SUMMARY:

The AAP Committee on Infectious Diseases and Committee On Fetus And Newborn has released a report to help educate healthcare professionals regarding alternative perinatal practices specifically related to infection risk. The goal is to provide information to help with counseling as well as manage neonates who may be exposed to these practices.

Water Immersion for Labor and Delivery

• Describes giving birth in warm water
• Current data
  • First stage labor
    • Decreases use of regional anesthesia
    • No impact on mode of delivery
  • Second stage of labor
    • No benefit identified
    • Time period of studies too short to demonstrate infections that may have longer incubation periods
• ACOG and AAP acknowledge benefit in first stage but advise caution regarding use in second stage due to insufficient evidence with case reports of complications such as hypothermia, near drowning, respiratory distress and infections
• The current report states

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

Midwives and obstetricians offering this option must ensure that appropriate infection-control strategies (including rigorous cleaning and disinfection) are in place to reduce risk of infection

Vaginal Seeding

• Inoculation of infant born via cesarean delivery, using cotton gauze or swab, with maternal vaginal fluid applied to newborn’s mouth, nose and/or skin
• Purpose is to restore newborn microbiome that is more typical of vaginal delivery
• Current data
  • Epidemiologic studies have demonstrated a relationship between cesarean delivery and increased risks for various conditions such as allergies
  • Nonvaginal delivery may be associated with changes in infant’s microbiome (although changes do not appear to persist)
  • Other factors may be related to initial colonization beyond mode of delivery (e.g., gestational age or transfer via breastfeeding)
  • Vaginal seeding has potential to transfer pathogens to newborn that are associated with vertical transmission (e.g., GBS, HIV, HBV and syphilis)
• Both the AAP and ACOG recommend against vaginal seeding outside of a research setting
• The current report states

Families should be counseled regarding the risk of exposure to pathogens that may occur despite negative screening because of possible false-negative results or acquisition of the pathogen after the screening was completed

These concerns are compounded by the increased risk of infections in preterm infants, and vaginal seeding should not be considered in this population

Umbilical Nonseverance

• Also known as lotus birth
• Placenta via the umbilical cord remains attached to the infant following birth
• Placenta eventually dries (using preservatives and salting) until cord detaches (typically within 3 to 10 days)
• Current data
  • No evidence currently available regarding effects on cognitive or emotional development of infants or possible benefit
  • Case reports suggest potential for infections (including endocarditis from Staphylococcus lugdunensis, and omphalitis) also clear infectious link is not always present
  •  No data available regarding late-onset sepsis
• No formal recommendations are available from professional societies
• The current report states

Providers should conduct the routine assessment and management of an ill-appearing neonate

Any placenta and umbilical cord attached to the affected child should be immediately removed (particularly if necrotic tissue is evident)

This tissue should be cultured because isolation of the same pathogens from the placental and umbilical tissue and the infant may establish pathogenesis of the illness

Given that a few case reports note the growth of coagulase-negative staphylococci, it may be prudent to include vancomycin as initial empirical coverage

Antimicrobial coverage for anaerobic bacteria may be included with the usual coverage for early-onset neonatal sepsis

Placentophagy

• Also known as placental consumption
• Ingestion of placenta for spiritual or perceived medicinal purposes
• Commonly prepared by steaming followed by dehydration, grinding to powder and then encapsulated
• Current data
  • No human studies beyond self-reported surveys regarding benefits
  • There is literature with evidence of direct neonatal harm involving GBS due to horizontal transmission
• Risks include bacterial contamination either from maternal genito-urinary flora or during preparation
  • Optimal preparation temperatures to eradicate various viruses and bacteria are unknown and there is no industry standard
• This current report states

Placentophagy should be avoided because there is no evidence of benefit to the caregiver, and one case report links this to recurrent GBS sepsis in a neonate

Evaluation of symptomatic infants exposed to this practice should not differ from other neonates

Nonmedical Deferral of the Hepatitis B Vaccine Birth Dose

• Infants exposed to HBV perinatally have a high risk of infection
  • HBsAg-positive HBeAg-negative birth parents: 5% to 20%
  • HBeAg-positive birth parents: 90%
• Current data
  • Single HBV vaccine dose within 24 hours of birth is 75% to 95% effective at HBV prevention
  • HBV vaccine is safe and well tolerated
  • Receipt of an HBV vaccine dose prior to discharge is highly associated with completion of the full HepB series at 19 to 35 months of age vs delaying vaccine to 6 to 12 weeks
• The CDC and AAP recommend all medically stable infants weighing ≥2000 g receive a birth dose of HBV vaccine before 24 hours of age
  • Administer HBV vaccine and hepatitis B immune globulin (HBIG) for infants born to HBV-infected women within 12 hours of birth

The current report states

…nonmedical deferral of the birth dose should be discouraged

The birth dose of HepB serves as a critical safety net for prevention of HBV infection in situations in which the records of the pregnant person are never obtained, ignored, incorrectly transcribed, misinterpreted, or falsely negative, such as may occur with acquisition of HBV infection late in pregnancy after a negative initial test result

Deferral of Ocular Prophylaxis

Ocular prophylaxis is effective for treating some causes of ophthalmia neonatorum, particularly in high-risk situations, such as limited prenatal testing for causative organisms in high-risk populations and in areas with high endemicity

Adequate prenatal testing significantly reduces the risk of ophthalmia neonatorum

Deferral of ocular prophylaxis may be considered in low-risk situations but may be impacted by state legislation 

• Ophthalmia neonatorum
  • Conjunctivitis presenting in the first 4 weeks of life
  • Most important cause is Neisseria gonorrheae which can lead to blindness
• Current data
  • US cases: 0.4 cases per 100 000 live births in 2018
  • Related to cases of GC with highest rates in those born to mothers ≤24 years of age
  • Risk of transmission to infants: 30% to 50% of infants
    • 20% corneal involvement | 3% blindness
  • Erythromycin ointment can prevent gonococcal ophthalmia neonatorum with no associated harms
• AAP and USPSTF recommend ocular prophylaxis with 0.5% erythromycin ointment and is required by law in most US states
• The current report states

Ocular prophylaxis is effective for treating some causes of ophthalmia neonatorum, particularly in high-risk situations, such as limited prenatal testing for causative organisms in high-risk populations and in areas with high endemicity

Adequate prenatal testing significantly reduces the risk of ophthalmia neonatorum

Deferral of ocular prophylaxis may be considered in low-risk situations but may be impacted by state legislation

Delayed Bathing

• Bath of neonate not performed until several hours after birth
• Many hospitals have integrated this practice to promote breastfeeding initiation and exclusivity
• Current data
  • Best time for delaying bathing is unclear
  • Retrospective studies demonstrate increased breastfeeding rates
  • Limited data on potential harms
• WHO recommends delay until >24 hours with a minimum of 6 hours if cultural reasons prohibit delay
• The current report states

Parents contemplating breastfeeding should be counseled that delaying the first bath is beneficial for successful and sustained efforts

However, bathing should be initiated as soon as possible after delivery in cases in which newborn infants are exposed to active HSV genital lesions or when there is a known history of bloodborne pathogens (HIV, HBV, or hepatitis C virus)

Learn More – Primary Sources:

AAP: Risks of Infectious Diseases in Newborns Exposed to Alternative Perinatal Practice

ACOG Committee Opinion 679: Immersion in Water During Labor and Delivery

CDC: Hepatitis B Vaccination of Infants, Children, and Adolescents

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