Tag: pediatrics

Physicians re-evaluate use of lead aprons during X-rays

When you get routine X-rays of your teeth at the dentist’s office or a chest X-ray to determine if you have pneumonia, you expect the technologist to drape your pelvis in a heavy radioprotective apron. But that may not happen the next time you get X-rays.

There is growing evidence that shielding reproductive organs has negligible benefit; and because a protective cover can move out of place, using it can result in an increased radiation dose to the patient or impaired quality of diagnostic images.

Shielding testes and ovaries during X-ray imaging has been standard practice since the 1950s due to a fear of hereditary risks — namely, that the radiation would mutate germ cells and these mutations would be passed on to future generations. This concern was prompted by the genetic effects observed in studies of irradiated fruit flies. However, such hereditary effects have not been observed in humans.

“We now understand that the radiosensitivity of ovaries and testes is extremely low. In fact, they are some of the lower radiation-sensitive organs — much lower than the colon, stomach, bone marrow and breast tissue,” said  Donald Frush, MD, a professor of pediatric radiology at Lucile Packard Children’s Hospital Stanford.

In addition, he explained, technology improvements have dramatically reduced the radiation dose that a patient receives during standard X-ray films, computerized tomography scans and other radiographic procedures. For example, a review paper finds that the radiation dose to ovaries and testes dropped by 96% from 1959 to 2012 for equivalent X-ray exams of the pelvis without shielding.

But even if the radioprotective shielding may have minimal — or no — benefit, why not use it just to be safe?

The main problem is that so-called lead aprons — which aren’t made of lead anymore — are difficult to position accurately, Frush said. Even following shielding guidelines, the position of the ovaries is so variable that they may not be completely covered.  Also,  the protective shield can obscure the target anatomy. This forces doctors to live with poor-quality diagnostic information or to repeat the X-ray scan, thus increasing the radiation dose given to the patient, he said.

Positioning radioprotective aprons is particularly troublesome for small children.

“Kids kick their legs up and the shield moves while the technologists are stepping out of the room to take the exposure and can’t see them. So the X-rays have to be retaken, which means additional dose to the kids,” Frush said.

Another issue derives from something called automatic exposure control, a technology that optimizes image quality by adjusting the X-ray machine’s radiation output based on what is in the imaging field. Overall, automatic exposure control greatly improves the quality of the X-ray images and enables a lower dose to be used.  

However, if positioning errors cause the radioprotective apron to enter the imaging field, the radiographic system increases the magnitude and length of its output, in order to penetrate the shield.

“Automatic exposure control is a great tool, but it needs to be used appropriately. It’s not recommended for small children, particularly in combination with radioprotective shielding,”  said Frush.

With these concerns in mind, many technologists, medical physicists and radiologists are now recommending to discontinue the routine practice of shielding reproductive organs during X-ray imaging. However, they support giving technologists discretion to provide shielding in certain circumstances, such as on parental request. This position is supported by several groups, including the American Association of Physicists in Medicine,  National Council on Radiation Protection and Measurements and American College of Radiology.

These new guidelines are also supported by the Image Gently Alliance, a coalition of heath care organizations dedicated to promoting safe pediatric imaging, which is chaired by Frush. And they are being adopted by Stanford hospitals.

“Lucile Packard Children’s revised policy on gonadal shielding has been formalized by the department,” he said. “There is still some work to do with education, including training providers and medical students to have a dialogue with patients and caregivers. But so far, pushback by patients has been much less than expected.”

Looking beyond the issue of shielding, Frush advised parents to be open to lifesaving medical imaging for their children, while also advocating for its best use. He said:

“Ask the doctor who is referring the test: Is it the right study? Is it the right thing to do now, or can it wait? Ask the imaging facility:  Are you taking into account the age and size of my child to keep the radiation dose reasonable?”

Photo by Shutterstock / pang-oasis

This is a reposting of my Scope story, courtesy of Stanford School of Medicine.

Behind the scenes with a Stanford pediatric surgeon

In a new series, “Behind the Scenes,” we’re inviting Stanford Medicine physicians, nurses, researchers and staff to share a glimpse of their day.

