Goldie

Nicely done! You hit many of the points that I see and hear.

News reports came out this week regarding a consensus statement that more studies be done on the safety of acetaminophen in pregnancy (Bauer, Swan, Kriebel, Liew, Taylor, Bornhag, et al, 2021). Some of the headlines are alarming: FOX news headline stated, “Common painkiller acetaminophen could alter fetal development, researchers warn”, and the Daily Mail stated, “Pregnant women should NOT routinely take Tylenol because it may harm the development of babies in the womb”. PDF Report attached or you can find it at Paracetamol use during pregnancy — a call for precautionary action. Nat Rev Endocrinol (2021). What did the report say? What should we tell our patients? Acetaminophen, whose most common brand name is Tylenol and is also known as APAP, is one of the most common pain and fever-reducing medications. Per the Consumer Healthcare Organization, “Acetaminophen is the most common drug ingredient in the United States. It’s found in more than 600 different medicines, including prescription and OTC pain relievers, fever reducers, and sleep aids as well as cough, cold, and allergy medicines.” It has long been considered the safest option in pregnancy, and a benign treatment. Many patients leave Acetaminophen off their list of over-the-counter medications because it is considered so common and safe. This consensus report, though, will raise questions from patients about its safety. This article will try to drill down on how to talk to our patients about the news report. Benefits of Acetaminophen We have few alternatives for pain and fever in pregnancy. Non-steroidal anti-inflammatory agents (NSAIDs) can delay closure of the ductus arteriosus so are not used in late pregnancy. Given the increase in opiate use disorders in the US, as well as other adverse side effects, opioid use is also minimized. We know that one common use of Acetaminophen, to reduce fever, may decrease the incidence of fever-related fetal effects such as neural tube defects, oral clefts, and congenital heart disease. Women with migraine headaches often rely upon Acetaminophen for pain relief. Concerns about Acetaminophen We know that Acetaminophen does cross the placenta, but it has not been associated with major congenital malformations, miscarriage, or stillbirth. However, after maternal overdose, there may be an increase in fetal death or miscarriage if treatment is delayed (UpToDate, 2021) The concerns raised by this panel are not new, but they revolve around two areas: the idea that acetaminophen is an “endocrine disrupter”, which may have adverse effects on the urogenital system of the developing fetus, and that neurobehavioral development may be affected as well. The panel feels that the preponderance of evidence, with study limitations, led them to call for further research and awareness. What is an endocrine disrupter? Many chemicals, both natural and man-made, may mimic or interfere with the endocrine system. Called endocrine disruptors, these chemicals are linked with developmental, reproductive, brain, immune, and other problems, according to the National Institute of Environmental Health Sciences. Endocrine disruptors are becoming more widely identified as they are found in many common household goods, such as BPA plastics, detergents, toys, and cosmetics (NIH.gov). APAP exposure in rodent studies has been shown to cause reproductive disorders of the male urogenital tract, including abnormalities in testicular function, sperm abnormalities and sexual behavior. Experiments have also shown disruption of female ovarian development resulting in reduced oocyte number and subsequent early female pubertal development, ovarian insufficiency and subsequently reduced fertility (Bauer, et al, 2021). Neurobehavioral effects: The scientists in the report review increasing incidence of cognitive, learning, and developmental problems. They report that epidemiological studies consistently suggest prenatal APAP exposure might increase the risk of adverse neurodevelopmental and behavioral outcomes, pointing to attention deficit hyperactivity disorder (ADHD), autism spectrum disorder, language delay (in girls) and decreased intelligence quotient. However, adverse events such as wheezing and asthma in early childhood and adverse neurodevelopmental effects such as ADHD following acetaminophen exposure have been evaluated in multiple studies. The outcome information was inconclusive, and a causal association has not been established (UpToDate, 2021). The scientists putting together the consensus report were an “international group of experts, which included clinicians (specializing in neurology, obstetrics and gynaecology, and paediatrics), epidemiologists and basic scientists (specializing in toxicology, endocrinology, reproductive medicine and neurodevelopment)” (Bauer, et al, 2021). They acknowledge the limitations of many of the studies they reviewed, but given the evidence from multiple disciplines, are calling for more research that would control for confounding factors, genetic factors, and the timing and dosing of acetaminophen and its effects on the developing fetus In 2017, Kilcoyne wrote that Acetaminophen is recommended to be used at the lowest effective dose for the shortest duration of time to effectively treat the mother and protect the health of the fetus (Kilcoyne 2017). The summary of the consensus opinion is the same, with a call for further research and additional warning labels on the packaging of products containing Acetaminophen: “We recommend that APAP should be used by pregnant women cautiously at the lowest effective dose for the shortest possible time. Long-term or high-dose use should be limited to indications as advised by a health professional. Packaging should include warning labels including these recommendations. Given the high prevalence of APAP use by pregnant women, the public health implications of use reduction might be substantial.” (Bauer, et al, 2021) Summary As nurses, patients turn to us for guidance. Although this report is initially alarming, our advice to patients should remain the same. Avoid medication use in pregnancy. If you have a fever, consult your provider. Acetaminophen, and all other medications, should be used in the lowest dose and for the shortest duration as possible. If they are pregnant now, and alarmed about potential effects of the medications they have taken, talk with them about the report and how more research may be needed to assess the risks. References: Paracetamol use during pregnancy — a call for precautionary action Kilcoyne KR, Mitchell RT. Assessing the impact of in-utero exposures: potential effects of paracetamol on male reproductive development. Arch Dis Child. 2017;102(12):1169-1175. [PubMed 28588045] Acetaminophen | Consumer Healthcare Products Association (chpa.org) Endocrine Disruptors (nih.gov) Bauer, A.Z., Swan, S.H., Kriebel, D. et al. Paracetamol use during pregnancy — a call for precautionary action. Nat Rev Endocrinol (2021). Paracetamol-use-during-pregnancy-call-or-precautionary-action.pdf

