Tuesday, April 28, 2009

Our Trip to the Dentist- Or, How I'm a Flossing Failure...

So, returned from a trip to Son #1's dentist this morning...

At our last visit ~6 months ago, he was found to have areas of decalcification ("almost-cavities") between his molars. At that point, he was still not the best at cooperating with tooth-brushing and used to swallow the toothpaste, which meant that we couldn't use fluoride-based toothpaste. We were instructed to optimize the brushing, start flossing, and switch to fluoride toothpaste.

We did great! Well, the flossing could have been a little better, but otherwise, we did great! Twice a day, without fail, spending plenty of time focusing on the molars. Very limited juice, candy only on Halloween and birthdays... our only weakness was ice cream, but he always drank water afterwards.

Despite our best efforts, half of the areas of decalcification have progressed to cavities, and now we're facing having the teeth fixed with a pulpotomy and the placement of ugly stainless steel crowns, which will remain until the baby teeth fall out (probably another 6-8 years from now).

Needless to say, I feel as though I have failed in my motherly duty to keep my kid healthy. Being a pediatrician makes the failure all the more acute, because after all, aren't I supposed to be a parenting and health expert? I felt only marginally better when the dentist told me that his own child required the same treatment (his wife was really mad at him, or so I'm told)...

I agree with our dentist that we can't allow to decay to progress unchecked... children's enamel is much thinner than adults, and the oppositional surface area of the molars is also larger than in permanent teeth- this means that this risk of cavity progression and abscess formation is theoretically larger. I'm not keen on waiting until it hurts to eat, drink or brush. A root canal? No, thanks!

However, the thought of replacing my child's beautiful little smile with a mouthful of gray metal is decidedly unappealing. My son's dentist (a pediatric specialist) does not offer esthetic (tooth-colored) posterior crowns, because he feels they are not as durable as stainless steel.

I'm incredibly disappointed, and concerned that a mouthful of metal is going to affect my son's self esteem at a very sensitive time in his social development. I know I should be more concerned about his health than his appearance, but I can't help it.

I am going to look into a second opinion, and will post updates as I learn more.

Tuesday, April 21, 2009

Prebiotic Supplementation May Decrease Allergic Antibodies in At-Risk Infants

Researchers from the Netherlands have reported in the March issue of Allergy that supplementation with a mixture of short-chain galacto-oligosaccharides (GOS) and long-chain fructo-oligosaccharides (FOS) appears to decrease total levels of the allergic antibody IgE, as well as IgG subclasses 1, 2 & 3, while increase levels of the "blocking" antibody IgG4.

These oligosaccharides are known as "prebiotics", and they supply a nutrition source for the "good bacteria" (probiotics) that colonize our gastrointestinal tracts shortly after birth.

The microbial environment in the gut may be an important factor in the risk of developing allergic disease, such as atopic dermatitis (eczema).

The interesting thing about this study is that it demonstrated that despite the overall decrease in antibody levels, the immune response to vaccinations was preserved. This is important, because antibodies are essential to protecting us from infection, and a decrease in allergic risk at the expense of adequate immunity against infection would not be not especially helpful.

So, should we be rushing to supplement the diets of our infants with prebiotics to skew the developing immune systems of our kiddos towards a less-allergic phenotype?

Not necessarily.

Breastmilk has plenty of oligosaccharides, and there's not evidence that infant formula supplemented with oligosaccharides is any better at preventing allergy than breastfeeding.

So when worried expectant moms come to me and ask what they can do to decease allergy and asthma risk in their soon-to-be-born babies, this is what I recommend:

1) Don't worry too much about what you eat during pregnancy- sensitization does not appear to occur in utero.

2) Actually, don't worry too much during pregnancy in general! (see my previous post about stress during pregnancy increasing asthma risk)

2) Try to have a vaginal delivery, so that your baby's gut can be colonized with beneficial bacteria as soon as possible.

2) Breastfeed!!! (but don't delay the introduction of solids beyond 6 months)

3) If you must transition to formula, consider a partially hydrosylated formula with prebiotics.

The evidence is emerging and recommendations continue to evolve- this is definitely an area of allergy which I will continue to follow closely...

Thursday, April 16, 2009

Insider Tips on Surviving a Hospital Stay

Just visited my husband's grandmother in the hospital today... being a physician gives me a slightly different perspective when I am on the "patient-side".

Being hospitalized is always stressful, even when for a joyous occasion such as for the birth of a child. You're out of familiar surroundings, usually not in the best of health, sometimes in pain, and certainly NOT in control of what happens to you, at least not in the way that you are accustomed to being. You and your family are eager to get home as soon as possible. Under these circumstances, the inefficiencies and "unique" communication issues in our healthcare system can be frustrating at best.

