Colic, ADHD, Home Birth – PediaCast 267

Join Dr Mike in the PediaCast Studio for another Research Round-Up! Topics this week include infant colic & migraine headaches, ADHD & injuries, unfilled prescriptions, and home births. We’ll deconstruct the studies, explore the results, and add a practical spin for moms and dads.

Topics

  • Infant Colic & Migraine Headaches

  • ADHD & Injuries

  • Unfilled Prescriptions

  • Home Births

Links

 

Transcription

Announce 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast. We are a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It's Episode 267 for October 9th, 2013. We're calling this one "Colic, ADHD and Home Birth". I want to welcome everyone to the program.

Of course, we have 5a little bit more for you lined up than just those three topics and we'll get to the rundown here in just a moment. First, I want to give a nod to my friends and listeners in Chicago. My son and I and my wife…

[Laughter]

Dr. Mike Patrick: My wife was actually attending a conference in Chicago. And I had a couple of days off, so my son and I tagged along with her. And we had to get into some sort of trouble so we took a Metra Train into downtown. It was about an hour ride. Toured around downtown, saw the Bean. I've been down there before, but this is the first time that my son had been down there. And he actually, when he heard we're going to Chicago, he's like, "Can we see the Bean?"

So, those of you who are familiar with the Windy City know what I'm talking about. Yup, it's exciting — a big metallic object that looks like a bean. But it's cool. If you go to Chicago, you got to see it.

Then we hopped on an 'L', the Red Line, and took that to, I think, Addison. Right, Addison? To Wrigley Field and caught a Cubs-Braves game. And this was a first time for me. I haven't been to Wrigley before. And we just had a great time. It was really a lot of fun.

0:02:09

You have seen the place. It's on TV, many times. And when I think of Wrigley Field, I just have this visions — and I'm dating myself here a little bit — but of Harry Caray leaning out the window and leading the crowd in "Take Me Out to the Ball Game". So, it brought back a lot of memories there and seeing the stands on the rooftops across the street.

It was great. We had a wonderful time. And so, I just wanted to give a little nod to my friends and listeners in Chicago. Great city. We had a great time there.

All right, we are going to do something this week that we haven't done in a long, long, long time. Now, listeners who go way back with the show will remember something I like to call a Research Roundup. Now, I know, the newbies out there — and there are lots of you — you may be scratching your head and saying, "What in the world is a Research Roundup? I thought you did News Parents Can Use, and answer Listener Questions and interviewed pediatric experts."

Yeah, those are the typical natures of our program, but if you go way back in the Archives, you'll find a fourth type of program, the Research Roundup. And it goes something like this, I choose three actual journal articles. Ones I think will be interesting for moms and dad, something with a little bit of a practical application, but also meaty enough for the practitioners in the crowd. And I provide the link to the actual articles on PubMed.

So you can take a look. If you're a science type myself, and you want to see the research article, the original writing of it, you can do that and we'll put links in the Show Notes for the actual articles that I used. And then, I kind of deconstruct the study. We identify the question before the researchers. We examine their methods, we look at their results, we consider their conclusion. And we discuss it with an eye for making it practical.

0: 04:01

So, what topics will we be examining under the microscope in this particular PediaCast Research Roundup? First up is colic and migraine headaches. If you have a colicky baby at home, is he or she more likely to suffer from migraine headaches in the future? It's an interesting question and one that views colic as a neurological issue, rather than a gastrointestinal problem.

And then, we move on to ADHD and injuries. And more specifically, are kids with ADHD more or less likely to injure themselves when they are not taking their stimulant medication compared to when they are taking it? So, a lot of times when we think about ADHD and what's the medicine doing for you, we think about a child's behavior and we think about their school performance. But what about getting injured? Could that be a reason or at least another data point in your decision to put a child on ADHD medication?

