Related Terms

• Acquired immunodeficiency syndrome, AFP test, AIDS, ALD, alpha-fetoprotein test, amniocentesis, amniotic banding syndrome, ancephaly, Apgar Scale, arcuate nucleus, biliary atresia, Brazelton scale, chlamydia, chorionic villi, chorionic villi sampling, Clostridium tetani, CVS, cystic fibrosis, diaper rash, Down's syndrome, duodenal atresia, esophageal artresia, FAE, FAS, fetal alcohol effects, fetal alcohol syndrome, fetal echocardiography ultrasound, fluoride, folic acid, genital warts, gonorrhea, hemoglobin, hepatitis B, herpes, HIV, HPV, human immunodeficiency virus, human papilloma virus, Huntington's chorea, hyperbilirubinemia, IgA, IgD, IgE, IgG, IgM, immunoglobulin D, immunoglobulin E, immunoglobulin G, immunoglobulin M, infant botulism food poisoning, infant brain development, infant development, infant eye development, infant health, infant mortality, infantile colic, listeria, neonatal adrenoleukodystrophy, neonatal care, neonatal jaundice, neonatal lupus, neonatal myasthenia gravis, neonatal ophthalmitis, neonatal respiratory distress syndrome, neonatal tetanus, neural tube defects, omega-3 fatty acids, placenta previa, prenatal care, Rh factor, sickle-cell anemia, SIDS, spina bifida, stomach sleeping, sudden infant death syndrome, syphilis, Tay-Sachs, toxoplasma, transabdominal CVS, transcervical CVS, trichomoniasis, unconjugated bilirubin, vaccination.

Background

• A healthy start in life is important to every newborn baby. The first 28 days, called the neonatal period, is especially critical. It is during this time that fundamental health and feeding practices are established. It is also during this time that the child is at highest risk for death.

• Newborns have the highest risk of death among all children.

• Angola in Africa has the highest infant mortality rate (180.21 deaths per 1,000 infants). The United States has 6.26 deaths per 1,000 infants. Singapore has the lowest infant mortality rate (2.31 deaths per 1,000 infants). It has been estimated that about four million newborns die every year, which represents 40% of all deaths to children under age five. Death rates among children under age five have declined in recent decades, but newborn death rates have not changed significantly in the United States.

• Some common neonatal disorders include sudden infant death syndrome (SIDS) and neonatal jaundice. SIDS is the leading cause of death among infants who are one month to one year old. According to the American SIDS Institute, about 2,500 infants die from this condition each year in the United States. Neonatal jaundice is jaundice that begins within the first few days after birth. Jaundice is a yellowish discoloration of the skin, conjunctiva (a clear covering over the sclera, or whites of the eyes), and mucous membranes caused by hyperbilirubinemia (increased levels of bilirubin in red blooded animals). Neonatal jaundice is usually harmless but should be monitored by a qualified healthcare provider as a precaution.

• Most newborn deaths could be prevented if women had access to basic healthcare, such as immunizations to protect expectant mothers and newborns against tetanus, breastfeeding to provide nutrition and immune support, timely and appropriate treatment of newborn infections, and proper attention to hygiene of the newborn.

• Routine visits to the doctor are important to a newborn's health. Babies will get their recommended immunizations during routine visits. Routine exams and screenings help to prevent and treat health problems in infants, as well as chart their growth and development.

• A baby's immune system is not fully developed until he/she is about six months old. In the meantime, pregnant mothers pass immunoglobulin antibodies from their bloodstream, through the placenta, and to the fetus. These antibodies are an essential part of immune system. They identify and bind to harmful substances that enter the body, such as bacteria, viruses, and fungi. The antibodies then trigger other immune cells to destroy the foreign substance and prevent infection and disease.

• A specific type of immunoglobulin, called immunoglobulin G (IgG), is the only antibody that crosses the placenta to the fetus during pregnancy. IgG antibodies are the smallest, but most abundant antibodies, making up 75-80% of all the antibodies in the body. They are present in all body fluids and they are considered to be the most important antibodies for fighting against bacterial and viral infections. These antibodies help protect the fetus from developing an infection inside the womb.

• Immediately after birth, the newborn has high levels of the mother's antibodies in the bloodstream. Babies who are breastfed continue to receive antibodies via breast milk. Breast milk contains all five types of antibodies, including immunoglobulin A (IgA), immunoglobulin D (IgD), immunoglobulin E (IgE), IgG, and immunoglobulin M (IgM). This is called passive immunity because the mother is "passing" her antibodies to her child helping protect the baby from diseases and infections.

• During the next several months, the antibodies passed from the mother to the infant in breastfeeding steadily decrease. When healthy babies are about two to three months old, the immune system will start producing its own antibodies. Initially, the infant produces antibodies at a much slower rate than adults. Once healthy babies reach six months of age, their antibodies are produced at a normal rate.

Neonatal Health

• Prenatal care: Getting early and regular prenatal care is one of the most effective ways to ensure a healthy pregnancy. Prenatal care is very important and includes education and counseling about how to handle different aspects of pregnancy, such as nutrition and physical activity, what to expect from the birth itself, and basic skills needed to properly care for the infant.

• Prenatal visits also give the woman and her family a chance to talk to a healthcare provider about any questions or concerns related to pregnancy, birth, or parenthood.

• The objective of prenatal care is to monitor the health of the pregnant mother and fetus. It is important to visit the doctor as soon as a woman suspects she is pregnant. At each visit, a doctor examines the person and make sure that the baby and the mother are healthy. This examination includes: monitoring weight gain or loss, blood pressure, circumference of the abdomen, position of the fetus, and fetal heartbeat. Such variables are going to be closely followed during the course of the pregnancy.

• A doctor may schedule monthly visits during the first two trimesters (from week one to week 28 of pregnancy), every two weeks from weeks 28-36 of pregnancy, and weekly after week 36 (until the day of delivery that could be between 38 to 40 weeks).

• Food and nutrition during pregnancy: It is important for an expectant mother to eat a healthful diet. Unless she has a specific health problem (such as diabetes mellitus), common sense nutritional advice should be followed: balancing carbohydrates, fat, and proteins and eating a variety of foods, including dairy products and several fruits and vegetables daily. A pregnant woman should consult her obstetrician for specific advice. Some specific nutritional needs for pregnancy are listed below.

• Energy needs increase in the pregnant woman only about 15%. However, pregnancy does not mean increasing the caloric intake. The individual should increase his/her intake of certain nutrients, including folate (folic acid), iron, and calcium. Pregnant women need to choose nutrient-dense foods to assure an adequate nutrient intake without increasing calories. For many women, this requires some change in their current eating habits. Grains, fruits and vegetables, protein (red meat), dairy (for calcium), healthful fats (such as omega-3 fatty acids), and plenty of water (6-8 glasses daily) are recommended.

