Oh Baby! Handling Instability in Newborns

August 20, 2021

One of the greatest joys of pediatrics is being present to welcome a new baby into the world. And some of the most harrowing moments many pediatric clinicians experience is when something goes wrong in those earliest moments of a baby’s life. Join this conversation with Dr. Tara Zamora, medical director of Children’s NICU in Minneapolis, as we discuss what can be done when newborns are in distress and when and how to transfer unstable newborns to the NICU when needed. Learn tips from our NICU expert for handling unexpected premature deliveries and babies who experience distress during and immediately after birth.


Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, where the complex is our every day. Each week we bring you intriguing stories and relevant pediatric healthcare information as we partner with you in the care of your patients. Our guests, data, ideas, and practical tips will surprise, challenge and perhaps change how you care for the most amazing people on earth, kids.

Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. As a primary care pediatrician, there are few things as amazing as meeting a newborn baby for the first time and helping a family welcome a new child into their lives. Also as a primary care pediatrician, there are few things more terrifying than when something goes wrong with that new baby.

Here to talk to us today is Dr. Tara Zamora, neonatologist and medical director at Children’s Minnesota here in Minneapolis. She’s going to be talking to us today about the role of neonatology and helping in situations when things go wrong with newborns, and reminding us of some really common things that we can do when we’re in those situations so that we don’t panic. So thank you, Dr. Zamora, for joining us today.

Dr. Tara Zamora: Thanks for having me.

Dr. Angela Kade Goepferd: So, I think your story is interesting. You did your medical school training in New Mexico, and then you came here to Minnesota for residency and fellowship. And you actually spent some time as a pediatric hospitalist before becoming a neonatologist. Can you tell us a little bit about that?

Dr. Tara Zamora: I was a peds hospitalist at a community hospital. My husband was in medicine and it was sort of a planned thing where I was going to take a couple of years to work as a peds hospitalist and decide if neonatology was truly what I wanted to do at that point. It definitely helped me realize that babies were my thing, but it also made me appreciate how hard it was to be kind of that first-line pediatrician.

And in this community setting, we were the peds hospitalist, but we also did not have pediatric ER. So every time there was a kid that came in through the ER or in the delivery room or from the clinic, we would see them. And so it was really good, but there was a lot of stuff that came up that I had not encountered in training, that you had to sort of navigate through. And there were always those super sick kids. And even as someone who is planning to do a critical care fellowship in neonatology, being just scared out of my mind or not really knowing how to do the things I needed to do, especially without the support of a whole children’s hospital.

Dr. Angela Kade Goepferd: I did my training here at Minnesota. I became employed at Children’s Minnesota immediately after residency, so I’ve always practiced newborn care right next to the NICU.

Dr. Tara Zamora: Yeah.

Dr. Angela Kade Goepferd: So, it’s been really great. So if there’s ever something that is going wrong in the newborn nursery, someone’s there minutes away, if I need help. That’s not the case for many of our listeners who are practicing pediatric scenarios where there’s not a NICU right next door. And you were sharing with me that you’ve had some pretty terrifying experiences when you were a hospitalist, where you had ill babies and had to figure out what to do in the moment.

Dr. Tara Zamora: There is one that stands out, in particular. There was a neonatal nurse practitioner on that day and they were called to something else. For some reason, I was covering deliveries. And I went to a delivery that I thought was supposed to be relatively routine. Probably just have to stand there, maybe make sure the kid was breathing okay. And then it just sort of went from bad to worse. The kid got stuck. There was a lot of yelling. The baby finally came out. And then the cord, it got cut, but didn’t get clamped-

Dr. Angela Kade Goepferd: Okay.

Dr. Tara Zamora: … so just the drama of blood spraying and stuff.

Dr. Angela Kade Goepferd: Yeah. Oh, my gosh.

Dr. Tara Zamora: The baby was fine. That just sort of amplified the experience. And so, the baby was limp and blue. And the only thing I could think about, first was like, “Oh, my gosh. Oh, my gosh. Oh, my gosh.”

Dr. Angela Kade Goepferd: Yeah.

Dr. Tara Zamora: “Someone call the NMP.” And then secondly, it was just kind of falling back on words that I heard during residency from one of my NICU attendings about, doesn’t matter if you can intubate a baby, necessarily. Most people don’t come out with a ton of experience, but it’s the giving good, positive pressure ventilation. And just being able to do that for as long as you need to. And so, that was the only thing that just kept going through my mind. And we gave positive pressure. The NMP did come and help, which was fantastic. And the baby ultimately got transferred for total body cooling, so had findings of neonatal encephalopathy. But it just stood out, because in that moment you’re supposed to be the expert, and it was just terrifying.

