Newborn Myths

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					     Newborn Myths

         Bryan Burke MD
University of Arkansas for Medical
             Sciences
  Arkansas Children’s Hospital
       Common Knowledge is
         Sometimes Wrong
• Sherlock Holmes never said “Elementary,
  my dear Watson.”
• In Casablanca, Ilsa Lund never said “Play it
  again, Sam.”
• Whales and dolphins are not fish – they are
  mammals.
• “Irregardless” is not a word.
• “Sherbet” does not have an “r” after the
  second “e”.
   Common Medical Knowledge is
      Sometimes Wrong, too
• Galen bled people to get rid of “evil
  humors”.
• Purgatives.
• Carter’s Little Liver pills.
• The correct spelling of the stool test for
  occult blood is “guaiac”, not “guaic”.
• Prophylactic antibiotic therapy for recurrent
  otitis media – mea culpa.
   Formula Supplementation of
      Breast-fed Newborns
• Reasonable only for a very few indications
  – hypoglycemia, greater than 10% weight
  loss from birth.
• Never reasonable because “my milk hasn’t
  come in yet” in a newborn less than 48
  hours old.
• Never reasonable because “he doesn’t seem
  satisfied” after breastfeeding.
   Formula Supplementation of
      Breast-fed Newborns
• Every nursery seems to be full of medical
  personnel who tell mothers that, for some
  reason, their babies need formula too.
• Unicef/WHO Baby-Friendly Hospital
  Initiative clearly states “Give infants no
  food or drink except breast milk, unless
  medically indicated”.
• Why then is this pattern so widespread and
  entrenched?
     Infants Who Require Phototherapy
              Need IV fluids
• Unless there is evidence of dehydration,
  routine IV fluid supplementation of term
  and near-term infants receiving
  phototherapy is not necessary.1
• Even with mild dehydration, the best fluid
  supplementation is done orally, with a milk-
  based formula or breast milk., because it
  inhibits the enterohepatic circulation of
  bilirubin.
•   1. American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia.
    Management of Hyperbilirubinemia in the newborn infant 35 or more weeks of
    gestation. Pediatrics, 2004;114:297-316.
   Breast Milk is Complete Nutrition
    for a Healthy Term Newborn
• The American Academy of Pediatrics
  (AAP) recommends all breastfed infants
  receive 200 IU of Vitamin D until they are
  getting at least 500 ml per day of Vitamin
  D-fortified formula or milk.2
• This supplemental vitamin therapy
  should start before the baby is two
  months old, preferably at discharge
  from the nursery.
2. AAP’s Pediatric Nutrition Handbook, Fifth Edition, page 71.
    Pacifier Use is Bad for Newborns –
      Conflicting Recommendations
• Baby-Friendly Initiative states “Give no
  pacifiers or artificial nipples to
  breastfeeding infants”.
• The AAP says “Pacifiers should not be used
  until breastfeeding is well established”.2
• Now pacifier use has been showed to cause
  a decrease in SIDS.3
•   2. AAP’s Pediatric Nutrition Handbook, Fifth Edition, page 70.
•   3. Hauck FR, Omojokun OO, Siadaty MS, Pediatrics, 2005:116;716-723.
Newborn Emesis is an Indication
    for a Formula Change
• Most newborn emesis is normal. It is easy
  for parents – and us - to over interpret
  normal as abnormal.
• While emesis due to gastroesophageal
  reflux can be a manifestation of milk
  allergy, a newborn has not had time to
  develop an allergy to his formula.
      Breast Milk Jaundice is Best Treated by
      Stopping Breastfeeding for 24-48 hours

• Only needed if the infant is felt to be at risk
  for needing an exchange transfusion.1
• Often touted as a safe and economical way
  to diagnose and treat breast milk jaundice.
• The main thing this approach accomplishes
  is to stop mothers from breastfeeding.
• Even with the best of reassurances, many
  mothers stop breastfeeding because “there
  must be something wrong with my milk”.
•   1. American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia.
    Management of hyperbilirubinemia in the newborn infant 35 or more weeks of
    gestation. Pediatrics, 2004;114:297-316
     Conditions Wrongly Felt to be
    Contraindications to Breastfeeding
• Mothers on magnesium should not breast
  feed.
• One hears this old saw all the time, from
  doctors and nurses.
• It is simply wrong.4,5