So, we'll look at that. And then, unfilled prescriptions, parents take their children in to see doctors. Doctors frequently prescribe those children medications. But do parents actually comply with the doctor's instructions by filling and giving said medication? How many prescriptions go unfilled? So, we'll take a look at that.

I will tell you this. I figured the number would be high, but I wasn't prepared for just how high. In addition to the numbers, we'll also take a look at some of the reasons that prescriptions go unfilled and talk about some of the things doctors and parents can do to improve compliance.

And then, finally for my final word this week, I'll have some numbers and some comments for you on home births. So, be sure to stick around at the end of the show for that.

I do want to remind you that PediaCast is your show. So, if you have a comment or a question or a topic idea, or if you want to point me in the direction of a new story or journal article, it's easy to get in touch and I personally read every message that comes through. Just head over to pediacast.org and click on the Contact link.

Also, I want to remind you, the information presented in our show is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So, if you have a concern about your child's health, what do you do? You call your doctor and you arrange a face-to-face interview and hands-on physical examination. Got to do this kind of thing in person, no practicing medicine over the Internet or over a podcast.

0:06:29

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you'll find at pediacast.org.

All right, let's take a quick break. And by the way, this interlude music that I'm going to kind of go under the break with is called "Windy
City". So, Chicago, this one's for you.

[Music]

Dr. Mike Patrick: All right, we are back. So, Research Roundup, let's get right to it. First off, colic in babies and migraine headaches. This was a research study that was done by multiple institutions in France and Italy. So, this is a European study, but it was published in the Journal of the American Medical Association in April of 2013.

And again, I'll have a link to the PubMed article. So, if you are interested in seeing it for yourself, just head over to the Show Notes — pediacast.org, Episode 267 — and we'll have a link to the original article for you.

So, the question before the researchers was, among children who suffer from migraine headaches, is there an association with infantile colic in that same child when they were a baby?

0:08:00

So the researchers identified children who were between the ages of six and eighteen years of age who presented to emergency departments for a chief complaint of headache between April 2012 and June 2012. Each child was evaluated by a pediatric neurologist, using the ICHD 2 Criteria for Diagnosis. What in the world is that? That is the International Classification of Headache Disorders Second Edition.

And so, the point here is just that they did have a neurologist. A pediatric neurologist actually examined each of these kids and they had strict criteria for what was going to constitute a migraine. So, it wasn't just a parent saying, "Yeah, my kid suffers from migraine." We really wanted to know, we wanted to identify children who really do have migraine headaches and headaches that would be classified as truly migraine.

And those who met the criteria for migraine headache, they were placed in Group Number 1. So this is going to be the experimental group. And those with tension type headaches were placed in Group Number 2. So, we still do want to identify, we wanted to see if other types of headaches might also be associated with colic. So, we have the migraine headaches in Group 1, the tension headaches in Group 2.

And then, investigators also wanted a control group comprised of kids in the same age range who presented to the emergency department for something other than headache. So these are kids who don't have a headache and when questioned, they don't have a history of chronic headaches. And they had just come to the emergency department for minor trauma. So, they had some scrapes or minor lacerations or some bruises, or strains or sprains — you know that kind of thing. So, minor trauma, no headaches, we're going to also get a group of them together and find out what the incidence of colic was when they were babies.

And then, parents of the children in all three groups were given a structured questionnaire which asked about the history of infantile colic symptoms using the Wessel criteria. So, investigators used an objective tool, not only to determine whether the child had migraines, but also, did they meet the criteria for actually having colic. Not that, Did you have fussy baby, but was it really truly colic?

0:10:13

Now, there's a little bit of an issue here, because parents have to think back. And at the minimum, these kids are six years old. So it's at least six years ago, but it could have been as much as eighteen years ago. And so, there is a little bit of a problem with parents remembering the exact symptoms to see, Hey, did your kid meet the Wessel criteria?

