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Alternative Birth Practices: What the Pediatrician Should Know: Grand Rounds Episode! · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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Music.
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A fascinating talk. Let's listen in. I'm very pleased to be introducing Dr.
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Kang for Pediatric Grand Rounds today.
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She is a pediatrician and a neonatal perinatal medicine fellow graduating this
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year from our fellowship program, and she'll be presenting today on alternative birth practices.
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Dr. Kang, take it away. We're excited to hear from you. Thank you.
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Thank you so much. I chose this topic. Hopefully, it was an eye-catching enough headline,
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and this is something that I've come across some interesting scenarios being
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in deliveries and just kind of wanted to know a little bit more about some of
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these things that parents and OBs were asking me and so kind of looked more
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into the literature about this and so hopefully you guys will find it as interesting as I did.
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So there is a lot of things that can be talked about with this topic and so
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I tried to pick some of the ones that I've either come across or kind of had
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questions about some interesting things and I think you can kind of go into
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the weeds a little bit here on some of these,
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but I tried to just do a very kind of brief overview or at least highlights
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kind of some of the most important things for each of these topics.
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You know, hopefully interesting, like I said, not just for those of us in the
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NICU, seeing these babies at deliveries and possibly managing them in the ICU,
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but even for our pediatric colleagues that either work in the nursery or in
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the outpatient clinic setting, just some important things to know.
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Should any of their patients have had these practices happen or if parents bring
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up these questions, hopefully some good things I can share with you guys about each of these topics.
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Again, kind of the reason why I looked into this, alternative birth practices
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as a whole have really increased in recent years.
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I think there's a lot of movement in kind of the mom and baby world as far as
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trying to, you know, see what is out there as far as safe for,
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you know, delivery processes and for babies.
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And I think the science is slowly starting to catch up.
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And I think a lot of these, unfortunately, there's not a lot of great evidence-based
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literature, but we'll kind of get into that more in each particular topic.
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But definitely myself as a NICU fellow, even in residency, I came across situations
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where I was asked questions about some of these recommendations or practices
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or kind of what I thought about them.
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And then being involved in the care and evaluation of these infants,
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just some things I wish I had known or had to go and look up kind of after the
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fact so I could be better informed.
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And so just wanting to highlight, you know, at least a cursory knowledge of
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some of the risks and benefits in these practices are important for those of
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us taking care of these patients and counseling these families.
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So I did use a few resources when I looked into this.
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There's a really great clinical report from the AAP back in January of 2022
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that kind of looks more at the infectious concerns for some of these practices.
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So it's a really good article, not too long of a read, so definitely recommend
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it for anybody that's interested to look into things a little bit more.
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It has some good references as well. And then this was another article I really
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enjoyed from the Journal of pediatrics in October of 2023.
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So definitely kind of use these very heavily for kind of looking at the literature,
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kind of the response from some organizational bodies for some of these recommendations.
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Without further ado, going into our first topic is water immersion for labor and or delivery.
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This is something where warm water is used for the mother really to benefit
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pain control or for pain relief during the labor process and or delivery.
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The numbers are very hard for this practice.
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And so it's estimated that it is about, you know, less than 1% of the births
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that are happening in the U.S.
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Are by water birth. And this is really just, again, an estimate from the number
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of home births that there are
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in the U.S., and that's around 1 to 1.5 percent of all births in the U.S.
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Occur outside of the hospital, such as, you know, birthing center at home with
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the midwifery service or things like that.
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So, again, hard to get some numbers, not too common of a practice as far as
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the water birth part, but definitely
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the water immersion for labor is becoming more and more popular.
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We even have the option for that in our hospital at university that I'll get
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into here in a little bit as well. But I did find an estimate of about 10% or just under U.S.
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Hospitals are offering this option for moms, and that's specifically the water immersion for labor.
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There aren't any hospitals currently offering water birth in-house,
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and we'll get into why that is the case.
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I found some other interesting data in other countries. We know practices are
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very different, you know, country to country, but there were some European countries.
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I found in the U.K. and Sweden that immersion rates were as high as 25 to 50%.
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This is something that's definitely utilized across the world,
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and I think we're trying to, you know, get better recommendations for it here in the United States.
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So, like I said, there are benefits to this, and they have been proven in studies
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as far as during the first stage of labor, working towards cervical dilation.
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And so, it's been shown to reduce the requirement for regional anesthesia,
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decrease labor duration, and it has been found to not have any increased risk
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to the neonate when it is used for that portion of labor.
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However, into the second stage of labor, so that's when mom is 10 centimeters
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and actively pushing, there are some concerns that come into play at that standpoint
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as far as neonatal infection,
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aspiration if baby is born in the water, and then even cord abulsion has been reported as well.
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So for these reasons, ACOG and AAP recommend against the use of water immersion
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beyond the first stage of labor.
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And really, for those that they recommend this practice for,
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if moms are interested, they really try and limit it to those very low-risk
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cephalic pregnancies just to try and make sure that there aren't any other risk
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factors to be concerned about.
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There haven't been any increase in adverse events noted in clinical trials.
