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Paced Bottle Feeding- What is it?

Liliana Cruz, MS4, Drexel University College of Medicine

Many new moms are hesitant to see lactation consultants if they are not choosing to breastfeed their newborn, thinking that they will be shamed for formula feeding or that we only want to help breastfeeding moms. However, paced bottle feeding is a useful technique that breastfeeding and formula feeding moms alike can use to help prevent overfeeding and improve digestion for their baby.

 When using the paced bottle feeding technique, babies are positioned in an upright sitting position, and the bottle is held horizontally to their mouth. Instead of just accepting the flow from a bottle with minimal effort from the baby, which is what often happens when babies are fed laying down, baby needs to use their suckling strength to draw milk from the bottle, similar to what happens when a baby is breastfeeding. Moms are also encouraged to pause and burp their baby periodically throughout the feed to ensure that baby is only taking in as much as they need in that moment and to help smooth digestion.

We often advise breastfeeding moms to feed “on demand” or whenever their baby is exhibiting hunger cues like suckling on their hands or rooting. Babies who are fed at the breast will only take in as much milk as they can handle at that moment, often returning for a short “snack” or “dessert” after their main feed if they feel hungry again. With paced bottle feeding, formula fed babies are also only taking in as much as they need in the moment, and thus will also need to be fed in a similar on demand fashion. Feeding then becomes less about how many ounces have been consumed and more about the signals your baby is showing you.

Paced Bottle Feeding can also be useful for breastfeeding moms if they have to be away from their baby and another caregiver needs to feed the baby. Because paced bottle feeding mimics breastfeeding, babies are less prone to develop nipple confusion, an occurrence where babies start to prefer bottles to the breast due to their “easy access” flow of milk.

Thus, Paced Bottle Feeding is a technique that all moms can benefit from. We hope to encourage more moms to meet with us, even if they are not exclusively breastfeeding. Most lactation specialists will always encourage moms to breastfeed when they can, they serve as a support to all moms in feeding their baby!

Trauma-Informed Care – The Pelvic Exam

 Leila Hilal, MS4, Drexel University College of Medicine

As healthcare workers, we have a unique privilege in society; patients trust us at their most vulnerable moments and rely on us to help them reach their greatest potential in terms of their health.  Patients who have experienced sexual assault are at an even more vulnerable position when it comes to routine gynecologic exams to for cervical cancer prevention.  Trauma acts as a barrier to accessing healthcare. However, by providing patient-centered care with a trauma-informed approach, we can support our patients while providing the healthcare they need.

Within the past decade, there has been a large societal shift in the discussions around sexual assault and autonomy, best shown by the #MeToo movement.  It is a clinician’s daily choice, and a necessary one at that, to be mindful of traumas that our patients carry, whether they choose to share them or not.  In this blog, I’d like to review some of the ways to care for patients during a pelvic exam which can be a very stressful and triggering experience for survivors of sexual assault.  

The basic framework of any clinical institution should recognize the 4 “R”s established by the Substance Abuse and Mental Health Services Administration (SAMHSA) as the foundation for trauma-informed care: Realize the impact of trauma and the potential for recovery, Recognize signs and symptoms of trauma, Respond by integrating knowledge about trauma into policies, and actively Resist Re-traumatization⁴. 

 So how do we follow these 4 Rs?

 SAMHSA suggests 6 key principles to follow: Safety, Trustworthiness and Transparency, Peer Support, Collaboration and Mutuality, Empowerment Voice & Choice, and Cultural Historical and Gender Issues⁴. 

Safety:

Ensuring that the patient and staff feel safe creates a calmer trusting environment.

1)      Have a chaperone in the room 

2)      Offer a safety person to accompany patient into the room

3)       Listen carefully to concerns or questions

4)      Allow for extra time – this prevents an exam from being rushed       

5)      Use the smallest speculum possible while still optimizing viewing

6)      Use lubricant       

7)      Offer shifting of clothing rather than clothing removal

8)      Avoid potentially triggering phrases such as “spread your legs” or “stirrups”, and instead choose phrases such as “allow your legs to fall open to the side” or “footholds”.

Trustworthiness and Transparency:

By being open and honest with your patient, a rapport of trust can be established.

1)      Explain everything you will be doing in advance, and while you are doing it¹ – (but ask the patient if they would like the explanation prior to giving it).

2)      Show the tools you will be using prior to starting an exam – but ask first! This may or may not help the patient.

3)      Keep the patient covered, exposing only areas necessary for examination.

 Peer Support:

Having resources to other trauma survivors can promote healing, but this does not play a large part during a pelvic exam.

