Too Cool for the NICU

By: Dr. Marietta Sperry, DNP, MSN, RNC-IBCLC, IBCLC

When your baby is born early,
but too good for the NICU...

"Do all babies born early need to go to the NICU?"

Some babies born between 34-37 weeks might need to go to the neonatal intensive care unit (NICU) after birth, but not all do! Many now can be cared for with mom in the regular Mother/Baby unit.

Some “transition” to life outside the womb good enough to be with you in the regular mother-baby unit. Even though they are early, and their counterparts might need a few days or even weeks before they are ready to go home, your baby may not need to go to the NICU.^1,2

"Great Pretenders"

Some babies born too early may look just like a full-term baby (born between 38-40+ weeks), but do not always act like them. They may look like they are eating well and are making great efforts. However they may lack the strength to feed well or sleep too much, which could result in weight loss. They might still have breathing problems such as not knowing how to such, swallow, and breathe in a coordinated way. Sometimes they may even get jaundiced (yellow skin) because they are not eating enough. Some of these might happen after you go home. Some may be readmitted for problems that are continuing

Characteristics of Late Preterm/Early Term Infants³

"So what should I do if my baby is born early and too good for the NICU?"

Some things you can do⁵:

1. Follow up- Check with your pediatrician at regular intervals to make sure your baby is gaining weight adequately after discharge. Notify them if something just doesn’t feel right! Typically you may be asked to return to your pediatrician within 1-2 days after discharge.
2. Don’t let your baby sleep too long, even while still in the hospital. The old adage about never waking a sleeping baby does not apply to babies born too early! Newborns should eat 8-12 times in 24 hours. Wake them up to eat if they are sleeping longer than 3-4 hours. Ask for guidance on a feeding plan tailored to your baby.
3. Follow Safe Sleep Guidelines
   https://www.nichd.nih.gov/sites/default/files/publications/pubs/Documents/NICHD_Safe_to_Sleep_brochure.pdf
4. Review with your provider the signs of adequate intake: 8-10 wet diapers a day and 2 poops a day by the end of their 1^st week. Their pee should be pale yellow and not dark or concentrated.
5. Ask questions-“Is there anything else I should know?” to your healthcare provider before hospital discharge with your "too cool to go to NICU? baby.

Want more info about early or late pre-term infants?

Follow the links below for more resources.

For more about late preterm (babies born between 34-36 weeks, and early term infants (babies born between 37-38 6/7) see the following:

"What Parents of Late Preterm (Near-Term) Infants Need to know"
https://my.awhonn.org/productdetails?id=a1B2E000008LOXeUAO

Brigham and Women’s Hospital Letter for parents of babies born between 35-37 weeks
https://www.brighamandwomens.org/assets/BWH/pediatric-newborn-medicine/pdfs/caring-for-late-preterm-infant-letter-inf-bwh-hms.pdf

Late Preterm Infants Brochure-CHI health
https://www.chihealth.com/content/dam/chi-health/website/documents/continuinged/LatePretermInfantsBrochure.pdf

Or check out these videos!

March of Dimes-Developmental milestones for premature babies
https://youtu.be/k-MrCxDLAZo

For more in-depth information geared towards healthcare providers see
Dr. Valencia Walker, MD. Late Preterm Infants
https://youtu.be/G-OlH9PfTxA

Marietta Sperry, DNP, MSN, RNC-MNN, IBCLC

Dr. Sperry is a nurse with a Doctor of Nursing Practice degree. She has over 40 years of experience in Maternal-Newborn nursing with a National Certification. She is an International Board-Certified Lactation Consultant. She obtained her DNP and Master of Nursing Education degrees from Indiana State University and is currently pursuing a Ph.D. in Nursing at the University of Utah. Her passion is improving outcomes for the Maternal Newborn population. She loves spending her spare time with her grandchildren.

References

1. Engle, W. A., Tomashek, K. M., & Wallman, C. (2007). “Late-preterm” infants: A population at risk. Pediatrics, 120(6), 1390–1401. https://doi.org/10.1542/peds.2007-2952
2. Mefford, L. C., & Alligood, M. R. (2011). Evaluating nurse staffing patterns and neonatal intensive care unit outcomes using Levine’s conservation model of nursing. Journal of Nursing Management, 19(8), 998–1011. https://doi.org/10.1111/j.1365- 2834.2011.01319.x
3. Young, P. C., Korgenski, K., & Buchi, K. F. (2013). Early readmission of newborns in a large health care system. Pediatrics, 131(5), e1538–e1544. https://doi.org/10.1542/peds.2012-2634
4. Brigham and Women's Hospital. (2016). Caring for late preterm infant [PDF]. Women's and Brigham's Hospital. https://www.brighamandwomens.org/assets/BWH/pediatric-newborn- medicine/pdfs/caring-for-late-preterm-infant-letter-inf-bwh-hms.pdf
5. Cox, Wendy-Author’s photos https://www.wendycoxphotography.com/#MTop

A Vision for Change: Revealing the Impact on Social Determinants and Overall Health

 Katie Feldner

College of Nursing PhD Student

University of Utah

 Social Determinants of Health

There is a shift in acknowledging social determinants and how they influence overall health. Social determinants of health (SDOH) reflect the environment and conditions in which people are born, live and die. Determinants can have positive or negative consequences depending on the forces which have shaped one’s daily life (Healthy People 2030).

 In context, SDOH are influenced by income and occupation, lifestyle, social behavior, community characteristics, housing and neighborhoods, discrimination and inequality, and economic situations, which are defined as determinants, social factors or needs. These factors once regarded as a secondary affliction to negative health outcomes are now being recognized as primary causative factors of chronic illnesses (Cockerham et al. , 2017).

