tag:theconversation.com,2011:/africa/topics/neonatology-1247/articlesNeonatology – The Conversation2019-12-19T13:50:23Ztag:theconversation.com,2011:article/1286072019-12-19T13:50:23Z2019-12-19T13:50:23ZGiving pregnant women antibiotics could harm the lungs of preemies, according to study in mice<figure><img src="https://images.theconversation.com/files/306434/original/file-20191211-95149-1gyrcya.jpg?ixlib=rb-1.1.0&rect=71%2C44%2C5919%2C3943&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Premature infants are at higher risk for lung diseases.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-premature-baby-being-held-fathers-580721992">Sarahbean/Shutterstock.com</a></span></figcaption></figure><p>Born after just 23 of the normal 40 weeks of pregnancy, the extremely preterm baby is small enough to fit in the palm of my hand and weighs just one and a quarter pounds. <a href="https://www.researchgate.net/profile/Kent_Willis">I am a neonatologist</a>, a physician that cares for these preterm babies in intensive care. Most of these preterm infants, particularly the smallest and sickest who require oxygen to help them breathe, are at high risk of developing lung inflammation and <a href="http://dx.doi.org/10.1016/S1084-2756(02)00193-8">scarring</a>. </p>
<p>This early damage will lead to a chronic lung disease called <a href="https://www.nhlbi.nih.gov/health-topics/bronchopulmonary-dysplasia">bronchopulmonary dysplasia</a>. Bronchopulmonary dysplasia can be one of the most severe and long-lasting complications of being a preterm baby. Many require oxygen for years and often have severe asthma-like episodes during which they are hospitalized for difficulty breathing. </p>
<p>Bronchopulmonary dysplasia affects many of the tiniest preterm babies that I care for and often leads to severe long-term disability. But it’s tricky to prevent preterm babies from developing bronchopulmonary dysplasia, and the situation is a bit of a Catch-22. That is because oxygen and breathing machines, which are essential for keeping these babies alive, also increase the likelihood of developing bronchopulmonary dysplasia. This dilemma has inspired my research into lung disease in preterm babies to discover new ways of preventing bronchopulmonary dysplasia.</p>
<h2>The gut-lung axis</h2>
<p>In newborns, research into <a href="http://dx.doi.org/10.1126/scitranslmed.aab2271">asthma</a> and <a href="http://dx.doi.org/10.1126/scitranslmed.aaf9412">pneumonia</a> has indicated that the microbial communities, known as the microbiome, that live inside the human gut can influence inflammation – the response of the body to pathogens or cellular damage – in their host. This may happen because of changes in the host immune system, which in turn may shape the course of lung diseases that result from <a href="http://dx.doi.org/10.1016/j.jaci.2014.06.027">inflammation</a>.</p>
<p>This recently discovered connection between the gut microbes and lung health or disease is called the <a href="https://doi.org/10.1513/AnnalsATS.201503-133AW">gut-lung axis</a>, and it may reveal new ways to treat lung diseases.</p>
<p>Over the last several years, neonatologists have done retrospective studies in which they looked back over several years of babies’ records to see if they could identify events that happened to babies who later developed bronchopulmonary dysplasia. These studies were designed to try to identify new exposures that might cause bronchopulmonary dysplasia. </p>
<p>One potential trigger for bronchopulmonary dysplasia was <a href="http://dx.doi.org/10.1016/j.jpeds.2014.09.041">antibiotics</a>. One thing that stood out to researchers, including myself, was a potential link between the mother being exposed to antibiotics and babies who developed <a href="http://dx.doi.org/10.1016/j.jaci.2014.06.027">bronchopulmonary dysplasia</a>. However, because a lot of babies and mothers are given antibiotics, this research wasn’t enough to prove that antibiotic exposure causes bronchopulmonary dysplasia.</p>
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<a href="https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=369&fit=crop&dpr=1 600w, https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=369&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=369&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=464&fit=crop&dpr=1 754w, https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=464&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=464&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A premature baby with neonatal infant pulse oximeter.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/premature-baby-legs-neonatal-infant-pulse-1073367044">Kristina Bessolova/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Maternal antibiotic exposure worsens bronchopulmonary dysplasia</h2>
<p>In my <a href="https://doi.org/10.1152/ajplung.00561.2018">latest study</a>, I used mice to test whether there was a causal link between the state of the gut-lung axis and how bronchopulmonary dysplasia develops. </p>
<p>I wanted to investigate how maternal exposure to antibiotics affects the lung development of offspring. I thought this research would not only lead to a better understanding of the gut-lung axis but also identify a new way to potentially prevent bronchopulmonary dysplasia. </p>
<p>My colleagues and I sorted pregnant mice into four groups and exposed the mothers to antibiotics at different points during gestation. </p>
<p>The first group of mother mice was exposed to antibiotics throughout their pregnancy and for the first two weeks of their pups’ life while they nursed. The second group was exposed just during pregnancy, but not after. Group three was exposed just while nursing. The fourth group wasn’t exposed at all. After the pups were born, we also exposed some to oxygen – just as we would do for a premature infant – which triggered bronchopulmonary dysplasia. </p>
