New Zika travel alerts especially for pregnant women

The Pediatric Insider

© 2016 Roy Benaroch, MD

What animal kills more people, year to year, than any other on the planet? The lowly, annoying mosquito. They fly around poking their snouts (I think) into person after person, spreading infections like malaria, yellow fever, and dengue. And new infections, too—like West Nile virus, which first appeared in Uganda in 1937. Infections don’t seem to recognize the borders of countries and continents, and West Nile has now become the most common mosquito-borne encephalitis in the US.

Now, the CDC is warning travelers against an even newer virus named “Zika”. Like West Nile, Zika was first found in Uganda, in a research station in the Zika rainforest (Zika means “overgrown” in the local language.) It remained an uncommon cause of human infection until the mid-2000’s, when the virus was first spotted outside of Africa and Southeast Asia. Since then, it has spread worldwide, throughout the warmer areas of the globe, leading to a large outbreak in Brazil that may have started with visitors to the 2014 Soccer World Cup. Brazil has probably had 500,000-1.5 million cases of Zika virus infection in the last few years.

Zika had been thought to cause only mild disease, with fever, rash, and joint pains. But at around the same time as the cases spiked in Brazil, health authorities there noted an alarming increase in health problems in newborns, especially a failure of brain growth called “microcephaly.” It’s since been shown that an unborn fetus can catch Zika virus across the placenta, and it’s very likely that the Zika virus infection is causing problems in the developing baby. We don’t know exactly how that’s happening, or when, or exactly when pregnant moms and babies are vulnerable.

What we do know is that like malaria, dengue, West Nile, and Chikungunya, Zika virus is spread by mosquitoes, and the best way to prevent transmission is to prevent mosquito bites. Stay inside at dusk, wear protective clothing, and use a chemical mosquito repellant containing DEET or picaridin.

The CDC has also now issued a “Level 2 Travel Alert” for areas with active Zika transmission, including Brazil, Puerto Rico, Mexico, and most of the rest of Central and South America. That means “practice enhanced precautions”, and applies especially to pregnant women.

Meanwhile, in the US, the first reported case of Zika virus infection occurred in Texas in November, 2015, in a woman who had recently traveled to El Salvador. And a resident of Puerto Rico recently developed Zika with no history of travel off the island—meaning that Zika is probably being transmitted by local mosquitos, now. It is only a matter of time for mosquitos in the rest of the warmer parts of the US to start spreading it around here.

It’s a big world, and the health problems of Africa are our health problems, too. New infections will continue to emerge. We’d better keep paying attention, and keep an eye on those mosquitoes.

Pregnant women should get influenza vaccines to protect their babies and themselves

The Pediatric Insider

© 2014 Roy Benaroch, MD

The kids are heading back to school, and my zucchini vines are withered—that means summer’s almost over, and we’re heading back into flu season. This year, I’m going to try my best to convince as many of you as possible to get yourselves and your children vaccinated.

Why? Because I don’t like to see people suffer and die. We’ve got a good, safe, effective way to prevent influenza—and the more people vaccinated, the better it works. There are very few medical contraindications, and the CDC recommends that everyone aged 6 months and over get the vaccine each year. That helps protect us all.

Today I’m going to focus at the beginning of the life cycle, with pregnancy. We’ve known for a long time that pregnant women are especially prone to complications and death from influenza infection, and ACOG (The American Congress of Obstetricians and Gynecologists) has recommended since 2010 that women receive a dose of injected influenza vaccine during pregnancy. Uptake has been poor, in part because of lingering safety concerns.

There have been several recent studies that provide solid reassurance about the safety and effectiveness of influenza vaccines during pregnancy. In 2013, the New England Journal published a study from Norway that looked at 117,347 pregnancies—vaccinated moms were less likely to get influenza, and less likely to have their babies die. Another study, BMJ 2012, looked at about 55,000 pregnancies in Denmark, showing no increased risk of birth defects, preterm birth, or fetal growth problems after vaccination. That same Danish group published a second study from their data set showing no increased risk of fetal death. The Danish studies looked rigorously for adverse reactions, finding no support for any significant problems, though these studies were not designed to look at the effectiveness of the vaccines.

The effectiveness of these vaccines has already been demonstrated, both to protect mom and to protect baby. Pregnant women ought to make the safe choice: get vaccinated against influenza. It’s the right thing to do for you, and the right thing to do for your baby.

The safest place to have a baby is in a hospital

The Pediatric Insider

© 2014 Roy Benaroch, MD

Two big studies have been published in the last few weeks, both of which have confirmed previous data: home birth is not as safe as hospital birth. These studies show that having a baby at home increases the risk of your baby dying by about 4 times. That really is a big increased risk—especially considering that most home births are supposedly low-risk pregnancies. Those babies should be less likely to die.

