February 6, 2015

Exposure to Certain Chemicals During Pregnancy Might Affect Fetus

Researchers have found a link between a fetus’ exposure to two common household chemicals and a lower IQ among the children several years later.

The scientists from Columbia University’s Mailman School of Public Health published their research in the journal PLoS ONE last month. In a news release, they described how children exposed during pregnancy to elevated levels of di-n-butyl phthalate (DnBP) and di-isobutyl phthalate (DiBP) had an average IQ score more than six points lower than children exposed to those chemicals at lower levels.

DnBP and DiBP are found widely in consumer products ranging from dryer sheets to vinyl fabrics to lipstick, hairspray, nail polish and even some kinds of soap. In the U.S., according to the Consumer Product Safety Commission, six kinds of phthalates are banned from toys and other child-care products. But no measures have been taken to protect a developing fetus, such as alerts to pregnant women about potential exposure. In fact, according to the Columbia release, in the U.S., phthalates seldom are listed in a product’s ingredients.

For the study, researchers followed 328 women and their children. They assessed the mothers' exposure to four phthalates — DnBP, DiBP, di-2-ethylhexyl phthalate and diethyl phthalate — during their third trimester of pregnancy by measuring levels of the chemicals' metabolites (signals of how a body processes a substance) in urine. When they were 7, the children were given IQ tests.

Children of mothers exposed during pregnancy to the highest 25% of concentrations of DnBP and DiBP had IQs 6.6 and 7.6 points lower, respectively, than children of mothers exposed to the lowest 25% of concentrations.

The pattern held when specific aspects of IQ were tested, including perceptual reasoning, working memory and processing speed.

The researchers found no associations between the other two phthalates and child IQ.

It’s especially worrisome that, as the study’s lead author said in the news release, "Pregnant women across the United States are exposed to phthalates almost daily, many at levels similar to those that we found were associated with substantial reductions in the IQ of children."

Another scientist involved with the research said, “A six- or seven-point decline in IQ may have substantial consequences for academic achievement and occupational potential.”

It’s impossible to avoid all phthalates in the U.S., but the researchers recommend that pregnant women try to limit their exposure by:

  • not using plastic when they microwave food;

  • avoiding scented products such air fresheners and dryer sheets; and

  • not using recyclable plastics labeled as 3, 6, or 7.

The Columbia results advance earlier research showing an association between prenatal exposure to DnBP and DiBP and children's cognitive and motor development, and behavior when they are 3. And a couple of months ago, Columbia researchers reported a link between prenatal exposure to phthalates and risk for childhood asthma

Although it's not clear how phthalates affect child health, numerous studies show that they disrupt the actions of hormones, including testosterone and thyroid hormone. So it’s best to avoid them if you can.

To see the degree to which pregnant women are exposed to all kinds of chemicals, see our blog of a few years ago, “Dangerous Products Found in Virtually All Pregnant Women.”

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January 16, 2015

Fetal Scans Are a Medical, Not Entertainment, Event

There’s an increasing awareness of the risks to patients of getting unnecessary imaging tests, but only recently have these concerns arisen about fetuses. Last month, the FDA issued a consumer warning that undergoing unnecessary fetal ultrasounds or fetal Doppler heart beat monitoring might endanger the tiny residents of a womb.

As explained on AboutLawsuits.com, Doppler heartbeat monitors and ultrasound scans are prescription devices to be used only by trained health-care professionals. But a lot of parents-to-be are paying for these images and videos of their fetuses as keepsakes, when there is no real medical need. Some, the story said, turn the prenatal photo sessions into entertainment; some parents stage “ultrasound parties,” and post the images and videos on the internet.

We won’t comment on the material someone chooses to make electronically viral. But a procedure once done only under doctor’s supervision has become a novelty event for many people, and we’re concerned about consequences they might not anticipate.

The FDA acknowledges that ultrasounds generally are considered safe, but they have potential biological effects. Ultrasound can heat body tissue slightly, which produces small bubbles, or pockets of gas, in body fluids or tissue, a condition called cavitation.

Long-term effects of ultrasound and the potential for cavitation to a fetus are unknown, so the feds encourage consumers not to use the machines as over-the-counter devices or for the mere purpose of capturing the image of a human developing in utero.

“In creating keepsake videos there is no control on how long a single imaging session will last, how many sessions will take place or whether the ultrasound systems will be operated properly,” according to the consumer update.

The health watchdogs understand the appeal of ultrasound imaging to parents, they understand that it can “promote bonding between parents and the unborn baby.” But parents can achieve the same result from the procedures given during regular prenatal care appointments.

Regarding the Doppler fetal ultrasound heartbeat monitors, often sold over-the-counter as Doptones, the FDA said casual use exposes the fetus to prolonged, unsafe energy levels. And the monitor might yield information parents interpret incorrectly. That can lead to unnecessary worry and expense for follow-up care.

Ultrasound imaging is the most widely used medical imaging method during pregnancy, AboutLawsuits noted. Doctors have used it for a generation to check on fetal health, including breathing, movements and size. It renders real-time images from high-frequency sound waves moving inside the uterus. Unlike X-rays, it doesn’t involve radiation. (See our blog, “Kids and CT Scans: Not So Fast, Parents.”)