The History of Social Factors and Health

Social factors that affect health outcomes can be linked all the way back to the 14^th century with the black plague. The black plague was a global epidemic caused by Yersinia Pestis; bacterium that was transmitted from rodents to humans. The epidemic killed over 25 million people in Asia and Europe and those of lowest socioeconomic status were predominantly affected (Cockerham et al., , 2017). Social factors, however, are not limited to infectious disease. Cardiovascular, diabetes, stroke, cancer, kidney, and pulmonary diseases serve as direct causes of chronic diseases influenced by “ More than 21-chronic diseases, 12 types of cancer, six types of cardiovascular disease, diabetes, and obstructive pulmonary disease (Cockerham et al., , 2017, p. 2, para 2). The use of tobacco products for example, has been correlated with social influence. A person who spends time with family, friends, or a spouse who actively smokes is more likely to adopt this behavior.

Western Medicine “The Quick Fix”

Traditionally, the U.S. health care system has focused on treating an illness caused by a specific disease, not the person. This is also known as the “quick fix”.  While treating an acute illness is important, adopting a holistic approach requires a different mindset. It requires clinicians to get to know their patients environmental, social, cultural, circumstances and to think about how this contributes to their overall well-being (Grubin, 2015).

Clinicians as Catalysts for Change

Clinicians play an active role in addressing SODH because they are at the frontlines of health care and important catalysts for change. They are well-positioned to support their patients in dealing with social needs and “ To raise awareness of the human cost and suffering as a result of  poverty, discrimination, violence and social exclusion. To advocate for better living conditions, reduce health inequities, and increase awareness in systems to care for those in need” (Andermann, 2016, p.4 para 6).

Addressing Social Factors

Social needs should be approached in a compassionate and caring way. Evidence suggests patients are more forthcoming about their concerns when therapeutic communication is utilized. A trusting relationship yields a more accurate diagnosis and timely interventions. Once a social need diagnosis is made it is imperative to connect the patient with supportive resources beyond the health care system (Andermann, 2016).

Addressing SODH is also a collaborative effort with communities. Public health sectors are aware resources available in the community and can aid in facilitating community based interventions. Clinical– community relationships foster relationships that can have meaningful outcomes for people with social needs (e.g., offering low-cost daycare and early childhood education opportunities, introducing violence prevention programs in schools, increasing the number of parks and green spaces, banning soda-vending machines, creating bicycle lanes or introducing farmer’s markets to combat food deserts). The earlier clinicians engage in a partnership with public health, the more impactful health promotion and disease prevention are (Andermann, 2016).  

Current Barriers and Potential Facilitators

Barriers	Facilitators
Patient Discrimination	Identify a safe space for communication Establish trust Foster a therapeutic relationship
Avoid Bias	Adopting a holistic approach to health care Adopt cultural inclusivity Role model positive behavior
Time	Empower systems to consider active vs. reactive approaches to health Anticipatory care is central to disease prevention
Deficient Knowledge in Resources	Become an active member in community Partner with Public Health officials Obtain a list of resources for referrals Advocate for ongoing training
Resistance	Influence Policy Change Be an Activist

 

References:

Andermann, A., & CLEAR Collaboration (2016). Taking action on the social determinants of health in clinical practice: a framework for health professionals. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 188(17-18), E474–E483. https://doi.org/10.1503/cmaj.160177

 Grubin, D. (2015). Defining Challenges: How Disease-Based, Doctor-Centered Medicine Is Failing Us. Retrieved on April 25^th, 2022, from: https://rxfilm.org/problems/how-diseased-based-doctor-centered-medicine-is-failing-us/

Cockerham, W. C., Hamby, B. W., & Oates, G. R. (2017). The Social Determinants of Chronic Disease. American journal of preventive medicine, 52(1S1), S5–S12. https://doi.org/10.1016/j.amepre.2016.09.010

Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved on March 31, 2022, from https://health.gov/healthypeople/objectives-and-data/social-determinants-health

Impact of COVID 19 on the delivery of palliative care for cancer patients

 Nemeh Manasrah 

PhD Student, College of Nursing 

         World Health Organization (WHO) defines palliative care (PC) as "an approach that 

improves the quality of life of patients (adults and children) and their families who are facing 

problems associated with a life-threatening illness." Its goal is to decrease and minimize the 

physical, social, and spiritual suffering associated with cancer disease signs and symptoms (1),

the WHO perceives palliative care as fundamental to human rights and as an essential aspect 

of public health. 

        The pandemic of COVID-19 brought severe suffering that negatively affected well-resourced 

countries and low-income countries, causing much harm to families, communities, 

and economic situation (2). It affected health care organizations all over the world. Low-income 

countries have a heavy load in controlling the health situation, delivering different 

health care services in a fragile health care system, decreasing readiness for the outbreak of 

the disease, shortage of medical technology, and decreased commitment to the rules and 

regulations for infection prevention protocols. (2)

         COVID-19 patients are expected to have limited access to health care services delivered at 

hospitals and to receive family care at home, with the shortage of personal protective 

equipment and decreased training. (3). The number of patients and access to health services 

providing interdisciplinary and person-centered care has decreased because of the spread of 

COVID-19. Equity issues arise in cancer patient care. (6)

         The number of patients who came to health centers for diagnosis and first treatment 

decreased because of limited access to transportation and fear of getting the disease. Many 

patients refused to come to the clinic to start their scheduled treatment. It takes a long time to 

convince patients to start their treatment or to receive palliative care. (6)

        COVID-19 arises as an obstacle and decreases the family involvement at the end of life 

care. There are many limitations, including funeral arrangements and restriction of personal 

protective supplies in some healthcare settings (3). These elements affect the psychological 

aspects of patients, their families, and healthcare workers. The burnout among healthcare 

workers, mainly nurses, increased because of their closer relationship with patients. Many 

tried to cut out their relationship with families and social relationship networks to commit to 

their work requirements (1).

         According to Buntzel et al., more than 70% of cancer patients felt unstable, and 21% 

became isolated because they were afraid of the higher incidence of the spread of COVID-19 

among this group compared to other populations. (1). The number of cancer diagnosis cases 

has been affected by COVID-19 worldwide. (1) The actual number of cancer cases in 2020 

was lower in comparison to the years before the pandemic. Screening programs were 

decreased and some treatments were also delayed or modified. The priority is to follow strict 

protocols to minimize the spread of infection.

