Join Alicia and Dr. Megan, anesthesiologist, to discuss Pain management options in Labour
AP: Welcome to the Growing Healthy Podcast. Today we are fortunate to have Dr. Kelsey Mills with us to talk about Menopause!! Dr. Mills is an obstetrician and gynecologist who has extra training in the Hot topic of Menopause! Thanks for joining us Kelsey!
KM: Thanks Alicia, it is my pleasure to chat with you today! This is a topic that can get women all fired up!
AP: Why don’t we start with the basics; what is menopause?
KM: That’s a great place to start. Menopause is defined as the permanent absence of menstrual periods for one year, in the absence of other reasons for a period to stop, such as pregnancy. We have had a couple women tricked into thinking they were in menopause when in fact they were pregnant!
AP: What a surprise that would be!!! Can you tell us a little more about Menopause.
KM: The average age of menopause in Canada is 51.4 and anything after 40 is in fact in the realm of normal. If a woman enters menopause under the age of 40, we search for other diseases, or reasons why that could happen. In natural menopause, a woman stops having periods because her ovaries have essentially used up their pool of eggs (oocytes) and are no longer ovulating each month. Therefore, there isn’t an episode of bleeding that follows ovulation, so all bleeding stops. When women don’t ovulate anymore, there are much lower levels of circulating estrogens in their body which may or may not result in menopausal symptoms.
AP: But the transition is not necessarily an on/off switch is it....
KM: Nope...it sure isn’t! On average, women start to experience symptoms of perimenopause for 4-5 years prior to not getting a menstrual period any more. These symptoms can include irregular or erratic cycles, cycles that fluctuate in heaviness (one month light, one month very heavy), mood changes, hot flashes, night sweats, sleep disturbances and vaginal dryness.
AP: I often have women coming in around that time with musculoskeletal complaints as well....
KM: There are some other common concerns that happen around the time of menopause and certainly increase with aging, like “brain fog”, memory changes, hair loss, weight gain, and muscle and joint pains.
AP: So lets talk about the menopause-specific symptoms a bit more and how we can manage them.
KM: Great. So I find that the symptom that bothers women the most, are what we call “vasomotor symptoms” which include the hot flashes and night sweats. We know that about 80% of women in the menopausal transition experience hot flashes, but unfortunately only about 20% of those women will seek medical attention for them. Studies have shown that women find it difficult to discuss menopausal concerns with their primary care providers, and in particular find discussing vulvo-vaginal or sexual symptoms to be the most challenging. But back to hot flashes, these are generally described as a feeling of heat starting in the chest and then spreading over the upper body, face and neck. They can be accompanied by heart palpitations and sweating, and they generally last for 2-4 minutes. Hot flashes are so interesting, because some women never experience them, and some women will flash several times an hour in menopause. Hot flashes can also be different woman to woman; some women describe a prickling or skin-crawling sensation, some women describe a sense of impending doom! This is serious stuff. Menopause researchers used to believe that hot flashes only lasted for 4-5 years, but we now know that they can last much longer, perhaps 8 years on average, and some women will flash for the remainder of their life.
AP: Are there any factors that can make it more likely that women will have worse hot flashes?
KM: Well we know obesity and smoking both increase the risk of hot flashes. Interestingly, certain ethnic backgrounds, such as being of African descent, may make a woman more likely to have hot flashes.
AP: Hot flashes can happen at night as well....often drenching beds with sweat etc. and this leads into our next symptoms of menopause....sleep disturbance! We know that about 40% of women struggle with sleep in the menopause transition - this can be related to hot flashes, or our next topic....mood changes - namely depression. They can also be related to things like restless legs or sleep apnea - so please make sure you talk to your family doctor if you are having sleep disturbances as there may be some testing we need to do and something we can help you with!
KM: It is true...there are so many interconnected pieces within menopause, but we can't blame everything on it! The mood changes can often be attributed to the perimenopausal and early post menopausal time, especially in women who have not had mood disturbances before, and in these women, we often see it improve 1-2 years after menopause. Women with pre-existing anxiety and depression are at the most risk for worsening mood issues during the menopausal transition. Probably the number one descriptor of mood changes that I hear is an increase in a women’s “irritability”. But the midlife can be a very stressful time for women, and there are many reasons for mood changes in the midlife which may not be all attributable to hormonal changes.
AP: Vaginal dryness is often a complaint women have with menopause, can you speak about that a bit?
KM: Absolutely. This is a really important topic that I wish women felt more supported to discuss. Estrogens play an important role in our bodies and women can make several different kinds of estrogens. Tissues in a women’s vulva, vagina, lower urinary tract and bladder are very sensitive to the effects of estrogens. When those estrogens are withdrawn in menopause, this can result in something we term “genitourinary syndrome of menopause” which is a fancy name for when all those tissues become drier and less elastic. This can result in itching, bleeding, having to urinate frequently or urgently, getting recurrent urinary infections, and having pain with sexual intercourse. Unlike many other menopausal symptoms, the genitourinary symptoms often start later into menopause and will progress as a woman ages.
AP: And I also think it is important to note, that these symptoms, especially the itchiness and pain, are not always simply due to menopause, so again it is important to see your care provider to ensure it is not something else causing this!
KM: Indeed! These changes can be very uncomfortable and distressing for women....so please do not suffer unnecessarily...come talk to us...because we can help!!! And I want to take this moment to point out that although some women may bleed in menopause because of tissue dryness, post-menopausal bleeding is never normal and other sinister causes must be ruled out. Please speak to your doctor if you are menopausal and start bleeding again. Your doctor can help you with investigations to rule out worrisome causes of post-menopausal bleeding, like certain cancers.
AP: That’s a great reminder. Well lets chat about what we can do to help women going through menopause….
KM: First and foremost let’s talk about lifestyle modifications that women can do to help manage the menopausal transition. Anything that cools us down can help with hot flashes - having the room at a lower temperature, using a fan, using moisture wicking sheets or clothes, dressing in layers that can easily be removed and avoiding triggers like spicy food or stress can all help. Alcohol is a huge hot flash trigger for many of my patients. And alcohol contains a lot of empty calories, so cutting back can help with weight reduction and vasomotor symptoms. We also know that excessive alcohol consumption is a risk factor for breast cancer. So that’s another important reason to stop excessive drinking. Back to the notion of weight loss, if a woman is carrying extra weight, losing weight may reduce menopausal symptoms. Another very important point is that quitting smoking can have a large impact on vasomotor symptoms, bone health and overall health for women.
AP: Beneficial for menopause and beyond!!! Other changes that can help with mood changes, joint achiness and sleep disturbance include staying well hydrated, getting regular exercise, eating healthily and maintaining good sleep hygiene. Pulling in your support system, through what can be a challenging period in your life, is never a bad idea!! Mindfulness-based stress reduction is another tool that many women going through menopause, or other stressful times, find to be very helpful!
KM: Indeed...but most women who come to see me are suffering more than these measures can help, and that is why we often have a conversation about medications.
AP: My understanding is that when it comes to medications, you treat based on symptom severity, so not every treatment plan is the same...is that correct?
KM: Exactly. Women are so unique. Remember that there are some menopausal women who have never had a hot flash, and some who suffer hourly! If someone has vulvo-vaginal issues, and no other symptoms, then I will treat that, but if a woman has multiple issues the treatment plan might be much different!
AP: Shall we talk about treatment then?
KM: Yes, let’s do it. The simplest symptom to treat is vaginal dryness. Using a good lubricant with intercourse can be enough for some women’s concerns, but others may benefit from a vaginal moisturizer or local vaginal estrogen to help with their symptoms. Vaginal estrogens in Canada can come in the form of a cream, a vaginal suppository, or a vaginal ring that is worn daily for 3 months. Local estrogens are extremely safe and there is very minimal systemic absorption of these medications. In general, vaginal estrogens are safe for all women. They do not carry an increased risk of blood clot, or stroke. If a woman has had breast cancer, then this is a bigger conversation and I encourage her to discuss the role of local estrogens with her gynecologist and oncologist.
AP: So I have heard lots about vaginal rejuvenation.....lasers and vaginas....seems like a dangerous combination....
KM: Using lasers to treat vulvo-vaginal symptoms is a relatively new player in the menopause realm. And this is different from using lasers or surgery for cosmetic enhancement, or “rejuvenation”, of the vulva and vagina. I strongly advise women against cosmetic changes their vulva and vagina. But that is another topic for another day! Back to menopause, there is ongoing research looking into the safety, efficacy and long-term consequences of using a laser to treat vaginal symptoms, such as dryness, in menopause. Currently, vaginal laser treatments are not covered by Pharmacare or MSP, so women pay privately to use this device. I look forward to seeing further studies in this area so I can help women decide if investing in this treatment is appropriate and safe for them.
AP: So what if women have hot flashes as well? Will the vaginal estrogen help those?
KM: Good question Alicia. Hot flashes are treated with either hormonal or non-hormonal systemic medications. If hot flashes or night sweats are bothering the woman, then we will have a discussion around treatment options. The most common treatment is an estrogen and progesterone. There are certainly some women who should not take these medications for medical reasons, which is one of the reasons it is so important to have a good conversation with your care provider prior to starting any medications!
AP: Now you said estrogen and progesterone....isn't just estrogen the problem?
KM: In general, menopause experts believe that vasomotor symptoms are best treated with systemic estrogen. But, if we give a woman with a uterus only estrogen, we increase her risk of endometrial, or uterine cancer. The endometrium is the lining of the uterus that sloughs off every month when a woman has a period. The reason that it sloughs off, and just doesn’t keep growing and growing is progesterone. So to protect the lining of the uterus from thickening into a potential cancer, we use progesterone to keep the endometrium thin and healthy.
AP: I have it on good authority that progesterone can help with sleep as well!
KM: Certain forms, like micronized progesterone, are better for this than others! Many women find progesterone to be sedating, and so I always recommend that women take their progesterone at night before bed.
AP: So what is the goal with Hormone therapy?
KM: Our goal is to use the lowest dose, for an appropriate duration, to manage a woman's symptoms. This is individualized based on the woman’s symptoms.
AP: So you are not trying to get to a certain number in their hormone level?
KM: No...in fact we know that symptoms are not correlated with blood hormone levels, and I explain that to my patients by saying that a woman who has terrible hot flashes, and a woman who doesn’t know what a hot flash feels like, may have the same hormone levels! So we individualize the amount of hormone that women need (or don’t need!) based on how feel her symptoms are being controlled.
AP: So why are some practitioners checking levels, and compounding creams specific to those numbers....
KM: That’s an interesting question Alicia. Compounding hormones refers to mixing hormones in a specific base or oral preparation and then applying or ingesting those hormones. I worry about what exactly my patients are receiving when those hormones are mixed, because unlike pharmaceutical grade hormones (like pills, patches, or gels), no one is doing testing on those creams to check for components, quantities, purity, or to do batch testing. We also know that progesterone is not absorbed well across the skin, so I have major concerns when my patients come to me on progesterone creams and estrogen. No major professional organization advocates for the use of compounded hormones. Often compounded hormones are very expensive as well.
AP: So save your money and buy a new pair of shoes?
KM: Or hormones that work!
AP: Back to business.....So how can the estrogen and progesterone be taken?
KM: Well, once a woman identifies that she would like treatment for her vasomotor symptoms, we first consider reasons why it may not be safe to take systemic hormones. Although hormone therapy is extremely safe, we know that in certain cases, using menopausal hormone therapy may increase women’s chances of a blood clot, stroke and breast cancer. This is particularly true of older women, for example, over the age of 60 who have multiple health problems. After evaluating these risks, we generally prefer transdermal estrogen, which is estrogen that is given through the skin in a gel or patch. We believe that this lowers the stroke and blood clot risk associated with estrogens. Most of my patients (if they have a uterus), will use a micronized progesterone to protect their uterus and help with sleep. The exact doses and types of hormone therapy are often individualized to the woman.
AP: So we know that the HRT can help with some of the mood disturbance, but what if that is the main complaint as opposed to hot flashes?
KM: Well this is a topic you are probably better at managing than I am!! Treat the mood disturbance!! Although there are a few antidepressants that have shown some efficacy in improving hot flashes as well, so if women are suffering from mood disturbance and hot flashes and are not able to take HRT for some reason, we will try one of these medications to help manage both. These medications include Paroxetine, Venlafaxine and Desvenlafaxine. Now if you are on an antidepressant and not significantly affected by hot flashes, I would not switch to one of these, but if you have hot flashes, and your doctor is talking about starting an antidepressant, you could consider starting with one of these. Mood changes in menopause are not an indication for starting hormone therapy.