As a science writer, I talk to a lot of health care providers about their work. But I’ve often wondered what it is really like to be a surgeon. So I was excited to speak with pediatric surgeon Stephanie Chao, MD, about her day.

Chao is a pediatric general surgeon, an assistant professor of surgery and the trauma medical director for Stanford Children’s Health. In addition to performing surgeries on children of all ages, she has a range of research interests, including how to reduce gun-related deaths in children and the hospital cost associated with pediatric firearm injuries.

Morning routine
On days that I operate, I get up between 5:50 and 6 a.m., depending on whether I hit the snooze button. I typically don’t eat breakfast. I don’t drink coffee because I don’t want to get a tremor. I’m out the door by 6:30 a.m. and at the hospital by 7 a.m. I usually go by the bedside of the first patient I’m going to operate on to say hi. The patient is in the operating room by 7:30 a.m. and my cases start.

On non-surgical days, it’s more chaotic. I have a 3-year-old and 1-year-old. So every day there’s a jigsaw puzzle as to whether my husband or I stay to get the kids ready for preschool, and who comes home early.

Part of Stephanie Chao’s day involves checking on patients, including this newborn.

In the operating room
The operating room is the place where I have the privilege of helping children feel better. It’s a very calming place, like a temple. When I walk through the operating room doors, the rest of the world becomes quiet. Even if it is a high-intensity case when the patient is very sick, I know there is a team of nurses, scrub techs and anesthesiologists used to working together in a well-orchestrated fashion. So even when the unexpected arises, we can focus on the patient with full confidence that we’ll find a solution.

There are occasions when babies are so sick that we need silence in the operating room. Everyone becomes hyper-attuned to all the beeps on the monitors. When patients are not as critically sick, I often play a Pandora station that I created called “Happy.” I started it with Pharrell Williams’ “Happy” and then Pandora pulled in other upbeat songs, including a bunch of Taylor Swift songs, so everyone thinks I’m a big Taylor Swift fan.

The OR staff call me by my first name. I believe that if everyone is relaxed and feels like they have an equal say in the procedure, we work better as a well-oiled machine for the benefit of the patient.

“The OR staff call me by my first name,” Stephanie Chao said.

Favorite task
Some of the most rewarding times of my day are when I sit down with patients and their families to hear their concerns, to reassure them and to help them understand what to expect — and hopefully to make a scary situation a little less so. As a parent, I realize just how hard it is to entrust one’s child completely in the hands of another. I also like to see patients in the hospital as they’re recovering.

Favorite time
The best part of the day is when I come home. When I open the door into the house, my kids recognize that sound and I hear their little footsteps as they run towards the door, shrieking with joy.

Evening ritual
When my husband and I get home, on nights I am not on call, I cook dinner in the middle of the chaos of hearing about the kids’ day. Hopefully, we “sit down” to eat by 6:20 or 6:30 p.m., and I mean that term loosely. It’s a circus, but eventually everyone is somewhat fed.

And then we do bath time and bedtime. There’s a daily negotiation with my three-year-old on how many books we read before bed. On school nights, she’s allowed three books but she tries to negotiate for 10.

Eventually, we get both kids down for the night. Then my husband and I clean up the mess of the day and try to have a coherent conversation with each other. But by then both of us are exhausted. I try to log on again to finish some work, read or review papers. I usually go to sleep around 11 p.m.

Managing it all
When I can carve out time to do relaxing things for myself, like go to the gym, that is great. But it’s rare and I remind myself that I am blessed with a job that I love and a wonderfully active family.

The result sometimes feels like chaos, but I don’t want to wish my life away waiting for my kids to get older and for life to get easier. Trying to live in the moment, and embracing it, is how I find balance.

Photos by Rachel Baker

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Testing infants’ blood may predict psychological health, study finds

Many of us know that a lipid panel — a simple blood test that measures the levels of cholesterol and fats in the blood — can help predict the risk of heart disease in adults.

What may be more surprising is a Stanford study has now shown that the levels of cholesterol and fat in an infant’s blood can predict that child’s social and emotional development, as recently reported in Psychological Science.

