COVIDnt Jun20 PDF

NEONATOLOGY
TODAY
Volume 15 / Issue 6 | June 2020
Peer Reviewed Research, News and Information
in Neonatal and Perinatal Medicine
Guidelines for Management of Infants Delivered The Genetics Corner: Kabuki Syndrome in a Newborn
during the COVID-19 Pandemic in the USA and with a Complex Left-Sided Cardiac Lesion and Persis-
"Across the Pond" tent Hypoglycemia due to Hyperinsulinism
Ahmed Afifi, MBBCH, MSc, David Corcoran MD, Allison C. Walker, MD, Subhadra Ramanathan MS, MSc, Robin Dawn Clark MD
Alexandra Adamczak, M.D., T. Allen Merritt, MD, Jan Mazela, MD, PhD, .............................................................................................................Page 104
Thomas A. Clarke, MD
.............................................................................................................Page 3 40% of Babies Denied Preventive Treatment by Insurers
Susan Hepworth, Mitchell Goldstein, MD
HeRO Monitoring: .............................................................................................................Page 108
Does It Lead to Unnecessary Testing and Treatment? From The National Perinatal Information Center:
William E King, MS Making the Case: Accuracy of Race and Ethnicity
.............................................................................................................Page 33
Fellow Column: Data Reporting
Elizabeth Rochin, PhD, RN, NE-BC
A Neonate with Fetal Brain Disruption Sequence .............................................................................................................Page 114
Andrea Ho, MD, Robin Clark, MD, Gilbert Martin, MD Clinical Pearl: Aspects of Care of Newborns Born to
.............................................................................................................Page 41
When an Infant Dies: The Need to Acknowledge Mothers with Suspected/Confirmed Coronavirus-19
Grief and Find Bereavement Support (COVID-19) Disease
Joseph R. Hageman, MD
Barb Himes, IBCLC .............................................................................................................Page 118
.............................................................................................................Page 49
Using Volume Guarantee (VG) to Achieve Ventilatory Insurance Denials of NICU Hospital Claims
Eugene L. Mahmoud, MD
Efficiency in High-Frequency Oscillation (HFO) .............................................................................................................Page 120
Rob Graham, R.R.T./N.R.C.P. Letters to the Editor:
..............................................................................................................Page 55
NPA Position Statement: Black Lives Matter Failing Jet Ventilator in A Small Premature Infant
Shabih Manzar, MD, Mitchell Goldstein, MD, Editor in Chief
Jerasimos Ballas, MD, MPH, Viveka Prakash-Zawisza, MD, MS, MBA .............................................................................................................Page 128
...................................................................................................................Page 61
COVID-19 Update: The Future of Vaccine Treatments for Erratum
.............................................................................................................Page 131
Infants and Children Upcoming Meetings
Darby O’Donnell, JD and the AfPA Governmental Affairs Team
.............................................................................................................Page 71 Subscriptions and Contact Information
.............................................................................................................Page 133
Preemie Parent Perspective: Addressing Health Equity
and Cultural Competency in the NICU Editorial Board
Jenné Johns,MPH .............................................................................................................Page 137
.............................................................................................................Page 76 Neonatology Today: Policy on Animal and Human
None Are Protected If All Are Not Protected Research, Instructions for Manuscript Submission
Julia Koehler, MD .............................................................................................................Page 139
.............................................................................................................Page 81
Medical News, Products & Information Neonatology and the Arts
Herbert Vasquez, MD
Compiled and Reviewed by Mitchell Goldstein, MD .............................................................................................................Page 139
.............................................................................................................Page 85
Neonatology Solutions NICU Directory: Neonatology Today: Foxglove
Paula Whiteman, MD
The Directory is Even More Functional .............................................................................................................Page 140
Scott Snyder, MD Neonatology Today: A Bird of Prey
.............................................................................................................Page 98 Douglas Deming, MD
.............................................................................................................Page 141
NT
NEONATOLOGY TODAY Loma Linda Publishing Company
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Peer Reviewed
Guidelines for Management of Infants Delivered during the

COVID-19 Pandemic in the USA and "Across the Pond"
Ahmed Afifi, MBBCH, MSc, David Corcoran MD, Allison C. Walk- use of personal protective equipment and safety for healthcare
er, MD, Alexandra Adamczak, M.D., T. Allen Merritt, MD, Jan Ma- workers and management of mothers in Italy were published by
zela, MD, PhD, Thomas A. Clarke, MD Trevisanuto et al. (6) and Ng et al. in Hong Kong (7). The Ameri-
can Heart Association and the American Association of Critical
Care Nurses have recently published interim guidelines regarding
The COVID-19 pandemic has brought unprecedented contempo- neonatal resuscitation and support of children and neonates with
rary challenges to the delivery of health care to pregnant women suspected or confirmed COVID-19 (8)
and their infants. The World Health Organization (1), and the
Centers for Disease Control and Prevention (2), and the Ameri-
can Academy of Pediatrics (3) have issued guidelines regarding
mother-infant-postpartum care if a mother is COVID-19 positive “ The American Heart Association and
and emphasize the importance of a model of shared decision mak-
ing between mother, health care providers, and family members the American Association of Critical
regarding the need for separation of mothers and infants while Care Nurses have recently published
they are in the hospital. The guidelines from the American Acad-
emy of Pediatrics have been undergoing revision with the latest interim guidelines regarding neonatal
update provided on May 21, 2020. Key guidance focuses on the
use of delayed-cord clamping and that "there is no reason why
resuscitation and support of children and
the infant should not have the benefits of delayed cord clamping neonates with suspected or confirmed
and skin-to-skin contact after delivery." The amended guidance
acknowledges that "experts are divided" regarding rooming-in COVID-19 (8)”
for mothers. "While difficult to separate mother and infant, this is
the safest action, at least temporarily," as they may provide the
mother time to become less infectious," and the goal is not to Current data support the limited vertical transmission of COV-
separate a family from its newborn." The American Academy of ID-19 via the placenta with the greatest risk associated with ma-
Pediatrics strongly supports breastfeeding as "to date, breast milk ternal blood and aerosolized secretions occurring at the time of
is considered to be an unlikely course of transmission of SARS- birth or immediately afterward. Two recent reports from China
CoV-2 and encourages mothers who are COVID-19 positive to found no clinical findings or investigations suggestive of COVID
express breastmilk after appropriate hygiene which may be fed to 19 in neonates born to affected mothers, and all samples, includ-
the infant by an un-infected caregiver. If mothers prefer to nurse ing amniotic fluid, cord blood, and breast milk, were negative for
their infant, they should follow strict preventive precautions. Early SARS-CoV-2, the vertical maternal-fetal transmission cannot be
hospital discharge is discouraged, and frequent post-discharge ruled out. (6,7) Zeng et al. reported that 3 of 33 infants presented
follow is recommended. Guidance for visitation to the NICU is with early-onset SARS-COV-2 infection even when strict infec-
that mothers and partners who are COVID-10 positive or persons tion control measures were taken during delivery. The authors
under investigation should not enter the NICU until their status is conclude that the likely sources of the infant's infection were of
resolved. (www.aapnews.org May 21, 2020). maternal origin (9).
The initial Chinese response and guidance regarding neonatal In the Republic of Ireland had 25, 163 confirmed cases of CO-
management during the Coronavirus (COVID-19) outbreak was VID-19 with 1670 deaths (6.6%), Northern Ireland 4776 cases
reported by Ma and coworkers from Wuhan, China (4), in May with 535 deaths (11.2%) while in Poland 25410 cases and 1137
2020. In the April edition, Neonatology Today featured manage- deaths (4.4%) reported as of June 5, 2020 (https//www.statis-
ment guidelines for the SARS-CoV-2 virus in Ontario, Canada (5). ta.com/statistics/1043366/novel-coronavirsu-2019nvov-cases-
However, there are some important differences in these guide- worldwidebycounty.html). Other countries in Europe face similar
lines, and there has been some "push back" from some groups challenges with the exponential rise of cases in Italy, Spain and
regarding the duration of maternal-infant separation, restrictions Germany during April 2020. Neonatology Today, co-editors in Ire-
on mother's caring for their infant, including breastfeeding, or the land and Poland have shared their guidelines for the management
exclusive use of expressed breast milk rather than breastfeed- of infants in Ireland, Belfast, Northern Ireland, and Poland during
ing using some personal protective equipment (PPE). Obste- this worldwide pandemic.
tricians, midwives, nurses, neonatologists and paediatricians at-
tending deliveries are performing procedures that are associated Ireland
with aerosolization of infant respiratory secretions and maternal
blood and/0r vaginal secretions that pose hazards to those pro- Ireland has 19 maternity hospital departments and nurseries, and
viding care for mothers and their infants. Furthermore, suggested in Ireland, the Institute of Obstetricians and Gynaecologists of the
changes in "Neonatal Resuscitation Where the Mother Has a Sus- Royal College of Physicians of Ireland outlined recommendations
pected or Confirmed case of COVID-19" in terms of neonatologist for Neonatal Management for Maternal and Neonatal Manage-
NEONATOLOGY TODAY is interested in publishing manuscripts from Neonatologists,

Fellows, NNPs and those involved in caring for neonates on case studies, research results,
hospital news, meeting announcements, and other pertinent topics.
Please submit your manuscript to: [email protected]
NEONATOLOGY TODAYtwww.NeonatologyToday.nettJune 2020 3

ment (11). These guidelines for Neonatal Management are sum- neonatal unit. Babies of COVID-19 positive mothers who need
marized as steps to be taken at Delivery and Policies in the Neo- admission to the neonatal unit (NNU) for any reason should be
natal Nursery Unit, and Discharge Home. These are summarized isolated and managed in their own isolette in a designated isola-
as follows (please note spellings conform with this guideline). tion area, with dedicated staffing.
Delivery: The neonatal team should be informed of plans to de- Rooming-in and Infant Feeding
liver the baby of a woman affected by COVID-19 infection, as far
in advance as possible and should also be given sufficient notice Given the current lack of information, it seems reasonable to as-
at the time of birth, to allow them to attend and don PPE before sume that a newborn from a mother with COVID-19 at delivery
entering the room/theatre. However, COVID-19 infection in the could possibly be infected, either in utero or perinatally, and thus
mother is not per se an indication for the neonatal team to routine- should be placed in isolation to avoid exposure to other newborns.
ly attend low-risk delivery. Furthermore, there is a risk that medi- However, well term/near-term babies, not otherwise requiring neo-
cal staff attending such deliveries may be more difficult or have natal unit care should stay with their mother, if at all possible. If
delayed response time to concurrent emergencies. the mother is severely or critically ill, separation may then be nec-
essary, but the need for this should be regularly reviewed. Mater-
A designated member of the neonatal team should be assigned to nal illness is not in itself an indication for newborn admission to the
attend suspected/confirmed COVID-19 deliveries. The most se- NNU so that the baby may be cared for in an isolette in the nurs-
nior person likely to be required must attend in the first instance to ery or isolation with the mother, e.g., on a COVID-19 assigned
minimize staff exposure. If there is a high rate of maternal infec- ward. It is recommended that the baby is cared for at home if the
tion, units might choose to establish a dedicated COVID Neonatal mother is admitted to an Acute Adult Hospital to reduce the risk of
Team with a dedicated Registrar and Consultant during working infection to the baby. In light of current evidence, the benefits of
hours. Local units should make their own arrangements for des- breastfeeding outweigh any potential risks of transmission of the
ignating staff, but senior involvement is expected. PPE should be virus through breastmilk. If the woman is asymptomatic or mild-
donned in an adjacent room, and the team member should wait ly affected, breastfeeding should be supported by encouraging
outside the delivery room, ready to be called in should the baby, mothers in coordination with healthcare providers. Breastfeeding
require any intervention(s). If it is anticipated that the baby will can still be supported by encouraging mothers who have been
require respiratory support, appropriately skilled neonatal team separated from their babies to express milk. Either way, mothers
members should be present at delivery wearing PPE. should have a designated breast pump for exclusive use and local
infection being followed regarding equipment decontamination.
Neonatal resuscitation/stabilization should proceed as per guid-
ance. If additional equipment is required, this can be passed to
the team by a "clean" staff member outside the room. Neonates “Breastfeeding can still be supported
should be transferred in a closed incubator, although where the
baby is unwell, they may need to be transferred by resuscitaire or by encouraging mothers who have been
resuscitation warmer (with staff in full personal protective equip-
ment). Where possible, all procedures and investigations should separated from their babies to express
be carried out in a single room or an isolation room/bay with a
minimal number of staff present.
milk. Either way, mothers should have
a designated breast pump for exclusive
There is no evidence to suggest that antenatal corticosteroids for
fetal lung maturation cause any harm in the context of COVID-19, use and local infection being followed
except perhaps where the pregnant woman has a critical illness in
which case a multidisciplinary discussion is required to determine regarding equipment decontamination.”
their relative benefits. Steroids should, therefore, be given to
mothers anticipating preterm delivery where indicated, and urgent
delivery should not be delayed for their administration. Magne- In the case of rooming-in, the baby's cot should be kept at least
sium Sulphate should be given for neuroprotection of babies <32 2 meters from the mother's bed, and a physical barrier such as a
weeks' gestation as per the current guidance. curtain may be used. An incubator can also be used in the room
as a physical barrier. Babies requiring subsequent additional care
Regarding neonatal management of suspected, probable, and (e.g., intravenous antibiotics) should be assessed in the delivery
confirmed cases of maternal COVID-19 infection, the umbilical suite or postnatal wards and a decision made as to whether ad-
cord should be clamped, and the neonate should be transferred ditional care can safely be provided at the mother's bedside. NNU
to the resuscitation area for routine assessment and if appropriate admission should be avoided if at all possible and safe. Any need
assessment by the attending neonatal team. There is insufficient to separate mothers with COVID-19 infection from their newborns,
evidence regarding whether delayed cord clamping (DCC) in- with the consequence that they are unable to breastfeed directly,
creases the risk of infection to the newborn via direct contact. The may impede early bonding as well as the establishment of lacta-
most recent guidance clearly states that deferred cord clamping is tion. These factors will inevitably cause additional stress for moth-
still recommended, provided there are no other contraindications. ers in the postpartum period. As well as caring for their physical
The baby can be dried as normal while the cord is still intact. In wellbeing, medical teams should consider the mental wellbeing of
the case of a preterm baby, standard thermoregulatory measure, these mothers, showing appropriate concern and providing sup-
including the use of a plastic bag, should also be used. port when needed.
Whether DCC is practiced or not, the neonate should be trans- The Neonatal Paediatric COVID-19 guidance group have issued
ferred after delivery to the resuscitaire for initial assessment by recommendations for breastfeeding during the COVID-19 pan-
the attending midwife, or by the neonatal team as appropriate. demic. These state that the Faculty of Paediatrics encourage
An Immediate skin to skin approach with the COVID-19 positive breastfeeding to protect children and reiterate that "the benefits
mothers should not take place; this can be considered when the of breastfeeding outweigh the potential for exposure to the virus.
mother has taken appropriate hand hygiene and sterile PPE pre-
cautions. Asymptomatic well babies should not be admitted to the Testing:

There is currently no clinical indication to test any well-baby born Transfers should be limited to a minimum, and per network esca-
to a COVID-19 positive mother. Performing nasal swabs on as- lation policies. Exposure to COVID-19, in itself, is not a reason to
ymptomatic infants may also result in false negatives, and the transfer. All staff must adhere to the locally recommended PPE
optimal time of testing, in any case, is unclear. Asymptomatic guidelines before entering the isolation room. A register must be
patients, including infants, even if positive, are unlikely to transmit kept of all staff entering isolation rooms. All equipment coming
the virus, providing everyone adheres to basic hygiene measures. out of the isolation room should be cleaned. It is anticipated that
Viral RNA may be detectable in the stool for several weeks, but NNU capacity may become problematic either due to cot capacity
this does not mean that the faecal material is necessarily infective; or staff availability. Individual units should have agreed to staffing
providing caregivers adhere to the basic hygiene measures, the plans when optimal staffing plans cannot be achieved. The co-
risk is not thought to be significant. horting of confirmed positive cases may be necessary and should
follow local guidance.
Asymptomatic babies should not be routinely admitted to the
NNU. If subsequently admitted for other issues such as jaundice COVID-19 positive mothers should not visit their baby on the NNU
or hypoglycaemia they do not require testing unless their symp- until they are asymptomatic and have tested negative. Partners
toms fit the case definition. Case definition: newborns may not of COVID-19 positive mothers must adhere to the current advise
show all the features of influenza-like illness, particularly a fever, regarding self-isolation and the hospital policy regarding visiting
so clinicians should have a high index of suspicion in all babies the maternity wards and NNU, except under exceptional circum-
admitted to the NNU, and monitor for signs of respiratory illness stances.
during the admission.
Newborn Screening:
Babies of COVID-19 positive mothers who need admission to the
NNU for any reason should be isolated and managed in their own Newborn Infant physical examination should be completed as
isolette in a designated isolation area, with dedicated staffing. They usual in the hospital, prior to discharge. Newborn Blood Spot
must be monitored for signs of COVID-19 during their admission. screen should take place as usual. Audiology screening should
If they develop signs, they should be tested. Symptomatic babies continue in maternity units and on the NNU. The ability to perform
that meet the definition only by virtue of requiring respiratory sup- investigations and tests once the infant has left hospital will be
port for an anticipated non-COVID-19 respiratory pathology (e.g., restricted, and when possible, tests should be performed before
RDS) should be tested after 72 hours of age to avoid potential discharge from the maternity or neonatal units. Maternity units
early false-negative results. It is suggested to test again on day should aim to maintain sufficient staffing in order to perform the
five before declaring them negative and non-infected. necessary screening before discharge.
Babies can come out of isolation despite continuing to need for Discharge Home:
respiratory support, providing the tests on days 3 and 5 are nega-
tive, and the baby is following the projected clinical course (e.g., When babies and mothers are ready for hospital discharge, they
expected for RDS, etc.). If there is clinical concern that a baby should be provided with written advice regarding what to look out
who has been in isolation meets the case definition is not following for in terms of respiratory symptoms, lethargy or poor feeding,
a typical clinical course for an anticipated non-COVID-19 respira- and from whom to seek further advice should they have concerns.
tory pathology, they should be tested that day. They should be advised to self-isolate for 14 days. All measures
aimed at early discharge from the NNU should be scaled up,
Known COVID-19 positive babies should be isolated until their where possible, to avoid vulnerable infants with chronic lung dis-
symptoms resolve, and they no longer need respiratory support; ease attending clinics. Consider telephone/video consultation for
they can then be allowed out of isolation but must remain in an neonatal follow up when possible, to avoid vulnerable infants from
incubator and monitored respiratory signs and symptoms for a attending clinics.
further 14 days. Babies awaiting test results and less than seven
days of age can be cohorted in the same isolation room, provided
they remain in incubators; airborne transmission (except for aero- “Given the current lack of information,
sol-generating procedures) is not currently thought to be a major
mechanism of transmission in this clinical context. it seems reasonable to assume that a
Clinical investigations should be minimized whilst maintaining newborn from a mother with COVID-19 at
standards of care. In the absence of evidence, it is reasonable to
treat the baby's respiratory illness in the same way as if they were delivery could possibly be infected, either
not potentially exposed to COVID-19. The evidence in favour of in utero or perinatally, and thus should
early intubation is limited to adults and older children. All babies
requiring respiratory support should be nursed in an incubator. be placed in isolation to avoid exposure
Intubation is an aerosol-generating procedure, although the risk
of transmission soon after birth is thought to be low; however, it is
to other newborns. However, well term/
recommended that staff follow their local guidelines regarding the near-term babies, not otherwise requiring
use of appropriate PPE, even in an emergency. In-line suction
with an endotracheal tube should be used where possible. Where neonatal unit care should stay with their
possible, the use of a video-laryngoscope should be considered
for intubation, which might facilitate keeping the baby within the mother, if at all possible. ”
incubator. By reducing proximity to the baby's airway, this may
help to reduced exposure to the virus. Intubation should be un-
dertaken by staff with appropriate competencies. CPAP and high Advice should be provided to parents of those infants at increased
flow therapies are associated with aerosolization, and staff caring risk (e.g., immunocompromised, chronic lung disease, cardiac
for infants receiving these therapies must also adhere to their lo- disease) about reducing the risk of infection (reduced social con-
cal guidance regarding the use of appropriate PPE. tact, handwashing) and interventions aimed at preventing other
diseases (e.g., immunizations) should be optimized. Parents who

telephone NNUs for help should receive experienced advice, with direct patient contact, i.e., main corridors, tea room, canteen, and
the aim of minimizing direct contact with either neonatal or paedi- offices where NO PPE are required
atric services.
Amber Zone: These areas will contain infants, who may be under-
Among the 19 maternity hospitals and nurseries, or among mid- going aerosol-generating procedures, but have had no exposure
wives delivering at home (which is rare in Ireland) there has been to coronavirus and consist of the main clinical areas with the NICU
a survey or an audit of adherence to these recommended prac- and main delivery suite.—Standard PPE=Apron and non-sterile
tices; nonetheless, there is great hope that having a standardized gloves, fluid-resistant surgical face mask, and the use of eye pro-
approach will reduce maternal to infant transmission of COVID-19 tection should be considered if risks of splashes or droplets.
and protect professionals caring for both mothers and their ba-
bies." Red Zone: These areas will contain infants of mothers with sus-
pected or confirmed COVID-19 or infants who are at risk of hori-
Northern Ireland zontal transmission where enhanced PPE required. Attendance
at all deliveries of suspected or confirmed COVID-19 positive
At the Royal Maternity Hospital in Belfast, Northern Ireland, mothers, working within a COVID-19 cohort area with infants with
policies were developed in response to COVID-19, focusing on suspected or confirmed COVID-19 virus, where aerosol-generat-
specific guidance around infection prevention within the National ing procedures are being performed or anticipated, and when re-
Health Service of the United Kingdom. (12) suscitating the acutely collapsed infant regardless of maternal sta-
tus, will also require advanced PPE. This enhanced PPE includes
Hand Hygiene: Strict hand hygiene must be adhered to. Arms FFP3 respiratory mask, long-sleeved disposable gown, dispos-
should be bare to the elbows, with no hand and wrist jewelry ex- able eye protection, Gloves, Apron, disposable hat. All PPE must
cept for a single metal ring band), have clean short fingernails be donned and doffed in an established sequence, with specific
with no artificial nails or nail products, and any cuts or abrasions care and attention taken at each stage. Donning PPE with a "bud-
should be covered with waterproof dressings. The Seven-Step dy" ensures satisfactory technique and enhances user safety.
Technique should always be observed when washing or gelling
hands. Antenatal Admission and Delivery at Royal Maternity Hospital
(RMH), Belfast
Uniform: Staff are asked to travel to and from work in their own
clothes and change into scrubs once on site. Scrubs should then Entry to RMH: Everyone visiting or presenting to the RMH will
be removed at the end of a shift and placed in the appropriate now have to buzz for entry to the building with strict entry criteria
laundry bag. There are facilities available if staff wish to shower in place due to the restricted visiting policies. If entry is permitted,
before traveling home. the person will be allowed access to the reception area before be-
ing asked a series of questions including:
Social Distancing: Where possible, staff are asked to maintain a
distance of 2 metres between each other while at work. Additional Do you have a cough?
alternative areas for breaks will be made available. Measures
such as limiting the number of infants within a room, and limiting Do you have a temperature?
one parent to the bedside at a time are also being undertaken to
facilitate this. Do you have any shortness of breath?
Essential Personnel Only: Only essential personnel should physi- Are you/have you recently been, self-isolating?
cally attend work. Where possible staff should try and facilitate
working from home via remote access, video conferencing, and
other methods of remote access. Elective and non-urgent work
should be reviewed and either canceled or relocated as able. “All PPE must be donned and doffed in
Aerosol Generating Procedures requires additional care when an established sequence, with specific
performed on patients with suspected or confirmed COVID-19.
Aerosol Generating Procedures should only be carried out when care and attention taken at each stage.
absolutely necessary, with only essential staff present. These in-
clude:
Donning PPE with a "buddy" ensures
satisfactory technique and enhances user
Intubation, extubation, and related procedures, manual ventila-
tion, Less invasive surfactant administration, Open suctioning, safety.”
non-invasive ventilation, e.g., Bi-level positive airway pressure
(BiPAP and Continuous Positive Airway Pressure Ventilation
(CPAP), high-frequency oscillating ventilation, High flow Nasal Have you been in contact with anyone who is self-isolating
Oxygen, Tracheotomy/tracheostomy procedures. Placement of or had COVID19?
an oral or nasal gastric tube, use of low flow oxygen, nebulisers
and Entonox are considered to be aerosol-generating procedures. If the answer to any of these is 'yes' the person will either be de-
nied entry or treated as a patient with 'suspected COVID-19'. For
Personal Protective Equipment. On April 4, 2020, Public Health the purpose of this guideline, we are defining a mother with 'sus-
England recommend that due to sustained background transmis- pected COVID' as a person who has had swabs taken, but results
sion of COVID-19 within the UK, personal protective equipment is are not yet available.
required in every patient area regardless of infection status. This
led the Belfast Trust to categorise all hospital areas with a traffic Any woman presenting to admission with either suspected on
light "zoning" system. This has been modified with the Neonatal confirmed COVID-19 will be transferred to an active birthing cen-
Nursery Unit as follows: tre room. The donning area for these rooms is set up in the cor-
ridor just outside these rooms. The doffing areas are in the corri-
Green Zone: Areas that are generally considered "clean" with no dors between rooms. A dedicated COVID-19 resuscitation trolley

Less Than 27 Weeks Gestation
•Neonatal team to be informed at time of admission

Antenatal admission of •Senior neonatal team to meet and begin preparations
woman with suspected including: identification and allocation of staff
roles
or confirmed COVID-19 location of mother
<27 weeks gestation route for transfer of infant
intended admission location for infant
•Designated consultant and senior nurse to attend

delivery
•Attend delivery area and don appropriate PPE, in
designated donning area
•Only when delivery is anticipated, enter delivery area
and prepare resuscitaire and essential equipment
Delivery, resuscitation •Delayed cord clamping should be considered as per
and stabilisation unit protocol
•Infant should be moved directly to resuscitaire once
cord cut
•Resuscitate and stabilise as per NLS algorithm
•An in-line micro HME filter should be used with all
respiratory support
Maternal suspected or •Infant may be intially shown to parents but social

confirmed COVID-19: distancing should be observed
mother asymptomatic •Once infant stabilised, if the mother is able to apply a
surgical face mask and gel hands, she may have contact
or with her infant if desired and/or feasible, prior to
transfer to NICU
only mildly symptomatic
Maternal suspected or
confirmed COVID-19,
mother symptomatic •Infant may be shown to parents but social distancing
should be observed throughout
and/or
acutely unwell
•Once the infant has been stabilised, NICU should be
informed of the pending admission
•Transfer to NICU should be via the agreed route only
•Additional 'clean' helpers should be available to clear
Transfer to NICU corriders, and open doors etc
•Only the 'middle lift' should be used for transport
between floors
•Infants <27 weeks gestation should be transferred using
a resuscitaire
•Admit to designated cohort area within NICU

•Give a clear handover to the receiving team before
transferring the infant to the incubator
•The transport resuscitaire should be moved to the
Admission to NICU designated doffing area to have an initial clean, before
moving it to an area outwith the cohort area for further
cleaning
•Staff should doff PPE in the designated area before
exiting the cohort area
•The NNNI should be informed of all admissions of an

infant born to a mother with suspected or confirmed
Inform NNNI COVID-19
•Consideration should be made to whether a Network Call
should be scheduled
27 – 35 Weeks Gestation

•Senior neonatal team to meet and begin preparations
Antenatal admission of including: identification and allocation of staff
woman with suspected roles
or confirmed COVID-19 location of mother
route for transfer of infant
27 - 34+6 wks gestation intended admission location for infant
•ST4+ and senior nurse to attend delivery unless

infant considered 'high risk'
•Attend delivery area and don appropriate PPE, in
•Only when delivery is anticipated, enter delivery area
and prepare resuscitaire and essential equipment
Delivery, resuscitation •Delayed cord clamping should be consdiered as per
unit protocol
and stabilisation •Infant should be moved directly to resuscitaire once
cord cut
•Resuscitate and stabilise as per NLS protocols
•An in-line micro HME filter should be used with all
respiratory support
•All infants of this gestation will require admission
Maternal suspected or •Infant may be intially shown to parents but social

confirmed COVID-19: distancing should be observed
mother asymptomatic •Once infant stabilised, if the mother is able to apply a
surgical face mask and gel hands, she may have
or contact with her infant if desired and/or feasible, prior
to transfer to NICU
only mildly symptomatic
Maternal suspected or
confirmed COVID-19,
mother symptomatic •Infant should be shown to parents but social
distancing should be observed throughout
and/or
acutely unwell
•Once the infant has been stabilised, inform the
NICU of the pending admission
•Transfer to NICU should be via the agreed route
only
•Additional 'clean' helpers should be available to
Transfer to NICU clear corriders, and open doors etc
•Only the 'middle lift' should be used for transport
between floors
•Infants requiring respiratory support should be
transported on a resuscitaire. All other infants may
be transported in an incubator

•The transport resuscitaire or incubator should be
Admission to NICU moved to the designated doffing area to have an
initial clean, before moving it to an area outwith the
cohort area for further cleaning

infant born to a mother with suspected or confirmed
•Consideration should be made to whether a Network
Call should be scheduled
Greater Than or Equal to 35 Weeks Gestation

Antenatal admission of •Senior neonatal team to meet and begin preparations
woman with suspected or including: identification and allocation of staff
confirmed COVID-19 ≥ 35 roles
location of patient
weeks gestation route for transfer of infant
•Neonatal attendance at deliveries of infants ≥ 35 weeks

should be requested as per current RMH policy
Attendance at delivery •Suspected or confirmed maternal COVID-19 status is
NOT an indication in itself for neonatal attendance at
birth
•If neonatal attendance is required at delivery but the

is infant considered 'low risk' - ST4+ to attend
delivery
•If infant considered 'high risk' - consultant and senior
nurse to attend and be present in room prior to
delivery
•Attend delivery area and don appropriate PPE in
Delivery, resuscitation •Wait outside delivery area and only enter room if
and stabilisation newborn requires resuscitation (unless high risk). It is
the responsibility of the midwifery team within the
delivery area to have checked and prepared
resuscitaire
•Delayed cord clamping should be performed as per
unit protocol
•If required, resuscitate and stabilise as per NLS
algorithm
•Use an in-line micro HME filter filter for all respiratory
support
•If infant well, every effort should be made to keep the

infant and mother together postnatally
Maternal suspected or •Depending on maternal infection status and symptoms,
confirmed COVID-19: there should be consideration of maternal use of a face
mask when handling and feeding the infant while in
mother asymptomatic hospital, with distancing measures observed at other
or times. Infant should be nursed in an incubator
•Discharge home should be facilitated as soon as
only mildy symptomatic feasible
•Family should be educated in hygiene and distancing
measures to avoid viral spread
•Infant to be isolated from mother at birth. If the
Maternal confirmed infant is well it may remain within same room
COVID-19: initially, within an incubator, until a suitable carer or
care area can be identified (not NNU)
mother acutely unwell •Infant discharge with an alternative carer (clinically
well and not self isolating) should be considered
•If the infant requires admission, NICU should be

urgently informed of the pending admission
•Transfer to NICU via the agreed route only
•Additional 'clean' helpers should be available to
clear corriders, and open doors etc
Transfer to NICU •Only the 'middle lift' should be used for transport
between floors
•Infants requiring respiratory support should be
transported on a resuscitaire. All other infants may
be transported in an incubator

•The transport resuscitaire or incubator should be
moved to the designated doffing area to have an
Admission to NICU initial clean, before moving it to an area outwith the
cohort area for further cleaning

infant born to a mother with suspected / confirmed
•Consideration should be made to whether a Network
Call should be scheduled
Resuscitation Equipment
Newborn resuscitation should continue as per the standard NLS algorithm.
Although the vertical transmission of SARS-CoV-2 is considered possible, it remains to be definitively

proven. It is assumed that, even if an infant was infected at birth, the viral load would be either very
low or undetectable. This, in combination with the fact that infants’ lungs are not aerated at time
birth and much lower tidal volumes are used compared to adults practice, means that newborn
resuscitation, including AGPs, is considered to carry a low risk of infection.
However, we are advising a slight alteration to our standard equipment to further minimise risk of
transmission to staff. This is the inclusion of an in-line heat and moisture exchanger (HME) micro
filter during respiratory support. These filters should be used for both Neopuff/mask support and
when intubated. The photos below demonstrate their position within the equipment. Although
some recent work has indicated that tidal volumes and pressures delivered are not affected with the
inclusion of a filter, both the weight and the potential dead space of the circuit may be increased
and staff should be cognisant of this. Once the ETT position is confirmed with the Neostat and
visible chest rise, there is an option to remove the Neostat from your circuit.
Neopuff and Mask with In-Line HME Filter

Neopuff, Neostat and ETT with In-Line HME Filter
Transfer of a Newborn Infant to NNU

If a newborn requires admission to the NNU at birth, the Sister-in-charge should be informed as
soon as this decision is made in order to allow time for preparation and staff allocation.
The infant will be admitted to the cohort area within the NNU.
There are specified transfer routes out of both delivery suite and theatres and these should be
adhered to. Specifically, the potentially exposed team and infant should NOT use the back lift or
enter the NNU through the NICU area.
Additional identified members of staff will travel before and behind the neonatal transfer team to
ensure corridors are cleared and doors are open. They will remain at a distance of at least 2 metres
from the team and will not assist in the transport itself.
From Delivery Suite (Rooms 19 – 16): Exit out of the back door of the link corridor (doffing
area) onto the main hospital corridor. Travel to the middle lift and ascend to the 2nd floor. Enter the
NNU cohort area via the side door.
From Theatre (ground floor): Exit out of Theatre 2 onto the main theatre corridor. Travel out
through theatre reception into the main corridor and out onto the main hospital ground floor. Travel
to the middle lift and ascent to the 2nd floor. Enter the NNU cohort area via the side door.
Walk through videos of each of these routes have been made and shared with the wider group.
Admission to NNU: Suspected Newborns
All preterm or term unwell infants of mothers with either suspected or confirmed COVID-19 will be
admitted directly to the cohort area in the NNU (see below). Given the low likelihood that a
newborn will be COVID-19 positive at birth, medical treatment and management should be mainly
determined based on their pathology and clinical needs rather than being influenced by specific
considerations around coronavirus.
All infants should be nursed in a closed incubator for the duration of their stay within the cohort
area. This acts as a further layer of isolation.
COVID-19 Screening in Infants of Suspected or Confirmed Mothers

All infants of mothers who have a suspected or confirmed COVID-19 status, admitted to the NNU
immediately following birth, require screening. It has been suggested that optimal testing for
possible vertical transmission should include IgM / IgG analysis of cord blood at birth. This requires
written parental consent but is not being undertaken in RMH until reliable IgM/IgG testing has been
developed.
Current screening schedule for infants admitted at birth is:

- First set of swabs at admission
- Second set of swabs at 72hrs (day 3)
- Third set of swabs on day 5
Two dry swabs should be taken at each screen with one swab of the nasopharynx and one deep
throat swab. This should make the patient gag to be effective. If the infant is ventilated, then
secretions obtained by ET suction should be sent. The process for swabbing is outlined below with
further Trust guidance available on the Hub:
 Label the universal container before entering the cohort area. A hazard warning label should
be affixed to the container
 Do not take the paper request form into the cohort area. A hazard label should also be
added to the form
 Take the nasopharyngeal and throat swabs as above
 Place both swabs into the same universal container
 Wipe outside of sample with Difficil-S or Actichlor Plus (1/1000ppm)
 Place into a leak proof bag and wipe outside with with Difficil-S or Actichlor Plus
 Ideally a buddy should meet you at door and hold open a second bag for you to place leak
proof bag into
 Place the form into this bag too and seal
 A ‘COVID-19 biohazard’ label should be attached to the outside of the second bag
 The bag containing the samples must be hand transported to the lab by a porter. The
pneumatic tube system must not be used
Infant of mothers with suspected or confirmed COVID-19, requiring
admission to NNU from delivery suite or theatres
Admit to COVID-19 cohort area
Swab all infants at admission
Mother confirmed Mother confirmed

NEGATIVE POSITIVE
Further swabs on
Infant may be moved day 3 and
out of cohort area day 5 of life
immediately
Infant swabs remain Infant swab reported

NEGATIVE as POSITIVE
ANTICIPATED UNANTICIPATED NO
respiratory symptoms respiratory symptoms respiratory symptoms Discuss with
ID
Respiratory symptoms resolve Respiratory symptoms Infant may be moved Infant may be moved
out of cohort area
< 14days persisting for 14 days out of cohort area once
once all 3 swabs
symptoms RESOLVED negative
and
Infant may be moved out of Infant may be moved all 3 swabs NEGATIVE
cohort area once respiratory Must remain in
out of cohort area after
symptoms resolved incubator until at least
14 days if respiratory
symptoms remain Must remain in day 14 of life unless
Must remain in incubator until typical of non incubator until at least discharged #
at least day 14 of life unless COVID-19 pathology day 14 of life unless
discharged # discharged #
# Isolate at home until day 14

