April 7, 2023
On this Talking Pediatrics episode, Dr. Angela Kade Goepferd talks with Kid Expert, Dr. Heidi Kamrath, about what’s trending in the newborn nursery, including diagnosis and treatment for sepsis, jaundice and hyperbilirubinemia, and hypoglycemia.
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the kid experts where the complex is our every day. Each week we bring you intriguing stories and relevant pediatric health care 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 kids.
Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. For many of us in pediatrics, our trips to the newborn nursery to meet the newest members of our practices are some of the most heartwarming, but can also be some of the most anxiety producing. Here today to keep us up to date on what’s new in the newborn nursery is our newborn Kid Expert, Dr. Heidi Kamrath, neonatologist at Children’s Minnesota and medical director of Neonatal Transport. Heidi, thanks for joining us today.
Dr. Heidi Kamrath: Yes, good morning, Dr. Goepferd. It’s fun to be here.
Dr. Angela Kade Goepferd: So there’s a lot of topics that we could talk about probably relative to the newborn nursery. From my rounding days in the newborn nursery the big things I would always worry about because going and seeing the babies is the easy part, the things I would worry about were sepsis, hyperbilirubinemia and hypoglycemia. Can we dig into each of those a little bit today?
Dr. Heidi Kamrath: Absolutely.
Dr. Angela Kade Goepferd: So let’s start with sepsis, early onset sepsis. Any updates, things we need to know about when we’re seeing babies?
Dr. Heidi Kamrath: With early on sepsis, that’s certainly one of the scariest things we also see in the NICU. Much has not changed in that it still can be very unpredictable and babies still don’t give us a lot of signs that they’re unwell until they’re really sick. What we have found over time is that thankfully most babies do not have a serious infection and so most units around the country, both newborn nurseries and NICU, are transitioning to doing these early onset sepsis calculators and they take into account kind of local infection rates and some information from mom around the time of delivery to give us really a better risk profile for that individual baby.
And what that has led to is fewer babies actually coming to us in the NICU for antibiotics, and we’ve been able to show that we can safely decrease the antibiotic exposure from our kind of standard of 48 hours to a shorter time course of 36 hours. And that’s been done both around the country and then in the units here. So we are seeing fewer babies having to be separated from parents and the calculators really have been shown to be quite safe. And so if that’s something that you’re not currently using in your practice, in your unit, I think it’s worthwhile to look at those. Those really are for the babies who otherwise look well, certainly. A sick baby is someone we always want to see.
Dr. Angela Kade Goepferd: So you mentioned these early onset sepsis calculators. So if I was rounding in a newborn nursery and I wanted to use a tool like that, how would I find it?
Dr. Heidi Kamrath: Yeah, so the tool we are using here at Children’s Minnesota is from Kaiser Permanente and I go to my trusted source of Google and just type in Kaiser early onset sepsis calculator, and that pulls everything up. Most of this is really being done by our colleagues on the maternal side. And so we’re hearing from the labor and delivery ward about what mom’s sepsis score was. And it really gives you a grading of green, meaning you don’t really need to do anything, you can do routine vitals, and then goes on from there whether we need to do some lab work or start antibiotics.
Dr. Angela Kade Goepferd: Are there any changes in terms of what laboratory evaluation or newer tools such as procalcitonin or other things that we’re using more regularly that maybe we weren’t using in the past?
Dr. Heidi Kamrath: Not at this time. Those laboratory studies haven’t been shown to be as predictive in that early newborn period. And the reasons for that being there’s already a lot of inflammation just from labor and delivery itself. And so we can’t use them kind of early on in life.
Dr. Angela Kade Goepferd: All right. Let’s talk about jaundice and hyperbilirubinemia. It’s been a few years since I’ve rounded in the newborn nursery, but I still have the app on my phone to calculate a hyperbilirubinemia risk. Any updates there, ways we’re handling light therapy or things that are different?