So, in order to kind of put an internal check into all of this, the investigators confirmed whether a child had colic symptoms by reviewing each child's personal National Health booklet. In other words, each child's government-controlled medical record. They opened those up.
Because the government maintains all of this in the United Kingdom. And I'll make no comment on that. I'm sure some of my American friends might have a little something to say about the government controlling your medical record. But, we won't go there, because I'll just get myself in trouble.

So, the incidence of infant colic was determined for each of the three groups — so, those with the migraine headaches, those with the tension headaches, those without headaches. And then, investigators also identified the incidence of some potentially confounding factors for each of the three group. Things like history of headache or colic in first degree relatives. So, is there a family history in these problems? Gestational age, was this child a premature baby? Were they born on time? Were they born a little late? And what type of infant feeding they had — formula bottle versus breastfeeding?

All right, what did the investigators find? Well, first, let's look at the raw numbers. The number of kids in Group 1 – so those with migraines and again, ages six to 18 — they identified 208 children in that group. Group Number 2, so these are the kids with the tension headaches, they were a 120 children in that group. And then, Group Number 3, our control group, with no history of headaches, there were 471 children in that group.

0:12:12

Now, in terms of colic, there was a diagnosis of infantile colic in 73% of the kids who presented with migraine headaches. Now, we can compare that to 35% of the kids with tension headaches and only 27% of the kids in the control group. And the difference between the colic incidence and the migraine group, which again was 73%, and the control group, which was 27%, was statistically significant. While the difference between colic incidence and the tension headache group at 35% and the control group (again, 27%), that difference was not statistically significant. And after controlling for those confounding factors such as family history of headache and/or colic, gestational age and type of feeding, the difference the migraine group and the control group remained statistically significant.

So, the investigators conclude that the presence of migraine headache in children is associated with a history of infantile colic in that same child when they were a baby.

So, what does this mean? Does that mean that colic causes migraines? Well, that doesn't seem very likely. Does that mean that babies with colic have headaches? And that's why they're crying and fussy. Well, there's really no way to tell that since colicky babies can't tell us how they're feeling or what hurts or what's wrong. That just isn't happening. So we don't know.

Could it mean that there is an underlying neurological issue that causes infantile colic and migraines later in life in the same individual? Well, that seems most probable, but this study does not address that specific question. And it doesn't really attempt to explain any possible mechanisms for their findings. The study was designed to see if an association exist without characterizing the character or the mechanism of that relationship. And at the end of the day, it found a positive relationship.

0:14:13

Now, some of you may be asking, what does stomach problems in a baby have to do with migraine headaches later on in that same child? Well, keep in mind — and we've talked about this on PediaCast before — colic is not necessarily caused by stomach problems. We don't know with certainty what causes colic. It can certainly look like stomach problems. You know, these babies tighten their stomach muscles, they draw up their legs, they look angry, they're crying nonstop, they pass gas or have a bowel movement.

But if the root problem is neurological — so let's say they are responding to headache pain, let's say they're having a migraine — that could result in the baby getting angry and crying and tightening their belly, and drawing up their legs, and passing gas and having a bowel movement. Because if you lay on your back right now and tighten your belly and draw up your legs and push a little and fuss it around, you might just pass gas or stool. You know what I mean? So it doesn't mean that we're seeing is really caused by a stomach problem.

Maybe they don't have a headache at all. Maybe their central nervous system is, I don't know, immature or is different in these kids and their cry-get-angry centers starts firing, either on its own or maybe in response to sensory stimulation overload by late afternoon or early evening. The baby just had enough stimulation and crying nonstop blocks out the input coming from household noise and craziness. So they cry and look angry and stiffen their bellies and draw up their legs and pass gas or stool in order to block everything out. That's a possibility as well. Which again, we just don't know.

So, I think the take-home here for moms and dads is to realize that colic may not be a stomach problem. On the other hand, there have also been some recent studies which have found an association between infantile colic and intestinal microbes. So it may be that all colic is not the same.  And we just don't know. And to be honest with you, as doctors, that frustrates us. And as parents, I know that frustrates you because you just want an answer and you want to know why your colicky baby is crying and you want to get him to stop crying.

