So you’re ready to be a parent. Congratulations! That’s a big decision. To give yourself the best chance for a healthy pregnancy and baby, there are a few things to do before you get pregnant.

1. Go see your doctor before you conceive.

This preconception visit with your OB, family physician, internist or other care provider usually consists of a physical exam and a thorough discussion about your family history, personal medical history and any medications that you may be taking.  Certain medications are contraindicated during pregnancy and can lead to birth defects.  It’s important to switch to an alternative medication with the guidance of your health care provider before conception whenever possible.  Your provider will also make sure to discuss your weight, diet, exercise and whether or not you are up to date on your immunizations.  If you are at risk, you may also be tested for sexually transmitted diseases.

2. Start taking your prenatal vitamins 1-2 months before conception.

Folic acid supplementation during pregnancy is essential.  It is recommended that you get at least 400 mcg of folic acid daily for at least 1 month prior to conception because many young women have a folic acid deficiency.  You should continue to take a vitamin containing folic acid throughout your pregnancy. According to the Centers for Disease Control (CDC), you can reduce the risk of birth defects like neural tube defects and spina bifida by 50-70% with just this small measure.

When shopping for a prenatal vitamin, also make sure that it does not contain more than recommended daily allowance of 770 mcg of vitamin A.  Too much vitamin A can also cause birth defects and toxicity to the developing fetus.

3. Give up smoking, drinking, and/or drugs.

This is an obvious tip, but please seek help if you are having a hard time giving up smoking, alcohol or drugs.  Many scientific studies have demonstrated that these substances can lead to miscarriage, premature birth, and low birth weight.  They can also negatively impact your fertility.

4. See your dentist.

That old wives’ tale of “gain a child, lose a tooth” may be true.  Oral health during pregnancy is crucial because hormone shifts in pregnant moms predispose them to gum disease that can potentially lead to loss of a tooth.  Increased estrogen and progesterone levels during pregnancy can result in swollen, tender gums that may bleed more easily during flossing.  Whatever you do, don’t stop flossing!

It is advisable to see your dentist before pregnancy and again for a cleaning at least once or twice during pregnancy.  Gum disease and oral infections have been linked to preterm birth.

5. Reduce environmental risks to reduce birth defects.

There are so many environmental hazards lurking around us and you cannot eliminate all of them, but you can minimize them.  If your job requires you to be in contact with chemicals, radiation, or consistently loud noises, you may need to make some changes prior to conceiving.  At home, also try to minimize contact with cleaning products, paint, pesticides and solvents. If you live in an older house, it may be worthwhile to check if there are high levels of lead in your paint or in your pipes that could be released into your water supply.  I recommend talking to your doctor about these potential hazards and ways to avoid or minimize your exposure to them.

Best Wishes for a happy, healthy pregnancy.

Do you have any tips for people before they get pregnant? What type of advice did you receive before conceiving?

The Borneo rainforest is 130 million years old making it the oldest rainforest in the world.  It is home to 15,000 species of flowering plants, 3,000 trees species, 221 species of terrestrial mammals and 420 species of birds.  It is one of the only remaining natural habitats for the endangered Orangutan.  In Indonesian, the word orang-utan means ‘forest man’.  (A fun fact is that orangutans share 96.4% of our human genes.)

While in Borneo, I witnessed firsthand the rich biodiversity seen in the rainforest and the sad reality of illegal logging and palm oil plantations, which are destroying it.  When someone first mentioned ‘the evil palm’ I had no idea what was being spoken about.  The evil palm is a term used to describe the palm trees that are being planted throughout Borneo for the production of palm oil, an edible vegetable oil that can be used for cooking, packaged foods, or consumer goods.  The conflict here is that profit-driven investors are destroying thousands of hectares of rainforest to clear land for these palm oil plantations.  And, as a result, the natural habitat of orangutans is being destroyed.  In fact, they are currently listed as a critically endangered species by the International Union for Conservation of Nature.  After visiting these orangutans in their natural habitat and observing their playful nature, I realized that it would be nothing short of tragic to lose this amazing species just because we were unable to protect their home.

