7 Vitamin K Myths Busted

Social media has allowed the sharing of misinformation about many things, especially medically related things. When the specifics of something are unknown to a person, pretty much anything that's said can sound reasonable, so people believe what they hear. This happens with many things, such as vaccine risks, chelation, and vitamin K.

I am especially frustrated when parents refuse to give their newborns vitamin K after birth. Since 1961, the American Academy of Pediatrics has recommended giving every newborn a single shot of vitamin K given at birth. This is a life saving treatment to prevent bleeding. Life saving.

Vitamin K works to help our blood clot. Insufficient levels can lead to bleeding in the brain or other vital organs. Vitamin K deficiency bleeding or VKDB, can occur any time in the first 6 months of life. There are three types of VKDB, based on the age of the baby when the bleeding problems start: early, classical and late. Unfortunately there are usually no warning signs that a baby will have significant bleeding, so when the bleeding happens, it's too late to do anything about it. Why parents don't want to give this preventative life saving treatment is usually based on incorrect information.

This is a matter of a fairly low risk of bleeding if you don't give vitamin K: 250-1700 per 100,000 within the first week, and 4-7 per 100,000 between 2 and 12 weeks. You might notice that the number is variable - it's hard to study since the large majority of babies have gotten vitamin K over the years and the risk is low even without vitamin K. However, when there is bleeding it has significant consequences: lifelong disability or death. And we also know that there's very low risk from the vitamin K and it works very well to prevent bleeding. So why take the chance of not giving it?

Conspiracy Theories, Misunderstandings, and Science

This is not a governmental conspiracy to somehow kill children. It's a world wide attempt to help children survive and thrive. The World Health Organization (WHO) guidelines:

• All newborns should be given 1 mg of vitamin K intramuscularly [IM] after birth [after the first hour during which the infant should be in skin-to-skin contact with the mother and breastfeeding should be initiated]. (Strong recommendation, moderate quality evidence) 

Most people look at scientific information and can't make heads or tails of what it means.

Photo Source: Hemorrhagic Disease of the Newborn

That coupled with the fact that things we read that make us react emotionally (such as fear that something will harm our child) makes us remember and associate with the information that created the emotion, whether it is right or wrong. This can lead parents to make dangerous decisions for their children while trying to do the right thing.

Myth Busting

I'm going to attempt to de-bunk the most common concerns I've heard because the best way to combat misinformation is to help explain the facts as we know them.

1. If every baby's born with too little vitamin K, that's the way we're supposed to be.

Babies are born with very little vitamin K in their body. If they don't get it with a shot, they need to either eat it or make it. Breast milk has very little vitamin K and babies won't be eating leafy greens for quite awhile. Formula does have it, but it takes several days for vitamin K to rise to protective levels with formula and the highest risk of bleeding is during that first week of life. (Of course if you're using this argument because you want babies to be all natural, you probably won't be giving formula at this point.) 

Bacteria help us make vitamin K, but babies aren't colonized at birth with these gut bacteria. 

Just because they're born that way doesn't mean they're supposed to stay that way. Inside the mother the baby is in a very different situation. They don't breathe air. They don't eat. They don't have gut bacteria. Their heart has a bypass tract to avoid pumping blood to the lungs. This all works well in utero, but must change once they leave the womb. Change takes time, and during this time they are at risk. Why not minimize the risk if we know a safe way to do it?

2. The package insert has a big warning at the top that it can kill.

There are many reasons why we should not use the package insert of a medicine or vaccine to make healthcare decisions. These have been discussed before so I won't go into all the details but please see these great blogs on how to read and use package inserts:

•  ChristopherJohnsonMD 

• HarpocratesSpeaks   

• TheLogicOfScience   

• SkepticalRaptor    

• ScienceBlogs

It is true that there is a black box warning on the top of the vitamin K package insert. This has scared some parents from wanting to get the vitamin K shot for their newborn. 

Screen Shot from Package Insert 

Reactions to IV (intravenous) vitamin K are much more common than IM (intramuscular) injections. The difference is anything given by IV goes directly into the bloodstream and back to the heart. But we don't give vitamin K by IV to newborns. 

IM injections go into the muscle, allowing very slow absorption of the medicine. This not only decreases reactions to the injected vitamin, but also helps the level of vitamin K stay elevated for a prolonged time after a single injection. 

I only found one report of a newborn with a significant reaction to vitamin K. The authors of the paper did note that IM vitamin K has been given for many years to babies all over the world without significant reactions and could not explain why the one infant had such a significant reaction. 

Since we must always look at risk vs benefit, the very, very low risk of a serious reaction from receiving vitamin K IM is preferable to the benefit of the prevention of VKDB.

Another great resource on this topic is Dr. Vincent Iannelli's That Black Box Warning on Vitamin K Shots. 

3. Vitamin K causes cancer.

Many years ago there was a small study that suggested vitamin K led to childhood cancers. This issue has been extensively studied since then and no link has been found. 

Vitamin K does not cause cancer. 

Rates of cancer have not increased in the years since vitamin K has been given to the large majority of newborns worldwide. This is reported in the Vitamin K Ad Hoc Task Force of the American Academy of Pediatrics report Controversies Concerning Vitamin K and the Newborn.

4. Bleeding from vitamin K deficiency is rare or mild.

In the US bleeding from vitamin K deficiency is rare because most babies get the vitamin K shot soon after birth. In countries where vitamin K is not used routinely, bleeding is not rare at all. Some communities of the US where vitamin K is being refused by parents are seeing an increase in newborn bleeding.

Early VKDB occurs within 24 hours of birth and is almost exclusively seen in infants of mothers taking drugs which inhibit vitamin K. These drugs include anticonvulsants, anti-tuberculosis drugs, some antibiotics (cephalosporins) and blood thinners to prevent clots. Early VKDB is typically severe bleeding in the brain or gut.

Classic VKDB typically occurs during the first week of life. The incidence of classic VKDB ranges from 0.25-1.7 cases per 100 births.

Late onset VKDB occurs between 2 and 12 weeks usually, but is possible up to 6 months after birth. Late VKDB has fallen from 4.4-7.2 cases per 100,000 births to 1.4-6.4 cases per 100,000 births in reports from Asia and Europe after routine prophylaxis was started.

One out of five babies with VKDB dies. Of the infants who have late VKDB, about half have bleeding into their brains, which can lead to permanent brain damage if they survive. Others bleed in their stomach or intestines, or other vital organs. Many need blood transfusions or surgeries to help correct the problems from the bleeding.