But it might involve other complications as yet unknown that present with overuse, and inappropriate use. It’s normal to be curious about the life forming in your womb. But curiosity is best served by careful medical application.

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September 6, 2013

Study Showing Association Between Induced Labor and Higher Autism Risk for Boys Is Sloppy Science

A study published last month in JAMA Pediatrics indicated that boys whose mothers needed help to initiate or move the process of labor along may have a higher risk of autism.

But there are several reasons why the research contributes less to the body of knowledge and more to the mass of misinformation.

As reported by Bloomberg.com, induced labor, which stimulates the uterus in order to prompt contractions, and augmented labor, which increases the strength, duration and frequency of contractions, showed a 35 percent greater risk of autism in boys than babies whose mothers didn’t need those procedures.

According to the Centers for Disease Control and Prevention, 1 in 50 U.S. children between 6 and 17 years old is diagnosed with an autism spectrum disorder (ASD). Few childrens’ psychological disorders have been given more attention recently than autism, leading to a breathtaking wealth of misinformation about its causes, from vaccinations to diet.

The study was published in JAMA Pediatrics, a prestigious publication that, suggests writer Emily Willingham, should know better than to publish such incomplete research as the induced labor-autism risk study … or at least fully explain its considerable shortcomings.

In her analysis of the study on Forbes.com, Willingham points out that the study “did not show a cause and effect between induced (initiated) or augmented (hastened) labor and autism. It found an increased odds that a child born following a labor induction and augmentation would later be labeled as autistic by special education services. Yet there are problems with reaching even that conclusion.”

Instead of the cause-and-effect conclusion the researchers drew, Willingham said, they could just as easily have said, “Labor induction risk may be raised when child is autistic.”

Willingham noted several possibly influential factors that weren’t included in the study, probably, she surmised, because they weren’t available: mother’s BMI [body mass index, a measure of fitness that identifies percentages of fat and muscle] from pre-pregnancy; father’s age; child head circumference; specific child birth weight; mother’s insurance status; presence of any sibling births in the cohort; and whether or not the child had autistic siblings. “Lack of availability of relevant data,” Willingham states, “can sometimes make a study untenable, at least, and at best should warrant considerable caution in interpretation and speculation.”

Willingham goes into interesting detail about the study’s take on chances of an autism diagnosis and whether or not the mother has a college degree, or smokes, demonstrating, again, that science isn’t simple. We’d go a step further: Social pressure can’t overcome our desire to make it so.

To be clear, the researchers didn’t conclude that standard clinical practices be changed as a result of their study. “The results,” the lead author told Reuters, “don’t dictate there be any change in any clinical practices surrounding birth. The dangers to the mothers and the infants by not inducing or augmenting far outweigh the elevated risk for development of autism.”

In some circumstances, of course, induced labor can help reduce deaths among mothers and babies. But more studies are required to understand more fully why such procedures might be associated with the risk of disorders as elusive as autism.

Willingham’s conclusion reinforces what we hope readers will always consider when reading about research studies, even in the original form:

“This study didn’t show that induction or augmentation during childbirth substantially increases the risk for autism, although it hints at a greater influence of socioeconomic status and by implication, healthcare access. If anything, based on earlier literature, it adds a slight if only mathematical confirmation of the perception that births involving autistic children can be associated with more complications, such as the presence of meconium [fetal defecation], gestational diabetes and fetal distress, than births involving nonautistic children. And that points to induction and augmentation as useful in these situations, not as problematic, and certainly does not affirm them as a risk.”

For more information, see our blogs, “Autism Rates Rise,” and “Helping Parents Through the Autism Maze.”

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July 19, 2013

Waiting Longer to Cut the Umbilical Cord Helps the Newborn

During a medical procedure, the difference between 30 and 60 seconds often is critical only for emergency situations. But a new study supports the idea that cutting the umbilical cord slightly later is better for the newborn baby and poses no harm to the mother.

Most doctors, as described by the New York Times, generally clamp and sever the umbilical cord within one minute of birth. This the-quicker-the-better approach has been thought to reduce the risk of the mother hemorrhaging. But the new study, published in The Cochrane Database of Systematic Reviews found that waiting at least a minute after birth to clamp the cord allows more blood flow from the placenta, improving the baby’s iron and hemoglobin. There was no additional risk of severe postpartum hemorrhage, blood loss or reduced hemoglobin levels to the mother.

The Cochrane review analyzed data from 15 randomized trials involving 3,911 women and infant pairs.

The Times’ story indicates that the timing of clamping—which occurs in two places along the umbilical cord, the cut to be made between the clamps—has been controversial for a long time.

The Cochrane paper showed higher hemoglobin levels 24 to 48 hour after birth in newborns whose cords were clamped later. These babies also were less likely to be iron-deficient three to six months after birth, compared with term babies who had earlier cord clamping. Birth weight also was significantly higher in the late clamping group, partly because babies received more blood from their mothers.

The World Health Organization (WHO) recommends clamping of the cord from one to three minutes after birth, according to The Times, because it “improves the iron status of the infant.” Sometimes, delayed clamping can cause jaundice in infants because of liver trouble or an excessive loss of red blood cells. The WHO says that where later clamping is practiced, jaundice treatment should be available.

