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Back to Sleep or Preventing SIDS

baby_1917_1918
Baby (Cradle) by Gustav Klimt 1917/1918
Twenty years ago, I graduated from medical school and began my journey into obstetrics and gynecology. One of the messages I had to give to new parents was “back to sleep”. Since then, the rate of SIDS deaths has dropped dramatically, but every so often, I hear of parents who lose a child to SIDS. No one should ever have to experience the death of a child to Sudden Infant Death Syndrome. The Washington Post has put out a great article on preventing SIDS that I would like to share with you. This article was printed 8/9/2013.
SIDS rate has declined, but 2,300 U.S. babies still die annually
By Kendall Powell
I still put my 2-year-old to sleep on his back even though each morning he’s snuggled on his tummy, head shoved into a corner of his crib. The “back to sleep” message has become ingrained in my new-parent psyche, as the campaign to reduce Sudden Infant Death Syndrome was designed to do when it began 20 years ago after studies showed that placing babies to sleep on their stomachs tripled their SIDS risk.
SIDS, in which an infant dies during sleep from an undetermined cause, can be a huge source of anxiety for new parents — and rightly so. Even after Back to Sleep efforts helped cut the SIDS rate by more than half from 1994 to today, it is still the leading cause of death among U.S. infants aged 1 month to 1 year, with 2,300 cases annually.
The latest research into SIDS is giving parents clearer guidelines for protecting babies during sleep. For example, a recent analysis of more than 1,400 SIDS cases found that having a baby sleep in the parents’ bed increases the risk of SIDS by a factor of five for infants younger than 3 months old. Bed sharing presents a risk because, as Children’s National Medical Center pediatrician Linda Fu explains to new parents, the airflow around the baby may not be good enough, “and that is all it takes.”
In the past decade, researchers identified how low oxygen levels, combined with an underlying brain defect, can cause SIDS. Scientists believe a triple-risk model explains many SIDS cases: A baby has a defect in an area of the brain that controls breathing and arousal; the baby is at an age when those brain areas are still immature; and the baby is exposed to an external stress that compromises his breathing or oxygen levels, or that causes overheating.
“To have a SIDS death, you have to have at least one of those [factors], and you have a higher risk if you have two or three of those happening at the same time,” says Fern Hauck, a professor of family medicine at the University of Virginia School of Medicine in Charlottesville.
A problem of oxygen flow
Sleeping face down on a soft surface or with soft bedding that can press up against the face can decrease a baby’s oxygen flow too much. When this happens, a normal baby will auto-resuscitate by gasping, crying, turning his head or moving. “It’s thought that SIDS infants have a defective arousal mechanism, which means they stay in that position and gradually suffocate,” Hauck says. Overheating is thought to lead to SIDS in a similar way, by suppressing an infant’s arousal response.
The Back to Sleep public-health campaigns — now named Safe to Sleep — solved much of the problem, as parents were told that sleeping on the back was best for babies. The SIDS rate fell dramatically, from almost three in 2,000 live births in the late 1980s, to one in 2,000 live births now.
Many parents have stopped using soft bedding and bumper pads in cribs (the sale of bumper is even banned in Maryland) and switched to wearable blankets to lower the risk of suffocation.
Yet since 2001, “the SIDS rates are not falling as one might hope,” says Bob Carpenter, the medical statistician at the London School of Hygiene and Tropical Medicine who led the bed-sharing study. He calculates that if all preventable risk factors — including mothers’ smoking while pregnant, babies’ sleeping on their stomach and bed sharing — were eliminated, the rate of SIDS would drop more significantly, to close to 1 in 10,000 live births.
The connection between brain defects and SIDS was raised definitively in 2010, when researchers at Children’s Hospital Boston discovered that SIDS babies were deficient in the brain-signaling chemical serotonin in the brain stem. In fact, according to some research, 50 to 75 percent of infants who die of SIDS have a serotonin defect. In a study published this year, Kevin Cummings, a physiologist at the University of Missouri in Columbia, showed that he could improve auto- resuscitation in newborn rats that had genetically lowered serotonin levels by giving them caffeine. Because caffeine is an effective treatment to stimulate breathing in premature infants, Cummings says it may hold promise as a SIDS prophylactic in high-risk infants.
Other researchers have found that about 10 to 15 percent of SIDS deaths can be traced to babies with a genetic predisposition for long QT syndrome, a heart rhythm disorder that can go undetected and lead to cardiac arrest, says Marta Cohen, a pediatric pathologist at Sheffield Children’s Hospital in England. Also, SIDS researchers say smoking tobacco while pregnant may cause a rewiring of the unborn baby’s brain in areas important for breathing and arousal, making maternal smoking one of the largest risk factors for SIDS.
It’s conceivable that newborns might one day be screened for low serotonin levels in the brain stem or for genes that are involved in faulty arousal, Cohen says, but that day is far off.
So what should parents of newborns do?
According to Hauck, who helped write the American Academy of Pediatrics guidelines about SIDS, parents should:
●Avoid smoking, alcohol and illegal drugs during pregnancy and after birth.
●Place the baby on his back every time he is put to sleep.
●Use a firm sleep surface, with no soft objects or loose bedding in the crib. “Putting a baby into an empty crib looks awful, like you are torturing them,” Hauck acknowledges. “But the truth is, the babies don’t really care.” All that comfy stuff is really for the parents, she says.
●Share bedrooms but not beds. Many SIDS researchers believe an uptick in bed sharing may explain the plateauing of SIDS rates in developed countries. They report that 50 to 70 percent of new SIDS cases in the past few years have occurred in a bed-sharing scenario.
“We’re now in the position we were 20 years ago with sleeping prone,” Carpenter says. “If we could get rid of bed sharing, the whole picture could change with SIDS. That’s our hope.”
●Practice breast-feeding. No one is sure why this helps, but breast-fed babies have a lower risk.
●Consider using a pacifier for naps and bedtime (after the first month, if the baby is breast-feeding).
●Avoid overheating the baby and the baby’s room.
●Follow the routine immunization schedule.
●Finally, avoid products marketed as reducing the risk of SIDS. (None have been proved to do so.)
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It’s All in the History