From the January, 2014 issue of the American Journal of Obstetrics and Gynecology comes a study of over 10 million babies born in 2007-2009. This study looked only at term deliveries, excluding small babies and twins and babies with congenital anomalies (that’s now the preferred term. We don’t really say “birth defects” any more.) The babies were then divided into groups by the setting of their delivery: in a hospital, in a free-standing birth center, or at home. The results are stark. The neonatal mortality among babies delivered by a midwife in a hospital was 3.1 per 10,000 births. For midwives delivering at home, the death rate was 13.2 per 10,000 (about four times the hospital risk.) There were far more babies born in the hospital than at home, but plenty of home births were analyzed, including over 48,000 by midwives. This was a large study with a reliable data set cross referenced from CDC data, and if anything it underestimates home birth mortality because babies transferred to the hospital because of complications during home birth counted as hospital babies.

The second January, 2014 study came out in the Journal of Midwifery and Women’s Health. This study did not have a built-in comparison group—it collected data only from women intending to have a home delivery by midwife from 2004 to 2009. The authors looked at many outcomes, including whether the babies successfully delivered at home, Apgar scores, and their use of medical interventions. The overall intrapartum death rate was 13 out of 10,000—and that includes only deaths during labor itself (not including babies who died shortly after birth.) Note that the death rate, 13 out of 10,000, just about matches the death rate for home midwife births from the ACOG study, which was 13.2 per 10,000. Though this study had no built-in comparison group, the rate is much higher than the hospital death rate from the ACOG study. And, again, the four-fold increased death rate is very likely an underestimate—this number does not include babies who barely survived delivery and died shortly afterwards. Also, data submission was entirely voluntary, capturing only 20-30% of home births. I’m thinking that midwives who delivered dead babies may have been somewhat less motivated to submit their data.

Though the total number of deaths was not large—the vast majority of deliveries in either setting were successful—a four-fold or more increase in death risk is not something I think most families would consider acceptable. The fact of the matter is that obstetric complications are not always predictable, and that hospitals are the place where medical interventions can be done quickly. These studies concerned deaths, but keep in mind that for every dead baby, there are many more that suffer brain damage with lasting handicaps.

Based on these and other good, large studies, a hospital birth dramatically improves the safety of delivery compared to having a baby at home. Further studies could improve the safety of home births—by developing stricter criteria to limit home births to the lowest risk pregnancies, and by making sure that home birth midwives are qualified to handle complications. But even in an optimal home birth situation, with a very competent midwife, some mothers and babies will suffer complications like massive bleeding or strokes or placental separations or umbilical cord catastrophies that will require near-instant hospital assistance to help mom and baby survive. Sometimes, there just isn’t time to wait for an ambulance. If you want the safest choice for your delivery, choose a hospital. And then bring your healthy baby home.

Cord blood: Donate it, don’t bank it

The Pediatric Insider

© 2013 Roy Benaroch, MD

Add this to the list of things expecting couples have to deal with: heavy-handed sales pitches from companies urging private banking of cord blood. They say “It could save your baby’s life!” How could anyone say no?

You’re not going to hear the whole story from these private, for-profit companies. They’ve got an estimated 1 billion dollar-a-year industry cooking, and there are things they do not want you to know:

• It is phenomenally unlikely that your privately banked cord blood will ever be used by anyone.
• Even if your baby ends up needing a cord blood transplant, he’ll almost certainly need someone else’s cord blood—not his own.
• Even if by some remarkable chance you baby needs his own cord blood, many of the donated samples may not be suitable for use. No tests will be done to determine this until the blood is retrieved—you may have paid thousands up front plus a substantial year fee to store, well, nothing at all.

Cord blood is the blood that’s left in the umbilical cord and placenta after birth. It’s usually incinerated. However, cord blood is rich in stem cells—cells that have the potential to develop into many different body tissues. In an emerging field of research and therapeutics, cord blood has been used successfully to treat a number of diseases, including cancer, diabetes, metabolic disorders, and rare genetic syndromes. About 2000 cord blood procedures are performed each year worldwide, and that number is probably growing. Communities and non-profits are setting up public banks, similar to blood banks, for families to donate the cord blood at no cost so that other families in need can find cord blood that matches.

But competing with these public banks are private companies trying to convince parents to pay thousands to bank the cord blood only for themselves. Their web sites (and you’ll notice I’m not linking to any of them) are rife with misinformation, half-truths, and slimy marketing weasel-talk that’s designed not to help your family’s health, but to get the money out of your family’s wallet. There have been troubling charges of kickbacks to doctors and hospitals for their lucrative referrals, and the industry itself has grown 2100% over the last seven years. We’re talking Big Money here, billions of dollars a year, and the competition for new customers is heating up. In other words: someone is getting hosed. And you could be next.