• Folic acid, also called folate or vitamin B9, is strongly recommended by healthcare professionals at the start of pregnancy and even before conception. Folic acid is needed for the closing of fetus' neural tube. In the developing fetus, the neural tube is the precursor to the central nervous system, which includes the brain and spinal cord. Folic acid thus helps prevent neural tube defects, including spina bifida and anencephaly. Folates are abundant in spinach (fresh, frozen, or canned) and are also found in green vegetables, salads, melon, and eggs. In the United States and Canada, most wheat products (such as flour or noodles) are supplemented with folic acid.

• Calcium and iron are particularly needed by the rapidly growing fetus who needs these minerals more than the average individual. Pregnant women should eat the recommended daily allowance of dairy products (for calcium) and red meat (for iron) if they are not lactose intolerant or vegetarian. Women who do not eat dairy or meat can obtain calcium and iron from fortified soy milk and juice, soybeans, and certain leafy greens. Doctors may prescribe iron supplements if pregnant women develop anemia. Calcium is effective only if women also obtain enough vitamin D. Milk and dairy products are good sources of vitamin D. Salmon and fatty fishes are also good sources.

• Fluoride helps to build strong teeth by changing the nature of calcium crystals. If water or salt does not contain fluoride, it is wise to take fluoride mini-pills at the end of pregnancy and during breastfeeding, but high doses are toxic. In many American cities, drinking water is supplemented with fluoride.

• Oils from salmon, trout, tuna, herring, sardine, mackerel, and some chicken eggs contain omega-3 fatty acids that are needed to build neuron membranes. Thus, fatty fish intake during pregnancy may provide nutrition for proper brain and retina development of the fetus. However, large fish such as tuna and swordfish, may contain too much toxic mercury and one should balance risks with benefits; fish two or three times per week seems to bring enough good fat, but not too much mercury. Omega-3 fatty acids are also present in walnuts, flaxseed, and marine algae.

• Dangerous bacteria or parasites may contaminate foods, particularly listeria and toxoplasma. To avoid those two hazards, hygiene rules should be strictly adhered to: carefully wash fruits and raw vegetables, overcook meats, avoid raw-milk cheeses (due to listeria), try to avoid contact with cat feces (due to toxoplasma), and clean the fridge often with diluted bleach (then rinse).

• It is best to maintain a healthy weight and diet and to exercise regularly before, during, and after pregnancy. Pregnant women should talk to their doctors to determine what types of exercise and how much physical activity is safe during pregnancy. In general, healthcare professionals recommend that pregnant mothers avoid smoking, alcohol, and drug use before, during, and after pregnancy.

Selected Neonatal Health Conditions

• Sudden infant death syndrome (SIDS):

• Sudden infant death syndrome (SIDS) is the sudden and unexplained death of an infant younger than one year of age. It is a frightening prospect because it can strike without warning, usually in a seemingly healthy infant.

• SIDS is the leading cause of death among infants who are one month to one year old. According to the American SIDS Institute, about 2,500 infants die from this condition each year in the United States. Most SIDS deaths are associated with sleep (hence the common reference to "crib death"), and infants who die of SIDS show no signs of suffering.

• When considering which babies could be most at risk, no single risk factor is likely to be sufficient to cause a SIDS death. Rather, several risk factors combined cause an at-risk infant to die of SIDS.

• Most deaths due to SIDS occur between two and four months of age, and incidence increases during cold weather. African-American infants are twice as likely and Native American infants are about three times more likely to die of SIDS than Caucasian infants. More boys than girls fall victim to SIDS. Other potential risk factors include: smoking, drinking, or drug use during pregnancy; poor prenatal care; prematurity or low birth-weight; mothers younger than 20; smoke exposure following birth; overheating from excessive sleepwear and bedding; and sleeping on the stomach.

• Stomach sleeping: The most common risk factor for SIDS is stomach sleeping. Numerous studies have found a higher incidence of SIDS among babies placed on their stomachs to sleep than among those sleeping on their backs or sides. Some researchers have hypothesized that stomach sleeping puts pressure on a child's jaw, therefore narrowing the airway and hampering breathing.

• Another theory is that stomach sleeping may increase an infant's risk of "rebreathing" his or her own exhaled air, particularly if the infant is sleeping on a soft mattress or with bedding, stuffed toys, or a pillow near the face. In that scenario, the soft surface could create a small enclosure around the baby's mouth and trap exhaled air. As the baby breathes exhaled air, the oxygen level in the body drops and carbon dioxide accumulates. Eventually, this lack of oxygen could contribute to SIDS.

• Also, infants who succumb to SIDS may have an abnormality in the arcuate nucleus, a part of the brain that may help control breathing and awakening during sleep. If a baby is breathing stale air and not getting enough oxygen, the brain usually triggers the baby to wake up and cry. That movement changes the breathing and heart rate, making up for the lack of oxygen. But a problem with the arcuate nucleus could deprive the baby of this involuntary reaction and put him or her at greater risk for SIDS.

• Neonatal jaundice:

• Neonatal jaundice is jaundice that begins within the first few days after birth. It is normal for bilirubin levels in the blood to become elevated in almost all infants during the first few days following birth, and jaundice occurs in more than half of newborns. For all but a few infants, the elevation and jaundice represents a normal physiological phenomenon and does not cause problems.

• The cause of normal, physiological jaundice is well understood. During life in the uterus, the red blood cells of the fetus contain a type of hemoglobin (the oxygen carrying protein in the blood) that is different than the hemoglobin that is present after birth. When an infant is born, the infant's body begins to rapidly destroy the red blood cells containing the fetal-type hemoglobin and replaces them with red blood cells containing the adult-type hemoglobin. This destruction of red blood cells floods the liver with bilirubin derived from the fetal hemoglobin. The liver in a newborn infant is not mature, and its ability to process and eliminate bilirubin is limited. As a result of both the influx of large amounts of bilirubin and the immaturity of the liver, bilirubin accumulates in the blood. Within two or three weeks, the destruction of red blood cells ends, the liver matures, and the bilirubin levels return to normal.

• There is another uncommon syndrome associated with neonatal jaundice, referred to as breast-milk or breastfeeding jaundice. In this syndrome, jaundice appears to be caused, or at least accentuated by, breastfeeding. Although the cause of this type of jaundice is unknown, it has been suggested that there is something in breast milk that reduces the ability of the infant's liver to process and eliminate bilirubin. With breast-milk jaundice, the bilirubin levels rise and reach peak levels in about two weeks, remain elevated for a week or so, and then decline to normal over several weeks or months. This timing of the elevation in bilirubin and jaundice is different than normal physiological jaundice described previously and allows the two causes of jaundice to be differentiated. The real importance of the more prolonged jaundice associate with breast-milk jaundice is that it raises the possibility that there is a more serious cause for the jaundice that needs to be sought, for example, biliary atresia (destruction of the bile ducts). Breast-milk jaundice alone usually does not cause problems for the infant.

• Neonatal jaundice and breast-milk jaundice usually do not cause problems for the infant; however, there is a concern that high or prolonged elevations in levels of unconjugated bilirubin (the main type that is present in physiologic and breast-milk jaundice) will cause neurological damage to the infant. Therefore, when unconjugated bilirubin levels are high or prolonged, treatment usually is started to lower the levels of bilirubin.