The researchers analyzed data compiled by the Born in Bradford project, which followed children born in the United Kingdom city of Bradford between March 2007 and December 2010.

The Stanford team examined the levels of high-density lipoproteins (HDL) known as “good cholesterol,” very-low-density lipoproteins (VLDL) known as “bad cholesterol” and triglycerides in the umbilical cord blood of 1,369 newborns. Unlike the placenta, all the cells in cord blood are from the fetus.

They then correlated the blood results with the children’s psychological status — including their self-awareness, emotional regulation and interpersonal relationships — as measured five years later by their teachers using standard tests.

The study showed children born with higher levels of HDL, lower levels of VLDL and lower levels of triglycerides were more likely to receive higher teacher ratings than their peers with lower “good cholesterol.”

“It is surprising that from early in life, these easily accessible and commonly examined markers of blood lipid levels have this predictive correlation for future psychological outcomes,” said Erika Manczak, PhD, in a recent Stanford news release. “What our study showed is really an optimistic finding because lipids are relatively easy to manipulate and influence.” Manczak participated in the research as a postdoctoral fellow in psychology at Stanford and is now an assistant professor of psychology at Denver University.

The study, so far, has demonstrated only correlations, not causations. But the findings were consistent across different ethnic and socioeconomic backgrounds and both sexes, where the study participants were 38% white British, 51% Pakistani British, 11% of other ethnicity and 52% male. The associations also held regardless of the mother’s psychological or physical health during pregnancy or the children’s physical health, body mass or neurodevelopmental status.

“The fact that the only solid predictor for the Born in Bradford children’s psychosocial competency assessment scores was their fetal lipid levels really argues in favor of a connection between the two,” Manczak said in the release. “Now we need to find out what exactly this connection may be.”

In the paper, the authors suggest some potential explanations, noting that lipids are involved in many biological processes important to psychological health, such as brain development and inflammation. If future work confirms their findings, they hope lipid screening can help identify and guide treatment for children who are prone to mental illnesses.

Photo by ThorstenF

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Creativity can jump or slump during middle childhood, a Stanford study shows

 

Photo by Free-Photos

As a postdoctoral fellow in psychiatry, Manish Saggar, PhD, stumbled across a paper published in 1968 by a creativity pioneer named E. Paul Torrance, PhD. The paper described an unexplained creativity slump occurring during fourth grade that was associated with underachievement and increased risk for mental health problems. He was intrigued and wondered what exactly was going on.  “It seemed like a profound problem to solve,” says Saggar, who is now a Stanford assistant professor of psychiatry and behavioral sciences.

Saggar’s latest research study, recently published in NeuroImage, provides new clues about creativity during middle childhood. The research team studied the creative thinking ability of 48 children — 21 starting third grade and 27 starting fourth grade — at three time points across one year. This allowed the researchers to piece together data from the two groups to estimate how creativity changes from 8 to 10 years of age.

At each of the time points, the students were assessed using an extensive set of standardized tests for intelligence, aberrant behavior, response inhibition, temperament and creativity. Their brains were also scanned using a functional near-infrared spectroscopy (fNIRS) cap, which imaged brain function as they performed a standardized Figural Torrance Test of Creative Thinking.

During this test, the children sat at a desk and used a pen and paper to complete three different incomplete figures to “tell an unusual story that no one else will think of.” Their brains were scanned during these creativity drawing tasks, as well as when they rested (looking at a picture of a plus sign) and they completed a control drawing (connecting the dots on a grid).

Rather than using the conventional categories of age or grade level, the researchers grouped the participants based on the data — revealing three distinct patterns in how creativity could change during middle childhood.

The first groups of kids slumped in creativity initially and then showed an increase in creativity after transitioning to the next grade, while the second group showed the inverse. The final group of children had no change in creativity and then a boost after transitioning to the next grade.

“A key finding of our study is that we cannot group children together based on grade or age, because everybody is on their own trajectory,” says Saggar.

The researchers also found a correlation between creativity and rule-breaking or aggressive behaviors for these participating children, who scored well within the normal range of the standard child behavior checklist used to assess behavioral and emotional problems. As Saggar clarifies, these “problem behaviors” were things like arguing a lot or preferring to be with older kids rather than actions like fighting.

