Naturally Forced to be Reckoned With

Sunday, August 8, 2010

Delayed Cord Clamping Should Be Standard Practice in Obstetrics

There are times in our medical careers where we see a shift in thought that leads to a completely different way of doing things. This happened with episiotomy in the last few decades. Most recently trained physicians cannot imagine doing routine episiotomy with every delivery, yet it was not so long ago that this was common practice.

Episiotomy was supported in Medline indexed publications as early as the 1920s(1), and many publications followed in support of this procedure. But by as early as the 1940s, publications began to appear that argued that episiotomy was not such a good thing(2). Over the years the mix of publications changed, now the vast majority of recent publications on episiotomy focus on the problems with the procedure, and lament why older physicians are still doing them (3) (4). And over all this time, practice began to change.

It took a long time for this change to occur, and a lot of data had to accumulate and be absorbed by young inquisitive minds before we got to where we are today, with the majority of recently trained OBs and midwives now reserving episiotomy only for rare indicated situations.

Though this change in episiotomy seems behind us, there are many changes that are ahead of us. One of these changes, I believe, is in the way obstetricians handle the timing of cord clamping.

For the majority of my career, I routinely clamped and cut the umbilical cord as soon as it was reasonable. Occasionally a patient would want me to wait to clamp and cut for some arbitrary amount of time, and I would wait, but in my mind this was just humoring the patient and keeping good relations. After all, I had seen all my attendings and upper level residents clamp and cut right away, so it must be the right thing, right?

Later in my career I was exposed to enough other-thinking minds to consider that maybe this practice was not right. And after some research I found that there was some pretty compelling evidence that indeed, early clamping is harmful for the baby. So much evidence in fact, that I am a bit surprised that as a community, OBs in the US have not developed a culture of delayed routine cord clamping for neonatal benefit.

I think that this is a part of our culture that should change. This evidence is compelling enough that I feel like a real effort should be made in this regard. So to do my part in this, I am blogging about it.

As this is Academic OB/GYN, of course I am going to lay out this evidence I speak of. But before I do that, I want to present some logical ideas under which this evidence ought to be considered.

Prior to the advent of medical delivery, and for all time in animals, it has been the natural way of things for a baby to stay on the umbilical cord for a significant period of time after delivery. Depending on culture and situation, the delay in cord separation could be a few minutes or even a few hours. In some cultures the placenta is left on for days, which of course I find excessive and gross (5). But whatever the culture and time on cord, the absence of immediate cord clamping allows fetal blood that was previously in the placenta to transfuse back into the baby. Studies have demonstrated that a delay of as little as thirty seconds between delivery and cord clamping can result in 20-40 ml*kg-1 of blood entering the fetus from the placenta (6).

Considering this data, I have to think about evolution and function. I am a strong believer in evolution, but even under creationist thinking I have to believe that if the system meant for babies to have been phlebotomized of 50-100 cc of blood at birth, we would have been born with higher hemoglobins. Clearly the natural way of things is for this not to happen.

So does this mean that early cord clamping is necessarily harmful? Absolutely not. But what it means is that the burden of proof is on us to prove that early cord clamping, which amounts to planned fetal phlebotomy, is a beneficial thing. Otherwise, all things being equal we ought to give the tykes a few minutes to soak up what blood they can from the placenta before we cut’em off.

So the question is whether or not there is strong data either way.

It is easy to imagine a randomized study of immediate vs. delayed cord clamping, with quantitative analysis of fetal lab values and clinical outcomes. So easy in fact, that it has been done many times – and in just about every study, there is a clear benefit to delaying cord clamping, even if it is just for 30 seconds after delivery. These benefits include important outcomes such as decreased rates of intraventricular hemorrhage and necrotizing enterocolitis in preterm neonates. Furthermore, aside from some intermittent reports of clinically insignificant polycythemia and hyperbilirubinemia in term infants, there appears to be no harm that can be linked to delayed cord clamping. It feels like being a doctor 10-15 years ago looking to see if there is any data about episiotomy, and finding that there’s a lot, and it says we’ve been doing it wrong for awhile now.

