Evidence for Common Interventions during the Newborn's ...reache.info/.../uploads/2016/03/RebeccaDekkerNewbornProceduresH… · REACHE Conference Do not reproduce without prior written

REACHE Conference

Do not reproduce without prior written permission from the author 1

Evidence for Common Interventions during the Newborn's Golden Hour

Rebecca Dekker, PhD, RN, APRN

Learning Objectives: 1. Describe evidence for two best practices

for newborns in the golden hour • Skin-to-skin • Delayed cord clamping

2. Discuss evidence for procedures that often take precedence over skin-to-skin and bonding • Suction, hatting, bathing • Hep B, Vitamin K, eye ointment

For which group was the term “Golden Hour” first used? A. Term infants B. Preterm infants C. Trauma patients D. Heart attack

patients

REACHE Conference


What % of infants in WA are ever breastfed?

A. 80% B. 84% C. 92% D. 95%

How many WA infants are exclusively breastfeeding at 6 months?

A. 20% B. 30% C. 40% D. 50%

What about Baby-Friendly? � Global initiative of the World Health

Organization (WHO) and the United Nations Children's Fund (UNICEF)

� “Ten Steps to Successful Breastfeeding” � Extensive process before hospitals are

designated as baby-friendly � What % of babies in WA are born at baby-

friendly hospitals? https://www.babyfriendlyusa.org/

REACHE Conference


History of Cord Clamping � Several decades ago, hospitals began using

immediate cord clamping (ICC) � Part of active management of the 3rd stage:

Giving oxytocin

Clamping and cutting within 30 seconds

Gentle downward traction

� New evidence shows the ICC part of the package is unnecessary and harmful!

Placental Transfusion � When cord clamping is delayed (1-5

minutes), infants receive fluid volume, red blood cells, and millions of stem cells

� Rapid cord clamping = lose access to 1/3 of blood supply

� Blood helps with fetal transition = lungs go from receiving 10% of blood supply pre-birth to 45-55% post-birth

DCC does not lead to Jaundice � Cochrane review = 4.4% jaundice with DCC

vs. 2.7% with ICC1 Based on one unpublished dissertation study

Did not report bilirubin levels; unblinded

� Another systematic review did not include this study and found NO relationship between DCC and jaundice2

1. McDonald, Middleton (2008). Cochrane Review. 2. Hutton, Hassan (2007). JAMA

REACHE Conference


Effects of DCC on Babies � Higher hemoglobin (Hgb) levels at birth � Higher Hgb and hematocrit at 24 hours � Higher iron levels at 3-6 months � NO increased risk of:

� Thick blood

� Low Apgar scores

� NICU admission

� Breathing problems

Effects of DCC on Mothers � DCC is a harmless practice for mothers � No increased risk of:

Postpartum hemorrhage

Low hemoglobin

Blood transfusion

Length of third stage of labor

What is the #1 barrier to DCC for your clients??

A. Staff go on auto-pilot B. Need for resuscitation or

suctioning C. Physician fear of gravity D. Cord blood banking

REACHE Conference


Types of skin-to-skin � Birth or immediate = starts in first minute � Very early = within 30-40 minutes � Early = any skin-to-skin in first 24 hours

Rates of skin-to-skin are lowest in the

Southeastern U.S. and highest in the Pacific

What % of WA hospitals provide ≥30 minutes skin-to-skin in the first hour after an uncomplicated vaginal birth?

A. 98 B. 92 C. 88 D. 84

Evidence for skin-to-skin (S2S) � Systematic review of 34 randomized trials � Babies randomly assigned to early S2S were

2x more likely to be EBF at 3-6 months

The benefits of skin-to-skin care are so clear that in 2003 the World Health Organization

recommended ALL newborns receive skin-to-skin care, no matter the baby’s weight, gestational age,

birth setting, or condition at birth.

