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Monday, November 5th, 2012
A recent review paper published in Human Reproduction has shined a light on an emerging debate concerning the use of antidepressants in women who are seeking treatment for infertility. The issues extend, of course, to all pregnant women (whether or not they sought treatment for infertility), and they are serious and complex. Here I’ll summarize my take on the most important take-home messages.
First, if you have seen the headlines about this study, you may think twice about getting treated for depression if you are trying to get pregnant or are currently pregnant. This is not the point of the debate. Any level of depression should be treated. The issue being discussed is how it should be treated.
The authors of the review paper make the argument that use of serotonin selective reuptake inhibitors (SSRIs) during pregnancy – which include the commonly prescribed drugs Celexa, Prozac, and Zoloft – is associated with a number of potentially serious problems. These include pregnancy complications, preterm birth, and neurobehavioral compromise in infants. There are studies which back up these claims (click here and here for recent papers on the topic). As the authors note, these studies do not provide definitive evidence – clearly more studies need to be done to get better estimates of the level of risk. But the current findings should, at a minimum, be on the minds of women who are dealing with depression when trying to get pregnant or currently pregnant. They need to be factored into considerations of the benefits, and risks, of taking antidepressants.
Expanding on that, perhaps the most important guideline to keep in mind is that SSRIs are most effective as a treatment for severe levels of depression. A recent review published in the Journal of the American Medical Association (JAMA) provided compelling data that SSRIs had no greater effect than a pill placebo when treating mild to moderate levels of depression. In contract, SSRIs were significantly more effective in managing severe depression.
Putting it all together, an argument can be made that women who are dealing with mild to moderate depression may want to consider using only non-drug treatments if they are trying to get pregnant or are pregnant. Many forms of psychotherapy are also effective but of course do not carry to potential biological risks of SSRIs. The more complex assessment of risk and benefits of SSRIs would apply to women who are suffering from severe depression. Severe depression can be a debilitating disorder and can compromise health and well-being. As there is no simple solution in this case – especially if a woman has a history of severe depression along with a history of positive response to an SSRI – the potential risks and benefits of SSRI use during pregnancy should be an active discussion point with both an obstetrician and psychiatrist. It may be worthwhile to consider, and try, only non-drug treatments. In this case the good counsel of the attending physicians and open discussion of the issues will be essential to promote the health of both mom and baby.
Pregnant woman via Shutterstock.com
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Thursday, September 27th, 2012
The scientific paper describing the increases in DNA mutations that correspond to increases in paternal age – published last month (click here to see my discussion of the scientific aspects of the study) – has generated lots of discussion about the need for reconsidering how age may affect paternity and fathering. See, for example, Lisa Belkin’s thoughtful discussion about the utility of men hearing the ticking of a biological clock.
It can be argued that the biological role of fathers, with respect to age, has not received as much attention because we think of the biological clock as primarily representing the probability of being able to reproduce – with those effects being, of course, most pronounced for females. What is now emerging into the public awareness (based on a number of studies conducted over a number of years) is that paternal age – like maternal age – may be associated with an increased risk for passing on certain genetic risk factors that may confer risk for disorders.
We may get to a point where there are risk charts that quantify the increasing probability of paternal mutations that correspond to age and associations with risk for various disorders in offspring (much of the interest right now comes from the potential links between paternal age and autism). Consider, for example, this chart showing the increasing probability of having a child with Down syndrome as predicted by maternal age.
The complexity here is that prospective parents have to consider, in most cases, probabilities rather than certainties (unless there is a screening for a known genetic disorder that runs in a family). Is a 1% chance, versus a .5% or a .01% chance, enough to change someone’s family planning? This is tough to answer. For some people, it may be highly influential. For others, social and personal factors may override such probabilities. What is clear is that genomic research will continue to deliver more and more probabilities in the future (near and far) – and the information that is generated will pertain to both prospective moms and prospective dads. And that prospective parents will have to make more and more complicated choices that are partially (but not fully) informed by genomics.
Statistics and probability via Shutterstock.com
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Wednesday, August 8th, 2012
Have you heard about the charter school in Louisiana that holds the right to require a girl to take a pregnancy test? (By the way, the school can choose the doctor as well). That’s not all. If she refuses, the school can expel her. And if she does take the test, and is pregnant … the school can expel her.
There is a legal issue here. The American Civil Liberties Union (ACLU) of Louisiana is pursuing this vigorously. They suggest that it violates the U.S. Constitution and federal laws pertaining to sexual discrimination.
There are also other issues here. Jeanne Sager has written a great piece suggesting what I believe many parents would think. They would want to be in the loop if the school suspected anything about their child. They would want to take the lead on bringing their daughter to a doctor. And, they would think it horrendous that a school would kick a girl out for being pregnant (especially since teen pregnancy is a primary reason why girls quit school).
I agree with all of the above. In addition, I suggest that schools have an obligation to work with parents when sensitive issues come up. It’s not just pregnancy; it could be, for example, suspected drug use. I would hope that schools would partner with parents to try to serve the kid in question the best – meaning securing an appropriate referral (if necessary) and working out a plan to keep the kid engaged in school. Of course, there are going to be situations where a school may reach out to parents and find that the parents are not properly involved or unwilling to take appropriate actions. That’s a tough bind for a school and then the issue gets a bit fuzzy. But the solution is not for a school to have complete control over a kid’s life – and enact a severe punishment that denies a kid an education.
I’m anticipating that lots of parents will have lots to say about this. I’d love to get your take on it.