<p>At the end of the experiment we looked at the lung structure of the baby mice. All the newborn mice that were exposed to oxygen developed bronchopulmonary dysplasia to some extent, but the mice whose mothers were exposed to antibiotics developed more severe disease. In fact, mice exposed to antibiotics at any stage were more deformed and had a more simplified structure than the animals that were never exposed to antibiotics. </p>
<p>A simplified lung structure, with giant, partially formed air sacs instead of tiny, well-shaped air sacs, is the hallmark of bronchopulmonary dysplasia. The more abnormal the air sac structure, the worse the bronchopulmonary dysplasia. These changes in lung structure are evidence that antibiotic exposure caused more severe bronchopulmonary dysplasia in these mice. </p>
<p>My colleagues and I were also surprised to find that antibiotics given to the mother also increased scarring in the lungs of their babies, abnormal blood vessel structure and more white blood cells in their lung tissue. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Giving antibiotics during pregnancy causes more severe lung damage in the pups. This figure created with the aid of BioRender.</span>
<span class="attribution"><span class="source">Kent Willis</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Reshaping the gut-lung axis to prevent bronchopulmonary dysplasia</h2>
<p>Finally, to understand what the gut-lung axis had to do with bronchopulmonary dysplasia, we looked at the microbes in the guts of the baby mice during the first two weeks of life. My colleagues and I found that that giving antibiotics to their mothers likely prevented them from acquiring normal bacterial communities like those found in the guts of pups with no antibiotic exposure.</p>
<p>However, the way we administered the antibiotics did not directly affect the pups. Rather, the antibiotics altered the mother’s microbiome. The pups then inherited this altered set of bacteria from her. We also showed that molecules that allow gut microbes to signal to the lungs about the status of the microbial communities in the gut in newborn mice were reduced in newborn mice with abnormal microbial communities.</p>
<p>These experiments imply that the gut-lung axis may be involved in causing bronchopulmonary dysplasia. Because a lot of human mothers and preterm babies are given antibiotics, our research suggests that physicians should consider the risks to the fetus when giving a pregnant mother antibiotics and only do so when there are no other alternatives.</p>
<p>A lot more research needs to be done. First, we would like to test if we can change the microbial communities in newborn mice so that they are more resistant to getting bronchopulmonary dysplasia. Next I plan to investigate what part of the microbial communities alters the gut-lung axis. This may reveal a way to make human preterm babies resistant to developing bronchopulmonary dysplasia.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/128607/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kent Willis does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Prenatal and postnatal antibiotic exposure combined with oxygen treatment led to lung inflammation and altered immunity in a study in mice.Kent Willis, Assistant Professor of Neonatology, University of TennesseeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/755912017-04-20T23:18:36Z2017-04-20T23:18:36ZWhy are we dragging our feet when more automation in health care will save lives?<figure><img src="https://images.theconversation.com/files/165698/original/image-20170418-32726-ro3ifj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">From closed-loop ventilators to smarter vital sign monitors, automation has untapped potential to improve medical outcomes.</span> <span class="attribution"><span class="source">From www.shutterstock.com</span></span></figcaption></figure><p>As a neonatologist, I worry about patients with <a href="https://pulmonaryhypertensionnews.com/pulmonary-hypertension-newborns/">pulmonary hypertension</a>. This unforgiving disease, sometimes seen after premature birth, can end with sudden death from constricting blood vessels in the lungs. One minute a baby in the neonatal ICU may be sleeping comfortably; moments later, doctors and nurses are giving chest compressions and rescue medications.</p>
<p>A pulmonary hypertension crisis, as these frightening episodes are called, starts with a drop in the blood oxygen level. That drop triggers a monitor to beep. It’s up to the nurse to hear the sound, come to the bedside and take action.</p>
<p>The first and most effective step in stopping a pulmonary hypertension crisis is simple: Give oxygen. But a nurse caring for another patient might be delayed for 30 seconds, and the loss of that time can lead to brain injury or death.</p>
<p>In an age of <a href="https://www.wired.com/2016/12/google-self-driving-car-waymo/">self-driving cars</a> and 400-ton <a href="http://www.usatoday.com/story/travel/columnist/cox/2014/02/09/autoland-low-visibility-landings/5283931/">airplanes that can land themselves</a> in blinding fog, it makes no sense that hospitalized patients are surrounded by lifesaving machinery that can be activated only by a person pressing a button or turning a knob. </p>
<p>Modern transportation augments human judgment and reaction times with a computer’s superior ability to continuously respond to dozens of fluctuating variables. Yet in medicine, safety remains stubbornly reliant on human intervention.</p>
<h2>FDA regulation impedes innovation</h2>
