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Burn Awareness: tips on burn prevention from the physicians and staff at UC San Diego Regional Burn Center

Did you know that 80 percent of burn injuries occur in and around the home?  The team at the UC San Diego Regional Burn Center treats thousands of children every year, often for burns that could be avoided.

“Burn injury is traumatic with both physical and psychological pain,” said Janine Dubina, RN, nursing manager at UC San Diego Regional Burn Center.  “We urge parents and caretakers to take the time to make your environment and the environment of those you love a safe place.  Together we can conquer preventable injury.” 

Burn Prevention Tips

• Turn pot handles toward back of stove. Keep long cord appliances toward back of counter.
• Keep children at a safe distance from all hot items by using playpens, high chairs, etc. Don’t cook with children underfoot.  Create a safe zone.
• Never hold an infant or child while pouring or drinking hot liquids.
• Turn water heater temperature down to 120 degrees Fahrenheit.
• Always check water temperature before placing child in tub.
• Advise your babysitter to NEVER leave your child unattended in the kitchen or bathtub.
• Put sunscreen on you and your children.
• Use safety plugs to cover electrical outlets.
• Keep a screen or glass cover over your fireplace.
• Keep matches and lighters in a locked box, out of reach of children.
• Install smoke alarms on every level and in every sleeping area of your home. Test them once a month and replace batteries when necessary.
• Always place hot items on a secure surface to avoid accidental tipping.
• Never, never bury hot barbecue coals: extinguish with water.

First Aid for Burns

• Cool small burns with water: DO NOT USE ICE.
• Do not use ointments or butter. Apply a soft, clean, dry dressing to the burned area.
• Burns that involve face, hands, feet, genitalia or major joints should seek immediate treatment at a qualified Burn Center.

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Never say diet

As we all sit back and ruefully ponder just how much food we ate at Thanksgiving (the typical holiday meal, according to the Calorie Control Council, contains a whopping 4,500 calories and 220 grams of fat), here’s one bit of news that might aid digestion: Subtracting calories doesn’t necessarily add years to your life.

A new study published in Nature reports that rhesus monkeys kept on a sharply restricted diet (30 percent less than normal) for years did not live any longer, on average, than counterparts fed  normally.

For decades, there has been a strong argument made by some scientists and others that a severely calorie-restricted diet lengthened lifespan, most notably by UCLA researcher Roy Wahlford who conducted widely publicized experiments involving mice and rats. Animals fed significantly less than normal, he reported, tended to live 30 to 40 percent longer than normal.

(The basic idea is that when animals, including humans, are confronted by a food shortage, their bodies adapt by shutting down energy-demanding processes, such as reproduction. A side benefit is that the aging process supposedly slows down too.)

Rhesus monkeys are genetically closer to humans than rodents and naturally live long lives. In the 1980s, two major studies were launched using monkeys to examine the calorie restriction/lifespan hypothesis, one at the University of Wisconsin and one at the National Institute on Aging.

In 2009, the Wisconsin researchers published their results, announcing that calorie restriction appeared to extend the monkeys’ lives – as long as deaths from non-aging-related causes were excluded. If those deaths were included, there was no extension benefit.

The NIA study essentially says there is no apparent benefit, exclusions or not. The calorie-restricted monkeys didn’t live any longer on the whole than control monkeys. They did enjoy some health benefits, but even these were mixed. Male monkeys on a restricted diet had significantly lower cholesterol levels, but not females. Fewer calories appeared to lower the incidence of cancer, but also caused a slight rise in cardiovascular disease.

How much these findings will impact the calorie restriction movement and things like the Okinawa diet remains to be seen. It appears that individual genetics and a healthy lifestyle probably play bigger – or at least comparable – roles.

“One thing that’s becoming clear is that calorie restriction is not a Holy Grail for extending the life span of everything on Earth,” lead NIA study author Rafael de Cabo told the Wall Street Journal.

A life with fewer popsicles, it seems, does not guarantee a longer life of fewer popsicles.

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BPA’s Real Threat May Be After It Has Metabolized
Chemical found in many plastics linked to multiple health threats

Bisphenol A or BPA is a synthetic chemical widely used in the making of plastic products ranging from bottles and food can linings to toys and water supply lines. When these plastics degrade, BPA is released into the environment and routinely ingested.

