Posts Tagged ‘newborns’

Interview with Alice Callahan about Science of Mom: A Research-Based Guide to Your Baby’s First Year.

October 6th, 2015 by avatar

In an earlier post on Science and Sensibility, regular contributor Anne Estes, PhD reviewed Science of Mom: A Research-Based Guide to Your Baby’s First Year, a new evidence-based book focused on answering questions on health, sleeping, and feeding for an infant’s first year. The book grew out of author Dr. Alice Callahan’s blog, Science of Mom, that she began writing as a new mother. Dr. Callahan took some time out of her busy schedule to talk with Anne about her new book and how it might be helpful for childbirth educators and new parents.  Readers will also want to pop over to Anne’s blog – Mostly Microbes, to listen to a podcast of  a more detailed interview with Dr. Callahan, the author of The Science of Mom. We’d also like to congratulate Amy Lavelle for being randomly chosen from the commenters on the original post. Amy wins herself a free copy of the book.  We hope that she will enjoy reading it.  – Sharon Muza, Community Manager, Science & Sensibility.

Science of Mom Cover HiDefAnne Estes: What do you see as the role of this book for childbirth educators and other birth professionals?

Alice Callahan: First, my book gives a really in-depth look at several newborn medical procedures, including timing of cord clamping, the vitamin K shot, and eye prophylaxis, plus shorter sections on newborn screening, the hepatitis B vaccine, and the newborn bath. Childbirth educators will take away a clear understanding of the evidence behind these procedures, and they can pass that knowledge onto students and clients. Second, and just as useful, those in-depth sections serve as excellent case studies for how to look at scientific evidence. My hope is that this background will give readers the tools needed to evaluate scientific evidence on their own as they encounter new questions – and I’m sure birth professionals are constantly faced with new questions!

AE: Why should childbirth educators suggest your book as a resource for interested parents?

AC: New parents are often taken off guard by the number of questions they have about childbirth and caring for a new baby. In online forums and playground conversations, they’re suddenly thrown into discussions of what is best for babies, and they find themselves trying to sort through lots of conflicting opinions and misinformation, trying to make the best choices for their own babies. It’s tremendously valuable and empowering to be able to understand how science can inform these decisions and how to find evidence-based resources. My book not only gives parents evidence-based information on infant health, feeding, sleep, and vaccines, but it also illustrates for parents how to find it themselves.

AE: What message from your book is most important for childbirth educators to share with their students?

AC: Seek evidence to inform your decisions. Be very skeptical of everything you read on the Internet, and make sure you’re getting your information from an accurate source. There’s so much misinformation out there that can be very misleading and even dangerous for parents and their babies. Don’t assume that something more natural or involving less intervention is always better. That isn’t always the case. Instead, look for objective evidence of risks and benefits, and make an informed choice.

AE: How did you choose the topics for your book? Was it difficult to decide what to leave out?

AC: I tried to choose topics that I think are some of the most common causes of confusion and anxiety for parents, based on questions that I get on my blog or that I see in online parenting forums. To be honest, my original proposal for this book included several more topics, but as I fleshed out chapters, I realized that it was more interesting to look at several topics in a really in-depth way rather than skim the surface on lots of different topics. But honestly, if I’d been able to devote another year or two to it, it could easily have been twice as long, because there are just so many great questions that parents have about the first year of life. I would have liked to cover topics like emerging research on the microbiome and concerns about chemical exposures, for example, but I may have to save those for another book!

AE: What do you feel is the most controversial topic in your book? 

AC: The safety of bedsharing is probably the most controversial topic in the book. Sleep practices are just so personal, and many parents really value bedsharing with their babies for cultural, emotional, or practical reasons. This is an area where you’ll find very conflicting advice, and everyone cites scientific studies to back their stance. In the book, I do my best to look honestly at the evidence for and against bedsharing safety. I explain that multiple studies do show risk of bedsharing in certain circumstances, especially with babies in the first few months of life, but I acknowledge the limitations of those same studies. And I also point out that individual factors, such as ease of breastfeeding or alternatives to bedsharing (including the risks of falling asleep with your baby on a couch or trying to drive a car while severely sleep deprived, for example) might make careful bedsharing a reasonable choice. I think we need to share all of this information with parents and discuss how to set up a bed to make bedsharing as safe as possible if that is the choice.

AE: Could you describe how you determine which findings from the scientific literature are best for answering a parenting question?

AC: In the book, I give a rough guide to types of study designs and explain which ones are most likely to give us strong evidence that is relevant to parenting decisions. Systematic reviews and meta-analyses are usually most useful, because they combine the results of multiple studies so are more likely to give us a big picture consensus about a question. (This assumes that the authors selected high quality studies for the review, so you have to be a little careful here.) Looking at single studies, randomized controlled trials are the best quality, whereas observational studies are usually limited by confounding factors and can only show correlations, not causation. Studies conducted in animal models or cell culture are an important step in scientific research, but we really want to see follow-up in human studies before we change our lives over the results. As you look at studies, you also want to pay attention to how many people were included in the study and whether or not the population is similar to your own. Evaluating scientific evidence takes some practice, and I go into lots more detail in the book.

