January 13, 2011, 10:14 am — Updated: 10:14 am -->

Remedies: Chewing Gum for Heartburn

By ANAHAD O'CONNOR

Tony Cenicola/The New York Times What alternative remedies belong in your home medicine cabinet?

More than a third of American adults use some form of complementary or alternative medicine, according to a government report. Natural remedies have an obvious appeal, but how do you know which ones to choose and whether the claims are backed by science? In this occasional series, Anahad O’Connor, the New York Times “Really?” columnist, explores the claims and the science behind alternative remedies that you may want to consider for your family medicine cabinet.

The Remedy: Chewing gum.

The Claim: It relieves heartburn.

The Science: It may be hard for most people to think of chewing gum as a remedy for anything other than a case of bad breath. But several studies in recent years have shown that it can in fact help alleviate the symptoms of gastroesophageal reflux disease, better known to most people as GERD or heartburn.

Chewing on a piece or two of gum, it seems, helps force fluids back into the stomach and flood the esophagus with alkaline saliva, neutralizing acids that cause the characteristic burning sensations.

One independent study demonstrating this, published in 2005 in The Journal of Dental Research, involved 31 patients who were recruited for testing after they showed up at St. Thomas’ Hospital in London with symptoms of heartburn. The scientists conceded that their hypothesis going into the study “was that chewing gum does not have any effect on the clearance of reflux from the distal esophagus.”

Ultimately, they were surprised. On two separate days, they asked subjects to fast for four hours, then fed them a “refluxogenic” lunch that would give just about anyone heartburn: two bars of full-fat cheddar cheese, green salad with two tablespoons of mayonnaise, 15 large chips and half a pint of full-fat milk. On both days, some of the subjects were then randomly selected to chew sugar-free gum for half an hour after the meal.

After monitoring the subjects for two hours after the meals, they found that acid levels were significantly lower when the participants chewed gum. The study was financed by King’s College London School of Medicine and Dentistry.

Another study, this one in 2001, involved 36 people, some of them with diagnosed cases of GERD and others who were healthy controls. The study found that chewing sugarless gum for an hour after a large breakfast reduced acid reflux in both groups for up to three hours, particularly in the heartburn group. The study was carried out by gastroenterologists at Veterans Affairs hospitals in New Mexico and Illinois, and financed by the American Digestive Health Foundation.

The Risks: Frequently chewing sugary gum may damage tooth enamel and increase cavities. But sugar-free varieties containing xylitol — which helps inhibit tooth-eroding bacteria — can have a protective effect.

Realities of life as a midwife.

Where (exactly) to stick a needle into your patients bum.

By impactEDnurse • Aug 15th, 2010 • Category: the nurses desk:, tips and tricks

Today a new-graduate nurse taught me how to give an intramuscular injection.
No, really….

After studiously watching one of our senior staff give an intramuscular (IM) injection, the new-grad informed us that, in fact, she was not taught to give injections into the upper-outer quadrant.
This is were I have been sticking my needles for many years now, and I have given thousands (if not millions) of injections this way.
We were about to re-orient her….but as this student is no dummy,  the senior staff member and I thought we had better get our facts straight before engaging our mouths.
We quickly slipped away under the pretext of ‘going to check for leaks in the pan room’ to find out what exactly is best practice for selecting a site for an adult IM injection in the buttocks.
Turns out she was right.

OUT: The Dorsogluteal IM injection site.

This site been used by nurses for years as the target of choice for IM injections.
It is found in the area of the superior lateral aspect of the gluteal muscles, commonly known as the ‘upper outer quadrant’.
It is located by dividing the buttock into four equal quadrants. This is usually done by drawing an imaginary cross (bisecting it vertically and horizontally).

Problems that have been identified with using this site include:

• Presence of major nerves and blood vessels in this area, including the sciatic nerve and superior gluteal artery.
  It has been taught that you will probably avoid this by further dividing the upper outer quadrant into another quadrant and giving the injection into the upper outer of the upper outer.
  Despite this, there have been reports of injuries to the sciatic nerve leading to problems ranging from foot drop to paralysis of the lower limb.
• Thickness of fat in this area. A number of studies have found that the depth of muscle in the dorsogluteal region is often greater then the length of a standard needle used for IM injections, resulting in a failure to achieve intramuscular deposition of the medication.
  In fact, one study found the success rate of IM injections to be 32% (which fell to 8% in female patients)!
  With the increasing incidence of obesity amongst our patients we are probably going to be delivering subcutaneous injections if we choose this location.
• Pain receptors are located in the subcutaneous layer, not in muscle tissues and so medication delivered into this area may be more painful.
• Dorsogluteal site has a decreased absorption rate increasing the possibility of a depot effect with drug build up and potential for overdose.

IN: The Ventrogluteal IM injection site.

The ventorgluteal (VG) site has less subcutaneous fat and a thicker muscle mass than the dorsogluteal site with an almost certain probability of penetrating muscle with a standard needle.
The VG site is also sparse of any major innervating nerves or blood vessels whilst remaining well perfused from smaller branches.

