Courtesy Christopher Briscoe

Jennifer Margulis (shown with Leone, 17 months; Etani, age 6; Hesperus, 10; and Athena, 8) delivered her oldest child in a hospital and the other three at home.

Back in 2001, when Jennifer Margulis decided to give birth to her second baby in the comfort of her own home, most doctors were stridently opposed to any deliveries outside the hospital. They’d wag their fingers and lecture women on the dangers of home birth, often implying that anyone who refused to give birth in a hospital was a bad mother.

But that stance seems to have softened – at least a little bit - in the intervening decade. In a 2011 position statement, the American College of Obstetricians and Gynecologists said that while it still views the hospital as the safest place to deliver, it “respects the right of a woman to make a medically informed decision about delivery.”

In response to that statement - and the growing number of home births in the U.S.- the American Academy of Pediatrics released a set of guidelines Monday for the care of infants born at home. The guidelines were published in the AAP’s journal, Pediatrics.

“We felt that it needed to be stated that no matter where a baby was born, the care needs to adhere to the same standards,” said the guideline’s lead author Dr. Kristi Watterberg, a professor of pediatrics and a neonatologist at the University of New Mexico. “One thing we feel very strongly about is that there needs to be one person present at the birth whose primary responsibility is care of the baby. While it’s uncommon for both the mom and the baby to get into trouble, it does happen.”

The guidelines detail the care and monitoring an infant should receive in the first hours and days after delivery. For example, babies born larger or smaller than expected should be tested for high blood sugar; caregivers should make sure breastfeeding is going without a hitch; blood should be drawn and screened for genetic abnormalities like cystic fibrosis.

The fact that the AAP has issued guidelines doesn’t mean the group supports home births, Watterberg said. “We concur with ACOG that hospitals and birthing centers appear to be the safest settings for birth in the U.S., but respect the right of women to make their own decisions about delivery,” she added.

Simply telling pregnant women not to choose a home birth “doesn’t work and isn’t helpful or constructive.” she said.

When it comes to care of the infant after delivery, the guidelines closely follow what is done in the hospital. Watterberg and her colleagues hope they will help standardize the care babies born at home get, whether that care is provided by a pediatrician, a family practitioner, or a midwife.

“I suppose we as a society are moving towards a spirit of tolerance,” said Dr. Dennis Woo, an associate clinical professor at the David Geffen School of Medicine at the University of California, Los Angeles, and former chief of pediatrics at the UCLA Medical Center, Santa Monica.

If new parents are going to opt for a home birth, there are some things they need to consider, he said. “The article makes the point that the pregnancy should be low risk, that there should be an experienced, certified midwife in attendance, and there should be a Plan B ready as a back-up.”

Though still relatively uncommon, home births have been on the rise. Between 2004 and 2009, home births rose by 29 percent, according to the National Center for Health Statistics. The increase was driven mostly by a 36 percent increase for non-Hispanic white women. Among this group of women, one out of every 90, about 1.1 percent, will choose to have her baby at home.

Many doctors argue that moms who choose to give birth at home are putting themselves and their babies at risk. If labor becomes obstructed, both the mother and the baby can be at risk. And though it is rare, a woman can hemorrhage and, in some cases, lose blood so quickly that in minutes she can go into shock and suffer organ failure, said Dr. Sindhu Srinivas, director of obstetrical services at the Hospital of the University of Pennsylvania and a professor of maternal-fetal medicine at the Perelman School of Medicine at the University of Pennsylvania.

At least one midwife group, the Midwives Alliance of North America, welcomed the new guidelines.

“We are very happy to see that these new guidelines overlap completely with the standard of care that is expected of certified professional midwives,” said Melissa Cheyney, chair of the division of research at  MANA and an associate professor at Oregon State University as well as a practicing midwife. “It’s clear that [AAP] supports birth centers and hospitals, but they also acknowledge that home birth is on the rise and they state that if a woman chooses homebirth, this is the standard of care she should expect.”

Cheyney agreed that a woman should expect two midwives to attend the birth, one to focus on the mom and one to focus on the baby. “Having two at the birth is essential,” she said. “The mother may need something at the same time as the baby. If the baby needs to be resuscitated, that requires two individuals.”

Margulis said that when she had her first baby in a hospital, she felt the experience was impersonal and insensitive. “There was a labor and delivery nurse who was physically rough with me,” said the 43-year-old Ashland, Ore., mother of four. “I was in labor for over 22 hours and she made us feel so rushed and stressed – and then we were left to sort of fend for ourselves. It was a joyless situation.”

