Thermoregulation of the Neonate

Ben Courchia, MD: Hello, everybody. Welcome back to the incubator podcast. We are here today for the first episode of our special series focusing on thermal regulation. Daphna, first of all, how are you?

Daphna Yasova Barbeau, MD: I'm doing great this mini-series has been a long time in planning and so it's nice to finally roll it out. I'm going to go ahead and start the video.

Ben Courchia, MD: very excited about our first episode. You're still under the weather, but you're getting better. So, we're happy. That's good. And we are starting this mini-series with a super interesting guest. We have with us today, Dr. John Ibrahim, who is a neonatologist. He's also an assistant professor of pediatric in the newborn medicine division at UPMC. For those of you outside the US, UPMC is a very prestigious institution. It is the University of.

Daphna Yasova Barbeau, MD: Yeah, better getting the...

Ben Courchia, MD: Pittsburgh Medical Center. John, thank you so much for making the time to be with us today.

Dr. John Ibrahim: Thank you, guys, for inviting me.

Ben Courchia, MD: You have published articles on so many different topics and you are almost like a savant of neonatology. You're juggling so many different pathologies. But today we wanted to talk a little bit about thermal regulation, maybe in the context of history, global health and the delivery room. I think what's very interesting is that thermal regulation of the newborn, especially after birth, is something that's

Daphna Yasova Barbeau, MD: This is...

Ben Courchia, MD: since the dawn of time has been on the minds of the doctors, of the obese, of the parents. So can you tell us a little bit about what have you read about in terms of the historical aspect of keeping babies warm after birth?

Dr. John Ibrahim: Yes, yes. I think thermoregulation is one of the topics that, despite a lot of publications, has been something that not a lot of people pay attention to. There's a lot of rigorous guidelines that have been published by a lot of organizations. But interestingly, if you read the history, there has been a lot of thought about incubators, particularly in the past with Coney Island, incubators and boxes. And a very fascinating history that you read about it. A lot of vulgar practices also that I've read about with being followed in the unitary cessation and how this all evolved from these practices, people trying to really warm these babies, but inadvertently causing harm or the benefit until the current evolution of incubators and now going to the intricacies like after delivery and the plastic bags and the radiant warm and the warm towels. But warm towels,

pre-warmed incubators. But it's very interesting stuff. I think if you go back and look at the Coney Island incubators and how these babies were placed in these incubators for people to come around and take a look at them. And they used to call these premature babies’ weaklings because they thought that when these babies are born premature, they kind of have some sort of an abnormality. And they were not, all of the time, they were not resuscitated to.

Ben Courchia, MD: So, and hold on, am I on mute? No.

Daphna Yasova Barbeau, MD: No.

Ben Courchia, MD: And I think that's very interesting because you read some of these. We had on the podcast, Don Raffle, who wrote a whole book about the Coney Island, I guess, NICU, if you want to call it, but where Dr. Cooney was keeping babies in incubators. And the idea that the incubators were such an innovative technology and all they pretty much did was just try to keep the baby warm. And when you read the history of the incubators.

Daphna Yasova Barbeau, MD: Uh huh.

Ben Courchia, MD: It's interesting how it took them a little bit of time to figure out how to get them to the right temperature, because sometimes they were overheating them and sometimes, they were not heating them properly. But she was telling us stories of like parents who had a baby born preterm and they would like to put them in the shoe box with like the feathers and some, some parents putting the baby in the oven to try to keep them warm. So, it's so interesting that we are still talking about thermal regulation and it's probably one of the first aspects of neonatal care that we ever thought of.

Daphna Yasova Barbeau, MD: Mm-hmm. Mm-hmm. Warm.

Dr. John Ibrahim: And I'm doing a...

Daphna Yasova Barbeau, MD: And that was, I'm sorry, episode 14, if anybody wants to take a look at our interview with Don Raffle.

Ben Courchia, MD: Yeah.

Dr. John Ibrahim: And to your point, Ben and Daphna, it's impressive how the parents acknowledged that these babies kept warm, and they were trying to keep them warm. So, they got this concept long time ago, but they were not able to figure out a safe way to do it.

Daphna Yasova Barbeau, MD: Mm-hmm.

Ben Courchia, MD: Right.

Daphna Yasova Barbeau, MD: I think you brought up another interesting point, and we feel that way even in our high-tech units, is that we know about thermoregulation, we learn about it, but then it kind of falls by the wayside. And I think that's interesting in terms of the historical perspective where at some point time all we had to offer was keeping babies warm. That was the mainstay of neonatal care and then figuring out how to feed them.

Um, so where along the history do you feel like we just got so comfortable that sometimes we even forget, you know, that, you know, the, especially here in the United States, the incubator does its job. The thermal mattress does its job. Um, but sometimes when things are not going well, we've, we've forgotten that we have to check and see what, what the temperature is doing.

Dr. John Ibrahim: I mean, definitely, I think, like with our data routine and the number of deliveries that we attend, sometimes it becomes like second nature, all these pre-warmed incubator, pre-warmed towels, pre-warmed IV fluids, plastic bags in the delivery room. But I think the thing that you're pointing out too is how can we track these changes? How can we make sure that these changes are working? Because you're not only talking about hypothermia, some of these interventions, if combined together, can lead to hypothermia, which is another problem that we need to keep an eye on.

Daphna Yasova Barbeau, MD: Mm-hmm.

Dr. John Ibrahim: But despite, I mean, some of the surveys that came out recently said that despite these strong recommendations about practices to prevent hypothermia neonates, not a lot of units, particularly even the United States follow these. And I can give you an example of the delivery room temperature. It's been a hot topic, right? With obstetrics and gynecology and our colleagues. Yeah, right. They thought we talk about how we can we need to adjust the delivery room temperature. But and where should it be?

No one knows, but there is a lot of papers published about 23 Celsius, 23 to 25, more than 26. A lot of talks about it, but it's been a hot topic, and it also points to the controversy about thermoregulation. Also, a lot of mixed data about long-term outcomes with thermoregulation. Does it really have a benefit? Does it really not have a benefit? I mean, the L-Core...

published two meta-analyses. One of them pointed to decreased mortality and the most recent one that just came a few months ago said that they couldn't really ascertain if there are long-term benefits from thermoregulation. So again, it's a lot of controversy but I agree with you, sometimes we become so comfortable that we lose track and don't follow up these interventions and make sure they're doing the job they're supposed to do.

Ben Courchia, MD: Yeah, I think it's a great follow up to the discussion we were just having about history, where I think in one of the first books about neonatology, like The Nursling by Pierre Boudin in France, right? He basically said that the principle

aspect of taking care of a baby is really to just keep the baby warm, give the baby breast milk and nurture the baby. And these were the only three things that were assigned to do to a baby and then turned out what turned out. There wasn't really nothing else. And then our care of the newborn has gone, as you guys said, so much more sophisticated. And we have almost forgot about keeping thermal regulation. And so, I think there's several interesting things about thermal

It's definitely something that we will need to be discussing when it comes to the preterm infants, but it is also something that affects the term infant very much. And you mentioned the ambient temperature of the room in the EOR or in the delivery suite. But can you tell us a little bit about what is, especially for full term babies, because these also tend to be shrubbed off. It's like, OK, full term is going to be OK. But what are the importance and the ramifications

of keeping a baby normothermic, and what happens if we don't keep a baby normothermic at a full-term gestation.

Dr. John Ibrahim: That's a very interesting question. And I agree with you, Ben. I mean, there's a lot of data published about preterm infants, but not much about the term baby. It's like a term baby doesn't really need to be born or no one really pays attention to that. But I think there's been ramifications about short term, at least outcomes with these babies. There were some reports about increased mortality with hypothermia in infants in general or newborns. Obviously, this increases with preterm.

infants. And also, respiratory distress and hypoxemia, particularly is one of the other things you need to worry about in a term being exposed to hypothermia at birth. And sometimes these babies when they're exposed to hypothermia, they don't transition well and it's something that obviously we see a lot, particularly babies born in the community and transferred to a bigger center.

Ben Courchia, MD: Yeah. Any? Okay. I thought you were going to say something, Daphne, but you're muted. Okay. So then in terms of the full-term infants, I think in the US, at least, or at least in maybe in other developed countries, this is something that is pretty well established. And I think we tend to lose focus of the fact that normal thermia for full-term infant is still very much a struggle outside the US and specifically in low- and middle-income countries. Have you had any experience with regulation of temperature for these infants on the global health stage?

Dr. John Ibrahim: That's a question I love because on both aisles, I actually trained in my medical school back in Egypt and I did have several of my rotations. I was working in the intensive care units in one of the biggest hospitals in the capital, Cairo. And it's very fascinating because this concept of thermoregulation we did not have. Her baby born was essentially bond given to the mom.

But what really impressed me and really fascinated me how these moms impressed this concept of skin-to-skin and breastfeeding, obviously. We never as physicians paid so much attention. We were never educated about it. We were never paying attention to it. We never knew the associations with impair like short-term morbidities. But these moms were always keen about getting these babies to do skin-to-skin. I do remember at one point we have incubators that came from the US.

and they were parked outside the NICU. And I came outside the NICU, I was like, what is this, what's this? And they were like, oh, it's from Viva. So, I was like, okay, so what does it do? And no one knew nothing about it. No one knew how to park it. No one knew how to keep it in maintenance, but they were just shipped, and we never used them in the NICU. So, I think it has evolved over time by the time I left.

Daphna Yasova Barbeau, MD: Ha ha! Hmm

Dr. John Ibrahim: But it was some of the very impressive things. I mean, also incubators, as you know, has evolved over time from the part from Coney Island until now and have been more and more better at keeping these babies warm.

Ben Courchia, MD: I think this is a point that I definitely want to ask you a follow-up question, because hearing this story, I think it's fascinating. And I guess I'm wondering if you had to describe, how has your understanding of thermal regulation evolved? As you were a trainee, like you were a student, and to where you are now.

I'm just curious how has your perception evolved over time?

Dr. John Ibrahim: I can tell you very well I so much appreciate skin to skin. And I believe that it's a very strong mechanism for thermo-degradation in term babies. Something that I didn't really pay attention to when I was doing my training back in my home country. And I don't think a lot of physicians paid attention to. But these moms who did not have a lot of education were always keen about asking us to deliver the baby to the bed so they can do the skin to skin and enjoy these moments.

Ben Courchia, MD: Mmm.

Daphna Yasova Barbeau, MD: Mmm.

Dr. John Ibrahim: When I came here during my residency training, I started appreciating the importance of thermoregulation, but not in that depth. And in my fellowship, I was so focused on the big things, like training and never paid attention to the small stuff like thermoregulation delivery room, like always seeking all the big pathologies and getting comfortable with the difficult cases, but not paying attention to that aspect.

Daphna Yasova Barbeau, MD: Okay.

Dr. John Ibrahim: Then when I transitioned as a junior faculty and I was tasked with the mission of establishing a golden hour program here in our unit, I started paying more attention to importance of thermoregulation and reading about it. I was like, wow, that's a big issue. That's something that has a lot of interventions, a lot of studies. The fact that the L-Core has published two meta-analysis and systematic reviews about it says how much the scientific bodies here in the United States pay attention to it.

Daphna Yasova Barbeau, MD: Mm-hmm. Yeah.

Dr. John Ibrahim: But it's also a hot topic and it's an area of, there's a lot of resistance sometimes to certain aspects of it, so.

Daphna Yasova Barbeau, MD: It's also hot, huh? Mm-hmm.

Ben Courchia, MD: Very nice pun saying a hot topic on this subject.

Daphna Yasova Barbeau, MD: Hot topic. But I think you bring up such an extraordinary point because in low- and middle-income countries, low resource settings, I mean, they are very adept at using skin-to-skin care for thermoregulation as a primary modality of keeping the babies warm.

And I find that here, even in the highest resource settings, the shiniest I see is the fanciest I see is we struggle at keeping babies warm during skin-to-skin care. And I wonder where the disconnect is there. I also feel like the parents that I interact with, I mean, they know the temperature of their baby. Like they know it. They tell us like, I feel like my baby's warm today. Maybe he's cool today.

I feel like parents are very in tune, especially with temperature for their babies. And the parent who's doing skin-to-skin often knows when the baby's getting cold before anybody else does. And so, I wonder where the disconnect is there. I think you just have such an interesting perspective on where we're missing a step there between our fancy technology and interfacing with parents in this way.

Dr. John Ibrahim: I think it's all about training. And it's very impressive when you go to delivery and make your call to delivery, and this is a term baby that transitions well, we still bring him to the bed and do our exam. Meanwhile, we can leave him on do skin to skin and to just do our exam there because we think they're doing well. I think it's more about spreading awareness and the culture of importance of skin to skin. For these farms actually also, these are precious moments after delivery and also for these babies warm.

Daphna Yasova Barbeau, MD: Yeah.

Dr. John Ibrahim: It's actually one of the things, like I just was reading a survey that mentioned that the majority of the units in Africa keep their ambient temperature more than 26 Celsius, while only 50% of the units in the US keep the temperature, the ambient temperature, more than 23 Celsius. So, you wonder, like all this research and recommendations, but we're still struggling with one of the first steps of adjusting.

Ben Courchia, MD: If you just switch the thermostat a little bit, you might have your solution. I wanted to go back to this aspect of the evolution of your perception, because I think that there's something that I felt, especially when I was a trainee, where we feel like thermoregulation is sort of the nurse's job.

Daphna Yasova Barbeau, MD: Mm-hmm. That's right. That's.

Dr. John Ibrahim: Thank you.

Daphna Yasova Barbeau, MD: Hmm.

Ben Courchia, MD: You feel like, oh, the nurse is going to keep the baby warm. I'm here for the heart rate and the breathing. And the way you describe this, it's interesting how it's sort of almost like a boomerang, right? It sort of came back on your lap as a junior attending, where you realize this is something that we as physicians and as providers have to really pay very close attention to. This is not like...

Daphna Yasova Barbeau, MD: This is...

Ben Courchia, MD: cutting the cord or clamping the umbilical cord where really, it's, I can let somebody else take care of this, right? What would be your advice for trainees and for people who are young in their careers about some of these things, thermal regulation being one of them, but also all these other things that sometimes we say, oh, that the nurse takes care of this, and I don't really pay attention to too much of that.

Dr. John Ibrahim: That's an excellent question, man. I think one of the things that we need to embrace as physicians and particularly trainees also are neonatal resuscitation is just not providing respiratory support to a baby that's struggling to breathe. Neonatal resuscitation starts also with thermoregulation. And even if a baby is a term baby that doesn't need neonatal resuscitation, just doing the skin-to-skin or maintaining thermoregulation is a step on neonatal resuscitation. So, you're technically providing neonatal resuscitation to this baby.

The concept that the baby is fine, and we just need to examine him and just leave. I think you're bringing up a good point. It's the responsibility of everyone in the delivery room to make sure that this baby's warm. If the baby's fine, just take him to the mom and let her enjoy these moments. But I agree with you. It's a joint responsibility, not only the nurse's responsibility.

Ben Courchia, MD: Uh-huh.

Ben Courchia, MD: Is it okay, definitely if we move on to preterm babies, because I have a lot of questions that I wanted to ask John about. Please, that's why I'm asking that.

Daphna Yasova Barbeau, MD: I have one more question about the full-term baby. Well, and I think this will be a good segue even into the preterm baby because it affects both. You mentioned something that especially when we are being attentive to the preterm baby in golden hour, but I see this happening in the newborn nursery all the time, thermia, and dysregulating in the other direction.

Daphna Yasova Barbeau, MD: that. I think where we think about it most strikingly is in the baby that we're trying to keep normothermic or moving towards cooling for therapeutic hypothermia. And so, we know there are risks to hyperthermia in that situation, but even just to the, certainly to the preterm, but the term newborn in hyperthermia.

Dr. John Ibrahim: I think definitely we're talking about both aisles, right? We're trying to avoid hypothermia, but also not trying to induce hyperthermia. And besides, I mean, hyperthermia obviously would lead to tachycardia, obviously would lead to difficult transition. And with tachycardia, it just impairs the cardiac filling of these babies and can lead to issues with also with perfusion. So, we have to pay close attention to both. Now, not a lot of studies have...

looked at hyperthermia in normal term babies, so I can speculate what the outcomes would be, but obviously hyperthermia in a baby with neonatal insulopathy is detrimental. But I think maintaining the baby in the athermic range is the best practice and implementing hypothermia measures to prevent hypothermia with the caveat that we have to keep close track. I mean, one of the things that...

when we started implementing the golden hour here, we paid attention to with preterm and term babies is documenting the temperature in the delivery room. Because what usually happens is you document the temperature and admission to the NICU. And then if these babies are cold, right. And you know they got cold in the delivery room. They got cold in transport. So, we started implementing, we need to document the temperature in the delivery room because we need to know what these babies are doing. Are we providing practices? And this applies to preterm and term.

Daphna Yasova Barbeau, MD: Mm-hmm. It's too late at that time.

Dr. John Ibrahim: And then once we document in the delivery room, then we documented an admission to the NICU and this way we can gauge at what point there is a disconnect or something that needs to be fixed.

Daphna Yasova Barbeau, MD: And I think Ben is gonna want to move into the golden hour practices. But before we do that, I don't wanna miss the component about resuscitation and how hypothermia affects our ability to resuscitate effectively.