         Rules and regulations to manage the spread of COVID-19 through closures and social 

distancing raised preeminent issues for patients and health care workers as well as the 

palliative healthcare team. Patients need to be treated without coming to hospitals or 

outpatient clinics to decrease the spread of the infection, which develops a problem in 

symptom management and time of the treatment. (1)

         COVID-19 decreases the infrastructure and staffing in the cancer services. Some 

difficulties in decision-making were taken as continuous access to the operating room for 

cancer patients who need necessary operation. Delivery of palliative care is prioritized at a 

low leading to decreased symptom management and the diminished possibility of hospital 

admission.

        According to Jane et al. 2020, a toolkit was developed by a multidisciplinary team to 

manage the situation during the pandemic. Many health care programs were also developed 

to help the clinical team to have a complete consultation. (4)

         The pandemic of COVID-19 negatively impacts the delivery of palliative care for cancer 

patients by restricting hospital visits for them, decreasing end-of-life support, and isolating 

patients at the end of life. (5)

        Health care professionals faced many challenges during the pandemic of COVID-19 as to 

how to manage the patients' emotional issues and deliver quality care for dying patients and 

their families (6). They are aware, that if they don’t follow the infection control protocol 

related to COVID-19, they will pass the infection to cancer patients. Another challenge is 

decreasing health care staffing confronted by the increasing workload in the hospitals and 

other healthcare delivery clinics due to healthcare workers testing positive for COVID-19. (6)

         In general, there is a small number of patients treated by palliative care after the spread of 

the pandemic. This can be attributed to a decreased number of referrals from the primary 

clinics, a lower number of deaths in palliative care hospitals, and diminished quality of life. 

There is a need for a palliative care network to provide optimal patient care. (1)

References:

1. Beltran-Aroca, Ruiz-Montero, R., Llergo-Muñoz, A., Rubio, L., & GirelaLópez, E. (2021). Impact of the COVID-19 Pandemic on Palliative Care in Cancer Patients in Spain. International Journal of Environmental Research and Public Health, 18(22), 11992. https://doi.org/10.3390/ijerph182211992
2. Radbruch, Knaul, F. M., de Lima, L., de Joncheere, C., & Bhadelia, A. (2020). The key role of palliative care in response to the COVID-19 tsunami of suffering. The Lancet (British Edition), 395(10235), 1467–1469. https://doi.org/10.1016/S0140-6736(20)30964-8
3. Spicer, Chamberlain, C., & Papa, S. (2020). Provision of cancer care during the COVID-19 pandemic. Nature Reviews. Clinical Oncology, 17(6), 329–331. https://doi.org/10.1038/s41571-020-0370-6
4. deLima Thomas, Leiter, R. E., Abrahm, J. L., Shameklis, J. C., Kiser, S. B., Gelfand, S. L., Sciacca, K. R., Reville, B., Siegert, C. A., Zhang, H., Lai, L., Sato, R., Smith, L. N., Kamdar, M. M., Greco, L., Lee, K. A., Tulsky, J. A., & Lawton, A. J. (2020). Development of a Palliative Care Toolkit for the COVID-19 Pandemic. Journal of Pain and Symptom Management, 60(2), e22–e25. https://doi.org/10.1016/j.jpainsymman.2020.05.021
5. Mayland, Hughes, R., Lane, S., McGlinchey, T., Donnellan, W., Bennett, K., Hanna, J., Rapa, E., Dalton, L., & Mason, S. R. (2021). Are public health measures and individualized care compatible in the face of a pandemic? A national observational study of bereaved relatives’ experiences during the COVID-19 pandemic. Palliative Medicine, 35(8), 1480–1491. https://doi.org/10.1177/02692163211019885
6. Hanna, Rapa, E., Dalton, L. J., Hughes, R., Quarmby, L. M., McGlinchey, T., Donnellan, W. J., Bennett, K. M., Mayland, C. R., & Mason, S. R. (2021). Health and social care professionals’ experiences of providing end of life care during the COVID-19 pandemic: A qualitative study. Palliative Medicine, 35(7), 1249–1257. https://doi.org/10.1177/02692163211017808
7. Motlagh, Yamrali, M., Azghandi, S., Azadeh, P., Vaezi, M., Ashrafi, F., Zendehdel, K., Mirzaei, H., Basi, A., Rakhsha, A., Seifi, S., Tabatabaeefar, M., Elahi, A., Pirjani, P., Moadab Shoar, L., Nadarkhani, F., Khoshabi, M., Bahar, M., Esfahani, F., … Malekzadeh, R. (2020). COVID19 Prevention & Care; A Cancer Specific Guideline. Archives of Iranian Medicine, 23(4), 255–264. https://doi.org/10.34172/aim.2020.07

Domestic Violence: Attention to Prevention

 Heather Brown 

PhD Student, College of Nursing

April 27, 2022

Thriving in the Present for the Future while Learning from the Past: Reflection of a religious 

woman’s journey as a Domestic Violence (DV) Survivor.

    It is hard to immediately remember the pain from the past. The pain she daily learns to leave behind 

and move forward. She continues to seek help after the violence. The emotional and physical violence 

experienced being married to abuse. Protecting children as he “disciplined”. Protecting herself silent 

unaware of being a victim. Silent not knowing how to admit “it” to her mother and father. The shame. 

Silent not knowing how to share with religious leaders and friends. The reaction. Silent not knowing 

how to seek and find help. Society. Silent believing, she is not enough. Not enough for herself, her 

family, her community, her God. She remained silent for 18 years. Why? 

                                                                                                            (Anonymous Vignette, 2022)

Definition

Domestic Violence. A person’s behavior to intimidate and/or harm another person 

to gain power and control over another. (NCADV, 2020) The original Duluth model below 

describes DV behaviors. (Salari, 2017) https://www.theduluthmodel.org/wheel-gallery/

Today

Change. Attention to the need for prevention of DV in the vignette above has been elevated as 

the Violence Against Women Act (VAWA) was voted into law on March 9, 2022. The law 

provides increased funding not only for survivors after victimization but for individuals, families, 

communities, and society to learn the necessary skills and qualities that decrease the likelihood 

of violence among women, men, and families. (VAWA, 2022)

Driving Force

Statistics. The initiative for admitting and addressing DV has increased slowly overtime despite 

glaring statistics. The National Coalition Against Domestic Violence (NCADV) 2020 survey 

reports the following data.