AE: I was shocked to read that immediate cord clamping and cutting and stomach sleeping were practices changed in the mid-1900s without any evidence. Could you talk about how one of those practices began, the implications, and what it took (or will take in the case of umbilical cord clamping) for the original practices to be put back into place?

AC: It’s surprisingly difficult to pin down exactly when the shift to immediate cord clamping occurred, but it probably happened in the early to mid-1900s. Before this, it was likely standard practice to wait a few minutes or until the cord stopped pulsing before clamping it. The shift to immediate cord clamping seemed to coincide with the movement of birth from the purview of midwives in homes to obstetricians in hospitals. Immediate cord clamping was also part of the practice of active management of the third stage of labor, which was introduced in the 1960s. However, there was no evidence then that immediate cord clamping was beneficial to either mom or baby, and studies show that delayed cord clamping does not increase the mom’s risk of postpartum hemorrhage (which was a belief for a while).

Immediate cord clamping is an example of an intervention put into place because it was convenient, not because it was evidence-based. We now have good evidence that delayed cord clamping is beneficial to infants, especially those born preterm. For term infants, the biggest benefit is a boost in iron stores that can prevent iron deficiency later in infancy. There is some evidence that the risk of jaundice is increased, but as I discuss in the book, this is controversial. We’re seeing some obstetricians making delayed cord clamping their standard of care, but practice is really mixed in the U.S. At this time, ACOG recommends a delay of 30-60 seconds for preterm infants, but they refrain from making any recommendation for term infants, citing insufficient evidence. I actually appreciate that they’re careful to ensure there is adequate evidence before changing practice, but I do think we have enough evidence now that we should really be going back to delayed cord clamping whenever possible. I think that with a little more time and a few more studies, delayed cord clamping will again become standard practice, especially with doctors in the U.K. testing a resuscitation trolley that allows the cord to remain attached even if the infant requires resuscitation.

AE: What did you do to feel prepared for your labor and birth, and first weeks of parenting? Did you choose to take a childbirth class?  Do you feel it helped you feel prepared and confident?

AC: Before the birth of my first child, I took a childbirth class through a local hospital. It was very helpful in terms of knowing generally what to expect with labor and learning some ways to cope with discomfort. To prepare for the birth of my second baby four years later, my husband and I both read The Birth Partner by Penny Simkin. I liked that it was evidence based and a straight-forward source of information, and my husband put Simkin’s suggestions into action to truly be a great birth partner.

One of the most important aspects of birth preparation for me was developing a trusting and respectful relationship with my healthcare providers. My babies were delivered by two different OBs, and both were wonderful at communicating options to me as things progressed. Based on our discussions throughout pregnancy, I knew that I could trust them to be evidence based in their practice, and that helped me relax in labor and focus on my job of giving birth.

How did I prepare for the first few weeks of caring for a newborn? I did what women have been doing throughout the history of our species – I invited my mom to come and help! She was a wonderful help after the birth of both of my babies, and I felt lucky to have her.


AE: What future topics are you looking forward to writing about next?

AC: Readers of my blog keep me well-supplied with questions about parenting, and I have a huge list of topics that I’d like to tackle. One of my favorite areas of focus is nutrition, as that is the field of my PhD training, so I’d like to develop more information about infant nutrition on my blog.

While I was researching and writing my book, I had three miscarriages. That brought up lots of questions for me about miscarriage and infertility, but I didn’t have time to write much about these topics because I was working so hard on The Science of Mom. I’d like to write more about them now. I think there is a real need for compassionate and evidence-based writing about these tough topics.

About Anne M. Estes, PhD

AnneMEstes_headshot 2015Anne M. Estes, PhD is a postdoctoral fellow at the Institute for Genome Sciences in Baltimore, MD. She is interested in how microbes and their host organisms work together throughout host development. Anne blogs about the importance of microbes, especially during pregnancy, birth, first foods, and early childhood at Mostly Microbes.

Babies, Book Reviews, Childbirth Education, Evidence Based Medicine, Guest Posts, Newborns , , , , , ,

Book Review: The Science of Mom: A Research-Based Guide to Your Baby’s First Year

September 3rd, 2015 by avatar

By Anne M. Estes, PhD

Today on Science & Sensibility, Anne M. Estes, PhD reviews a new book – The Science of Mom: A Research-Based Guide to Your Baby’s First Year.  Lamaze International and Science & Sensibility are all about providing families and professionals with evidence based information that can help inform decision making.  Seems like this book might fit in nicely with the philosophy that Lamaze has held for decades.  Regular contributor Anne M. Estes, PhD shares her review on this new book and lets us know if it might be something to add to our resource list for new parents.  See the end of the review to learn how you can enter to be chosen for a free copy of this book courtesy of the author,  Alice Callahan. – Sharon Muza, Community Manager, Science & Sensibility. 