“In our cohort, the aggression and rule-breaking behaviors point towards enhanced curiosity and to not conforming to societal rules, consistent with the lay notion of ‘thinking outside the box’ to create unusual and novel ideas,” Saggar explains. “Classic creative thinking tasks require people to break rules between cognitive elements to form new links between previously unassociated elements.”

They also found a correlation between creativity and increased functional segregation of the frontal regions of the brain. Certain functions of our brain are done by regions independently and other functions are done by integration, when different brain regions come together to help us do the task. For example, a relaxing walk in the park with a wandering mind might have brain regions chattering in a segregated independent fashion, while focusing intently to memorize a series of numbers might require brain integration. And our brain needs to balance between this segregation and integration. In the study, they showed that increases in creativity tracked with increased segregation of the frontal regions.

“Having increased segregation in the frontal regions indicates that they weren’t really focusing on something specific,” Saggar says. “The hypothesis we have is perhaps you need more diffused attention to be more creative. Like when you get your best ideas while taking a shower or a walk.”

Saggar hopes their findings will help develop new interventions for teachers and parents in the future, but he says that longer studies, with a larger and more diverse group of children, are first needed to validate their results.

Once they confirm that the profiles observed in their current study actually exist in larger samples, the next step will be to see if they can train kids to improvise and become more creative, similar to a neuroscience study that successfully trained adults to enhance their creativity.

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Tips for discussing suicide on social media — A guide for youth

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Photo by kaboompics

There are pros and cons to social media discussions of suicide. Social media can spread helpful knowledge and support, but it can also quickly disseminate harmful messaging and misinformation that puts vulnerable youth at risk.

New U.S. guidelines, called #chatsafe: A Young Person’s Guide for Communicating Safely Online About Suicides, aim to address this problem by offering evidence-based advice on how to constructively interact online about this difficult topic. The guidelines include specific language recommendations.

Vicki Harrison, MSW, the program director for the Stanford Center for Youth Mental Health and Wellbeing, discussed this new online education tool — developed in collaboration with a youth advisory panel — in a recent Healthier, Happy Lives Blog post.

“My hope is that these guidelines will create awareness about the fact that the way people talk about suicide actually matters an awful lot and doing so safely can potentially save lives. Yet we haven’t, up to this point, offered young people a lot of guidance for how to engage in constructive interactions about this difficult topic,” Harrison said in the blog post. “Hopefully, these guidelines will demystify the issue somewhat and offer practical suggestions that youth can easily apply in their daily interactions.”

A few main takeaways from the guidelines are below:

Before you post anything online about suicide

Remember that posts can go viral and they will never be completely erased. If you do post about suicide, carefully choose the language you use. For example, avoid words that describe suicide as criminal, sinful, selfish, brave, romantic or a solution to problems.

Also, monitor the comments for unsafe content like bullying, images or graphic descriptions of suicide methods, suicide pacts or goodbye notes. And include a link to prevention resources, like suicide help centers on social media platforms. From the guidelines:

“Indicate suicide is preventable, help is available, treatment can be successful, and that recovery is possible.”

Sharing your own thoughts, feelings or experience with suicidal behavior online

If you’re experiencing suicidal thoughts or feelings, try to reach out to a trusted adult, friend or professional mental health service before posting online. If you are feeling unsafe, call 911.

In general, think before you post: What do you hope to achieve by sharing your experience? How will sharing make you feel? Who will see your post and how will it affect them?

If you do post, share your experience in a safe and helpful way without graphic references, and consider including a trigger warning at the beginning to warn readers about potentially upsetting content.

Communicating about someone you know who is affected by suicidal thoughts, feelings or behaviors

If you’re concerned about someone, ask permission before posting or sharing content about them if possible. If someone you know has died by suicide, be sensitive to the feelings of their grieving family members and friends who might see your post. Also, avoid posting or sharing posts about celebrity suicides, because too much exposure to the suicide of well-known public figures can lead to copycat suicides.