Moore (2012). Cochrane Database. 5: CD003519

REACHE Conference


Risks of NOT having early S2S � Risks to Mothers

More breast engorgement/pain More anxiety More incisional pain after CS

� Risks to baby Instability of baby’s HR, RR, temp, and blood sugar 12 times more likely to cry

Moore (2012). Cochrane Database. 5: CD003519

Highly Unethical Study � Randomly assigned 124 infants in Russia to

early separation/swaddling OR early S2S � All babies were separated from mothers for

25 minutes for mandatory routine care � Half the babies were then returned to their

mothers’ arms; the other half were tightly swaddled and kept separate for 2 hours

� Babies were filmed playing with their mothers 1 year later

Bystrova et al. (2009) Birth 36(2): 97-108

Results at One Year � Babies who were separated were more

irritable and dysregulated, and mothers showed less reciprocity and mutuality

� Mothers of swaddled babies were less responsive to their infants

� S2S in the first hour of life is critically important for mother-infant bonding

� The risk of separation was not lessened by “rooming in” afterwards

Bystrova et al. (2009) Birth 36(2): 97-108

REACHE Conference


Which of these procedures do you routinely see done in the 1st hour?

A. Suction B. Hatting C. Bathing D. Weighing E. Hep B F. Vitamin K G. Eye Ointment

Which of these procedures is almost always medically necessary for the 1st hour of life?

A. Suction B. Hatting C. Bathing D. Weighing E. Hep B F. Vitamin K G. Eye Ointment

Oronasopharyngeal suction � 170 healthy newborns at term, with head-

first positioning and clear amniotic fluid � Randomly assigned to:

Immediate suction after birth using a sterile plastic tube OR

Only visible material removed

� Placed into warmer and monitored pulse oxygenation and heart rate

Nejad et al. (2014) J Obstet Gynecol 34: 400-402.

REACHE Conference


No Suction = Faster oxygenation � The no suction group reached 92% O2 by 9

minutes, compared to 11 minutes in the suction group

� Results are consistent with other randomized trials (Gungor 2005, Gungor 2006; Carrasco 1997)

� Additional trial showed suctioning did not prevent Meconium Aspiration Syndrome (Vain 2004)

Nejad et al. (2014) J Obstet Gynecol 34: 400-402.

Newborn Bath � Initial purpose = remove blood, fluids, and

pathogens Prevent outbreaks of staph infections in hospital nurseries

Prevent HIV and Hep B transmission

� Skin = largest organ in the body Very sensitive to environment

Colonization with normal flora creates barrier

Does Bathing remove Bacteria? � Randomized trial with 140 term vaginally

born newborns One group bathed with mild soap/water

One group bathed with water alone

� Infants were swabbed before the bath, 1 hour after the bath, and 24 hours after bath

� No difference between groups � Skin colonization is a function of time

Medves & O’Brien (2001). Birth 28(3): 161-165.

REACHE Conference


Bathing and Breastfeeding � Boston Medical Center changed its protocol

Before = bath in nursery at 2 hours, then placed under warmer (n = 348)

After = bathed in mother’s room at 12 hours, then placed skin-to-skin (n = 354)

� Infants born after the protocol change were: 1.4X more likely to exclusively breastfeed, 1.6x more likely to near-exclusively breastfeed, and 2.7x more likely to have any breastmilk

Preer et al. (2013). Breastfeeding Med 8(6): 485-490

Academy of Breastfeeding Medicine

“Despite evidence that delaying postpartum interventions to the newborn is associated with

improved breastfeeding outcomes, many hospital policies still dictate immediate weighing, measuring, administering eye prophylaxis and vitamin K, and an early initial bath, all of which interfere with early and continued skin-to-skin and breastfeeding initiation.”

Holmes et al. (2013). “ABM Clinical Protocol.” Breastfeeding Med 8(6): 469-473

Hatting

� Research on hatting is almost all from the 1970s-1980s

� In one study, term newborns were separated from mothers and placed naked in a closed chamber (81 deg.) with a hat OR a similarly-sized pad on the abdomen

� Not surprisingly, wool-lined hats helped preserve body temperature

Stothers (1981). Archives of Disease in Childhood 56: 530-534.

REACHE Conference


“Hats for the newborn” � Randomized controlled trial in England (n =

104 infants not under a warmer) � Baby was assessed, wrapped in blankets,

briefly given to the mother, then removed � Hats resulted in a smaller fall in

temperature in the first 30 minutes of life � On average babies were naked for 7

minutes Chaput et al. (1979). BMJ

2: 570-571.

