What does a birth doula do?

A birth doula in blue top smiles at a pregnant woman seen from the side wearing a hospital gown

Childbirth — painful, messy, unpredictable — has been part of humankind for time immemorial. And in the US, which has surprisingly high rates of avoidable complications and maternal deaths, more people seem to be seeking out doulas for additional care during pregnancy and birth, says Natalia Richey, interim chief midwife in the Department of Obstetrics and Gynecology at Massachusetts General Hospital.

Some research suggests that doula care may benefit both mother and baby. But what does a birth doula do? While neither a midwife nor a doctor, a professional doula can provide emotional and physical support to women during pregnancy and throughout the birthing process.

Here’s what to know if you’re considering doula care.

What’s the difference between doulas and midwives?

Midwives and doulas tend to have a few overlapping duties. But there’s a key difference: midwives provide medical care and doulas don’t.

  • Midwives: Their primary responsibility is to maintain the physical health of a woman and her baby throughout childbirth. Certified nurse-midwives like Richey are also trained nurses, but most midwives have undergone some type of medical training. This may vary depending on state laws.
  • Doulas: Unlike midwives, doulas don’t perform any medical tasks. Their main role is to help laboring women remain comfortable and calm using various methods, including suggesting comfort measures and optimal positions for labor and pushing.

“Many women hire doulas if they’re trying to have an unmedicated birth,” Richey says. “Doulas are really good at knowing what techniques — such as walking, showering, massage, or aromatherapy — can help a woman through the pain. It’s like having a coach.”

Are doulas trained or licensed?

Be aware that doula training varies widely. There are no formal rules requiring licensing or certification. Many doulas, however, seek certification from the more than 100 independent organizations that offer some type of doula training and credentials, according to the National Health Law Program.

Is doula care covered by insurance?

Private insurers often do not cover doula care, which can cost several thousand dollars when arranged for privately.

However, some employers — including Walmart — will help pay for doula care. And some hospital systems, particularly in low-income or medically underserved areas, have doula programs aimed at improving maternal care during and after pregnancy. Others may arrange doula support for people with limited resources who might otherwise be alone during the later stages of pregnancy and birth.

As of February 2023, 10 states and the District of Columbia provided Medicaid coverage for doula services. Other states are in the midst of implementing coverage. Most of the states that provide Medicaid coverage for doula care require doulas to be trained or certified by an approved organization.

Can working with a doula improve birth outcomes?

A 2023 analysis in the journal Cureus reviewed 16 individual studies done over 22 years. It found doula support was linked with better birth outcomes, such as fewer C-sections and premature deliveries, and shorter length of labor.

Additionally, the emotional support provided by doulas was associated with less anxiety and stress in birthing mothers. Among low-income women, doula support was shown to improve breastfeeding success.

“It’s impressive,” Richey says. “I think those improved outcomes are due to having an expert in the labor process who isn’t a medical person but is just there for you from moment to moment.”

How do people collaborate with doulas?

Agreements about care vary. Typically, doulas meet with women every few months through their pregnancy to discuss their goals for birth (such as skipping pain medication, for example), and to build rapport with both the expectant person and their spouse or partner.

Like obstetricians, doulas are on call 24/7 to support clients who have gone into labor or who have their labor induced. Doulas stay throughout the birth process.

“Having someone there who’s seen quite a few births, who can support and advocate for them, can be a huge comfort,” says Richey.

This may be especially important to women with limited resources, particularly those who might otherwise be alone during the later stages of pregnancy and birth. “Doulas remind women that they’re okay and can get through this process — all the things many of us take for granted,” Richey says.

How might a doula work with the OB/GYN team?

Usually, this is a seamless process, Richey says. If a hospital arranges for a woman’s doula, OB/GYN team members may meet the doula a couple of times before childbirth. Meanwhile, a doula who’s been hired privately will usually only meet the larger OB/GYN team when the woman arrives at the hospital to give birth.

When everyone sticks to their assigned roles, all goes smoothly. For a doula, that may mean suggesting nonpharmacological ways to ease pain and help labor progress. Boundaries are important, though, when medical intervention is needed.

“If the baby’s heart rate is down, for instance, the expertise needs to be left to the midwife or doctor,” Richey explains.

What questions should you ask if you’re interested in working with a doula?

Richey suggests starting by asking yourself:

  • What are my hopes and goals for the childbirth process? Might a doula enhance my ability to achieve them?
  • How do I envision my support team during delivery? Do I have a partner, a mom, or a friend I want there? Would a doula add to any support I already have?
  • Do I have friends or family members who have used doulas in the past? What were their impressions of the experience? Can they recommend a doula?

If you contact a doula to explore your options, ask about:

  • their training and certification
  • how many births they’ve attended
  • how they believe they can help you during your pregnancy and during labor
  • how they will collaborate with your partner or spouse and the medical team
  • whether they provide support after a birth — if so, what type of support and for how long?

“Take the time to meet with any doula you’re considering and make sure they’re a good fit,” Richey advises, “because this is someone who will be there during one of the most vulnerable times of your life. Having someone there who doesn’t make you feel safe and comfortable can affect birth in a major way.”

About the Author

photo of Maureen Salamon

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

About the Reviewer

photo of Howard E. LeWine, MD

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD


Veins are a key player in the body: Here’s why

3-D illustration of cross-section of a vein carrying red blood cells and white blood cells; background is blurred pink and white

Blood circulation is vital to our health. Our arteries deliver oxygen, energy-rich nutrients, hormones, immune cells, and other essentials throughout the body. When deliveries are cut off, organs and tissue can be irreversibly damaged within minutes.