Responding to someone who may be suicidal

Before you respond to someone who has indicated they may be at risk of suicide, check in with yourself: How are you feeling? Do you understand the role and limitations of the support you can provide?

If you do respond, always respond in private without judgement, assumptions or interruptions. Ask them directly if they are thinking of suicide. Acknowledge their feelings and let them know exactly why you are worried about them. Show that you care. And encourage them to seek professional help.

Memorial websites, pages and closed groups to honor the deceased

Setting up a page or group to remember someone who has died can be a good way to share stories and support, but it also raises concerns about copycat suicides. So make sure the memorial page or group is safe for others — by monitoring comments for harmful or unsafe content, quickly dealing with unsupportive comments and responding personally to participants in distress. Also outline the rules for participation.

Individuals in crisis can receive help from the Santa Clara County Suicide & Crisis Hotline at (855) 278-4204. Help is also available from anywhere in the United States via Crisis Text Line (text HOME to 741741) or the National Suicide Prevention Lifeline at (800) 273-8255. All three services are free, confidential and available 24 hours a day, seven days a week.

This is a resposting of my Scope blog story, courtesy of Stanford School of Medicine.

Bill for later school start times is defeated, but Stanford sleep specialist isn’t

 

Photo by Santiago Gomez

The medical evidence is clear — teens are suffering physical and mental health problems due to chronic sleep deprivation. That’s why the American Academy of Pediatrics and many other health organizations recommend starting classes at all middle and high schools at 8:30 am or later.

“We’ve known for decades that teenagers are not getting enough sleep,” says Rafael Pelayo, MD, a clinical professor in psychiatry and behavioral sciences with the Stanford Center for Sleep Sciences and Medicine. “Senate Bill 328 came out of presenting the strong evidence-based, peer-reviewed data to elected officials. Even the people opposed to the bill accept the science.”

So if everyone agrees that our teens need more sleep, why didn’t the bill pass? The main objection of teachers, school boards and ultimately Governor Jerry Brown centers on giving the local community control of individual school decisions.

“We’ve stepped into this ongoing battle between state control and local control of schools,” Pelayo says. “But I don’t consider this a political issue. This is a public health issue. Hundreds of schools have already changed and they see the same result — kids are healthier and perform better. This is a matter of honoring kid’s biology. It doesn’t work to just say they should go to bed earlier.”

Pelayo’s push for later school start times is also inspired by his professional experiences. “My career as a sleep doctor began through my knowledge of adolescent sleep. During medical school, my research found a link between suicidal thinking and sleep problems in teenagers. I’ve been learning about poor sleep and mental health issues in teens since the 1980s.”

Despite this recent setback, Pelayo plans to keep volunteering. For years, he’s been giving talks about sleep at many local high schools and middle schools. “Teenagers are interested in sleep apnea, their dreams and all aspects of sleep. I’ve given a bunch of talks on sleep for years,” Pelayo says.

He’s also recently become a director of a national organization called Start School Later. Overall, he hopes to promote more education, research and funding for this issue.

“About 300 school districts have already mandated a later school start time,” Pelayo says, adding that San Diego schools are planning to implement later start times by 2020. “If California had passed SB 328, it would have accelerated this process. Instead, we’ll have to do it piecemeal. And that’s too bad, since kids need sleep now.”

But, Pelayo says, “This issue is not going away, it is actually gaining momentum.”

This is a reposting of my Scop blog story, courtesy of Stanford School of Medicine.

Stanford and Common Sense Media explore effects of virtual reality on kids

Photo by Andri Koolme

Although we’re still a long ways off from the virtual reality universe depicted in the new movie “Ready Player One,” VR is becoming a reality in many homes. But how is this immersive technology impacting our kid’s cognitive, social and physical well-being?

Stanford researchers and Common Sense Media are investigating the potential effects of virtual reality on children. And a  just-released report provides parents and educators with a practical guide on VR use.

“The truth is, when it comes to VR and kids, we just don’t know that much. As a community, we need more research to understand these effects,” Jeremy Bailenson, PhD, a Stanford communication professor and the founder of Stanford’s Virtual Human Interaction Lab, wrote in an introduction to the report.