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The AAP reports do comment that these are, you know, quote, low quality,
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but there are case reports of some, you know, complications in death,
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so that's why the recommendations have been to only allow it during the first stage of labor.
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The infectious concerns really come from waterborne organisms.
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It can be very hard to manage or, you know, clean the tub or the equipment and
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things like that, or you have to be very specific in how you go about that process
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and their recommendations for that.
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But specifically, Legionella and Pseudomonas are two of the biggest ones from that standpoint.
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And there was a case scenario if you, you know, have the history of having an
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infant being born by water birth
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and they're, you know, presenting with respiratory distress, pneumonia,
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you're having culture negative sepsis, just something to keep in the back of
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your mind if you do see an infant like this that, hey, they could be at risk
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for Legionella or Pseudomonas.
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And so, like I said, there aren't any universal guidelines for this practice,
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but there are some specific state-level or public health guidelines.
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And these kind of really came about after some reported cases of complications.
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And unfortunately, there was a case in 2014 in Texas of a baby that did pass
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away from legionellosis after a water birth, and it was from a home midwifery service.
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And so after that, Texas did create some guidelines for home midwives on kind
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of how they're supposed to clean their equipment and prevent this and kind of
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how to go about it for best safety for moms and babies.
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And like I said, as far as our own institution here at university,
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as of May 5th, so the beginning of this month, the university is now offering water immersion.
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And I underlined during the first stage of labor only to eligible mothers.
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And so we actually have two rooms in L&D that have this capability that have a tub in the room.
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And there is a very extensive list of requirements and conditions and I didn't
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want to include all that because it's multiple pages and so essentially just
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really trying to limit it to those very low risk mothers and again just for
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the first stage of labor for pain relief and some of those other benefits that we talked about.
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The next topic I wanted to bring to y'all's attention is called vaginal seeding
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and this is one I had heard about, haven't been asked about necessarily but
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I found it pretty interesting.
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So this is something where you know there's a lot of you know conversation that,
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baby's microbiome is influenced by the exposure to maternal bacteria in the
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vaginal canal during delivery.
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We know that that's a very positive occurrence for babies and their influence of their microbiome.
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So vaginal seeding is the process for these babies that are born by C-section
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to actually be inoculated with the vaginal fluid from the mother.
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And there's various ways of doing this.
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I kind of saw that kind of the most common is using either a cotton gauze or
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swab to kind of collect the sample from mom and then kind of covering the infant's
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nose, mouth, and her skin and to provide that bacterial exposure to the baby.
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ACOG and AAP don't actually recommend this practice outside of research setting
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just because data is still very limited as far as the risks and benefits,
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and it's really only recommended to be studied in term infants.
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They really don't recommend this for premature infants just because of their
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impaired immune function.
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And so really outside the research setting and things like that,
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this is not something that is recommended.
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And the reason for that is that there is concern for infectious risk of exposure
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to vertically transmitted pathogens, things like GPS, HIV, herpes, syphilis.
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And so if any of these risk factors are present in the mother,
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there are very strong recommendations against this practice.
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And the thought behind it is there's, like I said, there's a lack of literature
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as far as our preventative strategies if they are effective in this setting.
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So, you know, we have, you know,
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antibiotics for GPS prophylaxis and treatments for these other things.
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But there's just a question of, is the secondary or, you know,
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the act of inoculating the infant with the fluid, is that kind of a heavier
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dose of potentially those bacterial pathogens as opposed to the natural vaginal birthing process?
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And so there's just not enough literature or data to support that those prevention
9:31
strategies are safe and effective.
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And so definitely something that could be seen in the future.
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I didn't really see a very strong negative kind of thought process behind this,
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but it was more just kind of cautious when I was reading recommendations.
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I think more in the mind of more needs to be studied to know that what we're
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doing is safe and that we're not causing, you know, unexpected harm or potentially
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increasing risk for some of these things for our babies.
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And so outside of the research setting, it is not recommended and that is something
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we should discuss with our families.
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But I did even find it in one of the maternity books I've been reading.
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And so it's definitely something that is out there in the mom and baby blogs
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and all that kind of thing. So you may come across it.
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So kind of the conversation as far as, you know, trying to give baby a positive
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exposure for their microbiome development.
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I looked into a few studies that they referenced in these articles.
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And they really talked about, you know, there is a difference in the microbiome
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based on delivery for the first few months, I think up to six or seven months or so.
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But really after that standpoint, those differences don't really persist.
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And so other things are kind of seen as more important as factors that are influencing
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that infant's microbiome.
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And so we know those things are like gestational age, duration of hospitalization,
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exposure to other pathogens, and most particularly antibiotic exposure is a very big one.
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We know that definitely alters infant's microbiomes and then even the home environment
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and things that they're exposed to on a daily basis.
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So there are some other options if this is something families are interested
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in doing as far as positively impacting their baby's microbiome.
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And so breastfeeding is a phenomenal option. And so we do know that it significantly
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influences the microbiome.
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And this is, you know, regardless of the mode of delivery. So whether it's vaginal
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or C-section, this is something that all moms are able to do if they so desire.
