On Thursday, guest poster Christina began by sharing the first 5 decisions... today she continues on with 5 more decisions for parents of newborns.
6. Newborn Heel Prick Metabolic Disorders Screen
Babies usually have a single heel prick to draw a drop or two of blood, which is put on filter paper and run through a tandem mass spectrometry test to screen for an average of 20+ inherited metabolic disorders, including PKU, cystic fibrosis & sickle-cell anemia. Some states recommend two such tests- one immediately after birth and one just before hospital dismissal.
Why might I want this?
Many see the trade off of a single heel prick for the screening of so many diseases --many both potentially fatal AND treatable-- as quite worthwhile. If you know that any of the diseases tested for run in your family, this seems especially a wise choice. (However, different regions test for different diseases, so ask for a full list from your pediatrician or intended place of delivery.)
Why might I want to opt out?
All of the diseases screened for are very rare. The blood screen's rate of false positives is relatively high. Thus many parents receive news their child needs further (more invasive) tests, may be advised to suspend breast-feeding in the meantime, and are understandably concerned, only to be told that the diagnosis was negative. Additionally, some of the disorders have no treatment or cure, or have variations in forms which may require no intervention (despite showing up as "positive"). For these reasons, some doctors such as Dr. Robert Mendelsohn (in his book How to Raise a Healthy Child in Spite of Your Doctor) recommend waiting for signs of a disease before testing or testing specifically for a disease that runs in your family, and certainly asking for further information and testing if a screen comes back positive.
Your options: Assent to the standard heel-prick screen as a precaution (see below for some steps to make it easier), test specifically for diseases for which your family has a history, or wait and see if any problems manifest, then pursue definitive testing. If one disease in the screen comes back with a positive result, know that many of these are false positives: continue breast-feeding, pursue further diagnostic testing, and try not to stress about it in the meantime.
**Please note that while the diseases are rare and the vast majority of kids will be fine with no screening, for the few that DO have a disease, an early detection often means the difference between life & death, or normal development & severe (often permanent) disability. For many metabolic diseases, which can appear with no family history, the symptoms are subtle and likely to be overlooked until potentially irreversible damage has been done. With this in mind, here are 4 steps you can take to make the screen easier & more accurate for your baby, if you choose to assent to it: 1. wait to do the test, ideally 3 days after birth, so metabolic factors have stabilized, 2. make sure baby is warm --especially warm baby's foot in your hands for several minutes before prick to ensure that blood flows easily, 3. request that nurse hold baby's foot until she stops kicking and only then prick, and 4. offer baby something to suck during prick (finger, binky, bottle or breast).
7. Vitamin K Injection
Vitamin K is a fat-soluble vitamin we get chiefly from bacteria in our gut (it's also in leafy green veggies). It is crucial in blood clotting & bone health. Babies are born with lower clotting factors than adults, perhaps because their intestines lack the bacteria which provide most of ours. A Vitamin K deficiency can lead to "vitamin K deficiency bleeding"-- severe internal bleeding.
Why might I want this?
Bleeding in infants due to vitamin K deficiency can be severe, leading to hospitalizations, blood transfusions, brain damage and death. While formula is enriched with Vit K, breast-milk tends to be lower in it. Intra-muscular injection (i.e. a shot) of Vitamin K is quite effective in preventing internal bleeding. There are several risk factors for VKDB, including: preterm delivery & difficulty feeding, low birth weight, delivery by forceps or vacuum extraction delivery, prenatal maternal use of certain medicines (including antibiotics, anticoagulants, & anticonvulsants), liver disease, extremely fast, or extremely prolonged labor, particularly during the pushing phase, and delivery by C-section.
Why might I want to opt out?
Many question whether God would design a faulty system-- why would all babies be deficient in a vitamin that was also lacking in their natural food? Some feel that it's preferable to instead supplement the breast-feeding mother's diet with Vitamin K, both/either through a diet high in leafy greens & probiotics, or a supplement, rather than giving a newborn a painful injection. Colostrum, which precedes milk, is quite high in Vitamin K. An injection is an unnatural means of getting a vitamin that is usually absorbed through the gut wall, and, like all injections, provides an opportunity for contamination to be introduced, as well as potentially toxic preservatives. The amount of Vitamin K injected is also very high: 20,000 times the level present at birth. Lastly, high Vitamin K levels are a cause of jaundice in newborns.
