What About Afterward?

We talk a lot about pregnancy and birth on this blog, but what about after baby comes? There are so many options to consider before baby even makes her arrival, from vaccination and circumcision, to breastfeeding and diapering, there are so many things to work through. This post will, hopefully, set you on a course to helping navigate all of the choices in early parenting that you will be faced with.

Immediately after birth, you will have some choices to make. These choices include circumcision, vaccinations, routine baby care, and breastfeeding. We will take a look at each of these and I will provide links to additional online sources after each one.

Cord Clamping
Cord Clamping tends to occur immediately after birth. Doctors want this to occur for a number of reasons: to hasten the birth of the placenta (traction on the cord stump), to finish a patient's care quickly, to be able to separate baby from mom to complete newborn assessment and routine procedures, and because they may fear jaundice as a result of delayed clamping. Let's address the last reason first because it is the only important one, the rest are only for convenience of the doctors: regular physiological jaundice results from delayed clamping, whereas other types of jaundice (premature, breastfed, or Rh) are not due to delayed clamping.

There are many reasons to WAIT (even if it is only for 2-3 minutes) to cut the cord. The blood in the placenta rightfully belongs to the baby, and babies not receiving this blood have the deal with the equivalent of a major blood loss or hemorrhage at birth. It is estimated that early clamping deprives the baby of 54 to 160 ml of blood, which represents up to half of a baby’s total blood volume at birth. To prevent anemia, the iron in the cord blood is vital to babies early health. Babies benefit from the increased oxygen available to them from cord-blood while waiting to take their first breaths. Earlier cord iclamping increases the incidence of respiratory distress syndrome. The last cord blood acts as a source of nourishment that protects infants against the breakdown of body protein.

For more information see below:
PubMed
Cord Issues
JAMA
Reuters

Erythromycin
This is the eye goop that they put in baby's eyes right after birth. This ointment is an antibiotic given to prevent ill effects of Chlamydia, Syphilis, or gonorrhea, so if a mother knows she does not have these infections, she might choose to refuse this intervention all together. BTW, if you or someone you know is expecting to give birth in the next 4 months, you may want to doubly consider skipping this treatment because there is a shortage of the Erythromycin eye ointment that is normally used for newborns, so many birth facilities are using substitute ointments without warning parents that there are increased risks of the side effects associated with Erythromycin.

If a parent (mother or father) has an allergy to antibiotics in this class, a baby's risk for side effects/allergic reactions increases. The ointment does cause the eyelids to become red and puffy for about 12-24 hours, as well as blurring their vision. Risks include: Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); bloody stools; diarrhea; stomach pain, as well as less severe reactions (blurred vision, skin irritation, peeling). The ointment is not supposed to sting the eyes. Many families who choose to have the erythromycin applied to their baby's eyes choose to wait for 2 hours postpartum, so that early infant/mother bonding can occur without inhibition of cloudy vision.

See below for more information:
Drugs.com
Clinical Trials

Vitamin K Injection
The vitamin K injection is a routine injection given to all newborns. This is because babies are born, for the most part, without Vitamin K, a component necessary for blood clotting, so that cells can divide and multiply during gestation. Historically, newborns began getting Vit K shots when circumcision and forceps deliveries became routine. Additionally, at that time they found that some babies suffered from HDN (blood clotting disorder - brain bleeds). We now know that there are two types of HDN:

Early onset "Classic" HDN (also called Vitamin K Deficiency Bleeding) occurs in the first week of life. It is an iatrogenic condition, meaning that it is caused by medical care:

• premature clamping/cutting of the umbilical cord deprives babies of up to 40% of their natural blood volume, including platelets and other clotting factors
• the use of vacuum extractor or forceps often causes bruising or internal bleeding, which uses up the baby's available clotting factors
• the use of antibiotics inhibits the baby's generation of clotting factors

Late-onset HDN (true HDN) occurs in specific circumstances:

• maternal medications interfere with vitamin K, such as anticonvulsants, anticoagulants, and antibiotics
• infant antibiotic use
• infant liver disorders (more prevelant when there is a history of liver disorders)
• infant diarrhea, hepatitis, cystic fibrosis (CF), celiac disease, and alpha1-antitrypin deficiency

In these situations, if your baby is born by vacuum or forceps assistance, or if you are planning ton have your newborn circumcised before discharge, Routine Vit K is wise.

OTOH, the other side of the debate is that babies are born without Vit K for a reason. Levels are adequate by 8 days after birth (the same day that Jewish/Christian God said to circumcise Hebrew boys), but they continue to increase for the first six weeks of life.

Studies show that there is an increase risk of childhood leukemia in children who have received the vitamin K shot as newborns, erythrocyte aggregation, jaundice and kernicterus, flushing, sweating, a sense of chest constriction, peripheral vascular collapse, and nerve or muscle damage at the injection site.

