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Dr Monroe is clinical assistant professor and quality lead for the Pediatric Hospital Medicine Division, University of Michigan C.S. Mott Children’s Hospital, Ann Arbor.
Dr Skoczylas is clinical assistant professor and medical director of the Well Newborn Nursery, University of Michigan C.S. Mott Children’s Hospital, Ann Arbor.
Dr Burrows is clinical associate professor in the Division of General Pediatrics and pediatric residency program director at the University of Michigan, Ann Arbor.
Parental refusals of protocols in the newborn nursery do happen. Providers need to know how to respond to parents with patient-centered yet medically safe care for their newborns.
“No, thank you.” Although care in the newborn nursery tends to follow a predictable pattern, parents are increasing requesting alterations to standard protocols. It can be a challenge to remain aware of and knowledgeable about all the possible alternative practices, but this is critical in order to effectively counsel parents as they make these decisions. In this article, we review some of the common (and not so common) requests that parents make in our newborn nursery.
Lotus birth, or umbilical nonseverance, is the practice of not cutting the umbilical cord after birth. The placenta then remains connected to the baby until it detaches naturally,1 usually up to 10 days after birth.2 The placenta is often placed in a bag or wrapped in a piece of fabric3,4 and may be treated with lavender oil, salts, rosemary, or other herbs to decrease the odor.3,5 The idea began in 1974 in the United States and Australia as “a logical extension of natural childbirth, and invites us to reclaim the so-called third stage of birth, and to honor the placenta, our baby’s first source of nourishment.”6
Little information has been published on the safety or medical benefit of this practice, yet it is occurring more often on the labor and delivery unit. In 2008, the United Kingdom’s Royal College of Obstetricians and Gynaecologists warned of its potential risk of placental infection,1 as once delivered, the placenta is no longer actively transferring blood so it becomes dead tissue. The government of Western Australia’s Department of Health has available a set of clinical guidelines regarding lotus births with recommendations to follow for signs of infection.7 No cases of adverse outcomes related to lotus births in terms of infection or hemorrhage have been reported,2 although a case report from 2015 showed a possible link to neonatal idiopathic hepatitis.8 Parents may cite a psychologic benefit from avoiding the traumatic cutting of the cord,5 however, no research has been published to support these claims.2
Current management recommendations do not exist for lotus births in the United States. Although appreciably different, the next most closely related newborn practice is delayed cord clamping. In 2015, the American College of Obstetricians and Gynecologists (ACOG) included a recommendation for delayed cord clamping for 30 to 60 seconds in vigorous term and preterm newborns9 (see “ACOG Committee on Obstetric Practice recommendations regarding timing of umbilical cord clamping after birth”). The benefits of delayed clamping may include: improvement in transitional circulation, increased red blood cell volume, and increased hemoglobin levels at birth, resulting in improved iron stores for several months after birth. However, delayed clamping may also lead to a slight increase in cases of jaundice requiring phototherapy in term infants. Research on the safety of delayed cord clamping beyond that measured in minutes is lacking. In the meantime, some medical providers will likely be asked to take care of newborns still attached to their placenta. Being mindful of the potential risks for jaundice and infection is necessary when the placenta remains attached after delivery.
Consumption of the human placenta is another practice that may be encountered that has not been part of contemporary human culture but is increasing in frequency. Methods of preparation of the placenta for consumption include: raw, cooked, frozen, dehydrated, encapsulated, or incorporated into smoothies and tinctures. Encapsulation, typically after steaming and dehydration, is probably the most common preparation.
Families may choose placentophagy for suggested physical and psychological benefits. However, these proposed benefits have yet to be proven. Recently, the Centers for Disease Control and Prevention (CDC) described an infant who suffered both early and late onset sepsis attributed to group B Streptococcus (GBS) disease, despite negative GBS testing on maternal prenatal screening.10 During the infant’s second hospitalization, it was discovered that the mother had been consuming her encapsulated placenta. Evidence of GBS was found in the placenta, and isolates from the placenta and the infant’s blood were indistinguishable.
