Tuesday, October 30, 2007

Newborn Care

October 2007 Journal of Family Practice

Newborn Care: 12 beliefs that shape practice (But should they?)
Common beliefs that require a second look

#1. Breast milk is a complete nutritional source for a healthy term newborn

The Evidence: Breast milk is not a complete nutritional source for heatlhy
term newborns. In fact, breast milk provides the ideal source of nutrition,
and it is almost a complete and perfect source of nutrition--with one
important exception. The AAP recommends that all breast-fed newborns
receive 200 IU/day of Vitamin D until they are getting at least 500 mL/day
of vitamin D formula or milk.

The purpose of the supplementation is to prevent vitamin D defiency and
subsequent rickets. The AAP makes no mention in its recommendation of
infant pigmentation or the expected amount of exposure to sunshine. The AAP
recommends that vitamin D supplementation begin by the time they infant is 2
months old.

#2. Supplementing with formula because the mother's milk hasn't come in yet
is a reasonable, routine practice.

The Evidence: Formula supplements are not necessary as routine practice.

Formula supplements are counterproductive, taking away the primary stimulus
for breast milk production---nursing at the breast. Infant dissatisfaction
with the initial volume of breast milk produced actually works to the
infant's advantage, driving the child to the breast more often, and thus
increasing the likelihood of successful breastfeeding. In certain
circumstances, formula supplement can be reasonable, such as when an infant
is hypoglycemic or when the baby is receiving phototherapy and experience
excessive weight loss and becomes severely dehydrated. However, formula
supplementation is not reasonable or necessary as routine practice.

#3. Mothers on magnesium therapy should not breastfeed their infants.

The Evidence: Mothers on magnesium therapy may continue to breastfeed their

The misguided recommendation that mothers who are being treated with
magnesium therapy should not breastfeed is based on an unreasonable fear
that magnesium therapy can cause hypermagnesemia in breastfed newborns due
to excessive magnesium levels in the breast milk. Supplemental magnesium,
usually given intravenously to mothers with severe preeclampsia, does not
cross over into breast milk in any significant amount, even when the mother
continues to need intravenous magnesium after the birth of her baby.

#4. Mothers who are positive for hepatitis B surface antigen or who are
carriers for hepatitis C should not breastfeed.

The Evidence: Mothers who are hepatitis B surface antigen positive or
carriers for hepatitis C can safely breastfeed their newborns.

The idea that mothers who are infected with hepatitis B or C should not
breasteed their babies at first seems obvious to many who care for newborns,
as the diseases are transmitted through blood exposure, and nipple cracks
with associated blood loss are common in mothers when they begin to
breastfeed. The hepatitis B immunization protocol for infants born to
hepatits B surface antigen positive mothers takes care of the first
infectious concern. In addition, no case of hepatitis C transmission from
breast milk has evern been reported. The Centers for Disease Control and
Prevention confirms that the transmission rate of hepatitis C from infection
mothers is the same whether the babies are breast or bottle fed.

#5. Mothers who are febrile should not breastfeed.

The Evidence: In most cases, febrile mothers may safely breastfeed their

The advice for mothers not to breastfeed while febrile seems intuitively
true because of concern that the infection might pass over into the breast
milk to the baby. This rarely happens. There are only 4 contraindications
to breastfeeding during maternal fever.
a. Active, untreated maternal tuberculosis
b. Mother who are human T-cell lymphotropic virus type I or II positive
c. Mothers who are HIV-positive
(I think some newer studies have
refuted this--saying that as long as the mother EXCLUSIVELY breastfeeds and
no formula, she can safely breastfeed)

d. Mothers with a herpes simplex lesion on the breast.

#6. Mothers who smoke or drink alcohol should not breastfeed.

The Evidence: While this recommendation seems self-evident, the research
proving harmful effects to the infant is lacking.

In fact, in its most recent statement on "The Transfer of Drugs and Other
Chemicals Into Human Milk," the AAP removed nicotine from a table of drugs
for which adverse effects have been reported on infants during
breastfeeding. While it would be ideal if no breastfeeding mother smoked or
drank alcohol, the fact of the matter is that some do. In light of this,
it's wise to encourage the mother to smoke outside the home, and to change
her clothes before holding her baby. In so doing, she will avoid exposing
her baby to most of the effects of secondhand smoke. In addition, while
mothers who breastfeed their infants should, of course avoid alcohol abuse,
a singel, occasional small alcoholic drink is acceptable.

#7. Pacifiers are bad for newborns.

The Evidence: It is not clear whether pacifiers are "bad" for newborns.

