by Emily Oster
THE EXPECTED . . .
Newborn Baths
When the baby comes out, it is all covered in stuff. Not to get too graphic, but a lot of that is blood. There is some amniotic fluid, and a waxy covering called the vernix that protects the baby from infection in the womb. At some point, someone may suggest you wash the baby off.
I recall the nurse attempting to show us how to wash Penelope in an infant tub, probably a day or so after her birth. We watched carefully and then agreed among ourselves that it was impossible to do that and we’d probably just wait until she could do it herself. We made it two weeks, at which point we finally gave in to the spoiled milk in her balled-up fists. We memorialized this bath in pictures of a totally panicked infant who probably has still not forgiven us.
But I digress.
It used to be common to wash the baby immediately—like, within the first few minutes, perhaps even before it was handed off to Mom. There is now some pushback against this for two reasons. First, there is an increasing trend toward immediate skin-to-skin contact (more on that below) and toward leaving Mom and baby alone for a couple of hours right after birth. One of the benefits of skin-to-skin contact seems to be increased breastfeeding success. Perhaps for this reason, breastfeeding success also seems to be increased by delaying the bath past the first few hours.1 Since there is no actual reason to give the baby a bath, this is a perfectly sensible reason to delay.
The other concern about early bathing is that it may affect infant temperature. When they are first born, infants sometimes have trouble maintaining their body temperature. Bathing them—and then, more important, taking them out of the bath wet—is hypothesized to have some negative impacts on this process. This turns out not to be well supported in the data. In studies that look at bathing immediately after birth, there are no sustained consequences for the baby’s temperature.2
There does seem to be some evidence that infants given sponge baths in particular experience more temperature variability in the short term—i.e., during the bath and very immediately after.3 There’s just more time when the wet, naked infant is exposed to the air. Temperature variability is not so much a problem in itself, but it could be misinterpreted as a sign of infection. This could lead to other unnecessary interventions. For this reason, tub baths are the mode of choice in most hospitals.
So a bath isn’t a terrible thing, but there is also really no reason to bathe your kid other than some gross-out factor. Most of the blood can just kind of be wiped off. I should perhaps not admit this, but they never bathed Finn in the hospital at all, and we still waited the family-standard two weeks to actually give him a bath at home. Nothing bad happened as a result, and given Finn’s reaction when we did it, Jesse still feels we should have waited longer.
Circumcision
Male circumcision is a procedure in which the foreskin of the penis is removed surgically. Circumcision is documented as long ago as ancient Egypt, and is practiced widely by many different societies. It’s not clear why this arose; there are a variety of theories—my favorite of which is that some leader was born without a foreskin and therefore made everyone else remove theirs—and the practice might have begun for different reasons in different locations.
Circumcision can be performed at various ages, and in some cultures is traditionally done at puberty as part of an initiation ritual. In the US, however, if a boy is circumcised, it is typically shortly after birth. For people who practice Judaism, circumcisions are done in a ritual called a bris when the baby is eight days old. Outside a traditional bris, your child may be circumcised before they leave the hospital, or as an outpatient procedure a few days later. In principle, circumcision can be done more or less as soon as you can confirm that the penis is working properly (i.e., after the first time the kid pees).
Circumcision is an optional procedure. It’s not common everywhere—for example, Europeans typically do not circumcise. It has historically been quite common in the US, although circumcision rates have declined some over time, from an estimated 65 percent of births in 1979 to 58 percent in 2010.
If you are part of a religious group in which this is traditionally done, you’ll very likely circumcise your child. For people outside this set, there is a healthy debate about whether circumcision is a good idea. There are those who strongly oppose it, feeling it is a risky form of mutilation, and those who support it, arguing in favor of health benefits. The conversation can get heated, so it helps to see the data.
The major risk from circumcision, like any surgical procedure, is infection. For infant circumcisions performed in a hospital, these risks are very small. The most comprehensive estimates suggest that perhaps 1.5 percent of infant circumcisions result in minor complications, and virtually none result in serious adverse complications.4 These figures are based on studies that include some developing countries, so even the minor adverse consequences are likely to be less frequent in the US.
Another risk is what is sometimes called “poor aesthetic outcome”—basically, residual foreskin that will require further surgery. There aren’t great estimates of how common this is, although it seems to be somewhat more common than the overall rate of adverse complications.5
Very rarely, babies can develop meatal stenosis, a condition in which the urethra (the tube through which urine passes) is compressed, making it hard to pee. This is more common in circumcised than uncircumcised boys, making it fairly clear that the condition is associated with circumcision, but again, the condition is extremely rare overall.6 Repairing meatal stenosis is possible, but requires a second surgery. There is some limited evidence that it may be prevented by slathering Vaseline (or Aquaphor) on the penis for the baby’s first six months.7
There is also some discussion—especially in the anticircumcision camp—about loss of penis sensitivity as a result of circumcision. There simply isn’t any evidence for this either way. Small studies of penile sensitivity (conducted by poking the penis with stuff) do not show any consistent results on circumcised versus uncircumcised men.8 The researchers also likely deduced that no one likes to have their penis poked, intact foreskin or not.