Dr. Heidi Kamrath: So we’ve had a big update on neonatal jaundice as many of the audiences may be familiar with the American Academy of Pediatrics just came out with a new hyperbilirubinemia guideline and it is in many ways, much more permissive. So we aren’t starting phototherapy quite as early as we used to.
Dr. Angela Kade Goepferd: And are those neonatal kind of bilirubin risk calculators, are they still relevant? Do we still use those?
Dr. Heidi Kamrath: We do. It’s been updated with the new guideline and that has definitely been a big change for our community both in the hospital as well as out in the primary clinics. We’re now seeing the babies who come in to get admitted often being a little bit older. It’s not as soon as their newborn discharge might have been in the past.
Dr. Angela Kade Goepferd: And did the guidelines talk about any updates in terms of phototherapy? I know that there’s been a little bit of back and forth on phototherapy in the hospital, phototherapy at home, Biliblankets versus Bili lights, any updates or insights there?
Dr. Heidi Kamrath: The guideline still does have in it some flexibility so that if a baby’s phototherapy threshold, if they’re getting close to that, there is a recommendation for starting phototherapy even a point or two below. And with that in mind of a baby who might be close to going home, this could potentially prevent a readmission. It doesn’t go into the level of detail with kind of Biliblanket versus in hospital intensive phototherapy. So there’s still certainly a lot of clinical expertise in making those decisions.
Dr. Angela Kade Goepferd: Any particular advice that you would give to folks who are out rounding in newborn nurseries relative to hyperbilirubinemia?
Dr. Heidi Kamrath: One of the biggest things to look at is make sure you know that baby’s risk factors. So all of those continue to play a role. So the blood type between mom and baby, the baby’s gestational age, all those continue to modify their risks for needing intensive phototherapy. So it’s important to really know those when you’re putting in the calculator because a baby without risk factors is going to have a much higher level for starting, and we don’t want babies to be sent home who maybe should have had phototherapy started sooner.
Dr. Angela Kade Goepferd: All right. Let’s finish up this round with hypoglycemia. So even I know that there have been some new guidelines for hypoglycemia, and I know this because the board questions show up on my board review questions and when I’m taking my certification questions for my pediatric boards. So let us know what’s new in hypoglycemia and maybe how we need to be altering our practice in newborn nurseries.
Dr. Heidi Kamrath: A few years ago, literature came out supporting the use of dextrous gel for hypoglycemia, and that is something that has really again, increased our ability to keep moms and babies, families and babies together because we’re now able to increase their blood glucose levels without having to start IV fluids. This has been adopted in I think all the units that I currently round in on the labor and delivery side, on the postpartum wards, and has made a difference as far as safely correcting the hypoglycemia and preventing admissions to the NICU.
Dr. Angela Kade Goepferd: And in terms of threshold for treating hypoglycemia or algorithms to follow, have there been some updates there?
Dr. Heidi Kamrath: Yeah, that’s the age-old question and continues to be the topic of much debate. I was just at one of our national conferences recently, and so I know that this is being looked at through the academy and they have a work group going together. So right now there are still differences, unit to unit, as far as what is the level for intervention. Generally speaking, most units are probably using somewhere around 50 to 60, and those come from different guidelines that are out there. I think the most important thing is just making sure that the unit you’re working in has a guideline that everyone’s aware of what the different triggers are as far as dextrous gel or IV fluids, and then keeping your eyes and ears out for when this new guideline we’ve all been waiting for finally hits publication.
Dr. Angela Kade Goepferd: Anything else you wanted to add about hypoglycemia?
Dr. Heidi Kamrath: Hypoglycemia I think is one of those things that remains a huge challenge for pediatricians and neonatologists because what we know about it scares us, and it’s hard for us to identify the babies who are most at risk. So we know that babies who have low blood sugars can go on to have abnormal MRIs and risk to their neuro development, but we also know that correcting hypoglycemia too quickly may be associated with those same findings. And I think it is a place where it’s a delicate balance of wanting to make sure we’re keeping babies safe. And I think it’s going to be an area of continued research in pediatrics where we learn truly what the best practice is.