Locating the VG site.
The ventrogluteal site is located halfway between the hip and the head of the femur. One method to locate the correct site is:

1. First, place the heel of your  hand (use your L hand if injecting into the patients R VG and vice-versa) over the patients greater trochanter, and feel for the anterior superior iliac spine with your index finger.
2. The middle finger then slides across to make a peace-sign pointing up to the iliac crest.
3. The injection site is in the middle of this peace-sign.
4. Wipe site with alco-wipe in a circular motion and allow to dry.
5. Use your peace sign to spread skin taut.
6. Insert needle at 90 degree angle. Take care as you are inserting needle in proximity to your fingers.
7. There is no evidence for the need to aspirate the plunger when using the VG site.
8. Inject medication slowly (around 10 seconds per ml), remove needle quickly, and gently apply pressure to site for 10 seconds.

So, the ventrogluteal site is indeed the best practice location for delivering an adult IM injection.
You live and learn.

References:
Intramuscular injections: a review of best practice for mental health nurses:
COCOMAN A. & MURRAY J. (2008) Journal of Psychiatric and Mental Health Nursing 15, 424–434

Are techniques used for intramuscular injection based on research evidence? (NursingTimes.net)

I wonder if this is being taught in New Zealand?

While recent medical advancements mean most preemies will survive, preventing early birth in the first place is a different story. Doctors have no way of knowing which pregnancies will be preterm, and in about half of all cases, they don't know why a mother delivers early. However, science is beginning to divulge some clues, such as social stress, bacterial infection and hereditary influences, which might be tied to early births.

Inconsolable crying is the most frequently reported reason by caregivers for losing control with a child, Green said.

And it only takes a few seconds for the damage to occur.

“Because of a baby’s relatively heavy head and weak neck muscles, shaking makes their fragile brains bounce back and forth inside the skull and causes bruising, swelling and bleeding,” she explained.

Symptoms can vary from mild to severe and include loss of consciousness, lethargy, extreme irritability, decreased alertness, pale or bluish skin, vomiting, convulsions and no breathing.

Hope Galantino, clinical educator for labor and delivery at Washington County Hospital, said shaking an infant usually comes about out of frustration at not being able to soothe a fussy baby.

“When a baby starts to cry, many parents think their child is crying for a reason,” Galantino said. “But many infants cry for no reason.”

This is identified as PURPLE crying by the National Center on Shaken Baby Syndrome.

The term PURPLE, Galantino said, is an acronym intended to help caregivers recognize when this type of crying is occurring. (See box at left.)

Green said inconsolable crying is most common in babies up to five months.

As the parent becomes frustrated in trying to soothe the baby, she said, he or she reaches a breaking point and that breaking point triggers violence.

“We want parents to know that it’s normal for babies to cry,” she said. “But when the pressure gets to you, find someone else to give you a break. If there is no support system, it’s important to know that it’s OK to put the baby safely in the crib and take a few minutes to collect yourself.”

Galantino said there is no socioeconomic, age, racial or cultural group more likely than another to shake their babies.

Parents who are unable to stop their children’s crying have one thing in common: feeling inadequate.

Giving parents the tools

In an effort to educate parents, Galantino said members of three local chapters of the Exchange Club worked together about one year ago to secure more than 1,000 DVDs called “Did You Know Your Baby Would Cry Like This.” The videos were obtained from the National Center on Shaken Baby Syndrome and given to the Washington County Hospital’s Family Birthing Center to pass on to new parents.

The hospital purchased an additional 1,100 copies of the DVD so they would be able to give a copy to every new parent over the next year, Galantino said. 

Green said the video emphasizes steps parents can take to comfort their crying babies. The most important step, she said, is easy to remember: Never shake or hurt a baby.

It’s also important, she said, to always check with your doctor to see if there is something wrong that is causing the crying.

Parents are encouraged to watch the video before leaving the hospital, Green said. The staff is then available to answer any questions parents or caregivers might have before they take their babies home. They also are urged to show the DVD to anyone who will help take care of the baby. 

“Hopefully, the DVD will make a difference,” Galantino said. “We can talk to people about not shaking their baby. We teach it. But there is no impact like watching the DVD. It’s a more effective way of reaching parents.”

Green said staff members have taken the DVD out into the community to further raise awareness about abusive head trauma. She also noted that pediatricians are aware of the DVD and have the ability to go online to purchase it.

“It’s our hope that these DVDs will save innocent lives,” she said.

Ways to comfort a baby:

• Meet the baby’s basic needs. Check to see if he is sleepy, hungry, needs burping, needs changing or is too hot or cold.

• Rock, walk, sing or dance with the baby.

• Give the baby a warm bath.

• Take the baby for a walk in a stroller or for a ride in the car.

• Hold the baby close to you with skin-to-skin contact. Breathe slowly and calmly. The baby may feel your calmness and become quiet.

• Lower any surrounding noise and lights.

These ideas won’t work every time, but they may be able to reduce crying by about 50 percent. Remember: You should always check with your doctor to see if there is something wrong that is causing prolonged crying.

— Provided by the National Center on Shaken Baby Syndrome

For more information on PURPLE crying, visit the National Center for Shaken Baby Syndrome Web site at www.dontshake.org.

PURPLE:

P: peak of crying

U: unexpected

R: resists soothing

P: pain-like face

L: long-lasting

E: evening, which is when this type of crying more commonly occurs.

— National Center on Shaken Baby Syndrome