New research, however, from the University of California, San Diego School of Medicine suggests it is the metabolic changes that take place once BPA is broken down inside the body that pose the greater health threat.

More than 90 percent of all Americans are believed to carry varying levels of BPA exposure. 

In recent years, numerous studies have reported alarming associations between BPA exposure and myriad adverse health and development effects, from cancer and neurological disorders to physiological defects and, perhaps, a cause of childhood obesity.

Of particular concern is that BPA exposure is correlated with disruption of estrogen signaling.  The chemical’s molecular structure is similar to that of estradiol, one of the human body’s three main estrogens, suggesting that BPA binds to estrogen receptors. The estrogen receptor is designed to grab and hold estradiol and related estrogens. Disparate chemicals, however, can share some structures found in estrogens, enabling them to bind to the estrogen receptor. When that happens, problems can occur.

In binding to the estrogen receptor, BPA can disrupt the body’s endocrine or hormone system, with consequences especially worrisome for fetuses, infants and young children. Earlier this year, the U.S. Food and Drug Administration banned BPA in baby bottles and sippy cups. Its use is more broadly banned elsewhere in the world.

In new research published in the October 4 online issue of the journal PLOS ONE,  two scientists at UC San Diego School of Medicine say three-dimensional modeling suggests a metabolite of BPA – a molecule produced when BPA is metabolized or broken down by the body – actually binds to the estrogen receptor much more strongly than BPA itself. The finding could point the way to development of a new class of drugs designed to specifically inhibit excessive estrogen activity linked to disease.

According to Michael E. Baker, PhD, UCSD professor of medicine, and Charlie Chandsawangbhuwana, a graduate student in the UCSD Department of Bioengineering, several research labs have reported that BPA binds weakly to the estrogen receptor, suggesting that something else is interacting with this receptor.

In 2004, Shin’ichi Yoshihara, PhD, and colleagues at Hiroshima International University, discovered that another compound, dubbed MBP, was produced when BPA was metabolized.  MBP has a 100-fold to 1,000-fold stronger bond to the estrogen receptor than BPA. However, the structural basis for MBP’s high affinity for the estrogen receptor was not investigated further.

In their PLOS ONE study, Baker and Chandsawangbhuwana revived Yoshihara’s research by creating three-dimensional, molecular models of MBP and BPA in the estrogen receptor and matching it against the crystal structure of estradiol in the estrogen receptor. They found that MBP’s longer structure allows both ends of the chemical to interact with the estrogen receptor in a way similar to estradiol. The shorter BPA molecule contacts the receptor at just one end, resulting in a weaker connection, providing an explanation for BPA’s lower affinity for the estrogen receptor.

“In other words, MPB is basically grabbing onto the estrogen receptor with two hands compared to just one hand for BPA,” said Baker. “Two contact points makes a much stronger connection.”

Baker said the 3D modeling supports the idea “that BPA is not the endocrine disruptor culprit. Instead, MBP is one (of perhaps several BPA metabolites) that causes disruption of estrogen signaling in humans and other animals.”

He said the research points to the need to measure MBP levels in urine and blood of patients suspected of BPA-mediated health effects, and may fuel development of a new therapeutic treatment for conditions linked to excessive estrogen levels and activity, such as some forms of breast and prostate cancers.

“One could use MBP, which has a novel structure, as a template to develop a new class of chemicals that could bind to the estrogen receptor with high affinity,” Baker said. “The goal would be to have these chemicals inhibit the action of estradiol instead of activating the estrogen response. These chemicals could control unwanted growth of estrogen-dependent tumors.”

Image: Contacts between the ends (red) of estradiol and the estrogen receptor are critical for biological activity. BPA is too short to have both contacts; MBP is longer and can mimic the sex hormone estradiol in the estrogen receptor.

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While the phenomenon of postpartum depression has received increased attention and research over the last decade, less is known about prenatal depression – the sense of hopelessness, fear and anxiety that can afflict women during their pregnancy.

The condition isn’t uncommon – it occurs in roughly 10 percent to 15 percent of women, about the same prevalence rate as postpartum – but hasn’t yet achieved common conversation. Experts say many obstetricians are not well-trained in recognizing it or treating it. Indeed, prenatal depression seems counterintuitive: Aren’t would-be mothers supposed to be happy, glowing with life and anticipation?

