One of the trends in newborn care is that more and more parents are declining various interventions. It’s not entirely dissimilar to declining or delaying vaccines, which–in case you missed it–has been a bit of an issue recently. Sometimes, these parents have good reasons for the decisions they make. Sometimes, they are misinformed. And sometimes, they just don’t understand the reasons behind what we do–mostly because we don’t do a very good job explaining it.

In some ways, I think this is a good thing. I think it’s fantastic that parents are thinking for themselves instead of blindly accepting what the doctor tells them. It also keeps doctors on our toes. We’ve certainly been wrong before, and the simple fact that we have to defend the things we do every day makes us examine the reasons why we do them. But it can also be dangerous. It’s dangerous when parents believe that a couple hours of internet “research” trumps the education and experience of the experts that make these recommendations. While it’s certainly possible that the experts are wrong, it’s far more probable that the person that wrote a post on a mommy blog or “natural” news site didn’t know what they’re talking about.

For new parents, these can be tough decisions. They are some of the first decisions that parents make for their children, and many of these choices can’t be taken back. A little healthy hesitation is to be expected. So, with that said, I want to take some time to discuss some of the most commonly-declined interventions in the newborn nursery–not to convince you to do things my way, but to equip you with the knowledge you need to make informed decisions for your baby. Let’s get to it.

1. Hepatitis B vaccine

While vitamin K is also given by injection, the hepatitis B vaccine is the only true immunization given shortly after birth. I know it seems early, but there’s a reason. And this is the only vaccine routinely given prior to the 2 month visit, so you have a little bit of time to think about the rest. For now, let’s focus on hepatitis B. I’m not going to address the more global concerns about vaccine safety here, as I’ve done this numerous times in the past.

Hepatitis B is a viral infection of the liver that can be either acute or chronic. Older children and adults will typically clear the infection quickly and never go on to have chronic hepatitis. But when the infection is acquired as an infant, it tends to last a lifetime. In fact, 90% of children who acquire the hepatitis B virus during the first year of life will go on to develop chronic hepatitis–the kind that causes cirrhosis, liver failure, and cancer. About 25% of people with chronic hepatitis B infection will die as a result of this disease. Additionally, by immunizing a population that is at the highest risk of chronic disease, we can reduce the spread of the disease decades later–a step that is key in eliminating the disease entirely.

Aside from the typical reasons that people delay or decline vaccines, there are a couple specific reasons that parents question the hepatitis B vaccine. One is that many mothers are screened for hepatitis B during pregnancy (since our biggest concern is infants who would be exposed the the virus during birth); if the mothers don’t have it, they feel that it’s unnecessary to protect the infant. Another is that hepatitis B is often referred to as a “sexually-transmitted disease.” Which, of course, it is…but calling it that trivializes the other ways that is can be spread–like exposure to blood or open wounds, sharing razors or toothbrushes, contaminated needles, and (rarely) blood transfusions.

It’s true that infants born to mothers with no history of hepatitis B are at very low risk. But it’s not no risk, and the complications of exposure can be catastrophic. Some mothers don’t get tested, some tests are falsely negative (although these are very rare), and there is always the potential that other members of the family carry the virus.

We know there is benefit in providing the hepatitis B vaccine, and that the earlier it is given, the more of a chance it has to provide protection. So the real question is this: is there any significant harm in giving it withing the first 12-24 hours of life? And, aside from a brief needle stick and maybe some temporary emotional trauma for the new parents, the answer to that question is no. Of course, if you’re extremely uncomfortable with this vaccine and would like to talk to your pediatrician about it at the newborn visit (assuming you tested negative for hepatitis B), that’s reasonable; a couple days probably won’t make a difference.

2. Eye ointment/drops

Another potential infectious complication of delivery is neonatal conjunctivitis. This is an infection of the eyes that is usually caused by chlamydia or gonorrhea (but can also be caused by several species of Staph and Strep as well as herpes). Maybe you don’t have chlamydia or gonorrhea. Hopefully, you never have. And you may be thinking that there’s no reason to treat your baby for something that she could not possibly have gotten from you.

But, just for a minute, pretend it isn’t you we’re talking about, but somebody you went to high school with. And then look at it from a doctor’s perspective. I’ve had patients who have “never had sex” that have tested positive for gonorrhea or chlamydia. Sometimes, both at once. I even had an adolescent girl who swore that she got pregnant in a hot tub–not by having sex in the hot tub (which I would have believed), but simply by soaking in water that apparently contained some very determined sperm. People lie. People cheat. People sleep with people that they didn’t think were cheating. STDs haven’t survived for millennia because of monogamy–just being real.

The reason we care about neonatal conjunctivitis is because it causes permanent blindness. And because the outcomes of this disease can be so devastating, we take several steps to prevent these infections:

• Routinely testing expectant mothers for gonorrhea and chlamydia (among other standard labs).
• Treating mothers who are found to have these diseases, then re-testing to make sure the infection is gone.
• Cleaning each infant’s eyes and treating with antibiotic eye drops/ointments.

