Food Allergies in Kids (Kelso, 12/18/2024)

 A recording of this week's Grand Rounds is available HERE. 

This was an excellent presentation by a pediatric allergist, Dr. John Kelso. I learned a lot, but I'm a little behind on writing up a summary.

Check back for my notes shortly.

Physiologic Birth in the Hospital (Saedi-Kwon, 12/11/24)

 A recording of this presentation is available HERE. 

Thanks to Dr. Ryley Saedi-Kwon for her presentation this week on Physiologic Birth. As usual, a recording of the presentation is available above. Dr. Saedi-Kwon covered a wide range of birth topics, see my highlights below.

Physiologic Birth, as outlined in a 2012 consensus statement of US midwifery organizations includes:

• Spontaneous onset and progression of labor
• Includes biological & psychological conditions that promote effective labor
• Results in the vaginal birth of the infant and placenta
• Results in physiological blood loss
• Facilitates optimal newborn transition through skin-to-skin contact
• Supports early initiation of breastfeeding

2018 systematic qualitative review found that

• Most wanted a physiological labor and birth while acknowledging that birth can be unpredictable and frightening and they may need to ‘go with the flow’

• Small minority birth was physical process that should be conducted as quickly and painlessly as possible

What matters to birthing patients is:

• Giving birth to a healthy baby in a clinically and psychologically safe environment
• Practical and emotional support from birth companions and competent, reassuring, kind clinical staff
• Individualized care
• Sense of personal achievement and control through active decision-making

Birth Setting

Possible birth settings include hospital, home, or birth center birth. There are advantages and disadvantages to all three settings, and may patients' options are limited/controlled by financial and insurance decisions rather than personal decision-making. Whereas the hospital setting has demonstrated benefit in "high risk" deliveries, there is plenty of data showing that both home birth and birth center birth can be just as safe in "low risk" patients. Whereas hospitals offer expert and facile access to testing and timely interventions, they tend to be less private, less comfortable and allow limited freedom of movement. Birth centers have demonstrated less interventions and some improved outcomes with similar safety outcomes to hospital birth in a select patient population.

   

Racial and ethnic disparities exist. As we know, BIPOC women have increased rates of maternal mortality but also have increased rates of discrimination and mistreatment in the hospital setting, including higher rates of feeling "pressured into interventions". In one study, 30% of BIPOC patients experience mistreatment during hospital birth compared to 6.6% of patients who delivered in a birth center. 

***

There are many evidence-based and non-evidence based interventions patients and providers use/recommend to promote physiologic birth. These very across the stages of labor. Dr. Saedi-Kwon reviewed briefly the use and evidence for these interventions/options:

First stage of labor

"natural birth preparation" or "natural induction"

• Red raspberry tea 
• Dates
• Castor oil
• Primrose oil

Pain Management is an important consideration for laboring patients. IVs, medications, and pharmaceutical interventions can have a tethering effect for women, and non-pharmacological interventions have some high level evidence. These include:

• Continuous labor support (i.e. doulas and/or partner support): associated with decreased length of labor, increased rates of vaginal birth, reduced procedural deliveries, decreased pain medications and increased patient satisfaction. Continuous labor support also allows someone to be present who is advocating for the patient during their labor. Of note, Medi-Cal now covers doula services. 
• maternal position: upright and walking has demonstrated better outcomes
• hydrotherapy/water immersion: decreases anxiety and improves pain without any evidence of harm 
• counter pressure: mixed data but some studies show improved pain scores

How can we limit interventions in birth?

• Delayed admission to L&D
• Outpatient cervical ripening: pharm or non-pharm placed in the hospital (misoprostol or foley) with return in 12-24 hour for recheck
• Whereas current guidelines do recommend immediate induction of labor if a patient has PROM, 95% of patients with PROM will go into spontaneous labor within 24-48 hours
• Intermittent auscultation for fetal monitoring (via doppler)

2nd Stage of Labor

• Perineal massage: metanalysis found a decrease rates of 3rd and 4th degree lacerations, more significant in primigravida
• starting at 34 weeks, 3-9 o'clock posterior perineum, clean hands, lubricant (water-based or food based oil)
• can by done by partner or self
• even as infrequently as 1-2x week has benefit
• Warm compresses held to perineum during/between pushing also has some evidence of decreased 3rd/4th degree lacerations
• "Hands on" vs. "Hands poised" position (by provider): mixed evidence, comparing the two, hands on shows no reduction in anal sphincter injury
• Pushing (studies done in patients with epidurals)
• immediate vs. delayed, immediate pushing does decrease length of second stage and reduces rates of chorioamnionitis, but there is no different in vaginal operative delivery, laceration, or post-partum hemorrhage
• open vs. closed glottis: closed glottis does again decrease length of second stage but does also increase risk of abnormal post partum urodynamics
• opening the pelvis with knees wide (traditional lithotomy) vs. with internal rotation of the knees: internal rotation does increase size of pelvic outlet
• pushing position: upright and side lying (as opposed to lithotomy) does increase rates of intact perineum
• 