So here’s the data:

Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial(7)

Randomized 72 VLBW infants (< 1500 grams) to immediate or delayed cord clamping (5-10 vs. 30-45 seconds). Delayed cord clamp infants had significantly less IVH (5/36 in delayed group vs. 13/36 in immediate group, p = 0.03) and less late onset sepsis (1/36 vs. 8/36, p = 0.03).

The Inﬂuence of the Timing of Cord Clamping on Postnatal Cerebral Oxygenation in Preterm Neonates: A Randomized, Controlled Trial (8)

Randomized 39 preterm infants to immediate clamping vs. 60-90 second delay, and examined fetal brain blood flow and tissue oxygenation. Results showed similar blood flow between groups, but increased tissue oxygenation in the delayed group and 4 and 24 hours after birth.

Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomized controlled trial(9)

Randomized 476 infants to immediate or 2 minute delayed clamping and followed them for 6 months. Delayed clamped babies had higher MCVs (81 vs. 79.5), higher ferritins (50.7 vs. 34.4), and higher total body iron. Effects were greater in infants born to iron deficient mothers. Delayed clamping increased total iron stores by 27-47mg. A follow up study showed that lead exposed infants with delayed clamping also had lower serum lead levels than immediate clamped infants, likely due to iron mediates changes in lead absorption.

A randomized clinical trial comparing immediate versus delayed clamping of the umbilical cord in preterm infants: short-term clinical and laboratory endpoints(10)

Infants delivering at 30 to 36 weeks gestation randomized to immediate vs. 1 minute delay. Delayed group had higher RBC volumes (p = 0.04) and hematocrits (p < 0.005), though there was no difference in RBC transfusions. There was a small increase in babies requiring phototherapy in the delayed group (p = 0.03) but no difference in bilirubin levels between groups.

Immediate versus delayed umbilical cord clamping in premature neonates born < 35 weeks: a prospective, randomized, controlled study (11)

Randomized 60 infants to clamping at 5-10 seconds vs. 30-45 seconds. Delayed clamping infants had higher BPs and hematocrits. Infants < 1500 grams with delayed clamping needed less mechanical ventilation and surfactant. Trend towards more polycythemia in delayed group, but not statistically significant.

And that’s just some of it. I’ll be happy to send you an Endnote file with a pile more of you’d like it. If the burden of proof is on us to prove that immediate clamping is good, that burden is clearly not met. And furthermore, there is strong evidence that delaying clamping as little as 30 seconds has measurable benefits for the infant, especially in premature babies and babies born to iron deficient mothers.

So basically, we should be doing this. I’m going to try to effect some change in my department, but there are a lot of things that need to happen for us to change as a general culture. It can’t just be the OBs. L and D nurses and pediatricians need to buy in as well.

Some people will argue that premature babies need to be brought to the warmer right away for resucitation. I don’t know the answer to this, but it’s worth study. One might think that it is important to intubate a very premature baby right away, but I have to wonder if that intact cord will be better at delivering oxygen to the baby for 30-60 seconds than the premature lungs. Particularly in cases of fetal respiratory acidosis, there is strong logical argument that a baby might be better resuscitated by unwrapping the cord and letting it flow a bit than trying to oxygenate it through its lungs. Until that placenta is detached, you have a natural ECMO system. Why not use it? Certainly there are exceptions to this logical argument, abruption being the biggest one, and perhaps even severe pre-eclampsia and other poor feto-maternal circulation states.

I wonder at times why delayed cord clamping has not become the standard already; why by and large we have not heeded the literature. It is sad to say that I believe it is because the champions of this practice have not been doctors, but midwives, and sometimes we are influenced by prejudice. Clearly, midwives and doctors tend to have some different ideas about how labor should be managed, but in the end data is data. We championed evidence based medicine, but tend to ignore evidence when it comes from the wrong source, which is unfair. It is fair to critique the research and the methods used to write it, but it shouldn’t matter who the author is. In this case, Mercer and other midwives have done the world a favor by scientifically addressing this issue, and their data deserves serious consideration.