AP: Right, and remembering managing any mood disturbance the best place to start is talking and lifestyle optimization! So talk to your doctor, talk to a counsellor or friend if possible, pull in your support system. Get outdoors and exercise, make sure you are following a healthy way of eating, staying hydrated and minimizing alcohol.
KM: Before we wrap up I just wanted to chat a bit about "natural/herbal" medication in menopause care because this is something I see a lot of. In general, I tell women that if they are using a herbal supplement and they find it helpful, then it is likely a fairly low risk thing to do. The studies show that most herbal supplements in menopause have a strong placebo effect, and women generally find their symptoms return around the 3 month mark. I see a lot of women who have tried all of the herbal supplements and not had relief of their symptoms. I once had a patient come to my office with a laundry basket full of supplements! She had tried everything, and was still having terrible hot flashes. This is common and your care provider can help you discuss medical options to help manage your symptoms more effectively.
AP: Great! Well thanks for coming and chatting about Menopause with me....something to look forward to in the coming years!!
Keep on Growing Healthy.
Dr. Sonja Mathes, orthopedic surgeon, joins us to speak about this very common condition.Alicia Power: Welcome to Growing Healthy Podcast! Today we are a lucky to have Dr. Sonja Mathes with us to talk about a very common problem….Osteoarthritis. Sonja is an orthopaedic surgeon here in Victoria and we will get to this discussion right after this little reminder!
The Growing Healthy Podcast and website is meant for general medical information only. this does not apply to every situation. If you have questions, or if you have received different advice please contact your health care provider. The views expressed by growing healthy and our guests are not representative of any institution with which we are affiliated.
Alicia Power: Sonja, Thanks for coming to talk to us today! SM: No problem Alicia, Thanks for having me!! This is a very common problem which I see every day…and I think it is important to get more info out there about it! Alicia Power: well lets get started!! Tell us a little bit about osteoarthritis. SM: Well, Osteoarthritis, or OA is the most common type of arthritis, and it affects millions of people world wide. It occurs when cartilgae, the protective coverings of ends of bones in joints, , breaks down. This starts with roughening of the cartilage, and it can go on to thin and get so thin that eventually the bone is exposed, causing bones to rub on bones.. This can cause pain, stiffness and swelling in joints. Some of the most common joints that are affected are the hands, hips, knees and spine. Alicia Power: Do we know why it happens? SM: Not entirely. We think that in part, it is worsened by asking the joint to do more - things like repetitive stress or use of a joint - some professions could increase this risk. But there are also some genetic factors that seem to play a role. Lifestyle factors can definitely increase the risk of OA.…… Alicia Power: What do you mean by lifestyle factors? SM: well weight certainly increases the risk of arthritis.The more we weigh the more force is put onto our joints with even simple activities such as walking. People who are significantly overweight have a 40 times higher risk of developing arthritis of their knees. Also the longer we have been using our joints, the higher the risk of OA is, so the older we are, the more risk we have of getting OA. Alicia Power: what about injuries? SM: yup certain injuries also can increase the risk of the cartilage breakdown leading to OA, this is often an issue in the knee and ankle where jumping and twisting injuries can cause damage that protective layer quite easily. Also certain abnormalities in the alignment of joints can increase the risk. Alicia Power: okay so age, repetitive use, obesity, previous injury or alignment issues in certain joints can all contribute to osteoarthritis….Is it more common in men or women? SM: it seems to be more common in women, but we aren’t certain why that is. Alicia Power: all right so we have an idea what can cause it, and the symtpoms we get from it - joint pain, swelling and stiffness. But how do we know it is Osteoarthritis as opposed to another form of arthritis. SM: There is a pretty typical pattern for osteoarthritis, at the beginning a sharp stabbing pain associated with certain activities. Usually, the pain comes and goes when the arthritis is milder. This can progress to a more constant dull aching pain with periods of swelling and sharper pain which starts to affect daily function which can then progress to significant debilitating pain. Usually affecting one to two joints, as opposed to many as we can see with other types of inflammatory or autoimmune arthritis like rheumatoid arthritis. We can confirm our diagnosis with conventional xrays, and rarely we need other types of imaging if the symptoms are a bit different than we might expect. Alicia Power: its quite interesting, i’ve had some patients with minimal pain and severe OA on their X-rays and others with sever pain with what appear to be very minor changes. Would you say it is important in OA to manage the symptoms as opposed to the xrays? SM: yes, very much so. I always tell patients that we treat patients, not xrays. osteoarthritis can look and feel differently in everyone. So our goal is managing your pain and stiffness, to allow you to do the things you like to do! Alicia Power: Is there anything we can do to prevent it from happening, or from worsening if we do have it? SM: Almost all of us will develop arthritis in some joint as we age, but not all of us will have pain or symptoms from the osteoarthritis. Many people think that they should be less active to try to prevent worsening wear and tear on their joints, however, moderate activity is actually really helpful for managing symptoms. By keeping the muscles around a painful joint strong, you can take the pressure off the joint. Especially for osteoarthritis in the legs, using non or low impact activities like walking, cycling or pool based exercise can dramatically improve pain and stiffness. Alicia Power: If you do have it, and it is causing pain, how can we manage it? SM: Our goals with managing OA are to improve the pain, improve the patients function - i.e. what they can do day to day and to help slow down the progression of arthritis symptoms. i have already talked about the benefits of staying active It is important to lose weight if you are overweight or obese, as this decreases the stress on your joints. In fact by losing 10% of your body weight you can decrease your pain by up to 1/2! Pretty amazing! and great for so many aspects of your health as well. Using aids for walking - such as walking poles can help with hip or knee arthritis. Also sometimes braces can help to improve the way that the joint moves taking pressure off of the more damaged parts of the joints. Exercise and strengthening are very important - and the knowledge of a good physiotherapist or exercise prescription expert can be very useful. Alicia Power: okay so those are things that you can get started on even before seeing the doctor! Great…what about other ways of helping such as medication or surgery? SM: So generally if you have done the lifestyle changes and you are still experiencing pain we usually start with topical anti inflammatories or tylenol. If these are not effective then we move onto oral anti inflammatories as needed. these are used to treat the pain, they do not change the progression of the disease. Please make sure to stay well hydrated, and if you are using them more than occasionally see your family doctor to make sure your blood pressure is normal, and there are no reasons in your medical history why you should not be taking them. Occasionally we can use an antidepressant which is shown to help with some pain conditions, if you have mood concerns as well. Alicia Power: now what about injections into joints, such as steroids or hyaluronic acid - what I like to call a Lube job for the knee? SM: Well we can use steroid injections for an arthritic joint. This can work well if there has been a sudden worsening or flare of the arthritis. This isn't a permanent solution, but for many patients who are trying to delay or avoid surgery it can be an option. But it often wears off fairly quickly within two to six months. The lube job or Hyaluronic acid injections can help many patients with mild to moderate arthritis and can give longer benefit,maybe up to 10 months. They are expensive at up to 450 per injection but the studies show that not all patients benefit from them, but certainly I have had patients that have had good effect from this and it is relatively safe, so may be worth a try. Alicia Power: What about more natural substances people might be looking into. SM: well if you are going to try something, topical capscasin has some evidence to it, but can be irritating to the skin. And in some studies, oral fish oil and chondroitin have shown some positive benefits. Alicia Power: there is all kinds of talk about the anti - inflammatory nature of turmeric….do you know anything about this? SM: Well the active ingredient known as Curcumin has again some evidence for it, but it is poorly absorbed in our bowels, so you need to take a supplement that has been formulated to improve its absorption in our GI tract. Alicia Power: Great…so we spoken about lifestyle changes, medications and injections. What if none of these help and you are suffering daily and unable to do what you enjoy doing in life…what is the next step? SM: Surgery is an option for most kinds of osteoarthritis when patients have disabling symptoms. For most large joints - the shoulder, knee and hip - surgery to replace the joint, a joint replacement is the most effective option. Arthroscopic surgery through where a as small camera goes into the joint - usually ankle or knee - can used to "clean up" a joint if there is locking or cathcing in select patients. But most patients don't get any benefit from arthroscopic clean up and it is usually not recommended for arthritis. Total joint replacement surgery can have dramatic improvements in quality of life for patients who have advanced arthritis and are disabled. Joint replacement surgeries are big operations and although the majority of patients are satisfied, there are risks to the operations and not all patients are happy after having their joint replaced. About 20% of knee replacements and 9% of hip replacements report ongoing pain after surgery - so its important to have realistic expectations and know that you may not be entirely pain free after your surgery. If you have multiple painful joint, depression or other health issues, its more likely that you may have pain after a joint replacement. Alicia Power: OK so I think we have done a pretty good review of OA, are there any other pearls or tidbits that we haven’t mentioned that you think are important for people to know about? Or any new treatments coming out? SLots of patient ask me about two newer types of treatments for arthritis - stem cell injections and platelet rich plasma injections. What we are all hoping for is a treatment that can grow new cartilage. However, this doesn't exist yet. Once the cartilage has thinned in arthritis, there is no way to bring it back. Stem cell therapy is still an experimental treatment that does not have any strong studies to support it yet. Platelet rich plasma injections has some studies that show benefit for patients with mild to moderate arthritis in the knee, it is still fairly experimental. I have seen many patients who have chosen to have these treatments and often spent a lot of money on them and not had any benefit, so i really encourage patients to talk to their physicians or an orthopaedic surgeon before they consider these treatments. Alicia Power: Well That is some great information! Thanks Sonja for coming on the Growing Healthy Podcast….it’s a beautiful day out so i’m going to go do some moderate joint strengthening activity….So keep on Growing Healthy!
Welcome back, folks!
MK - After we talked about the top 5 things I wish I knew about the post-partum period...that glorious time in every glowing mother's life, we also wanted to cover the top 5 things that I wish I had known about that little wrinkled being that just came out of me!
I'll never forget when my husband and I watched the birthing video at our prenatal class and he's like, "what's wrong with that baby".
I'm like, "yeah, babies come out blue"
Info bit #1: Babies are blue at birth.
AP: yes they will be, as you can imagine, goes through quite a journey both physically and physiologically during the delivery process. They go from getting all they need to survive through the umbilical cord, to needing to breath and manage all their needs on their own. This transition goes surprisingly well and quickly for most babies....but they do come out a bit blue to start off, and as their lungs start to fill with air, and it gets pumped around their body they start to pink up. In some baby's for a variety of reasons, this transition from inside to outside takes a little longer and they need more support, sometimes we need to help them to breathe a bit while they are figuring it out, and the vast majority of time they are doing it all on their own by 10 minutes of life. So don't be too worried if we need to help your baby out a bit, we will keep you informed and get them back to you, where they belong, as soon as it is safe for both of you to do this!
AP - Info bit #2: Your baby will lose weight...and then regain it.
MK: it is normal for you baby to lose up to 10% of their birth weight in the first few days of life. We generally expect them to gain back this lost weight, and be at their birth weight by 10-14 days of age.
AP - Info bit #3: Your baby will be jaundiced, but you may not recognize it. Maria, can you describe jaundice to us?
MK: Yes, ALL babies get jaundiced, it just depends on how jaundice they get as to whether we need to treat them. Jaundice is that yellow tinge to skin and eyes that babies get. It is caused by the breakdown products of the red blood cells of babies, as they are transitioning from their baby hemoglobin, or red blood cells, to their adult hemoglobin. This product is then broken down in the liver and transferred out of the body in the baby's pees and poops. There are a number of reasons why this may not happen as efficiently as it could, which would then cause higher bilirubin levels and more jaundice.
AP: why do we care if baby's are a bit jaundiced? can it cause them any harm?
MK: Well we definitely care, because once the bilirubin gets to a certain level, it can cross what we call the blood brain barrier and cause irreversible damage to your baby's brain.
AP: are there any risk factors that we can watch out for in babies to predict a higher risk of getting jaundice?
a) gestational age - the younger a baby is the less mature their liver is and therefore the less capable it is at keeping up with the need to breakdown these products quickly, and therefore levels can rise in the blood. So this is premature babies.
b) Ethnicity - Babies of east asia ethnicity (including china, japan, korea, taiwan etc) are at a higher risk for jaundice requiring therapy. The bilirubin levels are often higher, and peak a bit later, and take longer to resolve. This is due to a decrease in the enzyme which helps breakdown the bilirubin in baby's blood. About 1/5 baby's of this ethnicity will require treatment to bring their bilirubin down.
c) Blood type - If baby has a different blood type than mom, and mom has created antibodies against this blood type, then baby will often be born with these immune cells from mom which will break down the baby's red blood cells more quickly. This occurs with mom's who are RH - and baby is RH +, or if mom has blood type O and baby is a different blood type (A, B or AB)
d) There are certain genetic causes that can increase baby's risk of being jaundiced, these can be as a result of the shape of the blood cells, or red blood cells are broken down more quickly leading to more bilirubin in baby's blood, or because the enzymes that help to break down bilirubin don't work as well.
d) If you had a previous baby with jaundice requiring treatment under the phototherapy lights, then we are much more cautious with subsequent babies, as they are at a higher risk of needing treatment generally because of one of the above reasons.
