Why you gotta love "Plan B"

Excellent news!

"Plan B", a "morning-after" pill to prevent pregnancy, has been cleared by the FDA to be sold without a prescription to anyone over 18 years of age.

• To ensure the age requirement is met, Plan B will be stored behind the counter in pharmacies. IDs will be checked.
• Under age 18 requires a doctor's prescription {more about that later}.

I hope we all agree that this a much-needed, major step forward in preventing unwanted pregnancies. And I hope we all agree that this is a worthy goal, that every child should be a wanted child. Did you know:

• There are an estimated 3,000,000 unwanted pregnancies/year (about 1/2 of all pregnancies!) in the U.S.
• Of these, about 1/2 are terminated by abortion and 1/2 are carried to completion.
• Among poor women in 1994-2001, unintended pregnancies resulting in live births increased by almost 50%, while it declined for women in families whose income was at least twice the poverty level.*

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Top 5 reasons you gotta love Plan B:

1. "Plan B"could be the coolest name of any medication in the history of the known universe.
2. Unlike RU-486 (another "morning-after" pill which prevents the fertilized egg from implanting in the uterus), Plan B works by preventing ovulation in the first place. Since there is no fertilized egg, the moral qualms expressed by some with the use of RU-486 (see my blog on embryo rights) are not in play at all.
3. Plan B is a high dose of natural hormone (progestin - found in birth control pills) and, when given as a single dose, appears to be very safe.
4. When used within a few days of intercourse, it is about 89% effective in preventing pregnancy.
5. Plan B gives women a much better ability to prevent unwanted pregnancies, thereby decreasing the frequency of abortions.

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So what's not to love? Not much, but a few caveats about Plan B:

• It fails to prevent the pregnancy in about 1 of 10 cases (the sooner after intercourse it is taken, the more effective it is), so it is less effective than almost any other birth control method.
• Side effects, while not serious, are common: nausea (23%), abdominal pain (18%), fatigue (17%) , headache (17%), and menstrual changes.
• It does not prevent sexually transmitted diseases.
• It costs $25-$40. Will it be affordable to poor women? Will insurance pay?

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What about teenagers and Plan B?

Here is where Dr. P gets to rant (hey, it's my blog).

The current ruling represents a compromise between those who wanted Plan B available over-the-counter to anyone and those who wanted its availability to teenagers restricted. My understanding is that their rationale (and my response) is:

1. "There hasn't been sufficient research as to side effects in the younger ages." I have to believe this is a smoke screen for their real agenda (see below). It's not unusual for there to have been less research on children and Plan B -- which is only given as a one-shot deal and is a long-used hormone, not a new medication -- is very unlikely to be any less safe for a 14-year-old than for an 18-year-old.


2. "Plan B would increase teen sexual activity." I assume these are the same groups that have pretty much opposed any information or programs (other than abstinence) to address teen sexuality with this concern. Problem is, in every case so far they've been proven wrong:

• "Sex education in the schools will lead to increased teen sex." Didn't happen.**
• "Condom availability in the school will lead to teens gone wild." Didn't happen***
• "Abortion availability will encourage irresponsible teen sex." Teen sexual activity has decreased over past years, not increased.****

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Not to mention that anyone who actually thinks in this way demonstrates a profound cluelessness about what makes teenagers tick and what does and does not change their behaviors. Consider these two possible scenarios:

• Plan B is available to all and, because of that, a teenage girl, who otherwise would have remained virginal, decides to have sex and/or not use contraception.
• A 14-year-old has unprotected sex (or the condom breaks). She is mortified to tell her parents about it and so tells no one and so doesn't go to a doctor and so can't get Plan B and so has an unwanted pregnancy with which to deal.

You tell Dr. P which you think is a more likely scenario.

Still, the glass is three-quarters full and this new compromise ruling by the FDA makes a decent start. Now let's work to make Plan B available to anyone who desires a safe way to prevent an unwanted pregnancy.

