Dr. B's Baby Buzz

Warm Weather Tips for Mom and Baby

While we are all happy to shake of the winter doldrums and anticipate our summer plans, it is also a good time to anticipate issues for taking care of infants in the warmer weather. Here are some questions I have been asked frequently and the answers I give to parents:

Can I take allergy medication while nursing? In general, over-the-counter allergy medications are safe to take while nursing. These would include such medications as Claritin (Loratidine)and Allegra (Fexofenadine) which are non-sedating ("won't make you sleepy") antihistamines. Acitifed (Triprolidine) and Benedryl (diphenhydramine) are also safe antihistamines to take, but have sedative effects. Sudafed (phenypropanolamine) is a decongestant that is also found to be safe to take while nursing. Of the medications mentioned, Claritin in particular seems to have a very low transmission rate into breast milk. Although non-sedating antihistamines are longer acting, they have a less sedating effect on the infant and are preferred. Despite the fact that these medications are considered safe to take while nursing, I am a strong advocate of limiting the baby's exposure. This can be done by taking these medications right after nursing, and optimally 3 to 4 hours before the next nursing session.

When can I use sunscreen or bug repellent on my baby? The best policy here is avoidance. Sun exposure can be minimized by having infant wear lightweight clothing that covers arms and legs and a wide brimmed hat. The American Academy of Pediatrics has stated that it is acceptable to use a small amount of sunscreen with an SPF of at least 15 on infants in small areas if covering up with clothing is not an options. To minimize attracting insects, some simple hints include avoiding scented soaps, shampoos and lotions on you or your baby. It is also a good idea to avoid dressing the infant in brightly colored or flowered clothing. Small infant who are sitting outside in a car seat or stroller can have mosquito netting placed over the seat. Use of insect repellent has been a controversial issue since exposure to the common ingredient DEET has been associated with neurologic symptoms in children. Products containing DEET should never be used on infants under 2 months of age. The Center for Disease Control and the American Academy of Pediatrics both state that the use of DEET in concentrations of 30% or less is safe in children older than 2 months. I have always recommended in addition to be proactive about avoidance, parents should first try DEET-free products such as those containing citronella. If you are in an area with a very high risk of insect exposure, then infants older than 2 months can have small amounts of repellent applied to exposed areas (excluding hands and fact), as well as on clothing, but never under clothing. Avoid use of combined sunscreen/insect repellent products in infants and children since frequent reapplication for the sunscreen benefits can overexpose the child to the insect repellent.

Our family would like to go on a summer vacation. When can I travel on a plane with my baby? Years ago I took care of a family who was in the process of adopting their second child from another state. They picked the baby up from the hospital and assumed they could fly back home with their baby who was less than one week old. They would have made it onto the plane, except their very precocious and excited 3 year old daughter explained to the airline worker that the baby was "really small, not even a week old". That particular airline had a policy not to allow babies less than one week old to fly. Several hours and many inquiries later, they did manage to find and airline that would allow them to take the baby on board. Lesson learned: contact individual airline regarding travel with infants (and while pregnant, for that matter). It is also important to know that every individual, including infants, will be required to go through the scanner at the airport. A parent should never be asked by TSA (Transport Security Administration) to be separated from their infant. Also, it is good to know that the TSA has modified its rule for transporting liquids with regards to infant formula and breast milk. As long as these items are declared initially, they may be allowed to be carried on board in volumes greater than three ounces. A parent should never be formed to drink formula or breast milk to "prove" that it is safe. This is in violation to the TSA policy statement posted on their website.

When it is really hot out can I give my baby extra water to drink? A breastfed baby does not need supplemental water in the diet. Breast milk already has high water content, particularly the foremilk (milk at the beginning of the feeding.) Breastfed infant may simply feed for shorter intervals more frequently in the hot weather. Formula fed infant also generally get adequate water in their diets and don't require extra water supplementation. They should be allowed to take in the amount of formula they want. Too much water can potentially be hazardous in the first few weeks of life since the baby's kidneys are not mature and may not be able to adjust to extra water. Once again, being proactive can help. Keep the baby in the shade when outdoors in hot weather. Avoid being outside midday, which is usually the hottest time of day. Monitor the baby's number of wet diapers to make sure that the baby isn't getting dehydrated.

How Green is Your Baby?

