounds).

  • Stillbirth and newborn death

  • Preeclampsia

One little known fact is that even women who are carriers of sickle cell trait are at risk for pregnancy complications that can result pre-term birth. Women who are carriers of the sickle cell trait are more likely to have urinary tract infections during pregnancy and a condition called pyelonephritis  during pregnancy. (Pyelonephritis is a serious and potentially life-threatening condition where the kidneys develop inflammation from a bacterial infection.) With the increased risk of kidney/urinary tract infections comes an increased risk of preterm birth and even death for the mother and baby. This could be a strong contributing factor to the distressingly high rates of maternal and infant morbidity and mortality among African-American women.

What Can We Do?

If you read the above link to the CDC’s short article on the high rates of preterm birth for African-American women, you can see that they’re not talking about SCD and SCT as a possible contributing factor. The March of Dimes mentions “clotting abnormalities” as one of many possible contributing factors. Awareness about how much this could be impacting African-American women seems to be pretty low in the public health and medical fields. The relationship between pregnancy and sickle cell disease and sickle cell trait is still relatively new. But with an increasingly diverse population in the United States which includes immigrants from India, the Caribbean and the Middle East, SCD/SCT related pregnancy complications could become an even bigger problem if it’s not addressed.

There are a few things that moms who are at risk for SCD/SCT can do:

  1. Get tested for your sickle cell status. The blood test can be performed on adults and will tell you whether you are a carrier, have SCD or are unaffected. If other women in your family have had serious infections during pregnancy or given birth prematurely it might be an indicator that SCD/SCT runs in your family. The CDC has a short pamphlet on SCD and pregnancy that you can find here.
  2. Know the signs and symptoms of preeclampsia and preterm birth. Having SCD is a HUGE risk factor for preeclampsia and other hypertensive disorders of pregnancy. If you are experiencing any of the following symptoms during pregnancy and have SCD, DO NOT IGNORE IT. With symptoms like changes in vision, you should go to the emergency room immediately. Changes in vision can be a sign that the preeclampsia has progressed to a life threatening stage. I recommend reading the updated guidelines for diagnosing preeclampsia. ACOG revised their guidelines because they found that even women who weren’t displaying “classic” signs of preeclampsia like spilling protein in urine or blood pressure greater than 160/110 were still developing organ damage from hypertensive disorders of pregnancy.
  3. Keep a record of your blood pressure. High blood pressure in pregnancy can be a sign of preeclampsia. But the catch is that blood pressure readings can vary from person to person, so even if you have “low” blood pressure, you could still have preeclampsia. Keep a record of your blood pressure; maybe even request a copy from your doctor at each visit. With a record of your blood pressure readings, you can help the doctors and nurses at the ER better understand your condition if you ever need to go there.
  4. Get help! People with SCD have to strike a fine line on exercise and activity. If they do too much, it can bring on a sickle cell crisis (clotting problems and pain), but doing too little could increase problems with congestive heart failure and lung problems. Getting too cold, hot or over tired can trigger a sickle cell crisis, so get whatever help you can with housework, cooking and caring for older children both before and after the baby comes.
  5. Stay healthy. Eat plenty of fruits, vegetables, protein and whole grains. Drink water and cut back on soft drinks, fast food, sugar and processed food. Wash your hands to prevent viral and bacterial infections and help everyone else in the household to do the same. For exercise, listen to your body and stay as active as you can without getting too overtired.

Communities should get involved too:

  • Hold awareness events- Encourage women to get screened for SCD/SCT, even they are not pregnant yet.
  • Help out- In some European countries, all mothers are entitled to in-home visits from a nurse to help the mother and family adjust to the baby. They typically refer mothers to resources that might help them, watch for signs of postpartum depression or postpartum complications, and even just listen to the mother talk about her situation. Unfortunately, we don’t have that kind of option in the US, but we can provide support to expectant mothers- with and without SCD/SCT- through community groups, churches, family and friends. Visitors who help the mother by caring for older children, preparing meals or doing housework can actually be very welcome if their focus is on helping instead of just “seeing the baby”. (Got dietary restrictions? Check out this post on how neighbors, friends and family can help out with meals.)