5. It's just as good to use oral vitamin K.

Early onset VKDB is prevented well with the oral vitamin K in countries that have oral vitamin K available, but late onset VKDB is an issue. Children with liver or gall bladder problems will not absorb oral vitamin K well. These problems might be undiagnosed early in life, putting these kids at risk for VKDB if they are on an oral vitamin K regimen.

There is no liquid form of vitamin K that is proven to be effective for babies in the US. That is a huge issue. Some families will order vitamin K online, but it's not guaranteed to be safe or even what it claims to be. This is an unregulated industry. It is possible to use the vitamin K solution that is typically given intramuscularly by mouth, but this requires a prescription and the taste is questionable, so baby might not take the full dose. It would be an off-label use so physicians might not feel comfortable writing a prescription. The other issue that might worry physicians is with compliance in remembering to give the oral vitamin K as directed, since most studies include babies with late onset bleeding who had missed doses. 

Most of us get vitamin K from gut bacteria and eating leafy green vegetables. Newborns don't have the gut bacteria established yet so they won't make any vitamin K themselves. They may get vitamin K through their diet, but breastmilk is very low in vitamin K, so unless baby is getting formula, they will not get enough vitamin K without a supplement. It is possible for mothers who breastfeed to increase their vitamin K intake to increase the amount in breast milk, but not to sufficient levels to protect the baby without additional vitamin K.

Many countries that have used an oral vitamin K protocol, such as Denmark and Holland, have changed to an intramuscular regimen because the oral vitamin K that was previously used became no longer available.  

There are various oral vitamin K dosing strategies that can be reviewed in the linked abstract. In short:

•  Australia and Germany: 3 oral doses of 1 mg vitamin K are less effective than a single IM vitamin K dose. (In 1994 Australia changed to a single IM dose and their rate went to zero after the change.) 

• Netherlands: A 1mg oral dose after birth followed by a daily oral dose of 25 mcg vitamin K1may be as effective as parenteral vitamin K prophylaxis.

• Sweden: (a later study) 2 mg of mixed micellar VK given orally at birth, 4 days, and 1 month has a failure rate of one case of early and four cases of late VKDB out of 458,184 babies. Of the failures, 4 had an undiagnosed liver issue, one baby's parents forgot the last dose.

When vitamin K is given IM, the chance of late VKDB is near zero. Oral vitamin K simply doesn't prevent both early and late bleeding as well -- especially if there is an unknown malabsorption disorder, regardless of which dosing regimen is used. 

6. My baby's birth was not traumatic, so he doesn't need the vitamin K.

Birth trauma can certainly lead to bleeding, but the absence of trauma does not exclude it. Late vitamin K deficient bleeding (VKDB) cannot be explained by any birth traumas since they can occur months later. 

7. We're delaying cord clamping to help prevent anemia and bleeding. Isn't that enough?

Delayed cord clamping can have benefits, but decreasing the risk of bleeding is not one of them. There is very little vitamin K in the placenta or newborn, so delaying the cord clamping cannot allow more vitamin K into the baby.  

Still not convinced?

Read stories about babies whose parents chose to not give vitamin K:

• Judah's story
• Olive's story, more on Olive, and the final words on Olive's story
• Tennessee babies

For More Information:

Evidence on: The Vitamin K Shot in Newborns (Evidenced Based Birth)

Frequently Asked Questions (FAQ’s): Vitamin K and the Vitamin K Shot Given at Birth (CDC)

Hemorrhagic Disease of the Newborn (eMedicine)

Vitamin K in Breast Milk - Can it Replace the Shot? (Nurse and Nourish)
Vitamin K in neonates: facts and myth (NCBI) 

Help! I'm sick and I have a baby at home.

When we have newborns we don't want to expose them to germs. We avoid large crowds, especially during the sick season. We won't let anyone who hasn't washed their hands hold our precious baby. We might even wash our hands until they crack and bleed.

But what happens when Mom or Dad gets sick? What about older siblings? How can we prevent Baby from getting sick if there are germs in the house?

In most circumstances it is not possible for the primary caretaker to be completely isolated from a baby, but there are things you can do to help prevent Baby from getting sick.

• Wash hands frequently, especially after touching your face, blowing your nose, eating, using common items (phone, money, etc) and toileting. Wash Baby's hands after diaper changes too. Make this a habit even when you're not sick... you never know when you're shedding those first germs!

• Wipe down surfaces. Viruses that cause the common cold, flu, and vomiting and diarrhea can live on surfaces longer than many expect. Clean the surfaces of commonly touched things such as doorknobs; handles to drawers, cabinets, and the refrigerator; phones; and money frequently when there is illness in the area. 

• Avoid touching your eyes, nose and mouth - these are the "doors" germs use to get in and out of your body. Pay attention to how often you do this. Most people touch their face many times a day. This contributes to getting sick.
• Resist kissing Baby on the face, hands, and feet. I know they're cute and you love to give kisses, but putting germs around their eyes, nose, and mouth allows the germs to get in. They put their hands and feet in their mouth, so those need to stay clean too. 
• Cover your cough. I often recommend that people cover coughs and sneezes with their elbow to avoid getting germs on their hands and reduce the risk of spreading those germs. When you're responsible for a baby, the baby's head is often in your elbow, so I don't recommend this trick for caretakers of babies. Cover the cough or sneeze with your hands and then wash them with soap and water or use a hand sanitizer if soap and water aren't available.
• Vaccinate. If you're vaccinated against influenza, whooping cough, and other vaccine preventable diseases, you're less likely to bring those germs home. Encourage everyone around your baby to be vaccinated. If you get your recommended Tdap and seasonal flu vaccine while pregnant, Baby benefits from passive immunity. See Passive Immunity 101: Will Breast Milk Protect My Baby From Getting Sick? by Jody Segrave-Daly, RN, MS, IBCLC to better understand passive immunity.
• Breastfeed or give expressed breast milk if possible. Mothers frequently fear that breastfeeding while sick isn't good for Baby. The opposite is true - it's very helpful to pass on fighter cells against the germs! Again see Jody Segrave-Daly's blog for wonderful explanation of how breast milk protects our babies. 
• Limit contact as much as possible. If possible, keep Baby in a separate area away from sick family members. Wash hands after leaving the area of sick people. If the primary caretaker is sick and there is no one available to help, wear a mask and wash hands after touching anything that might be contaminated.
• Insist on a smoke-free home and car. Even if someone is smoking (or vaping) in another room or at another time, Baby can be exposed to the airborne particles that irritate airways and increase mucus production. These toxic particles remain in a room or car long after smoking has stopped. If you must smoke or vape, go outdoors. Change your shirt (or remove a coat) and wash your hands before holding Baby.