The companies that provide encapsulation inquire about preexisting conditions including sexually transmitted infections, but do not ask about intrapartum or postpartum infections. Additionally, there are no standards for placental preparation such as minimum temperature or length of time for processing. At this time, the CDC recommends against human placentophagy because of the risk of disease transmission.11
The American Academy of Pediatrics (AAP) has recommended intramuscular (IM) vitamin K since 1961 to prevent vitamin K deficiency bleeding (VKDB). With IM vitamin K, the rates of VKDB, in particular late-onset VKDB, are essentially zero.12 In 2013, there were 4 cases of late-onset VKDB reported in Tennessee.13 In each case, the families had refused vitamin K prophylaxis. Parents typically refuse IM vitamin K because of information they find on the Internet, citing concerns over synthetic or toxic ingredients, “excessively” high doses, and the belief that it is “unnatural.” In a recent study,14 many parents who refused knew there were risks of bleeding associated with refusal of vitamin K but were unaware of the specific risk of intracranial bleeding or death.
Some parents request oral vitamin K, which is used in various regimens in several European nations (Table). However, there is not a licensed oral form of vitamin K for infant prophylaxis available in the United States and oral regimens are less effective at preventing late onset VKDB.15 We do not encourage oral vitamin K as an alternative to IM vitamin K. Anecdotally, some families are purchasing emulsions of vitamin K online, reporting concerns about synthetic additives to oral formulations compounded by hospital pharmacies. Those families who either refuse all vitamin K or request oral vitamin K are asked to sign a refusal form as well as receive education surrounding the risks of vitamin K refusal. We will not circumcise infants when parents refuse IM vitamin K.
Erythromycin eye ointment is applied within the first hour after birth to prevent gonococcal ophthalmia neonatorum: 0.5% erythromycin ophthalmic ointment is instilled within each eye.16 Many states require this by law. The most effective manner of preventing ophthalmia neonatorum is testing mothers for gonorrhea and chlamydia early in pregnancy, and for those at high risk, again in the third trimester as is recommended by the ACOG.17 Parents who decline eye ointment typically express concern for eye irritation, lack of perceived risk, or interfering with parent-child bonding because of blurring of the infant’s vision. Although erythromycin ointment can cause chemical conjunctivitis, in our practice this is a rare occurrence.
If the mother and her partner are tested and are negative for these diseases and they are in a monogamous relationship, the likelihood that the infant will be affected by the disease is zero. Although many countries, including Canada, Denmark, Norway, Sweden, and the United Kingdom no longer recommend universal prophylaxis, the 2011 recommendations from the United States Preventive Services Task Force (USPTF)18 continue to recommend prophylaxis as not all mothers receive prenatal care. At our institution, we ensure that mothers are tested for gonorrhea, and we ask that parents who decline erythromycin eye ointment sign a waiver witnessed by a medical professional. This can be done prenatally with the maternal provider or after birth by the infant’s provider.
All infants in the United States are screened after birth for a variety of congenital conditions. Most of these conditions are screened for by blood spots obtained by a heel stick and collected on a card that is tested at a state laboratory. Samples are collected after a feeding and at least 24 hours after birth for optimal detection of disease. Extra blood spots are saved by the state, and may be de-identified and used for quality assurance and population studies.
Although the AAP Newborn Screening Task Force recognizes that the newborn screen requires informed consent and that parents have the right to refuse the test, state laws differ in their allowances for such refusals. In the event of parental refusal, physicians should counsel parents on the risks and benefits of the testing. Parents may decline the testing because of concerns that the heel stick is painful or because they are distrustful of the state storing unused blood spots. In our state, parents must opt in to allow their infant’s blood spots to be used for research. If they opt out, the state keeps the blood spots indefinitely. Parents have the right to request that the blood spot card is destroyed.19,20
Because of the severe consequences of a missed diagnosis after refusal of the newborn screen, information sheets are provided and the parents are asked to sign a refusal form. Newborn hearing screening and the critical congenital heart disease (CCHD) screen are also included within the newborn screening program. As the hearing screen and CCHD are noninvasive tests, it is incredibly rare for parents to refuse them.
Pediatricians commonly encounter requests to delay or deviate from the recommended vaccine schedule published by the AAP and CDC.21 This problem commonly presents first in the well-newborn nursery with refusal of or request to delay hepatitis B vaccine (HBV). In our county, the birth hepatitis B vaccination decline rate is 22.2% for 2015, and for the state of Michigan it is 21%.17 All mothers should be screened for hepatitis B during their pregnancy. For women who are positive, up to 90% of their infants go on to have chronic hepatitis B if they are not vaccinated and given hepatitis B immunoglobulin within the first 12 hours of life.
