Breastfeeding increases the risk of newborn readmission. Now what do we do?

The Pediatric Insider

© 2019 Roy Benaroch, MD

An August 2018 paper in Academic Pediatrics found an unsettling conclusion: breast-fed newborns have about double the risk of needing to be hospitalized in their first month of life, compared to babies who were formula-fed. The numbers are solid, and they jibe with the real-life experience of many pediatricians, including me. So what should we do about it?

The study itself looked at about 150,000 healthy, normal newborns born in Northern California hospitals from 2009 to 2013. The study authors were able to collect data on how these babies were fed in the few days following birth from hospital records (dividing them into groups of all-breast, all-formula, and a mixed group that did some of both.) They were then able to track these babies over the first month of their lives to see which ones ended up hospitalized for any reason. Most of the hospitalizations were related to dehydration and jaundice, which are closely linked to inadequate feeding.

The good news is that relatively few of these babies ended up back in the hospital – whether bottle-fed, breast-fed, or both, most babies did great. But babies who were breast-fed were much more likely than formula-feeders to end up underfed and hospitalized. Among vaginal deliveries, the risk of rehospitalization was 2.1% for bottle-fed babies versus 4.3% for breast-fed babies (the risk for mixed feeders was in between.) That’s about double the risk. Mathematically, the “number needed to harm” was 45. That is, for every 45 babies exclusively breast fed, one extra baby would end up in the hospital. Not good.

Among Caesarian births, the differential was less, with an increased risk of hospitalization of 2.1% (breast) versus 1.5% (formula). Both of these numbers are lower than the risk of rehospitalization for vaginal deliveries, probably because c-section babies already spend an extra day or two in the hospital. This provides more time for good feeding to be established (whether breast, bottle, or both.)

Does this mean we should discourage breast feeding? Of course not. Most breast-fed babies do great, and there are some health advantages of breastfeeding. But we need to be honest with ourselves, and honest with moms who are trying to do the best thing for their babies. Nursing isn’t perfect. It’s not a perfect food*, and it’s not a perfect method. There are pros and cons to both nursing and formula feeding, and parents (and babies) deserve an honest appraisal.

Nursing moms also need support. That includes “technical support” (ie “How to do it”) but also emotional and medical support – which should include time for rest, and an honest evaluation of how both moms and babies are doing. There is a role for formula, both for moms who choose to use it and for situations where babies aren’t getting enough to eat. Families, pediatricians, nurses, and lactation specialists all need to work together, without guilt or finger-pointing, to help keep babies and moms healthy.

*Human breast milk is an inadequate source of vitamin D from birth, and an inadequate source of iron by 4-6 months of life.

Is 24% the correct goal for c-section rates?

The Pediatric Insider

© 2017 Roy Benaroch, MD

Yesterday I wrote about a recent Consumer Reports article about c-sections and how to avoid them by choosing a hospital with a low c-section rate. I’m not convinced that’s the best way to choose a hospital.

In their piece, Consumer Reports quoted an overall “goal” for c-section rates of 23.9%, as determined by the US Department of Health and Human Services’ Office of Disease Prevention and Health Promotion (That’s right, the USDHHSODPHP. Yes there will be a quiz.) I was kind of flip in my dismissal of that number – I may have said something about it being “made up” or “pulled from the USDHHSODPHP’s nethers” – because to my knowledge there’s no data supporting an exact c-section rate that’s ideal for maternal and baby health.

In the spirit of pretending to be a journalist, I looked into that number a bit further. And it turns out I was right. It really was pulled out of USDHHSODPHP’s nethers.

Here’s where it comes from, see for yourself: MICH-7.1, a goal to “reduce cesarean births among low-risk women with no prior cesarean births.” They took the 2007 rate –estimated at 26.5% — and reduced it by a target of 10%. Not 11% or 5% or 15%, but 10%, because that’s a nice number. And that’s it. Our current official goal rate of 23.9% is exactly where we were, reduced by a nice round percentage.

The number has nothing to do with healthy babies or moms – they didn’t even try to figure out what c-section rate results in the best health outcomes. Or even the lowest cost, or the best patient satisfaction, or anything like that. It’s just an arbitrary number that could as easily been set higher or lower. I mean, if a 10% reduction is good, why not 15%? Or 41.5%?

