- Neonatal Hospitalist
- Neonatal Resuscitation
Clinical Professor, Pediatrics - Neonatal and Developmental Medicine
Director, Neonatal Hospitalist Program, Division of Neonatology (2005 - Present)
Associate Director, Packard Intermediate Care Nursery, Division of Neonatology (2005 - Present)
Boards, Advisory Committees, Professional Organizations
Co-Chair, AAP SOHM Neonatal Hospitalist Subcommittee (2017 - Present)
Member, SOHM Liaison, NRP Steering Committee (2015 - Present)
Steering Group/Executive Board Member, AAP SOHM Neonatal Hospitalist subcommittee (2015 - Present)
Residency: Stanford Health Care at Lucile Packard Children's Hospital (2002) CA
Internship: Stanford Health Care at Lucile Packard Children's Hospital (2000) CA
Medical Education: Vanderbilt University School of Medicine (1999) TN
Board Certification: American Board of Pediatrics, Pediatrics (2002)
Residency, Stanford University - LPCH, Pediatrics (2002)
M.D., Vanderbilt University, Medicine (1999)
B.S., Duke University, Biology, Psychology (1995)
Fewer glucose checks and decreased supplementation using dextrose gel for asymptomatic neonatal hypoglycemia.
Journal of perinatology : official journal of the California Perinatal Association
OBJECTIVE: Evaluate the impact of a neonatal hypoglycemia (NH) clinical pathway implementing buccal dextrose gel in late preterm and term infants.STUDY DESIGN: Quality improvement study at a children's hospital associated birth center. Number of blood glucose checks, use of supplemental milk, and need for IV glucose were followed for 26-months after implementation of dextrose gel and compared to previous 16-month period.RESULTS: After QI implementation, 2703 infants were screened for hypoglycemia. Of these, 874 (32%) received at least one dose of dextrose gel. Special cause shifts with reductions in mean number of blood glucose checks per infant (pre 6.6 vs. post 5.6), use of supplemental milk (pre 42% vs. post 30%), and need for IV glucose (pre 4.8% vs. post 3.5%) were found.CONCLUSION: Incorporating dextrose gel into a clinical pathway for NH was associated with a sustained reduction in number of interventions, use of supplemental milk and need for IV glucose.
View details for DOI 10.1038/s41372-023-01638-z
View details for PubMedID 36871107
Variation in United States COVID-19 newborn care practices: results of an online physician survey.
1800; 22 (1): 55
BACKGROUND: Newborn care practices that best promote the health and well-being of mother-infant dyads after birth while minimizing transmission of COVID-19 were uncertain at the onset of the COVID-19 pandemic.OBJECTIVE: Examine variation in COVID-19 newborn care practices among U.S. birth hospitals and by hospital characteristics (U.S. census region, highest level of neonatal level of care, and Baby-Friendly hospital status).STUDY DESIGN: We surveyed physicians via American Academy of Pediatrics email listservs and social media between 5/26/2020-6/8/2020. Physicians identified the birth hospital in which they provided newborn care and their hospital's approach to obstetrical and newborn care related to COVID-19. Chi-square tests were used to examine variation in hospital practices by U.S. census region, highest level of neonatal care, and Baby-Friendly hospital status.RESULTS: Four hundred thirty three physicians responded from 318 hospitals across 46 states. Variation in care of SARS-CoV-2 positive mother-infant dyads was greatest for approaches to location of newborn care (31% separation, 17% rooming-in, and 51% based on shared-decision making), early skin-to-skin care (48% prohibited/discouraged, 11% encouraged, and 40% based on shared-decision making) and direct breastfeeding (37% prohibited/discouraged, 15% encouraged, and 48% based on shared-decision making). Among presumed uninfected dyads, 59% of hospitals discharged at least some mother-infant dyads early. We found variation in practices by U.S. census region.CONCLUSION: Approaches to newborn care and breastfeeding support for mother-infant dyads with positive SARS-CoV-2 testing differed across U.S. birth hospitals during the COVID-19 pandemic. Early discharge of presumed uninfected mother-infant dyads was common.
View details for DOI 10.1186/s12887-022-03129-0
View details for PubMedID 35062906
Standardized Evaluation of Cord Gases in Neonates at Risk for Hypoxic Ischemic Encephalopathy.
