Routine Post-natal Care For Your Baby

After the birth

There are several procedures that are a routine part of post-natal care for your baby. As with routine medical intervention during birth, it can be very valuable to consider these procedures as options and to do some research as to the pros and cons of each of these options.

Apgar scoring

This is just a quick check by the midwife or attending doctor, more for them than you to help them decide how to proceed with your babies care. The Apgar score is named in honour of one of the first paediatricians to specialise in newborn (neonatal) care, Dr. Virginia Apgar. She developed this scoring system to identify babies at risk for complications from delivery.

The baby is scored by the attending midwife or obstetrician at one and five minutes of age. If there are problems with the baby an additional score is given at 10 minutes. A score of 7-10 is considered normal, while 4-7 might require some resuscitative measures, and a baby with a score of 3 and below requires immediate resuscitation (preferably still attached to the placenta with an unclamped cord).

Apgar Scoring System
	0	1	2
Appearance (colour)	Pale	Blue	Pink
Pulse	Absent	<100	>100
Grimace This is the annoyed response to suctioning (hopefully not needed) or foot stroking.	Absent	Grimace	Cry Active
Activity Movement: this may need provoking in a relaxed baby who has had an unmedicated birth	Limp	Some tone	Active
Respiration How your baby is breathing	Absent	Irregular	Regular & Cry

Zero, one, or two points are awarded for each category. The total of the individual category scores is the Apgar score for that scoring session. For example a baby who at one minute was a bit blue, with heart rate 120, an active cry, actively squirming, and taking regular breaths would receive an Apgar score of 1+2+2+2+2 = 9. That is about as good as they come at one minute; only an occasional baby gets a 10. Even though there are plenty of babies who are pink all over, breathe normally, have normal heart rates, show strong muscular movement, and have a good cry; most normal, healthy newborns do not achieve perfect scores. This is because it takes a few minutes for a newborn’s circulatory system to adjust to life on the outside, especially if there has been active management of third stage. It is quite normal for a newborn to have blue hands and feet for the first few hours. Also, some babies are naturally quiet immediately after birth. It is common in babies who have experienced a drug free birth to be in a state of quiet alertness at five minutes, but they would lose points on their Apgar for not crying.

This is a test which tells medical personal whether there is any need for careful observation of the new baby, it tells parents nothing about how good or not so good their baby is nor are the scores predictive of any possible long term problems.

Vitamin K

The issue

Babies are routinely given a vitamin K injection very soon after birth in order to prevent a rare problem of bleeding into the brain in the first 12 weeks following birth. This is known as haemorrhagic disease of the newborn.

Vitamin K promotes blood clotting. In the uterus the baby has low levels of vitamin K as well as other factors needed in clotting. The baby’s body maintains very precise levels of vitamin K during the pregnancy and this does not change regardless of how many vitamin K rich foods the mother eats.

Toward the end of the pregnancy, the baby begins to develop some of the other clotting factors; developing two key factors just before it is ready for birth. It has recently been shown that the tight regulation of vitamin K levels help to control the rate of rapid cell division during the pregnancy. It appears that high levels of vitamin K can allow cell division to get out of hand, potentially leading to cancer.

Breastfeeding will gradually raise the baby’s vitamin K levels after birth so as to maintain the perfect levels to allow for normal development. Also the clotting system of the healthy newborn is well establish without high levels of vitamin K, so healthy breastfed babies do not suffer bleeding complications, even without any vitamin K supplementation, nor do they show any signs of vitamin K deficiency.

Infant formulas are supplemented with high levels of vitamin K, which are generally sufficient to prevent intracranial bleeding in the case of a liver disorder and in some other rare bleeding disorders. Although formula feeding is seen to increase overall childhood cancer rates by 80 percent, this is not thought to be related to the added vitamin K. What this means for a formula fed baby is that a vitamin K injection is not required.

Although breastmilk usually contains only small amounts of vitamin K, it also contains substances that help the baby to build up a healthy amount of digestive bacteria which will allow the baby to start producing its own vitamin K. These factors are not present in formula, so it takes much longer for a formula fed baby to start making its own Vitamin K.

The pros

• The problem of bleeding into the brain occurs mainly from three to seven weeks after birth in just over five out of 100,000 births (without vitamin K injections) Forty percent of these babies suffer permanent brain damage or death. In most cases, if the baby is given a vitamin K injection at birth, this is a totally avoidable tragedy.
• The cause of haemorrhagic disease of the newborn is generally liver disease that is rarely picked up until the bleeding occurs. Several liver problems can reduce the liver’s ability to make blood-clotting factors out of vitamin K; therefore extra vitamin K helps this situation and those babies at risk from brain damage or death.
• Babies who have been exposed to drugs or alcohol through any means are especially at risk, as are those from mothers on anti-epileptic medications. These complications reduce the effectiveness of vitamin K, and in these cases, the high level of vitamin K found in the injection could prevent brain damage or death of the baby.