To quote Levy et al (12) “Although a tailored approach is required in the case of cord clamping, the balance of available data suggests that delayed cord clamping should be the method of choice.” We ought to heed this advice better. Like episiotomy, this change in practice may take awhile, but we should get it started. I’m going to work on it myself. How about you?

Time to Abloish Cribs?

by Jan Hunt, M.Sc.
author of The Natural Child: Parenting from the Heart

Two hundred years ago, Arthur Schopenhauer wrote that, "All truth goes through three stages. First it is ridiculed. Then it is violently opposed. Finally, it is accepted as self-evident." This observation has certainly passed the test of time. Copernicus's writings, in which he claimed that the earth moves around the sun, were banned for decades, and led to an Inquisition trial and house imprisonment for Galileo. Today, of course, the earth's orbital movement is accepted as "self-evident".

Unfortunately, child-rearing practices and beliefs in the areas of sleeping, feeding, and discipline seem to be moving in the wrong direction. Our society has moved away from trust and toward an unnatural, mistrustful, and distant approach to children. Parents who treat their children with the same love and trust that was "self-evident" for generations now face ridicule and opposition. In earlier societies, a child's need to be close to his parents during both night and day was a "self-evident truth", and the obvious way to meet that need was to provide safety, closeness and comfort. Throughout most of human history, mothers slept next to their babies, which fostered the bond between them, and encouraged and facilitated breastfeeding.

Breastfeeding babies who sleep next to their mother take in three times as much milk during the night as do isolated babies, thus enjoying a more natural nutritional pattern. Mothers sleeping next to their children are also reassured about their safety. Babies sleeping away from their parents have perished in fires, have been abused by relatives, have been abducted from their beds, have suffocated after vomiting, have been attacked by pets, and have died or been injured in numerous other ways. Many - if not most - of these tragedies might well have been averted had a parent been present and aware of the baby's welfare through the night. Family co-sleeping can also help prevent parental abuse by reducing the stress of raising babies and young children. A child in a family bed does not need to suffer needlessly or cry to bring his mother, and the mother can remain in bed and nurse half-asleep.

Research has shown that comatose adults have an improved heart rate, heart rhythm, and blood pressure when another person is present. It seems reasonable to suppose that infants and children derive similar health benefits from having others near them during the night. Many parents have found that siblings who share the night as well as the day build a deep and lasting relationship. And finally, Dr. James McKenna's sleep research, at the Center for Behavioral Studies of Mother-Infant Sleep, shows that a mother's breathing can provide important cues to her infant, reminding him to take a breath following exhalation, thus lessening the chances of a SIDS death. But the parents of long ago (and of most third-world countries today) did not need to weigh these benefits against other approaches, they simply followed their natural drive to love, protect, and nurture their children.

Why have we not followed Schopenhauer's predicted path? Why do we not abandon cribs, where so many babies have died, and many more have been injured? Why have the numerous deaths and injuries in cribs not led to a call for its abandonment, or at least a switch to "bedside co-sleepers" (partial cribs that fit next to the parents' bed)? When babies are injured in cribs, parents are never told to avoid cribs; they are told how to purchase and use safer cribs. But when a baby dies in a family bed, there is an entirely different response. Instead of being educated on safety factors, we are told never to place our babies in adult beds – period.

Rather than calling for the end to such an age-old, beneficial, and healthy arrangement, the causes of each situation should be investigated, and parents should be educated accordingly. We should be warned against the real dangers of bed sharing: intoxication, overly-medication, the use of a waterbed, loose blankets or soft bedding, gaps between the mattress and the frame, and leaving a baby unattended. If a baby dies in a car, we are never told to keep babies out of cars, we are advised about safety measures. The same approach should be taken with co-sleeping.

Cribs force babies to face the long night alone years before they are psychologically equipped to do so. Isolation teaches harmful lessons of mistrust, powerlessness, and despair, creating a deep sense of loneliness that no teddy bear can fulfill. Judging from the reports of adults in hypnotherapy, art therapy, and psychoanalysis, experiences of forced separation from parents in infancy and childhood are traumatic, with long-term effects on the adult personality.