As noted in our backgrounder, jaundice is an uncommon type of birth-related brain injury; the yellow skin signaling jaundice means the baby has too much bilirubin, the yellowish color in bile, in his or her blood.

A committee of the American College of Obstetricians and Gynecologists last year reviewed much of the same evidence as the Cochrane study, but came to a different conclusion from the WHO. It found the material “insufficient to confirm or refute the potential for benefits from delayed umbilical cord clamping in term infants, especially in settings with rich resources.”

The committee said that the risks of jaundice and the relative infrequency of iron deficiency in the U.S. meant that the long-standing practice of immediate clamping should not be changed.

There are circumstances in which early clamping is required—if an infant requires resuscitation or aspirates its own stool. The new analysis found a 2% increase in jaundice among babies who got delayed cord clamping. Those babies should tested three to five days after birth.

Dr. Eileen Hutton, a midwife who teaches obstetrics at McMaster University in Ontario and published a systematic review on cord clamping, said the Cochrane report was “comprehensive and well done,” but she would have preferred a conclusion that was even stronger in favor of delayed cord clamping.

“The implications are huge,” Hutton told The Times. “We are talking about depriving babies of 30 to 40 percent of their blood at birth—and just because we’ve learned a practice that’s bad.”

Dr. Tonse Raju, a neonatologist at the National Institute of Child Health and Human Development agreed: “It’s a good chunk of blood the baby is going to get, if you wait a minute and a half or two minutes,” he told The Times. “They need that extra amount of blood to fill the lungs.”

Healthy babies manage to compensate if they do not get the blood from the cord, Raju said, but researchers do not know how.

Because the Cochrane review had few subjects who had undergone Caesarean delivery, “We don’t have enough information on the effects of delayed cord clamping for someone undergoing a Caesarean delivery in terms of postpartum hemorrhage,” Dr. Cynthia Gyamfi-Bannerman, medical director of the perinatal clinic at Columbia University, told The Times. “Waiting 30 or 60 seconds in a vaginal delivery in a low-risk patient is probably something we could do and wouldn’t have maternal consequences, but in a Caesarean delivery, you’re cutting into a pregnant uterus that has a huge amount of blood.” In some scenarios, “there’s an increased risk of postpartum hemorrhage.”

Also, there was no data on long-term neurological outcomes. But, according to The Times, improved iron stores might help reduce the risk of learning deficiencies and cognitive delay in children. Those problems have been linked to iron-deficiency anemia in school-age children.

If you are expecting, discuss the timing of cord clamping and cutting well before your due date. Your doctor or midwife should give you as complete a picture as possible of the nature of your pregnancy, and whether you and your new family member are candidates for waiting just a bit longer to cut that cord.

For more information, see our backgrounder on prenatal care.

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April 19, 2013

Hospitals Show Progress in Clamping Down on Early Elective Deliveries

A few months ago, we recalled a case in which Patrick Malone represented a family who sued a group of obstetricians when their baby was delivered early and suffered brain damage. As we noted in that blog, except when there are real medical complications, the American College of Obstetricians and Gynecologists recommends against delivering babies or inducing labor before 39 weeks of gestation.

Earlier this month, a study published in the journal Obstetrics & Gynecology not only confirms the wisdom of waiting to full-term before delivering the baby, but shows that hospitals that promote full-term delivery can realize excellent results.

As described by KaiserHealthNews.org, the study profiled 25 hospitals in five states that were able to cut their rates of elective early deliveries from nearly 28 in 100 to fewer than 5 in 100 in one year.

Such efforts are critical to lowering the rates of deliveries, which can put babies at risk of serious health issues including feeding, breathing and developmental problems. The latter often turn out to be long-term problems—one study by researchers at Emory University found that babies born before 38 weeks had lower scores on standardized tests in first grade.

Because 10 to 15 of 100 U.S. babies are delivered early without a medical reason, the value of full-term gestation needs to have wider appreciation among both parents and doctors. It is not uncommon for either party to opt for early delivery not because it’s optimal for the wee ones, but simply because it’s more convenient. That is, too often early delivery is a matter of scheduling preference than medical need.

Hospitals are starting to accept that they are on the frontlines of preventing the long-term negative effects of early delivery, and so must the rest of us. As the lead author in the hospital survey said, “This quality improvement program demonstrates that we can create a change in medical culture to prevent unneeded early deliveries and give many more babies a healthy start in life.”

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February 8, 2013

Electing Early Delivery Is Seldom Wise

It has been nearly 35 years since the American College of Obstetricians and Gynecologists (ACOG) recommended against delivering babies or inducing labor before 39 weeks of gestation, except when there are medical complications, such as the mother's high blood pressure (pre-eclampsia; see our recent blog on the Downton Abbey all-too-real plot line), diabetes or signs that the fetus may be in distress.

So why, then, are an estimated 10 to 15 out of 100 U.S. babies delivered early every year for no medical reason?

That reality is examined in a recent story by Kaiser Health News and the Washington Post. "After 37 weeks, patients really push for it because they are miserable and don't want to be pregnant anymore," Alfred Khoury, director of maternal-fetal medicine at Inova Fairfax Hospital, told KHN/Washington Post. "Or they say, 'My mother is here' or 'I have to be in a wedding.'"