Transfer Out of the COVID-19 Cohort Area
The flow chart above also outlines timeframes for when the infant may be considered for transfer
out of the cohort area.
If an infant is admitted to the cohort area due to maternal ‘suspected’ status, and maternal results
are subsequently reported as negative, the infant may be moved out of the cohort area
immediately. There is no need for a further period of isolation within an incubator, and normal
neonatal care should continue.
For infants of mothers with confirmed COVID-19, the duration within the cohort area is mainly based
on the presence and nature of their respiratory symptoms.
No Respiratory Symptoms: If the infant has been admitted for reasons other than respiratory
support, and they have no respiratory symptoms, they may be transferred into the general clinical
areas once all 3 sets of swabs are reported as negative. Examples would include late preterm infants
who are admitted due to gestation and feeding support but require no respiratory support.
Anticipated Respiratory Symptoms: Anticipated respiratory symptoms are defined as

clinical features in keeping with the diagnosed pathology. Examples would include respiratory
distress and x-ray changes in keeping with surfactant deficiency in a 25 week preterm infant.
Unanticipated Respiratory Symptoms: Unanticipated respiratory symptoms are defined

as clinical features that are outwith the expected clinical course for an infant of their gestation or
pathology. An example would be a 36 week infant with no antenatal concerns who required
intubation due to increased work of breathing and climbing oxygen requirements, with no acute
pathology to account for this.
If an infant is able to be moved out of the cohort area, into either the general clinical areas within
the NNU or the PNW, before 2 weeks of age they should remain within an incubator until day 14 of
life regardless of weight etc.
Finally, if an infant is ready for discharge home prior to a full set of swab results being performed,
they may be discharged home directly from the cohort area. No further swabs will be required. The
family should be advised to self-isolate at home until the infant is 2 weeks of age.
Admission to NNU: PNW Infant
Whilst COVID-19 should be considered as a possible diagnosis in PNW infants who become unwell, it
is anticipated that the majority of admissions will be more likely due to common pathologies such as
hypoglycaemia or infants requiring lumbar puncture. Accordingly, the vast majority of these infants
will be able to be admitted to the NNU as normal, rather than the COVID-19 cohort area.
It is expected that all cases will be discussed with the consultant on duty, regardless of symptoms. As
shown in the flowchart below, an infant admitted from PNW with unanticipated respiratory
symptoms, or whose mother is suspected or confirmed Covid, should be admitted directly to the
COVID-19 cohort areas (Bay 3 or 4) initially. These infants should have swabs performed at
admission with 2 more sets performed at 48hrly intervals.
In the situation where the mother has no suspicions of COVID-19 but her infant is swabbed, the
mother must also be swabbed regardless of symptoms and is unable to visit the NNU until her
results are confirmed negative.
If an infant is considered fit for discharge either back to the PNW or home, prior to completing a full
set of screening swabs, they should be discharged and no further swabs are required. If an infant has
been investigated for coronavirus, the family should self-isolate for 14 days after the onset of
symptoms, regardless of swab results.
The flow chart below aims to represent the journey of a PNW admission. We have endeavoured to
represent the range of reasons for PNW admissions and try and encompass the various clinical
outcomes, but recognise the complexity of the chart as a result.
PNW infant requiring admission to NNU from
PNW
Maternal Suspected or Confirmed COVID-19
Admit to COVID-19 cohort area regardless of

symptoms
Swab infant at admission to cohort area
Mother confirmed Mother confirmed

POSITIVE NEGATIVE
Infant will require 2 further If symptoms concerning of

swabs at 48hrly intervals If NO concerning features
COVID-19 present:
of
COVID-19: Infant requires 2 further
May move out of cohort sets of swabs at 48hrly
intervals
area immediately
No furter swabs required
If symptoms concerning of
If NO concerning
COVID-19 present:
symptoms of COVID-19: Infants may be moved out
May move out of cohort
May move out of cohort of cohort area once x3
area once Must remain in incubator
area once x3 swabs negative swabs, regardless
symptoms RESOLVED and for 14 days after onset of of symptoms
NEGATIVE
x3 swabs NEGATIVE symptoms unless
discharged
Must remain in incubator Must remain in incubator Must remain in incubator

for 14 days after onset of for 14 days after onset of for 14 days after onset of
symptoms unless symptoms unless symptoms unless
discharged discharged discharged
PNW infant requiring admission
to NNU
No maternal COVID-19
concerns
No symptoms / concerns of
Clinical symptoms / concerns of possible COVID-19 possible COVID-19
Admit to COVID-19 cohort Admit to ICU / HDU /

area SCBU as required
Do NOT swab
Swab mother
Swab infant at admission to
cohort area
If at any point
infant develops any
Mother unable to visit symptoms in
Will require 2 further swabs keeping with
until swab confirmed
at 48hrly intervals
NEGATIVE possible
COVID-19,
immediately
transfer to the
cohort area and
Infants may be moved out of
swab
cohort area once x3 negative
swabs, regardless of
symptoms
Nurse within
incubator
Must remain in incubator for

14 days after onset of
symptoms unless discharged Discharge back to PNW or home
when able
COVID-19 Concerns in NNU Inpatient
Although strict general IPC protocols remain in place and visiting has been significantly restricted,
our vulnerable patients within the NNU remain at theoretical risk of infection with COVID-19 from
both parents and staff.
If an infant within the general NNU areas has an unexpected deterioration, COVID-19 should be
considered as a differential diagnosis if they fit the ‘case definition’ as defined by Public Health
England:
 They are an inpatient

AND
 have either clinical or radiological evidence of pneumonia
OR
 acute respiratory distress syndrome
OR
 influenza like illness (fever ≥37.8°C and at least one of the following respiratory symptoms,
which must be of acute onset: persistent cough (with or without sputum), hoarseness, nasal
discharge or congestion, shortness of breath, sore throat, wheezing, sneezing
However, the RCPCH have also noted that “newborn infants may not show all the features of an
influenza-like illness, particularly a fever, so clinicians should have a high index of suspicion in all
infants admitted to NICU and monitor for signs of respiratory illness during the admission”.
It remains essential however to consider all other possible pathologies that are encountered within
routine neonatal care and there should be a discussion with either the consultant on service or on-
call before investigating or cohorting an infant from the general NNU area, for suspected COVID-19.
Below is a flowchart designed to aid with decision making around these infants.
Of note, we again advise that, if an infant is moved to the cohort area and screened for possible
COVID-19, the mother should also be swabbed regardless of her symptoms. She will be unable to
visit the NNU until her swab is confirmed negative.
Neonatal inpatient, within general clinical
area, who develops symptoms of possible
COVID-19
Admit to COVID-19 cohort area
Swab infant at admission to
Swab Mother cohort area
2 further swabs at 48hrly
Mother unable to visit NNU intervals
until swab confirmed
NEGATIVE
Respiratory symptoms Respiratory symptoms
resolved within 5 days of Infant swab reported
persisting at 5 days post
onset as POSITIVE
onset
Infant may be moved out of Infant may be moved out
cohort area if respiratory of cohort area once 3 Discuss with ID
symptoms resolved and 2 NEGATIVE swabs,
NEGATIVE swabs regardless of symptoms
Must remain in incubator Must remain in incubator
for 14 days after onset of for 14 days after onset of
symptoms unless symptoms unless
discharged # discharged #
# Isolate at home until day 14 of symptom onset
has been created and is situated in the corridor outside the rooms. Postnatal Management of the Term, Well Infant
If the infant requires NNU admission, transport should be via the
designated route. If the infant can remain with the mother, PPE Term infants who remain well at the time of delivery should remain
must be doffed before leaving. with their mother even if she is COVID-19 positive, as long as the
mother is physically able to care for her child. The pair should
Working Within The Cohort Area: be cohorted into an individual room where possible. There is no
indication to test the well term infant for COVID-19, regardless of
COVID-19 NNU Cohort Areas: With the exception of a facemask maternal status, unless they become symptomatic.
(surgical or FFP3), all PPE should be doffed at the door of the
infant bays before exiting. The facemask should then be removed For mothers who are confirmed COVID-19 positive or suspected,
just outside the bay before exiting into a Green Zone. Corridors the following measures apply, regardless of the symptoms:
between infant bays are screened off, and foot traffic between
these areas is discouraged. Staff will be allocated to work within - Strict hand hygiene measures at all times
the cohort area at staff handover. The principle of the minimum
number of staff entering infant rooms during a shift should be ob- - The infant should be nursed in an incubator within the room
served, and records should be kept of all staff entering the cohort
area. Staff who are pregnant or have significant chronic health - Social distancing is observed where possible
conditions will not be assigned to the cohort area.
- Use of surgical face mask when feeding
When working within the cohort area:
- Early discharge of the pair should be considered, with clear
1. All staff must wear appropriate PPE. Masks, gowns, and handover to the community team
hats should be used on a sessional basis. The fluid-resis-
- Staff should wear appropriate PPE when working within the
tant surgical mask has a lifespan of approximately 4 hours,
room
with the FFP2 respirators lasting up to 12 hrs unless they
become wet. There is no need to change scrubs when out - If the mother is acutely unwell and unable to care for her
on a break. If an infant within the cohort area is ventilated, child, the infant should be isolated from the mother, and at-
closed suction should be used. tempts should be made to identify an alternative non-quar-
antined caregiver or relative that could provide care for the
2. Due to the risk of contamination, patient notes and observa-
infant at home.
tion charts should NOT be kept within the cohort area where
possible. If any paper records or charts are used within the Term Infants Requiring Review, Investigation and/or Treatment
cohort area, they must be digitally imaged and archived with-
in the patient record and stored/disposed of once the patient Routine procedures such as Newborn Hearing Screening and
leaves the area. Electronic versions of nursing care notes pre-discharge physical examination should be undertaken by mid-
and observation records have been made available. When wives and audiology staff as normal. An infant who is cohorted
possible, the drug Kardex should NOT be used within the with the mother in an individual room due to maternal proven or
room, it should remain outside the cohort room, and drugs suspected coronavirus should have these procedures performed
should be double-checked with a clean helper where pos- beside the mother, within the individual room.
sible. If a Kardex is used within the cohort area, it must be
digitally imaged and archived within the patient record and Management of the Term Infant with Acute Collapse
stored/disposed of once the patient leaves the area.
3. The use of reusable equipment should be avoided if possi-

ble. If used, it should be decontaminated in the doffing area New subscribers are always welcome!
prior to removal from the cohort area. A dedicated blood gas
analyser and ultrasound machine have been made available
for use with the cohort area. Blood investigations should be
NEONATOLOGY TODAY
rationalized to a minimum with Point of Care used where
possible. If more than one infant within the cohort area re- To sign up for free monthly subscription,
quires blood draws, these should be coordinated and per- just click on this box to go directly to our
formed at the same time if able. Blood samples must be
handled and transported to the labs with additional precau- subscription page
tions: Perform the blood sample as routine, apply a patient
identification label and biohazard sticker to both the sample
tube and request form, wipe outside of sample tube with dis-
infectant, place into a clear leak-proof bag attached to the
request form and wipe outside of the bag with disinfectant.
Ideally, a buddy should meet you at the door and hold open
a second bag for the sample to be placed into. Attach the
"COVID-19 biohazard" label to the outside of the second Readers can also follow
bag, and these must be hand-carried to the lab. No use of
the pneumatic tube system is permitted. NEONATOLOGY TODAY
Parents are permitted to visit their infant whilst they are in the
cohort area, as long as they are COVID-19 suspected or positive via our Twitter Feed
but also in adherence to the general restrictions for visiting, as
outlined in the visiting policy. @NEOTODAY

If the neonatal team is called urgently for an acutely unwell infant, 3. Specific COVID-19 cleaning procedures should be used
the infant will be deemed as potentially infected with COVID-19 when cleansing the breast pump
regardless of maternal infection status. Given this, it is imperative
that staff don full enhanced PPE prior to resuscitating the infant, 4. Breastmilk should be expressed, labeled, stored, and trans-
as your own personal safety is paramount. This is essential, even ported to the neonatal unit in line with local infection/ CO-
if it results in a short delay in the initial treatment. Staff will be is- VID-19 control procedures.
sued with their own fit-tested FFP3 mask, which should be carried
with them while on duty. This will ensure appropriate protection is Delivery of EBM to NNU from Mothers with Suspected or
available for each individual regardless of location. Upon full con- Confirmed COVID-19
sideration of available equipment and space within the postnatal
areas, we are currently recommending that in event of an acute Unfortunately, parents will not be permitted to visit the unit during
collapse, the infant should be transferred out of their room or bay the period that their infant is in isolation. However, it is important
and onto the resuscitaire within the ward Treatment Room. While that maternal milk continues to be used for these infants where
this is not ideal from an infection perspective, it will allow full ac- possible. Mother's will be given advise as follows:
cess to resuscitaire and emergency equipment. Neonatal resus-
1. Milk should be labeled and stored at home in the home
citation should continue per standard algorithm. Once stabilized,
fridge/freezer until transported
inform the Bed Manager of the pending admission to the NNU
should be informed as additional help will be required to ensure 2. Parents should arrange for milk to be transported to the
a clear route during transfer, and this should be undertaken via NNU. This needs to be someone who is not requiring isola-
designated routes when possible. tion for any reason and not from the same household. The
milk should be transferred in a cool bag.
Infant Feeding
3. Staff will meet that person in the reception area. The staff
Breastmilk and breastfeeding have many significant benefits for
member will wear an apron and gloves to receive the milk.
mothers and babies. This is particularly true for an infant born pre-
The milk bottles should be transferred from the cool bag into
maturely where breast mild is known to help protect against respi-
a plastic bag. The NICU staff will take the milk to the storage
ratory infections and necrotizing enterocolitis. There is currently
area and clean with detergent before placing it in the identi-
no evidence to date that COVID-19 is transferred to breastmilk,
fied area.
and the benefits of breastfeeding are thought to outweigh any
potential risks of transmission of coronavirus through breastmilk. 4. Extra expressing bottles, labels, and pump attachments
Therefore, an infant born to mothers with suspected probably, or should be ordered for collection by phone and picked up at
confirmed COVID-19 should be fed according to standard infant reception when delivering milk.
feeding guidelines, while applying necessary precautions.The
main risk for infants breastfeeding is the close contact with the 5. Maternal Expressed breastmilk will be stored in a dedicated
mother and the potential exposure to her infective airborne drop- COVID 19 fridge/freezer within the NICU.
lets. It is, therefore important that the benefits of breastfeeding
and any potential risks associated with COVID-19 transmission Of note, when handling this milk at the bedside, staff should con-
are discussed with the mothers. Infants on the Postnatal Ward or tinue to comply with current hand hygiene and PPE policy. As an
Discharged Home extra precaution, it is advised that staff wipe the outside of bottles/
syringes containing expressed breastmilk with a decontamination
1. Wash their hands before touching the baby, breast pump or wipe before and after any handling.
bottles
Visiting Policy
2. Try and avoid coughing or sneezing on your baby while feed-
ing at the breast During these challenging circumstances of the COVID-19 pan-
demic, visiting across all hospital sites has been prohibited except
3. Consider wearing a face mask while breastfeeding for exceptional circumstances. Although having a child within
neonatal intensive care is a special circumstance, restrictions will
4. Where mothers are expressing breastmilk in hospital, a ded- apply. Currently, the restrictions are:
icated breast pump should be used
1. Visiting is limited to parents or named guardians only
5. Follow recommendations for pump cleaning after each use
2. Only one parent is allowed at the bedside at a time
6. Consider asking someone else who is well to feed expressed
breastmilk 3. Siblings are not allowed to visit the unit
7. For women bottle-feeding with formula or expressed breast- 4. Parents will not be present on ward rounds
milk adherence to sterilization guidelines is recommended.
5. Parents or guardians with confirmed or suspected COV-
Infants within the Neonatal Unit ID-19 are not permitted to visit the hospital until they are fully
recovered and completed the self-isolation period.
For infant admitted to the neonatal unit whose mother is suspect-
ed or confirmed as having COVID-19 6. Parents or guardians in self-isolation are not permitted to
visit the hospital
1. Breastfeeding should be encouraged through supporting
mothers who have been separated from their baby to ex- 7. In accordance with infectious disease advice, COVID-19
press milk suspected or confirmed mothers should not visit the NNU
until symptom-free and at least seven days after the onset of
2. Mothers should have a designated breast pump for exclu- their illness.
sive use

8. In cases where visiting has been restricted, alternatives midwives is decided on by the Head Midwife.
such as video call may be considered.
2. The natural birth or caesarean section takes place in a sepa-
Discharge Home and Follow-up rate isolation zone in the Admission Room. The zone may in-
clude the entire Admission Room or a temporary Admission
For COVID-19 suspected or confirmed mothers with a term well Room for patients with signs of infection. The extension of
infant, the aim is to facilitate early discharge home as soon as the isolation zone to encompass the entire Admission Room
is appropriate and safe. These family must self-isolate at home is done in response to a clinical case (confirmed SARS-
for 14 days following discharge. Several NHS parental informa- CoV-2 infection) and a greater number of patients requiring
tion sheets are available on illness in newborns and coronavirus. hospitalisation in the GPSK.
For infants who have been admitted to the NNU, whose mother
is confirmed COVID-19, the need for the family to self-isolate at 3. Depending on the clinical circumstances (suspected or con-
discharge will depend on the timing of maternal infection relative firmed viral infection in the mother), members of the neona-
to the infant's admission. All infants with confirmed COVID-19 in- tological team must use personal protective equipment dur-
fection will require outpatient follow-up, although the timing and ing the delivery, including:
duration of this are currently unclear. These infants should be dis-
cussed with Infectious Disease consultants regarding appropriate - if the mother shows no symptoms (but she has been in
follow-up arrangements prior to discharge. contact with the virus) – barrier gown with long sleeves,
safety gloves, face mask with FFP3 or FFP2 filter, safety
POLAND glasses;
In Poland, the Ministry of Health assembled national experts in in- - if the mother shows clinical symptoms and infection with
fectious diseases and neonatologists to promulgate guidelines for SARS-CoV-2 is confirmed – protective overalls, face
the management of pregnant women and their infants (13). This mask with FFP3 or FFP2 filter, safety glasses. Protective
group of experts published practice guidelines for managing labor clothing is available in the Admission Room.
as well as neonatal care guidelines.
4. If the newborn is isolated from the mother and placed in a
The Polish Guidelines are as follows: closed incubator, members of personnel must wear a bar-
rier gown with long sleeves, safety gloves, a face mask with
The Instruction sets out the rules for the management of neonates FFP3 or FFP2 filter, and safety glasses while performing
born in the Gynaecology and Obstetrics Research and Teaching neonatal examinations and providing care.
Hospital by mothers with a suspected or confirmed diagnosis of
infection by, or after contact with, the SARS-CoV-2 coronavirus Neonates not requiring hospitalisation in the NICU
causing COVID-19.
1. After birth, the newborn remains isolated from the mother in
The Instruction applies to all Hospital Units/Subunits and the Bed a closed incubator on any premises of the Admission Room
Management Department. other than where the mother is recovering.
The Head of the Hospital Unit/Subunit, the Head Nurse/Midwife, 2. The newborn does not require hospitalisation for more than
and the head of the organisational unit, are responsible for com- two days.
municating the contents of the Instruction to their subordinate per-
sonnel. 3. While being hospitalised, the newborn can be fed with ex-
pressed breast milk, provided that the mother complies with
I. Diagnostic criteria the sanitary regime (face mask with filter, safety gloves, ap-
propriate hand hygiene procedure) – at the neonatologist's
Considering that: discretion.
1. there is no definite evidence that babies can be infected in 4. After two days of hospitalisation, the newborn may be dis-
the womb, no proof for vertical infection, charged and taken home by the legal guardian.
2. the effect of the mother's infection in the first and second 5. At discharge from the hospital, the legal guardian should be
trimesters of pregnancy on the baby is unclear, instructed to observe the baby for signs of respiratory dis-
tress for 14 days after birth.
3. there is no conclusive evidence for virus transmission from
the mother to the baby during natural childbirth, 6. The legal guardian should be instructed to report to the hos-
pital designated by the governor of Wielkopolska Province
the likely route of transmission of the virus from the mother to (Appendix 1) for medical consultation if the baby develops
the baby has been established. Non-compliance with the sanitary symptoms such as fever, cough, shortness of breath, diffi-
regime during childbirth, relating to the mother's failure to use a culty breathing, or an increased breathing rate.
face mask with filter, increases the risk of neonatal infection with
SARS-CoV-2 by the droplet route. 7. The legal guardian should be informed about the possibility
of calling an emergency medical team to transfer the baby
II. Procedures to follow from home to a selected hospital.
1. The delivery of a neonate by a mother with a suspected or 8. The neonatologist must notify the District Sanitary Inspector
confirmed diagnosis of infection by, or after contact with, the in charge of the territory of the patient with suspected SARS-
SARS-CoV-2 coronavirus causing COVID-19, requires the CoV-2 infection (24-hour telephone service: 609 794 670).
appointment of a neonatological team including a physician
from the Neonatal Isolation Unit (7 am – 3 pm) and from the Neonates not requiring hospitalisation in the NICU, but requiring
Neonatal Unit (after 3 pm and at night). Additional staffing of treatment in a hospital with an infectious diseases unit

1. After birth, the newborn remains isolated from the mother in 14. The isolation zone should be provided with the necessary
a closed incubator on any premises of the Admission Room. equipment for the treatment and care of the isolated new-
born. The equipment must remain in the zone for the entire
2. The newborn is urgently transferred to a hospital with an in- period of isolation.
fectious diseases unit designated by the Governor of Wiel-
kopolska Province in accordance with Appendix 1 to the In- 15. Waste and bedding must remain in the lock of the insulation
struction. zone until being collected directly by the cleaning services
(laundry staff, waste transport workers) according to the dai-
3. The patient (in a closed incubator) may be transported to ly schedule.
the hospital with an infectious diseases unit by the hospital's
neonatal ambulance. 16. Hospital bedding must be placed securely in a red plastic
bag and marked with a black marker: CAUTION – CON-
4. The neonatologist must notify the District Sanitary Inspector TAMINATED BEDDING, SUSPECTED SARS-CoV-2 IN-
in charge of the territory of the patient with suspected SARS- FECTION.
CoV-2 infection.
17. The cleaning of the isolation zone is carried out according
Neonates without clinical symptoms of SARS-CoV-2 infection but to the cleaning company's procedures approved by the hos-
requiring hospitalisation in the NICU because of their clinical con- pital representative. The person responsible for overseeing
dition after birth the proper conduct of the procedure is the Specialist for Epi-
demiology.
1. After the natural birth or caesarean section, the newborn is
placed in a closed incubator and transferred to the Neonatal 18. After the end of the isolation period, it is advisable to have
Isolation Unit. the premises disinfected by fogging, subject to arrange-
ments with the unit management personnel. Responsible
2. An isolation zone should be designated within the continu- Person: Specialist for Epidemiology.
ous care subunit in the Neonatal Isolation Unit. No other pa-
tients may be hospitalised in this zone. 19. Any questions or concerns should be directed to the Special-
ist for Epidemiology
3. While being hospitalised in the isolation zone of the Neo-
natal Isolation Unit, the baby should be placed in a closed There have been no critical analyses of whether adherence to the
incubator until the isolation is completed (at least 14 days guidelines published in Ontario, Canada, the American Academy
after birth). of Pediatrics, Ireland, Northern Ireland or Poland have been thor-
oughly implemented by all maternity and infant care units. Such
4. Taking samples from the baby for identification tests for an international survey would permit an analysis of different ap-
SARS-CoV-2 should be considered (as set out in the Ap- proaches and their effectiveness in mitigating the transmission of
pendix). COVID-19, and establish if these approaches are unnecessarily
restricting the support of mothers during labor and delivery inter-
5. Separate personnel should be appointed to care for the fering with attachment and feeding of her infant. Furthermore,
baby. ideal methods for ongoing infant and mother evaluation and care
during the 4th trimester after birth evaluating growth, physical de-
6. For patient care, medical personnel must wear protective
velopment, and providing recommended immunizations between
clothing: barrier gown with long sleeves, disposable diag-
6-8 weeks after birth are still under development.
nostic gloves, face mask with FFP3 filter, or FFP2 filter in the
lock (intermediate space before the isolation zone). Based on empirical evidence through May 2020, vertical transmis-
sion of the virus through the placenta, amniotic fluid, or breastmilk
7. After handling the newborn baby, the procedure is to remove
has not been demonstrated. Further, neonatal mortality rates
gloves first and disinfect the hands. In the lock (intermediate
specific to COVID-19 are minimal with reports from China, Italy,
space), the personnel should take off the barrier gown, re-
and one two-center report from New York City (14,15). These re-
move the safety glasses and face mask, and perform an ex-
ports to date have been of limited numbers, and have shown vari-
tended hand hygiene procedure (washing and disinfection).
ation in mother-infant dyad separation and postpartum practices
8. The maximum duration for wearing a single mask with a filter between reporting centers. Vertical transmission cannot be ruled
is 8 hours and a standard surgical mask – 1 hour. out. Horizontal transmission from mother to infant may occur, thus
increasing exposure risk to care personnel caring for the newborn.
9. As the risk of transmission of infection from the mother to Sutton and coworkers reported from New York City that universal
the baby during childbirth is very low, there is no need for the screening of 215 women presenting to labor and delivery units,
personnel to wear protective overalls. 4 (1.9%) of whom has a fever or other symptoms of COVID-19
and all 4 tested positive, while of 211 without symptoms on ad-
10. Protective overalls should be worn if the neonatal medical mission, 29 (13.7%) were found to be positive for COVID-19 but
personnel assists in the delivery of a patient with a confirmed asymptomatic at presentation. Of these, three women developed
infection by SARS-CoV-2, causing COVID-19. a fever prior to hospital discharge (mean time two days), and two
were treated with antibiotics for presumptive endomyometritis.
11. The standard hand hygiene procedure should be extended One patient was felt to have COVID-19 received supportive care.
to washing hands with soap and water, followed by disinfec- (16) These authors suggest that universal testing of all women
tion with an alcohol-based antiseptic. admitted to Labor and Delivery suites is beneficial better, informs
healthcare providers of appropriate isolation procedures and bed
12. The newborn should be isolated for 14 days after birth. assignments, informs neonatal care providers, and more appro-
priate allocation of PPE, and thus lessening transmission of the
13. During this period, the baby should be fed with a formula. virus. In Southern Connecticut, 782 women presenting for child-
birth were screened for COVID-19; 1.5% were previously diag-

nosed with COVID, and of the remaining 770 women 30/ of 770 In conclusion, the main threats presented by COVID-19 to the
(3.9) tested positive for COVID-19 of whom 73.3% were without safe provision of maternity care are related to the prevalence of
symptoms. The overall prevalence of positive test results among the condition in the community and to the possibility that asymp-
asymptomatic women was 2.9% to 5% over the month of testing. tomatic carriers could expose other mothers or hospital staff to
No asymptomatic women who tested negative developed symp- infection. Large scale staff reductions due to the need for iso-
toms during their hospital stay and no healthcare workers were lation or due to infection will reduce the safety and efficiency of
removed from work due to SARS-CoV-2 exposure or transmission maternity care provision. Even in countries with high prevalence
from a known positive mother via patient contact (17) and high numbers of fatalities, serious illness in mothers seems
rare, and seriously affected infants are thankfully extremely rare.
Neonatologists must also be concerned with late-onset sepsis as- This may be due to effective self-isolation being practised by a
sociated with COVID-19. As reported in addition to this issue, and vast majority of expectant mothers. As "stay at home" or "lock-
Munoz et al. from Houston (18) who reported on a three-week-old downs" ease in the coming months, the pressure to reduce visitor
infant and born at 36 weeks gestation with a 2-day history of nasal restrictions will increase, with an inevitable increase in risk to staff.
congestion, tachypnea, and reduced feeding who had received The staff will need to be vigilant regarding the risk which mothers
a 48-hour course of antibiotics for suspected sepsis but in whom and their partners present and will need to wear appropriate PPE
bacterial cultures were negative. The initial chest radiograph to mitigate this risk. More importantly, they need to be aware of
showed bilateral linear opacities and consolidation in the right up- the risk they present to each other and to ensure adequate hand
per lobe. Oxygen was administered, and ampicillin and gentamicin hygiene and social distancing to avoid congested communal staff
were initiated. After transfer to a children's hospital, he required facilities such as rest areas, and dining areas, and to be aware
intubation, volume support, and vasopressors. Reverse-tran- of the surface transmission risks presented by shared comput-
scription PCR testing to detect SARS-VOV-2 on admission to the ers and keyboards. Team building and educational activities have
children's hospital was positive by day seven, and he was treated rapidly migrated to electronic platforms, and these enhanced ef-
and discharged on day 9. Only one of eight household contacts forts will need to be sustained for the foreseeable future. For the
was symptomatic, but none were tested for SARS-CoV-2. In the present, and probably for months, there will be a reversion to what
May issue of Neonatology, Liu and Stovall (19) reported a 33- has been "normal practice."
week infant whose mother on day 6 had a syncopal like episode
while visiting her infant but did not have symptoms consistent with As in North America and "across the pond," we do indeed live in
COVID-19, and she continued to visit her baby. On the infant's challenging times.
19th day of life, the mother was hospitalized for cough, fever, and
hyperglycemia and was found to be SARS-CoV-2 PCR positive. References:
The infant was weaned from expressed maternal milk, placed on 1. World Health Organization. (April 22, 2020) What matters to women
premature formula, and placed in a negative pressure room. On in the postnatal period? http://www.who.int/news-room/detail/22-04-
the infant's 22nd day of life, the infant's SARS-Cov-3 PCR was 2020-what-matters-to-women-in-the-postnatal-period.
positive. On days of life 23 through 25, the infant had mild na- 2. U.S. Department of Health and Human Services, Centers
sal congestion, occasional sneezing, and cough. Contact trac- for Disease Control and Prevention (April 4, 2020)
ing was rigorous, and 74 potential exposures were documented; Considerations for inpatient obstetric healthcare settings.
however, secondary exposure risk to healthcare personnel was https://cdc.gov/coronavirus/2019-ncov/hcp/inpatient-
deemed low exposure to the mother within 6 feet for >5 minutes obstetric-healthcare-guidance.html.
with contact through the portals of the incubator with the mother 3. Puopolo, KM, Hudak ML, Kimberlin DW, Cummings J. Initial
holding and feeding without either a mask or gown. Buonsenso et Guidance: Management of Infants Born to Mothers with
al. reported outcomes, seven pregnant women, with documented COVID-19: April 2, 2020, American Academy of Pediatrics
SAR-CoV-2 infection, one woman had a spontaneous abortion at 4. Ma X, Zhu, J, Du, Uzhong. Neonatal Management During the
eight weeks gestational age, four women recovered and contin- Coronavirus Disease (COVID-19) Outbreak: The Chinese
ues to be followed, and of the two newborns delivered both were Experience. NeoReview May 2020 , 21(5) e293-2297.
negative at birth, but one was found to SARS-COV-2 positive at 5. Ontario Health Toronto: Toronto Region COVID-19 Hospital
eight days. (20) Thus, the horizontal transmission was strongly Operations Table Version Date March 17, 2020, taken from
inferred. These cases suggest that infants presenting with a clini- Graham R. Covid-19 and he NICU Balancing Safety and
cal presentation consistent with late-onset neonatal sepsis require Care. Neonatology Today, April 2020. 15(4): 25-28.
an expanded search for pathogens, including the SARS-Cov02 6. Trevisanuto D, Moschino L, Doglioni N, Roehr, CC, Gervasi
test by PCR. MT, Baraldi E. Neonatal Resuscitation Where the Mother
Has a Suspected or Confirmed Novel Coronavirus (SARS-
According to the aforementioned guidelines, taking simple pre-
cautions such as assigning designated staff for attending deliver- CoV-2) Infection: Suggestion for a Pragmatic Action Plan.
ies (if intervention is anticipated), allowing rooming-in of the baby Neonatology April 24, 2020, DOI 10.1159/000507935.
with its mother and monitoring breastfeeding while keeping ap- 7. Ng, PC. Infection control measures for COVID-19 in labour
propriate physical barrier, staff adherence to the appropriate PPE suite and neonatal unit-A commentary Neonatology 2020
policy, and facilitating respiratory support inside incubators (if DOI:10.1159/000508002
needed) would allow safe management of those suspected cases. 8. American Heart Association. Interim Guidance for Basic
This would apply to ether infants of asymptomatic mothers with a and Advanced Life Support in Children and Neonates with
history of significant COVID-19 contact or infants of symptomatic suspected or confirmed COVID-19. Pediatrics 2020 doi:
mothers awaiting COVID-19 test results. It is clear that addition- 10.1542/peds.2020-1403
al resources are needed, including increased physical distance 9. Zhu H, Wang L, Fang C, et al. Clinical analysis of 10 neonates
and, moreover, PPE not only for healthcare workers but also for born to mothers with 2019-nCOV pneumonia. Transl. Pediatr.
parent(s) visiting one at a time for short intervals, and rapid testing 2020; 9(1):51-60 dol: 10.21037/tp.2020.02.06
with acceptable sensitivity and specificity need to be made avail- 10. Chen H. Guo J, Wang C et al. Clinical characteristics and
able to neonatologists. Also, additional incubators must be avail- intrauterine vertical transmission potential of COVID-19
able to safely care, ideally in a negative pressure environment, for infection in nine pregnant women: a retrospective review
the medical needs of mothers and their babies, and for the health of medical records. Lancet 2020; 396(10226):809-815
care workers to be able to care for them safely. dol:10.1016/S0140-673(20)30360-3.

11. Royal College of Physicians and Surgeons, Ireland: Institute
of Obstetricians and Gynaecologists of the Royal College of
Physicians of Ireland outlined recommendations for Neonatal
Management for Maternal and Neonatal Management, April 2020.
12. Walker A. Royal Maternity Hospital Neonatal Unit COVID-19
Policy., Edition April 5 29, 2020. Belfast Health and Social
Care Trust, Belfast, Northern Ireland.
13. Ziarnik M, Sosnowska J, Chmaj-Wierzhowska K, Figlerowicz
M, Wysocki J, Mazela J. COVID-19 -epidemiologia, obraz
kliniczyny oraz postepowanie z ciezarna I noworodkiem. Ahmed Afifi, MBBCH, MSc
Standary Medyczne Pediatria/April, 2020. Neonatal/Paediatric Registrar,
14. Zeng L, Xia S, Yuan W. et al. Neonatal Early-Onset infection Rotunda Hospital,
with SARS-CoV-2 in 33 neonates born to mothers(https// Dublin, Ireland
www.statista.com/statistics/1043366/novel-coronavirsu-
2019nvov-cases-worldwidebycounty.html) rs with COVID-19
in Wuhan, China. JAMA Pediatr. March 26, 2020 (online)
doi:10.1001/jamapediatrics.2020.0878.
15. Breslin N, Baptiste C, Gyamfi-Bannerman C, Miller R.
Martinez R, Bernstein K, Goffman D. COVID-19 infection
among asymptomatic and symptomatic pregnant Women:
Two weeks of confirmed presentation to an affiliated
pair of New York City hospitals. American J. Obstet & Principle Author
Gynceol MFM. Advance online publication. Doi: 10.1016/
ajogmf.2020.100118.
16. Sutton D, Fuchs K, D'alton M, Goffman D. Universal screening
for SARS-CoV-2 in Women Admitted for Delivery. N Engl J.
Med 2020 382: 2163. Doi: 10.1056/NEJMc2009316.
17. Campbell, KH, Tornatore JM, Lawrence et al. Prevalence
of SARS-CoV-2 Among Patients Admitted for Childbirth in
Southern Connecticut. JAMA May 26.2020. doi:10.1001/
David Corcoran MD FRCPI IMC 9632
jama2020.8904.
Consultant Neonatologist and Paediatrician
18. Munoz AC, Nawaratne U, McMann D, Ellsworth M, Meliones
J, Boukas K. NEJM April 22, 2020: 382.e49 doi: 10.1056/ Clinical Associate Professor of Paediatrics
NEJMc2020614. Rotunda Hospital ,
19. Liu W and Stovall S. Case of a preterm newborn with the Royal College of Surgeons in Ireland
nosocomial Acquisition of COVID 19 Infection in the Neonatal Dublin, Ireland
Intensive Care Unit and Contract Tracing. Neonatology
Today 15(5) May 2020: 12-20.
20. Buonsenso D, Costa S, Sanguinetti M et al. Neonatal
Late COVID-19 Infection with Severe Acute Respiratory
Syndrome Coronavirus 2. Am J Perinatology 2020 doi:
10.1055/s-9949-1710541.
21. Note added in proof: On May 20, 2020, the Centers for Disease
Control and Prevention Revised their recommendations on
"Evaluation and Management Considerations for Neonates
At Risk for COVID-19 and Care for Breastfeeding Women
for the USA.
Disclosures: The authors do not have any disclosures.
The authors wish to acknowledge the special assistance of

Thomas A. Clarke, MD, Retired Consultant, Rotunda Allison C. Walker, MD,
Hospital, Dublin, Ireland, Co-Editor Consultant Neonatologist,
Royal Maternal Neonatal Unit
Belfast, Northern Ireland
NT

Corresponding Author
Thomas A Clarke, MD
T.Allen Merritt, MD Emeritus Consultant in Neonatology
Professor of Pediatrics The Rotunda Hospital,
Loma Linda University School of Medicine Dublin. Ireland
Division of Neonatology
Department of Pediatrics
email: T. Allen Merritt <[email protected]>
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more informatio
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Angling f iuskabinutrition.com
sen
www.fre
Omegaven ®
(fish oil triglycerides) injectable emulsion
The first and only fish oil emulsion

for pediatric patients with parenteral
nutrition-associated cholestasis
(PNAC) in the U.S.1
A source of calories and fatty acids in

pediatric patients with PNAC
Patients receiving Omegaven achieved

age-appropriate growth
Omegaven-treated patients experienced

improvement in liver function parameters
Limitations of Use
• Omegaven is not indicated for the prevention of PNAC. It has not been demonstrated
that Omegaven prevents PNAC in parenteral nutrition (PN)-dependent patients.
• It has not been demonstrated that the clinical outcomes observed in patients treated
with Omegaven are a result of the omega-6: omega-3 fatty acid ratio of the product.
Contraindications
• Omegaven is contraindicated in patients with known hypersensitivity to fish or egg
protein or to any of the active ingredients or excipients, severe hemorrhagic disorders
due to a potential effect on platelet aggregation, severe hyperlipidemia or severe
disorders of lipid metabolism characterized by hypertriglyceridemia (serum triglyceride
concentrations greater than 1000 mg/dL).
Please see Brief Summary of Prescribing