Science of Mom Cover HiDefMitchell Kapor once said, “Getting information off the Internet is like drinking from a fire hydrant.” New parents and child care professionals are certainly easily drenched by all the information that can be acquired on the internet from a variety of sources. As newly minted scientist-mom seven years ago, I was frustrated at the number of opinion and experienced-based baby books that lacked scientific support. The Science of Mom: A Research-Based Guide to Your Baby’s First Year, now fills that gap. Alice Callahan, a PhD in nutritional biology and mom of two, systematically examines common questions and concerns about infant care from a scientific perspective. In each chapter, she discusses the historical practice of the question, recommendations of different organizations, the current research, and the risks and benefits of a practice. Dr. Callahan does an excellent job presenting the strengths and limitations of particular studies and the logic behind different recommendations. Although The Science of Mom is science-focused, it is well-written and easy to read. The style of the book is personal and conversational. Personal experiences are intermingled with the science to illustrate her points well. A list of both the references used for each chapter and recommended books and websites are also given to help parents identify credible resources instead of getting lost in the fog of Internet “experts”.

Potential readers

For childbirth professionals and parents or parents-to-be interested in evidence-based practices for birth and an infant’s first year, The Science of Mom is a new and invaluable resource. Questions covered include: When is the right time to cut the umbilical cord? Which newborn treatments are necessary? How do newborns experience and explore their world? What are the differences between breastmilk and formula feeding? Where and how can babies sleep safely? What is the evidence for vaccinations? When and what kinds of solid food are best for babies?

Importance of evidence based decisions

Perhaps it’s also my bias as a scientist, but I greatly enjoyed reading such an insightful description of the process of science, the importance of scientific consensus, differences in quality across studies, and how scientific data can assist families in making informed decisions. Though readers of an evidence based blog like Science and Sensibility may already understand these points, the introduction could be helpful when introducing the rationale behind evidence based practices during child birth classes. It also serves as a guide for anyone who wants to research their own questions in the scientific literature.

I was particularly surprised to read about two instances where changes to medical practices in the early to mid 1900s had occurred without any evidence based support. One example was timing of cutting the umbilical cord. The author speculates that perhaps due to efficiency or convenience, the umbilical cord began to be cut before all the blood was pumped into the newborn. This practice is now being reconsidered due to the increased iron stores in the first 6 months of life of infants when cord clamping is delayed. Such an example certainly reinforces the importance of having evidence of benefit before new procedures are introduced or changes are made in traditional birth procedures.

Filling a gap in the bookshelf

In science and medicine there are no borders and no “right” answers. The Science of Mom is the same. Throughout the book, the author explores how a variety of countries and cultures deal with issues from giving Vitamin K to newborns (oral vs injected) to sleep practices (bed/room sharing vs separate sleeping arrangements). Different personal health conditions and prevalence of disease differ across the globe, making the need for some newborn treatments, such as eye prophylaxis, less clear. Dr. Callahan provides the data and information for people to make informed choices for their own family’s practices and situations. I found the honest, open, and nonjudgmental tone throughout the book refreshing.

Callahan author photo

Author Alice Callahan and her newborn © Alice Callahan

What a scientist-mom adds to the conversation

Each profession trains people to strengthen different skill sets. Training in the life sciences, especially at the PhD level, encourages a person to gather resources, sort through different quality data, synthesize data, and reach a conclusion based on that data for a given situation. Add to that training first-hand experience with raising two kids – knowledge of what it’s like to be in the parenting trenches, experience the “mommy wars”, and feel the exhaustion and yet love and concern of being a parent – and you’ve got a winning combination. The author is not a medical professional and most likely has only attended the births of her own two kids. However, in Science of Mom, Alice Callahan, PhD combines the critical eye of a scientist with the heart of a mother to create a helpful resource for all people interested in evidence based infant care and parenting.

What is missing?

What The Science of Mom does not do in general is to give you prescriptives for answering many of the parenting questions she poses. Data are still being collected and debated for many birth and parenting questions. There simply may not be one “right” way. In these cases, the scientific data are presented, the pros and cons of the different perspectives are addressed, then Dr. Callahan recommends following your baby’s lead and doing what feels best for your own family. After all, parenting is an art as well as a science.

In situations where scientists have reached a consensus, such as with the benefits of vaccines or back sleeping for infants, the author provides insight into how and why that consensus was reached by the scientific community. In such cases, Dr. Callahan provides additional information such as the role of each ingredient in the vitamin K shot in order to provide additional comfort to worried parents.

