Top Papers of the Month

3 Top Papers You May Have Missed in January 2022

AUTHOR:
Scott T. Vergano, MD
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA

CITATION:
Vergano ST. 3 top papers you may have missed in January 2022. Consultant360. Published online February 12, 2022.

Now that the omicron-variant surge has started to abate (in my office, it is declining as quickly this month as it appeared in December), perhaps you have the time to focus your attention on more routine pediatric issues. Here are some notable publications that you may have missed in the busy month of January. Please feel free to share with your colleagues, discuss in your offices, and write to editor@consultant360.com with your thoughts and opinions.

Risks of Infectious Diseases in Neonates Exposed to Alternative Perinatal Practices1

This report from the American Academy of Pediatrics (AAP) details the known and unknown risks of various perinatal practices that are not endorsed by the AAP, in order to permit effective counseling of parents/guardians who might be considering such practices. The specific alternative practices described include water immersion for labor and delivery, vaginal seeding, umbilical cord nonseverance, placental consumption by adults, nonmedical deferral of birth hepatitis B vaccination, deferral of ocular prophylaxis, and delayed bathing. The report also discusses recommendations for evaluation of sick infants exposed to these alternative perinatal practices. The risk of refusal of vitamin K prophylaxis has been documented elsewhere and is not included in the aforementioned publication.2

The report documents:

  1. Case reports of waterborne infections due to water immersion during labor
  2. Concerns for transmission of group B Streptococcus (GBS), herpes simplex virus (HSV), and other vaginal pathogens due to vaginal seeding
  3. Case reports of early-onset sepsis from umbilical cord nonseverance (lotus birth)
  4. Significant risks of bacterial contamination in placental consumption
  5. A strong recommendation against deferral of the birth dose of the hepatitis B vaccine, including a surprisingly high estimate of 1000 cases of perinatally acquired hepatitis B virus infection in the United States every year, which is dramatically higher than the actual numbers of reported perinatal cases
  6. The AAP position that routine neonate ocular prophylaxis be reexamined and that erythromycin ointment may not be necessary if appropriate prenatal screening for maternal gonococcal infection has been documented
  7. Potential benefits of delayed bathing of neonates not exposed to maternal HSV or bloodborne pathogens

What have your experiences been? Other than refusal of the birth dose of the hepatitis B vaccine, I have seen only a few parents/guardians whose implementation of these alternative perinatal practices was concerning. I will use this data for better counseling of these families. I frequently cite the information contained in the statement regarding refusal of perinatal vitamin K prophylaxis.2 I have found it invaluable to educate families about this alternative practice, which always makes me anxious about the potential for adverse neurologic outcomes and death in these infants.

Delivery Characteristics and the Risk of Early-onset Neonatal Sepsis3

This retrospective study examined risk factors for early-onset neonatal sepsis (EOS) in 53,575 neonates born over a 5-year period at the high-risk perinatal units at 2 academic medical centers in Philadelphia. The authors attempted to define low-risk criteria for EOS. They postulated that neonates born via cesarean delivery with rupture of membranes at delivery without labor or concern for intra-amniotic infection or nonreassuring fetal status would be at low risk for EOS. Of the infants included in the study, 41 were found to have EOS. Among the 1121 who met low-risk criteria, regardless of gestational age, none had EOS. The authors note that 901 of the 1121 infants in the low-risk groups were evaluated for EOS and started on antibiotics.

It is noteworthy that the neonates in this study were born from 2009 to 2014, an era in which evaluation for EOS was more common. The implementation of GBS screening and intrapartum antibiotic prophylaxis against early-onset GBS disease has led to a significant decrease in the incidence of EOS in neonates.4 More recently, the use of a readily available and well-validated EOS calculator has further decreased the number of these neonates undergoing evaluation for EOS.5,6 This study adds recognition of additional low-risk criteria for early-onset neonatal sepsis.

There are 2 take-home messages: neonates born via cesarian delivery with rupture of membranes at delivery and no concern for intra-amniotic infection or nonreassuring fetal status are at exceedingly low risk of EOS, and the incidence of EOS in the current era (0.5% of all neonates in this study) is low, regardless of gestational age, even at high-risk perinatal units like the 2 in this study.

Increase in Human Rabies Cases Linked to Bats in the United States7

This report from the Centers for Disease Control and Prevention (CDC) documents 5 cases of rabies deaths caused by bat exposures in 2021, compared with none in the prior 2 years. The CDC statement explains that rabies transmission may occur from any exposure to saliva, even in the absence of a documented scratch or bite. It emphasizes the importance of postexposure prophylaxis in all cases of potential saliva exposure, as prophylaxis is almost 100% effective, whereas rabies is nearly always fatal once symptoms appear 1 to 3 months later.

Having practiced in a town in which a resident had died from exposure to a bat in the absence of a bite several years ago, I am unfortunately familiar with how devastating these cases can be, given the efficacy of rabies prophylaxis and the inextricable progression of neurologic symptoms in untreated patients. From experience, I wholeheartedly support education about bat exposures for both clinicians and patients.

References:

  1. Nolt D, O'Leary ST, Aucott SW; Committee on Infectious Diseases and Committee on Fetus and Newborn. Risks of infectious diseases in newborns exposed to alternative perinatal practices. Pediatrics. 2022;149(2):e2021055554 https://doi.org/10.1542/peds.2021-055554  
  2. Loyal J, Shapiro ED. Refusal of intramuscular vitamin K by parents of newborns: a review. Hosp Pediatr. 2020;10(3):286-294. https://doi.org/10.1542/hpeds.2019-0228
  3. Flannery DD, Mukhopadhyay S, Morales KH, et al. Delivery characteristics and the risk of early-onset neonatal sepsis. Pediatrics. 2022;149(2):e2021052900. https://doi.org/10.1542/peds.2021-052900
  4. Verani JR, McGee L, Schrag SJ; Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases. Prevention of perinatal group B streptococcal disease: revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010;59(RR-10):1-36. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5910a1.htm
  5. Kuzniewicz MW, Puopolo KM, Fischer A, et al. A quantitative, risk-based approach to the management of neonatal early-onset sepsis. JAMA Pediatr. 2017;171(4):365-371. https://doi.org/10.1001/jamapediatrics.2016.4678
  6. Probability of neonatal early-onset sepsis based on maternal risk factors and the infant’s clinical presentation. Neonatal early-onset sepsis calculator. Kaiser Permanente Research. Accessed February 8, 2022. https://neonatalsepsiscalculator.kaiserpermanente.org/
  7. CDC reports increase in human rabies cases linked to bats in the U.S. News release. Centers for Disease Control and Prevention; January 6, 2022. Accessed February 8, 2022. https://www.cdc.gov/media/releases/2022/p0106-human-rabies.html