• Fortunately, because of modern management of pregnancy, this cause of jaundice is rare.

• Other neonatal complications:

• Pregnancy complications: Pregnancy takes about 40 weeks. If contractions cause the cervix to open earlier than normal, between the 20th and 37th week, labor may be premature. This may result in the birth of a premature baby. Babies born before the 37th week may have trouble breathing, eating, and keeping warm. The signs of premature labor include: uterine contractions every 10 minutes or faster; repeating or constant menstrual-like cramps in the lower abdomen; abdominal cramps with or without diarrhea; pelvic pressure that feels like the fetus is pushing down; increase or change in vaginal discharge; sudden gush of watery fluids from the vagina (water breaking); or a feeling like the fetus is "balling up."

• In some pregnancies, known as high-risk pregnancies, the mother and/or fetus are at an increased risk of experiencing complications. A pregnancy may be classified as high risk for a number of reasons, including:

• Mother's age: Women older than age 35 have an increased risk of having children with certain chromosomal abnormalities, such as Down's syndrome, as well as placental problems (such as placenta previa). Studies also suggest an increased risk of miscarriage and low birth weight in pregnant women in this age group. In addition, teen mothers are more likely to give birth prematurely than woman older than age 20.

• Multiples: Women carrying two or more babies are at an increased risk for a number of complications, including premature labor and low birth weight.

• Previous premature births: Women who have already delivered a premature baby are more likely to have pregnancy complications, including additional premature births.

• STDs: A number of STDs can be transmitted to a baby before, during or after birth, resulting in medical complications. STDs include: herpes, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), genital warts (caused by human papilloma virus, or HPV), hepatitis B, chlamydia, syphilis, gonorrhea, and trichomoniasis.

• Drugs: Women who were exposed to diethylstilbesterol (DES, a hormonal drug) when their mothers took the drug during pregnancy are at an increased risk for a number of complications, including ectopic pregnancy and preterm delivery.

• Alcohol-related birth defects: Physical or cognitive deficits, which can range form mild to severe, that a child experiences as the result of alcohol consumption by its mother during pregnancy. This term includes, but is not limited to, fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE).

• Fetal alcohol syndrome (FAS) refers to certain birth defects and serious, life-long mental and emotional impairments that may be suffered by a child as the result of heavy alcohol consumption by its mother during pregnancy. Symptoms of mental and emotional deficits may include significant learning and behavioral disorders (including attention deficits and hyperactivity), poor social judgment, diminished cause-and-effect thinking, and impulsive behaviors.

• Fetal alcohol effect (FAE) is a disorder associated with cognitive and behavioral difficulties in children whose birth mothers drank alcohol during their pregnancy. Symptoms are similar to Fetal Alcohol Syndrome (FAS), but less severe or comprehensive.

• Other conditions: Other health conditions that may occur in infants include: blue baby, a condition where the baby is born with a "blue" color due to congenital heart defects; childhood nephrotic syndrome, a condition where the kidney loses protein in the urine causing protein in the blood to drop and water to move into body tissues resulting swelling (edema); classic neonatal adrenoleukodystrophy (ALD) or a serious progressive, genetic disorder where the adrenal gland becomes wasted and ceases to function normally, which leads to progressively severe symptoms (occurs in boys); diarrhea; diaper rash; hemolytic disease of the newborn; infant botulism food poisoning; infantile colic; neonatal lupus, an autoimmune condition; neonatal myasthenia gravis, a lack of muscular control; neonatal ophthalmitis, inflammation of the eyes; neonatal respiratory distress syndrome, a syndrome caused in premature infants by developmental insufficiency of protein production and structural immaturity in the lungs; and neonatal tetanus, an often fatal infection with toxins from the bacterium Clostridium tetani.

Diagnosis

• Normal newborn weights and measurements include: normal weight, between seven and eight pounds; normal length, between 19-21 inches; and normal vision, 20/40. Vision is clear at a 12-inch distance.

• Neonatal testing:

• The Apgar Scale: The Apgar Scale is used within the first five minutes after birth; the infant's heart rate, respiratory effort, muscle tone, body color, and reflexes are analyzed.

• The infant receives a score of zero, one, or two for each of the above mentioned health signs. This is performed by an obstetrician or nurse. Results should be: seven to 10 = normal or good condition; five = may have developmental difficulties; three or below = high or increased risk of death.

• The Brazelton Scale: The Brazelton Scale is used to assess the newborn hours after birth. Evaluations include neurological development, various reflexes, and reactions to people in different circumstances. Results of the test are shown by terms such as: "worrisome", "normal," or "superior."

• Diagnostic therapies:

• Ultrasound: An ultrasound exam is a procedure that uses high-frequency sound waves to scan a woman's abdomen and pelvic cavity, creating a picture (sonogram) of the baby and placenta. Although the terms ultrasound and sonogram are technically different, they are used interchangeably and reference the same exam.

• Fetal echocardiography: Fetal echocardiography ultrasound waves assess the baby's heart anatomy and function and check for congenital heart defects.

• Ultrasounds may be performed at any point during pregnancy, and the results are seen immediately on a monitor during the procedure.

• Amniocentesis: Amniocentesis involves extracting and examining DNA and chromosomes from the mother in order to determine if the baby has a chromosome disorder or fetal lung maturity. Amniocentesis may be recommended or suggested under many different circumstances, including if the woman is older than 35 years of age. This is done mainly to determine if the fetus has Down's syndrome, which is more prevalent among children with older mothers. If the woman has had another child or a close relative that has had a neural tube defect in the past, a doctor may recommend an amniocentesis to rule out the possibility of a defect in the child. If both the mother and the father are carriers for an autosomal recessive inherited disorder, such as Tay-Sachs or sickle-cell anemia, amniocentesis may be recommended. If a child has already been born with a chromosomal abnormality such as Down's syndrome, an amniocentesis will be able to determine if the fetus exhibits the same abnormality. If the mother is a carrier for an X-linked (or sex-linked) genetic disorder, an amniocentesis can identify whether the baby has inherited the gene from the mother and determine the gender in order to see if the baby will be affected by the presence of the genetic defect. If the mother or the father has an autosomal dominant disorder, such as Huntington's chorea, amniocentesis may be performed to determine if the fetus has inherited the disorder. If any type of infection of the fetus or the mother is suspected, amniocentesis may be performed

• Amniocentesis is best performed at 15-17 weeks of gestation, but occasionally as early as the 14th or as late as the 20th week. Amniocentesis can also be performed in the last trimester to assess the maturity of the fetal lungs. Test results are usually back in one week.

• The expectant mother is positioned on her back with her abdomen exposed. Using ultrasound technology, the location of the fetus and placenta are located. This is in order to reduce the chance of accidentally damaging the fetus. The abdomen is then swabbed with antiseptic solution and sometimes a local anesthetic. A long, hollow needle is then inserted through the abdomen and into the uterus. A small amount of amniotic fluid is then withdrawn. Before, during, and after the procedure, the mother's vital signs and the fetus' heart tones are monitored to ensure no complications are experienced. From start to finish, the entire procedure should not take more than 30 minutes.