The belief that newborns should not have pacifienrs cam into being for a
well-intended reason; breastfeeding advocates were concerned that newborns
would spend too much time sucking on the pacifier and too little time
sucking at the breast undermining the mother's ability to breastfeed
successfully. Consensus on the matter though is lacking. The UNICEF World
Health Organization Baby-Friendly Initiative, for instance, recommends that
pacifiers not be used. The AAP, however, advises that pacifiers can be used
once breastfeeding is well established. The research is also mixed. On the
one hand, new evidence indicates that pacifier use may decrease the
incidence of sudden infant death syndrome. On the other hand, pacifier use
for longer than 48 months has been linked to orthodontic problems and dental
caries. Thus, while prolonged pacifier use may be harmful to dental
hygiene, newer evidence allows that pacifiers may be acceptable in the first
few years during breastfeeding.

#8. Newborn emesis is an indication for a formula change.

The Evidence: No literature supports the belief that is is appropriate to
change an infant's formula in response to emesis in the first 2 weeks of

The overwhelming majority of vomiting episodes in newborns have no
accompanying medical problems. A 2002 study by Miyazawa et al that looked
at more than 900 infants showed more than 47% of Japanese infants < style="color: rgb(255, 204, 51);" style="color: rgb(255, 204, 51);">(So your chances of infection are higher if your babe is born in hospital) Umbilical cord infections sometimes occur even when the cord area is kep clean and dry, so healthcare
providers must be attentive to signs of possible infection.

#10. It's easy to spot when a newborn is jaundiced.

The Evidence: Jaundice is actually difficult to detect in darkly pigmented
babies and in babies sent home within 24 hours of birth, because bilirubin
levels reach maximum levels between the third and fourth days of life.

Years ago, when infants stayed longer in the nursery, doctors had the chance
to see them when their bilirubin level was highest and when the babies were
most jaundiced. The current emphasis on early discharge does not allow this
practice. The AAP recommends clinical assessment of a newborn's state of
jauncie and that a bilirubin level be obtained whenver a physicain is in
doubt about the degree of clinical jaundice. The AAP also recommends that
physicans consider obtaining a routine screening bilirubin in all newborns
at the time of hospital discharge even if by clinicl assessment, the child
is not jaundiced. The AAP made these recommendations because of an
increasing concern that the incidence of kernicterus in American is rising.

(Too much pitocin use perhapsor Vit K supplement, cutting the cord too early,
not enough time and frequency on the breast?

Risk Factors for Hyperbilirubinemia in Newborns

Maternal factors
Blood type ABO or Rh incompatibility
Drugs: diazepam (Valium), oxytocin (Pitocin)
Ethnicity: Asian, Native American
Maternal illness: gestational diabetes


#11. All infants who require phototherapy need IV fluids to prevent
dehydration and enhance excretiono f bilirubin.

The Evidence: Unless the baby is clinically dehydrated, IV fluid therapy
for infants under phototherapy is not needed.

Though IV fluid therapy is commonly used to increase the excretion of
bilirubin and combat dehydration, the research tells us that IV fluids do
not bring down bilirubin levels and that even with mild dehydration, the
best fluid therapy is breast milk or formula because it inhibits the
enterohepatic circulation of bilirubin. Intravenous fluid therapy should be
reserved for jaundiced newborns with moderat to severe dehydration or those
with milk dehydration who are not able to take fluid by mouth.

#12. Breast-milk jaundice is best treated by stopping breastfeeding for
24-48 hours.

The Evidence: Breastfeeding should not be discontinued as a way to treat
breast-milk jaundice.

In fact, breastfeeding should not be discontinued for jaundice due to any
cause, as demonstrated in the opening scenario, unless you believe a bab is
at risk of requiring an exchange transfusion. The need for phototherapy
alone is not sufficient reason to discontinue breastfeeding. Breast-milk
jaundice is a common problem facing parents and physicans, but it is not a
disease and does not represent an abnormality in and of itself. Rather this
normal physiologic condition gains its importance only in that it must be
distinguished from pathological causes of newborn jaundice. Breastmilk
jaundice is believed to affect 1% to 33% of breastfed infants. One
treatment measure--to stop breastfeeding--began, in part, as a
cost-effective way to diagnose breast-milk jaundice. Rechecking the
bilirubin 24 to 48 hours after breastfeeding is discontinued would reveal a
significant drop in the bilirubin level, confirming the diagnosis of
breast-milk jaundice and obviating the need for testing for more serious
medical illness. The consequence of this misguided treatment approach,
idscontinuing breastfeeding, is that some mothers are more likely to stop
breastfeeding altogether.

What do you think?