So, here are my insider tips for optimizing communication in the hospital setting.

1) Please be patient. I know, not what you want to hear. But it's important to realize that the physicians and nurses caring for you and your loved ones are also responsible for the medical care of many other patients as well. If they had to drop everything to discuss a patient's treatment according to each individual family's timetable, they would never be able to attend to their most important task- helping your loved one get well!

2) Have your loved one's medical history available at all times- this is easy to do with a flash drive and a .doc file. Include the most essential information: Name, date of birth, active medical conditions, past surgical history, immunization history, food and drug allergies (include what the reaction is), current medication list (include generic names and doses), immediate family medical history (we don't need to know about Aunt Edna's bunion surgery), and names and contact information of primary care physician and specialists. Have the primary care physician review the document for accuracy at least once a year, and note the date of review on the document. Print a few copies to distribute to the ER physicians and consultants who may be asked to see your family member during his/her hospital stay. This will ensure that all doctors have the most accurate, up to date historical medical information- and will free up their time to focus on the issue at hand (and spend more time answering any questions you may have!).

3) Make friends with your nurses! Your R.N. is an integral part of the healthcare team, has a direct line of communication to the physicians, and is trained to be your advocate. Treat your nurse with the respect that his/her training deserves, and you will not be disappointed with the care and valuable information you receive. (Tip- if you have a child or an elderly family member who has delicate veins, kindly ask your nurse if she can hold off on placing the IV line until the physician has determined which labs to order. That way, labs can be drawn from the IV before fluids are infused. This cannot always be done, but if it can, your nurse is usually happy to oblige.)

4) Designate one adult family member as a "point-person" for healthcare communication, preferably someone with a cool temperment and perhaps even a medical background. This person is responsible for relaying information from the healthcare team to other family members. In my opinion, it is unreasonable to ask the physician or nurse come in to repeat the same information each time a new relative comes to visit and wants to know what's going on. As I mentioned earlier, this diverts resources from their primary task- caring for the patients!

5) At your first visit with each of your physicians, ask if they have a window of time during which they expect to round, so you can plan to be present to be apprised of the plan of care, and to ask any questions you may have. Most physicians tend to round on their patients at around the same time each day- usually in the morning, but not always.

6) If no one from the family is available during the times when the healthcare team is rounding, arrange to have a notebook where you can leave your most pressing questions for the doctors. Ask your nurse to have the team look at the notebook each day. Although liability reasons may prevent the team from writing answers to your questions in the notebook, the answers can be relayed to your nurse or "point-person" verbally. Also include in the book the name and contact information of your "point-person", so the team knows who to call.

7) As the time for discharge home approaches, ask your physicians and nurses if there is anything your family can do to facilitate getting home as smoothly as possible. Most hospitals have discharge coordinators who will be happy to discuss the issues with you and ensure that you are as prepared as possible.

I hope you don't have to deal with a hospital admission anytime soon. But if you do, the tips above will help you and your family stay informed, and simulateously improve your relationship with the healthcare team.

Wednesday, April 15, 2009

Anxiety During Pregnancy Increases Asthma Risk

A study in the April issue of the Journal of Allergy and Clinical Immunology reveals that prenatal maternal anxiety, especially late in pregnancy, is associated with higher rates of asthma in children at approximately 7 years of age.

Why might this be the case? Maternal stress hormones, such as cortisol, may have a negative-feedback effect on the developing fetal adrenal glands, leading to relatively low levels of anti-inflammatory hormone production in the child.

Makes one wonder... knowing that women tend to display higher levels of anxiety than men during times of economic downturns... will the current economic crisis result in increased pediatric asthma rates a few years down the road? One can only speculate, but it certainly makes the case for prenatal yoga!

Tuesday, April 7, 2009

Does "the Pill" Increase Asthma Risk- a New Study Says Yes!

Further evidence that hormonal influences really do affect allergic disease...

A European study published in the Journal of Allergy & Clinical Immunology has shown an increased risk of asthma in normal weight (odds ratio 1.45) and overweight (odds ratio 1.91)women using oral contraceptives.

Lean women (with a body mass index of >20 kg/m2) taking OCPs, however, were less likely than their non-OCP-taking counterparts to have asthma.

These findings support the theory that metabolic status may influence how susceptible a woman is to the effect of sex hormones on the airways.

However, the study authors take care to note that women should not abruptly discontinue OCPs without first discussing their concerns with their physician, as the health risk of an unexpected pregnancy may be greater than the small increase in asthma risk associated with oral contraceptives.

I agree. But although I won't be recommending blanket discontinuation of OCPs, I'll definitely consider that possibility that hormonal supplementation might be contributing to asthma, or exacerbations thereof, especially in those patients interested in losing a few pounds!