Clinical Focus


  • Pediatrics
  • Pediatric Hospital Medicine
  • Infant, Preterm

Academic Appointments


Honors & Awards


  • Jennifer Daru Memorial Award (Best Manuscript), Hospital Pediatrics (2019)
  • AAMC Medical Education Scholarship Research and Evaluation Award of Excellence, AAMC (2014)
  • Dean’s Prize for Research and Scholarship: Health Professions Education, UCSF (2014)
  • Advocacy Training Scholarship, American Academy of Pediatrics (2011)
  • Dean’s Research Fellowship, UCSF (2011)
  • Chancellor's Service Award, UCLA (2010)
  • College of Letters and Science Honors Program, UCLA (2010)
  • Distinguished Senior Award, UCLA (2010)
  • Phi Beta Kappa, Phi Beta Kappa Society (2010)
  • Mortar Board National Honor Society, Mortar Board (2009)
  • Rose Gilbert Honors Scholarship, UCLA (2009)
  • Dean's Honors List, UCLA (2006-2010)

Boards, Advisory Committees, Professional Organizations


  • Subspeciality Board Certification, American Board of Pediatrics, Pediatric Hospital Medicine (2022 - Present)
  • Fellow, American Academy of Pediatrics (2017 - Present)
  • Diplomate, American Board of Pediatrics (2017 - Present)

Professional Education


  • Board Certification: American Board of Pediatrics, Pediatric Hospital Medicine (2022)
  • Master of Science, Stanford University, EPIDM-MS (2022)
  • Fellowship: Stanford Pediatric Hospital Medicine Fellowship (2022) CA
  • Residency: Stanford Health Care at Lucile Packard Children's Hospital (2017) CA
  • Internship, Lucile Packard Children's Hospital Stanford (2015)
  • Medical Education: University of California at San Francisco School of Medicine (2014) CA
  • BS with Honors, University of California, Los Angeles, Physiological Science (2010)

Stanford Advisors


All Publications


  • Resource Utilization and Costs Associated with Approaches to Identify Infants with Early-Onset Sepsis. MDM policy & practice Guan, G., Joshi, N. S., Frymoyer, A., Achepohl, G. D., Dang, R., Taylor, N. K., Salomon, J. A., Goldhaber-Fiebert, J. D., Owens, D. K. 2024; 9 (1): 23814683231226129

    Abstract

    Objective. To compare resource utilization and costs associated with 3 alternative screening approaches to identify early-onset sepsis (EOS) in infants born at ≥35 wk of gestational age, as recommended by the American Academy of Pediatrics (AAP) in 2018. Study Design. Decision tree-based cost analysis of the 3 AAP-recommended approaches: 1) categorical risk assessment (categorization by chorioamnionitis exposure status), 2) neonatal sepsis calculator (a multivariate prediction model based on perinatal risk factors), and 3) enhanced clinical observation (assessment based on serial clinical examinations). We evaluated resource utilization and direct costs (2022 US dollars) to the health system. Results. Categorical risk assessment led to the greatest neonatal intensive care unit usage (210 d per 1,000 live births) and antibiotic exposure (6.8%) compared with the neonatal sepsis calculator (112 d per 1,000 live births and 3.6%) and enhanced clinical observation (99 d per 1,000 live births and 3.1%). While the per-live birth hospital costs of the 3 approaches were similar-categorical risk assessment cost $1,360, the neonatal sepsis calculator cost $1,317, and enhanced clinical observation cost $1,310-the cost of infants receiving intervention under categorical risk assessment was approximately twice that of the other 2 strategies. Results were robust to variations in data parameters. Conclusion. The neonatal sepsis calculator and enhanced clinical observation approaches may be preferred to categorical risk assessment as they reduce the number of infants receiving intervention and thus antibiotic exposure and associated costs. All 3 approaches have similar costs over all live births, and prior literature has indicated similar health outcomes. Inclusion of downstream effects of antibiotic exposure in the neonatal period should be evaluated within a cost-effectiveness analysis.Of the 3 approaches recommended by the American Academy of Pediatrics in 2018 to identify early-onset sepsis in infants born at ≥35 weeks, the categorical risk assessment approach leads to about twice as many infants receiving evaluation to rule out early-onset sepsis compared with the neonatal sepsis calculator and enhanced clinical observation approaches.While the hospital costs of the 3 approaches were similar over the entire population of live births, the neonatal sepsis calculator and enhanced clinical observation approaches reduce antibiotic exposure, neonatal intensive care unit admission, and hospital costs associated with interventions as part of the screening approach compared with the categorical risk assessment approach.