Sometimes, it’s a matter of provider availability. Physicians who work alone or in rural areas might prefer to schedule deliveries before 39 weeks for time-management purposes. That’s a bad idea, but, said Helain J. Landy of the department of obstetrics and gynecology at MedStar Georgetown University Hospital, "The reality of caring for patients, or [doctors'] day-to-day needs, may sometimes interfere with following the guidelines."

In 2012, Patrick Malone represented a family in a medical malpractice lawsuit against a group of obstetricians for brain damage to a baby that resulted from misconceived plans for an early delivery. In that case, the doctor followed outdated medical literature that suggested babies of mothers with gestational diabetes should be delivered early even if monitoring shows the baby is doing fine. Mr. Malone's closing argument of the trial on behalf of both baby and mother can be read here.

Now, poor doctoring and patient ignorance are coming under the control of some government and private insurers, who are discouraging and sometimes penalizing doctors and hospitals for delivering babies early without cause.

It’s a good idea from both a health and financial perspective.

Often, prematurely delivered babies develop problems ranging from breathing and heart disorders to anemia and bleeding in the brain that land them in the neonatal intensive care unit (NICU) where, according to KHN/Washington Post, the average charge is $76,000 per stay. (Learn about NICU injuries in our backgrounder.)

The folks who pay most of that tab also want to avoid subsequent medical costs to treat problems including jaundice, feeding difficulties and learning and developmental issues. Sometimes the health problems of preemies last their whole life.

As reported in the story, UnitedHealthcare, the nation's largest private health insurer, pays hospitals more if they take steps to limit early deliveries without medical cause and show a drop in their rates. And as of July, Medicare, which pays for disabled women to give birth, will require hospitals to report their rates of elective deliveries before 39 weeks. Hospitals might be penalized beginning in 2015 if their rates remain high.

Some insurers refuse to pay for unnecessary early deliveries at all. The South Carolina Medicaid program and BlueCross/BlueShield of South Carolina don’t reimburse providers for performing early deliveries without medical cause. Those two insurers cover more than 8 in 10 births in that state. Several other states either have or are considering such policies.

We’re reluctant to endorse such sweeping measures because individuals have different needs. But unnecessary early delivery is never a good idea.

Even without official prodding, some hospitals have taken steps to curtail elective early deliveries, and some simply won’t perform them. After St. Joseph Medical Center in Houston stopped performing them in 2011, NICU admission rates for babies born between 37 and 39 weeks dropped 25 percent in the first year.

Unfortunately, sometimes brawn works better than brain in encouraging practitioners to curb elective early births. One study mentioned by KHN/WP found that educating doctors about the risks was less effective in reducing rates of early deliveries than having medical staff simply prohibit the practice.

But some physician groups don’t like being told how to practice medicine.

"We oppose the legislative control of medicine," said Jeanne Conry, president-elect of ACOG told KHN/WP. Conry says her organization has developed its own "clear, effective guidelines" laying out clinical markers for determining when early delivery might be appropriate.

And as one obstetrician noted, when states or insurers get involved, doctors may hesitate to deliver early even when there are clinical reasons to do so. "Outcomes are best when there is a doctor-led process, rather than a legislative or payment mandate," he said.

Even the March of Dimes, that notable champion of safe birth practices, is wary of using financial rewards or penalties. "Payment is a really big hammer, and we want to have a comfort level with a policy so we don't cause unintended consequences [such as making doctors reluctant to perform early deliveries even when they are needed],” Cindy Pellegrini, a March of Dimes executive told KHN/WP.

Some doctors welcome the oversight, as one obstetrician said, to help "us all do the right thing" and make it easier to educate women.

But decades after the ACOG guidelines, only 1 in 3 hospitals reports rates of elective early deliveries at or below the goal of 5 in 100, according to the Leapfrog Group, an organization of businesses focused on patient safety. Many still have rates higher than 15 in 100.

Some of the resistance, unfortunately, might be because NICUs are profit centers for many hospitals.

The best way to address the wisdom of full gestation is to educate patients. There’s some work to do there—one survey from a couple years ago involving 650 women who had recently given birth found that half considered it safe to deliver before 37 weeks.

If you are expecting, or expecting to be expecting, make sure you and your obstetrician are on the same page regarding the optimum time for delivery. Do not accept any reason other than medical necessity for inducing labor before the due date, or otherwise delivering prematurely. It’s bad medicine with potentially lifelong consequences.

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December 14, 2012

New Prenatal Test Is Less Risky but Less Trustworthy

Prospective parents who want to know if their baby has a genetic disorder such as Down syndrome are advised to consider amniocentesis or chorionic villus sampling (CVS). Amnio, generally performed during the second trimester, involves inserting a needle into the amniotic fluid surrounding the fetus. The CVS probe removes a sample of the sac surrounding the fetus toward the end of the first trimester. Both carry a small risk of miscarriage.

So some people are choosing a different procedure that can be done as early as 10 weeks into the pregnancy and involves only drawing the mother’s blood. Three versions of the test have been available for a year, and although its convenience is appealing, according to a recent story by Kaiser Health News and the Washington Post, the decision to use it is complicated. The technology is not subject to regulation by the FDA, and the body of research about its accuracy is slim.