After her health baby girl, Hesperus, was born, she was whisked away from her parents. “The staff insisted on taking the baby away from me and my husband,” Margulis said. “They took her to the nursery to wash her off and locked my husband out. But he saw how they were handling the babies – like they were little footballs.”

She was sure there had to be a better way. “The thing I wanted was for my babies to experience love and gentleness in the moments after they were born,” said Margulis, a senior fellow at the Schuster Institute at Brandeis University and author of “The Business of Baby.”  

Margulis has had three babies at home and feels she made the exact right choice in all three cases. “At home I felt totally at ease and comfortable,” she said. “No one was telling me what to do and I could just listen to my body and move around freely.” 

Shayna Marie Perkinson echoes those sentiments. The 27-year-old Ashland, Ore., mom, who gave birth at home to her son Milo 4 months ago, said “I felt like being at home I would be able to just allow the experience rather than being told what to do.”

One thing that made Perkinson comfortable with home birth was the family’s proximity to medical care: there is a hospital just five minutes away. The situation might be different if the hospital was a lot further away, she said, adding “I know families [who decided on home birth] who have come to stay with friends when the time was close so they’d be near the hospital.”

Watterberg and other doctors can understand how moms get turned off.

“Hospitals are where the vast majority of women give birth,” Watterberg said. “We need to continue to work on our hospitals to make the experience more gentle.”

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Don't take the cinnamon challenge. That's the advice from doctors in a new report about a dangerous prank depicted in popular YouTube videos that has led to hospitalizations and a surge in calls to U.S. poison centers.

The fad involves daring someone to swallow a spoonful of ground cinnamon in 60 seconds without water. But the spice is caustic, and trying to gulp it down can cause choking, throat irritation, breathing trouble and even collapsed lungs, the report said.

Published online Monday in Pediatrics, the report said at least 30 teens nationwide needed medical attention after taking the "challenge" last year.

The number of poison control center calls about teens doing the prank "has increased dramatically," from 51 in 2011 to 222 last year, according to the American Association of Poison Control Centers.

"People with asthma or other respiratory conditions are at greater risk of having this result in shortness of breath and trouble breathing," according to an alert posted on the association's website.

Thousands of YouTube videos depict kids attempting the stunt, resulting in an "orange burst of dragon breath" spewing out of their mouths and sometimes hysterical laughter from friends watching, said report co-author Dr. Steven E. Lipshultz, a pediatrics professor at the University of Miami Miller School of Medicine.

Cinnamon is made from tree bark and contains cellulose fibers that don't easily break down. Animal research suggests that when cinnamon gets into the lungs, it can cause scarring, Lipshultz said.

Dr. Stephen Pont, a spokesman for the American Academy of Pediatrics and an Austin, Texas pediatrician, said the report is "a call to arms to parents and doctors to be aware of things like the cinnamon challenge" and to pay attention to what their kids are viewing online.

An Ypsilanti, Mich., teen who was hospitalized for a collapsed lung after trying the cinnamon challenge heartily supports the new advice and started her own website - http://nocinnamonchallenge.com - telling teens to "just say no" to the fad.

Dejah Reed, 16, said she took the challenge four times - the final time was in February last year with a friend who didn't want to try it alone.

"I was laughing very hard and I coughed it out and I inhaled it into my lungs," she said. "I couldn't breathe."

Her father, Fred Reed, said he arrived home soon after to find Dejah "a pale bluish color. It was very terrifying. I threw her over my shoulder" and drove to a nearby emergency room.

Dejah was hospitalized for four days and went home with an inhaler and said she still has to use it when she gets short of breath from running or talking too fast. Her dad said she'd never had asthma or breathing problems before.

Dejah said she'd read about the challenge on Facebook and other social networking sites and "thought it would be cool" to try.

Now she knows "it's not cool and it's dangerous."

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Pediatricians treating teenaged girls should consider writing just-in-case prescriptions for the morning-after pill,  the American Academy of Pediatrics (AAP) said on Monday.

It’s the second recommendation in a week from a major doctor’s group that would make contraception more widely available to women. Last week, the American College of Obstetricians and Gynecologists recommended making all birth control pills available over the counter.

The Food and Drug Administration says emergency contraception – the so-called morning after pill – should be available to any woman who needs it without a prescription. But Health and Human Services Secretary Kathleen Sebelius overruled the FDA a year ago. Now, federal policy says girls under 17 need a prescription to get it.