Besides destruction of the rainforest, the palm oil plantations are causing massive CO2 emissions.  Indonesia is now the world’s third largest emitter of greenhouse gases as a result.  In fact, by 2020 Indonesian Borneo is projected to contribute more CO2 emissions to the atmosphere than all of Canada.

Seeing these palm oil plantations firsthand, though, was the most powerful aspect of my education on deforestation.  As far as the eye could see, there were rows upon rows of dusty palm trees next to small patches of remaining rainforest.  It was very clear to see that all of those birds, animals, flowers and trees will soon be a distant memory if this rampant rainforest destruction does not stop.  Sadly, I do know that most Americans are probably unaware that we are even unintentionally supporting the palm oil industry as palm oil is being used in many of products we use and consume including breakfast cereals, girl scout cookies, and even household cleaning products and soap.  In fact, palm oil is used in 50% of all consumer goods from lipstick to body lotion.  It is our own North American food and agriculture companies that own and operate these palm oil plantations and also purchase from them.

The best way to help stop the destruction of our precious forests is through education and awareness.  If more people knew about how rapidly and senselessly the rainforest is being destroyed in Borneo, we would be much better equipped to demand change.

For more information on palm oil plantations, please visit Rainforest Action Network or Health in Harmony.

Growing a baby is hard work, I can attest to that.  Pregnancy is such a special time in a woman’s life, but it comes with a great deal of responsibility.  As a first time expectant mom, I sometimes find myself struggling to ensure that I am eating a healthy, balanced diet full of the key nutrients necessary to grow a healthy, happy baby.  I love the thought of a fun summer salad, but those deep leafy green salads don’t particularly excite me.  In fact, I often find myself drenching them in calorie-rich dressing just to get those nutrients down.  So, I had to find an alternative way to get my folic acid, iron and antioxidants.  That’s when I started drinking green smoothies.  I think fresh juices are great, but smoothies, which retain all of the fiber and goodness of your ingredients, are better!

And now that I’m in my third trimester, I feel like a green smoothie expert after much experimentation.  And, lucky for you, I have found some simple ways to make green smoothies taste delicious because who wants a drink that just tastes like blending spinach or kale.  I look forward to the extra boost of energy that comes from a green smoothie in the morning and I’m sure baby loves it too.

My favorite green smoothie recipe: The Tropical Green Smoothie

• ½-1 cup of organic apple juice (or white grape juice)
• a handful of ice cubes
• 1-2 large leaves of kale
• 1-2 cups of spinach
• 1/3 cup chopped fresh pineapple
• ¼ small lime with peel removed

Optional additives:

• chia seeds or flax seeds
• avocado
• flaxseed oil
• protein powder

Combine all of the ingredients in a blender and blend until smooth or according to your preferred texture. Makes 1 large serving or 2 medium servings. Then enjoy!

The great thing about blended smoothies is that you can substitute ingredients without sacrificing taste.  For instance, try banana instead of pineapple or add some yogurt for a creamier texture.  Everything is customizable and the options are limitless.  And, since the blender does all of the hard work for you, your digestive system just gets to kick back and enjoy all of the amazing nutrients!

If making green smoothies doesn’t appeal to you, look for local vendors that sell green blended smoothies, but try to stick to fresh smoothies because often store bought varieties lose much of their nutritional content due to oxidation.

I’ve recently gotten hooked on busheljuices.com because they deliver right to your door in the San Francisco/Bay Area!

Do you have any green smoothie tips or recipes that you like? Have you found any good fresh smoothie vendors in your area?

I never planned on getting pregnant and travelling to a third world country for a medical service trip.  It just happened that way. As a third year internal medicine resident at Stanford Hospital, I applied for a 6 week global health fellowship that would allow me to work in a remote rural clinic in Borneo, Indonesia’s largest of 17,000 islands.  The job description was simple.  I would be seeing patients in a well-established local clinic run by a wonderful organization called Alam Sehat Lestari/Health in Harmony.  In addition, I would supervise a few smart recent graduates from Indonesian medical schools, teach them in lecture style settings and attend to any emergencies that walked through the clinic door.  It sounded like a fantastic experience.  And then, my husband and I found out that we were expecting our first baby.  I wrestled with the decision to go versus staying home, but in the end, I knew this was my last chance to do something this adventurous and meaningful in the realm of global health.  I packed my bags and went to Borneo.

