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January 2011 Issue for Perinatal Post

In this issue...

• Disordered Eating and Pregnancy
• Breastfeeding and Influenza
• Lamaze Childbirth Education: 50 Years and Going Strong!
• Minute to Ask Website
• STABLE from July 2010 newsletter
• Upcoming CE programs

Disordered Eating and Pregnancy

Few data are available on the prevalence of disordered eating specifically in pregnancy, since it can be difficult to adequate capture this information from women. Pregnant women may have needs for secrecy and denial, and not readily give information about a history of an eating disorder to health care providers. Interestingly, the developmental tasks of pregnancy are often similar to those in women with eating disorders - body changes, alterations in roles, and concerns about a woman's own mothering.

There is no consensus on the precise cause of eating disorders such as anorexia nervosa and bulimia. A combination of psychological, biological, family, genetic, environmental and social factors are considered to be involved in causation of these conditions. Psychiatric conditions generally associated with disordered eating include anxiety disorders, personality disorders, substance abuse, obsessive-compulsive disorder and affective disorders.

Anorexia Nervosa

Incidence rates for anorexia have increased in the past 25 years; it affects 1% of adolescent females and has been seen in patients as young as 6 years old. The rates for men are only 10% of those seen in women.

DSM-IV criteria for this eating disorder include patient refusal to maintain weight within a normal range for height and age (more than 15% below ideal body weight), fear of weight gain, severe body image disturbance in which body image is the predominant measure of self-worth with denial of the seriousness of the illness, and the absence of menstrual cycles in post-menarchal females.

Signs and symptoms associated with anorexia are dry skin, cold intolerance, blue hands and feet, constipation, bloating, scalp hair loss, weakness/fatigue, short stature, osteopenia and pitting edema. Others may include delayed puberty, amenorrhea, fainting, orthostatic hypotension, breast atrophy, atrophic vaginitis, cardiac murders or sinus bradycardia.

Treatment of this disorder with medications has generally not been found to be effective. However, they have been found to be helpful for treating co-morbid conditions such as depression and OCD. Hospitalization may be required if a woman has the following: severe malnutrition (< 75% ideal body weight), dehydration, cardiac dysrhythmia, electrolyte disturbances, arrested growth and development, physiologic instability or acute psychiatric emergency. The nutritional goal for patients is to regain weight up to 90 - 92% of their ideal body weight. Inpatient treatment may include oral liquid nutrition, nasogastric tube feedings, a gradual caloric increase with table food or parenteral nutrition in rare cases.

One study reported that about 25% of individuals with anorexia nervosa will develop a chronic course, even after treatment.

Bulimia

This eating disorder occurs in 1 - 5% of high school girls, and the incidence is as high as 19% in college age women. The prevalence of binge eating orders in pregnancy has been reported to be between 1.2% and 4.5%.

DSM-IV criteria for this disorder include episodes of binge eating with a sense of loss of control, binge eating followed by compensatory behavior of the purging type such as self-induced vomiting or non-purging type such as fasting, and dissatisfaction with body shape and weight. The binges and resulting compensatory behavior must occur a minimum of two times per week over a period of three months for the diagnostic criteria to be met.

Signs and symptoms associated with bulimia are mouth sores, dental caries, pharyngeal trauma, heartburn/chest pain, esophageal rupture, muscle cramps and weakness. Others that may be seen are bloody diarrhea, bleeding/easy bruising, irregular periods, swollen parotid glands or hypotension. Impulsivity with stealing, alcohol abuse, drug/tobacco use may also be evident.

Cognitive behavior therapy of bulimia has been found to be very effective. Pharmacotherapy also has a high success rate, with the use of such medications as Fluoxetine, TCAs, Topiramate and Ondansetron.

Pregnancy and Postpartum Outcomes

Appropriate counseling measures for a woman with a diagnosed eating disorder may include a discussion about nutrients and food during pregnancy. It may be necessary to design an individual food plan and determine the optimal range of weight gain for each woman. A discussion of hydration shifts in pregnancy and a need for adequate oral intake is important.