It's never easy being sick, and being a parent adds to the level of difficulty because you not only have to care for yourself, but someone else depends on you too. As with everything, you must take care of yourself before you can help others. Drink plenty of water and get rest! Most of the time medicines don't help us get better, since there aren't great medicines for the common cold. Talk to your doctor to see if you might need anything. Don't be falsely reassured that you aren't contagious if you're on an antibiotic for a cough or cold. If you have a virus (which causes most cough and colds) the antibiotic does nothing. You need to be vigilant against sharing the germs!

Stool colors & patterns in infants: What's normal & when should you worry?

Help! My baby is constipated. She hasn't pooped for days.

We hear versions of this all the time.

Constipation isn't defined by how often babies have a bowel movement. A breastfed baby might have a bowel movement every time he eats (and in between) or he might go less than once a week. (Watch out when it finally comes - it often escapes the diaper!) Most formula fed babies have a bowel movement 1-3 times a day. Babies who get some breast milk and some formula can have characteristics of each feeding type.

During the first few days of life the stool looks black and is thick. This is called meconium. It occurs in both breast fed and formula fed babies. If your baby doesn't have meconium within 24 hours of birth an evaluation to decide if there's a problem should be done. Be sure to talk with your baby's doctor if he doesn't poop within 24 hours of birth or if the meconium is formed like a plug. (See a photo on Stanford's newborn page.)

Meconium stool. Photo by Azoreg via Wikimedia Commons

After the first few days there is a period of transition stool. The stools become more green and sticky. This is the meconium mixed with breastmilk or formula stools. It happens earlier in formula babies and after mother's milk comes in for breast fed babies.

After the transitional stools, the stools will vary in color and consistency depending on if the baby gets breastmilk or formula. If breastmilk is the primary food, the stools can vary quite a bit. They often look like yellow cottage cheese, with a lot of liquid and chunks. It often becomes a bit thicker (like pudding) as a baby gets older. It is not diarrhea just because it is watery. Breast fed stools can vary in shades of yellow to brown or green, often changing depending on what the mother ate. Bright green and frothy stools can indicate a low fat diet in a breast fed baby. The fore milk has less fat than the hind milk, so if the baby consistently has frothy bright green stools we will monitor the baby's weight closely to ensure adequate growth and evaluate the amount of milk the mother is producing and baby is drinking.

If a baby is taking formula, the stools can look shades of yellow and brown and be the consistency of peanut butter, pudding, or thick oatmeal. Formula fed stools tend to smell more foul than breast milk stools, but even breast fed baby poops can stink.

Once a baby eats solids (or pureed foods) the stools can thicken a bit but should never be hard. They usually become more foul smelling at this time. Sometimes chunks of food (especially carrots, corn, and raisins) can be seen in the stool. This is normal.

If a baby takes an iron supplement the stools might turn dark green or black. This is normal and not a concern. This does not happen from the amount of iron in baby formula. All formula should have iron. It is an important nutrient for all babies and low iron formula is not recommended.

What's important?

• A term baby should gain about 15-30 grams per day after the first week of life.
• Blood in the stool can be from swallowed blood (often from a crack in mother's nipple), constipation, food allergy (usually cow's milk protein), or infection and should be evaluated.
• It is normal to have different shades of yellow, brown, and green stools.
• A baby with a swollen (distended) abdomen and discomfort or a change in feeding patterns should be examined.
• A baby should not have formed stools as long as they are on primarily breast milk or formula.
• Poop should never be a shade of white (liver concerns), red (blood), or black -if not on iron supplements (digested blood).
• Mucus in stool could be simply swallowed mucus but can be a sign of infection or food allergy.

Choosing a Physician For Babies and Children

I'm taking a break in the middle of my Learning and Behavior Series to answer a question that is often asked: How should parents choose a physician for their children?

photo source: Shutterstock

Most parents will spend a lot more time and effort in choosing a doctor for their children than they do picking a doctor for themselves. Finding the right fit is important. If you disagree with the doctor's treatments or don't feel comfortable asking questions, they aren't the right fit.

This blog will list a lot of questions to consider. It is mostly geared toward new parents, but if you have children already you should have an idea about what you liked and disliked about your child's last doctor. Use that knowledge to pick the new doctor. Unless you can book a three hour appointment with a doctor (I will say right now that no one really wants that), you will not get to all of these questions, so look ahead on their websites to see if you can find answers, then prioritize the questions that are important to you to ask first.

Pediatrician vs Family physician?

Family physicians and pediatricians both care for newborns. Some family physicians have quite a bit of experience with babies and children, others not so much.

I am of course biased toward pediatricians because they spend their entire three years of residency training after 4 years of medical school learning to take care of children birth through adolescence and transitioning into young adulthood. We continue to do continuing education in the area of children, giving us the opportunity to keep up on the newest recommendations. If you choose a pediatrician, ask how long they will see children. Most will see kids at least until 18 years of age. Many of us will see kids through college.

Family doctors learn to take care of people from birth until old age in that same three year period of residency, and much of their training is in the problems associated with getting old. Many do not keep up with the newest recommendations for children as research changes guidelines because there is so much information to keep up with adult medicine. If you choose a family physician, be sure they have experience with infants and young children.

References 

Ideally you will be able to ask friends, coworkers, and family members what they like and dislike about their pediatricians. Remember that everyone has different goals and experiences, so ask specific questions that might make a difference to you and remember that their view is colored by their experience. They might just say "the doctor's schedule is difficult to work with and they don't work with me" but they don't share that they had to reschedule an appointment because they were 30 min late and they were upset when they demanded that the doctor call out a prescription without being seen and the doctor refused. Or maybe they say that the doctor never does the right thing because they want "quick fixes" for all illnesses but the doctor uses standardized recommendations to avoid antibiotics for viral illnesses. Getting a variety of opinions helps to see if there's a trend toward that problem or if it's an isolated event.

Insurance

Unless you plan to go concierge, one of the first things you should do is look at the insurance of your future baby (or current children) to see which physicians are on the list. Compare the list of providers to the list of references you get from your friends and family. Don't forget to add your child to the insurance plan as soon as possible! There is usually a time limit of 30 days, and if you miss the opportunity, you will have to wait until the next open enrollment period. Mothers often assume the baby will be automatically added to her insurance, but if they don't get the paperwork and payment from you, baby is not added. Also watch your mail... insurance companies often will send a coordination of benefits that you must return to state whether or not baby is on another plan in addition to the one you signed up for. I suspect it is a delay tactic for paying claims, but  that is for another blog.