    View details for DOI 10.1177/23814683231226129

    View details for PubMedID 38293656

    View details for PubMedCentralID PMC10826394

  • Early Experiences With Nirsevimab: Perspectives From Newborn Hospitalists. Hospital pediatrics Aragona, E., Joshi, N. S., Birnie, K. L., Lysouvakon, P., Basuray, R. G. 2023

    Abstract

    RSV, the leading cause of bronchiolitis, primarily affects young children. According to the Centers for Disease Control and Prevention (CDC), RSV accounts for an annual 2.1 million outpatient visits, 58,000-80,000 hospitalizations, and 100-300 deaths in children <5 years old.1 Infants <6 months of age are at greatest risk of hospitalization, with the highest morbidity and costs in infants born prematurely.2,3 In addition, RSV infections lead to economic productivity loss and heightened parental emotional stress.4 Along with Coronavirus Disease 2019 (COVID-19) and influenza, respiratory season can significantly strain the healthcare system, as was seen and experienced by many pediatric hospitalists during the 2022-2023 "tripledemic."

    View details for DOI 10.1542/hpeds.2023-007639

    View details for PubMedID 38115681

  • Changes in perceptions of antibiotic stewardship among neonatal intensive care unit providers over the course of a learning collaborative: a prospective, multisite, mixed-methods evaluation. Journal of perinatology : official journal of the California Perinatal Association Qureshi, N., Kroger, J., Zangwill, K. M., Joshi, N. S., Payton, K., Mendel, P. 2023

    Abstract

    To assess clinician perceptions towards the value and implementation of antibiotic stewardship (AS) in neonatal intensive care units (NICU).We performed a mixed-methods study of AS perceptions (prescribing appropriateness, importance, activity, capacity) using surveys and interviews in 30 California NICUs before and after a multicenter collaborative (Optimizing Antibiotic Use in California NICUs [OASCN]).Pre-OASCN, 24% of respondents felt there was "a lot of" or "some" inappropriate prescribing, often driven by fear of a bad outcome or reluctance to change existing practice. Clinicians reported statistically significant increases in AS importance (71 v 79%), perceived AS activity (67 v 87%), and more openness to change after OASCN (59 v 70%). We identified other concerns that lessen AS effort.OASCN increased perceived AS activity and openness to change in AS practices among NICU prescribers. Greater attention to subjective concerns should augment AS improvement.

    View details for DOI 10.1038/s41372-023-01823-0

    View details for PubMedID 38001155

    View details for PubMedCentralID 4958232

  • Evaluating Epidemiologic Trends and Variations in NICU Admissions in California, 2008 to 2018. Hospital pediatrics Pang, E. M., Liu, J., Lu, T., Joshi, N. S., Gould, J., Lee, H. C. 2023; 13 (11): 976-83

    Abstract

    Previous research suggests increasing numbers of and variation in NICU admissions. We explored whether these trends were reflected in California by examining NICU admissions and birth data in aggregate and among patient and hospital subpopulations more susceptible to variations in care.In this retrospective cohort study, we evaluated NICU utilization between 2008 and 2018 for all live births at hospitals that provide data to the California Perinatal Quality Care Collaborative. We compared hospital- and admission-level data across birth weight (BW), gestational age (GA), and illness acuity categories. Trends were analyzed by using linear regression models.We identified 472 402 inborn NICU admissions and 3 960 441 live births across 144 hospitals. Yearly trends in NICU admissions remained stable among all births and higher acuity births (mean admission rates 11.9% and 4.1%, respectively). However, analysis of the higher acuity births revealed significant increases in NICU admission rates for neonates with higher BW and GA (BW ≥ 2500g: 1.8% in 2008, 2.1% in 2018; GA ≥ 37 weeks: 1.5% in 2010, 1.8% in 2018). Kaiser hospitals had a decreasing trend of NICU admissions compared to non-Kaiser hospitals (Kaiser: 13.9% in 2008, 10.1% in 2018; non-Kaiser: 11.3% in 2008, 12.3% in 2018).Overall NICU admission rates in California were stable from 2008-2018. However, trends similar to national patterns emerged when stratified by infant GA, BW, and illness acuity as well as Kaiser or non-Kaiser hospitals, with increasing admission rates for infants born at higher BW and GA and within non-Kaiser hospitals.

