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Volume 5, No. 8, September 2007
Features
American College of Obstetricians and Gynecologists
Prevention of Deep Vein Thrombosis and Pulmonary Embolism
Summary of Conclusions and Recommendations
The following recommendations are based on good and consistent scientific evidence (Level A).
- Alternatives for thromboprophylaxis for moderate-risk patients include the following:
- Graduated compression stockings placed before initiation of surgery and continued until the patient is fully ambulatory
- Pneumatic compression devices placed before the initiation of surgery and continued until the patient is fully ambulatory
- Unfractionated heparin (5,000 units) administered subcutaneously 2 hours before surgery and every 12 hours after surgery until discharge
- Low molecular weight heparin (dalteparin 2,500 antifactor-Xa units, or enoxaparin 40 mg) administered subcutaneously, 12 hours before surgery and once a day postoperatively until discharge
- Alternatives for prophylaxis for high-risk patients undergoing gynecologic surgery include the following:
- Pneumatic compression devices placed before surgery and continued until hospital discharge
- Unfractionated heparin (5,000 units) administered subcutaneously 2 hours before surgery and every 8 hours postoperatively and continued until discharge
- Low molecular weight heparin (dalteparin 5,000 antifactor-Xa units or enoxaparin 40 mg) administered subcutaneously, 12 hours before surgery and once daily postoperatively until discharge
The following recommendations are based on limited scientific evidence (Level C).
- Alternatives for prophylaxis for highest-risk patients include the following:
- Combination prophylaxis (such as the combination of pneumatic compression and either low-dose unfractionated heparin or low molecular weight heparin)
- Consideration of continuing low molecular weight heparin prophylaxis as an outpatient for up to 28 days postoperatively
- If administration of low molecular weight heparin 12 hours before surgery is impractical, initial dosing should commence 6–12 hours postoperatively.
- Low-risk patients who are undergoing gynecologic surgery do not require specific prophylaxis other than early ambulation.
- Until more evidence is accumulated, patients undergoing laparoscopic surgery should be stratified by risk category (and provided prophylaxis) similar to patients undergoing laparotomy.
Prevention of Deep Vein Thrombosis and Pulmonary Embolism. ACOG Practice Bulletin No. 84. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:429-40.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666620
Sexual Misconduct
ABSTRACT: The physician-patient relationship is damaged when there is either confusion regarding professional roles and behavior or clear lack of integrity that allows sexual exploitation and harm. Sexual contact or a romantic relationship between a physician and a current patient is always unethical, and sexual contact or a romantic relationship between a physician and a former patient also may be unethical. The request by either a patient or a physician to have a chaperone present during a physical examination should be accommodated regardless of the physician's sex. If a chaperone is present during the physical examination, the physician should provide a separate opportunity for private conversation. Physicians aware of instances of sexual misconduct have an obligation to report such situations to appropriate authorities.
Sexual Misconduct. ACOG Committee Opinion No. 373. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:441-4
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666621
Nalbuphine Hydrochloride Use for Intrapartum Analgesia
ABSTRACT: Nalbuphine hydrochloride (formerly marketed as Nubain) is a synthetic opioid agonist– antagonist analgesic commonly used for intrapartum analgesia. Concerns for fetal safety have been raised by one pharmaceutical company that no longer manufactures this agent ( www.fda.gov/medwatch/safety/2005/aug_PI/Nubain_PI.pdf). To date there are insufficient data to support these concerns or to recommend any change in the administration of this medication for analgesia in labor .
Nalbuphine Hydrochloride Use for Intrapartum Analgesia. ACOG Committee Opinion No. 376. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:449.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666624
Expert Testimony
ABSTRACT: It is the duty of obstetricians and gynecologists who testify as expert witnesses on behalf of defendants, the government, or plaintiffs to do so solely in accordance with their judgment on the merits of the case. Obstetrician–gynecologists must limit testimony to their sphere of medical expertise and must be prepared adequately. They must make a clear distinction between medical malpractice and medical maloccurrence. The acceptance of fees that are greatly disproportionate to those customary for professional services can be construed as influencing testimony given by the witness, and it is unethical to accept compensation that is contingent on the outcome of litigation.
Expert Testimony. ACOG Committee Opinion No. 374. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:445–6
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666622
Brand Versus Generic Oral Contraceptives
ABSTRACT:The U.S. Food and Drug Administration considers generic and brand name oral contraceptive (OC) products clinically equivalent and interchangeable. The American College of Obstetricians and Gynecologists supports patient or clinician requests for branded OCs or continuation of the same generic or branded OCs if the request is based on clinical experience or concerns regarding packaging or compliance, or if the branded product is considered a better choice for that individual patient.
Brand Versus Generic Oral Contraceptives. ACOG Committee Opinion No. 375. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:447–8 .
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666623
American Family Physician**
Screening and Treatment for Sexually Transmitted Infections in Pregnancy
Many sexually transmitted infections are associated with adverse pregnancy outcomes. The Centers for Disease Control and Prevention recommends screening all pregnant women for human immunodeficiency virus infection as early as possible. Treatment with highly active antiretroviral therapy can reduce transmission to the fetus. Chlamydia screening is recommended for all women at the onset of prenatal care, and again in the third trimester for women who are younger than 25 years or at increased risk. Azithromycin has been shown to be safe in pregnant women and is recommended as the treatment of choice for chlamydia during pregnancy. Screening for gonorrhea is recommended in early pregnancy for those who are at risk or who live in a high-prevalence area, and again in the third trimester for patients who continue to be at risk. The recommended treatment for gonorrhea is ceftriaxone 125 mg intramuscularly or cefixime 400 mg orally. Hepatitis B surface antigen and serology for syphilis should be checked at the first prenatal visit. Benzathine penicillin G remains the treatment for syphilis. Screening for genital herpes simplex virus infection is by history and examination for lesions, with diagnosis of new cases by culture or polymerase chain reaction assay from active lesions. Routine serology is not recommended for screening. The oral antivirals acyclovir and valacyclovir can be used in pregnancy. Suppressive therapy from 36 weeks' gestation reduces viral shedding at the time of delivery in patients at risk of active lesions. Screening for trichomoniasis or bacterial vaginosis is not recommended for asymptomatic women because current evidence indicates that treatment does not improve pregnancy outcomes. Am Fam Physician 2007;76:265-70, 272.
http://www.aafp.org/afp/20070715/265.html (see Patient Education)
Recommendations for Preconception Care
Every woman of reproductive age who is capable of becoming pregnant is a candidate for preconception care, regardless of whether she is planning to conceive. Preconception care is aimed at identifying and modifying biomedical, behavioral, and social risks through preventive and management interventions. Key components include risk assessment, health promotion, and medical and psychosocial interventions. Patients should formulate a reproductive life plan that outlines personal goals about becoming pregnant based on the patient's values and resources. Preconception care can be provided in the primary care setting and through activities linked to schools, workplaces, and the community. Am Fam Physician 2007;76:397-400
http://www.aafp.org/afp/20070801/397.html
Turner Syndrome: Diagnosis and Management
Turner syndrome occurs in one out of every 2,500 to 3,000 live female births. The syndrome is characterized by the partial or complete absence of one X chromosome (45,X karyotype). Patients with Turner syndrome are at risk of congenital heart defects (e.g., coarctation of aorta, bicuspid aortic valve) and may have progressive aortic root dilatation or dissection. These patients also are at risk of congenital lymphedema, renal malformation, sensorineural hearing loss, osteoporosis, obesity, diabetes, and atherogenic lipid profile. Patients usually have normal intelligence but may have problems with nonverbal, social, and psychomotor skills. Physical manifestations may be subtle but can include misshapen ears, a webbed neck, a broad chest with widely spaced nipples, and cubitus valgus. A Turner syndrome diagnosis should be considered in girls with short stature or primary amenorrhea. Patients are treated for short stature in early childhood with growth hormone therapy, and supplemental estrogen is initiated by adolescence for pubertal development and prevention of osteoporosis. Almost all women with Turner syndrome are infertile, although some conceive with assisted reproduction. Am Fam Physician 2007;76:405-10 http://www.aafp.org/afp/20070801/405.html
Varenicline (Chantix) for Smoking Cessation
Varenicline (Chantix) is a selective alpha4-beta2 neuronal nicotinic acetylcholine receptor partial agonist approved as an aid to smoking cessation therapy. This receptor is believed to play a significant role in reinforcing the effects of nicotine and in maintaining smoking behaviors. The agonist effect of varenicline at the nicotinic receptor is approximately half that of nicotine, which may lessen craving and withdrawal without inducing dependence. In theory, stimulation of the nicotinic receptor by a partial agonist could provide enough stimulation to reduce craving and withdrawal while competitively blocking the binding of smoked nicotine.1,2 Varenicline represents a new approach to smoking cessation by mitigating some of the satisfying and reinforcing aspects of smoking.
