Transcript Newborn Myths - University of Arkansas for Medical Sciences

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 milkbased 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;776789.
9. Anderson PO. Alcohol and breastfeeding. Journal of Human Lactation. 1995;11:321323.
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 (79mm) 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
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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
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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
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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.