No, this isn't a blog about some rare skin disorder in newborns.  With all the attention (and rightfully so) being given to consumer consumption, the environment, and our "carbon footprint", it was just a matter of time until people started looking at the this from the perspective of raising a child.  Realizing that I needed to become more educated on this topic, I recently read Raising Baby Green:  The Earth-Friendly Guide to Pregnancy, Childbirth, and Baby Care, by Alan Greene, MD. This book is literally packed with information regarding environmentally friendly choices that parents can make and, as advertised on the book's cover, includes "more than 300 best green baby products of smart parenting choices."  I admit that when I first opened that Amazon.com package that the book arrived in and read the cover, I paused a moment to consider that there actually exist more than 300 green baby products. My curiousity picqued, I proceded on.

Smart Parent

The unlying assumption in this book is that after you have read the information about a green home for your baby, you will be a smarter parent.  My children are quite out of the baby phase and no doubt are plodding their carbon footprints all over the place. 

To "circ" or not to "circ"

One of the most frequent questions I have been asked by parents is whether their newborn son should be circumcised.  The issue of circumcision has been debated for years and even has been the subject of lawsuits by grown children.  My traditional stance is that parents should do their due diligence about the pros and cons of this procedure before making this decision. The information I provide here isn’t meant to sway opinion one way or the other, rather to help present some information to assist parents in their decision-making.

Early References to Circumcision

The practice of male circumcision is historically documented across many cultures.  Perhaps the earliest known reference to circumcision originates in Egypt in tomb artwork from the Sixth Dynasty (2345 - 2181 BC).  Many who read this are no doubt familiar with references to circumcision of infant males in the Old Testament originating with convenent between Abraham and God in Genesis.  In fact, many cultures over the centuries have accepted circumcision as a practice, citing beliefs that have cultural, religious and medical origins.

Circumcision in the United States

In more recent times there have been broad swings in public opinion regarding perceived advantages or disadvantages of circumcision. In the United States an initial shift in the cultural norm favoring newborn circumcision occurred around the onset of the 20^th century.  As a result the United States continues to have a wider sphere of acceptance of this practice than in other parts of the world. The reason for that initial shift in practice seems to stem from a number of factors.  These include emerging knowledge of germ theory and the accompanying belief that circumcision promotes hygiene, belief that there would be less risk for syphilis, and, in a period of time that saw the emergence of temperance, belief that circumcision would promote chastity and prevent masturbation. Additionally, the increase in births occuring in hospitals rather than at home in the mid-20th century, correlates with an increase in rate of circumcision at that time.

Table 1: International circumcision rates
Country	Year	Neonatal circumcisions (%)
United States	2003	55.9%
Canada	2003	< 14%
Australia	2004	10%-20%
New Zealand	1995	0-5%
**Samoans, Tongans and Niueans in New Zealand continue to practice circumcision, but not in public hospitals, to which these data refer. There are significant ethinc and regional differences in circumcision practices within the United States.  In general, circumcision is more likely to be performed on non-Hispanic white male infants, whereas Hispanic infants have the lowest rate of circumcision. Statements by the medical community, in particular by the American Academy of Pediatrics in 1971, 1989, and 1999, as well as a reaffiramation statement in 2005, have historically taken the position that circumcision is not medically indicated, and in the past several decades more parents opted not to have the procedure performed on their newborn sons. Emerging Medical Data

Although major medical societies in the US as well as in the United Kingdom, Australia, and Canada have formally stated that circumcision is not medically necessary, a series of recent studies have strongly indicated that circumcised males benefit from decreased risk of a number of health problems:

1. Urinary tract infection. There appears to be a significant decreased risk of urinary tract infection in circumcised males. The compilation of data from numerous studies indicates that incidence of urinary tract infections in uncircumcised males is about 1:1000 versus about 1:100 in circumcised males.
2. Cancer of the penis.  In general, this is a relatively rare condition occurring in about 1:100,000 men annually in the United States.The majority of those cases occur in uncircumcised men, and invasive penile cancer, the most severe form, occurs almost exclusively in uncircumcised males.  Of note, cancer of the penis is almost unheard of in Israel, where almost all males are circumcised.
3. Sexually transmitted disease.  Numerous studies have shown decreased transmission of STDs such as syphilis, Chlamydia, human papilloma virus, and herpes not only to circumcised males, but also from males to their female partners. Given the association of HPV with cervical cancer in women, there has been evolving opinion that circumcision is a women's health issue as well. More recently a series of studies in Africa has shown a 60% reduction in the rate of transmission of HIV to males that have been circumcised versus those who are uncircumcised. This is significantly better than the 30% reduction of risk that was target goal of a future AIDS vaccine.

This last point, reduction in transmission of STDs and HIV, has fanned the embers of the circumcision debate.  There have been some strong voices of dissent to the AAP statement calling for a reevaluation of circumcision as an effective means to stem the tide of HIV, particualrly in developing nations.