• If a genetic disorder is detected, individuals will be referred to a genetic counselor for further counseling and decision making. The genetic counselor can answer questions and suggest further tests to help see how the child's health may be affected. In many cases, a genetic counselor can reassure the individual that the risk to the baby is lower than feared.

• Amniocentesis gives healthcare providers the ability to extract and examine the fluid from the amniotic cavity. It is reported to be significantly accurate in diagnosing potential health conditions for the baby, such as Down's syndrome. Amniocentesis may cause fatigue, mild cramping, and slight vaginal bleeding or leakage of amniotic fluid in the mother. In rare occasions, the woman may experience infection as a result of the procedure or even more severe complications that may lead to miscarriage. It is suggested that it may raise the risk of fetal loss by 0.5%. Amniocentesis should only be used when the benefits outweigh the risks.

• Chorionic villi sampling: Chorionic villi sampling (CVS) is done to determine if the child has a chromosomal disorder, such as Tay-Sachs, sickle-cell anemia, most types of cystic fibrosis, or Down's syndrome. Chorionic villi sampling involves placing a small needle or catheter either through the abdomen or through the vagina near the uterus in order to collect a small sample of placental tissue called chorionic villi. Ultrasound is used at the same time in order to guide the needle or catheter away from the baby and the placenta. The test can be done as early as 10 weeks and is most commonly done between the 10th and 13th weeks of pregnancy.

• CVS is performed in the first trimester, and it can give results or reassurance early in pregnancy. It is important to note that tests results are not reliable; parents should consider all of the possibilities before making any serious medical decisions.

• CVS is normally performed in a hospital. The sample of cells from the placenta is taken via the vagina and cervix (transcervical CVS) or via a needle inserted in the abdominal wall (transabdominal CVS). Though this is a fairly common procedure, some discomfort, ranging from mild to severe, may be present during a CVS.

• Transcervical CVS involves the insertion of a long thin tube into the vagina. Guided by ultrasound imaging, the doctor directs the tube to the tissue that will eventually become the fetal half of the placenta. A sample is then trimmed off for further study.

• With the transabdominal CVS procedure, the doctor will again use ultrasound to determine the exact location of the placenta and to find a safe place where to insert the needle to minimize any trauma to the mother or child. A needle is then inserted through the abdomen and uterus to the edge of the placenta. At this point, a narrower needle is inserted through the guiding needle and a small sample of cells is taken from the chorionic villi for diagnostic study. It is generally recommended that those undergoing the procedure arrange to have someone drive them home afterward and that they make no other plans for the rest of the day since it can be emotionally and physically taxing.

• After the samples have been taken, further diagnostic study is performed on them. Since the cells in the sample are actually of fetal origin, they can be used to generate a detailed picture of the genetic makeup of the developing fetus. In most circumstances, the results from the test are available within three to five days.

• Most studies so far have indicated that CVS is safe and reliable. However, the procedure is slightly riskier than amniocentesis. An important fact to remember is that there is a miscarriage rate associated with this test. There are also some studies that suggest that there may be a slight increase in the number of limb deformities from amniotic banding syndrome. Inexperience of the technician performing the procedure appears to be the cause of these more rare complications.

• The primary advantage of chorionic villus sampling is that results are available much earlier in pregnancy. Since it can be performed in the first trimester, CVS can give results earlier in pregnancy than amniocentesis, which is usually performed after the 16th week. Thus, if results are abnormal, the fetus can be treated prenatally; abnormal tests results may be inaccurate so it is important that parents make an educated decision that considers all of the possibilities. The risks have to be weighed against this benefit of earlier diagnosis and should be discussed at length with a doctor. If a genetic disorder is detected, individuals will be referred to a genetic counselor for further counseling and decision-making.

• Glucose screening: With good medical care, women with preexisting or gestational diabetes can have an uncomplicated pregnancy and a healthy baby, as long as blood sugar levels are well controlled. A glucose screening can let the woman know if she is at risk. Most practitioners check for gestational diabetes at about 28 weeks.

• Apha-feto protein: The alpha-fetoprotein test (AFP test) is where a blood sample is drawn from the mother to check the levels of AFP. AFP is a protein secreted by the fetal liver and excreted in the mother's blood. It is generally used to provide a screening for neural tube defects like spina bifida and ancephaly. It can also indicate: abdominal wall defects, esophageal and duodenal atresia, some renal and urinary tract anomalies, Turner syndrome, some low birth-weight fetuses, placental complications, and the presence of Down's syndrome.

• Triple screening: The triple screen, also known as a maternal serum screening test or MSS, is a simple and completely safe blood test that measures not only AFP, but hCG and estriol as well. These are all hormones produced by the fetus and passed into the mother's bloodstream. The test is performed between the 15th and 18th weeks, with the results usually available within one week. Elevated levels of AFP in the mother's blood can indicate a neural tube defect in the baby such as a deformity of the spinal canal known as spina bifida. Lower levels of AFP suggest a possible child with Down's syndrome or other chromosomal defects.

• Triple screening is more accurate and screens for additional genetic problems; it is beginning to replace the standard AFP. Generally speaking, any combination of the testing will identify 60% of the babies with Down's syndrome and 80-90% of the babies with neural tube defects. The AFP test is generally most sensitive between the 15th and 17th weeks of pregnancy, while the triple screen can be done a bit earlier.

• Quadruple screening: A fairly recent addition to the screening tests, the quadruple test is almost identical to the triple screen, except that it tests for one more marker. Again, using a sample of the mother's blood, a quadruple screen measures a woman's levels of alpha-feto protein, hCG, estriol, and inhibin to indicate her baby's risk of Down's syndrome. The quadruple test is about 81% effective and is usually performed around the 16th week of pregnancy. If a risk of Down's syndrome is indicated, amniocentesis can be performed to confirm the diagnosis.

• Choosing to have the test is a very hard decision and a very personal one. Some women feel that no matter what is wrong, they would not terminate the pregnancy and therefore, do not want the test. Others are very happy to have the normal results, even knowing that there are no guarantees. The individual may wish to seek advice from a healthcare provider that specializes in genetic counseling or other trusted medical, religious or spiritual professionals.

• Rh incompatibility: One of the first prenatal tests a doctor will give the mother is a blood test to see if she is Rh negative or positive. On the surface of many red blood cells is a protein commonly referred to as Rh factor. Those individuals with Rh factor are thought to be Rh-positive while those without it are Rh-negative. If the mother is Rh-negative (which means the blood cells do not have Rh factor on them) but the child is Rh-positive (meaning the child does have Rh factor on their blood cells), the mother's body's immune system may attack the child's blood cells, which can cause life-threatening complications.

• Women who are Rh positive have little chance of an adverse reaction to their child's blood. If, however, it is deemed that the mother is Rh-negative and there is a chance that the baby is Rh-positive (such as if the father is Rh positive), then both the mother and the baby will be at an increased risk for potential problems during pregnancy. Administration of a vaccine-like injection of Rh known as a RhoGAM can help avoid these problems.