The vaccine alone is 75% to 90% effective at reducing vertical transmission. Therefore, in October 2016, the Advisory Committee on Immunization Practices (ACIP) recommended that the hepatitis B vaccine be given within 24 hours of life for medically stable infants weighing greater than or equal to 2000 g to avoid mistakes in interpretation or errors in communication about the mother’s results that would lead to severe consequences for the infant. This was affirmed by the AAP policy statement in October 2017.22
In order to reduce refusal, we have given all nurses on the mother/baby unit standard, evidence-based language to use when discussing the vaccine. We do not require parents to sign a refusal form. In our hospital, it is rare for infants to be seen by their primary care provider (PCP) while they are in the newborn nursery. Therefore, if parents refuse hepatitis B vaccine in the hospital, we document this and encourage an ongoing conversation with the PCP.
Safe sleep positioning (supine, alone on a firm mattress, without extraneous items) is critical for decreasing the risk of sudden infant death.23 Studies have shown that many infants in the newborn nursery are placed on their side because of inaccurate beliefs about their risk for aspiration when prone.24 In addition, parents often hold infants and fall asleep, leading to unplanned bed sharing. When healthcare providers see and permit these practices, parents interpret this as endorsement of their safety and may continue them after leaving the hospital.25
It is very important that all newborn nurseries follow the AAP recommendations and help parents conform to them as well. Hospitals that implement safe-sleep policies can apply for Safe Sleep Hospital Certification26 to recognize their efforts. When providers see unsafe infant positioning, it is critical to educate parents about correct sleep positioning. To promote breastfeeding, skin-to-skin contact should be encouraged in the first hour of life as long as the mother is able to respond to the infant. After that, if the mother is sleeping or attending to other needs, the baby should be supine on a firm mattress without extra blankets, clothing, or other supplies left in the bassinet.23
Early discharge is defined as discharge of the mother and infant within 48 hours of birth. The typical length of stay for the mother-infant dyad decreased from the 1970s to the 1990s. Most hospitals implemented early newborn discharge policies in the 1990s and most mother-infant dyads were routinely discharged 24 hours after delivery. Concerns that insurance companies were pressuring hospitals into early and unsafe discharges led to the passage of the Newborns’ and Mothers’ Health Protection Act, which “prohibits the restriction of mothers’ and newborns’ benefits for hospital length-of-stay in connection with childbirth to less than 48 hours for a vaginal delivery or 96 hours for a cesarean delivery.”27 Although the Act was welcomed by many women, some would prefer a shorter length of stay. This places the newborn provider in a position where safe and patient-centered care may be in conflict when the mother who prefers a shorter stay has an infant who requires a longer one.
In 2015, the AAP released a policy statement on the hospital stay for healthy term newborn infants, stating that the length-of-stay should be “based on the unique characteristics of each mother-infant dyad, including the health of the mother, the health and stability of the infant, the ability and confidence of the mother to care for her infant, the adequacy of support systems at home, and access to appropriate follow-up care.”28 It recommended 17 criteria to be met before discharge of a term newborn (those born between 37-0/7 and 41-6/7 weeks of gestation after an uncomplicated pregnancy, labor, and delivery). Some of the criteria include: stable vital signs for >12 hours in an open crib; at least 2 successful feedings; passage of stool; age-appropriate voiding; screening for jaundice or other medical problems; ensuring the family’s ability to care for the newborn; an appropriate car seat and knowledge on how to use it properly; and the family’s access to medical care for follow-up. In addition, social and family risk factors need to be evaluated.
Infants with certain conditions will require longer hospital stays for appropriate monitoring. Discharge timing for jaundiced newborns should be based on the availability of outpatient office, laboratory, and home-care services; and follow-up timing should be guided by gestational age and other clinical risk factors.29 Late-preterm infants (34- to 36-6/7 weeks’ gestational age) are at increased risk for temperature instability, infection, respiratory distress, apnea, hypoglycemia, feeding difficulties, weight loss, and jaundice. For those late-preterm infants born via cesarean delivery, a longer length-of-stay may decrease readmission risk.30,31 For infants at risk for neonatal abstinence syndrome, current recommendations are to monitor infants who are exposed to short-acting substances for at least 3 days and up to 4 to 7 days for long-acting substances such as methadone or buprenorphine.32
In some cases, parents may not appreciate the risks of these conditions and the importance of in-hospital monitoring for an infant who appears healthy and may need further education. If the infant’s stay is longer than the mother had hoped for, it is then the newborn provider’s job to provide the “why” behind his or her medical decision-making process.