0:16:20

So I understand the frustration. But, unfortunately, it's just one of those things that we don't know. But studies like this are giving us a little bit more insight into what may be going on.

By the way, I do provide a few additional words on colic. In fact, I cover it pretty extensively in PediaCast Episode 241, which is our Parenting 101: Baby Basics episode. So, if you're expecting a baby or you have a newborn, or you know someone who does, be sure to check it out — PediaCast 241 over at pediacast.org.

And if the association between colic and migraine headaches sounds familiar, back in Episode 202, I covered a similar study from neurologists at the University of California-San Diego, which actually show a similar association. So if you like to hear more on that, check out PediaCast 202, again over at pediacast.org.

One last piece of wisdom, if you have a young baby who is very fussy at home — this is important — don't just assume it's colic. It may very well be. But there are other medical conditions that result in fussy babies, some of them life-threatening. So, fussy babies need to see a doctor. Let the doctor diagnose colic. Don't make the diagnosis by yourself at home. You've been warned.

All right, let's move on. Our next study comes from the University of North Carolina at Chapel Hill and was published in the Journal of Injury Prevention in June 2013.

And again, I'll put a link to the actual article, the PubMed version of it, which has links to the get to the real thing. You may have to pay a little bit if you are really interested in reading the original one. Because they're in journals, and the journals, they need to make a buck. They got to pay for the publishing and their staff. So, if you want to see any of these articles, you can get the abstract at PubMed. But there are links there to get the entire article. Like I said, you may have to pony up a few pennies to do that.

0:18:15

All right, so the question before the researchers for this particular study, among children diagnosed with ADHD — so Attention-Deficit Hyperactivity Disorder — does treatment with stimulant medication decrease their risk of injury?

Now, this study has an interesting design whereby each enrolled child serves as their own control. So, what do I mean by that? Well, investigators looked at children in the United Kingdom who were 18 years of age or younger and who had a diagnosis of ADHD. Now, why the United Kingdom? Why are researchers at the University of North Carolina at Chapel Hill and publishing the results in an American journal, why are they going to the United Kingdom for their sample population? Well, it's because, again, as I mentioned in the last study, their public health service provides a database of health information.

And again, I'll provide no additional comment here. Just an FYI, the government got their health records. And so, the researchers can peruse them and mine the database.

So, how does one serve as his or her own control? Well, you look at kids diagnosed with ADHD and you divide their life into periods when they are taking stimulant medication and periods when they aren't. Then, you count the number of reported injuries during each time period and you compare the two numbers. So, time periods when the child is taking the stimulant medication is going to be our experimental group and periods of time when those same children are not taking their stimulant medication, that's going to be our control group. Clever.

Although, it does become important to define each of these periods in a bit more detail. So treated periods start the day that a stimulant medication is prescribed and extends through the end of the period in which refills are given, plus a 30-day grace period. Because it was thought kids might have some leftover medication that they may be taking during the 30 days after they run out of their prescription.

0:20:29

And then, untreated periods are going to be defined as periods of time before a stimulant was prescribed or between episodes of ongoing stimulant prescription. Let's say parents took their kids off in the summer, that kind of thing, or after the last stimulant was prescribed as long as the child wasn't in that 30-day grace period that I had mentioned.

I don't know, sounds a little confusing. It's really pretty easy here folks. Either they had an active prescription plus 30 days or they didn't. That's the difference between the treated and the untreated groups.

OK, so what about the injuries? Well, only medically attended injuries were counted. So, since we're not really asking the parents anything here, we're just going into the medical record and there has to be a record of their injury. So, only medically attended injuries were counted. So the child had to seek medical care. In other words, the National Health database had to know about the injury.

Researchers also controlled for some possibly confounding variables, such as the child's age. The season of the year was another one that they controlled for.