Adoption and Breastfeeding

YES!!! It’s possible!

Even if you have never given birth.

Even if you have never been pregnant.

Even if you can’t get pregnant.

You can breastfeed a baby!

How it works…

Lactation does not actually start with the mammary glands.

It starts with the pituitary gland, a pea-sized gland located at the base of the brain.

The pituitary gland produces a hormone called prolactin in response to suckling (or pumping) at the breasts. Prolactin then stimulates milk production.

How You Can Use It To Your Advantage…

You can induce lactation through pumping at any point in the adoption process- before or after your new baby comes home. The most ideal situation is that you have a specific timeframe when the baby will be coming home and you can start pumping and stockpiling a couple of months in advance. (You can keep milk in the freezer for about three months if it’s stored properly.)

However, even if you have short notice, have to travel a long distance or even if your baby is older when she arrives home, you can still get going. Older babies who have never been breastfed may take a little more patience and time to get used to breastfeeding, but it can be done. (Skin-to-skin contact can help.) Even with a later start, you can still get going and make milk.

There are herbs and medications that can be used to help the process along, but pumping is the key component. Without suckling/pumping, the body will stop producing high levels of prolactin and the milk starts to dry up. Lactation teas and cookies may help boost your supply a little, but they can’t take actually induce or sustain a milk supply.

How Much Milk Can You Make?

This is hard to predict. Most moms who induce lactation do need to partially supplement with formula. But this is where I think we as Americans need to get away from the “all-or-nothing” breastfeeding mindset. For many diseases like childhood leukemia and pre-menopausal breast cancer, any amount of breastfeeding offers some protection. Your milk also provides immune protection against particular antigens in your local environment- something that formula can’t do. For feedings where you need to supplement with formula, you can use a supplementary nursing system to help your baby feed at the breast.

Where To Go For More Info…

An awesome book on breastfeeding and adoption is Breastfeeding the Adopted Baby by Debra Stewart Peterson. Debra breastfed all three of her children who came into their family through adoption. She was a WIC breastfeeding counselor for several years too.

The La Leche League has some stories from moms on how they navigated breastfeeding through many different types of adoptions.

I have a breastfeeding class available on breastfeeding and adoption. You can find it here.

 

 

Becoming A Milk Donor

 

Stace rainbow shirt

“I’ll share my lunch with you.”

Newborn Baby Inside Incubator

“Thanks!”

 

Today I am officially a milk donor. After one phone interview, two paperwork packets, a visit to the rural health clinic, a blood test, 100+ oz. of milk, and several calls to FedEx Peri Ship, my donation arrived and was accepted today.

I first started to consider becoming a milk donor during my breastfeeding educator certification when I did a handout on milk banking. I found out that the demand that milk banks receive far outstrips the supply. I’ve had a baby in the NICU and it’s hard. You want to do whatever it takes to get your baby well and take him home.

I was able to breastfeed my son exclusively, but I know that a lot of moms have trouble breastfeeding- especially after a difficult birth or emergency c-section. Donor breastmilk reduces the risk of a premature baby developing necrotizing enterocolitis, a potentially fatal disease of the intestinal tissue that affects formula fed premature babies, so while it’s still second best when compared to a mother’s own milk it can be life-saving.

I’m one of those moms that has plenty of milk. I can give another mom’s baby a fighting chance. So I called the milk bank and got started.

It’s not easy becoming a milk donor for a reputable milk bank because they are so careful to make sure that there is no risk that the receiving baby will receive milk that could be contaminated by a blood borne illness and that the donor mother and her baby are healthy enough to donate. But it was so worth it.

If you’re interested in becoming a donor, please think about it.  I donated to the Mother’s Milk Bank in San Jose, California. Just call up your closest milk bank to get started. You do not need to live right by the milk bank. (I live in the rural forest 7,000 feet above sea level and several hours away from San Jose. The folks at Fed Ex make it happen!!!)