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Sources cited:
*http://www.washingtonpost.com/wp-dyn/content/article/2006/05/04/AR2006050400820.html

** Franklin, C., et al. "Effectiveness of prevention programs for adolescent pregnancy: a meta-analysis." Journal of Marriage and the Family, 59, 551-567, 1997.

***Susan M. Blake, et al. Condom Availability Programs in Massachusetts High Schools: Relationships With Condom Use and Sexual Behavior. American Journal of Public Health, June 2003.

****http://www.kff.org/youthhivstds/upload/U-S-Teen-Sexual-Activity-Fact-Sheet.pdf

Related Topics: Many Teens Use Condoms Incorrectly, The Teen Brain (WebMD Video)

Technorati Tags: Plan B, emergency contraception, birth control

Vitamin D, infants and teenagers: Your basic rock and hard place

Lately there have been a bunch of good news / bad news studies about vitamin D.

The good news: its benefits and preventive properties. The bad news: low levels of vitamin D in teenage girls and breast fed infants.

What should a pediatrician or a parent make of this new information? That's a tough question because it's not yet clear what it all means nor what (if anything) we should do about it.

Even tougher (at least for me): one of the conclusions I've come to from the new information contradicts some of my previous advice! That doesn't bother me: the beauty of science is that you must always be open to being wrong; you always need to re-evaluate in the face of new evidence.

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Advice-giving and sausage
Some advice-givers feel their advice should be like sausage: better to just consume the final product, but never see how it is made.

But I want you guys to be informed consumers of medical and parenting advice. Whenever possible, I'd like you to understand the science (or lack) that goes into the latest recommendations. And I'd like you to keep an open, questioning mind about about what people like me advise you to do.

Anyway, I've done my homework about vitamin D. Here is what I've found and here is my opinion.

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First, a crash course on vitamin D

• Vitamin D is more like a hormone than a vitamin. It plays a vital role in regulating the calcium in our bodies and making our bones strong.
• Vitamin D is usually made by converting a natural form of cholesterol - via exposure to ultraviolet (UV) light while in the blood vessels of our skin - to a non-active vitamin D, which is then further transformed in the kidneys and in the liver into its active form.
• Sun exposure is the most important source of vitamin D.
• As teenagers, we add on about 1/3 of our adult bone mass. It is widely accepted that if weaker bones are made during adolescence, there is a greater risk for softer bones ("osteoporosis") in later life.
• Breast milk contains inadequate vitamin D.
• Before cow's milk was supplemented with vitamin D, a nasty bone disease called rickets was quite common in children.
• The Institute of Medicine estimates that 2000 International Units (IUs)/day (e.g., found in 16 ounces of milk or formula) is needed to maintain good levels (some believe it should be even higher in older children and adolescents).
• The darker the skin, the less efficient the sun's rays are in activating vitamin D.

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The benefits of vitamin D
There is good scientific data to suggest that adequate vitamin D levels in children and adolescents has major benefits, including:

• Stronger bones as adults (especially in post-menopausal women).
• Better lung function in teens.***
• A protective effect against contracting some cancers (e.g., colon, breast****, prostate, ovarian).
  

Low vitamin D levels
Two very recent studies suggest that low vitamin D levels may be a lot more common than we thought:

• In a study of 51 (14 white/37 non-white) teenagers in England, 73% had low vitamin D levels. Dark-skinned girls were especially likely to have much lower levels. The low levels were felt to be due to reduced sunshine exposure, not to reduced vitamin D intake*.
• 78% of breast fed infants in Iowa who did not receive supplemental vitamin D were deficient (especially in the winter). **

Now, it's not clear how low is "too low" and what the consequences of low levels might be (if any). I'm going to make the leap - given what has been learned of its potential benefits - that low levels are not a good thing (especially in adolescence) and that children should maintain good levels of vitamin D.

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The rock and the hard place
Not so long ago I railed against direct sun exposure and urged you to obsessively apply sunscreen to your kids. That's my story and I'm sticking to it (pretty much).

