Dr. David Berger, MD, FAAP, is the owner and medical director of Wholistic Pediatrics in Tampa, Florida as well as an assistant professor at the University of South Florida College of Nursing. He recently took the time to answer a few questions via email for the ICAN Blog, which are reprinted below.
How long have you been practicing pediatrics?
I have been a board certified pediatrician since 1997.
What is your general theory of medicine?
That the human body, when given proper nutrition and avoiding things that are harmful, has a wonderful ability to fight off most disease conditions. I take a wholistic, individualized approach to medicine. I also believe that a patient or family is best served when offered choices on how to proceed and then make a decision together as to what would be the best way forward.
In your experience with your patients, have you observed a difference in those born by cesarean vs vaginally? If so, in what ways, ie cognitively, developmentally, etc? Have you seen or do you know of any research studies done comparing the outcomes (cognitively, developmentally, etc) of cesarean vs vaginally born babies?
Although many of my patients are born at birthing centers with midwives, I suggest that all hospital based births have a prenatal consultation with me during the early third trimester, so we can talk about things such as hypnobirthing and vaginal stretching massage/exercises, which I find both help facilitate a natural, vaginal birth. I also talk to them, especially if it is a first pregnancy, that it is normal for women to go past their due date and to avoid induction as much as possible. Failed inductions, especially if before the baby is ready to come out, will end up with a c-section.
I find that women have much less success with breastfeeding when they have a c-section, and establishing good breastfeeding is critical to me. I find that a baby born by c-section is less likely to be breastfeeding at 2 months of age, and studies have indicated that babies who are breastfed will run an IQ about 3-5 points higher than formula fed babies.
The March of Dimes is pushing to end elective cesareans and inductions before 39 weeks. Have you noticed, in your personal experience, any differences in babies who gestated longer than the others? What are your opinions on early elective deliveries?
I believe a woman should be aware of all of their options. But if true informed consent occurs, and a woman understands all of the risks associated with c-section, more likely they would opt for a vaginal birth.
There has been some research on the impact of beneficial bacteria acquisition in newborns born vaginally vs those born by cesarean (for example, here). What are your thoughts on this?
I fully agree with this. If a baby is not colonized with the good bacteria, there is a greater chance that undesirable organisms such as candida will populate the baby’s gut. I advocate giving probiotics to babies born by c-section to help facilitate the beneficial bacteria growth.
Have you noticed, in your personal experience, any differences between babies who gestated longer than others? For example, what is the real difference between a 37-week baby and a 40-week baby? How might those differences affect lifelong health?
The main thing is their size and neurological development. The younger the baby, the smaller the baby, likely the weaker the suck and therefore the greater the potential for breastfeeding problems. I think that otherwise, a non-complicated delivery for a baby who latches and nurses well going forward, there wouldn’t be that much of an effect on long term health.
It’s wonderful that you are so supportive of breastfeeding! In your opinion, why do post-cesarean moms have more difficulty establishing and maintaining a breastfeeding relationshiop? How might a woman who has had a cesarean mitigate those effects?
Some of it is the discomfort that the mom will experience, often not able to get into a comfortable position post surgery, or unable to put the baby in a good position without putting pressure on the abdomen and being bothered by the surgical wound. Women often do not feel great after surgery, which can affect their zest to nurse, and of course if there are surgical complications the mother may be in no health to nurse. Mom also may be on pain medication [sic] could effect her or the nursing baby.
I do not have a great way to mitigate those effects, but I would think that both the mental and physical health of the mom could have a positive or negative effect on how the nursing will go.
How do you feel about ICAN? Why do think this type of support organization is helpful/important?
I think ICAN is very important. Getting the word out that c-sections can have major impact on the post-natal period, even if there are no significant complications, needs to be done. Also providing support and advocacy for VBAC in low risk mothers is important. Most women would not even think about doing a VBAC unless they know the option is available.
Do you ever refer your patients to ICAN for support or VBAC resources? If so, what kind of feedback do you get about it?
Yes I have referred patients to the ICAN webpage and told about our local group. Feedback in my practice is good, but that is what I would expect for a wholistic practice 🙂
Tell us a little bit about the biology of a newborn baby. Babies born by cesarean often do not get immediate skin-to-skin contact, have their umbilical cord clamped and cut almost immediately, and frequently must stay in the NICU for observation even if they are not showing signs of distress. What, if, any, setbacks might occur to the newborn from these interventions?
I disagree with your comment that c-section born babies “frequently” must go to the NICU. I have not seen the data, but I would suspect that there is a higher incidence of NICU visits for c-sections….but I think it would be important to clarify if there was an elective c-section, a “routine VBAC,” or if a c-section was performed because there was some type of complication (ie fetal distress) that lead [sic] to the c-section. In this later situation, I would expect more NICU visits because there may have been something wrong with the baby.
Babies born by c-section will miss out on the colonization of bacteria from the vagina and could miss or get delayed skin-to-skin contact. Personally, I have not seen much difference in babies who have had the clamping of the cord delayed. The way I see it, the baby was getting cells and nourishment through the entire pregnancy, so I do not see how there would be that much more obtained by delaying the clamping of the cord. Also, I am an advocate for Stem Cell banking, and if the cord is not clamped until after the cord has stopped pulsating, then the Stem Cells cannot be harvested.
Often, after a cesarean, a newborn is given glucose or formula while the mother is in the recovery room. How do you feel about this practice as a pediatrician? When is it warranted, and when is it overly cautious?
The only reason that I would ever suggest this is if there was a real possibility of hypoglycemia such as with a mom who had gestational diabetes. Babies are born with plenty of extra fluid…they will not get dehydrated if feeding is delayed for a little while. Part of my recommendation for putting together a birth plan is so that the parents can state they do not want other oral feeding to occur (if there was a real concern, an IC could be placed to get the baby fluids until ready to feed). I also recommend not allowing for pacifiers, as this may cause nipple confusion. If a baby had to take something by mouth besides the breast, I would recommend using a syringe or finger feeder.
If you could give just one piece of advice to a couple considering non-medically indicated cesarean, what would it be?
I would discuss with them the risks, benefits and alternatives, but ultimately it would have to be their decision. It is important to find out what was leading the decision to move in the direction of a non-medically indicated c-section in the first place.
Thank you again to Dr. David Berger for taking the time to respond to our questions!