But a second part of blood circulation is also vitally important: the return trip. After our arteries deliver the goods, our blood must return to the lungs to pick up more oxygen, stock up on nutrients, get rid of carbon dioxide, and head back to the heart to be pumped out again. In this way, blood is in continuous motion, ensuring organs and tissues get what they need while waste products are removed.

The vessels designed for the return trip are your veins. Read on for answers to questions about how veins work, what can interfere with their ability to work smoothly, and five ways to keep thousands of miles of these blood vessels healthy.

What are veins and what do they do?

Perhaps you haven't thought much about your veins. Or if you have, maybe you focused on varicose veins, those swollen, unsightly purplish vessels that may be visible just beneath the skin of the legs. Or perhaps you had a blood test and the person taking the blood had a hard time finding a "good vein." But these are just a small part of vein world.

Veins make up a network of connecting tubes throughout the human body, ranging in size from 1 mm (about the size of a pencil point) to 2 cm (about the size of a quarter), that bring blood low in oxygen back to the lungs to reload with oxygen. Then four pulmonary veins carry oxygen-rich blood from the lungs to the heart. (Fun fact: some people have three or five pulmonary veins, but most of us have four.)

Often, major veins are found alongside similarly named arteries, like a highway with cars moving in opposite directions: in the upper arm, for example, the axillary vein lies next to the axillary artery; in the kidney, the renal vein runs alongside the renal artery.

How do veins help keep blood flowing?

Let's start by picturing tiny red blood cells loaded up with oxygen. Now imagine you're a red blood cell that has just traveled from the heart through the arteries to a calf muscle of someone who is jogging. After you drop off the much-needed oxygen and pick up waste products like carbon dioxide, you need to get back to the heart — fast! — because exercising muscles need extra oxygen.

But wait. As you head back to the lungs to load up on more oxygen and release carbon dioxide, there's a steep climb straight up. How can you make it back to the lungs without help?

Fortunately, veins have tiny valves within them that allow blood to flow in only one direction. When muscles contract near larger veins, they pump blood toward the lungs. In addition, taking in a breath creates a sort of suction that pulls blood toward the lungs. Without these forces encouraging blood to flow in the right direction through the veins, blood flowing into the legs would pool there, causing dangerously high pressure and swelling.

Why are veins blue?

Actually, they aren't. People think they're blue because that's often how they appear in diagrams and illustrations. But that's just to set them apart from the bright red arteries.

The veins on the back of your hand may appear blue if you have light-colored skin. That's an illusion due to the way light is absorbed by the skin. In people with darker skin tones, veins tend to blend in more.

If you could look at veins directly, without any skin in the way, they'd appear pale because they are naturally colorless, or dark red due to the blood inside them.

What sort of problems can occur in veins?

Blood clots, varicose veins, and venous insufficiency are some of the most common health conditions affecting the veins:

  • Deep vein thrombosis (DVT) occurs when a blood clot forms in a deep vein, blocking blood flow. This condition is potentially serious because clots in deep veins can travel to the lungs, causing a life-threatening pulmonary embolism by blocking an artery that delivers blood to part of the lungs.
  • Superficial thrombophlebitis is a blood clot in a small vein just under the skin. This causes inflammation and pain.
  • Varicose veins are small veins under the skin that swell and twist. While these may be harmless, they can cause pain and are occasionally complicated by blood clots.
  • Venous insufficiency occurs when the valves in veins are damaged — due to aging or prior blood clots, for example. The blood flow through the veins may be impaired, leading to leg swelling, increased pressure, inflamed skin, and poor healing.

One far more rare condition goes by the impressive name of phlegmasia cerulea dolens. It is a serious complication of DVT in which the obstruction of blood flow through a deep vein leads to blocked blood flow through nearby arteries. That can cause gangrene and the need for amputation.

All of these conditions can affect circulation temporarily or in a lasting way. Treatments are aimed at restoring circulation, if possible.

Top 5 ways to improve vein health

Healthy veins help the heart, brain, and every other part of your body. Here are five ways to improve vein health, even if you already have vein disease:

  • Be active. Exercise regularly and avoid prolonged standing or sitting.
  • Choose healthy foods, such as those in a plant-based, heart-healthy diet.
  • Maintain a healthy weight.
  • Don't smoke.
  • Wear compression stockings if you already have vein disease such as venous insufficiency.

And of course, seek medical care for unexplained swelling, inflammation, or ulcers on your legs, ankles, or feet.

The bottom line

Our veins are busy around the clock, shuttling blood from distant sites back to the lungs and heart, which pumps enriched blood out again. Without veins, blood circulation could not happen. They're a good example of how many parts of your amazing body are easy to overlook until something goes wrong.

About the Author

photo of Robert H. Shmerling, MD

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD


Kidneys, eyes, ears, and more: Why do we have a spare?

Colorful Cubist art –– red, green, blue, pink purple –– shows two faces with extra eyes placed randomly all over

One of the many underappreciated things about the human body is that it has a lot of excess capacity. That is, our organs have more reserve than most of us will ever need.

It’s as if our bodies were designed with the idea that we might need backups in case of illness or injury. And voila: when all goes well, we arrive at birth with two kidneys, not just one!