Nice article!

Connecting with Patients I love being a nurse. One of the great things about our job is the ability to connect with someone on a deeper, more intimate level than we normally do. Our patients or clients, whether sick or well, are in a more vulnerable position when in the healthcare setting. They rely upon nurses, one of the most trusted professions *, to soothe their fears, explain things in language they understand, and be their ally as they walk their healthcare journey. We help new overwhelmed parents learn to care for their newborn, how to breastfeed through pain and uncertainty. We help our cancer patients through what might be the most challenging fight of their lives. We sit with our dying patients and soothe their last moments. Using Our Superpower It is these connections that will allow nurses to stem the Covid tide. It is easy to feel separate from our communities if we feel “they just don’t get it”, or “they don’t know what it’s like”. We are upset at their innocence but forget we have a superpower—our ability to connect with other humans. How often have you held the hand of someone who hates getting blood drawn, and helped them through it? How many times have you translated a scary diagnosis for your patient who was terrified, and eased their fears? Our ability to meet someone where they are, and build bridges, will help us communicate truth about this virus, the vaccine, and how masks and social distancing can help us get through it. Telling Our Stories We need to tell our stories, whenever, wherever. To our families, to our friends, to the schools, at the dog park. Tell the stories of your patients, your coworkers, yourself. Rally their support for you, their community hospital, their clinic. Make them see what you see, every day. Don’t whine, however, that you are a Peds nurse who was floated to Med-Surg. They won’t get it. Tell them, instead, that the care of those patients was probably not as good as a Med-Surg nurse could provide. Listen to them complain about their surgery postponement, then tell them they might be lucky, as they may have an OB nurse caring for their surgical wound and will get discharged before they’re ready, because we need their bed. Tell them about the cars outside your ER with patients waiting to be seen. Tell them what Crisis Care really means to their families. Tell them about how your unit only had half the nurses it needs to run smoothly last night. How was care affected? This is not normal hospital care. We are not in normal times. It won’t be normal until we all make connections, until we all rally together against our common enemy. This killer doesn’t care who you voted for or what flag you fly. We are all up against the same enemy. We need our nurses, who excel at connections, to help rally the troops. Outside hospitals often need to transfer pregnant patients to high risk providers, because we have a NICU. Preterm moms with Covid sometimes get better if we deliver their babies, no matter how preterm. In my career experience, most parents would prefer not to have a premature baby. They especially would not want to be intubated in the ICU while their baby is alone in the NICU. No one in the family can visit or hold the baby because they are all in isolation for Covid. This is the story I told at my dog park. Everyone got a bit quiet, and I made a little joke about it being my soapbox. In the end, I feel it was worth it. Maybe I could convince someone whose best friend is pregnant and avoiding the vaccine until after she delivers. Maybe one less mother would be at risk from severe disease. Nurses are seen as trusted healthcare experts. What if we could make our clinical expertise part of the discussions at church, school, and our partners’ workplaces? Yes, we are tired. We’ve never been challenged with working from home, because that has never been an option. We are tired and discouraged that no one is listening. Maybe we aren’t telling the right stories. Maybe we need to create a connection—ONE—that wasn’t there before. We’re good at that because we’re nurses.