Why Do We Keep Getting It Wrong In Neonatology?
Jae Kim, MD, PhD / March 2017
I started in pediatrics a few decades ago. Back then, it was commonplace to provide postnatal corticosteroids in very high doses from the first few weeks of life to dampen the massive inflammation that occurs in chronic lung disease of prematurity. The result was often visible improvement and the ability to get an infant off a ventilator.
We found out years after this practice became popular that the use of high dose dexamethasone was particularly harmful for the developing brain and caused a number of treated infants to suffer worse neurodevelopmental outcomes. The ensuing yo-yo of practice from moratorium of corticosteroid use to the introduction of judicious use of less potent dosing of postnatal corticosteroids has been challenging for any of us practicing neonatology.
The sea change in indications for intubation in the newborn is remarkable too. Walk into any NICU now compared to two decades ago and you will see dramatically fewer infants intubated at the start of life or continued to be so for weeks to months on end.
Infants were more capable of breathing with less support than we thought, and had much less lung damage as a result.
In term infants, we have moved away from immediately intubating vigorous and now finally non-vigorous infants born with suspected meconium aspiration. What changed the practice paradigm was a change in our basic understanding of pathophysiology and confirmation with solid clinical data to support the change. We became smarter about the inflammatory trigger that intubation causes in premature infants and that meconium aspiration is an intrauterine event. In the gap between these opposing practices, however, many infants took the toll of noxious intubations.
Practice changes in human milk nutrition
There are also examples of tectonic practice changes in the area of nutrition. Early on, for many practical reasons, we moved away from the use of human milk for preterm infants as the energy and nutrient demands were so high for this group. Commercially designed preterm formulas were an impressive start for better growth and bone development. However, we shortly found out that many of our poor outcomes, particularly feeding intolerance, infections, and necrotizing enterocolitis were due to the absence of the benefits of mother’s milk and the negative effects of bovine protein.
Many infants suffered (and sadly many still suffer) the consequences of an artificial diet instead of a physiologic and biologic one based on human milk. Unfortunately, this mirrored the failure of introducing infant formula powder to the developing world in the 1970’s that hiked up infant mortality rates by removing the immunoprotection that breastfeeding confers.
Microbiome health for preterm infants
More recently, in the age of the microbiome, we have awakened a new understanding of the important role of microbes in our environment and in our bodies. In the past, we were strongly encouraged to have the perspective that preterm infants are immunologically vulnerable to infection and therefore deserving of automatic protection with very broad spectrum antibiotics. But having the right balance of microbes is essential for metabolic and immunologic health.
The consequences of the pervasive practice of wide antibiotic use (still in a process of weaning through a series of antibiotic stewardship efforts across the country) are only being recognized and catalogued now. One of the more compelling associations with excessive antibiotic use in the NICU is the higher association with NEC. Getting rid of too many microbes carries risk.
So why do we make such apparent missteps?
I don’t think in most cases this is a result of carelessness, negligence or zealous early adoption. In most of these examples, there is a large component of not enough knowledge. Lack of a true understanding of the disease processes can lead to incorrect assumptions that end up sometimes looking pretty silly (or horrifying) staring back at these practices.
As clinicians, we face the big challenge of trying to figuring out which of our current practices are going to be defunct in 5-10 years and recognize this before too many infants suffer a suboptimal outcome. Couple this with the reality that change does not take place easily. Moving a team from one practice to another is like moving a mountain. Part of the inertia here for many of us is the risk of making a move, particularly when all the data is not there, and then realizing that it was the wrong move.
Human touch impact
One situation I suspect strongly will rear itself in the near future has to do with the power of human touch. Many of our newer NICUs have been striving for advanced and futuristic environments: ones that are spacious, super clean, and friendly to the family-centered care we desire. In the process, we may be giving out a subconscious message that modern medicine can do it all. We have all the right equipment, bells, and whistles (and alarms) to grow a baby from birth to discharge. Minimal handling and minimal stimuli. I see it in the eyes of parents, an unsolicited comfort that we can manage everything.
This hygienic approach may end up directing us away from what is best for our babies. Our intuition tells us that all babies need physical comfort and contact, but this is a costly commodity.
For the many of us who have pets, it would never occur to us to deliberately leave them without prolonged physical touch on end, particularly when they are roaming in our presence. But pets are mobile and free to move, while our infants, on the other hand, lack the independence and communication skills to let us know what they need. I know of not one NICU in the US where anywhere close to half of the babies or more are being held by someone (mother, nurse, volunteer) for at least 4 out of the 24 hours each day. The concerns raised recently that an isolated, unstimulated infant may not develop normally should be the basis of new ways to take care of our infants collectively as a team.
Finding a solution to the human touch problem is not easy, as tremendous change in culture is required and the costs need to be reconciled. It will require much more parental involvement, even in the face of such poor parental leaves offered in our country. More skin-to-skin care practices. More volunteers to hold and cuddle our babies when parents are not around. It will require better nurse staffing ratios. It will also require that we are clear what our endpoint of discomfort for our infants are.
Waiting to hear infants wailing is a terminal stress event, and picking up cues of discomfort or pain well before this stage are needed. We need to revalidate the power of human touch as the ultimate wellness factor and non-verbal communication form.
Let’s put more power to the mother-infant dyad and support this physical melding each day. It is an insatiable and unsaturable need. It is always time to touch!
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.