Prenatal visit 

Many physicians offer a prenatal visit. Some do individual one on one visits, others do a group visit so people can meet many faces at the same time. This is a time to get to know the practice style and bedside manner of the doctor. Don't limit your "interview" to just the doctor though... Look to see if the office is clean. Are the faces friendly? When you called to schedule was there a phone tree or did you talk to a live person? Are staff members helpful answering questions? I always recommend interviewing at least two offices so you can compare, even if your friends only have great things to say about one of the offices. You would never buy a house after just looking at one, right? See your options.

Hospital care

Once you limit the list of names down to a few that you can personally meet, see if they are on staff where you plan to deliver. Most hospitals require the baby's hospital doctor to examine him/her within 24 hours of birth, but their physician is usually not at the delivery. While it is not imperative that your child meets his pediatrician at the hospital (there will be plenty of time to get to know one another the first few months after birth), it is nice to know if you will need a different pediatrician in the hospital. If your chosen doctor is not on staff where you're delivering, you can ask if they recommend someone on staff at the hospital to "babysit" while you're there. I really think it is less important for a doctor to see your child in the hospital than many new parents perceive. They are often disappointed if a non-chosen doctor (even in the same group) is doing hospital rounds the days they are there, so they miss their chosen doctor. In reality, the hospital course is important, but with good communication between the hospital doctor and the long term doctor, good care will still happen. There is a lot of time later to get to know one another in the office setting. If you think about it, if your child's doctor spends too much time in the hospital doing rounds, he or she won't have as much time in the office to see your for visits for the next 18-22 years! Most newborns should be seen 1-2 days after discharge (unless they have been in the hospital longer than the typical 36 - 72 hours). Ask the doctors you interview when they usually see babies for the first visit in the office.

Office Availability and Policies and Physician's Practice Style

It is important that the office is accessible as much as possible. If it is far from home, work, and daycare, it will not be easy to run in when your child falls ill. The more hours they are open, the easier it will be to be able to go there for care, but the less likely you will see the same person each time. Things to consider (not all of these will be important to everyone, so think what your needs and goals are):

• What are the hours for scheduled appointments?
• Are there walk in hours, and if so what are they? Are they billed with an urgent care charge or a regular office visit?
• What are after hour options if a child is sick or injured? 

• Do they use a triage phone service or do they take their own calls? 
• Are there charges for after hour services? 

• Where do they recommend patients go after hours if needed? 

• How long is the average wait time for an appointment for a sick visit? 
• How long is the wait for a well visit (physical exam)? 
• Do they charge for forms to be filled out and will they fill out forms outside of visits?
• Do physicians outside of the office cover on weekends, vacation time, or after hours? If they do, how is that handled with billing and insurance? (Many solo or small group practices team up with trusted colleagues outside of their practice to help them all have a personal life. Yes. It's true. Even doctors like to see their families sometimes.) 
• Is there a portal that allows secure electronic messaging for non-urgent questions?
• Do they offer on line appointment requests or scheduling?
• Do they offer on line bill pay?
• Do they use electronic health records? If so, do they think it slows them down or has more benefits? Will you have access to the records?
• Do they have an in-house billing staff or do they use a billing service?
• How are medical questions during office hours handled? Is there a set time for phone calls to be returned or is it done throughout the day? Can you call and speak to a nurse? Do you have to schedule an appointment to talk to the doctor?
• Is the location convenient to home, work, and/or daycare? Is parking convenient? If there are multiple locations, does your doctor have set hours at each location or at just one? Will you be expected to drive to various locations depending on day of the week or time of day?
• If you choose a doctor in the practice, are you able to see other providers in the office if it is easier on your schedule or are you limited to just that doctor?
• If they have physician extenders (nurse practitioners and physician assistants) will there be times that you must schedule with or use them? Can you choose an NP or PA instead of a doctor if you like their style best?
• Are there other specialists in the office, such as nutritionists, psychologists, lactation nurses, etc?
• What is the general schedule for well visits? 
• Are immunizations available at the office?
• Are labs and X-rays done at the office or at a location preferred by insurance?
• Do they offer general advice on their website? Is it their own advice or do they purchase rights to use another database of information? If it's their own, is it updated regularly or out of date information?
• Is there a separate waiting room for well and sick kids? I included this because it's on just about every list of questions to ask and I think it's a really bad question. I have admitted two kids in my 15 years in practice from their "well visit" -- both times the parents knew the kids were sick, but waited until the well appointment so they wouldn't have to come in twice in one week. Both kids had pneumonia and required oxygen and iv antibiotics in the hospital. Both would have sat in the "well" waiting room if we had it structured that way. In the winter most kids have a runny nose and cough at their well visits. Research shows that it is falsely reassuring to sit in the "well" waiting room for a scheduled physical, because kids come in for "well" visits sick or have siblings with runny noses that tag along. Some "sick" appointments are for injuries-- should they sit next to the kid with the vomiting bucket? I prefer that the waiting room is regularly cleaned and people don't spend much time there. Exam rooms can be cleaned before each family, and if families spend most of the wait in the room, it is less risky for catching something. I also think toys in a doctor's office are means to spread germs. Bring your own toys and books. And have everyone wash (or sanitize) hands when they leave.
• Another question I usually see listed but don't like is "Do you run on time?" If they say "always" either they are 1. not popular, 2. brand new, or 3. lying. (I guess concierge docs can probably say always because they only see a few people per day.) Most doctors can run late at times -- it just takes one really sick patient, one parent with a lot of questions, or a room of behaviorally challenged children, to get a doctor behind. It happens. They can run on time 99% of the time, but if you're waiting with sick screaming kids, that doesn't help. What do they do to get back on track? Do they have other providers in the office help? Do they have "catch up time" built into the schedule? Do they shorten later visits to catch up? Do patients just wait? For more on waiting times, please see my previous post on Waiting Times.
• How do they educate and update parents on new practice information or new pediatric recommendations? Do they have a social media presence? Do they send out newsletters? Does their website have a News section -- and is it updated regularly? If you're not online, do they offer paper copies of that same information? 
• Are physicians board certified or board eligible? After residency new physicians must pass a standardized test to become board certified. Between the time they finish residency and pass the test they are considered board eligible. If they do not pass after 7 years (for pediatrics) they are no longer considered board eligible. They might just be bad test takers, but...