And I would add just one little thing too, that with dextrous gel, which has been incredibly effective and really has changed practice in newborn nurseries across the country, it’s really important that when we’re giving the gel, we’re also feeding with that. So whether that’s moms or expressed breast milk, whether that’s formula, we want to make sure we’re giving the gel with a food to have the most impact.
Dr. Angela Kade Goepferd: All right. My next question is about COVID-19. Obviously that has changed all of our practice in pediatrics over the last two years, but I know there’s been a lot of discussion and debate about how susceptible newborns may or may not be to COVID-19. What do we need to know about COVID-19 and newborns?
Dr. Heidi Kamrath: We’ve learned a lot about COVID-19 and its transmissibility to our tiny patients. Thankfully, we’ve learned that we can, for the most part, keep families together even when a parent has a diagnosis of COVID-19. So most recent evidence supports that families can stay rooming in together. We no longer need to separate even symptomatic parents from their newborn, and we just would ask that families continue to try to keep some distance. So maybe the bassinet’s not right up next to the bed. And during times of feeding and diaper changing that families wear masks, wash hands, do good hand hygiene, and that can really decrease that risk of transmission even with active and symptomatic COVID infections.
Dr. Angela Kade Goepferd: And I’m a little bit ignorant in this area because I don’t practice in the NICU and I’m not rounding in the nursery. Have we had a lot of babies who’ve been quite ill with COVID-19 or needed to be in the NICU with COVID-19, or are we just not seeing that?
Dr. Heidi Kamrath: We have had a hand full. Babies who come to us either during their newborn admission or in that first month of life and actually looking at the most recent data out there for admissions under two years of age under one month old make up about a quarter of them. So around the country, these babies are getting admitted. Typically, it’s that kind of febrile infant reason for admission. And then we find COVID to be the cause. Thankfully, we haven’t seen many serious neonatal complications. There have been certainly some cases reported with more significant impacts to either mom or baby, but for the most part, transmission seems to be quite low. And when babies do get it, they tend to do well.
Dr. Angela Kade Goepferd: And I presume as in all things vaccination for COVID-19 leads to milder cases in parents and therefore less risk to infants.
Dr. Heidi Kamrath: Yes, absolutely. And we know that one of the concerns with COVID-19 infection in moms are that babies have an increased risk of being born premature, and there can be some additional complications for the pregnant woman who has a COVID-19 infection. So we strongly recommend that everybody who’s of appropriate age be vaccinated, and particularly for someone who may be pregnant or be considering pregnancy in the near future to be updated on your vaccines to decrease risk during that pregnancy.
Dr. Angela Kade Goepferd: Another thing that I definitely remember from my newborn nursery days that I think still is an issue is combating misinformation about some of the typical interventions that we perform after birth. Things like application of antibiotic eye ointment, vitamin K injections, hepatitis B vaccination. any tips or trick that you have for working through these types of questions with families?
Dr. Heidi Kamrath: This remains a challenge for all of us taking care of our infants and children and pediatrics and neonatology is certainly not immune to it. I think approaching those conversations with true curiosity makes a difference. When families feel from us that we’re truly open to having that conversation about what their worries and concerns are and being able to give true information about the risks of not doing an intervention. I think there is a lot of misinformation as to why physicians are recommending vaccination, erythromycin, vitamin K, and for many parents being able to sit down, have that really open, honest discussion about the risk to their baby if we don’t give vitamin K. For many, this was advice given by a concerned and loving friend or family member who really didn’t have a lot of true facts about the intervention.
Dr. Angela Kade Goepferd: So in terms of parents advocating for their infants for maybe specific birth plans for things that they want to be a part of their birth experience and their newborns first days of life, anything that you’re seeing more of or less of when it comes to parent requests?