But now I'm thinking I may have gone a little overboard in saying the only good sun exposure is no sun exposure, since it looks like too little direct sun exposure may lead to low vitamin D levels. (Alas, sunscreen probably blocks vitamin D production in the body. For more details, see this story)

So, what to do? Sun or no sun? Vitamin supplements or no? The rock or the hard place?

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There is no clear-cut answer. In trying to look at all the data and listening to the experts, I've come up with the following three recommendations:

1. All exclusively breast fed infants should receive vitamin D supplementation until they are taking in sufficient vitamin D from other sources, e.g., fortified cereal, milk, oily fish (unlike the next two recommendations, this is not controversial).


2. All kids should get about 10-15 minutes of direct sun exposure (i.e., no sunscreen and not through a window) on his/her neck, arms and legs a few times a week -- perhaps a little more in winter, a little less in summer; a little more if your child is dark-skinned, a little less if s/he is very fair.


3. Teenagers should take a vitamin D supplement (preferably the active vitamin D3 form), perhaps 500 Units or so.

-- Beware: With regard to vitamin D supplements, more is not better. Vitamin D is "fat soluble," meaning that, unlike "water soluble" vitamins (in which any excess is just peed out of the body), vitamin D is stored in fatty tissues and can be toxic after a certain high level is reached. The safe upper limit taken per day for adults is felt to be 2,000 IUs / day (although some argue that is too low).

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What about for your own self? Hey, it's tough enough for me to figure out what to advise for kids, so I'm not going there! For a sensible way to deal with this as an adult, see this article ). Personally, I'm taking 1,000 IU of vitamin D3/day.

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Having watched the sausage being made, you no doubt realize this is hardly the last word on this important topic. Yes it's confusing and, yes, there are no clear answers and, yes, it's kind of arbitrary. But, based on what we know now, it's my best judgment.

Stay tuned and watch medical science in action. As we learn more, we'll be able to refine (or change) these recommendations. That's how "evidence-based" medicine works. That's the kind of advice you should be looking for from your doctor.

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Articles cited:
* Hypovitaminosis D among healthy adolescent girls attending an inner city school.
Das G, et al. Archives Diseases of Childhood, July 2006

** Vitamin D deficiency in breastfed infants in Iowa
Ziegler E, et al. Pediatrics, August 2006.

*** http://www.webmd.com/content/article/122/114787.html

**** Boston Globe: Does Vitamin D Reduce The Risk of Cancer?

Related Topics: Pregnant? Vitamin D Aids Baby's Bones, Vitamin D. May Lower Some Cancer Risk

Technorati Tags: vitamin d, sun exposure, infants, teens

JonBenet Ramsey: Are there lessons to be learned from her tragic story?

JonBenet Ramsey is back in the news, ten years after her heartbreaking murder.

This story is every parent's worst nightmare. We all remember how it caught hold of the mass media and the American public, with its irresistible themes of ambiguous evidence, suspicion if JonBenet knew her killer or not, and heinous child victimization - all entangled somehow with a world of financial privilege and childhood beauty pageants and disquieting images of a highly made-up and precociously sexy appearing 6 year old.

In the relentless 24/7 cable coverage of the case, every pundit on the planet got his 15 minutes of fame, each hawking his favorite pre-existing theory: "It's usually the weird parents." "The poor parents are being unjustly accused." "The hyper-sexualized world of young children led to her being abused and killed." "Selfish parents don't keep track of their kids." "It's our sick society."

But - sadly, in my view - the most powerful message to emerge was this: "The world is a very dangerous place. There are zillions of maniacs out there just lying in wait to wreak havoc and destruction and abuse and murder on your kids. Be afraid. Be very afraid."

What should you as a parent to make of this story? Were the pundits right? Should you teach your children what a scary, dangerous world this is? Are there nut jobs who mean them harm lurking on every corner? Should you obtain child IDs that include fingerprints and DNA testing as a precaution? How much money should we as a society invest (e.g., in universal "amber alerts") to prevent such this worst-case scenarios?