• What is the physician's recommendation for common questions, such as breastfeeding, circumcision, car seats, use of antibiotics, starting solids, etc? Pick topics that mean something to you. If they are not on the same page as you with these, they will probably not be on the same page for other things.
• How does the doctor keep up to date with current recommendations?
• Do physicians admit sick children to a hospital or do they refer to hospital based physicians? Use of hospitalists is becoming more common throughout the country and in some markets is standard.
• How does the doctor feel about specialist referrals? Some doctors like to handle a variety of issues, others are quick to refer before beginning a basic evaluation and treatments. Being able to stay in the medical home is great if the doctor is competent and comfortable managing issues. It is less expensive, comprehensive, and often more convenient for families. 
• Do physicians in the office handle minor emergencies, such as laceration repair, broken bones, concussions, etc? How do they work that in to their schedule?
• Are physicians able to manage most children with asthma? Can they monitor oxygen levels, do breathing treatments, check lung function, etc? 
• What is the policy on calling out medications? 
• Do the physicians in the office treat ADHD, depression, anxiety, and other mental health issues?
• What is the physician's view on vaccines? Do they require them? 
• Does the physician have an area of interest, such as infectious disease, endocrine, or behavior? 
• If you have a special needs child, does the physician have experience with that disorder? I'm not saying they should be excluded if they don't. Are they willing to learn about the disorder and help you identify needs? I have a couple patients with different rare disorders I had never heard of before knowing them. They also see specialists locally and each have a guru specialist outside of the area that is nationally known for that disorder since there are few patients with the issue. The important thing is that I was willing to spend time learning about the issues associated with each disorder and how to help the families get the help they need.

I really think that the most important thing in a doctor/patient relationship is trust. If you feel uncomfortable talking to the doctor or if you disagree with what they say, it is hard to have trust. If you and the doctor are constantly butting heads about treatment plans, it is best to find someone more on the same page as you. If you know you want an antibiotic for every runny nose, but the doctor limits antibiotics to medically indicated instances, you will not be happy. If you do not plan on immunizing your child and the doctor's office requires vaccines, it obviously won't be a good situation. 

Remember that there are many choices in parenting. Most of the time you will make the right one, but if not you can usually change directions and find what works for your family. The same is true with the choice of a physician. Pick the one that seems like the best fit. If you are having problems, talk with the doctor. Often times this is best done as a phone call or letter so that a long discussion does not interrupt their patient schedule, making others wait. But is still important to share your concerns. He or she might not realize that the front staff was rude or that it took so long to get an appointment. They might presume you were happy with the treatment plan because you didn't ask questions or state your opinion. If you don't speak up, they will never know. Lack of communication is the root of most problems. If after discussing your concerns things don't change, then it is time to make a change to someone that makes a better fit.

Bumps, ridges, and soft spots on baby's head

Parents often worry about lumps and bumps on a baby's head unnecessarily. Babies normally have ridges and soft spots on their head for a while after birth. Many have a type of swollen gland that parents can feel when rubbing the head.

All of this is normal.

Let's begin with a brief overview of a baby's head. We are born with many bones in our skull. This allows the head to be squeezed out of the birth canal as the boney plates move together or even overlap one another.

photo source: Shutterstock

Sometimes you don't really notice much with these bones, but other times they still overlap one another noticeably after birth. A baby might have a cone shaped head after birth, but this usually quickly reshapes into a round head over a couple days.

There are 1-2 "soft spots" at birth. Usually the one on top to the head (the anterior fontanelle) remains open enough to feel for the first 18-24 months of life. The one towards the back of the head (the posterior fontanelle) is unable to be felt by about 2 months of age. Many parents fear that touching the soft spot will somehow damage the baby's brain. Normal touching won't hurt, even from a 2 year old sibling. There are several layers of skin and other tissues protecting the brain. Doctors will feel the soft spots during routine check ups to be sure they are the right size for the growth of the baby's head. (There's a lot of variation here, so if you question the size of your baby's soft spot, discuss it at a visit with the doctor. He or she will need to not only feel the soft spot, but also will look at overall head growth, baby's development, and the shape of the head.)

Coming out of the birth canal can be traumatic for both mother and baby (and often for fathers too). Sometimes babies have a big soft or squishy bump on one side of the head, which usually is essentially a large bruise. The two most common causes for this are cephalohematoma and caput saccedaneum. A cephalohematoma develops when there is bleeding between the skull and the bone lining called periosteum. Since it is outside the skull, it doesn't affect the baby's brain. It covers only one of the bones, and never crosses one of the suture lines. A caput is from bleeding one layer above the periosteum in the skin. It can cross the bone areas since it's not limited by the lining of the bone (periosteum).  Both of these conditions can lead to increased risk of yellow jaundice due to breakdown of the blood collections, but usually self resolve without complications. If baby seems uncomfortable due to this area, discuss with your hospital nurse or doctor.

This picture attempts to show the layers of bleeding described here and includes more uncommon (and more concerning) types of bleeding.

photo source: http://en.wikipedia.org/wiki/File:Scalp_hematomas.jpg

Flat spots are common, especially if babies prefer to always look to one side. This can cause the forehead to seem to bulge on one side or an ear to appear closer to the face than the other ear. This is usually due to baby laying one direction most of the time, allowing the brain to grow all directions but spot baby is laying on. It is important to get baby to lay looking right sometimes, left other times. Supervised tummy time is helpful too. (I recommend starting tummy time day one. The earlier you start tummy time the less they seem to hate it!) When you hold and feed baby, alternate arms because they will look toward you and by simply holding in the right arm sometimes, left arm other times, they will turn their head. If your baby resists turning his head, check out this Torticollis information.

One of the most common head worries that brings parents to the office is a pea-sized (or bigger) movable bump on the back of baby's (or even an older child's) head. This is usually an occipital lymph node. When I say it's just a lymph node, some parents automatically worry about lymphoma. Don't go there. Most of us remember having a swollen lymph node (AKA swollen gland) under our jaw or in our neck when we are sick. When they develop on the back of the head, it is usually from something irritating the scalp, like a scalp probe during labor, cradle cap, or bug bites in older kids. They can remain large for quite a while (often seeming to come and go when kids have scalp irritations), but unless they hurt to touch, enlarge rapidly, are red and hot, or a child looks sick otherwise, I don't worry about them.

photo source: Shutterstock

In short, most lumps and bumps on your baby's head are normal. If you're worried, bring your baby in to have your pediatrician look and feel.

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Common Sleep Myths - by guest blogger Kerrin Edmonds

made at www.quickmeme.com

Social Media really is shrinking the world. How else would I be able to keep up with my friends without leaving my living room? I've realized that people I know from different aspects of life somehow know each other because they are friends of friends. I can easily share great information with hundreds of people with one easy click.

Business networking through social media is a wonderful tool. I have recently been contacted by a number of sleep consultants who found me through Facebook. Since there are always so many questions about sleep, I'm excited that many of these certified sleep consultants have offered to share articles when they write them. Some have been published on other sites, and I have (or will) post those articles on my Social Media sites. For those who have great information to share but don't have a website to link, I will have them guest blog here.