Of course, the kidneys are not the only example. So, why are we built with natural redundancy? And which of your body parts can safely fail or be removed without impairing your health?

Why do our organs have so much reserve?

The likely answer is evolution: early humans with a genetic makeup that produced organs with functional space to spare were better able to survive, thrive, and reproduce than others without such a genetic makeup. As a result, genes associated with excess organ capacity — remember: two kidneys, not one — were more likely to be passed down to future generations.

Meanwhile, evolutionary ancestors without as much reserve may not have survived long enough to reproduce, and so weren’t as successful at passing their genes along. Over thousands of years, this power of natural selection has led to modern-day humans having organs with plenty of reserve.

Eyes, liver, lungs, and more

Here’s just a partial list of body parts with plenty of reserve:

  • Eyes: You can be perfectly healthy with one eye, although you may miss the depth perception and larger field of vision provided by having two. Even losing both eyes does not directly lead to poor health, though obviously blindness can pose challenges and impact quality of life. Additionally, studies suggest that significant vision impairment may raise the risk of Alzheimer’s disease.
  • Ears: Although having two ears allows us to locate sounds from all directions, losing hearing in one or both ears doesn’t immediately impact overall health. But as with vision loss, quality of life can be diminished by hearing loss. And as with vision loss, recent studies suggest that people with hearing impairment are at an increased risk of developing cognitive problems.
  • Gut: Relatively large portions of the small and large intestines can be removed without having a major impact on your health. In fact, the entire colon can be removed (an operation called pancolectomy) without shortening a person's life, although diarrhea or other digestive symptoms may follow. Removing a section of bowel is a relatively common operation (for colon cancer, for example), but the removal of part of the bowel doesn’t itself impair health or shorten lifespan.
  • Kidneys: Most people can live perfectly well with only one kidney. That's why people can donate a kidney to someone in need. However, the remaining kidney must work harder, and the risk of future kidney failure does increase somewhat. In addition, an injury, infection, or other disease affecting the remaining kidney can lead to kidney failure more quickly than usual.
  • Lungs: When necessary, an entire lung can be removed, and you can rely on the other lung and function quite well. A lung may be removed due to a tumor, but occasionally it's done because of infection or emphysema.
  • Liver: A relatively large portion of the liver can be removed (assuming the rest of the liver is healthy) because there is so much “reserve” liver tissue, and because the liver has an ability to regenerate.

Does this mean many parts of our bodies are truly expendable?

Maybe. If you’re only considering survival, you could view many of our body parts as expendable. Indeed, you could survive without your spleen, much of your liver, your eyes, your ears, a lung, a kidney, and other parts.

But clearly, there are factors to consider other than survival, especially quality of life. So, no one would suggest parting with even the least useful organs without a good reason.

The bottom line

It’s fortunate that our organs have so much reserve: millions of people worldwide owe their very survival to the fact that our organs have so much redundancy. And living organ donors can give up a kidney or a portion of another organ to help others live well and still be healthy.

So, even if some parts aren’t absolutely necessary, it’s good to know there’s so much reserve available. You never know when it might come in handy.

About the Author

photo of Robert H. Shmerling, MD

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD


What to do if you think your child has the flu

A child with dark hair lying in bed looking sick, mother in pink shirt has one hand on his forehead, the other on his hand

Once influenza season is underway, it’s natural that if you hear your child start coughing, you wonder: could this be the flu or another virus? And if you think it is the flu, what should you do?

Is it the flu, RSV, COVID –– or just a cold?

It’s not always easy to tell these illnesses apart, especially at the beginning.

  • Flu: The flu usually comes on suddenly, and its symptoms can include fever, runny nose, cough, sore throat, headache, muscle aches, feeling tired, and generally just feeling rotten. Some people have vomiting and/or diarrhea, too. Not everyone has all these symptoms, and the illness can range from mild to severe.
  • RSV: Along with fever and sore throat (and feeling tired and rotten), RSV often causes a lot of nasal congestion and a mucusy cough. In some babies, it causes wheezing.
  • COVID causes similar symptoms to flu and RSV, but the cough generally isn’t as mucusy, the fatigue can be worse, and some people will lose their sense of taste and/or smell.
  • The common cold generally causes similar symptoms to flu, RSV, and COVID, but milder and often without a fever. However, some people have bad colds — and some people have mild cases of the flu, RSV, or COVID.

Call your doctor for advice

Because these illnesses are so similar, it’s a good idea to call your doctor’s office if your child has cold symptoms. You don’t necessarily need an appointment, but you should call for advice. Describe your child’s symptoms. Based on the symptoms, and your child’s particular situation (such as any medical problems they might have, or vulnerable people like infants or elderly living with you), your doctor

  • may suggest testing for COVID, flu, or RSV
  • may want you to bring your child in
  • may want to prescribe antiviral medication.

Because every child and every situation is different, you should call and get advice that is tailored to your child and family.

What helps when your child has the flu?

Once you’ve called your doctor for advice or have a diagnosis of flu, the steps below will help your child feel more comfortable and speed recovery.

Stock up on supplies

There are a few things that make getting through the flu easier, including:

  • acetaminophen and ibuprofen for fever and aches
  • a reliable thermometer, if you don’t have one
  • hand sanitizer (buy a few to keep all over the house)
  • tissues
  • fluids to keep your child hydrated, such as clear juices, broth, oral rehydration solution (for infants), and popsicles (which are great for sore throats, and eating them is the same as drinking). If you don’t have a refillable water bottle (one with a straw is great if kids are lying down), get one of those too.
  • honey (if your child is older than a year) and cough drops (if your child is at least preschool age)
  • saline nose drops
  • a humidifier, if you don’t have one
  • simple foods like noodle soups, rice, crackers, bread for toast.