<p>My patients with pulmonary hypertension are often attached to a respirator with adjustable oxygen settings. The respirator sits inches below the monitor that indicates how much oxygen is in the blood. But the two machines can’t communicate with each other. If they could, it would be possible to increase the flow of oxygen automatically the moment a crisis is detected.</p>
<p>In 2009, engineers developed just this kind of <a href="http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2013-1834">closed-loop respirator</a> and introduced it in several hospitals as part of a feasibility study. It increased the time premature babies spent at a safe oxygen level by more than two hours per day. But no biotechnology company has marketed the idea.</p>
<p>There are other examples of automated systems with unrealized potential to save lives, and not just in the neonatal ICU. <a href="https://www.ncbi.nlm.nih.gov/pubmed/26616400">Software that scans an ECG for subtle heartbeat variability</a> can identify patterns – undetectable to the human eye – that indicate an elevated risk of heart attack. <a href="http://cdn.laerdal.com/downloads/f2644/ReviewCPRdevices06_09.pdf">Hospital beds that play audible feedback during an emergency</a> promote more effective CPR. Yet patients are not benefiting because neither of these tools has been commercialized.</p>
<p>Why haven’t these innovations attracted the industry backing necessary to make them widely available?</p>
<p>One reason is that <a href="https://its.utmb.edu/documents/FDA-Medical-Device-Regulatory-Process-Timeline.pdf">the process of getting FDA approval for new devices</a> – particularly those deemed “life-sustaining” – is often <a href="http://progressivefix.com/wp-content/uploads/2011/06/06.2011-Mandel_How-the-FDA-Impedes-Innovation.pdf">even more complicated</a> and expensive than getting approval for drugs. In the Journal of Public Economics, Harvard Business School professor Ariel Dora Stern recently described how <a href="http://www.aami.org/productspublications/articledetail.aspx?ItemNumber=3807">FDA hurdles discourage companies from investing in innovation</a>.</p>
<p>Often, the more profitable strategy is to wait for someone else to spend the time and money required to get approval for a new device, and then enter the market later with something similar that will face less scrutiny. Dr. Stern estimates that regulatory obstacles add an average of US$6.7 million to the cost of introducing a new medical device. For a company developing an ICU monitor, for instance, that will ultimately sell for less than <a href="http://www.zdnet.com/article/how-philips-maintains-monitor-price-points/">$35,000 per unit</a>, this up-front commitment can be prohibitive.</p>
<p>A consequence is that small biotechnology firms (with annual revenue less than $500 million) rarely gamble on getting new inventions approved. Dr. Stern’s paper notes that less than 17 percent of novel device applications to the FDA come from small companies. This is different from new drug applications, the majority of which originate at smaller firms.</p>
<p>What’s behind this discrepancy? Research has shown that while companies pay a steep price for pioneering new medical devices, the first firm to market a new type of drug often gets <a href="https://academic.oup.com/jleo/article-lookup/doi/10.1093/jleo/ewp002">favorable treatment from the FDA</a>. This raises the incentive for pharmaceutical startups to pursue innovation. In contrast, when it comes to medical devices, the current system discourages all but the biggest players from entering the arena.</p>
<p>And even when a new device has been approved, there is no strong impetus for hospitals and clinics to buy in. Even if they can afford upgrades, medical sites are free to use older equipment, with fewer safety mechanisms, long after improved versions become available.</p>
<h2>A chance for Washington to improve health care</h2>
<p>In contrast, a variety of government initiatives prod transportation companies to modernize. For example, the Federal Aviation Administration <a href="https://www.faa.gov/nextgen/equipadsb/rebate/">offers rebates</a> to aircraft owners to offset the cost of advanced navigation technology that prevents midair collisions. The Federal Rail Administration is overseeing mandatory, nationwide installation of <a href="https://www.fra.dot.gov/ptc">a GPS-based system to slow down speeding trains automatically</a>.</p>
<p>There is an opportunity here – beyond the messy Obamacare debate – for the White House and congressional Republicans to stimulate economic growth in the biomedical sector while improving patient safety. Streamlining the approval process for new devices and offering financial incentives for early adopters would not threaten anti-regulatory groups, and would allow the new administration to claim progress in health care.</p>
<p>President Trump has expressed interest in <a href="https://theconversation.com/faster-access-to-new-drugs-doesnt-always-mean-better-treatment-74369">expediting pharmaceutical approvals</a>, something FDA commissioner Scott Gottlieb <a href="https://www.forbes.com/sites/scottgottlieb/2016/10/24/epipen-drug-pricing-challenge/4/#15f88b7146ad">also supports</a>. But most drugs help only a small segment of the population.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=642&fit=crop&dpr=1 600w, https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=642&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=642&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=806&fit=crop&dpr=1 754w, https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=806&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/165711/original/image-20170418-20614-1khl4av.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=806&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Dr. Scott Gottlieb, nominee for FDA commissioner.</span>
<span class="attribution"><span class="source">J. Scott Applewhite/AP</span></span>