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And as far as some numbers, a study I looked at found that about 28% of the
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bacteria of an infant's microbiome actually came specifically from the human
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milk. So that's a good portion. And then, you know, an additional 10% from the areolar skin.
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And so there is a pretty good way you can positively influence that if families are interested.
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And so something, you know, like breastfeeding and skin-to-skin contact are
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something that we very routinely recommend and are supported by the AAP,
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as long as there are no other risk factors present.
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So something that you can offer as an alternative to families that are bringing
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up this practice or desire to perform vaginal seeding, you can talk about some
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other options that are safe and approved for a baby.
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Should you come across a baby that has had this done, you know,
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if mom and baby are, you know, clinically asymptomatic, really there's not any
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further evaluation that you have to perform.
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However, if either mom and or baby become symptomatic, definitely something,
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you know, you need to have in the back of your mind evaluating for sepsis.
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And really at that point, even if baby was delivered by C-section,
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really considering them as if they were delivered vaginally with the potential
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for some of those preventative strategies to not have been as effective.
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And so just something to highlight there if you ever come across a baby that
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has undergone this practice.
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As far as the next topic is called umbilical non-severance or lotus births.
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This is something I have been asked about.
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I haven't actually had any patients that felt very strongly about this,
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kind of just more questions than anything.
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We have seen this a time or two as far as the conversation coming up.
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And so this is where they allow or parents desire for the umbilical cord and
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placenta to remain attached to the infant until spontaneous cord detachment.
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And that can be anywhere from 3 to 10 days of life.
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And they do this by using preservatives and salting to assist in the drying
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process of the cord and the central tissues.
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And kind of the positive thought behind this is it's considered,
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you know, a nonviolent method of cord detachment.
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So I have the hardest time probably wrapping my mind around this one of some
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of these practices, but definitely something that I have heard discussed from some of our moms.
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And so surprisingly enough, there aren't any formal recommendations from any
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medical organizations and there have been no clear evidence-based benefits to this practice to date.
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However, I did like this comment just to kind of provide some context or understanding for the providers.
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And so one of the articles I looked at did say, you know, providers should appreciate
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that parents may regard the placenta as a spiritual entity and may not recognize
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that the tissue is capable of being contaminated with pathogens that would harm their infant.
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And so just trying to kind of understand the parent's standpoint.
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And when we were counseling them, we're giving recommendations.
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And so just having an awareness there, I think, is important when we have these
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discussions, because I think for us on the medical side, we can feel very strongly
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about things that are, you know, quote unquote,
14:00
unsafe or risky, but making sure that we, you know, take into our counseling
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with these families, the understanding that they are coming from a place of
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wanting to do good for their baby.
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So obviously, you know, we have concerns about this practice because when there's
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an absence of circulation in the placenta after delivery, this leads to necrotic tissue.
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And we all know very well that necrotic tissue is a perfect breeding ground
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for bacteria. There can be multiple sources for that bacteria,
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you know, the maternal G.U.
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Tract, the caregiver hands or gloves that handle the placenta after delivery,
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even the surrounding environment as well.
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And then, you know, even the things that are used to, quote unquote,
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preserve or to dry out the placenta, such as, you know, the preservatives,
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the salt, the cloth wrappings, even those can be contaminated as well.
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And so definitely just something that is concerning for risk of infection for baby.
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There have been some case reports, early onset sepsis. Some of the infectious
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organisms have been from coag-negative staph.
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There were also reports of neonatal endocarditis from another staph species
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that I will not attempt to pronounce, but you can see there,
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and then even umphilitis as well.
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And I think just since it's the short nature of how long the cervix is attached
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to the baby, there have not, interestingly enough in any case,
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reports of late onset sepsis.
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But if you do ever experience an evaluation of a patient that,
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you know, is either still attached to their umbilical cord or,
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you know, has had this history.
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And they are, you know, you're concerned for infection, if they do have the
15:23
placental tissue still available, using that to try and culture to see if you
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can potentially get an ID on the organism that could be potentially the culprit of the infection.
15:31
Some of the other recommendations I saw when treating or evaluating these infants
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are kind of broadening your typical sepsis antibiotic coverage to include things like nicomycin,
15:41
even anaerobic coverage as well while you're awaiting culture results,
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just because there could be a whole host of things that could be involved with this.
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Another one I have a difficult time understanding, but definitely have heard
15:51
people practice or have had questions about, is placentophagy.
15:55
And so this is actually the practice of consuming the placenta for its reported benefits.
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You know, there's lots of discussion as far as the benefits.
16:04
You know, it does all sorts of things such as, you know, decreasing postpartum
16:08
depression, increasing mom's milk supply, reducing postpartum pain and or bleeding
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and even increased energy.
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I was looking into other things and found that it actually can be traced back
16:18
to China even over 2,000 years.
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And the thing that's kind of difficult to stomach, and I feel part of my wording
16:26
there, but it can even be, or at least the way that people consume it can be
16:31
in various different ways.
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And so some people do consume it raw, some do cook it like any other food product.
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But the most common method that is kind of used at least nowadays is to actually
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steam it, then dehydrate it and grind it into a powder that they can then encapsulate.
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And there are actually various companies that will do this for families.