The research team surveyed over 3600 U.S. parents about their family’s use of virtual reality. “Until this survey, it was unclear how, and even how many, kids were using virtual reality,” said Bailenson in a recent Stanford news release. “Now we have an initial picture of its adoption and use.”

The report summarizes results from this survey and previous VR research. Here are its key findings:

  • VR powerfully affects kids, because it can provoke a response to virtual experiences similar to actual experiences.
  • Long-terms effects of VR on developing brains and health are unknown. Most parents are concerned, and experts advocate moderation and supervision.
  • Only one in five parents report living in a household with VR and their interest is mixed, but children are
  • Characters in VR may be especially influential on young children.
  • Students are more enthusiastic about learning while using VR, but they don’t necessarily learn more.
  • VR has the potential to encourage empathy and diminish implicit racial bias, but most parents are skeptical.
  • When choosing VR content, parents should consider whether they would want their children to have the same experience in the real world.

Ultimately, the report recommends moderation. “Instead of hours of use, which might apply to other screens, think in terms of minutes,” Bailenson wrote. “Most VR is meant to be done on the five- to 10-minute scale.”  At Stanford’s Virtual Human Interaction Lab, even adults use VR for 20 minutes or less.

One known potential side effect from overuse is simulator sickness, which is caused by a lag in time between a person’s body movements and the virtual world’s response. Some parents also reported that their child experienced a headache, dizziness or eye strain after VR use.

In addition, the researchers advise parents to consider safety. Virtual reality headsets block out stimuli from the physical world, including hazards, so users can bump into things, trip or otherwise harm themselves.

A good option, they wrote, is to bring your child to a location-based VR center that provides well-maintained equipment, safety spotters and social interactions with other kids.

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

How does burnout affect NICU caregivers and their patients?

a_nurse_examines_a_newborn_baby
Photo by U.S. Navy

We’ve all felt burned out at work due to prolonged stress — physically and emotionally exhausted, unmotivated, frustrated and maybe even cynical. But in the health-care field, burnout can harm patients as well as workers.

That concern prompted Stanford researchers to investigate the prevalence of caregiver burnout in neonatal intensive care units (NICUs) to determine whether it is correlated with healthcare-associated infections. The study is reported in the Journal of Perinatology.

The research team analyzed survey data from the California Perinatal Quality Care Collaborative, including responses from over 2000 providers — physicians, nurses and other workers — in 44 California NICUs who cared for over 4000 very low birth rate infants. One quarter of the respondents reported symptoms consistent with burnout on average, but burnout prevalence varied from 7.5 to 54.4 percent within each NICU.

I spoke recently with the study’s lead author, Daniel Tawfik, MD, a critical care fellow at Lucile Packard Children’s Hospital.

What inspired you to investigate caregiver burnout in NICUs?

“Throughout my medical training, I received very little education on the concepts of mindfulness and medical provider well being. But the challenging experiences and stressful situations encountered every day in the hospital must have some impact on the providers’ mental health and the care they deliver to their patients. This study was a way to evaluate this relationship and hopefully spur greater awareness of burnout and encourage research to address its role in patient care.”

What did you find? Were there any surprises?

“We expected to find increased healthcare-associated infections in NICUs with high levels of burnout, since preventing infections in these vulnerable patients takes a great deal of vigilance.

We were a little surprised that there wasn’t a strong relationship apparent when we analyzed the data. This may be due to the relatively small number of NICUs and the fact that infections were fortunately not very common in this group of infants.

Although our most recent analyses show increased burnout among large NICUs, our research group previously reported improved outcomes among large NICUs. It’s possible that the largest NICUs have increased burnout, but they also have systems in place to improve the quality of care — counteracting the effect that burnout may have on quality indicators.

We were also a little surprised to find that physician burnout [approximately 17 percent] was less prevalent than non-physician burnout [approximately 28 percent]. But this discrepancy is also in line with our previous studies in which nurses reported lower ratings of safety culture and a desire for more respect and input in decision-making. It’s possible that these differences contributed to increased burnout among nurses, who made up the majority of our survey respondents in our new study.”

How can your results be used to improve NICU care?