Information for Omegaven on the reverse side.
OMEGAVEN (fish oil triglycerides) injectable emulsion, for intravenous use ADVERSE REACTIONS
The most common adverse drug reactions (>15%) are: vomiting, agitation, bradycardia, apnea and
BRIEF SUMMARY OF PRESCRIBING INFORMATION viral infection.
This brief summary does not include all the information needed to use Omegaven safely
and effectively. Please see full prescribing information for Omegaven (fish oil triglycerides) Clinical Trials Experience
injectable emulsion for intravenous use at www.fresenius-kabi.com/us. The safety database for Omegaven reflects exposure in 189 pediatric patients (19 days to 15 years of
age) treated for a median of 14 weeks (3 days to 8 years) in two clinical trials.
INDICATIONS AND USAGE
Omegaven is indicated as a source of calories and fatty acids in pediatric patients with parenteral Adverse reactions that occurred in more than 5% of patients who received Omegaven and with
nutrition-associated cholestasis (PNAC). a higher incidence than the comparator group are: vomiting, agitation, bradycardia, apnea, viral
infection, erythema, rash, abscess, neutropenia, hypertonia and incision site erythema. Patients had a
Limitations of Use: complicated medical and surgical history prior to receiving Omegaven treatment and the mortality was
Omegaven is not indicated for the prevention of PNAC. It has not been demonstrated that Omegaven 13%. Underlying clinical conditions prior to the initiation of Omegaven therapy included prematurity,
prevents PNAC in parenteral nutrition (PN)-dependent patients. low birth weight, necrotizing enterocolitis, short bowel syndrome, ventilator dependence, coagulopathy,
It has not been demonstrated that the clinical outcomes observed in patients treated with Omegaven intraventricular hemorrhage, and sepsis.
are a result of the omega-6: omega-3 fatty acid ratio of the product. Twelve (6%) Omegaven-treated patients were listed for liver transplantation (1 patient was listed
DOSAGE AND ADMINISTRATION 18 days before treatment, and 11 patients after a median of 42 days [range: 2 days to 8 months] of
Prior to administration, correct severe fluid and electrolyte disorders and measure serum triglycerides treatment); 9 (5%) received a transplant after a median of 121 days (range: 25 days to 6 months) of
to establish a baseline level. Initiate dosing in PN-dependent pediatric patients as soon as direct or treatment, and 3 (2%) were taken off the waiting list because cholestasis resolved.
conjugated bilirubin levels are 2 mg/dL or greater. The recommended daily dose (and the maximum One hundred thirteen (60%) Omegaven-treated patients reached DBil levels less than 2 mg/dL and
dose) in pediatric patients is 1 g/kg/day. Administer Omegaven until direct or conjugated bilirubin levels AST or ALT levels less than 3 times the upper limit of normal, with median AST and ALT levels for
are less than 2 mg/dL or until the patient no longer requires PN. Omegaven-treated patients at 89 and 65 U/L, respectively, by the end of the study.
Median hemoglobin levels and platelet counts for Omegaven-treated patients at baseline were 10.2 g/dL
CONTRAINDICATIONS and 173 x 109/L, and by the end of the study these levels were 10.5 g/dL and 217 x 109/L, respectively.
Omegaven is contraindicated in patients with known hypersensitivity to fish or egg protein or to any Adverse reactions associated with bleeding were experienced by 74 (39%) of Omegaven-treated
of the active ingredients or excipients, severe hemorrhagic disorders due to a potential effect on patients.
platelet aggregation, severe hyperlipidemia or severe disorders of lipid metabolism characterized by Median glucose levels at baseline and the end of the study were 86 and 87 mg/dL for Omegaven-treated
hypertriglyceridemia (serum triglyceride concentrations greater than 1,000 mg/dL). patients, respectively. Hyperglycemia was experienced by 13 (7%) Omegaven-treated patients.
WARNINGS AND PRECAUTIONS Median triglyceride levels at baseline and the end of the study were 121 mg/dL and 72 mg/dL for
• Risk of Death in Preterm Infants due to Pulmonary Lipid Accumulation: Deaths in preterm infants Omegaven-treated patients respectively. Hypertriglyceridemia was experienced by 5 (3%) Omegaven-
after infusion of soybean oil-based intravenous lipid emulsions have been reported in medical treated patients.
literature. Autopsy findings in these preterm infants included intravascular lipid accumulation in The triene:tetraene (Mead acid:arachidonic acid) ratio was used to monitor essential fatty acid status
the lungs. The risk of pulmonary lipid accumulation with Omegaven is unknown. Preterm and in Omegaven-treated patients only in Study 1 (n = 123). The median triene:tetraene ratio was 0.02
small-for-gestational-age infants have poor clearance of intravenous lipid emulsion and increased (interquartile range: 0.01 to 0.03) at both baseline and the end of the study. Blood samples for analysis
free fatty acid plasma levels following lipid emulsion infusion. This risk due to poor lipid clearance may have been drawn while the lipid emulsion was being infused and patients received enteral or
should be considered when administering intravenous lipid emulsions. Monitor patients receiving oral nutrition.
Omegaven for signs and symptoms of pleural or pericardial effusion.
Postmarketing Experience
• Hypersensitivity Reactions: Omegaven contains fish oil and egg phospholipids, which may cause The following adverse reaction has been identified with use of Omegaven in another country.
hypersensitivity reactions. Signs or symptoms of a hypersensitivity reaction may include: Life-threatening hemorrhage following a central venous catheter change was reported in a 9 month-old
tachypnea, dyspnea, hypoxia, bronchospasm, tachycardia, hypotension, cyanosis, vomiting, nausea, infant with intestinal failure who received PN with Omegaven as the sole lipid source; he had no prior
headache, sweating, dizziness, altered mentation, flushing, rash, urticaria, erythema, fever, or chills. history of bleeding, coagulopathy, or portal hypertension.
If a hypersensitivity reaction occurs, stop infusion of Omegaven immediately and initiate appropriate
treatment and supportive measures. To report SUSPECTED ADVERSE REACTIONS, contact Fresenius Kabi USA, LLC, at
• Risk of Infections: The risk of infection is increased in patients with malnutrition-associated 1-800-551-7176, option 5, or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
immunosuppression, long-term use and poor maintenance of intravenous catheters, or immuno-
DRUG INTERACTIONS
suppressive effects of other conditions or concomitant drugs. To decrease the risk of infectious
Prolonged bleeding time has been reported in patients taking antiplatelet agents or anticoagulants
complications, ensure aseptic technique in catheter placement and maintenance, as well as in the
and oral omega-3 fatty acids. Periodically monitor bleeding time in patients receiving Omegaven and
preparation and administration of Omegaven. Monitor for signs and symptoms of early infections
concomitant antiplatelet agents or anticoagulants.
including fever and chills, laboratory test results that might indicate infection (including leukocytosis
and hyperglycemia), and frequently inspect the intravenous catheter insertion site for edema, USE IN SPECIFIC POPULATIONS
redness, and discharge. • Pregnancy: There are no available data on Omegaven use in pregnant women to establish a
• Fat Overload Syndrome: A reduced or limited ability to metabolize lipids accompanied by prolonged drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes.
plasma clearance may result in this syndrome, which is characterized by a sudden deterioration Animal reproduction studies have not been conducted with fish oil triglycerides. The estimated
in the patient’s condition including fever, anemia, leukopenia, thrombocytopenia, coagulation background risk of major birth defects and miscarriage in the indicated population is unknown.
disorders, hyperlipidemia, hepatomegaly, deteriorating liver function, and central nervous system All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the US
manifestations (e.g., coma). general population, the estimated background risk of major birth defects and miscarriage in
• Refeeding Syndrome: Administering PN to severely malnourished patients may result in refeeding clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
syndrome, which is characterized by the intracellular shift of potassium, phosphorus, and magnesium • Lactation: No data available regarding the presence of fish oil triglycerides from Omegaven in
as the patient becomes anabolic. Thiamine deficiency and fluid retention may also develop. human milk, the effects on the breastfed infant, or the effects on milk production. Lactating women
To prevent these complications, closely monitor severely malnourished patients and slowly increase receiving oral omega-3 fatty acids have been shown to have higher levels of omega-3 fatty acids in
their nutrient intake. their milk. The developmental and health benefits of breastfeeding should be considered along with
• Hypertriglyceridemia: Impaired lipid metabolism with hypertriglyceridemia may occur in conditions the mother’s clinical need for Omegaven, and any potential adverse effects of Omegaven on the
such as inherited lipid disorders, obesity, diabetes mellitus, and metabolic syndrome. Serum breastfed infant.
triglyceride levels greater than 1,000 mg/dL have been associated with an increased risk of pancre- • Pediatric Use: The safety of Omegaven was established in 189 pediatric patients (19 days to 15 years
atitis. To evaluate the patient’s capacity to metabolize and eliminate the infused lipid emulsion, of age). The most common adverse reactions in Omegaven-treated patients were vomiting,
measure serum triglycerides before the start of infusion (baseline value), and regularly throughout agitation, bradycardia, apnea and viral infection.
treatment. If hypertriglyceridemia (triglycerides greater than 250 mg/dL in neonates and infants • Geriatric Use: Clinical trials of Omegaven did not include patients 65 years of age and older.
or greater than 400 mg/dL in older children) develops, consider stopping the administration of
Omegaven for 4 hours and obtain a repeat serum triglyceride level. Resume Omegaven based on OVERDOSE
new result as indicated. In the event of an overdose, fat overload syndrome may occur. Stop the infusion of Omegaven
• Aluminum Toxicity: Aluminum may reach toxic levels with prolonged parenteral administration if until triglyceride levels have normalized and any symptoms have abated. The effects are usually
kidney function is impaired. Preterm infants are particularly at risk because their kidneys are imma- reversible by stopping the lipid infusion. If medically appropriate, further intervention may be
ture, and they require large amounts of calcium and phosphate solutions, which contain aluminum. indicated. Lipids are not dialyzable from serum.
Patients with impaired kidney function, including preterm infants, who receive parenteral levels of REFERENCES:
aluminum at greater than 4 to 5 mcg/kg/day accumulate aluminum at levels associated with central
1. Omegaven Prescribing Information, Fresenius Kabi USA, LLC. 2018.
nervous system and bone toxicity. Tissue loading may occur at even lower rates of administration.
• Monitoring and Laboratory Tests: Routine Monitoring: Monitor serum triglycerides, fluid and
electrolyte status, blood glucose, liver and kidney function, coagulation parameters, and complete
blood count including platelets throughout treatment. Essential Fatty Acids: Monitoring patients
for laboratory evidence of essential fatty acid deficiency (EFAD) is recommended. Laboratory tests
are available to determine serum fatty acids levels. Reference values should be consulted to help
determine adequacy of essential fatty acid status.
• Interference with Laboratory Tests: The lipids contained in Omegaven may interfere with some
laboratory blood tests (e.g., hemoglobin, lactate dehydrogenase, bilirubin, and oxygen saturation)
if blood is sampled before lipids have cleared from the bloodstream. Lipids are normally cleared
after a period of 5 to 6 hours once the lipid infusion is stopped.
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Peer Reviewed
HeRO Monitoring:
Does It Lead to Unnecessary Testing and Treatment?
William E King, MS crease in survival when assessing other outcomes can change
the result. Indeed, we have previously reported that length of stay
Introduction among this cohort was longer among the HeRO-display group
when failing to account for the competing outcome of mortality,
Evidence continues to build that HeRO monitoring improves out- but shorter when so doing. (4)
comes of premature infants, including all-cause NICU mortality,
(1) mortality after infection, (2) mortality at 18-22 months, (3) We hypothesized that metrics of blood culture rates and antibiotic
mortality-or-severe-cerebral-palsy at 18-22 months, (3) and NICU usage would favor HeRO-monitoring after adjusting for the com-
length of stay. (4) Yet some neonatologists find themselves hesi- peting outcome of mortality.
tant to adopt HeRO monitoring for fear that it may lead to higher
rates of testing and antibiotic usage. Here, we examine whether Methods
those fears are well-founded and the hesitancy justified.
We calculated the following composite metrics for each patient:
number of days alive without antibiotics, number of days alive
without a blood culture, and number of days alive without a nega-
“Yet some neonatologists find themselves tive blood culture for suspicion of sepsis. Event days were as-
hesitant to adopt HeRO monitoring for fear sessed discretely—that is, if there were any antibiotics/cultures
on a particular day of life, that entire day was assessed as having
that it may lead to higher rates of testing antibiotics/cultures. The mean values of each metric were calcu-
lated for the HeRO display group and the control group. The differ-
and antibiotic usage. Here, we examine ence in distributions was assessed using a two-tailed t-test, with
whether those fears are well-founded and statistical significance set at P<0.05. Data were queried from the
SQL database (Microsoft Corporation) and analyzed using R (R
the hesitancy justified.” Core Team). (33) Data were analyzed from birth through 120 days
of life (a departure from the report of the RCT, where data were
analyzed from randomization (mean 3.8 days after birth) to 120
days post randomization (1)). We performed a sensitivity analysis
Background to determine whether analyzing the 120 days beginning at ran-
domization changed the results.
The HeRO Score (aka HRC Index) is calculated every hour and
identifies abnormal heart rate patterns of reduced variability and
transient decelerations that are associated with cytokines (5-7) “When comparing the number of days
and often precede sepsis(8-18) UTI, (19) NEC, (20,21) , meningi-
tis, (19) neuro trauma, (22-25) respiratory decompensation, (26) alive and without a negative blood culture
extubation readiness, (27,28) and death. (23,25, 29-31) HeRO
monitoring has been utilized as an early warning system, (32) and for suspicion of sepsis, the benefit of
Moorman et al. hypothesized that it may lead to early diagnoses, HeRO-monitoring was significant (110.5
earlier interventions, and improved outcomes. In the largest RCT
ever published among premature neonates, 3003 VLBW patients days versus 108.4, P=0.048).”
at nine hospitals were randomized to either receive standard of
care monitoring, or standard of care monitoring plus HeRO. (1)
While mortality and other outcomes described above were statis- Results
tically significantly improved for those patients randomized to the
HeRO-display group, Moorman et al. described non-significant Baseline demographics of the patients enrolled in the RCT have
trends toward increased testing and antibiotics: “Infants whose been described in previous reports and were not statistically sig-
HRC monitoring results were displayed had 10% more blood cul- nificantly different between the two arms (1).
tures drawn for the suspicion of sepsis (1.8 per month compared
with 1.6, P = .05) and 5% more days on antibiotics (15.7 com- The results of this analysis are presented in Table 1. Patients ran-
pared with 15.0, P = .31, Table).” (1) domized to HeRO-display had non-significant trends toward more
days alive and without antibiotics in their first 120 days than con-
Mortality, however, is a competing outcome with both cultures trols (96.1 versus 94.5, P=0.187) and more days alive without a
drawn and antibiotic days, and properly accounting for the in- blood culture in their first 120 days (109.0 versus 107.1, P=0.071).


Outcome Control HeRO Delta P
Component Outcomes
Days alive 110.2 112.4 2.2 0.029
Days with antibiotics 15.7 16.3 0.6 0.350
Days with a blood culture 3.06 3.43 0.37 0.010
Days with a negative blood culture for suspicion of 1.74 1.96 0.22 0.014
sepsis
Composite Outcomes
Days alive and without antibiotics 94.5 96.1 1.6 0.187
Days alive and without a blood culture 107.1 109.0 1.9 0.071
Days alive and without a negative blood culture for 108.4 110.5 2.1 0.048
suspicion of sepsis
Table 1. Mean days alive, days with an event, and days alive without an event for Control (standard of care cardio-respiratory monitoring)
versus HeRO (standard of care cardio-respiratory monitoring plus HeRO).
Figure 1. Days alive without antibiotics

Figure 2. Days alive without blood culture
When comparing the number of days alive and without a negative analysis, we attempt to both (a) assess over-testing and over-
blood culture for suspicion of sepsis, the benefit of HeRO-monitor- treatment of VLBW neonates in the context of the competing
ing was significant (110.5 days versus 108.4, P=0.048). Results outcome of improved mortality, and (b) contextualize the relative
were similar and statistical significance was not affected when we costs of death versus over-testing/over-treatment. Toward both
analyzed 120 days beginning at randomization rather than birth. ends, we tested the composite outcomes of days alive and without
antibiotics, days alive and without blood culture, and days alive
In Figures 1, 2, and 3, we present curves comparing the differ- and without unnecessary blood culture (i.e., a negative blood cul-
ence between the Control and HeRO-display arms of the RCT in ture that was drawn for suspicion of sepsis).
each of the three composite outcomes. The x-axis represents the
number of days a patient was alive and without antibiotics, alive All three metrics trended in favor of HeRO monitoring, and one
without a blood culture, or alive without a negative blood culture of the three was statistically significant. Arguably, the statistical
drawn for suspicion of sepsis, respectively, during their first 120 equivalence demonstrated by the other two metrics also favors
days of life. At a particular point along the x-axis, the y-axis repre- the adoption of HeRO monitoring, as they indicate that there is no
sents the fraction of patients that had at least that number of days increase in death-or-testing and death-or-treatment.
alive and without event. These plots can be interpreted much like
Kaplan-Meier survival curves, with the provisos that the outcome Moorman et al. reported a number needed to treat of 48 patients
plotted is a composite of death and/or event, and that the data to save a life with HeRO monitoring. (1) Here we report that He-
are right-censored at 120 days. By definition, all trends originate RO-monitored patients had 0.22 more days with an unnecessary
at 1.0 at 0 days, separate based on differences in the measured blood culture (defined as a negative blood culture drawn for suspi-
outcome, and converge to 0.0 at 120 days. cion of sepsis) and an estimate of 0.6 additional days of antibiotics
per patient. Among VLBWs in a NICU, the price of saving one life
Discussion with HeRO monitoring is 10.6 unnecessary blood cultures (48 x
0.22) and 29 days of antibiotics (48 x 0.6). Importantly, all of the
Concern regarding over-testing and over-utilization of antimicro- additional days of antibiotics went to septic patients per Fairchild
bials among neonatologists has grown in recent years and may et al, (2) Table 1, where the authors reported non-septic patients
have led many to hesitate in adopting HeRO monitoring. In this had identical days of antibiotics (7.6 days for HeRO versus 7.6 for

Figure 3. Days alive without unnecessary blood culture
controls), while septic patients had 32.1 days with HeRO versus that it treats a day with an event as equivalent to a day deceased.
29.0 for controls (P=0.047). Obviously, this overestimates the relative cost of antibiotics and
cultures versus death.
Furthermore, the concern that the excess testing or excess ther-
apy will have later consequences is unwarranted because the
number needed to treat of 48 is based on the all-cause mortality “Nevertheless, when examining those
improvement—the net effect of HeRO monitoring on NICU mortal-
ity where any possible consequences of excess testing/treatment concerns after controlling for, and in the
were built into the calculation. And among the ELBW patients
with a neurodevelopmental follow-up, Schelonka et al. reported context of, the mortality improvement
that the mortality benefit of HeRO monitoring persisted at 18-22 associated with HeRO monitoring,
months3.
hesitancy in adopting the technology is not
A possible weakness of analyzing days alive and without event
(antibiotics, a blood culture, or an unnecessary blood culture) is justified.”
But this weakness is also a strength because it paints a stark con-
NEONATOLOGY TODAY trast. It is axiomatic that a day with antibiotics or an unnecessary
culture is better than death. If no parent would ever choose to
exchange the death of their child to avoid an unnecessary blood
via our Twitter Feed culture or course of antibiotics, why would some neonatologists,
who serve as advocates for their patients, choose to do so?
@NEOTODAY Conclusion

Previous reports have indicated trends toward increased test- 12930915.
ing and treatment associated with HeRO monitoring, so clinician 10. Griffin MP, O'Shea TM, Bissonette EA, Harrell FE Jr, Lake
concern is well-founded. Nevertheless, when examining those DE, Moorman JR. Abnormal heart rate characteristics
concerns after controlling for, and in the context of, the mortal- preceding neonatal sepsis and sepsis-like illness.
ity improvement associated with HeRO monitoring, hesitancy in Pediatr Res. 2003 Jun;53(6):920-6. doi: 10.1203/01.
adopting the technology is not justified. PDR.0000064904.05313.D2. Epub 2003 Mar 19. PMID:
12646726.
References: 11. Griffin MP, Lake DE, Moorman JR. Heart rate
1. Moorman JR, Carlo WA, Kattwinkel J, Schelonka RL, characteristics and laboratory tests in neonatal sepsis.
Porcelli PJ, Navarrete CT, Bancalari E, Aschner JL, Whit Pediatrics. 2005 Apr;115(4):937-41. doi: 10.1542/
Walker M, Perez JA, Palmer C, Stukenborg GJ, Lake peds.2004-1393. PMID: 15805367.
DE, Michael O'Shea T. Mortality reduction by heart rate 12. Moorman JR, Lake DE, Griffin MP. Heart rate
characteristic monitoring in very low birth weight neonates: characteristics monitoring for neonatal sepsis. IEEE
a randomized trial. J Pediatr. 2011 Dec;159(6):900-6. Trans Biomed Eng. 2006;53(1):126-132. doi:10.1109/
e1. doi: 10.1016/j.jpeds.2011.06.044. Epub 2011 Aug 24. TBME.2005.859810
PMID: 21864846; PMCID: PMC3215822. 13. Griffin MP, Lake DE, O'Shea TM, Moorman JR. Heart
2. Fairchild KD, Schelonka RL, Kaufman DA, Carlo WA, rate characteristics and clinical signs in neonatal sepsis.
Kattwinkel J, Porcelli PJ, Navarrete CT, Bancalari E, Pediatr Res. 2007 Feb;61(2):222-7. doi: 10.1203/01.
Aschner JL, Walker MW, Perez JA, Palmer C, Lake DE, pdr.0000252438.65759.af. PMID: 17237726.
O'Shea TM, Moorman JR. Septicemia mortality reduction 14. Moorman JR, Delos JB, Flower AA, Cao H, Kovatchev
in neonates in a heart rate characteristics monitoring BP, Richman JS, Lake DE. Cardiovascular oscillations
trial. Pediatr Res. 2013 Nov;74(5):570-5. doi: 10.1038/ at the bedside: early diagnosis of neonatal sepsis using
pr.2013.136. Epub 2013 Aug 13. PMID: 23942558; PMCID: heart rate characteristics monitoring. Physiol Meas. 2011
PMC4026205. Nov;32(11):1821-32. doi: 10.1088/0967-3334/32/11/
3. Schelonka RL, Carlo WA, Bauer CR, Peralta-Carcelen S08. Epub 2011 Oct 25. PMID: 22026974; PMCID:
M, Phillips V, Helderman J, Navarrete CT, Moorman PMC4898648.
JR, Lake DE, Kattwinkel J, Fairchild KD, O'Shea TM. 15. Fairchild KD. Predictive monitoring for early detection
Mortality and Neurodevelopmental Outcomes in the Heart of sepsis in neonatal ICU patients. Curr Opin Pediatr.
Rate Characteristics Monitoring Randomized Controlled 2013;25(2):172-179. doi:10.1097/MOP.0b013e32835e8fe6
Trial. J Pediatr. 2020 Apr;219:48-53. doi: 10.1016/j. 16. Lake DE, Fairchild KD, Moorman JR. Complex signals
jpeds.2019.12.066. Epub 2020 Feb 4. PMID: 32033793; bioinformatics: evaluation of heart rate characteristics
PMCID: PMC7096280. monitoring as a novel risk marker for neonatal sepsis. J
4. Swanson JR, King WE, Sinkin RA, Lake DE, Carlo WA, Clin Monit Comput. 2014 Aug;28(4):329-39. doi: 10.1007/
Schelonka RL, Porcelli PJ, Navarrete CT, Bancalari E, s10877-013-9530-x. Epub 2013 Nov 19. PMID: 24248424;
Aschner JL, Perez JA, O'Shea TM, Walker MW. Neonatal PMCID: PMC4026344.
Intensive Care Unit Length of Stay Reduction by Heart Rate 17. Hicks JH, Fairchild KD. Heart rate characteristics in the
Characteristics Monitoring. J Pediatr. 2018 Jul;198:162- NICU: what nurses need to know. Adv Neonatal Care. 2013
167. doi: 10.1016/j.jpeds.2018.02.045. Epub 2018 Apr 24. Dec;13(6):396-401. doi: 10.1097/ANC.0000000000000031.
PMID: 29703576. PMID: 24300957.
5. Fairchild KD, Saucerman JJ, Raynor LL, Sivak JA, 18. Pugni L, Ronchi A, Bizzarri B, Pietrasanta C, Araimo G,
Xiao Y, Lake DE, Moorman JR. Endotoxin depresses
heart rate variability in mice: cytokine and steroid
effects. Am J Physiol Regul Integr Comp Physiol. 2009
Oct;297(4):R1019-27. doi: 10.1152/ajpregu.00132.2009.
Epub 2009 Aug 5. PMID: 19657103; PMCID: PMC2763816.
6. Fairchild KD, Srinivasan V, Moorman JR, Gaykema
RP, Goehler LE. Pathogen-induced heart rate changes
associated with cholinergic nervous system activation.
Am J Physiol Regul Integr Comp Physiol. 2011
Feb;300(2):R330-9. doi: 10.1152/ajpregu.00487.2010.
Epub 2010 Nov 10. PMID: 21068197; PMCID:
PMC3043803.
7. Raynor LL, Saucerman JJ, Akinola MO, Lake DE, Moorman
JR, Fairchild KD. Cytokine screening identifies NICU
patients with Gram-negative bacteremia. Pediatr Res. 2012
Mar;71(3):261-6. doi: 10.1038/pr.2011.45. Epub 2012 Jan
25. PMID: 22278182; PMCID: PMC3552187.
8. Griffin MP, Moorman JR. Toward the early diagnosis of
neonatal sepsis and sepsis-like illness using novel heart
rate analysis. Pediatrics. 2001 Jan;107(1):97-104. doi:
10.1542/peds.107.1.97. PMID: 11134441.
9. Kovatchev BP, Farhy LS, Cao H, Griffin MP, Lake DE,
Moorman JR. Sample asymmetry analysis of heart
rate characteristics with application to neonatal sepsis
and systemic inflammatory response syndrome.
Pediatr Res. 2003 Dec;54(6):892-8. doi: 10.1203/01.
PDR.0000088074.97781.4F. Epub 2003 Aug 20. PMID:

Ghirardi B, Casciati MC, Perniciaro S, Casartelli M, Mosca PDR.0000119366.21770.9E. Epub 2004 Jan 22. PMID:
F. [HEART RATE CHARACTERISTICS INDEX SCORE: Is 14739356.
it Useful to Predict Neonatal Sepsis?]. La Pediatria Medica 30. Griffin MP, Lake DE, Bissonette EA, Harrell FE Jr,
# Chirurgica - Medical and Surgical Pediatrics Volume 37, O'Shea TM, Moorman JR. Heart rate characteristics:
N. 1, January-March 2015. Italian. novel physiomarkers to predict neonatal infection and
19. Weitkamp JH, Aschner JL, Carlo WA, Bancalari E, Perez death. Pediatrics. 2005 Nov;116(5):1070-4. doi: 10.1542/
JA, Navarrete CT, Schelonka RL, Whit Walker M, Porcelli P peds.2004-2461. PMID: 16263991.
Jr, O'Shea TM, Palmer C, Grossarth S, Lake DE, Fairchild 31. Sullivan BA, McClure C, Hicks J, Lake DE, Moorman JR,
KD. Meningitis, urinary tract, and bloodstream infections Fairchild KD. Early Heart Rate Characteristics Predict
in very low birth weight infants enrolled in a heart rate Death and Morbidities in Preterm Infants. J Pediatr. 2016
characteristics monitoring trial. Pediatr Res. 2019 Dec 4. Jul;174:57-62. doi: 10.1016/j.jpeds.2016.03.042. Epub
doi: 10.1038/s41390-019-0701-4. Epub ahead of print. 2016 Apr 22. PMID: 27113378; PMCID: PMC5672906.
PMID: 31801155. 32. Fairchild KD. Predictive monitoring for early detection of
20. Stone ML, Tatum PM, Weitkamp JH, Mukherjee AB, sepsis in neonatal ICU patients. Curr Opin Pediatr. 2013
Attridge J, McGahren ED, Rodgers BM, Lake DE, Moorman Apr;25(2):172-9. doi: 10.1097/MOP.0b013e32835e8fe6.
JR, Fairchild KD. Abnormal heart rate characteristics before PMID: 23407184.
clinical diagnosis of necrotizing enterocolitis. J Perinatol. 33. R Core Team (2019). R: A language and environment
2013 Nov;33(11):847-50. doi: 10.1038/jp.2013.63. Epub for statistical computing. R Foundation for Statistical
2013 May 30. PMID: 23722974; PMCID: PMC4026091. Computing, Vienna, Austria. URL http://www.R-project.org/
21. Sullivan BA, Fairchild KD. Predictive monitoring for sepsis
and necrotizing enterocolitis to prevent shock. Semin Fetal Disclosure: Mr. King is Chief Executive Officer of Medical
Neonatal Med. 2015 Aug;20(4):255-61. doi: 10.1016/j. Predictive Science Corporation, where he has developed
siny.2015.03.006. Epub 2015 Mar 29. PMID: 25823938. and coded real-time implementations of algorithms to predict
22. Addison K, Griffin MP, Moorman JR, Lake DE, O'Shea infection in neonates based on physiological monitoring data,
TM. Heart rate characteristics and neurodevelopmental obtained FDA and other regulatory approvals, developed an
outcome in very low birth weight infants. J Perinatol. 2009 FDA compliant quality system and sold devices to customers
Nov;29(11):750-6. doi: 10.1038/jp.2009.81. Epub 2009 Jun throughout the world. Mr. King is employed by MPSC,
25. PMID: 19554011; PMCID: PMC2834345. manufacturer of HeRO.
23. Fairchild KD, Sinkin RA, Davalian F, Blackman AE,
Swanson JR, Matsumoto JA, Lake DE, Moorman JR, NT
Blackman JA. Abnormal heart rate characteristics are
associated with abnormal neuroimaging and outcomes Corresponding Author:
in extremely low birth weight infants. J Perinatol. 2014
May;34(5):375-9. doi: 10.1038/jp.2014.18. Epub 2014 Feb
20. PMID: 24556979.
24. Kayton A, DeGrazia M, Sharpe E, Smith D, Perez JA,
Weiss MD. Correlation Between Heart Rate Characteristic
Index Score and Severity of Brain Injury in Neonates With
Hypoxic-Ischemic Encephalopathy. Adv Neonatal Care.
2020 Jan 27. doi: 10.1097/ANC.0000000000000686. Epub
ahead of print. PMID: 31895138. Will King
25. Vergales BD, Zanelli SA, Matsumoto JA, Goodkin HP, CEO
Lake DE, Moorman JR, Fairchild KD. Depressed heart Medical Predictive Science Corporation, an ISO registered
rate variability is associated with abnormal EEG, MRI, and company
death in neonates with hypoxic ischemic encephalopathy. 1233 Cedars Court, Suite 201
Am J Perinatol. 2014 Nov;31(10):855-62. doi: 10.1055/s- Charlottesville, VA 22903
0033-1361937. Epub 2013 Dec 17. PMID: 24347263. (434) 220 0703
26. Clark MT, Vergales BD, Paget-Brown AO, Smoot TJ, (800) 394 1625 x1113(toll-free)
Lake DE, Hudson JL, Delos JB, Kattwinkel J, Moorman Email [email protected]
JR. Predictive monitoring for respiratory decompensation
leading to urgent unplanned intubation in the neonatal
intensive care unit. Pediatr Res. 2013 Jan;73(1):104-
10. doi: 10.1038/pr.2012.155. Epub 2012 Nov 8. PMID:
23138402; PMCID: PMC5321074. New subscribers are always welcome!
27. Alonzo CJ, Fairchild KD. Dexamethasone effect on heart
rate variability in preterm infants on mechanical ventilation.
J Neonatal Perinatal Med. 2017;10(4):425-430. doi: NEONATOLOGY TODAY
10.3233/NPM-16157. PMID: 29286932.
28. Goel N, Chakraborty M, Watkins WJ, Banerjee S. To sign up for free monthly subscription,
Predicting Extubation Outcomes-A Model Incorporating just click on this box to go directly to our
Heart Rate Characteristics Index. J Pediatr. 2018
Apr;195:53-58.e1. doi: 10.1016/j.jpeds.2017.11.037. Epub subscription page
2018 Jan 10. PMID: 29329913.
29. Griffin MP, O'Shea TM, Bissonette EA, Harrell FE
Jr, Lake DE, Moorman JR. Abnormal heart rate
characteristics are associated with neonatal mortality.
Pediatr Res. 2004 May;55(5):782-8. doi: 10.1203/01.

Iranian village to a university professor in the United States of America in this memoir.
012314545challenges as a remedy. At age
As a boy, his unruly behavior was sedated by scholastic
twelve, he left home for junior high school in a provincial " capital. At
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esteem led him to stumble, but he soon found the courage to tackle his subjects with
vigor. He became more curious about the world around him and began to yearn for a

new life despite his financial limitations. Against all odds, he became one of the top stu-
dents in Iran and earned a scholarship to study medicine in Europe. Even though he was
culturally and socially naïve by European standards, an Italian family in Rome helped
him thrive. The author never shied away from the challenges of learning Italian, and the
generosity of Italy and its people became part and parcel of his formative years. By the
time he left for the United States of America, he knew he could accomplish whatever he
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Peer Reviewed
Fellow Column:
A Neonate with Fetal Brain Disruption Sequence
Andrea Ho, MD, Robin Clark, MD, Gilbert Martin, MD
Less than twenty-four hours after arrival to the pediatrics unit, the
Introduction: neonate had bradycardic events with heart rate in the 80’s and
desaturations to 60% despite tactile stimulation and nasal can-
Fetal brain disruption sequence (FBDS) is a condition with many nula 1 LPM. A cardiopulmonary arrest was suspected. A code
causes that is characterized by severe microcephaly of prenatal was called, and ROSC was achieved after five cycles of chest
onset, overlapping sutures, scalp rugae, neurological impairment, compressions with bag-mask ventilation. The neonate was then
normal hair pattern, and occipital bone prominence. FBDS is pos- transferred to the NICU.
tulated to result from a disruption in brain development during the
second or third trimester, which leads to decreased intracranial The mother of this neonate was 24-years-old at the time of his
hydrostatic pressure with the consequent collapse of the fetal birth. She is healthy, though she reports having a “small head.”
skull. Overlapping sutures, occipital bone prominence, and scalp She is of Russian, French, German, and Italian descent. The fa-
rugae follow as a result of this collapse. Preservation of hair for- ther is 37-years-old. He has numbness of the hands and feet as
mation is explained by otherwise normal development during the well as constant migraines, and he has been referred to a neu-
first 18 weeks of gestation, the period when hair follicles develop. rologist. He is of Spanish and possibly French-Canadian ances-
try. The parents denied consanguinity and previous miscarriages.
Case History: Their head circumferences are unavailable. The neonate has a
3-year-old full sister who is healthy.
A two-day-old male was transferred to Loma Linda University
Children’s Hospital for cyanosis associated with feeding, desatu- The neonate had the following additional physical anomalies: a
rations, and hypothermia. The mother was a 24-year-old G2P2 prominent occipital ridge that extended in the transverse plane,
female. The mother used tobacco before she came to the knowl- overriding occipital sutures, deep scalp folds, small for gestational
edge of her pregnancy and did not receive prenatal care. She age, narrow and sloped forehead, downward slanting palpebral
denied the use of illicit drugs. Based on the last menstrual period, fissures, high and broad nasal bridge, low set and posteriorly ro-
the neonate was 41 weeks 6 days gestation at birth. The mother tated ears, micrognathia, dry skin, high-arched and narrow palate,
reported an untreated urinary tract infection and pubic folliculitis sacral indentation, sustained arm extension when eliciting Moro
at 30-33 weeks of gestation. Parents also stated that they were reflex, absent Babinski reflexes, absent rooting response, and
exposed to mold during the entire pregnancy and that the fam- optic nerve hypoplasia of both eyes. The infant’s head circumfer-
ily moved at 39 weeks of gestation. He was born via spontane- ence at two days of life was 26cm, which represents a Z score
ous vaginal delivery at home, where the parents noted that his (standard deviation) of -7.34 for infants of this gestational age.
head was small and misshapen. Paramedics arrived shortly after The first recorded weight available, on day 2 of life, was 2.885kg,
delivery and transported the neonate to an outside hospital. The which correlates with a Z-score of -2.49. Due to transient hyper-
parents were told that he had anencephaly, and they brought him tonic episodes followed by periods of low tone, a video EEG was
home for hospice care. On day two of life, he was at the pediatri- performed, which showed a burst-suppression pattern with gen-
cian’s office breastfeeding when he choked and became cyanotic
and limp. He was taken to an outside hospital, where he was hy-
pothermic to 94.3 F, had periodic breathing, desaturated to 84%,
and required nasal cannula 1 LPM. He was treated with ampicil-
lin and gentamicin. Chest x-ray showed ground-glass opacities. A
brain MRI showed diffuse symmetric microcephaly with abnormal
sulcation suggestive of a simplified gyral pattern, a 7mm subdural
hematoma, a thin corpus callosum, mild symmetric dilation of the
occipital horns, a diminutive appearance of the optic nerves, and
fluid in the mastoid air cells. The neonate was then transferred to
our facility for genetics, and pediatric neurology consults as well
as for further management of respiratory failure.
“Less than twenty-four hours after

arrival to the pediatrics unit, the neonate
had bradycardic events with heart rate
in the 80’s and desaturations to 60%
despite tactile stimulation and nasal
cannula 1 LPM. A cardiopulmonary arrest
was suspected. "

eralized myotonic seizures and generalized tonic seizures consis- This neonate’s prominently rugated scalp, overlapping sutures,
tent with Ohtahara syndrome. Despite the resolution of the subdu- occipital bone prominence, profound microcephaly, and normal
ral hematoma on brain MRI, the neonate’s seizures persisted. He hair pattern are consistent with the diagnosis of FBDS. His micro-
was treated with levetiracetam for an indefinite duration as well as cephaly, characterized by head circumference Z score of -7.34,
phenobarbital. Due to poor feeding, the neonate later required a was more severe than the reported average Z score of -5.8. Ad-
gastrostomy tube. Due to optic nerve hypoplasia, an evaluation for ditionally, the neonate’s brain MRI findings of occipital horn di-
panhypopituitarism was performed, which showed no abnormali- lation and a simplified gyral pattern are consistent with colpo-
ties. An echocardiogram revealed no congenital heart disease. cephaly and lissencephaly from the report of Corona-Rivera et
al. Although the cause of FBDS in this neonate is unknown, one
Laboratory studies were not revealing. The newborn screen was contributing factor from the gestational history is maternal tobacco
normal. Laboratory tests for congenital infections were negative. smoking. Smoking is known to increase vascular resistance of the
Zika virus PCR was negative. IgM and IgG antibodies for CMV placenta, which limits blood flow to the fetus. Using the Swed-
and toxoplasma were negative. The chromosomal microarray was ish Medical Birth Registry, information on 1,362,169 infants born
normal. Microcephaly Next Generation Sequencing (NGS) panel during 1983-1996, Källén (2000) found a highly significant as-
(Fulgent Diagnostics, 76 genes tested) and Lissencephaly NGS sociation between small head circumference for gestational age
panel (Fulgent Diagnostics, 15 genes tested) also revealed no and maternal smoking. CMV and Zika virus infections were ruled
abnormalities. Plasma amino acids, ammonia, urine organic acid, out by laboratory results. There is no known association between
and acylcarnitine profile were within normal ranges. prenatal mold exposure and microcephaly. Although the Micro-
cephaly NGS panel, which includes the NGE1 gene, and the Lis-
sencephaly NGS panel were normal, ALG11, which is responsible
for ALG11-congenital disorder of glycosylation, was not included
“FBDS was first recognized in 1984 in these panels. In retrospect, a whole-exome sequencing test
would have been a more comprehensive and cost-effective genet-
in three infants who had a pattern ic strategy in this circumstance. Due to the lack of prenatal care,
it is uncertain whether other environmental agents or infectious
of microcephaly, occipital bone etiologies contributed to FBDS in this neonate; however, genetic
prominence, overlying sutures, and counseling will be offered to this family because an autosomal
recessive disorder has not been ruled out.
scalp rugae. (7)"
Practical Applications:
1. Consider the diagnoses of fetal brain disruption sequence

Discussion: when the pattern of microcephaly presents with scalp rugae,
overriding sutures, and occipital bone prominence.
FBDS was first recognized in 1984 in three infants who had a
pattern of microcephaly, occipital bone prominence, overlying su- 2. In infants with fetal brain disruption sequence is diagnosed,
tures, and scalp rugae. (7) A 2001 review of twenty cases of FBDS brain imaging and ophthalmologic evaluations help detect
identified the most common features of this sequence as normal structural abnormalities of the brain and eye that may re-
scalp hair pattern, scalp rugae, overlapped sutures, and occipi- quire further intervention.
tal bone prominence; microcephaly was a cardinal feature, with
an average standard deviation of occipitofrontal circumference of 3. Investigate deletions on chromosome microarray, especially
-5.8. (1) Autopsy and CT head findings in these subjects included at 16p13.11, with comprehensive genetic testing (exome)
the destruction of cerebral hemispheres, hydranencephaly, a defi- because a deletion may unmask a deleterious variant on the
cit in cortical tissues, ventriculomegaly, small cerebellum, intra- other intact chromosome.
cranial calcification, intracranial hemorrhage, porencephaly, col-
pocephaly, small gyri, and lissencephaly. Proposed mechanisms 4. After prenatal infection with CMV and Zika virus have been
of FBDS include viral infections, disruptions of vascular supply to ruled out, order trio whole-exome sequencing test, which is
the fetal brain, and genetic disorders. When viral infections are im- more comprehensive and less costly than serial gene panels
plicated, the most common viruses are CMV and Zika virus. Vas- that may miss some causative genes. Offer genetic counsel-
cular disruption events that cause FBDS include prenatal cocaine ing to families of infants with unexplained severe congenital
exposure, trauma, death of a co-twin, and DIC. (1) Autosomal microcephaly, because autosomal recessive traits could in-
recessive genetic disorders can cause fetal brain disruption-like crease recurrence risks for future pregnancies.
phenomenon, such as ALG11-congenital disorder of glycosylation
5. Refer to early infant stimulation and other intervention pro-
and deletion of 16p13.11, which can unmask a pathogen variant
grams for children with developmental and intellectual de-
in the NDE1 gene on the intact homolog, creating a biallelic loss
lays.
of function for this gene. (5, 6)
This infant’s numerous scalp folds suggested cutis verticis gyrate

(CVG) to some examiners. CVG presents as symmetric, redun- References
dant scalp folds that exhibit deep furrows and convolutions mim- 1. 1- CDC COVID-19 Response Team. Coronavirus Disease
icking that of cerebral gyri. CVG presents in adults or adolescents 2019 in Children - United States, February 12-April 2, 2020.
and is rare in infants and children. It is focal with tightly arranged MMWR Morb Mortal Wkly Rep. 2020; 69 (14):422. Epub
and fixed folds. It can be seen with psychiatric disorders, seizures, 2020 April 10
and intellectual disability, but it is not associated with congenital 2. Breslin, N. B.-B. (2020). COVID-19 infection among asymp-
microcephaly. This patient has scalp skin folds that are not char- tomatic and symptomatic pregnant women: Two weeks of
acteristic of CVG: they are diffuse, involving the entire scalp. They confirmed presentations to an affiliated pair of New York
are loose and are not fixed firmly in place. City hospitals. American Journal of Obstetrics & Gynecology
MFM, 100118.