Why this matters: women are trying to make good decisions for their own health and the health of their babies. Arbitrarily telling them that c-sections are bad and that hospitals that do fewer of them are good is, well, silly and paternalistic and insulting. We can admit that we really don’t know the perfect percentage for a c-section rate, which means it’s OK that it’s not the same at every hospital. Whether you get a c-section should depend on your health, your baby’s health, and a frank and honest discussion with your OB or midwife about the risks and benefits of a vaginal or c-section delivery. Let’s leave the USDGGSODPHP out of it.

Great news about pertussis protection for newborns: Vaccinate mom!

The Pediatric Insider

© 2017 Roy Benaroch, MD

Pertussis (AKA “whooping cough”) is a nasty bear of an illness in older children and adults. People with pertussis cough for about 100 days – and it’s a horrible cough that sometimes makes people puke, pass out, or wet their pants. Seriously. Three months of that.

But it’s even worse for little babies, especially newborns, who just don’t have the lung power to expel the mucus. They cough, sure, but a lot of them get encephalitis and seizures, and some of them just stop breathing. So it’s especially important to protect the youngest babies.

Rates of pertussis have been climbing, in part because the newer vaccine that we started using in the 1990s doesn’t seem to give as lasting immunity as the old-school, whole-cell vaccine of earlier days. And as more pertussis circulates in communities, it’s the little babies who suffer the most. Pertussis vaccines are given to babies at 2, 4, and 6 months – and that means they build own protection slowly over the first year. Fortunately, a study published today shows that we can prevent most cases of newborn pertussis – even in babies too young to have gotten the full benefit of their own vaccines.

Researchers from the Kaiser Group of Northern California looked at records of all of the babies born at their facilities from 2000-2015 (those years spanned two big California pertussis outbreaks, in 2010 and 2014.) They hypothesized that a strategy of vaccinating pregnant women against pertussis, recommended since 2011, would help prevent pertussis in their newborns. Since people enrolled in Kaiser get all of their care at Kaiser locations, they could track which babies caught pertussis and they could tell which moms got a dose of pertussis vaccine during pregnancy.

They had a lot of babies to track – about 150,000. 17 of those babies caught pertussis in the first 2 months of their lives, and 110 caught it within the first year. The authors compared the rates of pertussis among babies whose mom got the Tdap (tetanus-diphtheria-pertussis) vaccine during pregnancy versus those who did not.

Of the 17 newborns less than 2 months with pertussis, only 1 had a mom who was vaccinated during pregnancy – working out to a vaccine effectiveness of about 90%. Looking down the road as the babies got older and received their own doses of pertussis vaccine, the effectiveness of maternal Tdap remained strong throughout the first year. There were no signs that maternal vaccination interfered with the effectiveness of the babies’ vaccines.

This is great news – an easy and effective easy way to prevent a potentially devastating disease of young babies. Previous studies have shown that this vaccine is also very safe for both pregnant women and their babies. Keep your babies safe – make sure, moms, you get a dose of Tdap during every pregnancy.

Vitamin K can save your newborn’s brain. Get it.

The Pediatric Insider

© 2013 Roy Benaroch, MD

Some topics I enjoy writing about. Some give me no satisfaction whatsoever. Still: I never want to read about another baby going through a completely avoidable catastrophe again. So pay attention, especially those of you about to have a baby, or those of you who might someday have a baby, or those of you who ever talk to couples who are having a baby. Just all of you, pay attention here.

Hemorrhagic disease of the newborn is a real thing. Newborns aren’t born with good stores of Vitamin K, so they can’t make their own clotting factors well. Sometimes—rarely, but it does happen—they develop spontaneous bleeding. It might be from their umbilical cord, or in their gut, or in their brain. If the bleeding isn’t treated quickly, the baby will bleed to death or suffer brain damage.

Hemorrhagic disease of the newborn, you say? You’ve never heard of that? You’ve never heard of it because it’s rare to begin with, about .24-1.7 cases per 1000 live births, and because there is a nearly 100% effective way to prevent it. The AAP has recommended that all babies receive vitamin K shortly after birth since 1961, and multiple studies have confirmed that this is completely safe and just about 100% effective in preventing hemorrhagic disease.