Ben Courchia, MD: Oh, I will. So, before we even get into this, because I think when we're talking about, but you're talking, I mean, if we're talking about resuscitation, I was going to ask in the delivery room, the interventions that we have.

just for the people listening, I'm sure everybody knows this. So, I'm just going to get it out of the way. You have your resuscitation table, which has a radiant warmer. You have a thermal mattress that you crack open and generates heat. And then we have these little plastic wraps or bags that we put the preterm babies in. Can you give us, I've seen so much crap being done in the delivery room with the mattresses, with the bags, people like...

I think every institution pokes a different hole in the plastic bag. That can you give us how you would set this up and how do you bring a baby to the resuscitation table so that it's done in the most optimal conditions?

Dr. John Ibrahim: So, when are you talking more about preterm or term or.

Ben Courchia, MD: Yeah, yeah, I'm talking, I mean, in this case, I would be talking about preterm because I think I want to hear what you do with the mattress and the plastic bag and so on.

Dr. John Ibrahim: When we were talking about the golden hour, it took a lot of discussion. So, it's very interesting. And different people do different sequences, right? But what we decided to do is we decided to have the plastic back. So, if you're going to do a delay core clamping on a preterm, the maximal heat loss happens in the first 10 to 20 minutes of life. And head is big.

portion of the heat loss in premature babies. So, what we've decided is we drop the plastic bag sterilely in the operating field at the discretion of the nurse, the surgical nurse. And then OB, if they're going to do the late core clamping, they put the plastic bag around the baby and then do the late core clamping. Obviously, you have to have a pre-warmed incubator. You have to have warm towels. You have to have a warm pre-warmed head ready for the baby.

We can talk about the plastic lined heads versus the knitted heads, and which one is superior. But all of these have to be pre-warmed. So yes, I think the plastic bag. Another thing is you put the thermo mattress, you crack it, you get it ready because it generates heat within seconds. And actually, this heat can last for two hours. And you put it ready for the baby in the incubator. The baby in the plastic bag.

Ben Courchia, MD: Two hours is what I heard as well, yeah.

Dr. John Ibrahim: The thermo mattress has to be outside the plastic bag. Now, several studies have shown that the combo of plastic wrapping or plastic bag and thermo mattress can lead to hyperthermia. And that's where we came with check the temperature in the delivery room, check the temperature on admission, make sure that this is not happening, because also this is detrimental. I can talk about one of the funny challenges that we had is if you weigh the baby in the delivery room, would you subtract the weight of the plastic bag?

it counts in these tiny babies. And yeah, we actually went so crazy, and we started weighing these plastic bags to see how much they weigh and subtract it from the weight of the baby. But just to the point again about the plastic bag and the Thurman mattress, you really need to collaborate with your OB colleagues. And they were very kind to accommodating this practice in the unit. Now, if the baby doesn't need a delay core clamping, you can have the plastic bag at the radian warmers just transfer the baby to the...

Daphna Yasova Barbeau, MD: Right?

Ben Courchia, MD: Yeah. Yeah, but you're right. I mean, we are reviewing so many papers that are recommending delayed chord clamping. And I think it was very... That's exactly right. Like I think initially to me, delayed chord clamping was 32nd. And then we had a discussion with a new Katheria who...

Daphna Yasova Barbeau, MD: precious time. And longer delayed core clamping.

Ben Courchia, MD: who really said 30 seconds almost should not even be considered delayed cord clamping. We were looking at 60 seconds. And as you said, the first few minutes are so precious that I love the idea of dropping the plastic wrap sterilely on the field so that the surgeons can actually put the baby in it until the cord is being clamped. Hold on. I have one more for you.

Dr. John Ibrahim: Now we can ask you a question, Ben. I'm going to repeat. OK.

Ben Courchia, MD: Do you put the baby's head on the mattress? That is something that I've argued with my colleagues so many times. Is the head of the baby on the mattress or outside the mattress? Outside the mattress. Okay, go ahead, I'm sorry.

Dr. John Ibrahim: outside the mattress. I'm going to reverse it and say, did Nukatiria talk about resuscitation with intact cords? Because that's another game changer, right? Because these babies will stay at the perineum after delivery, and you'll do the resuscitation. Yeah, right? So.

Daphna Yasova Barbeau, MD: Ha ha. Longer. Yeah.

Ben Courchia, MD: Yeah, and I think we did, he did speak about this, obviously, and I think this is the optimal way of being there for the baby and in a family-centered manner. And I think we're going to have challenges in terms of normothermia, but I have a paper that I'm actually due to review that actually reports how implementing delayed cord clamping and so on actually did not affect how providers could maintain normal thermia. And so, I think as this practice is becoming more prevalent, it's going to be very interesting to get that kind of data to show how it does not need to compromise the thermal regulation of the baby. I'm actually pulling the paper. It's a letter actually in the archives of disease in childhood, and it's called thermal care for preterm infants in the delivery room has not been compromised since the routine adoption of delayed core clamping in our unit. And I think these experiences are gonna be so valuable to make us more comfortable to go closer to the operating field or closer to the perineum and do all the work that we need to do right there in them. And obviously Anoop was very sharp in his answer when he said that we're talking about babies where extensive resuscitation is not needed. You're not putting in lines and doing chest compression on the perineum. He says, but there's all these babies that need just a little bit of CPAP and then they're good. This you can potentially, if you bring your Neopuff close to the delivery site, then you can probably do this. And he obviously said, if you need an extensive resuscitation, then obviously you take the baby to a proper resuscitation table and you perform your resuscitation there.

Daphna Yasova Barbeau, MD: Yeah.

Dr. John Ibrahim: Yeah, I was going to say that neonatal thermoregulation has evolved through history. And as we understand the physiology, and if we continue to study the day-core clamping and resuscitation with inter-core clamping, I think we need to be creative about maintaining eothermia in these babies. And it shouldn't be a barrier. It sounds like papers are coming out saying that it has an effect, thermoregulation in preterm babies or term babies.

Daphna Yasova Barbeau, MD: Mm-hmm.

Ben Courchia, MD: Yeah.

Daphna Yasova Barbeau, MD: But you did bring up an interesting point, and I'd love to hear more about the hats.

Dr. John Ibrahim: Yeah, so there's been a lot of studies about use of plastic lined hats, knitted hats, use of hats with polythene plastic wraps, use of plastic wraps that cover the head. And the recent meta-analysis showed that plastic hats are essential because they prevent heat and hypothermia. We started using plastic lined hats because studies have shown that they're superior to the knitted hats. And we've seen good results.

You know, the largest surface area, the head is the large surface area and most of the heat loss and preterm babies happen through the head. And so always when delivery room, I always say put the hat on, put the hat on, put the hat on. Don't forget it. It's the first step before you start doing anything. And yeah, it's an interesting concept.

Ben Courchia, MD: You know you're saying it too much when they start making t-shirts for you that says put the hat on. That means you've said it too much. But it's interesting because you know I was recording our incubator podcast in French yesterday with Gabriel Altat who's practicing in Montreal.

Daphna Yasova Barbeau, MD: Where's that?

Dr. John Ibrahim: I'm sorry.

Ben Courchia, MD: And we were talking about delivery room management on one of the papers. And he was saying how the plastic coverings that they have for their ELBWs in Montreal actually is more like a poncho. It's more like has like the plastic and the little hat that they put on, which obviously then goes back to your point, John, of having a head covering that's made of plastic. So, I think that's very interesting to see to see the variability. 

 

And again, if you are a loyal neonatologist and you practice in one institution for such a long time, you don't know all these other things that are being done in and around the country. So that's kind of, that's kind of cool. So, let's go to golden hour, because we've talked about golden hour. And I think golden hour has become like, it's, it's become a metric and I dislike that so much because it is an approach to the care of a, of an extremely fragile newborn.

Daphna Yasova Barbeau, MD: This is

Ben Courchia, MD: And now it's sort of almost become this sort of checkbox of like, what time did we come in? What time did we finish doing this? What time did we finish doing that? But can you, can you first of all, give us some context as to what is golden hour? Why is it important? Why are we even doing this?

Dr. John Ibrahim: Actually, I love this question, Ben. And to your point, sometimes we worry so much about numbers and focus so much on getting everything done, getting the isolate closed within one hour, and something that we have also encountered. So, the goal in ours is a simple concept, is standardization of practice provided to babies in the first hour of life. But I always teach and always say that it's not only about the first hour of life.

It's making sure that everyone knows their role, and everyone is assigned a role. And it's like an oil machine that's working very smoothly and efficiently to provide the care the baby needs. Now, I don't believe that there's a, like coolest all the centers that are able to have the golden hour and the isolate closure within one hour, but that's not the goal. The goal is to have clear role assignment, have an oil machine of what needs to be done for this baby from the time the baby is born until the isolate is closed.

Now, if you do everything efficiently, you, with the application of the golden hour, you can avoid hypothermia, hypoglycemia. You can get your lines in quickly. It's, I think the goal of the golden hour is more of alerting people that things need to be done efficiently and quickly in a safe way and not really bother so much about, we need to close the ice in an hour. Because one of the funny stories, or one of the funny things is,

You can close the ice, but then open the side walls and continue doing your stuff and just document that it was closed within one hour. But that's not truly golden hour. But just going back to the history because I love history and you guys brought up the history. The golden hour was actually adopted from the adult trauma and first injury used to neonatology in 2009. And since then, it has continued to evolve. And more and more aspects are being included in this golden hour, including the hypothermia approaches, including starting.

through a PIV, including transport shuttles or transport isolates into how quickly you can get an x-ray because sometimes you're on an x-ray and you're waiting there, and the tech is going to the emergency room or going to the other room and you're waiting and waiting and waiting. So, it's all about overcoming these barriers, making sure that priority is given to these tiny, frail sick babies.

Ben Courchia, MD: And so, I think the golden hour, we should probably have John back on for a whole discussion on golden hour. But I think in terms of the thermal regulation, it feels like we do these spot checks of like I'm going to and sometimes these spot checks for golden hour purposes where we check the temperature, I guess, on admission. Sometimes that's what some people require. We do one check and then and then we say, OK.

Daphna Yasova Barbeau, MD: Mm-hmm.

Ben Courchia, MD: That 37.2 and let's begin doing lines. Right. And now it's like, well, what's going to happen to that temperature after you're doing lines. And so, you mentioned already one thing that was so valuable that you said, just check the temperature in the delivery suite. What is your approach to because the goal really, I mean, let's be honest, the goal is not to play with the numbers. Who cares if you if you can check the box on the freaking piece of paper. The goal is to maintain normal thermia.

Daphna Yasova Barbeau, MD: Mm-hmm.

Ben Courchia, MD: And so how has your center evolved in terms of the approach to golden hour, not just to quote unquote, make a golden hour, but also to make sure that the baby remains normothermic throughout the admission process.

Dr. John Ibrahim: So, I can tell you we're one of the busiest delivery hospitals in the States. We have a very active fetal center and a lot of premature deliveries. And the Golden Hour once started in our center, we had a lot of buy-in from everyone involved, starting from the OB to the NICU, to the nurses, to the fellows, residents, physicians.

And you're bringing a good point, Ben. I just want to go back to one point that I really feel passionate about is, when you set your OR temperature or the delivery room temperature, that doesn't mean that this is the temperature of the delivery room. You have to check the ambient temperature. You have to make sure that because you can set it up at 23, but the actual reading is not 23. And check the ambient temperature.

Daphna Yasova Barbeau, MD: Yeah.

Ben Courchia, MD: We live in Florida. We know that what you said on the thermostat is not the temperature of the room.

Daphna Yasova Barbeau, MD: It's not the temperature, though.

Dr. John Ibrahim: Because that's one thing that you can miss. But the reason why we started checking temperatures in the delivery room, because we really wanted to see, where's the disconnect? Why do these babies get cold? And once we check the temperature in the delivery room, as soon as we hit the NICU, we check the temperature again, because we want to see, is our transport efficient in keeping these babies warm? And then the thing is, with the Guggenauer, if you're able to have an experienced provider place your central lines.

Ben Courchia, MD: Right.

Dr. John Ibrahim: in an efficient way, have the radiology tech come, grab your x-rays, confirm your lines, close the isolate. It's not about the golden hour at this point. It's more of how we can get this baby that's lying under the drapes waiting for 20, 30 minutes for an x-ray to be done in the isolate with the humidity and the temperature this baby needs. So, we started looking at admission temperature.

Daphna Yasova Barbeau, MD: Yeah.

Ben Courchia, MD: Okay.

Dr. John Ibrahim: deliver room temperature and temperature after we place the lines after we close the isolate because this way you can track what's the problem. And with us getting the x-rays to the bedside, with us having the experience providers placing the central lines, we were able to decrease our hypothermia rates from 40% to 20% by more than half. But it also gave us a lot of insight about the whole process.

where the problem is, and it's an evolving process, so things change, you have new learners, you have new nurses, new fellows, new residents, and the thing is you need to continue education. You need to provide continued education, refreshers, and reminders.

Ben Courchia, MD: Do you approach a delivery different? I think this is something that we sort of alluded to. You've mentioned this before, but I think we should just like go nip it in the bud and just are you more concerned about thermal regulation if you're going to a vaginal delivery versus a C-section?

Dr. John Ibrahim: I would say yes. I think operating rooms are a little bit cold and they are still cold. As I mentioned before and alluded to the survey, an international survey that showed only 50% of the operating rooms in the United States adjust their temperatures. Even in Europe, it was one of the surveys that came out that showed it's also still a problem. But I pay more attention when in the operating room, understandably because of the temperature.

the potential that these rooms might have cooler temperature.

Ben Courchia, MD: Yeah.

Daphna Yasova Barbeau, MD: I have a question. I'm particularly interested in the golden hour when you've identified that a baby's fallen out of range and the corrective steps. So, I think people say, yeah, we got an abnormal temperature and there's this potential knee-jerk reaction. We may not have discussed it as a team. Someone took it upon themselves to do some sort of corrective measure.

swings in temperature, which we know is probably the worst-case scenario for the smallest babies. Is it part of your protocol what the corrective measures look like, especially in particular, to how it relates to temperature?

Dr. John Ibrahim: That's an interesting point, Athne. It's not part of our protocol, but you're bringing up a good, good point, is the swings in the temperature from a baby being cold to someone taking it, because sometimes people just take it on their own and just try to fix the baby's temperature as quickly as possible, and we know that this is also not good. So yeah, I mean, we talk about gradual rewarming, but the...

of these babies because these big swings from hypothermia to hypothermia, because if you're warming them very quickly, you can overshoot and lead to hypothermia. But again, as we always speak, the best way is to avoid it and avoid hypothermia and avoid severe degrees or...

worse hypothermia by being cognizant about the temperature and keeping tabs on it all the time.

Daphna Yasova Barbeau, MD: And I'd also love to hear more, obviously you have alluded to this, how important the education around golden hour and not just the tasks, but the rationale behind the steps that we do. In my experience in lots of places, people say, okay, these are the steps, we're supposed to get the fluids in, we're supposed to get the antibiotics in, but this final step of getting the top down is actually critical to thermoregulation and humidity.

which goes hand in hand, the humidity piece with maintaining and especially consistent temperature with thermoregulation. So, I think a lot of places have done a good job outlining the tasks, but maybe not the rationale. And so, I'd love to hear how you've tackled that from an educational perspective.

Dr. John Ibrahim: That's an excellent question because if you really, it's easy to say these are the tasks, these are the role assignments, we need everyone to do this, and people will do it but after some time they'll forget. But if people understand why they're doing this, why do we have to do this? What effect does this have on the baby, short term and long term? They will embrace the concept and they will keep that concept and also teach their colleagues. So, when we were.

planning to roll out this golden hour, we did a lot of education to the nurses about the importance of being expeditious and efficient all the steps to the fellows, to the residents during their orientation when they start the neonatal resuscitation rotation. But also, we did it to the RTs, to the pharmacy about the importance of sending up these fluids quickly.

We implemented warming of the IV fluids, which is one of the concepts that's very important. Not enough data published about it too, but it's a common sense of you can give a baby cold IV fluids and expect the baby to keep the temperature. And then the heated humidified gas, again, the recent Midotanis didn't show a lot of robust benefit or certainty behind this practice.

But it's one of the things that we also focus upon is if the baby's on CPAP and you don't have a heater and you're providing this cold air to the baby, the respiratory tract is one of the systems that can lose heat. So again, here comes the education for the respiratory therapist about importance of providing the heating, modified gas if the baby is on CPAP, obviously not intubated. And as I mentioned, the fellows, the residents.

It always becomes tricky because people like to practice like placing lines. But again, if you have an experienced provider that placed the lines, you can place it efficiently and close this stop in a timely manner. But if it's a training opportunity, then it becomes a problem because this can lag for quite a bit. So, the other thing is we talked about

Daphna Yasova Barbeau, MD: Yeah.

Dr. John Ibrahim: radiology technicians of why they need to come to the bedside. And we implemented this golden hour code in the radiology order so that they are reported that, hey, this is a priority. This cannot work.

Daphna Yasova Barbeau, MD: Mm-hmm.