Make sure your child rests

Turn off or at least limit the screens, as they can keep children awake when their body needs them to sleep. Keep rooms darkened, and limit activity. If they aren’t sleeping, quiet things like reading (or reading to them), drawing, card games, etc. are best.

Push fluids, don’t worry about food

When children are fighting the flu, the most important thing is that they stay hydrated. They need a bit of sugar and salt too, which is why juices and broths are good choices. If they only want water, give them some crackers to get the sugar and salt — but don’t worry too much if they don’t want to eat more than that. They will eat more when they feel better.

Watch for warning signs

Most children weather the flu fine, but some children get very sick, and there can be complications. Call your doctor or go to an emergency room if your child has

  • a high fever (102° F or higher) that won’t come down with acetaminophen or ibuprofen, or a new fever after your child seemed to be getting better
  • any trouble breathing
  • severe pain of any kind
  • severe sleepiness, so that it’s hard to wake them or keep them awake
  • trouble drinking or keeping fluids down
  • anything that seems strange or worries you (I always respect a parent’s “Spidey sense”).

Keep your child home until they are well

That doesn’t necessarily mean they can’t go to school or daycare until they are cough- or runny nose-free, but it does mean that they have to be fever-free for at least 24 hours, not coughing constantly, able to eat and drink, and have enough energy to do whatever school or daycare entails. Not only is this important for your child’s recovery, but it’s important for preventing the spread of influenza. Which leads me to the last point…

Do your best to keep others from getting sick

Besides keeping your child home (and staying home yourself if you catch it), there are other things you can do, such as:

  • Make sure everyone in the house washes their hands frequently (that’s where the hand sanitizer all over the house comes in handy).
  • Teach everyone to cover coughs and sneezes (they should do it into their elbow, not their hands).
  • Don’t share cups, utensils, towels, or throw blankets.
  • Wipe down surfaces and toys regularly.
  • Discourage visitors (use technology for virtual visits instead).
  • Be thoughtful about physical contact. Some degree of contact and snuggling is part of parenthood, but siblings may want to keep a bit of distance, and you can always blow kisses and do pretend hugs instead of the real thing.

Remember, too, that it’s never too late to get a flu shot if you haven’t already.

To learn more about the flu and what to do, visit

About the Author

photo of Claire McCarthy, MD

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD


A tough question: When should an older driver stop driving?

Abstract of traffic on city highway at night with glaring headlights forming big, colored dots

Part 1 of a two-part series on making decisions about driving as we age. Read Part 2 here. 

When my grandmother repeatedly clipped the mailbox backing out of her driveway, she always had a ready explanation: "the sun was in my eyes" or "your grandfather distracted me." Our family knew we needed to take action. But no one wanted to be the one to ask her to stop driving. She was fiercely independent, didn't agree that her driving was a problem, and didn't appreciate our concerns.

Maybe there's a similar story unfolding in your family. Or maybe you're starting to wonder about your own skills. As part one in a two-part series, this post aims to help people understand red flags to watch for, and why driving abilities change as people age. It also describes a few ways to improve impaired driving, and challenges to navigate.

A second post will address ways to strike a balance that respects dignity — and safety — while providing action plans for older drivers and their families.

How safe are older drivers on the road?

Unsafe drivers can be any age, particularly when drinking is involved. But fatal traffic accidents have risen in both young drivers and older drivers, according to data from the National Safety Council:

  • Fatalities occurring in crashes involving a driver ages 15 to 20 rose nearly 10% between 2020 and 2021, accounting for 5,565 deaths.
  • Among drivers 65 or older, fatalities rose 15% between 2020 and 2021, accounting for more than 8,200 deaths.

While younger drivers may be inexperienced or more likely to be distracted or reckless, older drivers often overestimate their driving abilities. That may be one reason many unsafe older drivers continue to drive despite failing driving skills.

Per mile driven, the rate of motor vehicle accidents is higher for drivers ages 80 and older than for almost every other age group, according to the Insurance Institute for Highway Safety. Only the youngest drivers have higher rates. And the rate of fatal motor vehicle accidents per mile driven is higher for drivers aged 85 and older than for every other age group.

These statistics reflect the reality that an older driver may not be the only one injured or killed in a crash — occupants in one or more vehicles may be, too. And then there are pedestrians and cyclists at risk.

Clearly, the stakes are high when any unsafe driver is on the road. For older drivers with waning driving skills, it's important to recognize the problem and understand why it's happening. The following four steps are a good start.

1. Seeing any red flags?

As people get older, driving skills may decline so slowly that it's not obvious worrisome changes are happening. Even when mishaps and near-misses occur, there are so many possible contributors — especially other drivers — that it may not be clear that the older driver was at fault.

Red flags that might mean an older person is an unsafe driver include:

  • concerned comments from family or friends
  • reluctance of others to ride with them
  • input from other drivers (why is everyone honking at me?) or traffic authorities (why am I getting all these traffic tickets?)
  • getting lost on familiar roads
  • consistently driving too slowly or too fast
  • unexplained dents or scratches appearing on the car
  • frequent accidents or near-misses.