Safety
Studies of more than 4,500 patients have established a favorable safety profile for varenicline, and there have been no reports of abuse or serious safety issues. Because varenicline is excreted by the kidney, the manufacturer recommends reducing the dosage in patients with impaired renal function. There are currently no known drug interactions, and the safety of varenicline used in combination with other smoking cessation therapies has not been established. Because smoking may alter the metabolism of some medications (e.g., warfarin [Coumadin], theophylline), dosing adjustments of other drugs the patient is receiving may need to be made upon smoking cessation.2 Varenicline is U.S. Food and Drug Administration pregnancy category C.
Tolerability
The most common adverse effect associated with varenicline is nausea, which occurs in about 30 percent of patients taking the maintenance dose. Although the nausea is not typically severe, it may persist for the duration of treatment in a small number of persons. Other common adverse effects that occur in more than 10 percent of patients include headache, insomnia, abnormal dreams, and flatulence. The rate of discontinuation because of side effects was 12 percent for patients receiving varenicline compared with 10 percent for patients receiving placebo.2
Effectiveness
Varenicline has been compared with placebo in five studies3-7 and with sustained-release bupropion (Wellbutrin SR) in three studies of healthy persons highly motivated to quit smoking.5-7 On average, patients had been smokers for 20 to 25 years and reported smoking approximately one pack per day. Most patients (approximately 90 percent) had tried to quit at least once.3-7 Based on these studies, about 20 percent of patients taking varenicline will be continuously abstinent from smoking one year after treatment compared with less than 10 percent of patients taking placebo. In other words, for approximately every nine patients treated with varenicline instead of placebo, one additional patient will remain abstinent for one year.3-7
Varenicline treatment seems to be as effective or more effective than treatment with sustained-release bupropion. Two studies found that treatment with varenicline had similar results to treatment with bupropion,5,7 and one study found better abstinence rates with varenicline at one year compared with bupropion (23.0 versus 14.6 percent, respectively).6
Varenicline has not been compared with nicotine replacement therapy or for use in combination with other smoking cessation therapies. Also, varenicline has not been studied in patients who use tobacco products other than cigarettes or in patients who have significant cardiopulmonary disease or psychological disorders.
Price
A one-month supply of varenicline will cost approximately $120 for the maintenance dose. This is more than the cost of generic sustained-release bupropion ($116) but less than the cost of Wellbutrin SR ($150). Patients who smoke one pack per day will spend an average of $130 per month on cigarettes.8
Simplicity
Varenicline is taken with a full glass of water twice daily after a meal. The initial dose is 0.5 mg once daily starting one week before the quit date and increased to 0.5 mg twice daily after three days. At the start of the second week, the dose is increased to 1 mg twice daily and continued for 12 weeks. If a patient relapses during the 12 weeks of therapy or after therapy is completed, he or she should be encouraged to make another attempt to quit once contributing factors have been identified and addressed. Patients unable to tolerate the side effects at the maintenance dose should have the dose lowered temporarily or permanently. Patients with pronounced renal dysfunction (creatinine clearance less than 30 mL per minute [0.5 mL per second]) should take half the usual dose.2
Bottom Line
For every nine highly-motivated patients who use varenicline instead of placebo, one will not be smoking one year later. Although the cost of therapy is a limitation (total cost is approximately $360 for a three-month course), the easy dosage titration, lack of drug interactions, and favorable side-effect profile make varenicline an appealing alternative to sustained-release bupropion for smoking cessation
http://www.aafp.org/afp/20070715/steps.html
CDC Publishes Statement on Cough and Cold Medications in Children
Cough and cold medications that contain expectorants, antihistamines, nasal decongestants, and cough suppressants are commonly used to treat symptoms of upper respiratory infection in children younger than two years. However, in 2004 and 2005 an estimated 1,519 children younger than two years were treated in U.S. emergency departments for adverse events associated with use of cough and cold medications. Although the U.S. Food and Drug Administration (FDA) has approved the use of cough and cold medications for children two years and older, no FDA-approved dosing recommendations exist for children younger than two years. Therefore, the Centers for Disease Control and Prevention (CDC) has released a statement on the risks of cough and cold medications in children younger than two years. The statement appears in the January 12, 2007, issue of Morbidity and Mortality Weekly Report.
Evidence of the effectiveness of cough and cold medications in children younger than two years is limited. Systematic reviews of controlled trials involving these medications conclude that they are no more effective than placebo in reducing symptoms of upper respiratory tract infection. Additionally, cough suppressants containing codeine (Robitussin AC) and dextromethorphan (Delsym) have not been proven effective, and their use could lead to potential adverse events in children younger than two years.
Health care professionals should advise parents against administering cough and cold medications to children younger than two years because of the risk of toxicity and the lack of dosing recommendations. As an alternative to pseudoephedrine (Sudafed) and other nasal decongestants, physicians should recommend clearing the child's nasal congestion with a rubber suction bulb or using saline nose drops or a cool-mist humidifier to soften secretions.
Health care professionals also should be aware of the risks of serious illness or fatal overdose in children younger than two years who have been given cough and cold medications. To avoid overdose, physicians should prescribe these medications with extreme caution and should inquire about additional over-the-counter medications the child is being given. Additionally, physicians should be certain that parents understand the importance of administering these medications only as directed and are aware of the risk of an overdose if the child is given additional medications with the same ingredients.
http://www.aafp.org/afp/20070715/practice.html
Common Problems in Endurance Athletes
Endurance athletes alternate periods of intensive physical training with periods of rest and recovery to improve performance. An imbalance caused by overly intensive training and inadequate recovery leads to a breakdown in tissue reparative mechanisms and eventually to overuse injuries. Tendon overuse injury is degenerative rather than inflammatory. Tendinopathy is often slow to resolve and responds inconsistently to anti-inflammatory agents. Common overuse injuries in runners and other endurance athletes include patellofemoral pain syndrome, iliotibial band friction syndrome, medial tibial stress syndrome, Achilles tendinopathy, plantar fasciitis, and lower extremity stress fractures. These injuries are treated with relative rest, usually accompanied by a rehabilitative exercise program. Cyclists may benefit from evaluation on their bicycles and subsequent adjustment of seat height, cycling position, or pedal system. Endurance athletes also are susceptible to exercise-associated medical conditions, including exercise-induced asthma, exercise-associated collapse, and overtraining syndrome. These conditions are treatable or preventable with appropriate medical intervention. Dilutional hyponatremia is increasingly encountered in athletes participating in marathons and triathlons. This condition is related to overhydration with hypotonic fluids and may be preventable with guidance on appropriate fluid intake during competition. Am Fam Physician 2007;76:237-44
http://www.aafp.org/afp/20070715/237.html
AHRQ
Women: Stay Healthy at Any Age, Your Checklist for Health
The Agency for Healthcare Research and Quality (AHRQ) now has available 2 evidence-based checklists designed to help men and women understand which medical checkup tests they need to stay healthy at any age. Each list uses the US Preventive Services Task Force (USPSTF) recommendations to inform patients about screening tests, preventive medicine, and other healthy lifestyle behaviors.