Antenatal complications generally seen in the literature related to disordered eating include intrauterine growth restriction, pregnancy related hypertension, edema, preterm birth, gestational diabetes mellitus and vaginal bleeding. Other problems reported include hyperemesis and anemia. Neonatal characteristics found in the this population include low birth weight, smaller head circumference, small for gestational age and microcephaly. It has been difficult to assess pregnancy complications related only to anorexia nervosa, since the fertility problems associated with this disorder mean that pregnancy occurs in only the less severe cases.

It is of note that in a general population of postpartum women, eating disorder behaviors increase markedly in the first 3 months postpartum and remain high for the next 9 months. Some women will actually first experience clinical eating disorders during the postpartum time frame. One study reported that changes in eating disorder pathology in the postpartum period were largely due to changes in body weight. It may be necessary for the care provider to carefully assess the new postpartum mother's exercise level; a nonpurging type of compensatory behavior for a woman with bulimia may be excessive exercise activity. A suggestion to join an exercise group or with new mothers group can be an avenue to normalize weight concerns during this time period.

Infant feeding may pose challenges for the postpartum women with an eating disorder. Care providers should offer assistance with parenting concerns voiced by the new parents. Staff members can also provide information about infant feeding, such as the infant's cues and signals related to hunger.

Maternal Obesity

The rates of obesity are increasing world-wide, and obesity occurring before pregnancy has been associated with the risk of several adverse outcomes. Diagnosis of pregnancy related problems may be difficult since menses tend to be irregular in this group of women. AFP values are lower in obese women due to the increased plasma volume in this population and blood pressure monitoring may be more challenging.

Antepartum concerns in obese pregnant women include a higher rate of neural tube defects, even with folic acid supplementation. There is an increased risk for both chronic and pregnancy related hypertension, along with a greater risk for severe preeclampsia. A pregnant woman who is obese has an increased risk of gestational diabetes mellitus, insulin dependent diabetes and non insulin dependent diabetes. Increased twining and increased UTI frequency are also seen in this population.

Obesity also negatively affects fetal outcomes. Morbidly obese women have an increased risk of preterm delivery, with 25% of these preterm births being indicated due to a maternal medical or obstetric problem. Unfortunately, the rate of stillbirth in overweight women is twice that of weight with normal weight. The rate of stillbirth in morbidly obese women is 240% greater than the rate for women with a normal weight.

Many differences exist in labor and birth outcomes among women who are obese. There is an increased incidence of cesarean birth in nulliparous women, with the rates being reported to be as high as 48% in women with a BMI between 35 and 40. VBAC success rates have been reported to be as high as 71% in normal weight women, but significantly lower at 55% in obese pregnant women. Surgical births have more complications associated with obese women - such as longer operative times, increased blood loss, differences in responses to anesthesia, and increased risk of post-operative complications. In addition, women who are obese are more likely to give birth to large for gestational age infants.

-- Ryan Stone, MD
Fellow, Maternal Fetal Medicine, Department of Obstetrics and Gynecology, WFU School of Medicine
-- Mona Brown Ketner RN, MSN
Nurse Educator, NW AHEC, WFU School of Medicine

Breastfeeding and Influenza

The cold winter months heighten our concerns about influenza. Vulnerable populations become the target of our education concerning vaccination. The question of who should be vaccinated and when seems to be the age old debate. Lactating mothers are concerned about whether or not they or their babies should receive the flu vaccine. After all, isn't human milk considered the first immunization for an infant?

The CDC recommends that both mom and baby get vaccinated against influenza, stating that "neither inactivated nor live vaccines administered to a lactating woman affect the safety of breast feeding for women or their infants." Thomas Hale PhD, the foremost expert on medications and human milk, ranks the Flu Vaccine and Flu Mist as a lactation risk category of L1. A L1 is deemed the safest type of medication, meaning that "controlled studies in breastfeeding women fail to demonstrate a risk to the infant and the possibility of harm to the breastfeeding infant is remote." Infants older than 6 months should receive the injectable form of the vaccine.