2. Why do driving skills tend to wane with age?

While people of advanced age can safely drive (and many do!), driving skills may wane due to:

  • medical conditions, such as arthritis, neuropathy, or dementia
  • medications, such as sedatives or certain antidepressants
  • age-related changes in reaction time
  • trouble with vision or hearing
  • other physical changes related to aging, such as less flexibility or strength
  • difficulty processing rapidly changing information. For example, an older driver may be more likely than a younger driver to accidentally press the gas pedal instead of the brake when needing to stop suddenly.

3. What can — and can't — be reversed to improve driving?

Some changes that impair driving can be reversed or a workaround can be found. For example, if driving is impaired due to cataracts, cataract surgery can restore vision and improve driving. If night driving is difficult, it's best to drive only during the day. If memory problems are starting to arise, it may still be possible to drive safely in more limited circumstances.

Driving problems due to advanced dementia or a major stroke affecting judgment and physical skills are much less likely to improve.

4. Accept that conversations about not driving are challenging

If there is no simple way to reverse or work around declining driving skills, accept that there will be many challenges to navigate, whether you're the older driver or a family member.

Challenges facing the driver:

  • It's not easy to acknowledge declining function. Driving impairment is an unsettling milestone, an indication that the future may include further loss of abilities.
  • It can feel unnecessary and unreasonable. Most older folks facing a decision about whether it's safe to continue driving were good drivers not so long ago. They may still see themselves as competent drivers, and see efforts to restrict their driving as overly cautious or demeaning.
  • Denial and defensiveness are common. Even when all the signs are there, it may be tempting for a poor driver to deflect blame (for example, blaming other drivers).
  • Not driving is a loss of independence. Sure, there are other ways to get around and nondrivers can certainly be independent. But few alternatives rival the independence that comes with being able to drive yourself. And, depending on where you live, public transportation or other alternatives to driving may be limited.

Challenges facing the family:

  • Often, the older driver doesn't share their family's concerns about driving safety. This can lead to arguments, confrontation, and resentment.
  • The safety of others is at stake. The older driver with waning skills may endanger many people besides themselves: passengers in their care, other drivers and their passengers, cyclists, and pedestrians.
  • It's hard to know when the time is right. Speaking up too soon may lead to unnecessary restrictions on a loved one's favored means of transportation, not to mention family strife. Waiting too long can lead to avoidable tragedy.

Finding a path forward

As for my grandmother, none of us knew what to say. Should we try to get her to agree to stop driving entirely or let her ease into the idea over time? Maybe she could stop driving at night or limit her driving to short distances. Should we bring it to the attention of her doctor and let them direct the next steps? Or should we take an even harder step and report her to the authorities?

If you're asking similar questions — or if you're starting to wonder about your own driving abilities — you may feel strongly that it's important to respect individual preferences, dignity, and independence. Yet you also want to protect everyone from harm.

What are the best ways to strike a balance? Can you test and improve how an older driver is doing behind the wheel? Can you navigate tough conversations in ways that allow room for both independence and safety? These are the subjects to be tackled in Part 2.

About the Author

photo of Robert H. Shmerling, MD

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD


Small pets are delightful, but some carry dangerous bacteria

The lower part of a child's face leaning forward to kiss a bright green frog with a brown eye that she's holding in her hand

Small animals like turtles, iguanas, and frogs are often chosen as first-time pets for children because they are easy to interact with and low maintenance for busy households. While they can be fun, it may be best to avoid them.

The reason? “Reptiles and amphibians can carry germs that make people sick, the most common of which is the Salmonella bacteria,” says Dr. Elizabeth Hohmann, an infectious disease expert with Harvard-affiliated Massachusetts General Hospital. “These animals live in warm and wet environments where Salmonella thrives.”

Outbreaks of illness across the US

Reptiles and amphibians often carry Salmonella in their digestive tracts, although the bacteria doesn’t affect them. The risk of illness from these pets became so severe this year that the CDC warned about adopting tiny pet turtles after reported outbreaks of Salmonella illnesses and hospitalizations in 24 states. (Other small pets such as mice or hamsters, and farm animals like chickens, may also carry and spread the bacteria.)

How is the bacteria transferred from pets to children and adults?

People become exposed to Salmonella through physical contact with the animals, their droppings, food, items like toys or food dishes, and habitats such as cages, tanks, aquariums, and water.

“They get the bacteria on their hands and then inadvertently touch their mouths or nose,” says Dr. Hohmann. This is especially likely in younger children.

Once exposed to the bacteria, people can get an infection called salmonellosis.

Who is more likely to get sick?

Anyone can get salmonellosis, but children younger than age 5, adults 65 and older, and people with chronic conditions are at higher risk for severe illness and even hospitalization.

“Kids that are very young don’t always follow proper personal hygiene or understand safety protocol when handling these animals,” says Dr. Hohmann. “Older adults and people with chronic conditions like diabetes can have weakened immune systems that make them more susceptible to illnesses.” In the most serious cases, the bacteria can reach the bloodstream and from there infect other places within the body.

What are the symptoms of this infection?

The hallmarks are diarrhea, fever, and abdominal cramps. These symptoms usually appear within six hours to four days after infection and last about four to seven days.

Call your pediatrician or primary care team for advice if you have a pet that potentially carries Salmonella.

When should you seek immediate medical care?