Ben Courchia, MD: Yeah, this is not just like checking the line on a baby that's been here for two weeks like this is a golden hour Uh-huh. That's so good. I'm taking notes by the way people don't know but I'm like writing down all these things. These are awesome

Dr. John Ibrahim: Exactly.

Dr. John Ibrahim: So essentially, don't go to the emergency room to grab an x-ray on someone that's obviously every patient needs an expeditious care, but this is a priority. So, once we place this golden hour code, they come immediately and expeditiously to the bedside to get the x-ray. Sometimes they're waiting before the baby comes down. But we also explain the rationale behind it and why this is important. And I mean, it's not, it has been nothing but wonderful with everyone understanding the

Daphna Yasova Barbeau, MD:

Right. Hmm.

Dr. John Ibrahim: pathology behind it, the physiology behind it, and why these babies are at risk, and everyone kind of accommodating it. And also, in big institutions with the turnover of staff, we also maintain this regular educational series for everyone involved in the care of these babies.

Ben Courchia, MD: I would love to get your PowerPoint on thermoregulation. It sounds like it's a great one. And you mentioned, I'm assuming you mention all the things that we've talked about, and you mentioned mortality. Is there, this is now very much not objective, but when you do this education component with the medical students, the residents, the trainees, the nurses, is there one aspect of thermoregulation that when you mentioned the risk, people are like, oh my God, I didn't know that. Like, is there, what is the one that usually gets people to just have this realization?

Dr. John Ibrahim: I'm not serious. So I think then IVH is one of them, even though the evidence is, again, not strong behind it, but also respiratory distress. I always say that if a cold baby, you cannot transition well, so might have worsening issues with respiratory distress, metabolic acidosis, coagulopathy. And one of the funny things just outside the preterm baby is all these cold babies that come from the nursery and get a sepsis evaluation because they're cold,

Daphna Yasova Barbeau, MD:

Mm-hmm.

Dr. John Ibrahim: there stay upstairs and or the nursery, you can say, oh, this is more environmental, it's unlikely to be sepsis or concern for sepsis. And so, the one thing I think the big thing is, yes, they get cold, and we teach them that there's a risk for short term morbidities, including IVH, respiratory distress. And these are the things that really catch their attention. And I think laptop, I just what like lagging behind about

The study that came a while ago and showed, laptop actually, showed that there is 28% increase in mortality for every 1 Celsius degree decrease in temperature. And that the chances of ill-immunital death was 1.64-fold higher in infants with admissions than 36. And I think this is one of the cliche statements I state. And we state to the learners, and it immediately catches their attention.

Daphna Yasova Barbeau, MD: Wow. Yeah.

Ben Courchia, MD: Dr. Laptock from Brown. And just I want to say this again, because that's something that I reference as well, that one degree of hypothermia equals 28% increase in mortality. And I think even if you look for variability, because I've looked at what is the range.

Daphna Yasova Barbeau, MD: Mm-hmm.

Ben Courchia, MD: I think the lowest number I've seen is like even 10% where, so even 10% from like 10 to 20, this is insane. And we're talking about, yeah, and we're talking about one degree in Celsius, right? Yeah. My last question for you, John, we could keep talking for hours, but my last question to you is, how important is it for providers to get familiar with the technology that is available around them in order to be able to be proficient at maintaining

Daphna Yasova Barbeau, MD: Thanks a lot.

Ben Courchia, MD: Because I've seen many times where some, as a fellow, I had no clue how the freaking temperature probe worked. I didn't know how the temperature was being measured. I didn't know that there were free thermometers that we could use and so on and so on. So, in your opinion, how has your understanding of the tech that is available to you allowed you to be better at maintaining normal thermia?

Dr. John Ibrahim: That's also another, that's an excellent question because it's, you have a lot of aspects. You have the radiant warmer, you have the temperature probe, you have the transport isolate or transport shuttle, and then the BB. I think that brings into account or brings the importance of pre-delivery huddle where the fellow or the physician or whoever in charge preparing for the delivery huddles once, I mean, it's not always possible.

every case, but if you know that extreme and golden hour baby or extremely premature babies being delivered, if you huddle and just talk start talking about what needs to be done, go up to the delivery room or the operating room, check your equipment, familiarize yourself with the equipment, turn the incubator radiant warmer on or incubator on. That's the key, right? You can be reactive; you have to be proactive and be prepared before these babies arrive.

So that's one aspect. And I just want to point about one of the important things that we encountered and a lot of tends to be overlooked is the frequent transfer of the babies between different beds on admission. So, resuscitate the baby on a radiant warmer, then transport the baby to a transport isolate, and then weigh the baby on admission, and then transfer the baby to the isolate where the baby will stay. So, one of the things that you really need to pay attention to is these frequent transfers can lead to

Daphna Yasova Barbeau, MD: Hmm... Hmm-hmm...

Dr. John Ibrahim: heat loss, whether it's evaporated heat loss, whether it's convective heat loss, whether it's radiation heat loss. So how can you overcome that is using whether it's a transport shuttle to keep this baby warm. So, you transfer the baby from your resuscitator in a convertible isolate and then connect the shuttle, take the baby down to the NICU, and this is the baby's bed, and you can weigh the baby on the bed.

Daphna Yasova Barbeau, MD: Yeah.

Ben Courchia, MD: Yeah, that's what we've been starting to do in our institutions where we resuscitate the baby pretty much in the isolate that they will be placed in the NICU. So, yeah, that's making a huge difference.

Dr. John Ibrahim: Do you guys have issues with isolate shuttle space in the operating room?

Ben Courchia, MD: all the time.

Daphna Yasova Barbeau, MD: But less so in our new facility. We are very fortunate that it was designed in such a way that we have way more space than we did before. Yeah, very lucky. I know we're getting to the end of the time together, but I would be remiss if we didn't talk about one more aspect of thermoregulation. We talked a lot about the new baby, but obviously there are lots of times where a baby needs a procedure or a baby needs an imaging study, the baby has to leave the NICU or especially

Dr. John Ibrahim: I'm going to go to bed.

Ben Courchia, MD: Yeah.

Daphna Yasova Barbeau, MD: code situation where we see babies getting cold. And maybe you can talk a little bit about the impact that has on babies and our ability to do the things we need to do, I'd say, or be even successful in a code situation.

Dr. John Ibrahim: Yeah, so I think one of the issues is, obviously, in a code situation, things are very hectic. But if you have a baby going for certain imaging, let's say an MRI, or a baby that's going to have a procedure, you really have to think about how we can keep this baby warm during this procedure or during this imaging. I mean, term babies can be bundled, but if you really have to do some sort of an imaging

Dr. John Ibrahim: isolate that incubator, sorry, that's pre-warmed, then you can have the baby on and get the MRI or the imaging that's needed. Or even if you have to use a thermal mattress, and if it's a long procedure, a long testing, you can check the temperature. The other thing is in operating rooms, if baby, let's say baby needs a surgical intervention or surgical procedure, the step in, the communication between the NICU team, anesthesiologists, and the surgeons.

is a key before going to the NICU. And I think the anesthesiologist is doing a wonderful job checking these temperatures during the operating room and adding whatever intervention is needed to keep them warm and then checking the temperature as soon as you hit the NICU back, making sure that they are athermic. During a cold, it's very hectic, it's very hard. It's very difficult to keep these babies warm because your main focus is trying to resuscitate them and avoid any big complications.

Ben Courchia, MD: Thank you.

Daphna Yasova Barbeau, MD: Yeah.

Ben Courchia, MD: This was a phenomenal conversation. Dr. Ibrahim, thank you so much for making yourself available, for being such a pleasure to talk to. I had a fantastic time. I took some great notes that I'm going to hope to bring back to our institution. So, thank you so much for making the time to be with us today.

Daphna Yasova Barbeau, MD: Mm-hmm.

Dr. John Ibrahim: Thank you, guys, for hosting me and I really enjoyed this conversation.

Daphna Yasova Barbeau, MD: Her pleasure. Bye.

Ben Courchia, MD: Take care, Daphne.

Ben Courchia, MD: Hello, everybody. Welcome back to the Incubator podcast. We are back with another episode of our mini-series on thermal regulation of the newborn infant. And today, we are joined by Dr. Daniele Trevisanuto, who's an associate professor of pediatrics in the Department of Women's and Children's Health at the University of Padova in Italy. Daniele, thank you for making the time to be with us. And I think you are our first Italian guest on the podcast.

Dr. Daniele Trevisanuto: Thank you. I am honored to be the first Italian invited person for this opportunity. So thanks for this invitation.

Ben Courchia, MD:  Yeah. I'm sorry. No, of course, of course. You've done a lot of work on thermal regulation, and you've done a lot of studies. You're extensively published. You've done work both in Italy and both in a more global health setting. And I'm just curious about what keeps bringing you back to this topic. It seems to be a topic of interest to you that seems to be fascinating you. And I'm just curious about what is it about thermal regulation that you find so interesting.

Dr. Daniele Trevisanuto:  Probably the most important thing is that as I've been working in low resource setting, I had many projects in Asia, in Africa in particular, and as hypothermia is a real killer in this country, for two reasons, I was very interested in how to try to solve such a, how to say, it seems a very simple problem to solve.

We don't need too much, probably we don't need too much. We need technology, but probably we need other aspects that are low cost, and we can try to solve this problem. And so probably this was my first interest, because I was interested in improving in such a low resource setting this aspect. And of course, it's probably, I discovered it is also important probably in high resource setting.

Ben Courchia, MD:  Yeah, yeah, I think it's interesting how in the first, if we want to call this in the developed world, how we are being reminded of the importance of temperature regulation by all the work being done in, like you said, low resource settings, where we tend to see the effect that not maintaining temperature can have on the baby. And it reminds us in the developed world, my God, like we're doing all these little interventions that are supposed to increase outcome by a few percent point, and then we sometimes forget how just maintaining temperature can have such a dramatic impact on so many variables, survival, comorbidities. Is that something you've noticed as well, where this is something that as the care of the newborn in the first world country has become so sophisticated, we can often forget about thermoregulation?

Dr. Daniele Trevisanuto:  Yes, I agree because we think that sometimes we think that temperature is allowed to say a minor problem or it's a nurse problem, is not a doctor problem. But I think that is a great error, a great mistake to have such an approach because to make attention to the temperature means really to improve.

Ben Courchia, MD: Mm-hmm.

Dr. Daniele Trevisanuto:  a clinical critical outcome such as mortality, such as intraventricular hemorrhage. And so there are many studies that have confirmed the association or the relationship between hypothermia, ethnic transmission, and we play the match during the first 20 minutes of life. And you can make the difference. And so I think that is very important to come back to the basic management of the patient in addition to the

Ben Courchia, MD:  Mm.

Dr. Daniele Trevisanuto: New advanced technology, of course.

Ben Courchia, MD:  When I was speaking to people about this and saying, what do you think about thermal regulation? Many people said to me, you know, I don't think about it too much because I have the warmer or I have the isolate. So like the baby's temperature is automatically taken care of. And I was never thinking about this from a clinician standpoint where we've delegated the thermal regulation task to the machine. And I'm wondering if you can, is that something you've noticed as well, where we assume that the machine is gonna do the work and that it's gonna maintain normothermia for us?

Dr. Daniele Trevisanuto:  I think that technology is very important, but human behavior is very important, the approach of the team. Just to give an example, we published, I think, two years ago, a multi-center randomized control trial on the use of servo control versus no servo control in delivery room.

Ben Courchia, MD:  Mm-hmm.

Dr. Daniele Trevisanuto:  I don't remember more than 400 patients, very low, but in Italy. We had 15 centers and the primary outcome was normal thermal range, ethnic transmission. What we found was that we didn't find any difference between the two approaches. But what was the most important result, in my opinion, was that

Ben Courchia, MD:  Yeah.

Dr. Daniele Trevisanuto: only 40% of very low-birth term infants arrive normothermic in Italy. And we have all of these hospitals are level 3 hospitals. All these hospitals have the same, more or less the same equipment, more or less, of course. But there was a very large range in normothermia. And the range was between

Ben Courchia, MD:  Of course.

Dr. Daniele Trevisanuto:  3% in one hospital, and the best hospital had 75%, 78% of normal thermo and NICU admission. And so it is just to confirm you that the intervention, in addition to the technology, also the organization, the small aspects are very important to prevent hypothermia at NICU admission, also in our setting.

Ben Courchia, MD:  Yeah, this was a paper that your team published in the archives of disease and childhood in the fetal and neonatal edition. In I think 2021, you had 450 infants in the study, as you mentioned. And it was very shocking to see what you just said, how despite the use of servo controlled system, the amount of babies that arrived with no more thermia was, I think, 39.6% in one group, 42.2% in another. And so technology alone cannot do it alone, basically. That there are many aspects of the care of the newborn that is involved in the time of transition after birth, and that we need to pay attention, because I was expecting to see higher numbers. Can you tell us a little bit, what does that mean, servo-controlled? I think I know, but I'm sure that there are some people listening to this podcast who said, I've always heard servo-controlled, temperature, whatever. But what is that?

Dr. Daniele Trevisanuto:  Yeah.

Ben Courchia, MD: What does that mean practically speaking?

Dr. Daniele Trevisanuto:  Practically speaking, is a several control means that you give the organization or the management of the thermal control to the machine, fully to the machine. So you put a sensor on the skin of the baby, and the machine decides the power of the temperature that has given to the baby according to the temperature of the baby. So the machine understands what is the temperature and what is the power that it has to give to the patient. While no servo control means that you set, the clinician set the temperature, the temperature, the entity of the temperature, the magnitude of the temperature that has to give to the patient.

Ben Courchia, MD:  The intensity, yeah.

Dr. Daniele Trevisanuto:  In that study, we found no differences. We set the temperature that the machine had to give to the patient was 37. We discussed this also with the reviewer if it was the case to increase the goal, to say to the machine to set the machine to 37.5, for example. According to the result of the study, if I could or we would do another study, I suggest, OK, we increase the goal because there is a large thermal dispersion in the room or there are other aspects that has to be considered. And so the machine work well, but probably we have to increase the set of the temperature that has to achieve being achieved by the machine.

Ben Courchia, MD:  Mm-hmm. And you have an extensive, many years of experience in this field. I'm just wondering that when you are working in the clinical setting, what to you are some of the biggest challenges we are facing today in trying to be performing at a level that is sufficiently high to maintain temperature? What are the pitfalls that you see where we lose opportunities to keep normothermia and we fall into hypothermia.

Dr. Daniele Trevisanuto:  We have said that the team is strategic. I think the education of the team is probably one of the most important. When a baby arrives hypothermic at our NICU, we discuss with the team, we have a pediatric resident that they are the team leader. Why this patient, and with the nurses of course, why this patient arrives hypothermic at the delivery room? Where we can improve for the next patient. And so this is rare, because we have a good normotermia rate. But sometimes we have this problem. And it depends, maybe the temperature of the room and so on. Try to answer to your question in a more specific way.

I think that we don't know where we have the drop of the temperature. It is immediately after there. We spent more or less 30 minutes from the birth to the admission to the NICU, and 25, 30 minutes, at least in our hospital. So the question is, where is the drop of the temperature? It is already in the womb of the mother because the mother is hypothermic, is immediately after birth because you have a acute drop. It's during the minutes where you do the resuscitation. We know from some study that patients who receive intubation, for example, or some maneuvers, resuscitative maneuvers, they have a higher risk to be hypothermic during the transfer to the NICU, when we put them in the incubator. And so I tried to do a study. I would like to do a study. We received some devices from GE and Europe. They were very kind. Just to try to monitor, strictly monitor, minute by minute, what happened. And if you are able to find that, a specific point, we can work on that point or that reason. 

Ben Courchia, MD:  So, on that moment of when that drop happens. And so it's more, it's very common for all of us to deal with patients who are after birth, not normothermic, right? I mean, as we spoke, it's achieving normothermia is a high standard and we may achieve it for many patients, but there are still some that may find themselves not within that range. I think there's a lot of beliefs around

Dr. Daniele Trevisanuto: Yeah, yeah, that is.

Ben Courchia, MD:  How am I supposed to handle the baby that is not normothermic? And should I just rewarm them pretty quickly? Should I take it slow? I think there are a lot of people who still think like HIE, where I have to warm. If I rewarm a baby, I have to do it slow. But in your experience, what is the right approach when the target is not met and now I have a baby that needs to be brought back to the normal range? How do you approach that?

Dr. Daniele Trevisanuto:  This is another great question. And really, we don't know. There are two, I think, two very old randomized control trials with very low patient, conducted in low-resource setting but I think 30 or 40 years ago. And so a patient with normal weight, so full-term newborns. And so I think that is not, we cannot use that studies. There are some, there is one physiological study that say that we can, we have to avoid to go too fast, higher than 1.5 grade per hour, degree per hour, because we increase the oxygen consumption. But these are all studies, so I don't know if it is correct. 

Now we have some observational study, retrospective study. One was conducted in our hospital, we had 400 extremely low-built weight patients, extremely low-built weight infants, less than one kilo. We compared retrospectively what happened to the patient who had hypothermia, who had re-wormed faster compared to the patient who had re-wormed in a short, in a slowly, slower, yes, sorry. And what we find is interesting because this is, this study has many limitation because it's not a randomized controlled trial. But what we found was that not if the cutoff was, as the cutoff was 0.5 degrees per hour, okay, as we do for the rewarming in during,

Ben Courchia, MD:  Slower, yeah. That's okay.