BACKGROUND: Umbilical-cord acidemia may indicate perinatal asphyxia and places a neonate at increased risk for hypoxic ischemic encephalopathy (HIE). Our specific aim was to develop a standardized clinical care pathway, ensuring timely identification and evaluation of neonates with umbilical-cord acidemia at risk for HIE.METHODS: A standardized clinical care pathway to screen inborn neonates ≥36 weeks with abnormal cord blood gases (a pH of ≤7.0 or base deficit of ≥10) for HIE was implemented in January 2016. Abnormal cord blood gases resulted in a direct notification from the laboratory to an on-call physician. Evaluation included a modified Sarnat examination, postnatal blood gas, and standardized documentation. The percentage of neonates in which physician notification, documented Sarnat examination, and postnatal blood gas occurred was examined for 6 months before and 35 months after implementation.RESULTS: Of 203 neonates with abnormal cord gases in the post-quality improvement (QI) period, physician notification occurred in 92%. In the post-QI period, 94% had a documented Sarnat examination, and 94% had postnatal blood gas, compared with 16% and 11%, respectively, of 87 neonates in the pre-QI period. In the post-QI period, of those evaluated, >96% were documented within 4 hours of birth. In the post-QI period, 15 (7.4%) neonates were cooled; 13 were in the NICU at time of identification, but 2 were identified in the newborn nursery and redirected to the NICU for cooling.CONCLUSIONS: A standardized screening pathway in neonates with umbilical-cord acidemia led to timely identification and evaluation of neonates at risk for HIE.
View details for DOI 10.1542/hpeds.2021-006135
View details for PubMedID 34854918
A Feasibility Study of a Novel Delayed Cord Clamping Cart.
Children (Basel, Switzerland)
2021; 8 (5)
Delaying umbilical cord clamping (DCC) for 1 min or longer following a neonate's birth has now been recommended for preterm and term newborns by multiple professional organizations. DCC has been shown to decrease rates of iron deficiency anemia, intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and blood transfusion. Despite these benefits, clinicians typically cut the umbilical cord without delay in neonates requiring resuscitation and move them to a radiant warmer for further care; this effectively prevents these patients from receiving any benefits from DCC. This study evaluated the feasibility of a delayed cord clamping cart (DCCC) in low-risk neonates born via Cesarean section (CS). The DCCC is a small, sterile cart designed to facilitate neonatal resuscitation while the umbilical cord remains intact. The cart is cantilevered over the operating room (OR) table during a CS, allowing the patient to be placed onto it immediately after birth. For this study, a sample of 20 low-risk CS cases were chosen from the non-emergency Labor and Delivery surgical case list. The DCCC was utilized for 1 min of DCC in all neonates. The data collected included direct observation by research team members, recorded debriefings and surveys of clinicians as well as surveys of patients. Forty-four care team members participated in written surveys; of these, 16 (36%) were very satisfied, 12 (27%) satisfied, 13 (30%) neutral, and 3 (7%) were somewhat dissatisfied with use of the DCCC in the OR. Feedback was collected from all 20 patients, with 18 (90%) reporting that they felt safe with the device in use. This study provides support that utilizing a DCCC can facilitate DCC with an intact umbilical cord.
View details for DOI 10.3390/children8050357
View details for PubMedID 33946912
NEWBORN CARE AND DELIVERY ROOM MANAGEMENT
JOURNAL OF HOSPITAL MEDICINE
2020; 15: 106–7
View details for Web of Science ID 000538159300048
Revisiting the Latest NRP Guidelines for Meconium: Searching for Clarity in a Murky Situation.
View details for DOI 10.1542/hpeds.2020-0002
View details for PubMedID 32094238
Sustainability of a Clinical Examination-Based Approach for Ascertainment of Early Onset Sepsis in Late Preterm and Term Neonates.
The Journal of pediatrics
View details for DOI 10.1016/j.jpeds.2020.05.055
View details for PubMedID 32511960
Management of Chorioamnionitis-Exposed Infants in the Newborn Nursery Using a Clinical Examination-Based Approach.