Surgical Procedure

Circumcision is a surgical procedure, and as such, has associated risks.   In general, the risk of a complication from circumcision is very low (~1/500,000).  These risks include, but are not limited to, bleeding, infection, scarring, incomplete resection of foreskin, and partial amputation of the penis.  In the not too distant past circumcision was performed without anesthesia owing to an ill-conceived notion that infants do not experience pain.  Thankfully, we have come along way, and the current practice of circumcision involves a local anesthetic. The most commonly performed in-patient newborn circumcision methods are done with either a clamp (Gomco or Mogan) or with a Plastibell.  The results can vary depending on the method used and the skill of the person performing the circumcision.  Just as with any surgery, the method and procedure should be explained clearly to you by the person performing the surgery.

As mentioned previously, post-operative complication rate is extremely low and your baby's medical care provider will review how to care for the baby after the procedure.  There are certain infants who should not be circumcised in the neonatal period.  These would include ill newborns, premature infants, infants born with congenital anomalies of the penis ( e.g. hypospadius)  or infants who have a bleeding disorder such as hemophilia.

The "No Circ" Viewpoint

There are strong voices of opposition to circumcision.  The core points are well outlined be the National Organization of Circumcision Information Resource Center (www.norcirc.org). As stated in their website:

No national or international medical association recommends routine circumcision.

Only the USA circumcises the majority of newborn boys without medical or religious reason.

Medicalized circumcision began during the 1800s to prevent masturbation, which was believed to cause disease.

Today's parents are learning that the foreskin is a normal, protective, functioning organ.

Today's parents realize circumcision harms and has unneccesary risks.

Circumcision denies a male's right to genital integrity and choice for his own body.

With regards to the recent studies regarding circumcision and decreased HIV transmission, they strongly advocate more funds being shifted to education on HIV and safe sex. For those who want more information regarding the counter-argument regarding circumcision as a means to reduce the spread of HIV, read the statement from Doctors Opposing Circumcision.

Ultimately, the decision for circumcision is a personal one.  Educate yourselves and make an informed decision for your baby.

Sudden Infant Death Syndrome

The death of an infant is a tragedy unimaginable to most of us, yet for every 100,000 births in the

United States

more than 50 seemingly healthy infants will succumb to Sudden Infant Death Syndrome (SIDS). Another 20 infants per 100,000 will die unexpectedly from causes such as accidental suffocation. Since the “Back to Sleep” campaign was initiated by the

American

Academy

of Pediatrics in 1994 promoting placing infants on their backs rather than their stomachs to sleep, we have seen the rate of SIDS decrease by about half, but there has been no significant decline in SIDS rate for several years. Additionally we have seen an increase in other causes of unexpected infant death.  This may be in part due to better classification of SIDS such that we are no longer grouping accidental suffocation into the same category as SIDS.  However, it does illustrate that, in addition to true SIDS, accidental death also is a significant threat to the newborn.

Sudden Infant Death Syndrome is defined as the death of an infant less than one year of age that remains unexplained after thorough examination event including autopsy, examination of the death scene and assessment of the infant’s medical history.  There appears to be a moderately higher incidence of SIDS in male infants.  There are also ethnic differences in incidence, with SIDS occurring more than twice as often in African-American and Native American infants as compared to white, Hispanic and Asian infants.

There does not appear to be a single cause of SIDS.  A more recent hypothesis is the “triple risk model” which states that SIDS can occur when the following three conditions exist:  a vulnerable infant, a critical period of development in that infant, and an exogenous stressor.

What makes an infant vulnerable to SIDS? Unfortunately, we are not able to identify every vulnerable infant in advance since they appear healthy prior to succumbing to SIDS. However, we do know that some infants with certain prenatal conditions have increased risk. For example, infants born to mothers who smoke and/or consume alcohol during their pregnancy are at increased risk for SIDS. It has been suggested by some scientists studying SIDS that there may a neurodevelopmental effect of these substances on the fetus that ultimately makes them more vulnerable.  Additionally, preterm infants are a vulnerable population having a SIDS rate more than double that of term infants.

The most common time for SIDS to occur in term infants is between 2 and 4 months of age, and about 90% of SIDS cases occur before 6 months of age.  In preterm infants, the peak incidence of SIDS is several weeks later than in term infants.  For the many infants this time period defines a critical period of development, which, when combined with other factors, may increase likelihood of SIDS.