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<p>The president and Dr. Gottlieb should commit to advancing commonsense technology that makes health care better for all.</p>
<p>I’m not suggesting that machines should take over for health professionals. As in the manufacturing industry, the medical field is experiencing mounting anxiety about job displacement. There are many perceived threats, from <a href="https://www.technologyreview.com/s/600706/ibms-automated-radiologist-can-read-images-and-medical-records/">artificial intelligence X-ray interpretation</a> to <a href="http://www.thedailybeast.com/articles/2016/09/24/robot-nurses-will-make-shortages-obsolete.html">robot nurses</a>.</p>
<p>Those things might become commonplace, but they will never supplant the human relationships and insights at the core of medical practice. Neither will the kinds of safety innovations I’m recommending. With help from our leaders, physicians can take better care of patients by bringing more automation into our wards and offices.</p><img src="https://counter.theconversation.com/content/75591/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas Hooven owns shares of Atricure, a biotechnology company.</span></em></p>In planes, trains and cars, we increasingly entrust our lives to automated safety systems. It’s time for medical technology to catch up.Thomas Hooven, Neonatologist, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/634042016-08-05T01:21:34Z2016-08-05T01:21:34ZCommon method of preventing early births may be causing more<figure><img src="https://images.theconversation.com/files/133034/original/image-20160804-12192-tj896x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Preterm babies are at significant risk of health and development problems, highlighting the need to get prevention strategies right.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>New research has found a commonly used method of preventing early or preterm birth (delivery of a baby before 37 weeks) may in fact be causing more to occur, and leading to further problems.</p>
<p>The “cervical cerclage” is a surgical procedure involving stitching the neck of the womb (the cervix) closed in pregnancy. The cerclage stitch prevents preterm birth as it provides support to a weakened cervix. </p>
<p>This <a href="http://www.sutureonline.com/wound-closure-manual">prevents the cervix from opening</a> too early in pregnancy, and <a href="http://www.ncbi.nlm.nih.gov/pubmed/12114901">also acts a barrier</a>, protecting the baby from vaginal infection.</p>
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<a href="https://images.theconversation.com/files/133186/original/image-20160805-484-4s3ba6.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/133186/original/image-20160805-484-4s3ba6.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/133186/original/image-20160805-484-4s3ba6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=756&fit=crop&dpr=1 600w, https://images.theconversation.com/files/133186/original/image-20160805-484-4s3ba6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=756&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/133186/original/image-20160805-484-4s3ba6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=756&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/133186/original/image-20160805-484-4s3ba6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=950&fit=crop&dpr=1 754w, https://images.theconversation.com/files/133186/original/image-20160805-484-4s3ba6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=950&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/133186/original/image-20160805-484-4s3ba6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=950&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The cerclage stitch prevents preterm birth as it provides support to a weakened cervix.</span>
<span class="attribution"><span class="source">Screenshot</span>, <span class="license">Author provided</span></span>
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</figure>
<p>Some two million cervical cerclages are performed annually to prevent preterm birth. Worldwide, 80% of doctors use a tape-like braided suture material for the <a href="http://www.tandfonline.com/doi/abs/10.3109/14767058.2013.870551?journalCode=ijmf20">cerclage stitch</a>. A minority of doctors use a thinner “monofilament” material (like fishing line), although until now there has been no evidence to support this alternate practice.</p>
<p>Our study looked back at pregnancies across ten years at five United Kingdom university hospitals. Comparing the two suture materials, we found rates of stillbirth were three times higher in women who had a braided rather than monofilament cerclage, as were rates of preterm birth – 28% in women with braided suture compared to 17% with monofilament.</p>
<p>While larger studies will be required to replicate our findings, we estimate switching to the thinner monofilament thread for all cerclage procedures in the meantime could prevent 170,000 premature births globally every year, and 172,000 stillbirths across the world.</p>
<h2>What we did</h2>
<p>To investigate why preterm and stillbirth rates were higher in women who had a braided cerclage, vaginal fluid was sampled from high-risk women receiving either a braided or monofilament cerclage in pregnancy. At the same time, ultrasound scans were performed to see how the cervix was affected by the different suture material types. </p>
<p>Using lab-based techniques to assess the bacteria in the birth canal – called the microbiome – we revealed the traditional braided suture material caused a five-fold increase in abnormal and potentially harmful bacteria during pregnancy. </p>