Your options: Choose to have the injection as a precautionary measure, especially if your child had a traumatic birth, if your prenatal diet was low in Vitamin K, or if you took medications tending towards VKDB. Take a non-interventionist approach of a late-pregnancy diet high in leafy greens, delayed cord-clamping, and immediate breastfeeding. Or opt for the oral method of vitamin K supplementation.
Image by jonty.fisher
8. Sleeping Arrangements
Many hospitals now offer the option of "rooming-in," in which baby & mother are kept together in one room, as well as the former model of nursery care, in which babies are tended by nurses in a separate room. Few hospitals recommend that the baby stay in the nursery throughout the day, though it is always an option if you need a break. Fathers are usually welcome to accompany the baby into the nursery during any screens or tests (and if they aren't, they can insist upon it!).
Why might you prefer the nursery model?
Many moms (and their spouses!) are exhausted after delivery and will be facing months of sleepless nights tending a newborn. The chance to have someone else changing diapers and keeping an eye out for problems can be a welcome and unique break, especially if you deliver at a hospital friendly to breast-feeding who will bring your baby to you to be fed at the first sign of hunger.
Why might you prefer to "room-in"?
Some new moms don't want their precious children away from them at any point, especially if their hospital tends to force standard procedures (injections, eye ointment, etc.) on newborns despite parental preferences, or if they are likely to give a hungry baby a pacifier or a bottle of formula. As newborns have very little stomachs (large as a thimble), ounces of formula really sabotage their metabolism & eagerness to nurse (in turn interfering with maternal milk production). Entire nursing relationships have been sabotaged by bottles given before hospital discharge.
Your options: Ask around and find out what hospital policy is regarding bringing babies to moms for feedings or giving them bottles-- ask other patients and your doctor/midwife what this hospital's reputation in this area is like. If it's parental-preference friendly, you may want to take advantage of the nurses ability to watch over your child during the night (so you and Daddy can both sleep). If, however, the hospital nursery seems a risky place, keep baby with you, perhaps trading off with Daddy or another family member to tend to baby's non-nutritive needs.
Note that you can begin one way and then switch as needed: I personally began with our daughter in our room, but when it became apparent that my husband & I were too tired after our 45-hour labor to adequately care for her, we gladly surrendered her to the nursery nurses, who faithfully brought her to me for feedings throughout the night and recorded her every diaper on her chart so I'd stay informed (Our hospital is stellar with respect to honoring parental wishes in all areas.).
9. Artificial Nipples (pacifiers or bottles)
Hospital nurses only have 2 arms, just like all of us, and tend to pacify crying babies with a pacifier rather than with cuddles. Some feel that sucking on a pacifier tires a baby out, decreasing their desire to eat. And some babies just plain old spit them out.
Why might you want to allow pacifiers?
Some babies like to suck. It's a comfort thing-- babies have been caught sucking fingers, thumbs, tongues, and hands in utero. As anyone who was a child-hood thumb-sucker knows, it's hard to break those habits. Some parents would prefer that their baby's "non-nutritive sucking" needs are met through a paci, which can be detached, washed, and eventually discarded instead of through a body part, which is always around (and often dirty).
Why might you want to avoid artificial nipples?
Some lactation experts warn of nipple confusion; with babies getting into poor latching habits after sucking on a paci or bottle (these require entirely different tongue positions). Many parents would prefer to allow their newborn to suck frequently at the breast, even if only for the first few days, to ensure a good milk supply, as well as to maximize skin-to-skin contact.
What are your options? Allow pacifier use, limit it to times when baby isn't hungry or your breasts are sore from a feeding, or request that no artificial nipples be used at all. If your baby is too weak to nurse or has a poor latch, you can still use systems other than a bottle --such as a supplemental nursing system (with expressed breast milk or formula), finger-feeding, or a dropper. Here's a handy trick: latches can usually be "re-set" by simply allowing a baby to suck a finger, which gets the tongue in the correct position for breast-feeding.
Image by [derekmswanson]
10. Time of Discharge
Most hospitals keep mom & baby for 24-48 hours after an uncomplicated vaginal delivery. For moms with c-sections, 3 days is the minimum, and for complicated births moms & babies may be kept any number of days.