There is no other way to prevent hemorrhagic disease of the newborn. It doesn’t matter how much vitamin K mom has—it doesn’t cross the placenta. It doesn’t matter whether baby nurses—vitamin K is not present in human milk. Commercial formulas do contain vitamin K, but not enough to “fill up the tank” when babies are born.

The best, most effective, and safest way to give vitamin K to a newborn is by injection. Though oral vitamin K is used in some countries, oral vitamin K fails to prevent all hemorrhagic disease, leading to about 1.2-1.8 cases per 100,000 births, versus zero cases after injected vitamin K.

There are no known side effects of vitamin K. There are no downsides to any baby getting this injection, which prevents death and brain damage.

Still, some parents choose to NOT allow their babies to get this injection. Their worry is based on completely unfounded internet hoopla, but that’s the way it is. Random internet stupidity trumps science, pediatricians, and the recommendations of public health agencies worldwide. Apparently it’s becoming trendy to skip the vitamin K injection.

The internet, as usual, exaggerates the freaky and uncomfirmable stories, and fails to tell the boring stories about the millions of babies who do great after receiving good routine care. Parents are tricked into worrying about the wrong things. Instead of protecting their babies, they place them in harms way. That’s a tragedy we all need to fight.

Safe swaddling for babies

The Pediatric Insider

© 2013 Roy Benaroch, MD

Swaddle ‘em right, and it can help babies sleep and relax. Swaddle ‘em wrong, and you can mess up their little hips and get you arrested. Yikes!

As usual, too much of a good thing ends up being…. less of a good thing. I like swaddling, and I like to demonstrate a good swaddle for new parents, especially they’re a little anxious about knowing how to soothe their new baby. A nice swaddle can help  everyone relax.

But something you shouldn’t do is wrap up 7 – 12 month old babies so tight they can’t move, use knots to hold them in place, and throw blankets on their heads. That didn’t work out well for these two sisters, who used to run a daycare in California before they were arrested for child abuse.

What you can do is a simple, easy swaddle as demonstrated in videos on this page, from Children’s Healthcare of Atlanta. Safe swaddling involves holding the upper body still and in place, while allowing the legs and hips to move. Though they’re stylish, you don’t need a special blanket to do it right. Once babies start to wiggle out of swaddles (typically by four months), it’s probably a good time to stop swaddling altogether.

Some states have banned any kind of swaddling in day care centers, for fear that it can increase the risk of SIDS. One study did show that, but it didn’t look at the position babies had been left in—and we know that back-sleeping protects against SIDS. That study also found the strongest predictors of SIDS were parental use of alcohol or drugs,  cosleeping, or smoking during pregnancy. Other studies have refuted the SIDS-swaddling link, include ones that show that swaddled babies are less likely to sleep in unsafe positions, and one that showed better arousal in swaddled babies despite overall improved sleep patterns.

The best ways to avoid SIDS are outlined here, and current evidence certainly isn’t strong enough to convict swaddling as a cause. I’d also guess that since swaddling helps parents get better sleep themselves, that may end up actually being protective against SIDS and post-partum depression as well.

Apart from the (unsubstantiated) fear of increasing SIDS, the other concern with swaddling is that it can contribute to hip problems, specifically developmental dysplasia of the hips. But this really has only been seen in cultures that bundle up legs to hold them fixed and extended—that’s rarely done in the US. The current swaddling fad has not led to an increase in hip problems here. Still, review the video above, and make sure that if you do swaddle, Junior’s legs and hips are free to move around.

Swaddling is a safe and effective way to soothe a young baby, and parents can safely do it with a brief lesson and a little common sense. That’s one fewer thing to worry about!

The Fisher-Price Rock ‘n Play Sleeper is NOT for sleeping

The Pediatric Insider

© 2013 Roy Benaroch, MD

You might think a thing sold by a huge manufacturer of children’s toys and furniture as a “sleeper” would a safe, appropriate place for a baby to sleep. It is, after all, called a “sleeper.” But it is not a safe place for your baby to sleep.

The Fisher-Price Newborn Rock ‘n Play Sleeper is a sling-shaped baby holder sort of gizmo, fitted into a frame that allows it to rock back and forth. The baby is held kind of snuggled in a pouch, in a sitting-like position, tilted up maybe thirty degrees or so. The name implies that it’s for rocking (that seems right, though I don’t think they’re talking about this kind of rocking—give that man a towel) and for playing. The problem I’m worried about is that last word in the name, the “Sleeper”. This slingy soft thing is not a place to leave your baby to sleep.