Cribs, especially if located outside the parents' room, are dangerous in other ways too. An isolated baby has no protection from secret physical or sexual abuse. Night-time separation lessens the critical emotional bond between parent and child, and between siblings. Cribs keep working parents from spending the only real block of time they have left with their children.

There is probably not one baby in the world who would choose cold isolation over loving proximity if they were only given the choice. Our babies' cries and screams should be more than sufficient to convince us of the emotional harm and moral wrongness of such separation. Why do we not hear what they try so hard to tell us?

Cribs are dangerous, and prevent parents from intervening quickly in emergencies. The U.S. Consumer Product Safety Commission, the same organization that recently warned about family beds, has reported 40 to 50 crib deaths per year, and thousands of serious injuries. Their own web site is filled with warnings of the potential hazards of crib use. Yet they never consider the possibility that cribs should be abandoned. This is a nonsensical double standard that no one seems to be questioning.

Cribs are lonely cages for babies who deserve to have their age-old needs met with love and compassion. Cribs have no real benefits at all. Let's abolish them!

Read article at...
http://www.drmomma.org/2009/12/time-to-abolish-cribs.html

Happy Breastfeeding Week!

Breastfeeding your baby for even a day is the best baby gift you can give. Breastfeeding is almost always the best choice for your baby. If it doesn't seem like the best choice for you right now, these guidelines may help.

IF YOU NURSE YOUR BABY FOR JUST A FEW DAYS, he will have received your colostrum, or early milk. By providing antibodies and the food his brand-new body expects, nursing gives your baby his first - and easiest - "immunization" and helps get his digestive system going smoothly. Breastfeeding is how your baby expects to start, and helps your own body recover from the birth. Why not use your time in the hospital to prepare your baby for life through the gift of nursing?

IF YOU NURSE YOUR BABY FOR FOUR TO SIX WEEKS, you will have eased him through the most critical part of his infancy. Newborns who are not breastfed are much more likely to get sick or be hospitalized, and have many more digestive problems than breastfed babies. After 4 to 6 weeks, you'll probably have worked through any early nursing concerns, too. Make a serious goal of nursing for a month, call La Leche League or a Lactation Consultant if you have any questions, and you'll be in a better position to decide whether continued breastfeeding is for you.

IF YOU NURSE YOUR BABY FOR 4 MONTHS, her digestive system will have matured a great deal, and she will be much better able to tolerate the foreign substances in commercial formulas. If there is a family history of allergies, though, you will greatly reduce her risk by waiting a few more months before adding anything at all to her diet of breastmilk. And giving nothing but your milk for the first four months gives strong protection against ear infections for a whole year.

IF YOU NURSE YOUR BABY FOR 6 MONTHS, she will be much less likely to suffer an allergic reaction to formula or other foods. At this point, her body is probably ready to tackle some other foods, whether or not you wean. Nursing for at least 6 months helps ensure better health throughout your baby's first year of life, and reduces your own risk of breast cancer. Nursing for 6 months or more may greatly reduce your little one's risk of ear infections and childhood cancers. And exclusive, frequent breastfeeding during the first 6 months, if your periods have not returned, provides 98% effective contraception.

IF YOU NURSE YOUR BABY FOR 9 MONTHS, you will have seen him through the fastest and most important brain and body development of his life on the food that was designed for him - your milk. You may even notice that he is more alert and more active than babies who did not have the benefit of their mother's milk. Weaning may be fairly easy at this age... but then, so is nursing! If you want to avoid weaning this early, be sure you've been available to nurse for comfort as well as just for food.

IF YOU NURSE YOUR BABY FOR A YEAR, you can avoid the expense and bother of formula. Her one-year-old body can probably handle most of the table foods your family enjoys. Many of the health benefits this year of nursing has given your child will last her whole life. She will have a stronger immune system, for instance, and will be much less likely to need orthodontia or speech therapy. The American Academy of Pediatrics recommends nursing for at least a year, to help ensure normal nutrition and health for your baby.