I know that the demand for donor milk is not sufficient for the supply and that a lot of moms are not able to get breast milk for their babies. This has led to more casual buying and selling of extra milk through online classifieds and Facebook groups. If you’re having difficulty breastfeeding a full-term and otherwise healthy baby, I do recommend getting help to breastfeed before you resort to buying unscreened milk.

If your milk supply has dropped or you’re no longer lactating, chances are that with the right information and help you can still breastfeed. There are several ways to drive your supply up again or even get your milk supply back if it has dried up. It’s far safer to partially breastfeed and supplement with formula for a time than use “black market” milk.

If your baby is in the NICU and you are struggling to breastfeed, come take my class. I have tons of info on how to breastfeed in the NICU, build your supply after a planned or emergency c-section and even induce lactation. Even if you need to supplement for a time, your milk is still best for your baby because your body will customize the immune enhancing factors and nutrition to meet your baby’s needs. And your freshly pumped milk can be fed to your baby straight up without pasteurization, so it is superior to donated milk.

To those moms of the babies who will get my milk, my heart goes out to you. I’ve been there. My daughter and I are happy to share with you. =)

Does Your Baby Really Need Zantac?

This is a new phenomenon I’ve been hearing about. Apparently in my area, there are many doctors prescribing Zantac for breastfed babies because the baby spits up after feeding. It sounds as though some doctors and parents are concerned that spitting up after feeding means the baby has gastroesophageal reflux disease or GERD. GERD can be a big deal- but spitting up is normal. Because it’s such a misunderstood topic, I spent a whole section in my breastfeeding class dealing with it.

Now, I’ve met a few moms who have had babies with genuine GERD. Their babies were not gaining weight well, fussy all the time, arching the back, etc. For these moms and babies, a medication like Zantac can provide relief and allow the baby to take feedings without being in pain. But not all babies who spit up have GERD.

A few points to remember if you’re concerned about whether your baby has GERD:

  1. Breastfed babies are not at a higher risk of GERD. The actual incidence of GERD between formula fed and exclusively breastfed infants is about the same. However, breastfed babies tend to have fewer and shorter episodes of GERD.
  2. Happy Spitters vs. Scrawny Screamers. If your baby is spitting up but happy, gaining weight well and feeding well, it’s very unlikely that she has GERD (Happy Spitter). If your baby is frequently fussy and not gaining weight well, it’s quite possible your baby does have GERD and might need medicine to reduce the inflammation (Scrawny Screamer). Because their stomaches are so small, little babies often spit up if they get too much milk too quickly. It’s actually quite normal!
  3. Babies with GERD may not always spit up. “Silent reflux” is when the contents of the baby’s stomach come back up to the esophagus and are then re-swallowed- so there’s reflux but no spitting up or vomit. These babies are in pain and very fussy, but they’re not spitting up.
  4. An antacid is not the “first line” against GERD. Generally an antacid is only prescribed after you’ve tried sleeping and feeding changes with no success and/or the baby is not gaining weight well. (Disturbingly, the above link tells parents to thicken the baby’s feeds with cereal, a practice which is not backed up by evidence. At best, thickened feedings may be moderately helpful at reducing reflux in formula fed babies, but these thickened feeding studies have not used cereal.)
  5. It’s not a good idea to give babies a medication if they don’t have an actual need for it. Zantac is generally safe for babies, but like any medication it has side effects including headaches and malaise. It also means that you are changing your baby’s stomach acid ph when GERD may not be present.
  6. Signs of severe GERD include:
    • Severe fussiness associated with feeding
    • Baby taking too little or too much milk during feeding
    • Arching the back
    • Poor weight gain
    • Breathing problems
    • Weird spit up, i.e. with blood or greenish-yellowish fluids
    • Dehydration
    • Trouble swallowing
    • Frequent nasal congestion or sinus/ear infections
    • Refusing the breast or formula feedings.

Unless your baby is at the severe GERD stage, medication for GERD is probably not necessary.

Let Me Ruin Your Day- Let’s Talk About Pertussis

Part of me feels like I should be saying, “Sorry!!!” for brining up this issue. No one really wants to hear about it. On the other hand, a bigger part of me thinks, “Why should I be sorry for telling people about an actual health threat that is backed up by current medical research and isn’t widely discussed? After all, it could potentially save a life.”