Thousands of the tests have been performed (at a cost of as much as $1,900) while they remain under review. Insurance companies don’t (yet) cover the cost, and because the test is so new, it’s unclear if, eventually, it will reduce miscarriages and the cost of complications by reducing the use of the more invasive tests. Will the tests, instead, increase costs because women who otherwise would pass on amniocentesis will opt for the blood draw?

According to the KHN/Post story, amnio is performed about 200,000 times every year in the U.S. In the Washington, D.C. area it costs about $2,500. As a standard test, it’s generally included in maternity coverage.

The new tests, typically, are offered only to women whose age and medical history put their fetus at a higher risk of having a chromosome abnormality; standard screening tests often are offered to all pregnant women.

The risks of having a fetus with a genetic disorder are greater if the mother:

  • is 35 or older;

  • has a history of miscarriages or children born with birth defects;

  • has a family history of genetic disease.

In addition, prenatal genetic testing is recommended if either parent has a family history of genetic disease or is known to be a carrier of a genetic disease.

The new test examines DNA fragments to see if a fetus carries three instead of the normal two copies of chromosomes 21, 18 or 13. An extra copy of 21, a called trisomy 21, is the main cause of Down syndrome; and extra copy of 18, called trisomy 18, causes a less common disorder, Edwards syndrome. Trisomy 13 is also known as Patau syndrome. All three are linked to serious developmental and medical problems.

Earlier this year, we wrote about the fate of babies handicapped by two of these conditions.

The test checks the mother’s blood levels of pregnancy-associated proteins and hormones and includes an ultrasound to see if there’s extra fluid at the back of the fetus' neck. The two procedures appear to detect about 9 in 10 cases of Down syndrome, and an even higher ratio of trisomies 18 and 13.

As the KHN/Post story says, 5 in 100 tests result in a false-positive—that is, showing a defective gene when there isn’t one. Only amniocentesis or CVS provide definitive answers.

Last month the American College of Obstetricians and Gynecologists said that the tests "should not be part of routine prenatal laboratory assessment." The organization hedged that statement, however, by noting that the tests can be offered to patients at increased risk of having a baby with a trisomy, but must be preceded by counseling about their limitations. Other professional groups, the National Society of Genetic Counselors and the International Society for Prenatal Diagnosis, agreed.

Given the lack of research proving the accuracy of the new test, all three organizations recommend that anybody who received a positive result undergo amniocentesis or chorionic villus sampling to verify the diagnosis.

So the question arises: If you have to confirm a diagnosis, should you have the test in the first place? Is the minimal risk of complication, in comparison to the greater, but still small risk of miscarriage with the standard, proven tests, worth it?

Maybe, especially if you are in the high-risk group for fetal genetic abnormalities. And although cost might be a factor, at this point, the companies who market the tests offer considerable subsidies. According the KHN/Post story, “[T]he most that women with insurance have to pay out of pocket is $235 for the MaterniT21 Plus test (list price $1,900) and $200 for Verifi (list price $1,200), even if their plan declines to cover the test. Both companies offer self-pay options for women without insurance: The price is $450 to $500 for MaterniT21 Plus and an ‘introductory price’ of $495 for Verifi.”

Insurance companies regularly review new technologies and treatments to make decisions about covering them. As the research file about the maternal blood tests grows, if the evidence of their accuracy is compelling, the tests eventually could be considered “standard.”

But that’s not their status today, and their worth must be determined on an individual case basis after frank and full discussion between the obstetrician and the parents.

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October 19, 2012

Is It Safe for Pregnant Women to Eat Fish?

Americans are conflicted about fish. Some of us like to catch them, some of us like to release them and many of us eat them. Health professionals say that fish is good for us (it’s high in protein, most varieties are low in fat and many have heart-healthy properties), that we should eat more. Others take care to note that some varieties of fish are particularly prone to toxic exposure to mercury.

So what’s a pregnant woman to do, especially in light of a new study that shows that a prospective mom’s fish-rich diet can offer protection against the child later developing behaviors associated with attention-deficit/hyperactivity disorder (ADHD)? Especially in light of the Journal of the American Medical Association’s advice (JAMA) that for pregnant women, mothers who are breastfeeding and women of childbearing age, fish consumption is important for its DHA, an omega-3 fatty acid that aids infant brain development?

The new study, published in the Archives of Pediatric and Adolescent Medicine, involved children born during the 1990s in Massachusetts; 515 women who had just given birth completed a dietary survey and about 420 provided samples of their hair for mercury testing. About eight years later, researchers tested the kids to assess behaviors associated with ADHD.

The results, as reported on ScienceNews.org, ranged from children with almost no ADHD-related behaviors to some with clear clinical disease. The mother’s hair-mercury level related to where her child fell along the spectrum.

The data, the researchers said, demonstrate that a woman can eat fish regularly, but also maintain a low-mercury diet. “It really depends on the type of fish that you’re eating,” one of the authors told ScienceNews. Some study participants had been eating more than two servings of fish weekly but tested for relatively little mercury.

Like lead, mercury is a potent neurotoxin that has been linked to many health problems, including delays in neural development. To see our post about the toxic nature of lead, click here.

In the study, children of women with hair mercury levels in the top 20 percent of those tested showed a 50 to 60 percent increased risk of ADHD-related behaviors. But the kids with ADHD-related traits “were still considered to be within the normal range,” the researcher said, “and not maladaptive.” (On some components of the childrens’ assessment for attention, boys showed a greater sensitivity to mercury than girls.)

