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Analysis

Neonatology Leader Shares Specialty Trends, Maternal Mortality Prevention

By Christopher Cheney  
   March 13, 2019

Focal points in neonatology include better communication with families and sepsis screening.

Maternal mortality and sepsis detection are two of the most vexing challenges in obstetrics and neonatology.

Neonatologist Meg Prado, MD, who was recently appointed as president of Women's and Children's Services at Nashville-based Envision Physician Services, recently discussed these challenges with HealthLeaders.

Prado joined Envision in 2001, practicing as a neonatologist at Miami Children's Hospital. She most recently served as vice president of Women's and Children's Services for Envision. Prado began her new role in February.

She received her medical degree from the University of Miami and completed both her residency and fellowship at Jackson Memorial Hospital in Florida.

The following is a lightly edited transcript of Prado's conversation with HealthLeaders.

HL: Why did you pick neonatology as your specialty?

Prado: When I was in medical school going through all the rotations, I tended to have an affinity for the higher energy and intensive care situations. Once I did my rotation in the neonatal ICU, the deal was pretty much sealed because I already knew I wanted to go into pediatrics, and I wanted to improve healthcare for infants.

HL: Has practicing as a neonatologist lived up to your expectations?

Prado: It has been so much more than what I expected because of the life lessons learned from the parents and their babies.

For example, I was taking care of a baby that was born prematurely, and at a couple months old he was just not progressing the way I wanted him to. By this time, I would have expected this little baby to be off his respiratory support, taking a bottle, or nursing from his mother. He just didn't have the ability to do that because of his lung disease.

I remember taking the parents into the room and telling them how sorry I was that the baby was not as healthy as I wanted him to be. They said, "Dr. Prado, it's not your fault. You're doing everything you can for the baby, and when it's time for him to get better, he will get better."

HL: What are the main trends in neonatology?

Prado: The primary trends are in the softer areas, which include improving communication with parents and families, and not just when a baby is in a NICU. We need to have access to a woman when she gets admitted to a labor ward if she has broken her water early and is at high risk of infection or delivering prematurely. We need to talk with families ahead of time to let them know national and center-based data, so parents can know what to expect for the long-term outcome of their infant.

Including parents on rounds can help them know that their opinions matter. While I am not going to necessarily let a father or mother make an important decision that I need to make as the attending physician, involving them on rounds and making them feel they are part of the decision-making process is vital.

Good medicine is not just good diagnosing and treating, but also making sure we are open and transparent, which is vital to trust and reducing litigation. Even if you have an adverse outcome for a patient, if you have communicated fully the chances of a claim being filed are less likely.

Another trend is introducing skin-to-skin contact early—when you allow a parent to hold a small premature infant even when the baby is on a ventilator or has central lines in place. We need to buy into this idea because we know babies' vital signs stabilize when they are being held by their caregiver. It can potentially improve neurodevelopmental outcomes.

Another major focus is improving nutrition. Neonatologists need to do everything they can to optimize the use of breast milk, especially in low birthweight infants. At Envision, we believe this is best practice, so we work with our hospital partners to make sure that breastfeeding is encouraged. When breastfeeding cannot occur for any reason, we promote the use of donor milk.

HL: You have overseen the development of an innovative neonatal sepsis screening tool. How can we rise to the challenge of screening babies for sepsis?

Prado: The primary challenge of sepsis screening is deciding which infants need antibiotics at birth. At the birth of neonatology, the philosophy was if a baby was sick enough to be in a NICU the baby was sick enough to be on antibiotics. The idea was that any baby who was in a NICU was predisposed to an infection and warranted antibiotics.

In recent years, the increasing instances of antibiotic-resistant organisms in the community as well as in hospitals has prompted calls to decrease use of antibiotics. My concern is the pendulum could be swinging against antibiotics too far. We could be dismissing signs of infection and not administering antibiotics in symptomatic infants.

After an adverse outcome, one of our doctors in Phoenix developed a sepsis screening tool for babies over 34 weeks—babies under 34 weeks are very small and physicians have to exercise their best judgment on whether to start antibiotics. We use a sepsis calculator developed by Kaiser Permanente in conjunction with the baby's symptoms.

HL: Gauge the country's effort to reduce maternal mortality.

Prado: As physicians, we are making sure that the issue is being brought to the forefront and that we are aggressively addressing the issue with proper policies and protocols. However, we are addressing the problem after it has already occurred. It would be better to address poor health challenges before they happen.

As a society, we should be making every effort possible to be healthier because the downstream effects are contributing to increased maternal mortality.

One of the things that has been happening on the OB-GYN front is reducing C-section rates, especially for first-time pregnant women who are at relatively low risk—they only have one baby and the baby's head is presenting down. There's a big effort across the country to reduce the C-section rate, which hopefully will affect maternal hemorrhage.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


KEY TAKEAWAYS

Pregnancy-related deaths increased from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014, the CDC says.

Neonatal sepsis is a deadly condition, particularly for low birth-weight infants.

Trends in neonatology include improving infant nutrition.


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