<p>In contrast, the monofilament suture maintained high amounts of good lactobacillus bacteria in the vagina, throughout pregnancy. We also noticed this overgrowth in bad bacteria observed in the braided suture material was associated with an increase in potentially harmful levels of inflammation as well as abnormally early changes to the cervix, detected by ultrasound scan. </p>
<p>There is now strong evidence that infection is an important cause of the cervix opening too early in pregnancy, which results in preterm birth. The cerclage, the thicker woven structure of the braided thread, shown to encourage the growth of dangerous bacteria in our study, may increase the risk of adverse pregnancy outcomes in certain women. </p>
<p>Importantly this study finds this overgrowth of harmful bacteria was not observed in the thinner and simpler structure of the monofilament.</p>
<h2>Why this matters</h2>
<p>Preterm birth affects about <a href="http://www.who.int/bulletin/volumes/88/1/08-062554/en/">7-15% of pregnancies worldwide</a> and affects babies’ breathing, feeding and ability to fight infection. </p>
<p>Preterm babies are therefore at <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2006.01118.x/abstract">significant risk</a> of longer-term brain damage as well as learning difficulties, blindness and deafness. </p>
<p>Some babies are so unwell <a href="http://digital.nhs.uk/hes">they may not survive</a> the stress of prematurity, with preterm birth being the <a href="http://www.who.int/gho/child_health/mortality/causes/en/">largest single cause of death</a> in children under the age of five. </p>
<p>Preterm birth <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa041367">places major strain</a> on families coping with the substantial emotional and financial health care costs of medical problems resulting from being born too early. </p>
<p>Caring for a premature baby in a neonatal intensive care unit <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2005.00577.x/full">costs an estimated</a> GB£317,166 (A$555,000) per night in the UK, and many preterm babies are admitted for weeks and even months. In the United States <a href="http://www.ncbi.nlm.nih.gov/pubmed/21219170">preterm birth is thought to cost</a> more than US$26 billion every year.</p>
<p>Despite a significant increase in research focused on preterm birth over the last 20 years, rates remain largely unchanged. The major priority in tackling this important condition is in understanding how to prevent preterm birth in women at risk.</p><img src="https://counter.theconversation.com/content/63404/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lindsay Kindinger does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New research has found a commonly used method of preventing early or pre-term birth (delivery of a baby before 37 weeks) may in fact be causing more to occur, and leading to further problems.Lindsay Kindinger, Prematurity Clinical research fellow, Imperial College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/424062015-06-14T20:18:44Z2015-06-14T20:18:44ZDelay clamping babies’ umbilical cords for better health and development<figure><img src="https://images.theconversation.com/files/84636/original/image-20150611-6810-7f9bpx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">During the first few minutes after birth a baby can receive 80-100 millilitres of blood – nearly a third of their blood volume.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-91033490/stock-photo-newborn-cute-infant-baby-with-hand-holding-clip-on-umbilical-cord-at-a-hospital-nursery.html?src=ylq5A8piUn9hJ7VfItXAvg-1-14">Paul Hakimata Photography/Shutterstock</a></span></figcaption></figure><p>One of the most common surgical procedures in the world today – one that every human alive has undergone – is the <a href="http://www.mindfulmum.co.uk/health/2011/benefits-of-waiting-to-cut-the-umbilical-cord/">clamping and cutting</a> of the umbilical cord at birth. There is no dispute that we need to clamp and cut the umbilical cord. But there remains controversy over how soon after birth this should occur.</p>
<p>Early clamping of the cord began in the 1950s and 60s with the introduction of active management of the <a href="http://www.nct.org.uk/birth/third-stage-labour">third stage</a> (birth of the placenta) in order to lower the rate of haemorrhage after birth. This involves giving women an injection of Syntocinon (synthetic oxytocin) with the birth of the baby, clamping and cutting the cord and pulling the placenta out using <a href="http://library.med.utah.edu/nmw/mod2/Tutorial2/DSCN0765.html">controlled cord traction</a>.</p>
<p>Interestingly, when the first commercial cord clamp device was released in the 1890s, instructions published in the Lancet directed that they should not be used until the cord stopped pulsating and blood flow ceases. Somehow over the years we have moved the process of cutting and clamping the cord closer and closer to the moment of birth.</p>
<p>The problem is, during the first few minutes after birth a baby can receive 80-100 millilitres of blood, which is nearly a third of their blood volume. The volume decreases with the height the baby is held in relation to its mother and the length of time before the cord is clamped. But <a href="http://www.youtube.com/watch?v=W3RywNup2CM">most of the blood volume</a> passes to the baby in the first two to three minutes.</p>
<p>A Swedish study by Ola Andersson and colleagues just published in <a href="http://archpedi.jamanetwork.com/article.aspx?articleid=2296145">JAMA Pediatrics</a> has followed up children at four years of age who were part of a randomised controlled trial comparing immediate clamping of the umbilical cord (ten seconds or less after birth) with delaying clamping (for three minutes or more). </p>