BACKGROUND: Antibiotic use in well-appearing late preterm and term chorioamnionitis-exposed (CE) infants was reduced by 88% after the adoption of a care approach that was focused on clinical monitoring in the intensive care nursery to determine the need for antibiotics. However, this approach continued to separate mothers and infants. We aimed to reduce maternal-infant separation while continuing to use a clinical examination-based approach to identify early-onset sepsis (EOS) in CE infants.METHODS: Within a quality improvement framework, well-appearing CE infants ≥35 weeks' gestation were monitored clinically while in couplet care in the postpartum unit without laboratory testing or empirical antibiotics. Clinical monitoring included physician examination at birth and nurse examinations every 30 minutes for 2 hours and then every 4 hours until 24 hours of life. Infants who developed clinical signs of illness were further evaluated and/or treated with antibiotics. Antibiotic use, laboratory testing, and clinical outcomes were collected.RESULTS: Among 319 initially well-appearing CE infants, 15 (4.7%) received antibiotics, 23 (7.2%) underwent laboratory testing, and 295 (92.5%) remained with their mothers in couplet care throughout the birth hospitalization. One infant had group B Streptococcus EOS identified and treated at 24 hours of age based on new-onset tachypnea and had an uncomplicated course.CONCLUSIONS: Management of well-appearing CE infants by using a clinical examination-based approach during couplet care in the postpartum unit maintained low rates of laboratory testing and antibiotic use and markedly reduced mother-infant separation without adverse events. A framework for repeated clinical assessments is an essential component of identifying infants with EOS.
View details for PubMedID 30833294
Clinical Monitoring of Well-Appearing Infants Born to Mothers With Chorioamnionitis.
2018; 141 (4)
The risk of early-onset sepsis is low in well-appearing late-preterm and term infants even in the setting of chorioamnionitis. The empirical antibiotic strategies for chorioamnionitis-exposed infants that are recommended by national guidelines result in antibiotic exposure for numerous well-appearing, uninfected infants. We aimed to reduce unnecessary antibiotic use in chorioamnionitis-exposed infants through the implementation of a treatment approach that focused on clinical presentation to determine the need for antibiotics.Within a quality-improvement framework, a new treatment approach was implemented in March 2015. Well-appearing late-preterm and term infants who were exposed to chorioamnionitis were clinically monitored for at least 24 hours in a level II nursery; those who remained well appearing received no laboratory testing or antibiotics and were transferred to the level I nursery or discharged from the hospital. Newborns who became symptomatic were further evaluated and/or treated with antibiotics. Antibiotic use, laboratory testing, culture results, and clinical outcomes were collected.Among 277 well-appearing, chorioamnionitis-exposed infants, 32 (11.6%) received antibiotics during the first 15 months of the quality-improvement initiative. No cases of culture result-positive early-onset sepsis occurred. No infant required intubation or inotropic support. Only 48 of 277 (17%) patients had sepsis laboratory testing. The implementation of the new approach was associated with a 55% reduction (95% confidence interval 40%-65%) in antibiotic exposure across all infants ≥34 weeks' gestation born at our hospital.A management approach using clinical presentation to determine the need for antibiotics in chorioamnionitis-exposed infants was successful in reducing antibiotic exposure and was not associated with any clinically relevant delays in care or adverse outcomes.
View details for PubMedID 29599112
Optimal Criteria Survey for Preresuscitation Delivery Room Checklists.
American journal of perinatology
2016; 33 (2): 203-207
Objective To investigate the optimal format and content of delivery room reminder tools, such as checklists. Study Design Voluntary, anonymous web-based surveys on checklists and reminder tools for neonatal resuscitation were sent to clinicians at participating hospitals. Summary statistics including the mean and standard deviation of the survey items were calculated. Several key comparisons between groups were completed using Student t-test. Results Fifteen hospitals were surveyed and 299 responses were collected. Almost all (96%) respondents favored some form of a reminder tool. Specific reminders such as "check and prepare all equipment" (mean 3.69, SD 0.81) were ranked higher than general reminders and personnel reminders such as "introduction and assigning roles" (mean 3.23, SD 1.08). Rankings varied by profession, institution, and deliveries attended per month. Conclusions Clinicians perceive a benefit of a checklist for neonatal resuscitation in the delivery room. Preparation of equipment was perceived as the most important use for checklists.
View details for DOI 10.1055/s-0035-1564064
View details for PubMedID 26368913