This covers the risks. There are also some possible benefits to circumcision. The first is the prevention of urinary tract infections (UTIs). Circumcised boys are much less likely to get these. About 1 percent of uncircumcised boys will get a UTI during childhood. For circumcised boys, the estimate is just 0.13 percent.9 This is highly significant, and it is generally accepted that this protection is real. However, it is worth saying that the benefit is small in absolute terms: you’d have to circumcise one hundred boys to prevent one UTI.
Uncircumcised boys can also develop a condition called phimosis, where it becomes impossible to pull the foreskin back. This will need treatment—typically with a steroid cream—and possibly require a circumcision at an older age. The overall risk of needing a later circumcision for this condition (or related ones) is estimated at 1 to 2 percent—so, rare, but not unheard of.10
The last two cited benefits of circumcision are a lower risk of HIV and other sexually transmitted infections (STIs) and a lower risk of penile cancer. In the case of HIV and other STIs, there is good evidence from a number of countries in Africa suggesting risks are lower for circumcised men. This is in a context where most transmission of HIV is heterosexual; in the US, most transmission is through men who have sex with men (this is the technical jargon) or through IV drug use. It is unclear from the data whether the circumcision protections extend to cases of men having sex with men—they certainly do not to IV drug use.11
Penile cancer is extremely rare—affecting an estimated 1 in 100,000 men. The risk of invasive penile cancer increases with lack of circumcision, especially among boys who had phimosis as a child.12 Again, however, even a large increase in the relative risk translates to a tiny number of cases.
The American Academy of Pediatrics suggests the health benefits of circumcision
outweigh the costs, but they note correctly that both benefits and costs are quite small. This decision will often come down to personal preference, some type of cultural linkage, or just a desire to have your son’s penis look a particular way. These are all valid reasons to do it or not do it.
If you do choose to circumcise, there is the consideration of pain relief. People used to believe that small babies didn’t experience pain the way adults do, and as a result it was common to do circumcisions with no pain relief treatment—or maybe just some sugar water. This is wrong, and indeed, it seems that infants who experience pain during circumcision have a worse reaction to pain from vaccinations even four to six months later.13
In light of this, it is now strongly recommended that infants have some type of pain relief during this procedure. The most effective type seems to be a penile nerve block (typically called a DPNB), which involves injecting a painkiller into the base of the penis before the circumcision. Your baby’s doctor may also use topical anesthetic in combination.14
Blood and Hearing Tests
The medical staff at the hospital will take advantage of the time you’re there to do at least two additional tests on your baby: a blood screening and a hearing test.
The newborn blood screening is used to test for a very wide variety of conditions. Depending on the state, the exact number varies; California (for example) is on the high end, with sixty-one. Many of these conditions relate to metabolism and test for inability to digest particular proteins or produce enzymes.
A good example—likely the most common disorder detected in this way—is phenylketonuria (PKU). PKU is a genetic condition that affects about 1 in 10,000 births. People with this condition lack a particular enzyme that breaks down the amino acid phenylalanine into another amino acid. For people with PKU, eating a low-protein diet is crucial, since protein contains a lot of phenylalanine. In a person with PKU, protein can build up in the body, including in the brain, and cause extremely serious complications, including severe intellectual disability and death.
Once PKU is detected, however, dietary modifications make it extremely manageable and the negative consequences can be avoided. The problem is that if PKU is not detected at birth, brain damage can occur pretty much immediately, since breast milk and formula both have significant amounts of protein. Without testing, you wouldn’t know until too late.
Testing for this condition—and others like it—at birth is therefore crucial to improve prognosis. These tests are all done with a small heel prick, and there is no risk to the baby. If your child doesn’t have any of these conditions (by far the most likely scenario), you will not hear anything more about it.
Medical staff will also do a hearing test on the baby, which involves a large and complicated machine; sometimes this is wheeled into your room and the test is conducted there, other times in another location. Hearing loss is relatively common, affecting perhaps 1 to 3 in 1,000 children. There is an increasing emphasis on early detection of hearing loss, as early intervention (for example, with hearing aids or implants) can improve language acquisition and decrease the need for intervention later.
As you might imagine, you cannot run a hearing test on an infant as you would on an adult—babies don’t raise their hands when they hear a beep, and honestly, they’re probably asleep anyway. Instead, these tests use sensors on the head or ear probes. The sensors or probes can detect whether the middle and inner ear are responding as expected to a tone.15
These tests are quite good at detecting hearing loss (they catch 85 to 100 percent of cases), but turn up a lot of false positives. By some estimates, 4 percent of infants will fail this test, while only 0.1 to 0.3 percent actually have hearing loss. A failed hearing test will typically generate a referral to a formal audiological center, which is a good idea given the need to catch hearing problems early. But it’s also a good idea to remember that most babies who fail this do not have hearing problems; if your baby fails on the first round, it may be a good idea to try again while you’re in the hospital, as a second test can catch some false positives.