Dr. Angela Kade Goepferd: Yeah. I mean, it has been since residency for me, that I’ve had to intubate a small infant. So I would feel similarly terrified in that situation. Now, you’re a neonatologist here at Children’s. You’re the medical director here in Minneapolis. Can you talk a little bit about the role of the NICU team, not just in taking care of obviously preterm and ill infants in the NICU, which is what you do every day, but in supporting pediatric clinicians out in the community and what the role of the neonatologists here is?

Dr. Tara Zamora: The goal is always to have the babies in the place where they need to be, but to keep them with their family. And for a small portion of kids, that’s a high level NICU, like the one here at Children’s. But for a good portion of the kids, their community hospitals, or a near level two or something, makes a lot of sense. And the goal is, to still be a resource and to be available and helpful to those providers and families in those locations, as well as the ones that happened to be hospitalized here.

And so for us, that means, always being available. So we are, through Physician Access, and we get calls, not just for transfers, but just questions,-

Dr. Angela Kade Goepferd: Sure.

Dr. Tara Zamora: … sidelines, sometimes even talk to our pharmacists and find out what dose of this antibiotic we generally use for this age group. We also have a virtual care that we use, which actually puts our neonatologist and neonatal nurse practitioners in contact with some of the community hospitals, kind of virtually, to be there as a support person and kind of help them through that process.

Dr. Angela Kade Goepferd: Is that similar to a telehealth type interaction with video?

Dr. Tara Zamora: It’s totally the same thing. So, there’s a video that we can connect through. And this has been well studied in both neonatology and pediatrics at large. But in neonatology, they actually find that with that support, babies tend to need to be intubated less, corrective steps, as far as MR SOPA and NRP are easier to follow. There’s more confidence for the people on the other side. Safety’s a little bit better. And the idea is just to have that support there. And some of those kids transferred to us or to another place, but at least 30 to 40% of the time, they stay at their home hospital. But hopefully they’re staying in a situation where those providers and stuff feel confident that they’re doing the right thing, and they know what to do next and how to get extra help if they need it.

Dr. Angela Kade Goepferd: And when those babies do need to transport to us, we have a transport team that goes and gets the babies. Is that correct?

Dr. Tara Zamora: Right. So, we have a neonatal transport team that’s housed here at the hospital and through the NICU. So if you call, we can mobilize them right away. And they can do a lot of things. Sometimes people will call because they have a 24 weeker and mom can’t be moved and they’re going to deliver. And we can try and send the team to actually be present and attend that delivery and support them. They have capabilities to do all the things in critical care, from intubation to high-frequency, to total body cooling. They come with the antibiotics and prostaglandins and all those things that can be so hard to pull together, even if you have access to it-

Dr. Angela Kade Goepferd: Sure.

Dr. Tara Zamora: … at another community site.

Dr. Angela Kade Goepferd: If a pediatric clinician is in trouble or worries that something may be going south, their first step would be to call and reach the NICU team here. And then the team would help them through what comes next.

Dr. Tara Zamora: So through those different methods, we oftentimes are talking directly to the physicians. Sometimes there’s something going on and a nurse in the room just calls us and says, “Hey, we need help now.”

Dr. Angela Kade Goepferd: Yeah.

Dr. Tara Zamora: And we get the team going. And then when they can actually talk us through it or tell us what they need, we’ll get some more information. So, there’s a lot of different ways that can look.

Dr. Angela Kade Goepferd: Let’s talk about a few examples of maybe words of wisdom or advice from the neonatologist, for situations in which pediatric clinicians may find themselves with a kid who is worrying them. Or they’re worried something might be going wrong. Might you think of a few sort of common situations that you could coach people through, things to remember, things they can sort of try at home, so to speak, in their hospital?

Dr. Tara Zamora: I think one of the common calls that we get, is from providers who have a baby who was down initially and then sort of bounced back.

Dr. Angela Kade Goepferd: Okay.

Dr. Tara Zamora: And it’s like, “What do I do with this? The kid looks great now. Do I need to send them or not?” And the biggest thing we think about when you have… it’s a shoulder dystocia or something, that there’s this period of stress, is neonatal encephalopathy or kind of that ischemia that could have happened. And so the thing with that, is that it’s very time sensitive. If you’re going to treat it with total body cooling, it has to happen within the first six hours of life. And they can fool you. They can look pretty good for a moment and then look less good an hour or two later.