3. Sutton, D. K. (2020). Universal Screening for SARS-CoV-2
in Women Admitted for Delivery. New England Journal of
Medicine.
4. Chandrasekharan, P. V.-C.-2. (2020). Neonatal Resuscita-
tion and Postresuscitation Care of Infants Born to Mothers
with Suspected or Confirmed SARS-CoV-2 Infection. Ameri-
can Journal of Perinatology.
5. Tran, K. C.-S. (2012). Aerosol generating procedures and
risk of transmission of acute respiratory infections to health-
care workers: a systematic review. PloS one. Gilbert I Martin, MD, FAAP
6. Puopolo, K. M. (2020). Management of Infants Born to Moth- Division of Neonatal Medicine
ers with COVID-19. American Academy of Pediatrics Com- Department of Pediatrics
mittee on Fetus and Newborn, Section on Neonatal-Perina- Professor of Pediatrics
tal Medicine, and Committee on Infectious Diseases. Loma Linda University School of Medicine
7. Dubler, S. Z. (2016). Bacterial and viral contamination of [email protected]
breathing circuits after extended use - an aspect of patient Office Phone: 909-558-7448
safety? Anaesthesiologica Scandinavica.
8. Zeng, H. X. (2020). Antibodies in infants born to mothers
with COVID-19 pneumonia. JAMA.
9. Yu, N. L. (2020). Clinical features and obstetric and neona-
tal outcomes of pregnant patients with COVID-19 in Wuhan,
China: a retrospective, single-centre, descriptive study. The
Lancet Infectious Diseases.
10. Zeng, L. X. (2020). Neonatal early-onset infection with
SARS-CoV-2 in 33 neonates born to mothers with COVID-19
in Wuhan, China. JAMA pediatrics.
11. Chen H, G. J. (2020). Clinical characteristics and intrauter-
ine vertical transmission potential of COVID-19 infection in
nine pregnant women: a retrospective review of medical re-
cords. Lancet.
12. Cao, Q., Chen, Y. C., Chen, C. L., & Chiu, C. H. (2020). Robin Clark, MD
SARS-CoV-2 infection in children: Transmission dynamics Professor, Pediatrics
and clinical characteristics. J Formos Med Assoc, 119(3), Loma Linda University School of Medicine
670-673. Division of Genetics
13. Xia, W. S. (2020). Clinical and CT features in pediatric pa- Department of Pediatrics
tients with COVID-19 infection: Different points from adults. [email protected]
Clinical Pathology.
14. Zhu, H. W. (2020). Clinical analysis of 10 neonates born to
mothers with 2019-nCoV pneumonia. Translational Pediat-
rics, 51.
15. Wang, L., Shi, Y., Xiao, T., Fu, J., Feng, X., Mu, D., ... &
Lu, G. (2020). Chinese expert consensus on the perinatal
and neonatal management for the prevention and control of
the 2019 novel coronavirus infection. Annals of Translational
Medicine, 8(3).
Fellow's Column is published monthly.

Disclosure: The authors have no disclosures
• Submission guidelines for “Fellow's Column”:
NT • 2000 word limit not including references or title page. Ex-
ceptions will be made on a case by case basis
• QI/QA work, case studies, or a poster from a scientific meet-
Corresponding Author ing may be submitted..
• Submission should be from a resident, fellow, or NNP in
training.
• Topics may include Perinatology, Neonatology, and Younger
Pediatric patients.
• No more than 20 references.
• Please send your submissions to:
Andrea Ho, MD Elba Fayard, MD
Pediatric Resident Interim Fellowship Column Editor
Loma Linda University Children's Hospital [email protected]
Email: Ho, Andrea <[email protected]>

Newly-Validated Online
NICU Staff Education Caring for Babies and their Families:
Providing Psychosocial Support to NICU Parents
based on the “Interdisciplinary Recommendations for Psychosocial
Support for NICU Parents.”
Contact [email protected] for more information.

Brought to you by a collaboration between
National Perinatal Association
Patient + Family Care
Preemie Parent Alliance
Transform Your NICU www.mynicunetwork.com

Access free online education
Earn free CME/CNE credits from virtually anywhere
through our online portal. The MEDNAX Center for
Research, Education, Quality and Safety provides both
live and online learning to meet your educational needs.
Center for Visit mednax.cloud-cme.com to search, filter and browse
Research, Education, Quality & Safety the complete array of learning opportunities and register
for courses. Many of our online activities are available on
demand and offered at no charge!
DON’T MISS OUR UPCOMING NEONATOLOGY GRAND ROUNDS WEBINARS
Endoscopic Craniotomy for Synostosis

presented by Mark Proctor, MD
Wednesday, May 6, 2020 • 4:00pm ET
Sponsored by Abbott Nutrition

Practical Considerations for
Probiotics in the NICU
presented by Ravi M. Patel, MD
Wednesday, June 3, 2020 • 4:00pm ET
Current Management of Pulmonary

Arterial Hypertension in the BPD Infant
presented by Steven H. Abman, MD
Wednesday, July 1, 2020 • 4:00pm ET
Webinar topics and speakers subject to change.

For more information and to register: mednax.com/NEOGR2020
Accreditation statements reflect the designated credit for each educational webinar identified above:
The MEDNAX Center for Research, Education, Quality and Safety is accredited by the Accreditation Council for Continuing Medical Education
(ACCME) to provide continuing medical education for physicians.
The MEDNAX Center for Research, Education, Quality and Safety designates this Internet Live activity for a maximum of 1.0 AMA PRA Category
1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
The MEDNAX Center for Research, Education, Quality and Safety is accredited as a provider of continuing nursing education by the American
Nurses Credentialing Center’s Commission on Accreditation. (#PO258)
The MEDNAX Center for Research, Education, Quality and Safety designates this Internet Live activity for a maximum of 1.00 nursing contact
hour(s). Participants should only claim credit commensurate with the extent of their participation in the activity.
June 17-19, 2020 | 9am – 5pm | Columbia University | New York City
Next-Level Perinatal/Neonatal
Comfort Care Training
Creating an Interdisciplinary Palliative Care Plan for
Each Baby and Their Family
A 3-day intensive training of seminars and hands-on activity sessions to provide
an overview of the methods, elements, and strategies needed to create a
comprehensive neonatal comfort care plan for the entire perinatal team.
Perinatal detection of congenital anomalies leads to the identification of infants who are affected by life-limiting conditions with a
short life expectancy. Moreover, a significant number of newborns admitted to the neonatal ICU in critical condition face potentially
adverse prognoses. Perinatal palliative care offers a plan for improving quality of life of the infant and the family, when extending
the baby’s life is no longer the goal of care or the complexity of the medical condition is associated with uncertain prognosis. The
evidence base for perinatal palliative care continues to grow. However, there is no consensus about best clinical practice in
promoting support for the family or comfort for the neonate. Support for the family is achieved through appropriate pre- and
postnatal consults, shared-decision making, and advance care planning. A state of comfort for the neonate is achieved when basic
needs such as bonding, maintenance of body temperature, relief of hunger/thirst, and alleviation of pain/discomfort are met.
This three-day training will cover virtually all aspects of perinatal palliative care, including information about the successful
experiences of the Neonatal Comfort Care Program in providing perinatal palliative care for over a decade at Columbia University
Irving Medical Center (CUIMC). Faculty will discuss evidence-based rationale, practical aspects and strategies for implementing
and applying aspects of comfort care to provide support for families and achieve a state of comfort for newborns with limiting or
life-threatening conditions. Additional mphasis will be given to hands-on simulations and case studies. Health professionals at all
career stages are welcome to attend. Registration is required.
Elvira Parravicini, MD, Columbia University and New York Presbyterian/Morgan Stanley Children's Hospital, Director of Columbia
University’s Neonatal Comfort Care Program
Brian Carter, MD, University of Missouri-Kansas City and Children’s Mercy Hospital
Alexandra Mancini, RN, Chelsea & Westminster Foundation Trust & True Colour Trust, London, UK
Charlotte Wool, PhD, RN, York College of Pennsylvania; Perinatal Palliative Care Consultant
See site for full instructor list.
Continuing Medical Education (CME) and Continuing Nursing Education (CNE):

This course has been approved for CME credits. CNE credits pending.
Accreditation Statement: The Columbia University Vagelos College of Physicians and Surgeons is accredited by the Accreditation Council for Continuing Medical Education
to provide continuing medical education for physicians. AMA Credit Designation Statement: The Columbia University Vagelos College of Physicians and Surgeons
designates this live activity for a maximum of 20.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
More details and registration: mailman.columbia.edu/comfort-care

SAFETY IN THE NICU
New tubes, new problems?
A new tubing design meant to eliminate

tubing misconnections has introduced new
challenges for the NICU population. Pediatric
providers must deliver medication in small
volumes to tiny patients with high levels of
accuracy. The new tubing design, known
as ENFit®, could present dosing accuracy
and workflow challenges.
New subscribers are always welcome! moat
NEONATOLOGY TODAY
To sign up for a free monthly subscription, feeding
tube
just click on this box to go directly to our DOSING ACCURACY
subscription page • The moat, or area around the syringe barrel,
is difficult to clear. Medication can hide there,
inadvertently increasing the delivered dose when
the syringe and feeding tube are connected;
patients may receive extra medication.
INFECTION RISK
Readers can also follow • The moat design can increase risk for infection if
residual breast milk or formula remains in the moat
NEONATOLOGY TODAY and transfers to the feeding tube.
via our Twitter Feed WORKFLOW ISSUES

• Increased nursing workflow is seen with additional
steps for clearing syringe moats, cleaning tube
@NEOTODAY hubs, and using multiple connectors.
Improved standards are important to protect patients

from the dangers of tubing misconnections. But
we must avoid mitigating existing risks by creating
new ones.
Individual hospitals should consider all factors

impacting their NICU patients before adopting a
new tubing design.
ENFit® is a registered trademark of GEDSA
A collaborative of professional, clinical, community

health, and family support organizations focused on
the health and safety of premature infants.
infanthealth.org

Peer Reviewed
When an Infant Dies: The Need to Acknowledge Grief and

Find Bereavement Support
Barb Himes, IBCLC education, while providing support for grieving families who have
suffered a loss.
This bereavement support takes several forms and specifically

assists different causes of infant loss:
• A 24-hour grief line. Grief counseling day or night for a fam-

ily member in need, offering one-on-one support and access
to materials and local support services.
• Bereavement library. Resources on surviving the death of

a baby, guidance on coping with birthdays, anniversaries,
holidays, and difficult considerations such as having another
child, as well as ways for families to honor the memory of
their baby.
• Peer-to-peer online support groups. A safe and support-

ive environment for individuals and families to talk about
pregnancy and infant loss. Group members connect and find
an empathetic outlet for their feelings of grief, anger, anxiety,
and depression, sharing personal experiences and offering
First Candle's efforts to support families during their one another emotional comfort and moral support. There are
most difficult times and provide new answers to help separate groups that specifically address infant loss due to
other families avoid the tragedy of the loss of their baby SIDS and other sleep-related causes, stillbirth, and miscar-
are without parallel. riage.
We are finding that the nature of this Covid-19 time can add com-
We are in a time when pandemic conditions have placed an ad- plexity to the already painful burden of infant loss and that grief
ditional burden on grief, not only because coronavirus brings its itself can widen, as we hear not only from families suffering an
own paths of mortality with it, but because it complicates feelings immediate loss but also from those who are re-experiencing grief.
of grief and bereavement even when the losses are not related It may be for an infant who died years past, and the memory of
to it. that loss is being rekindled in this period of global morbidity and
mortality, or it may even be a feeling of grief for another lost family
member that is even heavier now.
“We are in a time when pandemic It brings to light the reality that there is a patchwork of existing
conditions have placed an additional bereavement support services that is further diminished – such as
restriction or unavailability of in-person group gatherings – during
burden on grief, not only because this pandemic, and underscores the value of those services that
do exist. People will turn to what they can find in their time of need.
coronavirus brings its own paths of
It also reminds us that experiencing infant loss and addressing
mortality with it, but because it complicates grief can be part of the prenatal, perinatal and postpartum health
feelings of grief and bereavement even care professional's environment, presenting difficulties for both
the grieving family seeking counsel and support and for the health
when the losses are not related to it.” professionals themselves, as their overriding drive is at all times
to save the infant and maternal life. The focus is on survival, not
death, and dying.
First Candle's mission is the elimination of Sudden Infant Death
Syndrome (SIDS) and other sleep-related infant deaths, through So there may, therefore, be times when simple, straightforward

guidance around bereavement situations can be helpful. For hos- All of these may present themselves in unique ways from individu-
pitals, this can include: al to individual, and support services should work to give parents a
caring hand in their pain and also help them to work their personal
• Listen. The number one way to support a grieving person is way through the grieving process and emerge into resolution and
to let them talk and then listen. recovery. Grief is an intense, lonely and personal experience, and
for parents, it can be further affected by whether this is their first
• Recognize. Say the baby's name. experience with death, whether they have other children or may
consider having them in the future, and how they will incorporate
• Be open and sincere. "I'm sorry." "I can't imagine what you the memory of this infant in their lives going forward. The grief
are going through." "I am here for you." may be so intense that they find themselves struggling for ways to
relate to each other as well as to their friends and relatives.
• Avoid cliché. "At least you have your other children." "God
needed another angel." "You can have another." "It's God's For health care professionals, it is the awareness that the families
will." will need immediate attention to their grief and that they them-
selves may not be immune to the effects of infant loss.
• Offer keepsakes. A lock of hair; foot and handprints; pic-
tures. All parties need to be caring for themselves.
• Explain. Share what will happen next (autopsy, funeral Information on First Candle and its bereavement support services
home, coroner's office). can be found on the First Candle website. The Grief Support Line
is 1-800-221-7437.
• Identify grief support resources. This could include the hos-
pital chaplain, First Candle's bereavement support services, References:
or local support groups. 1. Surviving the Death of a Baby: Grief Resources from First Can-
dle. https://firstcandle.org/wp-content/uploads/2018/04/Surviv-
For physicians, this can also mean offering to review the infant's
ing-the-Death-of-a-Baby.pdf
autopsy results and counseling the parents to look after them-
selves, so that they may continue to provide for each other and
the rest of the family. This does not, however, mean pushing grief Disclosure: The author is the Director of Education and
aside in order to appear strong, another area bereavement sup- Bereavement Services of First Candle, Inc., a Connecticut not for
port can help both mothers and fathers address. profit 501c3 corporation.
NT
“For physicians, this can also mean
offering to review the infant's autopsy
results and counseling the parents to Corresponding Author
look after themselves, so that they may

continue to provide for each other and
the rest of the family.”
This last point also matters for professionals. We know from ex- Barb Himes, IBCLC
perience that when the intense daily focus is on saving babies' Director of Education and Bereavement Services
lives, and one is lost, there can be a debilitating emotional impact First Candle
on providers, making it important for them to identify resources for 49 Locust Avenue, Suite 104
their own support as well as for their patients.
New Canaan CT 06840
As we discuss in our support programs, infant death can unleash Telephone: 1-203-966-1300
a range of emotions: For Grief Support: 1-800-221-7437
[email protected]
• Guilt. Self-blame, founded or unfounded. www.firstcandle.org
• Anger. Self-directed or at others.
• Fear. An overall sense of dread, which can affect daily living

and interpersonal relationships.
• Depression. Episodes of fatigue, sadness, feelings of worthlessness.

The Survey says RSV

In January, heaven
gained a new angel - Still a Preemie?
Laura Reno. Some preemies are born months early, at extremely low
birthweights.They fight for each breath and face nearly
insurmountable health obstacles.
But that’s not every preemie’s story.
Laura was a SIDS mom
and a guiding force at
Born between
First Candle.
34 and 36 weeks'
gestation?
She worked tirelessly to Just like preemies born much earlier,

these “late preterm” infants can face:
end SIDS and was a source
of comfort for many of our
Jaundice Feeding issues Respiratory
berieved families. problems
And their parents, like all parents

of preemies, are at risk for
postpartum depression and PTSD.
Laura will be greatly

missed.
Born preterm
at a “normal”
weight?
Though these babies look healthy,

they can still have complications
and require NICU care.
But because some health plans
determine coverage based on a
preemie's weight, families of
babies that weigh more may
face access barriers and
unmanageable medical bills.
Born preterm
but not admitted
Readers can also follow to the NICU?
Even if preterm babies
NEONATOLOGY TODAY don't require NICU care,
they can still face health challenges.
Those challenges can extend through
via our Twitter Feed childhood, adolescence and even
into adulthood.
@NEOTODAY
New subscribers are always welcome!

NEONATOLOGY TODAY Some Preemies
Will spend weeks
All Preemies
Face health
in the hospital risks
To sign up for free monthly subscription, Will have lifelong Deserve appropriate
just click on this box to go directly to our health problems
Are disadvantaged
health coverage
Need access to
subscription page from birth proper health care
www.infanthealth.org

Raising Global Awareness of RSV
Global awareness about respiratory syncytial virus (RSV) is lacking. RSV is a relatively unknown
virus that causes respiratory tract infections. It is currently the second leading cause of death –
after malaria – during infancy in low- and middle-income countries.
The RSV Research Group from professor Louis Bont, pediatric infectious disease specialist in the
University Medical Centre Utrecht, the Netherlands, has recently launched an RSV Mortality
Awareness Campaign during the 5th RSV Vaccines for the World Conference in Accra, Ghana.
They have produced a personal video entitled “Why we should all know about RSV” about
Simone van Wyck, a mother who lost her son due to RSV. The video is available at
www.rsvgold.com/awareness and can also be watched using the QR code on this page. Please
share the video with your colleagues, family, and friends to help raise awareness about this
global health problem.
The RSV awareness video was produced in collaboration with the Bill & Melinda Gates Foundation
Peer Reviewed
Using Volume Guarantee (VG)

to Achieve Ventilatory Efficiency
in High-Frequency Oscillation (HFO)
Rob Graham, R.R.T./N.R.C.P. 1980s demonstrated the importance of this approach during HFO.
I dedicate this column to the late Dr. Andrew (Andy)

Shennan, the founder of the perinatal program at Wom- “With HFO, there is more to efficiency
en’s College Hospital (now at Sunnybrook Health Sci-
ences Centre). To my teacher, my mentor and the man than compliance; regardless of
I owe my career as it is to, thank you. You have earned compliance, there is a point at which
your place where there are no hospitals and no NICUs,
where all the babies do is laugh and giggle and sleep. settings can be adjusted to use less
pressure (amplitude) to provide
Efficiency is the relationship between how much energy goes into sufficient minute ventilation.”
a system and how much work comes out of it. Peak efficiency
is the point at which maximum output is achieved with the least
amount of energy consumed per unit. We usually think about effi-
ciency when talking about electrical items like appliances, air con- With HFO, there is more to efficiency than compliance; regardless
ditioners, and so forth, or a vehicle's fuel economy, but the same of compliance, there is a point at which settings can be adjusted
concept applies to ventilation. to use less pressure (amplitude) to provide sufficient minute ven-
tilation. Frequency (f) plays a large part here. Due to the fixed
Optimum compliance is the point at which the lungs accept the inspiratory to expiratory (I:E) ratio, increasing frequency gives less
most volume using the lowest ventilating pressure. As functional inspiratory time to get volume in, and less expiratory time to get
residual capacity decreases or increases compliance decreases it out. This may lead to gas trapping in and of itself, but since
as the lungs are no longer at the top of the compliance curve, the only way to maintain volume when raising frequency is to use
more pressure must now be used to deliver the same volume. All higher amplitude, the risk of creating pinch points also increases.
modes of ventilation produce better results when optimum compli- Because amplitude is above and below the set mean airway pres-
ance is reached. As well, the lung is most protected when being sure (MAP), higher amplitudes create larger troughs during the
ventilated at or near optimum compliance. Clinically we refer to expiratory phase as well as higher peak pressure on inspiration.
this as the "open lung" approach. The infamous "HIFI" trial of the As end-expiratory pressure approaches critical closing pressures,
Figure 1: Oscillatory waveform above and below MAP. "PEEP" is the lowest point in the waveform (2)

Figure 2: Pinch points occur when extraluminal pressure exceeds airway pressure during exhalation in HFO (2)
airway instability and micro-atelectasis may result. If expiratory result in alterations to flow characteristics, i.e., creating turbulent
pressure is low enough, "pinch points" occur in the conducting flow, which reduces efficiency.
airways, preventing gas from exiting the lung.
Oscillators used in the U.S. to date pose a conundrum for clini-

cians since they do not provide enough information at the bed- “The workaround has been to use higher
side. Amplitude is adjusted as "power," and while the amplitude
is expressed as the pressure in cmH2O, no such measurement frequencies, but as time constants get
is available, and "chest wiggle" is the basis for amplitude adjust-
ment. When dealing with smaller babies, there is another prob-
longer, using higher frequency greatly
lem: the amplitude on these first-generation machines is too high increases the risk of gas trapping. As
at lower frequencies to be used safely. The workaround has been
to use higher frequencies, but as time constants get longer, using well, the higher amplitude necessitated
higher frequency greatly increases the risk of gas trapping. As
well, the higher amplitude necessitated with higher frequency may with higher frequency may result in
Readers can also follow alterations to flow characteristics, i.e.,
creating turbulent flow, which reduces
NEONATOLOGY TODAY efficiency."
via our Twitter Feed
@NEOTODAY The equation for CO2 clearance during HFO is expressed as
"DCO2". DCO2 = f*Vt² where Vt is HFO tidal volume. (2) In prac-
tice, this means that changes in frequency linearly alter CO2 while


changes in volume increase CO2 exponentially. This is particu- the move is not a wise one. This is true of other modes of ventila-
larly true when using frequencies above 5 Hz. (2) (This is an ex- tion as well: if adjusting PEEP in a conventional mode or high-
cellent primer by Dr. Jane Pillow courtesy of Drager). Clinically frequency jet ventilation necessitates using higher pressure to
this means decreases in frequency can be compensated for by achieve the same results, the message is the same. An increase
a small increase in Vt. In order to do that, however, it is helpful to in oxygen requirements is another indicator, but derecruitment
know what that volume is. This is where VG comes into play. may show up as higher ventilating pressure before oxygen re-
quirements change significantly. If the maximum amplitude is ad-
Third generation oscillators soon to be available in the U.S. pro- justed fairly closely to amplitude used, a clinician also is given an
vide measurements for both Vt and minute volume and provide early warning of decreasing compliance when the machine gives
the option to set a target volume in HFO mode. Chest wiggle is no an alarm that it cannot deliver set volume.
longer the indicator of how much ventilation a machine is provid-
ing since these machines not only tell us; they allow us to adjust While HFO/VG represents a brand-new concept in HFO, it is im-
the volume. In reality, what is altered to achieve a set target vol- portant to note that this mode has been used outside the U.S.
ume is amplitude. safely and with success, and the adjunct is now available from
several manufacturers, including Drager, Lowenstein Medical,
Where does efficiency come into play? When decreasing frequen- and Maquet. As with any new modality, buy-in from clinicians has
cy, we can now compensate for lost volume by simply increasing been mixed. In Canada, there seems to be a great divide; those
the target volume; adjustments are made in increments as small west of Ontario appear not to use the adjunct frequently, if at all.
as 0.1 ml. Typical Vt during HFO is usually 1-2 ml/kg, and while Units in Toronto have embraced HFO/VG, and it is used exten-
higher volumes may be used, it stands to reason that using higher sively here, especially in the unit where I practice.
volumes during HFO may decrease the lung protectiveness of the
mode. It is my practice not to exceed 3 ml/kg when using HFO Finally, allow me to wish everyone a good summer. Stay healthy
with VG unless the amplitude necessary to deliver the volume is and stay safe during these trying times. As our mothers have told
relatively low, or the larger volume is not required for a prolonged us, "this too shall pass."
length of time.
.References:
In clinical practice, decreasing frequency while increasing VG
may result in lower amplitude being used, sometimes as low as 5 1 Figures 1 and 2 courtesy of Bunnell Inc.
cmH2O. This demonstrates increased efficiency and reduces the 2 https://www.draeger.com/Library/Content/hfov-bk-9102693-
risk of gas trapping in two ways: lower amplitude decreases the en.pdf
risk of creating pinch points, and lower frequency gives more time 3 https://link.springer.com/article/10.1007/BF02072632
for gas to escape. This, arguably, is a good thing. It is worth not- 4 https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1399-6576.1989.
ing that while increasing frequency using VG increases CO2 elimi- tb03006.x
nation linearly, this is only true if the increased frequency does
not result in gas trapping and that the machine is able to provide Disclosures: The author receives compensation from Bunnell Inc
enough amplitude to do so. Otherwise, CO2 clearance may actu- for teaching and training users of the LifePulse HFJV in Canada.
ally be impaired. He is not involved in sales or marketing of the device nor does
he receive more than per diem compensation. Also, while the au-
Resonance frequency also plays a role in CO2 clearance. Ventilat- thor practices within Sunnybrook H.S.C. this paper should not be
ing with frequencies near pulmonary resonant frequency increas- construed as Sunnybrook policy per se. This article contains ele-
es ventilatory efficiency. Resonance frequency decreases with in- ments considered “off label” as well as maneuvers, which may
creasing compliance (3) and varies depending on pathology and sometimes be very effective but come with inherent risks. As with
size. Rates used during high-frequency jet ventilation are closer to any therapy, the risk-benefit ratio must be carefully considered
resonant frequency (4) than those typically used during HFO and before they are initiated.
are generally less than 10 Hz. Increasing frequency during HFO
NT
“It is worth noting that while increasing

frequency using VG increases CO2
elimination linearly, this is only true if the
increased frequency does not result in
gas trapping and that the machine is able
to provide enough amplitude to do so.
Otherwise, CO2 clearance may actually be Rob Graham, R.R.T./N.R.C.P.
Advanced Practice Neonatal RRT
impaired." Sunnybrook Health Science Centre
43 Wellesley St. East
Toronto, ON
may reduce any benefit derived from the resonant frequency. Canada M4Y 1H1
Email: Rob Graham <[email protected]>
Another benefit of the greater monitoring capability of these ma-
Telephone: 416-967-8500
chines is the ability to monitor compliance in real-time. If an ad-
justment in MAP results in the machine using more amplitude to
maintain volume, this reflects decreased compliance and tells us

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Thirteen-year-old Emily Rose Shane was tragically murdered on April 3, 2010 on
Pacific Coast Highway in Malibu, CA. Our foundation exists to honor her memory.
Each year, the Emily Shane Foundation SEA(Successful Educational Achievement)

Program provides academic and mentoring support to over 100 disadvantaged middle
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To: Goldstein, Mitchell
Subject:
Peer Reviewed
[EXTERNAL] Reminder: BLACK LIVES MATTER
CAUTION: This message originated from outside the LLUH email system. Do not open attachments or follow links unles
you have verified the legitimacy of the sender and its content. If you receive a suspicious email, you may forward it to
NPA Position Statement: Black Lives Matter
[email protected] and then delete the suspicious email.
Jerasimos Ballas, MD, MPH, Viveka

Prakash-Zawisza, MD, MS, MBA
The National Perinatal Association

(NPA) is an interdisciplinary organiza-
tion that strives to be a leading voice for
perinatal care in the United States. Our
diverse membership is comprised of
healthcare providers, parents & caregiv-
ers, educators, and service providers,
all driven by their desire to give voice to
and support babies and families at risk

across the country.
Members of the NPA write a regular To all NPA members,

peer-reviewed column in Neonatology
This is the time to stand together with our Black community and reaffirm our
Today.
commitment to improving the lives of pregnant patients, their newborns, and
their families.
This starts with confronting the systemic racism that pervades our social,
political. and medical establishments, as well as the implicit biases we all carry
within ourselves.
Our statement aims to not only bring attention to this issue, but to also to shine
a light on actions we all can start taking right now to effect positive change.
Be well. Stay safe.

As a national organization dedicated to

the advocacy and support of vulnerable
babies, parents, and families, the National
Perinatal Association stands in solidarity
with the Black Lives Matter movement.

The foundational principles of the move- Jerasimos (Jerry) Ballas, MD, MPH
ment help to inform NPA’s mission and Maternal-Fetal Medicine
remind us that the work is not done. We President, National Perinatal Association
pledge to better embody those principles
in our own organizational structure and op-
erations and have laid out our action plan 1
in a statement reprinted here, originally re-
leased on June 4, 2020.
Viveka Prakash-Zawisza, MD, MS, MBA

President-Elect
Disclosure: The National Perinatal Associa-
tion www.nationalperinatal.org is a 501c3 or- Newly-Validated Online
ganization that provides education and ad- NICU Staff Education Caring for Babies and their Families:
vocacy around issues affecting the health of
mothers, babies, and families. Providing Psychosocial Support to NICU Parents
NT Support for NICU Parents.”
Readers can also follow Contact [email protected] for more information.
NEONATOLOGY TODAY Brought to you by a collaboration between
via our Twitter Feed Patient + Family Care
@NEOTODAY Transform Your NICU
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NPA Position Statement 2020
Black Lives Matter
To the families of George Floyd, Breonna Taylor, and Ahmaud Arbery, the National Perinatal
Association speaks their names and grieves with you. To all Black people who suffer under an
unjust system devised to perpetuate oppression, we see you.
We hear you. We stand with you.
We are long past the time for simply bearing witness to such injustice.
As an organization devoted to caring for pregnant people, their newborns and their families,
NPA is acutely aware of the gross inequities and disparities that pervade our society.
Black women die in pregnancy at three times the rate of their white counterparts, even when
controlling for education and income.1 They are 50% more likely to deliver prematurely.2
Their babies are twice as likely to die compared to their peers’.3
Despite every attempt to explain away these disparities through statistical modeling or medical
deduction, they stubbornly persist. It is abundantly clear that when researchers cite “race” as a
risk factor for poor health outcomes, what they are actually measuring is the insidious effects
of racism. One needs to look no further than the current pandemic to see how racial inequities
along social, medical, and economic fault lines have led to Black communities being
disproportionally ravaged by Covid-19.4
This evidence alone should be a call to action for healthcare providers throughout the United
States to address the rampant systemic racism in our communities and within our medical
practices. As an organization, NPA commits to doing better, to listening more actively, to
facing ourselves, and to being anti-racist.
We all must act now to:
 Be actively anti-racist. If we are going to end racism as a society, we first have to

confront it in ourselves. Identify implicit biases in ourselves, our colleagues, and our
practice and take the necessary and uncomfortable steps to address it.
www.nationalperinatal.org
 Speak truth to power that Black lives matter. Do not accept that healthcare
professionals should “stay in their lanes” when it comes to social advocacy. In fact, our
understanding of the social determinants of health positions us to be leaders in many of
these fights.
 Recognize and address racism – not race - as a risk factor for poor health outcomes.
This deceivingly simple change in language is a powerful tool that can radically advance
the way we approach the health of our Black communities.
 Educate ourselves on how to be true allies. Read. Research. Seek out resources created
by Black voices such as Ibram X. Kendi, Rachel Cargle, and Ijeoma Oluo. Don’t ask Black
folks in our lives to carry the labor of educating us; take on the labor ourselves.
 Listen to Black voices without defending or centering ourselves. Create safe, inclusive
medical practices. Fight against unjust legislation and racist policies.
None of these actions will be easy. It’s easier to deny the realities of racism if we haven’t been
directly impacted. Listen, pay attention, and believe the Black experience. Sit with discomfort
and use it to catalyze change. Take actions today to start saving Black lives.
In solidarity,
The National Perinatal Association
References:
1. Petersen EE, Davis NL, Goodman D, et al. Racial/Ethnic Disparities in Pregnancy-Related Deaths
— United States, 2007–2016. MMWR Morb Mortal Wkly Rep 2019;68:762–765. DOI:
https://www.cdc.gov/mmwr/volumes/68/wr/mm6835a3.htm?s_cid=mm6835a3_w
2. March of Dimes. Peristats.
https://www.marchofdimes.org/peristats/ViewData.aspx?reg=99&slev=4
3. Ely DM, Driscoll AK. Infant Mortality in the United States, 2017: Data from the Period Linked
Birth/Infant Death File. National Vital Statistics Report 2019.
4. Yancy CW. COVID-19 and African Americans. JAMA. 2020;323(19):1891–1892.
doi:10.1001/jama.2020.6548
www.nationalperinatal.org
Postpartum Revolution@ANGELINASPICER
Viveka Zawisza, MD FACOG

National Perinatal Association Board Member
[email protected]
Jerasimos (Jerry) Ballas, MD, MPH, FACOG

Assistant Professor of Obstetrics, Gynecology, and Reproduc-
tive Sciences
University of California, San Diego
President, National Perinatal Association
[email protected]

SHARED DECISION-MAKING
PROTECTS MOTHERS + INFANTS
DURING COVID-19
KEEPING MOTHERS +
INFANTS TOGETHER
Means balancing HORIZONTAL INFECTION
the risks of... SEPARATION AND TRAUMA
EVIDENCE
We encourage families and clinicians to
remain diligent in learning up-to-date evidence.
S EEK PARTICIPATION
PARTNERSHIP SHARED
H ELP EXPLORE OPTIONS
DECISION-MAKING
What is the best A SSESS PREFERENCES
R EACH A DECISION
for this unique dyad? E VALUATE THE DECISION
TRAUMA-INFORMED FEAR
Both parents and providers GRIEF
are confronting significant... UNCERTAINTY
LONGITUDINAL DATA
We need to understand more about outcomes for mothers
and infants exposed to COVID-19, with special attention to: ..
MENTAL HEALTH POSTPARTUM CARE DELIVERY
NEW DATA EMERGE DAILY. NANN AND NPA ENCOURAGE PERINATAL CARE PROVIDERS TO ENGAGE IN CANDID CONVERSATIONS
WITH PREGNANT PARENTS PRIOR TO DELIVERY REGARDING RISKS, BENEFITS, LIMITATIONS, AND REALISTIC EXPECTATIONS.
Partnering for patient-centered care

when it matters most.
nann.org nationalperinatal.org
NICU Awareness
Did You Know?

