P4P Circumcision
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[00:00:00] Dr. Alicia Power: Welcome to the Pregnancy for Professionals Podcast. Today, we have Dr. Ellen Forbes, who is a urologist with a specialty in male infertility with us today to talk about circumcision, mostly in newborn infants. And when we talk about circumcision today, we're talking specifically around penile circumcision, but we'll also broach on in the childhood and adult days as well.
[00:00:24] [00:01:00]
[00:01:14] Dr. Alicia Power: So Dr. Forbes, Ellen, why don't you start by telling us a little bit about yourself.
[00:01:20] Dr. Ellen Forbes: Thank you so much, Alicia. And thank you for having me. I'm Ellen Forbes. I am a physician and a board certified urologist with a fellowship in male fertility and reproductive health. So I'm from the east coast of Canada. Originally. I went to Dalhousie Medical School in Halifax, Nova Scotia. I moved to Western Canada to complete my residency at the University of Alberta, followed by a fellowship in male fertility at the University of Toronto. So I, as a urologist, I see all sorts of urology issues. So that's the urinary tract of men and women. But my specific niche or area of expertise [00:02:00] is specifically in male reproductive health and fitness.
[00:02:04] Dr. Alicia Power: Awesome. Thank you. And thanks for talking about this topic, because I think as care providers, sometimes it can be a bit challenging to have these conversations with patients who are wondering about kind of circumcision. And so I think hopefully today we'll break it down a little bit so that people, we can have more informed discussions with our patients and answer their questions a bit more effectively. So first of all, why don't we just, I know most people already know what this is, but why don't we just say, what is penile circumcision?
[00:02:27] Dr. Ellen Forbes: Exactly. So penile circumcision is removal of the distal portion of the foreskin. So the portion that goes out over the glands of the penis is excised or removed. And then the remaining skin from the penile shaft heals back together with the distal skin of the penile shaft. And then you no longer have that foreskin hanging over the glands or head of the penis.
[00:02:53] Dr. Alicia Power: And we just did a podcast for our, for pregnant people. So we have another podcast for patients [00:03:00] and anyway, so Ellen describes it as taking the turtleneck off the turtleneck and making it into a crew neck sweater. So I thought that was a good way of describing it to people. So can we talk a little bit about prevalence of circumcision. So how many newborns and let's talk about newborn infants here. How many newborns are getting circumcised and how has this kind of changed over the past few decades?
[00:03:19] Dr. Ellen Forbes: Yeah. So this is a fascinating topic. You can really go down a rabbit hole online in terms of the history of circumcisions, and there's all sorts of ancient artifacts, tombs in Egypt. There's chose circumcision from like the two thousands years BC. So it's been around a long time. And there's been massive fluctuations in the prevalence of circumcision. And this is highly variable from country to country and even from province to province, and decade to decade. So overall, currently in the world and in Canada, the prevalence is about 30% of infants being circumcised. But back in the seventies, it [00:04:00] was quite a bit higher. It was upwards of almost 50%. And then it declined from the seventies through to the nineties by the nineties, it was about 30% where it has remained. But between provinces there's really massive variation. There have been a couple of big studies done, which have shown in certain territories, the Yukon was upwards of 75%, whereas a province such as Newfoundland, it was only one to 2%. So it's really depending on where you live and the population of people within within that province and the composition of the population has a big effect as well.
[00:04:35] Dr. Alicia Power: So interesting hey, and I think in BC, you're right. We're about kind of 30 ish percent. And that's what I always tell my patients too. That's always my kind of approximate guess.
[00:04:44] Dr. Ellen Forbes: Yeah. I suspect it's probably going to decline a bit further if we had an updated study done soon, I suspect it would be a bit into the twenties, a high twenties, but yeah, that's, I think it's due to a couple of different factors, but yeah, we're close to [00:05:00] 30%.
[00:05:01] Dr. Alicia Power: Yeah. So when counseling kind of patients and parents of newborns, how do you, what do you how do you help guide that decision? Or what kind of factors go into making those decisions?