Why? Because we know that to best prevent Sudden Infant Death Syndrome, and to best encourage normal physical and motor development, babies ought to be put down to sleep flat on their backs, on a firm, flat surface. The Rock ‘n Play Sleeper is not firm, and it’s not flat—so it is not a safe place to routinely sleep.

The AmericanAcademy of Pediatrics published detailed guidelines about safe sleeping environments for babies in October, 2011. The Rock ‘n Play Sleeper clearly doesn’t fulfill many of these evidence-based criteria. I contacted Fisher-Price in February, and spoke with a very nice person, the “Manager-Risk Management.” I’ve sent her a detailed e-mail with my concerns that she said she would forward to the Director of Safety Management. Since then, all I’ve heard from Fisher-Price is:

Thank you for your inquiry and comments. We did receive your email on February 7. 2013.  We have provided these comments to the appropriate people within Fisher-Price.

The Rock ‘n Play Sleeper complies with all applicable standards.  We encourage consumers who have questions or concerns about providing a safe sleeping environment for their babies to discuss these issues with their doctors or pediatricians.

We appreciate your taking the time to contact us.

OK, since they say they encourage consumers to discuss these issues with their pediatricians, let’s discuss it!

Below is what I had sent to Fisher-Price: the details of my concerns, based on the AAP’s recommendations in bold. The numbers refer to each recommendation in the AAP document.

1. To reduce the risk of SIDS, infants should be placed for sleep in a supine position (wholly on the back) for every sleep by every caregiver until 1 year of life.

The Newborn Rock ‘n Play Sleeper does not keep a baby wholly on the back, but rather in an inclined position. It is not a safe way for babies to sleep.

2. Use a firm sleep surface—A firm crib mattress, covered by a fitted sheet, is the recommended sleeping surface to reduce the risk of SIDS and suffocation.

The Newborn Rock ‘n Play Sleeper is not a firm crib mattress.

2e. Sitting devices, such as car safety seats, strollers, swings, infant carriers, and infant slings, are not recommended for routine sleep in the hospital or at home.

Though this sentence doesn’t specifically mention your product, the Newborn Rock ‘n Play Sleeper is shaped like the devices in this category, and is therefore not recommended for sleep.

2e. If an infant falls asleep in a sitting device, he or she should be removed from the product and moved to a crib or other appropriate flat surface as soon as is practical.

Again, babies should not be left to sleep in a device like your Rock ‘n Play Sleeper.

16. Media and manufacturers should follow safe-sleep guidelines in their messaging and advertising.

From your website describing this product, at http://www.fisher-price.com/en_US/products/51903, I quote: “The seat is also inclined, which makes napping more comfortable for babies who need their heads elevated.” This implies that babies need their heads elevated, or that perhaps some of them need their heads elevated for comfort for napping. This is incorrect and contradicts the AAP, and is inconsistent with the safe sleeping guidelines.

In short, the Fisher-Price Newborn Rock ‘n Play Sleeper does not meet the standards established by the AAP for safe sleep. Parents, do not leave your babies sleeping in this gizmo. Their safety is too important.

Babies know when they’re hungry

The Pediatric Insider

© 2012 Roy Benaroch, MD

There seem to be two styles of baby-feeding: scheduled versus on-demand. Strict schedulists stress that babies need regularity, and that parents know best what and when and how much their babies ought to eat. In the opposite corner are the on-demand feeders, sometimes thought of as a bit more Earthy-crunchy, the hippie tie-dye, anything-goes crowd. Who’s right?

If preventing obesity is your goal, here’s one more point for the hippies.

A recent study from 2011 presented inAustralia looked at about 300 babies, comparing those fed on-demand to those who were strictly scheduled. The scheduled babies weighed more, on average, at 14 months of age. We know from a good body of prior research that overweight toddlers are much more likely to become overweight children and overweight adults, so that weight difference at 14 months does have important predictive powers.