Dr. Daniele Trevisanuto:  …therapeutic hypothermia. We know that when we do therapeutic hypothermia, in full term, in fact, we have to use 0.5 as a rate. But what we found was no differences in the main important outcomes, such as hypoglycemia, IVH, mortality, and so on. The only difference that we found was the incidence of RDS. Patients who were re-warming slowly RDS. And so it is consistent because when we give surfactant, we warm the surfactant. And so the surfactant in hypothermia or hypothermia increased RDS because you have an inhibition of surfactant in the lungs. And so I enjoy it.

I was very happy for this for what we found for the result. Another study that we conducted was in low resource setting, including preterm and full term newborns. And also in this case, I think that the study was published one or two years ago in children. And also in that study, we did not find any different because faster or slower rewarming rate. 

One of the peak questions in the ERCOR task force is, what is the best way to reward the baby, but also the conclusion of this review and meta-analysis that included our study. And only observation study is that we don't know, really, if it is better to go fast or to go slow. 

Ben Courchia, MD:  And yeah, it's interesting. You would think that with how bad we are at maintaining normothermia that we would have figured out if we should correct fast or slow. But yeah, we'll put all the links to the articles that you are referencing, by the way, in the episode's show notes so that if people are interested in reading these papers, which are very interesting. I think the other paper you mentioned was published in the Journal of Pediatrics. We will put all that in the episode show notes. As we're talking about rewarming and we're talking about normothermia, I think that there are many products that have come out as a result of our initiatives to maintain normothermia after delivery, whether they are, we talked about the warmer, but they are blankets, they are hats, they are polyethylene bags. And you've done a lot of studies to look at different things, whether it was the wool hats, or I've seen a study that you looked at maybe like almost like a shower hat, like the plastic shower hats on babies. Can you tell us a little bit about some of these and how the different material, different products, how does that play a role in maintaining the thermoregulation?

Dr. Daniele Trevisanuto:  OK, yes, it seems that by based on the study that we conducted, I think a few years ago, many years ago, we published it in, I think, Journal of Pediatrics. We were interested in covering the head of the baby with a shower cap. Because of course, the head, the surface of the head 0.8% of the entire body surface. And so it's a very large part of our body. When you are newborn, when you become adult, you become micro-safety. And so now you have an example here. And so the baby has a very large surface in the head. And so in that study, it was a randomized controlled trial. We were interested in covering the head with a plastic bag or with a shower cap was effective. And really, we found it was effective. And so I think that is effective as well as I think a woolen cap. We know that cotton cap does not work. We know the woolen cap are effective in preventing hypothermia. And our study, I think that is the only study. And so it should be nice to repeat. Or another group could repeat it.

Ben Courchia, MD:  Mm-hmm.

Dr. Daniele Trevisanuto:  To cover the death of a baby with a plastic cap it could be reasonable to avoid thermodispation. We are referring to extremely low-bit-to-weight-infra, very low-bit-to-weight-infra. With regard to the material, there is one bank study that has been published, I think, two years ago in archives of disease in childhood.

Ben Courchia, MD:  Yeah.

Dr. Daniele Trevisanuto:  that show that polyethylene bag is more effective than polyurethane bag. And so also the material is make the difference of counts. So please be sure that you have the polyurethane. Yes, the right one, the right material.

Ben Courchia, MD:  The right, yeah, the right material. I think we did review that study from the archives on the podcast. I forget when it came out not too long ago, you're right. And we did review it because it was a very interesting one. In terms of maintaining temperature, I think there's been this question that we've, we're curious to hear from our various guests about. We've set the standard of normal thermia, especially in, in preterm infants, I think the importance of maintaining normal thermia in extremely low birth weight infancy is so important. But we've also set the standard for golden hour where we're hoping to get all the admissions sort of complete within the hour. And I am just wondering, what are your thoughts on sometimes how normal thermia and golden hour can become competing entities where we're trying to finish everything, uh, like the lines and everything, but sometimes it can happen at the expense of the temperature of the baby. How has been your experience in managing all this in your NICU?

Dr. Daniele Trevisanuto:  In my NICU, the baby is managed in an incubator. The incubator is we use it depends if you have extremely low B2H-infinity, the temperature and also in particular the humidity is very high, 90% during the first hour. And we try to give warm fluid.

Ben Courchia, MD:  Mm.

Dr. Daniele Trevisanuto:  And yes, and we try to do a lot of attention. The temperature is continuous monitoring. And this is the way. One of the most important risk is when you do a procedure when the patient arrive. During some time, we found that the patient arrived normothermic at NICU admission.

Ben Courchia, MD:  Mm-hmm.

Dr. Daniele Trevisanuto:  But during the first hour, when you try to put the umbilical catheter, or you do some, for example, you give surfactant and so on, there, there is a risk that you can, after one hour, you can have a drop of the temperature. Not so important, but you can lose 0.5, 0.3 degrees compared to the temperature admission.

And yes, this is important to be careful during the admission in the NICU. And if I can move to low-resource setting, we conducted a very nice study in Beira. Beira is the second city in Mozambique.

Ben Courchia, MD:  Yes, please.

Dr. Daniele Trevisanuto:  And there we have a great collaboration with our, because our PDH residents have the opportunity to spend six a month in that hospital. They have a tutor, a local, but also an Italian tutor. And we work with NGO. The name is QAM Doctor with Africa. It's a NGO from Padua, but there is a strong relationship with our university and NGO. And one of the questions in this low-resource setting was, okay, 65% of babies arrive hypothermic in the NICU. Okay, but what happened the first day of life? Okay, we know that we lose the match during the first 30 minutes of life, or one hour of life, but what happened during the fifth day? And what we find was very interesting because, okay, if you have money, if you have dollar or euro, you put your euro in the first 13 minutes of life. But what we found was that if you arrive hypothermic and you become normothermic in the fifth day of life, your rate of mortality is 40%. But if you arrive hypothermic, and you remain hypothermic during the first 24 hours of life, your mortality rate is 75%. And so it's terrible. And so, of course, we have to take care of hypothermic baby to avoid hypothermia during the first one hour.

Ben Courchia, MD:  Wow, 40%.

Dr. Daniele Trevisanuto:  of life, but also during the fifth day, really, it counts. It has an important impact on the survival of this patient. So the conclusion of this study that we published, I remember, I think, one, two years ago, was, OK, please, be careful during the, make attention during the fifth hour, but also during the fifth day, because the fifth day could be, could add an important risk to your possibility to survive if you remain hypothermic. And so this is, I think, the first study they tried to put to see the temperature, to look at the temperature over time, not only one point, but also after 24 hours from admission. It was interesting information for me.

Ben Courchia, MD:  Yeah, I think that's a very interesting because it's right. We talk a lot about termoregulation in the immediately postnatally, but we rarely think about this beyond that point. So I think that's an interesting point. What has been the drive for you to continue looking at termoregulation on a, always comparing the global health aspect versus what you're doing in Italy, which is a developed country, obviously, but that you seem to be very interested in comparing what we're doing in both places because your papers are not solely studies taking place in low and middle income countries, but there's always a mix. And I'm just curious as to, is this just because the opportunity is there or is there something beyond that you wanna compare all the time?

Dr. Daniele Trevisanuto:  I think that a small thing can change more life in low resource settings. So we try to save 400 grand babies. At least I can understand the family is asking to do everything and so on. But with small, how to say, changes, you can save more life in low resource settings. And I can't say you how to say an anecdote, just to give the idea of what happened in some setting. Last January, I was in a hospital, the only hospital with the CPAP, the availability of CPAP in the NICU in Burkina Faso, in the capital we were there. And the nurses are very expert in the use of the CPAP machine. And we arrive in the morning, 8 a.m., to do the ground round. And we were in the NICU, in the room. And what I saw was this patient was dying. He was a preternuble. The built weight of this patient was 1.5 kilogram. And we put him in the CPAP because we treated him with the CPAP because he was some apnoic episodies. And so it was the reason. But the FIO2 was always 21%. OK. We arrive in the morning, the second day of life, and the baby was dying. And the nurses said, oh my god, this patient is dying for prematurity.

Ben Courchia, MD:  Okay.

Dr. Daniele Trevisanuto:  And so we decided to look at the chart of the night. And what we found was that this patient, the temperature of this patient was 35 at midnight, or 35 at 3 AM, was 35 at 6 AM, and was 35 at 8 AM. And so this nurse was able to measure the temperature in this patient. And so he was not interested. 

She was able to register the temperature. But the point was that she didn't did an action to improve this problem. I would say, and also there was another problem because the weight was 1.2 kilogram. So there was 20% of weight loss. And so just to give you some example of what we discussed with them. OK, no, this patient was the reason of the death of this patient was not prematurity, but was severe hypothermia, was hypothermic collapse. And so it is very important to help this group, these our colleagues, in knowing this aspect. 

They do everything, but also if they register the problem in this case, and so probably they don't believe that the action or they don't believe that the hypothermia is so important because everything was correct. The SIPA machine was set correctly. The nasal canal where is in the right place. So it was not a technical problem. It was a, I would like to say cultural problem, probably. And so just to give you some ideas of how we can impact. And so the technology is important, but yes, the education, yes, the education is make the difference, is the same in our setting. Because, for example, if you look at the last radio

Ben Courchia, MD:  The education.

Dr. Daniele Trevisanuto:  one month ago with the HILCOL group, how to prevent hypothermia in preternum bones. There are many things that we can do. For example, pre-warmer mattresses. Is it important or not? For example, in my NICU, we don't use pre-warmer matrices, but we have less hypothermia than some article that have published this approach. And there is a study, for example, for Colmodone, they show that exothermic matrices can increase the rate of hypothermia. There are some studies that show that, for example, the use of heat and warmer gases, there is also metanalysis.

The short is, but it depends when you work, when you work, what is your setting. For example, in this moment, we don't use pre-warmed and humidified gases in our delivery room, but we have really a very low incidence of hypothermia, lower than, for example, some study from Australia, from, for example, Holland, Netherlands. And so it is interesting. So all the treatment recommendations, for example, from this document, if you go to, you can read them in the Ilkor website, is that when the resources are low and when you think that rate of hypothermia in your setting is important, you can consider the use of gases, ether gases.

Ben Courchia, MD:  Yeah.

Dr. Daniele Trevisanuto:  You can use the exothermic mattress and so on. And so I think that all these measures are important, but they have arranged according to your situation, according to your delivery room setting. If you have hypothermic, for example, if you have 22 degrees in your delivery room, yes, in that case, it could be reasonable to have the pre-warmer mattresses.

Ben Courchia, MD:  Yeah, that's so interesting. As we're getting close to the end of this conversation, I'm just curious about, based on all the work you've done, what are the things you are currently working on or the current studies you have in the works? And where do you think is the future of that area of study going to be?

Dr. Daniele Trevisanuto:  OK, thanks for this last question. Now we are an ongoing randomized control trial, multi-center. We have involved 20 hospitals, level 3 hospitals in Italy. And the question is in the PICO question is in very better infants or less than 30 weeks gestation is the drying of the patient before putting him or her in the plastic bag or not drying the baby. This is the dry trial. The name is the dry trial. And so we are interested because in the big patient or large patient is important to dry. But we don't know if it is important for the small patient. We put them in the plastic bag. 

This is that we are now have enrolled 110, 8, 10 patients. We are in the one-third of the enrollment. We are planning to enroll 360 patients. And we have to give another answer to this, I think, very practical question. I like clinical question and clinical study, because most things can make, I don't want to change important thing, but can change the technical practice, yes. This is relevant to me.

Ben Courchia, MD: What's your hypothesis on this study on the dry trial? What do you think is the right way?

Dr. Daniele Trevisanuto:  No, the hypothesis is that if we dry the baby, we can increase the rate of normothermia. The primary outcome is normothermia. That is important. More important than hypothermia because we want to avoid hyper and hypothermia. Yes, the hypothesis, I don't know if this will be confirmed. We are very curious, but yes, let's see what happens.

Ben Courchia, MD:  Of course. I don't know, we will have to see.

Let's see what we'll be looking out for this publication. Daniel, thank you. Thank you so much for making the time to chat with us this morning. I think it was a very instructive conversation. And congratulations on the body of work that you've been able to publish on this topic. Because all the papers you mentioned and many more that we haven't touched on are so well written. And they're such nice studies that we'll try to link even more of these on the website. And they're super interesting. So congratulations for that. And again, thank you. Thank you for making the time to be with us today.

Dr. Daniele Trevisanuto:  Thank you very much, Ben. I appreciated his invitation. I was happy to be involved. Thank you.

Ben Courchia, MD:  Yeah, we were very happy to have you. Thank you.

 

 

Ben Courchia, MD:  Hello everybody, welcome back to the incubator podcast. We are back with a new episode of our special series on thermal regulation. And today we are joined by none other than Dr. Jessica Jones. Jessica, how are you this morning?

Dr. Jessica Jones:  I'm good. Thank you so much for having me.

Ben Courchia, MD:  No, it's a pleasure to have you on. I'm just gonna go through your bio quickly for people who are not familiar with your work. You are a nurse practitioner with 21 years of neonatal nursing experience. You've practiced as an NNP for the last 16 years, and you're currently the coordinator of advanced practice providers with Pediatrics Medical Group in Tampa, Florida. Shout out to our home state. She's, you're also the, you're also a clinical assistant professor at Baylor University's Louise Harrington School of Nursing, and you completed your Doctor of Nursing Practice degree at the University of Florida in 2023. Your areas of interest include management of ELBW infants, thermal regulation, obviously, as this is the topic of this episode, fluid and electrolyte management, as well as improving communication between nurses and physician through education. Jessica, thank you so much for making the time to be with us today.

Dr. Jessica Jones:  Thank you so much. I'm really excited to be here.

Ben Courchia, MD:  My first question has nothing to do with hormone regulation, but I am looking, I was looking at your bio, I was doing research for this podcast and it seems like you have had a career where you've always looked for that step to continue getting both personally and professionally better on your own, but also providing a tremendous added value to your team. I'm wondering where does that, for many of us, we're always looking for, one day I'll arrive at this stage.

Dr. Jessica Jones:  All right.

Ben Courchia, MD:  And I'm done, you know, like it's the student syndrome, you know, you're, you're in nursing school, a medical school, and you say, one day I'll be a doctor. And that's it. And I'm done. But I see someone like you and it looks like you're never done and you're always reaching. And I think that's kind of fun and that's kind of cool. Where does that passion come from?

Dr. Jessica Jones:  Yes, yes. Yes.

Dr. Jessica Jones:  Um, I honestly have to kind of attribute that to my parents. A lot of it was how I was raised, just kind of always striving for excellence. And my, you know, my dad, that voice in my head, um, you know, never do things halfway. And so that's kind of been my, my life's work is to, to be like that and also to impart that into my children. And so, um, to be honest with you, when I graduated from nursing school, many moons ago, I never considered becoming a nurse practitioner, but my mom harassed me to the point where I was like, fine, I'll do it, you know, and now I couldn't be more grateful, um, that she really kind of.

Ben Courchia, MD: Mm-hmm. Right.

Dr. Jessica Jones:  have got me to that position. And I was fostered in a NICU that had such a growth mindset. And I really, I've worked with some amazing neonatologists as a nurse and they are now my colleagues. I work side by side with them. And so I think really having an environment that was healthy and fostered growth and learning and piqued that interest really is what did it for me.

Ben Courchia, MD:  I love that answer. And I think the growth mindset that you're mentioning is sometimes something that could be very scary for institutions because it involves maybe a leap of faith on the part of, of the team. And I'm wondering for you, what did that growth mindset look like, um, with the team that you were working with?

Dr. Jessica Jones:  So I think definitely in the beginning, it was interesting because when I was training as a nurse practitioner, as a student, it was kind of still where NNPs were a new concept. So there were no nurse practitioners in our unit. The neonatologist who did my clinical training while I was in school kind of didn't know what to do with me. So they essentially trained me like a fellow. One of the neos, which is at the end, middle of the 24 hour, 30 hour shift would say, just don't call me unless somebody needs ECMO, you know, pretty much that kind of mindset. So it was a lot of it, you know, throwing you into the deep end,

Ben Courchia, MD:  Mm. Uh-huh.

Dr. Jessica Jones:  But it was just never being afraid to ask that question and always the whys, the whys, the whys, going back to the whys and that's my mentality now and in talking to nurses and teaching the future generation of nurse practitioners just remember why are we doing what we're doing.

Ben Courchia, MD:  That's great. Yeah, I think that's such an important point. As a nurse practitioner, I feel like it's sometimes can feel like a huge upgrade on the amount of responsibilities that you carry going from nursing to being a nurse practitioner. And yet for you, you continue to look for opportunities to participate in quality improvement initiative, research activities. I feel like when I was a fellow, and I started these things, you feel a very big sense of imposters and it's like, I don't know, I don't know how to do that stuff. Like, what do you mean? Like, I'm gonna take on this clinical question. And I think this is something that we all go through in the first things that we tackle. Was that something that you, not struggled, but something that challenged you and how did you overcome this particular aspect of growing into this new role when it came to quality improvement research and other activities?