The cons

• There have been several studies which have shown a link between Vitamin K injection and an increased risk of developing childhood leukaemia. Credibility of  these studies is questionable at this time. It has been shown that the cell division that continues after birth continues to depend on precise amounts of vitamin K if it is to continue at the proper rate. Vitamin K injections contain 20,000 times more than that found in the uninjected newborn. The most current analysis of six different studies suggests it is a 10- 20 percent increased risk, which in my opinion is a significant number of avoidable cancers in children who were never at risk of haemorrhagic disease of the newborn. Current literature given out by NSW health states that these studies are not credible.
• Research shows that higher levels of clotting factors double the death rate of babies from bacterial meningitis.
• You are injecting not only high levels of vitamin K, but also preservatives and stabilisers directly into the blood stream. We don’t really know the long term consequences of this practice.
• There are very few babies who are at risk of developing haemorrhagic disease of the newborn.
• There are other safer and more natural methods of giving vitamin K which more closely mimic the system that nature has put in place while still being an effective preventative for haemorrhagic disease of the newborn.
• Any injection creates a risk of infection.
• The vitamin K injection rarely causes an overgrowth of scar tissue at the site of the injection which can occur many months after birth. This is known as pseudoscleroderma. This is thought to be an autoimmune response to one of the preservatives in the injection.
• Injections may be emotionally traumatic to newborn babies

The risk assessment

Looking at data from available literature reveals that there are 1.5 extra cases of leukaemia per 100,000 children due to vitamin K injections, and 1.8 more permanent injuries or deaths per 100,000 due to brain bleeding without injections. Taking into account the reported cases of infection from the injections that is rarely seen with the vitamin K injections, as well as the possibility of healthy survival from leukaemia, the benefits of vitamin K supplementation seems to outweigh the risks for breastfed babies, though there does seem to be better options than the injections given to babies immediately following their birth.

A formula fed baby appears to be at very, very little risk of haemorrhagic disease of the newborn because formula is supplemented with vitamin K.

Still, I have a lot of trouble saying that Mother Nature may have gotten this wrong.

Your options

As far as I see it you have five options when it comes to the vitamin K decision. If you choose anything other than the first option you will need to write your wishes in your birth plan as well as have someone write it in both your file and your baby’s file.

• Give the injection.
• Give the baby several oral doses of liquid vitamin K
• The breastfeeding mother can take vitamin K supplements daily or twice a week for 10 weeks. This has been shown to be an effective method of increasing the amount of vitamin K in the breast milk and subsequently in the new born baby. It has been shown that supplementing the mothers diet at 2.5 mg per day provides more vitamin K through breastmilk than formula. This is more than is actually required to eliminate the risk of haemorrhagic disease of the newborn. See Vitamin K rich foods below.
• Wait and see if your baby has any of the following risk factors before making your decision.
• Premature babies
• Delivery interventions such as forceps or vantouse,
• Babies that are quite jaundiced
• Babies of mothers who have taken epilepsy medication during pregnancy
• Babies of mothers who have been exposed to drugs or alcohol during the pregnancy. Since there is no data available on the subject this could include passive smoking
• Babies who are quite bruised after birth

Vitamin k rich foods

• A breastfeeding mother can eat foods rich in vitamin K close to the birth and for the first 3 months of the baby’s life and pass the vitamin K through to the baby through her breast milk.
• Spinach
• Broccoli
• Brussel sprouts
• Cauliflower
• Watercress
• Egg yolk
• Cows milk
• Supplementing the mother’s diet with bifido bacteria can also help to colonise the baby’s digestive system and help the baby to begin making its own Vitamin K more quickly, reducing the need for supplementation.

Hepatitis B vaccination

The pros

• Infants are easier and cheaper to vaccinate than when they are older and at greater risk of contracting the virus.
• Routine vaccination protects newborns of mothers who are carrying the virus
• It is thought that immunising as a young baby will protect the child through its teenage years if they engage in risky behaviours.
• By vaccinating every baby born, we are helping to prevent the spread of the disease while allowing for the fact that the vaccination is not effective for all those who receive it.
• If given as a young child the vaccine is found to be effective in around 90% of people vaccinated but is much less effective in those over 30.
• Injections are emotionally traumatic to newborn babies

The cons

• The vast majority of newborns are not at risk of contracting Hep B, risk factors are intravenous drug use, tattooing, sexual contact and working as a health care worker. The only risk factor appropriate to the newborn is a mother who has the virus. In an Australian study conducted from 1991-1998, it was shown that the annual notification rate of hepatitis coming from children under the age of 15 was around 0.2 out of every 100,000 cases of Hep B reported. This is a tiny percentage.
• The insert in the product packet that is currently in use in Australia states that immunity from the vaccine begins to wane after 3 years and is insignificant after 5 years.
• The vaccine is routinely given to babies as within 12 hours of birth. We have no idea what long term effects this has on such a young baby.
• The vaccination contains aluminium to enhance the immunological response as well as preservatives to allow for shelf life. We have no idea what the consequences of administering these substances directly into the blood stream of a newborn can do.