We asked Kathryn Hirst, MD, a reproductive psychiatrist and director of the UC San Diego Maternal Mental Health Clinic, to discuss the sometimes daunting mental trials some women experience in the months before becoming mothers.

Q: Why is so little known about prenatal depression?

A: The most important reason is that there is a significant stigma associated with depression during pregnancy, likely even stronger than that associated with depression during other periods of a woman’s life. People are expected to react to a pregnancy with joy and excitement, so when a pregnant woman is depressed, she often feels socially isolated and has difficulty talking about it with other people.

Women with prenatal depression are also at very low risk for suicide, but that risk increases in postpartum depression. The tragic outcome of a mother committing suicide receives a large amount of media coverage and societal attention, and may be another reason that postpartum depression is talked about more often.

Q: How does prenatal depression differ from postpartum? Does it have a different underlying biology?

A: Prenatal depression does not differ biologically from postpartum depression for most women. However, there does seem to be a very small group of women who have significant mood changes in response to hormone fluctuations, so have more severe premenstrual symptoms and can also have more severe postpartum depressive episodes. Their postpartum episodes tend to begin within the first few weeks postpartum in response to the dramatic drop of hormones that occurs after delivery. Women with this kind of hormone sensitivity are often more stable during pregnancy because (despite the myths) hormones are relatively stable during that time; they don’t increase or decrease as rapidly as they do during the menstrual cycle or immediately after delivery.

It is important to keep in mind, however, that most women with depression during pregnancy or postpartum are not those with sensitivity to hormone change, but rather those who have a history of depression at another time in their lives, a family history of depression or other mental illness, or severe stressors that can precipitate a depressive episode. Some women suffer from prenatal depression without any of the risk factors discussed.

Q: Many women who take medication for depression stop use before or during a planned pregnancy, thinking this will be better for their unborn baby. Is this assumption correct? What are the upsides and downsides of remaining on a prescribed antidepressant like Prozac or Zoloft during pregnancy?

A: A good question with a very complex answer. Every woman is different, so every discussion of the risks and benefits of using or not using medications is slightly different.

However, every woman should consider both the risks of staying on medication during pregnancy and the risk of untreated depression during pregnancy. Most people think only about the risk of medication exposure in pregnancy, but depression is another type of exposure that has also been associated with negative outcomes, such as lower birth weight, preterm delivery, preeclampsia and changes in babies and children’s behaviors.

The most common group of medications used for depression – selective serotonin reuptake inhibitors – is also the most studied class of medicine in pregnancy and does not appear to cause a pattern of birth defects that would make the medications teratogenic (adversely affecting the growth or development of an embryo or fetus).

There are some risks associated with taking the medication in third trimester, but a woman may consider those risks large or small depending on how severe her depression has been in the past – how much it affects her relationships, work and life.

The most important piece of advice for any woman with prenatal depression who is contemplating medication during pregnancy is use a reputable source when looking up information on medication. The best place for most women is California Teratogen Information Service, which has a toll-free number, 800-532-3749, and an excellent website: ctispregnancy.org.

Finally, it is extremely important to include talk therapy in any treatment plan for prenatal or postpartum depression. Talk therapy can be more important than medication, especially for women who have not required medication for depression in the past.

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Carpal tunnel syndrome: a Q & A with Reid Abrams, chief of hand and microvascular surgery

Carpal tunnel syndrome (CTS) is not a modern affliction. It has plagued workers since at least the Industrial Revolution and the dramatic rise in jobs requiring repetitive, physically stressing movements, from assembly-line workers to meat-cutters and machine operators.

There may be fewer of those jobs these days, but plenty of other ways to develop CTS, from dental hygienists and supermarket cashiers to bank tellers and baseball pitchers.

Women are three times more likely to develop CTS than men, according to the National Institutes of Health, though the reasons are unclear. Evidence suggests 3 percent of women and 2 percent of men will be diagnosed with CTS during their lifetime. Age is major risk factor. Peak prevalence for CTS occurs in women older than 55.

