I wanted to write about "Detoxing..."

...but this guy did it for me.

The Detox Myth: What your Alternative Health Provider isn't telling you

I won't recreate the wheel here. Cheers.

EV68 and Associated Horrors

Remember when I said I was going to update and talk all about my awesome baby shower?

That'll happen. But first, let's rant about EV68.

This post is brought to you by the sign I saw in my OB's office this morning, which stated that siblings would not be able to visit their brand new baby sisters and brothers on the postpartum floor due to concerns over the rapidly-spreading virus. It's also brought to you by the 30 minute segment on NPR this morning. And also the fact that I saw twenty-eight patients yesterday, had at least one nebulizer running at all times, and didn't get home until about 9:00 PM.

I'd like to start by saying what this post is not about. It's not about how EV68 is not a big deal because it is. It's also not about how EV68 is a big deal and how everyone in the country needs to go to their doctors YESTERDAY because that's not exactly the case either. Mostly, its just me venting, but I'm hoping to also present some good info on both the virus and also on how we should be responding to it.

EV68 is an enterovirus. Do you know what else is an enterovirus? EVERYTHING. Polio is an enterovirus. The Common Cold is an enterovirus. Remember that huge outbreak of Hand Foot and Mouth Disease this summer? That's caused by something called coxsackie virus, which - you guessed it - is also an enterovirus. When we say something is an enterovirus, we're basically describing the viral structure (single-stranded RNA), how it reproduces (positive sense), and what types of hosts it tends to infect (mammals).

The media is calling EV68 a "respiratory illness," which is an incredibly vague description almost to the point of not being a real thing. Some people who come in contact with EV68 will have zero symptoms. Some will have a little runny nose and cough. Others will launch into full-blown respiratory distress. Generally speaking, this is no different from any other virus that can cause "respiratory illness." Things like croup, laryngitis, and bronchitis are all respiratory complications that are caused by viral infections. EV68 is just another name on the list of things that can cause these problems. And just like those other viruses, how likely you are to develop complications depends mostly on your age, your current health, and the state of your immune system.

That being said, EV68 is proving to be a particularly nasty virus, most likely because we haven't seen much of it in the past 30-40 years. That means that those of us under 30-40 years of age have little-to-no immunity, and are therefore that much more susceptible to infection. The medical world doesn't often do specific diagnostics for viral infections - exceptions being baddies like RSV and the Flu, which show up every year and consistently reek havok wherever they go - so it's difficult to know for sure that EV68 has been dormant. We're actually not really even testing for it now because the test takes forever to process and is therefore really only for epidemiological purposes. But all evidence seems to point to the fact that it's here and it's legit.

Case in point, my practice recently received word from our local area hospital that we could no longer directly admit patients with respiratory symptoms because there were no beds available. If we had patients who could not be stabilized outpatient, we would need to send them to the hospital vis-a-vis the emergency room. EV68 is a thing. And it's for sure making people sick.

But that doesn't mean that it's making you sick, or that it will make you sick, or that if it does make you sick, you automatically need to go to the hospital and start on supplemental oxygen.

Probably not you.

Our office received this memo from the DPH a few days ago. They summarize the situation brilliantly:

"...EV68 this year is behaving more like a [common cold], even to the extent of causing disease with little or no fever...No antiviral medications are currently available for treating of EV68 infections. Many infections will be mild and self-limited, requiring only treatment of the symptoms. Some people with severe respiratory illness caused by EV68 may need to be hospitalized and receive supportive care. There are no licensed vaccines for protection against...infection." (Bolds are mine)

In so many words, this memo explains that there is absolutely no need to panic, or even to seek medical attention, unless you are having severe respiratory symptoms such as wheezing, chest tightness, and/or shortness of breath.

So what should you do?