So, what did they find? Well, researchers looked at the records of 4,234 children diagnosed with ADHD who were treated with at least one course of stimulant medication. But of those 4,234 kids, only 328 of them had a medically attended injury. So, we're only really looking at 328 kids here. Of those 328 kids, 87% were male. The mean age of ADHD diagnosis was 9.7 years and 98.5% were treated with methylphenidate. That was the specific stimulant medication that was used.

0:22:13

Methylphenidate is just the old-fashioned Ritalin. And in the United Kingdom, where they have nationalized health care, they don't so much get in to prescribing any of the fancier, newer ADHD medications that my American friends may be used to hearing about. Things like Focalin, Adderall and Concerta, Metadate. So those are more expensive and you know when you have a national health care plan, you want to avoid spending that kind of money.

And I'm not assigning whether that's a right or wrong thing. I mean, certainly, you do want to keep cost down. But the fact of the matter is, 98.5% of these kids were treated with methylphenidate which gives you an idea what's going on in terms of all kids with ADHD in the UK, in my opinion. But again, I won't assign value to that, because that would get me in trouble.

The most common types of injuries that were documented were fractures, head injuries, strains and sprains, contusions and superficial skin injuries.

So, how did the treated versus untreated periods compare with one another? Well, fewer injuries were seen during the treated period compared to the untreated period, and this difference was statistically significant at all age ranges. But it was the most statistically significant among 10 to 14-year-old males. So, the authors conclude that the use of stimulant medication in children with ADHD results in fewer injuries compared to periods when the children are not taking stimulant medication.

So, this study is interesting. It's not without flaws. In fact, there are several. For instance, just because a child had a prescription for stimulant medication doesn't mean he or she was actually taking that prescription on the day or days before their injury occurred, right? Also, what about injuries that weren't medically attended? What if Doctor Mom took care of the problem? We really want to know about those injuries as well.

0:24:16

So it's not a perfect study. But I think it does have some merit. And when we run the results through our common sense filter, we can see the point. Kids with ADHD tend to be less hyperactive and less impulsive when taking their medication. They're more likely to think before they act. And if you have a kid with ADHD, you know exactly what I'm talking about.

So it makes sense that we would see fewer injuries when a child with ADHD is on their medication. I think the take-home here for moms and dads is that ADHD isn't just about behavior and your child's ability to complete their homework. Injuries may be at stake as well. And I think that's another data point you may want to keep in mind if you're trying to decide whether to continue giving your child his or her medication during school breaks, when injuries are perhaps more likely to occur. Or are you going to take them off?

So, a lot of parents do that. They'd say, Well, let's give him a break in the summer. But just remember, they're a little bit more prone to getting injured because they're going to be more active. They're going to be more impulsive, might not make as good a decision when they are off their medication. And this study gives us some evidence to back that up. As always, make sure you talk to your child's doctor. He or she should be a part of that decision-making conversation.

All right, let's move on to our final topic in this week's Research Roundup. And we're going to turn our attention to unfilled prescriptions. And this comes from the Ann & Robert H. Lurie Children's Hospital of Chicago. And no, I did not pick this study because I just visited Chicago. I did play the Windy City interlude because I just visited Chicago. But this study, it's just coincidence, folks.

This was published in the Journal of Pediatrics. It's a little bit of an older study. This one comes from October of 2012. But it probably was such an interesting one, I had to put it in here. And it brought up some important points I think that we needed to discuss.

And as with the other two, there'll be a link in the Show Notes to the PubMed version, the abstract, with links to the actual article. So, you can check that out. Again, this is PediaCast 267. So just go to pediacast.org, find the Show Notes for 267 and you'll find the links to the original journal articles that we're talking about.

0:26:34

OK, so this one, the question before the researchers, among Medicaid-insured pediatric patients, what is the rate of unfilled prescriptions and what factors influence this rate?