When families leave the hospital before 48 hours, they will need follow-up at home or in the hospital within 48 hours. Occasionally, parents will request discharge prior to 24 hours. Although some hospital systems may be set up to provide around-the-clock access to items that typically occur before discharge (newborn screen, CCHD, hearing test), most are not. If a child is discharged before 24 hours, it is necessary to identify a process for obtaining the newborn screen after the baby is 24 hours old. This requires access to a lab with the appropriate testing cards and expertise in obtaining the samples correctly.
Additionally, parents may need further explanation of the importance of this testing so that they prioritize it correctly. Babies discharged early may not have their clinic appointments made before leaving the hospital and hospitals should track these babies to make sure they are not lost to follow-up. Discussions with the newborn’s PCP are helpful when discharging on an earlier timeline.
Communication between the hospital and PCPs is a critical aspect of safe discharge. Particularly for newborn care, which usually follows a standard protocol, it is important to clearly inform PCPs when this standard has not been followed. Discharge documentation should be formatted to highlight any nonstandard care, such as declined therapies. This allows prompt recognition of increased risks (such as VKDB) as well as tailored communication strategies (such as HBV refusal). Sharing details about the discussions that have been had as well as specific parent concerns enables the PCP to plan for optimal counseling in the office. In addition, these infants may need targeted follow-up and special services such as newborn screening tests.
Determining whether or not a refusal form is needed should be a conversation with the legal department. Typically, documentation in the medical record is adequate. Refusal forms can be helpful to ensure that patients are receiving appropriate education surrounding the risks and benefits of interventions. In addition to a refusal form, we also provide standard information sheets outlining the risks and benefits. It should be made clear to the parents that if they sign a refusal form, they can change their minds and have a medication administered.
Parental refusals in the newborn nursery do happen. Providers need to be aware of alternative practices and know how to respond to them with patient-centered yet medically safe care. Assuming the mother is healthy and ready for discharge, it is often the newborn who then signals when he or she is ready for discharge with feeding ability, weight, jaundice, and other signs. Being informed of the alternative practices described in this article will equip the provider with information that will prove useful when rounding in the newborn nursery.
1. Royal College of Obstetricians and Gynaecologists. RCOG statement on umbilical non-severance or “lotus birth.” Available at: https://www.rcog.org.uk/en/news/rcog-statement-on-umbilical-non-severance-or-lotus-birth. Published December 1, 2008. Accessed January 3, 2018.
2. Hanel E, Ahmed MN. Is it “time to cut the cord?” Clin Pediatr (Phila). 2009;48(8):875-877.
3. Buckley SJ. Lotus birth: a ritual for our times. Midwifery Today Int Midwife. 2003;(67):36-38.
4. Burns E. More than clinical waste? Placenta rituals among Australian home-birthing women. J Perinat Educ. 2014;23(1):41-49.
5. Westfall R. An ethnographic account of lotus birth. Midwifery Today Int Midwife. 2003(66):34-36.
6. Buckley SJ. Gentle Birth, Gentle Mothering: The Wisdom and Science of Gentle Choices in Pregnancy, Birth, and Parenting. One Moon Press; 2005.
7. Department of Health Western Australia. Intrapartum care: management of a lotus birth. Available at: http://www.wnhs.health.wa.gov.au/development/manuals/O&G_guidelines/community_midwifery_program/Intrapartum Care/CMP Management of a Lotus Birth.pdf. Published 2015. Accessed January 3, 2018.
8. Tricarico A, Bianco V, Di BlasÃ© AR, Iughetti L, Ferrari F, Berardi A. Lotus birth associated with idiopathic neonatal hepatitis. Pediatr Neonatol. 2017;58(3):281-282.
9. American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. Delayed umbilical cord clamping after birth. 2017;684. Available at: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Delayed-Umbilical-Cord-Clamping-After-Birth. Published January 2017. Accessed January 3, 2017.
10. Buser GL, Mato S, Zhang AY, Metcalf BJ, Beall B, Thomas AR. Notes from the field: late-onset infant group B Streptococcus infection associated with maternal consumption of capsules containing dehydrated placenta-Oregon, 2016. MMWR Morb Mortal Wkly Rep. 2017;66(25):677-678.
11. Farr A, Chervenak FA, McCullough LB, Baergen RN, GrÃ¼nebaum A. Human placentophagy: a review. Am J Obstet Gynecol. 2017;S0002-9378(17):30963-30968.