Takashi Murakami. 727. 1996

Takashi Murakami. 727. 1996

    People go to see the doctor for many reasons.  Sometimes it is just a check up or medication refill or for not feeling well.  Sometimes it is because of pain. Pain is tricky.  It can come on all of a sudden.  It can ebb and flow.  It can last seconds, minutes, hours, days, weeks, months or years.  It can start from excessive use or a strain.  It can show up after an accident.  It can start out very mild and grow.   It can start in one place and travel to another.  It can occur in the middle of the night or during the menstrual cycle.  It can cause vomiting or come with a fever. As a gynecologist, the pain I see is mostly in the abdomen or belly.  More often than not, the pain is in the lower belly or pelvis.  Because the reproductive organs are in this region, many people come to see me.  It is my job to tease out the pain and try to define it.  How do I do this? It is all in the history.  I ask you all about the pain. How long has it been going on?  How did it start?  What does it feel like?  When does it occur?  Does it radiate from one place to another?  Did you try anything to make it better? Have you seen anyone else for this pain, and if you did, what was done?  Does anything make it better?  Does anything make it worse?  Does anything else happen when you get this pain? Is there any fever or vomiting?  Has your appetite changed?  Do you have trouble with constipation or diarrhea?  Any difficulty with urinating?  Discharge?  The list goes on and on….It may seem tedious to ask these questions, but the more information I have, the better to help you. Additionally, I like to know about any medical problems you may have.  Past surgeries, past gynecological history, past obstetrical history, and social history also help me try to figure out the pain.   There have been occasions when family history has provided important clues to the source of pain. The history of your pain helps to guide us in determining what the name of your pain is and how to treat it.  If you have been living with pain and are thinking about coming to be seen, here is what I have for you. Take a moment to think about the pain.  When did it start?  What does it feel like?  Some people keep a pain diary, and write down when it occurs, for how long, what else occurs during the episode.  You may want to write down your concerns and questions about the pain.  Sometimes when we see the doctor we forget to ask the questions that form in our mind before we get there.  Believe it or not, I have forgotten my questions when I go to my doctor!  Lastly, we may send you out with a long list of things to do such as laboratory work and radiology requests.  If it is a long list, have your doctor write it down for you. Pain can be from many different causes—some serious such as appendicitis and some not like menstrual cramps.  It is still pain and it is pain that is affecting your quality of life.  Our goal is to determine the cause and treat it.  The best place to start is with a good history.   Cynthia Wilkes MD Stafford Women’s Health Associates Stafford VA
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Memorial Day