The results, to me, make sense. An ongoing struggle I have with counseling families trying to control weight is to stress the simple concept: Eat when you’re hungry, but stop eating when you’re not hungry. Unfortunately, many of us eat for too many reasons. We’re bored, we’re upset, we’re anxious, we’ve been taught we need to clean our plates. It is crucial, even from a very early age, to allow babies to develop their own, internal sense of appetite, and to develop the ability to decide themselves how much to eat. After all, it’s the baby himself how knows if he’s hungry, or how hungry he is.

Efforts to over-schedule meals and intake prevent this normal development of a child’s internal hunger-meter. If mom and dad are the ones deciding when and how much to eat, Junior may just eat whatever’s put in front of him, hungry or not.

That’s not to say there are no benefits to scheduling. Schedules help babies sleep at more regular intervals, including through the night. And schedules are essential for working families, who need to get their babies where they need to be, fed, at a certain time. Some sort of schedule is certainly a good idea, at least for the timing of meals.

But at mealtimes, it really is best—from a very young age—to allow babies to decide how long to nurse, or how much to take from the bottle. Try not to second-guess your baby, or push more intake. Trust your own baby to know when she’s hungry, and help her learn that it’s OK to stop eating when her little tummy is full.

How much milk does a newborn need?

The Pediatric Insider

© 2010 Roy Benaroch, MD

Honk honk honk. (Traditionally, this would be “beep beep beep,” but I have my phone set to alert me with a bicycle honk for new text messages. It’s a riot at 3 am.)

“Newborn nursery.”

“Yeah, this is um… the doctor, calling back…someone.”

“The nurse needs to reach you, please hold.”

…and that’s why you shouldn’t kiss a pig. Did you know it’s bicycle safety awareness week?Your call is very important to us. Please hold for the next available…

“Yes, this is the nurse. What do you need?”

“You called me.”

“Who?”

“Me. The doctor. Doctor Me.”

“About Baby Grisham?”

“I don’t know who about. You called me. I’ll be there in the morning.”

“This can’t wait. The baby is spitting a lot, and needs a change in formula.”

“What?”

“We’ve been giving him Enfalac, but he’s spitting, so I need an order to change him to Simamil.”

“How old is this baby? What baby?”

Sigh. “Baby Grisham, born at 2300 hours.”

Doing math in my head. I can’t ever figure out those ‘hours’ times. “So he’s…three hours old?”

“Yes, mom’s not breastfeeding, and he’s spitting up his Lactosimacare.”

“How much?”

“A lot.”

“No, I mean, how much are you giving him?”

“Only 2 ounces.”

“OK, here is what I want you to do. Let the baby sleep in the room with mom, and stop feeding him so much. In two or three hours, give him just a little bit.”

“A little bit?”

“Yes, just a teaspoon. Five ccs, that’s it.”

“He’ll be hungry!”

“No he won’t. Normal newborns less than a day old barely need anything to eat. If you look at breastfed babies—and those are the babies eating the way they’re really supposed to eat—they get maybe, tops, an ounce of milk taken in over the whole first 24 hours of life. And they do fine. Just stop drowning this baby, and he’ll be fine, too.”

A study just published in The Journal of Pediatrics confirms what I’ve been saying for years: normal newborn babies need to take in very, very little over their first day of life. Ninety healthy, term, exclusively-breastfed babies were weighed very carefully with an ultra-sensitive scale before and after feedings to determine exactly how much milk was ingested. The average intake for the entire first 24 hours of life was 15 ccs—that is, one tablespoon. The range was from 1 to 30 ccs. That fits with exactly what we ought to expect from the physiology of a newborn and of a new mom. A newborn has just been through a traumatic transition, and has a gut that’s filled with sticky mucus. The normal “peristaltic waves” that push food along through the gut to help digestion haven’t yet begun. So it makes sense that a normal newborn isn’t quite ready to accept a full meal on the first day of life. It also fits exactly with what we know about a normal, healthy mom. Milk doesn’t “come in” until about 48-72 hours after a baby is born. Moms aren’t supposed to have a good milk supply during a baby’s first day of life. Now, some babies are going to get impatient and yell about this. That doesn’t mean they’re extra-hungry. It does mean that some babies, like some nursery nurses, don’t like to wait!

All of this assumes a healthy full term baby without additional risk factors for low blood sugar or other problems. If you’ve got a baby with special health circumstances, you need more specific advice and guidance.