After the 36 hour journey to Sukadana, the remote Bornean village where I would spend my summer, I found that I was in for a much richer and far deeper experience than I had anticipated.  Sukadana is the kind of fantastic place that lives in your imagination.  It is nestled in the rainforest and yet manages to boast a pretty brown sandy beach that gets framed by marvelous rainbows during the rainy season.  Its people are otherworldly with their deep sincere smiles that never seem to end, their big hearts, and their gratitude.  There is little to no internet, running water, or air conditioning even amidst sweltering tropical heat and humidity.  The place is even untouched by the sweeping influence of coca-cola products.  Showers are taken with buckets and monkeys frolic outside of homes early in the morning.  People maintain a simple and organic diet consisting of freshly caught fish, local vegetables and the bane of my existence- white rice.  During my time there, I rode a bicycle everywhere, became accustomed to using an eastern toilet (aka squat toilet), and even found a way to coexist with an unusual roommate: a giant foot-long exotic biting lizard.

Living in Sukadana was the greatest adventure I could have asked for, but it was my time in that tiny rural clinic that really shaped me as a doctor.  The clinic was housed in a small building and consisted of two patient examination rooms and three beds for inpatient care. (Interestingly, in accordance with Indonesian custom, people would remove their shoes before entering the building.)

Being trained as an internist means that you become an expert at diagnosing and managing adult medical conditions, but in this clinic, all of a sudden, I became the community doctor.  Anything that walked through the door was fair game.  Eye emergencies, trauma, obstetrics, gynecology, infant care, and neurologic emergencies all found their way to me and with the limited testing resources available to us, all we could do was our best.  There were moments that really challenged my emotional fortitude.  I particularly remember a 43-year-old woman who was brought in unconscious by her family.  One moment she was preparing dinner in her kitchen, and the next she was being rushed to the clinic after being found unresponsive on the floor.  There was not a CT scanner or an MRI machine or even xray capability available to us, but using the most basic medical diagnostic skills, we were able to determine that she had suffered from a massive stroke.  As we managed her supportively with IV fluids, and blood pressure monitoring, I could not help but think how things would have been so different for her had she been at any American hospital.  After a few short hours, she passed peacefully with family by her side, but the feeling of not being able to do anything for her in those last moments really struck me.  I was so used to using mechanical ventilators, transferring patients to a higher level of care and even sending them for emergency surgery when indicated.  None of these were options in Borneo.  Patients were just thankful to be seeing a trained physician instead of a local medicine man.

In those trying moments when all you can do is your best, you somehow find the strength to do even better than you thought you could.  Sometimes, many times, even that is not enough.  It really sends home the message that death cannot be escaped.  I think that experiencing medicine in that type of environment forces you to think faster, harder, and more critically.  You end up relying less on fancy tests or imaging and find a way to make the diagnosis by relying on physical exam, patient history, and your own intellect.  Being there in that clinic, I think, made me a stronger person, a better doctor and someone with a greater passion to help patients through preventative education.  If I can help prevent one death from diabetes or high blood pressure, then my purpose has been fulfilled.

Have you ever had a formative experience that changed your perspective and made you a stronger person? I’d love to hear about it.

For more information on Health in Harmony including the ASRI clinic, or to donate or volunteer, please visit HealthInHarmony.org.

Everyone has heard the phrase ‘soft as a baby’s bottom’.  As a society, we cherish the belief that babies have the most perfect skin.  In fact, as we age, it becomes the ideal touted by anti-aging products and the media.  It is certainly a romantic notion, but infant skin is not completely resilient and fully developed so we have to learn how to protect and nourish it.  Even for the smoothest of bottoms, there are dangers lurking in common skin care products in the form of toxins, preservatives, and chemicals.