Seek medical care immediately if you or your child have any of these severe symptoms:

  • diarrhea and a fever higher than 102° F
  • diarrhea for more than three days that is not improving
  • bloody diarrhea
  • so much vomiting that you cannot keep liquids down
  • signs of dehydration such as not urinating much, dry mouth and throat, or feeling dizzy when standing up.

What if you already have a pet turtle?

If you already have a pet turtle or similar high-risk pet, make sure everyone follows these safety steps from the CDC. Children may need frequent reminders about washing hands and playing safely.

Wash hands. Always wash hands for at least 20 seconds with plenty of soap and warm water right after touching or feeding your pet, and after handling or cleaning the area where it lives and roams. “Adults should make sure to teach young children how to wash their hands properly,” says Dr. Hohmann.

Play safely. Don’t kiss or snuggle the pet, and don’t eat or drink around it. Keep it out of the kitchen and other areas where you eat, store, or prepare food.

Properly clean. Use cleaning materials like a wash tub, sponge, and scrub that are reserved only for your pet. Always clean cages, tanks, and other pet items outdoors. Avoid using a kitchen sink, as this can increase the risk of spreading germs to your food.

But perhaps the best safety advice is to simply avoid these animals as pets — or at least wait until your kids are much older, says Dr. Hohmann. “It’s probably safer to stick with dogs and cats.”

About the Author

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Matthew Solan, Executive Editor, Harvard Men's Health Watch

Matthew Solan is the executive editor of Harvard Men’s Health Watch. He previously served as executive editor for UCLA Health’s Healthy Years and as a contributor to Duke Medicine’s Health News and Weill Cornell Medical College’s … See Full Bio View all posts by Matthew Solan

About the Reviewer

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Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD


Lead poisoning: What parents should know and do

Peeling pieces of paint arranged to spell the word lead; concept is lead poisoning

You may have heard recent news reports about a company that knowingly sold defective lead testing machines that tested tens of thousands of children between 2013 and 2017. Or wondered about lead in tap water after the widely reported problems with lead-contaminated water in Flint, Michigan. Reports like these are reminders that parents need to be aware of lead — and do everything they can to keep their children safe.

How is lead a danger to health?

Lead is poisonous to the brain and nervous system, even in small amounts. There really is no safe level of lead in the blood. We particularly worry about children under the age of 6. Not only are their brains actively developing, but young children commonly touch lots of things — and put their hands in their mouths. Children who are exposed to lead can have problems with learning, understanding, and behavior that may be permanent.

How do children get exposed to lead?

In the US, lead used to be far more ubiquitous than it is now, particularly in paint and gas. Yet children can be exposed to lead in many ways.

  • Lead paint. In houses built before 1978, lead paint can sometimes be under other paint, and is most commonly found on windowsills or around doors. If there is peeling paint, children can sometimes ingest it. Dust from old paint can land on the floor or other surfaces that children touch with their hands (and then put their hands in their mouths). If there was ever lead paint on the outside of a house, it can sometimes be in the dirt around a house.
  • Leaded gas. While leaded gas was outlawed in 1996, its use is still allowed in aircraft, farm equipment, racing cars, and marine engines.
  • Water passing through lead pipes. Lead can be found in the water of older houses that have lead pipes.
  • Other sources. Lead can also be found in some imported toys, candles, jewelry, and traditional medicines. Some parents may have exposure at work or through hobbies and bring it home on their hands or clothing. Examples include working in demolition of older houses, making things using lead solder, or having exposure to lead bullets at a firing range.

What can parents do to protect children from lead?

First, know about possible exposures.

  • If you have an older home, get it inspected for lead if you haven’t done so already. (If you rent, federal law requires landlords to disclose known lead-based paint hazards when you sign a lease.) Inspection is particularly important if you are planning renovations, which often create dust and debris that increase the risk of exposure. Your local health department can give you information about how to do this testing. If there is lead in your home, don’t try to remove it yourself! It needs to be done carefully, by a qualified professional, to be safe.
  • Talk to your local health department about getting the water in your house tested. Even if your house is new, there can sometimes be older pipes in the water system. Using a water filter and taking other steps can reduce or eliminate lead in tap water.
  • If you have an older home and live in an urban area, there can be lead in the soil. You may want to have the soil around your house tested for lead. Don’t let your child play in bare soil, and be sure they take off their shoes before coming in the house and wash their hands after being outside.
  • Learn about lead in foods, cosmetics, and traditional medications.
  • Learn about lead in toys, jewelry, and plastics (yet another reason to limit your child’s exposure to plastic).

Second, talk to your pediatrician about whether your child should have a blood test to check for lead poisoning. The American Academy of Pediatrics recommends:

  • Assessing young children for risk of exposure at all checkups between 6 months and 6 years of age, and
  • Testing children if a risk is identified, particularly at 12 and 24 months. Living in an old home, or in a community with lots of older homes, counts as a risk. Given that low levels of lead exposure that can lead to lifelong problems do not cause symptoms, it’s always better to be safe than sorry. If there is any chance that your child might have an exposure, get them tested.

How is childhood lead exposure treated?

If your child is found to have lead in their blood, the most important next step is to figure out the exposure — and get rid of it. Once the child is no longer exposed, the lead level will go down, although it does so slowly.

Iron deficiency makes the body more vulnerable to lead poisoning. If your child has an iron deficiency it should be treated, but usually medications aren’t used unless lead levels are very high. In those cases, special medications called chelators are used to help pull the lead out of the blood.