Dr. Jessica Jones:  I mean, it's definitely something you hear about, right? That imposter syndrome. And thankfully, I mean, I've been a nurse practitioner for so long, I feel like that's kind of, that door has closed as far as feeling like, oh, what am I doing? But definitely my role is as a new faculty and as kind of trying to launch quality improvement initiatives and having these discussions, you start to kind of question, like, am I really equipped to do this? And I think, again, having a strong team surrounding you saying, hey, we can do this, let's do it together. What are those questions that you have kind of enforcing yourself into the uncomfortable area, right? If I don't, I don't know a lot about this. We tend, our nature is just to stay away from it, right? Well, I'm just not even gonna, you know, but no, just...

Ben Courchia, MD:  Yeah, we don't want to seek discomfort.

Dr. Jessica Jones:  Yes, yes, and kind of forcing us ourselves into that discomfort zone and saying, okay, I don't know a lot about thermoregulation, but let me just start reading. Let me just start looking into it. Let me just start putting myself into those positions where I'm going to have to know more, which is a hard thing to do. But that's kind of what I've had to do with myself as I kind of go to that next chapter. Okay, let me just look more into this. Let me start reading more about quality improvement and evidence-based practice and not just, you know, okay, I see this research study idea, but really how did that even come about? How did they develop that clinical question and how did they get the nurses on board and how did they get the neo team on board and bridge that gap between everybody? So definitely kind of forcing yourselves into that uncomfortable zone has been what I've had to do to get to that point.

Ben Courchia, MD:  Mm-hmm.

Ben Courchia, MD:  Yeah, for me, that was when I started drafting my first protocols. I'd like the question I was familiar. I was like, okay, I can draft a question. I had the literature review pretty well. I had it down. Like I had read the papers, but then you're like the stats and it's like, Hmm, don't know how to do that. Uh, and where do we go from here? And like you said, I think it's about learning. I think to me, what you're describing is learning the skill to be able to roadmap your way to success because you're not like, you're not, it's not the matrix, you're not going to press a button and all this stuff is going to be downloaded into your brain.

Dr. Jessica Jones:  Yes.

Ben Courchia, MD:  but being able to say, all right, I'm gonna leverage this resource, that resource, and slowly make progress, I think, is something that we don't recognize as much. So our topic of the day is thermal regulation, and I wanted to ask you, of all the aspects, I mean, everything in neonatology is up for question, up for debate, up for reassessment, but what drove you to thermal regulation specifically? Does it have to do with your background or is this something that happened one day in the unit? Where did that come from?

Dr. Jessica Jones:  Thanks for watching! I think yes to all of that. I think one of the things that I love about thermoregulation is first and foremost, I'm a nurse. I'm a nurse at heart. That's where I started off is at the bedside. Thermoregulation is a clinical practice that really is fully nurse-owned. They're completely autonomous in that area with ventilatory support and RDS and you're looking at sepsis or cardiovascular issues within the baby. It's definitely a team effort obviously and you need RT's help and physician help and input and all of those things, but thermoregulation, like that's, that's fully on the nurse. And in a world where sometimes nurses, I feel like, don't feel like they get the respect or they don't really have a voice. This is where you have a voice. And not only do you have a voice, you have the opportunity to make a huge impact on the outcomes of your patient. And when you look at those statistics, you know, that, that 28% increase in mortality with one degree Celsius below, you know, a normal admission temperature on those elbow babies, that's a huge impact that you have right off the bat.

That's what kind of drove me as a nurse, being able to look at my fellow nurses and say, hey, you have the opportunity to really make a huge impact on the outcome of your baby. And let's start with just that basic vital sign, right? Thermoregulation. You have control over that. You have full autonomy over that. And so let's run with it. And then just looking at our statistics and some of the issues where we were struggling within our own unit and saying, okay, we identify a problem of admission temperatures being an hour, you know, our admission temperatures are great, but at one hour of life, all of a sudden, now we've overheated the baby or now we're, you know, we've done too many procedures and left that baby exposed to the elements for too long and now their temperature is low. And so just kind of, again, something that's a, you know, should be an easy fix. And looking at that, we always talk about like that low hanging fruit, right? Let's give them a win. Let's do something that we can give them full autonomy over and set them up for success because that's what you build on, right? 

Hey, look, this quality improvement , we went from 25% abnormal or hypothermia hyperthermia on admission to now we're 98%. Great job. And let's build on that. Now let's look at what our temperatures look like in the first six hours of life. And the nurses are encouraged because they've seen the success. They've seen that they've had a say in this. They've been able to contribute to that team and to the outcome. And so just kind of starting with that low hanging fruit and then building with that.

Ben Courchia, MD:  Yeah. So many things to unpack there because I think thermal regulation, I don't know if you agree, is kind of the perfect example of how perfection can be the enemy of good enough, where we try to do so many things during golden hour. Try to do so many things in a certain way that sometimes thermal regulation gets forgotten and then you realize that you're finicking with maybe, I don't know, with a line, with something and then you've forget that there's an aspect of the care that has dramatic impact on morbidity, mortality as well. And so I think it's interesting that you mentioned that how as institutions sometimes try to improve on A, B, C and D, and then finally realize, shoot, we now have made, we've regressed on the, in the process of thermoregulation. How do you guys navigate that to, because the same way that we have bundles that we put in place to minimize certain outcomes. I feel like thermal regulation is part of a bundle where we try to think of all sorts of interventions that we would like to accomplish all the while in a timely manner and do it in such a way that the baby's temperature is maintained. How did you guys tackle that practically speaking?

Dr. Jessica Jones:  So really giving the nurses a voice, to be honest with you, because again, you're looking at group dynamics and you're looking at, okay, well, we've got these neonatologists or NMPs who are putting in lines and that's their area of expertise. And they obviously, baby needs IV access and all of those things. Well, the nurses kind of sometimes end up feeling like they're taking a backseat and when do I speak up? That's a huge issue of the climate and the type of environment that you're working in. And so really, again, empowering these nurses with the education. I can talk about that in a little bit, but to give them a voice where we say like, Hey, thermoregulation is important. And now at 15 minutes, every 15 minutes during that golden hour, we do a temperature check. It doesn't matter what you're doing, who's putting in lines, who's giving servanta, you know, what they're doing, but we stop and we get a temp check and we document to make sure we're still in a good position with that baby so that an hour into it, you know, we don't all of a sudden take a temperature and we're two degrees below our target. And so again, really focusing on communication and empowering nurses to feel like they have a voice. And thankfully we work in a really healthy environment. I can't speak enough about our practice where the nurses do feel like, hey, I'm heard. And the neonatologists and the advanced practice providers respect them enough to stop and listen. And I think really fostering that type of environment is crucial.

Ben Courchia, MD:  Yeah, it's interesting that you mentioned that because obviously this series on thermoregulation has, we have a five part series involving doctors and nurses, but what's interesting is that this message has been echoing throughout the series where doctors have been saying also the same thing, where they said we've sort of grown into this new reality where thermoregulation has always

quote left to the nurses and we completely ignored it. And now there's this realization that yes, the nurses are in the driving seat, but we have to be this co-pilot that helps them achieve this outcome. And how do we do our things to allow them to be successful at achieving thermal regulation and then become active members of this initiative? And I think this is a huge shift, um, in our way of practicing. And, and I think that's, that's probably going to be one of the big takeaways of this series. Did you encounter any resistance from this new dynamic? I know you've been praising the team, so I'm assuming you're going to say no, but I think change is always difficult, especially in the ICU because it's such a high intensity environment.

Dr. Jessica Jones:  Yes.

Dr. Jessica Jones:  Yes, yes. And I think, honestly, I can't say we received a lot of pushback or challenges. I think the biggest thing is learning that it's okay to speak up. And in fact, we had a bedside lap done a couple of weeks ago and, you know, surgeons can be scary, you know, even 21 years into this, pediatric surgeons sometimes can be a little intimidating. And we, you know, as a tiny baby who needed a, you know, a drain put in and, you know, they're cleaning the site of course, voided all over the bed. And I said, like, you know what, let's just stop. And I asked the surgeon, can we just take a minute? We'll get a warming mattress to put underneath the baby. We'll get some hats, all of those things. I said, I know that's not a huge, you know, important thing to you, but for us that thermoregulation. And she actually stopped. She said, you know what, I appreciate that because we're now seeing the outcomes of temperature regulation and thermoregulation on babies from surgical outcome standpoint. And so absolutely that's one of their initiatives. So I would not have known that if I not, you know, had not kind of stopped and spoken up, which again, even 21 years into this can be a little bit intimidating, but that's where I think again being able to arm these nurses with the knowledge and the statistics to say like, Hey, this does make a difference. And I know that it does. And here's why. And so I think that has been one of the biggest takeaways for me is always, you know, being ready to have that, that answer of like, okay, well, here's why we're doing what we're doing and making sure that nurses feel comfortable and educated enough to be able to speak up. But thankfully, no, there wasn't too much pushback because everybody wants to know about those outcomes. When you start talking about thermoregulation and obviously mortality and outcomes, but even the way that affects fluid and electrolyte balance, right? Your use of humidity. And you look at, okay, well, you've got excessive, you know, water losses and that leads to increased risk of PDA and IVH and BPD because all of the ways that we manage that. And so it does spiral out. And so again, it kind of looks like, well, we're just talking about a temperature. But when you look at those key outcomes that we're looking at from a Vermont Oxford Network standpoint, you know, those are all key drivers, right? IVH, BPD, huge benchmarks that we look at. And it all, in my head, kind of starts with regulation, thermoregulation.

Ben Courchia, MD:  Right. What does that education, I guess we can call it this way, of the team and the staff about outcomes look like? Because it's one of these things about thermal regulation where the data is very impressive. And I think if you were practicing in an isolated part of the world with no support whatsoever, you might see a very dramatic difference. But when you're talking about the United States, which is a developed country and with all these resources, sometimes it can be difficult to see the change and to grasp the effect of what we're doing on our population because thankfully our outcomes are good and we have good survival. So how do you provide that education to the team and how do you go beyond the one slide with the number on it to try to get people to grasp the magnitude of what these little changes can have on the baby and your population?

Dr. Jessica Jones:  Yeah, that's a great question. And it's something I'm actually really excited about. One of the things that we came up with, some of it stemmed from my doctoral project that I was working on, looking at thermoregulation and the use of humidity in this patient population. But one of the things that kind of stemmed from that was a class that we started developing myself and Jane Solomon, who is a dear colleague, brilliant woman. She's in charge of all of our quality improvement outcomes. But we titled it Care and Calculations. And it was a kind of free class that we set up. I come up with my first one was on fluid and electrolyte balance and fluid management in this patient population developed my PowerPoint presentation and we offered it at two times during the month of I think we started in February and we had the support of our hospital management so they actually paid the nurses to join online via Teams from home. 

Ben Courchia, MD:  That's an unlikely occurrence to happen, by the way.

Dr. Jessica Jones:  That was 100%, because it is hard to say, hey, on your day off, nurse who is already tired and overworked and probably working overtime because of staffing issues, will you just, you know, yes.

Ben Courchia, MD:  Let me stop you right there. The business world, it is very well accepted that if you are attending some form of training for your job, you are paid for the time you spend training. And when I spoke to my friends who are working in whatever accounting and all these things, and you tell them, yeah, my day off and they're like, you get paid for this, I'm like, no, I'm just do this for. And they're like.

Dr. Jessica Jones:  100%. No, it's just expectation, professional expectation, right?

Ben Courchia, MD:  It's nuts.

Dr. Jessica Jones:  Yes, 100%. And then you think about, well, why are nurses getting burnt out? Because we're asking so much of them, right? And so that was a huge win. And again, I speak to the culture in our unit. But having that support from the administration to say, hey, we'll pay you for that hour that you're logging in from home. We try to do one in the morning, one in the afternoon to capture both night shift and day shift nurses. We don't want night shift nurses to feel left out. And so we sat there. I did the lecture on teams. We had a couple of practice questions,

Ben Courchia, MD:  Shoot.

Dr. Jessica Jones:  Here's again why we're doing what we're doing when you're looking at protocol or when we look at why we're concerned about the effect of humidity and insensible water losses on the outcomes of this baby. Here's why. And we really kind of just went back to basics and gave them that knowledge. And we've done that pretty much every month. We've had a topic, hey, what are you guys worried about? What's going on in our unit? Are we having some issues with light onset sepsis? Okay, well, let's look at that and let's look at what contributes to that. Let's look at how the physician's management of it impacts your role as a nurse. And so that's one of the things that we did.

Ben Courchia, MD:  Mm-hmm.

Dr. Jessica Jones:  something that I'm super proud of. I love, I wouldn't have been able to do it without the, you know, again, the support of the team and the administration, but we've had those classes and the nurses have, I mean, showed up in droves. I'm really proud of them for really taking ownership of it and saying, okay, this is something that we wanna do. And it's empowered, it's, I think, led to better communication during multidisciplinary rounds. It's led to them feeling more empowered to go up to the physician and say, hey, I see this, you know, your sodium looks like this and I'm worried about this having, you know, just empowering them to have those discussions, I think, has been a huge, huge factor in it.

Ben Courchia, MD:  Absolutely. Yeah. I mean, it's such an important point as well, just because of the fact that there's not a big investment on the part of the community at large when it comes to education of healthcare professionals. Even, I think I can speak on behalf of nurses and doctors and everybody else. There's not a great way to keep up. It's really the burden is on the individual. And for a lot of us, there's other forces and it's difficult to find the time. So I think this is huge and the fact that the hospital is supporting this in a meaningful manner, not just saying, hey, go tap on the shoulder, great job. I think that's huge. That is huge. Yeah, exactly.

Dr. Jessica Jones:  Here's your pizza, right? That's your free pizza for lunch. So no, I do, because especially when you look at the demographics of most nurses, you know, like they're moms, right? Like it's a great career. I've got four children of my own. And so asking them to do even more on their time off, it's a lot. It's a big ask. And I think that's when you, as physician provider groups, also have to kind of look and say, how do I invest in these nurses, right? How do I foster an environment that makes it healthy and safe for them to ask those questions because guess what? You're being held accountable for those outcomes of IVH and BPD and PDA, right? It's all of that is tied together. Well, guess where it starts? It starts at the bedside, truly. And so if those nurses aren't your best friends and they don't feel comfortable coming to talk to you, there's going to be some trouble. And I think really going back, like you said, you're talking about like physicians that really kind of never paid attention to thermoregulation, you know, to a certain extent. I don't know that many of them know how to work those incubators and, and do all of that.

Ben Courchia, MD:  Right. Yeah, that's right.

Dr. Jessica Jones:  And so making sure that we foster a healthy environment is crucial.

Ben Courchia, MD:  Yeah. And so going back to that aspect, obviously, of trying to improve thermal regulation, we were talking earlier about sometimes the tasks we take on and how difficult they can be. I mean, thermal regulation, I think, is particularly a difficult one, because when you're looking at trying to improve this particular outcome, so many factors are involved. Every aspect of what we do, if we are, and I think this applies both for just right after birth.

And when we were talking like this about surgical babies who are being operated on, I think you're looking at it and everything we do affects the more regulations. So how did you guys approach this in a systematic manner so that you could not get overwhelmed by the task and actually make a dent on a progressive basis?

Dr. Jessica Jones:  Well, I think some of it was just going back to basics, right? I think once we kind of get comfortable, we start cutting corners sometimes. We start not necessarily doing things the right way. Um, and nobody wants to be that person that's like, Hey, we're not supposed to do this, but I think them knowing that this was kind of a focus of mine, especially through my doctoral project, I started going, you know, when I was going to some of the elbow deliveries, I noticed the nurses were cutting open, um, that, that polyethylene bag, right? They were just kind of laying the baby on it and just kind of cutting it open. Cause of course you need to access to the baby and all things but also completely, you know takes away the purpose of that bag, which is to maintain those, you know, the thermoregulation and minimize this insensible water losses. So even going back like, Hey guys, we're not supposed to be cutting the bag open. The baby's not just laying on a plastic bag and it's soaking wet. So let's make sure that we're doing things the right way. Which again, nobody wants to kind of be that, you know, the police officer, but looking at chart audits and again, kind of reminding like, well, here's why we're doing what we're doing. And although it can and the breath sounds and things like that, there's a purpose to it. And so just starting back with looking at what are we doing right now and are we doing it effectively in the way that it's meant to be done? And that in of itself can take some time. And I think that's what's hard to grasp. I think sometimes as healthcare providers, we want those immediate results. We wanna give that medication and see the result right away. And so knowing that those PDSA titles can take some time to kind of go through and pinpoint, okay, what exactly is the problem? Or you go through one cycle

except one problem, but that's opened up the door to a whole other problem, right? It's never ending. And so I think that's some of the challenge of it for sure. Yes, 100%, yes.

Ben Courchia, MD:  I've been there. Yeah. I think I know the answer to this question, but I'm gonna ask it anyway. How do you make sure that, like you said, you don't wanna be the police and policing people around, but how do you walk that fine line in order to get things to improve without hurting your stock within your team that people then just see you and they're like, ugh, here she comes.

Dr. Jessica Jones:  Yes.