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You kind of just ship off the placenta, they do all these things and then send it back to you.
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And so there isn't any FDA regulation of this process.
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And so a lot of these companies, you know, you have to kind of take their word
17:01
for their sterility of their procedures.
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And so there's just a very strong concern of risk for bacterial contamination,
17:07
even in the processing of the placenta.
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And the The concerning thing is that there actually have been case reports of
17:14
a mother who was taking encapsulated placental pills and her infant was having
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recurrent episodes of GBS sepsis.
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And when they cultured the pill and got the strain from the infant,
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they actually were the exact same strain.
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And so they felt that was the source of baby's repeated exposures to GBS.
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And so definitely something that's interested in just recommendation really
17:38
against this practice in the sense that it could increase risk of infectious exposure to baby.
17:44
So now a positive one as far as different practices, and thankfully this is
17:47
something I can go into a little bit more as far as the aspect of delayed bathing.
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So this is something where the first bath is not performed for the first several hours after birth.
17:56
Our practice at university from the new OB visit packets that I've seen says
18:02
that traditionally it's about eight hours for university hospital,
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or at least after that point they will perform the first bath.
18:08
Interestingly enough, the WHO has a recommendation that bathing can be performed
18:12
24 hours after birth, and they've kind of had this in place since the early 90s.
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They do comment that if there are any other cultural or other limitations,
18:19
you know, trying to get at least six hours before the first bath.
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They don't have any rationale or summary of evidence behind this recommendation,
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and they're, interestingly enough,
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also the only organization to have recommendations about this practice.
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But there are some thoughts as far as the benefits for this practice.
18:35
And so we do know that it does increase the rates of breastfeeding.
18:38
And the thought is, you know, you're decreasing that separation time between
18:42
mom and baby, lower likelihood of hypothermia or influencing factors that support
18:46
breastfeeding when you don't have that separation.
18:49
There is a suggestion that it can preserve the neonatal skin microbiome.
18:53
And definitely the presence of Vernix can provide some protection against neonatal pathogens.
18:57
And I looked into some of the studies that they referenced, and it was really
19:00
interesting when they looked at some of the components of Vernix.
19:04
It has these enzymes, lactoferrin and lysozyme, and they kind of tested those
19:08
against various organisms and actually found that they did inhibit the proliferation
19:12
of things like GBS or Klebsiella or even Listeria. So it's definitely very interesting.
19:17
Even this is something I've probably seen most commonly that families ask for.
19:21
One of the most common things that families will ask for is for us not to remove the vernix.
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If NICU is ever called to evaluate, we usually bring the baby over to a warmer,
19:30
warm, dry stem and all of that as far as NRP. But I've had some families very
19:33
specifically request for us
19:35
not to try and really wipe or remove that vernix if we can at all help it.
19:38
And so I definitely think that's coming from this practice of substantial benefits to baby.
19:43
Obviously, if you do have to do any skin-breaking procedures,
19:46
using aseptic techniques should prevent transmission of pathogens.
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The important thing to note, however, is a lot of these studies that did look
19:52
at the benefits of delayed bathing, they really excluded babies with risk factors
19:56
such as prematurity just because we know their skin barrier is very different.
20:00
And then also something important to know is they did exclude babies that had
20:04
any known maternal history of blood-borne pathogens.
20:06
This is something that the AAP gets very specific on really just for HIV.
20:10
This is the only explicit recommendation for immediate bathing in the Red Book,
20:15
is if there is maternal HIV.
20:18
We, in the AAP, I believe, have extended that out to other similar blood-borne
20:21
pathogens listed here, you know, Hep B, Hep C, active, general HSV, and syphilis.
20:27
And so the recommendation is to bathe, you know, quote, as soon as possible.
20:30
But as far as the ones that say immediate bathing, it's really just maternal
20:33
HIV. So I thought that was kind of interesting.
20:35
But I have seen that in our practice as well, as far as those babies that get
20:38
baths a bit sooner than others.
20:41
So, to carry on, the next topic is planned home birth.
20:45
And so, first to talk about home birth in general, and then we'll get to the
20:49
planned home birth portion.
20:50
But as far as home birth, again, the numbers for this are very difficult just
20:53
because the process in most states, or the process between states can be very
20:57
different as far as how they're documenting the birth location.
21:00
Some of the states don't have a spot to place, you know, where infant was born
21:04
and where infant was, you know, the plan for infant to be born was at.
21:08
And so the numbers are estimated to be about 1 to 1.5 percent of all births
21:13
in the U.S. are born at, those infants are born at home.
21:16
And the trend in the past few years, and this is definitely increasing among
21:19
white non-Hispanic women, that's definitely something that we have seen.
21:23
Home birth in general, and this is including all those planned and unplanned,
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and so just an important caveat for these next two bullet points here,
21:31
but home birth is associated with a two- to three-fold increased risk of neonatal
21:35
mortality, and the number they give is about one death per 1,000 non-anomalous
21:39
live births, so pretty high, in my opinion.
21:42
And then there's an increased risk of low APGAR scores and neonatal seizures,
21:46
but again, the caveat that this does include those home births where they were
21:50
not planned or not prepared adequately for.