• An average of 20 people per minute are being physically abused equaling to 10 million people per year. 
• Nationally, 1 in 4 women and 1 in 9 men are victims of severe DV. 
• 1 in 7 women and 1 in 25 have been injured. 
• 1 in 10 women are raped. The data for men is not available.
• are provided in the 2020 National Coalition Against Domestic Violence survey. 

Paradigm

Barriers. A large reason why DV prevention has not naturally surfaced is rooted in societal 

norms such as family privacy, religion, culture, and other examples found in the World Health 

Organization Social Determinants of Health guidelines. (WHO, 2019) The Ecological Iceberg of 

Family Mistreatment model below shows how important knowledge of DV remain hidden. Only 

the tip of a DV iceberg is typically known and measured. Other critical information of DV 

remain silent and unmeasured making awareness and prevention difficult. (Salari, 2017)

https://www.researchgate.net/figure/Systems-thinking-process-iceberg-model_fig1_327262141

        I watched trying to restrain the man from the children, crying, pleading “Stop.” The 

violence raged for 18 years. The man jumped from job to job. The man controlled the 

money. What money? Bills went unpaid. Checks bounced. Surprised, I saved the car seat 

as the car was repossessed. Shocked, the home was being foreclosed. No food, we were 

hungry. The man did not allow us welfare. That could reveal “it”. How would I leave? 

What happens to me and my children? No one knew. Shame. I am not accepted, supported, 

or believed. Community. I had nowhere to turn and did not know-how. Paralyzed. 

        I privately asked my parents for help to pay the bills and buy shoes, and clothes for 

my children. Wanting me to avoid divorce they did. My children facing hunger, pushed me 

to quietly speak with my bishop for welfare, food, toilet paper, and soap. Trying to prevent 

divorce he provided welfare and paid utilities. I took the hit later from the man. 

I accepted it. 

                                                                                (Anonymous Vignette, 2022) 

Paradigm

Shift. On September 30, 2021, United States President Joseph Biden proclaimed October as 

National Domestic Violence Awareness and Prevention Month. 

“For too long, domestic violence was considered a “family issue” and was left for families 

to address in private….I call on all Americans to speak out against domestic violence and 

support efforts to educate young people about healthy relationships centered on respect; 

support victims and survivors in your own families and networks; and to support the efforts 

of victim advocates, service providers, health care providers, and the legal system, as well 

as the leadership of survivors, in working to end domestic violence.” 

https://www.whitehouse.gov/briefing-room/presidential-actions/2021/09/30/a-proclamation-on-national-domestic-violence-awarenessand-prevention-month-2021/

 The call inspires organizations (CDC, 2022) and society to take action in shifting efforts and 

resources for DV awareness and prevention. Supporting evidence is recommended by literature 

stating that programs and policy changes must occur to decrease DV for women, men, and 

families in society. (Haselschwert et al., 2011; Goodmark, 2018; Family and Youth Services 

Bureau, 2021)

    I am a female DV survivor with an urgency to bring attention to the need of awareness and 

prevention programs that promote survivors’ ability to thrive in the present for the future while learning from the past. 

                                                                                (Anonymous Vignette, 2022)

http://www.ncdsv.org/images/equalitywheelnoshading.pdf

 Resources 

https://www.youtube.com/watch?v=53RX2ESIqsM 

https://www.joinonelove.org/about/ 

https://www.joinonelove.org/

https://www.youtube.com/watch?v=8gm-lNpzU4g 

https://www.ywcautah.org/ 

https://www.cdc.gov/violenceprevention/communicationresources/pub/technical-packages.html

References

Center for Disease Control and Prevention, CDC 24/7Saving Lives, Protecting People, Violence 

Prevention, April 2022, https://www.cdc.gov/violenceprevention/about/socialecologicalmodel.html

Domestic Abuse Intervention Programs, Home of The Duluth Model, April 2022,

https://www.theduluthmodel.org/wheel-gallery/

Family and Youth Services Bureau (FYSB). The Administration for Children and Families.

(2021, November 22). Retrieved February 15, 2022, from https://www.acf.hhs.gov/fysb 

Goodmark. (2018). Decriminalizing Domestic Violence (1st ed., Vol. 7). University of California

Press. https://doi.org/10.1525/j.ctv5cg9wh

Haselschwerdt, Hardesty, J. L., & Hans, J. D. (2011). Custody Evaluators’ Beliefs About

Domestic Violence Allegations During Divorce: Feminist and Family Violence 

Perspectives. Journal of Interpersonal Violence, 26(8), 1694–1719. 

https://doi.org/10.1177/0886260510370599

National Coalition Against Domestic Violence, April 2022, https://ncadv.org/STATISTICS

National Center on Domestic and Sexual Violence, April 2022,

http://www.ncdsv.org/images/equalitywheelnoshading.pdf

ResearchGate, April 2022,

https://www.researchgate.net/figure/Systems-thinking-process-iceberg-model_fig1_327262141

Salari, S. (2017). Family Violence Across the Life Course– 2nd ed. Kendall Hunt. 

The White House Briefing Room, April 2022,

https://www.whitehouse.gov/briefing-room/presidential-actions/2021/09/30/a-proclamation-on-national-domestic-violence-awareness-and-prevention-month-2021/

The White House Briefing Room, April 2022

https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/16/fact-sheet-reauthorization-of-the-violence-against-women-act-vawa/

World Health Organization. Social determinants of health: what are social determinants of 

health? [Internet]. Geneva: WHO; [cited 2019 Dec 17]. https://www.who.int/social_determinants/en

Improving Maternal Health in the United States by Addressing Preventative Inflammatory Disorders

 Amy Mhatre-Owens

STATUS OF MATERNAL HEALTH IN THE UNITED STATES

Peer nations that have exceeded performance metrics in healthcare include Japan, Germany, France, 

Netherlands, and Switzerland where these nations did better than the United States in terms of maternal 

mortality. 