Most NICU babies have special needs that last longer than their NICU stay. Many will have
special health and developmental needs that last a lifetime. But support is available.
Learn about the programs in your community. Seek out other families like yours. Then ask for
help. Working together we can create a community where our children will grow and thrive.
Special Health Needs Special Developmental Needs Special Educational Needs

Babies who have had a NICU Any NICU stay can interrupt a baby's Every child has their own unique
stay are more likely to need growth and development. developmental needs and every
specialized care after they go student has their own unique and
home. Timely follow-up Needing specialized medical care often special educational needs.
care is important. means that they are separated from their
parents and from normal nurturing. Take advantage of the services and
NICU babies have a higher support that can meet your child
risk for re-hospitalization. So While most NICU graduates will meet all where that are and help them reach
every medical appointment is their milestones in the expected their future educational goals.
important. Especially during developmental progression, It is typical
cold and flu season when for them to be delayed. This is especially Call your local school district to
these babies are especially true for preterm infants who are still request a free educational
vulnerable to respiratory "catching up" and should be understood evaluation. Learn about all the
infections. to be developing at their "adjusted age." available programs and support.
Who Can Help Who Can Help Who Can Help

pediatricians IBCLCs and lactation consultants Preschool Program for Children
neonatal therapists Early Childhood Interventionists with Disabilities (PPCD)
pulmonologists developmental pediatricians Special Education programs
neurologists occupational therapists (OTs) under the Individuals with
gastroenterologists physical therapists (PTs) Disabilities Education Act
cardiologists speech therapists (SLPs) (IDEA)
nutritionists WIC - Special Supplemental Nutrition educational psychologists
CSHCN - Programs for Program for Women, Infants, and speech therapists (SLPs)
Children with Special Children occupational therapists (OTs)
Health Care Needs social workers and case managers reading specialists
Find more resources at nationalperinatal.org/NICU_Awareness

My NICU Network
Online NICU Staff
National Perinatal
Association
Patient+Family
Care
NICU Parent
Network
Education Program
Caring for Babies and their Families:

Providing Psychosocial Support in the NICU
www.mynicunetwork.com
Looking to improve
NICU staff skills in
communicating with
and supporting parents?
This educational
program works!
Read the study by Hall
et all in Advances in
Neonatal Care,
published online in
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FOUNUA �lU


The Gap Baby:
An RSV Story

community health, and family support


from PTSD/ PPD

FDA label

for pregnant and breastfeeding mothers
Safe, accurate medical devices and


Peer Reviewed
COVID-19 Update: The Future of Vaccine Treatments

for Infants and Children
Darby O’Donnell, JD and the AfPA Governmental Affairs Team
Alliance for Patient Access (AfPA)
“So, what is appropriate in this new
The Alliance for Patient Access (allianceforpatientaccess.org), environment with regard to wellness visits,
founded in 2006, is a national network of physicians dedicated existing vaccines, and other preventive
to ensuring patient access to approved therapies and appropri-
ate clinical care. AfPA accomplishes this mission by recruiting, treatments, in the form of neonatal and
training and mobilizing policy-minded physicians to be effective
advocates for patient access. AfPA is organized as a non-profit
childhood immunization, administered
501(c)(4) corporation and headed by an independent board of di- based on well-established schedules for
rectors. Its physician leadership is supported by policy advocacy
management and public affairs consultants. In 2012, AfPA es- babies and children?”
tablished the Institute for Patient Access (IfPA), a related 501(c)
(3) non-profit corporation. In keeping with its mission to promote
a better understanding of the benefits of the physician-patient So, what is appropriate in this new environment with regard
relationship in the provision of quality healthcare, IfPA sponsors to wellness visits, existing vaccines, and other preventive
policy research and educational programming. treatments, in the form of neonatal and childhood immunization,
administered based on well-established schedules for babies and
children? Should families delay childhood immunizations for the
sake of safety during the COVID-19 pandemic, perhaps until there
is a vaccine for that illness? Finally, what happens to those best
practices associated with immunization for the last few decades -
particularly as young families contemplate the return to brick and
mortar schools, if viable, in the fall?
Societal Value Placed on Childhood Immunizations
Adult patients are deferring or delaying care because they

lack access to open facilities, the financial strain of the cost of
treatment, or for fear of being infected with COVID-19 through
interactions with the public. For children, like adults, this delay of
care encompasses preventive care - namely immunization.
Since the rise of COVID-19 infections in the United States this
past March, parents/guardians of children have faced a difficult As pediatricians and neonatologists are aware, government
number of questions regarding isolation versus socialization. For entities and health professionals have collaborated (1) to
example: Is it safe to … leave the house? Go to school? Play with establish birth through age 18 immunization schedule, (2) which
other children? Visit elderly relatives? the Centers for Disease Control and Prevention (CDC) publishes.
The CDC estimates that for every $1 invested in vaccines in the
In recent months, government entities and healthcare professional U.S., $10.20 is saved in direct medical costs, according to the
organizations have provided guidance for American families on American Academy of Family Physicians (AAFP). (3)
mitigation of the virus, wellness, and safety. Even more, are being
issued as the country returns to familiar social activities in the age Vaccines have been hotly debated by medical professionals,
of "social distancing." scientists, and American families for their usefulness and the
possible consequences of administration. Without revisiting
During the stay at home orders, families have missed out on that debate, existing science and treatment outcomes support
many scheduled events - including regular, well-care visits to
the pediatrician focused on preventive treatments, such as
vaccinations. In the midst of re-opening pediatric centers of care, Readers can also follow
children's hospitals, and other outpatient units, a heightened
sensitivity has emerged for public safety and social distancing, NEONATOLOGY TODAY
in all public spaces. To coincide with these measures, however,
doctors, health care professionals, and families are also beginning via our Twitter Feed
to focus on the issues of delayed care and missed health care
appointments, and the implications it could have on patients and @NEOTODAY
the public health in the future.

that vaccines have eradicated serious illnesses (4) through early
intervention in American children - the most commonly known of
these vaccinations being the polio vaccine.
Still a Preemie?
Some preemies are born months early, at extremely low
For a more recent example, there was the measles outbreak in
birthweights.They fight for each breath and face nearly
2019. Measles is a highly contagious and serious disease that insurmountable health obstacles.
can be deadly. Prior to the recent outbreak, measles cases were
But that’s not every preemie’s story.
relatively low. According to the Centers for Disease Control and
Prevention (CDC), the majority of cases in the 2019 outbreak
were among people who did not get a measles vaccination. (5)
Born between
34 and 36 weeks'
Vaccines prevent disease. Some consider them better than gestation?
a cure, and many researchers are in agreement that they are
cost-effective. The World Health Organization estimates that Just like preemies born much earlier,
immunization currently prevents 2-3 million deaths every year, these “late preterm” infants can face:
(6) and suggests that 1.5 million more deaths could be avoided if
global vaccination coverage increases.
Jaundice Feeding issues Respiratory
problems
And their parents, like all parents

of preemies, are at risk for
“Vaccines prevent disease. Some

postpartum depression and PTSD.
consider them better than a cure, and

many researchers are in agreement Born preterm
at a “normal”
that they are cost-effective. The World weight?
Health Organization estimates that Though these babies look healthy,

they can still have complications
immunization currently prevents 2-3 and require NICU care.
million deaths every year, (6) and But because some health plans
determine coverage based on a
suggests that 1.5 million more deaths

preemie's weight, families of
babies that weigh more may
face access barriers and
could be avoided if global vaccination unmanageable medical bills.
coverage increases.”
Born preterm
but not admitted
Recent AAP Guidance to the NICU?
Even if preterm babies
The American Academy of Pediatrics (AAP) put out "Guidance on don't require NICU care,
Providing Pediatric Well-Care During COVID-19" (7) last month, they can still face health challenges.
recognizing the challenge when immunizations are missed. Those challenges can extend through
The Academy acknowledges that "concern exists that delays childhood, adolescence and even
into adulthood.
in vaccinations [since the onset of COVID-19], may result in
secondary outbreaks with vaccine-preventable illnesses."
The advent of telehealth and the recent surge in telemedicine use
Some Preemies All Preemies

Will spend weeks Face health
in the hospital risks
Will have lifelong Deserve appropriate

health problems health coverage
Are disadvantaged Need access to

from birth proper health care

- and modified health insurance coverage plans for it - has been vaccines still hold value - they have been proven to keep
a great improvement in allowing patients of all ages to continue Americans safe and healthy. Hopefully, this delay in pediatric care
their healthcare routine during the coronavirus outbreak. Yet, will not be so great to overcome. Nevertheless, for the time being,
the current technology is not capable of administering childhood it may prove to be yet another, unforeseen, trickle-down effect of
immunizations directly. That still requires a physical location, the COVID-19 pandemic.
(8) such as a parking lot staffed by health care professionals,
as the stand-in for an in-person visit. However, technology References:
may be imperative to documenting "state-based immunization 1. https://www.aafp.org/patient-care/public-health/immuniza-
information" to support pediatricians as they get their patients tions.html
back on schedule, so to speak, according to the AAP. 2. https://www.aafp.org/patient-care/public-health/immuniza-
tions.html
The report goes on to provide suggestions to ensure safety 3. https://www.aafp.org/patient-care/public-health/immuniza-
for those in-person visits. AAP suggests measures such as tions/schedules/child-schedule.html
scheduling well visits for children in one area of the facility of 4. https://www.aafp.org/patient-care/public-health/immuniza-
the clinic, or scheduling certain days of the week for alternating tions.html
well patient visits with sick patients visits. Practically speaking, 5. https://www.cdc.gov/vaccines/parents/diseases/forgot-
however, with family-centered care facilities and smaller, private 14-diseases.html
clinics currently facing furloughs, layoffs, and other impacts on 6. https://familydoctor.org/childhood-vaccines-what-they-are-
staff, this separation solution may prove difficult to execute. The and-why-your-child-needs-them/
AAP also suggests "collaborating with providers in the community 7. https://www.who.int/news-room/facts-in-pictures/detail/immu-
to identify separate locations for providing well visits for children." nization
8. https://services.aap.org/en/pages/2019-novel-coronavirus-
Back to School & Daycare covid-19-infections/clinical-guidance/guidance-on-providing-
pediatric-well-care-during-covid-19/
Another pressing concern for the families of school-aged children: 9. h t t p s : / / w w w . a a f p . o r g / n e w s / h e a l t h - o f - t h e -
exposure to another child who has not been vaccinated or missed public/20200323covidtelehealth.html
vaccinations during COVID-19. Parents may feel pressured 10. https://www.cdc.gov/vaccines/acip/recommendations.html
to move quickly over the summer to catch up on the required 11. https://www.ncsl.org/research/health/immunizations-policy-
vaccination schedule before the typical, August-September start issues-overview.aspx
of the school calendar. 12. https://www.cdc.gov/media/releases/2014/p0424-immuniza-
tion-program.html
State-based immunization laws inform school and daycare 13. https://www.cdc.gov/media/releases/2014/images/p0424-im-
requirements and reflect guidance from The Advisory Committee munization-program.pdf
on Immunization Practices (ACIP) (9) and their written 14. https://www.ncsl.org/research/health/immunizations-policy-
recommendations on vaccine schedules, according to the National issues-overview.aspx
Conference of State Legislators. (10) These state laws are subject
to exemptions, such as an intervening medical reason to skip the
immunization, however. The author has not indicated any disclosures.
NT
Of greater societal concern, families who are jobless due to the
health pandemic or cannot afford wellness care visits for the family
may struggle with access to get their child vaccinated. Fortunately,
a roadmap exists to help those families. In 1994, the Vaccines for
Children program (VFC) (11) was "launched in direct response to Corresponding Author
a measles resurgence in the U.S. that caused tens of thousands
of cases and over a hundred deaths, despite the availability of a
measles vaccine since 1963." (12) The VFC program provides
vaccines to children at no cost to families that might not otherwise
get their child vaccinated based on affordability. There are also
state programs that supplement the federal VFC fund. For more
information on the VFC program statistics, see https://www.cdc.
gov/media/releases/2014/images/p0424-immunization-program.
pdf 913) Darby O'Donnell, JD
Alliance for Patient Access (AfPA) Government Affairs Team
Conclusion 1275 Pennsylvania Ave. NW, Suite 1100A Washington, DC
20004-2417
The CDC estimates that vaccinations will prevent more than 21 202-499-4114
million hospitalizations and 732,000 deaths among children born [email protected]
in the last 20 years. (14)
The COVID-19 pandemic has impacted the number of children
getting vaccinated, but the recommended infant and childhood

Peer Reviewed
Preemie Parent Perspective: Addressing Health Equity

and Cultural Competency in the NICU
Jenné Johns, MPH
Jenné Johns, MPH is the mother of a micropreemie, author,
In 2016, I published Once Upon A speaker, advocate, and national senior health equity leader. As an
Preemie, a first- of its kind children’s
advocate for reducing healthcare disparities, Jenné found herself
book written to comfort parents of
premature infants during their jour- advocating for the needs of her son, as his survival depended on
ney through the Neonatal Intensive it. She also learned the power of reading to her son daily. Jenné
Care Unit (NICU). During my journey, wrote, “Once Upon a Preemie,” which is the first of its kind chil-
I discovered that reading to my mi- dren’s book written for the parents of preemies while they are in
cropreemie was the one activity as a the NICU. This bedside companion seeks to motivate, encourage,
mother that I could offer my son that and inspire preemie babies and families until they go home.
helped normalize my overwhelming
and traumatic NICU experience. Dur- Her preemie parent contributions include consulting and blog-
ing our nearly three-month stay in the ging for fortune 500 companies on preemie parent needs from
NICU, I read to my son every day as research studies suggest a cultural lens and reading as a tool for growth, development,
that reading stimulates healthy brain development in preemies, and bonding. She serves on numerous advisory committees ad-
and also helps to form a bond between parent and baby. Many of vocating for preemie babies and eliminating health disparities,
the bedtime stories that we read ended with a parent tucking the including NICU Parent Network, The National Coalition on Infant
child into bed at home with Mommy and Daddy. That wasn’t our Health, and March of Dimes Prematurity Prevention Collabora-
reality for three months. There were no books about us. tive.” She has presented at numerous conferences as a preemie
parent, including Congressional Black Caucus Annual Legisla-
Little did I know that in publishing my deepest emotions carried
during and post NICU would lead me to become an author and tive Conference, National Neonatal Nurses Association Confer-
speaker, but also an advocate and advisor for the needs of pree- ence, National Perinatal Social Workers Congressional Briefing,
mie parents, especially African Americans. As the mother of a Preemie Parent Alliance, and National Perinatal Association
micropreemie and miracle baby born at 26 weeks and weighing Annual Conference. Jenné was featured in the Baby First Blog,
1 lb 15.3 ounces, I found myself advocating for his needs as I Preemie World, Heart and Soul Magazine, iHeart Radio, CBS
knew his life depended on it. Despite my 10-year career working Philly News Radio, Disruptive Women in Healthcare Blog, and
to eliminate racial and ethnic disparities in health care, nothing Women of a New Sisterhood.
prepared me for the heart-wrenching experience of my son’s pre-
mature birth. “Disparity” became real for me as my son joined the In her professional capacity, Jenné is a National Senior Health
ranks of the nearly 500,000 premature babies born in the United Equity Thought Leader. Most recently, Jenné served as Director
States, nearly half to African American and Hispanic mothers. It of Quality Improvement and Health Equity at Blue Cross and Blue
was through this dual role that I experienced the NICU, one as a Shield, Illinois, where she was responsible for leading strategies to
vulnerable micropreemie mother, and the other as a health equity improve health outcomes, reduce cost, and reduce racial and eth-
professional. nic healthcare disparities with a focus on maternal and child health
innovations. She also co-chaired the enterprise-wide Equity Steer-
ing Committee. Prior to Blue Cross and Blue Shield Illinois, Jenné
“My advocacy skills were tested daily, served as Director of Health Disparities at AmeriHealth Caritas.
She led innovations to reduce healthcare inequities for 5 million
as his life depended on how well I could lives in 19 states in the areas of maternal and child health, pe-
speak “neonatology” language, I had to diatric asthma, diabetes, and cardiovascular disease. Jenné has
over a decade of experience advocating for policy, business, and
be his voice and articulate his needs. community changes to improve health outcomes for low-income
communities through her work with Policy Link, Summit Health In-
This was challenging because, after all, stitute for Research and Education, Robert Wood Johnson Foun-
“I’m just a Mom,” an African American dation, and the National Nursing Centers Consortium.
Mom, and not a doctor.” Jenné is a graduate of the Disparities Leadership Program led
Harvard Medical School. Her advisory appointments included:
Pennsylvania Office of Health Equity (Advisor); Mid-Atlantic Re-
gional Health Equity Council (Co-Chair); Regional Cancer Dis-
At birth, my son required life-saving medical interventions; oxy- parities Initiative at Thomas Jefferson Hospital (Co-Chair); Board
gen, phototherapy lights, feeding tubes, a heart monitor, medi- Member, Pebbles of Hope. Her awards include Certificate of Rec-
cation, vitamins, and even caffeine. Over our nearly three-month
ognition from the Honorable Congresswoman Robin Kelly (D-IL),
stay in the NICU, I traveled through snowstorms and blizzards, to
Chair Congressional Black Caucus Health Braintrust; 40 Under
parent and nurture my baby. I only missed three days (two due
to inclement weather and one self-care day). A typical day in the Forty 2018 Achievement Award (The Network Journal); Top 100
NICU lasted from 7 am until midnight, with many breaks to pump Diverse Leaders Under 50 (Diversity MBA Magazine); Certificate
breastmilk. My lactation consultant promised that my breastmilk of Recognition for the President’s Commission on White House
was liquid medicine. Midway through our NICU journey, I had to Fellowships Program (Regional Finalist); Certificate of Commen-
return to work, unlike many of my new NICU parent friends who dation-HHS Office of Minority Health, and Philadelphia Leader
were Caucasian. My advocacy skills were tested daily, as his life on the Move-Philadelphia Business Journal.

depended on how well I could speak “neonatology” language, I gies ensures layers of accountability, allocation of funding,
had to be his voice and articulate his needs. This was challenging measurement, and documentation of outcomes. One ex-
because, after all, “I’m just a Mom,” an African American Mom, ample of an important health equity priority includes staff di-
and not a doctor. versity. Peer-reviewed studies have shown that cultural con-
gruence among patients and providers yields better health
outcomes, better communication, and trust.
“I now believe, that with trauma-informed 2. Make health equity, cultural competency, and implicit bias
and implicit bias training among hospital training mandatory for all NICU Staff. Participating in an an-
nual training program is a great start to begin addressing
staff, the professional staff would have and delivering equitable care to all NICU families. However,
been better equipped to communicate one-time training is not sufficient. Integrating health equity
and implicit bias content into clinical rounds, staff develop-
and support my delicate and fragile ment, and training opportunities are critical to reducing racial
and ethnic disparities in the NICU.
nature.”
3. Communicating in lay terms should be standard in every
NICU. Literacy and health literacy levels are important con-
As a mother, my NICU journey was traumatic and filled with a siderations for family-centered and culturally appropriate
sea of emotions, including fear, anxiety, helplessness, and isola- care in the NICU. Regardless of one’s educational level, the
tion. Much of which NICU parents are facing due to the current NICU terminology is overwhelming and confusing for a new
COVID-19 pandemic. Many of my fears, concerns, and feelings of parent entering the NICU. Literacy and health literacy con-
isolation were due to the NICU environment, which was not as cul- siderations are also important factors for families who are
turally friendly and supportive, as I assumed it would be. I’m being limited or non-English speaking. Break the communication
generous by saying there was little cultural diversity; it was dismal barriers by speaking the same language and utilizing inter-
at best. There were times when the lack of cultural sensitivity and preters even if everyone speaks English. I had a great deal
bedside manner caused more pain than my son’s actual health of respect and appreciation for the NICU staff who used lay
status, and it made me very uncomfortable because as the end of terms and avoided NICU jargon when communicating with
each night, I had to trust my most prized possession with nurses me. In time, I began understanding the NICU language;
and doctors who I did not always trust. Another challenge I faced however, that wasn’t my job as a preemie parent. Preemie
as an African American preemie parent, was that although our parents should be made to feel as comfortable speaking and
larger hospital system had active and robust NICU parent support interacting with NICU staff regardless of their literacy and
groups, these resources were not made available at the smaller health literacy levels.
hospital where I delivered my son. This hospital served more Afri-
can American and lower-income families than the other hospitals. 4. Partner with parents to address the cultural competency,
Many of the parents I developed a relationship with, felt as if our spiritual diversity, and unconscious biases that exist in the
socio and emotional needs did not matter and were oftentimes NICU. Listen to the voices of parents with multicultural back-
dismissed because of this missing resource. Lastly, I experienced grounds to be more sensitive to racial, ethnic, language,
inconsistent positive communication and relationships with many income, education, transportation, and spiritual needs. En-
of the NICU staff. Although I now believe that all of the members courage preemie parents to speak up. Staff should value
of my son’s care team, held his safety and the quality of care they their input. Allow parents to give their insights on their baby’s
delivered to him with the utmost regard, our daily communication health status, and any gut feelings they may have about a
and interaction lacked humility, respect, and sensitivity. I will ad- diagnosis or new development. This is extremely important
mit, I was not always the easiest or most cheerful mother to deal for minority parents who assume their voice and parental
with, I now believe, that with trauma-informed and implicit bias role is undervalued.
training among hospital staff, the professional staff would have
been better equipped to communicate and support my delicate 5. Engage and establish culturally congruent NICU family sup-
and fragile nature. ports. Many minority parents may not immediately express a
need for mental or emotional help while in the NICU for fear
Overall, a good deal of our NICU experience was positive; some of being labeled. Where and when possible, make cultur-
experiences left permanent and negative memories that, to this ally congruent resources available to support these parents,
day, cannot be erased. As much as I tried checking my profes- even if the supports are outside of the NICU.
sional credentials at the door before entering the NICU, my inter-
actions with the NICU staff begged, yelled, and warranted us to 6. Make digital technology and virtual solutions available to
have those tough cultural sensitivity conversations. Not in a nega- parents with transportation, competing work schedules, or
tive way, but as an opportunity for forming better communication, other barriers to delivering care to their preemies. This is
respect, and, most importantly, trust. most critical during the current COVID season, where pa-
rental fears and social distancing may prohibit them from
In my professional view, the NICU is a microcosm of the larger
hospital system on steroids, particularly NICU’s serving low in- Readers can also follow
come and racially, ethnically, and linguistically diverse popula-
tions. Health disparities impacting the NICU are also a reflection
of a larger hospital ecosystem. Below are my preemie parent and NEONATOLOGY TODAY
professional recommendations for integrating health equity and
cultural competency in the NICU: via our Twitter Feed
1. Prioritize health equity and cultural competency as strategic
priorities and goals. Establishing opportunities for integrating
@NEOTODAY
and addressing health equity in short and long terms strate-

visiting their baby. Creating safe opportunities for parents to
connect with their babies is vital bonding via smart devices
or other safe technology solutions. Why PREMATURE INFANTS Need Access
to an EXCLUSIVE HUMAN MILK DIET
“This November, as we go purple in
recognition of Prematurity Awareness
Month, we hope that you will join us as
we launch the Once Upon A Preemie
Academy, a virtual health equity and In the United States, more than
1 IN 10 BABIES ARE
cultural competency training program for BORN PREMATURE.
Micro preemies are born
preemie professionals and parents.” severely premature, weighing
less than 1,250 grams.
This November, as we go purple in recognition of Prematurity

Awareness Month, we hope that you will join us as we launch the MICRO PREEMIES are NEC occurrence
Once Upon A Preemie Academy, a virtual health equity and cul- at risk for Necrotizing increases when a
tural competency training program for preemie professionals and Entercolitis (NEC), which: preemie consumes
parents. For more information about the Once Upon A Preemie Damages intestinal tissue non-human milk
products.
Causes distended abdomen, infection,
Academy and for additional health equity and cultural competency low blood pressure and shock When that happens:
resources, please join our listserv and visit these online resources: Threatens infants' lives
17%
1. Once Upon A Preemie Academy Listserv: www.onceupona-
preemie.com 5%
12%
1%
2. BabyFirst Blog Post: Culture Matters in the NICU https:// on Exclusive Human
Milk Diet2
on Non-Human
Milk Products
www.babyfirst.com/en/blog-posts-jenne-johns/culture-mat- Micro preemies

ters-in-the-nicu/ who get NEC
Micro preemies requiring

surgery to treat NEC
3. BabyFirst Blog Post: The Importance of Reading to your
Preemie. https://www.babyfirst.com/en/blog-posts-jenne-
johns/the-importance-of-reading-to-your-preemie/ of micro preemies
30% needing surgery
will die from NEC3
Disclosure: The author has no disclosures.
NT
HOW TO HELP PREVENT NEC:
EXCLUSIVE HUMAN MILK DIET
What is an Exclusive Human Milk Diet?
NO cow’s milk NO sheep’s milk NO goat’s milk NO formula

mother’s milk
human donor milk
human milk-based
Why Is An Exclusive Human fortifier
Milk Diet Important?
An Exclusive Human Milk Diet gives vulnerable infants the best chance
to be healthy and reduces the risk of NEC and other complications.
Jenné Johns, MPH

Mother of a micropreemie, author, speaker, advocate, and When a micro preemie can access an
national senior health equity leader EXCLUSIVE HUMAN MILK DIET:
email [email protected]
Mortality is Feeding Chances of
reduced by intolerance NEC are reduced
75%2 decreases4 by 77%2
HUMAN MILK = MEDICINE

LEARN MORE
1
Hair AB, et al. “Beyond Necrotizing Enterocolitis Prevention: Improving Outcomes with an Exclusive Human
Milk–Based Diet “. Breastfeeding Medicine DOI: 10.1089/bfm.2015.0134
2
Abrams SA, et al. “Greater Mortality and Morbidity in Extremely Preterm Infants Fed a Diet Containing Cow Milk
Protein Products.” Breastfeeding Medicine July/August 2014, 9(6): 281-285
3
Hull MA et al. “Mortality and management of surgical necrotizing enterocolitis in very low birth weight
neonates: a prospective cohort study.” J Am Coll Surg. 2014 Jun;218(6):1148-55.
4
Assad M, Elliott MJ and Abraham JH. "Decreased cost and improved feeding tolerance in VLBW infants
fed an exclusive human milk diet" Journal of Perinatology advance online publication 12 November 2015;
DOI: 10.1038/jp.2015.168

Peer Reviewed
None Are Protected If All Are Not Protected
Julia Koehler, MD at stark risk of infection: work, transportation, and home. Work-
places of frontline low-income workers have been unsafe since
The apparent on-camera murder by slow asphyxiation of George the beginning of the epidemic. As some examples, grocery store
Floyd, arrested for an alleged $20 forgery, drives ongoing pro- cashiers long lacked sneeze guards and masks; hospital janitors,
tests throughout Massachusetts. Together with yet more shooting nursing home staff, as well as home care attendants, lacked train-
deaths of Black people in recent weeks, it highlights not only how ing in the use of personal protective equipment (if they even had
acceptance of police violence against Black people was written such equipment available); bus drivers lacked enclosures; and
into law. It also comes at a time when the vastly disproportionate food production workers were closely crowded together. Current
rates of COVID-19 infection and death in Massachusetts’ Black policies, in which detailed protective measures at each type of
and immigrant communities have risen into public awareness, workplace are not mandated, still drive businesses to skirt safety
even as our state’s distinction of having the fourth-highest death measures, because the most conscientious businesses are finan-
rate in the country has not. cially penalized. Occupational health experts, workers’ centers,
and unions know the workplace realities on the ground to formu-
late needed detailed guidelines. Employees requesting adherence
“Together with yet more shooting to guidelines must be protected from retaliation. In current circum-
stances, with rampant food insecurity and with the specter of an
deaths of Black people in recent weeks, employer calling ICE to rid himself of a sick undocumented worker,
it highlights not only how acceptance employees are afraid to ask for adherence to workplace guide-
lines if they are not robustly shielded from dismissal or worse.
of police violence against Black people Presumption of occupational exposure of COVID-19 passed into
was written into law. It also comes at a law or ordered in 12 states, rewards businesses that protect their
workers rather than punishing them for doing so, and enables em-
time when the vastly disproportionate ployees to stay home as long as they are infectious.
rates of COVID-19 infection and death
Unsafe transportation endangers not only MBTA staff but also rid-
in Massachusetts’ Black and immigrant ers who must get to work. In fact the undocumented, who com-
communities have risen into public prise a significant number of essential workers, still lack the right in
our state to take a driving test and obtain a drivers’ license; we call
awareness, even as our state’s distinction on the governor to endorse the Work and Family Mobility Act that
of having the fourth highest death rate in would unite us with our neighbors Connecticut, New York and Ver-
mont in disconnecting drivers’ licenses from immigration status.
the country has not. ” Similarly, the Safe Communities Act, delinking public safety po-
licework, like traffic monitoring by State Police, from immigration
enforcement, can help foster more trust of immigrant communities
We posit that devaluation of Black and immigrant lives is implicit in state authorities. The absence of this trust currently makes ef-
in policies that accept these infection and death rates as inevi- fective COVID-19 contact tracing impossible. Safe transport will
table and that successful control of the pandemic here in Mas- require constant monitoring of conditions on trains and buses and
sachusetts hinges on political decisions to proactively remedy the correction of deficits because it is the essential workers who can-
factors that render these communitie so vulnerable. We call on not work from home.
elected officials at every level of our Commonwealth, starting with
Governor Baker, to focus on these policies with maximal urgency Higher risks at home are the third arena in which Black and immi-
as reopening is being advanced. This will require inviting repre- grant communities find themselves in harm’s way from COVID-19.
sentatives of these communities to the table, as the CEOs who Our Commonwealth has tolerated significantly higher levels of
currently populate the governor’s reopening board lack the knowl- pollution in their residential areas, increasing their risk for chronic
edge of their life circumstances that representatives like Gladys lung conditions that contribute to more severe disease. Skyrocket-
Vega of the Chelsea Collaborative and Reverends Ray and Gloria ing housing costs also force families to choose between intense
Hammond of Bethel AME Church can bring. It is the voices of the crowding or homelessness. Families who now have no food are
affected communities that can best clarify the realities excluded even harder pressed for rent. An explosion of evictions, foreclo-
from Governor Baker’s statement that safe reopening hinges on sures, and family homelessness threatens to throw accelerant on
personal responsibility. Black and immigrant individuals desire the epidemic unless tenants, homeowners, and small landlords
nothing more than to protect themselves but must place them- are further protected before the current moratorium expires.
selves into dangerous environments to put food on the table and
keep a roof over their heads. A second wave of infections would be devastating not just for the
health and life of all Massachusetts residents, including the resi-
Three parts of daily life put Black and immigrant men and women dents of sheltered towns who count on the health of their nannies,

housecleaners, and food workers. (This was amply demonstrated courts-judge-police-use-force/594832/
by the second surge in Singapore, driven by infections among 3. h t t p s : / / w w w . n y t i m e s . c o m / i n t e r a c t i v e / 2 0 2 0 / u s /
low-income migrant workers.) It would also deeply disrupt the op- massachusetts-coronavirus-cases.html
erations of small businesses, of the farms in the Western part of 4. https://www.bostonglobe.com/2020/05/09/nation/disparities-
our state, the ability of daycare centers and schools to plan and to push-coronavirus-death-rates-higher/
function, and hence the financial lifeblood of many people in our 5. https://www.bostonmagazine.com/news/map-coronavirus-
state. The idea that a second wave is inevitable is deeply harmful, cases-by-county-massachusetts/
as the Massachusetts High Technology Council has pointed out. 6. https://www.bostonglobe.com/2020/05/09/nation/disparities-
Preventing more infections is not only right because every human push-coronavirus-death-rates-higher/
life is precious. It is also critical for a strong economy. 7. https://www.bostonglobe.com/2020/04/26/metro/saving-
chelsea/
8. http://www.bethelame.org/our-pastors
“We can be hopeful that similarly 9. https://www.boston.com/news/coronavirus/2020/05/18/
charlie-baker-massachusetts-reopening-plan-livestream-
beneficial outcomes result from our video
current COVID-19 pandemic, whether 10. http://www.masscosh.org/publications/featured-articles/
comprehensive-information-covid-19
that be an acceleration of research into 11. https://www.southcoasttoday.com/news/20200413/new-
therapeutics and vaccines, or improved bedford-seafood-workers-report-overcrowding-poor-
sanitation
preparedness for the next pandemic yet 12. http://www.masscosh.org/
to emerge.” 13. https://www.masslegalservices.org/content/worker-centers-
massachusetts
14. https://www.1199seiu.org/massachusetts
15. https://www.washingtonpost.com/national/in-an-immigrant-
If our affirmation that Black lives matter and that we are a welcom- community-battling-coronavirus-essential-means-
ing state is more than a beautiful sentiment but is meant to truly vulnerable/2020/05/08/c25cdb4e-8e1e-11ea-a9c0-
protect the lives of those who have already suffered so dispropor- 73b93422d691_story.html
tionately in the epidemic, concrete steps are needed now. The 16. https://www.wbur.org/news/2017/05/17/ice-arrest-workers-
voices and expertise of the most intensely impacted groups must comp
be called on. For COVID-19, justice and science converge: none 17. https://www.jdsupra.com/legalnews/illinois-legislature-
are protected if all are not protected. passes-covid-19-78617/
18. https://www.ncsl.org/research/labor-and-employment/covid-
Julia Koehler, MD 19-workers-compensation.aspx
Pediatric Infectious Diseases specialist and Assistant Professor 19. https://www.gazettenet.com/Bill-to-allow-undocumented-
of Pediatrics, Harvard Medical School residents-drivers-licenses-reported-out-of-
committee-32524158
Robert Husson, MD 20. https://www.miracoalition.org/our-work/safe-communities/
Pediatric Infectious Diseases specialist and Professor of Pediat- 21. https://www.t4ma.org/covid-19
rics, Harvard Medical School 22. https://www.mass.gov/info-details/ago-environmental-
justice-brief
Regina LaRocque, MD MPH 23. http://www.clvu.org/covid19
Adult Infectious Diseases specialist and Associate Professor of 24. https://www.bostonglobe.com/2020/04/20/business/baker-
Medicine, Harvard Medical School signs-bill-blocking-evictions-during-coronavirus/
25. https://www.bloomberg.com/news/articles/2020-04-28/virus-
References: surge-in-southeast-asia-migrant-workers-serves-as-warning
26. http://www.mhtc.org/events/covid-19-response/
1. h t t p s : / / w w w. w a s h i n g t o n p o s t . c o m / p o l i t i c s / c u r r e n t -
law-gives-police-wide-latitude-to-use-deadly-
f o r c e / 2 0 1 4 / 0 8 / 2 8 / 7 6 8 0 9 0 c 4 - 2 d 6 4 - 11 e 4 - 9 9 4 d - The author has no conflicts to disclose
202962a9150c_story.html
2. https://www.theatlantic.com/politics/archive/2019/08/how- NT
THE The Brett Tashman Foundation is a 501©(3) public charity. The mission of the
Foundation is to find a cure for Desmoplastic Small Cell Round Tumors
(DSRCT). DSRCT is an aggressive pediatric cancer for which there is no cure
BRETT TASHMAN and no standard treatment. 100 percent of your gift will be used for research.
There is no paid staff. To make your gift or for more information, go to
“TheBrettTashmanFoundation.org" or phone (909) 981-1530.
FOUNUA �lU
OPIOIDS and NAS
When reporting on mothers, babies,
and substance use
LANGUAGE MATTERS
I am not an addict.
Julia Koehler MD I was exposed to substances in utero.
I am not addicted. Addiction is a set of
Specialist in Pediatric Infectious Disease
behaviors associated with having a
Assistant Profesor of Pediatrics, Substance Use Disorder (SUD).
Harvard Medical School
Boston, Massachusetts
email: [email protected] I was exposed to opioids.
While I was in the womb my mother and I
shared a blood supply. I was exposed to
the medications and substances she
used. I may have become physiologically
dependent on some of those substances.
NAS is a temporary and

treatable condition.
There are evidence-based pharmacological
and non-pharmacological treatments for
Neonatal Abstinence Syndrome.
My mother may have a SUD.