You can download these checklists for distribution to your patients, by clicking on:
Women: Stay Healthy at Any Age, Your Checklist for Health
http://www.ahrq.gov/ppip/healthywom.htm
Men: Stay Healthy at Any Age: Your Checklist for Health
http://www.ahrq.gov/ppip/healthymen.htm
Today's teen smokers are more likely to engage in risky behaviors than teens who smoked in the early nineties
http://www.ahrq.gov/research/jul07/0707RA3.htm
Inadequate communication of mammogram results may prevent women from fully benefiting from screening
http://www.ahrq.gov/research/jul07/0707RA6.htm
Prophylactic antibiotics given to prevent surgical site infections are more timely if given in the operating room
http://www.ahrq.gov/research/jun07/0607RA12.htm
While most diabetes drugs provide similar glucose control, some offer important advantages
http://www.ahrq.gov/research/jul07/0707RA1.htm
Mandatory limits on medical resident work hours may constrain hospital house staff and affect patient outcomes and resource use
http://www.ahrq.gov/research/jul07/0707RA18.htm
Incentives combined with peer counseling are a cost-effective way to get adolescents to adhere to a tuberculosis control program
http://www.ahrq.gov/research/jun07/0607RA8.htm
Better outpatient care processes can improve the quality of life for patients with chronic disease
http://www.ahrq.gov/research/jun07/0607RA11.htm
Risk factors can help predict which patients with hospital-acquired urinary tract infections will develop blood infections
http://www.ahrq.gov/research/jun07/0607RA16.htm
Rate of childbirth-related hospital stays decreases for girls under age 18
http://www.ahrq.gov/research/jun07/0607RA20.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
Prevent Fetal Alcohol Spectrum Disorders: A Toolkit
A toolkit to help Native communities protect their children from the harm caused by drinking alcohol during pregnancy is now available from the Substance Abuse and Mental Health Services Administration.
The American Indian/Alaska Native/Native Hawaiian Resource Kit is designed to help mothers-to-be and their friends, relatives, health professionals, and leaders understand and prevent fetal alcohol spectrum disorders. FASD describes the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications.
Each year, at least 40,000 babies are born with an FASD in the United States, and Native communities have some of the highest rates. This new resource will support prevention and treatment efforts in American Indian, Alaska Native and Native Hawaiian communities.
The kit, which was developed and reviewed by representatives from Native communities and FASD experts, includes the following:
- Current data and statistics on FASD
- Fact sheets and brochures for women, men, youth and communities on how to prevent FASD and how to find help
- Strategies for FASD education and prevention
- Posters that can be copied and shared
- FASD--The Basics , a slide presentation for people with no prior knowledge of or experience with FASD
- A CD with an electronic version of the entire resource kit
The American Indian/Alaska Native/Native Hawaiian Resource Kit is available on the Web at http://ncadistore.samhsa.gov/catalog/productDetails.aspx?ProductID=17702.
Copies may be obtained free of charge by calling SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727). Request inventory number SMA07-4264.
Breastfeeding - Suzan Murphy, PIMC
Progress toward achieving Healthy People 2010 objective for breastfeeding
Further research is needed to identify successful programs and policies to support exclusive breastfeeding, especially among subgroups with the lowest rates. Healthy People 2010 objectives for breastfeeding initiation and duration were updated in 2007 to include two new objectives on exclusive breastfeeding: (1) to increase the proportion of mothers who exclusively breastfeed their infants through age 3 months to 60% and (2) to increase the proportion of mothers who exclusively breastfeed their infants through age 6 months to 25%.
The authors found that
* Among infants born in 2000, breastfeeding rates for the early postpartum period, 6 months, and 12 months were 70.9%, 34.2%, and 15.7%, respectively. For infants born in 2004, these rates had consistently increased to 73.8%, 41.5%, and 20.9%, respectively.
* Based on the revised questions, rates for exclusive breastfeeding through ages 3 and 6 months were 30.5% and 11.3%, respectively, among infants born in 2004.
* Disparities were observed in rates of exclusive breastfeeding among infants born in 2004. Rates of exclusive breastfeeding through age 3 months were lowest among black infants (19.8%) and among infants of mothers ages 19 and younger (16.8%), those who had a high school education or less than a high school education (22.9% and 23.9%, respectively), those who were unmarried (18.8%), those who resided in rural areas (23.9%), and those who had an income-to-poverty ratio of less than 100% (23.9%).
Scanlon KS , Grummer-Strawn L, Shealy KR, et al. 2007. Breastfeeding trends and updated national health objectives for exclusive breastfeeding: United States, birth years 2000-2004. MMWR Weekly 56(30):760-763 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5630a2.htm?s_cid=mm5630a2_e
Cup feeding not be recommended over bottle feeding as a supplement to breastfeeding
AUTHORS' CONCLUSIONS: Cup feeding cannot be recommended over bottle feeding as a supplement to breastfeeding because it confers no significant benefit in maintaining breastfeeding beyond hospital discharge and carries the unacceptable consequence of a longer stay in hospital.
Flint A, et al Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD005092
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17443570
Despite the benefits of early breastfeeding, many women find it unexpectedly difficult and painful http://www.ahrq.gov/research/may07/0507RA18.htm
New IHS Breast feeding Family Support web page: Have pictures to share?
When family and friends support breastfeeding,
it makes the challenges easier.
Your encouragement will touch a lifetime.
Tell mom that she is doing great.
Let dad know that his patience is beautiful.
Let the new family how proud you are of them.
Praise grandparents/aunts/uncles/cousins/friends
for their wonderful care and wisdom.
Give the new family a boost:
- Tackle some household chores
- Bring a meal over
- Change some diapers
- Make the trip to the grocery store
- Give the baby a bath
- Take the new siblings to the park
- Read a book or watch TV with the new siblings
- Keep mom resting, bring the baby to her
If you have pictures to share, please email them to suzan.murphy@ihs.gov
http://www.ihs.gov/MedicalPrograms/MCH/M/bfFamily.cfm
What to do when Mom says, “My newborn likes the bottle better.”
Why does it happen?
In a normal, healthy newborn, bottle preference is usually from overuse of a bottle and/or pacifier. However, it is helpful to rule out unusual newborn issues that can effect sucking like a short frenulum or thrush.
What is the cause?
Formula or breast milk comes out of the bottle quickly, just a little tug. Also, the plastic nipple can rub the roof of the mouth, stimulating the suck. It is not much work for the baby - and there is no waiting for let down. It is easy. Breastfeeding takes more work. Often, but not always, a baby will begin to favor the bottle and avoid breastfeeding. Unfortunately, it is hard to know which baby will be influenced by frequent bottles/pacifiers.
In the first couple weeks, there is probably still time for the mom’s supply to bounce back. To get mom and baby back to breastfeeding:
Assure the mom that her baby is getting enough:
Have her count diaper changes - if her baby has least 6 in 24 hours, her baby is probably has an adequate intake.
Check her baby’s weight gain – ½ oz – 1 oz per day, 3.5 - 7 oz per week is normal
Tell the mom to breastfeed about 2 hours – 8 to 12 times in 24 hours. The baby’s suck muscles and mom’s milk supply will get up to speed together and the frequency will slow down within a couple days.
Discourage the “pump and feed” method – it has a near 100% burn out rate.
Tell the mom to praise her baby for sucking well. The baby knows mom’s happier voice and will respond appropriately.
Recommend less use of the bottle. If the bottle can be weaned down to once or twice a day, the mom’s milk supply will probably be protected. Less is best in the first 4-6 weeks.
Suggest that the pacifier be avoided – and saved for difficult times like car trips with screaming a baby or challenging moments.
If it looks like it really is a supply issue, or the “bounce back” is not happening, consider medication. Clinical studies indicate that metoclopromide can increase milk supply in difficult situations. For more information, refer to Thomas Hales’ text, Medications and Mother’s Milk or sources like the San Diego Breastfeeding Coalition web page.
If the baby won’t latch, refer the mom to WIC or a Lactation Consultant. It is OK to call us for over-the-phone-ideas at 1- 877-868-9473. It is toll-free - best times are 7 am – 10 pm, Mountain Standard Time.
What about extra fluids?