[00:05:11] Dr. Ellen Forbes: That's a great question. So I talked to the parents of the child regarding circumcision as it being a choice that they're making for the child, but they really need to put the best interest of the child in mind. So keep that at the forefront. I think that should always be our priority when we're making decisions for our children is what do we really believe is best for the children? There was a big survey done called the Canadian Maternity Experience survey. Thousands of mothers in this instance were surveyed and the ones that had chosen to circumcise their infants were questioned regarding the reasons for doing so. And the most popular reasons were because of health or hygiene beliefs that was given about 44% of the time. The next most common was to [00:06:00] be like the father of the baby or the siblings of the baby or their peer group, that was about 35 to 36% were doing it for that reason. And then religious reasons made up about 17% of the decision making. There's a few different factors that people consider. But really it's, you want to keep the best outcome of the child in mind.
[00:06:22] Dr. Alicia Power: And what are our pediatric societies telling us? So we often try to follow what are our provincial or national guidelines are, what are we hearing from them?
[00:06:31] Dr. Ellen Forbes: So there are a couple of societies that have the statements that are updated regularly. So there this, the Canadian Pediatric Society, and there's also the American Academy of Pediatrics who both hold the position that a routine circumcision is not medically indicated, so that's not coming out and saying that they necessarily, are forbidding it or telling people that it should not be done. But they're saying that [00:07:00] there's no evidence that that it's necessarily beneficial medically to routinely circumcise infants.
[00:07:08] Nowadays they include conversation or some comments regarding the infection risks. That's where the population that you're treating really comes into consideration. For example, if you are in Sub-Saharan Africa, where there's a high prevalence of HIV, then you are going to consider a circumcision more strongly because it is showing that the benefits do outweigh the risks. Whereas if you're in North America where we have a very low prevalence of HIV that risk, the benefits that you're getting from circumcision in terms of reducing your risk of HIV is quite minuscule, just because it's so rare to begin with.
[00:07:45] So it's, you really have to look at what your patient population is when you're deciding whether or not to recommend it. But for most north American patient groups, there's not enough risk there to recommend routine circumcision.
[00:07:59] Dr. Alicia Power: [00:08:00] Okay. So why don't we talk a little bit about what the benefits are and what are the risks associated with that? So you touched on decreasing the risk of STIs is including HIV. And I think we were saying decreases it by 50 to 60%. Is that correct?
[00:08:13] Dr. Ellen Forbes: Yes, that's right. So upwards of 60% decrease in HIV risk, but there's also a fairly significant decrease in a couple of STIs, which are more common in our population. So HSV and HPV, which we know can also lead to penile cancer and cervical cancer, or decreased the risk of those by about 30% with circumcision. So that's not, in significant that's something that we do want to consider when we're counseling patients. It's worth mentioning to them because the prevalence of those two STI is relatively common in our population,
[00:08:48] Dr. Alicia Power: Although I guess the risk of HPV is decreasing dramatically with the vaccine, with the vaccination. So now making the decision, that's going to be a very different discussion than it was 30 years ago, right? Because that's a [00:09:00] very low should be hopefully, continues to go a low prevalence of HPV resulting in cervical cancer and penile cancer from that those specific risk.
[00:09:10] Dr. Ellen Forbes: Exactly. Yeah. And penile cancer was already quite rare. It was about one and a hundred thousand. So to circumcise based on reducing that risk is it's not necessarily that beneficial.
[00:09:22] Dr. Alicia Power: Okay. And then, so those are benefits. So what are risks associated?
[00:09:27] Dr. Ellen Forbes: So there's a couple of other benefits, including decreasing the risk of urinary tract infection in the first year of life. Risk of UTI with an infant male is fairly rare. And so we don't routinely recommend neonatal search to prevent UTI in the infant. But if you do have an infant who is having recurrent UTI, then it may be recommended by your physician. It also prevents foreskin issues. So fibrosis, tight foreskin or balanoposthitis, inflammation or infection of the foreskin skin [00:10:00] is basically eradicated with circumcision, and then other considerations would be things like personal preference or religious preference, religious beliefs, cosmetic preference things like that.
[00:10:12] Dr. Alicia Power: All right. So why don't we go chat about risks of circumcision.
[00:10:18] Dr. Ellen Forbes: Yeah. Obviously no procedure is without risk. And I feel that it's important to reiterate to patients that this is technically a surgery. Anytime that you're altering the body or in removing a portion of the body that should be considered seriously because although it is very common and people may think it is just a routine part of having a baby boy, it does certainly come with risks. So about one to 3% result in minor complications. So this could be persistent bleeding or infection. So I counsel patients that it's normal to have some blood in the diaper, especially for the first 24 to 48 hours, but it should be a small amount of blood, so smaller than a toony and not a [00:11:00] continuous flow from the penis.
