A 10-day-old, full-term newborn is seen for a weight check. The history is notable for a water birth. Physical exam is unremarkable.
Question: What additional interventions (sepsis evaluation, antibiotics) are needed?
Answer: If otherwise well-appearing, a child born by water birth does not need additional evaluation.
A 5-day-old newborn is seen in the emergency department for one day of low-grade fever and poor feeding. The birth parent states that vaginal seeding was administered to the baby following cesarean section.
Question: What additional interventions (sepsis evaluation, antibiotics) are needed?
Answer: History of vaginal seeding does not necessitate additional components to the sepsis evaluation or different empiric antibiotics in an ill-appearing child, but risk assessment should address exposures as if it were a vaginal rather than cesarean birth.
A pregnant individual is contemplating umbilical nonseverance (lotus birth).
Question: What would you counsel as to risk and benefit to the newborn?
Answer: There are no scientific reports of benefit. Risk includes bacterial sepsis to the baby due to necrotic tissue of the retained placenta/umbilical cord.
An increasing number of alternative peripartum and neonatal practices have emerged, including water immersion for labor and delivery, vaginal seeding, umbilical nonseverance (also known as lotus birth), placentophagy (placental consumption), delayed bathing and nonmedical deferrals of the birth dose of hepatitis B vaccine and of ocular prophylaxis.
While the prevalence of these practices is unclear, medical practitioners likely will encounter one or more of these practices in both prenatal counseling and in the care of newborns.
A new AAP clinical report discusses the known risks and benefits of these practices and possible infections that may occur in exposed neonates. Information in the report can assist medical practitioners in providing balanced education and counseling to families and in evaluating and treating an exposed neonate.
The report Risks of Infectious Diseases in Newborns Exposed to Alternative Perinatal Practices, from the Committee on Infectious Diseases and Committee on Fetus and Newborn, is available at https://doi.org/10.1542/peds.2021-055554 and will be published in the February issue of Pediatrics.
Key points
- Water immersion for labor and birth has been shown to improve comfort of the pregnant person in the first stage of labor, but benefit has not been shown for the second stage of labor or delivery. Potential neonatal infections associated with this practice, such as with Legionella and Pseudomonas species, are rare but serious.
- Vaginal seeding may expose infants to vaginal pathogens such as group B streptococcus (GBS) or herpes simplex virus (HSV) and has no known benefits. Evaluation of symptomatic infants born by cesarean section after exposure to vaginal seeding should be the same as for those who are delivered vaginally.
- Umbilical nonseverance has no clear benefit to date and can increase risk of neonatal sepsis attributable to the presence of necrotic umbilical/placental tissue.
- Placentophagy should be avoided. There is no evidence of benefit to the postpartum parent, and one case report linked this practice to recurrent GBS sepsis in a neonate. Evaluation of symptomatic infants exposed to this practice should not differ from other neonates.
- The birth dose of hepatitis B vaccine serves as a critical safety net for prevention of hepatitis B infection, and nonmedical deferral of the birth dose should be discouraged.
- 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. Deferral of ocular prophylaxis may be considered in low-risk situations but may be impacted by state legislation.
- Delayed bathing may promote initiation and exclusivity of breastfeeding. Delayed bathing should be discouraged in neonates exposed to active HSV genital lesions or with known history of human immunodeficiency virus infection in the birth parent.
Dr. Nolt is a lead author of the clinical report and a member of the Committee on Infectious Diseases.