Clinical studies have not agreed with the common practice of encouraging fluids to increase milk supply. Unfortunately the studies were small, each with less than 30 participants, and did not correct for climate issues – such as excessive heat/cold, or the typical amount of outdoor exposure the mother experienced. So while encouraging water is a healthy practice, excessive fluids are not necessary. A reasonable recommendation is to keep water nearby and drink to thirst.
Please note: If it is believed that a specific (safe) beverage will help, it probably will. Confidence is a powerful tool with parenting, especially breastfeeding.
References
Dusdieker LB et al. Prolonged maternal fluid supplementation in breast-feeding. Pediatrics,
1990 Nov;86(5):737-40.
Morse JM et al. The effect of maternal fluid intake on breast milk supply: a pilot study.
Canadian Journal of Public Health, 1992 May-Jun;83(3):213-6.CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
Highlights include
- Within the Hidden Epidemic: STDs and HIV/AIDS Among AI/AN
- American Indian / Alaska Native population has the shortest timeline HIV to AIDS
- VBAC: Smaller attributable risk than previously reported
- LEEP doubles risk of preterm delivery: Patients need to be informed
- Physical Activity Alone May Not Reduce Obesity in Children
- Teratogenicity of SSRIs--serious concern or much ado about little?
- Management of Herpes in Pregnancy: Practice Bulletin
- What to do when: Mom says, “My newborn likes the bottle better.”
- IHS-ACF DV Project: Conference CD: Patient Education, Safety Planning, etc….
- Waiting until the menses to start hormonal contraceptives: Needless Obstacle
- Can oral or sublingual misoprostol be used for postpartum hemorrhage?
- Integrated case management software application release
- Maternal survival redux: a view from Malawi - Failure of justice
- Who needs liquor stores when parents will do?
- Taking a harder line on blood transfusions
- Nausea and Vomiting in Pregnancy
- Hormone Replacement Therapy Linked to Ovarian Cancer
- Midwifery’s approach to pre-labor SROM supported by professional organization’s journal
- The evolution of management of Actinomyces on a Pap report
- Health Care Without Harm: Nurses Take Action
- Preconception Health of Women Delivering Live-Born Infants — Oklahoma, 2000–2003
- Anemia in Pregnancy: The Common to the Unusual – including IV therapy
- Chronic Renal Disease: How is Primary Care Effected?
- Updated Screening for Chlamydial Infection Recommendations, USPSTF
- (How) can we prevent type 2 diabetes?
- Why do Native American women have the poorest 5-year survival for breast cancer?
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_07.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence – Denise Grenier, Rachel Locker
Sexual assault among American Indian/Alaska Native women
Colleagues:
The URL below will take you to the page on the National Public Radio website featuring their story on sexual assault that they featured last night on their news show “All Things Considered”.
Contact Carolyn.Aoyama@ihs.gov
http://www.npr.org/templates/story/story.php?storyId=12203114
Elder Care News
'What Older Women Want' launches new website for doctors and patients: New Website
Urinary incontinence, memory loss and exercise top the list of older women's unmet health needs and concerns
A Canadian study of older women's health needs and concerns published in the Canadian Medical Association Journal and reported widely in the media, has sparked a new website directed at both patients and health practitioners: www.wowhealth.ca
Known widely as 'WOW' or the 'What Older Women Want' study, conducted by Drs. Cara Tannenbaum, Nancy Mayo and Francine Ducharme, the study asked 5000 older women across Canada which of their health needs they felt were not being met or addressed adequately by their health practitioners.
Their answers surprised many in healthcare provision, since the key topics the women highlighted were not concerned so much with critical care concerns or disease treatment, but primary care and disease prevention.
Among the top unmet concerns Canadian senior women mentioned were: screening and treating urinary incontinence; counselling about memory loss (or perceived memory loss); and exercise strategies to address falls and functional decline.
"Women were very satisfied with the care they were receiving to treat their blood pressure and prevent heart attacks and stroke, but emphasized gaps in care surrounding more 'taboo' issues, such as discussing urine or memory loss," says Dr. Tannenbaum, a Geriatrician at the Institut universitaire de gériatre de Montréal, and lead author of the WOW study.
"It may be that women are uncomfortable talking about these issues with their physicians because it is embasrassing, because they believe it is a part of normal aging or because they are unaware that treatments exist."
In order to address this gap in primary health provision and give older women what they want, Dr. Tannenbaum teamed up with the Canadian Women's Health Network and the Centre de recherche de l'Institut universitaire de gériatrie de Montréal to create the WOW website.
The website contains a portal for health consumers that provides health information on the three unmet health needs of older Canadian women:
urinary incontinence, memory loss and exercise. The information is clear, straight-forward and easy-to-read, with engaging illustrations and diagrams. The focus is on prevention, with tips on diet, lifestyle changes and exercise; treatment options are also provided.
But the onus is not left only up to older women to seek and address their own health needs. The WOW website also has a portal for health practitioners, outlining the kinds of questions that practitioners should be asking their older female patients routinely, and the ways in which they can provide prevention and improvement strategies to their patients for urinary incontinence, memory loss, as well as the particular exercise needs of older women.
"When asked, clinicians admitted that they often do not pursue these issues because there is rarely enough time during the medical visit and they often get the impression that their patients are reluctant to talk about it," states Dr. Tannenbaum. "That is why it is so important that we get the message out that something like urinary incontinence can be effectively treated in up to 75% of patients with simple behavioural techniques, and that clinicians should routinely screen for it."
"The goal with the WOW website was to find an effective means to translate the research we have done on older women's health concerns into tangible results. We want women to be able to articulate their needs and clinicians to learn what questions they ought to be asking," Dr.
Tannenbaum adds.
The WOW website is the essential first step to make sure that older women's unmet health needs and concerns are present in health care provision, and communicated in ways that both senior women and their health practitioners can understand.
For full study details on the What Older Women Want study, visit:
www.wowhealth.ca/pdf/wowCMAJ.pdf
Tannenbaum C , Mayo N , Ducharme F . Older women's health priorities and perceptions of care delivery: results of the WOW health survey. CMAJ. 2005 Jul 19;173(2):153-9.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16027431
A fall management program in nursing homes improves care and reduces use of physical restraints
http://www.ahrq.gov/research/jun07/0607RA10.htm
Certain resident and facility characteristics and medications increase the risk of fractures among nursing home residents
http://www.ahrq.gov/research/jul07/0707RA7.htm
Family Planning
Various Implantable Contraceptives Equally Effective in Preventing Pregnancy
CONCLUSIONS: Implanon, Norplant and Jadelle are highly effective contraceptive methods. No significant differences were found in contraceptive effectiveness or continuation. The most common side-effect with all implants was unpredictable vaginal bleeding. Time taken for removal of Implanon and Jadelle was less than that for Norplant.Although this systematic review was unable to provide a definitive answer on relative effectiveness, tolerability and acceptability of contraceptive implants in comparison to other contraceptive methods, it has raised issues around the conduct of contraceptive research.
Power J, French R, Cowan F. Subdermal implantable contraceptives versus other forms of reversible contraceptives or other implants as effective methods of preventing pregnancy.
Cochrane Database Syst Rev. 2007 Jul 18;(3):CD001326
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17636668
Oral Contraceptives Today: Changes, Challenges, Risks, and Benefits: Medscape CME
http://www.medscape.com/viewprogram/7384?src=mp
Featured Web Site David Gahn, IHS MCH Portal Web Site Content Coordinator
New Online Training Tool Available for Treatment of Adolescents with HIV
A new online training program developed for health care providers entitled Treating Adolescents with HIV: Tools for Building Skills in Cultural Competence, Clinical Care, and Support will be launched Monday, July 23. Continuing education credits are available for participating in this training which can be accessed at www.hivcareforyouth.org
This project is supported by the Department of Health and Human Services' Health Resources and Services Administration's HIV/AIDS Bureau. The series begins, and is framed, by an introductory module covering best practices in adolescent care and the impact of the AIDS epidemic on minority youth. The four additional modules in this series: Psychosocial Issues, Antiretroviral Treatment and Adherence, Transitioning Care, and Prevention with Positives address core issues in HIV care for adolescents. The expert authors and editors come from diverse clinical settings around the country, and present course information from the perspective of a culturally aware care provider. Throughout the course, practical tools are provided to assist with "operationalizing" culturally sensitive best practices in the clinic setting.