So I’m going to ruin your day.

Here we go…

You and your kid are at risk for pertussis.

Even if you are vaccinated…

…Even if your child is vaccinated…

…Even if that ice cream party at your kid’s class worked and everyone in your kid’s class is vaccinated…

…And even if you don’t have any symptoms…

You’re all at risk for pertussis. Or more accurately pertussis and parapertussis.

(Quick note on whooping cough and bordetella pertussis- whooping cough is the illness caused by the bacteria Bordetella pertussis. Our current vaccines are only for the bordetella pertussis strain of the bacteria, but other strains are out there like Bordetella holmesii and now Bordetella parapertussis. More parapertussis in a minute.)

Pertussis

If we could describe the current state of affairs for pertussis control with a Facebook relationship status, it would be: “It’s complicated”.facebook-relationship-status

The CDC started noticing a rise in pertussis cases in pertussis cases back in the 1980’s. There have been a four different hypotheses for this: 1) waning immunity from vaccination or natural infection 2) evolution of the B. pertussis bacteria to escape protective immunity 3) low vaccine coverage and more recently 4) asymptomatic transmission from individuals vaccinated with the currently used acellular B. pertussis vaccines- in other words, you’re vaccinated, not showing any symptoms and still spreading the disease.

Pertussis and Waning Immunity

Waning immunity doesn’t explain the rise because waning immunity would occur mostly in older age groups as their immunity dies off. But the rise was seen across all age groups.

The Switch from DTP to DTaP

The acellular pertussis vaccine (DTaP) that is currently used is supposed to be less effective than the older whole cell pertussis vaccine (DTP) that was used until the 1990’s. But there’s a catch to the old DTP vaccine- it had a higher rate of both mild and serious adverse events. (How serious was “serious”? Long story short, multiple large case-control studies found that babies who received the DTP vaccine were more likely to develop encephalopathy- a term that is used for brain damage, disease or malfunction. And follow-up showed that ten years later that children who had experienced a serious neurologic illness after receiving DTP were more likely than children in the control group to have chronic nervous system dysfunction ten years later. If you want the long story, you can read it here- the stuff on DTP starts on page 22. This is an interesting read from a public health perspective. It’s the September 6, 1996 Weekly Morbidity and Mortality Report from the CDC. It’s interesting to kind of take a ride in a time machine and understand what the CDC was looking at around the time the DTP vaccine was removed from the American schedule.

But it still couldn’t account for many cases. For example, in 2005 there was an outbreak in Lithuania where DTP was still in use and 75.7% of the children who had laboratory confirmed pertussis were fully vaccinated with DTP.

Low Vaccine Coverage

This has received the most media attention, but is probably the least likely to account for the rise in pertussis. If you look at the CDC’s chart of reported pertussis cases between 1922 and 2015, rates of pertussis have been rising despite the widespread use of Tdap vaccines for adults. There are some places where vaccine coverage is lower, but low vaccine coverage can’t account for the resurgence of pertussis in these areas because pertussis cases have been found in vaccinated individuals and in infants who were “cocooned”. For example, Boulder, Colorado is known for having lower rates of vaccination, which made it a great case study for low vaccine coverage. An article in the Atlantic from 2002 tried to examine the pertussis resurgence from this perspective. But in the middle of his piece though, the author is confronted with a paradox and states: “Although unvaccinated children are six times as likely as vaccinated children to get whooping cough during an outbreak, about half the cases in Colorado have involved vaccinated children.”  Even with low vaccine coverage, vaccinated children were not getting anywhere near the levels of expected protection.

An outbreak of pertussis in San Diego presented a similar problem. Of the 1,000 adults and children who tested positive for pertussis in 2010, over half had been vaccinated. A survey of nine other counties in California showed that between 44 and 83 percent of individuals with pertussis had been immunized.