21:53
From the other standpoint, as far as some numbers on really the planned home
21:56
birth side, Canada actually has done a good job kind of looking at this.
21:59
And so in the province of British Columbia in Canada, they did a study from
22:04
2000 to 2004, and they had just under 3,000 babies.
22:08
And they actually showed no increase in neon mortality.
22:11
But again, this was in all those planned home births with midwife service.
22:15
And so potentially some positive data there for this practice.
22:20
But as far as, you know, policy statements, AAP put out one in 2013 that said
22:26
that they agreed with the ACOG statement that really affirmed that hospitals
22:30
and birthing centers are the safest settings for birth in the U.S.
22:34
And that AAP also in agreement with ACOG, you know, really don't support the
22:38
provision of care by lay midwives or any who are not certified by the American
22:42
Midwifery Certification Board.
22:44
And really just trying to highlight that as far as who you have and where you
22:48
have delivery, just making sure you have the best qualified personnel and location
22:53
and resources available to you should anything happen.
22:57
I like this chart that I found from one of the articles. It was,
23:00
this is what is kind of used from that British Columbia study that they kind
23:03
of referenced. And so these are some of the recommendations for families that
23:07
are considering planned home births. They have different kind of qualifying features there.
23:10
And so interestingly enough for ACOG, this is in the U.S., they actually,
23:15
if mom has had a previous C-section, that is an automatic contraindication for planned home births.
23:20
They don't list that here, but that is something that is different in the U.S.
23:22
Compared to Canada. But some of the other things are very similar as far as,
23:26
you know, mom has to have a very low risk pregnancy.
23:28
So no pregnancy disease, no disease during the pregnancy, having,
23:33
you know, one baby, cephalic presentation, 37 to less than 41 weeks.
23:38
And then as far as the systems needed to support the
23:41
planned home birth this is something that is kind of really highlighted in
23:44
a lot of these articles that I looked at and so having you
23:47
know that certified you know nurse midwife midwife or
23:49
physician available for care of the infant and specifically if this is something
23:53
things are considering very very strong recommendations that they have at least
23:58
one person there who is primarily responsible for the care of the infant not
24:02
necessarily having one person there for mom and baby it's just safe as having
24:06
one baby there or one person there just for baby.
24:09
Just because you never know what can happen, mom and baby might both need care at the same time.
24:13
Also recommending that there's ready access to a consultation and that there
24:16
should any problems arise, you have
24:18
the ability to provide safe and timely transport to a nearby hospital.
24:22
And so I think all very good recommendations. Definitely a practice that makes me nervous to consider.
24:27
And so I think just having good understanding of things as far as what's safe
24:31
versus what's not and kind of things like that. But AAP, again,
24:34
does recommend hospitals or birthing centers to be the safest place for birth.
24:38
If a baby is born at home, there is some subsequent care that AAP recommends.
24:43
And this is really adherent to what we do in the nursery as far as the traditional newborn care.
24:48
And so I've listed out those things here. You know, that really good transitional
24:52
care in the first 48 hours, doing a good exam, making sure baby is tolerating
24:56
that transition to life well.
24:57
You know, monitoring if there's any GBS disease, doing glucose screening, doing eyes and thighs.
25:03
Assessing how they're eating, looking at their bilirubin levels,
25:06
getting their newborn screen, hearing screen, and making sure all of this newborn
25:10
care is documented well and can be transitioned on to the provider that will
25:14
be taking care of the infant moving forward.
25:16
And so definitely something that takes a lot of planning.
25:20
And again, I think there are very strict requirements on who would be eligible
25:24
for this practice, but just things to be aware of if this ever does come up in discussion.
25:30
So as far as, I have three more topics to go, and I think we're doing okay on time.
25:34
And so the next ones are something that I think we see probably most commonly.
25:39
And so this is kind of refusal or deferral of some of the things we do after baby is born.
25:44
And so the first one that we're going to talk about is the non-medical deferral of the Hep B vaccine.
25:49
So we do know that a single dose of Hep B given within 24 hours of birth is
25:53
75 to 95% effective at preventing vertical transmission.
25:58
And as far as the numbers in the U.S., there's an estimated 1,000 new cases
26:01
every year of perinatally acquired hep B.
26:04
So it's definitely something that can happen and does happen.
26:07
And then as far as the risks for based on what mom's serologies are for baby,
26:13
if mom's surface antigen is positive, but her envelope antigen is negative,
26:17
baby or there is a 5 to 20 percent risk of transmission to the infant.
26:21
However, if that envelope antigen is positive, the risk goes up very high,
26:25
and that increases to 90%.
26:27
And then some of the studies I looked at did say that, you know,
26:31
if baby does become infected, 90% of those will go on to have chronic infection.
26:35
So definitely something, you know, if we are able to prevent would be ideal.
26:40
And then, you know, we have the Hep B series as part of our routine immunizations,
26:44
but really the birth dose is kind of a separate category really for this,
26:48
you know, critical safety net.
26:49
And I've heard a lot of discussion as far as, you know, well,
26:52
mom's testing is negative. Why do we have to give this or different things like that?
26:56
And I think there's, you know, reason to have a conversation with families in that scenario.