From Lori de Ravello Lori.deRavello@ihs.gov
Frequently asked questions
Moderate morning sickness only partially responding to doxylamine and pyridoxine
QUESTION One of my patients suffers from a moderate-to-severe form of morning sickness. She responded only partially to doxylamine and pyridoxine, and I wish to try adding another medication. What should my priority be?
ANSWER
An algorithm used by Motherisk to manage thousands of patients takes a hierarchical
approach to this condition. This approach is evidence based with regard to fetal
safety as well as efficacy. (Go to ‘algorithm used by Motherisk’ and
scroll down page to see algorithm, link below)
Nausea and vomiting of pregnancy (NVP) affects an estimated 80% of all pregnant women, making it the most common medical condition during pregnancy. In most cases, symptoms are worse in the morning; severity usually peaks by 8 to 12 weeks' gestation. Some women are affected throughout the day, and the condition sometimes continues beyond the first trimester and even until the birth.
Hyperemesis gravidarum is the most severe form of morning sickness, affecting 0.05% to 1% of pregnant women. Hyperemesis gravidarum is characterized by dehydration and electrolyte imbalance, and might require hospitalization. Nausea and vomiting of pregnancy has serious detrimental effects on the lives of women, even those with a milder presentation. Termination of otherwise wanted pregnancies among women suffering from severe and prolonged NVP has been reported.
Inappropriate treatment common
Ample evidence indicates that most women with NVP do not receive appropriate
pharmacologic or nonpharmacologic treatment for the condition. In 1996, the Motherisk
Program in Toronto, Ont, initiated the NVP Healthline (1-800-436-8477) to counsel
and support women and health professionals in managing NVP. Members of Motherisk
systematically review available data on treatment in an attempt to obtain the
best available evidence on efficacy and safety. Callers and clinic patients are
advised on both pharmacologic and nonpharmacologic management.
This paper provides clinicians with a simple evidence-based algorithm on the efficacy and safety of treatments for NVP.
Rationale
In planning and evaluating management of NVP, fetal safety is clearly the primary
concern, followed by efficacy. This order of priorities dictates that, in general,
older medications, for which there are more data on fetal safety, are preferred
over newer, perhaps more effective, drugs for which there are as yet fewer data
on safety.
Methods
The algorithm is based on a recent systematic review of the literature on safety and efficacy of management of NVP conducted by members of the Motherisk Team. The course of NVP ranges in severity, length, and response to treatment. We addressed treatment of NVP in a decision tree (Figure 1, at link below) It begins with pharmacologic management of relatively mild cases and progresses to treatment of patients who cannot tolerate oral treatment or are dehydrated, or both. At any stage of the algorithm, physicians can add or, when there is improvement, withdraw treatment. The systematic review included meta-analyses whenever the data permitted.
The quality of the evidence on fetal safety and maternal efficacy varies. There is large and convincing evidence on the safety and efficacy of doxylamine and pyridoxine (Diclectin). Evidence on the safety of other H1 blockers is as strong, but evidence of efficacy is less strong. Many studies on the efficacy of phenothiazines offer convincing evidence, but the number of studies on safety is much smaller (birth defects are generally rare). Evidence on the safety and efficacy of ondansetron and metoclopramide is preliminary.
The hierarchy presented in the algorithm is based on the strength of evidence for fetal safety, and only treatments shown to be efficacious were included. It has been used by the Motherisk Program for treating a large number of patients.
Levichek Z et al Nausea and vomiting of pregnancy: Evidence-based treatment algorithm Canadian Family Physician 2002;48:267-8,277.
http://www.motherisk.org/prof/updatesDetail.jsp?content_id=348
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
September 2007
-First time that prophylaxis for infective endocarditis has been written using evidenced based guidelines. The difference is significant.
-RPMS Immunization Package: Version 8.2 coming this summer
-Substance abuse in Native American communities. It is no secret that substance abuse poses a serious threat to the health of children, youth, families, and communities all across the nation.
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN907.doc
Information Technology
Save 750 mega watts/hour per year: It is easy
If Google had a black screen, taking in account the huge number of page views, according to calculations, 750 mega watts/hour per year would be saved.
In response, Google created a black version of its search engine, called Blackle, with the exact same functions as the white version, but with lower energy consumption: http://www.blackle.com/
iCare Training
The IHS Office of Information Technology is pleased to continue offering WebEx training for the new iCare (Population Management) software application. You will be able to participate in the training from the comfort of your office or conference room and will not be required to travel to obtain this training.
iCare is a tool with multiple uses for a wide variety of providers that presents diverse RPMS data through an easy to use graphical user interface (GUI).
There are two types of training offered:
- iCare Technical Overview
- iCare – Nuts and Bolts
The target audience is any provider who cares for patients (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
NOTE:You must register for these classes. They are NOT limited to participants in a particular Area; they are open to all, however, space is limited so be sure to register right away. Below are the agendas and date/times for both classes. It is recommended that you attend them sequentially.
Each session is limited to 30 participants. Therefore, if there is a group of people who would like to attend at your facility, our recommendation is that you attend as a group and have only one person register for the session. For the group, you will need a conference room, conference phone, computer and projector. Please ensure someone at your facility is responsible for taking care of these arrangements.
Please note this is a live, internet-based training, not a recorded session, and people will be able to ask questions and actively participate in the class.
NOTE: All training times shown above are for the Pacific Daylight Time zone. Please ensure you adjust the time for your particular time zone.
Training Schedule
- iCare – Nuts and Bolts
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Set Up and Background (Server) Processes
- Establishing and Changing User Preferences
- Panel Creation
- Panel Modification
- Flags
- Diagnostic Tags
- National Performance Measures
- Patient Record
- Question and Answer Session
| Session | Date and Time | Reg Password | |
| iCare Nuts and Bolts | Mon 07/16/2007 | 12:00-14:00 PDT | coyote |
| Tue 07/31/2007 | 11:00-13:00 PDT | coyote | |
| Thur 08/23/2007 | 09:00-11:00 PDT | coyote | |
| Mon 08/27/2007 | 13:30-15:30 PDT | coyote | |
| Fri 09/14/2007 | 10:30-12:30 PDT | coyote |
- The Practical Use of iCare
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Scenarios
- Tips
- Using the Performance Measure views to improve outcomes
- Questions and Answers
| Session | Date and Time | Reg Password | |
| The Practical Use of iCare | Wed 07/18/2007 | 09:00-10:30 PDT | coyote |
| Thur 08/02/2007 | 09:30-11:00 PDT | coyote | |
| Fri 08/24/2007 | 10:00-11:30 PDT | coyote | |
| Thur 08/30/2007 | 12:00-13:30 PDT | coyote | |
| Wed 09/19/2007 | 11:00-12:30 PCT | coyote |
Registration Information
- Click this link:https://ihs-training.webex.com/
- At the Search For box, type in "iCare" (do not type in the quotation marks) and click the Go button. NOTE: If you do not see the Search For box, ensure the Training Center tab is selected at the top of the WebEx window, immediately under “webex.”
- All of the scheduled sessions will then be displayed in the window below. Choose the one you want to attend and click “Registration” in the Status column.
- Enter the Registration password that is shown above that corresponds to the class you want to attend.
- Click the OK button.
- Complete the registration form.
- Click the Register button.
- A Registration confirmation is displayed that contains all of the information for the training session, including the link for the session and the password to enter when you are ready to attend the session. Click the OK button to finish.
Setup (Software Install) Information:
You must have the WebEx software installed on your computer prior to attending the WebEx session. You should setup the software at least a day before the training session. You should not need anyone such as the Site Manager to install it for you. Below are the instructions.
- Click this link:
https://ihs-training.webex.com/ihs-training/mywebex/
default.php?Rnd0969=0.20680128403018566
- On the left side of the window, click Set Up.
- Immediately under Set Up you will see two options: Training Manager, Preferences.
- Click Training Manager.