So are hats necessary? � Yes– if separated from the mother and/or

exposed to the environment � Large body of evidence shows that skin-to-skin

is highly effective at regulating temperature Example: Preterm twins skin-to-skin on mother– each breast temp vacillates depending on twin’s individual temp

� With skin-to-skin, no evidence that hats are necessary!

Ludington-Hoe et al. (2006). J Obstet Gynecol Neonatal Nurs 35(2): 223-231.

Vitamin K’s role: � Fat-soluble vitamin necessary for clotting –

activates certain molecules to help blood clot

� With low Vitamin K, blood less able to clot � At certain low point, blood can no longer

clot and spontaneous bleeding can occur

Shearer, M. J. (2009). “Vitamin K deficiency bleeding (VKDB) in early infancy.” Blood Rev23(2): 49-59.

REACHE Conference


Patterns of Bleeding � Early Vitamin K Deficiency Bleed (VKDB): first 24

hours Bleeding usually in skin, brain, abdomen

� Classical VKDB: days 2-7 Vitamin K levels lowest; common bleeding sites: gastrointestinal system, umbilical cord site, skin, nose, and circumcision site

� Late VKDB: after first week, usually weeks 3-8 Bleeding in brain often first sign

Shearer, M. J. (2009). Blood Rev23(2): 49-59.

Late VKDB � If No Vitamin K at birth, late VKDB develops in Europe: 4.4-10.5 infants per 100,000 Asia: 1 infant per 6,000 � If Oral Vitamin K given at least three times in

infancy, then late VKDG develops in 1.4-6.4 infants per 100,000

� If Vitamin K shot at birth, virtually no cases of late VKDB

Shearer, M. J. (2009). Blood Rev23(2): 49-59.

Risk factors: � Exclusive breastfeeding

� Not receiving the Vitamin K shot

� Less common risk factors: Undiagnosed gallbladder/liver disease Cystic fibrosis Chronic diarrhea Antibiotic use

Virtually all cases of VKDB happen in infants who are exclusively breastfed and who have not received the

shot.

REACHE Conference


What happened to these infants? Age/Sex Birth history Feeding Symptoms Diagnosis Outcome

5 month old male

Home birth, no Vitamin K, no circumcision

Exclusively breastfed

Vomiting, bruising, sleepiness, poor feeding

Brain bleed

Brain surgery, good outcome

2 month old female

Hospital birth, no Vitamin K


Vomiting, fever, lethargy

Brain bleed

Mild neuro delays

3 month old female

Home birth, no Vitamin K


Bloody stools

GI bleed No long term effects

What happened to these infants? Age/Sex Birth history Feeding Symptoms Diagnosis Outcome

6 week old male

Born in hospital, no Vitamin K


Fussiness, sleepiness, poor feeding

Brain bleed Brain surgery, stroke, severe deficits

7 week old male (twin)

Born in hospital, no Vitamin K


Fussiness, vomiting, pale, poor feeding

Brain bleed Transfusions, moderate deficits

3 month old female

Born in birth center, no Vitamin K


Vomiting and clay-colored stools

CT of head not done

Bile duct cyst removed

What did they have in common? � Parents declined Vitamin K � Exclusively breastfed � Normal vaginal births (no instruments, no

Cesareans) � Lab tests showed severe Vitamin K

deficiency � No antibiotics, no illnesses, no restrictive

diets of the mothers, no head trauma, no abuse

REACHE Conference


Comparing Regimens Country Years Medication Incidence

Australia 1993-1994 1994-1995

Oral Vitamin K 3 times IM Vitamin K once at birth

2.5 per 100,000 0 per 100,000

United Kingdom

1988-1990 None Oral Vitamin K1 once at birth IM Vitamin K1 once at birth

4.4 per 100,000 1.5 per 100,000 0.64 per 100,000

Sweden 1987-1989 Oral Vitamin K1 once at birth IM Vitamin K1 once at birth

6 per 100,000 0 per 100,000

Switzerland 1986-1988 Oral Vitamin K1 once at birth IM Vitamin K1 once at birth

6.4 per 100,000 0 per 100,000

Shearer, M. J. (2009). Blood Rev 23(2): 49-59. Cornelissen et al. (1997) Eur J Pediatr156(2): 126-130.