Memorial Day for many signifies the start of summer.  It is the time for summer vacations, weddings, and graduations.   We start off Memorial Day with sales, barbeques, and  picnics.  Families get together to celebrate.  It is also a time to honor our war dead.   Prior to the War in Afghanistan and September 11, 2001, many of us thought of Memorial Day primarily as the start of the summer season with a fleeting thought turned to our war dead.  Over the past dozen years, the news of Afghanistan/Iraq, deployments, IEDs, and deaths gives a more somber feel to Memorial Day.   The practice of paying respects to the war dead has been around since ancient times.  It was because of the Civil War that Memorial Day eventually became a national holiday. So many young men died that almost every family in the US was affected.  If we combined all the deaths of all the wars that the US has ever been in, it still would not even come close to the number of Civil War dead. Because of the Civil War, our opinions on citizenship, rights, and responsibilities of the individual and of the government changed.  We recognized that we have rights and responsibilities to the nation, and the nation has rights and responsibilities to each individual citizen.  If you are interested in learning more about the Civil War and how it changed us, I recommend reading Drew Gilpin Faust’s book, “Death and the Civil War”.     It really brings to life what the Civil War was like on families during this time.   Cynthia Wilkes MD Stafford Womens Health Associates Stafford VA 22554
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HIV Testing in Pregnancy

During your pregnancy, we do many types of tests.   Many of these tests require blood.   During the first OB visit, we usually draw the most blood.  Many of these tests check for infections that can cause problems in pregnancy.  One test I’d like to discuss today is the HIV test. Most women who become pregnant today do not know about a time before HIV.  HIV has been in our community for their entire lives.  I do remember what life was like when HIV  entered our society, and how it changed the way we go about things.  There was a time when HIV caused fear and panic for the public.  Those who had the disease were subjected to ostracism, violence, homelessness, and unemployment.  Because of this discrimination, we now have to get permission to do a HIV test.  This is why you have to sign a form for it when you don’t have to sign a form for any of the other infectious disease testing.   Occasionally, I run into some women who chose to NOT have the test.  Today, I would like to discuss WHY you should have it done.  Yes, Yes,... I know you don’t have any risk factors for contacting the disease.  Please consider this; just to know that the HIV test is negative will be one less thing to worry about during pregnancy.   Did you know that 18% of all HIV infected people do not know they are infected?  Should a woman who is infected with HIV become pregnant, she can transfer the HIV to the baby.  Almost all cases of HIV in young children today are because of perinatal transmission.  Today, we give medication during pregnancy that can prevent this transmission.  Also, there are other things we can do to prevent transmission of the HIV virus to the baby.   If you still do not want the test done while pregnant, our pediatricians DO want to know your child’s HIV status.  This means that if they do not know your status, they will test the baby.  The baby will have to have more blood drawn in addition to all the other blood tests done.   If you have questions about HIV testing, please discuss this with your physician.  You can also go to the CDC for more information.   Cynthia Wilkes MD Stafford Womens Health Associates  
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Vaccinations for the Grown Up

In the past, I have written about vaccinations for children and for the adults taking care of children.  Today, I would like to discuss vaccinating the adult.   Because of vaccinations, we are living better.  Few of us have been exposed to such diseases as hepatitis, meningitis, influenza, measles, tetanus and on and on.   Heck, the majority of Americans don’t even know anyone who has even had these diseases.   Unfortunately, these diseases are still out there, and at times can flourish.   For those who have experienced the above diseases, they know how terrible these diseases are.  These diseases can make people very ill and very ill for a long, long time.  Performing such tasks as bathing, eating, working, and cleaning are very difficult to do while ill and in some instances are not done at all by the sick person.  Should the illness enter the recovery phase, there may be permanent long lasting reminders of the illness.  This can be anything from permanent pain,  organ failure, and/or loss of limbs to name a few.   The CDC (Centers for Disease Control and Prevention) has vaccination tables for all ages.  You should check with your physician first to see if these vaccinations are right for you.  

Adult Vaccinations for ages 19-65+

  • Flu shot yearly for all Americans.
  • Hepatitis A and B two and three doses if not done in childhood.
  • Varicella (Chickenpox) two doses if not done in childhood.
  • Tetanus, diphtheria, pertussis (Tdap/Td) Tdap once then Td every 10 years.
  • Meningococcal one or more doses.
  • Pneumococcal one to three doses.
  • Measles, Mumps, and Rubella (MMR) one or two doses if not done in childhood.
  • HPV three doses for women and for men from ages 11 to 26.
  • Zoster (Shingles) after age 60.
  • Pertussis (Tdap) for pregnant women between 26-37 weeks pregnancy.
  Cynthia Wilkes MD Stafford Womens Health Associates
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