Sales pitches are strongest at the OB’s offices—where pamphlets abound, and expectant couples are at their most vulnerable. I know that at least one of these cord blood banking companies flies the doctors to paid luxury junkets to convince them to let their sales people leave material at the practice. Just a brief positive response from the docs to their patients is money in the bank.

There is one exception: if there is a sibling or another family member who has a specific need for a cord-blood transplant, discuss the situation with a knowledgeable hematologist during the pregnancy to see if the cord blood might be useful.

Expecting couples should look into cord blood donation to a public facility. As more families donate, there will be more cord blood available both for treatments and for research. That makes a whole lot more sense to me than spending thousands of dollars to let your baby’s cord blood sit unused in a freezer.

Adapted from a post originally published 2/2009

Cord blood: Donate it, don’t bank it

Add this to the list of things expecting couples have to deal with: heavy-handed sales pitches from companies urging private banking of cord blood. They say “It could save your baby’s life!”—How could you say no?

You’re not going to hear the whole story from these private, for-profit companies. They’ve got an estimated 1 billion dollar-a-year industry cooking, and there are things they do not want you to know:

• It is phenomenally unlikely that your privately banked cord blood will ever be used by anyone.
• Even if your baby ends up needing a cord blood transplant, he’ll almost certainly need someone else’s cord blood—not his own.
• Even if by some remarkable chance you baby needs his own cord blood, many of the donated samples are not suitable for use. No tests will be done to determine this until the blood is retrieved—you may have paid thousands up front plus a substantial year fee to store, well, nothing at all.

Cord blood is the blood that’s left in the umbilical cord and placenta after birth. It’s usually incinerated. However, cord blood is rich in stem cells—cells that have the potential to develop into many different body tissues. In an emerging field of research and therapeutics, cord blood has been used successfully to treat a number of diseases, including cancer, diabetes, metabolic disorders, and rare genetic syndromes. About 2000 cord blood procedures are performed each year worldwide, and that number is probably growing. Communities and non-profits are setting up public banks, similar to blood banks, for families to donate the cord blood at no cost so that other families in need can find cord blood that matches.

But competing with these public banks are private companies trying to convince parents to pay thousands to bank the cord blood only for themselves. Their web sites (and you’ll notice I’m not linking to any of them) are rife with misinformation, half-truths, and slimy marketing weasel-talk that’s designed not to help your family’s health, but to get the money out of your family’s wallet.

I’ve heard that the sales pitches are the strongest at the OB’s office—where pamphlets abound, and expectant couples are at their most vulnerable. I know that at least one of these cord blood banking companies flies the doctors to paid luxury junkets to convince them to let their sales people leave material at the practice. Just a brief positive response from the docs to their patients is money in the bank.

There is one exception: if there is a sibling or another family member who has a specific need for a cord-blood transplant, discuss the situation with a knowledgeable hematologist during the pregnancy to see if the cord blood might be useful.

Expecting couples should look into cord blood donation to a public facility. As more families donate, there will be more cord blood available both for treatments and for research. That makes a whole lot more sense to me than spending thousands to let you baby’s cord blood sit unused in a freezer.

Pregnant women should get flu vaccine

As published this week in the New England Journal of Medicine, a study has shown that giving pregnant women a single dose of influenza vaccine reduces her newborn’s chance of getting flu by 63%. The vaccine triggers mom’s immune system to make antibodies against the flu virus, which cross the placenta to protect the baby even after Junior is born. The CDC has been recommending flu vaccines for pregnant women for several years to protect her own health, and also to prevent her from spreading flu to her young child, but this study shows that vaccinating mom while pregnant will safely and effectively confer flu protection to her baby. It’s 2 for the price of 1, and it’s pretty neat.

The story was reported here, where mistakenly the story also says that flu vaccine is recommended for children aged 6 to 24 months. This hasn’t been true since 2006. The current recommendation is for flu vaccination to be given to all children from age 6 months to 18 years.

Visit the CDC web site for more info about influenza and vaccinations.

Pregnancy: Foods to avoid, foods to enjoy

A study published in January, 2008 confirmed a strong link between a common item in many women’s diets and miscarriage. This inspired me to do some research outside of my usual field. I’m a pediatrician, not an obstetrician– but as they say, “An ounce of prevention is worth a pound of cure.” Since pregnant women are said to be eating for two, I figured we might just be able to get the equivalent of two pounds of cure out of a few simple dietary steps. Along the way, I also found some intriguing studies with new information about what pregnant women should eat more of—and the news is good. Eating more of your favorite foods might really be able to help your unborn baby.