AP: how do we monitor for jaundice?
MK: here in Victoria, we have recently started a program where we can take a skin measurement of baby's bilirubin levels.
I actually really love this little gadget because it's very Star Trek.
We do this multiple times over the first few days of life. If your baby's bilirubin levels are high on this skin test, we need to confirm with a blood test. On discharge from the hospital, if your baby's jaundice level is not too high, but not too low, we get your baby to go to public health and have these skin checks done until we know it is improving. If your baby has a high blood level, then we either have to monitor closely with more blood tests or start treatment.
AP: How do we treat Jaundice?
MK: The treatment of jaundice is by keeping your baby hydrated, as the broken down bilirubin is excreted through your baby's pee and poo, and by using ultraviolet light to help breakdown the bilirubin. This looks like a little tanning booth for your baby. We put them into this, in a diaper with eye protection and leave as much skin exposed to the lights. It is important for your baby to be under this as much as possible, so other than breastfeeding your baby should be under the lights...which is hard because it decreases the snuggle time with your baby. But we do have a "bili blanket" which wraps around your baby so you can continue to snuggle and feed while receiving treatment. However, sometimes, your baby will still need to go under the tanning bed.
Very rarely your baby's bilirubin is so high that we have to do more invasive treatment which requires what we call exchange transfusions, but this rare.
If we need to treat your baby, we will need to follow up with bloodwork to ensure that the levels stay on the lower side and don't bounce back up.
Info bit #4: One of the things that new parents in particular are always asking me is "how much do baby's need to eat" and "how to know if they are getting enough"?
AP: When babies are born, their stomachs are just wee, and that is normal. As we discussed previously mom produces just small amounts of colostrum for the first few days before her milk comes in, and mom and baby are designed to work together. So baby will feed often and get little amounts over the first couple of days of life. This allows your babies stomach size to slowly increase with mom's milk production, and also gets that frequent feeding and skin to skin time, which is so important for both revving up mom's milk supply and for baby's attachment to mom to start forming and regulating temperature. So trust yourself and your body! If you are in the hospital, we make sure that your baby has not lost too much weight. Also to make sure your baby is getting enough, check the wet diapers. Over the first few days to a week they should be having as many wet diapers as they are days old...ie 2 wet diapers on day two of life, 4 on day four of life etc!
AP: Speaking of diapers....make sure you are well prepared, because in those first few weeks of life you are going to go through a lot!!! your baby will pee 5-10 times a day, and although poo varies from every feed to once a week expect more than less at the beginning...and you want to get that poo away from their skin as it can cause the skin to break down and get raw and irritated....poor little bums...so frequent bum changes and if the skin starts to break down...using a barrier cream such as vaseline petroleum jelly, penetin etc will help. If it gets really bad go see your health care provider because they may need a prescription cream to help it heal.
MK: I love Vaseline. Not just because it's cheap, easy and effective, but because it was a staple of my childhood. I have numerous photos of me with very shiny chubby cheeks.
Alicia, Do you find some baby's are more prone to diaper rashes:
AP: Yes! like us adults, some babies have very sensitive skin, and if that is your baby you will want to consider not using the "big brand" diapers that have been bleached, scented etc. I usually recommend the seventh generation or Earth's best. Also take a look at your wipes, some people have to use just warm water on a cloth to clean their baby's bums! For prevention cloth diapering is an option in those very sensitive baby's, but this is not for every family!
MK - Info bit #5: Your baby will fool you by sleeping so soundly and beautifully for the first few weeks.....during the day anyways!!
AP: They sure will! babies sleep lots in the first month of life. Unfortunately for us adults that is usually more during the day and less at night! This often starts to transition over around 6 weeks of age, when they will have more awake periods during the day, and sleep longer chunks at night. So be prepared!!! and try to get a nap in during the day, or tag team with your partner/support person at night the best you can. Try to encourage sleep at night by not reacting every time your baby makes a peep. The nature of sleep is that baby's and adults come to the edge of waking and then sometimes will go back into a deeper sleep, unless they are disturbed by a well meaning parent! so if your baby is not crying, give them a minute or two to see if they will settle. And some baby's are just noisy sleepers...don't worry...if they are hungry they will call for you. But...during the first few weeks, until you know your baby is gaining well, you should be feeding them at least every 3 hours during the day and 4 hours from start to start at night, in reality it will probably be more often than this!
MK: So there's our Top 5 things to know about your baby in the post partum period. I'm sure there are so many more questions and helpful advice that many of you have, so please give us some feedback through youtube, facebook, apple iTunes, or even in person. We love hearing helpful feedback.
AK: Thanks again for listening, folks and keep on Growing healthy!
Preparing for Birth
Whether it’s your first pregnancy or your third as your due date approaches you begin to think more and more about what your labour is going to be like and if there is anything you can do to prepare…
AP: Dr. Sarah lea is a family doctor specializing in obstetrics and has specialized training in women’s health. She is also the mother of three children and therefore is a double expert in preparing perineums for delivery!!!
SL: That’s right Alicia/Dr. Power. I just had my third baby in November and the lead up to my delivery was actually the inspiration for this podcast. I have had difficult deliveries in the past so wanted to do everything I could in my power to prepare and make the labour as smooth as possible.
AP: That being said. Let’s dive in. I’m curious what you came across in your research.
SL: Well, the first think I wondered about was how best to prepare the perineum (do we define what this is?) to minimize the risk of tearing and the need for episiotomy (? Define) and stitches following delivery. I know this is on everyone’s mind regardless of whether it’s your first delivery or your third!
AP: For sure…I know a few recommendations out there include perineal massage before labour. What did you find out about that?
SL: Well Alicia, the literature out there shows that for women who had never given birth vaginally before reduced the likelihood of perineal trauma (mostly episiotomy) and ongoing perineal pain. The evidence wasn’t as clear for women who had had previous vaginal deliveries but on review of additional studies, although there is no clear benefit there is definitely no harm In doing so.
AP: That’s fantastic news! So perhaps we should be letting our patients know about the benefits of perineal massage and provide them with some information about how to perform perineal massage.
SL: Absolutely! There are some great resources available and perhaps we could post them on our Show Notes.
AP: So what else did you find? I’ve had some women ask me about shaving in preparation for labour and delivery as a means to reduce risk of infection. Is this something we should be recommending?
SL: Interesting you should ask! This is a common myth and misperception that many women have and believe it or not there are even studies about this! The general consensus from the literature is that there is no benefit to shaving or waxing. It doesn’t decrease the risk of infection, and can actually be associated with multiple side effects including irritation, itching/burning of the vulva.
AP: Now that you mention this I think I recall a colleague in another province saying they actually had a campaign a few years back called ‘Leave the hair down there’. Just like American Apparel did!
SL: You’re right. I’d say if a women gets regular bikini waxes there is no need for her to stop in pregnancy and around the time of delivery but I’d actually recommend against waxing and definitely tell patients if it’s not something they routinely do there is no need for them to get it done!!!
AP: Excellent. So so far, we would recommend perineal massage for preparation but no neeed to shave or wax.
SL: Yout got it! I’ve also had women ask me about enema or ‘bowel prep’ before labor. And this is an understandable question as this is something that was routinely done in the past.
AP: Enema – something I think most people wouldn’t look forward too.
SL: Agreed – and fortunately the evidence agrees too. No need for routine, or even ‘elective’ enema for that matter!
AP: Something I often have patients asking me is what they can do to help deliver on time and avoid going overdue. Some patients ask me about acupuncture. Do you have any thoughts about this?
SL: It just so happens I do! I have actually gone for acupuncture for cervical ripening in two of my previous pregnancies. I also took a look at the literature and it seems that there is a bit of evidence out there that acupuncture done by appropriately trained individuals MAY improve cervical readiness for labour, but the evidence is pretty weak. There hasn’t been a lot of safety data but what has been reported hasn’t show any harm.
AP: So it seems the limited research show so far no harm and possibly some improvement in cervical ripening?
SL: That’s right Alicia. In addition to acupuncture which I often discuss with patients I’ve had people ask me about castor oil.
AP: Ah yes, castor oil I understand it can bring labour on but can also bring on a whole host of undesirable side effects, like your doctor trying not to vomit on your vagina as I you are delivery your baby into a puddle of diarrhea…..
SL: You’re right there Alicia. And interestingly the evidence actually doesn’t show any benefit as there hasn’t been enough studies done but they have found that women reported more negative side effects including nausea and diarrhea. A few things you’d likely not want to experience before going into labour
AP: I’ve had two kids of my own so can definitely agree labour is hard enough without adding some GI upset in there. What about ‘membrane sweeping or as I like to say “The old stretch and sweep”? I think this is something most of us at GROW offer our patients after 38 weeks. Can you comment on how effective this can be?
SL: Absolutely. For those listeners who don’t know, a membrane sweep is when your doctor does a pelvic exam and passes a finger through the cervix and separates the amniotic sac or membranes from the uterus. There have been lots of studies looking into the effectiveness and it’s been show to reduce the duration of pregnancies going post-dates (beyond 41+ weeks), and therefore avoiding induction because you are overdue.
AP: That’s good to know since I know most of us offer this to patients. Did they say how many times it has to be done to be successful? Or if there were any negative side effects?
SL: I’m glad you asked. Membrane sweeping is safe and the most common side effects are bleeding and pain/cramping following the procedure, which you will also experience in early labour. And in terms of how many times, basically you need to do a membrane sweep on 8 patients to send one into spontaneous labour.
AP: I’d say that’s a pretty decent number given how many patients we see and offer this to.
SL: I agree, and it’s such a safe and low risk intervention that I think it’s reasonable to offer to all women as long as they are aware of the likelihood of going into labour and to expect to experience some bleeding and pain following.
AP: That’s what I do regularly in my practice, but good to know I’m following the evidence so I’ll keep it up!
SL: So Alicia, there is a lot more to talk about but I think we’ve covered a few key topics people would want to know about when preparing to push, wouldn’t you agree?
AP: I do! SO let’s review. First things first, we should start recommending perineal massage and will put some resources up on our show notes. Secondly, we’ll tell our patients no need to shave or go for a bikini wax and that doing so may actually increase their risk of infection and that they should ‘keep the hair down there’!
SL: Totally. Thirdly, if people are hoping to avoid going overdue we can offer our patients a membrane sweep at term to try to induce spontaneous labour and avoid women going overdue and we can also chat about using acupuncture and advise that although more studies need to be done there is some evidence of benefit when it comes to cervical ripening but that they should avoid castor oil as a means to induce labour!
AP: Well, this has been educational and informative for me and hopefully for our listeners.
SL: Me too! I really enjoyed doing the research for this and look forward to joining you to chat about another topic soon!
Alicia Power: Great! Keep on growing healthy!
Perineal Massage Info:
Pelvic Physio Victoria, BC:
We did a segment on a bit more advanced sleep training issues recently...but we thought we should do one on the basics....We are going to talk about the core principles of sleep training for your infant or toddler right after this quick reminder...
AP: Maria....Sleep...we all need it, it is such an important thing for our physical and mental health...you know how crabby and exhausted I am physically and mentally when I don't get sleep.....
MK: Yup...you are a bit of a crabster and you definetly don't preform as well at our workouts when you are dragging your butt after a long call night!!!
AP: That's for sure...and it is the same for our wee ones!! They need their sleep to be the best kiddos they can be ...and that is at the core of why we need to help them to learn this skill!
MK: Alicia, that is true. We need to remember that sleep is a skill that needs to be learnt just like, walking, talking and having good manners, and it is our responsibility as parents to help guide our children in learning this important skill. So much stuff happens when we sleep, we reconcile all we have learnt that day, we dream, our body heals itself.
AP: Not only that, when our kids sleep, we as parents usually sleep. One of the major contributors to mental health issues is lack of sleep, and that is not different in our moms and dads who are getting sleep deprived in those first months and years after they have kids. Having an infant that does not sleep, doubles the risk of depression. And at 6 months of age, 45% of moms report infant sleep problems....that is almost 1/2 of moms!!!