For more information, visit the Centers for Disease Control and Prevention website on lead poisoning prevention.

About the Author

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Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD


Do toddler formulas deliver on nutrition claims?

Toddler with curly, brown hair drinking milk through through straw, on blanket outdoors, next to gray and white cat with saucer of milk

Once babies are a year old, those who have been drinking infant formula don’t need it anymore. By that age, they can and should get most of their nutritional needs met by solid foods. Drinking cow’s milk, or a fortified plant milk such as soy milk, is perfectly fine. And honestly, they don’t even need that much of it.

A 2023 report from the American Academy of Pediatrics (AAP) looked closely at what toddlers actually need for healthy growth and development — and toddler milks didn’t make the cut. Here are a few key takeaways for parents.

Is toddler formula more nutritious than milk?

No. But for some parents, it feels odd and uncomfortable to stop formula and give cow’s milk. They feel like formula is more nutritious and maybe even more easily digested. That may not be surprising: a lot of marketing money has encouraged people to think this way.

So it’s understandable that some parents turn to formulas marketed for toddlers. It’s especially understandable given the claims that formula companies make about the nutritional advantages of toddler formula. You may have seen — or bought — these products marketed purely as “follow-up formulas,” “transition formulas,” or “growing-up milks.” These formulas do not have a medical purpose. They simply help companies keep the customers they would otherwise lose once babies turn a year old.

Not only are toddler formulas unnecessary, some of them are actually worse than cow’s milk. That’s the main message shared by the AAP, which hopes to help parents understand what older infants and toddlers actually need — and see through the marketing claims.

Do some toddlers need specialized formulas?

Yes. Just to be clear, I am not talking about specialized formulas for children over 12 months who have digestive, metabolic, or other medical problems.

Are toddler formulas regulated in any way?

No. Because infant formulas must meet all the nutritional requirements of babies less than 12 months of age, they are regulated by the FDA. The FDA has requirements about what they must and must not contain, and it makes sure that the facilities where infant formulas are made are regularly inspected.

This is not true of toddler formulas. They are not regulated, and not required to prove any of the claims they make about their nutritional benefits.

What might make a toddler formula unhealthy?

Given the lack of regulation, it’s not surprising that there is wide variation in the composition of toddler formulas. But what is particularly worrisome, says the AAP, is that some of these products are actually unhealthy. They may have too little or too much protein, or have added sweeteners. These added sweeteners can build a child’s “sweet tooth” and set them on the path to obesity.

Additionally, toddler formulas are more expensive than cow’s milk, creating a financial burden for families — one that is definitely not worth it.

Is your toddler’s diet healthy?

Instead of reaching for a toddler formula, try to take a broader look at your child’s diet. Toddlers should eat from the same healthy food groups we all need. This includes

  • fruits and vegetables
  • whole grains
  • protein (such as meat, fish, beans, and nut butters)
  • dairy or dairy substitutes fortified with calcium and vitamin D.

Limit added sugars, and after age 2 try to limit less-healthy fats in the child’s diet as well. The best way to build healthy lifetime habits is to start early, and this is particularly true of nutrition.

About the Author

photo of Claire McCarthy, MD

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD


When should you hire in-home help or health aides?

A home health aide wearing a blue striped shirt helping an older man, seated and wearing a yellow and black top, with his daily shave

Most people want to age in place and live at home for as long as possible: according to an AARP survey, three-quarters of people 50 and older are hoping to do so.

But managing this successfully may mean hiring outside help, such as health aides who can assist you with daily activities that have become challenging. You might wonder when exactly it will make sense to seek that service. How will you know when it’s time? What can aides do for you? What are the costs and how can you make the most of their help?

Is it time to hire in-home help?

An easy way to know if it’s time for outside help is if your health takes a sudden turn for the worse — perhaps as the result of a fall that affects your mobility. But more often, the need for professional assistance at home isn’t so obvious. It develops gradually, as certain abilities — such as cooking, cleaning, or driving — become more difficult.

Even if you’re busy, happy, and able to do your own tasks and errands now, there may come a time when the balance shifts and daily activities become challenging.

“A lot of times these observations are made by family members or friends, and they start the discussion about getting help,” says Dr. Suzanne Salamon, associate chief of gerontology at Harvard-affiliated Beth Israel Deaconess Medical Center.

Start here: Ask yourself hard questions

You don’t have to wait until family and friends urge you to get outside help. Dr. Salamon recommends that you periodically assess your abilities and how well you’re managing on your own.

For example:

  • Is it harder to get in and out of the bathtub because of muscle weakness or balance problems?
  • Has driving become difficult because of vision changes, arthritis, or other reasons?
  • Are you keeping up with your medication regimen, or are you sometimes not sure if you’ve taken pills?
  • Are cooking and cleaning becoming much more of a chore than they used to be?
  • Do you find grocery shopping or errands a little overwhelming?
  • Do you need help bathing or getting dressed?

Be honest about the answers, and let your needs be your guide. “You might not need a home health aide yet. Maybe you only need a cleaning service to come in every other week,” Dr. Salamon says. “But if you need more assistance, it’s probably time to hire health aides.

What do health aides do?

Health aides are professional caregivers. There are two main types of aides.