Other options are to use oral Vit K drops throughout the first few weeks of life (to baby), or increase maternal diet of green leafy veggies or vit K supplement to transfer from breastmilk to baby.

See below for more information:
Administration of Vit K To Newborns
To Inject Or Not
Making Informed Choices

PKU
The Newborn Screening Test (aka PKU test) is an analysis of the baby's blood to look for evidence of certain genetic diseases or inborn errors of metabolism. The test is performed by collecting a blood sample from the baby onto special paper, which is then sent to a laboratory for analysis of red blood cells, hormones and metabolic by-products to assess whether the findings are outside the normal range.

This is "law" in every state (I believe, verification of your personal state is appreciated) although you have a right to refuse any treatment or test. Typically, baby is taken to the nursery, the heel is warmed with a heat pack, and then the nurse or doctor will perform a heel stick and collect blood samples from the heel. Alternatives are: to refuse the test outright, to require babies collection to be done in your presence, while nursing or soothing, or to use a more humane device.

There is low risk of infection, a small risk of nerve damage at the collection site, and the risk of the breastfeeding relationship being disrupted and/or emotional trauma.

See below for more information:
Newborn Screening Test
Medline Newborn Screening
March of Dimes Newborn Screening

Breastfeeding
Breastfeeding is an option for every woman who gives birth. Breastmilk is the best nutrition for a newborn/baby. It is normal and natural, BUT many women encounter obstacles along the way because, even though it is normal and natural, it is not always easy. Some hurdles that might be encountered: nipple confusion, low milk production, inverted nipples, mastitis, tongue tie, high cleft, plugged ducts, and engorgement.

Nearly all breastfeeding hurdles can be overcome by support, lactation consultation, special attention or apparatus'/treatments, perseverance, and encouragement.

Breastfeeding success can be inhibited by: premature introduction of a bottle or pacifier, formula supplementation or introduction, medications of mom or baby, prematurity, or recovery (from cesarean or other surgery). Avoiding these situations, if possible, can greatly increase your breastfeeding success.

Benefits of breastfeeding to baby include:

• Less chance of obesity - Longer periods of breastfeeding greatly reduce the risk of being overweight in adulthood as well as reduces the risk of adolescent obesity.
  
• Healthy teeth, eyes, and ears - Formula-fed babies tend to run a higher risk of jaw misalignment and are more likely to need orthodontic work as they get older. Breastfeeding improves the development of facial muscles and the shape of the palate. Breastfeeding reduces the incidence of ear infections and vision problems.
  
• Overall Health - breastfed babies have a reduced risk of severe upper respiratory infections, wheezing, pneumonia and influenza. They have less risk of diarrhea, gastrointestinal infections and constipation. Formula feeding carries a four fold increase in risk for SIDS.
• Intelligence/Coping - breastfed babies tend to score higher on IQ tests and cognition testing. Breastfed babies also tend to be more vertical in the corporate world later in life. A recent study indicates that breastfed children cope better with stress later in life. The bonding rather than the breast milk is a likely explanation.
• Later Life - Formula-fed babies have a raised risk of heart disease, juvenile/type 1 diabetes, and multiple sclerosis. Recent research indicated that breastfeeding can postpone allergies and asthma. Breastfeeding may also play a role in preventing digestive diseases, such as ulcerative colitis and Crohn's disease, as well as childhood cancers including leukemia. Other studies indicate a reduce risk for both eczema, food allergy, and respiratory allergy--throughout childhood and adolescence.

Benefits to Mom:

• Less Fatigue - women who nurse report being better rested, less stressed, and more content. This is because of a number of factors and include: no need to prepare formula/bottles, the ability to readily access nourishment for a child during nighttime feedings (which allows a woman to do this as second nature and not fully rouse), the hormone prolactin releases olfactorily, soothing a stressed mama and family members and promotes a feeling of overall well being.
  
• Weight Loss - While nursing, you will burn an additional 500+ calories every day. So, unless you continue to "eat for two", the breastfeeding may help you loose weight. The 'spare tire' around a woman's waist is actually a 'milk store' a fatty deposit that nature gave women to sustain her milk production in hard times. Women who nurse tend to loose more of this spare tire, which would otherwise continue to be a 'problem area' throughout her life.
  
• Uterine Health - The hormone oxytocin, which is released in your body during breastfeeding, helps the contraction of your uterus back to normal. Besides looking pregnant for a shorter time period after giving birth, this also means that you may have a shorter postpartum bleeding. Some studies suggest that this also reduces uterine risks later in life including prolapsed uterus, the rate/necessity of hystorectomies, and the like.
  