MK: Wow....I'm not suprised though...I have a lot of parents who feel that they are going to cause damage to their kids by "sleep training" them, or by letting them cry. They feel that their attachment to their baby will be harmed by these actions. We have to remember the bigger picture though....we spend so much time during the day, loving our kids, attending to their needs, interacting, playing and reading to them that a few minutes of crying in a 24 hour period will not cause harm. In fact there are quite a few studies out there comparing children who were sleep trained vs not and 5 years out there are no differences in the two groups, at 3 months and 2 years there are...there are benefits to sleep training in both moms and infants.
AP: It's not easy to hear your baby cry....but putting it in the context of learning a new skill....it makes it more understandable....if you child was learning to write, and getting frustrated about it...you wouldnt just say...well you don't need to learn to write....would you?
MK: Nope.....so lets get to it!!! We will chat about some generalities, that are the same regardless of what method you choose to use to help teach your child to sleep...we will then go into some of the different ways you can implement them.
AP: What is the most important thing with sleep training? The same thing with any parenting....Consistency. Kids need routine, they need to know what to expect. They need to have boundaries, which they may try to push, but that are consistent. If they don't have this, they can never learn what to do.
MK: That's right...so pick a routine and stick to it....Same time to bed at night, and same time up in the morning, also try to keep your naptimes around the same time as well. Generally speaking, around 3 months, you will notice a natural routine that your child will get into...this is generally a 3 or 4 hour cycle, of eat, play and sleep. Try to reinforce this.
AP: And then pick a bed time and nap time sleep routine. Generally the bedtime routine should be about 20-30 min long, and the nap routine 5-10 min long. As we said kids like routines, so you need to have something that you can maintain, and that can be replicated by all those taking care of your wee ones. For bedtime routines we generally recommend some combination of bath, book, feed and then put down on their back sleepy but awake. A cheery good night and out you go. Now some babies fall asleep while feeding, so if that is the case, you may want to switch the feed and book/song in the order. For a naptime you generally want to try to get your child to eat when awakening...so sleep, eat, play....so your naptime routine might be going into their room, putting them in their sleep sack etc, reading a quick book, putting them in their crib, on their back, sleepy but awake, singing a song and saying a cheerful goodnap.
MK: That is right....but lets remember different aged babies have different night time requirements....a baby that is 3-4 months of age still often needs a feed at night, but not more than two. Most 5-6 month old babies, who have been gaining weight appropriately, are able to go through the night without a feed. So, I agree we need to start working on routines, and allowing the baby to learn how to put themselves to sleep early on, but we should not be doing formal sleep training, which we are going to chat about next, until 6-8 months. For those infants who are older than 6 months and still waking to feed multiple times at night, you may need to decrease feeds at night prior to doing full on sleep training. they will naturally start eating more during the day to make up for it.
AP: exactly...but lets remind everyone...that the longer you wait to do it, the harder it can be to do!! a 6 month old, usually gets it within 2-3 nights, where as a 1 year old or 18 month old will often take closer to a week....Also I think it is important to remember that all babies and children are different, some are naturally good sleepers, and other than reinforcing routines, they don't need much help. Other children need a lot more help to learn this important skill...so stick to the basics, and it will work for most infants, but if not...get help....and we've posted a few books and local resources to contact should you need more advice. Another thing we need to remember about sleep training is that this is a team event. So all members of the household need to be on track with this for it to work....sit down with your partner, parent or friend, anyone who is willing to help you out with this and make a plan. because like we said before children need consistency....so they need to hear a consistent message between the actions of all caregivers....othrewise they will get confused. Well Maria...shall we get down to the nitty gritty of it???
MK: Yup lets do it. We will present you a couple of options, but you need to find a solution that fits your family, there are many ways to implement sleep training and not all will work in all families, so do some research and find a method that your family can implement together.
AP: We discussed bedtime routine...this needs to be manageable, and repeatable wherever you are. Kids thrive on consistency and knowing what to expect, so part of this is bonding with your child and helping them connect this routine with sleep, so they know that sleep is the next thing to come. So choose one you can do, your partner can do or any significant caregiver can do. One that you can do when you are at home or if you are travelling. Like we said generally this involves some kind of feed, book, song and cheery but quiet goodnight.
MK: Bedtime should also be relatively early for most kids in the infant or toddler stage, say somewhere between 6:30-7:30. If you wait for your child to show signs of tiredness, or let them get overtired, it often becomes much harder to get them to sleep. Some people notice that if their child naps too close to bedtime they will get harder to put to sleep, others dont notice this. So if your child is one that a later nap affects their bedtime significantly, it is probably time to cut out that night if possible in favour of an early bedtime.
AP: Sleep Environment is very important to baby's sleep. You want the room temperature to be between 19-21 celsius. If you need to put extra layers on your child because you cant control the temperature very effectively, use a sleep sack as they can not be kicked off. We need to keep loose beddings, pillows etc out of the baby's bed to make a safe sleep environment.
The room should be dark. This can be challenging to achieve at some times of years, or during nap times. Invest in a good pair of black out blinds for these times!.
Background noise can be very helpful for infants and some toddlers, having a white noise machine (or pink, rain storm etc) as it drowns out any noise from the outside world but also can remain on all night (ie not on a timer) , so if the child awakens, it is a familiar sound that they can then fall back asleep to. The goal of this is for children to be able to soothe themselves back to sleep when they wake in the night, which they will, because we all do....rather than need you to put them back to sleep.
MK: So we have set the stage for good sleep....now how do we actually make it happen...We have consistent routine, consistent dark environmnent, good white noise or fan....but a baby that is awake....
AP: Right...so now you just put the baby down, say a cheery goodnight and leave....easy as pie!
MK: HAHAHAHAHAHA.....I wish....Well that is the basics of it...but doesnt work for everyone. Lets start with putting your child down....Some say put them down drowsy but awake, others say wide awake....What is the answer? if your child is younger than 3-5 months..they can be drowsy when you put them down, but children older than that need to be a bit more awake...because those drowsy ones are have already started to enter that first stage of sleep....so technically they are not learning how to put themselves to sleep.
AP: Right...so put them down, awake and wish them a cheery good night and leave...what about soothers, blankies, stuffies etc...
MK: Well we want to try to avoid sleep props that they need to put them selves to sleep with that may not be present when they awake in the middle of the night...like a soother. If they cant get it...they will scream for you to come get it for them. So no soother. A loose blanket and stuffie in the crib is not safe when your child is young, but may be useful in those toddler years, but be sure to have a few of the same things in case one gets lost! and also make sure you rotate them so they all look worn!
AP: When you say goodnight to your infant, and leave the room, they may not be happy, and certainly may start crying to get you, their best friend to come back in and keep them company. They are smart little people, and of course want to hang out with their best friends as much as possible, but you have to remember why you are doing this...to help teach them how to learn the skill of putting themself to sleep. So the most important part of sleep training, is having a plan with your partner and sticking to it for a couple of nights at least. Or resetting your plan together if you realize your original plan is not working. But the more you do this, the more confusing it gets to your child, and the farther away from your goal you are going to get.
MK: Right...so lets talk about a few different ways you can do this.
Generally speaking, the harder they are on our souls as parents, the more efficient they are! The easier they are on our souls, the longer it takes..but that is fine, you need to be comfortable with whatever way you choose.
1) You can stay in the same room with your child, and shoosh your child to sleep with out touching them, and then when they are asleep leave the room, you can expect when your child wakes up in the middle of the night, they will need you to shoosh them back to sleep, but over a few nights, you can make the shooshing time shorter while still remaining in the room until you get to the point you do not need to shoosh and just be present in the room. You can then shorten the time you are in the room until you get to the point that you wish them a cheery goodnight and leave. I expect this process would take a couple of weeks to get to the final point.
2) You can say a cheery good night and leave. If your child starts crying you can then return in, soothe/talk/pat your childs back to reassure them that you are there and leave again. The next time you would wait a bit longer before returning. This will give some children the confidence that you are there if they need you, but also more quickly teach them the skill to put themself to sleep. Some babies get more riled up when you go in, and so this does not work for every family.
3) You can say a cheery good night and leave the room, go sit on the couch and eat some chocolate...Your child will scream the first few nights, but probably only for a couple of nights. If you have en enjoyable bed time routine, and dont get upset about things, anticipating screaming, they will still enjoy bedtime and generally will be happy to go to sleep. This method is by far the hardest on us, but generally the most efficient way. If after one week, the bedtimes are not getting easier, I would certainly try another method, as this one may not work for your child.
AP: okay, so we've talked about how to deal with the first to bed of the evening, but what about if they awaken during the night. Well depending on the age, and their need for a feed overnight you are going to do different things. Some children between 6-9 months of age still need one feed over night, they will usually sleep between 6-8 hours and then awaken for a feed then sleep another 4-6 hours. If your child, over the age of 6 months is awakening more than a couple of times a night, they do not need to feed. It is very hard, if you are breastfeeding to not feed a child during then night, they often will not settle for you if you are the breastfeeding parent, so sending the other parent in is a good idea, if it is not a feeding time. But don't run in right away, give your child the opportunity to settle themself. The older they are the more time you should give them to settle. Somewhere between 10-20 min from 6 months on. If they havent' settled you can go in and settle them, ideally without lifting them up from the crib, and then do the same routine you chose to do at the beginning of the night. Remember consistency is key. Children need to know what the rules are and they need to know what to expect.
MK: The last thing we should chat about is how much sleep infants and young children need each day. A 3 month old needs about 16-18 hours of sleep, and usually aren't awake for more than 1.5 hours at a time. A 6 month old needs about 14-15 hours and usually arent awake for more than 2.5 hours at a time. A 9 month old needs about 14 hours total, and awake time is no more than 3 hours at a time. A one year old needs about about 13.5 hours total, with awake periods being 3-4 hours at a time. A 18 month old needs about 13 hours with 1.5-3 hours of napping during the day. A 2 year old needs about 12 hours a day, with 1-2 being a nap. Sometimes kids give up naps at this stage and then get all their napping during the night, some children still continue to nap, which is fine, as long as they are not pushing back their bedtimes as a result.
Solve your child's sleep problems: Richard Ferber
Healthy Sleep Habit's Happy Child: Marc Weissbluth
Happiest Baby on the Block: Harvey Karp
Consultants (Victoria, BC):
Lets talk about sex....and all the things that can cause trouble to make it challenging for men! right after this quick reminder......
AP: The Growing Healthy Podcast and website is meant for general medical information only. this does not apply to every situation. If you have questions, or if you have received different advice please contact your health care provider.
MK: The views expressed by growing healthy and our guests are not representative of any institution with which we are affiliated.
MK: So Alicia....who would have thought sex was so complicated!!
AP: I know...so many different systems that have to come together at the same time to make an enjoyable and effective event happen! We thought we would start with male sexual dysfunction and tackle female sexual dysfunction at a later date.
MK: So I took this quote from up to date...which gives you a sense of the complexity of what we always think of as a fairly automatic thing....
"Normal male sexual function requires interactions among vascular, neurologic, hormonal, and psychological systems. The initial obligatory event required for male sexual activity, the acquisition and maintenance of penile erection, is primarily a vascular phenomenon, triggered by neurologic signals and facilitated only in the presence of an appropriate hormonal milieu and psychological mindset."
What that means is that to get an erection men need to want to, and have the proper amounts of hormones with properly functioning blood vessels and nerves....a lot to coordinate with a few areas for things to go wrong!
AP: Lets talk a bit more about normal erections. When men are younger, like teenagers, most erections are influcenced by thoughts and visual stimuli, these are called psychogenic and as men age these occur less, and erections become more as a response to touch and these are called reflex erections. Most men have nocturnal erections which occur 3-4 times a night, and most men will awaken with an erection in the morning. Nocturnal erections occur during REM sleep, and so those men who do not achieve REM sleep, for instance those who sleep fitfully or those men who are depressed may not have nocturnal erections.
Erections occur when blood flows into certain chambers in the penis and cause a certain amount of pressure that stops the flow out of the penis. And this is all controlled by a substance called nitric oxide....so you need proper blood flow and the appropriate amounts of nitric oxide. This nitric oxide proves an important factor in erectile dysfunction...so dont forget about it!
The hormone testosterone plays two roles...one back to the nitric oxide...it helps makes sure there is enough in the penis, and it increases the libido, or desire for sex.
MK: There are certainly some normal age related changes when it comes to sexual function and these include delay in erection, diminished intensity and length of orgasm and decrease force of ejaculation. It is reported that about 39% of men between 75-85 yrs of age are still sexually active.
MK: Lets talk about sexual dysfunction....and the different ways this can present...
AP: Sure... decreased Libido - this occurs in about 5-15% of men, it can be as a result of many things including medications, systemic illness, relationship challenges, alcholol and drug use, low testosterone, fatigue and depression to name a few. Many of these are manageable, so if you suffer from any of these make sure you talk to your health care providor.