- A message is displaying giving you information about the setup process. Click the Set Up button.
- After the software is installed, click the OK button.
Attending the Session:
When you are ready to attend the session, connect to the WebEx session first using the information contained in your registration confirmation e-mail and then connect to the conference line. The dial information for the conference line is shown below and is also included in your registration confirmation message.
Phone Number: (877) 781-4791
Passcode: 135963#
Questions? Contact Cynthia Gebremariam at Cynthia.Gebremariam@ihs.gov
International Health Update: Claire Wendland, Madison, WI
Sex, Soap & Social Change - The Sabido Methodology
As anyone who’s gotten seriously hooked on a TV drama knows, viewers can start thinking of fictional characters as real, even as friends. Health educators worldwide take advantage of this response by using serial dramas – soap operas – to reach diverse audiences with behavior-change messages through what has come to be called the “Sabido method.” Miguel Sabido, a Mexican TV executive in the 1970s, built on the social learning theory of Albert Bandura to produce telenovelas encouraging Mexican couples to use contraception. Sabido’s key insight was that television characters could be role models, allowing viewers to learn vicariously from the troubles and successes of others. To work, the shows had to be entertaining, and the audience had to become attached to the characters.
Acompaname, “Come Along,” was Sabido’s first serial drama to address health. It spared viewers none of the drama for which soaps are famous: infidelities, amnesia, unwanted pregnancies. Among the suffering heroines and evil villains, however, was Martha, the “transitional character” with whom the audience was meant to identify – a fallible but likeable protagonist who envied her sister’s small and happy family, and feared sharing the fate of her mother, burdened with too many children and not enough resources. As Martha and her husband tentatively began to use family planning, many of the members of her audience did too. Sales of over-the-counter contraceptives rose nearly twenty-five percent the first year the show was on the air, and there is evidence suggesting that Acompaname and Sabido’s next four telenovelas were important factors in the 34% drop in Mexico’s population growth rate over the next few years.
Fine-tuning the shows through audience research is an important part of their design. Wila Kasta (an Aymara-language radio show in Bolivia focused on HIV/AIDS and condom use) initially made the mistake of putting prevention messages in the mouth of a Western-trained doctor character. Though handsome, musical, and powerful, he was a far less popular character than anticipated. The show fared better, and the audience paid greater attention, when the same messages came through a grandmother midwife.
The formula for producing such dramas was exported by the mid-1980s, and serial dramas intended to create social change have hit the airwaves in a hundred countries, from Ethiopia (where the radio drama Yeken Kignit, “Journey of Life,” is credited with tripling HIV-testing rates among listeners) to India (where the musical soap Tinka Tinka Sukh, “Happiness Lies in Small Pleasures,” convinced at least one village to abolish the dowry system) to Burma (where the military junta has made listening to a shortwave drama on health and civil engagement a treasonous offence). They have addressed topics from literacy to agricultural techniques to women’s rights to condom use. In the twenty-first century, the urgent need to interrupt the HIV epidemic has spawned even more shows.
Do they work? It is very difficult to distinguish correlation from causation, and to some extent the jury is still out. After all, people who own a television or radio may also be better off, more comfortable with Western lifestyles, and already more likely to use a condom or get an HIV test than those who don’t. What little evidence there is, however, suggests an effect greater than that seen in more traditional public health campaigns. Perhaps it’s time to try the Sabido method in the US?
- Readers looking for more can find an overview in Global Health Watch at http://www.globalhealth.org/reports/ – click on “Sex, Soap & Social Change - The Sabido Methodology.”
- The best available summary of evidence on these programs’ efficacy is an open-access article from http://her.oxfordjournals.org – Bertrand JT, O’Reilly K et al. Systematic review of the effectiveness of mass communication programs to change HIV/AIDS-related behaviors in developing countries. Health Education Research 21(4):567-597, 2006
- Interested in making a serial drama for your own community? You can download a step-by-step guide free from the United Nations Population Fund at http://www.unfpa.org/upload/lib_pub_file/538_filename_training_guide.pdf
Other
Association of arsenic exposure during pregnancy with fetal loss and infant death: a cohort study in Bangladesh.
The authors evaluated the effect of arsenic exposure on fetal and infant survival in a cohort of 29,134 pregnancies identified by the health and demographic surveillance system in Matlab, Bangladesh, in 1991-2000. Arsenic exposure, reflected by drinking water history and analysis of arsenic concentrations in tube-well water used by women during pregnancy, was assessed in a separate survey conducted in 2002-2003. Data on vital events, including pregnancy outcome and infant mortality, were collected by monthly surveillance at the household level. The risk of fetal loss and infant death in relation to arsenic exposure was estimated by a Cox proportional hazards model. Drinking tube-well water with more than 50 microg of arsenic per liter during pregnancy significantly increased the risks of fetal loss (relative risk = 1.14, 95% confidence interval: 1.04, 1.25) and infant death (relative risk = 1.17, 95% confidence interval: 1.03, 1.32). There was a significant dose response of arsenic exposure to risk of infant death (p = 0.02). Women of reproductive age should urgently be prioritized for mitigation activities where drinking water is contaminated by arsenic.
Rahman A et al Association of arsenic exposure during pregnancy with fetal loss and infant death: a cohort study in Bangladesh. Am J Epidemiol. 2007; 165(12):1389-96
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17351293
MCH Alert
Preconception brochure released
A Woman's Guide to Preventing or Planning Pregnancy provides information on pregnancy and pregnancy-prevention program services in California, as well as tips for staying healthy before and during pregnancy. The brochure, developed by the Center for the Health Professions' Network for Multicultural Health, builds on the project undertaken by LEAD (LEADing Organizational Change: Advancing Quality Through Culturally Responsive Care) program Cohort 1, Contra Costa Health Services, and its focus on community outreach. The services of two specific programs are highlighted: (1) Family PACT, a state- and federally funded program to provide comprehensive family planning services to individuals with eligible incomes and (2) Presumptive Eligibility for Pregnant Women, a Medi-Cal program to provide immediate, temporary coverage for prenatal care pending a formal Medi-Cal application. The brochure may be downloaded and customized by inserting specific information on the back, center panel. http://futurehealth.ucsf.edu/TheNetwork/LinkClick.aspx?link=WomansGuide_English.pdf&mid=2181
School based programs decrease rates of violence among adolescents
"On the basis of this evidence, the Task Force on Community Preventive Services recommends the implementation of universal, school-based programs to prevent violent behavior," state the authors of a report published in a supplement to the August 2007 issue of the American Journal of Preventive Medicine. Violence is widespread and causes considerable morbidity and mortality in the United States. Research has shown that childhood violence is predictive of later violent pathways.
The report summarizes the findings of a systematic review of the effects of universal, school-based programs intended to prevent violent behavior. Information on interpreting and using the recommendation are provided. http://www.ajpm-online.net/issues/contents?issue_key=S0749-3797(07)X0126-0
The other systematic reviews of the effectiveness of selected population-based interventions designed to reduce or prevent violence by and against children and adolescents are available from the Guide to Community Preventive Service at http://www.thecommunityguide.org/violence/default.htm
MCH Headlines: Judy Thierry HQE
Motor vehicle restraint use in American Indian children: Meaningful interventions
Results: Of 775 children age 1-8 years, 29 percent were properly restrained, 30 percent were incorrectly restrained, and 41 percent were completely unrestrained in the vehicle. The strongest associations with proper child restraint use, rather than no restraint use, were seat eligibility (Odds Ratio [OR] for infant seat vs booster seat: 25.1; OR for child seat vs booster seat: 8.7), driver seat belt use (OR: 6.5), and driver relationship to the child (OR for parents vs non-parents: 3.9). Being subject to a state seat belt law was associated with both proper (OR: 4.4) and incorrect restraint use (OR: 6.6), rather than no restraint use, compared to children riding in areas with no law. Being subject to a tribal seat belt law was also associated with incorrect restraint use (OR: 2.4), rather than no restraint use, compared to children riding in areas with no law. The three factors that were differently associated with proper and incorrect restraint use were the child’s seat eligibility (OR for infant seat vs booster seat:15.7; OR for child seat vs booster seat: 7.5),seating position (OR for rear-outboard seated vs front seated: 1.9), and whether or not the child was riding with his or her own parent (OR for parents vs non-parents:2.9).