•   4. The Transfer of Drugs and Other Chemicals Into Human Milk, Pediatrics,
    2001:108;776-789.
•   5. Hale TW, Medications and Mothers’ Milk, 2004, pages 506-507.
     Conditions Wrongly Felt to be
    Contraindications to Breastfeeding
• Mothers who are Hepatitis B surface antigen-positive.6
• Mothers infected with Hepatitis C virus – having Hepatitis
  C virus antibody or Hepatitis C virus-RNA-positive
  blood.6
• Mothers who are seropositive CMV carriers – not recent
  converters if infant is term.6
• Mothers who are seropositive CMV carriers with babies
  less than 1500 grams – the evidence is less clear.7

•   6. American Academy of Pediatrics Red Book: 2003 Report of the Committee on Infectious
    Diseases. 26th edition; 2003:118-121.
•   7. Yasuda A, Kimura H, Hayakawa M, et al. Evaluation of cytomegalovirus infections transmitted
    from a real-time polymerase chain reaction assay. Pediatrics, 2003;111:1333-1336.
     Conditions Wrongly Felt to be
    Contraindications to Breastfeeding
• Mothers who are febrile.8
• True contraindications to breastfeeding
  while febrile include:
  1. Active untreated tuberculosis
  2. Being human T-cell lymphotropic virus
  type I or II positive.
  3. Mothers with a herpes simplex lesion on
  the breast.
•   8. Lawrence RA, Lawrence RM. Appendix E. Precautions and breastfeeding
    recommendations for selected maternal infections. Breastfeeding: A Guide for the
    Medical Profession. 5th Edition. 1999:868-885.
     Conditions Wrongly Felt to be
    Contraindications to Breastfeeding
• Tobacco smoking.4
• All maternal alcohol intake must be
  avoided, when in fact an occasional
  celebratory single, small alcoholic drink is
  acceptable, but breastfeeding should be
  avoided for 2 hours after the drink.9
•   4. The Transfer of Drugs and Other Chemicals into Human Milk, Pediatrics, :108;776-
    789.
•   9. Anderson PO. Alcohol and breastfeeding. Journal of Human Lactation. 1995;11:321-
    323.
    Transition Nurseries Help Us “Not
             Miss Anything”.
• Healthy infants should be placed and
  remain in direct skin-to-skin contact with
  their mothers immediately after delivery
  until the first feeding is accomplished.10
• A healthy infant can latch onto the breast
  within the first hour of birth. We should dry
  the infant, assign Apgar scores, and perform
  the physical exam while the infant is with
  the mother.
•   10. American Academy of Pediatrics Policy Statement, Breastfeeding and the Use of
    Human Milk, Pediatrics, 2005;115:496-505.
Transition Nurseries help us “Not
         Miss Anything”
• The mother is an optimal heat source for the
  baby.
• We should delay weighing, measuring,
  bathing, needle-sticks, and eye prophylaxis,
  and other uncomfortable procedures until
  after the first feeding is completed.
• Except under unusual circumstances the
  infant should remain with the mother
  throughout the recovery period.
   “My baby’s got water on his
           kidneys”
• Prenatal ultrasound is a good tool for
  diagnosing hydronephrosis before birth.
• The problem is that many babies have
  prenatal ultrasound findings of
  pyelectasis/pelviectasis that are simply
  variations of normal.
• All we as pediatricians ever hear from the
  parents is that “his kidneys are dilated”, or
  something like that.
• The end result is that many normal babies
  are getting unnecessary renal ultrasounds.
       “My baby’s got water on his
               kidneys”
• Neonatal evaluation is prudent if the renal
  pelvis diameter reaches 10mm at any point
  in gestation, or if calyceal dilation is noted.11
• Neonatal evaluation is prudent if the renal
  pelvis diameter exceeds 7mm at or beyond
  34 weeks gestation.11
•   11. Pates JA, Dashe JS, Prenatal Diagnosis and Management of Hydronephrosis, Early
    Human Development, 2005, article in press.
       “My baby’s got water on his
               kidneys”
• For those children with mild pyelectasis (7-
  9mm) and moderate pyelectasis (10-14mm),
  ultrasound alone is sufficient as a postnatal
  screening tool. Done on day 5, if the
  ultrasound reveals a renal pelvis dilation of
  less than 7mm, with a confirmatory
  ultrasound at 1 month, no further follow-up
  is needed.12
•   12. Ismaili K, Avni FE, Wissing KM, Hall M. Long-term Clinical Outcome of Infants
    with Mild and Moderate Fetal Pyelectasis: Validation of Neonatal Ultrasound as a
    Screening Tool to Detect Significant Nephrouropathies. Journal of Pediatrics, June
    2004;759-765.
   “My baby’s got water on his
           kidneys”
• The difficulty with this approach is that we
  need to know what the prenatal ultrasound
  showed.
• This information is not easily available –
  obstetricians and family practitioners have
  not been trained to send us this information.
 Umbilical Cord Care = Voodoo
• Topical ablutions to prevent infection are
  common.
• Antiseptics – alcohol, silver sulphadiazine,
  iodine, chlorhexedine.
• Dyes – triple dye, gentian violet,
  acriflavine, eozine.
• Antibiotics – bacitracin, neomycin,
  nitrofurazone, tetracycline.
    Umbilical cord care = Voodoo
• “No evidence that applying sprays, creams,
  or powders are any better than keeping the
  baby’s cord clean and dry at birth.”13
• All the data is from high-income countries –
  the situation may be different elsewhere.