Researchers have been studying CTS and other repetitive stress injuries for years, with clinical trials focusing on preventative measures and behaviors. We asked Reid Abrams, MD, professor of clinical orthopedic surgery at UC San Diego and chief of hand and microvascular surgery at the UC San Diego Medical Center, to talk about what’s known about CTS and how best to treat it.

Q: What is carpel tunnel?

A: The carpal tunnel is an oval-shaped canal at the base of the palm, about 1 ½ inches long and an inch wide. The tunnel is surrounded on three sides by bone and on the palm side by a thick ligament. All of the flexor tendons that control the fingers and thumb run through the tunnel, plus the median nerve. This is the nerve responsible for sensation in the thumb, index, middle and half of the ring finger, plus motor function for most of the muscles at the base of the thumb.  CTS is what happens when the median nerve becomes compressed.

Q: How do you know you have CTS?

A: The condition produces a constellation of symptoms, including intermittent or constant numbness or tingling in the thumb, index, long and ring fingers. There can be hand numbness, tingling or burning at night, which awakens patients; swelling or stiffness in the hand; grip weakness; a tendency to drop things.

Not all hand pain is caused by CTS. If the pain is not associated with hand tingling or numbness, it’s not CTS.  Also, not all hand tingling or numbness is CTS.  Other nerve problems originating in the hand, forearm, elbow, shoulder or neck can also cause these symptoms.

Q: What causes it?

A: CTS occurs when there is abnormally high pressure on the median nerve, so high that the nerve can’t function. That pressure can be the result of an injury that produces sudden swelling, like a wrist fracture, or something else in the canal crowding the nerve, like an engorged blood vessel or intruding muscle.

Most often, the cause is idiopathic or unknown. It’s often activity-related because the dimensions of the carpel tunnel change with different positions of the wrist and fingers. Activities such as driving, tightly holding a book or newspaper while reading, jobs that entail sustained periods of wrist flexion or extension while gripping or pinching, such as maneuvers performed by a dental hygienist, mechanic or construction worker, can bring on symptoms. Some summer activities can set off CTS, such as carrying a surfboard for long distances, cycling or racket sports.

It’s a myth that keyboard use causes CTS. It’s been shown that intense keyboard users have the same incidence of CTS as the general population. This is not to say that symptoms of CTS can’t be brought on by keyboard use. If keyboarding is performed in a non-ergonomic fashion, with the wrists in hyper-flexion or extension, CTS symptoms could arise.  Keyboarding can also be responsible for painful problems other than CTS.

Q: How is CTS treated?

A: In the mildest forms, keeping the wrist straight or wearing a splint at night may completely relieve symptoms. Avoiding extreme wrist positioning and repetitive or sustained heavy pinching and gripping can help. Cortisone injections into the carpal canal can also provide temporary relief, though severe CTS usually requires surgery.

Carpal tunnel release surgery enlarges the carpal canal by cutting the transverse carpal ligament.  We know the ligament heals with the canal 25 percent bigger. It’s highly successful with rare complications, failures or recurrences.

There are two basic techniques; both work. Endoscopic is done through one or two small incisions using a visualizing camera and a specialized small blade. It produces a modestly faster return to work, but has a three-fold higher incidence of transient median nerve injury. Open surgery through an incision in the palm has a slightly higher incidence of wound healing problems. 

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When macrophages take up massive amounts of cholesterol they form “foam cells,” characterized by multiple lipid droplets (stained red). Image courtesy of Marten Hoeksema, University of Amsterdam.

New Way of Fighting High Cholesterol Upends Assumptions

Atherosclerosis – the hardening of arteries that is a primary cause of cardiovascular disease and death – has long been presumed to be the fateful consequence of complicated interactions between overabundant cholesterol and resulting inflammation in the heart and blood vessels.

However, researchers at the University of California, San Diego School of Medicine, with colleagues at institutions across the country, say the relationship is not exactly what it appears, and that a precursor to cholesterol actually suppresses inflammatory response genes. This precursor molecule could provide a new target for drugs designed to treat atherosclerosis, which kills tens of thousands of Americans annually.

The findings are published in the September 28, 2012 issue of Cell.