Rooming In
During these first days in the hospital, you’ll see a lot of your baby. There is a question, however, of whether you want to be with them every minute. Childbirth is exhausting, and for many women, sleeping with their infant in their room is hard. Hospital nurseries have, historically, provided a way for women to take a break from their babies to recover and rest for a few hours.
However, this is no longer as true as it once was. In the past few decades, we’ve seen the rise of “baby-friendly hospitals.” Obviously, one would hope that all hospitals are baby friendly, but the baby-friendly hospital designation means something more specific. In particular, baby-friendly hospitals must follow a ten-point plan designed to improve breastfeeding.
These tenets include things like not giving infants formula unless medically indicated, not giving pacifiers, and informing all pregnant women about the benefits of breastfeeding. I won’t go into the breastfeeding part here, as there’s much more on that later in the book. And the practice of avoiding pacifiers, which is especially controversial, will also get more treatment in the chapter on breastfeeding.
But in addition to advice and avoidance of formula, one of the requirements of baby-friendly hospitals is that they must practice “rooming in.” That is, unless there is a medical reason the infant has to be out of the room, mothers and babies should be together in their room twenty-four hours a day.
This might seem great to you! Why would you want to be away from your baby? And, indeed, it can be lovely. When I had Finn, I ended up in a birthing room with a giant bed, and they let us stay there for an entire day (thanks, Women and Infants Hospital!). There was enough space for both Jesse and me to be in the bed, taking turns sleeping, with Finn between us. I think back on this as a really amazing twelve-hour start to Finn’s life.
On the other hand, this was somewhat unusual. More likely, you’re in a recovery room with the baby in a bassinet next to you, a much less comfortable setup. Babies make a lot of weird noises, and having them with you all the time—well, you may not be able to sleep at all. Before I had Penelope, more than one fellow mom told me to just send her to the nursery—even for a few hours—so I could get some sleep. (Which I did—Prentice Hospital in Chicago did not qualify as baby friendly at the time.)
There is some disagreement about the wisdom of rooming-in recommendations as policy. It’s always tricky to think about policies that rely on rules that effectively remove patients’ choices. On the other hand, there’s some evidence that this is very beneficial for some women—for example, those whose babies have neonatal abstinence syndrome (a result of maternal use of opioids during pregnancy)—so there are reasons to encourage both women and hospitals to do it.
From the standpoint of this book, however, I’m not interested in commenting on policy, but rather on what the data says you should do if you are given a choice. This choice could be in the form of rooming in or not, if you’re in a hospital that isn’t baby friendly, or it could be the choice of hospital in the first place.
There is a clear trade-off: rooming in will mean less sleep, but maybe it’s good for the baby. This is your first sleep test. Is rooming in beneficial enough to warrant some lost sleep in the first days? To answer this, we need to know more about the size of the benefits. And for that, we need the data.
The main purported benefit of rooming in is improved breastfeeding success. There really isn’t much evidence supporting this benefit. There are clearly correlations: women who keep their infant with them are more likely to breastfeed, but this is hard to interpret as causal since these women differ in other ways. Most notably, women who want to breastfeed may be more likely to keep their infant with them to try to figure out how to do it. The breastfeeding might cause the rooming in, rather than the rooming in causing the breastfeeding.
To the extent that we have any
evidence, the results are mixed. On one hand, in a large study conducted in Switzerland comparing the breastfeeding outcomes for babies born in baby-friendly hospitals there versus those born elsewhere, the authors found more breastfeeding for babies born in these hospitals. On the other hand, it’s hard to know if this is the result of rooming in or something else.16 These hospitals were different in many ways, and the study has no way to control for who chooses this type of hospital, which is likely linked to breastfeeding intentions.
In studying questions like this, the “gold standard” way to draw conclusions is with a randomized trial. Here’s how that would work in this case: First, we’d take a group of women and randomly pick half of them to do rooming in; the other half would not, but otherwise, we’d treat them the same. Since we picked the groups randomly, we can be confident in drawing conclusions by comparing them. If the rooming-in group has higher breastfeeding rates, then we should attribute that to the rooming in. On the other hand, if the breastfeeding rates are not different, this suggests there may not be a relationship.
In the case of rooming in, there is one randomized trial of 176 women studying this question. It is not very encouraging. The study finds no impact on breastfeeding at six months, and no impact on the median time of breastfeeding.17 This study does find some increase in breastfeeding at four days of life, although it is a bit hard to interpret since the researchers encouraged feeding on a fixed schedule for some groups and not others.
It would be hard to argue that the data strongly supports the breastfeeding benefits of rooming in; at best we can say that we can’t rule out some effects. But you’ll hear from hospitals who advocate rooming in that there’s no reason not to do this, so we should do it even if the benefits are uncertain.