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Dr. P's Pearl #231: Notorious stories usually make for bad policies and ill-advised parenting practices. This is one of them. Let me tell you why I think this is the case.

The media vastly overemphasize how risky the world is (hence, the newsroom adage: "If it bleeds, it leads"). Who wants to read how and why little Jimmy is having a wonderful childhood? Fear sells. Scare tactics make money.

Let me give you just a few examples*:

• From 1990-1998, the murder rate in the U.S declined by 20%. During the same period, network TV stories highlighting murder increased by 600%.
• 40% of all news stories about kids involve crime and violence.
• Most other stories about kids detail risks - however unlikely - to their well-being. Most of us have been led to believe the world has become increasingly dangerous for kids, despite the fact that in 1930, 1 in 10 children died before reaching the age of 20 and in 2000 it was about one in 100 (mostly due to non-intentional injuries).
• One of the most proven negative outcomes of frequent TV viewing is coming to see the world as much more hazardous than it really is. Big-time TV viewers vastly overestimate the chances of, for example, being a victim of a crime or contracting a disease.
• This instills a culture of fear to the some of the least risky possibilities, and diverts funding to from common to extremely rare risks, like your child being abducted by a stranger.

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What are the chances of your child being abducted and/or killed by a stranger? Let's put this risk in perspective. (Data largely taken from a 1999 study by the Department of Justice)

• About 69,000 children were abducted in 1999.
• Of those, 82% were abducted by known family members (usually due to custody disputes), 11% by friends and acquaintances, and 2-3 % by strangers.
• Of these 69,000, about 115 were "stereotypical type" of abductions. (These data are hard to gather; some claim the numbers should be closer to 200-300.). "Stereotypical abductions" are defined as abductions perpetrated by a stranger or slight acquaintance that involve a child who was transported 50 or more miles, detained overnight, held for ransom or with the intent to keep the child permanently, or killed.
• Thus, the risk of such an horrific abduction was about 1 in 600,000 U.S. children.
• Of the 115 abductees, 45 were murdered, a risk of about 1 in 1,500,000 U.S. children.

Now, let's compare this risk of death (50 children/year; odds of 1 in 1.5 million) to the following:

• About 1,500 children die each year from physical abuse.
• The odds of a child dying is 2 X more likely from influenza or pneumonia, 4 X more likely from heart disease, 17 X more likely from suicide, 20 X more likely from playing youth football, 30 X more likely as a pedestrian in a car accident, 100 X more likely from a car accident.
• The odds of being struck by lightning are 1 in 240,000. About 75 people /year are killed by lightning.

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Still, even with these relative odds in mind, when we see something on TV, we intuitively believe it much more likely to happen to us than it really is. And it's hard not to respond emotionally to this tragic story, not to envision worst-case scenarios happening to your child, not to feel you must choose between protecting a child or supporting a child killer, not to agree to do anything to prevent your child from being in the headlines.

When this story first broke nine years ago, I had parents in my pediatric practice who decided to teach their child to be ever vigilant to all the possible dangers on every corner. They chose to have her DNA tested and fingerprints stored for future identification. They refused to let her walk to school. They taught her how to elude a stranger who might try to abduct her. They succeeded in making her plenty scared.

Interestingly, these were the same parents who had refused to immunize their child with the whooping cough vaccine . At that time the vaccine carried a risk of 1 in 2,000 for a serious side effect (like shock or convulsions; it's much less now with the newer 'acellular' vaccine), compared to a risk of 1 in 50 for these to occur should their child actually contract the whooping cough.

Like many of us, they were great at responding emotionally to much-hyped, poster-child media stories. But they weren't too good at wisely playing the odds. (They are not alone. How else to explain why lotteries make a ton of money and Las Vegas has built a new, billion dollar hotel? After all, with all those happy winners on TV - of course, you don't get to see the millions of losers - why couldn't that just as easily be me?)