Dr. Jessica Jones: Yeah, 100%. I think a lot of it, I think a lot of it comes down to relationship, truthfully. I take a lot of...

Ben Courchia, MD:  I know the answer you're going to give, but I feel like people need to hear it.

Dr. Jessica Jones:  you know, a relationship with everybody, and then also a sense of humility and recognizing like, hey, I'm struggling with this too, or this is an area where as advanced practice providers we're not really doing great, or as physicians where we need help with that. And so really approaching it from a position of humility, but then also you have to have a relationship there in any type of scenario. And that doesn't just go down to medicine and nursing, but you know, in any area where you have to bring correction, to come from a place of, you know, of respect and relationship. You know, I can correct my kids or, you know, or correct a friend, not even correct, but just say like, hey, maybe we need to work on this or do this a little bit better when there's an established respect and relationship there. And I think that is where we get into the weeds a lot as advanced practice providers and as physicians and as nurses, there has to be a mutual respect and relationship in order to kind of have those hard discussions.

Ben Courchia, MD:  Yeah. And I think also the fact that you've involved them in the process, uh, makes it a fair endeavor and not just like, Hey, you have no voice in this. I tell you how you do it and you just do it. And yeah, I think that's a, yeah.

Dr. Jessica Jones:  Right, here's what you do. 100%. Yeah. And I just, and I do think, you know, I realized we were kind of having some, some challenges at our level two hospital a while ago, you know, and I'm like, why aren't they following the protocol? There's a protocol written for this. Like it's an easy, you know, like, why are you calling me at three in the morning? And I realized because the nurses didn't understand why they were doing what the protocol told them to do. Right. And it doesn't matter as nurses, you know, you're, you know, your license is on the line and they're going to call you if they're uncomfortable. And so kind of again, went back to like, let me explain to you why we're doing this and educating them and that helped tremendously where it wasn't just this authoritarian, you're going to do this and we're not asking your input. And so that has been a huge part of it is bringing the nurses into those conversations about writing protocols, writing guidelines for sure.

Ben Courchia, MD:  What has, you've mentioned the relationship between nursing and physicians, and you were talking about how you guys really honed in on communication. Can you tell us a little bit about what that looks like and how granular you guys took this on?

Dr. Jessica Jones:  Um, well, one of them was, you know, we don't, we're not a traditional teaching facility, so we don't have fellows. We don't have a lot of that environment where you've got three hour teaching rounds going on and things like that. And so one of the biggest things that we were trying to transition to was nursing led multidisciplinary rounds. We had always had it where the physicians kind of presented the patients and the nurses would maybe chime in if they felt comfortable enough to speak up about the patient or what the plan was. And so we really wanted to kind of reverse that and make the nurses.

Ben Courchia, MD: Mm-hmm.

Dr. Jessica Jones:  Feel more involved and invested in their patient care and again that kind of went back to okay Well, why don't they want to present to these physicians? Well, they were nervous about it, right? Nobody wants to look stupid. Nobody wants to feel like you know, their voice doesn't count So we had to go way back to you know, okay, let's start with the education. Here's a script. Here's why we're doing it Here's how you calculate fluids. Here's you know, how you interpret your CBC. Here's what we're looking for And so it definitely takes a lot of work and investment in time and resources to kind of go back to that, and making sure that the nurse is new. Like, hey, you should feel respected, you should feel heard. Now, granted, that doesn't mean that we're gonna do everything that you want us to do, right? There's a balance that has to be had there. And I don't know that we have it perfectly, but we definitely have a lot of dialogues back and forth about, okay, well, and I think that's, again, one of the things that I love especially about my role is I feel like I do speak both languages. I can go to the nurses and say, well, like, no, here's what they meant, where we're doing it. But then also go to the physicians and say, well, like, well, here's what the nurses are concerned about, right? They're the ones at the bedside for 12 hours doing what we're asking them to do. And so trying to translate between both roles, for sure.

Ben Courchia, MD:  And I think that makes a case for the value that people like you nurse practitioners with that dual background bring to the team in order to cement a good relationship between the nursing body and the physician body. I think that's again another great example of that. I wanted to ask you a little bit about taking on thermal regulation as a project. I often say on the podcast that there are some very, quote, sexy projects to take on where it's like, hey, if I take on plant extubation or if I take ventilator days, it's amazing. You then, less ventilators at the bedside, you look like a rock star and it's like, oh, look at that. We have much less BPD, this and that. Exactly. And there's some projects that are what I call the building of the highways, right? It's like, you build the highways, it's slow, it's long, it's not pretty, but then you think like, how would we do it without, how would we do without the highway?

Dr. Jessica Jones: Yeah. Yes, yes. Saving money, yeah.

Ben Courchia, MD:  And I feel like thermal regulation is one of these projects where it's not really tangible. Like there's not like one less machine at the bedside. There's not like one less device, but yet we know from the evidence that it, that it is a critical aspect of care. Um, what, what has been the, you've, you've been working on this for some time. It's not something that you've taken on and dropped within a few months. So what keeps you from returning to the, to the aspect of, of achieving, um, good temperature in your patients, and what is the feedback that you're getting from the staff, from the patients themselves, from the data that really reinforces this cycle of, we can always get better at this.

Dr. Jessica Jones:  Well, I think one of the hard, you're absolutely right. One of the hard things about thermoregulation is you can't always see the impact that it's making, right? You don't count that baby that didn't get the IVH or that baby that did not have that poor outcome, right? And so in some ways it's kind of intangible. You don't see that immediate result. And so it's hard because nurses want to see, hey, like, you know, we're doing, you know, X, Y, and Z, or, you know, we're doing surfactant or CuroSurf or whatever it is, and now we're down to 21%.

Ben Courchia, MD:  Yeah. Something we did exactly. Yeah. Tangible. Yeah.

Dr. Jessica Jones:  Weaning off the ventilator, like something that you can see, yeah, something that's super, you know, I can hold this in my hand and take, yeah, take pride in that. So it's definitely, you're definitely playing the long game. And that is the hardest thing is to keep the nurses and all of the, you know, everybody involved in the project and at the goal in hand because you're definitely playing the long game. And so, you know, one year, two years later, being able to look at, okay, well, our BPD rates are this and our mortality rate is now this.

That is what is hard. I think our physicians, we do have meetings every year. We call it the state of the unit. Not my title, I wish I would have come up with that. But our neo group does present our outcomes. Like here's where we are with IVH, here's where we are with BPD. So it is something where the nurses can see and help it to be tangible. But I think just keeping in mind, like you said, is that you never really have arrived. And I know that we do focus on that 28% statistic right but there's also a 2021 study that showed that the mortality rate for newborns in general who become hypothermic is five-fold higher when they become hypothermic within the first five days of life right so you have to take those tiny baby steps okay we're looking at the golden hour now we're looking at the first six hours but also reminding the nurses like it doesn't just stop at that after that first 72 hours these especially those elbow

Dr. Jessica Jones:  And even again, when you're talking about, we don't think sometimes about using humidity to help maintain thermoregulation, right? Like we kind of sometimes compartmentalize where there's humidity and then there's temperature, but making them understand how it all kind of works together and how that humidity is tied to insensible water losses and those insensible water losses can affect how we manage the baby. And then that affects BPD rates and PDA rates. And that sometimes you don't see until four weeks out, you know? And so I think just having those constant conversations, which again, I think is can be exhausting and tedious, but putting your mind to it and saying, no, we're going to force the issue. I don't know, people may cringe when they see me coming through the unit and asking those questions about temperature. But I think also when it becomes part of the culture and it's something that they get used to, like, all right, we're going to be asking what the temperature is. And it is hard, especially in the delivery room, right? We're worried about the airway. We're worried about securing an ET tube and all those things. And so I'm always the one that says, hey, let's put that servo probe on now. Let's not wait till we get upstairs, get the temperature. And so it is one more step. And I think a lot of it is putting it and that's sometimes on the providers like, Hey, let me not forget this last part. And like, let's motivate the nurses to do this and really work side by side with them.

Ben Courchia, MD:  So as we're getting close to the end of this conversation, I have two more questions. I guess my first question, and I'll end with the other one after that, but you're talking about temperature probe, you're talking about equipment. How important is it for the entirety of the staff to be familiar with the equipment that they have in order to achieve the goals that they set for themselves? Because that is something that to me sparked this whole mini series where I accidentally set.

Dr. Jessica Jones:  Mm-hmm. Okay.

Ben Courchia, MD:  I say accidentally because I had not intended to be there, but I had sat in on an in-service for our incubators. And I was like, I didn't know all these features were there. And then I realized that I'm working with a wooden stick here, and there's all these things that I could be using. So how did you guys leverage this to actually get the providers to be familiar with the technology they have available to achieve your target goals for thermal regulation?

Dr. Jessica Jones:  Mm-hmm. 100%.

Dr. Jessica Jones:  That's a great question. Well, one of the things that stands out to me is an experience that I had as a relatively new nurse practitioner. And I was working with a colleague and the baby came, or sorry, the baby didn't. The nurse came to us and said, hey, baby's temperature's all over the place, unstable. And where do you go? Like next, it's to a septic workup, right? And so I kind of stopped and said, well, wait, what is your temperature inside the incubator reading? They're like, what? And so go to the bedside and go start troubleshooting, correctly, it wasn't reading correctly, it was causing the baby to have some temperature instability, right? But the provider who's working with me did not necessarily know how that incubator worked. And so we were literally headed down this huge road of septic workup, you know, IV pokes, LPs, antibiotics, for just a knowledge gap that was there and that has just continued 17, 16 years later to stand out in my mind. And so I'm a big advocate of knowing how to use your equipment. When we have our nurse interns coming through the unit, I don't just give them the talk on the thermoregulation. I tell them, hey, go find an empty incubator, turn it on, see how it works. Because we don't use it to its fullest capabilities a lot of the time. We don't look at the trends and how it monitors trends, right? And sometimes you don't necessarily

Ben Courchia, MD:  Mm-hmm.

Dr. Jessica Jones:  won't see the baby's temperature drop low or go up high because the bed is doing the work for them, right? And so really understanding how the bed works is key, I think, to being able to maintain a thermonutral environment and making sure that the baby's temperature stays stable. We found out we were using the wrong temperature probes. We, somewhere along the line, you know, somebody found some that were cheaper and who doesn't want a cheaper, you know, set of temperature probes and so that's what they started ordering. We'll come to find out they were not the correct probes for what we needed.

Ben Courchia, MD:  Right.

Dr. Jessica Jones:  And so just little things like that, again, which sometimes I don't think we always look at, but they make a huge impact. As soon as we started changing out and used the proper probes, all of a sudden, we had a lot better success with our thermoregulation initiatives.

Ben Courchia, MD:  Do you think it is important for physicians as well to be familiar with that? Because I think that, as you said in the beginning, we tend to think that the nurses are in the driver's seat of this endeavor, but we also don't understand all the complexities that could be involved in the tech and the baby and all that stuff that can sometimes say, oh yeah, just put a blanket on it and it'll keep stay warm.

Dr. Jessica Jones:  100%. And I do think, I mean, when you consider how much people are investing in the equipment, truthfully, to not use it to its fullest capability really is a shame. And so I think it's absolutely important for the physicians and the advanced practice providers to understand how it works so that you can know what questions to ask. So when a nurse comes up to you and says, hey, the baby's temperature is now reading 35 degrees Celsius, and you want to start, well, let me give you the answer on how to fix it. OK.

Ben Courchia, MD:  Mm-hmm.

Dr. Jessica Jones:  what the actual problem is, there's an issue there, right? So being able to even understand which questions to ask is key and the only way to know that is to understand how the equipment works.

Ben Courchia, MD:  Mm-hmm. Yeah. Yeah. My last question for you today, Jessica, is you've demonstrated your degree of meticulousness and how you have an ability, I think through proper communication to really set the expectation for your team and show them that not only the expectation is at a certain place, but that they have the ability to reach that expectation. I think that's something that came quite transparently to us through this conversation. Can you tell us a little bit about the ripple effect of this, when you're talking about thermal regulation on how the team in your institution looks at achieving excellence in other areas, not just thermal regulation. Is that something you guys observe where the standard is raised across the board, even though you're not really sometimes picking on other aspects of care?

Dr. Jessica Jones:  Oh, 100%. I think because I do firmly, I'm obviously I'm biased, I'm a nurse, but I think it all starts at the bedside. And I think when you empower nurses and that you educate them and you really give them the ability to feel like they have a say, it, there is a hundred percent of ripple effect. And when you feel like, Hey, I can go to you with a problem now because there's a mutual respect there. Um, and I'm confident that I'm not going to get yelled at or belittled or any of those types of things. I think now more and more we see, you know, we're talking about, you know, having a psychological, you know, safety in the unit and feeling comfortable and how it so much does impact your overall outcomes. And I think that when you expect excellence out of everybody with the, but you approach it from a, from a place of humility and respect and relationship, I think it can't help but in effect all the other aspects of your team and the way that you work together.

Ben Courchia, MD:  I love it. It's sort of what we say at the incubator that we always say we have ambitious goal but in a humble approach. I think it is a good recipe. I love that, Jessica, thank you so much for making the time to be with us today. It was a great conversation. I think we learned a lot about how to approach aspects of quality initiative and I think you've gotten me at least excited about thermal regulation. So thank you for that and thank you for all the work that you do.

Dr. Jessica Jones:  Thank you so much for having me.

Ben Courchia, MD:  Thanks.

Ben Courchia, MD:  Hello, everybody. Welcome back to the incubator podcast. We are back with another episode of our special series on thermal regulation of the neonate. And today we are joined by none other than Dr. Emma Dunne. Emma, how are you?

Dr. Emma Dune:  I'm very good, thank you. I'm very happy to be here. Thank you for having me.

Ben Courchia, MD: Yeah, we're very excited to have you on. For people who are not familiar with your work, I just want to go through your bio quickly. You are a neonatal trainee born and trained and raised in Dublin, Ireland. You're a final year higher specialist trainee in neonatology at the Royal College of Physicians in Ireland. You're currently working in the NICU at the National Maternity Hospital in Dublin.

As part of your PhD with the University College Dublin, you undertook a series of observational and interventional studies on temperature control in babies born prematurely. And we will be talking about that today. You've recently been awarded the Young Investigator Award for 2023 by the Imperial College of London. Congratulations on that. And yeah, thank you and welcome to the show.

Dr. Emma Dune: As I said, thanks a million for having me. I really am very privileged to be here and I'm equal parts intimidated and nervous, I'd say.

Ben Courchia, MD:  Nah, this will be fine, don't worry. So I guess my first question is, what led you to neonatology? What is the aspect of neonatology that you've liked, that pushed you to pursue this as a specialty?

Dr. Emma Dune: I guess when I started medicine, I actually wanted to be a pediatric oncologist. I spent a few summers in Tanzania with an Irish doctor named Trish Scanlon, who has a unit out there in Dar es Salaam. And that was kind of in my head. That was the only path and the only thing for me. And as part of our training in Ireland, you have a mandatory rotation through neonatology when you're training in pediatrics. So.

Ben Courchia, MD: Hmm.

Dr. Emma Dune: when I started that job, I actually realized that I loved that a lot more than paediatric oncology. So I was easily turned. I think what I love about it is I absolutely love the delivery room. I love the adrenaline of it. I like the privilege of being there at someone's birth at such an important time in their life and being able to have a skill set that you can really help out and you can really make things better.

Ben Courchia, MD: Yeah.

Ben Courchia, MD: Yeah.

Dr. Emma Dune: And as I progressed through that job and worked in the NICU when I was further on in my training, I think I really appreciated the continuity of care, the relationships that you can form with parents and kind of the, I suppose, the multidisciplinary aspect in neonatology. And further to that, then I got involved in research. So I'm all in. I'm committed.

Ben Courchia, MD: Mm-hmm. Yeah, that's cool. And for us in the US, it's a six year process, right? You do three years of general pediatrics with a lot of different rotations and various subspecialties, and then you make a decision to follow that up with a three year fellowship in unitology. Is that the same in Ireland?

Dr. Emma Dune: So the pathway is a little bit different for us and we don't have to decide immediately when we finish university which direction we're going. We do a year of kind of a mix of medicine and surgery. So we do that initial year, we do two years of paediatrics and basic training. And then for neonatology, it's a further two years of paediatrics as I suppose it would be an attending and then three further years as a neonatology attending and usually some research in between.

Ben Courchia, MD:  Wow, that's quite long.

Dr. Emma Dune: and it is, but I mean, I'm near the end of my training now and I feel like I have gained something from every part, but I don't think it's the journey, I suppose, as opposed to the destination. I've been very lucky to have great training and great mentors, and I'm gonna go on fellowship next July when I finish for a couple of years.

Ben Courchia, MD: Absolutely.

Ben Courchia, MD: Very nice, very nice. What kind of fellowship are you thinking of?

Dr. Emma Dune: I'm going to go to Melbourne to work in the Royal Children's and then the Royal Women's as well.

Ben Courchia, MD: Very nice. And so you said you got involved in research. And one of the subjects of this, the subject of this series is thermal regulation. What about thermal regulation attracted you to pick your interest? Was it like a mentor that was working on this that you just followed in their footsteps? Or was it something that piqued your curiosity?