So, a child has a problem. Mom or dad brings the child in to see a doctor, presumably to get an opinion and treatment advice. The doctor renders a diagnosis, prescribes a medication, but mom or dad doesn't follow the advice. The prescription goes unfilled and the child does not receive the medication. Does that really happen? Yeah, it does.

So, let's define the scope of the problem. Researchers recruited Medicaid-insured patients from birth to 24 years of age at two large urban pediatric primary care clinics in Chicago over a two-year period. Prescribed medications were divided into eight categories: those for asthma and allergies, medication for skin problems, pain and fever medicine, oral anti-infectives which includes oral antibiotics, topical anti-infectives — so these are going to be like antibiotic ointment or anti-fungal ointment — nutritional supplements, gastrointestinal medication, and other. So things that didn't fit into the seven other categories.

Researchers identified each prescription from the enrolled patients electronic medical record. So, it happens in the United States, too. And then, they match each prescription against the Illinois Medicaid database. So, that way they could see what was prescribed and what was filled. And then, they could determine which prescriptions were filled and which ones were not.

0:28:24

So, what did they find? Well, 4,833 patients participated in the study and practitioners gave this patients a grand total of 16,953 prescriptions. Now, some demographic data — because this is going to be important to keep in mind who exactly are we talking about — the majority of the patients were Hispanic or African-American. And the majority were less than 11 years old. So, all told, 78% of the prescriptions were filled and 22% went unfilled. So, nearly a quarter of all the prescriptions did not get filled.

Now, just because 78% were filled, that doesn't mean that 78% actually took the medication correctly. So, this study doesn't look at that factor which is probably a considerable one. Medication category also made a difference with oral anti-infective agents. So, that includes oral antibiotics. Those were filled the most often at 91% and nutritional supplements were filled least often at 65%. African-American and Hispanic patients were significantly more compliant than white patients. So, they fill their prescriptions more often. And prescriptions given at sick visits were filled more often than those given during well-child checks. And electronic prescriptions, those sent directly to the pharmacy via a network, those were filled more often than paper prescriptions.

0:30:01

I still find it fascinating, though, that your kid is sick and you go in to see a doctor and the doctor prescribes an antibiotic, you think that those would be more like a 100%. But it's almost 10% of those even went unfilled.

The authors conclude that a significant number of prescriptions go unfilled and the rate of unfilled prescriptions is influenced by medication category, ethnic background of the family, type of office visit and the manner in which the prescription travels to the pharmacy, whether that be electronic or paper.

So, interesting study here. And I think there are a lots of take-home points for moms and dads and practitioners. Before we get to those, I really do wish the researchers had incorporated a means to not only see if prescriptions were filled but also if filled prescriptions were taken completely and/or correctly because I suspect the real non-compliance rate is much higher than 22%.

So, moms and dads, I have to ask you this — why go to the doctor to get an opinion, to seek advice, if you aren't going to follow the advice? It just seems like a waste of time to me and a colossal source of frustrations for us doctor types. Now, I do get some of the reasons. The prescription you receive may not be the one you were shopping for. Maybe you've tried that medication before and it didn't work. Or your child didn't like it and wouldn't take it. And you know, maybe your child magically improved between the doctor's office and the pharmacy.

So, lots of possibilities, and in all seriousness, I think the biggest reason at the end of the day — and here's the take-home point for the practitioners out there –  in my heart, I think the biggest reason… And again, I don't have any research backing me up on this one, I want to make that clear. But I think it's true, I think the biggest reason that prescriptions go unfilled is inadequate communication between doctor and the patient or the parent. We, doctors, have to do a better job of listening and explaining.

0:32:01

Now, moms and dads, you play a role here, too. Speak up and be heard. Tell your doctor why you think he or she might be wrong. Or why you don't want to try your doctor's course of action. Because you may have a very legitimate reason. The medicine not working in the past is a legitimate reason. Your child not taking the medicine, not liking the medicine, refusing it — that's a legitimate reason. Now, your doctor may say, "Well, you need to try harder. You're the adult, that's the kid, you got to get that medicine down." That may be the right answer but we do need to communicate with one another with concerns and counter-concerns and strip the pride away and really try to understand one another as doctors and patients and parents.  