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Dr. P's take:

Make no mistake: child victimization is a real concern and does merit your attention. It's just that abduction and murder is about as unlikely a risk as it gets.

• I'd suggest you try to put risks into perspective.
• Avoid the fear-mongering, induced hysteria that will surely be re-visited in the weeks to come.
• Don't scare your kids to death and promote in them an unwarranted culture of fear.
• Do teach kids how to lessen the likelihood they will be victimized in any way (such as physical and sexual abuse, being bullied and scape-goated, etc.). I'll deal with this in another blog, but a nice summary of effective, sensible programs can be found here.
• Blow up your TV.
• If you do happen to watch these kind of stories with your kids, be sure to discuss it with them, explain how rare an event it is, how TV shows exaggerate risk, reiterate that you will make certain they stay safe, and take them in your sheltering arms and reassure them that the world is mostly a friendly and joyous place to be a kid.

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* Book cited: The Culture of Fear: Why Americans are worried about the wrong things. Barry Glassner. 1999. Basic Books.

Related Topics: The JonBenet Case and Cruel Stress, Sexual Abuse Prevention

Technorati Tags: JonBenet Ramsey, child abuse, parenting

Is breast-feeding obscene?

Before getting into it, take a look at the cover of the August edition of Babytalk, a free magazine for new moms:


What's your first reaction? Beautiful? Offensive? Not a big deal either way? Would you have qualms if your kids were to see it?

Turns out, this cover has caused a lot of controversy. Babytalk received 700 irate letters (far more than they ever had). In a poll of 4,000 of their readers, about 1/4 felt the cover was "inappropriate"( "gross," "obscene," "offensive") .

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Two blogs ago ("Breast-feed or else") I raised the concern that American attitudes towards public breast-feeding and lack of support in the workplace are two reasons for the disappointing numbers of nursing mothers in the U.S. After reading about this brouhaha, I've done a little more research. Here's what I found in a recent study* of the attitudes of 5,000 U.S. adults to the following statements:

• Women should have the right to breastfeed their infants in public. (43% agree)
• It is appropriate to show a woman breastfeeding her baby on TV. (28% agree)
• Employers should provide flexible work schedules, such as additional break time, for breastfeeding mothers. (50% agree)
• Employers should provide extended maternity leave to make breastfeeding easier. (47% agree)
• Employers should provide a private room for breastfeeding mothers to pump milk at work. (43% agree)
• Public buildings need to have a room where women can breastfeed or pump milk. (41% agree)
• Shopping malls should provide a private place to help women breastfeed their babies. (52% agree)
• Breastfeeding education should be available as part of a high school health education curriculum. (33% agree)
• I would support tax incentives for employers who make special accommodations to make breastfeeding easier. (27% agree)
  

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Dr. P comments

The numbers (none more than 50%) speak volumes about our tepid support for breastfeeding moms. The authors did note that support of breast-feeding was higher in younger, better educated, and minority groups. Perhaps if the more culturally diverse younger generation is any smarter (OK, maybe I'm dreaming here), that support will rise over the next years.

But what seems especially unfathomable to me is the inability - indeed, the unacceptability - for a women's breast to be seen as anything other than a sexual object. For men, perhaps it's the "madonna or whore" complex - combined with a Playboy obsession with the female breast - being played out. After all, we men aren't great at multi-tasking. For some women, perhaps it's the desire to keep the breast mysterious and alluring, lest it lose its hold over men and be seen as just another working part of the ordinary eternal machinery.

Whatever the reasons, it seems to be perfectly acceptable to show titilating (sorry, couldn't resist) pictures of actresses with very revealing dresses on the cover of magazines. That we get. That we can accept. But show a picture of a breast being used, as it has for millions of years, to nourish an infant...

You got to admit, as John Prine sings, it's a big old goofy world.

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**Article cited

"Public beliefs about breastfeeding policies in various settings."

Li R, et al. Journal of the American Dietetic Association 104: 1162-1168, 2004.