In the past, we used silver nitrate drops, which were effective but frequently caused irritation to the eyes. Most facilities have switched to another medication–usually erythromycin drops or ointment. This medication has far fewer side effects–most commonly blurry vision, which probably isn’t a huge deal on day one.

And yes, we typically treat every baby. Even those whose mothers are respectable, upstanding citizens in monogamous relationships, who don’t appear in the least bit slutty. We’re not judging. In fact, we’re doing the opposite…so we don’t miss something and end up with blind (but respectable and monogamous) babies.

3. Vitamin K

Inside our blood, there exists an extremely complex and delicate balance between bleeding and clotting. Those of you with a medical background may have memorized and forgotten the coagulation cascade multiple times (you know the diagram I’m talking about). For the rest of you, the simple version is that there are proteins in the blood called “factors,” each of which is responsible either for making clots or for dissolving them. When the system isn’t balanced, you either bleed too much or clot too much–both of which can kill you.

Vitamin K is a nutrient used by the body to make these clotting factors. We obtain vitamin K from our diet–most notably from leafy greens, but from some other foods as well. There is also a limited amount produced by the beneficial bacteria that live in the gut. But when infants are born, they have low vitamin K stores because it doesn’t cross the placenta well. Additionally, a newborn’s gut is sterile, and there are very low amounts of vitamin K in breastmilk. Together, these factors place infants at risk for complications of vitamin K deficiency.

The main complication that we see due to low vitamin K levels is bleeding–a problem formerly known as “hemorrhagic disease of the newborn,” and now called “vitamin K deficiency bleeding.” There are three types of vitamin K deficiency bleeding (VKDB):

• Early-onset VKDB happens in the first 24 hours of life and can be very severe; it’s typically associated with mothers who were taking blood thinners, seizure medications, or medications for tuberculosis. This type of VKDB is rare, but can be devastating.
• Classical VKDB occurs between days 2 and 7, and is typically less severe (but still very concerning). There may be some bleeding from the umbilical stump, inside the intestinal tract, or from the circumcision site (assuming a doctor was foolish enough to circumcise an infant who hadn’t received vitamin K). But while it may be somewhat less severe, classical VKDB is no joke. It’s also very common, affecting roughly 1 in 100 infants who don’t receive vitamin K at birth.
• Late-onset VKDB happens later–anytime in the first 3 months, and often without warning. Half of these infants aren’t recognized until they have bleeding in the brain. 20% of infants with this condition die, and many of the survivors have severe brain injuries. Late-onset VKDB occurs in about 1 in 10,000 infants who doesn’t receive a vitamin K shot at birth, and breastfeeding is a major risk factor.

You may have some questions about why this happens. After all, if every baby is “deficient” in vitamin K, maybe that’s just the way they’re supposed to be. Maybe there’s a reason for it. I’ve wondered that, too, and I haven’t been able to find a good explanation. But honestly, it doesn’t matter a whole lot. Perhaps, some day we’ll find a reason for this “deficiency.” Maybe it will be shown to be protective against some other harmful condition, or have some other beneficial effect. It’s possible that we will look back 30 or 40 years from now and know that we were wrong; that’s certainly happened before. But we have to do the best we can with the evidence we have.

Fortunately, while VKDB is sometimes fatal, it’s also preventable. Since 1961, we’ve been recommending vitamin K shots at birth, and this practice has virtually eliminated VKDB. Of course, that’s until parents started declining the shot because it’s “unnatural” or “unnecessary.” Ironically, many of these parents will go on to give their children other vitamins that may very well be natural (whatever that means), but truly are unnecessary. For many parents, it’s the needle itself that is the deterrent, whether it’s a desire not to cause pain or an association with vaccines, which have been at the center of a fabricated controversy for the past several years. And for some parents, it’s a disproven association between injectable vitamin K and leukemia that causes lingering concerns.

Some of these parents will opt to give vitamin K by mouth instead, which seems like a reasonable decision–except that it doesn’t work. OK–it works a little. Oral vitamin K does decrease the risk somewhat, but it still leaves infants susceptible to VKDB–especially the frequently fatal late-onset variety. Oral vitamin K is also not available in a liquid formulation in the US, forcing parents who wish to use it to resort to unregulated supplies found at health food stores–not a great plan for preventing a life-threatening condition. Overall, the risks of a single injection of vitamin K seem to pale in comparison to those of a GI hemorrhage or brain bleed. Of all the things parents decline in the nursery, this may be the least wise.

4. The Bath

When I was rotating in the newborn nursery as a medical student, I distinctly remember the first time a nurse warned me that an infant’s parents had declined the bath. I think my response went something like, “Declined the what?” I had no idea that bath refusal was a thing. Honestly, it seemed a little gross. But, hey–we go to deliveries all the time, and there’s no stopping to bathe the baby when he’s limp and blue. So I shrugged, put on some gloves, and examined the baby. Later, I read about why parents would make such a decision.