Other studies have reached similar results. One based in Canada, according to ScienceNews, found an association between elevated mercury concentrations in children at birth and at school age, and an increased risk of ADHD by about age 11. That study also confirmed earlier evidence suggesting a link between lead and ADHD.

Some studies, however, indicate a genetic susceptibility to ADHD in some people. Environmental pollutants, too, are considered by some people to be risk factors. They include tobacco smoke and possibly polychlorinated biphenyls (PCBs), certain pesticides and bisphenol A (BPA).

The new study didn’t collect data on the species of fish the mothers ate. But its researchers said that previous studies have shown that tuna, swordfish and shark can be particularly high in mercury; salmon and cod tend to be relatively low in the toxic metal.

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August 3, 2012

Genetic Disorders Study Shows Some Doctors Dehumanize Handicapped Babies

In a touching post on Neonatalresearch.org titled “Our children are not a diagnosis,” Dr. Keith Barrington, a neonatologist and researcher at Sainte Justine University Health Center in Montréal, responded to a recently published study in the journal Pediatrics about families with children who have trisomy 13 and 18.

Those are chromosomal disorders that cause significant neurodevelopmental disability. Fewer than 1 in 10 babies born with them survives to his or her first birthday. Trisomy 13 occurs in about 1 in 5,000 births. Trisomy 18 occurs in about 1 in 3,000 births, and predominantly among girls. Often, the disorders are treated with palliative measures only—that is, patients are made as comfortable as possible, but not given medical interventions.

Barrington was disturbed by the study’s results not because it challenged assumptions about life with such severely disabled children, but because of what the parents reported about the medical establishment’s attitude toward them.

Caveats about the study concern the fact that survey participants were found through Internet-based support groups and Facebook groups dedicated to trisomy 13 or 18. Surveys were emailed to parents of children born with full or partial forms of the chromosomal disorders. Clearly, they might not represent all parents of children with congenital disorders.

More than 330 parents completed the questionnaire. Some had been given a diagnosis before their babies were born, and others had not. So those with a prenatal diagnosis might have had the option to abort, but did not. The study included only parents whose babies had been born alive.

About half of the parents chose palliative care, one-quarter chose limited medical care after birth and one-quarter wanted full intervention. The length of the children’s survival didn’t differ much among all the families.

Among the study’s findings was that the parents who regretted their choices about the extent of medical intervention were overwhelmingly the ones who had chosen comfort care only. Also, the children did show signs of developmental progress, all were able to communicate with their parents at some level and most parents reported their child as being happy.

But most gratifying was that the parents overwhelmingly reported that the experience of living with their disabled child had made a positive contribution to family life, irrespective of how long their afflicted children lived. The fact that their disorder had created substantial financial stress was irrelevant.

Here’s the disturbing part: Although 2 in 3 of the families met at least one medical provider they described as helpful, most had been given misinformation, and many of those who had chosen active care felt that they were judged negatively by providers for making that decision. They reported that providers often referred to their baby in dehumanizing terms, calling him or her “it” or “a T18.” The parents told of interactions with providers who never learned their baby’s name, only the diagnosis.

To a parent, a child is a child. He or she might be brilliant, disabled, athletically gifted or socially awkward. He or she might be gorgeous or homely, able to engage or closed off in his or her own world. A child with problems is no less a human being than one fortunate enough to be perfectly healthy.

Although adults can make honest mistakes because of ignorance or discomfort, anyone with compassion makes an effort to connect with people not as lucky as they. A person who has chosen medicine as a profession and refers to another damaged person by diagnosis instead of name is less a human being than a wad of protoplasm in desperate need of re-education.
As Barrington concludes, the study highlights “the uniqueness of each of these children and the heterogeneity of condition and survival. …[W]e cannot be definite about the duration of survival or the capacities of an individual.”

The researchers concluded that parents who engage with parental support groups may discover a positive perspective about children with T13 and T18 that might stand in contrast with that of medical practitioners.

Here are Barrington’s guidelines for medical providers when talking with parents who have received a diagnosis, prenatal or postnatal of T-13 or T-18. If you’re a parent in this situation, and your providers fail to observe them, let them know of their deficiencies, and seek help from others who are not so afflicted.

1. Don’t say that this is “‘incompatible with life”; it’s callous, and it’s a lie.

2. Don’t say that if they survive “they will live a life of suffering;” parents do think that their child had more pain than others, but they also had many positive times, and their overall evaluation was positive.

3. Human beings are not vegetables. These children are conscious and interact, even if at very limited levels. Carrots don’t.

4. Don’t predict marital disharmony or family breakdown. There is no evidence that it occurs more when a family has a baby with severe impairments. Families find meaning in the lives of their children. Whether those lives are unimpaired or lived with severe impairments. Whether they are very short or not.

5. Don’t suggest that the child is replaceable. If parents initiate the idea that they can have another child, fine, but for you to suggest it indicates that you think this child is worthless.

6. Don’t say that there is nothing you can do for them. There is a lot you can do. Empathy and a positive attitude, finding resources, respite care and enabling appropriate medical care are among what you have to offer.

7. Be explicit about medical decision making; come to an agreement about the limits of medical interventions (if you can’t, then find them another doctor who can); be open to changing the plan as time goes on.

