Newborn care: 12 beliefs that shape practice (But should they?)

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Applied Evidence

Newborn care: 12 beliefs that shape practice (But should they?)

J Fam Pract. 2007 October;56(10):802-807

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References

1. Gartner LM, Greer FR. Section on Breastfeeding and Committee on Nutrition. Prevention of rickets and vitamin D deficiency: new guidelines for vitamin D intake. Pediatrics 2003;111:908-910.

2. Greer FR. Issues in establishing vitamin D recommendations for infants and children. Am J Clin Nutr 2004;80(Suppl):1759S-1762S.

3. Kreiter SR, Schwartz RP, Kirkman HN, Jr, Charlton PA, Calikogl AS, Davenport ML. Nutritional rickets in African American breast-fed infants. J Pediatr 2000;137:153-157.

4. Pugliese MT, Blumberg DL, Hludzinski K, Kay S. Nutritional rickets in suburbia. J Am Coll Nutr 1998;17:637-641.

5. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia, Maisels MJ, Baltz RD, Bhutani VK, Newman TB, Palmer H, et al. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004;114:297—316.

6. Lew M, Klonis E. Emergency management of eclampsia and severe pre-eclampsia. Emerg Med 2003;15:361-368.

7. Touyz RM. Role of magnesium in the pathogenesis of hypertension. Mol Aspects Med 2003;24:107-136.

8. Cruikshank DP, Varner MW, Pitkin RM. Breast milk magnesium and calcium concentrations following magnesium sulfate treatment. Am J Obstet Gynecol 1982;143:685-688.

9. Hale T. Medications and Mother’s Milk: A Manual of Lactational Pharmacology. 11th ed. Amarillo, TX: Pharmasoft Medical Publishing; 2004.

10. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. 6th ed. Philadelphia: Mosby, Inc; 2005.

11. Hepatitis B. In: Pickering LK, Baker CJ, Overturf GD, Prober CG, eds. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003:118-122;318-334.

12. Centers for Disease Control and Prevention. Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease. Atlanta: US Department of Health and Human Services; 1998.

13. American Academy of Pediatrics committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics 2001;108:776-789.

14. Anderson PO. Alcohol and breastfeeding. J Hum Lact 1995;11:321-324.

15. Howard CR, Howard FM, Lanphear B, deblieck EA, Eberly S, Lawrence RA. The effects of early pacifier use on breastfeeding duration. Pediatrics 1999;103:e33-e38.

16. World Health Organization, Family and Reproductive Health, Division, of Child Health and Development. Evidence for the ten steps to successful breastfeeding. 1998 [cited May 22, 2006]; Available at: www.who.int/child-adolescent-health/New_Publications/NUTRITION/WHO_CHD_98.9.pdf

17. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2005;115:496-506.

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28. Boo N-Y, Lee H-T. Randomized controlled trial of oral versus intravenous fluid supplementation on serum bilirubin level during phototherapy of term infants with severe hyperbilirubinaemia. J Paediatr Child Health 2002;38:151-155.

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The purpose of the supplementation is to prevent vitamin D deficiency and subsequent rickets. (Rickets does continue to occur in the United States.^3,4) The AAP makes no mention in its recommendation of infant pigmentation or the expected amount of exposure to sunshine. The AAP recommends that vitamin D supplementation begin by the time the infant is 2 months old.

BELIEF 2: Supplementing with formula because the mother’s milk hasn’t come in yet is a reasonable, routine practice

THE EVIDENCE: Formula supplements are not necessary as routine practice (SOR: C).

Formula supplements are counterproductive,⁵ taking away the primary stimulus for breast milk production—nursing at the breast. Infant dissatisfaction with the initial volume of breast milk produced actually works to the infant’s advantage,⁵ driving the child to the breast more often, and thus increasing the likelihood of successful breastfeeding.

In certain circumstances, formula supplements can be reasonable, such as when an infant is hypoglycemic or when the baby is receiving phototherapy⁵ and experiences excessive weight loss and becomes severely dehydrated. However, formula supplementation is not reasonable or necessary as routine practice.

FAST TRACK

Encourage a mother who does smoke to do so outside the home and to change clothes before holding her baby

BELIEF 3: Mothers on magnesium therapy should not breastfeed their infants

THE EVIDENCE: Mothers on magnesium therapy may continue to breastfeed their babies (SOR: B).

The misguided recommendation that mothers who are being treated with magnesium therapy should not breastfeed^6,7 is based on an unreasonable fear that magnesium therapy can cause hypermagnesemia in breastfed newborns due to excessive magnesium levels in the breast milk. Supplemental magnesium, usually given intravenously to mothers with severe preeclampsia, does not cross over into breast milk in any significant amount, even when the mother continues to need intravenous magnesium after the birth of her baby.^8,9

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

THE EVIDENCE: Mothers who are hepatitis B surface antigen positive or carriers for hepatitis C can safely breastfeed their newborns¹⁰ (SOR: C).

The idea that mothers who are infected with hepatitis B or C should not breast-feed their babies at first seems obvious to many who care for newborns, as the diseases are transmitted through blood exposure, and nipple cracks with associated blood loss are common in mothers when they begin to breastfeed.

The hepatitis B immunization protocol for infants born to hepatitis B surface antigen positive mothers takes care of the first infectious concern.¹¹ In addition, no case of hepatitis C transmission from breast milk has ever been reported.¹¹ The Centers for Disease Control and Prevention confirms that the transmission rate of hepatitis C from infected mothers is the same whether the babies are breast- or bottle-fed.¹²

BELIEF 5: Mothers who are febrile should not breastfeed

THE EVIDENCE: In most cases, febrile mothers may safely breastfeed their infants (SOR: C).

The advice for mothers not to breast-feed while febrile seems intuitively true because of concern that the infection might pass over into the breast milk to the baby. This rarely happens. There are only 4 contraindications to breastfeeding during maternal fever:¹⁰

Active, untreated maternal tuberculosis
Mothers who are human T-cell lymphotropic virus type I or II positive
Mothers who are HIV-positive
Mothers with a herpes simplex lesion on the breast.

FAST TRACK

Pacifiers may be acceptable in the first few years during breastfeeding

BELIEF 6: Mothers who smoke or drink alcohol should not breastfeed

THE EVIDENCE: While this recommendation seems self-evident, the research proving harmful effects to the infant is lacking¹³ (SOR: C).

In fact, in its most recent statement on “The Transfer of Drugs and Other Chemicals Into Human Milk,” the AAP removed nicotine from a table of drugs for which adverse effects have been reported in infants during breastfeeding.¹³

While it would be ideal if no breastfeeding mother smoked or drank alcohol, the fact of the matter is that some do. In light of this, it’s wise to encourage the mother to smoke outside the home, and to change her clothes before holding her baby. In so doing, she will avoid exposing her baby to most of the effects of secondhand smoke. In addition, while mothers who breastfeed their infants should, of course, avoid alcohol abuse, a single, occasional, small alcoholic drink is acceptable.¹⁴

BELIEF 7: Pacifiers are bad for newborns

THE EVIDENCE: It is not clear whether pacifiers are “bad” for newborns (SOR: C).

The belief that newborns should not have pacifiers came into being for a well-intended reason: Breastfeeding advocates were concerned that newborns would spend too much time sucking on the pacifier and too little time sucking at the breast, undermining the mother’s ability to breastfeed successfully.¹⁵