MegaHospital (the one that our practice and every other nearby pedi practice bows to), recently sent out the following information to give to our patients:

• At home, wash your hands often, using soap and water, and wash for at least 20 seconds. Carry hand sanitizer when you are out and about.
• Don’t share cups or spoons, knives and forks, and wipe down toys and frequently-touched surfaces like doorknobs often.
• Keep your distance from visibly sick people and don’t let sick people hold or care for your baby. And if you or a family member is feeling sick, stay home.
• Teach your children to cover coughs and sneezes with the inside of the elbow or a tissue, not the hand.
• If your child has asthma or any other lung disease, make sure he or she continues taking any medications as prescribed.
• If someone in your family starts with the sniffles and a cough, don’t panic. Chances are that it is just a common cold. Keep a close eye and, if the cough gets worse or the person looks weak or is having trouble breathing, call your doctor or visit your local emergency room.

So there you have it, folks. EV68 is real. It sucks. But mostly likely, it's not going to affect your life.

My life on the other hand...well...my 38-week-pregnant self gets the privilege of working this weekend. Let's hope I survive.

--
Note: Sources are not cited to protect the anonymity of myself and my practice. As both sources were intended to be public service announcements, I feel that this action is in keeping with the purpose of the documents.

Scary Stories from the Interwebz: What is a GMO?

The Internet is a big, scary place. It contains a plethora of information on just about any available topic. That's the big. Unfortunately, there is very little regulation of the quality and accuracy of that information. That's the scary.

Like just about any other form of media, people have an overwhelming tendency to believe that everything they read on the Internet is true. Especially blog articles that use words like "studies," "research," and "scientists," and definitely when they discuss things like cancer and obesity and all of those other pervasive medical problems that are plaguing our generation.

I'd therefore like to start a new series affectionately titled Scary Stories from the Interwebz. I'll use this series to discuss hot topics that I come across at work and in my personal life that are largely misrepresented, and sometimes blatantly false. And I'll do my best to support my claims with evidence. Like, actual evidence. That I read. And understand (<-- that part is important!).

For our first Scary Story, let's talk about GMOs.

OMP and I were getting lunch today, and a nearby diner was telling his college-age sons about the dangers of GMOs.

"Yeah, it stands for 'Genetically Modified Orgasms.' I mean, ha-ha, 'ORGANISMS.' Yeah it's like, they take fruits and vegetables and animals and stuff and inject them with all sorts of chemicals and antibiotics. Montasanto is the name of the company that does a lot of it, and basically these chemicals are toxic and can cause all sorts of problems like cancer."



*FACE PALM*

I understand that the idea of dudes in labcoats injecting "TOXIC CHEMICALS" into fruits and veggies can be rather terrifying, but why don't we take a few minutes to discuss what a "Genetically Modified Orgasm Organism" actually is.

Genetic Modification (formerly known as selective breeding), goes back to the early days of farming. Selective breeding is the process by which farmers (or scientists, or people who are bored or whatever)

[breed] organisms with desirable traits in an attempt to produce offspring with similar desirable characteristics or with improved traits. 

Most of the animal and plant products that we consume today are the result of selective breeding. In fact, many of the products available today wouldn't even exist if it wasn't for selective breeding. Corn is a great example. Michael Polland's The Omnivore's Dilemma tells an amazing story about the history of corn (and also why the Corn industry is a little terrifying). You can also read all about the history of corn here. 

Image from http://learn.genetics.utah.edu/content/selection/corn/

As time goes on and technology improves, we're getting a little better at this this whole selective breeding thing. Now instead of providing a candlelight dinner and mood music to our various livestock, we can perform artificial insemination and DNA modification.

A 2011 literature review published in Genetics discusses how the genetic engineering of crops differs from traditional selective breeding

Genetic engineering differs from conventional methods of genetic modification in two major ways: (1) genetic engineering introduces one or a few well-characterized genes into a plant species and (2) genetic engineering can introduce genes from any species into a plant. In contrast, most conventional methods of genetic modification used to create new varieties (e.g., artificial selection, forced interspecific transfer, random mutagenesis, marker-assisted selection, and grafting of two species, etc.) introduce many uncharacterized genes into the same species. Conventional modification can in some cases transfer genes between species, such as wheat and rye or barley and rye (Ronald, P., 2011)

Basically, we can do it in a lab. Oh, and we're much, much better at it.

So what's the big deal? Well, it could be nothing.