So, doctors, first off, you got to shut your mouth and give moms and dads the opportunity to express their concerns. But then, it's time for moms and dads to shut their mouths. Doctors explain, parents listen. And then, when both parties have had their say, moms and dads, I would urge you at the end of the day to trust your doctor's opinion. I mean, if you can't, why did you see them in the first place? So, moms and dads and doctors, let's all recognize our part, which more often than not, I think, boils down to communication. That's my two cents anyway.

All right, that wraps up our Research Roundup edition of PediaCast. We do need more listener questions. So, we've had lots of great ones, we need some more. And, we'll get to those. As you folks know, the Listener Question episodes are probably among the favorites where we take your questions and we put a little evidence-based research into it and I give you an answer.

So, if you want to chime in, if you'd like to get your question answered here on the program, it's an easy thing to do. Just head over to pediacast.org and click on the Contact link. And I do read each and every one of those that come through. And we'll try to get your question on the show and get an answer for you.

0:34:04

All right. Let's take a quick break. Stay tuned. I'll be back with a final word on home births, right after this.

[Music]

Dr. Mike Patrick: All right, we are back.

While the number of home births in the United States has grown over the last decade, researchers at New York-Presbyterian Medical Center have found that babies born at home are roughly ten times as likely to be stillborn and almost four times as likely to have neonatal seizures or serious neurological dysfunction when compared to babies born in hospitals. This largest study of its kind, which includes data on more than 30 million US births, appears in the October issue of the American Journal of Obstetrics and Gynecology.

The risk is associated with the location of a planned birth rather than the credentials of the person delivering the baby. The risk of infant death is even greater for firstborns, 14 times the risk compared to babies born in a hospital. Dr. Amos Grunebaum, study author and chief of labor and delivery at New York-Presbyterian says the magnitude of risk associated with home delivery is alarming. And given this alarmingly high risk, he says obstetric practitioners have an ethical obligation to disclose the risk associated with planned home birth to expectant parents who express an interest in this delivery setting.

I think he makes an excellent point here. So many times, we don't want to insert our values on our patients. And that's becoming more and more of a trend in medicine. And so, obstetric practitioners are like, "You know, these parents really want to deliver at home. And even though, I really disagree with that, who am I to judge?"

0:36:23

And so, you don't really tell them the truth. I think that we really have to get away from that. We can say the truth with a little bit of love and grace. We don't have to say, "You're stupid for deciding this." But we do want to tell them what the risk is and say, "If it were me, I wouldn't do it. If you decide to do it, you're putting your son or daughter at risk and you need to know that."

And so, I think it is important that we do. We have an ethical obligation to disclose the risk and I think a lot of docs aren't doing that. Yeah, I think that Dr. Grunebaum makes a good point. He adds, "Parents to-be need to know that if they deliver at home, their baby has a greater risk of dying or having a serious neurological problem." That's his quote.

So, I mean, he's going to be blunt about it, I think. OK, you know, smile.

[Laughter]

Dr. Mike Patrick: As you give them that news.

Investigators examined birth certificates from the US Centers for Disease Control and Prevention's National Center for Health Statistics to assess deliveries by physicians and midwives in and out of the hospital from 2007 to 2010. The researchers identified five-minute Apgar score of zero, along with evidence of neonatal seizures and other serious neurological birth complications. The Apgar score is a screening test to quickly assess the health of an infant one minute and five minutes after birth. A five-minute Apgar score of zero is considered stillborn, although about 10% of these babies do end up surviving but usually with devastating health problems.

Co-author, Dr. Frank Chervenak, says, "The majority of these pregnancies go smoothly. But in some instances, there can be unpredictable complications requiring immediate surgical intervention. And when that occurs, every second is critical. If an emergency occurs at home, and transport to a hospital is required, it's often difficult to beat the clock to prevent infant death or serious neurological damage."