• Cancers and Longterm Health- Some studies indicate that the risk of getting both breast and ovarian cancer is reduced through breastfeeding. Some studies even indicate of lower incidence of osteoporosis later in life among women that have breastfed.

Breastmilk contains:

• Protein in breast milk is mostly whey, which is easier to digest than casein (main protein in cow's milk). Protein of breast milk has high amounts of amino acid taurine, which has an important role in the development of the brain and the eyes.
• Fats - These fats are nearly self-digesting, since breast milk also contains the enzyme lipase, which breaks down the fat. Fat is the main source of calories for babies, something babies need to continue postpartum growth and development. Also, fat in human milk has large amounts of omega-3 fatty acids, important for brain development.
• Vitamins and minerals - in human milk are bioavailable-meaning they get absorbed well. Breast milk contains substances that enhance the absorption of minerals and vitamins.
• Stem Cells - Breast milk is the only adult tissue where more than one type of stem cell has been discovered. That is very unique and implies a lot about the impressive bioactivity of breast milk and the consequential benefits to the breastfed infant (see this article for more great information)
  
• Immune boosters. breastmilk continually passes millions of white blood cells to baby to help baby fight off all kinds of diseases. Also, when mother is exposed to a germ, she makes antibodies to that germ and gives these antibodies to her infant via her milk. Breast milk also contains factors that prevent microbes from attaching, and a long list of other antiviral, antibacterial and antiparasitic factors.

"Even more amazing, if a baby contracts an illness that mom has not been exposed to previously, he will transfer this organism through his saliva to the breast, where antibodies are manufactured on site and then sent back to baby via the milk to help him cope. ... Mothers who wean their babies from the breast during the first and even second and third years of life often notice that their child becomes sick more than before, or for the first time." Examining the Evidence for Cue feeding of Breastfed Infants by Lisa Marasco and Jan Barger

• Hormones and enzymes. Breast milk has lots of digestive enzymes, and also many hormones. These all contribute to the baby's well being.

See below for more information:

Dr. Sears on Breastfeeding

Womans Health

Vaccinations
Vaccinations definitely have benefits, and there are stark risks as well. This, like circumcision, is a touchy subject.

The wonderful thing is, there are options. Your options include selective vaccination, delayed vaccinations, and no vaccinations.

Some things to consider when making your decision:

• Immunizations provide long-term immunity, not lifetime immunity.
• Breast-feeding protects the child from diseases (excluding pertussis) through the mother’s immunity. Some advocates of delayed vaccination state to wait until baby is weaned.
  
• Vaccination protection: typically, the 1st shot in a series provides full immunity to 70% of the population. The 2nd shot in the series brings it up to 80% & the 3rd to 90% of the population.
• All vaccines carry some risks, these risks are compounded the more vaccines a body recieves.
  
• The polio vaccine has been shown to, in some cases, cause polio.
• The mumps vaccine has been shown to, in some cases, cause meningitis, febrile convulsions and epilepsy.
• The HPV vaccine has been shown to cause high incidences of: death, paralysis, thrombosis, lupus, blood clots, fainting, stroke, siezures, long term dissabilities, and there is a question as to, longterm, if it will cause infertility issues.
• Questions as to vaccines correlating with the increased incidence of autism in developed countries routinely vaccinating.
  
• Vaccines can cause allergic reactions/sensitivities to certain foods like eggs & gelatin as well as certain medications (antibiotics). While preexisting severe allergies to eggs, gelatin or antibiotics can result in severe deadly reactions to a vaccine containing these substances.
• Consider the risks of contracting the disease in your decision to immunize your child. High risks include overseas travel, frequent plane or bus travel, day care or school, or your personal job exposure to vaccination diseases.

There are many options, and I recommend families reviewing the evidence for what is the best for their families.

See below for more information:

Center For Optimal Health

NVIC

Dr. Sears and Vaccinations

Circumcision
Circumcision is a very touchy subject for families. There are pros and cons on each side of the fence and has to be a subject/decision that families are confident in BEFORE it is performed. If, for any reason, there is dissension over circumcision, it is best to NOT have it done until all parties are in agreement. Culturally and religiously, there are arguments in favor of the procedure. As a routine surgery, the AAP discourages it.

Complications can arise, and do in about 3% of all circumcisions, and include: rash or irritation, poor cosmetic appearance, bleeding (hemorrhage) and/or infection, and complications due to faulty surgical technique (Buried penis (also called denudation - penile shaft buried below the surface of the pubic skin), Chordee (abnormal downward bend of the penis), Meatal stenosis (narrowing of the urine channel [urethra] at the top of the penis), Skin bridges (foreskin reattaching to the glans), and Penectomy (accidental partial or complete penile removal)).

It is a permanent procedure that cannot be reversed and is often times not covered by insurance. The procedure takes anywhere from 5-15 minutes.