Let me explain what medical science has taught us about baby’s delicate skin:

Human skin maintains some of the same functions from birth throughout all stages of life.  It serves as a physical barrier between the environment and us, helps regulate body temperature, prevents insensible fluid loss from our bodies, and plays a great role in immune function.  However, there are some fundamental differences between infant and adult skin.  For instance, the barrier function of infant skin is not completely developed.  Babies lose more water through the skin and absorb environmental toxins and chemicals more easily than adults [1].  They are also more prone to developing bacterial infections than adults [2].  It is remarkable to note that the application of safe, natural moisturizers to baby’s skin can enhance its barrier function and prevent some of these issues.  In a recent randomized, controlled trial, when premature infants were massaged with sunflower seed oil three times a day, they had a 41% decrease in serious life threatening infections and a 26% reduction in mortality [3].  Recent evidence suggests that barrier development continues to occur throughout the first year of life and that baby’s skin is notably thinner structurally than ours.  Its fragile nature, high surface area to volume ratio and baby’s decreased subcutaneous fat volume all make infant skin more prone to easily absorbing any chemicals or toxins applied to it.  This is all worsened by the fact that babies still have immature drug metabolism and detoxification systems.  Basically, their little bodies cannot eliminate any toxins they absorb in the same manner that adults can.  These compelling findings highlight the importance of only essential, safe, and gentle skincare for developing infants.

When it comes to bathing, oddly enough, there is increased evidence to suggest that washing with a washcloth during the first month of life actually causes dehydration of the skin when compared with simply soaking in water.  Another study found that bathing an infant in a tub was associated with higher risk of cord infection versus no washing at all.   And when it comes to cleansers, the consensus among dermatologists appears to be that a mild liquid cleanser may actually be less drying and less irritating than water alone after the first month of life. Additionally, bathing should be brief (10 minutes or less) and should occur no more than every other day.

What about sunscreen? Photoprotection or sun protection is incredibly important for babies and children as it is for adults because UV damage is cumulative.   We also have to take into account that children spend more time outdoors in the sun and that their skin is more vulnerable to damage.  In fact, in the case of infants, they are entirely at the mercy of their caregivers to practice sun protection because they cannot communicate when they have a sunburn.  However, when it comes to the application of sunscreen, over the years, many have expressed concern about the possible hormone disrupting chemicals found in many formulations.   And, as mentioned earlier, this is especially worrisome in infants and children because their skin absorbs chemicals more easily and their bodies cannot metabolize them as quickly and efficiently.  Therefore, this remains to be a very contentious topic where the jury is still out.  My personal suggestion would be to follow the recommendation made by the American Association of Pediatrics: to minimize the reliance on topical products in infancy by avoiding sun exposure and using sun-protective clothing whenever possible [4].

Even if you do not subscribe to the philosophy of using natural and organic skin care products for your own adult skin, there are significant and worthwhile benefits of going natural for your developing baby and child.  As parents, we all want what is best for our children, and the evidence points strongly towards special care for fragile infant skin.

As an expectant mom and physician-scientist with a keen interest in immunity, inflammation and autoimmune disorders of the skin, I am passionate about advocating for parents by educating them about the risks associated with the use of chemicals and toxins in common skincare products. However, chemicals are only part of the problem, the other important piece is education about healthy skincare practices and avoidance of unnecessary products applied to the skin.  Our babies deserve the best shot at optimum skin health and development.  And, we deserve to know that what we put on baby’s skin is safe from harsh chemicals, toxins and preservatives.

How many of you use natural or organic skin care products for your infants and children? Do you feel that they are worth the price? Do you wish that they were more readily accessible in mainstream stores?

References:

1. Shwayder T, Akland T. Neonatal skin barrier: structure, function, and disorders. Dermatol Ther. 2005;18(2):87-103.
2. Darmstadt GL, Dinulos JG. Neonatal skin care. Pediatr Clin North Am. 2000;47(4):757-782.
3. LeFevre A, Shillcutt SD, Saha SK, et al. Cost-effectiveness of skin-barrier-enhancing emollients among preterm infants in Bangladesh. Bull World Health Organ. 2010;88(2):104-112.
4. American Academy of Pediatrics. Recommendations on limiting sun exposure. Accessed January 9, 2013.