8. Refer to the child by name if there is one. Some doctors ask prospective parents if they have chosen a name, which demonstrates recognition that a fetus has potential as a human being.

9. Recognize that these babies will be loved, cared for and will leave a positive mark on their families.

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August 28, 2011

A Simple Heart Test for Newborns

One in 100 newborns has a malformed heart. It's the most common birth defect. Now, a federal advisory panel recommends a simple and painless test for all newborns to detect such defects before the babies are released from the hospital.

Pulse oximetry measures the amount of oxygen in the blood via a small light sensor taped to a baby's wrist, hand or foot. It's inexpensive ($5-$10), fast (five minutes) and can detect a life-threatening condition otherwise difficult to find in a physical exam. An infant's cardiovascular system might appear normal in the first few days after birth, even though it continues to mature.

According to WebMD, only two states -- Maryland and New Jersey -- legally mandate the test. Some hospitals elsewhere do it voluntarily, but it's not in widespread use.

The federal panel's advice has been endorsed by the American College of Cardiology, the American Heart Association and the American Academy of Pediatrics.

If you're expecting, and you don't live in Maryland or New Jersey, make sure your hospital knows you want the test to be performed before your bring junior home. The chances of heart problems are low, but it's better know if there is one -- and to address it -- before it presents far from where it can be treated.

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August 21, 2011

Learning from Tragedy: The Faces of Children Hurt by Medical Error

The Empowered Patient Coalition has put together a moving short video of some of the many children killed from malpractice and other medical errors. Watch it here.

Then check out the Coalition's website for tools on how you can be a safer, smarter patient for yourself and your loved ones.

Helen Haskell and Dr. Julia Hallisy are mothers of children harmed by medical error who founded the Empowered Patient Coalition to try to make the medical system better and safer for future patients.

Another touching video on turning medical tragedy into something positive was put together recently by Mary Ellen Mannix, a mom who lost a baby to medical mistakes in 2001. She went on to start James's Project, which focuses on patient safety to improve infant mortality and maternal health. Watch the video here.

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July 5, 2011

Good Oral Health Starts in Infancy

Pop quiz: Which of the following promote tooth decay?

(A). sugar;
(B). genetics;
(C). low immunity;
(D). watching "American Idol."

The correct answer, of course, is "all of the above" ... with a qualifier for (D). (You have to be snacking on Raisinettes or another sticky fruit while watching the show.)

Although sugar remains the primary suspect in the creation of cavities, people can be genetically disposed toward tooth decay, and low immune function can contribute, as can dietary habits generally considered healthful--sticky fruits such as raisins, although preferable to sucking on a Popsicle, also leave teeth vulnerable to the ravages of sugar residue.

So what can a concerned parent do?

It's hard enough for parents to control so many factors conspiring to turn their kids' mouths into a gaping maw of dental disaster, but now there's something else to consider. According to the Los Angeles Times, several studies have shown that cavity-causing bacteria can be passed from primary caregivers to wee ones.

Children are most susceptible as infants and toddlers, when their immune systems are works-in-progress. But any age before children have the motor skills necessary to brush well by themselves requires parental invervention for maximum protection.

If you want to hold the line on sharing the bacterial love that can compromise your child's oral health not only as a youngster but after the arrival of permanent teeth and into adulthood, first take care of yourself. Expectant mothers should address any dental decay or gum problems before Junior arrives to reduce the likelihood of transmitting disease. And the use of an antibacterial mouthwash during the lower-immune period of infancy and toddlerdom might be wise.

In addition, the dentist should become a close, personal friend of your child probably earlier than you expect. Measures you should take include:

  • schedule the first visit to a pediatric dentist at the time the first tooth appears or by the first birthday;

  • limit the contents of bottles and sippy cups to water except at mealtime;

  • limit snacking to a short interval--bacteria like any kind of sugar, whether from fruit, milk, honey or the refined white sugar in candy;

  • assist your child with tooth-brushing until he or she is old enough to tie shoes or write cursive--generally 7 to 9 years old.

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May 2, 2011

New York creates fund for babies with brain damage from malpractice errors

New York state has created a new fund to pay medical expenses for infants who are neurologically damaged as a result of malpractice and other medical mistakes, but opponents say it means families will have to fight with state authorities to obtain treatments as their children age.

The fund, which is due to go into effect on Oct. 1, 2011, allows medical costs to be provided on an annual basis to injured parties. Parents or guardians can still pursue medical malpractice actions on the basis of emotional distress and other losses.

Between 150 and 200 babies are expected to qualify annually for the new fund, according to Jason Helgerson, Gov. Andrew Cuomo's chief Medicaid reform adviser. Participation in the fund is mandatory for those seeking either Medicaid recompensation or filing medical malpractice suits.

Helgerson says the fund will offer a more accurate means of providing care for injured infants because it isn’t subject to inaccurate estimates made by judges and juries trying to arrive at an accurate figure for health-care costs under the current malpractice award system.

But opponents of the fund maintain that the system was championed by health-care providers and will subject the families of neurologically damaged infants to on-going battles with the state for treatments as their children age.