[00:11:02] If there is a little bit extra bleeding or seems to be oozing, then I recommend to patients that they apply pressure to get that, to stop typically with a couple of minutes or five or 10 minutes of pressure that, that will stop. If it doesn't stop, they should definitely be instructed that they need to contact their provider. Because there have been instances of babies who have had undiagnosed bleeding disorders, such as hemophilia. And there have rarely been instances of death because, the providers may have said some bleeding is normal and if it's too vague and the patients don't realize, they may think that excessive bleeding is normal and so it's really important to counsel patients what is normal and what's not. Infection, I counsel patients that if it looks a yellowish green with some pus or expanding redness over an area of the skin, notify your doctor, and that typically clears up quite quickly with antibiotics. [00:12:00] Some other risks of circumcision include poor cosmesis. So this is not all that unusual where parents come back maybe a year or two down the road and say, I didn't, it doesn't look right. Or I don't, there's something going on there that I didn't expect to be there. And oftentimes that can be what's called an adhesion or skin bridge where the skin from the shaft of the penis may form an attachment to the glands. And that might persist even as they grow up into teenage years and adulthood and can affect their self-confidence. And so sometimes we do have patients that come in and we fix that surgically, but it requires a procedure.
[00:12:40] Another thing that may require a procedure down the road is medial stenosis. So when the glands is exposed because you've removed the foreskin and it's rubbing against the diaper that can cause inflammation and irritation of the tip of the penis, which can cause scarring, narrowing of the urethra so if a patient comes [00:13:00] in and has an infant who has been circumcised, they're saying always seems to be hard when he pees, is having pain when he pees, where it's spraying all over the place, or it looks like a pin hole. It look, it used to look like a slit and now it looks like a pin hole, something like that. Then I would have a look with the concern that there might be some meatal stenosis and that would require treatment typically by a urologist.
[00:13:25] Dr. Alicia Power: And those two things is why, to prevent those two is why you use so much vaseline or petroleum jelly post-procedure, correct?
[00:13:31] Dr. Ellen Forbes: Exactly. Yeah. So I always recommend that you use, you can't use too much, so copious amounts of Vaseline afterwards. So that's to prevent the skin from sticking to the diaper while it's healing, which would obviously be uncomfortable for the child and also result in recurring sort of tearing of the skin and it having to heal again. But also to prevent it, the skin from the shaft to heal to the penis and prevent a irritation of the tip of the peanuts. So there's lots of reasons. [00:14:00] It's really good to keep that area moisturized with lots of Vaseline, right after for at least a few days. So
[00:14:06] Dr. Alicia Power: And I know serious complications are pretty rare, but why don't we touch on them briefly about what those are.
[00:14:11] Dr. Ellen Forbes: Yeah, so they're quite rare. But serious complications would include things such as removing too much skin. If you remove too much skin, then you can get what's called a, basically like a buried penis where it's tethered within the skin and that would require typically reconstructive surgery. And also there have been instances where the tip of the penis or the glands of the penis can actually be severed. So depending on your technique, which we'll talk about a bit later, I believe there are instances where the tip has been cut off and sometimes that requires urgent reconstruction or, it results in loss of that portion of the penis. And of course the death is the most severe complication and that is extremely rare. But in those instances where there's an undiagnosed bleeding disorder, unfortunately there have [00:15:00] been instances of death from neonatal services.
[00:15:03] Dr. Alicia Power: Okay, thank you for that. So you chatted a little bit about when you would recommend this. A patient with a penis had, has recurrent urinary tract infections that has recurrent irritation or inflammation of the foreskin, or that has kind of phimosis to that restrictive foreskin. So those would be three, three indications for circumcision. Are there any other that you can think of that you would recommend.
[00:15:27] Dr. Ellen Forbes: Yeah, that's right. There's also patients who have high grade reflux. So that's called urethral reflux where the urine is it's supposed to becoming one way street down from the kidneys to the bladder, but instead there's some back pressure and it's rinsing up back towards the kidneys, which is bad because it increases the pressure within the kidneys and causes sometimes a decrease in kidney function or infection that spreads up to the kidneys. So if they have high grade reflux and, recurrent UTIs and things like that, then then we want to do [00:16:00] everything we can to try and protect the health of the kidneys. And sometimes that means recommending circumcision.