AAP says many teenaged girls need emergency contraception, and their pediatricians should help make it easy for them to get it. “Studies have shown that adolescents are more likely to use emergency contraception if it has been prescribed in advance of need,” the group said in a policy statement.

“Despite significant declines over the past two decades, the United States continues to have teen birth rates that are significantly higher than other industrialized nations,” it added.

Morning-after pills can prevent pregnancy -- they don’t cause abortions -- if they are used within five days of intercourse.

Dr. Susan Wood, who resigned her job as assistant commissioner for women's health at the FDA in 2005 in a dispute over the then-Bush administration’s handling of the birth control issue, called the decision a significant one. “It's not often you see physician organizations saying that their patients are better off without the physician involvement,” Wood told Reuters.

"We do hope that pediatricians read the policy statement and follow the recommendations," said Dr. Cora Breuner, a pediatrician at Seattle Children's Hospital who led the AAP panel that produced the recommendations. "The Academy prides itself on a devoted membership."

Emergency contraception for adolescents has been one of the most politically fraught areas in health care for almost a decade.
 
In 2005 the FDA declined to approve any over-the-counter sales of the Plan B morning-after pill, overruling its own advisory panel, as well as its own scientists. Last December the FDA reversed  its stance when it approved over-the-counter sales with no age limits. When Sebelius overruled the decision, it meant many women must present proof of age to get the pills.

Virtually every medical organization with expertise in the area supports making emergency contraception available for sale to girls and women of all ages who might need it. The American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, and the Society for Adolescent Health and Medicine joined forces to denounce Sebelius’s action last year.

“The decision to continue restricting access to this safe and effective product is medically inexplicable,” AAP president Dr. Robert Block said in a statement at the time. One of the reasons Sebelius gave for her decision was the worry that girls as young as 11 might get the pills and might not understand the consequences. But the pediatricians have said they do not share that worry.

Arthur Caplan, head of the division of medical ethics at NYU Langone Medical Center and an NBC News contributor, calls it a "remarkable and innovative idea." 

"Having emergency contraception readily available will surely lead to fewer young women getting pregnant and fewer abortions.   The battle over abortion should not hinder making this sort of safe and reliable emergency pill easily available especially to those who may be coerced into sex, forget to take their birth control or have a partner whose birth control method fails," Caplan said. "Improvements in medicine are shifting the arena for discussing reproductive ethics from abortion clinics and surgical procedures to choices made by individual women talking to their doctor, nurse, pharmacist and others whom they trust.  Those on all sides of contraceptive availability need to come to terms with this new moral reality."

The most common form of emergency contraception is a high dose of a regular birth control pill such as Plan B and Plan B One-Step from Teva Pharmaceutical Industries Ltd or Next Choice from Watson Pharmaceuticals Inc. They generally sell for $10 to $80 and are most effective in the first 24 hours.

All work by preventing ovulation, not by stopping the implantation of a fertilized egg. "These are not abortifacients," said Breuner.

A 2006-08 survey found that 14 percent of sexually experienced girls had used emergency contraception, up from 8 percent in a 2002 survey. The most common reason given was condom failure, but 13 percent of the girls said it was because of rape.

A 2010 analysis of seven randomized studies of emergency contraception found that teens who had a morning-after prescription in were not more likely to have sex or less likely to use contraceptives.

"It's just common sense that requiring a prescription is a barrier," said Bill Alpert, chief program officer of the National Campaign to Prevent Teen and Unplanned Pregnancy. "If an august and respected medical group like AAP is suggesting providing emergency contraception to minors is OK, that is a big deal."

That is especially so when teens face other obstacles to getting emergency contraception. For instance, a 2012 study that had 17-year-olds telephone pharmacies asking about morning-after pills found only 57 percent of them correctly told the caller that she could get the drugs without a prescription.

Also, some physicians refuse to provide the prescriptions to teenagers, while others do so only in cases of rape, AAP's research shows, suggesting that the refusal "may be related to the physician's beliefs about whether it is OK for teenagers to have sex."

There are no good data on how many physicians write prescriptions ahead of time for emergency contraception. "But we do know that pediatricians don't even talk about it, let alone offer advance prescriptions," said Breuner. "We tend not to like bringing up stuff that's controversial."

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A new look at child abuse reports suggests there may have been a small but worrying rise in injuries to babies over the past decade or so. While most research suggests child abuse is down overall, the report published on Monday in the journal Pediatrics shows infants are far from safe.