Lurking within our arterial walls are immune system cells called macrophages (Greek for “big eater”) whose essential function is to consume other cells or matter identified as foreign or dangerous. “When they do that, it means they consume the other cell’s store of cholesterol,” said Christopher Glass, MD, PhD, a professor in the Departments of Medicine and Cellular and Molecular Medicine and senior author of the Cell study.  “As a result, they’ve developed very effective ways to metabolize the excess cholesterol and get rid of it.”

But some macrophages fail to properly dispose of the excess cholesterol, allowing it to instead accumulate inside them as foamy lipid (fat) droplets, which gives the cells their particular name: macrophage foam cells.  

These foam macrophages produce molecules that summon other immune cells and release molecules, signaling certain genes to launch an inflammatory response. Glass said conventional wisdom has long assumed atherosclerotic lesions – clumps of fat-laden foam cells massed within arterial walls – were the unhealthy consequence of an escalating association between unregulated cholesterol accumulation and inflammation.

Glass and colleagues wanted to know exactly how cholesterol accumulation led to inflammation, and why the macrophages failed to do their job. Using specialized mouse models that produced abundant macrophage foam cells, they made two unexpected discoveries that upend previous assumptions about how lesions form and how atherosclerosis might be more effectively treated.

“The first is that foam cell formation suppressed activation of genes that promote inflammation. That’s exactly the opposite of what we thought happened,” said Glass. “Second, we identified a molecule that helps normal macrophages manage cholesterol balance. When it’s in abundance, it turns on cellular pathways to get rid of cholesterol and turns off pathways for producing more cholesterol.”

That molecule is desmosterol – the final precursor in the production of cholesterol, which cells make and use as a structural component of their membranes. In atherosclerotic lesions, Glass said the normal function of desmosterol appears to be “crippled.”

“That’s the next thing to study; why that happens,” Glass said, hypothesizing that the cause may be linked to overwhelming, pro-inflammatory signals coming from proteins called Toll-like receptors on macrophages and other cells that, like macrophages, are critical elements of the immune system.

The identification of desmosterol’s ability to reduce macrophage cholesterol presents researchers and drug developers with a potential new target for reducing the risk of atherosclerosis.

Glass noted that a synthetic molecule similar to desmosterol already exists, offering an immediate test-case for new studies. In addition, scientists in the 1950s developed a drug called triparanol that inhibited cholesterol production, effectively boosting desmosterol levels. The drug was sold as a heart disease medication, but later discovered to cause severe side effects, including blindness from an unusual form of cataracts. It was pulled from the market and abandoned.

“We’ve learned a lot in 50 years,” said Glass. “Maybe there’s a way now to create a new drug that mimics the cholesterol inhibition without the side effects.” 

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Eating Your Way Healthy: how diet and exercise can help you fight cancer

Recent reports on NPR and MSNBC are highlighting the benefits of healthy eating and exercise for cancer patients based on several new research papers. The Healthy Eating & Living Program at UC San Diego Moores Cancer Center has promoted healthy eating since conducting the Women’s Healthy Eating & Living (WHEL) Study between 1995 and 2006. 

We’ve asked Vicky Newman, MS, RD, associate clinical professor in the UC San Diego School of Medicine’s Department of Family & Preventive Medicine three questions about how nutrition can affect cancer patients.

Question: How far ahead of the American Cancer Society’s recommendations was the Healthy Eating Program?

Answer: The UCSD Healthy Eating & Living Program has been helping cancer patients change to a healthier diet since 1995.  While the primary focus of the WHEL Study was on diet, the focus of the Healthy Eating & Living Program has broadened to include exercise and weight control as all of these lifestyle factors are increasingly being shown through research to influence risk of breast cancer recurrence. 

Q: In the MSNBC article, Dr. Kucuk of Emory University states that when it comes to dealing creating a course of treatment for cancer patients “Usually the last thing on their (the doctor’s) mind is to talk about diet and exercise.”  At what point do patients at Moores Cancer Center enter The Healthy Eating Program – is it an integral part of their treatment plan?