•   13. Topical Umbilical Cord Care at Birth – Review. The Cochrane Collaboration 2005.
Gowning in the Nursery for Visitors
         and Attendants
• Gowning is widely believed to decrease the
  incidence of nosocomial infection in
  newborns.
• Family members are virtually always asked
  to gown before entering.
• Doctors in street clothes are often asked to
  gown also.
    Gowning in the Nursery for Visitors
             and Attendants
• “The evidence from this systemic review
  and meta-analysis does not demonstrate that
  gowns are effective in limiting death,
  infection, or bacterial colonization in infants
  admitted to newborn nurseries.”14


•    14. Gowning by Attendants and Visitors in Newborn Nurseries for Prevention of
     Neonatal Morbidity and Mortality. Cochrane Collaboration 2003.
 Hepatitis B Vaccination at Birth
• Parents frequently like to wait because “His
  immune system is just not ready for it.”
• By this statement parents are usually
  expressing a concern that the immunization
  will somehow make their baby ill.
• Less frequently parents are concerned that
  the vaccine will be ineffective.
    Hepatitis B Vaccination at Birth
• This issue is complicated a bit by the fact
  that the AAP used to say that infants born to
  Hepatitis B negative mothers should get
  their first Hepatitis B vaccine between birth
  and 2 months of age.
• The 2006 immunization schedule
  recommends that the first vaccine be given
  at the time of birth.15
•   15. American Academy of Pediatrics 2006 immunization schedule.
        If My Baby’s On His Back
            Won’t He Choke?
• This issue still concerns some parents.
• We frequently forget to address this concern
  when talking with new parents.
• Babies placed on their abdomen in the
  hospital are more likely to be placed there
  after discharge, so an explanation may be in
  order.
• The evidence is clear – the “Back to Sleep”
  campaign has cut the SIDS rate in half.16
•   16. American Academy of Pediatrics. Changing Concepts of Sudden Infant Death
    Syndrome: Implications for Infant Sleeping Environment and Sleeping Position.
    Pediatrics; 105;5;650-656.
                      Car Seat Myths
• “I keep him in the front seat so I can see if
  he’s choking.”
• Easy to understand – but wrong.
• The rear seat is always the safest seat.17




•   17. Partners for Child Passenger Safety. CPS Issue Report May 2005.
          Circumcision is Medically
                 Necessary
• Many parents feel circumcision is medically advantageous.
• AAP’s policy statement is quite balanced.18
• Complications – bleeding, infection, scarring and
  deformity, reaction to anesthesia, as well as more rare
  severe problems.
• Advantages – prevention of UTI and foreskin cancer,
  decreased risk for syphilis and HIV.
• More accurate to say that the better approach is not clear.