A mom who is physically ill is more likely to decrease or completely cease breastfeeding due to her own fatigue, pain and concerns that she may make her baby ill. Recommending flu vaccine to lactating mothers and their infants six months and older should be a priority for primary prevention and to help promote, protect and support breastfeeding.

For more specific dosing schedule and additional guidance please visit: http://www.cdc.gov/flu/professionals/vaccination/vax-summary.htm

Hale TW. Medications and Mothers' Milk, Fourteenth Edition. 2010. Hale Publishing, Amarillo, Texas.
--Catherine Sullivan, MPH, RD, LDN, IBCLC, North Carolina Breastfeeding Coordinator, Nutrition Services Branch, North Carolina Division of Public Health, Greenville, NC.

Lamaze Childbirth Education: 50 Years and Going Strong!

At the Lamaze International and ICEA mega conference in October 2010, we celebrated 50 years of childbirth education. Thanks to pioneers, Marjorie Karmel and Elisabeth Bing, we have Lamaze educators across the world promoting and advocating for safe and healthy births. Fifty years ago, Lamaze education was most likely offered in the homes of educators and focused on the Lamaze "method" introduced by Dr. Fernand Lamaze. As a result of looking at the research and listening to mothers, Lamaze childbirth education has evolved from being a method for giving birth to the promotion of healthy birth practices, which communicates a simplified message of birth to expectant women and their partners. If you've ever considered becoming a childbirth educator, this is a great year to start!

Is childbirth education a new field for you? If so, you can qualify to sit for the Lamaze certification exam after attending a Duke AHEC Lamaze childbirth educator seminar and after completing a practice teaching experience. For the first time in 2011, those who enroll in the Duke AHEC Lamaze program will receive a complete childbirth education curriculum developed by a team of Lamaze certified childbirth educators.

If you have experience teaching childbirth education classes, but have not received formal childbirth education training, you can qualify for the exam after documenting 60 hours of teaching experience and 25 continuing education credits. You will earn 20 contact hours by attending a Duke AHEC Lamaze childbirth educator seminar.

The Duke AHEC Lamaze Program has a team of trainers and mentors to help you matriculate through the training components and prepare for the Lamaze certification exam. Be a part of the next 50 years of Lamaze childbirth education by becoming an educator this year!

The Duke AHEC Lamaze Program has scheduled the following seminars for 2011:
April 21 - 22, 2011 in Charlotte, NC;
May 10 - 11, 2011 in Winston-Salem, NC;
August 18 - 19, 2011 in Fayetteville, NC; and
October 18 - 19, 2011 in Raleigh, NC

Registration forms can be downloaded at http://dukeahec.mc.duke.edu. If you have questions, contact Tara Owens Shuler, M.Ed., LCCE, FACCE at tara.owens@duke.edu or 919.684.2648.

Minute to Ask - a New Website Organized to Help You Provide Tobacco Dependence Treatment in Your Practice

Minute to Ask - www.minutetoask.com

The North Carolina Health and Wellness Trust Fund recently launched a new tool for providers on tobacco cessation counseling and treatment. The website, Minute to Ask, includes information on "the 5As" (an evidence-based screening and brief intervention protocol), pharmacotherapy, and working with special populations. Some of the special populations include pregnant/postpartum women, parents/caregivers, youth, and racial/ethnic groups. The site also provides patient education materials and links to continuing education opportunities for healthcare professionals, including CMEs.

Minute to Ask is organized in a way that makes it easy to find what you need. It offers tools to help you with screening and brief intervention for tobacco use, quick and easy conversation starters, fact sheets and handouts that address common patient concerns.

While all five of the 5As are recommended by the Agency for Healthcare Research and Quality (AHRQ), North Carolina has resources available for your patients that will save you time and increase their chances of successfully quitting. These resources found on the Minute to Ask website can be printed to assist you in asking all patients about tobacco use, advising them to quit, and referring them to the phone-based cessation service, QuitlineNC. Tobacco users can reach QuitlineNC by calling 1-800-QUIT-NOW (1-800-784-8669). The QuitlineNC service is funded by the NC Health and Wellness Trust Fund and the NC Tobacco Prevention and Control Branch, making the service free to all callers.