27:01
You know, there are some situations where, you know, we don't have that maternal
27:03
testing where it's incomplete or in process, or it could be even have entered
27:08
into the system incorrectly, or mom could have been falsely negative if the
27:11
testing was done, you know, earlier on in pregnancy and she subsequently became infected with Hep B.
27:15
And so I liked one of the comments that one of the articles had,
27:19
you know, low risk is not the same as no risk. And so definitely something that...
27:26
That is a safely tolerated as hepatitis B vaccine.
27:29
That is something we definitely do recommend even for those,
27:31
you know, situations where we consider a baby to be at low risk of infection.
27:35
So I have had that conversation with families a few times as far as,
27:38
you know, why should we even do this if, you know, mom is negative and so on and so forth.
27:42
And so just having that understanding, I think, can be helpful.
27:46
As far as the eye prophylaxis, I've seen this as well. As far as families refusing,
27:50
this is part of their baby's treatment after birth.
27:53
And so as far as the reason behind our prophylaxis for this and so is really
27:58
to try and prevent one of the causes of ophthalmia neonatorum.
28:01
And so that's defined as conjunctivitis in the first four weeks of life.
28:04
It can be caused by multiple etiologies, but we're specifically targeting the
28:09
etiology of Neisseria gonorrhea.
28:10
And that is because it can lead to corneal scarring and blindness.
28:14
And thankfully, the numbers for this are very low. One of the reports I found
28:18
had a rate of about 0.4 cases per 100,000 live births. And they said that the
28:22
rate of this is directly related to the rates of gonorrhea in sexually active
28:25
persons, and that's kind of highest in those under 24.
28:28
And so that definitely makes sense as far as when you look at the numbers for that.
28:32
But as far as, you know, if mom is infected and baby doesn't get prophylactically
28:36
treated, or if mom is infected and she doesn't get adequately treated,
28:39
the transmission rate for the infant is actually pretty high if they don't receive that prophylaxis.
28:44
And so I found that it can be anywhere from 30 to 50%. If babies do become infected,
28:49
a good portion of them will go on to develop corneal involvement.
28:53
I saw 20% in some articles, and then 3% of those will be blind.
28:58
So definitely something that, even though the numbers are small,
29:00
something that can be a very significant outcome for something that we could potentially prevent.
29:04
So we do routinely use 0.5% erythromycin ointment, and this is recommended by
29:09
the AAP for prophylaxis due to its effectiveness and lack of what they describe as severe harm.
29:15
I didn't actually know this. I came across this in fellowship because it came
29:19
up one night when I was on call.
29:20
And so they're actually, most of the states in the U.S. do require this ocular prophylaxis by law.
29:26
And so I did look into the Texas law, And it's actually, interestingly enough,
29:29
a class B misdemeanor for failing to apply this prophylaxis within two hours of birth.
29:34
But that is unless it's due to an objection from the family.
29:37
So if family does object, then as long as you have adequate documentation of
29:41
that refusal, then there's nothing to be concerned about for the law from that standpoint.
29:45
But I thought it was interesting just because our practice here is to have families
29:49
sign a form whenever they do refuse ocular prophylaxis.
29:53
And so it's something I hadn't come across before coming here.
29:55
And so I think it's because of this legal. side of things.
30:00
From the other standpoint, there are kind of some more conversations happening
30:04
as far as this practice. Is it something that we should be doing routinely on
30:07
all infants? And so I looked more into that because I thought that was kind
30:11
of an interesting conversation or argument.
30:13
And so there's actually the Canadian Pediatric Society does advocate against
30:17
using routine ocular prophylaxis. That's on every baby that is born.
30:21
They say that a lot of the recommendation to do this on every baby is from the
30:25
pre-antibiotic era back when they were using silver nitrates.
30:28
Obviously, we've gone away from that just because of kind of that chemical irritation
30:31
or anything that can happen from using that on babies.
30:34
But they have some other things to support their position here.
30:39
They say, you know, that because of our, you know, widespread use of this,
30:43
there's increasing resistance among Neisseria gonorrhea species to erythromycin, which is concerning.
30:48
They didn't have any numbers that they were quoting, so I thought that was kind
30:51
of interesting. But they also talk about how, you know, erythromycin is really
30:54
only effective preventing, you know, neisseria gonococcal conjunctivitis.
30:58
It doesn't do really anything for comedial conjunctivitis.
31:01
They talk about, you know, it can cause some mild eye irritation,
31:04
interrupts the parent-infant bonding experience.
31:07
And they feel that a better option, as opposed to routine ocular prophylaxis,
31:11
would be to really focus on the prenatal side of things and really do effective
31:15
screening and treatment for moms before they deliver.
31:19
They argue would be the best way to go about that.
31:22
And I think those of us that are, at least from my experience,
31:25
it can be very difficult for, you know, moms that don't have any prenatal care or things like that.
31:30
But kind of their argument, I believe, is for more targeted treatment as far
31:33
as to, you know, carte blanche, giving it to every baby.