AP: Erectile dysfunction: which is basically the recurrent inability to get or keep an erection that is rigid enough for intercourse. This too can happen for a variety of reasons. This certainly increases with age, often because as we age we get more of the medical conditions that can contribute to this. We know that the fitter and healthier you are the lower the risk of you having erectile dysfunction. Diabetes, obesity, smoking (it decreases your nitric oxide), high blood pressure, high cholesterol and cardiovascular disease are the highest predictors of getting erectile dysfunction. Obstructive sleep apnea is also associated with erectile dysfunction, as is prostate cancer treatment. It is so important to talk to your health care provider about erectile dysfunction, as it may be one of the symptoms of these other medical issues, that needs to be investigated and managed appropriately.
About 25% of cases of erectile dysfunction can be linked to a medication men are taking, so it is important to discuss this with your health care provider and review your medications.
MK: I imagine nerve problems such as Spinal cord injuries, or strokes can also increase the risk for erectile dysfunction
AP: yup they sure can, as can hormonal levels.
AP: Hormones, including both testosterone and thyroid can also play a role in erectile dysfunction, and erectile dysfuction can improve if low states are corrected.
MK: So when looking at treatments, we really need to identify the cause. For example, if there are significant relationship stressors or depression - those issues need to be addressed with counselling to help improve symptoms. If a man is obese and smokes and has poor health generally, hopefully optimizing all of those things will help to decrease the dysfuction. If testosterone is low, then we can consider supplementing with testosterone once all other issues have been optimized. Can we talk about our first line therapy for erectile dysfunction.
AP: Our first line medical therapy with issue with erectile dysfunction are the PDE-5 inhibitors such as Sildenafil(Viagra), vardenafil (Levitra) and tadalafil (Cialis). These all work in the same way, but have different lengths of action and some will work more quickly than others. They act to increase that Nitric Oxide we were talking about earlier....but they only work if there is interest and desire there.....and just like you see in the movies...you should not take these if you are using nitrates for heart disease or a few other medications. Please have a good review by your health care provider prior to using these medications, if you have heart problems they can cause big troubles!!!
If these medications do not work, there are vacuum devices, drugs that you can inject into your penis and penile implants.
MK: Great, so we have reviewed decreased libido, and erectile dysfunction, what is the third type of sexual dysfunction?
AP: Premature ejaculation is the last topic we are going to discuss today. This is defined as < 1-2 minutes until ejaculation with no ability to control this and distress to the man or his partner. There are a few ways to help optimize this. Most of these treatments centre around decreasing the sensation of the penis. So the first option men can try on their own is condoms. Another option which is simple is the start stop method, which basically gets men to stop the stimulation when mid level excitment is present. and restart when excitement has decreased. See show notes for more details on this. There is also a squeeze technique which is just that, squeezing the penis before ejaculation occurs to decrease the erection.
We can also try treatments with medications if these methods do not help. These are often an antidepressant or SSRI, a topical anesthetic cream or spray applied to the glans penis 5-10 min prior to intercourse to decrease the sensation and psychotherapy or counselling to improve confidence, communicaiton and thereby increase the time to ejaculation. the most beneficial is a combination of medical and psychological...which tends to be the case for most things in life!!!
MK: Well there you have it....Male sexual dysfunction.....Make sure you talk to your health care provider, it is very common and there may be some relatively simple things that can improve your ability to and enjoyment of sex. Keep on Growing Healthy!
AP: Welcome to Growing Healthy, today we are speaking with Di, a lactation consultant about what are the common issues that come up in the beginning of the breastfeeding journey, and how can you manage them. We will get to them right after this little reminder.
The Growing Healthy Podcast and website is meant for general medical information only. this does not apply to every situation. If you have questions, or if you have received different advice please contact your health care provider. The views expressed by growing healthy and our guests are not representative of any institution with which we are affiliated.
Di, welcome! Tell us a little bit about yourself…. AP: So lets talk about engoregment…what is it? and why does it happen? Di: Engorgement sure can be a surprise, the breasts can become quite a bit larger, firmer and feel uncomfortably swollen. The body is preparing for feeding the newborn throughout pregnancy and breast changes are usually noted as birth nears. Colostrum (the early milk) is present at time of baby's birth, but full milk production is waiting for the signal that babe is born. This is a hormonal signal to the brain. The placenta releases progesterone, which tells the brain that the baby is still in utero - "not born yet, don't start the full milk production yet". So the body is all set, but waiting for the delivery of the baby and the placenta and the drop in progesterone.The best analogy that I've heard from a recent course, is thinking of the placenta like the e-brake on a car...the car can be revving up, but it's not until the e-brake is released that the car can then drive on. So, baby is born, the placenta is delivered and it's a GO - the body now starts the full-on milk production. Over the next few days the volume starts to increase, the milk ducts fill and the breasts become full. This is also combined with extra fluid and therefore some swelling can happen. Thus, engorgement! Moms can help this process and try to reduce the extent of breast engorgement by feeding their babies "early and often". If we can keep up with the production of milk and the emptying of the breasts with shorter intervals in the early days, then the milk ducts hopefully won't become painfully full. AP: Are there any tips and tricks you can offer to women and their partners to help manage engoregement? If engorgement occurs, continuing to feed baby every 2 hours, cold cloths following feeds to reduce swelling and expressing the milk can be helpful. We need to be cautious with pumping or manual expression, however, that it is just to move the milk for mom's comfort and not to signal to the body to make even MORE milk. Interestingly, cabbage leaves can help alleviate engorgement. So, you peel off the leaves of a green cabbage, crush it a bit with a rolling pin and place in your bra a couple of times a day. As the cabbage wilts the components help to reduce engorgement. Use with a bit of caution, however, as it can also reduce milk supply if used more than twice a day. As with any challenges with breastfeeding, please seek help early if you're having trouble latching your baby. Sometimes, when the breasts are very full and firm, the baby may have difficulty staying latched or may slide down on the the nipple and cause pain. AP: Yes! So important to get help when you need it! and you are right about the nipple pain. Lets chat a bit more about that! For sure there is some adjustment to having a babe (or two or three) at your breast feeding frequently! Likely the number one reason that we see moms for BF help is nipple pain, and thankfully is usually is the BF challenge that we can most quickly resolve with a latch assessment. I once overheard a conversation between two women that it was advised to 'toughen up' the nipples by scrubbing them with a toothbrush ahead of time! Please do not think that there is any need to toughen up your nipples. Yes, to a certain extent it takes some 'getting use to', having your baby nurse for many hours in the day, but your nipples should not be bearing the brunt of this. Remember: babies Breastfeed, not "Nipplefeed" as they might with a bottle. Maybe we can talk more about achieving a deep latch in a moment. If you have pain with latching your baby, please seek a latch assessment by a skilled breastfeeding support person- whether that's your Doctor, Public Health Nurse or Lactation Consultant. We are all more than happy to help alleviate that pain on latching. You do not need to 'just push through and get used to it', generally if there's pain there's an issue we can help resolve. AP: Now it’s not just a latch issue that can cause nipple pain…what are some of the other reasons that this can happen? There also might be other causes for nipple pain: if it's not just a latch correction, it might be something else going on with the nipple. For instance, there might be an overgrowth in yeast. We all have yeast, or candida, on our bodies and given the right environment it can have rapid overgrowth and cause discomfort. Symptoms of yeast overgrowth, or thrush, can include a burning discomfort on the nipples and areola, shiny, red skin on the areola and even some shooting pain following feeds. Anyone who has baked bread would know that yeast loves warmth, moisture, sugar and darkness-- all of these are present with soaked nipple pads, so change them out frequently and seek treatment options from your medical care provider. Thrush is generally easy to treat in the early stages. I have often heard that yeast pain described as like someone is stabbing you with a knife through your nipple into your back….not a pleasant experience! Definitely ask for help early! Sometimes, vasospasm may occur with the nipple either by the nipple being compressed during a feed and coming out looking blanched or occurring immediately after the feed. When vasospasm occurs after the feed it is generally a result of a latching challenge or a damaged nipple. Sometimes there are other conditions present like Reynaud's phenomenon. A woman may be aware that they have Reynaud's that shows up as vasoconstriction on fingers and toes and then it is exacerbated by breastfeeding. Keeping the nipples warm following a feed is key, either by immediate covering with a warm cloth or with your baby held to the breast. If this is not enough, speak to your doctor for other treatment options. AP: Raynaud’s of the nipple is often worse in the colder months, and you are right ….warmth is very helpful. sometimes I even suggested hand warmers behind the nipple pads to provide some extra warmth!
AP: Can we talk a little more about latch? Especially in those first few days it is soooooooo important to really focus on getting the best latch you can with your baby….. Absolutely, I agree that often we meet moms who have been so excited that their baby has latched on that they will endure any pain they might feel just to keep their precious babe feeding. As we've talked about, latch is key to successful breastfeeding. Over the last couple of decades we have realized that culturally we have been trying to breastfeed babies in a bottle-feeding position (as in, cradled in our arms on their back) and often we imagine that a mom's nipple should look like a bottle nipple. But, in fact, nipples can look very different and babies are born seeking to feed in a way that doesn't look like the classic 'bundled in your arms bottling position'. Babies are instinctively driven to seek out the breast by way of using all of their senses and all of their body. It's pretty cool to watch the videos on babes crawling up to latch onto the breast themselves, and although we might not have this exact experience, it is also very cool to watch your own baby seek out the breast by bobbing their heads around at the breast and batting their little hands around to initiate the letdown reflex. AP: It is great watching these videos! Lets post some in our show notes! What we know is that babies are 'ventral feeders' meaning that they are sort of 'hard-wired' to have their chests touching mom, ideally skin to skin. They tend to feel calmer, more regulated and focused on feeding when they are 'belly to belly, skin to skin' especially with the early feeds. We also know that the depth of the latch is important for both the comfort of mom's nipples and for the best transfer of milk. So, using gravity to babe's advantage, lying back and allowing baby to fall onto the breast during a feed is more productive than sitting straight up and having babe fall AWAY from the breast and onto the nipple during a feed. This is a little hard to describe without visuals, but we encourage moms to go with their intuitive, right-brain thinking when feeding their babies. One of the most impressionable talks I've attended over the last few years was from Nancy Mohrbacher (who has written several great breastfeeding books). She says something along the lines of, "just get comfortable and feed your baby, like in a TV watching position" to her breastfeeding patients. It is both mom and baby who need to 'learn' to acheive the best latch. Mom's can go with the comfort piece: if it hurts, is pinching or they're uncomfortable, then take babe off and try again. Babies learn by the best transfer of milk: the deeper on the breast they are, the more of a reward of milk they will get. Sometimes there can be difficulties with the latch due to baby's tongue shape, mom's breast shape (particularly with engorgement) or other barriers to achieving a deep and comfortable latch- again, please seek help, ideally in person.
AP: Great! Some great tips…now we talked earlier about feeding often, especially in those first few days….Part of the reason babies need to do that is to help mom’s milk come in and to signal to mom how much milk they need! One of the most common concerns that moms have is that they won't know exactly how much milk their baby is getting when breastfeeding. They may feel anxious about not feeding their baby enough, particularly when babies want to feed VERY often in the early weeks. It is completely normal for newborns to feed every 2hours, and sometimes clusterfeed in a way that feels like 'non-stop' for a few hours in a row. This does not mean that you don't have enough milk, it's just how newborns behave. We can determine if babies are getting enough milk at the breast by both their diaper output and weight gain. So, you will be given guidelines on what to watch for with both of these. For instance, we want to see that babies are peeing frequently (6-8 times/day by the time they are a week old) and that they are gaining appropriately. Your care provider will go over what healthy weight gain should look like for your baby. If your baby is sleepy, because of jaundice, for instance, you may need to wake your baby to feed. Human milk is designed for frequent feeds, and human babies are born needing to feed on cue. Another point that Nancy Mohrbacher makes is, remember that we are CARRY Mammals. Like chimpanzees and gorillas we are meant to carry our newborns and feed them often. We are not Follow Mammals like horses where the newborn needs to walk straight away and catch-up to their mom for a feed a few times a day, or Den Mammals that leave their newborns and return a few times to offer feeds in the den. We sometimes, collectively, like to think of ourselves as den mammals with creating lovely nurseries and cribs thinking that our newborns will politely sleep there and feed by the clock every 4 hours, (LOL) but our milk and our babies are not designed this way...so, know that it is completely normal when your newborn wakes up after an hour and a half to feed again. AP: Really glad you mentioned this….I think we all want to have a predictable schedule, including feeding times, and sometimes it gets there…but certainly not at the beginning….I asked a group of women once what they wish they knew in the first few days after giving birth…and one said…that if your baby seems hungry…feed it! don’t try to stick to a 3 hour schedule! So for those parents who are struggling..what can we do to support them? Di: So glad you mention the importance of support! In regard to breastfeeding, specifically, moms can check-in with their care providers for BF assessment, book an appointment with a community professional for a BF consult (with public health or a lactation consultant). You can also connect with your local La Leche League group. Having adequate support in the early weeks is so important in general for new parents. It means, perhaps, the difference of a mom being able to spend quiet skin-skin time with their newborn, instead of needing to shop or cook. Or, being able to catch up on a bit of sleep to allow them recovery time from birth. Or, even just to be able to talk about how you are feeling and feel heard and not alone in your new parent struggles can make moms feel validated and supported. We encourage you to reach out to who you would identify as a support person. There are many community baby groups that you can attend to meet other moms, whether through Public Health, the rec centres, libraries or the monthly groups here at Grow Health. Connecting with your doctor or nurse about how you are coping is often the best way to start identifying your best supports. We are not meant to do this alone! AP: Great advice Di! It is hard to ask for help sometimes….but trust me you will not regret that you did! A little help early on in the journey can make a huge difference in your infant feeding experience, and our hope is that it makes it more enjoyable for both you and your wee one….We will put some links to resources in and around Victoria BC, so check them out….and in the meantime…..Keep on growing healthy! Victoria Public Health Units La Leche League Victoria Nursing pads Milkies milk savers Haakaa Milk saver
AK - Maria, do you remember those first few days post partum?