I'm excited to introduce my first ever guest blogger, Kerrin Edmonds.

Kerrin grew up on California’s Central Coast and has lived there her whole life.

Growing up with a Mom who owned and ran her own preschool, as well as being the oldest of three kids, Kerrin has always been around children from the start. But her passion for babies and more particularly, for baby sleep issues, was born with her first baby. After weeks of crying and sleepless nights, she felt there had to be a better way……So she started her journey to a better sleep for her whole family. After graduating from the Family Sleep Institute, and becoming certified with the International Sleep Consultants Association, Kerrin founded “Meet You in Dreamland,’ where she helps families find and keep their restful nights sleep.

Kerrin also works with a local group called Pickles and Tickles, a organization that offers early intervention services to families with children under the age of three.

Kerrin lives in California's San Luis Obispo North County with her husband, daughter, son, funny looking little dog and sweet kitties.

Common Sleep Myths

By Kerrin Edmonds

As we parent our children in regards to sleep, there is a myriad of information, recommendations, myths, rules and even legends! It can be tough to sort through and make sense of it all. In this article I will respond to 5 of the most common Sleep Myths.

1. Putting Rice Cereal in a Babies Bottle will help them Sleep Longer-

This one has been around for decades! Many studies have  proven that babies who were given rice cereal in their bottle did not sleep any longer than those who did. Some parents have even found the opposite to be true….that babies who were given too much rice cereal or were given rice cereal at a young age suffered from indigestion and tummy upset.

2. Keeping a baby/child up later at night will make them sleep in.

This one couldn’t be further from the truth. While on the surface this makes sense, we must think biologically not logically when it comes to our child’s sleep. If we allow our children to become overtired they release a hormone called Cortisol, which is similar to adrenaline. This hormone makes it very hard for them to fall and stay asleep. Babies sleep better, longer, and cry less if they are put to bed early in the evening. Babies who go to sleep late in the evening are often "over tired", even though they seem to have energy. A typical and healthy bedtime, depending on how they napped during the day is between 6-8 pm.

3. A Baby should sleep through the night at 12 weeks-

While this would be nice, and does happen in some cases with some babies, it can be an unrealistic expectation and just cause stress if it doesn’t happen for you. It isn’t unreasonable for a baby to “need” a feeding during the night till around 9 months of age.

4. My child doesn’t need as much sleep as other children-

I hear this one a lot in my profession and while this might make a parent feel better about how little their child sleeps, it really isn’t true. It is true that some kids need/love sleep more than others but usually this varies by only an hour or two, not huge amounts that I tend to see. It is not uncommon for children to fight sleep but that doesn’t mean they don’t need it.  I am confident that all children can be taught to be good sleepers…..and isn’t that what we want?!

5. You can sleep train a newborn-

In all reality you can’t sleep train or schedule a newborn. Sometimes an infant might appear to be on a schedule until it suddenly changes. This is because our babies Circadian Rythmn or body clock is not biologically mature yet. This maturing starts around 4-5 months of age and this is when we can start scheduling naps, etc.

Most basic baby sleep myths can be busted by remembering to think biologically instead of logically in regards to our children’s sleep.  Respecting and encouraging our children’s need for sleep is something every baby deserves!

Feeding Your Newborn

I wrote today's blog as a new web page for our office website, but it works well for here too...

Determining what to feed your baby is a big decision when you become a parent. Regardless of whether babies get breastmilk, formula, or a combination of both, the most important thing to remember is that they need to be hydrated and get the nutrition needed to grow. Many parents are guilted into choosing one feeding over another based on friend's or family's opinions. Some parents have a feeding plan that simply doesn't work. You must choose what works best for you and your baby! Remain flexible if needs change.

Breastfeeding is the ideal way for many babies to be fed. Just a few reasons breast is best: it protects against illness, helps prevent allergies, is inexpensive, and even helps the mother in many ways! The American Academy of Pediatrics recommends breastfeeding for as long as mother and baby mutually desire. We think it is ideal to use exclusive breastmilk for 4-6 months, then add foods with breastmilk until at least 1 year of age.

Ideal does not mean this is the only option. Despite being natural, it is not always easy (or even possible) for mothers to breastfeed. We recognize this and support all parents in feeding their infants a nutritionally sound milk - whether it is formula or breastmilk.

Problems breastfeeding? We have several pages of breastfeeding topics on this link.

Some babies are born with a short frenulum under the tongue. Many people refer to this condition as "tongue-tied" (medically called ankyloglossia). Sometimes affected children may have trouble feeding or later talking. If it is a problem feeding in the newborn period, one of our physicians can clip the frenulum (the part that "ties" the tongue down) and release the tongue so it can move better. We will be happy to discuss and evaluate if you feel your child will benefit from this procedure.

We also have a Nurse Practitioner and nurse available in our office who have additional breastfeeding education (not IBLCE certified) and can coordinate a lactation consultant (IBLCE certified) to visit with you in our office or at your home. Just ask!

Formula has come a long way over the years to becoming more tolerable and nutritious. There are as many reasons parents use formua as there are brands available. There are even several varieties within each brand, making which formula to use a difficult choice for some. We support partially hydrolyzed formula as an initial formula for most babies who will take formula to reduce risks of milk protein sensitization. Soy formulas and lactose free formulas are not generally recommended unless there are specific medical needs. Discussion of why we have these recommendations is found on How to Choose What to Feed. There may also be benefit to whey formulas over casein products. Discuss any formula changes with your provider. We don't want babies to be on a new formula every other day... they don't tend to tolerate that well and it is difficult to determine their response to changes if they are made too frequently.

How much to feed? This common question varies by age and size of your baby. In general the first few feedings are measured in milliliters, regardless if breast or bottle feeding. Too much too soon tends to come back up!

Breastfed babies usually do well on colostrum alone until milk comes in (around day 3-4). They typically feed immediately after birth, but then are sleepy until about 24 hours of age, so might need encouragement to eat. We expect them to lose up to 10% of their birth weight during the first week. We want them to feed at least 8 times per 24 hours, which averages to about every 3 hours. They should wet at least 1 diaper the first day, 2 wet diapers the 2nd day, and 3 diapers the 3rd day. By day 4, milk should be in and they should have wet diapers about every time they eat. Some urine might hide in stool, so if they are feeding well, stooling, and not losing excessive weight, don't worry if they don't seem to be making urine. Most mothers will work with a lactation consultant and their nursery nurse while in the hospital. We watch their weight carefully until weight gain is established. Term babies should be back to birth weight by 2 weeks of age.  