She might be receiving Medication-Assisted
Treatment (MAT). My NAS may be a side
effect of her appropriate medical care. It is
not evidence of abuse or mistreatment.
My potential is limitless.
I am so much more than my NAS
diagnosis. My drug exposure will not
determine my long-term outcomes.
But how you treat me will. When you
invest in my family's health
and wellbeing by supporting
Medicaid and Early
Childhood Education you
Readers can also follow can expect that I will do as
well as any of my peers!
NEONATOLOGY TODAY
via our Twitter Feed Learn more about
Neonatal Abstinence Syndrome
@NEOTODAY at www.nationalperinatal.org

Medical News, Products & Information
among VLBW decreased from 16.7% in
Table 3. Clinical Outcome of Infants Born at Gestation Age of 22-29 Weeks at
Women’s Hospital During the Study Period pre-EHR era to 14% in post-EHR era.
Among babies born less than 1,500 grams,
Compiled and Reviewed by Mitchell Goldstein, MD The study P-Value
Editor in Chief 2015-2016
2013-2014 is being conducted in approximately
rates of necrotizing 40 sites
enterocolitis of the
and cystic
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(433) Pediatric
tantly, many study sites
Trials Network(link
are located
significantly
is
near (Table
affected diverse
external).
periventricular leukomalacia, were not Impor-
2).communities,
Retinopathy
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NIH-funded study to evaluate drugs
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given reports that COVID-19
and ethnicreduced
minorities
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from 28% all
across to ages(link
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prescribed to children with COVID-19
CLD 11.8 20.25 0.0130
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analyzethere
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dosage and safety for special
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syndrome and
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Researchers will assess
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ties not yet determined in children.
CONS 8.2 10.4 0.3221 3%, with a P-value of 0.7, VAP 2.1% vs
Act (BPCA) research program, which investigates drugs and ther-
1.6%, with a P-value of 0.08, and CONs
IVH 19.2 apies commonly
22.2 0.4930 prescribed to 2.1
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with a but not suf-
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ficiently tested in them.0.03
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(Table BPCA studies are available to
ROP 35.6 33
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through NICHD’s Data and Specimen Hub (DASH).
Researchers funded by the National Institutes of Health have
Cystic PVL 3.2 COVID-19 4.5 0.0705 Discussion
launched an effort to evaluate drugs prescribed to treat
About the Eunice Kennedy Shriver National Institute of Child
in NEC
infants, children and adolescents across the country. 8.4 The study 8.4 Several studies(NICHD):
have been conducted in
Health and0.2015
Human Development NICHD leads re-
leverages an existing clinical trial that examines drugs that are ambulatory services and less intensive
Average Length search and 0.139
training to areas,
understand human thedevelopment, improve
prescribed off-labeloftoStay in NICU
children 58±63
for a variety of medical conditions. 52.5±40 assessing information flow and
reproductive health, enhance
logistics the
of lives ofhealth
electronic children
careand adoles-
records on
Because many drugs have not been tested specifically for use in
Table 4. Infection Rate cents, and optimize abilities for of
the quality all.work
For performance.
more information, visit
12,13 These
children, physicians will often prescribe drugs off-label to children
studies claimed that the patient-related
https://www.nichd.nih.gov.
because they lack an alternative, approved treatment. Rate* P-Value outcomes were better in adult patients, with
enhanced overall patient care, less ordered
2013-2014 2015-2016 About the National Institutes of Health (NIH): NIH, the nation's
“As we search for safe and effective therapies for COVID-19, medications and lab requests. Cordero et al
medical research agency, demonstrated27the
includes Institutes and Centers
advantage and
of remote
weCLABSI
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youngest patients who may respond differently to these drugs,
VAP Services. NIH
0.08 is the primary federal agency conducting and sup-
compared to adults,” said Diana W.2.1 1.6
Bianchi, M.D., director of
porting basic, clinical, and translational medical research, and is
NIH’s
LOSEunice Kennedy Shriver National
3.7 Institute of Child Health
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treatments, the available
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and Human Development (NICHD), which oversees the project.
CONS 2.1 0.93 and rare diseases.
0.03 Forliterature, 12,13 longer
more information about NIH and its pro-
Researchers will * investigate several
Rate = Number drugs
of cases currently
/ Number given
of patient grams,
to X 1000
days visit duration assessment is not
www.nih.gov.
children diagnosed with COVID-19, including antiviral and anti-
Institute/Center an impact factor. In a
inflammatory drugs. Products will be added or removed from the
list as researchers learn more about the treatment needs of pa-
Eunice Kennedy Shriver cross-sectional study,
National Institute of Child Health Li
and Hu-
man Development (NICHD)
tients with COVID-19. The study is not a clinical trial with a con- Zhou et al, found no
trol group. Rather, healthcare providers who are already treating
Contact association between
patients with drugs on the list may enroll patients whose parents
Linda Huynh or Robertduration
Bock of using an EHR
or guardians have given their consent. The study is called Phar-
301-496-5133
macokinetics of Understudied Drugs Administered to Children Per and improved performance
Standard of Care. NT
with respect to quality of
care. Intensifying the use
Researchers will analyze blood samples collected from routine
medical procedures to understand how drugs move through the of key EHR features, such
bodies of children, from newborns to adolescents under 21 years
of age. They will also collect information on potential side effects NEONATOLOGY TODAY
as clinical decision
and patient outcomes, such as the duration and type of respi- support, may be needed to
ratory support that may be needed and length of hospital stay. via realize
our Twitter Feed
quality
The study is designed to gather information to refine dosing and
improve improvement
@NEOTODAYfrom EHRs”
Figure 1.safety forClinical
Overall infants, children
Outcome and adolescents;
Before and After EHS.it is not de-
signed to evaluate which drug is the best treatment for COVID-19.
1.25
The National Urea Cycle Disorders Foundation The NUCDF is a non-profit organization
dedicated to the identification, treatment
and cure of urea cycle disorders. NUCDF
is a nationally-recognized resource of
information and education for families
and healthcare professionals.
w w w. n u c d f . o r g | P h o n e : ( 6 2 6 ) 5 7 8 - 0 8 3 3
NEONATOLOGY TODAY t www.NeonatologyToday.net t March 2018 5

______________________________________ • Invitation for special programming AAP Division of Pediatric Practice
by the Section at the AAP’s National
American Academy of Conference. Department of Primary Care and Subspe-
Pediatrics, Section on • Access to and ability to submit re-
cialty Pediatrics
Advancement in Thera- search abstracts related to advanc- 630.626.6759

ing child health through innovations
peutics and Technology in pediatric drugs, devices, research,
[email protected]
______________________________________ clinical trials and information tech- Dedicated to the Health of All Children
nology; abstracts are published in
Released: Thursday 12/13/2018 12:32 Pediatrics. ###
PM, updated Saturday 3/16/2019 08:38,
and Sunday 11/17/2019 1020 AAP members can join SOATT for free. To The American Academy of Pediatrics is
activate your SOATT membership as an an organization of 67,000 primary care
The American Academy of Pediatrics’ AAP member, please complete a short ap- pediatricians, pediatric medical subspe-
Section on Advances in Therapeutics plication at http://membership.aap.org/Ap- cialists and pediatric surgical specialists
and Technology (SOATT) invites you to plication/AddSectionChapterCouncil. dedicated to the health, safety and well-
join our ranks! SOATT creates a unique being of infants, children, adolescents
community of pediatric professionals who The Section also accepts affiliate mem- and young adults. For more information,
share a passion for optimizing the discov- bers (those holding masters or doctoral visit www.aap.org. Reporters can access
ery, development and approval of high degrees or the equivalent in pharmacy the meeting program and other relevant
quality, evidence-based medical and sur- or other health science concentrations meeting information through the AAP
gical breakthroughs that will improve the that contribute toward the discovery and meeting website at http://www.aapexperi-
health of children. You will receive many advancement of pediatrics and who do ence.org/
important benefits: not otherwise qualify for membership in
the AAP). Membership application for af- NT
• Connect with other AAP members filiates: http://shop.aap.org/aap-member-
who share your interests in improv- ship/ then click on “Other Allied Health ___________________
ing effective drug therapies and de- Providers” at the bottom of the page.
vices in children.
Thank you for all that you do on behalf
NIH researchers iden-
• Receive the SOATT newsletter con- of children. If you have any questions, tify key genomic fea-
taining AAP and Section news. please feel free to contact:
tures that could dif-
• Access the Section’s Website and
Collaboration page – with current
Mitchell Goldstein, MD, FAAP, Section ferentiate SARS-CoV-2
Chairperson, [email protected] and
happenings and opportunities to get from other coronavi-
Christopher Rizzo, MD, FAAP, Member-
involved.
ship Chairperson and Chair Elect, criz- ruses that cause less
• Network with other pediatricians,
pharmacists, and other health care
[email protected] severe disease
providers to be stronger advocates Jackie Burke ___________________
for children.
Sections Manager Genomic features that differentiate less


severe forms of SARS-CoV-2 have been that are unique to SARS-CoV-2 and two ing, retrieving, preserving, and commu-
identified. other coronavirus strains with high fatal- nicating health information. It creates re-
ity rates, SARS-CoV and MERS-CoV. The sources and tools that are used billions
Thursday, June 11, 2020 identified features correspond with the of times each year by millions of people
high fatality rate of these coronaviruses, to access and analyze molecular biology,
A team of researchers from the National as well as their ability to move from ani- biotechnology, toxicology, environmen-
Library of Medicine (NLM), part of the Na- mal to human hosts. tal health, and health services informa-
tional Institutes of Health, identified ge- tion. Additional information is available at
nomic features of SARS-CoV-2, the virus These features include insertions of spe- www.nlm.nih.gov.
that causes COVID-19, and other high- cific stretches of amino acids into two
fatality coronaviruses that distinguish virus proteins, the nucleocapsid and the About the National Institutes of Health
them from other members of the coro- spike. These features are found in all (NIH): NIH, the nation's medical research
navirus family. This research could be a three high-fatality coronaviruses and their agency, includes 27 Institutes and Cen-
crucial step in helping scientists develop closest relatives that infect animals, such ters and is a component of the U.S. De-
approaches to predict, by genome analy- as bats, but not in four other human coro- partment of Health and Human Services.
sis alone, the severity of future coronavi- naviruses that cause non-fatal disease. In NIH is the primary federal agency con-
rus disease outbreaks and detect animal particular, the insertions in the spike pro- ducting and supporting basic, clinical,
coronaviruses that have the potential to tein are predicted, from protein structure and translational medical research, and
infect humans. The findings were pub- analysis, to facilitate the recognition of the is investigating the causes, treatments,
lished this week in the Proceedings of the coronavirus receptors on human cells and and cures for both common and rare dis-
National Academy of Sciences(link is ex- the subsequent penetration of the virus eases. For more information about NIH
ternal). into those cells. Finding these features in and its programs, visit www.nih.gov.
animal coronavirus isolates could predict
COVID-19, an unprecedented public the jump to humans and the severity of NIH…Turning Discovery Into Health®
health emergency, has now claimed more disease caused by such isolates.
than 380,000 lives worldwide. This crisis ###
prompts an urgent need to understand the “This innovative research is critical to
evolutionary history and genomic features improve researchers’ understanding of Institute/Center
that contribute to the rampant spread of SARS-CoV-2 and aid in the response to National Library of Medicine (NLM)
SARS-CoV-2. COVID-19,” said NLM Director Patricia
Flatley Brennan, R.N., Ph.D. “Predictions Contact
“In this work, we set out to identify genom- made through this analysis can inform NLM Office of Communications
ic features unique to those coronaviruses possible targets for diagnostics and inter- 301-496-6308
that cause severe disease in humans,” ventions.”
said Dr. Eugene Koonin, an NIH Distin- NT
guished Investigator in the intramural re- This press release describes a basic re-
search program of NLM’s National Center search finding. Basic research increases
for Biotechnology Information, and the our understanding of human behavior and
lead author of the study. “We were able biology, which is foundational to advanc-
to identify several features that are not ing new and better ways to prevent, di-
found in less virulent coronaviruses and agnose, and treat disease. Science is an
that could be relevant for pathogenicity in unpredictable and incremental process
humans. The actual demonstration of the — each research advance builds on past
relevance of these findings will come from discoveries, often in unexpected ways.
direct experiments that are currently get- Most clinical advances would not be pos-
ting under way.” sible without the knowledge of fundamen-
tal basic research.
Using integrated comparative genom-
ics and machine learning techniques, NLM, part of the NIH, is a leader in re-
the researchers compared the genome search in biomedical informatics and data
of the SARS-CoV-2 virus against the ge- science, and the world’s largest biomedi-
nomes of other members of the coronavi- cal library. NLM conducts and supports
rus family and identified protein features research in methods for recording, stor-


___________________
NIH to test one-dose
antibiotic for the pre-
vention of maternal
and infant sepsis
___________________
A potential novel therapy for prophylaxis of
sepsis.
Wednesday, June 3, 2020
Researchers supported by the National Insti-

tutes of Health and the Bill & Melinda Gates
Foundation will assess whether a single oral
dose of the antibiotic azithromycin during la-
bor reduces the risk of maternal and infant
bacterial infection and death in seven low-
and middle-income countries.
“We urgently need effective interventions to

reduce the death toll of pregnancy-related in-
fections worldwide,” said Diana W. Bianchi,
M.D., NICHD Director. “This study allows us
to test a low-cost intervention that has shown ing from cesarean delivery. The drug is low- “The NICHD Global Network provides the
promise in a smaller study.” cost and can be kept at room temperature, expertise and infrastructure needed to car-
which makes it suitable for parts of the world ry out this essential clinical trial,” said lead
The clinical trial is funded by NIH’s Eunice where refrigeration isn’t always available. An investigator Waldemar Carlo, M.D., of the
Kennedy Shriver National Institute of Child earlier study of more than 800 women in The Neonatology Division of the University of
Health and Human Development (NICHD) Gambia found that administering azithromy- Alabama at Birmingham. “We anticipate that
and the Gates Foundation. The trial will cin to pregnant women at the beginning of this study will provide important data to help
be conducted by researchers in NICHD’s labor reduced maternal and infant infections, us improve the standard of maternal care in
Global Network for Women’s and Children’s compared to a group that received a pla- low- and middle-income countries.”
Health Research, or NICHD Global Network. cebo. Azithromycin and other antibiotics are
not effective against COVID-19 and other The Foundation for the National Institutes
Maternal death from sepsis — a system- diseases caused by viruses. of Health, a not-for-profit organization that
wide reaction to bacterial and other infec- manages alliances with public and private
tions — is higher in many low- and middle- The current study plans to enroll up to 34,000 institutions in support of the NIH mission,
income countries, compared to wealthy women at NICHD Global Network sites in provided funding for the study with a grant
countries. This higher death rate results from Bangladesh, the Democratic Republic of the from the Gates Foundation.
a combination of factors, including a longer Congo, Guatemala, India, Kenya, Pakistan
time to diagnosis, lack of access to timely and Zambia. Half of the women will receive About the Eunice Kennedy Shriver Na-
drug treatment and chronic malnourishment. a single 2-gram dose of oral azithromycin, tional Institute of Child Health and Hu-
Infection during pregnancy and in the weeks and the other half will receive a placebo. The man Development (NICHD): NICHD leads
after birth account for roughly 10% of mater- women and their infants will be monitored for research and training to understand human
nal deaths worldwide, according to the World fever and other signs of infection during their development, improve reproductive health,
Health Organization. Infection accounts for hospital stay and again at one week and six enhance the lives of children and adoles-
16% of newborn deaths worldwide. weeks after giving birth. The study will also cents, and optimize abilities for all. For more
include records of unscheduled visits to information, visit http://www.nichd.nih.gov.
Azithromycin, an antibiotic effective against a health facilities outside of the network sites.
broad range of bacteria, has been shown(link About the National Institutes of Health
is external) to protect against infection result-

PAC/LAC offers continuing
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CONTINUING MEDICAL EDUCATION
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the 2018 Cultural & Linguistic Competency Award. This award recognizes a CME provider Family Therapists (LMFT)
that exemplifies the goal of integrating cultural and linguistic competency into overall program • Licensed Professional
and individual activities and/or a physician who provides leadership, mentorship, vision, and Clinical Counselors (LPCC)
commitment to reducing health care disparities
• Licensed Educational
Psychologists (LEP)
PAC/LAC is an accredited provider of continuing education by Accreditation Council for • Certified Health Education
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Registered Nursing, the California Association of Marriage and Family Therapists, the • Continuing Respiratory Care
National Commission for Health Education Credentialing, and the American Association for Education (CRCE)
What We Do
Perinatal AdvisoryRespiratory Council: Leadership, Advocacy,
Care. And Consultation
To inquireOur
about• mission
Continuing is toimprovement
Education
Perinatal quality
positively impact
Joint-Providership the
opportunities for health of women
your event please visit our www.paclac.org
and their families.
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How? By improving pregnancy and birth outcomes through the promotion of evidence-based practices, and providing leadership, education and support
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PAC/LAC’s core values for improving maternal and child health have
Learn More
remained constant for over 30 years – a promise to lead, advocate and
consult with others.
Leadership
Providing guidance to healthcare professionals, hospitals and healthcare

systems, stimulating higher levels of excellence and improving outcomes
for mothers and babies.
Advocacy
Providing a voice for healthcare professionals and healthcare systems to

improve public policy and state legislation on issues that impact the
maternal, child and adolescent population.
Consultation
Providing and promoting dialogue among healthcare professionals with the

expectation of shared excellence in the systems that care for women and
children.

(NIH): NIH, the nation's medical research tablish the risk of pregnant women with (NICHD)
agency, includes 27 Institutes and Centers COVID-19 infection transmitting the virus
and is a component of the U.S. Department to their fetus. Newborns will be monitored Contact
of Health and Human Services. NIH is the and assessed until they are discharged Robert Bock or Meredith Daly
primary federal agency conducting and sup- from the hospital. 301-496-5133
porting basic, clinical, and translational medi- NT
cal research, and is investigating the causes, In addition, the study will track more than
treatments, and cures for both common and
rare diseases. For more information about
1,500 pregnant women confirmed with
COVID-19 infection, monitoring their
___________________
NIH and its programs, visit www.nih.gov. health for six weeks after childbirth.
The study will be conducted by research-

Stop tobacco industry
NIH…Turning Discovery Into Health®
ers in the Maternal-Fetal Medicine Units exploitation of children
References
(MFMU) Network, a group of 12 U.S.
clinical centers funded by NIH’s Eunice
and young people
Azithromycin-Prevention in Labor Use Study
(A-PLUS). NICHD Global Network for Wom-
Kennedy Shriver National Institute of ___________________
Child Health and Human Development
en's and Children's Health. https://clinicaltri- Exploitation of children by the tobacco indus-
(NICHD). MFMU Network sites cover
als.gov/ct2/show/NCT03871491 try remains a problem
more than 160,000 deliveries a year, and
their racial, ethnic, and geographic diver-
### 29 May 2020 News release
sity allows researchers to generalize their
study findings to the U.S. population.
Institute/Center The World Health Organization is today
Eunice Kennedy Shriver National Institute MFMU Network investigators plan to con- launching a new kit for school students aged
of Child Health and Human Development tribute data collected from the current 13-17 to alert them to the tobacco industry
(NICHD) study to a larger registry to help inform tactics used to hook them to addictive prod-
future studies of how COVID-19 affects ucts. Every year the tobacco industry invests
Contact maternal health and pregnancy. more than USD 9 billion to advertise its
Robert Bock or Meredith Daly products. Increasingly, it is targeting young
301-496-5133 Who people with nicotine and tobacco products in
NT a bid to replace the 8 million people that its
NICHD Director Diana W. Bianchi, M.D.,
___________________ is available for comment.
products kill every year.
NIH-funded study to About the Eunice Kennedy Shriver

This year’s WHO’s World No Tobacco Day
campaign focuses on protecting children
investigate pregnancy National Institute of Child Health and
and young people from exploitation by the
Human Development (NICHD): NICHD
outcomes resulting leads research and training to understand
tobacco and related industry. The toolkit
has a set of classroom activities including
from COVID-19 pan- human development, improve reproduc-
tive health, enhance the lives of children
one that puts the students in the shoes of
demic and adolescents, and optimize abilities
the tobacco industry to make them aware
of how the industry tries to manipulate them
___________________ for all. For more information, visit https://
www.nichd.nih.gov.
into using deadly products. It also includes
an educational video, myth-buster quiz, and
Pregnancy outcomes during the pandem-
About the National Institutes of Health homework assignments.
ic
(NIH): NIH, the nation's medical research
Media Advisory agency, includes 27 Institutes and Cen- The toolkit exposes tactics such as parties
ters and is a component of the U.S. De- and concerts hosted by the tobacco and
Tuesday, May 19, 2020 partment of Health and Human Services. related industries, e-cigarette flavours that
NIH is the primary federal agency con- attract youth like bubble-gum and candy,
What ducting and supporting basic, clinical, e-cigarette representatives presenting in
and translational medical research, and is schools, and product placement in popular
The National Institutes of Health has youth streaming shows.
investigating the causes, treatments, and
launched a multipronged study to un-
cures for both common and rare diseas-
derstand the effects of the COVID-19 Even during a global pandemic, the tobac-
es. For more information about NIH and
pandemic during and after pregnancy. co and nicotine industry persist by pushing
its programs, visit www.nih.gov.
Researchers will analyze the medical products that limit people’s ability to fight
records of up to 21,000 women to evalu- NIH…Turning Discovery Into Health® coronavirus and recover from the disease.
ate whether changes to healthcare de- The industry has offered free branded masks
livery that were implemented as a result ###### and delivery to your door during quarantine
of the pandemic have led to higher rates and has lobbied for their products to be listed
of pregnancy-related complications and Institute/Center as ‘essential’.
cesarean delivery. They also seek to es- Eunice Kennedy Shriver National Institute
of Child Health and Human Development

Smoking suffocates the lungs and other or-
gans, starving them of the oxygen they need
showing tobacco or e-cigarette use on
screen
___________________
AAP Statement on Supreme Court Decision
to develop and function properly. “Educat- • Social media platforms ban the market- to Uphold Deferred Action for Childhood Ar-
ing youth is vital because nearly 9 out of 10 ing of tobacco and related products and rivals Program
smokers start before age 18. We want to prohibit influencer marketing
provide young people with the knowledge • Government and financial sector divest For Release:
to speak out against tobacco industry ma- from tobacco and related industries 6/18/2020
nipulation,” said Ruediger Krech, Director for • Governments ban all forms of tobacco
Health Promotion at WHO. advertising, promotion and sponsorship By: Sally Goza, MD, FAAP, President, Amer-
ican Academy of Pediatrics
Over 40 million young people aged 13-15 Countries can protect children from industry
have already started to use tobacco. To exploitation by putting in place strict tobacco "The American Academy of Pediatrics ap-
reach Generation Z, WHO launched a Tik- control laws, including regulating products plauds the U.S. Supreme Court’s 5-4 deci-
Tok challenge #TobaccoExposed and wel- like e-cigarettes that have already begun to sion rejecting the Trump Administration’s
comed social media partners like Pinterest, hook a new generation of young people. attempt to end the Deferred Action for Child-
Tinder, YouTube and TikTok to amplify mes- hood Arrivals (DACA) program. This ruling
saging. NT
is a major victory for immigrant families and
WHO calls on all sectors to help stop mar-
___________________ provides much-needed certainty to more
than 700,000 young people whose futures
keting tactics of tobacco and related indus- have been on hold as they awaited a deci-
tries that prey on children and young people:
AAP Statement on Su- sion.
• Schools refuse any form of sponsor-
ship and prohibit representatives from
preme Court Decision “DACA recipients enrich our communities.
nicotine and tobacco companies from to Uphold Deferred They are among our colleagues in medicine,
working on the frontlines of the COVID-19
•
speaking to students
Celebrities and influencers reject all of-
Action for Childhood pandemic, they have served our country in
uniform, and they are now parents raising
fers of sponsorship Arrivals Program children of their own. The Academy stands
• Television and streaming services stop

with them in celebration of today’s momen-
tous ruling.
talk to their Children cy statement on racism, recommend:
___________________ Check in with your child. Ask what they know,

"Research shows that protective immigra- American Academy of Pediatrics Condemns what they've seen, and how they are feeling.
tion policies like DACA have positive health Racism, Offers Advice for Families for How Validate their feelings and reassure them it’s
effects that are multigenerational. In our brief to talk to their Children normal to feel emotions. You know your child
before the Supreme Court, the Academy ar- best and what information they can handle.
gued that the unlawful termination of DACA For Release: For younger children, you can tell them what
put children’s health at risk and threatened 6/1/2020 you are doing to keep your family safe. For
families’ income and food security. Today’s pre-teens and older children, you can ask if
ruling is a step toward a more equitable sys- Itasca, Ill.—The killing of George Floyd and they’ve experienced mistreatment or racism,
tem for children in immigrant families, but our the subsequent protests across the country or witnessed this happening.
work is far from finished. have laid bare the nation’s legacy of racism Watch for changes in your child’s behavior
and discrimination and the ways it harms all – some children may become more aggres-
"We must now make DACA’s protections members of our communities. The American sive, while others will become withdrawn. If
permanent, which we urge Congress to do Academy of Pediatrics (AAP) condemns you are concerned about your child suffering
right away. The Trump Administration must racism of all forms, and notes that even vi- more severe anxiety, fear or distress, reach
stop advancing policies that further jeopar- carious racism – witnessed through social out to your pediatrician or mental health pro-
dize immigrant families’ health and safety. media, conversations with friends or family, vider for additional support.
And finally, racism and discrimination harm or media images – harms children’s health. Place limits on what your child sees in media.
everyone, including children. As we cele- Do not leave the TV on in the background.
brate today’s ruling, we continue to fight all “Racism harms children’s health, starting With older children and teens, watch with
forms of racism and urge policymakers to do from before they are born," said AAP Presi- them and discuss what you’re seeing. Listen
the same.” dent Sally Goza, MD, FAAP. “A growing to their observations and share your own.
body of research supports this, and we can- You can use commercial breaks, or pausing,
### not ignore the impact.” to have brief discussions. With younger chil-
dren, limit their exposure to media, including
The American Academy of Pediatrics is an The AAP recommends parents proactively TV, smartphones or tablets, and make sure
organization of 67,000 primary care pediatri- engage their children around these traumat- media exposure occurs in a common area
cians, pediatric medical subspecialists and ic events, taking into account their age and where parents can check in.
pediatric surgical specialists dedicated to development. As an adult, tune into your own emotions
the health, safety and well-being of infants, and check that you are ok. If you are not, ask
children, adolescents and young adults. For “As a parent, you have to assume children for help to deal with the trauma and emotion-
more information, visit www.aap.org and fol- of almost any age are hearing about what al impact of these images.
low us on Twitter @AmerAcadPeds is happening in our nation today,” said Nia Create a list of your own coping strategies,
Heard-Garris, MD, MSc, FAAP, chair of the and when you need to use them, tap into that
Media Contact: AAP Section on Minority Health, Equity and list.
Devin Miller Inclusion. “Ideally you can talk with your child For all families, this is a teachable moment,
202-347-8600 first before they hear the news from other when you can discuss the history of racism
[email protected] sources, and help to frame the events in and discrimination in the U.S. and equip your
an age-appropriate way. Parents should be children to make change.
NT having these conversations now.” If you struggle to find the “right” words,
consider using books or other resources to
___________________ Children may hear adult conversations, see
a video on social media platforms, or watch
share with your child. HealthyChildren.org
offers some tips in this article. You can share
news coverage of violent protests. Children with your children that no one is perfect, talk
American Academy of may be fearful about their own safety or their
family’s safety, or have questions about what
about what you are doing to be anti-racist,
what you have learned, and how you as a
Pediatrics Condemns the protests mean, or why people have been family can step up.
killed by police. “Parents can acknowledge that people are
Racism, Offers Advice treated differently based on the color of their
for Families for How to Dr. Heard-Garris and Jacqueline Dougé, skin and where they live, and share ex-
MD, MPH, FAAP, co-author of the AAP poli- amples of this happening,” said Dr. Douge.
nital/Structural Cardiologists & Cardiothoracic Surgeons Worldwide

ODAY CONGENITAL
TODAY

“Parents can also model how to make a pos- low us on Twitter @AmerAcadPeds continue to work with the WHO to combat
itive difference. For example, perhaps your COVID-19 and promote the health of chil-
family can call your city council person or For Release: dren globally.”
superintendent to advocate for issues faced 6/1/2020
by communities of color. Adults can also ###
confront their own bias and model how they Media Contact:
want their children to respond to others who Lisa Black The American Academy of Pediatrics is an
may be different than them.” 630-626-6084 organization of 67,000 primary care pediatri-
[email protected] cians, pediatric medical subspecialists and
The AAP holds that racism harms everyone, pediatric surgical specialists dedicated to
including children of all races and ethnicities. the health, safety and well-being of infants,
It is not a conversation that can be avoided, children, adolescents and young adults. For
said Joseph Wright, MD, MPH, FAAP, a NT more information, visit www.aap.org and fol-
member of the AAP Board of Directors and low us on Twitter @AmerAcadPeds
past chair of the AAP Task Force on Ad-
dressing Bias and Discrimination.
___________________ Media Contact:
Devin Miller
“These are conversations African-American
families have had to have for generations,”
AAP Statement on 202-724-3308
[email protected]
said Dr. Wright. “But if this is not something Withdrawal of U.S.
other families have discussed yet, what NT
is happening right now is an essential and from the World Health
unavoidable, teachable moment. If we are Organization ___________________
to progress in this country, it’s going to be
because we help our children, adolescents ___________________
AAP Statement on Withdrawal of U.S. from
and young adults learn not just that racism
exists, but that it is something all of us can the World Health Organization AAP Statement on
work together to dismantle. Racism is not New Data Showing
inexorable.” For Release:
6/1/2020 Declines in Childhood
In 2019, AAP published the policy statement,
By Mark Del Monte, JD, CEO\Executive
Immunizations
"Racism and Its Impact on Child and Adoles-
cent Health.” In it the AAP lays out an agen- Vice President of the American Academy of ___________________
da calling for equitable policies at the local, Pediatrics AAP Statement on New Data Showing De-
state and federal level to reduce disparities clines in Childhood Immunizations
and advance social justice. “The World Health Organization (WHO)
plays a leading role in protecting the health For Release:
“Failure to address racism will undermine of children and families around the world. 5/8/2020
our progress toward health equity. As an or- The agency has been on the frontlines of
ganization dedicated to the health and well- every global child health challenge over the By: Sally Goza, MD, FAAP, president of the
being of children, adolescents and young last seven decades, successfully eradicating American Academy of Pediatrics
adults, it is in our mission as the American smallpox, vaccinating billions against mea-
Academy of Pediatrics to fight all forms of sles, and cutting preventable child deaths by “Today the U.S. Centers for Disease Control
racism,” Dr. Goza said. “We must dismantle more than half since 1990. & Prevention published new data that docu-
racism at every level, from individual to insti- ments what pediatricians around the nation
tutional to systemic. Our nation did not get “The Trump Administration’s decision to have been reporting for weeks: many, many
here overnight, and the road to progress and withdraw from the WHO carries grave risks
healing will be long and difficult, but the work for the world’s children during an unprece-
we have before us is essential. Our chil- dented global health crisis. The decision to
dren’s future will be built on these moments withdraw risks causing a surge in polio cas-
of reckoning.” es and an increase in deaths of children from
malaria, and it will further delay life-saving
### vaccination campaigns.
The American Academy of Pediatrics is an “Withdrawing support from the WHO not
organization of 67,000 primary care pediatri- only harms the global response against CO-
cians, pediatric medical subspecialists and VID-19 and prevents the United States from
pediatric surgical specialists dedicated to engaging the agency to enact meaningful re-
the health, safety and well-being of infants, forms, but undermines the response to other
children, adolescents and young adults. For major health threats impacting children. The
more information, visit www.aap.org and fol- American Academy of Pediatrics urges the
administration to reconsider its position and

the placement of live microbes into the patient's body in a procedure
children have missed receiving important immunizations to protect
Family Centered Care is
similar to a colonoscopy.
them against diseases like measles, meningitis and whooping cough.
Mayo Clinic is a nonprofit organization committed to clinical practice,
education
“As and research,
a pediatrician, providingworrisome.
this is incredibly expert, whole-person
everyone who needs healing. For more information,
care to
I remember treating trendy, but are providers
children with these diseases as recently as the 1980s, and we do not
visit www.mayoclinic.org/about-mayo-clinic.
want to return to a time when parents had to worry their infant could really meeting parents
die of meningitis – especially when we have a vaccine to prevent
it.More
The COVID-19 pandemic
Extremely Preterm
inNeurological Impairment
what this vulnerability
is giving
Babies all of Live
Survive, us a Without
real-time education
feels like. Fortunately, we have vaccines to
needs in the NICU?
protect children and teens against 16 different diseases.
Babies born at just 22 to 24 weeks of pregnancy continue to have Consider the following:
sobering outlooks -- only about 1 in 3 survive.
“Immunizing infants, children and adolescents is important, and
should not be delayed.
But according to a new I’m
studyalso
ledconcerned that children
by Duke Health who have
and appearing Feb. Surveys show hospital
missed vaccines,
16th in the have also
New England Journalmissed other health
of Medicine, those care
rates that occurs
are showing
small those
during but measurable improvement.
visits, including Compared
physical exams, to extremely screen-
developmental preterm support groups are being
babies
ings, andborn a decade
other important earlier,
care thethatstudy found
should not abelarger percentage are
delayed. widely underutilized
developing into toddlers without signs of moderate or severe by parents.
cognitive and motor delay.
“We know parents are worried. We want to reassure all our families
that pediatricians
Changes have innovated
to prenatal ways togreater
care, including make visits
use even safer, in-in
of steroids
cluding
mothers setting
at riskdifferent hours
for preterm or locations
birth, could haveforcontributed
well and sick children,
to increased And only 10% of NICUs
survival sanitation
rigorous and fewer and signs of developmental
cleaning practices, delay in these infants,
and conducting the
portions surveyed connect parents
ofauthors
visits bysaid.
telehealth. The American Academy of Pediatrics urges all
with non-hospital
parents to contact their pediatrician to schedule a visit to catch up on
"The findings are encouraging," said lead author Noelle Younge, MD, support.
vaccines or for a and
a neonatologist well-child check-up.
Assistant ProfessorAAPof has published
Pediatrics new rec-
at Duke. "We
ommendations
see evidence of today to guide pediatricians
improvement over time. Butin we
managing
do needvisits safely
to keep an
and
eyeeffectively.
on the overall numbers, as a large percentage of infants born at Graham’s Foundation, the global support
this stage still do not survive. Those who survive without significant
impairment at aboutrestrictions
age 2 are stilltoatliftrisk for the
numerous organization for parents going through the journey
“As social distancing begin around country other
and
challenges to their overall health." of prematurity, set out to find the missing piece that
people begin to circulate, children and teens who are not vaccinated
will beresearchers
at higher risk for contracting a disease thatinfants
could be prevented would ensure all parents have real access to the
The analyzed the records of 4,274 born between
bythea vaccine.
22nd and While we wait
24th week for scientists
of pregnancy, farand doctors
earlier than to
thedevelop a
37 to 40
support they need.
vaccine
weeks for
of acoronavirus, let’s workThe
full-term pregnancy. together
babiestowere
protect our children
hospitalized at in
11
academic
every medical
way that centers
we can, in the Neonatal Research Network, part of
today.” See what they found by emailing
the Eunice Kennedy Shriver National Institute of Child Health and [email protected] to request a free copy
Human Development at the National Institutes of Health.
### of the 2017 whitepaper, “Reaching Preemie Parents
About 30% of infants born at the beginning of the study (between 2000 Today” (Heather McKinnis, Director, Preemie Parent
TheandAmerican Academy
2003) survived. ofproportion
That Pediatricsincreased
is an organization
to 36% forof babies
67,000born
pri- Mentor Program, Graham’s Foundation).
mary carethe
toward pediatricians,
end of thepediatric medical
study (from 2008subspecialists
to 2011), withandthe
pediat-
best
ricoutcomes for childrendedicated
surgical specialists born at 23toand 24 weeks.
the health, Overall
safety survival for
and well-being
ofbabies
infants,born at 22 adolescents
children, weeks remained
and the same
young throughout
adults. theinforma-
For more study, at You may be surprised to see what NICUs are doing
just 4%.
tion, visit www.aap.org and follow us on Twitter @AmerAcadPeds right and where their efforts are clearly falling short.
Over the 12-year study period, the proportion of infants who survived but
Media Contact:
were found to have cognitive and motor impairment at 18 to 22 months
Lisa Black
stayed about the same (about 14% to 16%). But the proportion of babies Graham’s Foundation empowers parents of premature babies through
who survived without evidence of moderate or severe neurological
630-626-6084 support, advocacy and research to improve outcomes for their
impairment improved from 16% to 20%.
[email protected] preemies and themselves.
"Researchers in the Neonatal Research Network reported in 2015

NT
that survival was increasing in this vulnerable population," Younge
said. "One concern was that the improved survival might have been
accompanied by a greater number of infants who went on to have
impairments in the long term, such as cerebral palsy, developmental
_____________________________
delay, hearing and vision loss. However, we actually are seeing a
slight improvement. Because children continue to develop over
Maternal obesity linked to increased
years, it's important to continue to track this data so families and
providers can make the best decisions in caring for these infants."
Visit www.GrahamsFoundation.org to learn more.
risk of early-onset neonatal sepsis

Improvements in survival and neurodevelopment may be the result of a
_____________________________
number of factors, including declining rates of infection in the infants, along
creases
of
with maternal obesity, according to a new study of University
the study, 58% of the expectant mothers had received steroids to boost
Michigan and the Karolinska Institute in Sweden.
with the intake
Maternal increased
mayuse of steroids
be related in expectant
to sepsis risk. mothers that can help fetal development. That figure increased to 64% by the end of the study.
mature and strengthen the fetus's lungs prior to birth. At the beginning of
Lead researcher Eduardo Villamor, a professor of epidemiology at
17-Jun-2020 12:45 PM EDT, by University of Michigan
U-M's School of Public Health, said the study builds on previous re-
search into exposure to motherly obesity and health risks to the baby.
ONewswise — The risk of early-onset neonatal bacterial sepsis in-
NEONATOLOGY TODAY t www.NeonatologyToday.net t April 2017 19

The study has been published in Clinical Infectious Diseases.
"We had found that maternal obesity is related to adverse pregnancy

outcomes and to some adverse developmental outcomes for the
children, such as cerebral palsy and epilepsy," Villamor said. "Now
we found that maternal obesity is also related to increased risk of
early-onset neonatal bacterial sepsis.
"Sepsis, popularly known as blood poisoning, is a generalized bacte-

rial infection that can be fatal, and even in children who survive it can
have long-lasting consequences, especially in terms of neurodevel-
opment."
Villamor and colleagues used a nationwide population-based retro-

spective cohort of about 1.9 million live singleton infants born in Swe-
den between 1997 and 2016.
The infants were followed through their first three days of life for a
culture-confirmed sepsis diagnosis. Mothers were categorized per
weight (BMI). The researchers also considered co-variables such as
maternal age, country of origin, education level, cohabitation with a
partner, smoking during pregnancy and year of delivery.
Villamor said sibling comparisons offered a unique opportunity to en-

hance causal inference by controlling associations for confounders
shared within families.
"By making comparisons within the family, between full siblings with
the same mother and father, you are basically controlling for every-
thing that does not change over time, like genetics, and some pre-
disposing characteristics," he said. "If you find that the association is
the same in the within-family comparison as it is in the conventional
comparison of children independent of kinship, that enhances your
ability to say there may be a causal link here.
"In the comparison among siblings, we found that when a child had
had sepsis, the mother had a higher BMI before pregnancy than
when she gave birth to the baby that did not have sepsis. One ex-
tra BMI unit between pregnancies, which is equivalent to about 6
pounds for a woman of average height and weight in this population,
would translate into an 8% increase in risk of sepsis for the baby."
Villamor said they were able to map out how the risk process might
lead from the mother having obesity to the child having sepsis. Ma-
ternal obesity increases the risk of preeclampsia, which leads to an
emergency cesarean section. Often, preeclampsia happens before
term.
"If you have a combination of these events, that could explain about
50% of the potential effect of maternal obesity on sepsis," Villamor
said. "The babies of preeclamptic mothers have fewer bacteria-fight-
ing cells in their blood, so they might be more likely to get infected.
"If they're born before term, their immune system might be immature
because it didn't have time to develop in utero. And if the mother un-
dergoes emergency C-section, that also puts them at a higher risk of
infection because it is an emergency surgical procedure."
Villamor said the research may also point to a clinical solution to pre-
vent sepsis among newborns: when mothers with obesity need an
emergency C-section, they might benefit from a higher dose of pro-

phylactic antibiotics than what is usually prescribed. Study: Maternal obesity and risk of early-onset neonatal bacterial
sepsis
"Until now, there was not a clear clinical reason to do it, but it was a
practice based on lab studies that showed that due to the obesity the Eduardo Villamor
antibiotics might not reach the concentration needed to be effective,"
he said. "This work contributes strong evidence as to why doctors NT
should really consider increasing the antibiotic dose when they have
to do preoperatory prophylaxis on a mother with obesity."
In addition to Villamor, authors included Mikael Norman, Stefan Jo-

hansson and Sven Cnattingius, all of the Karolinska Institute.