1)      Offer up trauma peer support materials at the end of an exam

 Collaboration and Mutuality:

The aim of this principle is to establish a partnership and lessen the power dynamic between the physician and patient to decrease discomfort during the exam.

1)      Establish rapport before the exam

2)      Greet the patient while they are still fully dressed and sitting upright

3)      Normalize any feelings of anxiety they may have about pelvic exams

4)      Explain the importance of the exam and its utility

5)      Check in regularly during the exam to monitor the patient’s stress levels

6)      Offer up distractions during the exam (e.g., talking or music)

7)      Offer self-insertion of speculum⁵

 Empowerment, Voice & Choice:

By supporting a patient to have space to become a stronger self-advocate, the power dynamic lessens between physician and patient thereby creating a calmer and safer environment.

1)      Give the patient as must control and choice as possible

2)      Allow a female provider to perform the exam if requested

3)      Ask the patient if they have suggestions on how they would be more comfortable

4)      Before starting the exam, tell the patient that the exam will stop if they feel uncomfortable - reinforce that they are in control

5)      Ask permission before beginning the exam

6)      Be willing and ready to reschedule the exam for a later time

Cultural, Historical and Gender Issues:

Recognize any move past any stereotypes, biases or cultural barriers that may impede on a connection based on trust

 As a patient, how can you advocate for your needs?

·         If you have experienced trauma, or find pelvic exams nerve-wracking, consider letting your physician know when they schedule your pap if you are comfortable.  This allows them to be aware in advance of how you are feeling and can be more sensitive to your needs during the exam. 

·         Know that it is a common experience for women to feel nervous for their pelvic exams & pap smears – talk to friends or family who have gotten it done, and how they reduce their anxiety.

·         If you have coping methods or grounding methods that you use during anxiety-producing situations, ask your physician how you may be able to incorporate these methods into the pelvic exam if you need them. 

·         If you would rather insert the speculum yourself, ask your physician to do so and ask for proper technique.

·         If you are more comfortable with a certain gender of provider, ask for this when scheduling your appointment.

·         If you would rather not get undressed for the procedure, talk with your provider on how the exam may be performed while staying dressed.

·         If talking/having a family member or friend there/listening to music/watching a video makes you more comfortable during an exam, ask the provider at the beginning of the office visit – they will be willing to accommodate you.

·         If you do not want to be told what is happening during a pelvic exam as it is going on, let your provider know so they don’t introduce more anxiety for you.

·         Know that you can always say no to an exam or stop an exam before or during the office visit.

·         Establish a word or signal that if said or done will make your provider stop the exam until you are ready for them to continue.

·         If you have considerable anxiety during such experiences, talk to your provider about any anxiolytic medications that may be used to help you complete your screening with less discomfort.

·         Check out this post by Dr. Glomski on other tips to help prepare for a pelvic exam: Mayo Clinic Health System - Preparing for your first pelvic exam².      

By recognizing trauma and approaching patients with care and compassion, clinicians can support resilience and empower them to overcome obstacles to their healthcare.  By normalizing trauma-informed care, sensitive clinical exams can become a less anxiety-producing experience for patients knowing that they can trust their provider and feel safe to obtain the care they need.

References

 1.      Bates C, Carroll N, Potter J. The Challenging Pelvic Examination. Journal of General Internal Medicine.2011; 26(6): 651-657.

2.      Glomski, Bridget, and Hannah Miller. “Preparing for Your First Pelvic Exam.” Mayo Clinic Health System, 22 June 2021, www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/preparing-for-your-first-pelvic-exam.

3.      Sharkansky E. Sexual Trauma: Information for Women’s Medical Providers. National Center for PTSD. 2014.

4.      Substance Abuse and Mental Health Services Administration . SAMHSA™s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884 . Rockville : SAMHSA ; 2014 .

5.      Wright D, Fenwick J, Stephenson P, Monterosso L. Speculum ‘self-insertion’: a pilot study. Journal of Clinical Nursing. 2005; 14(9): 1098-2111.

 

 

 

 

 

 

 

 

 

Racism in Medicine

When people think about racism, they often think about Jim Crow laws, red lining, the time of the Civil Rights movement, and, currently, many are also thinking about police brutality and the criminal justice system. We tend to place the blame of racism on those we think condone it; your neighbor who voted for Trump, or some police officers, the government, or anyone in power. But the general public often misses one arena where race still plays a significant role through which it can be associated with significant mortality: medicine.

The community looks to doctors as people who can heal and can help. And while that may be true, time and again research has demonstrated that Black people have worse outcomes than White people when it comes to their diseases, pain management, pregnancy, and so on. Is this because most doctors are racist? Is it because pharmaceutical companies are racist?