Formula fed infants typically take 10-15 ml with the initial feed. They eat about every 3 hours (range 2-4 hours), and slowly increase the amount of formula to about 30ml (one ounce) per feed over the first days. When they show hunger sooner than their schedule, it means they are ready to increase the volume per feed. Like breastfed babies, we expect them to lose weight the first week, although typically less is lost compared to a breastfed baby. By the end of the first week they take about 60ml (2 ounces) every 3 hours. They should be back to birth weight by their 2nd week birthday. By the end of the first month they take about 24 ounces per 24 hours (average 3 oz every 3 hours).

For more on feeding volumes, see Feeding Your 0-2 Month Old. 

Vaccine timing... is it too late?

It is common in the summer months for parents to worry about their child's vaccines being delayed by summer travel or simply scheduling conflicts.

The typical question I am asked is along the lines of, "He is due for his 4 month shots on July 5th, but we are on vacation. Is it okay to wait until the end of July?"

or

"Tweeny is getting her first HPV vaccine today, but she has a big out of town tournament the week she is due for the 2nd dose. Can she come later?"

The answer to both questions: yes.

Vaccines are recommended with minimal intervals (you can't give them too soon) but if there is a delay for whatever reason (missed appointments, scheduling conflicts, immune compromise-such as cancer in a child or their caregiver) it is recommended to catch up as soon as possible.  Doses do not need to be repeated if the interval has been longer than recommended.

Conversely, it is not appropriate in most cases to give vaccines at shorter intervals or before the recommended age.

The 12-15 month vaccines are occasionally given before the 1st birthday, which does not count in Kansas.  Some states have a leeway for giving doses early, but Kansas does not. This is an issue with some children moving to our state from a more lenient state. Maybe they get their MMR a couple days before their first birthday. Does this protect them against measles, mumps, and rubella? Probably. Does the school count it? No. They need to repeat it.

Another scenario is children traveling outside the US. It is recommended for international travelers over 6 months to get an MMR early due to worldwide outbreaks. This dose does not count toward the 2 doses typically given because younger children do not make immunity as reliably, but is felt to potentially benefit those at higher risk due to travel.

Another common scenario involves Hepatitis A and B vaccines due to the ages given and the intervals required.

The dosing interval for Hepatitis A is a minimum of 6 months. We typically give it at 12 months and 18 months, but if these appointments are scheduled with less than 6 months between, we typically wait until the 24 month visit to do the 2nd Hepatitis A vaccine. This delay is okay. 

Hepatitis B vaccine is given in 3 doses, with the second 4 weeks after the first, then the 3rd at least 8 weeks from the 2nd and 16 weeks after the 1st.  If a newborn does not get the first Hepatitis B vaccine on the date of birth for whatever reason (too ill, parental preference, prematurity) and the one month well check is less than 28 days from the first dose, we delay the 2nd Hepatitis B vaccine until a future visit. This will push the 3rd dose back in most cases.

Each year the CDC updates the recommended vaccine schedule. We know it is confusing to parents, but we will help keep your kids on track!

Decisions Parents Make: Use all the facts

Parents struggle with decisions

I was recently asked to clarify a comment I made on facebook, and the comment deserves more than a quick facebook blurb.


The original post:

If you ever plan on having kids, PLEASE make sure you educate yourself about this!

Myths about Circumcision You Likely Believe | Psychology Today

www.psychologytoday.com

CIrcumcision does great harm to babies By Darcia Narvaez, Ph.D....

My reply:
This is one way to use "studies" to distort facts. This article has so many inaccuracies I don't know where to start. 

One of the great things about our country is we have freedom of speech.  I highly support everyone being able to state their opinion, including those who disagree with my opinion.  But I also think we all need to look at opinions as opinions, not as hard fact.  Read articles critically and form your own opinion. Read articles from both sides of the line before you draw your conclusion.  When authors have an agenda (which is why most writers write, including myself here) you must be able to see when they are able to share both sides of a story and when they are simply stating the facts that support their cause.  I am not saying that it is wrong to just state your opinion, just that readers must know how to filter the information. I personally dislike/hate when an argument is actually based on emotion and fears, but comes off as science.  Too many parents are made to feel guilty because they have made a choice for their child that differs from a friend or relative. They read something that differs from what they did and they feel like they made the wrong choice. Regret is a dangerous thing, and is often misplaced.

The intent of my facebook comment above is not to support or discourage circumcision, but rather to warn that when authors have a strong agenda, the methods of persuasion often cause doubt and guilt in readers. I do not find this to be helpful in any way. Data and statistics can be used to distort reality, especially when studies are hand picked to only discuss the ones that support your cause and the ones supporting the contrary are omitted. This includes not only circumcision, but also breastfeeding, vaccines, home schooling, discipline, religion, government, and many, many other topics. 

The first clue that this is an article with a cause is the title and subtitle: “Myths about Circumcision You Likely Believe  CIrcumcision does great harm to babies”.  Simply reading this title alerts the reader that the author is going to persuade you that circumcision is a bad thing.  Their argument is one side of the circumcision debate, but you need to read the counter point from someone who supports circumcision before you make a decision.  

As a disclaimer and credentials for why I feel I can give an educated opinion:  I am a pediatrician who has performed many circumcisions during my 13+ years of private practice. I let parents make the decision to do or not do the circumcision and do not try to sway their decision in any way. I invite parents to watch every time, and nearly half of boys have one or both parents present. Typically parents are impressed by the overall brief procedure. Many have commented that it wasn’t as bad as they thought it would be. I have never had anyone comment how bad it was and have never had anyone (parents, nurses, medical students, or nursing students) become physically ill from watching. I admit that it could be awkward for a parent to express negative comments, so they could simply keep their thoughts to themselves, but experience tells me that when people are upset about things, they tend to complain.  So the many positive comments without any negative comments supports that parents have a generally good feeling about their decision even after watching the procedure.  Note: parents are self selecting here. The parents who don’t want a circumcision in the first place don’t agree to the procedure, and the parents who don’t want to watch are not able to comment on the actual procedure.