IF YOU NURSE YOUR BABY FOR 24 MONTHS, you will have continued to provide your baby's normal nutrition and protection against illness at a time when illness is common in other babies. Your baby is probably well started on table foods, too. He has had time to form a solid bond with you - a healthy starting point for his growing independence. And he is old enough that you and he can work together on the weaning process, at a pace that he can handle comfortably. A former U.S. Surgeon General said, "It is the lucky baby...that nurses to age two." [AAFP statement on nursing until at least 24 months.]

IF YOUR CHILD WEANS WHEN SHE IS READY, you can feel confident that you have met your baby's physical and emotional needs in a very normal, healthy way. In cultures where there is no pressure to wean, children tend to nurse for at least three years. The World Health Organization and UNICEF strongly encourage breastfeeding through toddlerhood: "Breastmilk is an important source of energy and protein, and helps to protect against disease during the child's second year of life."(1) Our biology seems geared to a weaning age of between 4 and 7 years(2), and it just makes sense to build our children's bones from the milk that was designed to build them.

Your milk provides antibodies and other protective substances as long as you continue nursing, and families of nursing toddlers often find that their medical bills are lower than their neighbors' for years to come. Mothers who have nursed longterm have a still lower risk of developing breast cancer. Children who were nursed longterm tend to be very secure, and are less likely to suck their thumbs or carry a blanket.

Nursing can help ease both of you through the tears, tantrums, and tumbles that come with early childhood, and helps ensure that any illnesses are milder and easier to deal with. It's an all-purpose mothering tool you won't want to be without! Don't worry that your child will nurse forever. Allchildren stop eventually, no matter what you do, and there are more nursing toddlers around than you might guess.

Whether you nurse for a day or for several years, the decision to nurse your child is one you need never regret. And whenever weaning takes place, remember that it is a big step for both of you. If you choose to wean before your child is ready, be sure to do it gradually, and with love.

http://www.drmomma.org/2009/12/if-you-nurse-your-baby.html

Saturday, August 7, 2010

Can ‘buying green’ save the planet?

Is she saying that our individual actions add up to nothing? That we are powerless to create positive change? That buying green is futile? To a degree, it’s true. You can’t just buy a better future – individual actions that affect you alone are not going to change the world. But what will change the world is when those individual actions spread, and inspire others to do the same (and more)....

Read more at...
http://eartheasy.com/blog/2010/04/can-buying-green-save-the-planet/

New Findings on Asthma and Breastfeeding

"Children who are exclusively breastfed for at least the first four months of life have a substantial reduction in the risk of developing asthma by age 6, suggests a study presented at the conference. The study of 2,834 Australian children found that the introduction of milk other than breast milk before four months of age was a significant risk factor for asthma in children. Wendy Oddy MPH, in work for her Ph.D at the TVW Telethon Institute for Child Health in West Perth, Western Australia, found that compared with children who were exclusively breastfed for the first four months of life, children who were not breastfed exclusively were 27% more likely to have doctor-diagnosed asthma by age six; 44% more likely to wheeze three or more times since the age of 1; 41% more likely to have wheezed in the last 12 months; and 74% more likely to have sleep disturbance due to wheeze within the last 12 months.

Dr. Oddy noted that asthma is the leading cause of hospitalization in American and Australian children, and the prevalence of asthma is increasing in both countries. In Australia, while nearly 90% of babies are breastfed when they leave the hospital, by age 3 months half are no longer exclusively breastfeeding. In the United States, even fewer 3-month-olds are exclusively breastfed, she said. She echoed the World Health Organization recommendation that, if possible, mothers should exclusively breastfeed for at least the first 4 to 6 months of a baby's life."

Read more at...
http://www.breastfeeding.com/all_about/all_about_latest_asma.html

Pesticides in kids linked to ADHD

Exposure to pesticides used on common kid-friendly foods — including frozen blueberries, fresh strawberries and celery — appears to boost the chances that children will be diagnosed with attention deficit hyperactivity disorder, or ADHD, new research shows.

Youngsters with high levels of pesticide residue in their urine, particularly from widely used types of insecticide such as malathion, were more likely to have ADHD, the behavior disorder that often disrupts school and social life, scientists in the United States and Canada found.

Kids with higher-than-average levels of one pesticide marker were nearly twice as likely to be diagnosed with ADHD as children who showed no traces of the poison.