The Science of Mom is an excellent new addition to the bookshelves of any birth professional or parent who is interested in evidence-based parenting practices. Although the copy of The Science of Mom that I reviewed was complementary, I have given copies to several scientist-mom friends with newborns who also enjoy the nonjudgmental and objective tone of the book. For those wanting to read more of Dr. Callahan’s excellent commentary on the science of parenting, you can find her writing at the blog, The Science of Mom.

Enter to win your own copy of The Science of Mom

Have you had a chance to read this book?  What did you think of it?  Does this sound like a book that you would like to read?  Would you consider adding it to your resource list?  Share your thoughts about the book, how necessary or needed a book such as this might be, or other favorite resources for families to get evidence based information in understandable and easy to digest formats in the comments section below and include your email address.  All comments will be entered in a drawing for your own copy of the book.  The winner will be announced next month when Anne Estes interviews Dr. Callahan about her book. – SM

About Anne Estes

AnneMEstes_headshot 2015Anne M. Estes, PhD is a postdoctoral fellow at the Institute for Genome Sciences in Baltimore, MD. She is interested in how microbes and their host organisms work together throughout host development. Anne blogs about the importance of microbes, especially during pregnancy, birth, first foods, and early childhood at Mostly Microbes.

Babies, Book Reviews, Breastfeeding, Childbirth Education, Evidence Based Medicine, Guest Posts, New Research, Newborns, Parenting an Infant , , , , , , , ,

Series: Brilliant Activities for Birth Educators – Nine Ideas for Using Knit Breasts in Breastfeeding Classes

August 20th, 2015 by avatar

babe breastfeedingAugust is National Breastfeeding Awareness Month (and August 1-7 was World Breastfeeding Week) and Science & Sensibility covered the WBW theme “Breastfeeding and Work: Let’s Make It Work!” in a post earlier this month.  August’s Brilliant Activities for Birth Educators will continue to increase the awareness about breastfeeding and breastfeeding education.  I would like to talk about how I and the families in my class use a set of  wonderful knitted breasts when I cover breastfeeding topics in my childbirth class.  You can find all the Brilliant Activities for Birth Educator posts here.

I currently teach a seven week series and cover the majority of  the breastfeeding topics on the last week.  The entire series is rich in information about breastfeeding, skin to skin, safe and healthy birth options, and other choices that support getting breastfeeding off on the best path possible.  Week seven is the nuts and bolts of breastfeeding, covering topics like latch, how the breasts make milk, positions for breastfeeding, is your newborn getting enough milk and common problems that new families experience as well as other information.

For the breastfeeding class, I use these wonderful handknitted breasts that I purchased from a talented colleague here in Seattle.  You can find similar patterns to make your own in the links below.  Each breast is unique in skin tone, nipple and areola size, overall size and weight.  Every family receives one breast and one baby. (I use these Ikea dolls, for their affordability, size and softness.)  Using these knitted breasts and dolls allows the families to experience common breastfeeding situations in a comfortable and humorous way, while gaining experience positioning themselves and their babies for comfortable and supportive breastfeeding.

Nine Breastfeeding Teaching Ideas Using a Knitted Breast

1. Having different size breasts with different size nipples and areolas gives me an opportunity to share that breastfeeding can be successful no matter the size of a person’s breast tissue or breast anatomy.  Large and small breasts can both feed a baby quite satisfactorily.  My collection is quite varied.

2. When a person uses their finger to press in on the tissue around the baby’s nose in order to “make space for air”during breastfeeding, it can change the angle of the nipple in the baby’s mouth and create unnecessary discomfort.

3. Supporting the breast with the “c-hold” and placing the fingers well back from the areola will help the baby to have a deeper latch and pull more breast tissue into their mouth.

4. Shaping and supporting the breast “like a hamburger” so the baby can get a good latch can reduce nipple pain and help the baby to transfer milk.

5. The five most common positions to breastfeed – laidback breastfeeding, cross cradle, cradle, football and side lying can feel awkward, but with practice will become second nature.  Everyone gets to try them using their “breast” and “baby”.  They can practice holding and positioning the knitted breast in the best way for each position.

6. Placing lots of pillows for proper support for the dyad can help keep breastfeeding comfortable.

7. A baby can nurse “around the clock” on the breast, with sometimes subtle position changes that allows the baby to stimulate and remove milk from all parts of the breast.

8. There is a small bead sewn into each of these weighted knitted breasts.  I can ask the families to find the little pea sized lump and can discuss how this might be a sign of a clogged duct, and how to resolve it.

9. Hand expressing milk if parents are separated from their baby after birth, can help with overall supply and volume while supplying valuable colostrum for their baby.  They can also use this skill to increase supply, or if they are experiencing engorgement.  Learning this skill on the knitted breast in class is great.