31:36
They do also say, you know, that there have been no reported increases in cases
31:41
of ophthalmia neatorum or blindness in countries that have eliminated routine
31:45
prophylaxis, kind of as an argument of, you know, we got rid of this and babies
31:48
aren't doing any worse, so maybe it is a good thing.
31:51
I think as far as the AAP is concerned, it is still a recommendation,
31:54
and so just wanted to kind of give a different perspective of things that I
31:57
had found when I was looking into this.
31:59
So in the case of parental refusal, you know, doing what we always do as far
32:03
as, you know, good evaluation of risk factors from mom's side of things.
32:06
And then, you know, documenting that maternal testing in the baby's charts and
32:09
then giving families, you know, really strong return precautions,
32:12
you know, should the infant go on to develop discharge, conjunctival discharge or inflammation.
32:17
And I think all of us do a really good job of giving good return precautions
32:20
should families want to diverge from routine medical care.
32:26
I believe this is our last topic. So this is deferral of vitamin K prophylaxis.
32:29
So again, another one that we see fairly commonly.
32:32
It is becoming more common in the recent years. But we give vitamin K prophylaxis.
32:36
It is very essential for optimal activity of some of our flooding factors, 2, 7, 9, and 10.
32:41
We know that if we don't have sufficient levels of these, we can have issues
32:44
with coagulopathy and bleeding.
32:46
And babies are deficient in this because the placenta doesn't do a great job
32:49
of transferring vitamin K over to the baby and that there's low qualities of
32:53
it in breast milk as well.
32:54
I have had some families ask about oral vitamin
32:57
k and this is something that's done I believe a lot in europe and
33:00
in some other countries but when the aap did look into it
33:03
it just appears to be not as efficacious as intramuscular injection
33:07
and so it's currently not recommended to give oral vitamin k from the aap the
33:11
aap really recommends just giving the the im dose at this point and the reason
33:16
we give this obviously is to prevent vitamin k deficiency bleeding we know that
33:19
there's early and late so early
33:21
is within the first week of life late is between two and 12 weeks of life.
33:25
And I have some numbers here as far as the incidence of this,
33:28
should babies go without prophylaxis?
33:30
So in the early category, kind of a higher risk, 0.25 to 1.7%.
33:35
And then for the late risk of bleeding without prophylaxis, that's about 10.5
33:41
to 80 per 100,000 births.
33:43
And really, as far as the dose, it was a 1940 study that looked at giving that
33:47
one milligram of IM vitamin K at delivery.
33:50
And they found that it led to a five-fold reduction of death from hemorrhage.
33:54
And they quote, you know, that using this practice, it had virtually eliminated
33:57
vitamin K deficiency bleeding.
33:59
But here in recent years, since there's been more and more of a discussion or
34:03
more families not wanting to give this,
34:06
either for, you know, misinformed reasons of thinking it is a vaccine or very
34:11
common one I hear is that, you know, it's a painful procedure,
34:14
they don't want their baby to be poked.
34:15
There have been increasing conversations or desires from parents to forgo this practice.
34:21
And so definitely something that we can hopefully potentially or positively
34:24
influence for our patients and families.
34:28
This, to kind of wrap us up here, I kind of went a little fast,
34:32
but this is a really good table I found that kind of just really quickly kind
34:36
of goes over a lot of things we talked about as far as, you know,
34:39
kind of what the practice is, what the risks and benefits are,
34:42
and then kind of the recommended response.
34:45
And so this was something that I kind of took a picture of when I came across
34:47
it, just so I can have something to reference when I'm having conversations
34:50
with families. The only one in this list that we did not have a separate category
34:54
to talk about today was leg cork clamping, and that's something that we do routinely do.
34:59
There can be conversations as far as, you know, the length of that and different things like that.
35:04
But I kind of wanted to focus more on some of these other ones that were kind
35:07
of newer to me or I didn't really know the literature behind them or if there
35:11
was any evidence-based, you know, recommendations or things I could give.
35:15
Just because I want to be able to, you know, appropriately counsel our families
35:19
and what is kind of safest for them and their child.
35:22
And there's definitely some evolving things. And I think, you know,
35:26
social media and word of mouth goes a long way in influencing things.
35:29
And so I think us as medical providers also need to be well informed on things
35:32
from our standpoint so we can appropriately counsel these families.
35:35
But that is kind of the overview of all these kind of interesting topics that
35:38
I wanted to go through. And to end us off, I've got kind of a cute little comic here.
35:42
And this is no offense to our OB colleagues. This is all in good faith.
35:46
But this, I think, is just kind of funny. We have this joke,
35:48
you know, OBs do such a good job of assessing fetal well-being throughout their
35:51
pregnancy. And then as soon as they're born, it's, you know,
35:53
here you go, pediatrics, here's your baby.
35:55
So I thought that was kind of funny. But at this time, we are a bit ahead of
35:59
schedule. So I can open up to any questions or comments.
36:04
But thank you all for listening. Thank you all for that wonderful presentation
36:06
on and alternative birthing practices.
36:10
There is already a comment by Dr. Gong in the chat box.
36:13
Remember, Canadians do not have barriers to access to care for prenatal care.
36:19
Any other questions, comments, or comments?
36:22
To can. And that's a very good point by Dr. Gong.