A: At Moores, patients are encouraged to attend an introductory lecture offered each month called “Fighting Cancer with Your Fork.”  Participants learn about dietary factors that strengthen the body’s immune and detoxification systems, and are provided with practical tips for optimizing intake of protective plant foods with BIG color and STRONG flavors because these contain the most plant protectors. Moores patients are also encouraged to attend monthly cooking classes in our Healing Food Kitchen where they learn to prepare and are able to taste delicious health-promoting recipes.  During treatment, patients are encouraged to consult with the Oncology Dietitian.  And after treatment, patients are encouraged to enroll in our Healthy Eating & Living Program, which provides the support and guidance of their own personal coach by telephone to help them make long-term changes to a healthier diet and more active lifestyle that will not only support their health, but also help them to maintain a healthy weight.

Q: What advice do you have for someone facing a cancer diagnosis about where to begin thinking about their diet and exercise?

A: The literature clearly shows that a healthy diet and regular physical activity are both important in reducing the risk of recurrence, and in supporting quality of life during treatment so the best advice is to begin working toward the diet and physical activity guidelines right away.  Just remember, slow and steady in the right direction.  This is where coaching can really help in setting short-term, attainable goals that are reachable and then to keep building on those.  If you are at three vegetable servings daily, make a goal to get to four servings.  When you have adjusted to that goal, consider increasing the goal to five vegetable servings daily.  And begin adding BIG color and STRONG flavor vegetables and fruits as soon as possible because these are the ones with most health-promoting benefits. 

With regard to exercise, think of wearing a pedometer.  Start by recording usual steps daily.  Set a goal for increasing your daily steps by 1,000 daily until you get to the 10,000 steps recommended.  Even if fatigued during treatment, move as much as possible.  Just walking around the house during each commercial break from your favorite television program is better for your body than continual sitting.  And some very interesting research is being reported showing the health benefits of many small bouts of exercise being even more protective of health than sitting all day and only exercising vigorously once.

For more information on our research, programs, and services, visit our website www.healthyeatingucsd.org

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How Infectious Disease May Have Shaped Human Origins
Inactivation of two genes may have allowed escape from bacterial pathogens, researchers say

Roughly 100,000 years ago, human evolution reached a mysterious bottleneck: Our ancestors had been reduced to perhaps five to ten thousand individuals living in Africa. In time, “behaviorally modern” humans would emerge from this population, expanding dramatically in both number and range, and replacing all other co-existing evolutionary cousins, such as the Neanderthals.

The cause of the bottleneck remains unsolved, with proposed answers ranging from gene mutations to cultural developments like language to climate-altering events, among them a massive volcanic eruption.

Add another possible factor: infectious disease.

In a paper published in the June 4, 2012 online Early Edition of The Proceedings of the National Academy of Sciences, an international team of researchers, led by scientists at the University of California, San Diego School of Medicine, suggest that inactivation of two specific genes related to the immune system may have conferred selected ancestors of modern humans with improved protection from some pathogenic bacterial strains, such as Escherichia coli K1 and Group B Streptococci, the leading causes of sepsis and meningitis in human fetuses, newborns and infants.  

“In a small, restricted population, a single mutation can have a big effect, a rare allele can get to high frequency,” said senior author Ajit Varki, MD, professor of medicine and cellular and molecular medicine and co-director of the Center for Academic Research and Training in Anthropogeny at UC San Diego. “We’ve found two genes that are non-functional in humans, but not in related primates, which could have been targets for bacterial pathogens particularly lethal to newborns and infants. Killing the very young can have a major impact upon reproductive fitness. Species survival can then depend upon either resisting the pathogen or on eliminating the target proteins it uses to gain the upper hand.” More here

In the above photo, Escherichia coli bacteria, like these in a false-color scanning electron micrograph by Thomas Deerinck at UC San Diego’s National Center for Microscopy and Imaging Research, cause a variety of often life-threatening conditions, particularly among the young. Varki and colleagues suggest a genetic change 100,000 or so years ago conferred improved protection from these microbes, and likely altered human evolutionary development.

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Don’t Get Burned by Sunscreen Label Delay

Today, June 18, 2012, was the original FDA deadline for sunscreen manufacturers to update their labels.  Now, those companies have a little extra time.  Manufacturers said they needed more than one year to change the labels and warned that there may be sunscreen shortages if the new labels were to go into effect today.  The FDA pushed back the “new label” implementation date to December 2012.  Smaller companies, with less than $25,000 in sales, will have until June 2013.  