Dr. Angela Kade Goepferd: Sure.

Dr. Tara Zamora: And so any time there’s a kid who needs resuscitation, and I think positive pressure, you had to really kind of turn them around, thinking about always having those cord gases. And if you can’t get the cord gases, at least having a baby gas within the first hour.

Dr. Angela Kade Goepferd: Okay.

Dr. Tara Zamora: Because between the story, the baby gas, and their current exam is essentially how we make the decision. I think there’re more babies that are qualifying, as we learn more about it. You may have a blood gas, which has a base deficit of 12, which isn’t usually enough to cool. But if you’re telling me this kid is still jittery or still needs C-PAP, that’d be a reason to come, but it’s that time-sensitive piece. So that one hour gas, and if that even runs through your mind, turning off the warmer. Just because the whole idea is that, it’s that second hit, that hyperthermia, the inflammation that really causes further down image.

Dr. Angela Kade Goepferd: Yeah. And can you teach us a little bit about what the outcomes look like for babies who do undergo cooling?

Dr. Tara Zamora: Total body cooling is the standard of care for any baby who has specifically moderate, moderate to severe neonatal encephalopathy. And it has been shown to improve their neurodevelopmental outcomes and improve survival in that population in particular. And this is a big deal for us because we used to not have a treatment for this. So in those kids, it’s a cooling period of 72 hours. And after the cooling and after discharge, they will have ongoing neurodevelopmental follow-up. But the studies have been very strong and convincing that in that population, there’s very strong benefits. So, that’s one of the best thing we can do for those kids that are at risk.

Dr. Angela Kade Goepferd: One of the other situations you mentioned to me was, extreme prematurity. And maybe some things that can be done when a baby comes extremely early, either immediately after birth or while waiting to get some input from the NICU. Can you talk through that a little bit?

Dr. Tara Zamora: Sure. This is one of those situations that, it’s high risk. It doesn’t happen super often, but when it does, it’s all hands on deck. And the common questions we get around this is, “How early is too early? And what do we tell these parents?” Certainly, OBs will try and transfer moms, if it’s at all an option. But a lot of times, these deliveries are still happening in ERs and different places, and they call the provider.

We generally will offer resuscitation to babies that are 22 weeks gestation and above. Obviously that’s a very high risk period, and these are kids that are 500 grams or less. And in those scenarios, obviously that’s the one where you just say, “Anyone call Children’s or call your local children’s hospital and get the transport team out here.”

Dr. Angela Kade Goepferd: Yeah.

Dr. Tara Zamora: And then the two common things I think can make a big difference, so this is when those kids are, if you can intubate, you just C-PAP them and give them positive pressure until you can get some help. Warmth, so these kids are coming out often in ERs or huge delivery rooms where they’re not used to delivering this age, and so they get cold super quick. When they get cold, they get acidotic, and so things just spiral super fast. So if you have nothing else available, keeping that kid warm, blankets, putting them in a plastic bag, a Ziploc bag, all of those things make a big difference.

And we always encourage people to do delayed cord clamping. And it seems a little counterintuitive because it’s really hard to wait.

Dr. Angela Kade Goepferd: Yeah.

Dr. Tara Zamora: A baby comes out and to just say, “Yeah, just give it 30 seconds.” But in these really small kids, it helps with that transition, that hemodynamic stability. And so, just 30 seconds of that delayed cord clamping can make a big difference in how they transition after birth and going forward.

Dr. Angela Kade Goepferd: Anything else that you can think of, quick tips for pediatricians who might be at the bassinet when something’s going wrong, and things that you’d want them to think of or things that you get commonly called about?

Dr. Tara Zamora: First of all, if there’s ever a question, just ask. Again, these Physician Access, these lines are for any question, not just transfers. And so if you need to check a dose, if you’re not sure if this glucose level in this age kid is okay, or how fast to run things, those are all things that we get very common. Jaundice is a very common question. I would say, just call. So just having that available and being able to ask.

Dr. Angela Kade Goepferd: I have so much appreciation for the work that you do and that your colleagues do in the NICU. And I know there are so many parents out there who are just so grateful for everything that you do. And so many of us clinicians who are really grateful to have you available to call. Thanks for joining me today, Tara. Hopefully we learned a few things, and we’ll have some tips with us at the bedside and know who to call when we need help. So, thanks again.

Dr. Tara Zamora: Yeah. Thank you.