MK - I sure do
AK - Today's episode is all about what women wish they'd known about the first few days after having their baby. But before we get into that, just a little reminder.
MK - Alicia, I know that you are doing post-partum group visits, which I think is just invaluable. You reached out to some new mom's and here's the top 5 things they had to say about what they wish they knew about in those first few days after having their baby.
1)Breastfeeding: This is a new skill set for both mom and baby...and takes some time for both to learn. Do not get discouraged, make sure you ask for help with your latch if it is painful. Public health and at our clinic lactation consultants early on can improve the latch to help minimize damage to your nipples. Milk coming in occurs around day 2 after a vaginal delivery and 3 days after a cesarean section. It can be quite dramatic, and uncomfortable as your breasts have probably never been this large before. It also can affect latch, so make sure you ask for help if you are struggling. Some women find if they express/pump some milk off it can relieve some discomfort and make the latch a bit easier. babies vary in how much they need to eat and how often. In the early days it can take one hour to feed your baby, and they may need to eat every 2 hours. This will improve over time, as baby gets more efficient. The let down can be fierce, and you can leak that precious milk everywhere! a couple of products I have just heard about that I wish I knew about are the Haakaa or Milkies
a way to catch that milk from the opposite side that would otherwise be lost to a nursing pad....oh yes...and dont forget the nursing pads! disposable or reusable....help save some of those t-shirts! You need to keep well hydrated and eat thourhgout the day. It takes an extra 500 calories to create food for your wee little one....and all that fluid production can lead to constipation in yourself...so have lots of water around everywhere, and you may need to add a little prune juice to the mix! most women are started on stool softeners in the hosptial...make sure you keep that going for a few days!
2) Bleeding - most women bleed like a heavy period for 2-5 days and then it gradually decreases over the following few weeks, when you go home it will probably increase a little bit, but as long as it is trending downward that is fine. This is a result of your uterus cramping back down to its normal size. The release of oxytocin while breastfeeding can lead to this cramping, which in some women can be quite uncomfortable. There will be some clots passed, but as long as heavy persistent bleeding does not follow (ie soaking a pad hourly for 3-4 hours) than it is most likely normal. We recommend nothing in the vagina for 4-6 weeks, so generally means you need to wear a pad. As your flow gets lighter you may want to switch to reusable or cotton pads with out the mesh covering as it can be very irritating on an already sensitive vagina! Speaking of sensitive vaginas...yours will be sore! use a peribottle (squeeze bottle given to you in hospital) and have epsom salt soaks a couple of times a day (try this sitz bath tub). Even if you have a c/s your vagina will probably need a little tlc. When we are breastfeeding, we are not producing the estrogens that keep our vaginal tissue plump and lubricated...so it can be quite dry and irritated by the pads and the sitting for long periods of time.
3)Baby blues: you have just gone through a huge event both physically and emotionally and that can take it's toll! Also your hormones are changing significantly during the first few days after birth and you are not sleeping much. All of this added up can lead to some baby blues. Most women experience some of this. For some it is much worse. Make sure you ask for help. Try to not have too many visitors in those first few days, and if you do put them to work! If you continue to struggle with your mood past the first week, please seek help from your health care provider. This includes worry or anxiety, you are going to be worried about your baby, checking them when they are asleep to make sure they are still breathing is completely normal while you settle in to get to know each other...but if it is interfering in your ability to enjoy this time....then seek help. Add to this the huge life changes, everyone trying to give you advice, tell you you are doing things wrong can be quite overwhelming. Make a plan with your partner/support system prior to delivery about how you can communicate in a safe and respectful manner, and think about what your parenting goals are going to be for that first month, and how to plan to support each other during this challenging but amazing time! Remember you are not alone, most moms go through challenges during this time. Talk to friends, families and ask for help. postpartumconfession.com
4) Sleep: You will not sleep for more than a couple of hours at a time for the first 4-6 weeks, unless you are one very lucky momma...so sleep when you can! during the first few weeks babies sleep more during the day and are up more at night, they then start to figure out their days and nights, and as they are growing sleep for longer windows at night. If you are able to, try to get a longer chunk every few days, this requires a supportive partner or friend, and either just a quick breastfeed or pumped bottle or formula. We all need at least a 3-5 hour chunk of sleep to keep going.....
5) Focus on your priorities. The laundry can wait, take out is just fine at this point, you can scrub your floors later. Your job is to focus on your family and get things off to the best start. Get your helpers in to cook you some meals (or do it before baby and freeze them as you can). Gift certificates to restaurants are great asks for a baby shower...
Milkies Epsom Salts Sitz Bath Tub Disposable Nursing pads Reusable nursing pad Stool Softener (safe in pregnancy/breastfeeding) Cotton postpartum pads
Letter: Dr. Kang and Dr. Power, my friend was talking about having a doula at her birth. I have no idea what role a doula would play? I worry my husband would find it weird having a stranger at the delivery....could you tell me more about Doulas?
Alicia Power: Welcome to Growing Healthy, today are lucky enough to have Laura Warren from Vida Doulas on the show to tell us all about what a Doula is and what they can offer to your pregnancy, delivery and postpartum experience. Just after this little reminder.
Alicia Power: Hello Laura, and thanks for joining us. Why don’t you start off by telling us a little bit about yourself.
Laura: Hi Alicia, thank you for having me on your show. I've been a doula for almost 20 years. I'm also a childbirth educator and breastfeeding counselor, but most importantly, the mother of three amazing young women and grandmother of four incredible boys. Alicia Power: For people who don’t know what a Doula is can you give us a quick idea?
Laura:A 'birth' doula is a person trained to provide continuous physical, emotional and educational support to women before, during and immediately after labour; that's what I do. A birth doula meets with the clients once or twice before the birth to discuss options and wishes for their birth. The doula will join the couple at home or hospital when they need her. She will help with comfort measures and reassurance throughout. She will remain with them throughout their labour and one to two hours after the birth, to assist with breastfeeding. Most doulas will do one to two post natal visits.By having a doula, the partner is able to participate at his comfort level and most, actually feel more confident to participate, knowing that there is someone experienced to offer suggestions.
AP: Laura, we are trying to be evidence based in our podcasts. Have there been many studies looking at the benefits of having a doula at your birth.
LW: In 2010, Dr. Amy Gilliland did a study about effective labour support where she theorised that doulas are effective because of the attachment that clients form with their doulas. This attachment creates trust and helps in the release of Oxytocin which promotes labour contractions. In 2017, Bohren et al published and updated Cochrane review on the use of labour support. Here, they found that overall, people who received continous labour support from a doula were more likely to have spontaneous vaginal births and less likely to have any pain medication, epidurals, negative feelings about childbirth,vacuum or forceps-assisted births and cesareans. In my opinion though, the most important and effective role of the doula is to help a couple achieve the most positive birth experience possible, regardless of how they gave birth; and we do that by making sure that they exercise informed consent every step of the way, that they feel nurtured and that they are treated with utmost respect.
AP: Laura, is there formal training or a liscencing body for Doulas?
Laura: Most doulas in Victoria do their training through DONA international which is the largest certifying organization. Clients hire a doula at different times. Most, do sometime during their second trimester, but I've been hired as soon as they find out that they are expecting, and I was once hired at ten days post dates (not that I recommend that ). My recommendation is that a couple start their search early on to make sure they get the doula they want Alicia Power: What is the cost of a doula? Are there any programs that you know of that may be able to help people out who can not afford a doula?
Laura: The cost of a doula varies greatly, depending on level of experience. We'd like to think that there is a doula for everyone. Some doulas work on a sliding scale and other's (like my group) who charge the same fee, but are happy to arrange a payment plan if it makes it easier. Roughly, I would say that doula fees range between $400 and $1000 dollars. The local doula trainer, keeps a list of doulas interested in attending births to get experience. In order to access those doulas, the client must have a referral from their care provider and the cost is on a sliding scale. Alicia Power: You work as a Doula with Vida Doulas - can you tell us about why you formed a group as opposed to being doulas on your own?
Laura: We decided to form Vida doulas because we wanted to make sure that we had back ups who had similar levels of experience and commitment to the profession. We wanted to make sure our clients would receive the same level of care if their primary doula couldn't be with them. Vida is : Jay Duncan, Ashley Brilhante, Barb Fraumeni and I. Besides being 'birth' doulas, Barb is also a post partum doula, I'm a breastfeeding counselor and Ashley has a birth pool rental business. Alicia Power: What other services do you offer - I know you run a great prenatal course that I often recommend to my patients…
Laura: Yes! We appreciate all the support that Grow Health has shown VIda; thank you.Jay and I are childbirth educators with years of experience. When we started Vida, I created the 60/40 class which is a quaint, small group class that is 60% childbirth preparation and 40% newborn care. Jay teaches a similar version of this class for larger groups. We also offer private classes in the client's home and of course we offer breastfeeding consultations.
Hi, Dr. Alicia Power here, and we are lucky enough to have Natasha and Kelsey from West Coast Sleep Consultants join us on Growing Healthy today. They are going to give us a quick primer on common sleep concerns in the first few years of life. We will get to that right after this quick reminder.
Welcome Natasha and Kelsey, so excited that you could come and speak with me today. Sleep is so important for both children and their parents, and yet it is such a challenging topic for so many families out there! Can we start by learning a bit about both of you and how you ended up being Sleep Consultants, and what you feel your role is in helping families sleep?
1. Sleep props - What is a sleep prop? (good and bad, and why) - When is it okay to use a sleep prop? 2. Sleep Training - what is it? - when is a good time to sleep train? - benefits of having a consultant? 3. Toddler Sleep - Bedtimes & normal sleep amounts? - when to drop the nap?
Help!! my son has horrible eczema. he is 5 years old and if flares for no obvious reason. we use the steroid cream prescribed, which helps...but then it comes back when we stop. What can we do to treat it? is there something that might be triggering it? The poor guy is so itchy when it happens....is there something we can do to help that?
AP: Maria, what is eczema and what causes it?
MK: well Alicia, Eczema, or dermatitis is a problem with the skin as a barrier to keep moisture in and bacteria and irritatants out. Lets first talk about what normal skin does. Healthy skin cells form a barrier to the outside world, they are plumped up by water and have fats and oils surrounding them to create a protective barrier against the outside world.
In eczema the structure of skin is a bit different, you may not have as much fat and oil between those skin cells and as a result your skin cells are not as able to keep as much water inside them. They get dry and gaps in the skin form which allow more moisture to leak out and irritants and bacteria to get in.
Some people are more prone to having eczema through genetics (ie family members have it or other conditions that are commonly linked such as allergies or asthma) or their profession, or daily activities increase the risk of eczema. Common things that might increase the risk of eczema are washing hands frequently, or repeated exposure to substances that pull away those healthy oils and fats. As a result your skin barrier breaks down and becomes dry, irritated, cracked and inflamed. This damaged skin is then even more susceptible to any substances that irritate it and it worsens.
The skin changes also are associated with significant itch, which can then lead to further skin damage when people scratch this itch! What a vicious circle!
