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.