Conclusions : AI/AN children are at risk for incorrect and non-use of motor vehicle restraints. Understanding barriers and facilitators to the use of child passenger restraint systems in tribal communities can guide prevention efforts for American Indian communities across the United States. Such interventions might include strategies to get all occupants (adults and children) to use proper restraints; stressing importance of regular use, even for short trips; increase availability of proper seats for all vehicles that children ride in regularly; include training on proper use, not only for parents, but all regular caregivers.
Nicole Smith, MPH
MCH Biostatistician
Northwest Portland Area Indian Health Board
Toolkit Supports Efforts in Native Communities to Prevent FAS Disorders
The American Indian/Alaska Native/Native Hawaiian Resource Kit is available on the Web at http://ncadistore.samhsa.gov/catalog/productDetails.aspx?ProductID=17702 .
Copies may be obtained free of charge by calling SAMHSA’s (working hours) Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727). Request inventory number SMA07-4264.
For related publications and information, visit http://www.samhsa.gov/ and the FASD Native Initiative Web site at http://fasdcenter.samhsa.gov/nativeinitiative/indexhtmlorflash.cfm
Sister Study seeks more Native women
The study must have 50,000 women participate; and in order to ensure accurate research results representative of the entire U.S. and Puerto Rican population, organizers hope to have at least 750 American Indian participants. As of August, 565 Native women were enrolled in the study. ''Breast cancer is the second leading cause of cancer death among Native women, and their five-year survival rate is lower than that of white women,'' said Sara Williams, the Sister Study's recruitment coordinator in charge of Native recruitment.
Previous breast cancer research has been limited to mostly white women, Williams said, and scientists are hoping to learn a great deal from the study. The participants must be between the ages of 35 and 74, must never have had cancer and must have a sister who was diagnosed with breast cancer.
Because there is so little known about the environmental causes of breast cancer, many women are compelled to join the study to try and help future families. The study was officially launched in 2004 after a few years of planning. Organizers have worked diligently to spread the word of the study, publicizing their intent and creating a user-friendly Web site. Reaching Indian country can be more difficult. ''We want the cohort to really be diverse and not have everyone in the study be white and middle-aged and work at a desk job,'' Williams said. Native women who sign up must be residents of the United States; however, they do not need to give their tribal affiliation.
''Because this is not a study comprised of only Native women, it was never the intention to study any differences in breast cancer risk at a tribal level,'' Williams said. ''There will only be broad analyses done among all Native women generally, regardless of tribal affiliation. Still, so much is going to be learned at this level.''
The Sister Study is a long-term research project. When participants sign up, they'll be asked to take part in two hour-long phone interviews in which they'll give detailed information about their medical history, environment and lifestyle. Then, the individual will set up an in-home appointment with a female examiner, who will draw blood and take a urine, house dust and toenail sample.
The participants will receive a kit in the mail that has all the information and questionnaires organized in tabbed form. After the initial period, the women will then be contacted every year for 10 years to provide updated information, such as any changes to their health.
''You don't have to take any medicine, you don't have to go anywhere,'' Williams stressed. ''You never even have to leave your house ... I think the most important message now is that you just have to step up to the plate and realize that this is really important to do for future generations of women.'' Women are not paid for their participation and their motivation to join comes from their desire to contribute to scientific research.
The study is being conducted by the U.S. Department of Health and Human Services through their National Institute of Environmental Health Sciences; and because it is a federally funded program, there isn't an open-ended budget. ''I wish we could say, 'Join this program and we'll give you $500!' Williams said. ''We are at the mercy of people's good will. To me, it's almost like a social justice issue. We're really working hard to encourage these women to enroll because we know so little [about Native breast cancer].''
To learn more about the study, visit http://www.sisterstudy.org/English/index1.htm
To sign up, call toll-free (877) 4SISTER
One size doesn't fit all: Helmet Safety Poster
Three page poster with chart and narrative matches’ helmet with activity from CPSC's Neighborhood Safety Network
The Neighborhood Safety Network has a very special poster to share with you this month. In March of this year, the Raffaelli family of San Mateo, Calif., tragically lost their son Casey, 20, after he fell from his skateboard. Casey’s parents and uncle have courageously partnered with CPSC to share a powerful safety message about the unquestionable importance of wearing a helmet when out on a bicycle, skateboard, scooter, etc. The visual and written message from the Raffaellis should motivate everyone to “strap a helmet on – it could save your life!”
To honor Casey and to help create a safer community where you live, we ask that you download this poster (www.cpsc.gov/nsn/helmets.pdf ) and share it with friends, family and neighbors.
Get Your Head in the Game
Concussion Tool Kit for Youth Sports Coaches, Parents, and Athletes
A concussion is a brain injury caused by a bump or blow to the head that can change the way your brain normally works. Even what seems to be a mild bump or blow to the head can be serious. As many as 3.8 million sports- and recreation-related concussions are estimated to occur in the United States each year.
To help ensure the health and safety of young athletes, the Centers for Disease Control and Prevention (CDC), in collaboration with 26 leading organizations, developed the new "Heads Up: Concussion in Youth Sports" tool kit for youth sports coaches, parents, and athletes. The tool kit offers important information on preventing, recognizing, and responding to a concussion—a type of traumatic brain injury—to coaches, parents, and athletes involved in youth sports.
CDC wants to equip coaches, parents, and young athletes across the country with the " Heads Up: Concussion in Youth Sports" tool kit, which contains a:
§ Fact sheet for coaches, parents, and athletes on concussion;
§ Clipboard with concussion facts for coaches;
§ Magnet with concussion facts for coaches and parents;
§ Poster with concussion facts for coaches and sports administrators; and
§ Quiz for coaches, athletes, and parents to test their concussion knowledge.
The "Heads Up: Concussion in Youth Sports" tool kit can be ordered or downloaded free-of-charge at: http://www.cdc.gov/ConcussionInYouthSports
To view the MMWR on sports- and recreation-related traumatic brain injury: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5629a2.htm
Usage of Booster Seats (NSUBS) are now posted online on the NHTSA website
The study is NHTSA’s first formal foray into the development of a reliable scientific estimate of booster seat use in the U.S. Three “Research Notes” analyzing and describing the NSUBS results are posted at www.nhtsa.gov
These are:
Child Restraint Use in 2006 -- Demographic Results
Child Restraint Use in 2006 -- Use of Correct Restraint Types
A fourth Research Note (“Preliminary Data Indicate That Booster Seat Laws Increase Child Safety Seat Use”) has been published in conjunction with the NSUBS findings. That link is:
Preliminary Data Indicate That Booster Seat Laws Increase Child Safety Seat Use
The NSUBS’ primary purpose is to estimate booster seat use among 4- to 7-year-olds, but it also collects very rich information on the restraint use of all children under age 13, and on race/ethnicity results on restraint use among all ages. In particular, the NSUBS provides the best data to date on the premature graduation of children age 0-12 to restraint types that are inappropriate for their height or weight.
The survey was conducted by NHTSA’s National Center for Statistics and Analysis (NCSA) in July 2006, and the second year survey is in the field this month.
Although clear progress in increasing booster seat use is evident -- thanks to a host of developments and interventions conducted by many people over many years -- much work remains to be done to more fully protect booster-aged/-sized child passengers.
FASD Online Course
Online Course: (2004) FASD 4-Digit Diagnostic Code - individual-start, self-paced,
fully online program. The course includes readings, exercises, quizzes and video
segments of an actual FAS Diagnostic Evaluation. This 20-hour course is designed
for completion in 4 weeks. Students may complete the course in less time or may
take up to 8 weeks. Students may start the course on any date. $100
COURSE FEE. RECOMMEND REVIEW OF THE INTRO VIDEO – LINK BELOW.