Eczema can be quite mild - day a bit of redness and itchiness behind the knees or in the elbow creases, to quite severe with red, itchy, weepy skin with crusts. It can also come and go, or be present for long periods of time and require ongoing treatment to keep it at bay!
Alicia, who gets eczema?
AP: Good question Maria! We know that 1 in 10 people will be affected by eczema. Most of these will have it before the age of 5. We also know that it can be associated with seasonal allergies and asthma. If one parent has one of these then kids are about twice as likely to get eczema, if both parents have these symptoms then it is 3-5 times more likely that the child will get it. In terms of decreasing risk, we know that early exposure to certain bacteria through day care, farm animals and having a dog at home can be protective, and decrease the risk of getting eczema.
Most cases of eczema in children will get better by the time they get through their teenage years.
Maria we know that in people who have eczema there are certain things that can make it worse or cause a flare...could you chat with us a bit about that?
MK: Sure. So anything that disrupts that skin barrier can bring on a flare or make eczema worse, and this is important to recognize for prevention and the ongoing management of eczema. Common things that can disrupt that skin barrier are soaps, bubble baths or anything else that strips those precious natural oils from our skin. Also trauma to the skin itself can increase flares of eczema - this can come from someone scratching their itchy skin, or wearing "scratchy" clothing such as wool next to skin. Also anything that increases the pull of moisture out of your skin can be a problem, these are things like low humidity and heat. Because eczema and seasonal allergies can be associated, there is always a question as to whether certain substances can cause flares of eczema. There is not great evidence that certain foods can trigger or worsen eczema, and it is important to see a doctor who specializes in allergies if you think this might be the case in your child or yourself before you eliminate it from their diet. The risk of foods triggering eczema in adults is very rare. There is some evidence that contact with dust mite and cat dander can worsen eczema in the areas that were exposed, but again, not in the majority of cases.
Alicia, Now that we know a bit more about eczema - how can we manage it.
AP: So there are a few things we can do on a daily basis as prevention for eczema in those people who have it. Some of these things we have already eluded to. Avoiding harsh soaps, fragrances and other substances that can strip our skins naturally occuring oils is a great first step. If you are having a bath, do not add bubble bath, and only use soap on your dirty bits in the last few minutes. Good options for cleansing include Cetaphil, Cera Ve and Aveeno skin cleansers. Also good if you have to wash your hands often, is to have some of these at all the sinks you use to wash your hands at, and right next to it...some good moisturizer!
AP - One of the most important things is to hydrate our skin, and in this case the goopier the hydrating cream the better! These create a better barrier to keep moisture in our skin. The commonly recommended products are thick creams such as Cera Ve and Glaxyl Base and ointment type products such as Vaseline, Aquaphor or Prevex. We should be applying these 2-3 times daily and after our skin has been wet (after a bath, washing hands etc). It is really important that we apply to wet skin, do not thouroughly dry it, and apply quickly after bath, shower or hand washing. Some people find the ointment products very greasy, so perhaps using the cream's during the day and ointment before bed may be more acceptable. Different creams and emollients work differently for people, so there is a bit of trial and error, and this may change based on the time of year as well.
Instead of using a typical soap to wash - emmolient soap substitutes such as the Cera Ve or non scented bath oil is fine. Also making sure water in our baths or showers are not too hot, as this pulls moisture out of the skin.
MK - I will add in that for babies and toddlers with very dry skin prone to eczema, I often recommend not using any soap at all. People are often taken aback by this but remember that all soaps will strip the natural moisture barrier. You still need to add in a good THICK moisturizer.
AP - Avoiding scratchy materials, such as wool, synthetics, tags and zippers that irritate the area. Avoiding excessive heat, overdressing.
MK - What about your favorite activity, Alicia? Laundry?
AP - I love laundry. For eczema and sensitive skin, remove all harsh and perfumed detergents. And try not to use dryer sheets. Anything that smells, really.
Maria, if doing these things regularly does not keep eczema at bay, what would the next steps be for managing a flare.
MK: So there are a variety of different techniques we can use to manage flares. First of all....keep up with all the preventative strategies!
In terms of managing the skin symptoms the mainstay is topical steroids. These are applied to the affected areas of the skin and help to decrease the inflammation and allow the skin to heal. Some milder options you can buy at a pharmacy are 1% hydrocortisone ointment, which you can apply twice daily to the flared area until it goes away, this may be all some people need. Remember there is a difference between cream and ointment. Ointment is thicker and will stay on longer. But it's greasy and can stain clothes. Others may have more significant flares and need a prescription based steroid for their skin. We generally recommend applying for 48 hours after a flare seems to have gone.
Occasionally eczema can get infected, and this often appears like a yellowy orange crust to the eczema, we can often manage this with a topical antibiotic, but if you think the eczema is infected, you should certainly see your health care provider to have it assesed.
For people who are getting infected eczema we also recommend 1-2 bleach baths a week, as long as there are no open areas on the skin, as a preventative measure. This is 1/4 cup of bleach in a half full (80 litres) of warm water and soak for about 10 minutes. Do not put your head under water and rinse off with warm water after, and then immediately apply your moisturizing cream or emollient to it.
Occasionally we also recommend Wet Wraps for those people with more severe eczema, these are applied over the emollient and/or steroid cream to help cool, improve moisturization and help with the itch. There is more information about this in the show notes, but certainly talk to your health care provider about this.
There are stronger topical medications then can also be applied if what we have reviewed is not effective, but most mild to moderate eczema can be managed with diligent prevention and quick treatment of the flares.
The other component to eczema is the itch...and this can be severe! Alicia, what do you generally recommend to your patients for this?
AP: In milder cases, the steroid cream itself and good moisturizing can certainly help with the itch. But some people need a bit more help, and it is really important to try to help control this itch, as we scratch itches...and this causes more damage to our skin, which will then worsen the eczema! So antihistamines such as benadryl, reactine etc can be used, and we dose these based on weight in kids, and please ensure if you are using any medication regularly in children that you use a proper measuring device, and not a kitchen spoon! There are also stronger medications that can be prescribed for the itch, so talk to your health care provider if you are still struggling.
MK: So I think that is the basics for Eczema, and of course there are some people out there struggling with severe eczema, for which they are needing oral medications to help control, but for those of you with mild to moderate eczema, we hope this helps to keep it at bay...and dont forget that eczema is a long term disease of the skin, and so it will flare if you dont use the daily preventative measures that we spoke about.
Keep on Growing Healthy!
Cera Ve Cleanser
Aveeno Soothing Cetaphil Gentle Skin Cleanser
Cera Ve Cream Aveeno Eczema Care Cetaphil Moisturizing Cream Creamy Vaseline
Aquaphor healing ointment Vaseline
AP:Well Maria....last time we spoke about preparing for pregnancy....now what about when you actually are pregnant!!!
MK: Well that is what we are talking about today...just after this quick reminder!
MK: So....where to start....mmm Iove food...what can we eat...and what should we avoid during pregnancy?
AP: Well in Canada we have pretty good food safety laws but if you want to be really safe we generally recommend fish and meats being properly cooked, avoiding deli meats (cured meats are fine if properly cooked) and making sure cheese is pasteurized.
MK: now i need a bit of pep in my step in the mornings...what about caffeine...
AP: a bit of caffeine is fine...1-2 coffee or tea a day is just fine, and also helps to keep those bowels moving...which can get a bit sluggish in pregnancy. But we should avoid pop or juice...try to stick to water and milk for your beverages. You want to try to keep weight gain to a reasonable amount....
MK: 15-25 lbs if you start at a healthy weight is what we are shooting for....
AP: now developmentally...as a pediatrician...what is your recommendation for alcohol, smoking and drugs?
MK: well we certainly emphasize risk reduction...and unfortunately we can not be 100% sure on all the answers but we certainly do know that.....
What about prescription medications in pregnancy???
AP: certainly prescription medications need to be reviewed on an individual basis, and you should certainly review these with your care provider prior to becoming pregnant if possible, or as early as possible during the pregnancy. If you do not need a medication it is probably best to not take it during pregnancy, but if a medication keeps you or your disease stable, then certainly have a discussion with your care provider sooner rather than later!
MK: we both like to exercise, what are the recommendations during pregnancy?
AP: anything you have been doing fine to keep doing. may need to modify as time goes on. Aim for at least 3-4 days a week for 30-45 min. Certain conditions which health care provider may want you to modify your activity.
Maria...when did you first see your prenatal care provider...
MK: well I was under the impression that you should reach out to your care provider as soon as you find out you are pregnant...the earlier you see them the better. It is great if you can touch base with them somewhere between 6-10 weeks pregnant. Generally they will order some screening bloodwork, get a dating ultrasound, and review options for prenatal screening - which is testing, that a couple can choose to do, to look at the risk of having a baby with a chromosomal abnormality such as down syndrome. Not every woman decides to do this, but the testing is started around 10 weeks so it is nice to have the discussion before this point should you with to!
Breast Tenderness: this is a positive sign of pregnancy, but can be more than annoying! make sure you have a good supportive bra, and you may want to sleep with a sports bra. Make sure to tell your partner what you are experiencing...as you may not want them to go near that area for a bit!!
Nausea: another good sign that you are pregnant...but annoying....some things you can try at home include eating small bits throughout the day...we tend to crave carbohydrates, but proteins are a good choice. There is an organic Gravol Ginger lozenge that can help, Sea Bandz are also a good option. Vitamin B6 10 mg three times a day is part of one of the medications (Diclectin) that we often prescribe to help.
Bloating is caused by increased progesterone, which is important in the support of early pregnancy. This pregnancy also causes loosening of our sphincters leading to more gas!! so watch out! not much to do about this....
Fatigue: the first trimester can be pretty tiring, your body is going through a lot of changes to help support the growing fetus. Give yourself a break! you will get some more energy in the second trimester. Take some time to rest when you are able, go to bed early and allow your cute little baby to grow! Dont' be too hard on yourself...these first few weeks can be pretty tough! Gravol Ginger Lozenge Vitamin B6 50 mg Sea Band Bracelet Prenatal Vitamin (inexpensive) Sleep/Nursing Bra
Dr. Kang and Dr. Power take care of both pregnant women and their babies....but we gotta start somewhere! Are you thinking of getting pregnant....Well this is the podcast for you!!
Generally women and their partners have quite a few questions about how to get their pregnancy off to the healthiest start! This podcast is to introduce us and answer these questions. Right after this little reminder!
Preparing for Pregnancy:
MK: Alicia, what are your recommendations for eating in pregnancy?
AP: there is some evidence that the diet you are eating around the time of conception can influence how your body diverts its energy to your placenta - so make sure you are eating a well balanced diet, of real food. Start taking a prenatal vitamin as soon as you find out you are pregnant, or better yet when you start thinking about getting pregnant. Maria...what about exercise???
MK: Exercise: is good! anything you have been doing, keep doing - 30-45 min 3-4 times a week.
AP: When it comes to alcohol during pregnancy, there is no safe amount of alcohol during pregnancy. Maria, what do you think about alcohol during pregnancy? MK - You are absolutely right. Most people have heard of Fetal Alcohol Syndrome or Fetal Alcohol Spectrum Disorders (FASD) and there is a broad range of effects to the baby including general size, brain size, development, learning disorders...these are lifelong problems that can affect the baby. There is no safe amount or safe time during the pregnancy to drink. And before you ask about all those women in Europe who drink during pregnancy, there are consensus guidelines out there, which means that even the European countries like France and Italy recommend avoiding alcohol during pregnancy. I looked into this and Bulgaria and the UK have come out with the guideline of no more than 1-2 units of alcohol once or twice a week. They still say that if you are pregnant or trying to get pregnant, you should avoid alcohol. This is probably has more to do with harm reduction and public health strategy. Bottom line, the earliest intervention we can promote is a healthy pregnancy and this starts with avoiding alcohol. AP: what about drugs, marijuana?
MK: This is a big topic. Drugs like heroin, cocaine and ecstasy complicate your pregnancy and can compromise blood flow to your baby. This means your baby may be very small and premature. Plus the smaller and earlier your baby is born, the more problems it can run into during those critical first few days and weeks of life. This can really affect brain development down the road. Another major problem immediately after babies are born is withdrawal. Babies will actively withdraw in the same way that adults do. They are sweaty, have high heart rates, have diarrhea, are in pain and can even have seizures. On top of that, withdrawing babies spend less time with their moms, have difficulty feeding and are hard to manage even for experienced moms and caregivers.
The effects of Mary J haven't been teased apart as much as heroin, cocaine and ecstasy but it's known as the "gateway drug". This means, that it easily paves the way for more illicit drug use. I think this is why the research is difficult to perform and to analyze, because there are not as many mom's using JUST marijuana.