Providers can also fax refer patients to QuitlineNC by completing a fax referral form found at www.minutetoask.com/Resources-for-Your-Practice.aspx, and they will receive a call from a quit coach at QuitlineNC. Fax referrals are one way to increase the likelihood that your patient will quit. Patients who agree to a fax referral have equivalent quit rates as those who initiate a call on their own.

Minute to Ask delivers practical step-by-step tools and trainings that assist you in easily and quickly integrating tobacco dependence treatment into your busy practice. Visit www.minutetoask.com to see all that the site has to offer to help with screening and brief intervention for tobacco use.

--Donna Dayer BS, RRT, CTTS
Tobacco Treatment Specialist, Tobacco Prevention and Control Branch NCDHHS, Division of Public Health

STABLE/NRP

The Neonatal Resuscitation Program (NRP) is designed to teach an evidence-based approach to resuscitation of the newborn through the introduction of concepts and basic skills of neonatal resuscitation. The causes, prevention, and management of mild to severe neonatal asphyxia are carefully explained so that health professionals may develop optimal knowledge and skill in resuscitation. NRP is designed for those who participate in neonatal resuscitation in the delivery room and newborn nursery. Although Pediatric Advanced Life Support (PALS) and Pediatric Education for Prehospital Professionals (PEPP) courses are appropriate for those who participate in resuscitations outside the delivery room, NRP also may be useful to pre-hospital providers who desire in-depth training specific to neonatal resuscitation. Completion of the program does not imply that an individual has the competence to perform neonatal resuscitation. A comprehensive instructional textbook, which includes an interactive multi-media DVD-ROM, forms the basic educational component of the program. NRP is offered through Life Support Education at Wake Forest University Baptist Medical Center. Information regarding a schedule of upcoming classes, course fees, and online registration can be accessed via Life Support Education's website (http://www.wfubmc.edu/Life-Support-Education). They may also be reached at 336-716-2800.

The Neonatal Resuscitation Program Instructor is often desired by those in the community to assist in the maintenance of provider status for those within their institution. This one day course is designed for the NRP Provider who has demonstrated excellence in NRP concepts and has a desire to achieve instructor status. NRP Instructor courses are offered through Life Support Education as frequently as 4 times a year. Information regarding the NRP Instructor Class schedule is available via Life Support Education's website or by calling 336-716-2800.

The S.T.A.B.L.E Program was developed to meet the educational needs of health care providers who must deliver this important stabilization care. S.T.A.B.L.E. education is critical to the mission to reduce infant mortality and morbidity and to improve the future health of children and their families. S.T.A.B.L.E. is the most widely distributed and implemented neonatal education program to focus exclusively on the post-resuscitation/pre-transport stabilization care of sick infants. Based on a mnemonic to optimize learning, retention and recall of information, S.T.A.B.L.E. stands for the six assessment and care modules in the program: Sugar, Temperature, Airway, Blood pressure, Lab work, and Emotional support. A seventh module, Quality Improvement stresses the professional responsibility of improving and evaluating care provided to sick infants. Any health caregiver involved with post-resuscitation and/or pre-transport care of sick newborns would benefit from the S.T.A.B.L.E. Program Learner/Provider course. Students who complete the S.T.A.B.L.E. Learner Course are awarded a course completion card. The S.T.A.B.L.E. Program is offered by the Brenner Children's Hospital Critical Care Transport Team in conjunction with Northwest AHEC of North Carolina. The program is offered twice yearly and can be scheduled at your institution if interest is present. This can be arranged by contacting Tammy Rush, RN BSN, C-NPT, nurse manager of the Brenner Children's Hospital Critical Care Transport Team at tarush@wfubmc.edu or by phone at 336-713-6444.

-- Heather M. Furlong, MD, Assistant Professor of Pediatrics, Neonatal-Perinatal Medicine, Wake Forest University Health Sciences; Medical Director, Neonatal Critical Care Transport Services, Brenner Children's Hospital, Winston-Salem, NC.