Open Mouthed Ikea Doll

If you are extra creative, there is a great “hack” that can be done to the Ikea doll to make the mouth open and include a tongue, (which can even be “tongue-tied”) to make the knitted breast/doll demo even more realistic.  Find this clever idea created by Tova Ovits, CLC here on Galactablog.

Bonus Diaper

© Sharon Muza

© Sharon Muza

I also use a knitted diaper that shows how a newborn baby’s stool changes over time from dark meconium to mustardy breastfed baby stool. A great visual aid and always gets lots of comments from families.  Thanks Betsy Hoffmeister, IBCLC,  for making me such a great tool to use in my Lamaze classes.

Family Reactions

At first, families may feel a little awkward handling the knitted breast, and may laugh if it is particularly large or small, or as an unusually large nipple.  But over the course of the night, they become comfortable in handing the breast, confident in finger placement and are eager to try different positions and experiment with their own additional suggestions for comfortable and useful techniques.  We all have fun, they leave class excited and ready to get breastfeeding off to a good start and knowledgeable in some of the basics to help them do so.

Knitted Breast Patterns

LCGB Knitted Breast Pattern

Breastfeeding Network Pattern

What interesting techniques and tools do you use to help your families during your breastfeeding instruction?  Share your ideas and resources in our comments section below.

Babies, Breastfeeding, Childbirth Education, Series: Brilliant Activities for Birth Educators , , , , ,

Congenital Heart Defect Awareness Week – Are You Up to Date?

February 10th, 2015 by avatar

 By Elias Kass, ND, CPM, LM

© Tammi Johnson

© Tammi Johnson

This week is Congenital Heart Defect Awareness week.  Critical Congenital Heart Defect screening can help identify and save the lives of newborns born with previously undetected but serious malformations of the heart that can significantly impact them as they transition to life on the outside.  Families can learn about the simple screening procedure in a childbirth education class and be prepared to discuss the screening with their health care providers.  Dr. Elias Kass, naturopath and midwife, shares 2015 information and updates on screening, stats on the incidence of CCHDs and how you can help spread the word on the importance of all newborns being screened. – Sharon Muza, Community Manager, Science & Sensibility 

There’s a new newborn screening being implemented in many birth settings – critical congenital heart defect screening, or CCHD. What is this screening? What does it look for, and how can you educate and prepare your childbirth education students for the screening and possible results?

Critical congenital heart defects refer to heart defects that babies are born with and that require surgical intervention within the first month (or year, depending on the defining organization). About 1 in 100 babies have heart defects (1%), and about 1 in 4 of those with a heart defect have a defect so severe that it needs to be corrected immediately (0.25% of all babies) Only some of these defects will be picked up by prenatal ultrasound, and they may not show up on exam before the baby goes home (or the midwife leaves in the case of a home birth). Depending on the defect, some babies may be able to compensate with structures that were in place during the fetal period but begin to go away after the baby is born.

Fetal circulation and changes after birth

By KellyPhD (Own work) [CC-BY-SA-3.0], via Wikimedia Commons

By KellyPhD (Own work) [CC-BY-SA-3.0], via Wikimedia Commons

Because a fetus receives oxygen through the placenta and umbilical cord, there’s no need for him to send a significant amount of blood to the lungs, so a fetus has very different heart and lung circulation than they will after making the transition to life on the outside. One of the big differences (simplified for this article) is the ductus arteriosis – this is a bypass that takes blood from the pulmonary artery and provides a shortcut to the aorta, instead of continuing on to the lungs. Another big difference is the foramen ovale – this is an oval-shaped window between the right atrium and left atrium, which allows blood to bypass being pumped out to the lungs entirely. After birth, pressure changes cause massive changes in flow. Pressure increases in the left atrium cause a flap to slam shut across the foramen ovale. Blood also finds it easier to flow to the lungs, so less blood flows through the ductus arteriosus. Over the course of days and weeks, the foramen ovale seals shut and the ductus arteriosus starts to shrivel.

Typically blood being pumped out to the body is loaded with oxygen. If there are structural problems, it’s possible that this blood would be a mix of oxygenated and deoxygenated blood – there would be less oxygen available in this blood, but at least it’s getting out to the body. Sometimes those fetal structures are what allows that mixed blood to circulate. So what if the baby was really depending on those shortcuts and bypasses? And then the shortcuts and bypasses go away? These babies may look well and do fine, until the fetal structures start to go away.

This March of Dimes article describes seven conditions considered to be part of CCHD:

  1. Hypoplastic left heart syndrome (also called HLHS)
  2. Pulmonary atresia (also called PA)
  3. Tetralogy of Fallot (also called TOF)
  4. Total anomalous pulmonary venous return (also called TAPV or TAPVR)
  5. Transposition of the great arteries (also called TGA)
  6. Tricuspid atresia (also called TA)
  7. Truncus arteriosis

See page for author [GFDL or CC-BY-SA-3.0], via Wikimedia Commons

Circulation after birth [GFDL or CC-BY-SA-3.0], via Wikimedia Commons

CCHD screening of the newborn is intended to catch babies who might need intervention, before they decompensate and their heart defects are made obvious.