Pregnancy Test via Shutterstock.com
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Wednesday, June 27th, 2012
Across the United States this year, 8,159 provisional pertussis (whooping cough) cases have been reported to the U.S. Centers for Disease Control and Prevention (CDC) as of May 5, 2012. This represents an 86.6 percent increase compared to the same time period in 2011. The Sounds of Pertussis® Campaign, a joint initiative from Sanofi Pasteur and March of Dimes, is alerting adults about what they can do to help stop the spread of pertussis. In particular, there is a current focus on making sure that parents get themselves – and other adults in contact with their kids – vaccinated. This is especially important if you have a baby in the house, as pertussis can cause serious complications in little ones, and in some cases, death. (Click here to read my post from last month that featured Seattle Mama Doc). Keep in mind that babies most often contract pertussis from the adults in their families.
To help increase awareness about the risks pertussis poses to babies, I had the opportunity to conduct an interview with Sounds of Pertussis® spokesperson Jeff Gordon and Felicia Dube of Lancaster, S.C., who lost her baby to pertussis. Please have a listen to what they have to say, as you will hear Jeff talk about his involvement in this campaign – and Felicia share her moving (and sad) story about her baby and why she is spreading the word about the importance of adult vaccination.
As Jeff mentioned, The Sounds of Pertussis Campaign is launching Take Pertussis Out of the Picture, a new initiative calling for families across the country to take a stand against the disease. To support this initiative, families can upload a family photo on the Campaign’s Facebook page [www.facebook.com/SoundsofPertussis] and by doing so, mark their commitment to protecting the babies in their lives by getting an adult pertussis vaccine and encouraging other adults to get one too. Once a photo is published, participants can spread the word by sharing their photo with friends and family and inviting others to participate in this important awareness effort. For every photo published, Sanofi Pasteur will donate $1 to March of Dimes (up to $10,000).
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Thursday, May 17th, 2012
Whooping cough (pertussis) is a serious (but preventable) disease that can be fatal for babies – in 2010 ten infants died from it in the state of California. There are periodic breakouts, such as the current one in Washington state, in which 1,484 cases have been reported through May 12 as compared to 134 cases during the same time period in 2011 (click here for the details from the Centers for Disease Control and Prevention). Given this recent outbreak, I thought it would be useful to share current information on whooping cough and advice on how to try to prevent it.
To this end, I sought out the perspective of Dr. Wendy Sue Swanson. Dr. Swanson sees patients at The Everett Clinic in Mill Creek, Washington and is on the medical staff at Seattle Children’s. Dr. Swanson is also a Clinical Instructor in the Department of Pediatrics at the University of Washington. In addition, she writes the Seattle Mama Doc blog, which I turn to frequently (as a professional and parent) for concise and up-to-date information and guidance on many pediatric issues. Dr. Swanson was kind enough to answer a number of questions I posed to her about whooping cough which I am pleased to share here.
1) What is whooping cough?
Whooping cough (also known as pertussis) is a highly contagious respiratory illness that can spread from one person to another with a single cough or sneeze. In older children and adults, it starts as a typical cold but can advance to a more prolonged/protracted cough that is serious, uncomfortable and disruptive. The cough can get so bad that it makes it difficult to eat, drink or even breath. Sometimes the cough causes a characteristic “whoop” and often it causes vomiting. But most dangerous is whooping cough in infants. In infants it can cause feeding delays, severe respiratory distress, pauses in their breathing and/or death. Infants under 6 months of age are at high risk, and those under 2 months of age are at severe risk for complications.
2) How is it spread?
Via coughing, sneezing, or other ways in which droplets spread from one to another.
3) Are children of all ages vulnerable?
Although infants are most vulnerable – particularly those under 2 months of age – all children are at higher risk. In Washington state during our epidemic, 80% of positive tests were in children under 18 years of age. That is primarily because it is more distressing to children and they are the ones who get treated. Most data supports the notion that during epidemics, only aboute 10% of those with whooping cough get tested.
4) Why do we see surges in it?
Whooping cough tends to cycle every 3-5 years with surges. Part of that has to do with immunity and the herd. Part of those surges have to do with the fact that we never develop lifelong immunity. After a whooping cough infection, our immunity to whooping cough wanes somewhere between 4-20 years and after the immunization it wanes somewhere between 4-12 years later. That is why it is recommended that all children over age 11 get a Tdap shot NOW. We also immunize infants with DTaP at 2,4, 6, 15 months and 4 years of age. It’s essential that pregnant women get the Tdap in their 3rd trimester (after 20 weeks gestation). All adults who will be around newborns should also get the Tdap. We know that newborns are most vulnerable to the serious complications from whooping cough so if we “cocoon” them with family and friends who are immunized we reduce the likelihood that they get an infection.
5) What symptoms should parents look for? What should they do when they observe these symptoms in their kids?
In infants, if your newborn or infant has a cold, difficulty feeding, vomiting with cough or coughing fits, see the pediatrician. In older children, if they have been exposed to whooping cough and present with a cold, or have a cough that lingers past 2 weeks, cough with vomiting, or a “whoop” sound, see the doctor immediately.
6) What should parents do to protect their kids and help prevent it?
The best way to protect against whooping cough is to get immunized (as detailed above). After you get immunized, ask that your family, your children’s daycare and school teachers, and all adults that come into your home get immunized, too. Grandparents of any age are recommended to get the Tdap shot, too!
If you would like to learn more, here are additional blog posts that Dr. Swanson has written on whooping cough:
Post on how to protect newborns:
What is the Tdap shot? (YouTube video and post w/list of resources):
All Grandparents need a Tdap shot:
Woman sneezing via Shutterstock.com
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