Why might you want to stay the full recommended 2 days?
State laws were passed in the mid-1990s regarding postpartum "Length of stays" (LOS) out of concern for maternal & infant health. Many health problems (such as a retained placental fragment, for instance) take a few days after birth to manifest themselves. Additionally, many mothers will not be going home to much help, so the rest and care they receive immediately after birth in the hospital can be very welcome.
Why might you want to ask for an early discharge?
Plainly put, even the best hospitals are dirty places-- they're mainly for sick, germy people. In this sense, getting a newborn and recovering mom out of there doesn't seem a bad idea. Some mothers also find sleeping difficult in a hospital bed, and being woken by nurses every few hours for vitals to be checked can be wearing. Some moms just recover faster in their own beds. Postpartum doulas-- hired help specifically trained to care for newborns and their mamas-- are far more available these days and can fill in the gap hospital nurses provide. Some midwives do house-calls, and many pediatricians or OBs will allow you to come in for a check-up 3 days post-partum, somewhat negating the need to spend all 48 hours under observation. Studies in California after the LOS laws were passed showed "a significant decline in neonatal readmissions [to hospitals] but not in 1-year mortality."
Your options: Enjoy the full 2-day hospital stay, or ask for an early discharge if your delivery was uncomplicated and un-medicated, and follow up with a 3-day postpartum checkup for both mama & baby. Consider hiring a postpartum doula or having Grandma stay and care for you once home. You will likely need to get your OB/midwife and pediatrician to put a request for early discharge in writing, ideally in your birth plan.
For Parents of Little Boys: Circumcision
This is such a complicated issue (worthy of a post all its own) that I will only briefly touch on it. American doctors are split down the middle on recommending circumcision or not. The AAP's official position states:
Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data arenot sufficient to recommend routine neonatal circumcision. Incircumstances in which there are potential benefits and risks,yet the procedure is not essential to the child's current well-being,parents should determine what is in the best interest of the child.
Basically, it's a preference issue. However, more boys are circumcised in the US than are not, often before leaving the hospital after birth.
Why might you want circumcision?
There do seem to be hygienic benefits to it: fewer yeast & urinary tract infections, lower cancer rates and drastically lower transmission rates of HIV, and STDs (even the female partners of circumcised men are slightly protected). There is a small percentage of men who require circumcision later in life for medical reasons, and circumcisions later in life are far more complicated than in an infant. Babies don't remember the pain of surgery. Many Christians feel that if God commanded it for generations, it likely has some health benefit to it, just as the dietary laws do. When performed by a mohel (Jewish rabbi specializing in circumcision) on the 8th day, the procedure is very quick (under a minute), usually done in the comfort of your home with your son held in familiar arms and anesthetized in non-invasive ways such as sugar pacifiers, drops of wine, and topical anesthetic cream.
Why might you want to skip this elective surgery?
The hygienic benefits of circumcision can usually be overcome through personal hygiene and a monogamous lifestyle later in life. It's a painful surgery, even if some form of anesthetic is used. In hospitals, it is probably terrifying for the baby, who is separated from his parents, strapped down, and in considerable pain for 10-20 minutes. As noted above, clotting factors are low in newborns and don't rise until 5-7 days after birth, reaching their apex at 8 days after birth-- surgery before then carries increased risk of hemorrhage. As some Christians have pointed out, modern hospital circumcision is quite different than the OT version in timing, method & environment.
Your options: Have the circumcision in the hospital before discharge (when it's still covered by insurance), using one of the following methods decided on beforehand: the mogen clamp, the plastibell, or the Gomco clamp. Research each as well as the doctor who will perform the circumcision. Alternatively, wait until the 8th day (as is Jewish custom due to Genesis 17:9-14) for the surgery at the hospital, or hire a mohel to perform the surgery in your home or the hospital, usually using the Jewish shield technique. Or, skip the surgery altogether and add extra emphasis to your son's personal hygiene.
(As a mom making this decision myself, I must say that, should we choose to circumcise our son, of all the methods the mohel-performed, Jewish shield technique seems the quickest, least painful, traumatic and risky; well worth the extra cost.)