The United States has held a poor reputation regarding maternal and infant mortality, and the overall 

pregnancy-related negative outcomes are significantly higher when compared to peer countries. 1

Recommended reading - Racial Disparities in Maternal and Infant Health: An Overview

ANNUAL HEALTH CARE EXPENDITURE

OECD data indicates the United States spends similar GDP percentages on public and private 

healthcare when compared among peer countries, however, the health outcomes when compared to 

others in the OECD were drastically different. 

Further analysis of this spending identified that the United States spending is higher because the prices 

for healthcare goods and services included pharmaceuticals are much higher compared to the other 

nations 2. 

PERIODONTITS

Periodontitis is an inflammatory disease affecting the soft and hard structures supporting teeth, and 

gingivitis is often an early stage of periodontal disease when the gums become swollen and red due to 

this inflammation3. 

Caused by poor oral hygiene, this disease can be easily prevented by periodic professional cleanings by 

dentists or dental hygienists. It can also be reversed with good oral hygiene, but neglectful oral hygiene 

can cause permanent gum tissue destruction, bone resorption around teeth and tooth loss4. 

HEALTH DISPARITIES

An imbalance in accessibility and utilization of health services within the United States can be 

explained by reviewing the social determinants of health of Americans. Contributors like the place 

where people are born, live, learn, work, play, and worship, affect which health services are offered. 

These resources are powerful indictors of one’s quality of life and is a significant influencer the 

community’s quality of health5. 

BLACK MOTHERS AND BABIES ARE DISPROPORTIONATELY DISADVANTAGED

Amongst those burdened with navigating the various social determinants of health, black mothers and 

children are more likely to suffer from untreated tooth decay and complications from co-morbidities 

due to poor oral care compared to other races and ethnicities within the United States6. In addition, 

Black mothers are disproportionately more likely to succumb to pregnancy related mortality and 

morbidities. Variability in social determinants of health prevent many black mothers and children from 

having equitable quality healthcare7.

BIDEN-HARRIS ADMINISTRATION CALL TO ACTION

Vice President Harris convened a meeting with leaders in healthcare to address the rising 

maternal mobility and mortality in the United States. During this meeting which occurred on April 

13, 2022 – during Black Maternal Health Week – a historic Call to Action to improve maternal and 

infant health outcomes was announced9. The Administration has set out many goals including but 

not limited to –

•  Extension of Medicaid and CHIP coverage to a full year post-partum under the American Rescue Plan. 

•  “Birthing-Friendly” Hospital designations for those hospitals that demonstrate a commitment to improvement of maternal and infant health outcomes.

•   Commitments to advance maternal health through stakeholder engagement within the health care community.

•  Strengthening the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programs by advancing innovations to support positive maternal and child health outcomes.

•  Implementation of State Maternal Health Innovation and Implementation programs that support the development and implementation of strategies that are proven to be effective.

•   Development of maternal health best practices for providers incorporating telehealth care through remote patient monitoring, screening, and treatment for prenatal and postpartum care.

•  Investing in Doulas and doubling the Health Start doula programs by hiring, training, certifying and compensating community-based doulas. 

Recommended Reading: Fact Sheet: Biden-Harris Administration Announces Additional Actions in 

Response to Vice President Harris’s Call to Action on Maternal Health

CONCLUDING REMARKS

Periodontal disease as an inflammatory condition in pregnant women and its association with poor 

health outcomes in mothers and babies is supported by literature10-13. Clinical practice shows 

periodontitis is preventable if symptoms are detected early, and infections are mitigated quickly. 

Social determinants of health also show that pregnant women often have many barriers to 

receiving optimal attention to their oral health needs14, 15. We know that early detection and 

intervention of periodontitis requires routine and recurrent dental visits, thus encouraging pregnant 

women to maintain their preventative dental visits during pregnancy could be a way to avoid the 

proliferation of gingival disease and mitigate poor pregnancy outcomes. Highlighting this 

preventative service as a necessary mitigation practice in prenatal care could help slow down the 

poor maternal and child outcomes and support the movement toward a healthy nation in 2030. 

REFERENCES AND READINGS -

1. Nisha Kurani EW. How does the quality of the U.S. health system compare to other countries? KFF. 2021.

2. Anderson GF, Reinhardt UE, Hussey PS, Petrosyan V. It's the prices, stupid: why the United States is so different from other countries. Health Aff (Millwood). 2003;22(3):89-105. Epub 2003/05/22. doi: 10.1377/hlthaff.22.3.89. PubMed PMID: 12757275.

3. Beck JD, Papapanou PN, Philips KH, Offenbacher S. Periodontal Medicine: 100 Years of Progress. J Dent Res. 2019;98(10):1053-62. doi: 10.1177/0022034519846113. PubMed PMID: 31429666.

4. Slots J. Periodontitis: facts, fallacies and the future. Periodontol 2000. 2017;75(1):7-23. doi: 10.1111/prd.12221. PubMed PMID: 28758294.

5. Promotion OoDPaH. Social Determinants of Health 2022 [2022-04-17]. Available from: https://health.gov/healthypeople/priority-areas/social-determinants-health.

6. Disparities in Oral Health | Division of Oral Health | CDC2021.

7. CDC. Working Together to Reduce Black Maternal Mortality 2022 [cited 2022 April 17]. Available from: https://www.cdc.gov/healthequity/features/maternal-mortality/index.html.

8. Petersen EE, Davis NL, Goodman D, Cox S, Syverson C, Seed K, Shapiro-Mendoza C, Callaghan WM, Barfield W. Racial/Ethnic Disparities in Pregnancy-Related Deaths - United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2019;68(35):762-5. Epub 20190906. doi: 10.15585/mmwr.mm6835a3. PubMed PMID: 31487273; PMCID: PMC6730892.

9. @whitehouse. Fact Sheet: Biden-Harris Administration Announces Additional Actions in Response to Vice President Harris’s Call to Action on Maternal Health | The White House. @whitehouse; 2022.

