The American Academy of Pediatrics (AAP) doesn’t always get it right when it comes to so-called alternative medicine. In fact, as I wrote back in 2017, they have a bit of an integrative medicine problem. So I was intrigued when I learned of a soon-to-be-published clinical report that is focused on the risks of infectious diseases in newborns exposed to various alternative perinatal practices.

In the report, authors representing the Committee on Infectious Disease and the Committee on Fetus and Newborn tackle seven alternative perinatal practices, a few of which you have undoubtedly heard of. Long time readers might even remember my previous posts discussing four of these seven practices, which I will link to shortly. The authors start with justifications for their effort:

An increasing number of alternative peripartum and neonatal practices have emerged in delivery settings. Pediatric providers may be asked about these practices during prenatal counseling, or they may encounter situations in which these practices have already occurred. Being familiar with the risks and benefits associated with these alternative practices allows the pediatric practitioner to provide balanced education and counseling to families and perform appropriate evaluation and treatment when indicated.

Let’s see how they did.

Water immersion for labor and delivery

Proponents of water immersion claim that it improves maternal comfort during the first stage of labor, while also reducing the need for surgical interventions, and eases the transition from womb to world for the baby during the second stage. Much like the claims of boosting the immune system made by supplement slingers, I have yet to see a meaningful definition of easing a newborn’s transition. It’s a sure sign that the person spouting them doesn’t have a firm grasp of newborn physiology.

My opinion on the subject hasn’t changed since writing about it back in 2014. The evidence for laboring in water is weak, but I could still be convinced that benefit outweighs the risk by better studies. It is virtually non-existent when it comes to delivering in water, however. And there are significant potential risks such as infection, hypothermia, injury, and drowning. Though rare, all of these outcomes have occurred and would be expected to increase if more deliveries take place in water.

In the AAP’s new clinical report, the authors reveal that more recent data provides a bit more support for the role of laboring in water as a means of improving comfort but does not support claims of preventing C-sections. Though the 2018 meta-analysis they discuss did not find benefit for actually delivering a baby in water, it also didn’t find an increased risk of adverse outcomes. The two studies included were small, however, and not well designed to look for the type of infections that might be seen in neonates born in water.

The authors conclude that risk outweighs benefit:

Families should be cautioned against water birth during and past the second stage of labor, in the absence of any current evidence to support maternal or neonatal benefit, and with reports of serious and fatal infectious outcomes in infants.

And please, for the love of Greb don’t have your baby in a stream or in the ocean with dolphin midwives.

Vaginal seeding

Few topics are as popular among both legitimate medical researchers and complete charlatans as the microbiome and various interventions aimed at nudging it in such a way as to improve health. In my opinion, the hype far outweighs the evidence. This is particularly true when it comes to vaginal seeding, which I wrote about in 2017, and my opinion hasn’t changed.

Proponents of vaginal seeding claim that infants born via C-section miss out on the important exposure to maternal vaginal bacteria, which they believe promotes the establishment of a healthy microbiome. Have a less than ideal microbiome might result in an increased risk of lifelong adverse health outcomes such as allergies, asthma, and obesity, all of which have been epidemiologically linked to C-section delivery. One way to mitigate this potential risk, they assume, is to swab a newborn’s mouth, nose, and/or skin with a swab covered in fluid from their mother’s vagina.

This is an incredibly complex issue and it is challenging to tease out the many variables at play when we look at how early environment alters health over the lifespan. We simply do not have evidence to support claims that different outcomes over time when comparing babies born vaginally to those born via a C-section are related to exposure to vaginal flora. Our understanding of the microbiome is limited by only being able to know what we can grow (or detect with PCR tech), and evidence to date has found that any differences associated with the mode of delivery disappear after a few months.

No evidence supports claims that this transient difference is meaningful. The factors that resulted in the need for a C-section delivery, rather than any brief alterations in the types of bacteria on a baby’s skin or in their gut, could play a much larger role. Correlation, after all, doesn’t necessarily equal causation. And as the authors of the report point out, caution is warranted when it comes to vaginal seeding:

Vaginal seeding may facilitate transmission of pathogens normally acquired by vertical transmission.

There are very important pathogens in the neonatal population, such as group B streptococcus, herpes simplex virus, HIV, hepatitis B, and syphilis that can be spread from mother to baby via infected vaginal secretions. Thoughtless vaginal seeding essentially exists as an unethical experiment that potentially exposes a newborn to increased risk of very serious diseases. The AAP report recommends limiting the practice to research settings, ensuring that appropriate screening of mothers has been performed, and counseling parents on the potential risks.

Umbilical nonseverance

During a typical birth, the umbilical cord is cut 30-60 seconds after delivery of the baby unless distress necessitates a more urgent evaluation for the need for resuscitation. Also known as “lotus birth”, umbilical nonseverance involves delivery of the placenta without cutting the cord until several days have passed. I wrote about lotus birth in a 2018 post and again in a 2020 post when news broke that it was implicated in the tragic death of an Australian newborn.

My opinion has not changed one bit since then:

There is no reasonable expectation of benefit from delaying clamping and cutting of the umbilical cord after delivery for more than a couple minutes. There is, however, plenty of plausible risk, particularly that of serious bacterial infection. Lotus birth is a dangerous practice and anyone promoting it is putting the lives of newborn babies at risk. Cut the cord.

What are the proposed benefits of lotus birth according to believers? Naturally, it involves a list of subjective nonsense and pseudoscience but the primary claim is of improved newborn emotional well being and maternal postpartum healing. But as the authors state in the new AAP clinical report, umbilical nonseverance has no clear evidence-based benefit. And while we can appreciate parental spiritual beliefs involving the placenta, we cannot ignore that it becomes dead tissue capable of rotting and causing life threatening infection in an attached baby.

In part 2 of this discussion, I’ll discuss what some mothers do with the placenta other than leaving it attached to their baby. Also covered in the AAP report are the risks of refusing the newborn hepatitis B vaccine and recommended antibiotic ointment for newborn eyes. I’ll wrap things up with a nuanced dive into the potential risk and benefits of delaying a newborn’s first bath.

See you next time.

Author

  • Clay Jones, M.D. is a pediatrician and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey. The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.

Posted by Clay Jones

Clay Jones, M.D. is a pediatrician and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @SBMPediatrics and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey. The comments expressed by Dr. Jones are his own and do not represent the views or opinions of Newton-Wellesley Hospital or its administration.