According to Greg Daniels, MD, PhD, clinical coordinator for the melanoma program at UC San Diego Moores Cancer Center, here are the key “things to know” about sunscreen and labels:

• Labels with the phrase “Broad Spectrum” must block both UVA and UVB rays.
  Terms such as “sunblock,” “waterproof,” and “sweatproof” will no longer be allowed.
• SPF50 is the highest allowed sun protection factor.  Anything higher than 50+ is considered unrealistic.
• Sunscreens with an SPF lower than 15 must include this warning:
  “This product has been shown only to help prevent sunburn, not skin cancer or early skin aging.” 
• New labels must explain how often the sunscreen should be reapplied. 

Image source: NPR

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In recent years, the popularity of doulas – women who assist and support mothers-to-be through childbirth – has markedly risen. In 1994, according to Doulas of North America International, there were 31 certified doulas in the United States. Today, there are more than 2,000 certified by DONA and other doula associations.

The growth is fueled in part by the demand and need for different birthing options and experiences. Research suggests doulas can provide significant health benefits to mother and newborn – and some insurance companies have begun to reimburse for doula fees.

Still, it’s probably safe to say most people don’t know what exactly a doula does, particularly in a hospital maternity room that may already be crowded with doctors, nurses and family members.

We asked Ann Fulcher, program manager of the University of California San Diego Hearts & Hands Volunteer Doula Program, which provides free services to families at the UC San Diego Medical Center in Hillcrest, to explain what doulas do and why.

Question: What’s the difference between a doula and a midwife?

Answer: Doulas often get linked with midwives because of the perception that they both serve only women who want a certain kind of prenatal care and birth experience that avoids medical interventions, including pharmaceutical pain management like epidurals. That perception is incorrect for both doulas and midwives.

Doulas are trained to provide nonmedical supportive care. Midwives are licensed health care providers who offer a full spectrum of well-woman care including prenatal and postpartum health care. They are experts in normal childbirth, including vaginal births after a previous cesarean, and other certain situations that require a somewhat higher level of medical care. Certified nurse-midwives working in hospitals, who write many kinds of prescriptions, including orders for pain relief drugs, are ultimately responsible for the health and well-being of mother and baby.

The hallmark of doula care is the continuous presence of an experienced woman who has no clinical responsibilities and so is free to focus on the whole family’s personal needs all the way through the birth experience. Doulas support women with epidurals as well as those who choose to forgo drugs, encouraging each to make their own choices. They work with both doctors’ and midwives’ patients, and see normal as well as high-risk births.

Q: Why is labor support important? How much of a difference does it make whether that support comes from a doula, a doctor, a friend or a family member?

A: I would venture to say that labor support is as important as medical care in many situations because it has been proven to have a strong impact on health outcomes. Doula care has been shown to decrease the length of labor (thus decreasing the odds of problems that can develop when labors are drawn out), decrease the need for medical inventions that have unwanted side effects and decrease the need for pain medication for women wishing to avoid it. Also, there are a lot of data showing a significantly lower cesarean section rate where doulas are present, and that’s good for everyone.

The fact that doulas are specifically trained and experienced in providing labor support makes them more effective than family and friends who are unfamiliar with the birthing room. The fact that they stay continuously – sometimes for extremely long hours, and with just one woman at a time – is the key difference between their support and that of nurses, midwives or doctors.

Labor support may mean massage, positioning for better laboring, talking a woman through the process or simply staying by her side and holding her hand.

Q: Doula services obviously focus upon the mother. What about the father?

A: Doulas are trained to attend to whatever makes the birthing mother comfortable – and sometimes that means making sure the father-to-be is comfortable. It’s common for the dads to worry about being displaced by the doula, so it’s her job to show him that this won’t happen. She can encourage him to play an active role, demonstrating effective techniques she knows will be helpful in a given stage of labor.

Q: How do you choose a doula? What are the chief considerations?

A: A doula needs to be very available on short notice, with flexible hours and a willingness to be up through the night for long hours. Believing she is there to support a woman’s preferences without any of her own is critical. A good doula is more intuitive than analytical, has both physical and emotional stamina, and she isn’t afraid of the raw human experience of childbirth, in all its forms.