Another example is a case from Israel in 2000 where a vaccinated 4 month old baby died of pertussis despite the parents, siblings, aunt and all the children at the siblings’ day care centers being vaccinated with DTP. The report examined 46 fully vaccinated children, five of whom tested positive for pertussis with laboratory diagnostic testing (not just basis of symptoms), Only two of those children met the World Health Organization’s diagnostic criteria for pertussis. The study concluded that even vaccinated, asymptomatic children can be carriers of pertussis.

And so we come to…

Asymptomatic transmission of pertussis

Asymptomatic means that you aren’t displaying any symptoms. Discussion of asymptomatic transmission of pertussis has mostly been in medical and epidemiology journals- though the CDC has hinted at this in their information for the public:

If you get pertussis after getting pertussis vaccines, you are less likely to have a serious infection. Typically, your cough won’t last as many days and coughing fits, whooping, and vomiting after coughing fits won’t occur as often. When vaccinated children get pertussis, fewer have apnea (life-threatening pauses in breathing), cyanosis (blue/purplish skin coloration due to lack of oxygen), and vomiting.”

Althouse and Scaprino (2015) found that asymptomatic transmission was the best fit for the observed changes in pertussis. It explained the changes in age-specific attack rates, the increased genetic diversity within the bacteria population, the increasing incidence and the failure of the “cocooning” strategy to protect infants. They also noted that asymptomatic transmission might bias assessments of vaccine efficacy that are made only on observations and not on laboratory confirmed testing.

Adults and teens may not display the “whoop”, they may have a very long, lingering cough. Of course, the tricky part is that a long, lingering cough can be caused by many things. Estimates are that 10-30% of long, lingering coughs are pertussis– but many of these cases may not be reported, which also makes the number of pertussis cases seem deceptively low.

Bordetella Pertussis has Adapted

In 1998, Dutch researchers used to DNA sequencing and found that the protein composition of Bordetella pertussis has changed. Bordetella pertussis proteins (P.69) are an important component in vaccines. Pertussis vaccines use the P.69A type of Bordetella pertussis proteins. That worked well for a while. Within the Dutch population, P.69A was the dominant type of pertussis in circulation from about 1949 to 1980. But in 1981, two different types emerged P.69B and P.69C. Within the Dutch population, these became the predominant Bordetella pertussis proteins circulating. Though Bordetella pertussis P.69A,B, and C are 93% similar, the vaccine only protects against P.69A. Basically, the bacteria adapted to a new threat- similar to what we’ve seen with antibiotic resistant strains of bacteria.

A study from Italy had similar findings: “Molecular analysis suggests that also in Italy B. pertussis strains differ from those included in the current vaccine.”

Bacteria are not smart, but considering that they can produce a new generation in hours, they are very adaptable.

CDC has also hinted at this too:

 “CDC is evaluating potential causes of increasing rates of pertussis, including changes in disease-causing bacteria types (“strains”). Unlike a foodborne illness where one strain causes an outbreak, multiple types or strains of pertussis bacteria can be found causing disease at any given time, including during outbreaks. Research is underway to determine if any of the recent genetic changes to pertussis bacteria may contribute to the increase in disease in the United States.”

Parapertussis

Bordetella parapertussis is a species of the Bordetella bacteria that causes whooping cough as well. Pertussis vaccines do not protect against it because it is a different species of Bordetella pertussis. But the resulting illness is very similar. There is no vaccine for it. Certain antibiotics can be used for it- at least for now. Estimateas are that parapertussis accounts for anywhere between 1% and 35% of Bordetella outbreaks. California’s public health department has put together an information sheet on it here.

Now obviously, if it’s 1% that’s not an enormous threat, but if 35% of Bordetella infections are parapertussis, it could actually be extremely common. There are other strains of Bordetella too like Bordetella bronchiseptica and Bordetella holmseii

 So What CAN We Do?!

Right now, we treat pertussis with antibiotics- but this isn’t exactly a “cure”. It’s not the actual infection with the bacteria that kills a person- it’s the secondary complications like pneumonia. Antibiotics can kill the bacteria bordetella pertussis, making the patient non-infectious, but antibiotics can’t actually halt the progression of the disease. Secondary conditions like uncontrollable vomiting, hypoxia, and dehydration can result from the severity of the coughing. This is why pertussis remains difficult to treat even with antibiotics.  And (more bad news) antibiotic resistant strains of pertussis have recently been isolated .