Dr. Emma Dune: I would love to say it was the latter. I would love to say that I had kind of like an innate sense that temperature was important and I was really interested in it. But the truth is that I had a lot of respect and admiration for the two of my two mentors who are Lisa McCarthy and Colin McDonnell. They've done plenty of research in the delivery room and they do really pragmatic trials where they ask simple questions that give simple answers. I really liked the work.

Ben Courchia, MD: Ha ha ha!

Dr. Emma Dune: they did and I really wanted to work with them. So luckily an opportunity came up to do some work on thermoregulation. Lisa had, about a decade ago now, she had published a randomised trial of exothermic mattresses and polyethylene bags in the delivery room and she had a lot of unanswered questions that I think had been churning around in her mind. So I was more than happy to participate and to kind of pick up the slack from that and look into thermoregulation.

Ben Courchia, MD: Mm-hmm. Yeah, that's a great segue into our first topic of conversation because one of the subjects and the questions you've tackled are just trying to compare thermometers and see how they fare in their use in newborn infants. I mean, that's something that we have never even considered. I mean, how do we actually put back on trial the tool itself? Well, like the tool measures and we use the output of the tool to make a decision. But rarely do we think, well, how well is that?

How well is that tool doing its job? So can you tell us a little bit what you found about, was that a productive endeavor to check how thermometers compare with one another?

Dr. Emma Dune:  Yeah, I like this was the first thing that I did on my very first day as a research fellow. And we went down to the engineering department, we got a water bath, and we tested out various thermometers at different temperatures and compared them to a control. And I think that I don't think I realized it at the time, but sometimes I think that actually the findings of these two studies are the most important findings of all of my research over the last couple of years. So what we did find was that the thermometer that we really, it's really commonly used in Ireland, the Welch-Allen thermometer. It's designed, or as most clinical thermometers are, to detect pyrexia or to detect fever in patients, not specifically to detect hypothermia in preterm neonates. So preterm neonates in themselves are, they're a different physiological animal to children or adults, and they're more prone to fluctuations in temperature. 

And I think the prevailing problem in this population is low temperature, we needed to make sure that the device we were using could accurately pick up low temperature. What we did find that day in the water bath was that the commonly used thermometer, it constantly overestimated the temperature and it didn't actually give low temperatures. It more likely gave you a temperature within the normal range when the bath was cold. So we went on to test a couple of thermometers in a cohort of very preterm infants on admission to the NICU.

And what we found then was the commonly used thermometer, the Wellchallan, it wasn't sensitive at detecting hypothermia. And if we use those readings or those rates of abnormal temperature, we would have been reporting a rate of 90 percent normal temperature in our unit when actually it was only 40 percent. So we actually we thought we had no problem. But in fact, we had a massive problem. So I think, you know, in any centre, if you think that you have no problem with abnormal temperature in your preterm infants, just have a look at your device and make sure that it's validated for use or that it's been studied in this population.

Ben Courchia, MD:  How did you guys, I mean, it sounds like just the ground falling under our feet. So how did you guys address this to make sure that you could, first of all, it is such, I have so many feelings hearing this because you're like, man, if there's, we thought we were doing something good and now we're going to find out that actually maybe not. That's so frightening. But then how did you guys correct for that? What is the approach then? Just swap the thermometer for another one, or was there a correction factor that you guys applied? How did that end up fixing this?

Dr. Emma Dune: So what we did was we found that a kind of a standard digital thermometer that we tested, it accurately measured the temperature in these babies and it was very well correlated with the control thermometer in the water bath. So we decided that for all of our studies we would use that. We stopped using that thermometer in our unit and we've published the results of the studies. So what we really need to do is disseminate that information and just get people to check out the thermometers that they're using. You know, you could even very simply in your own unit, when you get a newborn pre-term infant, you measure their temperature with the Welch Allen thermometer and then measure it with a digital one. And if that baby is cold you'll more than likely see a difference.

Ben Courchia, MD:  Right, right, very interesting, very interesting. And so then from that, I think one of the things that you're working on right now, which is very interesting, is looking at how our care in the delivery room does impact thermal regulation. One specific aspect that you're investigating is the implementation, thankfully, of delayed chord clamping and how trying to abide by the tenets of delayed chord clamping may actually lead us to a place where we're going to see more hypothermia. Can you tell us a little bit about your observations and how is that leading you to your next project?

Dr. Emma Dune: Yeah, sure. So we, I think hypothesize that potentially with the implementation of delayed cord clamping and not having any guidelines for thermal care before the cord is clamped and potentially not doing anything before the cord is clamped, it's like it's biologically plausible. It's simple to think about it that babies can potentially lose heat loss, heat during that time. You know, they're wet, they're naked, they've gone from a warm environment to a cold, small preterm thin skin. The list goes on. There isn't that much research specifically about thermoregulation before the cord is clamped or thermal care before the cord is clamped and as a result there aren't any changes to the guidelines or any advice in the guidelines. So I think what we wanted to do first off was do some preliminary studies. We wanted to see, we looked at over 100 videos of preterm infants that were born in our delivery room since we introduced delayed cord clamping. And at our centre we do 60 seconds and what we looked at was the timing of thermal care.

So what was actually happening was the time to place the baby under radiant heat, the time to place them in a polyethylene bag and the time to place a hat was greater than the one minute that was recommended, that is recommended by the neonatal resuscitation guidelines. And that seems, you know, people would say, well, of course, if you're delaying cord clamping for a minute, it's going to take longer. But we just want to, I suppose, to highlight that and to actually document it in the literature. We then looked at babies admission temperature since the introduction of delayed cord clamping. And we found that 54% of our babies were cold. So over half of them were cold on admission. And the only comparator that we had that was a similar cohort of babies in 2013 before we introduced delayed cord clamping, where our admission hypothermia rate was 6%. So quite a dramatic increase. 

And all the only change that we could identify in our practice was the introduction of delayed cord clamping. So those preliminary studies, I suppose, formed the hypothesis for a randomized trial that we completed the Apollo OPB trial, where we looked at, in very preterm infants, we compared placing a polyethylene bag before or after the cord was clamped and what we wanted to see was did that result in more babies with a normal admission temperature. We recruited nearly 200 babies over a couple of years but we actually found that it made absolutely no difference whatsoever.

Ben Courchia, MD: Hmm. And so for those of us who are not familiar with the protocol, that means that basically the OB most cases who's at the surgical field will be the one putting the baby in the polyethylene bag while waiting for delayed cord clamping, clamp, and then pass the baby in the bag to the resuscitation team.

Dr. Emma Dune: Yeah, pretty much. What we do at our centre is a member of the paediatric team would scrub and they would enter the field with a sterile bag and we have some really nice videos. It's actually the OB and the neonatologist do it together. And I suppose it's a nice activity to do during that minute where people are kind of looking around and wondering and counting time and whatever. So it was really well received at our centre and our of the other specialties were very welcoming and very kind of facilitating of the research and support of it. So it worked it worked out well but unfortunately didn't make a difference in temperature.

Ben Courchia, MD: I'm floored by that. I mean, theoretically that makes so much sense. How do you guys, do you guys have any ideas to why it didn't work? Is that not, do you think that the polyethylene bag is not sufficient? Like you're again, I'm just speculating, but like is your OR room so cold that the polyethylene bag is not going to make that much of a difference? I mean, did you guys figure out what was, what was going on?

Dr. Emma Dune: I was floored too. I really thought that it would work and I suppose we can only speculate as to why we think it didn't work. I think that when you look at all of the trials that examine interventions to prevent hypothermia in the delivery room, all of them, bar one or two, use radiant heat in both arms. So you have an external heat source. These babies have very little ability to generate heat so you have to give them something from the outside.

Ben Courchia, MD:  Yeah. Mm-hmm.

Dr. Emma Dune:  In this trial, I guess, we only had the bag. So you're preventing heat loss. You're not providing any external heat. I think that may have been a factor. And I also think that maybe the 60 seconds is actually probably was not enough time to see a difference between the two interventions. I suspect that with a trend in some sectors, certainly across Europe, towards physiological base-cord clamping or prolonging the time to cord clamping that maybe an intervention like that might actually make a difference when you're going to have a longer time where the baby's on the cord.

Ben Courchia, MD: Right. What was the response from the community to both your hype? I mean, is the Apollo trial findings published or not yet?

Dr. Emma Dune: They're in peer review at the minute.

Ben Courchia, MD: And so what has been the response? Because I mean, so many institutions are using, so many institutions are using delayed cord clamping. Did you get like a wave of support, people trying to figure this out with you, or did you receive, I don't know, people saying, well, we're not seeing this. Like, we don't know what you're talking about.

Dr. Emma Dune: I suppose a mixer, you'll get a really mixed bag. I think there are some people who don't believe that babies are susceptible to heat loss during delayed core clamping. And they would cite things like the transfusion from the placenta before the mom's warmed blood will keep the baby warm.

Ben Courchia, MD: Mm-hmm. Mmm.

Dr. Emma Dune:  I think you're going to talk to Steve Falk at another time, who is one of the engineers with GE Healthcare. He does some amazing explanations of the biological, the physiological reasons that babies will lose heat during cord clamping. So I'll leave that to him. But I kind of think of it of in Ireland, over Covid, a lot of people got really into sea swimming. People had nothing to do, so they just went out and got into the really cold sea for a dip and found it very refreshing, but it's really, really cold. And I equate, I suppose, that statement that the blood keeps you warm to getting into the sea, then getting out of it and having a cup of tea with no clothes on and thinking that the cup of tea is going to keep you warm when you're wet and you're exposed to, I suppose, the ambient temperature. There's lots of other ways to lose heat, even if you're providing some heat to yourself internally.

Ben Courchia, MD: Yeah. Finish. No, no, please.

Dr. Emma Dune: Go ahead. Other than that, I think people have very different experiences at their centers. And I think one of the things is that Ilcor recommend a combination of interventions to prevent heat loss. And we don't know what combination is best. And there was a really good survey recently published by a group in Italy. They surveyed over 400 units in Europe and found that there's just a huge heterogeneity of the practice in the delivery room when it comes to thermal care. So most people will use polyethylene bags and they'll use radiant heaters. But amongst the other interventions like heated and humidified gasses and exothermic mattresses, there's like different variable uptake. So a lot of people will say when I present the results of this trial, we do this or we do this and or we don't have a problem with temperature or that our temperature or our center is reporting very high rates of hypothermia.

So I think in some instances people think that they don't have a problem and maybe they don't. Maybe they do, we'll see.

Ben Courchia, MD: Or maybe they do. Are you thinking about next steps for this project? Are you going to leave it there, or are you going to start looking at other parameters in your process of managing the baby right after delivery to see if you can maybe identify the possible cause for this?

Dr. Emma Dune: I'm certainly not going to leave it there. I think we have, you know, really, really only scratched the surface. And I think we've probably in some of the other studies that I'll talk about later on, we've kind of opened a can of worms, I guess. I think when it comes to the delivery room, there are lots, lots of potential options and ways that we could look at it. And it's about, I suppose, picking the best one or the one that you think is most likely to work.

And I, personally, I think, and I feel very strongly about how we monitor babies in the delivery room and why we don't monitor their temperature continuously and adjust their thermal care according to the individual. So if you compare that to, for example, respiratory support in the delivery room, we provide oxygen to babies and we titrate the oxygen according to their oxygen saturations at the time. We don't just say, let's give every baby 40% oxygen and then when they get to the unit we'll see what their saturations are and we'll be surprised when some of them are outside the normal range. I think that it's more appropriate to take a baby as an individual and to apply you know whatever a standard set of interventions and add or subtract according to the baby's response in terms of temperature. I think what that requires is it requires an accurate continuous temperature monitor and one that will stay on the baby. It will stay on their skin and that we can use accurately. I think that's probably, that would be my ideal and that would be my ideal to test out.

Ben Courchia, MD: Absolutely. As a trainee, the Apollo study is something you've been... This is what got you, I think, one of these investigator awards, if I'm not mistaken. And so what is the feeling as a trainee to get negative results? I know that we all believe negative result is okay because it tells you where the path ends and it directs you to a new path. And we all believe in this. But when it happens to you, you're like, damn.

So I'm just curious, how did you deal with these outcomes?

Dr. Emma Dune: I've actually never been asked that before, how it made me feel. I've been asked was I surprised, but never how it made me feel. I think that when you set out, you really think that your intervention has the potential to make a difference. So I'd say there is a feeling of disappointment. But also, I'm very satisfied. Like the results were almost identical between the groups. So the question is answered without shadow of a doubt. The sample size or the trial was adequately powered to detect a difference. I think that I will still stand by and I'm very proud of the fact that we wanted to test a really simple intervention that can be used by anyone in high income settings, in low middle income settings. It requires very little training.

We were testing something very basic and that question has been answered. So it is it's just on to the next thing. And I'm proud of my contribution to that.

Ben Courchia, MD: As you should be. But you know, I mean, I think I've been in your shoes where it's like, man, I was really hoping that we were going to stumble upon this gold mine. Like, oh, we figured it out. This is the intervention. You do this and it's fixed. And so now it's like back to more research. As a trainee, how did you manage navigating the, I guess, quote unquote, politics of the delivery room with OB and neonatology? I think it's always very difficult.

Dr. Emma Dune: Hehehe

Ben Courchia: I mean, either you're very lucky and your institution has a very homogeneous body of physicians that are collaborators, want to work together. But for many of us, sometimes it feels like we're quote unquote, almost bothering the OB with all the things that we're trying to do. We're trying to invade their space in the OR and so on. So I'm just curious if that's something that you ran into and if you have any advice on how to foster a good collaborative team in the operating room at the time of delivery.

Dr. Emma Dune: I think that I think I was like really fortunate in that the National Maternity Hospital between Colin McDonnell and Lisa McCarthy and then Madeleine Murphy who followed after there's a well-worn path of performing trials in the delivery room immediately after birth. So they've been kind of knocking around there and doing various different things and randomising babies in the delivery room. So the OBs and the anaesthetists and the theatre staff, they're used to that. I guess that prior to this trial there was the POPR trial, which was the prophylactic oropharyngeal surfactant after birth, where babies were receiving surfactant the moment they were born. So that involved also going into the sterile field. So again, the path was worn to the delivery room, but it was also worn into the sterile field.

And I think in terms of of acceptability of the intervention. It's about, I suppose, talking to all the relevant stakeholders beforehand, getting their opinion, seeing if they think that it's OK, and then just going through the various processes to ensure the theatre staff are happy with your sterile bag and your equipment and how you're going to lay it out exactly where you're going to go in. But I have to say it was a pretty, pretty smooth process. And I think that goes down to the culture in the National Maternity Hospital. So I was very lucky.

Ben Courchia, MD:  That's really good. I know you wanted to talk about some more studies, but you said something, Afair, that I wanted to maybe bring up because you mentioned how you are, we talked about the initial steps after resuscitation. We were talking about golden hour. And you said that for you, it's more like the golden two hours. Can you tell us a little bit about that and why are you changing everything?

Dr. Emma Dune: That was actually off the record.

Ben Courchia, MD:  But even if you can't share too much, but I'm just curious about the thought process. What is prompting you guys to think about this in a bit of a longer timeframe?

Dr. Emma Dune:  So actually what I meant by that was that we generally don't complete the allocated tasks within the golden hour. Not that we're extending the golden hour, it just tends to take a little bit longer. So that's what I meant by that. What we did do following on from the delivery room was we started to look at babies' temperatures immediately after admission. So kind of just continuing on from the delivery room, I guess. The very preterm infants, they're really at risk of heat loss by the exact same mechanisms that they've lost heat in the delivery room. You know they're going to be exposed for procedures, they'll be under radiant heat, then their incubator will be closed, so there's lots of times that they can potentially get cold. And what we did was another randomised trial after admission where we randomised babies to peripheral cannula. I don't know, is that what you would call it in the States? Where you just place a simple cannula in the babies.

Ben Courchia, MD:  We would say, I know what you mean by cannula. We usually call these peripheral IVs, versus the central catheter, the umbilical catheter.

Dr. Emma Dune:  Yes, yeah, so we compared the two of them with the thinking that a peripheral IV would take a much shorter time and a baby could kind of be in their closed incubator, humidified, all packaged up much quicker than if you put in a number like LeCaster. We thought that would improve temperature two hours of life, but what we actually found in that trial was that there was absolutely no difference, once again.

Ben Courchia, MD:  Mm-hmm.

Dr. Emma Dune:  That, I suppose, whether that came as a surprise or not, is not important. But what we did find was that we continuously measured the temperature of a very small cohort of babies in that study. So 25 of them from the minute they were admitted until two hours of life. And what we saw was that their temperature was actually really well controlled during procedures. But when we closed the incubator down and we transitioned from radiant to convective heat, their temperature dropped and it actually stayed low for quite a long time.

Ben Courchia, MD: Mmm.

Dr. Emma Dune: And we think that potentially the transition from radiant to convective heat actually may be a time where babies are at real risk of hypothermia. So that's something that's a can of worms that we've opened that we need to explore further down the line.

Ben Courchia, MD: Is that finding part of this report that you guys published in Acta Pediatrica? Is that the correct reference? 

Dr. Emma Dune:  Er, nope, nope. We haven't published that yet.