12. Mihatsch WA, Braegger C, Bronsky J, et al; ESPGHAN Committee on Nutrition. Prevention of vitamin K deficiency bleeding in newborn infants: a position paper by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2016;63(1):123-129.
13. Centers for Disease Control and Prevention (CDC). Late vitamin K deficiency bleeding in infants whose parents declined vitamin K prophylaxis-Tennessee, 2013. MMWR Morb Mortal Wkly Rep. 2013;62(45):901-902.
14. Hamrick HJ, Gable EK, Freeman EH, et al. Reasons for refusal of newborn vitamin K prophylaxis: implications for management and education. Hosp Pediatr. 2016;6(1):15-21.
15. Weddle M, Empey A, Crossen E, Green A, Green J, Phillipi CA. Are pediatricians complicit in vitamin K deficiency bleeding? Pediatrics. 2015;136(4):753-757.
16. Kimberlin DW, Brady MT, Jackson MA, Long SS. Gonococcal ophthalmia. In: Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Villiage, IL: American Academy of Pediatrics; 2015:section 5;972.
17. American Academy of Pediatrics (AAP) Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. Guidelines for Perinatal Care. 8th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017.
18. US Preventive Services Task Force. Clinical summary: ocular prophylaxis for gonococcal ophthalmia neonatorum: preventive medication. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/ocular-prophylaxis-for-gonococcal-ophthalmia-neonatorumpreventive-medication. Published September 2017. Accessed January 3, 2018.
19. Michigan Department of Health and Human Services. Newborn screening general information. Available at: http://www.michigan.gov/mdhhs/0,5885,7-339-73971_4911_4916-233588--,00.html. Updated December 26, 2017. Accessed January 3, 2018.
20. Michigan Department of Community Health. Directive to destroy residual newborn screening blood specimen. Available at: http://www.michigan.gov/documents/mdch/Directive_to_Destroy_Form_revised_2.19.10_314558_7.pdf. Revised October 2014. Accessed January 3, 2018.
21. Kempe A, O’Leary ST, Kennedy A, et al. Physician response to parental requests to spread out the recommended vaccine schedule. Pediatrics. 2015;135(4):666-677.
22. Committee on Infectious Diseases, Committee on Fetus and Newborn. Elimination of perinatal hepatitis B: providing the first vaccine dose within 24 hours of birth. Pediatrics. 2017;140(3):e20171870.
23. Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5):e20162938.
24. Bartlow KL, Cartwright SB, Shefferly EK. Nurses’ knowledge and adherence to Sudden Infant Death Syndrome prevention guidelines. Pediatr Nurs. 2016;42(1):7-13.
25. Von Kohorn I, Corwin MJ, Rybin DV, Heeren TC, Lister G, Colson ER. Influence of prior advice and beliefs of mothers on infant sleep position. Arch Pediatr Adolesc Med. 2010;164(4):363-369.
26. Halo Innovations Inc. Cribs for Kids National Safe Sleep Hospital Certification. Available at: http://www.halosleep.com/national-safe-sleep-hospitalcertification/. Accessed January 3, 2018.
27. National Conference of State Legislatures. Final maternity length-of-stay rules published. Federal Register. 2008;73(203). Available at: http://www.ncsl.org/research/health/final-maternity-length-of-stayrules-published.aspx. Accessed January 3, 2018.
28. Benitz WE, Committee on Fetus and Newborn, American Academy of Pediatrics. Hospital stay for healthy term newborn infants. Pediatrics. 2015;135(5):948-953.
29. Chung EK, Gable EK, Golden WC, et al. Current scope of practice for newborn care in non-intensive hospital settings. Hosp Pediatr. 2017;7(8):471-482.
30. Goyal N, Zubizarreta JR, Small DS, Lorch SA. Length of stay and readmission among late preterm infants: an instrumental variable approach. Hosp Pediatr. 2013;3(1):7-15.
31. Moyer LB, Goyal NK, Meinzen-Derr J, et al. Factors associated with readmission in late-preterm infants: a matched case-control study. Hosp Pediatr. 2014;4(5):298-304.
32. Hudak ML, Tan RC; Committee on Drugs, Committee on Fetus and Newborn, American Academy of Pediatrics. Neonatal drug withdrawal. Pediatrics. 2012;129(2):e540-e560. Erratum in: Pediatrics. 2014; 133(5):937.