EVERYONE needs to be aware of the risk of pertussis transmission and parapertussis transmission. You should always assume that you could spread a bordetella infection and please do not assume that herd immunity will protect your baby.

  • Since cocooning hasn’t been effective at protecting infants, the CDC recommends that pregnant women get a Tdap shot in their third trimester with the idea that the mother will pass the antibodies through the placenta to her baby before birth. However, this will not protect against parapertussis or P.69B and C type pertussis.
  • Transmission mostly occurs through contact with saliva and mucus of an infected person. Wash your hands frequently and if you have a baby make sure everyone who is contact washes their hands frequently and keeps coughs and sneezes contained (vampire cough).
  • Breastfeed as much as you can. Antibodies against pertussis can be passed through breastmilk and can help give a baby further protection. Breastfeeding alone can’t protect against pertussis, but it may offer some degree protection. Though it hasn’t been studied, hypothetically speaking breastfeeding could give your baby some degree of protection against parapertussis and P.69 B,C pertussis since the mother’s body will adapt to produce antibodies to antigens in the environment. The relationship between pertussis and breastfeeding still isn’t fully understood, but it’s a good idea!
  •  Limit your baby’s contact with large crowds- especially in the first six months. Reduced exposure=reduced risk.
  • If you think your baby may have pertussis or parapertussis, get him into the hospital right away. The further the secondary complications progress, the greater the chances of death. Earlier treatment=better chances of survival.

How Worried Should I Be???

Pertussis rates are still much, much, much lower than they were during the 1920’s and 1930’s. (Though asymptomatic cases and cases in teens and adults mean that these numbers are not a complete representation of pertussis transmission.) Parapertussis is still not a notifiable disease, so it’s hard to know exactly how many cases are out there. Definitely take adequate precautions and be aware of all forms of pertussis and parapertussis, but chronic diseases still pose the greatest threats. The CDC gets about 10,000 to 40,000 reported cases per year and about 20 deaths per year are attributed to pertussis- most in young babies. By comparison, there were about 1,685,210 new cases of cancer diagnosed in the United States in 2016 with 595,690 deaths. In 2014, 1,960 children died of cancer. Or another comparison, in 2011-2012 5,300 children and young adults under the age of 20 were diagnosed with type 2 diabetes.

Happy Thoughts!!!

So this post may have been a little on the depressing side. So let’s lighten things up a bit:

Adorable animals.

Dogs greeting their humans who have come home from deployment.

East and West Germans tearing down the Berlin Wall.

84 year old woman in Alberta, Canada loses her engagement ring and then finds it growing on a carrot in her garden.

Life is still good.

What is the right time for twins?

37 weeks is becoming the due date for twins- which is actually considered too early for an elective induction or c-section for singletons. There’s a reason for this. In 2016 a large, international study came out saying that allowing twin pregnancies to continue to 38 weeks dramatically increased the chances of still birth.Breast-feeding Twin Babies At Home.

But if you have been in the home birth community for a while, you may have heard stories of a few rare moms who had home births twins at 39 or 40 weeks. There are some stories here.

It’s an interesting divide.

Who is “right”?

Well, first of all, I don’t think this subject is about getting the right answers. I think it’s actually about asking the right questions.

It’s A BIG Study. Is That a Good Thing?

The authors said they included all studies in the “Medline, Embase, and Cochrane Library using the NHS Evidence website and Cochrane online library platforms from inception until December 2015 for studies on twin pregnancies that reported rates of stillbirth.” The studies reviewed in this study covered different countries. They looked only at dichorionic pregnancies- twin pregnancies where the babies each had their own placenta. (Monochorionic-monoamniotic pregnancies are rarer and known to carry additional risks. These occur only in identical twins.)