There have been many outside influences, or exogenous stressors, that have been strongly associated with increased risk for SIDS. We already are well aware of the association of SIDS risk with placing an infant on his or her stomach to sleep. Even placing an infant on the side rather than the back increases the risk of SIDS. Other things associated with increased risk include overheating the infant by overdressing, maternal smoking, having an infant share a bed with a caregiver who is overtired or under the influence of drugs, medications or alcohol, and multiple persons sharing a bed with an infant.

With our increased knowledge of SIDS and SIDS risk, we now know that there are strategies we can adopt to further reduce an infant’s chance of dying unexpectedly.  While the “Back to Sleep Program” addressed the important risk factor of sleep position and, as a result, has no doubt saved many infant lives, we can expand our efforts to further reduce risk.  At

Anna

Jaques

Hospital

we have adopted a “Safe Sleep” Campaign which focuses on addressing a number of risk factors and interventions important for SIDS prevention.  Our teaching points spell out the word “SLEEP”:

Safest place is in a crib with no loose bedding

Lay baby to sleep on the back – ALWAYS!

Eliminate cigarettes and alcohol

Educate secondary caregivers

Pacifiers reduce risk

We also strongly promote breastfeeding, which in addition to the many well known benefits to mother and baby, also has been shown to reduce risk of SIDS.  Use of a pacifier has been shown to have a strong protective effect in SIDS prevention in multiple studies, but the

American

Academy

of Pediatrics recommends that if choosing to use a pacifier it should not be introduced until after one month of age in breastfeeding mothers.

We all hope to see further progress in the area of SIDS prevention.  Taking the time to learn these important facts and interventions could save a baby’s life.

      

Term limits

I remember the moment that I knew that I was pregnant with my second child.  I had gotten home from a shift at the hospital and was feeling both nauseous and hungry at the same time.  (In hindsight, that should have been a tip-off all by itself...)  I opened the refrigerator and found a Happy Meal bag with leftover chicken nuggets on the bottom shelf, the leftovers from a trip my 2 1/2 year old son had to McDonald's with Grandma.  I actually sat down on the linoleum floor in front of the open refrigerator and ravenously devoured every remaining cold, stale chicken nugget, even the ones that my son had taken a small bite out of.  Somewhere between chicken nugget number two and three, the light bulb went off.  A home pregnancy test confirmed what I already knew, and I adjusted my life plan to prepare for pregnancy number two.

For many women that "ah-ha" moment shifts us from "me" mode to "we" mode.  Decisions about health, travel, work, and relationships are made in the context of the pregnancy.  We think and act both consciously and subconsciously in ways that will protect us and our unborn child. We consider our "due date" as the inflection point between life as we now know it and the next phase of life that includes our baby.

Due dates, however, are nebulous things.  A birth plus or minus a couple of weeks of the due date is be considered "term", and the vast majority of these babies are healthy.  An infant is born prior to 37 weeks, though, is considered to be premature.  These babies require special attention, and depending on the degree of prematurity, can have prolonged hospital stays after delivery. Clearly, the best thing for babies is to stay in the womb until term. So, keeping that in mind, are there things that expectant moms can do to increase the likelihood of carrying a pregnancy to term?  In the broadest sense the answer to that question is yes, but warrants a discussion of the factors that are associated with prematurity.  Like many other things in life, some are within our control and some are not.

Perhaps an oversimplification, but I generally think of premature birth as resulting from a situation in which the environment that the infant is in somehow is no longer favorable. Sometimes this can be due to something abnormal with the uterus itself, sometimes due to a medical condition or illness in the mother, and sometimes due to a condition with the infant.  For the sake of discussion, we can break this down to three categories:  The Uterus, The Mom, and The Baby. The following is by no means a comprehensive review, but should give a general idea of the role each has in pregnancy and some conditions which can affect pregnancy outcome.

The Uterus:

The uterus is truly an amazing structure.  In the non-pregnant women it is about the size of a plum.  By the sixth week of pregnancy it is the size of a small orange.  Fast-forward to the midway point of pregnancy at 20 weeks, and the top of the uterus can be felt at the level of the belly button. It serves multiple functions throughout the pregnancy.  It protects the developing infant in a microenvironment that adjusts to changes in the size of the baby.  It is the conduit of nutrition to the infant at its interface with the placenta.  Ultimately it somehow senses when to start the process of labor and begin the series of contractions that result in birth.  Conditions that adversely effect the normal growth of the uterus during pregnancy can adversely effect the pregnancy.  Examples include structural problems such as a bicornuate or unicornuate uterus, or large uterine fibroids which effectively reduce the size of the uterine cavity, and polyhydramnios in which there is excessive amniotic fluid production and the uterus expands beyond the expected size for a given gestation.  These conditions can be restrictive to the continued growth of the fetus and/or can bring about uterine muscle irritability and the onset of labor.