• RhoGAM®, or Rh-immune globulin, is an injection given to Rh negative women during their 28th week of pregnancy and then again within 72 hours of birth, miscarriage, amniocentesis, or chorionic villus sampling. This injection contains antibodies that will help kill off any of the baby's red blood cells that may have entered the mother's blood stream, thereby preventing the woman's body from developing its own antibodies to the baby's blood.

• Cystic fibrosis (CF) carrier screen: Cystic fibrosis is an inherited disease that affects breathing and digestion. It is caused by an abnormal gene involved in mucus production in the body. The mucus is important in preventing infections and absorbing food within the body. Sufferers of cystic fibrosis lead an average lifespan of 30 years. A test can determine if the baby will potentially develop cystic fibrosis.

• SIDS diagnosis: While most conditions or diseases usually are diagnosed by the presence of specific symptoms, most sudden infant death syndrome (SIDS) diagnoses come only after all other possible causes of death have been ruled out through a review of the infant's medical history and environment. This review helps distinguish true SIDS deaths from those resulting from accidents, abuse, and previously undiagnosed conditions, such as cardiac or metabolic disorders.

Treatment

• General: Nutrition is a fundamental pillar of human life, health, and development across the entire life span. From the earliest stages of fetal development, at birth, and through infancy, childhood, adolescence and on into adulthood, proper food and good nutrition are essential for survival, physical growth, mental development, performance, productivity, health, and well-being.

• Sudden infant death syndrome (SIDS): Individuals can take steps to help reduce the risk of sudden infant death syndrome SIDS in the infant. First and foremost, put the infant to sleep on his or her back if the baby is younger than one year old.

• In addition to placing healthy infants on their backs to sleep, healthcare professionals suggest the following measures to help reduce the risk of SIDS: place the baby on a firm mattress to sleep, never on a pillow, waterbed, sheepskin, or other soft surface. To prevent re-breathing, do not put blankets, comforters, stuffed toys, or pillows near the baby. Make sure the baby does not get too warm while sleeping. Keep the room at a temperature that feels comfortable for an adult in a short-sleeve shirt. Some healthcare professionals suggest that a baby who gets too warm could go into a deeper sleep, making it more difficult to awaken.

• It is recommended not to smoke, drink, or use drugs (unless prescribed by a doctor) while pregnant. Pregnant mothers and newborns should not be exposed to secondhand smoke. Infants of mothers who smoked during pregnancy are three times more likely to die of SIDS than those whose mothers were smoke-free, and exposure to secondhand smoke doubles a baby's risk of SIDS. Smoking may affect the central nervous system, starting prenatally and continuing after birth, which could place the baby at an increased risk. It is also recommended to receive early and regular prenatal care. Make sure the baby has regular checkups.

• Breastfeeding is important, if possible. There is some evidence that breastfeeding may help decrease the incidence of SIDS. Substances found in breast milk may help protect babies from infections that increase the risk of SIDS.

• It is recommended to put the baby to sleep with a pacifier during the first year of life. If the baby rejects the pacifier, do not force it. Pacifiers have been linked to a lower risk of SIDS. If breastfeeding, try to wait until after the baby is one month old to use a pacifier so that breastfeeding can be established.

• While infants can be brought into a parent's bed for nursing or comforting, parents should return them to their cribs or bassinets when they are ready to sleep. It is a good idea to keep the cribs and bassinets in the room where parents sleep or within earshot of the parents. Placing the crib in the parent's bedroom has been linked with a lower risk of SIDS.

• Neonatal jaundice: Treatment for neonatal jaundice may be started earlier in infants who are born prematurely, since their livers take longer to mature and the risk of higher and more prolonged elevations of bilirubin is greater. Treatment is usually unnecessary. Treatment involves phototherapy with artificial or natural sunlight and, if phototherapy is not successful, exchange transfusion in which the infant's blood is exchanged for normal blood from blood donors. Artificial lights work by helping to break down bilirubin in the skin. The infant is placed naked under artificial light in a protected isolette to maintain constant temperature. The eyes are protected from the light. Isolettes are enclosed beds used to help babies that are either too small to maintain their own temperature or those who are sick and their temperature is not stable.

• In the most severe cases of jaundice, an exchange transfusion is required. In this procedure, the baby's blood is replaced with fresh blood. Studies have shown that treating severely jaundiced babies with intravenous immunoglobulin (IVIG) is very effective at reducing the bilirubin levels to safe ranges.

• In all cases, it is important to keep the baby well-hydrated (breast milk and formula are preferable to glucose water) and encourage frequent bowel movements by feeding frequently. This is because broken down bilirubin is carried out of the body by the intestines in the stools (bilirubin is what gives stools their brown color).

Integrative Therapies

• Note: All integrative therapies for neonatal disorders should be used only under the supervision of a qualified healthcare provider.

• Strong scientific evidence:

• Folic acid: Folic acid and folate are forms of a water-soluble B vitamin. Folate occurs naturally in food and folic acid is the synthetic form of this vitamin. Folic acid is well-tolerated in amounts found in fortified foods and supplements. Sources include cereals, baked goods, leafy vegetables (spinach, broccoli, lettuce), okra, asparagus, fruits (bananas, melons, lemons), legumes, yeast, mushrooms, organ meat (beef, liver, kidney), orange juice, and tomato juice. Folic acid is frequently used in combination with other B vitamins in vitamin B complex formulations. Studies have found that folate consumption aids in the prevention of pregnancy complications, including folate deficiency, anemia, birth defects such as neural tube defects, and pregnancy loss.

• Avoid if allergic or hypersensitive to folate or any folate product ingredients. Use cautiously if receiving coronary stents or with anemia or seizure disorders. It is recommended that pregnant women consume 400 micrograms of folate daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.

• Riboflavin: Riboflavin is a water-soluble vitamin, which is involved in vital metabolic processes in the body and is necessary for normal cell function, growth, and energy production. Small amounts of riboflavin are present in most animal and plant tissues. Riboflavin supplementation is included in the treatment of neonatal jaundice with phototherapy.

• Avoid if allergic or hypersensitive to riboflavin. Since the amount of riboflavin a human can absorb is limited, riboflavin is generally considered safe. Riboflavin is generally regarded as safe during pregnancy and breastfeeding.

• Good scientific evidence:

• Music therapy: Music is an ancient tool of healing that was recognized in the writings of Pythagoras, Aristotle, and Plato. Good evidence supports the use of music therapy for infant development and neonatal care. There is evidence that music played to the womb during late pregnancy may lead to children being more responsive to music after birth. Soothing music may help newborns be more relaxed and less agitated. Pre-term newborns exposed to music may have increased feeding rates, reduced days to discharge, increased weight gain, and increased tolerance of stimulation.

• Unclear or conflicting scientific evidence:

• Acupuncture: Acupuncture is commonly used throughout the world. According to Chinese medicine theory, the human body contains a network of energy pathways through which vital energy, called "chi," circulates. These pathways contain specific points that function like gates, allowing chi to flow through the body. Needles are inserted into these points to regulate the flow of chi. Moxibustion has been used historically in acupuncture to correct breech presentation by turning the fetus' head in utero. Further studies are needed to determine its role in the correction of breech presentation.

• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, neurological disorders, or if taking anticoagulants. Avoid on areas that have received radiation therapy and during pregnancy. Avoid electroacupuncture with irregular heartbeat or in patients with pacemakers. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with a history of seizures.

• Arginine (L-arginine): L-arginine helps maintain the body's fluid balance (urea, creatinine), and aids in wound healing, hair growth, sperm production (spermatogenesis), blood vessel relaxation (vasodilation), and fights infection. Early studies in pregnant mothers suggest that arginine supplements may decrease intrauterine growth retardation. Additional studies are needed.

• Avoid if allergic to arginine. Avoid with a history of stroke or liver or kidney disease. Avoid if pregnant or breastfeeding. Use cautiously if taking blood-thinners, blood pressure drugs, antidiabetic drugs, or herbs or supplements with similar effects. Blood potassium levels should be monitored. L-arginine may worsen symptoms of sickle cell disease.

• Borage seed oil: Borage (Borago officinalis) is an herb native to Syria that has spread throughout the Middle East and Mediterranean. Borage flowers and leaves may be eaten and borage seeds are often pressed to produce oil very high in gamma-linolenic acid (GLA). Essential fatty acid supplementation may be beneficial for infant development and neonatal care of preterm infants. Gamma linolenic acid supplementation may increase cognitive development, weight gain, and length gain, particularly in boys. High quality study is needed in this area.

• Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Avoid in patients with weakened immune systems. Use cautiously with bleeding disorders or if taking warfarin or other anticoagulant or antiplatelet (blood-thinning) agents. Use cautiously with epilepsy or if taking anticonvulsants. Avoid in pregnant patients, as borage oil may be contraindicated in pregnancy given the teratogenic and labor-inducing effects of prostaglandin E agonists, such as borage oil's GLA. Avoid if breastfeeding.

• Color therapy: Color therapy uses the proposed healing abilities of colors to treat emotional and physical problems. Color therapy is based on the idea that different colors evoke different responses in people. Studies have tested the use of integrative therapies, including color therapy, for infant development and neonatal care. Additional study is warranted.

• Color therapy is generally considered safe. Exposure to bright light may cause eye injury, such as retinopathy. Strobe lights may cause seizures in susceptible individuals. Use cautiously during pregnancy and breastfeeding.

• Flaxseed and flaxseed oil: Flaxseed and flaxseed oil/linseed oil are rich sources of the essential fatty acid alpha-linolenic acid (omega-6). It has been proposed that alpha-linolenic acid, provided as flax oil capsules, may delay the timing of spontaneous delivery, but the available evidence does not support this use.

• Flaxseed has been well-tolerated in studies for up to four months. Avoid if allergic to flaxseed, flaxseed oil, or plants in the Linaceae family. Avoid large amounts of flaxseed by mouth and mix with plenty of water or liquid. Avoid flaxseed (not flaxseed oil) with a history of esophageal stricture, ileus, gastrointestinal stricture, or bowel obstruction. Avoid with a history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis, or inflammatory bowel disease. Avoid topical flaxseed in open wounds or abraded skin surfaces. Avoid with prostate cancer, breast cancer, uterine cancer, or endometriosis. Avoid ingesting immature flaxseed pods. Use cautiously with a history of bleeding disorders or if taking drugs that increase the risk of bleeding. Use cautiously with high triglyceride levels, diabetes, mania, seizures, or asthma. Avoid if pregnant or breastfeeding.

• Ginseng: For more than 2,000 years, the roots of ginseng have been valued in Chinese medicine. Based on available evidence, it is unclear if ginseng improves birth outcomes, including anoxemic encephalopathy. Additionally, early studies have found that components of Panax ginseng might be useful in treating intrauterine growth retardation. However, larger, well-designed studies are needed in this area.

• Avoid ginseng with known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.

• Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. Researchers have studied the effects of giving birth in water on labor pain, duration of labor, perineal damage to the mother, and birth complications. Further studies of effectiveness and safety are needed before a conclusion can be drawn.

• Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, or impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physicians before starting hydrotherapy.

• L-carnitine: The human body produces L-carnitine in the liver, kidney, and brain. It is unclear if L-carnitine helps prevent miscarriage.

• Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, high blood pressure, alcohol-induced liver cirrhosis, or diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.

• Magnesium: Magnesium (Mg) is the second most abundant intracellular cation (positively charged ion) in the human body and is involved in more than 300 enzymatic reactions. Many women, especially those from disadvantaged backgrounds, have intakes of Mg below recommended levels. Mg supplementation has been administered during pregnancy with the aim of reducing fetal growth retardation and preeclampsia and increasing birth weight. Currently, there is insufficient evidence that oral Mg as a pregnancy nutritional supplement can improve maternal, neonatal, and pediatric outcomes. Additional research is needed in this area.

• Avoid use as a laxative in patients with gastrointestinal disorders, such as obstruction or ileus. Avoid intravenous magnesium in women with toxemia during the first few hours of labor. Use cautiously with bleeding disorders. Use cautiously if taking antiplatelets agents, antidiabetic agents, blood pressure-lowering agents, or antibiotics. Use topical magnesium sulfate cautiously. Use intravenous magnesium sulfate cautiously with eclampsia.

• Massage: Various forms of therapeutic superficial tissue manipulation have been practiced for thousands of years across cultures. Chinese use of massage dates to 1600 BC, and Hippocrates made reference to the importance of physicians being experienced with "rubbing" as early as 400 BC. There are references to massage in ancient records of the Chinese, Japanese, Arabic, Egyptian, Indian, Greek, and Roman nations. References to massage are also found in the Bible and the Vedas. Terms for massage include the French word masser, the Greek word for "knead," a Hindu word for "press," and an Aramaic word that means "to press softly." Massage has been used in pre-term infants by therapists or mothers with a goal to improve infant development and weight gain. It is not clear from existing studies if this is a beneficial therapy.

• Avoid with bleeding disorders, low platelet counts, or if taking blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with a history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.

• Moxibustion: Moxibustion uses the principle of heat to stimulate circulation and break up congestion or stagnation of blood and chi (energy). Moxibustion is a long-used traditional remedy in China for cephalic version (a way to try to turn a baby from breech presentation to head-down position while still in the mother's uterus), including as a self-administered technique at home by mothers. The available evidence confirming its efficacy, while showing some promise, is mixed. More studies are needed to verify whether there are predictable benefits in moxibustion for cephalic version.

• Avoid with aneurysms, any kind of "heat syndrome," heart disease, convulsions or cramps, diabetic neuropathy, extreme fatigue and/or anemia, fever, or inflammatory conditions. Avoid areas with an inflamed organ, contraindicated acupuncture points, allergic skin conditions, ulcerated sores, or skin adhesions. Avoid over the face, genitals, head, or nipples. Avoid in patients who have just finished exercising or taking a hot bath or shower. Avoid if pregnant or breastfeeding. Use cautiously over large blood vessels and thin or weak skin. Use cautiously with elderly people with large vessels. It is considered not advisable to bathe or shower for up to 24 hours after a moxibustion treatment.