0:38:19

Dr. Chervenak again stresses the study's findings are based on the birth setting, not whether the provider is a physician or a midwife. He says it's all about location. When a complication arises, your baby needs quick access to a team of skilled specialists with training and technology in place to handle emergency procedures. In the home, none of these options are available. You don't have an OR in your room or at home.

While this study sheds new light on home birth, investigators suspect the findings actually understate the actual risk. Dr. Grunebaum explains, in the CDC data set, if care begin at home followed by transfer to a hospital due to complications, then the birth was actually reported as a hospital delivery. If these cases had been reported as home deliveries, then complication rates for home deliveries would likely be much greater.

Along with warning parents about the potential risk, investigators say it's critical for caregivers and hospitals to create a welcoming and comfortable birthing environment, often a primary motivation for a planned home birth.

Dr. Chervenak says, "Childbirth is one of the most wonderful moments in humanity, and we recognize that parents may expect that giving birth at home will enhance the experience. In the end, we need to be frank with parents about the risks. But, at the same time, physicians, midwives and other practitioners" — and hospital administrators –  "need to do everything we can to contribute to the compassionate care of mothers-to-be and their infants."

So, there you have it, babies born at home are ten times more likely to die. Unless you're a first born, then you're 14 times more likely to die. And if you survived, you're four times more likely to have potentially devastating neurological outcomes. So, parents to be, for the sake of our future son or daughter's life, please don't plan on delivering at home. And that's my final word.

0:40:15

In keeping with the spirit of our Research Roundup show this week, even though I didn't deconstruct this particular study for you like I did the others, I will include a link to the original article on PubMed in the Show Notes for Episode 267. And again, that's over at pediacast.org.

All right, I want to thank each and every one of you for taking time out of your day to make PediaCast a part of it. It's like we're a big family here. And I really just appreciate all the kind words that I get through the contact page over at pediacast.org. Lots of kind words, and I know a lot of you appreciate this program. And I just want you to know that I appreciate you as well.

One of the things that helps this show out quite a bit — because we really do not have an advertising budget at all — is your reviews and your comments in iTunes and also on iHeartRadio Talk. So, if you have something nice to say about the program, it's great that you let me know, I really appreciate it. But if you could just take a few moments of your time to write a review or a comment in iTunes for PediaCast and on iHeartRadio for PediaCast and for PediaBytes, our short format single-topic episodes that you'll find over at iHeart.com and in the iHeartRadio app. You just got to look for the Talk. I think it's in Beta right now. So, it will say Talk Beta and that's kind of your intern's way into their talk show programming of which PediaCast is a part.

Links, mentions, shares, retweets, re-pins on all your favorite social media sites are also important to us. PediaCast is on Facebook, Twitter, Google+ and Pinterest.

Be sure to tell your family, friends, neighbors and co-workers about the program. Most importantly, I think, tell your child's doctor. We want pediatricians and family docs out there to know this resource exists, so they can point their patients in its direction so that we can have evidence-based information for more moms and dads. And we do have posters available under the Resources tab at pediacast.org.

0:42:25

Once again, the contact link is available. If you have a question or a comment or a topic idea, or you want to point me in the direction of a new story or a journal article, feel free to do that with the Contact link at pediacast.org. One of the links says 'Contact Dr. Mike'. That's where you ask questions, provide comments and suggest your topics.

Another links says 'Connect With A Pediatric Specialist From Nationwide Children's'. This is for referrals and appointments. It's just a quicker way for moms and dad in our audience to get connected with a specialist here if you do need an appointment or referral. It may be that once you make that connection, they say, "Hey, we need a referral from your doctor." But they can help to facilitate that process for you.

All right, let's go ahead and wrap things up for this week. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids.

So long, everybody!

[Music]

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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