“These results highlight the prevalence of burnout among NICU providers, particularly among nurses. Whether or not this burnout affects quality of care in measurable ways, it suggests that we need interventions to prevent and reduce burnout in NICUs and likely in other care settings.

The NICU at Lucile Packard Children’s Hospital is one of several NICUs around the country participating in the WISER randomized-controlled trial, which is evaluating the effectiveness of burnout interventions such as daily recall of positive events using the Three Good Things tool. The study is being led by Jochen Profit, MD, and Bryan Sexton, PhD, who have been my mentors and co-authors. It’s our hope that if this intervention proves beneficial that it could be expanded to other hospital units and clinics.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Kangaroo Mother Care: Researchers search for biological basis of its effectiveness

Photo by Tom Andriaenssen
Photo by Tom Andriaenssen

My niece just had a son. Despite the 110-degree summer heat, she has been holding him against her bare chest using a special newborn carrier because she knows kangaroo mother care is important. This bare skin, chest-to-chest contact has many demonstrated health benefits, including reduced mortality for low-birth-weight infants.

I recently spoke with neonatologist Vinod Bhutani, MD, about kangaroo mother care and his new pilot study — in partnership with Kari McCallie, MD, Susan Crowe, MD, and David K. Stevenson, MD — that is examining exactly how it works.

How is kangaroo mother care beneficial?

“The primary advantages of kangaroo mother care are keeping the baby warm and improving maternal-infant bonding, but there are additional benefits. When the baby is put on the mother’s breast, he is more likely to root and breastfeed. The baby also hears and feels the vibrations of the mother’s voice as she speaks or sings, and he feels the soothing rhythm of the mother’s heart that he’s used to hearing inside the womb. Finally, it improves the brain development of the baby on a long-term basis. We think skin-to-skin care is particularly important for premature babies, since their brains are not fully developed at birth. Fathers and other family members can participate too; many benefits of skin-to-skin care are not just limited to the mother.”

What barriers prevent effective kangaroo mother care?

“There are three main types of barriers: cultural ones, sick or premature babies and healthcare providers’ lack of knowledge or comfort level.

In most developed communities, the baby is separated from the mom for the first six hours after birth while the baby is being evaluated. Wearing clothes is also very important in western society, so direct skin-to-skin contact is not uniformly practiced — particularly in communities where babies are delivered at home or sent home soon after birth and mothers don’t have privacy.

In addition, sometimes babies are very sick so they are separated from their mother, placed in incubators and attached to medical devices. Studies have shown that a premature baby stabilizes better on his mother than in an incubator, but there are problems with implementation. Most hospitals in the U.S. and Western Europe discharge the mother after two days, so there are no places in the hospital for her to sleep with the baby and do kangaroo mother care. Often mothers also need to go back to work to save their maternity leave for when the baby stabilizes and comes home. And sometimes the baby is very sick and is attached to lots of technology, which can be intimidating and frightening to parents. Plus many healthcare providers aren’t convinced that kangaroo mother care is beneficial, particularly for premature or sick babies.”

What are you researching now?

“Our study stems from observations in horses made by our colleagues at the Univeristy of California, Davis led by veterinarian expert John Madigan, DVM. He found that foals exhibiting abnormal behavior shortly after birth had elevated fetal levels of neurosteroids, which was ameliorated by squeezing their chest to mimic the birth canal.

In our pilot study funded by the Gates Foundation, we looked at nine key “brain” hormones in 39 human babies, measuring hormone levels in the umbilical cord blood and 24 hours later in the baby’s blood. We studied the natural history of these neurosteroid hormones to see how they’re related to infants’ sex, mode of delivery (vaginal birth or cesarean section), maturity, and duration of skin-to-skin care.

We just finished collecting the data. Our preliminary analysis shows a significant decrease in most stress hormone levels over the first day. The decrease is more apparent in vaginal deliveries, underscoring the need to institute kangaroo mother care after a C-section. Once our analysis is complete, we hope to identify one or two key hormone levels that are the best index of birthing stress. In future work, we want to develop a test for these key hormones from the baby’s saliva to be used as a point-of-care test. A saliva test is something that a health provider could do to determine if the baby is stressed.