[00:16:07] Dr. Alicia Power: And what are your, you have your number needed to treat on those?
[00:16:10] Dr. Ellen Forbes: Yeah, that's right. So the number needed to treat, in the general population where, the risk of a UTI is generally about 1% for these baby boys, it's about 111% for the number needed to treat. So, it goes to show you that, although it does prevent UTIs, it's not necessarily something that you should routinely be recommending because the risk is so low, but once you have a baby who has recurrent UTI or high grade reflux or something that, that is more concerning, then, if the risk of recurrence of the UTI is about 10 to 30% within the first year that your number needed to treat drops to the kind of five to 10. So it's a lot more valuable of a procedure when you have a patient who has [00:17:00] recurrent UTIs.
[00:17:01] Dr. Alicia Power: Okay. And what population are you not recommending or asking to delay until appropriately counseled by a urologist.
[00:17:10] Dr. Ellen Forbes: Exactly. So in babies who have hypospadias. So it's important if you have a patient who's requesting a circumcision, it's important to do an exam and have a look at what does the foreskin look like to begin with. So hypospadias, as we all know, is the condition where the opening of the urethra is not quite at the tip. And it typically goes along with abnormalities of the foreskin where the foreskin has not fused completely all the way around the penis. So if you have a look and either the whole the meatus is not quite at the tip, but it's more on the underside of the of the glands where it's even further ventral down under the shaft. Or if, even if the hole's at the tip, but the skin itself is bunched up dorsally and it doesn't circle all the way around the penis, [00:18:00] that is hypospadias. So it can be mild. But you still want to refer typically to a pediatric urologist to have a look before offering circumcision, because we actually like to use that excess skin from the foreskin during the reconstructive process. So if they have the hole, the meatus, on the underside of their penis. And we'd like to get it at the tip of the penis because we want them to be able to pee straight, pee standing up, we want ejaculated semen to get where it's supposed to go when they're older, if they're trying to start a family. And so we use that skin to actually reconstruct and relocate the tip and that kind of thing. So it's important to, to have those patients seen by a urologist before offering circumcision.
[00:18:40] Dr. Alicia Power: And if you've never seen a failed, or a hypospadias before, it looks like a cobra.
[00:18:45] Dr. Ellen Forbes: Yeah. Yeah.
[00:18:46] Dr. Alicia Power: A colleague described that to me. Does it, I came out, I was like, there's something not right with this penis. Like, it looked like a Cobra. I was like, it does indeed!
[00:18:53] Dr. Ellen Forbes: Yes, exactly. Yeah. And it can be mild. And if you're not sure just ask, I'm more than happy. [00:19:00] Sometimes you get, a text message. Can I send you a photo with the patient's permission? And it's yeah, that's a hypospadias, you don't want to offer surgery. You want them to be seen because that foreskin is valuable. We want to use it for good. So don't, we don't want it to be thrown in the garbage bin. Some other instances in which it would not be recommended is if there's any family history of bleeding disorders. So you want to ask your patients who are interested in a certain decision if they, or their parents, or cousins or anything like that have been known to have a bleeding disorders such as hemophilia. And the other issue is if they're premature, so little tiny babies, we want to wait until they're full-size until they're at that to full term and without other significant, co-morbidities before offering circumcision.
[00:19:47] Dr. Alicia Power: All right. So we're going to put away the medical reasons for getting a circumcision right now. We're just going to talk specifically about those kinds of common, newborn penile circumcisions [00:20:00] for nonmedical reasons. When is the ideal time to be getting to be advising families to get that done if they're choosing to do so.
[00:20:08] Dr. Ellen Forbes: Yeah. So in general, the advice is the earlier the better, ideally within the first week or so of a week or two of life. So within the first eight days is the best. But within the first couple of weeks is certainly reasonable. So that's based on a couple of studies. There was a study done in 2009 and that used the neonatal infant pain scale to score the severity of pain based on signs that infants exhibit to show that they're in pain. So changes in their breathing pattern, movement of their limbs, crying, all that kind of stuff. So they're given a score based on all of these appearances that allows us to judge approximately how much pain they seem to be in and a score of two or higher is what is considered a painful procedure.