When considering the ability of the uterus to remain pregnant until term, it is also important to assess the cervix.  The cervix is the opening of the uterus which ideally remains closed until the onset of labor at term.  When the cervix begins to shorten and thin out prior to term it is referred to as being "incompetent".  Although there often is no known cause for this, it can be associated with prior surgery to the cervix (e.g. a cone biopsy), trauma to the cervix (as with therapeutic abortion or previous difficult delivery), and anatomic abnormalities (such as those caused by exposure to DES).  Incompetent cervix is thought to be responsible for up to 25% of midtrimester pregnancy loss.

The Mom:

The bottom line here is to know your own medical history.  Preexisting as well as acquired medical conditions in the mother can have a significant impact on the pregnancy.  As much as we think of the uterus as the "house" of the developing fetus, the mom is the source of the "utilities".  A healthy mom provides a nice, rich blood supply to the infant via the placenta. That blood supply provides the baby with nutrients and oxygen, as well as carries away any waste products of metabolism which the fetus cannot process itself. When you go to your first prenatal visit, your care provider will no doubt ask many questions about things in your medical history that could affect you and your baby's health during the pregnancy. This is, in part, to assess early in the pregnancy risk for preterm birth. Specific topics include infection (for example, bacterial vaginosis, urinary tract infection, sexually transmitted diseases), use of prescription medications, recreational drug use, domestic abuse, and conditions that can cause insufficient blood flow to the uterus such as high blood pressure, diabetes requiring treatment with insulin, autoimmune disease such as lupus, and cigarette smoking. Regular prenatal visits monitor both the health of the mother and the growth of the fetus. Early detection of problems in the pregnancy can prevent minor issues from becoming major ones.

I'd also like to emphasize that pregnancy is a time for expectant mothers to be proactive about their health.  This means changing some lifestyle habits that might be harmful to the fetus.  I have already mentioned cigarette smoking as a concern, and I strongly encourage expectant women (and everyone else for that matter) to take active measures to quit.  Let's not forget our mother's advice to get plenty of rest.  Fatigue and stress are known to negatively influence pregnancy outcome.  A relative newcomer to the list of things to be proactive about in pregnancy is dental hygiene. A series of studies in the past few years have correlated poor oral hygiene and gum disease with preterm labor.  So, add a trip to your dentist on the list of things to do.

The Baby:

Premature onset of labor can result if a baby is not thriving inside the womb.  As outlined above, this can be secondary to things outside the infant, such as an abnormally shaped uterus, compromised blood flow to the uterus or infection in the mother,  but sometimes a primary problem with the developing fetus can be responsible.  Some examples include things like abnormalities in the baby's chromosomes which can impair normal growth, conditions in the infant that result in excess amniotic fluid (polyhydramnios) and over-stretching of the uterus, and twin or multiple gestation which also causes excessive stretching of the uterus. These conditions are often not apparent until the second trimester, so I will again emphasize the need for going to the recommended prenatal visits so the growth of the baby can be monitored.

What if...

What if you think you might be going into preterm labor?  Early recognition of the signs and symptoms of preterm labor can help prevent a preterm birth.  Contact your doctor if you think you are experiencing any of the following:

• Contractions of your uterus at regular intervals.  If they are occurring at intervals less than 10 minutes apart, notify your doctor immediately.
• Persistent low, dull backache
• Pelvic pressure
• Vaginal spotting or bleeding
• Watery vaginal discharge. The may be amniotic fluid and could mean your membranes are ruptured.

Putting it all together:

Let's get back to the question I posed a little earlier:  Are there things that moms can do to increase the likelihood of carrying a pregnancy to term?  Yes, by taking an active role in prevention.  The way to do this is attending regular prenatal exams to make sure that the health of both mom and baby are optimal throughout the pregnancy. Make sure to know your own medical history and relay it to your provider. Be honest about everything in your medical history, including things like drug use and past pregnancies and/or abortions.  Identify situations in your life that are potentially harmful or stressful and take steps to change them.  If you can't do this on your own, ask for help. Take measures to stay healthy by eating healthy foods, sleeping well, and to the extent you can, avoiding catching colds or the flu. (The flu shot is recommended for pregnant women.) Educate yourself about the signs and symptoms of preterm labor.

And finally, share the joy of your pregnancy. Shared joys are doubled.