3rd Stage of Labor

• Delayed cord clamping increased final blood volume of neonate by 20-30% and has proven benefit in neonates, >120 seconds
• in very preterm neonates (<28 weeks), cord milking may be preferred to allow for urgent resuscitation for non-vigorous infants
• To decrease rates of postpartum hemorrhage (PPH): 
• Pitocin at delivery of anterior shoulder decreases rates of severe PPH
• cord traction with counterpressure on uterus (risks are cord avulsion (5%)and uterine inversion (<0.1%), both of which are rare

And, finally, Dr. Saedi-Kwon ended her presentation with this beautiful montage from the National Association to Advance Black Birth - Black Birthing Bill of Rights. Please check them out HERE.

 

Osteopathic Manipulation in the Hospital (Earl, 12/4/2024)

A recording of this presentation is available HERE.  

Many thanks to Dr. Connie Earl for a FANTASTIC Grand Rounds presentation this week on Osteopathic Manipulation in the Hospital. Dr. Earl, who previously ran the Forestville Wellness Center through West County Health Centers, is currently doing a year of extra "residency" training on Osteopathic and Neuromuscular Medicine (ONMN) at Maine Medical Center. She shared with us her passion for Osteopathic Manipulation (OMM/OMT) and a TON of what she described as "really weird studies that demonstrate ways in which OMN may be used in the hospital setting".

As an allopathic-trained physician, I admit I am often envious of the anatomy knowledge and tremendous skills of my osteopathic colleagues-- and I can tell you from personal experience that Dr. Earl has amazing clinical skills (and hands!)

For those of us less familiar with OMT, she started with the four principles of osteopathy: 

1. The body is a unit; the person is a unit of body, mind and spirit.

2. The body is capable of self-regulation, self-healing and health maintenance.

3. Structure and function are reciprocally interrelated.

4. Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation and the interrelationship of structure and function.

Aren't these principles cool?  

Dr. Earl also contrasted OMT with allopathic medicine, which often focuses on treating/curing/preventing the disease; whereas osteopathy focuses on what we can do to protect the host. 

Well-structured randomized control trials of OMT are extremely challenging to create because of a wide variety of methodological variants. For example, OMT is a response to a personal and individual host. If you protocolize an OMT intervention (in order to standardize it), you are already compromising the validity of the treatment. OMT techniques vary widely, sham OMT is challenging to replicate, and many studies include trainees of varied levels of experience. 

Where she is currently training at Maine Medical Center, a 700 bed Level 1 Trauma Center, the OMN service typically treats 60-70 patients. These include patient post-CABG, poly-trauma patients, patients after GI surgeries, NICU babies, term babies and mothers, and more. 

Founding father of OMT, AT Still, is famous for his evocative quotes. One that captures another important tenet of OMT is a focus on the lymphatics system: "We strike at the source of life and death when we go to the lymphatics."

Dr. Earl shared some really amazing and interesting observational data of OMT during the 1918 Flu Pandemic, in which there was a remarkable 6% death rate for all-comers. Observational studies found that patients treated with OMT (there was no influenza treatment at the time) had closer to a 0.25% death rate. Dr. Earl stressed that these were not RCTs, and yet. . .OMT has been associated with improved respiratory function, supporting increased circulation and increased lymphatic flow. All of which certainly could have biologic plausibility in terms of helping with viral respiratory illness. 

Canine and rat studies both demonstrate improvement in lymphatic pumps with OMT. Human studies, whose lymphatic pumps are a little more challenging to study, demonstrate increased tidal volumes. 

Here are some examples of patients cared for by OMN providers at Maine Medical Center:

• post-CABG patients: improved peripheral circulation, improved cardiac indices, decreased time to dc (1/2 day), decreased time to first BM, increased functional independence
• post-sternotomy patients:: decreased pain, LOS, increased mean inspiratory volume
• GI surgeries, especially ileus: decreased LOS, decreased time to flatus, less pain, decreased time to first stool, decrease use of opioids
• IBS/constipation: decreased pain, bloating, constipation and increased quality of life
• Inpatient pediatric patients
• breast/chest feeding: latch issues, increased exclusive breastfeeding, better milk transfer, decreased pain
• birth trauma: hypoglossal nerve trauma/compression, hyoid connections and torticollis
• premature neonates/NICU for feeding tolerance
• 

  

Let me know if you want references to any of the OMT studies. I have them!