Related Topics: Breastfed Babies Less Stressed Later?, Breastfeeding in Public: A Mother's Rights

Technorati Tags: BabyTalk, breastfeeding

Embryo rights?

On 7/19/06 - for the first time in his presidency - President Bush vetoed a bill passed by Congress. This legislation would have allowed Federal funding of research on new lines of human embryonic stem cells.

Stem cell research holds the promise of new treatments - even cures - for a host of horrible diseases. Nevertheless, the President emphatically warned us, to use embryonic stem cells in this way "crosses a moral boundary our decent society needs to respect...This bill would support the taking of innocent human life in the hope of finding medical benefits for others."

I, too, consider myself an advocate for child protection and have long struggled with the questions: When does human life begin? When should an embryo or fetus be considered a person, and therefore entitled to all the protections of the law?

For me, at least, it is an excruciating question. Determining where to best draw that line has always seemed to be incredibly complicated, scientifically hard to sort out, and morally ambiguous. But the President's vision is crystal clear: a full-fledged human being exists once the egg and sperm unite. Period. End of discussion.

I've been thinking a lot about his unequivocal certainty and it has occurred to me that such a belief has major moral implications - over and above the embryonic stem cell research question - which neither he nor others seem to be addressing.

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First, some quick background on frozen embros (FEs):

• A FE is about a week old. It consists of about 30-150 cells in a ball. Here is a photo of what it looks like.
• There are about 400,000 FEs in the U.S. Most of them will neither be needed nor wanted, and eventually 'discarded.'
• FEs can not stay frozen forever (it's not clear how long, perhaps a decade or so). Storage fees are about $1,500 / year. About 50% of FEs survive the thawing process.
• To take nourishment and survive and grow, an embryo must "implant" in the wall of the uterus. This process takes about 10 days or so.
  

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Now, if a ball of cells (or even a single fertilized egg) is truly a "human being", it seems to me the following troubling moral and legal issues are raised:

• About 2/3 of all embyos normally do not implant into the uterus and are spontaneously expelled from the womb, usually unknown to the mother. Should we expend significant government research dollars to find ways to allow the mother to recognize what has happened? This would allow a proper mourning ceremony to occur so that the souls of those embryos can rest in peace.


• Intrauterine devices (IUDs) and the "morning-after pill" work by preventing the embryo from implanting into the uterus. By extension of the 'moral boundary' argument, they are taking a human life and should be illegal.
  


• The indefinite frozen "suspended animation" of FEs could be considered a form of child abuse. Some parents keep dozens of their embryos in the deep freeze, with no intention of some day providing them with the necessities to thrive and live. Should we not mandate that they fulfill their parental responsibilities to nurture all of their human children (perhaps by attempting a pregnancy with every FE or by finding "adoptive" parental wombs) or else face criminal charges of child abuse and neglect?



• The fate of hundreds of thousands of unwanted FEs is to be destroyed. Should that be considered genocide, with all the criminal sanctions such a characterization calls for?



• Aside from criminalization, should we not attempt to prevent the willful destruction of these FEs? Attempts at adoption (e.g., through the "Snowflakes Adoption" program) have led to only a small number being rescued. Should the government provide financial incentives to women to "rent" out their wombs to implant and nourish the unwanted embryos to delivery? Of course, then we would likely need to build many orphanages to raise these children. An imperfect solution, to be sure, but isn't a life without parents is still preferable to one cut tragically short at the 50 cell stage?

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I'm being quite serious here. This is no theoretical discussion. This debate must play out in one of two mutually exclusive ways. Either you follow the President and then are morally obligated to pour money and resources into the issues I have just discussed, or you do not consider a one week old ball of cells to constitute a human being and then are morally obligated to allow frozen embryos to be used for research that may unlock new ways to relieve the very real suffering of very real human beings.

Related Topics: Cord Blood Stem Cells: Your Questions Answered, New Technique for Stem Cell Research?


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