[00:20:58] So when we look at [00:21:00] babies who are circumcised within the first week of their life, only about six, six and a half of babies within that week showed any signs that there were in pain, so a pain score of two or more, but by the time they reached four weeks of life, that went up to actually a hundred percent of pain of babies were showing that they were in some discomfort based on a pain score of at least two. And so if you can have your infant circumcise within their first week or so, that is ideal. Most physicians who provide neonatal circumcisions will still provide it, at week two, week three but the earlier the better, and then once you reach a month, it's typically harder to find someone who is going to do it because it's, it can be a little bit more challenging because it is more painful.
[00:21:51] And so there's more movement and a little bit more distress of the infant. And so the earlier the better, and because of that, you really want to stress to your [00:22:00] patients, that this is a conversation to be having within the first couple of trimesters, because as we all know, babies can come at any point. It's not rare to have a premature infant, and this is not a decision that you want to be making with urgency. When you're immediately postpartum, you've got a crying infant. That's... you want to start the conversation in the early part of pregnancy. And some patients also change their mind. Some patients decide they wanted a circumcision, but then the baby's born and they think, I can't imagine doing that. And that's fine, but they want at least start the conversation within the earlier part of the pregnancy.
[00:22:37] Dr. Alicia Power: Yeah. And Ellen and I just did a podcast on, for patients, on a circumcision and decisions around it talking about much of the same information that we're talking about now, but more kind of patient focused. So certainly if you have patients who are curious, you can send them to our podcast, the She Found Motherhood Podcast to get a little bit more information around that piece of the puzzle. So we're talking about pain scale. So what kind of anesthetic is performed for these kinds of, [00:23:00] less than one month old, circumcisions.
[00:23:02] Dr. Ellen Forbes: Yeah. So in these babies, it's local anesthetic. So either the topical cream which numbs the skin or a needle of local anesthetic lidocaine, that kind of thing. Depending on your provider is really determine which type of anesthetic is used. But both of those have been shown to have good results. Obviously the injected anesthetic requires a needle, but it's usually a very tiny needle that is used and so it may be a quick little pinch. But then the area is typically quite numb for often two or three hours and that's a very good way of keeping the pain under control. And then the other factors that help to control pain include parenting, showing a lot of affection for the child and either nursing them or giving them milk, feeding them, and also things like sugar water, you can dip if they use a pacifier, you can dip it in some sugar water. And that has been shown to decrease pain as well in infants. So it's usually a [00:24:00] combination of sort of, keeping them comfortable and distracted with food and things that they like. And also the local anesthetic, and Tylenol can be used as well afterwards if needed.
[00:24:11] Dr. Alicia Power: Great. So now that we've got them properly anesthetized, why don't we chat about the different methods that can be used to perform the circumcision?
[00:24:19] Dr. Ellen Forbes: Yeah that's a great question. As a urologist, most urologists who are performing circumcision in adults and in children will do basically a free hand technique where we use a marking pen to delineate where we want the outer incision to be, and then remove the skin, using a scalpel and reconstruct it with sutures by hand, but most neonatal circumcisions are done using devices. So there's several different devices that have been designed specifically for this use. The Gomco Clamp may be the oldest one. I'm not sure if it's the oldest, but it's been around certainly a long time. So that's basically a bell shaped device. So you [00:25:00] open up the foreskin or and use a probe to, to get rid of the kind of attachment between the inner part of the foreskin and the glands. And then the ring portion of the clamp is, goes in the foreskin and over the head of the penis to protect it, the foreskin is pulled back up over the clamp and then that portion, sitting over where the head of the penis is, is removed, using a scalpel, and then it heals back together with secondary intention.
[00:25:29] A similar technique is the Plastibell technique, plastic instead of metal. But the difference with this is that there's a piece of suture tied around the foreskin over a plastic ring, and that cuts off blood supply to the foreskin. And the plastic ring is left on and falls off on its own about a week later. And it's a reasonable technique, but you have to make sure that you counsel patients appropriately because they're going home with a foreign body attached to the infant's penis. And [00:26:00] sometimes you can have migration where it moves proximately to a spot where it's not supposed to be, and that would be obviously concerning and they need to make sure that it falls off at an appropriate time, and all that stuff. So that one requires a little bit more close follow- up, I would say. And then the other clamp, which is commonly used as the Mogen clamp. So that's basically where the, again, the foreskin, the underside is a probe is used to undo those attachments to the glands and it's pulled over the head of the penis and then put into this clamp and the excess skin is cut off and, and the remaining skin heals with secondary intention. So similar to the mowing clamp, just a little bit of difference in that you don't have that bell that's placed in over the top of the clans itself.