• Omega-3 fatty acids: Dietary sources of omega-3 fatty acids include fish oil and certain plant/nut oils. Fish oil contains both docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), while some nuts (English walnuts) and vegetable oils (canola, soybean, flaxseed/linseed, olive) contain alpha-linolenic acid (ALA). Although laboratory and some clinical research supports the use of omega-3 fatty acids in infant eye and brain development, well-designed research is necessary before a clear conclusion can be reached.

• Pregnant and breastfeeding women should not consume doses of omega-3 fatty acids that exceed the Recommended Dietary Allowance (RDA). Potentially harmful contaminants, such as dioxins, methylmercury, and polychlorinated biphenyls (PCBs), are found in some species of fish and may be harmful in pregnant/nursing women. Methylmercury accumulates in fish meat more than in fish oil, and fish oil supplements appear to contain almost no mercury. Therefore, these safety concerns apply to eating fish but likely not to ingesting fish oil supplements. However, unrefined fish oil preparations may contain pesticides. Make sure to ask a healthcare provider about high quality fish oil supplements. Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid, or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure, or if taking drugs, herbs, or supplements that treat any such conditions. Use cautiously before surgery.

• Prayer, distant healing: Prayer can be defined as a "reverent petition," the act of asking for something while aiming to connect with God or another object of worship. Initial studies report fewer birth complications during labor in people who are religious or pray, although due to methodological problems, these results cannot be considered conclusive.

• Prayer is not recommended as the sole treatment approach for potentially serious medical conditions and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs conflict with standard medical approaches and require an open dialog between patients and caregivers.

• Probiotics: Probiotics are beneficial bacteria that are sometimes called friendly germs. They help maintain a healthy intestine and help the body digest foods. They also help keep harmful bacteria and yeasts in the gut under control. Most probiotics come from food sources, especially cultured milk products. There is currently not enough evidence to determine if probiotics can help prevent preterm birth and its complications.

• Probiotics, when added to formulas or breast milk, may foster better growth and higher counts of healthful bacteria in the gut of preterm infants. They may also boost the immune system and improve feeding tolerance. However, Lactobacillus GG may not be effective. More studies are needed to clarify specific guidelines for probiotics supplementation in preterm and very low birth-weight infants.

• Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.

• Reflexology: Reflexology involves the application of manual pressure to specific points or areas of the feet called "reflex points" that are believed to correspond to other parts of the body. Reflexology has been suggested as beneficial for fetal development. A small study reported that foot massage increased fetal activity in midgestation. Hand massage did not increase fetal activity.

• Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle or with severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, kidney stones, or with a pacemaker. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.

• Selenium: Selenium is a mineral found in soil, water, and some foods. Selenium supplementation has been studied in low-birth-weight infants. Additional evidence is warranted in this area before a clear conclusion can be drawn.

• Avoid if allergic or sensitive to products containing selenium. Avoid with a history of non-melanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.

• Vitamin A: Vitamin A is a fat-soluble vitamin. Maternal vitamin A deficiency is common in developing countries. Beta-carotene may reduce pregnancy-related complications and mortality in such individuals. However, excess intake of vitamin A has been reported to increase the risks of some birth defects. Vitamin A supplementation above the RDA is therefore not recommended in pregnancy. Use cautiously if breastfeeding because the benefits or dangers to nursing infants are not clearly established.

• Avoid if allergic or hypersensitive to vitamin A. Vitamin A toxicity may occur if taken at high dosages. Use cautiously with liver disease or alcoholism. Smokers who consume alcohol and beta-carotene may be at an increased risk for lung cancer or heart disease.

• Vitamin B6: Major sources of vitamin B6 include cereal grains, legumes (beans), vegetables (like carrots, spinach, peas), potatoes, milk, cheese, eggs, fish, liver, meat, and flour. Studies of birth outcomes with vitamin B6 supplementation during pregnancy have yielded mixed results. Further well-designed clinical trials may be helpful in this area.

• Vitamin B6 is likely safe when used orally in doses not exceeding the recommended dietary allowance (RDA). Avoid if sensitive or allergic to any vitamin B6 product ingredients. Some individuals seem to be particularly sensitive to vitamin B6 and may have problems at lower doses. Avoid excessive dosing. Use cautiously if pregnant or breastfeeding.

• Vitamin E: Vitamin E exists in eight different forms ("isomers"): alpha, beta, gamma and delta tocopherol; and alpha, beta, gamma and delta tocotrienol. Alpha-tocopherol is the most active form in humans. Premature infants are at risk of vitamin E deficiency, particularly when they are born with very low birth weight. There are numerous studies of vitamin E supplementation in preterm and very low birthweight infants to try to prevent potentially serious complications such as intraventricular hemorrhage (bleeding into the brain), retinopathy (eye damage), or death. The quality of published research is variable, and is not conclusive. Premature infants should be under strict medical supervision, and decisions regarding vitamin supplementation should be made with the infant's physician.

• Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously with bleeding disorders or if taking blood thinners. Avoid doses greater than the recommended daily level in pregnant women and breastfeeding women.

• Fair negative scientific evidence:

• Copper: Copper is a mineral that occurs naturally in many foods, including vegetables, legumes, nuts, grains, fruits, shellfish, avocado, beef, and animal organs, (e.g. liver and kidney). Supplementation with trace-elements alone, such as copper, during pregnancy does not appear to be of benefit for neural-tube defect prevention.

• Avoid if allergic/hypersensitive to copper. Avoid use of copper supplements during the early phase of recovery from diarrhea. Avoid with hypercupremia, occasionally observed in disease states, including cutaneous leishmaniasis, sickle-cell disease, unipolar depression, breast cancer, epilepsy, measles, Down syndrome, and controlled fibrocalculous pancreatic diabetes (a unique form of secondary diabetes mellitus). Avoid with genetic disorders affecting copper metabolism such as Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis. Avoid with HIV/AIDS. Use cautiously with water containing copper concentrations greater than 6mg/L. Use cautiously with anemia, arthralgias, or myalgias. Use cautiously if taking oral contraceptives. Use cautiously if at risk for selenium deficiency. The U.S. Recommended Dietary Allowance (RDA) is 1,000 micrograms for pregnant women. The U.S. RDA is 1,300 micrograms for nursing women.

• Physical therapy: The goal of physical therapy is to improve mobility, restore function, reduce pain, and prevent further injury. A variety of techniques, including exercises, stretches, traction, electrical stimulation, and massage, are used during physical therapy sessions. Physical therapy does not appear to help motor performance in infants born very preterm with very low birth weight. Besides the lack of benefit, available studies show a risk of causing fractures in preterm infants.

• Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with their qualified healthcare professionals before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature, although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used during pregnancy, and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

• Traditional or theoretical uses lacking sufficient evidence:

• Melatonin: Melatonin is a hormone produced in the brain by the pineal gland from the amino acid tryptophan. The synthesis and release of melatonin are stimulated by darkness and suppressed by light, suggesting the involvement of melatonin in circadian rhythm and regulation of diverse body functions. Levels of melatonin in the blood are highest prior to bedtime. Although human studies are lacking, melatonin has been traditionally used for sudden infant death syndrome (SIDS) prevention.

• Avoid melatonin supplementation in women who are pregnant or attempting to become pregnant. Use cautiously with bleeding disorders, seizure disorders, or if taking anticoagulants.

• Physical therapy: Physical therapy was first documented in China around 3000 BC with the use of joint manipulation and massage to relieve pain. The ancient Greek doctor Hippocrates wrote about massage and hydrotherapy in 460 BC, and splints and exercises were used to treat wounded Roman gladiators. The modern discipline of physical therapy emerged to treat soldiers wounded in World War II. Although human studies are lacking, physical therapy has been traditionally used for infant development and neonatal care.

• Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with their qualified healthcare professionals before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature, although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used during pregnancy, and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

• Reiki: Reiki is a Buddhist practice that is about 2,500 years old. The name "Reiki" is derived from two Japanese words: rei meaning universal spirit and ki meaning life energy. Mention of Reiki can be found in the Tibetan sutras and in ancient records of cosmology and philosophy. Although human studies are lacking, physical therapy has been traditionally used for various neonatal disorders.

• Reiki is not recommended as the sole treatment approach for potentially serious medical conditions and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Use cautiously with psychiatric illnesses.

• Selenium: Selenium is a trace mineral found in soil, water, and some foods. It is an essential element in several metabolic pathways. Although not studied clinically, selenium has been traditionally used for sudden infant death syndrome (SIDS).

• Avoid if allergic or sensitive to products containing selenium. Avoid with a history of non-melanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.

• Sweet annie: Sweet annie (Artemisia annua) is also known as Chinese wormwood or sweet wormwood. Although it is in the same genus as both wormwood (absinthe, Artemisia absinthium) and mugwort (Artemisia vulgaris), each of these herbs has different uses and should not be confused. Although not studied clinically, sweet annie has been traditionally used for neonatal jaundice.

• Avoid if allergic or hypersensitive to sweet annie (Artemisia annua), its constituents, or members of the Asteraceae/Compositae family (such dandelion, goldenrod, ragweed, sunflower, or daisies). Use cautiously in patients who are pregnant, taking angiogenic agents, or recovering from surgery or other wounds. Use cautiously if taking cardiotoxic or neurotoxic agents or with compromised heart or nervous system function. Use cautiously if taking immunostimulants or quinolines. Avoid if pregnant or breastfeeding.

Prevention

• For neonates (up to one month old) and infants (up to one year old), prevention and care for illnesses are both very important. In addition to healthy prenatal and delivery practices, prevention for these very young children includes important issues about breastfeeding and the appropriate introduction of complementary foods, hygiene practices, not smoking, and caring behaviours that contribute to the healthy development of the young child. Care for illnesses in infants and neonates is also very important, as young children can die very quickly if an illness is not recognized. Sick young infants must be taken immediately to a trained provider who can give appropriate care.

• Vaccinations: Healthcare professionals recommend that parents immunize children according to healthcare authorities in their area. For some of the most deadly childhood diseases, such as measles, vaccines are available and timely completion of immunization will protect a child from death. Since babies have underdeveloped immune systems, they are more vulnerable to infections and diseases than adults, even with the passive immunity they gain through their mothers. Thus, several vaccines are given to babies to help protect them against illnesses.

• Vaccines work by stimulating the body's immune system. Vaccines contain small amounts of inactivated, disease-causing organisms. This allows the immune system to produce antibodies to the foreign invader. Once antibodies are developed, the immune system is able to respond quickly to the infection if the disease-causing organism ever enters the body. After receiving a vaccine, the patient becomes immune to the specific illness.

• Babies typically receive vaccines for diphtheria, tetanus, hepatitis, pertussis (whooping cough), polio, measles, rubella (German measles), mumps, and a type of flu called Hemophilus B. influenza.

• Most vaccines are given when the baby reaches two months old because this is when the high level of antibodies passed on by the mother begins to decline. Many vaccines require more than one shot. These additional shots, also called booster shots, ensure that enough antibodies are produced to make the vaccine effective.

• Diarrhea: Diarrhea can be prevented by good hygiene and sanitary practices. When a child with diarrhea becomes dehydrated, rapid and appropriate treatment is necessary both at home and in the health facility (see Diarrhea Condition Monograph).

• Sudden infant death syndrome (SIDS): Getting medical care early in pregnancy, preferably within the first three months, followed by regular checkups at the doctor's office or health clinic, is important. It also is important to make every effort to assure good nutrition. These measures can reduce the risk of premature birth, a major risk factor for sudden infant death syndrome (SIDS).

• It is important not to smoke, use cocaine, or use heroin during pregnancy. Tobacco, cocaine, or heroin use during pregnancy increases the infant's risk for SIDS.

• Getting pregnant during the teenage years increases the infant's risk for SIDS; the more babies a teen mother has, the greater at risk they are.

• The SIDS rate decreases for babies born to older mothers.

• It is recommended by healthcare professionals to wait at least one year between the birth of a child and the next pregnancy. The shorter the interval between pregnancies, the higher the SIDS rate.

• Respiratory illnesses: Preventing respiratory illnesses, such as colds and influenza, in children is difficult. One contributing factor is indoor air pollution; air quality may be monitored with the use of various devices, such as radon detectors. Home owners may also wish to improve heating and ventilation systems. Children should wash hands frequently with soap and water. Surfaces prone to the growth of germs should also be washed frequently; examples include doorknobs, toys, and kitchen and bathroom counters and sinks.

• Malnutrition: Malnutrition is also a major contributor to childhood deaths. Mothers and other caretakers need to know how to feed their child correctly to prevent nutritional problems. If a child becomes malnourished, appropriate healthcare from a trained provider is essential.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

1. American College of Obstetricians and Gynecologists. www.acog.org.

2. American SIDS Institute. www.sids.org.

3. Centers for Disease Control and Prevention. www.cdc.gov.

4. Harding D. Impact of common genetic variation on neonatal disease and outcome. Arch Dis Child Fetal Neonatal Ed. 2007;92(5):F408-13. View Abstract

5. Hermansen CL, Lorah KN. Respiratory distress in the newborn. Am Fam Physician. 2007;76(7):987-94. View Abstract

6. Jovanovic L. Nutrition and pregnancy: the link between dietary intake and diabetes. Curr Diab Rep. 2004;4(4):266-72. View Abstract

7. Landi K, Gutierrez C, Sampson B, et al. Investigation of the sudden death of infants: a multicenter analysis. Pediatr Dev Pathol. 2005;8(6):630-8. View Abstract

8. Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.

9. Zhang J, Villar J, Sun W, et al. Zhang J, Villar J, Sun W, et al. Blood pressure dynamics during pregnancy and spontaneous preterm birth. Am J Obstet Gynecol. 2007;197(2):162.e1-6. View Abstract