The bottom line is: AVOID illicit drug use. But more importantly, if you are struggling with a drug and/or alcohol problem, please just get help. There are programs for pregnant moms who are struggling and it's not about taking your baby away. The more you seek out help and work at it, the better your baby will be in every aspect.
Get on board with a maternity care provider that you connect with. And reach out the the Addictions Outpatient Clinic - 1125 Pembroke Street here in Victoria, BC.
MK: what about health conditions? Alicia what do you normally counsel women on? AP: If you have medical conditions, it is important to be as stable as possible when you are trying to conceive - some examples of diseases that should be stable are diabetes, seizure disorders, crohn's or colitis, hypertension, kidney disease, depression and anxiety. Please tell your health care provider as soon as you think you may want to get pregnant, as certain medications are safer than others in pregnancy and so they may decide to change a medication to plan for pregnancy. Many people are on antidepressants and often ask the question about whether they should stop their medication prior to conceiving...this is a complicated question with no easy answer...but the most important part of the answer is that a stable mother is the most important thing to work towards. If your care provider is unsure, they can always ask someone who does this all the time for help. The docs at grow health are always happy to see women to discuss these issues prior to becoming pregnant!
Book an appointment with a care provider, and depending on where you live your options will be a midwife, nurse pratitioner, family doctor or Obstetrician. In Victoria bc, the options are a midwife or family doctor. We will be doing a future podcast on this topic.
MK: Now dad's also play a role in this, and probably good for them to be on the same track as future mom's. Eating healthy, exercising, stopping smoking/drugs and minimizing alcohol is always a good rule of thumb.
AP: now lets get to the nitty gritty of things....
Mk: yes indeed....what do you tell people about how to get pregnant!
AP: Basics on menstrual cycles and when to try to get pregnant. Most women have a 28 day cycle. This starts on the first day of your menstrual cycle, and ends the day before your next menstrual cycle. Most women ovulate around day 14, and the egg generally needs to be fertilized within 24 hours so I usually recommend women have intercourse on day 14, day 12 and day 16. If you really want to hedge your bets then you could add on day 10 and 18. We usually recommend 48 hours between intercourse to allow for the man's sperm to reaccumulate to a reasonable number. The majority of people, with consistent trying will be pregnant within 6 months of starting, if you are under the age of 36 and not pregnant by 6 months, it is probably a good idea to see your health care provider, if you are older than 36 years, i usually recommended seeking health advice after 3 months of unsuccesful trying.
AP: What is the latest on Zika virus and pregnancy....
MK: Current recommendations are that women consider a delay in conceiving a child for 2 months and that a male partner delay conceiving a child for 6 months after returning from travel to a Zika virus affected area.
MK - Alicia, we both get to field alot of questions about babies. Let's do a listener question:
AP - Dr. Kang and Dr. Power, my baby just turned 4 months old and my mom is telling me to start rice cereal already. This seems really young to me. When should I start trying out solids, and what should I start with. I am really worried my baby will choke.
MK - that's a common one.
AP - The WHO and CPS suggest starting solids between 4-6 months of age. General readiness signs include: 1) able to sit in chair that the infant will eat with good head control 2) interest in what family is eating and ability to take food from the front of the mouth and pull it to the back with their tongue.
MK - What do you think about holding babies in your lap and feeding solids?
AP - If they're able to hold their head up themselves that seems reasonable, but it can also get awkward to hold your baby in your lap and feed at the same time.
AP - what should parents start with?
MK - Because breast fed babies tend to run out of their iron stores by about 6 months of age, we generally recommend starting with an iron fortified cereal while your baby is learning how to process the food in their mouth. You can play around with how liquid you make the cereal as well. I like to remind parents that starting solids is practice. It's not about calorie intake. Most of that will come from breastmilk or formula, in the beginning.
You can then add in vegetables, meats and fruits slowly over time as your child get used to different substances.
MK - I get a lot of questions about food allergies and family history of allergies. What do you think parents should do in that case?
AP - If starting prior to 6 months of age we generally recommend adding one new food every three days, while continuing on with all the others they have already eaten. If starting after 6 months of age you can just add on as you like. If you have a high risk of allergies in your family, you may want to get the advice of your health care professional before you start solid foods.
We know earlier exposure to foods decreases allergies, so the only food you should avoid prior to one year of age is unpasteurized foods, such as honey and cheese.
We generally get you to start Cow's milk products such as cheese and yougurt after 9 months of age, and milk after one year of age, but other than that you can add on as you like. Please do not feed your child sugar or fruit juices, as these have no benefit and increase the risk of childhood obesity.
MK - That's a really important tip. Toddler obesity is associated with adult obesity and all the complications that are related. If you and your family don't have the best dietary habits, what a great time to start fresh. Remove those fruit juices and excessive treats from your home.
And what about water?
AP - water is great for your child, and we highly encourage starting to introduce it to your child at meals around 6-9 months of age. Using a sippy cup is great as it will also help enable your child to learn the skill of drinking from a cup.
MK - Just a word of caution here. Baby kidneys are still maturing, so too much free water (as we say) can actually be harmful. So I usually tell parents to limit their baby's daily intake of free water to 1 cup. But after 18 months or so, when your baby is more active and eating much more, you can consider increasing that.
I'm gonna bring us back to our listener questions. It sounds like they were worried about choking specifically. I know you've had experience with choking episodes. It can be a really scary thing.
AP - choking is always a concern with starting solids. Infant's choking reflex is much farther forward than adults, and so your child will at some point seem like they are choking.
It is a protective mechanism while they are learning to manage solid foods. For this reason we recommend all parents take an infant first CPR course...but the chances are you will not need to use it! Because their choking reflex is so much more forward they will probably just sputter and spit out the offending food...but always stay close by to your infant and child while they are eating, and
do not let them walk around with food, or eat in the car! You need to be able to react in a moment's notice on the rare occasion that they might need help!
MK - I've done back blows to my kids. It's so important to do an infant CPR course. You can access infant cpr courses at a variety places locally, like Mothering Touch.
So after being equipped with good knowledge on choking, you can move through the different tastes and textures as our baby tolerates them. You can experiment with more soft chunks, first larger chunks, then smaller ones, then more firm chunks as well.
AP - Family dinners are so important, to show your children how to eat, what to eat, how to act and most importantly to connect with each other at the end of the day! This is a great time to teach your children the art of communication. A great way of learning about your childs day is by the rose, the thorn and the bud!
MK - What a great reminder for parents. It's amazing to watch babies watch you!
Stay tuned, folks as we keep on....Growing Healthy.
Canadian Pediatric Society - starting solids:
World Health Organization:
Starting solids in allergic families:
AP - Skin is the biggest organ in our body, and we need to take care of it! We do this with eating healthy food, drinking lots of water and by what we put on it. Today's podcast is going to be about the basics of skin care. We will get to that, right after this quick reminder.
MK - Welcome to Skincare 101...we are going to talk about the basics we are not going to get into all fancy kinds of stuff...but if you can manage this you are in a good place! Obviously everyone has different skin types and needs and so there may be a bit of trial and error depending on your skin type and if you have any complicating factors such as eczema or acne. We will give you a few suggestions of products in each area and put links in the show notes if you are interested.
MK - Lets start by talking about a basic skin care regime - want to give big shout out to AishaMD.com where a lot of this information came from. She is an emergency physician in calgary that has a special interest in skin, and a great website!
AP - Your morning regimine should start off with a mild cleanser - such as cera ve, cetaphil or neutrogena. This is not the time to do your exfoliation, that will come in our evening routine. Next on goes the moisturizer, probably best to do a light one during the day, then sunscreen and if you choose after this would be your makeup. Certainly if you are hoping to add some more protection from the sun and environment a mineral powder make up will provide you with more protection.
MK - At the end of the day, you want to use a make up remover if you wear makeup. You then want to cleanse all the dirt of the day off of your face. This is the time that you can add in some mechanical exfoliation - use a washcloth (cheap is fine folks) to gently scrub some of those extra skin cells off. Be extra careful in the under eye are as this is a sensitive spot. You can also use a skin cleansing brush for this mechanical exfoliation. Then you want to apply your moisturizer, and this can be a bit thicker and more moisturizing for overnight and gently dab this in the under eye area so as to not damage the skin.
Some people choose to do a chemical exfoliation with fruit acids (the new fad is lactic acid) or similar products. This is also fine, but can be a bit harsher on the skin, so probably 1-2 times a week is plenty.
AP - If you are using retinoid product, then you could apply this 1-2 times a week. Not in combination with your chemical exfoliation with fruit acids though.
That is your basic skin care regimine...for your face....simple right!!
For the rest of your body, you want to use an emollient based cleanser such as Cera Ve, Cetaphil, or neutrogena to wash your hands during the day and body in the shower. After washing your hands or body, you want to make sure to moisturize quickly and frequently to maintain the hydration of your skin.
MK - This advice regarding care of your body skin also applies to babies and kids, use a gentle emollient based cleanser and good thick moisturizers to help maintain the integrity and function of their skin! I will add in that for kids with very dry skin prone to eczema, I often recommend not using any soap at all. People are often taken aback by this but remember that all soaps will strip the natural moisture barrier. You still need to add in a good THICK moisturizer.
Now that we spoke generally....lets get into the nitty gritty!
AP - Sunscreen is so important at helping to prevent the damage that is caused by ultra violet light in our skin. There are two main types of ultraviolet light that we are concerned about, UVA which are longer wavelengths and go deeper in the skin can cause premature ageing. UVB are shorter wavelengths and tend to cause more of the sunburns (although both can) and this is what we make vitamin D from. It takes about 5 min of sun exposure with shorts and t-shirt in fair skinned people to get the vitamin D we need!. Both UVA and UVB wavelengths can cause skin cancer. For these reasons, we should use sunscreen every day....every day....for day to day use SPF 30 is probably fine, but if you know you will be spending more time in the sun, and SPF of 60 is better. Also wearing wide brimmed hats, long sleeves and pants to protect agains those UV rays.
Choosing a sunscreen - you want one that covers both UVA and UVB rays. If you have dry skin, choose one that is more of a cream or ointment base, if you have oily skin or acne prone skin, you will want to choose one that has an alcohol based lotion, gel or spray.
MK - You may have heard some news about certain sunscreen products that cause significant irritation to baby skin and sensitive skin. This is a great reminder that you need to test out any sunscreen on a patch of skin before you go and lather it iall over.
AP - Applying sunscreen: none of us do this properly, we use way less than we should be using, so apply liberally, you should feel a film on your skin where the sunscreen was applied. Give it time to work, so apply about 30 minutes prior to going out in the sun, and reapply every 2 hours if you are going to be staying out in the sun. Also reapply after swimming, excessive sweating or if the sunscreen gets wiped off another way.
Retinoids are a topical substance, generally applied a couple of times a week to the face or affected area that are used to treat acne and help reduce some of the damage by the sun that shows up as ageing. It takes about 6 weeks to notice a difference with acne, and is used long term when being used for managing the signs of ageing. It is generally applied sparingly all over your face, and if you have sensitive skin wiped off after an hour or so. You can start with 1-2 times per week and as your skin gets used to it, increase the frequency and how long you leave it on. It can irritate the skin, so best to wait about 30 min after you have washed/exfoliated your skin prior to applying it if you can. As they work by peeling off the top layer of skin, they can cause some redness and irritation to your skin in the first few days to weeks of using them. If you have a severe reaction to them, they may be too much for your sensitive skin. Please be sure to use sunscreen on any skin being treated with retinoids.
We do not recommend topical retinoids in pregnancy or breastfeeding. Sunscreen for Oily Skin: Cetaphil Oil Control SPF 30 CereVe Moisturizing lotion am SPF 30 (daily) La Roche Posay Anthelios SPF 60 Skinceuticals Physical Matte Defense SPF 50 Rodan & Fields Reverse SPF 55 Sunscreen for Dry Skin: Neutrogena Healthy Defense SPF 45 Aveeno Positively Radiant SPF 30 (for daily) La Roche Posay Anthelios SPF 60 Skinceuticals Physical Defense SPF 50 Sensitive skin: La Roche Posay Toleriane ultra cleanser and serum Avene Clinderm Rodan & Fields Sooth Skin care products to avoid in pregnancy: retinoids (topical and oral) salicylic acid (glycolic acid is good option for pregnancy) Skin care lines for acne in pregnancy: La Roche Posay's Effaclar cleanser and Efflaclar Duo Spectro purplish blemish control line Reversa Solution for Acne Prone skin
Dr. Maria Kang and Dr. Alicia Power from Grow Health introduce themselves and why they started this podcast.