<p>The <a href="http://archpedi.jamanetwork.com/article.aspx?articleid=2296145">researchers found</a> delayed cord clamping of three or more minutes led to improved fine motor skills and social domains at four years of age, especially in boys. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/84637/original/image-20150611-6787-1aajgvf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/84637/original/image-20150611-6787-1aajgvf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/84637/original/image-20150611-6787-1aajgvf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/84637/original/image-20150611-6787-1aajgvf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/84637/original/image-20150611-6787-1aajgvf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/84637/original/image-20150611-6787-1aajgvf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/84637/original/image-20150611-6787-1aajgvf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Iron is important for developing brains.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-251541388/stock-photo-kids-playing-with-play-clay-at-home-or-kindergarten-or-playschool.html?src=awmKPHsxTflQp3NKDMvffw-1-57">Oksana Kuzmina/Shutterstock</a></span>
</figcaption>
</figure>
<p>The availability now of longer-term data on outcomes of the timing of this common intervention means an important knowledge gap has been filled. Hopefully researchers will continue to study these children so we have data on school performance in the near future.</p>
<p>In 2011, Ola Andersson and colleagues published a study that followed the same infants in their <a href="http://www.ncbi.nlm.nih.gov/pubmed/22089242">first four months of life</a>. The data showed that infants whose cord clamping was delayed had less iron deficiency and anaemia. There were no significant differences in breathing problems, or the need for phototherapy to treat jaundice, a common concern expressed by doctors.</p>
<p>Iron deficiency anaemia in young children is a major public health problem around the world and has <a href="http://jn.nutrition.org/content/133/5/1468S.long">been associated</a> with poorer brain development. Iron is important in brain growth and iron deficiency can lead to lasting <a href="http://ajcn.nutrition.org/content/85/4/931?ijkey=4714ab839298daaf4c3fce4948ae5507214bc0fe&keytype2=tf_ipsecsha&linkType=ABST&journalCode=ajcn&resid=85/4/931&atom=/bmj/343/bmj.d7157.atom">cognitive</a> and <a href="http://cel.webofknowledge.com/InboundService.do?UT=000244716300016&IsProductCode=Yes&mode=FullRecord&SID=V1gl3hb7docpKC87PpC&product=CEL&SrcApp=Highwire&action=retrieve&access_num=000244716300016&Init=Yes&customersID=Highwire&SrcAuth=Highwire&Func=Frame&link_type=ISI">behavioural</a> delays. This latest study appears to support the ongoing effects of this. </p>
<p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/17374818">2007 review</a> of 15 studies showed late cord clamping (at least two minutes) reduced the risk of anaemia by nearly half. Jaundice seems to be slightly increased with delayed cord clamping, however this usually resolved itself without the need for phototherapy treatment. </p>
<p>The most recent analysis of all the randomised controlled trials examining early or delayed clamping of the umbilical cord, the <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004074.pub3/abstract">2013 Cochrane Systematic Review</a> states: </p>
<blockquote>
<p>A more liberal approach to delaying clamping of the umbilical cord in healthy term infants appears to be warranted, particularly in light of growing evidence that delayed cord clamping increases early haemoglobin concentrations and iron stores in infants.</p>
</blockquote>
<p>No doubt the conclusions will be even stronger in the future in light of this new study.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/84639/original/image-20150611-6790-1vd32yh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/84639/original/image-20150611-6790-1vd32yh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=457&fit=crop&dpr=1 600w, https://images.theconversation.com/files/84639/original/image-20150611-6790-1vd32yh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=457&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/84639/original/image-20150611-6790-1vd32yh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=457&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/84639/original/image-20150611-6790-1vd32yh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=575&fit=crop&dpr=1 754w, https://images.theconversation.com/files/84639/original/image-20150611-6790-1vd32yh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=575&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/84639/original/image-20150611-6790-1vd32yh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=575&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many women are already asking for delayed cord clamping.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-154702094/stock-photo-newborn-asian-baby-girl-sleeping-in-mother-s-arms-inside-hospital-room.html?src=gSWzdEBa0tCZWJwyGrqsZA-1-92">szefei/Shutterstock</a></span>
</figcaption>
</figure>
<p>In 2013 I wrote an article on The Conversation asking, “<a href="http://theconversation.com/are-we-cutting-umbilical-cords-too-soon-after-birth-15420">Are we cutting umbilical cord too soon after birth?</a>” Two years later we continue to have policies that encourage this to happen in Australia and little has changed. Meanwhile, the scientific evidence keeps mounting that we may be causing harm by this routine practice.</p>
<p>In the United Kingdom, the highly respected <a href="http://www.nice.org.uk/guidance/cg190/resources/guidance-intrapartum-care-care-of-healthy-women-and-their-babies-during-childbirth-pdf">National Institute for Health and Clinical Excellence (NICE)</a> changed its recommendations in December 2014 following lobbying by <a href="http://www.dailymail.co.uk/health/article-3045167/Midwife-s-victory-decade-long-campaign-delay-cutting-umbilical-cord-says-provides-babies-precious-extra-blood.html">consumers and midwives</a>. It now recommends not clamping the umbilical cord before a minute and waiting up to five minutes or even longer if this is the woman’s choice. </p>