This study did very little to limit confounding variables. Confounding variables are these darling little factors that suggest correlation when there isn’t any. In this case, the confounding variables include:

  • Monozygotic (identical) vs. dizygotic (fraternal) twin pregnancy- monozygotic twins are considered to have more risks than dizygotic twins.
  • Spontaneous (no fertility treatments) vs. conceived with fertility treatments.
  • Age of mother (moms over 40 have a higher likelihood of twins, but also a higher risk of complications. Moms under 18 have higher rates of complications as well).
  • Nutritional deficiencies such as anemia or iodine deficiency- especially important if any of the included studies came from developing countries.
  • What type of prenatal care women were receiving, in fact the authors were aware of this variable and its potential for confounding and state that “The variation observed in the clinical management of twin pregnancies and neonatal care after delivery between centres could also have influenced the outcomes.”
  • Any pre-existing conditions the mothers may have had.

So because there was so little control for confounding variables, the authors of this study are like, “Oh gee! ALL twin pregnancies are at risk for stillbirth at 38 weeks!!!”

Twins at Home vs. Twins in the Hospital

In the few places where midwives are able to deliver twins (a number which is dwindling), the twin pregnancy would have to go past 37 weeks or the midwife would not be allowed to attend. So accounts of mothers who have had home births of twins are already in a different situation with gestation than many mothers who have delivered in a hospital. These are anecdotal accounts and there are very few- but I still think they are an interesting phenomenon to consider.

Mary Cronk, a British midwife with over 45 years of experience and who has delivered several sets of twins advises mothers that identical twins generally carry more risks. (You can read her guidelines for midwife care of twins at the above link.)

However, there are a few very rare cases of identical twins born at home in the 20th century, midwife Jeanine Parvati Baker’s being one of them. (I don’t know of any online publications of her twin birth but you can read about it in Elizabeth Noble’s Having Twins and More and Jeanine’s book Prenatal Yoga and Natural Birth.)

An interesting side note is that her twins were considered at risk for being “locked twins” because Baby A was in breech and Baby B was vertex. However, Jeanine didn’t have many of the other risk factors for locked twins such as small babies, first birth, oligohydramnios, uterine hypertonicity, early rupture of the second sac (and I think her twins were dichorionic). Her babies were born at term and healthy and lived to adulthood.

On the other hand, the study in the BMJ acknowledged that one of its limitations was that recommendations of delivery for twins have varied between 34 and 38 weeks- which means that some pregnancies that may have gone longer didn’t because a delivery was scheduled earlier. And as, the authors point out, because of the high rates of pre-term delivery (both spontaneous and planned) they had a smaller sample size of births going to 37 and 38 weeks. And a smaller sample size means that any anomaly can throw the numbers off. (One death in ten looks riskier than one in a thousand- even if that one in ten was a fluke.) So the bottom line is that we have very little good data on what it would mean to carry a twin pregnancy to 39 or 40 weeks because it doesn’t usually happen in a hospital setting and midwives attend very few twin births.

 

Are We Asking The Right Questions?

So the 2016 BMJ study merely found an average across a VERY broad spectrum of twin pregnancies and has urged that delivery for all twin pregnancies be based on this average.

But I don’t think the question should be “How can we schedule the delivery to avoid preterm complications and stillbirth?”

The question should be, “How do we get more precise about predicting which pregnancies are at risk of stillbirth?” Since delivery at 37 weeks can cause an increased incidence of issues like respiratory problems, are there some twin pregnancies that could go full-term without risk to the mother and babies? And along with that, how can we prevent preterm labor and delivery of twins? Shouldn’t we be looking for how we can do better than 37 weeks?

Feeding a Baby When An Emergency Strikes

I realize that for my readers living in the American Tornado Alley this post might be a little late. But if you’re living near the Atlantic Ocean, hurricane season is just getting started. (And NOAAA says this season is going to be a doozy.) And if you’re living on a fault-line the threat of an earthquake is ever present. After you’ve stockpiled your buckets of food, generator and jugs of water, what about the baby?