The screening process

CCHD screening involves using a pulse oximeter at two locations — the right hand (or wrist), and either foot. The right arm receives its blood supply before the ductus arteriosus enters the aorta, so it’s known as “pre-ductal.” The left hand and the lower body receive “post-ductal” blood.

The pulse oximeter senses oxygen saturation by shining light through the skin. Red blood cells that are loaded with oxygen deflect light differently than red blood cells without oxygen. The opposite sensor collects the light and calculates how much was lost. By using multiple wavelengths of light, the unit can isolate arterial flow and disregard venous flow (veins return blood to the heart after the tissues have ‘used’ the oxygen the blood was carrying). For babies, an adhesive probe is typically wrapped around the hand or wrist, and then around a foot. The thin strip might be covered with a foam band to help block out the room light. Some facilities use reusable probes that are more like clips. Not all pulse oximeters are well suited for this purpose – they need to be able to sense low saturations and not be confused by an infant’s constant motion.

There are three possible results from the screening – pass, fail, and an in between, or “try again.”

If a baby’s oxygen saturation is ≥ 95% in the right hand or foot, and there is less than a 3% difference between the two readings, then she passes the screening.

For a baby whose saturations are between 90-95%, or has a greater than 3% difference between the right hand and foot, the screening test is repeated in an hour. If she still doesn’t pass or fail, she can have one more chance. If she still doesn’t pass after three tries (one initial and two retries), that’s considered a fail, and she should be evaluated.

If a baby’s oxygen saturation is under 90% in either the right hand or foot, or she didn’t pass in three tries, this is considered a fail, or a positive screening. This baby should be referred to a pediatric cardiologist who can assess her and do an echocardiogram (ultrasound of the heart), and/or other workup. Depending on her health at the time, that might mean an immediate consult, or it might mean having her scheduled for a visit soon.

In Washington state, Seattle Children’s Hospital and the other regional pediatric cardiology groups are available to talk with the clinician who has a patient with a problematic screening and help figure out when and where the baby should be seen. If there is no local pediatric cardiology group, some cardiology groups can do telemetry or read studies remotely. Before implementing screening in their practice or facility, there should be a clear process for how to obtain consultation and referral (who should be called, how to contact them, how to transmit images if able, etc). Evaluation should be arranged before the baby is discharged because a baby’s condition can deteriorate rapidly.

There are tools available to help with this algorithm. The Center for Disease Control and Prevention (CDC) has a flow chart to help guide the screening process, and Children’s Health Care of Atlanta has a web site and Pulse Ox Tool app to help guide providers.

When should the screening be done?

The screening should be done between 24-48 hours after birth. Before 24 hours, there is an increased incidence of false positives, but a baby who passes before 24 hours is still considered to have passed (i.e., it still “counts”). If a baby is being discharged before 24 hours, the recommendation is to do it as close to discharge as possible. For babies born at home, this screening should be done at the 24-48 hour home visit, along with the metabolic screening. For the screening to be most accurate, baby should be awake and calm, but not feeding. (Feeding causes some decrease in oxygen saturation even in normal term newborns.)

What about a failed screen?

It’s helpful to know that not all babies with a failed screen have a critical congenital heart defect. Like all screening tools, this screening has false positives. The false positive rate overall is about 1/200 (0.5%), but it falls to 1/2000 (.05%) when the screening is performed after 24 hours of age according to the FAQ on the Seattle Children’s Hospital Pulse Oximetry Screening for Newborns resource page for providers. About a quarter of the babies who fail the screening truly have a Critical Congenital Heart Defect(true positive), while half have condition that causes low blood oxygen, like pneumonia and sepsis, and a quarter are well (false positive).

Who should be screened?

All babies should be screened, unless the baby is already known to have a critical congenital heart defect, identified during ultrasounds done during the pregnancy or immediately after birth. Most states mandate screening, either by legislation or regulatory guidance. One state has an executive order. Several states, including Washington, have introduced legislation that is currently being voted on. In states without mandated screenings, most birth settings have adopted the screening, but not all. For some settings there are logistical challenges in terms of purchasing equipment (particularly independent midwives who might not have other use for the pulse oximeter, although since it was recommended to be used as part of neonatal resuscitation that has begun to change), arranging for consultation (particularly in rural areas or regions without adequate pediatric cardiology support), or logistical challenges in terms of who will do the screening and when. The Secretary of Health and Human Services (HHS) has recommended that CCHD screening be added to the newborn screening panel (like metabolic screening and hearing screening). The American Academy of Pediatrics also supports the universal adoption of this screening.