The procedure- The baby is placed on his back with his arms and legs restrained and the penis and surrounding area are cleaned. A local anesthetic (e.g., cream applied to the skin, injection to the shaft or base of the penis) is used to prevent pain. Anesthetic cream takes effect in about 20-40 minutes. The injection takes less time to work, but the aftereffects may last longer. Sometimes the baby is given a sweetened pacifier to reduce stress (sweetie). The foreskin is pulled down (retracted) from the head of the penis and clamped in place using a metal or plastic ring. If a metal ring is used, the foreskin is cut off and the ring is removed. An antibiotic cream is applied and the penis is wrapped in loose gauze. Healing usually takes 5 to 7 days. If a plastic ring (called a Plastibell) is used, the foreskin is slit and wrapped back around the ring. A piece of thread (suture) is tied around the cut foreskin, pushing it into a groove in the plastic. This is left on the penis for 5 to 7 days, after which it falls off, leaving a completely healed circumcision. An antibiotic cream is applied to the penis.

There are DEFINITE benefits to leaving the prepuce intact, and would refer you to the video below for a full disclosure of that. Please take the moment to watch this video, whether or not you choose to circumcise, so as to be fully educated and make an informed decision about the process.

Functions of the Prepuce (Foreskin) @ Yahoo! Video

Several studies have been performed to find out if there is a medical benefit to infant circumcision. The American Academy of Pediatrics (AAP) says the benefits of circumcision are not significant enough to recommend circumcision as a routine procedure and that circumcision is not medically necessary.

A recent AAP report stated that circumcision does offer some benefit in preventing urinary tract infections in infants (which is easily treatable with antibiotics and occurs less often when the foreskin (prepuce) is left alone (not retracted to clean)). Circumcision also offers some benefit in preventing penile cancer in adult men. However, this disease is very rare in all men, whether or not they have been circumcised. Circumcision may reduce the risk of sexually transmitted diseases. Although a man's sexual practices (e.g., if he uses condoms, if he has more than one partner, etc.) has more to do with STD prevention than whether or not he is circumcised.

Study results are mixed about whether circumcision may help reduce the risk of cervical cancer in female sex partners, although this information is again skewed as to the male partners sexual practices as the cervical cancer is often a result of HPV.

Other arguements are social pressures: wanting a child to look like his father or male role model, not wanting a child to be made fun of growing up, wanting a child to 'fit in'. These arguments, IMHO, are not solid enough to base a decision to alter another persons reproductive organs on. No two penis' look alike, so the 'look like his father' argument is null and void - a child will have no issues with this discrepency as long as the father does not show any angst regarding his sons penis. The last two arguments are becoming a non-issue as more and more American males are not being circumcised. America, Canada, and the Middle East are the only locations where circumcision is prevelant, rate of incidences in the order listed.

Finally, taking into consideration all of the above information, we would be wise to think twice about the implementation of this procedure routinely.

See below for more information:

Family Doctor

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Well, I hope that the above information arms families with the starting point to begin to make the earliest choices for their children's healthcare. For more great reading, see below:

Parenting and Baby Care
Online Resources:

• 365
• Transition to Parenthood
• Real Savvy, All About Moms
• Dr. Sears
• Kelly Mom
• Mothering

Books:

• The Baby Book, Sears
• Mothering the New Mother, Placksin
• The Year After Childbirth, Kitzinger
• You and Your Newborn Baby, Linda Todd
• The Happiest Baby on the Block, Dr. Harvey Karp
• The Year After Childbirth, Sheila Kitzinger
  
• Your Amazing Newborn, Marshall and Phyliss Klaus

Breastfeeding
Online Resources:

• BFLRC - mostly for the professional
• Transition to Parenthood
• Kelly Mom
• ProMom
• La Leche League International
• Breastfeeding

Books:

• The Nursing Mother’s Companion, Kathleen Huggins
• *The Womanly Art of Breastfeeding, Anwar Fazal
• The Breastfeeding Book, Sears
• Nursing Mother, Working Mother, Gale Prior
• So That’s What They’re For! Breastfeeding Basics, Janet Tamaro
• The Ultimate Breastfeeding Book of Answers, Newman and Pitman

Maternal Support, PTSD, and Birth Trauma
Online Resources:

• Post Partum Support International - for help postpartum
• Depression After Delivery - for help postpartum
• Solace For Mothers - support for traumatic birth
• TABS - support for traumatic birth and PTSD
• Birth Crisis - for birth healing

Books:

• This Isn't What I Expected: Overcoming Postpartum Depression, Karen Kleiman
• The Postpartum Husband, Sandra Poulin
• The Mother-To-Mother Postpartum Depression Support Group, Sandra Poulin

My hope is that every woman can be confident of her educated decisions as a mother! Here's to full and informed consent (refusal).