    View details for DOI 10.1542/hpeds.2023-007190

    View details for PubMedID 37867440

    View details for PubMedCentralID PMC10593864

  • An unexpected cause of weight loss in a teenaged girl. Journal of paediatrics and child health Dong, E. E., Joshi, N., Tse, G. 2023

    View details for DOI 10.1111/jpc.16424

    View details for PubMedID 37171150

  • Rethinking Admission Location for Low Acuity Infants of 35 Weeks' Gestation. Pediatrics Joshi, N. S., Congdon, J. L., Phillipi, C. A. 2023; 151 (4)

    View details for DOI 10.1542/peds.2022-059996

    View details for PubMedID 36994640

  • Admission and Care Practices in United States Well Newborn Nurseries. Hospital pediatrics Joshi, N. S., Flaherman, V. J., Halpern-Felsher, B., Chung, E. K., Congdon, J. L., Lee, H. C. 2023

    Abstract

    OBJECTIVES: Late preterm and term infants comprise 97.3% of annual births in the United States. Admission criteria and the availability of medical interventions in well newborn nurseries are key determinants of these infants remaining within a mother-infant dyad or requiring a NICU admission and resultant separation of the dyad. The objective of this study was to identify national patterns for well newborn nursery care practices.METHODS: We surveyed a physician representative from each nursery in the Better Outcomes through Research for Newborns Network. We described the admission criteria and clinical management of common newborn morbidities and analyzed associations with nursery demographics.RESULTS: Of 96 eligible nursery representatives, 69 (72%) completed surveys. Among respondents, 59 (86%) used a minimal birth weight criterion for admission to their well newborn nursery. The most commonly used criteria were 2000 g (n = 29, 49%) and 1800 g (n = 19, 32%), with a range between 1750 and 2500 g. All nurseries used a minimal gestational age criterion for admission; the most commonly used criterion was 35 weeks (n = 55, 80%). Eleven percent of sites required transfer to the NICU for phototherapy. Common interventions in the mother's room included dextrose gel (n = 56, 81%), intravenous antibiotics (n = 35, 51%), opiates for neonatal abstinence syndrome (n = 15, 22%), and an incubator for thermoregulation (n = 14, 20%).CONCLUSIONS: Wide variation in admission criteria and medical interventions exists in well newborn nurseries. Further studies may help identify evidence-based optimal admission criteria to maximize care within the mother-infant dyad.

    View details for DOI 10.1542/hpeds.2022-006882

    View details for PubMedID 36843483

  • Epidemiology and trends in neonatal early onset sepsis in California, 2010-2017. Journal of perinatology : official journal of the California Perinatal Association Joshi, N. S., Huynh, K., Lu, T., Lee, H. C., Frymoyer, A. 2022

    Abstract

    OBJECTIVE: This study evaluated patterns of neonatal early onset sepsis (EOS) disease burden to guide approaches to EOS management.STUDY DESIGN: Retrospective cohort.RESULT: A total of 1535 EOS cases were identified amongst 2,872,964 neonates born between 2010 and 2017 at 136 NICUs within the California Perinatal Quality Care Collaborative. EOS incidence was 7.4 per 1000 (E coli: 4.3, GBS: 1.1) in preterm, 0.76 per 1000 (E coli: 0.29, GBS: 0.22) in late preterm, and 0.31 per 1000 (E coli: 0.07, GBS 0.13) in term neonates. There was no significant change in overall incidence, though an increase in E coli (p<0.001) and decrease in GBS (p=0.04) incidence were noted. After adjusting for gestational age, there was no difference in the odds of death by pathogen (p>0.2).CONCLUSION: The overall EOS incidence remained steady in California NICUs from 2010-2017, though an increase in E coli and decrease in GBS EOS incidence was noted.

