Vaginal Seeding Not Recommended by DSOG

Diana Phillips

August 24, 2017

The potential risks for vaginal seeding (VS) outweigh the hypothetical benefits of the practice, and there is insufficient evidence to support it, according to the Danish Society of Obstetrics and Gynaecology (DSOG). They say the practice could lead to a serious infection in the infant.

Thor Haahr, MD, PhD, from the Department of Obstetrics and Gynaecology at the Institute for Clinical Medicine, Aarhus University Hospital, Skejby, Denmark, and colleagues present the group's recommendations in an article published online August 23 in BJOG.

The authors acknowledge that VS, which involves swabbing the mother's vagina and wiping the swab over the baby's mouth, eyes, face, and skin shortly after birth, could hypothetically restore neonatal colonization in cesarean-delivered babies by exposing them to beneficial microbiota that vaginally delivered babies come in contact with in the birth canal. "However, at this point in time, there is no evidence to suggest that the proposed long-term benefits would outweigh the costs and potential risks of implementing VS," they write.

Recommendations

With the aim of assisting "fellow obstetricians and midwives with background information to adequately discuss and advise couples who are considering VS," the DSOG convened a group of experts on January 19, 2017, to develop national recommendations for the clinical management of parents who are considering the practice.

DSOG recommends that obstetric departments not perform the procedure or guide parents in how to perform it. In addition, the authors are "strongly against" the practice in preterm infants; those born to mothers who meet national criteria for group B streptococci prophylaxis during delivery; clinical situations in which cesarean delivery is recommended to prevent infection of the infant during vaginal delivery, such as primary vaginal herpes infection or HIV infection with HIV-RNA >50 copies/mL; and other clinical situations in which VS could be harmful to the infant, such as certain fetal malformations.

Practitioners should allow parents who wish to perform the procedure themselves to do so, "provided it does not interfere with or delay other procedures," the authors explain.

Clinicians should inform these parents about the lack of supporting evidence and the potential risks involved. Parents should be instructed to be aware of signs of disease in their newborn and instructed to tell their child's healthcare provider they have performed VS if the baby needs medical care.

"Finally, our suggestions for clinical management should not restrain investigators or participants from further elucidating this interesting area of research," the authors write.

Screening Strategy Difficult to Determine

Interest in vaginal seeding was piqued in February 2016, when researchers from New York University published the results from a pilot study of the practice in four infants who were delivered by cesarean. The results of that study, reported by Medscape Medical News, indicated VS led to the development of bacterial communities similar to those found on babies delivered vaginally.

Although the risk involved with VS "is probably very low," the absence of evidence or supporting data precludes a definitive statement about its safety, the authors explain. "From the only existing VS study, no conclusions can be drawn regarding safety, as only four participants received VS," they write. "In that study, mothers who chose to undergo VS were screened for potential pathogens such as HIV, Chlamydia, Group B streptococci...and bacterial vaginosis prior to VS. Whether this screening would actually secure safe transfer of healthy vaginal bacteria is, however, uncertain."

Further, determining a healthy vaginal microbiota is challenging, the authors state. "Should the risk inferred from VS be similar to that from vaginal delivery, a statement which could be questioned, it seems reasonable to suggest that the major immediate risk from VS could be early onset neonatal sepsis," they write.

Group B streptococci and Escherichia coli are microbes commonly found in the vaginal microbiota of pregnant women. Although they are common pathogens in neonatal sepsis, they are not always pathogenic, "which could make it difficult to decide the optimal screening strategy in relation to VS," according to the authors, who note that much additional research is needed to "unravel the huge complexity" of neonatal colonization.

David A. Eschenbach, MD, from the Department of Obstetrics and Gynecology, University of Washington, Seattle, agrees in an accompanying mini commentary, pointing out that there are currently more questions than answers surrounding VS.

He writes that some questions that need to be answered before adopting the practice are:

  • How much immune-derived disease prevention occurs from early exposure to maternal vaginal microbiota, and how much early exposure is required for effectiveness?

  • Can early exposure to these pathogens produce disease?

  • What is the cost–benefit?

With respect to the first question, he writes, "[w]e are several years ahead of ourselves in adequately addressing this issue. We first need to determine which of multiple vaginal and/or gut bacteria produce optimal benefit and least harm."

As for disease potential, determining which microbes to keep away from the neonate is both a necessity and an expensive prospect, which also informs the cost–benefit assessment. Considering that potential harm to the neonate is a real possibility, "[s]ignificant adult disease reduction has to occur to justify significant neonatal harm from this practice," he writes. "We simply are too far behind in knowledge to start this practice without heeding the Society's recommendations."

Parental Interest in VS Rising

In light of recent research suggesting cesarean delivery may be a risk factor for inflammatory and metabolic disease such as asthma, allergies, and other chronic immune disorders, as well as evidence indicating that mode of delivery is an important independent factor influencing neonatal colonization during the first months of life, "many patients have already adopted the concept of this new birth trend; thus, obstetricians, midwives and other healthcare professionals frequently encounter couples who are concerned regarding disrupted [neonatal colonization] after [caesarean delivery], and are querying the potential impact of VS," the authors write.

The authors suggest that clinicians whose patients express concerns about early neonatal colonization inform them of the importance of other factors that have an effect on neonatal colonization, including early skin-to-skin contact, breast-feeding, and diet during pregnancy.

The authors and editorialist have disclosed no relevant financial relationships.

BJOG. Published online August 23, 2017. Article abstract, Mini commentary extract

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