The study contradicts government data collected over the same time, and it shows that health officials need to take a better look at whether child abuse is getting better, worse or staying the same, experts said.

“I think it’s premature to make any conclusions about whether it is going up or down,” says Dr. James Anderst, chief of the section on child abuse and neglect at Children's Mercy Hospitals and Clinics in Kansas City, Mo., who was not involved in the study. “Medical providers may be getting better at identifying abuse over time.”

Either way, it’s still happening and that’s a concern, says Dr. John Leventhal of Yale University, who led the study. “Maybe parents are doing better and hurting their children less in general, but there is a small group where there continue to be substantial injuries that end in hospitalization,” Leventhal said.

Leventhal and colleague Julie Gaither looked at statistics on children admitted to hospitals for serious injuries. Writing in the journal Pediatrics, they said they found a nearly 11 percent increase over 12 years in serious injuries to babies a year old and younger.

This is at the same time that two major national surveys of child abuse found decreases of between 55 percent and 23 percent in child abuse injuries overall, for all ages, between 1997 and 2009. It's important to point out that each study goes to different sources for data -- this week's study looks at hospital admissions, while the government studies examined reports of abuse filed to Child Protective Services and other agencies by doctors and other sources.

Child abuse is a serious problem in the United States. The Centers for Disease Control and Prevention says more than 740,000 children and youth are treated in hospital emergency departments for injuries resulting from violence every year.

“Child abuse, neglect or violence can actually affect the development of a child’s brain – impacting the child now and for years to come. Our Adverse Childhood Experiences (ACE) studyshows a connection between child maltreatment and some of the nation’s worst health problems, including depression and heart disease,” CDC child abuse expert Linda Degutis says in a blog on the agency’s website. 

CDC declined comment on Monday’s study in Pediatrics.

“I would say that the experts in this area are still trying to make sense of the various trends in physical abuse and explain why there are divergences,” said David Finkelhor of the University of New Hampshire, who led one of the studies showing a decrease in child abuse injuries between 1997 and 2009. “This new report is helpful but does not resolve any of the outstanding questions.”

Leventhal said it’s important to get better data, but says it’s difficult. “It is probably harder to substantiate a physical abuse case now than it was 15-20 years ago,” he says -- mostly because agencies have tightened the rules for classifying cases as child abuse. “My colleagues in child protective services say it is much harder.” Many, he says, classify abuse cases as neglect instead. But it would be important to get data to back this up.

Anderst and Leventhal both said education is an important way to help prevent child abuse. “Over 50 percent of the kids on my study were infants. Thirty to 40 percent of those infants had abusive head trauma, often known as shaken baby syndrome,” Leventhal said. That suggests parents are caretakers who are frustrated and don’t know how to cope with a wailing baby, he said.

“I think, regardless of the cause, the message is too many children, particularly very young children are  getting hurt,” he said. “And pediatricians and others who look after children need to craft clear messages so that children are not hurt by abuse.

Yale’s hospital has an approach called “Take Five.” “If you feel like you are going to lose it, put the baby in a safe place, namely a crib, step back and take five,” Leventhal says. Some states are also giving new parents information about not shaking their babies – even seemingly gentle shakes can cause traumatic brain injury. “There are now systematic efforts funded in part by the CDC to see whether education about crying infants, about stepping away, about not shaking a baby, change the likelihood that children end up in the hospital with those injuries,” Leventhal added.

Sometimes people were themselves beaten as children, and pass this behavior along, Anderst said. “Some people are just ill-prepared to be parents and don’t know how to handle children. Some people come from violent backgrounds and that is how they handle their problems.”

So how to change this behavior? “It’s the same way we get people to quit smoking. It is the same way we get people to wear seat belts. It is a combination of laws and enforcement of those laws and also supporting people so they can be better parents,” Anderst said.

He said government officials should think about those consequences when they cut programs to save money in state budgets.

Sometimes it's not the parents who are doing the harm but someone outside the family.

Dr. Suzanne Starling, a pediatrician at Eastern Virginia Medical School, has made intensive studies of who’s hurting kids, and found a consistent pattern: men are far more likely to hit, shake or batter young children. One study she published in the Southern Medical Journal found fathers committed 45 percent of attacks, and boyfriends of the mothers another 25 percent.

“Parents need to believe that the people close to them might have the potential to lose it with a frustrating circumstance such as a crying baby,” Leventhal advised. “They need to say each of the people who looks after their child, ‘my baby cries sometimes and it gets frustrating. If you feel that way, call me. I will come home from work. But don’t hurt my baby’.”

