In my last post, I began discussing a clinical report on the risks of infectious diseases newborns face when exposed to certain “alternative perinatal practices” that has now been published in Pediatrics, the flagship publication of the American Academy of Pediatrics. In the report, authors representing the Committee on Infectious Disease and the Committee on Fetus and Newborn tackle seven of these practices. In my previous post, I went through the first three: water immersion for labor and delivery, vaginal seeding, and umbilical nonseverance. Today I will discuss the rest of them.
Placentophagy
Placentophagy, specifically maternal placentophagy, occurs when a mother ingests the placenta, or at least some portion of it, in order to derive a health benefit. This is a practice with no legitimate historical precedent that was invented in the 1970s but didn’t really become mainstream until celebrities like Kim Kardashian promoted the practice a few years ago. Another factor in its rise in popularity was the transition to dehydration and encapsulation of the placenta.
The authors of the AAP clinical report correctly point out that placentophagy is observed in nonhuman mammals, likely for nutrition or to reduce the risk of being eaten themselves during a vulnerable period. But this is conjecture. They leave out that marine mammals and camels do not consume their placentas and that dogs and rabbits do consume their own feces.
They mention claimed potential benefits of reducing postpartum depression, bleeding, and pain, improved breast milk production, less iron deficiency, and increased energy. But, as they also state in the report, there have been absolutely no studies that support these claims other than self-reported surveys. I’ll point out that there is also very little if any plausibility to these claims. For more detail, check out my 2017 post on placentophagy.
Risks to the newborn of a mother who is practicing placentophagy come from the potential for bacterial contamination with pathogenic bacteria from the gastrointestinal or genitourinary tracts. This could include group B streptococcus, the most common cause of invasive bacterial disease in newborns, but also HIV, hepatitis B virus, and hepatitis C virus. The authors point out correctly that preparation of placentas for consumption is an entirely unregulated industry and that there are no proven standards.
The authors discuss a case which they claim offers direct evidence of harm to a newborn from maternal placentophagy but I’m not so sure. I actually discussed this case, which involved recurrent group B streptococcal sepsis in a newborn, in my previous post on the subject linked to above. It is certainly possible that consuming a contaminated placenta increased maternal colonization and the chance of spread to the baby, but false negatives during maternal screening and recurrent disease in newborns occur without it.
Regardless of whether or not this one case report represents proven direct harm, the plausibility of potential for harm is high. Plausibility for potential benefit from placentophagy is extremely low and thus far unproven. Therefore the practice should be avoided.
Nonmedical deferral of the hepatitis B vaccine birth dose
Though uncommon, infants who become infected with the hepatitis B virus have a very high chance (around 90%) of developing chronic disease that will alter the course and possibly the duration of their lives in several unfortunate ways. What is fortunate, however, is that this can be prevented by screening of pregnant women, which is an imperfect human endeavor, and universal dosing of the hepatitis B vaccine for newborns. This vaccine is extremely safe and effective and there is no legitimate reason for a parent to refuse or defer it.
Sadly, this vaccine is often refused or deferred until later and hundreds of babies in the United States acquire the infection every year. There are roughly 4 million infants born every year and low risk is not zero risk. Some facilities have adopted recommendations by the AAP and CDC to have standing orders for the vaccine and “opt out” policies in order to increase uptake, but many children are increasingly born at non-hospital “birthing centers” or at home where these safety net policies are less likely to be implemented.
I wrote in greater detail about newborn hepatitis B vaccination back in 2015.
Deferral of ocular prophylaxis
Babies can develop infection of the eyes no differently than older children. Conjunctivitis, more commonly known as “pink eye”, is fairly common in kids, but eye infections in newborns are more worrisome because of the possibility of exposure to bacteria more typically associated with sexually transmitted infections. Neisseria gonorrhea in particular can cause a severe form of conjunctivitis in newborns that can lead to scarring of the cornea and blindness. It’s uncommon overall but a child born to a mother with gonorrhea has roughly a coin flip’s chance of eye infection if nothing is done to prevent it.