There’s a couple of things to know…

Breastfeeding During An Emergency

Breastfeeding is ideal during an emergency. Breastmilk straight from the breast is sterile and requires no water or power to prepare or store- both of which may be in short supply in a disaster scenario. Remember, after a serious hurricane, earthquake, etc. power and water will probably not be available. Even if you have powdered formula and stored water available, the bottles and nipples will still need to be sterilized for safe feeding and if there is no power available to heat water for cleaning and sterilizing and no refrigeration for stored formula then the baby is at risk for illness from contamination.

There is an idea circulating that women can’t breastfeed during a disaster because they won’t make milk or have a let down. This is only sort-of true. Adrenaline release during a stressful situation can inhibit the letdown reflex. And some women do experience a temporary supply drop during stressful times. But this doesn’t mean that you can’t or shouldn’t breastfeed during a disaster situation.

You can help both your milk supply and letdown reflex during stressful times by nursing your baby frequently and using relaxation techniques. Deep breathing skin-to-skin contact with your baby (if safe) can help reduce the levels of adrenaline and allow for letdown to occur. There are also some scripts and exercises for visualization and relaxation that have been shown to help mothers with inhibited letdown. Ask emergency workers if there is a quiet place for you to breastfeed, they should be willing to help because breastfeeding a baby will reduce the risk of the baby getting sick. You can still breastfeed even if your calorie intake drops for a short time or eating gets a little crazy during evacuation.

I did experience inhibited letdown and a supply drop during stressful time. My baby was nine months old, so we gave her a little more solids to be on the safe side and I just kept nursing her frequently- really frequently. The more a baby feeds at the breast, the more milk the mother will make, so if you keep nursing it will drive up your supply. My letdown returned and my milk supply came back up after about a day and returned to normal within about two days. I do wish I had tried a few more relaxation techniques though. I think it would have helped.

Formula feeding during an emergency

If you are partially or fully formula feeding, ready-to feed-formula is the safest choice!!! Make sure you have plenty in your emergency storage. Only use powdered formula if there is bottled or boiled water available and it can be put in sterilized bottles.

Supplies for Emergency Infant Feeding

From the International Breastfeeding Journal:

An emergency preparedness kit for exclusively breastfed infants should include:

  • 100 diapers
  • 200 wipes

The contents of an emergency preparedness for formula fed infants will vary depending on whether ready-to-use liquid infant formula or powdered infant formula is used.

For ready-to-use liquid infant formula, an emergency kit should include:

  • 56 servings of ready-to-use liquid infant formula
  • 84 L water
  • storage container
  • metal knife
  • small bowl
  • 56 feeding bottles and nipples/cups
  • 56 zip-lock plastic bags
  • 220 paper towels
  • dishwashing soap
  • 120 antiseptic wipes
  • 100 diapers and
  • 200 wipes.

If powdered infant formula is used, an emergency preparedness kit should include:

  • two 900 g cans powdered infant formula
  • 170 L drinking water
  • storage container
  • large cooking pot with lid
  • kettle
  • gas stove
  • box of matches/lighter
  • 14 kg liquid petroleum gas
  • measuring container
  • metal knife
  • metal tongs
  • feeding cup
  • 300 large sheets paper towel
  • dishwashing soap
  • 100 diapers
  • 200 wipes
  • The instructions on how to use all this are pretty lengthy, so see the article here.

If you’re concerned about the possibility of baby and mother being separated in a disaster situation, you can store materials for formula feeding as well.

To help with relaxation for milk supply and letdown, you can try storing some things like a vial of lavender essential oil to sniff. Kelly Bonyata says some mothers have used a homeopathic remedy called Rescue Remedy and it has helped them with inhibited letdown and stress.

You can also have printed and laminated scripts for visualization and relaxation in your kit  as well. Links for these are here, here (biofeedback techniques for pumping, but can be applied to relaxation for breastfeeding), and here (scroll down to the bottom the page, it’s the one called “relaxation and desensitization scripts by David Ross, College of Lake County”; it’s downloadable).

From the WHO- An article on supporting breastfeeding mothers during disaster and in refugee camps.

From Diana D. Bienvenu, Breastfeeding Coordinator and Pediatrician at LSU Health Sciences Center- Powerpoint on infant feeding during natural disasters.