<p><a href="http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf">The World Health Organization</a> recommends delaying cord clamping to one to three minutes following the birth and have designated this as a “strong recommendation”. </p>
<p>The leading midwifery and obstetric bodies in the United Kingdom – the <a href="http://www.google.com/webhp?hl=en&sa=N&tab=lw#hl=en&gs_rn=19&gs_ri=psy-ab&cp=7&gs_id=t&xhr=t&q=RCM+delayed+cord+clamping&es_nrs=true&pf=p&output=search&sclient=psy-ab&oq=RCM+del&gs_l=&pbx=1&bav=on.2,or.r_qf.&bvm=bv.48705608,d.aGc&fp=326e80fc9bfad7d7&biw=2150&bih=1257">Royal College of Midwives</a> and <a href="http://www.rcog.org.uk/what-we-do/campaigning-and-opinions/statement/rcog-statement-bmj-paper-benefits-delayed-cord-blood-c">Royal College of Obstetricians and Gynaecologists</a> – changed their guidelines in 2012 recommending delaying clamping of the cord for around three minutes after birth.</p>
<p>Now that we can add the evidence of longer-term benefits of delayed cord clamping to the growing list of advantages, it’s time to take a stand in Australia and move with the rest of the world in changing entrenched practice. Consumers are <a href="http://www.dailytelegraph.com.au/news/nsw/cutting-the-cord-harms-a-babys-health/story-fni0cx12-1227357349029">demanding delayed cord clamping</a> and health providers need to respond in light of the mounting evidence of benefits to the baby.</p><img src="https://counter.theconversation.com/content/42406/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen is affiliated with the Australian College of Midwives. She receives funding from NHMRC and ARC.</span></em></p>One of the most common surgical procedures undertaken in the world today – one that every human alive has undergone – is the clamping and cutting of the umbilical cord at birth.Hannah Dahlen, Professor of Midwifery, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/15432011-08-16T20:40:05Z2011-08-16T20:40:05Z‘Unethical and harmful’: the case against circumcising baby boys<figure><img src="https://images.theconversation.com/files/2526/original/NoVa_Hokie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The foreskin is the most sensitive part of the penis. </span> <span class="attribution"><span class="source">Flickr/NoVa Hokie</span></span></figcaption></figure><p>For centuries, children have been subjected to cultural and medicalised practices that were ultimately proven harmful and a violation of basic bodily integrity. Such practices have included foot binding, forehead flattening, scarification and genital cutting. </p>
<p>In English-speaking countries, the practice of cutting the genitals of male children was <a href="http://www.jstor.org/pss/3788341">gradually medicalised</a> over a period of 150 years with the benign-sounding label “circumcision.” </p>
<p>Today, there is increasing awareness that infant male circumcision – once deemed a “parental choice” – is really an unnecessary, irreversible and harmful bodily modification. </p>
<p>With the recently discovered <a href="http://www.ncbi.nlm.nih.gov/pubmed/17378847">functions of the foreskin</a> and a growth in awareness, we’re fortunately beginning to see the rights and experience of the child become the paramount consideration in discussions about circumcision.</p>
<h2>The foreskin</h2>
<p>The <a href="http://video.google.com/videoplay?docid=1482347046642439341">human foreskin</a> is a contiguous part of the skin system of the clitoris or penis. </p>
<p>In infant males, the foreskin is attached to the head of the penis (glans). The outer foreskin protects the more sensitive inner foreskin and the glans from abrasion and injury. </p>
<p>The <a href="http://www.youtube.com/watch?v=c8voOaGouDM&feature=related">moveable skin</a> facilitates sexual pleasure. In fact, the foreskin is typically the <a href="http://www.ncbi.nlm.nih.gov/pubmed/17378847">most sensitive area of the penis</a>. </p>
<p>When circumcised males lose sensitivity and skin mobility, it’s likely to significantly alter their <a href="http://www.youtube.com/watch?v=BgoTRMKrJo4">sexual experience</a>. </p>
<p>One recent <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=21672947">Danish cross-sectional study</a> concluded that male circumcision was associated with sexual difficulties for men and their female partners.</p>
<h2>Bioethics of a non-treatment surgery on minors</h2>
<p>Surgery without consent is ethical only in cases for: </p>
<p>1) incapacitated patients, in order to save their life</p>
<p>2) minors, with proxy consent from a parent or guardian, but only for surgery that addresses an underlying condition. </p>
<p>Excision of an infant’s foreskin for dubious medical or cultural purposes is an anomaly. Because it removes healthy, typically-developed tissue, the procedure fails to meet either of the above conditions.</p>
<p><a href="http://video.google.com/videoplay?docid=-6584757516627632617">Circumcision</a> of minors also stands in contradiction to other medical ethics principles, including:</p>
<ul>
<li><p>Avoiding causing needless harm</p></li>
<li><p>Promoting the patient’s medical well-being</p></li>
<li><p>Providing information on a procedure that a reasonable person would deem significant.</p></li>
</ul>
<h2>Complications</h2>
<p>Circumcision can cause <a href="http://www.circlist.com/glossarymale/m-anatdetail/skinbridge.html">skin bridges</a>, haemorrhaging, infection, as well as major penile damage.</p>