According to the American Association for the Advancement of Science, 

The World Health Organization, the American Medical Association, the U.S. National Acad-
emy of Sciences, the British Royal Society, and every other respected organization that has examined the evidence has come to the same conclusion: consuming foods containing ingredients derived from GM crops is no riskier than consuming the same foods containing ingredients from crop plants modified by conventional plant improvement techniques (Statement by the AAAS Board of Directors on Labeling of Genetically Modified Foods, 2012).

Like any new technology, GMO's have been subjected to absurd amounts of safety monitoring and scrutiny. If you have a few weeks of free time, you might want to read A Decade of EU-Funded GMO Research put forth by the European Commission. I'll be honest, I just skimmed it. But suffice it to say that there's been a fair amount of investigation, and the general consensus is that GMOs are filling an important need without introducing any significant risks.

Then why did my favorite soccer-mom blog tell me that GMOs are scary?

Despite the fact that the process of genetic engineering is not all that scary, the purpose of all this modification is worthy of some reflection. Genetic engineering can accomplish some amazing things. It can increase the protein and iron content of rice so that poor communities can afford nutritionally- and calorically-dense foods. It can create stalks of corn that stand up straighter, increasing the yield and the health of the plant. Actually, for the most part genetic engineering is pretty amazing, and has the potential to solve a lot of the world's hunger problems.

But, like any technology, it can be dangerous when taken into the wrong hands. For example, genetic modification can also make it so that plants can survive an offensive onslaught of herbicides and pesticides, and somehow manage to not die. 

ZOMG CHEMICALS.

Image from http://sci-ence.org/red-flags2/

I'll have to save my rant on how much I hate the word "chemicals" for another day. In short, "chemicals," aka man-made substances, are not inherently bad. That being said, if there's a substance potent enough to kill unwanted plants and animals, it's probably worth a second look. 

In addition to the bazillions of soccer-mom blogs, there's plenty of actual research that indicates a statistically significant correlation between certain herbicides/pesticides and adverse health outcomes. An herbicide known as Roundup (manufactured by the evil Montasanto company) has drawn considerable criticism (Richard, S., et al., 2005).

Does this mean that your salad is coming with a side of Roundup? Maybe. Unfortunately, that's only the tip of the iceberg when it comes to the true dangers of herbicides and pesticides. A short list of other concerns:

1. Herbicide resistance
2. Endangerment of species that are not "Roundup Ready"
3. Seed contamination
4. Endangerment of "non-targeted" species of insects and mammals (think: honeybees, deer, etc.)
5. Contamination of groundwater and endangerment of aquatic flora/fauna
6. Possible endangerment of the local human community

 There are too many sources to list, but you can start with the following:

http://web.mit.edu/demoscience/Monsanto/impact.html

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2984095/

http://pubs.acs.org/doi/abs/10.1021/ac991359c

Or just try wikipedia

In short, you shouldn't be worried THAT genes are being modified. You should be worried about WHICH genes are being modified. And unfortunately, grocery stores have yet to advertise that above their produce bins.

So what's a concerned consumer to do?

Honestly, don't worry about the whole GMO thing. It's over your head. Frankly, it's over my head. All you need to worry about is supporting sustainable agriculture. When possible, buy organic. Better yet, buy local AND organic. Sure those organically- and locally-grown apples might have been genetically modified at some point, maybe to make the trees grow taller or to make the apples a prettier color. But you can rest assured that you're not getting a healthy dose of Roundup in your fruit salad. More importantly, you're supporting an organization that, at least in some way, has examined how its growing practices impact both the environment and the people who consume its products. Win-win.

That concludes this week's Scary Story from the Interwebz. Stay tuned for an actual update on Babykirk. I promise I'll get to it eventually.

Proof that you've been in the game.

Hello dear neglected blog.

I'm way overdue for a Babykirk update, I know. There's a lot going on right now and I want to be able to record it all, but still waiting on a few things to fall into place so to say. Here is a more recent shot of the little nugget, a little more detailed than my MS paint drawings, but obviously lacking a certain aesthetic.

gawww.