Peer Reviewed
Neonatology Solutions NICU Directory:

The Directory is finally completed!
Scott Snyder, MD
“We would like to provide a humble

'thank you!' to the 5,368 new users
of Neonatology Solutions since our
inception just 10 months ago!"
Now that the Neonatology Solutions U.S. NICU Directory is use links on the website or email me directly at Scott@Neona-
complete, we have assembled State Summary Pages for each tologySolutions.com.
state to provide additional resources and information to our us-
ers. These summaries include total bed numbers per state, https://neonatologysolutions.com/state-summary/
broken down by Level. Additionally, Neonatology Group data,
We would like to provide a humble 'thank you!' to the 5,368
Fellowship Program information, Job Postings, Conferences,
new users of Neonatology Solutions since our inception just 10
and state-based neonatal resources such as hospital associa-
months ago!
tions and March of Dimes Chapters links are all included.
Stay healthy!"
“Additionally, Neonatology Group data, Thank you!!
Fellowship Program information, Job References:
Postings, Conferences, and state-based 1. https://neonatologysolutions.com/explore-nicus-and-pro-

grams/
neonatal resources such as hospital
The author is a principal of Neonatology Solutions, LLC.
associations and March of Dimes
Chapters links are all included." NT
Our goal continues to be able to provide the most comprehen-
sive, accessible, up-to-date, and free web source for all profes-
sionals providing care to neonates.
Suggestions for additional content can be sent via the easy-to-
Scott Snyder, MD, FAAP

System Medical Director
St. Luke’s Neonatology
Founder
Neonatology Solutions, LLC
Scott Snyder [email protected]

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Peer Reviewed
Kabuki Syndrome in a Newborn with a Complex Left-

Sided Cardiac Lesion and Persistent Hypoglycemia due
to Hyperinsulinism
Subhadra Ramanathan MS, MSc, Robin Dawn Clark MD
Genetics Evaluation:
Case History:
Because of restrictions due to the coronavirus pandemic, this
A genetics consult was requested for a 6-week old term female evaluation was done at a distance. The infant was in the cardiac
infant for suspected Kabuki syndrome because of persistent hypo- intensive care unit at the time of consult. Video examination of the
glycemia and presumed hyperinsulinism. This infant had Shone's infant was facilitated by unit staff. The examination revealed a
Complex, severe hypoplastic transverse arch, and coarctation of dysmorphic infant with microcephaly and hypotonia. She had long
the aorta. Her heart defect had been detected prenatally on fetal palpebral fissures that were everted laterally and faint eyebrows.
ultrasound. The pregnancy was complicated by polyhydramnios She had prominent fetal pads on all fingertips.
in the third trimester. The baby was born at term to a 31-year old
G4P2112 mother with these growth parameters: Her clinical features, including the cardiac defect, hypoglycemia,
facial features, and fetal finger pads, suggested Kabuki syn-
Birth weight: 2965 g (6 lb 8.6 oz) (21.97th percentile) drome (KS) to the care team, and the genetic consultant agreed.
Birth length: 49.5 cm (19.49") (39.05th percentile) Genetic testing was ordered for the causative genes, KMT2D
Birth head circumference: 34 cm (13.39") (50.01st percentile) and KDM6A, which detected a pathogenic variant in KMT2D:
c.15250del, confirming the clinical diagnosis. This novel variant is
Her heart defect was the initial focus of medical attention, and predicted to result in a frameshift and premature protein termina-
she had cardiac surgery at one week of age: modified Norwood tion: p.Leu5084Cysfs*6.
procedure, open atrial septectomy, right modified Blalock-Taussig
shunt, and PDA ligation. Her postoperative course was compli-
cated by two further aortic arch reconstruction procedures, plica- “The cardinal signs of Kabuki syndrome
tion of the right hemidiaphragm, and gastrostomy tube placement.
Hypothyroidism was treated with Synthroid. Chromosome micro-
(KS) make it possible to recognize in
array analysis was normal. the newborn period, although it is often
not diagnosed until later in infancy or
“Her postoperative course was childhood.”
complicated by two further aortic
arch reconstruction procedures, Discussion and counseling:
plication of the right hemidiaphragm, The cardinal signs of Kabuki syndrome (KS) make it possible to
and gastrostomy tube placement. recognize in the newborn period, although it is often not diagnosed
until later in infancy or childhood. There are characteristic dysmor-
Hypothyroidism was treated with phic facial features with long palpebral fissures and lateral ever-
Synthroid. Chromosome microarray sion of the lower lid. This appearance evoked the dramatic makeup
used by traditional Kabuki actors, which is how the syndrome got
analysis was normal.” its name. Eyebrows are arched and sparse laterally. The palate
may be a cleft palate. Skeletal anomalies include brachydactyly,
rib and vertebral anomalies, and hip
Although early glucose levels were stable at 50-70 until ten days dislocation. The prominent fetal pads
of age, by postoperative day 2, she had hypoglycemia (glucose persist in almost all affected infants.
29), treated with D25 bolus x1. By one month of age, she had There is mild to moderate intellectual
persistent hypoglycemia. She required progressively more glu- disability and postnatal growth defi-
cose to stabilize her: first D10 bolus x5, then continuous IV D15 ciency. About 70% of patients with
and, subsequently, D30. She had been weaned to D25 at the KS have a congenital heart defect,
time of the Genetics consultation. She had detectable levels of most commonly left-sided obstruc-
insulin during her hypoglycemic episodes, which, with a low beta- tive lesions.
hydroxybutyrate level, suggested hyperinsulinism. Subsequently,
she had a trial of Diazoxide, which was discontinued in favor of The composite face in Figure 1 is a
octreotide. Currently, at 12 weeks of age, her glucose levels are visualization of the KS phenotype
normal without treatment. in an infant that was generated by

Face2Gene. This resource for phenotype matching is available References:
at https://app.face2gene.com (and at the App store). This HIPAA 1. Niikawa N, Kuroki Y, Kajii T, et al. Kabuki makeup (Niikawa-
compliant app can be used to upload and analyze patient photo- Kuroki) syndrome: a study of 62 patients. Am J Med Genet.
graphs. Facial measurements and clinical features are used to 1988;31(3):565-589. PMID: 3067577
match patient phenotypes with known genetic syndromes. 2. Yap KL, Johnson AEK, Fischer D, et al. Congenital hyper-
insulinism as the presenting feature of Kabuki syndrome:
Transient hypoglycemia is common in all neonates. When it per- clinical and molecular characterization of 9 affected individu-
sists, it can be due to dysregulated insulin secretion by the pancre- als. Genet Med. 2019 Jan;21(1):233-242. Erratum in: Genet
atic β-cells, with the high insulin level causing recurrent episodes Med. 2018 Aug 11. PMID: 29907798.
of hypoglycemia. About 8-10% of patients with KS have neonatal 3. https://app.face2gene.com
or infantile hypoglycemia. Although hypoglycemia in response to
hyperinsulinism (HI) was considered rare, occurring in less than The authors have no relevant disclosures.
1% of newborns with KS, this is the second affected patient seen
in our institution, which is why the cardiac care team queried the NT
diagnosis of KS. In their review of 10 patients with Kabuki syn-
drome, Yap et al. noted that patients with HI do not necessarily
present with high insulin levels, but they have inappropriate levels
of insulin for their glucose measurements. Nine of the ten children
with KI and hyperinsulinism reported by Yap responded to diazox-
ide therapy alone, but one did not, and that child required a partial
pancreatectomy. These authors note that about 1% of neonates
with HI have Kabuki syndrome. The underlying mechanism for the
transient hyperinsulinism in KS is yet to be discerned. Growth hor-
mone deficiency and adrenal insufficiency have been proposed as
possible contributing factors.
Patients with Kabuki syndrome also have other endocrine per- Subhadra (Subha) Ramanathan, M.Sc., M.S.
turbances, such as early breast development in girls, precocious Licensed and Certified Genetic Counselor
puberty, growth hormone (GH) deficiency, hypothyroidism, and Assistant Professor, Pediatrics
diabetes insipidus; abnormal pituitary findings on magnetic reso- Loma Linda University Health
nance imaging have been rarely reported, with GH deficiency be- 2195 Club Center Drive, Ste A
ing the most common finding. Ongoing surveillance for endocrine San Bernardino, CA 92408
dysfunction is recommended in patients in KS. [email protected]
Practical applications:
1. Consider Kabuki syndrome in infants with long palpebral fis-

sures and multiple congenital anomalies, especially those
with left-sided cardiac lesions, with or without persistent hy-
poglycemia.
2. Investigate persistent hypoglycemia with insulin levels to

document inappropriate or elevated insulin levels associated
with hyperinsulinism. Robin Clark, MD
Professor, Pediatrics
3. Utilize phenotype-matching resources such as Face2Gene:
Loma Linda University School of Medicine
https://app.face2gene.com
Division of Genetics
Department of Pediatrics
4. Confirm the clinical diagnosis of a genetic disorder with
[email protected]
genetic testing whenever possible. This informs short-term
management, long-term surveillance and ends the diagnos-
tic odyssey for families and clinicians alike.

ODAY CONGENITAL
TODAY

Editors: Martin, Gilbert, Rosenfeld, Warren (Eds.)
Common Problems in the Newborn Nursery

An Evidence and Case-based Guide
 Provides practical, state of the art management
guidance for common clinical problems in the newborn
nursery
 Written by experts in the field in a clear, easy-to-use
format
 Utilizes a case-based approach
This comprehensive book thoroughly addresses common clinical challenges in newborns, providing an
evidence-based, step-by-step approach for their diagnosis and
management. Common Problems in the Newborn Nursery is an easy-to-use, practical guide, covering a
full range of clinical dilemmas: bacterial and viral infections, jaundice, hypoglycemia, hypotonia,
nursery arrhythmia, developmental dysplasia of the hips, newborn feeding, cardiac problems, late
preterm infants, dermatology, anemia, birth injuries, ocular issues, and hearing assessments in the
newborn.
Written by experts in their fields, each chapter begins with a clinical case presentation, followed by a
discussion of potential treatment and management decisions and various differential diagnosis. Correct
responses will then be explained and supported by evidence-based literature, teaching readers how to
make decisions concerning diagnosis encountered on a daily basis.
While this guide is directed towards health care providers such as pediatricians, primary care
physicians, and nurse practitioners who treat newborns, this book will also serve as a useful resource
for anyone interested in working with this vulnerable patient population, from nursing and medical
students, to nurses and residents in pediatrics or family practice.
ORDER NOW!
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Peer Reviewed
40% of Babies Denied Preventive Treatment by Insurers

Susan Hepworth, Mitchell Goldstein, MD A recently released Institute for Patient Access report card exam-
ines insurance claims for palivizumab, the preventive treatment
that protects premature infants from RSV. The report card sum-
marizes claims from January through December 2019, including
data from both commercial plans and Medicaid.
• Key Findings
• “Gap” Babies
Premature infants born between 29 and 36 weeks gestation are
subject to high rates of denial.
The National Coalition for Infant Health is a collaborative of
more than 180 professional, clinical, community health, and
• 40% denied by commercial plans
community
family health,focused
support organizations and family support
on improving the lives of • 25% denied by Medicaid
organizations
premature infants throughimproving the families.
age two and their lives ofNCfIH’s
mission is to promote These infants are sometimes called “gap” babies because they fall
premature infantslifelong
and clinical, health, education,
their families through and
into an insurance coverage gap. They have a higher gestational
supportive services needed by premature infants and their fam-
education
ilies. NCfIH prioritizes safetyand advocacy.
of this vulnerable population and age than severely premature infants, who are generally covered
access to approved therapies. by insurance policies, and a lower gestational age than term ba-
bies, who may not need palivizumab.
Health plans regularly deny coverage for preventive RSV treat-
Dr. Parents of premature babies face enough challenges. Trying ment for infants born 29-36 weeks gestation based on 2014 clini-
to access medication that could keep their baby safe from respira- cal guidelines suggesting that only severely premature infants
tory syncytial virus, a potentially deadly disease, shouldn’t be one needed protection. This recommendation has the effect of keep-
of them. But new national data shows that’s the case. ing babies from getting the preventive treatment their health care
providers have prescribed.


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FDA label

National Access Report Card | April 2020
National Statistics
Respiratory Syncytial Virus
About Respiratory Syncytial Virus

Respiratory syncytial virus, or RSV, is a contagious seasonal respiratory virus that can cause
bronchiolitis and pneumonia. It is also the leading cause of hospitalization in babies less than
one year old.1 RSV can be deadly for premature infants and at-risk infants with congenital
heart disease or chronic lung disease.
Preventive treatment called palivizumab can protect infants from RSV, but national claims
data shows certain babies aren’t getting access to this FDA-indicated therapy.
National Health Plan Coverage & Access

A national data supplier provided palivizumab claims for Medicaid and commercial health
plans across the nation from January 2019 through December 2019.
“Gap” Babies
Health plans deny 40% of
Commercial Plans Denied
palivizumab prescriptions for
40% premature infants born between
29 and 36 weeks gestation.
Medicaid: 25%
“In-Guidance” Babies
One in every four prescriptions
Commercial Plans Denied
is denied for infants who should
25% qualify for coverage under
standard insurance policies.
Medicaid: 14%
This includes severely premature infants born before 29 weeks gestation, babies born
before 32 weeks gestation who have chronic lung disease, and babies born with congenital
heart disease.
instituteforpatientaccess.org facebook.com/patientaccess @PatientAccess

36 weeks gestation, are left unprotected. These preterm infants are called “gap” babies due
to the insurance coverage gap they fall into.
IN-GUIDANCE BABIES GAP BABIES

25% Denied 40% Denied
(Weeks) 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Severly Premature Infants Premature Infants Term Infants
“In-Guidance” Babies References:

1. Nair H, Nokes DJ, Gessner BD, et al. Global burden of acute
Perspective
Even one in four high-risk babies typically covered by insurance
policies is going without the preventive RSV treatment their health
lower respiratory infections due to respiratory syncytial virus
in young children: a systematic review and meta-analysis.
care provider prescribed.
Disparities in access stem from 2014 guidelines fromLancet May 1 2015;
the American 375(9725):1545-
Academy 55.
of Pediatrics
Committee on Infectious Disease, which 2. The
recommend Impact-RSV
limiting the Study Group.
medication to Palivizumab,
only severely a humanized
• 25% denied by commercial plans respiratory syncytial virus monoclonal antibody, reduces
premature infants. Since the implementation of these guidelines, studies
hospitalization have shown
from respiratory an virus infection in
syncytial
• 14% denied by Medicaid
increase in hospitalizations related to RSV. 3 high-risk infants. Pediatrics Sep 1998; 102(3 Pt 1):531-7.
These “in-guidance” babies are severely premature babies born be- 3. Kong AM, Krilov LR, Fergie J, et al. The 2014-2015 National
The data
fore 29 weeks gestation, provided
babies in this
born before 32report card confirms
weeks gestation with that the guidelines
Impact have
of the 2014 createdAcademy
American substantial
of Pediatrics Guid-
barriers
chronic lung disease, for vulnerable
and babies infants whose
born with congenital ance for prescribe
health care providers
heart disease. Respiratorypreventive
Syncytial Virus
RSVImmunoprophylaxis
therapy. on
Preterm Infants Born in the United States. Am J Perinatol.
2018 Jan;35(2):192-200.
“Those Reference
faced with the challenge of
bringing virus
home a children:
preemie or at-risk
1. Nair H, Nokes DJ, Gessner BD, et al. Global burden of acute lower respiratory infections due to respiratory syncytial
in young a systematic
Disclosures: The author does not have any relevant disclosures.
review and meta-analysis. Lancet May 1 2015; 375(9725):1545- 55.
infant have enoughStudy
2. The Impact-RSV onGroup.
their mind.aThey
Palivizumab, humanized respiratory syncytial virus monoclonalNT antibody, reduces
hospitalization from respiratory syncytial virus infection in high-risk infants. Pediatrics Sep 1998; 102(3 Pt 1):531-7.
shouldn’t have to fight their insurance
3. Kong AM, Krilov LR, Fergie J, et al. The 2014-2015 National Impact of the 2014 American Academy of Author
Corresponding Pediatrics
companyGuidance
for a medication that can
for Respiratory Syncytial Virus Immunoprophylaxis on Preterm Infants Born in the United States. Am J
Perinatol. 2018 Jan;35(2):192-200.
protect their baby from complications of
infectious disease.”
Reactions
The rejection of prescriptions for at risk infants concerns infant
health providers. Just ask The
National Coalition for Infant Susan Hepworth
Institute for Patient AccessHealth
is a physician-led nonprofit 501(c)(3) research
Medical Director Mitchell Goldstein, organization
MD. Director
highlighting the benefits of patient-centered care.
National Coalition for Infant Health
“Now more than ever, we’re aware of the importance of prevent- 1275 Pennsylvania Ave. NW, Suite 1100A
ing infectious disease,” Dr. Goldstein said. “Those faced with Washington, DC 20004
the challenge of bringing home a preemie or at-risk infant have [email protected]
enough on their mind. They shouldn’t have to fight their insurance
instituteforpatientaccess.org facebook.com/patientaccess @PatientAccess
company for a medication that can protect their baby from compli-
cations of infectious disease.”
Suzanne Staebler, DNP, noted that the issue is not a new one.
“This data confirms what we’ve been seeing for years,” Staebler
explained, “that misguided policies are putting fragile babies at
unnecessary risk. Clinicians prescribe this preventive treatment
to vulnerable infants because they need it.”
Preventing RSV
While most children get RSV before the age of two, the virus can
be deadly for premature infants with underdeveloped lungs and Mitchell Goldstein, MD
immature immune systems. RSV is the leading cause of hospital- Professor of Pediatrics
ization for children under age one. Loma Linda University School of Medicine
Division of Neonatology
Palivizumab is FDA approved for all premature infants, all infants Department of Pediatrics
with congenital heart disease and infants born before 32 weeks [email protected]
with chronic lung disease. The preventive medication reduces
RSV infections and decreases hospitalizations by 55%.

National Coalition for Infant Health Values (SANE) OPIOIDS and NAS
Safety. Premature infants are born vulnerable. Products, treat- When reporting on mothers, babies,
ments and related public policies should prioritize these fragile and substance use
infants’ safety.
Access. Budget-driven health care policies should not pre-
LANGUAGE MATTERS
clude premature infants’ access to preventative or necessary
therapies. I am not an addict.
Nutrition. Proper nutrition and full access to health care keep I was exposed to substances in utero.
premature infants healthy after discharge from the NICU. I am not addicted. Addiction is a set of
behaviors associated with having a
Equality. Prematurity and related vulnerabilities disproportion- Substance Use Disorder (SUD).
ately impact minority and economically disadvantaged families.
Restrictions on care and treatment should not worsen inherent
disparities. I was exposed to opioids.
While I was in the womb my mother and I
shared a blood supply. I was exposed to
the medications and substances she
used. I may have become physiologically
dependent on some of those substances.
NAS is a temporary and

treatable condition.
There are evidence-based pharmacological
and non-pharmacological treatments for
My mother may have a SUD.

diagnosis. My drug exposure will not
determine my long-term outcomes.
But how you treat me will. When you
and wellbeing by supporting
Medicaid and Early
Readers can also follow Childhood Education you
can expect that I will do as
NEONATOLOGY TODAY well as any of my peers!

@NEOTODAY Learn more about
at www.nationalperinatal.org



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Peer Reviewed
From The National Perinatal Information Center:

Making the Case: Accuracy of Race and Ethnicity Data Reporting
Elizabeth Rochin, PhD, RN, NE-BC ever, these recommendations show a wide variation on accep-
tance and implementation. To further illustrate the use of "un-
known" or "other," specifically highlighted are Severe Maternal
The National Perinatal Information Center (NPIC) is driven Morbidity (SMM), Severe Maternal Morbidity (SMM) among
by data, collaboration and research to strengthen, connect Hemorrhage Cases, and Neonatal birth weights of < 2500
and empower our shared purpose of improving patient care. grams and < 1500 grams, respectively.
For over 30 years, NPIC has worked with hospitals, public AIM Severe Maternal Morbidity (SMM):
and private entities, patient safety organizations, insurers
and researchers to collect and interpret the data that drives The National Perinatal Information Center provides Alliance for
better outcomes for mothers and newborns. the Innovation of Maternal Health (AIM, https://safehealthcare-
foreverywoman.org/aim-data) comparisons that can provide
comparisons for the organization, as well as an overall bench-
marked rate. During the period 04/01/2018 – 03/31/2019, the
following trends were noted:
OIn July 2017, National Public Radio and ProPublica launched

the Lost Mothers series. This was a turning point in the national
conversation for maternal mortality; however, it created frustra-
tion and concern for those national organizations and hospi-
tals who had been sounding the alarm of maternal mortality for
years prior to this catalyst.
With the recent events surrounding racial inequality and injus-

tice that have again surfaced throughout the United States,
bringing data to this discussion continues to be a critical ele-
ment to supporting hospitals, perinatal and neonatal units with
their disparities reduction efforts. It is important to note that
within this discussion, the race is not a risk factor, and should AIM Severe Maternal Morbidity among Hemorrhage Cases
never be considered as such.
Again, Black women reveal the highest rate within races of
The National Perinatal Information Center provided an over- SMM among hemorrhage cases; however, there is an important
view of Racial and Ethnic Disparities data to its members in the facet of this data that cannot be overlooked. "Other" and "Un-
fall of 2019. This information was offered to serve as an addi- known" are 13.2% and 21.6% within the cases, respectively. In
tional adjunct to disparity work already underway at many orga- addition, within ethnicity, 28.9% of hemorrhage cases are other
nizations across the United States. However, the large part of or missing. The ability to track and identify racial and ethnic
the following discussion revolves around two unique attributes disparities within organizations and communities relies on ac-
of race and ethnicity reporting: outcome disparities for Black curate reporting of race and ethnicity at the time of admission
women, and completion of data elements in the electronic med- as well as at discharge and processing of the medical record.
ical record, particularly racial and ethnicity data reporting. In This information highlights an important element of data collec-
2009, the National Academies of Sciences, Engineering, and tion that must be a priority for organizations that are intent on
Medicine (formerly the Institute of Medicine) published Race, reviewing and acting upon disparities.
Ethnicity, and Language Data: Standardization for Health Care
Quality Improvement. This document highlighted a number of
recommendations for racial and ethnicity data reporting; how-


Very Low Birthweight (< 1500 grams)
Premature birth is a significant cause of infant and child mor-

bidity and mortality (Glass et al., 2009). Babies weighing less
than 1500 grams at birth can experience significant challenges
to multisystem organ involvement, including high resource uti-
lization and long NICU stays, which can compound challenges
to parental involvement, particularly for those with socioeco-
nomic challenges and other family responsibilities. Based upon
several studies reviewing racial and ethnic disparity in the
NICU environment, Black women are more likely to have more
perceived stress, more depressive symptoms, and less social
support than white women, regardless of income (Grobman et
al., 2018). However, in this particular metric, "Other" and "un-
known" data are much lower than the other metrics described,
which again could reflect multidisciplinary care teams' docu-
mentation processes.
Low Birth Weight (< 2500 grams)
One of the most widely studied birth outcomes is birthweight,

which is affected by conditions before and during pregnancy
that can have an impact on intrauterine growth as well as ges-
tational age (Ro, Goldberg & Kane, 2019). Infant birth weight is
a common measure of infant and maternal health and well-be-
ing (Department of Health and Human Services, 2020). Infants
weighing less than 2500 grams may experience significant cost
and health problems that can exacerbate short and long-term
costs of care. Within races, Black women have the highest rate
of low birth weight babies within the NPIC Perinatal Center Da-
tabase for this specific time period. Studies continue to support
the finding that non-Hispanic Black women have the highest
risk of low birthweight newborns, related to social determinants
of health (SDOH) and "weathering," described in 1996 within
a study of African American maternal age and birth weight as
the "erosion of health of African American women as a result of
social inequity" (Geronimus, 1996). It is important to note that
race is not being described here as a risk factor. The rate of
"Other" or "Unknown" within races, as well as "Missing" within Discussion and Recommendations:
ethnicity, is reduced for this data point, which may reflect both
perinatal and neonatal documentation teams for racial and eth- Based upon the NAESM/IOM Race, Ethnicity, and Language
nicity reporting. Data: Standardization for Health Care Quality Improvement
subcommittee report, here are several of the standardized rec-
ommendations for enhancing and improving race and ethnicity
reporting:
1) Self-Reporting: The opportunity for patients to directly

self-report their race and ethnicity into an electronic health
record with the expectation of privacy and confidentiality
cannot be overstated. According to Polubriaginof and col-
leagues (2019), when patients directly recorded their race
and ethnicity, 86% provided clinically meaningful informa-
tion, and 66% of patients reported information that was
discrepant with the electronic health record.
2) Training for frontline teams responsible for race and eth-

nicity reporting: According to the Subcommittee literature
review, the comfort level of clinical teams and admissions/
intake personnel was varied, and depending upon that
comfort level, data may have been assumed and entered
without expressly engaging with the patient. This discom-
fort was found to occur broadly and was not exclusive to
one race of clinicians. Assuring adequate training of the
importance of data reporting, as well as recognition of im-

plicit bias, provides a foundation for data reporting pro-
cess improvement.
3) Interoperability of Electronic Health Records and data re-

porting: Organizations attempt to refine and build racial
and ethnic reporting matrices that meet their own individ-
ual and system needs, but may create challenges when
attempting to compare themselves to others throughout
the US. OMB standards for data reporting may afford con-
sistency in not only monitoring data within a hospital or
system but also may be beneficial in benchmarking dis-
parity improvement processes across organizations and
nationally.
References:
Department of Health and Human Services. (2020). Medic-
aid. Live births under 2,500 grams. https://www.medicaid.
gov/state-overviews/scorecard/live-births-weighing-less-than-
2500-grams/index.html
Geronimus, A. T. (1996). Black white differences in the rela-
tionship of maternal age to birthweight: A population-based
test of the weathering hypothesis. Social Sciences Medicine,
42(4), 589-97.
Glass, H.C., Costarino, A. T., Stayer, S.A., Brett, C. Cladis,
F. & Davis, P. J. (2015). Outcomes for extremely premature
infants. Anesthesia & Analgesia, 1337-1351.
Grobman, W. A., Parker, C.B., Willinger, M…Reddy, U.M.
(2018). Racial disparities in adverse pregnancy outcomes and Available on Amazon
psychosocial stress. Obstetrics & Gynecology, 131(2), 328-
335.
Institute of Medicine. 2009. Race, Ethnicity, and Language
Data: Standardization for Health Care Quality Improvement.
Washington, DC: The National Academies Press.
Ro, A., Goldberg, R. E. & Kane, J.B. (2018). Racial and ethnic
patterning of low birth weight, normal birth weight and macro- NEONATOLOGY TODAY
somia. Preventive Medicine, 118, 196-204.
The author has no conflicts of interests to disclose. @NEOTODAY
NT
Corresponding Author:
Elizabeth Rochin, PhD, RN, NE-BC

President
National Perinatal Information Center
225 Chapman St. Suite 200
Providence, RI 02905
401-274-0650
[email protected]

RSV AWARENESS:
A National Poll of Parents & Health Care Providers
Respiratory syncytial virus, or RSV, is far from the monitor for the virus, which they report seeing
common cold. It can lead to hospitalization, lifelong regularly in their practices. Parents, however, feel
health complications or even death for infants and unequipped to protect their young children.
young children. In fact, it is the leading cause of
Meanwhile, specialty health care providers
hospitalization in children younger than one.
overwhelmingly report that health plan rules and
Yet a national poll of parents and specialty health insurance denials block vulnerable infants’ access
care providers reveals a startling divide in attitudes to preventive RSV treatment. Such barriers can put
toward the virus. While both groups acknowledge unprepared parents at a double disadvantage. The
RSV as a significant concern, the two populations survey does suggest, however, that education can
vary widely in their reported ability to meet RSV’s embolden parents to seek more information about
threat head-on. Health care providers vigilantly RSV and take steps to protect their children.
KEY FINDINGS
Preparedness
Parents of children age four and under report that Specialty health care providers reiterated these
understanding of RSV is lacking. That leaves them concerns; 70% agreed that parents of their patients
less than fully prepared to prevent their young have a low awareness of RSV. Meanwhile, specialty
children from catching the virus. health care providers themselves actively monitor
for RSV. They reported that:
PARENTS SPECIALTY HEALTH CARE PROVIDERS
Only 18% said parents know They treat RSV as a priority,

“a lot” about RSV, reflecting “often” or “always” evaluating
an awareness level that’s 18% 80% their patients (80% doctors;
roughly half that of the flu 78% nurses)
During RSV season, they

Only 22% of parents consider are especially vigilant about
themselves “very well
prepared” to prevent RSV.
22% 98% monitoring patients for
symptoms or risk factors
for RSV (98%).
1
Peer Reviewed
Clinical Pearl:
Aspects of Care of Newborns Born to Mothers with
Suspected/Confirmed Coronavirus-19 (COVID-19) Disease
In our May issue, a number of clinically helpful articles were “In contrast, from April 2-April 29, 2020,
presented, including a practical guide for the neonatologist by all patients admitted for childbirth to 3
Smith and Sharma (1-4). I presented a summary of some very
recent data about moms and their newborns (2), and Liu and
Yale-New Haven hospitals in southern
Stovall presented a premature infant who acquired COVID-19 Connecticut without a COVID-19 infection
nosocomially in the neonatal intensive care unit (NICU) (3). Ma,
Zhu, and Du reviewed aspects of neonatal management in China,
diagnosis were also screened, first with
including a clinical summary of 6 term neonates with confirmed clinical questions, then with np swabs
COVID-19 disease, all of whom had a relatively mild illness, did
not require intubation and fully recovered (Table) (4). Levine and and PCR testing (7).”
Goldstein further updated some of the recommendations for the
management of mothers and their newborns in the delivery room, screening with nasopharyngeal swabs (np) and quantitative
mother-baby unit, and the NICU (5). To further update our readers, polymerase-chain-reaction tests (PCR) (6). In contrast, from
I will try to answer some questions about the clinical aspects of April 2-April 29, 2020, all patients admitted for childbirth to 3
COVID-19 infection in pregnant women and newborns. Yale-New Haven hospitals in southern Connecticut without a
COVID-19 infection diagnosis were also screened, first with
How common is COVID-19 infection in asymptomatic pregnant clinical questions, then with np swabs and PCR testing (7). In this
women presenting to Labor and delivery for childbirth? series of 365 asymptomatic patients from April 2-15, 2 (0.5%)
were positive; 20/405 (4.9%) were positive from April 16-29,
Earlier in the pandemic in New York City (March 22-April 4, 2020), 2020 (7). In a personal communication from Dr. Allison Bartlett,
13.7% of 210 women who presented for childbirth with universal Hospital Epidemiologist and pediatric infectious disease specialist
TABLE. Clinical Characteristics of 6 Covid-19 Neonatal Cases in China

MOTHER SARS- HEST PHARYNGEAL/RECTAL
PATIENT/ CLINICAL COV-2RNA RADIOGRAPH/ SWAB FOR SARS-
CITY AGE PRESENTATIONSa RESULT CT SCAN COV-2 GESTATION OUTCOME
b,c
1/Wuhan 30 h Poor feeding, þ �/� þ/� Term Full
fever, vomiting recovery
2/Wuhanb 18 d Vomiting, lethargy �(with typical �/� þ/� Term Full
clinical and CT recovery
findings)
3/Wuhanb 12 d Sneezing (mild), þ �/nonspecific þ/þ Term Full
vomiting, lung recovery
diarrhea markings
4/Wuhanb 3d Fever, lethargy þ �/nonspecific þ/� Term Full
lung recovery
markings
5/Wuhanb 36 h Poor feeding, þ Pneumonia/ þ/� Term Full
lethargy GGO recovery
6/Xinyangd 5d Fever þ �/not done þ/not done Term Full
recovery
CT¼computed tomography; GGO¼ground glass opacity; plus (þ) sign¼positive; minus (�) sign¼negative.
a
None of the patients required intubation.
b
From Xiaoyuan et al. (9)
c
From Wang et al. (10)
d
From news media of hospital report.
Table from Ma X,, Zhu J, Du L. Neonatal management during the Coronavirus disease COVID-19) outbreak: The Chinese experience.
ventilator exhaled2020;21(5):
NeoReviews port viral filters, suction
e293-e297, catheters
with with a
permission STRATEGIES FOR NEONATAL OUTPATIENT FOLLOW-UP
sealed sheath, and disposable ventilator tubing systems, are DURING THE COVID-19 EPIDEMIC
used in the specialized ward or during transport by ambu-
During rigorous quarantine in early February 2020, the
lance. Staff are trained inNEONATOLOGY
infectious disease TODAYtwww.NeonatologyToday.nettJune
control, pre- 2020 118
National Health Commission of China recommended post-
vention, and the use and sequence of protective clothing,
at Comer Children’s Hospital at the University of Chicago, she New Engl J Med 2020; 382(22): 2163-2164.
reports that ~10% of asymptomatic pregnant women presenting 7. Campbell KH, Tornatore JM, Lawrence KE et al. Prevalence
for childbirth were COVID-19 + at the height of the peak (April 15- of SARS-CoV-2 among patients admitted for childbirth in
May 15). However, the rate has been 0 since May 24, 2020. The Southern Connecticut. JAMA 2020; published online May
universal COVID-19 screening recommendation is from the Illinois 26, 2020.
Department of Public Health Perinatal Advisory Committee as 8. Rasmussen SA, Jamieson DJ. Caring for women who are
universal COVID-19 testing is left to the discretion of the individual planning a pregnancy, pregnant or postpartum during the
institutions. This morning I found another update by Rasmussen COVID-19 pandemic. JAMA. Published online June 5, 2020.
and Jamieson in JAMA, which outlines suggested management 9. https://www.aappublications.org/news/2020/05/21/
of pregnant women with suspected/confirmed COVID-19 and covid19newborn052120
their newborn infants (8). These recommendations are based on 10. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html
the information and expert opinion from the American Academy 11. Kirtsman M, Diambomba Y, Poutanen SM et al. Probable
of Pediatrics (AAP) (8,9), Centers for Disease Control and congenital SARS-CoV-2 infection in a neonate born to a
Prevention (CDC) (8,10), and the American College of Obstetrics woman with active SARS-CoV-2 infection. CMAJ 2020.doi:
and Gynecology (ACOG) (8,9). 10.1503/cmaj.200821;early-released May 14, 2020.
12. Gross R, Conzelmann C, Muller JA et al. Detection of SARS-
Is there any new evidence for vertical transmission of CoV-2 in human breastmilk. Lancet published online May
COVID-19 from Mother to Infant? How about COVID-19 21, 2020 https://doi.org/10.1016/S0140-6736(2031181-8.
(SARS-CoV-2) virus in maternal breast milk?
The author has no conflicts to disclose
In a paper by Kirtsman and colleagues, a 40-year-old woman with
NT
familial neutropenia and confirmed COVID-19 infection delivered
an infant at 35 weeks 5 days by cesarean section with intact
membranes. There was no delayed cord clamping, skin-to-skin Corresponding Author
contact, and the infant was taken to a resuscitator 2 meters away
in the same room, did not require resuscitation, and had Apgar
scores of 9 and 9 at one and five minutes of age. A nasopharyngeal
swab from the neonate obtained on the day of birth was positive
by reverse transcription-polymerase chain reaction (RT-PCR)
prior to any contact with the mother (11). The clinical course of
the mother is detailed as well as samples from the placenta, serial
nasopharyngeal samples, and a blood and stool sample from the
infant, which were also positive for COVID-19 (SARS-CoV-2) (11).
This case is labeled as a probable congenital SARS-CoV-2 infection Senior Clinician Educator
because of the lack of detection of the SARS-CoV-2 gene targets Pritzker School of Medicine
in the umbilical cord tissue and the lack of availability of cord blood University of Chicago
for SARS-CoV-2 testing (11). Also, of note, the mother’s breast milk MC6060
was positive, but the baby’s nasopharyngeal swab was obtained 5841 S. Maryland Ave.
prior to breastfeeding contact (11), and contamination of the breast Chicago, IL 60637
milk cannot be ruled out, although breast hygiene was and cleaning Phone: 773-702-7794
was utilized (11). Gross and colleagues report evidence of SARS- Fax: 773-732-0764
CoV-2 by RT-PCR in the breast milk of 2 mothers with SARS-CoV-2 [email protected]
infection post-delivery (12).
References
1. Smith AG, Sharma AM. Fellow column: Clinical quick guide Clinical Pearls are published monthly.
for the neonatologist. Neonatology Today 2020; 15(5): 16-
20. Submission guidelines for “Clinical Pearls”:
2. Hageman JR. Clinical Pearl: COVID-19 pandemic: Mothers
and infants. Neonatology Today 2020; 15(5): 92-93. 1250 word limit not including references or title page.
3. Liu W, Stovall S. Case of a Preterm Newborn with the May begin with a brief case summary or example.
Nosocomial Acquisition of COVID-19 Infection in the Neonatal
Intensive Care Unit and Contact Tracing. Neonatology Today Summarize the pearl for emphasis.
2020; 15(5): 13-17.
4. Ma X,, Zhu J, Du L. Neonatal management during the No more than 7 references.
Coronavirus disease COVID-19) outbreak: The Chinese
Please send your submissions to:
experience. NeoReviews 2020;21(5): e293-e297.
5. Levine G, Goldstein M. Letter to the editor: The coronavirus outbreak: [email protected]
The current state. Neonatology Today 2020; 15(5): 99-100.
6. Sutton D, Fuchs K, D’Alton M, Goffman D. Universal
screening for SARS-CoV-2 in women admitted for delivery.