<p><a href="http://www.cirp.org/library/complications/">Dozens of case studies</a> describe severe complications, including penile amputations and death; several <a href="http://www.cirp.org/news/abc2011-05-06/">infant deaths</a> have been reported in the past few years. </p>
<p>A Canadian <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528673/">Coroner’s report</a>, issued in 2007 following the death of a baby in Ontario, recommended the Canadian Paediatric Society conduct a surveillance study on complications.</p>
<p>The most detailed <a href="http://www.ncbi.nlm.nih.gov/pubmed/6623741">assessment</a> of circumcision complications cites <a href="http://medical-dictionary.thefreedictionary.com/meatitis">meatitis</a> (affecting 8% to 31% of those circumcised), infection (affecting between 0.4% and 10%, age varying) and many other severe complications. </p>
<p>A more recent <a href="http://www.ncbi.nlm.nih.gov/pubmed/8242285">British literature survey</a> estimates complications, including infection and hemorrhage, at rates as high as 10%. </p>
<p>Paediatric urologist David M. Gibbons, commented on MensHealth.com:
“in a two year period, I was referred [more than] 275 newborns and toddlers with complications of neonatal circumcision … 45% required corrective surgery (minor as well as major, especially for amputative injury) …”</p>
<p>Another <a href="http://www.wtvr.com/wtvr-botched-circumcisions-20110517,0,4411553.story">urologist reported</a> repairing over 1,600 botched circumcisions over a three-year period.</p>
<p>Official rates of complications are likely to be under reported. But regardless of the actual complication rate, it is unethical to subject a child to these risks.</p>
<h2>Insignificant benefits</h2>
<p>While some use medical benefits to justify male circumcision, those gains rarely materialise in the real world, and the damage outweighs any gain.</p>
<p>For example, circumcision is purported to reduce female-to-male HIV transmission by 50% to 60%. But studies of the general population have failed to find <a href="http://www.hsrc.ac.za/Research_Publication-20839.phtml">any decrease in HIV infection rates</a> among circumcised men compared with uncircumcised men. </p>
<p>HIV rates are three to four times higher in American men (mostly circumcised) than in Europe (rarely circumcised). But factors far more significant than circumcision status determine HIV transmission. </p>
<p>While proponents claim circumcision reduces other sexually-transmitted infections (STIs), a 2008 <a href="http://www.ncbi.nlm.nih.gov/pubmed/18280846">New Zealand birth cohort study</a> did not find any such evidence.</p>
<h2>Misleading portrayal</h2>
<p>Despite potentially severe complications, hospital websites generally portray circumcision as values-neutral and safe.</p>
<p>Because most hospitals don’t give parents adequate information on the risks of circumcision to allow for true informed consent, few parents understand the effects their choice will have on their child and the adult he will become. </p>
<h2>Parental regret and survivor perspectives</h2>
<p>In blogs, <a href="http://www.youtube.com/watch?v=i1ZECchLIHo&feature=related">vlogs</a> and other online forums, <a href="http://www.drmomma.org/2009/09/ask-experts-circumcision-regret.html">many parents</a> have shared concerns about their child’s circumcision. </p>
<p>Experiences range from “If I knew what I know now, I wouldn’t have done it,” to “I will die hearing my baby’s screams”. </p>
<p>Many men have also expressed dissatisfaction with their circumcision, including a sense of “being violated,” “being sexually maimed,” and having feelings of anger toward parents or the medico who performed their circumcision. </p>
<p>On thousands of websites, Facebook groups and blogs, circumcised men go to <a href="http://www.foreskin-restoration.net/forum/">share their experiences and support one another</a>.</p>
<h2>Society’s role</h2>
<p>A cultural framework that considers circumcision ethically neutral and the foreskin “a useless flap of skin” omits important considerations. </p>
<p>Before debating supposed benefits, we need to ask why would we ever even consider cutting our children’s genitals.</p>
<p>The medical benefits of male circumcision are insignificant: no evidence to date justifies irreversible surgery on children unable to give consent.</p>
<p>Society has recognised the inherent right of minor females to be free from unnecessary genital cutting. </p>
<p>In the twenty-first century it is time to recognise the same rights of male children.</p>
<p><br></p>
<p><strong>Is infant male circumcision unethical and harmful? Have your say below.</strong></p>
<p>Read Brian Morris’ article <a href="http://theconversation.com/male-infant-circumcision-safe-convenient-cheap-and-fast-1541">Male infant circumcision: ‘safe, convenient, cheap and fast’</a></p>
<p><br></p>
<p><em><strong>For more of Ryan McAllister’s research in infant male circumcision, watch his recent university lecture: <a href="http://www.youtube.com/watch?v=Ceht-3xu84I">Circumcision, an Elephant in the Hospital</a>.</strong></em></p>
<p><em><strong>Watch John W. Travis’ video on infant wellness and circumcision <a href="http://www.youtube.com/watch?v=kN0rxo8y6WM">here</a>.</strong></em></p><img src="https://counter.theconversation.com/content/1543/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ryan McAllister does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.</span></em></p><p class="fine-print"><em><span>John W. Travis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For centuries, children have been subjected to cultural and medicalised practices that were ultimately proven harmful and a violation of basic bodily integrity. Such practices have included foot binding…Ryan McAllister, Research Assistant Professor of Physics and Oncology, Georgetown UniversityJohn W. Travis, Adjunct Professor of Wellbeing, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.