Dr. Heidi Kamrath: Something that I’ve seen become more common throughout my fellowship and now into practice as a neonatologist are the increase in kind of the non-hospital based birth center or families planning to have a delivery at home, either attended by a nurse or lay midwife. One thing I would say is that many times childbirth can be done very safely without a lot of need for medical intervention. That can be true here in the hospital setting where families can choose to have a midwife as their birth attendant rather than an obstetrician if that’s within their goals of care.
There are some additional risks that I want families just to be aware of if they’re choosing birth in a non-hospital setting. And that can be that should a complication arise, you’re just further from all of the expertise of our Mother Baby Centers here at Children’s or in your local communities. And that can lead to some delay in support for either mom or baby. And so those are things that I would encourage a family to look at and that if families aren’t aware that you can have a very natural unmedicated non-physician attended delivery, that’s very possible in today’s hospital environment where we’re really trying to partner with all families and make sure that their delivery experience is the one that they want for their family.
Dr. Angela Kade Goepferd: From a parent and a pediatrician standpoint, the thing that scares me the most is what we can’t expect or what we can’t anticipate.
Dr. Heidi Kamrath: Absolutely.
Dr. Angela Kade Goepferd: And as I was preparing for this podcast, I was reading that actually maternal mortality went up during COVID-19. And so I think as safe as childbirth can be and could be, there are sometimes risk factors and influences that are outside of our control.
Dr. Heidi Kamrath: Absolutely. We can’t predict everything no matter how we want to control the situation. Some things are just unexpected.
Dr. Angela Kade Goepferd: As someone who is obviously working in the NICU day in day out, anything else that you feel like is a significant update or information that folks caring for newborns in the community should know about?
Dr. Heidi Kamrath: One initiative that we’re just starting to work toward here with our Mother Baby Center is moving toward something called Eat, Sleep, Console. And this is for babies who are opioid exposed during pregnancy. We continue to have a significant opioid crisis in this country, and we want moms to be getting the help that they need to have a healthy pregnancy. And so we see both prescribed and non-prescribed opioid exposed babies being born in our units here locally and across the country.
So Eat, Sleep, Console is a program that was first published now about probably about a decade ago, and as we know, it takes time from publication to implementation for lots of practice change, and it’s been shown to be able to decrease the length of stay for babies and decrease the need for opioid medications, for withdrawal symptoms in opioid exposed babies.
Dr. Angela Kade Goepferd: Can you tell us a little bit more about what’s involved in that?
Dr. Heidi Kamrath: This program really does partner with the family, and so the goal is that we keep family together and we do education with that family about what the symptoms of withdrawal look like in a newborn, which could be different than what they may have experienced in their own life. And we teach them non-pharmacologic ways to calm and console their baby. And then there’s still certainly medical team involvement, nursing presence to look at their withdrawal score and be able to help guide when we say if the non-pharmacologic interventions aren’t working, then we still have medication because certainly we don’t want any baby to be in distress.
Dr. Angela Kade Goepferd: And I would imagine that given what I know about the opioid crisis and epidemic, that there are several more rural practicing clinicians who may not be taking care of babies in a NICU type setting. Where could someone go to find out more information about Eat, Sleep, Console or find some guidelines that they could help implement?
Dr. Heidi Kamrath: So there’s a publication through the American Academy of Pediatrics, which does describe Eat, Sleep, Console. And I think certainly once we have implemented that program for ourselves would be something we would be happy to partner with other organizations around the area to help give some education. So we’re still getting there ourselves, but I think it’s something that really is going to be change making for how we take care of babies and families in the near future.
Dr. Angela Kade Goepferd: I mean, anything that keeps families and babies together long term we know is going to be great. Thank you so much Dr. Kamrath for joining us today. This was a great conversation. Lots to learn about newborn updates, and appreciate you taking the time to join us.
Dr. Heidi Kamrath: Yes, absolutely. Thank you for inviting me to talk with you today.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amie Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.