36:26
I think, you know, the patient population of Canada is very different from the
36:30
population that we see, especially here in San Antonio.
36:32
So I think, you know, a lot of the recommendations are kind of perfect in the
36:34
ideal world, but I think definitely practicing to the patient population where you're at.
36:40
Hello. Hello, Jordan. It's Antonio. Excellent talk.
36:44
I was going to make a similar point. I think we need to be very cautious about
36:47
interpreting studies from other countries when it comes to home birth.
36:51
The difference not only in their patient care because they have universal health
36:56
care and the patient populations are generally a tad bit healthier.
37:00
The midwife training programs are also different. Their certifications are different.
37:04
The requirements for how they take care of babies are completely different.
37:08
And so I think whenever we look at those things, they're very successful in Europe at home births.
37:13
They're very successful in Canada, but it's not the same for the U.S.
37:17
Because generally those patient populations have a trust of the healthcare system,
37:22
and home births in the U.S.
37:24
Come generally from a place of mistrust of the healthcare system.
37:27
So it's, I think, continually different patient populations,
37:30
but excellent points that you made.
37:33
And I want to add on that, Antonio.
37:36
So TMA actually did a deep dive into the types of midwifery practices that are available in Texas.
37:44
So we have the certified midwives that go through a lay training and get a certification,
37:54
which is not a lot of training, but through time,
37:59
some of these women do get really good training.
38:02
And then you have the nurse midwives that go through a master's level program.
38:07
Those are actually very good midwives.
38:10
But then there's a population of midwives that are not certified.
38:15
They didn't go through the certification process. They just tell people they're midwives.
38:21
And that is the population that is very dangerous, the group that does things.
38:28
I'm sure that there are some that, because they've had a lot of experience do serve purpose.
38:34
But I think the issue with midwives in Texas is the way they are oversight.
38:43
So the certified midwives have oversight with a group that is not in the medical
38:51
group because apparently they don't practice medicine. So for the pediatrician.
38:58
If a baby is delivered by someone that can't practice medicine,
39:02
that means they can't do the medical care that is required for the baby.
39:07
And they have access to the baby for the first six hours.
39:11
So then there needs to be a transfer to someone who can take care of the baby
39:16
in terms of things like vitamin K, newborn screening, CCHD screening, and all those things.
39:23
So they need to have ahead of time told the parent what things that they can
39:30
and cannot do because they are not licensed to practice medicine.
39:35
And then for the population of midwives that are not under nurse midwives or
39:41
lay midwives or the lay certified midwives, there is no governance.
39:47
And so if you have a baby that comes to you that had that kind of delivery,
39:55
you may not be able to know what happened because they may not be able to tell
40:00
you, but they may not tell you.
40:02
So then it is very difficult to try to tease through what things need to be done for that baby.
40:10
But that document, the TMA, they have that all done.
40:17
Thank you. There is a question. How common are vitamin K problems if vitamin K is not given at birth?
40:25
That's a great question. So when I was looking at things, thankfully,
40:28
I wouldn't use the word common for issues.
40:31
The numbers I looked at, it looks like less than 2% chance of early onset vitamin
40:36
K deficiency bleeding and, you know, less than 1% or even I think less than 0.5% for late onset.
40:43
And so I think it's more, there have been, I saw some case reports,
40:46
intracranial hemorrhage, GI bleeding, bleeding from the emphylitis, things like that.
40:51
And so I wouldn't use the word common, it's just something that is a risk that would remain.
40:57
A lot of the literature has said, if you do give that prophylaxis,
41:00
there's essentially no risk for those.
41:03
I don't think you can say 100% that there's not a chance of any bleeding,
41:06
but it does seem that they use that word virtually eliminated the episodes of that happening.
41:11
And so I wouldn't use the word common, but there's just a possibility of risk
41:16
of bleeding from various sites if you're not given the prophylaxis.
41:21
A comment by Dr. Jones. Dr. Newton reported to me last week that some of our
41:26
ubegian department studies have shown an increased rate of phototherapy in term
41:31
infants with delayed cord clamping.
41:34
They don't doubt the benefit in preterm, but question the benefit in full-term infants.
41:39
Absolutely. That's something that I found in the literature as well.
41:42
Just something to know, if you do perform delayed cord clamping in term infants,
41:45
they do have a higher chance of having things like polycythemia or need for
41:50
phototherapy just because of the extra blood volume load that they are given.
41:54
Some studies quoted anywhere from 25 to 40 percent of baby's blood volume could
41:59
be given with an additional 22 minutes of delayed cord clamping.
42:03
And so definitely something that you can use to counsel families if they're
42:07
very adamant about wanting to do that practice in their term infant that,
42:10
you know, they may require phototherapy or might have some more potentially
42:14
things that need to be treated after the fact.
42:16
But definitely in preterm infants, it is recommended we routinely do this practice.
42:20
But I think in term infants, you can have that conversation with families that,
42:22
you know, if you want to go about this, there are signs that you might need
42:26
some phototherapy afterwards.
42:29
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42:39
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42:41
Pediatrics Now. Thank you so much for listening. I'll see you next week.
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