Best Oral Vitamin K Regimen � Since 1990, all infants in the Netherlands receive 1

mg oral VK after birth and breastfed infants receive 25 micrograms daily until the end of the 13th week

� In Denmark, they used 2 different regimens: Between 1994-2000, all infants received 2 mg oral Vitamin K after birth, then 1 mg orally weekly Since 2000, all infants received 2 mg IM at birth

� Danish regimens were more effective than the Dutch regimen at preventing VKDB in babies with gallbladder disease

Van Hasselt (2008). Pediatrics 121,e857.

What are reasons you’ve heard for declining Vitamin K?

A. It’s not natural B. It causes leukemia C. It’s full of toxins D. I eat a healthy diet E. My baby had a gentle birth F. My baby wasn’t circumcised G. My baby had delayed cord clamping

REACHE Conference


Delayed cord clamping & gentle births � There is no evidence to support these claims � Delayed cord clamping raises iron levels, but cord

blood has very low levels of Vitamin K1 (less than 0.05 mcg/liter)

� Vitamin K1 is stored in liver, not bloodstream � This is why delayed cord clamping can improve

iron levels, but not Vitamin K levels � A “gentle” birth should not impact late VKDB

which can happen weeks or months later

Shearer, M. J. (2009). Blood Rev 23(2): 49-59.

Take-away point on supplements � In studies on maternal supplements, infants

received BOTH Vitamin K supplements and maternal supplements

� Would not be ethical to randomly assign an infant to a NO vitamin K group

� Postpartum supplementation, when combined with infant Vitamin K administration, is very effective at raising infant levels

� However, no studies on actual bleeding rates (b/c would require huge sample sizes)

Nishiguchi, T.,et al. (1996). Br J Obstet Gynaecol 103(11): 1078-1084.

Greer et al. (1997). Pediatrics 99(1): 88-92.

Who knows? � As early as the 1800s we know that babies died

from Vitamin K deficiency � Nothing in life is perfect! � Evolutionary continuum—survival of the fittest

means some will not survive � Infants’ clotting systems (like nervous and immune

systems) need time to develop and come into full strength

� Not always an answer to ‘why’ questions about evolution

REACHE Conference


Hepatitis B (HBV) � Transmission

Infected blood (needles) Sexual transmission Mother-baby (90% chance if mom is +) Father-baby (65% chance if dad is +) Saliva (kisses, bites, sharing utensils) Lives on dry surface for 7 days

� Symptoms Clinical course varies from no symptoms (some are “carriers”) to complete liver failure/cancer 15-25% mortality rate in infants

Eradicating HBV

Long-term Immunity

� 76 high-risk infants in Thailand born to moms with HAV and HBV

� Received 4 doses of vaccine in infancy, plus one dose of immunoglobulins

� Twenty years later found 36 of the children: 64% very high levels of antibodies

92% had detectable levels of antibodies

Poovorawan et al. (2013). Hum Vaccin Immunother 9(8): 1679-1684.

REACHE Conference


Systematic Review

� 46 studies measuring antibodies 5-20 years after HBV immunization

� Took into account mother’s status, dosage, and lag time between doses

� 90% of children have antibodies 17 years after being born to non-infected mothers

Schonberger et al. (2013). Pediatr Infect Dis J 32(4): 307-13.

What I still plan to cover:

� Risks/side effects of the vaccine � Separating myths from fact � How vaccines work in the body � Pros/cons of delaying the HBV vaccine

In Summary � The “golden hour” should be a time focused

on the parent-baby relationship � Instead we have many procedures that take

precedence-- none of which MUST be done in the first hour

� Birth professionals can play a role in educating families and health workers, and creating “space” for bonding and breastfeeding

Evidence for Common Interventions during the Newborn's ...reache.info/.../uploads/2016/03/RebeccaDekkerNewbornProceduresH… · REACHE Conference Do not reproduce without prior written

Documents