It is tempting to look for individuals to blame, but the fault is found within the system of structural racism. Race, to be clear, is not a biological construct. It has been used throughout history to justify oppression and slavery, and this justification was often aided and abetted by doctors. These doctors made false claims that Black people were biologically different, that the way nature made them made it so that they were made to be enslaved. Combine this with the political justifications of racism, and you create a society that profits off of the subjugation of Black people.

 The effects of structural racism in our country have created environments that continue to create worse living conditions for Black people, Indigenous people, and People of Color. Our nation’s history has led to segregated communities that suffer from less access to healthy food, to quality education, to stable jobs, to healthcare, and to community programs that can offer support and resources. What does this mean? It means that the combination of these factors causes people of color to be more likely to not have access to adequate medical care for diseases that are direct consequences of structural racism.

This all leads to one crucial point: race is a social determinant of health. Black women are twice as likely to die of breast cancer than white women, they are four times as likely to die after childbirth, Black children are less likely to be given pain medications, Black people with kidney disease suffer worse outcomes than their white counterparts. The list goes on. So how can doctors combat racism in medicine?

This is a more difficult question to answer. On the one hand, change comes at an individual level. Having uncomfortable discussions with friends and colleagues ensures we call out problematic behavior when we see it, and also makes us more likely to recognize our own biases. But how do we promote change at the institutional level? At the national level? Medical students, doctors, and other health professionals must begin to actively engage in local government and politics, as well as politics at the national level, to advocate for the dismantling of the structures built on racism. We must amplify the voices of our Black patients and other patients of color.

Urooj Khalid, MS4

Drexel University College of Medicine

Why are women more predisposed to autoimmune conditions?

 Since the age of 17, I have been curious about autoimmune conditions. I had experienced drug lupus in the past. I was told that it was due to my acne medication at the time; however, I always wondered if maybe there was a correlation to my biological sex. Furthermore, in medical school we were told that women were more predisposed to autoimmune diseases. But why? Why did having two XX chromosomes make you a risk factor for conditions like RA or Lupus?

 Well.. did you know that researchers have speculated a correlation with having two XX chromosomes and autoimmune diseases? There are genes on one X that can initiate an autoimmune reaction, and females happen to have two of those. They are essentially getting a double dose of that specific gene. Since males have X and Y, they do not get that double exposure from the X chromosome. Furthermore, Females go through something called X inactivation. One of their X chromosomes will be inactivated in a cell causing the other one to be predominant. The X that is inactivated can now be seen as foreign to the body and provide itself as an antigen. When this happens, the body can form an immune response and hence a possible autoimmune disease. In fact, the process I just described is suggested to a potential cause for Lupus

 There are other possible causes for Lupus. I will describe one more. It is suggested that there are genes expressed on one X chromosome, CD40LG and CXCR3, that become overexpressed when one of those X’s fails to inactivate. There are still studies being done to further assess this theory. It is speculated that proper X inactivation may help decrease disease progression.

 It is also suggested that hormonal changes can exacerbate an autoimmune disease. Hormonal changes may not be the cause of a skin condition like Psoriasis; however, it is speculated that hormonal changes can make the skin more sensitive. The endocrine system and skin are closely linked, and an imbalance could increase the severity of Psoriasis.

 In addition, Rheumatoid arthritis and Sjogren’s syndrome are thought to be linked to hormonal changes as well. With RA, there are issues with the bones and joints. It is suggested that around menopause, a decrease in estrogen and progesterone can decrease protection of the bone and joints making RA more severe. Sjogren’s Syndome is also thought to be linked to a decrease in estrogen.

Now that hormones are thought to be a link, pregnancy and puberty are a concern. These are times where hormonal imbalances occur. With pregnancy, those changes can last until at least one year post pregnancy. It is also thought that a mother carry a baby could face a decreased immune system making autoimmune issues more likely. As far as puberty goes… a study done in Taiwan observed an increase in juvenile SLE in girls compared to boys. It is also suggested that there is an increase of multiple sclerosis for girls after the onset of puberty.

I’ve learned something new today, and I appreciate the review article on the prevalence of autoimmune disorders in women that was published in the Cureus Journal of Medical Science in May 2020.