  • A certified nursing assistant (CNA): This is a trained, licensed professional who can provide hands-on physical care, such as helping you get up and down from a chair or bed, bathing, dressing, feeding, brushing teeth, and using the bathroom. A CNA can also perform homemaker services, such as cooking, light housework, transportation, shopping, overseeing medication routines, or sharing meaningful activities or conversation.
  • A companion: This is a registered professional who can provide homemaker services but is not trained in body mechanics and cannot provide hands-on care.

The best place to find aides is through a private duty care agency, which vets and employs the aides, and takes care of their taxes and social security withholdings.

How can you find a reliable private duty care company, and what questions should you ask? Dr. Salamon suggests asking for recommendations from friends, your doctor, local senior services, or your local Area Agency on Aging.

How much does hiring health aides cost?

Private duty care is expensive. Costs average $25 to $30 per hour, typically with a three-to-four-hour minimum per week.

Those fees add up quickly. For example, if you need help two days per week for three hours per day, you’ll pay about $600 to $720 per month.

Costs are not typically covered by Medicare, but they are often covered by Veterans benefits. And they are sometimes covered fully or partially by long-term care insurance, state or local agencies on aging, or nonprofit groups.

What might hold you back from getting help you need?

Cost is a factor, of course. Even if it isn’t, you might not jump at the chance to hire home health aides. It could be that you feel you don’t need them yet, or that you’d be uncomfortable with strangers in your home.

But the sooner you can become accustomed to having professionals assist you with parts of your care as they become challenging, the better prepared you’ll be later, when you might require much more assistance. Trying services now can set you up with contacts — and caring people — you might need to lean on more often as time goes by.

How can you get over your reluctance? “Remember that you don’t have to commit to private duty care forever. Just try it for a few hours once a week. If it doesn’t go well, consider alternatives, such as eventually moving into assisted living,” Dr. Salamon says.

How far can a few hours of in-home help go?

What can an aide accomplish if you start out with just a few hours per week? Plenty.

You might want to set up a regular routine that includes doing laundry, changing bed linens, going on a walk with you, and making a large meal that can be frozen into smaller portions. Or you might want to focus on a theme for each once-a-week visit. For example, the aide can help you do errands one week, do some light house cleaning the next week, and help you cook the week after that.

“This is your opportunity to get the help you need, whether it’s with jobs around the house or basic activities of daily living,” Dr. Salamon says. “In the long run, it’s the kind of service that will keep you living on your own longer.”

About the Author

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Heidi Godman, Executive Editor, Harvard Health Letter

Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow … See Full Bio View all posts by Heidi Godman

About the Reviewer

photo of Howard E. LeWine, MD

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD


Talking to children about tragedies and scary headlines in the news

father and son talking while facing each other sitting on a concrete curb at a skate park, son has a skateboard leaning against his leg

The news these days is overwhelming in its awfulness. Acts of terrorism, wars, and heated conflicts constantly erupt throughout the world. Climate change looms, contributing to wildfires and flooding. Incomprehensible shootings occur with numbing regularity. The pandemic seems to be shifting from an immediate threat to health to an endemic illness — yet it’s still affecting us. The news has been so horrible, and so unrelenting, that it is hard to even process it.

Imagine processing it as a child?

Our first instinct is usually to shelter our children from the news and not say anything about it to them at all. That’s completely understandable, and if your child is very young or you are certain for some other reason that they aren’t going to hear about it, then not saying anything is a viable option.

But if they aren’t very young, or if you ever have the news on where they can see, or if they are ever in settings where people might have the news on or talk about it, it might not be so viable. If children are going to hear about something, they really should hear about it from you.

Also, as parents it’s important that we give our children the perspective and skills they need to navigate this scary world where, let’s be honest, bad things happen. The way you talk to children about tragedies in the news can help them cope not just now, but in the future.

The American Academy of Pediatrics has all sorts of resources to help parents talk with children about tragedies. Here are four simple things all parents can and should do:

1. Tell them what happened, in simple terms. Be honest, but skip the gory details. Answer their questions just as simply and honestly. If you think — or know — that your child has already heard something, ask them what they’ve heard. That way you can correct any misinformation, and know not only what you need to explain but also what you may need to reassure them about.

2. Be mindful of the media that your child sees. The news can be very graphic, and because the media are as much in the business of gaining viewers as of delivering news, they tend to make things as dramatic as possible and play footage over and over again. When the planes flew into the Twin Towers on 9/11, my husband and I were glued to the television, not realizing that one of our daughters, who was 3 years old at the time, thought that planes were literally flying into buildings again and again. It wasn’t until she said, “Are those planes going to come here too?” that we shut off the TV and didn’t turn it back on again until all the children were in bed.

3. Make sure your child knows that you and others are always doing everything you can to keep them safe. Talk about some of the ways you keep them safe, ways that are relevant to the tragedy you are talking about. Make a safety plan as a family for things like extreme weather or getting separated. Help them think about what they might do if they are ever in a scary situation, and who they could turn to for help. Which leads me to the most important thing to do…

4. Look for the helpers. The wonderful Fred Rogers often talked about how when he saw scary things on the news, his mother would tell him to look for the helpers, because there are always people who are helping. That may be the best thing we can do as parents: help our children look for the helpers. In all of the recent tragedies, as in all tragedies, there were so many helpers and heroes. When we concentrate on those people, not only do we give our children hope, but we may empower them to one day be helpers too.

The world can be a scary place, yet there is much we can do — from a very young age — to help children build strengths and nurture resilience, even in the face of tragedy.

About the Author

photo of Claire McCarthy, MD

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD