Going viral in the NICU: Lessons from 2014
Jae Kim, MD, PhD
The term “viral” has been in abundant use in our society these days with a rising frequency starting from the past classics such as the “Dancing Baby,” moving to “Gangnam Style” and “Susan Boyle” to this year’s holiday news of “Tipping a waitress with a car.”1 Apparently, “Mutant Giant Spider Dog” won 2014’s most viewed on YouTube. We understand something viral to represent an image, video or other piece of information that circulates rapidly across the Internet. But what makes viral things so infectious?
We frequently gravitate towards the novel, heart-wrenching, heart-warming, or shocking bits that not only makes an impact but are compelling enough that you want to share them with others. It also appears that as a society that we have a greater tendency to go viral as a consequence of our increased social connectedness.
The spread of another kind of viral entity has caught our attention this year with the Ebola crisis in West Africa that has made an Ebola epidemic very real as a worldwide threat given the increasing travel connectedness of our world. Ebola was always described as a flawed epidemic virus because of its high lethality that tends to burn out because people die too quickly for it to spread far; but combine this virus with a large mobile population and this dramatically changes the kinetics of its spread. In fact, the most recent Ebola outbreak is unlike past outbreaks in that the region involved at least 3 different countries and areas of high density and traffic. We have already witnessed transportation of both known and unknown cases to Dallas, New York City and Spain. The importance of this crisis did not go unnoticed by TIME magazine who just announced that the Ebola fighters in the heart of the crisis are the “Person of the Year” for 2014.
Recently our NICU had to deal with a serious outbreak of an otherwise innocent common cold virus, parainfluenza. Like many outbreaks, this was sudden and unexpected and hit us with two different index cases that made tracking and containment (especially in an open-bay unit) a nightmare, never mind the fact that we had to entertain the possibility of a lone shedder amongst us caregivers. Serial time mapping where all the contacts of the index and infected cases traversed and deciding who is “clean” and “dirty” were powerfully humbling experiences that reaffirmed we do not have the resources of CSI at our fingertips. The “dangerous” first index case was a simple 1800g child who had congestion and altered breathing. Managing full droplet precautions is very challenging as it is all too easy to spread if caregivers, including parents, are not extremely careful. The signs of a cold never seemed so terrifying.
In 2003, I was working in Toronto at the Hospital for Sick Children and witnessed firsthand the SARS (severe acute respiratory syndrome) outbreak. This was a frightening time because of the nature of SARS as a highly contagious respiratory virus that had mutated such that healthy middle aged adults could die from this disease and not just young children and the elderly. It was clear then that containing such a contagious virus was extremely difficult. Health care workers were getting ill from exposure despite personal protections put in place. Some were permanently harmed and some died. Short of full body suits, the risk of contamination is not fully removable. It is important to remember too that some viruses can stay on inanimate surfaces for several hours to days, adding to the difficulty of containment.
With the increase in the repertoire of microbial testing available to us, the frequency of identifying infectious agents in our NICUs is likely to increase. Tests can now detect many more different viral pathogens by highly sensitive PCR than ever before. Knowing more of what is hanging around is going to open up more issues that we have not anticipated yet, not necessarily making our babies safer but creating more work for us. For instance, now that rhinovirus can be detected, should we treat it with the same respect as with RSV?
Hospitals worry about MRSA, and they should, because these organisms are a result of the longstanding antibiotic use we have in hospitals. When we happen to screen for MRSA and find positive results we put forth immediate containment with contact precautions for infant and mother. Thankfully most of us permit mothers to continue skin to skin care contact. I know of no NICU that screens healthcare workers and parents for MRSA and so we are clearly only picking up a small number of the real numerator here. Fortunately MRSA is more an issue of colonization and is not something that transmits a high percentage of disease to patients. I would hazard to say that many of us probably harbor MRSA organisms and simply don’t know it. Imagine what would happen if we were all required in the future to be screened for carriage status of all pathogens we harbor. This sounds draconian but probably not far from reality in the near future.
The CDC recently put out a notice of the unexpected death of a 29 week gestation preterm infant who was given probiotics as a routine in their NICU.”2 This product was a mixture of three different probiotic agents but did turn out to have a fungal contaminant called mucormycete. This fungus was associated with severe mucormycosis that was associated with fulminant NEC that led to the infant’s demise. This is a serious warning to NICUs that have started wholeheartedly implementing routine probiotics, most that are not manufactured to the same safety standards of our pharmaceutical drugs. Furthermore, research has shown that our NICU colonized with the microbes present in the NICU. In fact the concern has been raised that introducing probiotics into the NICU is not only introducing it to the patients receiving it but has the potential to affect the other patients and caregivers in it.
Microbes are not all bad, however. The science of our gut microbiota is growing and we are discovering several important facts. First we are made of more bacterial cells than human cells, and at least ten-times the number. Second it is also known that these microbes are highly metabolically active and act like an “exogenous liver,” metabolizing the byproducts of digestion or even that of other microbes. Remember too that these bacteria are actually outside our body in the lumen of our gut. This remarkable exchange of products between the host and communal microbiota supports the largest immune and nervous system in the body, the GI tract. With such a large surface area (the size of a studio apartment) we need these commensal microbes then to protect us from a dangerous world outside. A further need for a healthy microbiota is also evident by data that suggest that prolonged exposure in childhood to microbes in rural areas such as on a farm versus urban settings can dramatically reduce one’s risk for allergy or asthma later in life.
Going viral in the NICU does not all have to be with negative things such as the spread of infection. The rapid spread of a good idea or evidence-based practice would be fantastic. For the past decade, I have been trying to figure out how to spread the message of more human milk in the NICU better and faster than how it has been happening. The good news is the spread is happening, the bad news is that it is just not fast enough for many of us in human milk research. Every day goes by and a child that did not get human milk may develop life threatening NEC. The consequences of this are huge and costly. The UK recently published research totaling some of the financial cost of not providing human milk or breastfeeding our babies.”3 They calculate an annual cost savings of 6 million pounds (~10million USD) with the prevention of NEC if human milk was provided to twice the current number of neonates in the NICU.
One avenue on the path to making human milk use go viral in the NICU that I have been excited to be involved with has been in the participation of a parent advocacy group called NEC Society (necsociety.org). This group of parents and its scientific advisory are taking a different tack in trying to spread the word of human milk and other measures to prevent NEC from happening. Member parents are particularly passionate about improving the medical system to avoid any or all of NEC from occurring since they have seen firsthand the ravages of this condition, many who have lost their child to NEC. With the rising interest in patient/parental engagement it may be that parents will be the ultimate factor in making the use of human milk go “viral.” I believe we are very close to the “tipping point” as a medical community in making it standard of care to have only human milk (mother’s own or donor) for all high risk preterm infants. Further standardization and consensus on feeding algorithms would also be helpful. Stay tuned as I want to share more progress in future blogs about this growing voice. Here’s to going viral in the NICU!
3. Pokhrel et al. Potential economic impacts from improving breastfeeding rates in the UK. http://www.ncbi.nlm.nih.gov/pubmed/25477310
About the Author
Jae Kim is an academic neonatologist and pediatric gastroenterologist and nutritionist at UC San Diego Medical Center and Rady Children’s Hospital of San Diego. He has been practicing medicine for over 23 years both in Canada and the USA. He has published numerous journal articles, book chapters, and speaks nationally on a variety of neonatal topics. He is the Director for the Neonatal-Perinatal Medicine Fellowship Program at UC San Diego and the Nutrition Director of an innovative multidisciplinary program to advance premature infant nutrition called SPIN (Supporting Premature Infant Nutrition, spinprogram.ucsd.edu). He is the co-author of the book, Best Medicine: Human Milk in the NICU. Dr. Kim is a clinical consultant with Medela, Inc.