For now, let's talk about stretch marks.

Aka striae gravidarum, these puppies are a common concern among pregnant women. Let's do a little myth-busting here.

...

1. Cocobutter prevents them.

Nope (Osman, H., et al., 2008).

2. Lol, there's no such thing as a cream that prevents them. They are 100% genetic so you're basically screwed.

Not exactly. Yes, there is shown to be a strong genetic link to the presence and severity of stretch marks. They're also more common in women of certain ethnicities, or women with a personal history of stretch marks (due to pregnancy or other reasons). But there are two products that have demonstrated some hope:

A product called Trofolastin, a cream that contains Centella asiatica extract, vitamin E, and collagen-elastin hydrolysates, has demonstrated some clinical effectiveness in the prevention of striae (Osman, H., et al., 2008). Also there is some evidence that early use of Tretonoin (aka Retin-A) might have some effect (Rangel, O., et al., 2001). 

I know it's not super encouraging, but for women who have a strong genetic risk, at least there's a glimmer of hope on the horizon.

3. If you gain less weight during pregnancy, you're less likely to get them.

This one actually has some merit to it. There are numerous reasons to gain a healthy amount of weight during pregnancy. But if that evidence isn't enough for you, a 2007 study did show a statistically significant correlation between the presence of striae and excessive weight gain in pregnancy (Rubeiz, N., et al., 2007).

4. You're less likely to get stretch marks when you're young.

Once again, false. First of all, I see plenty of teen mothers in my office who have just as many stretch marks as the next person. Anecdotal evidence aside, there is actually some scientific evidence that younger mothers (average age 26 versus average age 30) are actually more likely to develop striae than their older counterparts (Rubeiz, N., et al., 2007).

5. Drinking plenty of water is the best way to prevent them because it keeps your skin hydrated.

Ehh. Yes and no. Hydration is really important in general during pregnancy because you're effectively doubling your blood volume. Drinking plenty of water does also help to keep your skin hydrated, and there's some evidence that good skin hydration helps with the itchies that are common with stretching skin. But no clear evidence that it does anything to prevent stretch marks.

...

The take away here? Know your genetics, ask mom and grandma and see what your chances are. If you're really concerned, talk to your OB about some of the treatments listed above.

Or...don't? Stretch marks are like any scars. As my Dad used to say, it's proof that you've been in the game. Own them, ladies. You earned your stripes.

To snip, or not to snip

In 2012, the American Academy of Pediatrics published a statement regarding newborn male circumcision. The statement made more than a few waves - both in the medical community and beyond. The statement has been published, re-published, agonized over and interpreted down to the letter.

The statement is more or less summarized by the following sentence, taken directly from the AAP website:

Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. 

Since then, researchers have been cranking out piles of literature. A very large cohort of European scientists were quick to publish this review after the statement had been published, calling attention to some of the weaker statistics and pointing out what they identified as cultural bias. The debate rages on two years later, with the New York Times publishing this blog post recently, in response to a recent paper in the Mayo Clinic Proceedings.

And so the question remains; to snip, or not to snip?

When I first came across the AAP Statement, my interpretation was (I believe) similar to that of the masses; that this was the AAP's way of subtly recommending newborn male circumcision. But the more I thought about it, I realized that this was not necessarily the case.

The AAP had been decidedly neutral on newborn male circumcision prior to 2012, and America saw a steady decline in newborn circumcision rates. Health insurance companies took note of this. As important as health insurance is, companies will not waste a second to cease coverage if a procedure is not deemed to be medically necessary.

The above statement may or may not provide sufficient evidence in favor of newborn male circumcision. But it undoubtedly provides evidence for the continuation of health insurance coverage of the procedure. In publishing their statement, the AAP is not so much saying that individuals should circumcise their children as they are protecting the individual's ability to do so without breaking the bank.

What do I think? Well, I've done quite a bit of research, and have given it a lot of thought. I haven't been practicing long, and as a Pediatric Nurse Practitioner I don't know much about the long-term sexual effects of the procedure. But in terms of medical complications, I have seen far more in individuals with in-tact foreskins than I have in individuals without foreskins. I have not noticed any significant difference in breastfeeding or maternal bonding, and the literature seems to agree with me. So as for now, my vote is for the snip.