  18. Circumcision Policy Statement, Pediatrics, 1999:103;No.3;686-693.
    “I Can Tell When a Baby’s
            Jaundiced”
• Many times that is true. However…
• Newborns are being discharged before the
  time of the expected peak of the bilirubin
  value, so the degree of jaundice we are
  getting to see is more subtle than in times
  past.
• The darker the skin pigmentation the harder
  it is to see the jaundice.
      “I Can Tell When a Baby’s
              Jaundiced”
• If the infant has been under phototherapy all
  bets are off and clinical judgment cannot be
  used.
• The AAP states quite clearly that though the
  option of clinical assessment alone is a
  viable one, when in doubt get a serum
  bilirubin, and to consider getting a
  screening serum bilirubin on all newborns
  before discharge.1
  1. American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia.
  Management of Hyperbilirubinemia in the Newborn Infant 35 or more weeks of
  gestation. Pediatrics, 2004;114;297-316.
  “All my Babies Have Reflux”
• There’s a grain of truth here – all babies do
  have gastroesophageal reflux (GER) since
  all babies do spit up.
• We have to educate families about the
  difference between physiologic and
  pathologic GER – failure to thrive,
  aspiration, obstructive apnea, hematemesis,
  esophageal scarring with difficulty
  swallowing food, Sandifer syndrome, and
  asthma exacerbations.
           Iron in formula causes…
• Innumerable bad things! Constipation, gas,
  distension, vomiting, diarrhea, bloating,
  crying, colic, poor sleeping, decreased
  intake due to “bad taste”, abdominal pain,
  “he draws his legs up”; in short, everything
  bad that doesn’t get attributed to teething!
• There are no known medical
  contraindications to using iron-fortified
  formula.19
•   19. American Academy of Pediatrics, Committee on Nutrition. Iron Fortification of
    Infant Formulas. 1999;104:119-123.
                   Teething causes…
• Everything else! Fever, diarrhea, vomiting,
  decrease appetite, diaper rash, sleep
  disturbance, runny nose and cough, rashes –
  the list is limitless.
• Teething is not strongly associated with any
  significant symptoms.20
• Frequently delays seeking care for
  significant medical problems.
•   20. Wake M, Hesketh K, Lucas L, Teething and Tooth Eruption in Infants: A Cohort
    Study. Pediatrics, 2000;106;1374-1379.
Occasionally Wisdom Can Be Found
       in Unexpected Places
• Let’s finish this talk with 30 seconds from
  Chris Rock.
                           Question 1
•   1. Which of the following statements are true?
•   A. Few breastfed newborns ever require formula supplementation.
•   B. Breast fed infants should receive 200IU of Vitamin D until they are
    consuming 500 ml per day of Vitamin-D supplemented formula or, if they are
    old enough, the same amount of Vitamin-D supplemented whole milk.
•   C. Mothers receiving medicinal magnesium can safely breast feed.
•   D. Breastfeeding should not be stopped in newborns receiving phototherapy
    unless they are felt to be at risk for needing an exchange transfusion.
•   E. All the above.
                          Question 2
•   2. Which of the following statements is false?
•   A. Circumcision is not clearly advantageous for a newborn’s male health.
•   B. Supplemental iron in formula has never been shown to cause any newborn
    problem.
•   C. Jaundice is sometimes hard to detect on a clinical basis alone.
•   D. Term infants receiving phototherapy usually benefit from receiving IV
    fluids.
•   E. Term infants of Hepatitis B Surface Antigen negative mothers should
    receive the first dose of the Hepatitis B vaccine at birth.
                            Question 3
•   3. Which of the following are contraindications to breast feeding? Pick one.
•   A. Maternal smoking.
•   B. Maternal consumption of the occasional single alcoholic drink.
•   C. Mothers who are Hepatitis B Surface Antigen positive.
•   D. Mothers who are Hepatitis C Antigen positive.
•   E. Mothers with active untreated tuberculosis.

				
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