Starting with myth 1.  The foreskin is the distal skin of the penis and is removed during the circumcision. It is true that it is adhered to the glans of the penis in a newborn, and there are several means to break these adhesions. This is the most painful part of the circumcision in my opinion (but with adequate pain relief, this pain is diminished/eliminated-- see #3).  As for the surface area of the foreskin in an adult male, I do not see how that accounts for anything about a newborn’s circumcision. A newborn does not have 15 square inches removed. Adult males have wide variation in penile size, and therefore foreskin size.  What has been documented is the more foreskin surface area, the more likely a male will suffer from sexually transmitted diseases:

• Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis: Tobian A.A.R. et al. (2009) 

• Foreskin surface area and HIV acquisition in Rakai, Uganda (size matters) 

• Foreskin surface an  HIV acquisition  

Myth #2.  Procedures hurt, but that doesn’t mean pain isn’t managed. I agree that anesthesia helps, and this has been shown by several studies. The small study by Lander the author mentions shows that the best form of pain control is with the ring block, which injects lidocaine around the base of the penis. However the only form of anesthetic mentioned in the Myth article is the dorsal block, stating that it is the most common. In reading the article by Narvaez, it is stated that one patient in Lander's study suffered a seizure. Reading Lander’s summary, it appears the baby had apnea and loss of tone in the limbs. While this could represent a seizure, it could also be a choking episode, which is common with newborns feeding or crying. I have seen these in many newborns not associated with any procedure. It is difficult to presume it was a seizure from this documentation, and the conclusion of a direct cause/effect from the procedure cannot  be certain. The small sample size of the study limits the validity and generalizability of any findings, including problems encountered. I personally use sucrose pacification (sugar water on a parent or nurse finger or a pacifier) plus a ring block. Neither of these were mentioned by the author. Sucrose pacification has been shown to help with painful procedures the first 4 months of life. I use it to decrease the pain associated with the injection of lidocaine for the ring block and throughout the procedure. I find that babies tolerate the procedure very well the large majority of the time. What also wasn’t mentioned is that there are many types of circumcisions. Training of the physician typically dictates method used, but they each have their own risks and benefits and pain scores.

Myth #3.  See also #2. I do not know where the 45% of doctors using anesthesia number comes from. In my geographic area at the 4 hospitals in which I take care of newborns, anesthesia of some sort is used by all physicians doing circumcisions to my knowledge. In my area it is typically the pediatrician who performs the circumcision, and few obstetricians do it, not OBs.  As for it taking 30 minutes to achieve anesthesia, I have no idea where that number came from.  Local anesthetics have rapid onset once injected. Lidocaine takes 0.5-1 minute, prilocaine 1-2 minutes.  Topical preparations do take longer and should be placed at least 30 minutes prior to the procedure, and they are much less effective in general than injectable anesthetics.  

Myth #4. I cannot understand how this can be reliably tested. The process of birth itself is traumatic. The large majority of boys in the United States are circumcised, but I do not need to treat the majority of boys for Post Traumatic Stress Disorder. The choice of pain relief by Taddio in his studies (referenced in the Myth article) was a topical anesthetic, which is not as effective as other forms of anesthesia. This highlights that you can formulate the methods of your study to get the answer you are looking for, not necessarily the whole truth of the matter. If Taddio really wanted to prove that anesthesia made a difference, the choice of anesthesia should have either included several types ~ or at least the most efficacious, not the least.  Linking long term effects to a single newborn experience would be impossible in my humble opinion because there are too many confounding factors and it is impossible to isolate a single cause/effect relationship.  This is simply a ploy to get parents to regret a choice they have made for their children. This is horrendous in my opinion. We have many opportunities to feel guilt, please do not try to make parents feel guilty about a choice they have made that can impact the health of their son.

Myth #5. Yes, some babies sleep comfortably during the procedure. I have many parents that can agree with this statement after watching their sons undergo the circumcision.  Their babies did not cry themselves to sleep or go into a shock state. They were just sleepy babies. Most do not sleep ~ after all we are stimulating them by moving them around, washing the area, and otherwise touching them.

Myth #6. There are risks to all procedures. A physician should discuss the risks and benefits prior to the procedure. Parents have the right and responsibility to make choices for their children.  Of the complications listed, these are not unique to circumcised males. 

• Meatal stenosis is a narrowing of the urethra that both boys and girls can have, not necessarily after circumcision.  It can be a complication of circumcision from irritation, but is rare.

• Adhesions are NORMAL.  I mentioned above (Myth 1) that they must be broken to remove the foreskin. Without a circumcision they tend to release by 6 years of age. Some circumcised boys re-attach the foreskin without any need to do anything since they typically release on their own by 6 years of age. This is especially common if the pubic fat pad pushes the skin of the penis up and buries the penis (see next item).  While some physicians recommend breaking these adhesions, I have found that it is not required to break these attachments in most cases. This has been validated by Ponsky et al at Penile adhesions after neonatal circumcision. Rarely boys develop bridging adhesions which are different, and these do need to be repaired. 

• Buried penis is common when infants have a thick fat pad at the base of the penis. This happens in both circumcised and uncircumcised boys. It has nothing to do with the amount of foreskin removed. The worst I ever saw was in an uncircumcised toddler. He suffered complications to the point where he needed a circumcision as a preschooler to resolve the problems. This required general anesthesia which involved greater risk than neonatal circumcision.

• Infections are possible any time the skin is broken, yet I have never seen an infected circumcision. It is a risk that should be discussed prior to the procedure so parents know how to identify it early and seek help.  Poor sterile technique has been associated with infection and has made the news earlier this year. If done in a hospital setting with proper technique this risk is minimized. Those having a bris should find a qualified mohel with a good record for safety and proper hygiene.

• Death is very rare. Risk factors, such as family history of bleeding disorders should be discussed prior to the procedure. Vitamin K should be given prior to procedures to decrease risk of bleeding. After the circumcision the site should be routinely checked by trained persons to assess for bleeding. See also infection risk above.

Of course no mention of benefits was made by the author. This unbalanced view does not allow a full disclosure of both sides. 

• A significant decrease in sexually transmitted diseases has been shown among circumcised men. 

• Urinary tract infection risk can be decreased in infants. 

• Phimosis and balanoposthitis are infections caused by improper cleaning of the uncircumcised foreskin. I have seen phimosis once when working as a nurse assistant in a nursing home. It was painful and a horrible consequence of care takers not knowing how to care for the uncircumcised penis. Can this be prevented? Yes. But in our country where most men are circumcised, it is not common knowledge. 

• Improved hygiene in general is easier in circumcised males. I have instructed many families on how to care for the penis, but find that many boys don’t care for themselves properly as they become independent in the shower. Parents need to discuss this with their uncircumcised sons often!

• A decrease in penile cancer risk after circumcision.  

My intent on writing this is not to support or condemn circumcision, it is to simply show how only looking at one side of any conflict can lead to confusion and misinformation.  Learn to look at both sides of an argument to make a better informed decision that is right for you! Don't judge others for their decisions, and don't feel regret for decisions you made based on the information you had!