When babies are born, they are covered in amniotic fluid, blood, and sometimes poo (usually the baby’s–as magical as childbirth is, it ain’t always pretty). While there may be no biologically compelling reason to remove these substances from a baby’s skin, most of us tend to prefer clean babies to icky ones. So, traditionally in the first hour or two, the baby is whisked away for a bath, and then returned to the parents–squeaky clean and ready for pictures.

Also found on a newborn’s skin is a substance called “vernix caseosa.” The vernix (for short) is a white, cheesy substance that coats the infant’s skin and has traditionally been washed off with the first bath. However, there is some emerging research that suggests that vernix may possibly play a role in protecting the infant from infections and conditioning the skin. Possibly.

There are also some theories that early bathing can cause temperature instability or interfere with breastfeeding, but there haven’t been any great studies that compared early to delayed bathing. Ideally, we would take a big group of babies and randomly place them in two groups (early vs. delayed baths) and then see if there is any difference in outcomes. Strangely, nobody’s done that yet, so we don’t really know if it makes a difference.

But, alas, vernix doesn’t last forever, and kids who go to preschool with crusted meconium under their chins would be easy targets for bullying. At some point, we have to clean the baby off. Doing this prior to discharge from the hospital–but maybe not in the first few hours–allows both mom and dad to be present and facilitates education about proper infant care for new parents.

So when should your baby have his first bath? Honestly, I don’t know that it makes much of a difference. If you want to wait a while, I’ll throw on some gloves. It’s not my first rodeo with bodily fluids.

5. Circumcision (If your baby doesn’t have a penis, you can skip this section. Heck, even if your baby does have a penis, you can still skip this section. Doesn’t matter to me.)

Circumcision is probably the most polarizing procedure in pediatrics. It’s been a contentious topic for thousands of years, and I’m not going to attempt to bridge that divide today. Again, my goal is to provide you with the information you need to make an informed decision.

For some families, the decision of whether or not to circumcise a child comes down to a strongly-held religious or cultural belief. For others, it’s a purely cosmetic issue–they want their son to look like his father, or like others in his anticipated peer group. And then there’s the crowd that adamantly opposes circumcision for a number of reasons. One common claim is that it decreases sexual sensation later in life. I’m not sure how you would go about designing a study that would prove that (unless you survey men who had the procedure performed much later in life–which is a different case altogether). And based on the number of circumcised and sexually-active adolescents I’ve seen, it doesn’t seem to be much of a deterrent. I think we have enough data to conclude that circumcised sex feels pretty good.

Medically-speaking, just like any other procedure, there are risks and benefits. Circumcision is a surgical procedure, and while it is relatively mild as surgeries go, it does carry risks for infection, bleeding, and pain. Infections are very rare, as we use sterile techniques and instruments. Bleeding is usually minimal (as long as the infant got his vitamin K), but sometimes causes issues and may require further intervention (like a special dressing, and maybe even a stitch or two). The pain is real, but usually well-controlled with local anesthetics and perhaps a pacifier dipped in a sugar-water solution that we affectionately call “baby crack.”

Quite possibly, the most notable risk is that of a poor cosmetic outcome. Sometimes this is related to taking off too much or too little skin, not aligning the instruments properly, or some other problem with technique. Occasionally, there are anatomic problems with the penis that we don’t know about until the foreskin is partially removed–these are usually referred to a surgeon. And sometimes, things just don’t go well. Overall, bad outcomes from circumcisions happen in about 1-2% of cases, and they are almost always correctable.

As far as benefits go, they are real but relatively minimal. Circumcision reduces the chance of a urinary tract infection in a male infant during the first year of life from about 2% to about 0.2%–a 90% decrease, but one that affects a relatively small number of people. They can also reduce the spread of HIV and HPV and decrease the incidence of penile cancer (and cervical cancer in future sexual partners). But there are other ways to accomplish those goals (like condoms), and they don’t require a surgical procedure.

I’ve read journal articles written by urologists advocating circumcision as a “surgical vaccine.” Which, truthfully, I find a bit absurd. Compared to vaccines, circumcision has a higher complication rate, while offering a much smaller potential for preventing illness. It also does nothing at all to protect other individuals, leaving it squarely within the realm of a parent’s right to choose or refuse. The current stance from the American Academy of Pediatrics is that the benefits outweigh the risks, but not by enough to recommend it for everyone. This is one of those areas where you’re just going to have to make a decision. Welcome to parenting.

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Hopefully I’ve provided a little insight about why we do what we do in the newborn nursery. That’s my goal–to enable you to make informed decisions about your child’s health. These are some of the most controversial topics surrounding newborn care, and they tend to come up a lot. And they tend to come up at a time when parents are stressed out, sleep-deprived, and hormonally-challenged. Think about them, talk to your doctor before your baby is born, decide what’s best for your baby.

In upcoming posts, I’ll talk about some other (somewhat less controversial) things that happen in the nursery–things like cord clamping, umbilical cord care, newborn screens, and bilirubin checks. If you have any questions, feel free to send them my way. Thanks for reading and sharing with your virtual friends as well as your real ones. If you aren’t already, be sure to follow me on Facebook or Twitter for updates about new posts.

-Chad