FAS is a permanent birth defect syndrome caused by maternal consumption of alcohol during pregnancy. FASD is the leading known cause of mental retardation and developmental disabilities and is entirely preventable. Learn an interdisciplinary clinical approach to diagnosing FASD using the (2004) 4-Digit Diagnostic Code. The 4-Digit Code has been practiced by interdisciplinary diagnostic teams across the U.S. and Canada since 1997 with documented high performance. This online course includes case studies, animations, practice sessions and self-assessment.
The Online Course
is now open for registration.
Earn 2 Continuing Education Units.
The Course was developed by Susan J. Astley, Ph.D. and the University of Washington
FAS DPN Clinical Team. This course was developed in partnership with UW Extension,
Distance Learning Division.
Click here to view an introductory video of the Online Course. http://depts.washington.edu/fasdpn/htmls/online-train.htm
The video requires Windows Media Player software to view. If you are using a computer with Microsoft's Windows operating system, you may already have this software loaded in your computer. If you do not have this software, or the version you have is outdated, a free copy of the software can be downloaded from Microsoft.
Let me know if you are interested in taking this online course.
Medical Mystery Tour
Nausea and Vomiting in Pregnancy
As you recall from last month, we presented 3 case scenarios and then asked 3 questions. Here are the questions. The correct answers and explanations are given below.
Editorial Note
This month’s Perinatology Picks CCC Corner submission (below) offers background on Nausea and Vomiting of Pregnancy for these 3 questions. This background is based on the Perinatology Corner CME module on Nausea and Vomiting of Pregnancy
After you peruse this material and answer the questions, you should go to the link directly below, take the Posttest and receive free CME credit. http://www.ihs.gov/MedicalPrograms/MCH/M/NVP01.cfm
The module itself has many other available references and links to hundreds of other resources.
Case 1
MTB is a 24 y/o G1P0 at 10 weeks by her dates who presents to her first prenatal visit complaining of morning sickness. Her symptoms are not incapacitating, but she would like to feel better. She has tried various herbal teas without much relief. Your most useful recommendation at this initial visit would be:
- reassurance, small frequent intake, pyridoxine (vitamin B-6)
- prescribe a cholinomimetic agent (e.g., metoclopramide)
- prescribe a 5-HT-3 receptor inhibitor (e.g., ondansetron)
- clear liquid diet and bismuth subsalicylate (Pepto-Bismol)
Case 2
HB is a 30 y/o G3P2 at 9 weeks by her dates who presents for her first prenatal visit complaining of nausea with vomiting that lasts pretty much all day, but she is able to keep some food down. She says this has occurred with each of her pregnancies, but this time it is especially troublesome. She has had a small amount of spotting but no cramping. She appears to be well hydrated. Your initial work up at this time should include:
- complete metabolic panel, thyroid functions, amylase and lipase
- electrolytes, alanine aminotransferase, pelvic ultrasound
- upper abdominal ultrasound, H.pylori antigen testing, stool guiac testing
- no laboratory studies are indicated at this time
Case 3
EP is a 19 y/o G1P0 at 11 weeks by her dates who presents to the emergency department complaining of severe nausea and vomiting. She is wretching, appears ill, and is only able to produce a small amount of concentrated urine that is strongly positive for ketones. Your initial management should include:
- oral hydration, mental health consult
- intravenous hydration, admit for parenteral alimentation
- intravenous hydration, nasogastric tube, H2-blocker drip
- intravenous hydration, parenteral anti-emetics
Case 1
Correct answer: a
Ms B is a primigravida at 10 weeks who has mild pregnancy associated nausea.
It should begin to resolve by 12 weeks as serum HCG levels taper. In the meantime,
reassurance that this is a normal pregnancy symptom is appropriate. Dietary modification
in the form of small, frequent, usually dry, not fatty, meals is often helpful.
Pyridoxine, which is vitamin B6, is the pharmacotherapy that most often is helpful
for mild cases such as that described here, and usually has no side effects.
If pyridoxine is not helpful for her, she may supplement it with over the counter
doxylamine (the ingredient in mild sleep aids such as 'Sominex'). This combination
was formerly marketed as 'Bendectin ®', which is no longer available, but
which is definitely not a teratogen. It may also be supplemented with a phenothiazine
or an antihistamine anti-emetic for more severe symptoms, but she should know
that these are usually quite sedating. If these interventions are not helpful,
metoclopramide or a 5-HT-3 receptor inhibitor, such as ondansetron, can be added,
but mild symptoms, such as described, usually will not require these more costly
drugs, at least initially. Oral hydration is important, but fasting is not helpful.
Bismuth subsalicylate is often helpful for nausea in non-pregnant individuals,
but the high dose of salicylate is not recommended during pregnancy, and may
also cause constipation.
Case 2
Correct answer: b
Ms H is a multiparous woman at 9 weeks with symptoms which are quite distressing,
but she is able to accomplish some oral intake and does not appear to be dehydrated.
When we aren't able to offer a great deal therapeutically, we often 'go overboard'
diagnostically! Such 'mega work ups' for a problem that the patient knows is
recurrent each pregnancy is usually not cost-effective. A simple basic workup
is helpful however, and might include electrolytes (hypokalemia is the most common
abnormality encountered) and a screen for hepatitis. The alanine aminotransferase
(ALT, formerly known as SGPT or the serum glutamic pyruvate transaminase) is
usually the most sensitive. If it is abnormal, you can investigate further from
there. There is usually a history to suggest other gastrointestinal problems
(colicy RUQ pain radiating to the shoulder for gallbladder disease, epigastric
pain and pyrosis for peptic ulcer disease, a history of ethanol ingestion, etc.).
If your initial therapy proves unhelpful and the symptoms become worse or evolve,
then more of a GI work up may certainly be indicated later. While nausea and
vomiting is not a common symptom of hyperthyroidism, it has somehow become routine
to order thyroid functions on these women. If you have read a former 'Perinate's
Corner' on thyroid disease in pregnancy, you will recall that these women, who
typically have high human chorionic gonadotrophin (HCG) levels, will frequently
have an assay for TSH that often returns very low, suggesting hyperthyroidism.
This may occur in up to 20% of pregnant women in whom the newer third generation,
ultrasensitive TSH assays are obtained. These women may even have a mildly elevated
free T4, but they will be clinically euthyroid, without tremor, tachycardia,
hyperreflexia, or the other signs of hyperthyroidism. Both these biochemical
abnormalities will resolve by 18 weeks and anti-thyroid medications should not
be started. (They will not help the nausea and vomiting either!) They may cause
the fetus, who is totally dependent on its mother's thyroxine until its own gland
becomes functional at about 18 weeks, to become hypothyroid, with the accompanying
later intellectual deficits. 'Primum non nocere' (first do no harm)!
Case 2
Correct answer: d
Ms P is a 19 y/o primigravida at 11 weeks with symptoms probably severe enough
to be characterized as hyperemesis gravidarum. She is clinically dehydrated and
may well need to be admitted. She certainly needs an IV for hydration as she
is unlikely to tolerate PO. Despite a common belief that this disorder is largely
'psychological', there is no evidence that these women have any higher incidence
of mental health issues than other pregnant women who do not have such severe
symptoms. This patient will almost certainly need parenteral anti-emetics. Either
a phenothiazine or an antihistamine type may be very helpful here. Severe symptoms
such as these may also benefit from IV metoclopramide and/or dolasetron or ondansetron.
These classes of drugs are usually very effective, but the 5-HT-3 receptor inhibitors
are quite costly, usually upwards of $50 a dose, so they should be reserved for
women who are unresponsive to other forms of therapy. Nasogastric suction and
therapy aimed at reducing gastric acidity are usually not helpful for this disorder.
Further work up may well be indicated in patients such as this who have severe
and recurrent symptoms that are not amenable to therapy. Specific therapy can
then be tailored to any pathology that may be uncovered. Parenteral nutrition
was formerly used in hyperemesis patients who were unable to maintain oral intake,
but, as noted above, they have fallen out of favor because of the associated
complications.
After you absorb (sic) the material above and the Background in the Perinatology Picks below, you should go to the link directly below, take the Posttest and receive the free CME credit. http://www.ihs.gov/MedicalPrograms/MCH/M/NVP01.cfm