The Drink

I'm a coffee person. I have often said that my blood type is Venti Bold. If you want a break down on why coffee is the greatest thing in the world, check out ilovecoffee or talk to my husband for more than five minutes.

Now that BabyKirk™ has come along, I've been doing some research into the effects of coffee on fetal development. Coffee is one of the few million things that you are not allowed to consume during pregnancy, because of course you and the baby will spontaneously combust and THE ENTIRE WORLD WILL END.

Coffee is an especially tough one for me because it has become so much more than a drink. It's actually a pretty significant part of my life. My morning routine legit doesn't exist unless I get a cup of coffee. At work, I perk up at just the though of my mid-morning joe. If I work nights, a quick stop at Starbucks is what gets me through the second half of my shift. So if this was something that had to go, I wanted to be sure that it really had to go.

I started out by browsing UpToDate. If you're not familiar with it, it's basically like medical Wikipedia. Really awesome, well-written, and well-researched medical Wikipedia. Subscribers only (sorry guys), it presents the lastest data on a variety of medical conditions, diagnostics, and treatments.

I expected to troll around for a while and maybe come across a link or two to some interesting studies on the topic, but to my surprise and delight, I stumbled upon a very comprehensive literature review titled "The Effects of Caffeine on Reproductive Outcomes in Women." Jackpot.

Turns off that coffee turns so many heads in the scientific world because of how accessible it is to the developing fetus:

Maternal caffeine metabolism declines significantly during pregnancy; the half life increases three-fold in the third trimester, reaching a t_1/2 of 11.5 to 18 hours. The fetus metabolizes caffeine very slowly, mainly due to immaturity of caffeine-metabolizing hepatic microsome enzymes and lack of CYP 1A2 activity in the placenta. Therefore, even low maternal caffeine consumption can be expected to lead to prolonged fetal caffeine exposure, particularly when the mother is a genetically slow caffeine metabolizer.  (Nisenblat, V, Norman, R, 2013).

This sounds exceptionally terrifying at first read, but the review goes on to explain that, despite the ready absorption, the effect of caffeine on the developing fetus is largely unknown. There is precious little literature on the effects of caffeine on human subjects, and the literature that does exist is of poor quality. Furthermore, there are a large amount of cofounders that have made studying the effects of caffeine difficult, most notably that the only women who consume large amounts of caffeine during pregnancy nowadays are typically doing other not-so-great things - like smoking, drinking, not accessing prenatal care - at the same time.

Poor evidence aside, the review did examine the effects of caffeine on a variety of reproductive outcomes. Here's the rundown:

1. Probability of conception (fecundability): Inconclusive, caution advised
2. Spontaneous abortion: More likely with >300 mg per day
3. Congenital anomalies: More likely with >300mg per day
4. Fetal Growth Restriction: Some good evidence that caffeine intake is associated with fetal growth restriction, but the range of concern varies between 200mg and 600mg
5. Preterm delivery: No significant association
6. Gestational Diabetes: Unclear (actually some studies showed that it was beneficial!)
7. Gestational Hypertension: Slightly increased risk, but no increased risk of preeclampsia
8. Post-partum depression and long-term effects on infant psychology: No significant association

Upon review, I feel that there is good reason to be cautious with caffeine intake during pregnancy. Given the outcomes, the most sensitive period (like everything in pregnancy) appears to be in the first trimester. After some consideration, my plan is to avoid caffeine entirely for the first twelve weeks. And then after, limit myself to <300mg daily. Although given the amount of caffeine typically found at your average Starbucks, that might be pretty difficult.

source: Huffington Post

Who knows? Maybe I'll start to like this whole decaffeinated tea thing.

Probably not.

**

Nisenblat, V., Norman, R. "The Effects of Caffeine on Reproductive Outcomes in Women." UpToDate. September 11, 2013. Published by UpToDate Inc. [0503-50.169.70.108-4E541A501A-6.14-178603391]