    View details for DOI 10.1038/s41372-022-01393-7

    View details for PubMedID 35469043

  • A Culture of Too Many Blood Cultures Hospital Pediatrics Liang, D., Kim, J. J., Joshi, N. S. 2022
  • A Feasibility Study of a Novel Delayed Cord Clamping Cart. Children (Basel, Switzerland) Joshi, N. S., Padua, K. n., Sherman, J. n., Schwandt, D. n., Sie, L. n., Gupta, A. n., Halamek, L. P., Lee, H. C. 2021; 8 (5)

    Abstract

    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

  • Case 1: Rapidly Rising Bilirubin Level in a 3-day-old Term Infant. NeoReviews Tise, C. G., Joshi, N. S., Erice-Taganas, A. D., Blecharczyk, E. M. 2020; 21 (10): e687–e690

    View details for DOI 10.1542/neo.21-10-e687

    View details for PubMedID 33004562

  • Hands. Pediatric research Joshi, N. S. 2020

    View details for DOI 10.1038/s41390-020-01128-4

    View details for PubMedID 32919386

  • Short Parenteral Courses for Young Infants With UTI. Hospital pediatrics Joshi, N. S., Wang, M. E. 2020

    View details for DOI 10.1542/hpeds.2020-001685

    View details for PubMedID 32817063

  • Sustainability of a Clinical Examination-Based Approach for Ascertainment of Early Onset Sepsis in Late Preterm and Term Neonates. The Journal of pediatrics Frymoyer, A. n., Joshi, N. S., Allan, J. M., Cohen, R. S., Aby, J. L., Kim, J. L., Benitz, W. E., Gupta, A. n. 2020

    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. Hospital pediatrics Joshi, N. S., Gupta, A., Allan, J. M., Cohen, R. S., Aby, J. L., Kim, J. L., Benitz, W. E., Frymoyer, A. 2019

    Abstract

    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 PEDIATRICS Joshi, N. S., Gupta, A., Allan, J. M., Cohen, R. S., Aby, J. L., Weldon, B., Kim, J. L., Benitz, W. E., Frymoyer, A. 2018; 141 (4)
  • Clinical Monitoring of Well-Appearing Infants Born to Mothers With Chorioamnionitis. Pediatrics Joshi, N. S., Gupta, A. n., Allan, J. M., Cohen, R. S., Aby, J. L., Weldon, B. n., Kim, J. L., Benitz, W. E., Frymoyer, A. n. 2018; 141 (4)

    Abstract

    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

  • Physician Preferences Surrounding Urinary Tract Infection Management in Neonates. Hospital pediatrics Joshi, N. S., Lucas, B. P., Schroeder, A. R. 2017

    Abstract

    Variability exists in the treatment of neonates with urinary tract infection (UTI), potentially reflecting an overuse of resources. A cross-sectional vignette survey was designed to examine variability in physician preferences for intravenous (IV) antibiotic duration, genitourinary imaging, and prophylactic antibiotics and to evaluate drivers of resource use.The survey was administered to a random sample of pediatricians through the American Medical Association's Physician Masterfile. Respondents were provided with a case vignette of a 2-week-old neonate with a febrile UTI and asked to indicate preferences for IV antibiotic duration and rank drivers of this decision. Respondents were also asked whether they would obtain a voiding cystourethrogram (VCUG) and, regardless of preference, randomly presented with a normal result or bilateral grade II vesicoureteral reflux. The survey was delivered electronically to facilitate skip logic and randomization.A total of 279 surveys were completed. Preference for total IV antibiotic duration differed significantly (P < .001) across specialty, with a median duration of 2 days for general pediatricians/hospitalists, 7 days for neonatologists, and 5 days for infectious disease pediatricians. For the 47% (n = 131) who did not want a VCUG, 24/61 (39%) wanted prophylactic antibiotics when presented with grade II vesicoureteral reflux (P < .001).Subspecialty status appeared to be the most influential driver of IV antibiotic duration in the treatment of UTI. A substantial proportion of pediatricians who initially expressed a preference against ordering a VCUG wished to prescribe prophylactic antibiotics when results were abnormal, which suggests that even unwanted diagnostic test results drive treatment decisions.

    View details for PubMedID 29196453