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Circumcising baby boys has clear health benefits and parents should feel free to have it done, but they shouldn’t feel pressured to do so, the top U.S. pediatricians group said on Monday.

Circumcision lowers the risk of a range of diseases, from AIDS to herpes, and doesn’t hurt sexual performance or pleasure in adulthood, the American Academy of Pediatrics said. While the Academy doesn’t go so far as to recommend circumcision as routine, it’s the group’s strongest endorsement yet of the sometimes controversial procedure.

“Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks,” the AAP says in its latest update of its circumcision policy, released in the journal Pediatrics.

Noah Berger / AP

Benjamin Abecassis rests on a pillow surrounded by family members immediately following his bris, a Jewish circumcision ceremony in San Francisco. The nation's top pediatrician's group said the health benefits of procedure outweigh the risks, but stopped short of recommending it.

“Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns.” In other words: Health insurance should pay for it.

The decision is certain to anger anti-circumcision activists, who call the practice genital mutilation. Doctors who support circumcision say the Academy’s on-the-fence stance up to now has encouraged such groups.

“In the policy itself, the changes are actually fairly small,” Dr. Doug Diekema of the University of Washington, a member of the AAP’s task force, said in a telephone interview.

“What has changed mostly is the tone. The statement from 1999 said that there were some benefits of circumcision, there were some risks, and essentially it was a pretty close call. This time around the policy says, based on the evidence, it appears there are still some benefits of circumcision and those benefits outweigh the risks.”

Circumcision is becoming less and less common in the United States. It’s routinely done for religious and cultural reasons among groups such as Jews and Muslims, and U.S. hospitals once circumcised newborn boys routinely.

But the numbers dropped -- from around 79 percent of newborn boys in 1980 to around 55 percent to 58 percent in 2010, according to the U.S. Centers for Disease Control and Prevention. This is mostly because public insurance programs such as Medicaid often don’t pay for it any more. Eighteen states have stopped paying for circumcision under Medicaid, the state-federal health insurance plan for the poor.

News that the decision was coming started to leak out last week and groups opposed to circumcision -- there are more than a dozen -- have already prepared their responses.

“It is clear that the AAP is blind to the mounting worldwide movement against the genital cutting of boys,” Georganne Chapin, Executive Director of Intact America, said in a statement posted on the group’s website. “This American physician organization is disregarding the risks and harms of the procedure. It also is ignoring the fact that circumcision is rare in Europe, with no negative health consequences, and that European politicians and physician groups -- in increasing numbers -- are calling for doctors to refuse to perform the procedure,” she added.

Diekema said the Academy is familiar with the arguments. “I think every member of the task force has gotten thousands of emails, most of them copycat emails,” he said.

“Our task was not to base our decisions on which people yelled the loudest about the issue. Our task was to look at the evidence,” he said. 

The evidence shows circumcision rarely causes complications and can also reduce medical costs.

Earlier this month, a team at Johns Hopkins University projected that U.S. medical costs will go up as circumcision rates fall. They used data showing that urinary tract infections would triple and HIV rates would go up 12 percent if circumcision rates fell to 10 percent. The bill for all these extra infections? Half a billion dollars a year, they wrote in the Archives of Pediatrics and Adolescent Medicine. Already, the decline in circumcision rates has cost $2 billion, they calculated.

How does circumcision prevent infections? The foreskin of the penis, which is removed during the procedure, is loaded with immune system cells that are easily infected by viruses such as HIV and herpes. Bacteria can collect under the foreskin, causing infections in both males and their sex partners.

A circumcised penis develops thicker, strong skin that can more easily withstand little tears and cuts that admit germs, as well, infectious disease experts say.

A German court banned circumcision in June, saying the procedure was inflicting bodily harm on babies who could not consent. The ruling dismayed and angered Jews and Muslims.  There is a similar battle in Austria. 

In July 2011, a judge prevented activists from putting a circumcision ban on the ballot for November in San Francisco but groups say they’ll keep trying.

The AAP says that in the United States, the decision should be between the parents and doctors or certified professionals who perform circumcision. Pain relief is important for the baby and it’s important for doctors to be neutral in discussing the pros and cons of circumcision.

“I would like to see parents making this decision thoughtfully,” Diekema said.

Related stories:

• Circumcision advocate tackles the cringe factor 
• Circumcision rates declining
• Costs increase as circumcision rates drop