Your options

I see 3 options for this one.

• You can accept the Hepatitis B vaccination at birth
• You can refuse the Hep B vaccination entirely although you will need to get a form signed by your GP confirming that you understand the risks involved.
• You can delay the start of the vaccination schedule. You don’t have to follow the schedule exactly. Many parents would rather wait for their baby to be stronger and to have a more fully developed immune system before giving some or all vaccinations, often choosing to give them when the child begins day care, pre-school or school. Prior to this, there is little chance of the child coming in contact with vaccine preventable disease. If the child is breastfeeding then it will be receiving antibodies from the milk against anything its mother has come in contact with and so is protected to a great extent whether it has received the vaccination or not.

Newborn screening test

Newborn babies are routinely given this test before they go home from hospital, between 48 to 72 hours from birth. It is performed by taking a few drops of blood from your baby’s heel onto an absorbent paper. The dried blood sample is sent to your states Newborn Screening Laboratory.

The new born screening test allows for fast treatment for those babies affected by these rare genetic disorders. This means preventing severe complications or developmental problems as a result.

Many Australian states now test for over 30 rare disorders which can now be detected by the newborn screening test and about 90 babies with rare medical disorders are detected in NSW each year by newborn screening. As a bare minimum, every Australian state and many countries throughout the world routinely test for 4 significant genetic disorders. You can pay for the more comprehensive test if your healthcare system doesn’t provide it.

The test is performed by taking a few drops of blood from your baby’s heel onto an absorbent paper. The dried blood sample is sent to your states Newborn Screening Laboratory.

The pros

• It saves babies from serious developmental problems and possible death
• Depending on the skill of the person collecting the sample, many babies will not even cry. Some will even sleep through the procedure.

The cons

• Some babies don’t bleed so well making the collection of the few drops of blood more difficult and painful. Often the person collecting the sample will have to massage and milk the foot to get the blood out. The alternative to this is to slice the foot with a scalpel to allow for better bleeding.
• The usual timing of this test means that many babies are somewhat dehydrated because it happens before the mothers milk comes in. If this is the case, it can be extremely difficult to collect the blood.
• There is a fairly high false positive result for some of the conditions. This can cause unnecessary stress for anxious parents as well unnecessary hospitalisations for babies
• You are piecing the skin and this can be painful and traumatic to some babies, not mention mothers and nurses.

Your options

• You can follow your states recommendations. If you warm the foot for a good 5 minutes before hand, you have a much better chance of bleeding well. You can do this a warm heat pack (careful not too hot, babies burn easily). It also helps to have your baby upright, over your shoulder (like you are burping it) and if your baby is nice and relaxed. If your baby becomes upset, ask the nurse to stop and try again later.
• You can delay the test until your milk has come in and you know that your baby is well hydrated and more likely to bleed. It can done anytime within the first week within putting your baby at any risk
• You can contact your states Newborn Screening Department and make arrangements for the sample to be collected from cord blood. Out of the 30+ genetic disorders tested for the only thing that can’t be picked up from cord blood is rarer mild cases of PKU. This is not of a concern in breastfed babies because the early breastmilk doesn’t contain enough phenylalanine to cause any problem in these rare cases. For total and complete peace of mind, the test can then be followed up with a PKU urine test when your baby is 4 to 6 weeks old. The other concern with testing cord blood is that it increases the chance of misleading results because it is a mixture of both the mothers’ blood. The NSW newborn screening unit consider this to be unreliable, but this will vary from state to state. Also, in some countries there is a special newborn screening test designed for cord blood that can be organised in advance. Australia is not one of these countries.
• You can request that the test be done with a butterfly clip in the arm. This is a very fine needle and it will ensure that you can get enough blood to fill the dots on the card. It is no more painful than the heel prick. You could request this instead of the heel prick or you could try the heel prick and if the midwife has to start milking the foot and your baby becomes upset, you can ask her to stop and request a doctor to use the butterfly clip in the arm.
• This is an optional test, you can say no thank you.
• My experience with this is that I’ve never had any of my babies even cry for this test. They have all breastfed through the heel prick and appeared not to notice.