Under the new statute, the fund describes "birth-related neurological injuries" as "an injury to the brain or spinal cord of a live infant caused by the deprivation of oxygen or mechanical injury occurring in the course of labor, delivery or resuscitation or by other medical services provided or not provided during delivery admission that rendered the infant with a permanent and substantial motor impairment or with a developmental disability."

Medical care will be decided on a case-by-case basis. In the event the fund is reduced to 20 percent or less of its annual size, the law contains a default stipulation allowing suits to be brought for medical expenses.

The establishment of the fund was included in a host of recommendations by a Medicaid Redesign Team (MRT) appointed by Gov. Cuomo to halt escalating Medicaid costs. Another recommendation from the task force called for capping noneconomic damages in medical malpractice cases at $250,000. That proposal was fiercely opposed and eventually scrapped.

Source: New York Law Journal

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February 18, 2011

Fetal heart rate monitoring significantly cuts baby deaths

The use of fetal heart rate monitors lowers the rate of infant mortality, according to a new study. Previous studies were too small to definitively prove the effectiveness of fetal monitoring, and some obstetricians maintained that the technology had been adopted too quickly.

But the new study, which was presented at the Society for Maternal-Fetal Medicine's (SMFM) annual meeting in San Francisco, used data from the 2004 National Birth Cohort to get a large enough sample (1,945,789 singleton births that met the studies inclusion criteria) to gauge its effectiveness.

The study found that in 2004, 88% of singleton pregnancies had fetal heart-rate monitoring and associated the monitoring with significantly lower infant mortality (3.8 per thousand live births without monitoring vs. 3.0 with monitoring), which in turn was mainly driven by a 53% decrease in early neonatal mortality. The decreased risk was associated with both low- and high-risk pregnancies.

Source: Science Daily

You’ll find an abstract of the study here.

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January 19, 2011

Dangerous chemicals found in virtually all pregnant women, study says

Virtually all pregnant women in the U.S. are exposed to multiple and varied chemicals – some long banned, others currently used – that may harm the fetus during sensitive periods of development, according to a new study by researchers at the University of California San Francisco.

The study found that the bodies of virtually all pregnant women in the U.S. carry multiple chemicals, including some banned since the 1970s and others used in common products such as non-stick cookware, processed foods and personal care products.

The researchers used data from the National Health and Nutritional Examination Survey (NHANES) to determine whether 163 chemicals were in the blood or urine of 268 U.S. pregnant women sampled between 2003 and 2004.

According to the study - the first to look at a broad range of chemicals specifically in pregnant women - 99% to 100% of pregnant women carried polychlorinated biphenyls (PCBs), organochlorine pesticides, perfluorinated compounds (PFCs), phenols, polybrominated diphenyl ethers (PBDEs), phthalates, polycyclic aromatic hydrocarbons (PAHs) and perchlorate.

The health risks for mother and child associated with exposure to this many chemicals at detectable levels is not known. Low-level exposures to some of these chemicals during the prenatal period can cause long-term health effects, including birth defects, reproductive problems and cancer.

Surprisingly, DDE – a breakdown product of the long-banned DDT pesticide – was found in every woman and at some of the highest levels measured for any of the chemicals. Other chemicals found at high levels include perfluoroctane sulfonic acid (PFOS), which is found in food packaging and non-stick cookware; triclosan, found in antibacterial soap and products; and mono-ethyl phthalate (MEP), found in cosmetics and fragrances. Animal or human studies show all of these chemicals can interfere with the endocrine system.

In addition, many of the pollutants measured in the study can pass through the placenta from the mother to the developing fetus and have been measured in cord blood, fetal blood and amniotic fluid.

Source: Environmental health News

You can view the original report here.

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August 19, 2010

Maternity patient safety program improves health outcomes for newborns, mothers

A Canadian study is showing a positive way forward for making childbirth safer for mothers and babies, and reducing the devastating impact of malpractice on newborn children.

The Canadian “Managing Obstetrical Risk Efficiently” (MOREOB) patient safety program has a measurable, positive impact on the health of mothers and babies, according to a study published in the Journal of Obstetrics and Gynaecology Canada.

According to the study, the program results in a significant reduction in severe morbidity for newborns, as measured by the rate of serious complications such as respiratory distress syndrome, sepsis and severe intraventricular hemorrhage. For mothers, there was a significant reduction in third- and fourth-degree vaginal tears and length of stay in hospital.

MOREOB is a comprehensive, three-year, patient safety, professional development and performance improvement program for caregivers and administrators in hospital obstetrics units. The program structure's first priority is safety, followed by effective communication, teamwork, decreased hierarchy in emergencies, practice for emergencies, and reflective learning. It integrates evidence-based professional practice standards and guidelines with current and evolving patient safety concepts, principles and tools.

By learning and working together in their own practice environment, health-care teams use the shared knowledge, skills, attitudes and behaviors that contribute to safe, effective, patient-centered care in an efficient, collaborative, healthy practice environment.

“MOREOB is an innovative program that seeks to ensure that every pregnant woman receives optimal care. With the results of this new study, it is hoped that many other North American hospitals will emulate Alberta, and make MOREOB a key component of their hospitals’ training, standards and approach to obstetrical patient care,’ said Dr. André Lalonde, Executive Vice-President of the Society of Obstetricians and Gynaecologists of Canada.

Society of Obstetricians and Gynaecologists of Canada
You can view SOGC's press release here.

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