We need to understand the biological basis of kangaroo mother care to convince healthcare providers and policy makers of the importance of skin-to-skin contact. We need mothers and family members to be part of the healthcare team — they have a therapeutic role.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Superheroes to the rescue: a creative approach to educating patients about asthma

Video by © 2015 Booster Shot Media

Asthma affects over 6 million children and leads to approximately 1.8 million visits to the emergency room annually in the United States, according to the Centers for Disease Control and Prevention.

In order to effectively manage asthma and help eliminate trips to the emergency room, physicians must identify the correct daily control and emergency rescue medications for their patients. However, educating young patients and their families is also critical.

“Patient education needs to be done at every visit,” Richard Moss, MD, professor of pediatrics, emeritus at Lucile Stanford Packard Children’s Hospital Stanford, recently told me. “This includes a review of the asthma symptoms, proper use of medications, written action plan, test results, and educational handouts. The key is continuity of care and reiteration of important information at every visit.”

Last month, NBC News featured the work of an Illinois physician who has taken a non-traditional approach to patient education. Alex Thomas, MD, a cartoonist and pediatric allergist at the Center for Asthma and Allergies, created a multimedia asthma education program called Iggy and the Inhalers, which includes comic books, YouTube videos, posters, trading cards and stickers. I recently spoke with Thomas about this program and Booster Shot Comics, a partnership between Thomas and a health-communication specialist.

What motivated you to create the Iggy and the Inhalers comic book?

I started drawing Iggy characters when I was 11 years old. I grew up with asthma myself, so I drew as a way to understand my medications – turning them into superhero characters. My Mom is an allergist and she had a patient support group for kids with asthma. So I started drawing little comic strips about Iggy in the support group newsletter.

An interest in asthma and asthma education ultimately led me to go to medical school and become a pediatric allergist. When I was working on the pediatric wards, I noticed that a lot of kids were being admitted and readmitted to the hospital for asthma exacerbation due to confusion about their medications. So I eventually revisited my Iggy characters to create educational materials for physicians and patients, with the help of health communication specialist Gary Ashwal.

Can you describe the characters in Iggy and the Inhalers?

Iggy the Inhaler is the main character that teaches kids about the physiology of asthma. He has two teammates. One is Broncho the Bronchodilator, a rescue inhaler for quick relief of symptoms. The other partner is Coltron the Controller, a control inhaler that kids with persistent asthma need to take on a daily basis. There are also asthma trigger villains: Smokey Joe, Moldar, Pollenoid, Dust Mite, Roach and Hairy.

We wanted to create dynamic characters that embodied the mechanism of the medications that they represent, so kids can intuitively understand how the medications actually work. When kids look at a rescue inhaler, they imagine Broncho loosening the muscle bands around the airway because he’s a cowboy with a lasso. Whereas when they look at a control inhaler, they imagine Coltron decreasing inflammation inside the airways using his fire extinguisher arm.

How have families responded to Iggy and the Inhalers?

It has been very effective.

There was one family that really stuck with me. A mother came with a 3-year old son for an initial visit with a bag full of medications prescribed by an emergency room physician and subsequently doctors in urgent care. They were frazzled and overwhelmed, and the child was still coughing. I had them watch the basic Iggy video, while the Mom flipped through the comic book. When we talked afterwards, she said she finally understood the basic differences between the medications. She was very relieved and they went home with the Iggy stickers, comic book and trading cards.

The next week, the family returned for a follow-up. The son specifically asked to watch the Iggy video. He was reciting the words, wanting to play it again and again like an Elmo video. He was responding to the characters and the live actions in the video on how to use an inhaler. Since then, he’s done great. Every time I see him, he asks for more Iggy stickers.

What other projects is Booster Shot Comics working on?

We have plans for future issues of the Iggy comics and animated videos that will cover more specific topics on asthma and allergies, such as how to eliminate allergy triggers from the home. We are also working with physicians at the Children’s Hospital of Wisconsin to turn discharge instructions for a concussion into a comic book, as well as a comic book to teach kids and their parents how to treat pain.

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

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