10. Saadaoui M, Singh P, Al Khodor S. Oral microbiome and pregnancy: A bidirectional relationship. J Reprod Immunol. 2021;145:103293. Epub 20210219. doi: 10.1016/j.jri.2021.103293. PubMed PMID: 33676065.

11. Gil-Montoya JA, Leon-Rios X, Rivero T, Exposito-Ruiz M, Perez-Castillo I, Aguilar-Cordero MJ. Factors associated with oral health-related quality of life during pregnancy: a prospective observational study. Qual Life Res. 2021. Epub 2021/05/13. doi: 10.1007/s11136-021-02869-3. PubMed PMID: 33978891.

12. Micu IC, Roman A, Ticala F, Soanca A, Ciurea A, Objelean A, Iancu M, Muresan D, Caracostea GV. Relationship between preterm birth and post-partum periodontal maternal status: a hospital-based Romanian study. Arch Gynecol Obstet. 2020;301(5):1189-98. Epub 2020/04/11. doi: 10.1007/s00404-020-05521-6. PubMed PMID: 32274638.

13. Micu IC, Bolboacă SD, Caracostea GV, Gligor D, Ciurea A, Iozon S, Soancă A, Mureșan D, Roman A. Selfreported and clinical periodontal conditions in a group of Eastern European postpartum women. PLoS One. 2020;15(8):e0237510. Epub 20200818. doi: 10.1371/journal.pone.0237510. PubMed PMID: 32810155; PMCID: PMC7433868.

14. Dave BH, Shah EB, Gaikwad RV, Shah SS. Association of preterm low-birth-weight infants and maternal periodontitis during pregnancy: An interventional study. J Indian Soc Pedod Prev Dent. 2021;39(2):183-8. Epub 2021/08/04. doi: 10.4103/jisppd.jisppd_270_20. PubMed PMID: 34341239.

15. Tefiku U, Popovska M, Cana A, Zendeli-Bedxeti L, Recica B, Spasovska-Gjorgovska A, Spasovski S. Determination of the Role of Fusobacterium Nucleatum in the Pathogenesis in and Out the Mouth. Pril (Makedon Akad Nauk Umet Odd Med Nauki). 2020;41(1):87-99. Epub 2020/06/24. doi: 10.2478/prilozi-2020-0026. PubMed PMID: 32573481.

Navigating Uncharted Territory: Setting Sail Towards Understanding Pediatric Distress During Cancer Treatment

Christa Teller MSN, RN, OCN, CPHON

PhD Student, College of Nursing

University of Utah

WHAT IS DISTRESS?

In 2021, it was estimated that 15,590 children between the ages of 0 and 19 years old 

would be diagnosed with cancer (Cancer in children and adolescents, n.d.). It’s 

understandable that this time period can present multiple stressors for a patient and 

their family, but how can healthcare teams tell when too much is too much? What 

aspects of distress are identifiable and present an opportunity for interventions that can 

improve the quality of patient care and the patient’s symptom experience? Distress is 

normal and can occur at any point during the cancer care continuum. The National 

Comprehensive Cancer Network (NCCN) defines distress as an unpleasant experience 

that is mental, physical, social and/or spiritual in origin (Distress During Cancer Care, 

2020).

Distress can be mild, severe, or anywhere in between and can vary throughout the 

patient’s cancer care continuum. While symptoms of distress like sadness, fear, worry, 

anger, and anxiety are commonly found during specific times, such as diagnosis, it is 

the impact of unidentified, late identified, and unmet psychosocial needs that result in a 

significant impact on the quality of life and symptom experience (Distress During Cancer 

Care, 2020). The subjective nature of distress requires an individualized approach and 

not a “one size fits all” tactic to screening distress.

DISTRESS SCREENING: PROTECTION DURING THE STORM

Distress can vary from patient to patient, diagnosis to diagnosis, and moment to 

moment. So how can potentially extreme levels of distress brewing on the horizon be 

detected when distress, in general, is a common occurrence during and after a cancer 

diagnosis? In Canada, distress is recognized as the 6th vital sign, demanding to be 

frequently screened and assessed, especially among cancer patients. The NCCN 

developed the Distress Thermometer (DT) to provide healthcare teams with the ability 

to screen for distress and allow them to assess the “people part” of cancer care 

(Holland & Bultz, 2007). Each person has a level of defense or resistance, allowing 

them the ability to cope with mild to moderate distress, similar to an umbrella that keeps 

rain from overwhelming the person below. However, if that umbrella was met with more 

extreme bouts of rain, its level of protection permeable to the assault from above, the 

person below will fill the bitter sting of the storm around them. 

The NCCN published guidelines for distress screening at diagnosis and at every clinical 

touchpoint to detect distress, unmanaged distress, and identify when interventions are 

necessary. The goal of earlier identification and intervention is to improve the quality of 

life and overall outcomes in patients diagnosed with cancer (Riba et al., 2019). With a 

range from 46.2% to 65.9% of cancer patients experiencing high or extreme levels of 

distress, there is an essential need to identify and address these levels of distress to 

prevent long term effects that can negatively impact the quality of life during treatment 

and into survivorship (Peters et al., 2020). Additionally, the absence of screening and 

unmanaged allows a patient to be vulnerable to the negative aspects of mortality and 

morbidity, and a decrease in quality of life (Ercolano et al., 2018). With the protection of 

the distress thermometer and frequent screenings, healthcare teams can effectively 

screen for distress outside the times when symptoms are assumed most burdensome, 

as distress can continue to exist, even in the absence of apparent symptoms and 

symptom severity. Symptoms of distress do not need to be frequently reported or 

appear severe to result in high levels of distress for the patient (Linder, Al-Qaaydeh, & 

Donaldson, 2018). 

Currently, the American College of Surgeons Commission on Cancer (ACoS CoC) has 

standards that facilities adopt to obtain accreditation. These standards are vague and 

cast a hazy view of how healthcare teams can most effectively identify and manage 

distress in pediatric oncology patients (Optimal Resources for Cancer Care, 2021). The 

ACoS CoC offers accreditation with what appears to be more of a “one size fits most” 

approach, standing in contrast to the individualized patient-centered care known to 

provide patients with the best options for improved care, quality of life, and outcomes. 