It is standard of care for mothers to be screened for gonorrhea, among other sexually transmitted infections like chlamydia, syphilis, and HIV, but as with screening for hepatitis B this process is not perfect. In an effort to prevent newborn eye infection with gonorrhea, universal application of erythromycin ointment (previously the more irritating silver nitrate) has been required by law in the United States for decades. An increasing number of parents have been refusing this intervention, however.
The reason these parents refuse is often not based on legitimate concerns, but they aren’t completely off-base in questioning the practice. There is controversy regarding the universal nature of the current recommendation, and not ever country does this. Some organizations, such as the Canadian Pediatric Society, cite increasing resistance to erythromycin, effective treatments in the case of diagnosed eye infection, and reassuring data from other regions with a more targeted approach as reasons to avoid routine ocular prophylaxis.
The AAP has actually called into question the need for legal mandates, which are typically ignored by all involved parties, and recommends focusing on prenatal screening and treatment of infected mothers. The United States Preventive Services Task Force disagrees, and in 2019 reaffirmed their recommendation for universal prophylaxis of newborns. This was based on a conclusion that the intervention has reasonable benefit and is safe, which is true. There really is no downside to individual infants, though many parents who refuse have been told by people with no expertise in newborn medicine that it can suppress the immune system, cause allergic reactions, or interfere with bonding. None of this is accurate.
This is a tough one. When parents refuse this intervention, and mother has been screened and is low risk for an STI, I don’t get too worked up over it. I explain the reasoning behind the recommendation, provide reassurance in regards to any safety concerns, and counsel on signs to watch out for, but I don’t try multiple times to change their minds like I might in other circumstances. I certainly don’t involve the authorities. But people practicing in a different area with a different patient population might feel differently. Or they might just feel differently, and that’s okay. They aren’t wrong.
Delayed bathing
Newborns have traditionally been bathed soon after delivery, or at least within the first several hours. Over the past few years, however, there has been a significant change in this trend with many parents requesting a delay, with some wanting to wait more than 24 hours or even declining the newborn bath altogether. A growing number of hospitals have also changed their practice, establishing delayed bathing as a policy in an effort to help mothers initiate breastfeeding despite the lack of quality evidence that bathing somehow interferes with that goal.
Another claim made by proponents of delayed bathing involves the skin microbiome. This is similar to beliefs held by the vaginal seeding camp and is based more on speculation and hype than actual evidence. To be fair, there are potential risks from early bathing. We are cautious when it comes to premature infants and babies that are small for their gestational age because of the low risk of hypothermia. We also wouldn’t rush to bathe a baby that is unstable.
Obviously we take parental preferences into account when it comes to bathing. There are circumstances where cleaning the baby with soap and water is more important, however, such as when a baby has been potentially exposed to HIV or herpes simplex virus during a vaginal delivery. According to the report authors, there is also a lack of research into the risks of delaying the first bath. So, for example, it is unknown if delayed bathing increases the risk of infection with group B streptococcus, syphilis, or hepatitis B and C virus.
Refusing the newborn dose of intramuscular vitamin K
Refusal of the newborn dose of intramuscular vitamin K was not included in the report because there is no associated increased risk of an infectious disease. But it is certainly an alternative perinatal practice that puts newborns and young infants at risk of death and severe neurologic injury from catastrophic bleeding into the brain or intestines and it is something that we deal with much more frequently than lotus birthing. I wrote about this vital intervention back in 2013 and just wanted to include it here because it is extremely important to the health of babies.
Conclusion: Alternatives to standard newborn care practices are unproven and may expose a baby to significant risk of harm
With the potential exception of refusing newborn eye prophylaxis, so-called alternative perinatal practices are not based on good science or backed by reasonable evidence of safety and benefit. In many cases, the opposite is in fact true and they expose babies to the risk of potentially severe infectious diseases. Like vitamin K refusal, there are many more examples that could be discussed which do not involve increased risk of infection, and even some, such as the Baby Friendly Hospital Initiative, that are not considered to be alternative at many hospitals. This is what happens when belief and bias trump science in the newborn medicine.