Cost can be a barrier in offering this screening. There is currently no procedure (CPT) code for this screening, and insurance companies are generally bundling it into the general newborn care (and not reimbursing for it as a separate service), though there are groups working to change this, since there is significant up-front investment and on-going costs in terms of probes and staff time to provide the screening. Most appropriate pulse oximeters start at $500 and the disposable probes around $3-5. Using reusable probes can decrease the cost of providing this screening.

If the hospital or midwife doesn’t provide this screening, parents can ask their pediatric provider to perform the screening at the baby’s first office visit. The goal is to catch these conditions as quickly as possible, ideally before the baby’s condition decompensates. Getting a screening a little later is better than not getting it at all.The screening is no less accurate later on.

The childbirth educator perspective

As a childbirth educator, you can share information about this quick screening test, when you discuss other newborn care procedures. You can encourage your students to ask their midwife or doctor about the screening, or ask on the hospital tour. If the hospital or health care provider hasn’t yet implemented this screening, families can ask why not, and if there’s anyone they can talk to encourage implementation. Facilities and providers should hear from families that they know about this screening and expect it as part of their newborn’s care.  Universal screening will go a long way to identifying those children who were not previously diagnosed with a Critical Congenital Heart Defect and who can begin to receive care for the CCHD as soon as possible by pediatric cardiologists.  Your childbirth class may be the only opportunity for these families to hear about and understand the importance of the CCHD screening test.

Are you already talking about this screening test for CCHD in your classes? If not, might you begin to share this information as a result of what you learned today?  Are providers and facilities in your area already offering this test as part of normal newborn screening? Do you know any families who have had this screening and their baby was diagnosed with an heart defect? Share your experiences in our comments and let’s discuss.- SM

References and Resources

March of Dimes, with general information about CCHD screening targeted towards families
American Academy of Pediatrics – detailed information about screening and implementation, targeted towards providers and facilities
Dr. Amy Schultz (a pediatric cardiologist at Seattle Children’s) frequently presents on CCHD screening – this presentation, with detailed information about critical congenital heart defects and screening, was recorded and can be streamed online

About Dr. Elias Kass

elias kass head shot

Elias Kass, ND, LM, CPM

Elias Kass, ND, LM, CPM, is a naturopathic physician and licensed midwife practicing as part of One Sky Family Medicine in Seattle, Washington. He provides integrative family primary care for children and their parents, focusing on pediatric care. He loves working with babies! Practice information and Dr Kass’s contact info is available at One Sky Family Medicine.

Childbirth Education, Evidence Based Medicine, Guest Posts, Neonatology, Newborns , , , ,

Breastfeeding & Racial Disparities in Infant Mortality: Celebrating Successes & Overcoming Barriers

August 28th, 2014 by avatar
© mochamanual.com

© mochamanual.com

August has been designated as World Breastfeeding Month, and Science & Sensibility was happy to recognize this with a post earlier this month that included a fun quiz to test your knowledge of current breastfeeding information.  Today, we continue on this topic and celebrate Black Breastfeeding Week 2014 with a post from regular contributor, Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA sharing information about the increased breastfeeding rates rates among African American women.  Kathleen also discusses some of the areas where improvements can help this rate to continue to increase. 

Celebrating Successes

Many exciting changes occurred in 2013 in the breastfeeding world. One of the best trends was the increase in breastfeeding rates in the African American community. The CDC indicated that increased breastfeeding rate in African American women narrowed the gap in infant mortality rates.  As the CDC noted:

From 2000 to 2008, breastfeeding initiation increased…from 47.4% to 58.9% among blacks. Breastfeeding duration at 6 months increased from…16.9% to 30.1% among blacks. Breastfeeding duration at 12 months increased from… 6.3% to 12.5% among blacks.

Much of this wonderful increase in breastfeeding rates among African Americans has come from efforts within that community. In 2013, we saw the first Black Breastfeeding Week become part of World Breastfeeding Week in the U.S. Programs, such as A More Excellent Way, Reaching Our Sisters Everywhere (ROSE), and Free to Breastfeed, offer peer-counselor programs for African American women.

We can celebrate these successes. But there is still more to do. Although the rates of infant mortality have dropped, African Americans babies are still twice as likely to die. In addition, although rates of breastfeeding have increased among African Americans, they are still lower than they are other ethnic groups.

For each of the 2000–2008 birth years, breastfeeding initiation and duration prevalences were significantly lower among black infants compared with white and Hispanic infants. However, the gap between black and white breastfeeding initiation narrowed from 24.4 percentage points in 2000 to 16.3 percentage points in 2008.

Barriers to Overcome

In order to continue this wonderful upward trend in breastfeeding rates, we need to acknowledge possible barriers to breastfeeding among African American women. Here are a couple I’ve observed. They are not the only ones, surely. But they are ones I’ve consistently encountered. They will not be quick fixes, but they can be overcome if we recognize them and take appropriate action.