CHANGING COURSE TO PROMOTE OPTIMAL PATIENT CARE INSTEAD OF 

ANCHORING IN ACCREDITATION

Accreditation does not equate to optimal patient care. Accreditation can be acquired by 

doing just enough, meeting the requirements while not impacting patient care, quality of 

life, and patient outcomes. Facilities that seek accreditation may unintentionally 

overlook the effects of their quest on their patients. If accreditation standards are not 

clear, well-defined, and concise, the healthcare team may not see the chance to truly 

impact patient care. Individualized patient-centered care should efficiently suggest that 

all care, including distress screenings, be personalized. Forgoing the “one size fits all” 

approach to screenings will result in individualized screenings, developed and adapted 

to each patient’s needs.

REFERENCES

Cancer in children and adolescents. National Cancer Institute. (n.d.). Retrieved February 5, 

2022, from https://www.cancer.gov/types/childhood-cancers/child-adolescent-cancers-factsheet

Distress During Cancer Care. National Comprehensive Cancer Network. (2020). Retrieved 

           April 25, 2022, from https://www.nccn.org/patients/guidelines/content/PDF/distresspatient.pdf

Ercolano, E., Hoffman, E., Tan, H., Pasacreta, N., Lazenby, M., & McCorkle, R. (2018). 

           Managing psychosocial distress comorbidity: Lessons learned in optimizing psychosocial 

           distress screening program implementation. Oncology. 32(10): 488-493.

Holland, J. & Bultz, B.(2007) The NCCN guideline for distress management: A case for making 

           distress the sixth vital sign. Journal of National Comprehensive Cancer Network. 5(1):3-7. 

Linder, L., Al-Qaaydeh, S., & Donaldson, G. (2018). Symptom characteristics among 

           hospitalized children and adolescents with cancer. Cancer Nursing. 41(1): 23-32.

           https://doi.org/10.1097/NCC.000000000000469

Optimal Resources for Cancer Care, 2020 Standards. American College of Surgeons. (2021). 

Retrieved April 25, 2022, from https://www.facs.org/Quality-Programs/Cancer/news/2020-standards-020921

Peters, L., Brederecke, J., Franzke, A., de Zwaan, M., & Zimmermann, T. (2020). Psychological 

           Distress in a Sample of Inpatients With Mixed Cancer-A Cross-Sectional Study of Routine 

           Clinical Data. Frontiers in psychology, 11, 591771. 

           https://doi.org/10.3389/fpsyg.2020.591771

Riba, M., Donoban, K., Andersen, B., Braun, I., Breibart, W., Brewer, B., Buchmann, L., Clark, 

           M., Collins, M., Corett, C., Fleishman, S., Garcia, S., Greenberg, D., Handzo, G., 

       Hoofring, L., Huang, C., Lally, R., Martin, S., McGuffey, L., Mitchel, W.,…Darlow, S. 

           (2019). Journal of the National Comprehensive Cancer Network, 17(10), 1229-1249. 

           https://doi.org/10.6004/jnccn.2019.04

 

Alex Brown

 

Diabetes and Exercise: Unspoken Knowledge

 

People with type 1 diabetes mellitus who seek advice about exercise from their healthcare provider are frustrated, confused, and consequently, may become resistant to exercise.  This enhances the stereotype that people with T1DM are reluctant to exercise and don’t want to improve their health, blood glucose management, or increase insulin sensitivity.  The gap between educating people with type 1 diabetes mellitus (T1DM) and exercise is closing at a slow rate, however, this could be much faster if healthcare professionals included the three energy systems into their diabetes education.  This paradigm shift in diabetes education could be the beginning of a new standard of care.

 

Energy Systems

Understanding the type of energy used and how the energy systems effect people with T1DM is highly critical for blood glucose levels and succeeding at any exercise.  During aerobic and anaerobic exercise, athletes can experience the three energy systems: immediate, lactic acid (glycolysis) and oxidative.  The main result that athletes want to have during performance is the ability to maximize production of adenosine triphosphate (ATP), which is found in muscle fibers and synthesized from macronutrients (carbohydrates, fats, proteins) (Antonio & Smith-Ryan 2013). 

Figure 2: Energy system interaction. Phosphagen (immediate), glycolytic (lactic-acid), mitochondrial respiration (oxidative). This graph illustrates approximately the duration and ATP output of each energy system. Source: Baker et al., (2010)

Immediate Energy System

For T1DM patients that perform in short and powerful events, the immediate energy system is used, and the system is fueled by intracellular, stored ATP and creatine phosphate (CP), which are both in muscle fiber, and are coupled together (ATP-CP).  Due to the limited amount of stored ATP and CP, the immediate system is utilized for the initial 10-15 seconds of exercise.  T1DM patients must understand that this energy system does not use glucose for performance, thereby blood glucose levels do not typically lower.  Blood glucose levels typically rise through the immediate energy system due to glucose-raising hormones (Colberg 2015).  In this energy system, people with T1DM may adjust their nutrition and insulin intake to prevent negative outcomes.

Latic Acid Energy System

            T1DM patients who perform in short and high-intensity exercises will utilize the lactic acid energy system between 10 seconds and 4 minutes.   The lactic acid system requires the use of glucose and stored glycogen to generate ATP.  During this energy system carbohydrates are consumed to activate the glycogenolytic enzyme to degrade glycogen thereby allowing available glucose to be used to produce ATP (Antonio & Smith-Ryan 2013).  In addition, skeletal muscle will intake glucose from the blood, if blood glucose is increasing.  When carbohydrates and glucose are the main fuel source, blood glucose levels typically rise for T1DM patients and will rarely lower unless exercise is prolonged (Riddell et al 2017).  When utilizing the lactic acid system, nutrition and insulin balance may be necessary to optimize performance.