[00:26:53] Dr. Alicia Power: Great. And so we have already touched on this, but let's quickly go over what, how we can advise parents for kind of that post [00:27:00] circumcision care.
[00:27:00] We talked about lots of petroleum jelly, so using that a lot, all the time with every diaper change put on more than you think you need. That's right. I also chatted about what kind of a bleeding to expect and when to reach out for help, we talked about kind of infection, what to watch for. And then the other things that I know we had chatted about in our other podcast is assigned which we all know about as well, but don't forget to mention fever filled blister. The other thing is not urinating. And what do you usually guide parents on? What's your kind of frame for them to know?
[00:27:30] Dr. Ellen Forbes: So if the baby's not urinating within about 12 hours after the circumcision, that's a problem. Oftentimes the first thing that I recommend in any baby, who's not peeing is to put them in a warm bath and see what happens. Because often if there's something that hurts down there then they clench up and then they don't want to do anything that could potentially make things worse. So putting them in a warm bath and trying to distract them will often result in some urination. So [00:28:00] it can be a bit hard to tell whether or not they're peeing, but but that can help. And yeah. So the other thing that I think is important to manage expectations with patients before they go for the circumcision, because otherwise you're going to have a lot of phone calls afterwards. Often within the first week after circumcision, it really doesn't look great. It's swollen, it's, there's the incision, that's healing and there's granulation tissue that's coming together. And so it's not uncommon for patients to not freak out, but to be a little bit concerned regarding, oh my goodness, it doesn't look right. It's not like I expected it to look, did I make a mistake? Is there something wrong? And so it's important to manage expectations and let them know it's going to be swollen. It's not going to be pretty for the first week or so, watch out for the bleeding, watch out for the expanding redness or erythema watch out for [00:29:00] puss and fever and things like that, but just let them know that it's not going to look great for the first few days afterwards, what it looks like two months down the road is completely different. So if they're concerned that they made a mistake because it doesn't look good, that's not a concern initially. You want to watch out for the serious things and the signs of those, but don't worry so much about the cosmetic appearance because it looks completely different and a lot better after a month.
[00:29:29] Dr. Alicia Power: Awesome. Wow. That was lots to chat about and a big topic. And always hard to have those conversations in our society. I know for me, I have 10 or 15 minute appointments to do the prenatal care and then these questions come up and it's really hard to have these informed discussions with patients so, appreciate this information. Is there anything else that you wanted to chat about that we didn't talk about?
[00:29:49] Dr. Ellen Forbes: I don't think so. So in Canada, something to make sure patients are aware of is that it's not covered if it's not medically indicated. So if you have a patient who has recurrent [00:30:00] UTI or some other complication, phimosis something like that, then it will be covered by your provincial healthcare. But otherwise, if it's just the caregivers, the parents who are wishing to have it done for their own personal reasons, they're going to have to pay out of pocket. And the price is highly variable. For a neonatal circumcision in BC, it's typically in the range of a few hundred to $500.
[00:30:25] So just giving that information so that they can incorporate that into their decision making process. And then also referring them to, to whoever is in your town. Who has lots of experience to make sure they're comfortable with them. And that provider typically has lots of information to give those patients. So even if you don't have the time to run through the history of circumcision and all these details about hemophilia and everything if you want to send them along to that person, who's offering the circumcision, they typically have a great plethora of information to [00:31:00] provide those patients.
[00:31:01] Dr. Alicia Power: Awesome. Great. So if people are interested in finding you on social media, where can they find you Ellen?
[00:31:07] Dr. Ellen Forbes: Thank you so much. So I'm Ellen Forbes, MD I'm on Instagram and Facebook, and I'm going to be launching my own website and podcast, actually all about men's health with a specific focus on fertility. And so that's coming soon. So stay tuned to my social media channels for more information.
[00:31:27] Dr. Alicia Power: Awesome. Great. And then if you have pregnant or newly parenting patients and they need a little bit more support or you're looking for an evidence-based site for them to check out, then make sure, send them over to our site, She dot, Found dot Motherhood on Instagram or Facebook. And then we have our podcast, the She Found Motherhood Podcast. Thank you, Ellen so much for coming on and chatting with us.
[00:31:47] Thank you for having me. It's been great. Have a great day.
[00:31:50] [00:32:00]