1) Pathways for IBCLCs of Color

In their book, Birth Ambassadors: Doulas and the Re-Emergence of Women-Supported Birth in America, Christine Morton and Elayne Clift highlight a problem in the doula world that also has relevance for the lactation world: most doulas (and IBCLCs) are white, middle-class women. And there is a very practical reason for this. This is the only demographic of women that can afford to become doulas (or IBCLCs). The low pay, or lack of job opportunities for IBCLCs who are not also nurses, means that there are limited opportunities for women without other sources of income to be in this profession. Also, as we limit tracks for peer-counselors to become IBCLCs, we also limit the opportunities for women of color to join our field. I recently met a young African American woman who told me that she would love to become an IBCLC, but couldn’t get the contact hours needed to sit for the exam. That’s a shame. (I did refer her to someone I knew could help.)

2) We need to have some dialogue about how we can bring along the next generation of IBCLCs. We need to recognize the structural barriers that make it difficult for young women of color to enter our field. ILCA has started this dialogue and held its first Lactation Summit in July to begin addressing these issues.

These discussions can start with you. Sherry Payne, in her recent webinar, Welcoming African American Women into Your Practice, recommends that professionals who work in communities of color find their replacement from the communities they serve.  Even if you only mentor one woman to become an IBCLC, you can have a tremendous impact in your community. If we all do the same, we can change the face of our field. (Note, here is a wonderful interview with Sherry as she discusses “Fighting Breastfeeding Disparities with Support.”)

3) Bedsharing and Breastfeeding

 This is an issue that I expect will become more heated over the next couple of years. But it is a reality. As we encourage more women to breastfeed, a higher percentage of women will bedshare. As recent studies have repeatedly found, bedsharing increases breastfeeding duration. This is particularly true for exclusive breastfeeding.

Bedsharing is a particular concern when we are talking about breastfeeding in the African American community. Of all ethnic groups studied, bedsharing is most common in African Americans. It is unrealistic to think that we are going to simultaneously increase breastfeeding rates while decreasing bedsharing rates in this community. The likely scenario is that breastfeeding would falter. It’s interesting that another recent CDC report, Public Health Approaches to Reducing U.S. Infant Mortality, talks quite a bit about safe-sleep messaging, with barely a mention of breastfeeding in decreasing infant mortality.  A more constructive approach might be to talk about being safe while bedsharing. But as long as the message is simply “never bedshare,” there is likely to be little progress, and it could potentially become a barrier to breastfeeding.

Reason to Hope

BBW-Logo-AugustDates3Even with these barriers, and others I haven’t listed, Baby-Friendly Hospitals are having a positive effect. When hospitals have Baby-Friendly policies in place, racial disparities in breastfeeding rates seem to disappear. For example, a study of 32 U.S. Baby-Friendly hospitals revealed breastfeeding initiation rates of 83.8% compared to the national average of 69.5%. In-hospital exclusive breastfeeding rates were 78.4% compared with a national rate of 46.3%. Rates were similar even for hospitals with high proportions of black or low-income patients (Merewood, Mehta, Chamberlain, Phillipp, & Bauchner, 2005). This is a very hopeful sign, especially as more hospitals in the U.S. go Baby-Friendly.


In summary, we have made significant strides in reducing the high rates of infant mortality, particularly among African Americans. I am encouraged by the large interest in this topic and the number of different groups working towards this goal. Keep up the good work. I think we are reaching critical mass.

Additional resource: Office of Women’s Health, U.S. Department of Health & Human Services Breastfeeding Campaign for African American families.


Merewood, A., Mehta, S. D., Chamberlain, L. B., Phillipp, B. L., & Bauchner, H. (2005). Breastfeeding rates in U.S. Baby-Friendly hospitals: Results of a national survey. Pediatrics, 116(3), 628-634.

Reprinted with permission from Clinical Lactation, Vol. 5-1. http://dx.doi.org/10.1891/2158-0782.5.1.7

About Kathleen Kendall-Tackett

kendall-tackett 2014-smallKathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist, International Board Certified Lactation Consultant and Fellow of the American Psychologial Association in both the divisions of Health and Trauma Psychology. Dr. Kendall-Tackett is President-Elect of the Division of Trauma Psychology, Editor-in-Chief of Clinical Lactation, clinical associate professor of pediatrics at Texas Tech University Health Sciences Center, and Owner/Editor-in-Chief of Praeclarus Press, a small press specializing in women’s health. Dr. Kendall-Tackett has authored more than 310 articles or chapters and is the author or editor of 22 books on women’s health, maternal depression, family violence and breastfeeding. Dr. Kendall-Tackett and Dr. Tom Hale received the 2011 John Kennell and Marshall Klaus Award for Research Excellence from DONA International. You can find more from her at Uppity Science Chick


Babies, Breastfeeding, Childbirth Education, Guest Posts , , , , , , , ,

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