 Sabrina Billings MS4

Drexel University College of Medicine

 

 

 

Angum F, Khan T, Kaler J, Siddiqui L, Hussain A. The Prevalence of Autoimmune Disorders in Women: A Narrative Review. Cureus. 2020;12(5):e8094. Published 2020 May 13. doi:10.7759/cureus.8094

 

Miscarriage: The deafening silence that follows

I remember like it was yesterday. The tiny fingers that curled up into fists, fists literally clinging onto life. The tiny baby was delivered at 22 weeks, a stillborn. I was helping with the delivery and was able to cut the umbilical cord. Never would I imagine my first time cutting the cord would be in this situation. I remember hearing the mother’s pain through her screams and tears. As the healthcare providers, we helped in the delivery and aftercare of the labor. Afterwards, I was struck how there was no discussion or conversation with the mother who just lost her child. We closed the doors after the delivery and in turn closed the door on the traumatic experience that just occurred. I remember when my aunt herself had a miscarriage. Her family and friends all empathized with the loss but could not understand why my aunt was still feeling sad and depressed after many months after the incident. I saw my aunt spiral into a deeper depression as she could not find any support after miscarriage. Unfortunately, these are not isolated reactions to miscarriage in society.

            Miscarriage is one of the most common complications of pregnancy, occurring around 15% of all clinically recognized pregnancies. One in four women experience miscarriage in their lifetime. Many women following the loss of their child feel grief, sadness, and depression. These mental health issues are only exacerbated by society’s lack of consideration and belief that no loss has occurred. Mental health issues that these childless mothers face are perpetuated in this way. As healthcare professionals, we must do better and continuously monitor our patient’s moods and behaviors following their loss. Mental health services should immediately be offered to women who experience the loss to normalize their feelings and help mitigate any long-term consequences.

Ammarah Spall, MS4

Drexel University College of Medicine

Intimate Partner Violence And The Role Of The Healthcare Professional

Intimate partner violence is characterized by behavioral patterns that include physical abuse, emotional/psychological abuse, sexual abuse, threats, intimidation, stalking and deprivation5. These behaviors are normally perpetuated by one’s former or current intimate partner. According to the national coalition against domestic violence, an average of 20 people are physically abused by their intimate partners every minute. This means that approximately 10 million people in the US experience some form of intimate partner abuse annually3. Statistics shows that 25% of women and 7.6% of men will be victims of domestic violence in their lifetime4. IPV can happen to people of all ages, educational and cultural backgrounds.

The consequences and prevalence of intimate partner violence nationally makes it a health crisis that needs to be addressed and prevented. Unfortunately, most victims of intimate partner violence do not report the case to the appropriate authorities but often find excuses to justify the actions of the abusers. Research shows that health care professionals, especially Physicians can play an important role in detection, intervention and prevention of IPV due to the unique relationship they have with patients4.This is why it is important that physicians screen their patients for domestic abuse. Screening creates an opportunity for healthcare workers to educate their patients on the dangers and consequences of domestic abuse on their health.

Due to the sensitivity of domestic abuse, it is essential for physicians to be very discreet in their assessment when screening for it. Studies have shown that patients are more likely to open up about their feelings if asked in confidence away from family and in a nonjudgmental, respectful manner. There are two different ways of screening- written survey and oral screening using either direct or indirect questions. Since some people may be offended when isolated to be screened privately for domestic violence, it is recommended that physicians introduce the conversation with statements such as “Because violence is very common, I ask all my patients about their experience with violence”. Direct questions are preferred mostly in a situation when domestic violence is already suspected based on the observations made by the physician.

The response from the physician after a patient opens up about domestic abuse, is also very important. A nonjudgmental and supportive statement is essential to create a congenial atmosphere for the patients to explore solutions. The immediate concern for a physician should be the safety of the patient. Victims of domestic violence are at higher risk of death when they leave their partners, so it is important that they determine the best time to leave the relationship in order to ensure their safety. In states that physicians are not mandated to report intimate partner violence, the best way to help patients is to offer them resources that can help them plan for ways to ensure their safety, educate them on the physical and psychological effects of IPV and refer them to access services that are available to them.

Akua Boadu (MS4)

Drexel University College of Medicine

 

Resources

1. Lizdas C Kristen, Durborow Nancy, O’flaherty Abigail, Marjavi Anna; Compendium of State Statutes and Policies on Domestic Violence and Health Care, 2010, https://www.acf.hhs.gov/sites/default/files/fysb/state_compendium.pdf
2. Pennsylvania Coalition Against Domestic violence, 2018, http://www.pcadv.org/Learn- More/
3. National Coalition Against Domestic Violence, 2018, https://ncadv.org/statistics?gclid=Cj0KCQjw1q3VBRCFARIsAPHJXrFq0k5XaHQoXI W0zdld_NG1rMC02xsc1JPcPViYv65UafLDOe8NXwcaAtgBEALw_wcB
4. Cronholm Peter, Fogarty Colleen, Ambuel Bruce, Harrison Leonard Suzanne; Intimate Partner Violence, 2011, https://www.aafp.org/afp/2011/0515/p1165.html
5. Guidelines for the Health Care of Intimate Partner Violence, 2004, http://domesticabuse.stanford.edu/screening/law.html
6. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/index.html