Peer Reviewed
Insurance Denials of NICU Hospital Claims

Eugene L. Mahmoud, MD nicity of neonatal illnesses. Infants born earlier in gestation
and with more complicated medical courses tend to take longer
With regards to the defined principles of Medical Necessity and to achieve these physiologic competencies.
Standards of Medical Care, there have been significant differ-
ences among those who are primarily involved in patient care The American Academy of Pediatrics (AAP) Private Payer Ad-
among patients, physicians, insurance payers, and hospital advocacy Advisory Committee (PPAAC) identifies opportunities to
ministrations. In general, the concepts of experimental care engage private payers on pediatric issues, coverage and pay-
and investigational care are concluded to be the opposite of ment within the limits of antitrust regulations http://bit.ly/AA-
Medical Necessity and Standards of Care. As it relates to Neo- PHassleFactorForm. Several AAP chapters also have formed
natology, preterm birth and low birthweight birth exert signifi- pediatric councils to meet with local payers on pediatric issues.
cant, medical, social, and economic costs on affected families
and the United States healthcare system. Preterm birth is the To ensure that carriers consider the unique aspects of pediat-
leading cause of neonatal mortality and is a significant cause rics when making coverage determinations, the Academy has
of both short and long-term morbidity and disability. While the implemented a process with Anthem, United Health Corpora-
least mature newborns have the highest average per individual tion, and the Blue Cross Blue Shield Association in which pe-
medical expenditures, data from 2017 showed newborns born diatricians review medical policies that impact children. Such
at 26 weeks gestational age represent 4% of all preterm birth a review does not imply AAP endorsement of a carrier's policy
with the medical expenditure of 22.5%. But the more mature but advises the carrier on how the policy impacts pediatrics and
infants (at 33-36 weeks gestational age) as a cohort represent- pediatricians and advocates for appropriate benefits coverage.
ing approximately 80% of all preterm births have higher total
expenditures at 38%. In addition, these data do not include
mature term gestation newborns with complex congenital heart “To ensure that carriers consider the
conditions or other complex conditions noted at birth.
unique aspects of pediatrics when
“The physician's decision of when to making coverage determinations, the
discharge an infant from the hospital Academy has implemented a process
after a stay in the Neonatal Intensive Care with Anthem, United Health Corporation,
and the Blue Cross Blue Shield
Unit (NICU) is complex.”
Association in which pediatricians review
medical policies that impact children.”
The physician's decision of when to discharge an infant from
the hospital after a stay in the Neonatal Intensive Care Unit
(NICU) is complex. This decision is made primarily on the ba-
sis of the infant's medical status, and whether the specifically A study by the Government Accountability Office found that
indicated care needs may only be accomplished at the acute many denials can be traced to largely trivial bureaucratic is-
hospital level of care or if the care needs may be achieved sues, such as a missing form or an incorrect billing code. The
at a lower level of care – Normal Nursery, a rehabilitation fa- study found that when patients challenged the insurers' deni-
cility, or care at home with care by parents and other health als, about half of the rejected claims ended up being covered.
care professionals (nurses, therapists). Also, NICU Hospital
Discharge is complicated by the readiness of families for dis- Insurers employ warehouses full of claims adjusters who, as a
charge and pressures to contain hospital costs by shortening primary function, scrutinize claims for pretexts of lack of docu-
the length of stay. Insofar as possible, the determination of mentation to deny care, saying it is 'experimental,' 'must abide
the readiness for discharge should be based on current peer- by third party insurance decision guidelines,' or 'not medical-
reviewed scientific evidence. Historically, preterm infants were ly necessary' even when the medical treatment, prescription
discharged only when they achieved a certain weight, typically medication, diagnostic procedure or referral to a specialist is
2250 grams (5 pounds). Currently, randomized clinical trials recommended by doctors.
have shown that earlier discharge is possible without adverse Informed health care leads to the best patient outcomes, avoid-
health effects when preterm infants are discharged on the ba-
sis of physiologic criteria rather than body weight. The three
physiologic competencies that are generally recognized as es-
sential before hospital discharge of the preterm infant are 1.
Oral feeding sufficient to support appropriate growth. 2. The
ability to maintain a normal body temperature in a home envi-
ronment. 3. Sufficient mature respiratory control. These com-
petencies are achieved by most preterm infants between 36
and 37 weeks' postmenstrual age. However, maturation to the
point that allows safe discharge may take longer, occasionally
up to 44 weeks' postmenstrual age. Although interrelated, not
all competencies are achieved by the same postnatal age in a
given infant. The pace of maturation is influenced by the birth
weight, the gestational age at birth, and the degree and chro-

ing underuse or overuse of medical resources. Evidence-based since 1975 are required to provide an internal grievance pro-
care guidelines from Milliman Care Guidelines and InterQual cess, in which an enrollee who was denied coverage of the
Guidelines help providers, and health plans drive informed care desired treatment could appeal the decision. In response to ad-
in their own work and through the conversations that connect ditional appeals to health care organizations, the HMOs insurer
them. Sometimes, there can be confusion when some insur- payers provide an additional external independent medical re-
ance carriers adopt Milliman Care Guidelines, and others adopt view (IRO) for coverage denials. In the external review pro-
InterQual Guidelines. Because when the two guidelines do not cess, health plans, patients, providers, and medical institutions
match exactly, the approval for the NICU level of care can be take their disagreements to a regulatory board. Within this pro-
difficult to interpret. Each care guideline recognizes the four cess, requests for the involvement of reviewing physicians with
NICU levels of care, which include prematurity, severe condi- the same qualifications as those caring for the patient in ques-
tions, mild instabilities, and routine newborn care. However, tion aids in getting a just resolution.
high flow nasal cannula systems (HFNC) deliver oxygen via
a system that heats, humidifies, and then delivers a 24-100% References:
(0.24-1.0) ViO2 at body temperature through nasal cannula 1. Policy Statement: Hospital discharge of the high-risk neo-
prongs, HFNC is used to provide a high flow without causing nate. Pediatrics. 2008;122(5):1119–1126. Available at:
barotrauma. It appears to have similar clinical efficacy and http://pediatrics.aappublications.org/content/122/5/1119.
safety to nasal continuous positive airway pressure (CPAP) as Reaffirmed November 2018
a mode of noninvasive respiratory support. For infants up to 2. Heated, Humidified High-Flow Nasal Cannula Versus Na-
12 months of age, HFNC may be administered at rates as high sal CPAP for Respiratory Support in Neonates Yoder BA,
five (5) liters per minute (LPM). So, some insurance carriers Stoddard RA, Li M, King J, Dirnberger DR, Abbas Si Pe-
may accept HFNC for the highest level of medically necessary diatrics, May 2013, 131 (5) e1482-e1490
care who adopt the InterQual Guidelines, when those insur- 3. Estimates of Healthcare Spending for Preterm and Low-
ance carriers who adopt the only the Milliman Care Guidelines birthweight Infants in a Commercially Insured Population:
may not accept HFNC for newborns requiring the highest level 2008-2016 Beam AL, Fried I, Palmer N, Agniel D, Brat
of medically necessary care. As the Milliman Care Guideline is G, Fox K, Kohane I, Sinaiko A, Zupancic AF, Armstrong J
frequently updated, it is hoped that newborns receiving HFNC Journal of Perinatology (2020)
will be included with those at the highest levels of NICU care. 4. Independent Medical Review of Health Plan Coverage De-
nials: Early Trends Chuang K, Aubry WM, Adams Dudley
R Health Affairs Volume 23, Number 6, pp. 163-169
5. Subspecialists Benefit from AAP Private Payer Policy
“ So, some insurance carriers may accept 6.
Lander et al., AAP News, 2017
AAP continues to resolve issues with health insurance
HFNC for the highest level of medically companies Kressly SA, AAP News, 2019
7. Milliman Care Guidelines MCGTM General Recovery
necessary care who adopt the InterQual Care 17th Edition Introduction to Neonatal Levels of Care
Guidelines, when those insurance 8. InterQual 2017 Acute Pediatric Criteria- Nursery
9. Guide to Clinical Practice Guidelines: the Current State
carriers who adopt the only the Milliman of Play Kredo T, Berhardsson S, Shingai Machingaidze,
Young T, Louw Q, Ochodo E, and Grimmer K Int J Qual
Care Guidelines may not accept HFNC for Health Care. 2016 Feb; 28(1): 122–128.
newborns requiring the highest level of 10. Miles, A., Loughlin M. Models in the balance: evidence-
based medicine versus evidence-informed individuals
medically necessary care.”
For lack of documentation and coding of health care, the in-

surers are justified to deny care. However, these are rare cir-
cumstances. When taking care of extremely sick patients in
the NICU and Pediatric Intensive Care Unit (PICU) meticulous
documenting the complexity of care is reflected in detailed
progress reports and input from specialist consultation. Medi-
cal necessity means health care services that a physician, ex-
ercising prudent clinical judgment, would provide to a patient.
The service must be for the purpose of evaluating, diagnosing,
or treating an illness, injury, disease, or its symptoms. In the
treatment of severely ill patients, the physicians employ thera-
py based on current on peer-reviewed scientific evidence with
the Food and Drug Administration (FDA) support in accordance
with the standard of care.
By means of careful preparation, Neonatologists can minimize
potential audits and defend against inappropriate payer deni-
als and repayment demands. Since the introduction of health
maintenance organizations (HMOs) and other managed care
organizations that perform utilization review, there has been
public concern that decisions about insurance coverage for di-
agnostic and therapeutic services might be based on the cost
to the insurer rather than the clinical appropriateness. HMOs

care. Journal of Evaluation in Clinical Practice (2011)
17(4): 531-536
The author has no conflicts of interests to disclose.

NT
Corresponding Author:
Eugene L. Mahmoud, MD
Medical Reviewer- American Health Health Holding, Advanced
Medical Reviews, Dane Street, Medical Board of California
Past Staff Neonatologist- UCI Medical Center, Orange, CA and
Parkview Hospital Medical Center, Riverside, CA
Cell: (949)-683-0672
Fax: (626)-365-1344
Email: [email protected] or
[email protected]
Mailing address- 360 South Los Robles Avenue, Unit#- 11,
Pasadena, CA 91101

Will your PRETERM INFANT need
EARLY INTERVENTION services?
EARLY INTERVENTION
Preterm infants are:

2x more likely to
have developmental
delays
5x more likely
to have learning
challenges
1 in 3 preterm infants
will require support
services at school
Early intervention can help preterm infants:
Enhance Build more Process social and Address physical Prevent mild
language and effective learning emotional challenges difficulties from
communication techniques situations developing into
skills major problems
Early diagnosis
could qualify babies for their
state's early intervention …but many
services… parents are
unaware.
NICU staff, nurses,

pediatricians and social
workers should talk with NICU
families about the challenges
their baby may face.
Awareness, referral
& timely enrollment
in early intervention
programs can help
infants thrive and grow.
Visit CDC.gov to find contact

information for your state’s early
intervention program.

OPIOIDS and NAS Why PREMATURE INFANTS Need Access
When reporting on mothers, babies, to an EXCLUSIVE HUMAN MILK DIET
and substance use
LANGUAGE MATTERS
I am not an addict.
In the United States, more than
I was exposed to substances in utero. 1 IN 10 BABIES ARE
I am not addicted. Addiction is a set of BORN PREMATURE.
behaviors associated with having a Micro preemies are born
Substance Use Disorder (SUD). severely premature, weighing
less than 1,250 grams.
I was exposed to opioids.

While I was in the womb my mother and I MICRO PREEMIES are NEC occurrence
at risk for Necrotizing increases when a
shared a blood supply. I was exposed to Entercolitis (NEC), which: preemie consumes
the medications and substances she Damages intestinal tissue non-human milk
Causes distended abdomen, infection, products.
used. I may have become physiologically low blood pressure and shock When that happens:
dependent on some of those substances. Threatens infants' lives
17%
NAS is a temporary and 5%

12%
1%
treatable condition. on Exclusive Human
Milk Diet2
on Non-Human
Milk Products
Micro preemies
There are evidence-based pharmacological who get NEC
and non-pharmacological treatments for Micro preemies requiring

surgery to treat NEC
of micro preemies
30% needing surgery
My mother may have a SUD. will die from NEC3

HOW TO HELP PREVENT NEC:
EXCLUSIVE HUMAN MILK DIET
What is an Exclusive Human Milk Diet?
diagnosis. My drug exposure will not NO cow’s milk NO sheep’s milk NO goat’s milk NO formula
mother’s milk
determine my long-term outcomes. human donor milk
human milk-based
But how you treat me will. When you Why Is An Exclusive Human fortifier
Milk Diet Important?
An Exclusive Human Milk Diet gives vulnerable infants the best chance
and wellbeing by supporting to be healthy and reduces the risk of NEC and other complications.
Medicaid and Early

Childhood Education you When a micro preemie can access an
can expect that I will do as EXCLUSIVE HUMAN MILK DIET:
well as any of my peers!

Mortality is Feeding Chances of
reduced by intolerance NEC are reduced
75%2 decreases4 by 77%2
HUMAN MILK = MEDICINE

Learn more about LEARN MORE
at www.nationalperinatal.org 1
Hair AB, et al. “Beyond Necrotizing Enterocolitis Prevention: Improving Outcomes with an Exclusive Human
Milk–Based Diet “. Breastfeeding Medicine DOI: 10.1089/bfm.2015.0134
2
Abrams SA, et al. “Greater Mortality and Morbidity in Extremely Preterm Infants Fed a Diet Containing Cow Milk
Protein Products.” Breastfeeding Medicine July/August 2014, 9(6): 281-285
3
Hull MA et al. “Mortality and management of surgical necrotizing enterocolitis in very low birth weight
neonates: a prospective cohort study.” J Am Coll Surg. 2014 Jun;218(6):1148-55.
4
Assad M, Elliott MJ and Abraham JH. "Decreased cost and improved feeding tolerance in VLBW infants
fed an exclusive human milk diet" Journal of Perinatology advance online publication 12 November 2015;
DOI: 10.1038/jp.2015.168

NEONATOLOGY TODAY
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Why Pregnant and Nursing Women
Need Clear Guidance on
THE NET BENEFITS OF EATING FISH
2 to 3 servings per
week of properly cooked
fish can provide health
benefits for pregnant
women and babies alike:
Iron Omega 3 fatty acids
Earlier Milestones
for Babies
shrimp
salmon
canned
light tuna
pollock
cod
tilapia
catfish
But mixed messages from the media

and regulatory agencies cause pregnant
women to sacrifice those benefits by
eating less fish than recommended.
GET THE FACTS

ON FISH CONSUMPTION
FOR PREGNANT
WOMEN, INFANTS,
AND NURSING MOMS.
LEARN MORE

Letters to the Editor showed a weight of 995 grams, head circumference of 24 cm,
and length of 34.5 cm. The infant was vibrating well on HFOV. A
Failing Jet Ventilator in A Small Premature Infant large omphalocele was noted. There was no heart murmur. Back
showed thoracic scoliosis. No other congenital anomalies were
A male infant was born at 26 5/7 weeks gestation to a 29-year- noted. Pediatric surgery, due to the large mass and prematurity,
“Oh the Places You'll Go”**
old G2P0010. The dates were confirmed with an 8wk ultrasound.
Pregnancy was complicated by class B diabetes. The fetal US
decided to manage conservatively.
showed omphalocele and 2 vessel cord. Amniocentesis was neg- The infant was placed on HFOV with settings of MAP 12, ampli-
By Michael Narvey, MD 1986 – Opening
tude of 30,of 15
the Hz
New NICU
and at Children’s
IT 33%. Hospital
He received surfactant twice. On
ative for FISH and Microarray tests. Due to short cervix, a cer-
clage was placed. She was started on antibiotics, steroids, and day 4, he was noted to have an increased oxygen requirement. A
**“Oh the Places you'll Go,” by Dr. Seuss
magnesium. While under observation, the fetal heel was found trial of rescue inhaled nitric oxide was started with minimal ben-
(originally published in 1990)
to be protruding from the cervix, so an urgent C-section was per- efits. Chest x-ray (CXR) showed persistent right upper lobe atel-
formed. ectasis (Figure 3). On day 7, a decision was made to try HFJV.
Originally Published on:
At delivery, the infant was immediately intubated, omphalocele A CXR soon after starting Jet showed expansion up to 11 ribs
Allcovered
was Things Neonatal
with sterile gauze, and the infant was then transport- with a resolution of RUL atelectasis (Figure 5). Initial settings were
http://www.allthingsneonatal.com JET: PIP = 18, rate 420, IT 0.02 secs, I:E 1:6.1, CMV: rate 3,
edJuly
to the NICU, where she was
13, 2017; Republished here placed
with of HFOV. Physical exam
permission.
It is hard to be a Neonatologist who took the

path through Pediatrics first, and not use a
Dr. Seuss quote from time-to-time.
Winnipeg Free Press
If your unit is anything like ours where you
Sunday, October 5, 1986
work, I imagine you feel as if you are
Pages 5-16
bursting at the seams.
As the population grows, so do our patient

volumes. I often quote the number 10% as
being the number of patients we see out of
all deliveries each year in our units. When I
am asked why our numbers are so high, I
counter that the answer is simple. For every
extra 100 births, we get 10 admissions. It is
easy though, to get lost in the chaos of
managing a unit in such busy times, and not
take a moment to look back and see how far
we have come. What did life look like 30
years ago or 25 years ago? In Winnipeg, we
are preparing to make a big move into a
beautiful new facility in 2018. This will see us
unify three units into one, which is no easy
task but will mean a capacity of 60 beds
compared to the 55 operational beds we
have at the moment.
“What did life look like 30

years ago or 25 years
ago?”
In 2017, were routinely resuscitating infants

as young as 23 weeks, and now with weights
under 500g at times. Whereas in the past,
anyone under 1000g was considered quite
high risk, now the anticipated survival for a
Sign up for free membership at 99nicu, the

Internet community for professionals in neonatal
medicine. Discussion Forums, Image Library,
Virtual NICU, and more...”
w w w. 9 9 n i c u . o r g
NEONATOLOGY TODAY t www.NeonatologyToday.net t March 2018

NEONATOLOGY TODAYtwww.NeonatologyToday.nettJune 2020
15
128
PEEP 7, PC 10, IT 0.35. Blood gas 20 minutes after placing on to collapse. This may subsequently lead to alveolar collapse, as
these settings was 7.28/PCO2 63/PaO2 91. noted in the right upper lobe, the most “dependent” lobe, as well
as generalized hyperinflation, as the inspiratory flow is trapped
Follow up blood gases showed respiratory acidosis with CO2 re- by the “pinched” airway. Instead of going to HFJV, an alternative
tention. CXR showed RUL atelectasis again (Figure 6). ETT was strategy on HFOV might have included “paradoxically” increas-
adjusted with no benefits. A trial of higher exhalation time on Jet ing the mean airway pressure to insufflate the airway and prevent
(rate 360, I:E 1:7.3) was unsuccessful. Servo pressure remained negative flow and pressure at the wye, decreasing the amplitude,
stable at 2. The infant remained on 100% Oxygen with sats of 94- and proning the patient.
95%. The infant was then switched back to previous HFOV with
the resolution of respiratory acidosis. The infant is currently stable When transitioning to HFJV, one has to remember that the HFJV
on HFOV. amplitude is approximately half that of HFOV at similar delta P be-
cause the HFOV deflection is both negative and positive. If 7 H2O
The questions for experts are (where we went wrong with HFJV): is substracted from 18 H2O, the HFJV amplitude is 11 cm H2O;
with the correction applied – that is, 30 x 2 = 60 peak amplitude
With expansion up to 11 ribs (Figure 5), should we have tried high- negative to positive for HFOV, the relative amplitude supplied by
er PIP or PEEP? If yes, what is the risk? HFJV is approximately one-sixth of HFOV. Although the elimina-
tion of active exhalation resolved the right upper lobe atelectasis,
Would a higher rate on JET have made a difference? there was just not enough delta P to achieve appropriate ventila-
tion. A jet PIP of 40 would have been more appropriate. More time,
Should we have tried CPAP on CMV (0 rates)? as opposed to lower or higher mean airway pressure, would have
Any other suggestions? helped the hyperexpansion. CMV is often a surrogate for mean
airway pressure in HFJV. A CMV of 0 would not have helped this
Sincerely, situation, but in the long term would have exposed the patient to
Shabih Manzar, MD less barotrauma. The jet rate change may not have produced a
Associate Professor significant effect in this patient.
Department of Pediatrics, College of Medicine
Louisiana State University of Health Sciences Although HFJV can be challenging, a successful application of
1501 Kings Highway its strategies can lead to substantive improvements in ventilation.
Shreveport, LA 71130A single-center retrospective study NCfIH welcomes
Conversely, HFOVthe opportunity
physiology to discuss
favors higher mean airway pres-
Telephone: 318-626- compared
1623 the benefits and costs of an the
sures,forthcoming guidelines
lower amplitudes, andininperson or viapronating the patient
some cases
Fax: 318-698-4305 exclusive human milk diet in infants less than when atelectasis and hyperinflation are present. “An exclusiv
phone. Mitchell Goldstein, Medical Director
or
Email: [email protected] to 28 weeks gestation
than or equal to 1,500 grams vs. a
and or less for the National Coalition for Infant Health
can be reached at 818-730-9303.
diet is essent
combination of mother’s milk fortified with
Sincerely,
“medicine” fo
cow milk-based fortifier and formula, or a diet Sincerely,
Dear Dr. Manzar: of formula only. Primary outcomes were premature in
length of stay, feeding intolerance and time
Thank you for sending thisfeeds.
to full interesting case foroutcomes
Secondary analysis. The tran-
included
all agree fort
sition from one modetheof ventilation
effect to another
of the diet mode is challeng-
on the incidence of NEC required for p
ing. Although it appears thatcost-effectiveness
the presence of non-uniform lung Mitchell Goldstein, MD
and the
disease and hyperexpansion
human milk ondiet.
of an exclusive
the chest radiograph would favor Mitchell Editor inGoldstein,
Chief MD
growth. If we
the transition from HFOV to HFJV, the patient did not have a fa- Medical Director, to the former
NT
In those
vorable result and was babies back
transitioned fed an toexclusive
HFOV. human milk National Coalition for Infant Health
diet, there was a minimum of 4.5 fewer non-human f
additional days of hospitalization
First, let us discuss the HFOV strategy using HFJV physiology
$15,750 savings per ofday, 9 fewer
resulting
days
in
on References
any other for
arguments. With a mean airway pressure 12 cm H2O and ampli-
TPN, up to $12,924 savings per infant and a
tude 30 cm H2O, the patient is at risk for airway collapse or “pinch”
additives in t
NEONATOLOGY TODAY
reduction in medical and surgical NEC
during exhalation. Remember, during HFOV, exhalation is active,
resulting in an average savings per infant of
1.
Loma
Sullivan S, Schanler
“AnLinda Publishing
Exclusively
RJ, Kim JH
Company
Human
et al.
Milk-Based Diet
population ca
not passive. Amplitude of 30 exceeds the mean airway pressure
$8,167. And for those parents who get to
of 12 H2O by 18 cmtake
H2O.their
Although
A Delaware “not for profit”
Is Associated with a501(c)
Lower3 Corporation.
Rate of of the conver
baby the
home point at which
sooner, thethe process
impact is c/o Mitchell Goldstein,
Necrotizing MD
Enterocolitis than a Diet of
becomes a concernsimply
is a matter of debate, at greater than twice
priceless. 11175 Human
Campus Milk andSuite
Street, Bovine
#11121Milk-Based
the mean airway pressure, both airway pressure and flow can be- Loma P rLinda,
o d u cCA
t s ”92354
. J Pediatric. 2010
come negative at the wye. Increased
Although airway is
every effort resistance
made to prevents
start Tel: +1Apr;156(4):562-7.
(302) 313-9984 DOI: 10.1016/jpeds an Exclusive Hum
alveolar collapse, but the premature
feeding as soon compliant
as possible, airways
goodare prone
nutrition 2009-10.040.
[email protected] Breastfeeding Me
is essential, even if the baby is unable to 2. Assad M, Elliott MJ, and Abraham JH. 9. Hair AB, Bergner
be fed. ItTODAY is key isthat early nutrition “Decreased cost and improved feeding “Premature Infan
NEONATOLOGY interested in publishing manuscripts from Neonatologists, Weight Supplem
incorporates aggressive supplementation tolerance in VLBW infants fed an
Fellows, NNPs and those
of calories, involved
protein in caring
and essential fattyfor neonates
exclusive on human casemilkstudies, research
diet.” Journal of results,
Human Milk-D
hospital
acids. Without news, these meeting
in the right announcements,
balance, P e and
r i n a other
t o l o g pertinent
y ( 2 0 1 5 )topics.
, 1–5 Discharged Soo
the body goes into starvation mode; and doi:10.1038/jp.2015.168. M e d i c i n e ; 11
Please submit
before feedingyoureven manuscript
begins, the intestine,to: [email protected]
3. Cristofalo EA, Schanler RJ, Blanco CL, et 10.1089/bfm.2015
the liver and other parts of the body are al. “Randomized Trial of Exclusive Human 10. Ganapathy V, H
compromised. While an exclusively human Milk versus Preterm Formula Diets in “Costs of necroti
diet with an exclusively human milk-based Extremely Premature Infants.” The cost-effectiveness
fortifier will minimize the number of TPN Journal of Pediatrics December 2013. milk-based pr
days, TPN is essential to the early nutrition Volume 163, Issue 6, Pages 1592–1595. extremely pr
of an at-risk NEONATOLOGY
baby and is aTODAYtwww.NeonatologyToday.nettJune
predicate of e DOI:10.1016/j.jpeds.2013.07.011. 2020 129 Breastfeeding Me
good feeding success. 4. Ghandehari H, Lee ML, Rechtman DJ et DOI: 10.1089/bfm
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Will your PRETERM INFANT need Las nuevas mamás necesitan acceso
EARLY INTERVENTION services?
EARLY INTERVENTION a la detección y tratamiento para
LA DEPRESIÓN POSPARTO
Preterm infants are:
2x more likely to
have developmental
delays
1 DE CADA 7 MADRES
5x more likely AFRONTA LA DEPRESIÓN
to have learning
challenges POSPARTO, experimentando
Llanto Sueño Ansiedad

incontrolable interrumpido
1 in 3 preterm infants
will require support Desplazamientos en Ideas de hacerse Distanciamiento de
services at school los patrones de daño a sí mismas amigos y familiares
alimentación o al bebé
15%
Early intervention can help preterm infants: Sin embargo, sólo el 15%
recibe tratamiento 1
Enhance Build more Process social and Address physical Prevent mild LA DEPRESIÓN
POSTPARTO
language and effective learning emotional challenges difficulties from
communication techniques situations developing into
skills major problems
NO TRATADA La salud de la madre
PUEDE
AFECTAR:
Early diagnosis
could qualify babies for their
state's early intervention …but many La capacidad para
El sueño, la alimentación
parents are cuidar de un bebé
services… y el comportamiento
y sus hermanos
unaware. del bebé a medida que crece 2
PARA AYUDAR A LAS MADRES A

ENFRENTAR LA DEPRESIÓN POSPARTO
$
LOS ENCARGADOS DE LOS HOSPITALES PUEDEN:

$
FORMULAR POLÍTICAS Capacitar a los
PUEDEN:
NICU staff, nurses, Financiar los esfuerzos de
profesionales de la salud
para proporcionar apoyo
pediatricians and social despistaje y diagnostico psicosocial a las familias…
workers should talk with NICU Proteger el acceso al
Especialmente aquellas con
bebés prematuros, que son 40%
families about the challenges tratamiento más propensas a desarrollar
their baby may face. depresión posparto3,4
Conectar a las mamás con

una organización de apoyo
Awareness, referral
& timely enrollment
in early intervention
programs can help
infants thrive and grow.
1
American Psychological Association.
Accesible en: http://www.apa.org/pi/women/resources/reports/postpartum-depression.aspx
Visit CDC.gov to find contact 2

National Institute of Mental Health.
Accesible en: https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtml
information for your state’s early 3
Journal of Perinatology (2015) 35, S29–S36; doi:10.1038/jp.2015.147.
intervention program. 4
Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants:
www.infanthealth.org www.infanthealth.org a systematic review. Vigod SN, Villegas L, Dennis CL, Ross LE BJOG. 2010 Apr; 117(5):540-50.

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Academic Neonatologist Opportunity in Southern California
Loma Linda University Faculty Medical Group, Department of Pediatrics, Division of Neonatology, is
seeking board certified or board eligible Neonatologists to join their team.
The Neonatal Intensive Care Unit (NICU) at Loma Linda University Children’s Hospital is committed to
providing the highest quality of family-centered medical care with our skilled, multi-disciplinary neonatal
team. Our unit has 84 licensed beds for the most critically ill babies. As one of the few level 4 tertiary centers
in Southern California, we are equipped to provide the highest level of care for newborns with the most
complex disorders. Our facility has the largest Level IV NICU in California, serving approximately 25
percent of the state.
We have subspecialists in all medical and surgical areas that are available at all times and are supported by
hospital staff with technical, laboratory, and service expertise. Pediatric neurologists work together with us
in our NeuroNICU to diagnose, treat and monitor babies with neurologic injury or illness and we focus on
providing neuroprotective, developmentally appropriate care for all babies in the NICU. Very specialized
care is given in our Small Baby Unit to babies born at less than 30 weeks gestation. Babies at risk for
developmental delay are followed up to 3 years in our High-Risk Infant Follow-up Clinic. Genetics
specialists are available for evaluation and consultation.
Our Children’s Hospital is designated as a Baby Friendly Hospital that supports breastmilk feeding for both
term and preterm babies. Neonatal Social Workers and Child Life Specialists are
important members of our team. It is our goal to support babies and families in
culturally sensitive ways as our patients come from many different ethnic and
religious backgrounds.
Loma Linda is located in the center of Southern California. A sunny climate

augments the cultural benefits of Los Angeles and Palm Springs and the
year-round recreational opportunities of nearby mountains, deserts and beaches.
This opportunity is not eligible for a J1 Waiver.
For more information please contact:

Elba Fayard, MD Kelly Swensen
Division Chief of Pediatric Neonatology Physician Recruitment Coordinator
[email protected] [email protected]
Neonatal Nurse Practitioner
• Collaborative work environment
• Care of high acuity NICU patients
• State of the art technology
• 24/7 coverage provided by NNP team and Fellows
Who We Are
With over 900 beds in four hospitals, we operate some of the largest clinical programs in the nation. We also offer
the only Level I Regional Trauma Center and Children’s Hospital in the Inland Empire servicing the largest county
in the US. We lead in many areas of excellence; pediatrics, cardiac services, cancer treatment and research, mental
health, chemical dependency, and other essential clinical disciplines. All this adds up to endless possibilities for our
patients and for you.
The Neonatal Intensive Care Unit (NICU) at Loma Linda University Children’s Hospital is committed to providing
high-quality, family-centered care with our highly skilled, multi-disciplinary neonatal team. Our unit has 84 licensed
beds for the most critically ill infants and a new Tiny Baby Program focusing on improving survival and outcomes
of extremely low birth weight infants (<1000g at birth). As one of the only level 3 tertiary centers in Southern
California, we are equipped to provide the highest level of care for the most complex disorders. We have
subspecialists in all medical and surgical areas that are available at all times and are supported by hospital staff with
technical, laboratory, and service expertise.
At Loma Linda University Health, we combine the healing power of faith with the practices
of modern medicine. We consist of a University, a Medical Center with four hospitals, and a
Physicians Group. These resources have helped us become one of the best health systems in
the nation.
Contact Us
Please visit our website http://careers.llu.edu or contact Jeannine Sharkey, Director of
Advanced Practice Services at [email protected] or (909) 558-4486.
If you are an individual who understands and embraces the mission and purpose of Loma Linda University and its entities as premier
Seventh-day Adventist Christian institutions, please visit our website or call 1-800-722-2770. EOE/AA/M/F/D/V
NEONATOLOGY TODAY
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Loma Linda Publishing Company | c/o Mitchell Goldstein, MD | 11175 Campus St, Ste. 11121 | Loma Linda, CA 92354 |
[email protected]
© 2020 Neonatology Today | ISSN: 1932-7137 (digital). Published monthly. All rights reserved.
Editorial Board
Mitchell Goldstein, MD - Editor-in-Chief Thomas A Clarke, MD - Western Europe Editor
[email protected] ` Emeritus Consultant in Neonatology
Professor of Pediatrics The Rotunda Hospital,
Loma Linda University School of Medicine Dublin. Ireland
Division of Neonatology, Department of Pediatrics
Loma Linda University Children’s Hospital Jan Mazela, MD - Central Europe Editor
[email protected]
T. Allen Merritt, MD - Senior Associate Editor for Associate Professor
Contributions & Reviews Poznan University of Medical Sciences
[email protected] Poznan, Greater Poland District, Poland
Professor of Pediatrics
Loma Linda University School of Medicine Stefan Johansson, MD PhD - Scandinavian Editor
Division of Neonatology, Department of Pediatrics [email protected]
Loma Linda University Children’s Hospital Consultant Neonatologist, Sachs' Childrens Hospital
Associate Professor, Karolinska Institutet
Larry Tinsley, MD - Senior Managing Editor Stockholm, Sweden
[email protected]
Associate Professor of Pediatrics Francesco Cardona, MD - European Editor at Large
Division of Neonatology-Perinatal Medicine [email protected]
Loma Linda University Children’s Hospital Consultant, Medical University of Vienna
Department of Paediatrics and Adolescent Medicine
Elba Fayard, MD - Interim Fellowship Editor Vienna, Austria
[email protected]
Professor of Pediatrics
Division Chair Arun Pramanick, MD - India Editor
Division of Neonatology-Perinatal Medicine [email protected]
Loma Linda University Children’s Hospital Professor, Pediatrics,
Louisiana State University School of Medicine,
Shreveport, LA
Munaf Kadri, MD - International Editor
[email protected]
Executive Board Andrea Schwartz Goodman, MSW, MPH
UMMA Clinic Senior Editorial Project Director
[email protected]
Los Angleles, CA Washington, D.C.
Assistant Professor Loma Linda
Loma Linda University Children’s Hospital
Michael Narvey, MD - Canada Editor Herbert Vasquez, MD - Arts Editor

Section Head of Neonatology Associate Neonatologist
Children’s Hospital Research Institute of Manitoba Citrus Valley Medical Center, Queen of the Valley
Campus, West Covina, CA
Joseph R. Hageman, MD - Clinical Pearls Editor Giang Truong, MD - QI/QA Editor

Senior Clinician Educator Associate Professor of Pediatrics
Pritzker School of Medicine Division of Neonatology-Perinatal Medicine
University of Chicago Loma Linda University Children’s Hospital
Clara Song, MD - Social Media Editor Jerasimos Ballas, MD, MPH - Perinatology Editor
Assistant Professor of Pediatrics, Children’s Hospital at Associate Professor of Obstetrics and Gynecology
OU Medical Center University of California, San Diego
University of Oklahoma Health Sciences Center

Maha Amr, MD - Academic Affairs Editor
[email protected]
Assistant Professor of Pediatrics
Division of Neonatology-Perinatal Medicine
Loma Linda University Children’s Hospital
Dilip R. Bhatt, MD - Kaiser Fontana, Fontana, CA

Barry D. Chandler, MD
Anthony C. Chang, MD - Children’s Hospital of Orange County
K.K. Diwakar, MD - Malankara Orthodox Syrian Church Medical College
Willa H. Drummond, MD, MS (Informatics)
Philippe S. Friedlich, MD - Children’s Hospital Los Angeles
Kimberly Hillyer, NNP - Loma Linda University Children's Hospital
Andrew Hopper, MD, Loma Linda University Children’s Hospital
Lucky Jain, MD - Emory School of Medicine
Prakash Kabbur, MBBS, DCH (UK), MRCPCH (UK) - Kapiolani
Medical Center of Women & Children
Gail Levine, MD - Loma Linda University Children’s Hospital
Lily Martorell, MD - Loma Linda University Children' Hospital
Patrick McNamara, MD - Sickkids, Toronto, ON
Rita Patel, NNP - Loma Linda University Children’s Hospital
John W. Moore, MD - Rady Children’s Hospital
Raylene Phillips, MD, Loma Linda University Children’s Hospital
Michael A. Posencheg, MD - Children’s Hospital of Philadelphia
DeWayne Pursley, MD, MPH - Boston Children’s Hospital
Luis Rivera, MD - Loma Linda University Children's Hospital
P. Syamasundar Rao, MD - UT-Houston Medical School
Joseph Schulman, MD, MS - California Department of Health Care Services
Steven B. Spedale, MD, FAAP - Woman’s Hospital
Alan R. Spitzer, MD
Cherry Uy, MD, FAAP - University of California, Irvine
Dharmapuri Vidysagar, MD - University of Illinois Chicago
Farha Vora, MD, Loma Linda University Children’s Hospital
Leonard E. Weisman, MD - Texas Children’s Hospital
Stephen Welty, MD - Seattle Children’s Hospital
Robert White, MD - Memorial Hospital
T.F. Yeh, MD - John H. Stroger Jr. Hospital of Cook County and
Taipei Medical University's

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NEONATOLOGY

Guidelines for Management of Infants Delivered during the

NEONATOLOGY TODAY is interested in publishing manuscripts from Neonatologists,

NEONATOLOGY TODAYtwww.NeonatologyToday.nettJune 2020 3

NEONATOLOGY TODAYtwww.NeonatologyToday.nettJune 2020 4

NEONATOLOGY TODAYtwww.NeonatologyToday.nettJune 2020 5

NEONATOLOGY TODAYtwww.NeonatologyToday.nettJune 2020 6

•Neonatal team to be informed at time of admission

•Designated consultant and senior nurse to attend

Maternal suspected or •Infant may be intially shown to parents but social

•Admit to designated cohort area within NICU

•The NNNI should be informed of all admissions of an

•Neonatal team to be informed at time of admission

•ST4+ and senior nurse to attend delivery unless

Maternal suspected or •Infant may be intially shown to parents but social

•Admit to designated cohort area within NICU

•The NNNI should be informed of all admissions of an

•Neonatal team to be informed at time of admission

•Neonatal attendance at deliveries of infants ≥ 35 weeks

•If neonatal attendance is required at delivery but the

•If infant well, every effort should be made to keep the

•If the infant requires admission, NICU should be

•Admit to designated cohort area within NICU

•The NNNI should be informed of all admissions of an

Although the vertical transmission of SARS-CoV-2 is considered possible, it remains to be definitively

Neopuff and Mask with In-Line HME Filter

Transfer of a Newborn Infant to NNU

COVID-19 Screening in Infants of Suspected or Confirmed Mothers

Current screening schedule for infants admitted at birth is:

Admit to COVID-19 cohort area

Swab all infants at admission

Mother confirmed Mother confirmed

Infant swabs remain Infant swab reported

# Isolate at home until day 14

Anticipated Respiratory Symptoms: Anticipated respiratory symptoms are defined as

Unanticipated Respiratory Symptoms: Unanticipated respiratory symptoms are defined

Maternal Suspected or Confirmed COVID-19

Admit to COVID-19 cohort area regardless of

Swab infant at admission to cohort area

Mother confirmed Mother confirmed

Infant will require 2 further If symptoms concerning of

Must remain in incubator Must remain in incubator Must remain in incubator

Admit to COVID-19 cohort Admit to ICU / HDU /

Must remain in incubator for

 They are an inpatient

3. The use of reusable equipment should be avoided if possi-

NEONATOLOGY TODAYtwww.NeonatologyToday.nettJune 2020 23

NEONATOLOGY TODAYtwww.NeonatologyToday.nettJune 2020 24

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NEONATOLOGY TODAYtwww.NeonatologyToday.nettJune 2020 26

NEONATOLOGY TODAYtwww.NeonatologyToday.nettJune 2020 27

Disclosures: The authors do not have any disclosures.

The authors wish to acknowledge the special assistance of

NEONATOLOGY TODAYtwww.NeonatologyToday.nettJune 2020 28

Readers can also follow

Aleksandra M. Adamczak, MD NEONATOLOGY TODAY

Jan Mazela, M.D., Ph.D.,

NEONATOLOGY TODAYtwww.NeonatologyToday.nettJune 2020 29

(fish oil triglycerides) injectable emulsion