Oxidative Energy System

T1DM patients who perform in lower intensity exercise such as walking, running, swimming, rowing, or cycling, and for longer than 5 minutes, they will use the oxidative energy system.  The rate of production for ATP is not as aggressive as the lactic acid system therefore ATP is generated oxidatively (Antonio & Smith-Ryan 2013).  The sources of fuel will come from two macronutrients and one periodic table element; carbohydrates (degraded to glucose), fat and oxygen.  Glucose is obtained from blood glucose, either from carbohydrates or the stored glycogen in the liver.  Fat is obtained from muscle fibers and the blood, which is from adipose tissue lipolysis (Antonio & Smith-Ryan 2013).  The main point for T1DM patients to understand when they are in the oxidative system is that this system uses blood glucose to produce ATP to sustain prolonged exercises (Figure 3).  Consequently, the patient’s blood glucose will lower from the utilization of glucose to make ATP and the amount of insulin circulating throughout the blood (Riddell et al 2017).  T1DM patients will need to adjust nutrition and insulin intake to avoid potential health hazards and optimize performance.  

Figure 3:  An illustration of the lactic acid and oxidative energy systems and how they produce ATP in the cell. Source: Antonio & Smith-Ryan (2013)

Next Steps

As more T1DM patients are becoming physically active, it is important that healthcare professionals are knowledgeable about blood glucose management strategies for athletic performance as well as “an understanding of the pathophysiology of diabetes and its nuances” (Horton & Subauste 2016).  Expanding the knowledge of healthcare providers could involve education training sessions or restructuring “continuous education credit” (CEC) courses so they are more equipped to successfully support their patients.

References

American Psychological Association (2010). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author.

Baker, J. S., McCormick, M. C., & Robergs, R. A. (2010). Interaction among Skeletal Muscle Metabolic Energy Systems during Intense Exercise. Journal of nutrition and metabolism, 2010, 1-13. https://doi.org/10.1155/2010/905612

Colberg, S. (2015). Exercise Engery Systems: A Primer.  Retrieved: http://www.diabetesincontrol.com/exercise-energy-systems-a-primer/

Horton, W. B., & Subauste, J. S. (2016). Care of the Athlete With Type 1 Diabetes Mellitus: A Clinical Review. International journal of endocrinology and metabolism, 14(2), e36091. doi:10.5812/ijem.36091

Riddell, M., Gallen, I., Smart, C., Taplin, C., Adolfsson, P., Lumb, A., Kowalski, A., Rabasa-Lhoret, R., McCrimmon, R., Hume, C., et al. (2017) Exercise management in type 1 diabetes: a consensus statement. Lancet Diabetes Endocrinol. 2017 Jan 23 Published online 2017 Jan 23. doi: 10.1016/S2213-8587(17)30014-1

Sheri R. Colberg, Ronald J. Sigal, Jane E. Yardley, Michael C. Riddell, David W.Dunstan, Paddy C. Dempsey, Edward S. Horton, Kristin Castorino, Deborah F. Tate; Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care Nov 2016, 39 (11) 2065-2079; DOI: 10.2337/dc16-1728

 

Intestinal Microbiome: A Step Toward Personalized Medicine?

 Natalya Alekhina

A hidden universe                   

Over the past decade, the research on the human intestinal microbiome has grown exponentially. The gut has transformed from the body's most underrated organ to an unexplored universe of trillions of microbial species that engage in complex interactions with one another and the human host. While much about the composition of the microbiome and the intricate mechanisms guiding the interactions between the microbiome and immune system remain unknown, an increasing amount of research studies point to the significant role intestinal microbes play in many essential bodily functions including inflammation, metabolism, and even mood.

A shifting paradigm

My initial interest in the intestinal microbiome was spiked by a brilliant and witty book by Giulia Enders eloquently titled “Gut”. Dr. Enders embarks on a captivating journey through the digestive tract exploring the microscopic processes that take place in the gut and have a very significant effect on the overall health of the organism. It turns out that gut-healthy foods are essential not only for bowel regularity but also for nourishing the right kind of bacteria in the digestive tract that can protect their host from inflammation, leaky gut syndrome, obesity, and even cancer. A whole industry that emerged around probiotics, prebiotics, synbiotics, functional nutrition, and digestive enzymes is a manifestation of the paradigm shift in how the microbiome is perceived.

Exploring the unknown

The National Institutes’ of Health Human Microbiome Project conducted between 2007 and 2016, was one of the initial attempts to understand the microbial composition of the human microbiome and to establish the connection between microbial diversity and certain chronic conditions in human hosts. Though this extensive study has shed some light on the complexity of the microbiome, many of the insights gained in the process generated additional questions. Is there such thing as a "normal" or "standard" microbiome? How do foods we eat and medications we take affect the microbial diversity of the digestive tract? Can other factors such as the host's age, gender, ethnicity, exercise habits, chronic health conditions, and diet alter the composition of the microbiome? And most importantly, can the intestinal microbiome be manipulated to improve health outcomes? Studies on fecal microbiome transplant (FMT) in patients with antibiotic-resistant Clostridium difficile colitis suggest that this is indeed possible.

What is next?                            

 

 Though FMT is an expensive and invasive procedure, it holds the promise of using microbiome manipulation as a potential avenue for the treatment of certain medical conditions. With this in mind, new intriguing avenues of microbiome research are being explored, such as the connection between microbiome composition and obesity, the role of gut bacteria in the incidence of certain cancers, the effects of the maternal microbiome on newborn's gut health, and the "gut-brain" connection to name a few. While these topics are still there for microbiome researchers to ponder, one thing appears clear: we are witnessing a paradigm shift in how the intestinal microbiome is perceived and studied, with new insights bridging the gap between research and personalized medicine.

References

Enders, Enders, J., & Shaw, D. (2015). Gut. Greystone Books.

Ideacity. (2017, August 30). Giulia Enders | The Secret Life of the Gut [Video]. YouTube. https://www.youtube.com/watch?v=BJ-C99FwRHQ

NIH Human Microbiome Project - Home. (2007). Human Microbiome Project Data Portal. Retrieved April 13, 2022, from https://hmpdacc.org/