Ben Courchia, MD: Oh, you haven't published that. I'm so sorry. Okay. Cause I was, I was trying to like go back. I was like, man, I missed that.

Dr. Emma Dune: No, that's a new finding and something we were really surprised by. I suppose that goes back to my banging on about continuous temperature monitoring, but if we measure the temperature, for example, at two hours, that's a single point in time and you're actually missing out on so many other times where babies' temperature may be fluctuating going up and down or times where they're vulnerable to heat loss. So I think if I were to...

If I had loads of money and loads of resources and I could start something now, I would continuously monitor a baby's temperature from birth, you know, for the first, whatever, four or five hours, and really pick out the times where they're vulnerable to heat loss and then target them for, for randomised trials and for interventions.

Ben Courchia, MD:  Mm-hmm. Like in a two-step process, trying to identify these windows of time and then trying to find the intervention. That's very interesting. Do you feel like thermal regulation is a topic that, as we've discussed, you've mentioned a few more ideas. As you are embarking on your career, I think as trainees, sometimes we always have this anxiety of like, am I going to be typecast as the thermal regulation person? And your worry is that, is that aspect of neonatology going to be fruitful enough to give me enough material to feed some of my research interests? Is that something you're feeling like you could spend your career looking at or do you feel like this is a well that might run dry in the near term? Or are you even thinking about that?

Dr. Emma Dune: I'm very happy to pursue thermoregulation for the rest of my career. I think there's more than enough there. I think there's plenty to look at in the delivery room. There's loads to look at after the babies are born. Despite all of the decades of research and the fact that we've known for hundreds of years that babies getting cold or having abnormal temperatures is bad for them and puts them at risk of death, we're actually still really bad at it. So...

Ben Courchia, MD:  Mm-hmm.

Dr. Emma Dune: I can commit the rest of my life to that and I'm sure we still won't be very good at it. So any small improvements are good for me. I think I've been typecast already. Some people call me the bag lady.

Ben Courchia, MD: That's not nice. They could have find a better, a better, a cuter name for that. I mean, the bag lady sounds very morbid somehow. But yeah.

Dr. Emma Dune: Yeah.

Yeah, I mean, I'm OK with that. I don't mind. And I thought as well, listening to one of your previous episodes with Anne Hanson from Boston Children's, I was absolutely fascinated to hear about the dream warmer in terms of, like, I suppose, thinking of thermoregulation in low and middle income countries. But she also spoke about, you know, the version 2.0 that may actually that would have potentially can be plugged in. So you're eliminating the need for the thermos. And I think there are lots of kind of ideas and modifications you could make to that. And that could actually be really, really important in thermoregulation in the kind of the years and to come down the line. I think she's on to something really good.

Ben Courchia, MD:  Mm-hmm. I think so. I think she's a very innovative person and yeah, very excited to see what she comes up with. She's a perfectionist and so I think it's very cool to see what she comes up with. We asked this question to every guest this week and I think it's an interesting one. As you're taking a 35,000 foot view of newborn care thermal regulation, it's something we've known about forever, right?

Dr. Emma Dune: Mm-hmm.

Ben Courchia, MD: People have been putting babies in shoe boxes and in ovens to try to keep them warm since the dawn of time. And we're now in 2023. We're about to go into 2024. And we're still, like you said, we're still not very good at it. And this is probably one of the first few aspects of neonatal care that we've known of. Why do you think, what has been the problem in us not attaining a level of excellence when it comes to thermal regulation that would have been expected of our field, considering how much time we've had to address it?

Dr. Emma Dune: I think that's a really good question and I'm not sure if my answer will be adequate. I think that thermoregulation is not cool and it's not sexy, you know, it's not intubation, it's not echoes, it's not fancy tech and fancy machinery, it's very rudimentary and you actually you can't see it and I think that again that comes down to things like why do we monitor oxygen saturations continuously? Like why has that come about and why is that important? And why do we titrate and focus things on that? If we, I think if we had a continuous temperature monitor and people could see that the baby was cold or that the baby was hot and there were alarms, a lot more attention would be paid to it. And potentially we could be a lot better at it. I think you can't really be good or you can't improve on something that you can't see.

Ben Courchia, MD: Mm-hmm. That's a good, that's a good answer. It is.

Dr. Emma Dune:  And I think really important is, I suppose, raising awareness about the importance of it and then providing education. And a lot of it will come down to like simple, pragmatic things. I know you have you, Jessica Jones, on as well on a different podcast. She did a really interesting webinar, which I watched about thermal care and lots of the things were like really simple, practical things. Like if you're.

If you're raising the canopy of the incubator, you cover the baby in a plastic sheet. Like there are basic things that I think people don't think about a lot of the time or they're not thinking about temperature, particularly if it's an emergency situation. It's the last thing on someone's mind. So I think it's important to kind of to bring it to the forefront and raise awareness about it and hopefully attract more people to research it.

Ben Courchia, MD:  Very nice. As we're getting to the end of our time together, I'm just curious about, you've talked about continuous temperature monitoring. Any other aspect of thermal regulation that gets you excited or the future of thermal regulation that could get you excited? It doesn't really have to be grounded in anything, but I'm wondering, do you look at really the democratization of AI and stuff like that and think, oh, that's a cool tool I could potentially use in our arsenal to try to promote thermal regulation in our neonates. Anything like that, anything that anybody else is doing around the world that gets you excited for the future.

Dr. Emma Dune:  I think I've already mentioned, I think the Dream Warmer is, that's the most exciting thing I've heard about in a long time. I think it's amazing and I think future iterations of it or different versions of it for different settings and different socioeconomic settings will be really important. I think functions like, you know, if you had, do you know the tectotherm mattress that you use for neonates that are undergoing therapeutic hypothermia?

Ben Courchia, MD: Yep.

Dr. Emma Dune: Why can't we have something like that for a preterm neonate where you actually, you're using a servo control and providing, I suppose, the environment that they need to maintain their temperature.

Ben Courchia, MD: Going back to the first question that we talked about, I think some of the origin story of your career in pediatrics and neonatology starts with a concern and an appreciation for global health. Is that something today that when you're looking at thermal regulation, you're thinking of in terms of a solution that has to be found that would be accessible to everyone?

Or how do you think of low and middle income countries in the ongoing research for thermal regulation?

Dr. Emma Dune: Yeah, I think that was that was kind of central to our planning for the trial when we were sort of coming up with what we were going to what intervention we were going to test. We wanted to test something simple, something cheap, something that's readily available that anybody can use. And that's why we chose the timing of the polyethylene bag. And, you know, people were like, why don't you use a mobile resuscitation trolley or something like that? But they're not accessible to everyone. They're, you know, they're in specific centers, the results aren't widely applicable. So certainly with the group that I work with in the National Maternity Hospital we're always considering can our interventions be applied widely, as widely as possible across the world. So yeah for sure we're considering everyone when we design our research.

Ben Courchia, MD:  Love to hear that. Emma, thank you so much for making the time to be on with us. This was a super interesting conversation and I'm gonna be looking out for, you publish a lot in archives. So I'm gonna be looking in archives for an upcoming publication on continuous thermal regulation. And yeah, I mean, I think the way you're, I'm both, I'm ambivalent now because the way you presented, I'm like, yeah, for sure. Like that makes absolute sense. But as we've spoken on this podcast, sometimes even the things that make sense, you do the study and it comes out to be like, yeah, well, maybe not. So.

Dr. Emma Dune: Hehehe

Dr. Emma Dune: Mm-hmm.

Ben Courchia, MD: But I do think you're onto something when it comes to continuous temperature monitoring. So good luck with that and congratulations on already having a pretty impressive publication list as a neonatal trainee. Yeah, congratulations on that.

Dr. Emma Dune: Thanks so much for having me. It was a real pleasure.

Ben Courchia, MD: Same here, Emma. Thank you.

Dr. Emma Dune: Okay.

Ben Courchia, MD: Hello, everybody. Welcome back to the Incubator Podcast. We are back with this time a Tech Thursday. We are joined by Steve Falk from GE HealthCare. Steve, how are you?

Steve Falk: I'm doing great. Thanks, bud.

Ben Courchia, MD: For people who are not familiar with who you are, I'm just going to go through portions of your bio because your bio is quite extensive. You have over 35 years of product development, technical leadership experience in industry, both in startup environments and in large corporations. You're currently the chief engineer for the maternal infant care strategic business unit in GE HealthCare. You've been with the business for more than 31 years in a variety of roles and responsibilities, including senior engineer, engineering manager, lead program engineer, engineering director, CTO, and so on. You've been integrally involved with all phases of product development, including voice of customer, business development, business model generation, design verification, validation. And you also serve as the patent evaluation board leader. You have led the giraffe Omnibed and giraffe Panda platform product development efforts, which we are all very much familiar with. So it's very exciting to talk to you today about thermal regulation in the neonate.

Steve Falk: Thank you. Thank you.

Ben Courchia, MD: I guess my first question is, it's always very interesting to be able to speak to engineers because as physicians, as clinicians, we see things in a certain way, but as an engineer, what are the challenges that present themselves to you as you are trying to solve the problem of thermal regulation of a newborn?

Steve Falk: Oh, great question. So let me start with how we, as technicians, technical technologists, think about thermoregulation. It's really an energy balance of a particular control volume or control mass. This happens to be a premature baby, let's say. So when we think about that energy balance, we think, OK, how does the baby gain heat or gain energy? They do that by metabolism.

And so metabolism, as you know, glucose and oxygen come in, and energy in the form of ATP is produced. They're losing heat, they're losing energy in various ways. There's really four major ways, conduction, convection, radiation, and evaporation. Just real quick on those. Conduction is really a solid to solid thermal gradient. What that means is if the baby's lying on a mattress, it's going to lose heat or gain heat to the mattress. 

Convection, is where you're a solid, let's say the baby, in fluid, in air. So the heating, ventilating, and air conditioning, for instance, in the room, the baby can lose heat. What's interesting about this is it's not only proportional to the temperature differences, it's proportional to the velocity of the air. And most interesting, it's proportional to the surface area of the baby. The conduction one, by the way, is only proportional to the effective contact area.

So when you think about the baby lying on a mattress, it's not the whole surface area of the baby that's lying on the mattress. It's actually smaller, it's a smaller area than everybody thinks. So anyway, getting back to convection, proportional to velocity and surface area. With respect to radiation, it is the baby trying to lose heat to the next viewable solid. So what does that mean? I'm sitting in a crib and I'm losing heat to the walls, to the ceiling, to any solid that is that I can radiate to. What's interesting about that is it's proportional to the fourth power of temperature, as well as surface area. And then last is the evaporation, which is water loss. It's based on the humidity or the water concentration difference, as well as surface area. So when you think about that, you say, wow, I'm losing heat based on surface area, and my mass as a premature baby is small, my surface area to mass ratio is actually quite large. Mass is kind of directionally proportional to my metabolic energy and surface area is proportional to every which way I can lose heat. So as these premature babies are younger and younger, we think of them as engineers as a surface area to mass ratio and therefore the challenge is how do we keep these babies in a neutral thermal environment in where their comfort zone is so that they can grow, they can reduce any kind of caloric expenditure to getting warm, getting cold, and basically healing, growing, getting better. And so that's the challenge is that thermal management.

Ben Courchia, MD: What's interesting is I'm very interested in the historical evolution of thermal management of the newborn, and I think because it seems like a very simplistic problem, right? It's like, oh, baby gets cold, just wrap them up and keep them warm. And you look through history as how we've been trying to keep babies warm. And the range of ideas is just mind blowing. So obviously we have the late 19th century discovery of the incubator, inspired by incubators for chicks that were identified at the Paris Zoo. I've read reports of parents putting preterm babies in a box with feathers and putting it in the oven to try to keep a baby warm. So there, and we have mother skin to skin where we're trying to use another human being as a source of heat.

And so I think that when you're approaching this problem as an engineer and looking at all these attempts and all these iterations, how do you take the best of them and how do you create a solution that makes sense for the clinician at the bedside?

Steve Falk: Yeah, great. Also great question. And the one historical incubator you didn't mention that I always like to talk about is the one that was in the World's Fair where the baby is in a small partition above boiling water. And that boiling water, by the way, was heated with propane. So you can only imagine the fantastic issues that had.

Ben Courchia, MD: What? There's a lot of reports of burns in an attempt to try to keep babies warm. Sadly enough.

Steve Falk: Yes, yes, for sure. So I think how we think about everything you just mentioned was the thermal management has to be, it's a pretty tight control that we need to make. So there's evidence out there that suggests for premature babies that for every one degree centigrade, basically almost two degrees Fahrenheit, decrease in core temperature, there's a 28% chance more in mortality.

So we think of this sort of neutral thermal environment, this particular core temperature we want this baby to be is really plus or minus a half a degree or less in centigrade, so it's pretty tight. So when we start looking at different ways, as you mentioned, some of these, the feathers in the oven and all this other stuff, it has to be able to be controllable, and we think of the thermal time constant, so think of this, take your typical incubator even today.

And some of the challenges, okay, so we're gonna have a heater and a fan and it's gonna blow warm air over the baby in some fashion. And we need, because of we're trying to protect the brain and the neuroprotective care, the neurodevelopmental care, we want the sound in that incubator to be low. So I can't move air really fast, it's gonna be loud. So I gotta move it slow, but I gotta have the thermal time constant such that I gotta react to the baby getting cold or getting warm. 

So, the need to have that thermal time constant, that responsiveness, to be able to keep the baby within a half a degree centigrade and at the same time keeping it really low noise. So it's those kinds of interesting sort of requirements that almost butt heads against each other and finding that balance and that's where that simplistic problem becomes actually quite complicated.

Ben Courchia, MD: I think it's exciting to be able to talk to you because if you are, like me, interested in how things work, the idea of the giraffe Omnibed is something that is really, really â it's something that would pique your curiosity because it seems very straightforward, right? You have a temperature probe that's connected to the baby and an ambient temperature that is regulated based on the baby's temperature. But what's interesting about this is that it is not, these changes in temperature are not immediate, right? So they're progressive. And like you said, we have an imperative to try to keep the temperature of the baby within a tight range. And so when you are designing the algorithm that regulates the temperature of an incubator, how do you take all these parameters into account? Mainly how long is like, for example, a baby that is slightly has a temperature that's slightly higher than it needs to be, but it's suddenly decreasing. Is that pattern going to reach a point where we're crossing a certain threshold that leads to hypothermia? How quickly do we respond to changes in temperature? And how quickly are these changes in ambient temperature reflected on the baby? And how does that feedback mechanism work? I think I would love to hear more about that.

Steve Falk: Sure, sure. So for an incubator, so there's different algorithms, whether you're an incubator or in a warmer, radiant warmer, and for the Omnibed, there's actually both of those algorithms because the Omnibed can be an incubator or a radiant warmer. So let's take an incubator, for example. So, we, you know, the old version of incubators would basically turn on and off the heater, and maybe change the fan speed, but turn on and off the heater based on the baby temperature. And what happens is exactly what you said, which is how do you tune that algorithm to a particular baby who may have a slightly more sluggish way of changing temperature just naturally or a faster way depending on their gestational age or just in general their personality if you will. And so you end up chasing the temperature and what happens when you do that is that the heater will turn on and off and it will move the air temperature up and down as fast as it can and it generates this volatile kind of environment for the baby and it can generate some very bad things as you can imagine.

What we do at GE HealthCare, what the giraffe does, is what we call a cascade algorithm. So what we're doing is we're not directly changing the heater based on the baby's temperature or the baby's temperature changes. What we're saying is, we're gonna control the air temperature in incubator. What set point that we control that air temperature at could change slightly based on how the baby's reacting to it. And it kind of takes the time, thermal time constant, if you will, away and a little less relevant. It is similar to if you're in your home and you're slightly chilly and you go to your thermostat and you raise it up, let's say, a half a degree or a degree and then you kind of see how that plays out for a certain amount of time. And if that helped, fantastic. If you're still chilly, you knock it up another degree. So think of it as this constant or continual modification of the air temperature to keep the baby temperature where it's at.

That sort of sluggishness that we purposely put in there gets a more comfortable control. It allows the baby to change their temperature at whatever rate they're gonna change their temperature and that we would keep up.

Ben Courchia, MD: That's so interesting. As we were talking about these functionalities, I think some people that may be listening in the car may say, yeah, well, I knew how this worked out. I'm not very impressed by that. But I think sometimes what's lost on us is the degree of innovation that happens on a product or on a tool that we've been familiar with for many, many years. And I think as we are synthesizing a lot of the things you said, about the mechanism in which heat can be lost, about the mechanism in which an incubator functions, can you tell us a little bit about some of these other features that are present in an incubator that are allowing us to deliver the care we deliver on a day to day basis, all the while trying to keep that goal of maintaining normal thermia at the forefront? I'm thinking of portholes. I'm thinking of air boost, which I think many people are still not familiar with what air boost is.

Steve Falk: Mm-hmm.

Ben Courchia, MD: (12:49.627)

How do you, can you tell us a little bit about these different features?

Steve Falk: Sure, sure. So let's take the Omni-bed in the closed-bed mode or the incubator version, if you will. So what we do with our airflow in an incubator is we have what we call a double wall. So our doors or side panels have an inner wall and an outer wall, if you will. It's kind of like a double pane glass in your house. And the airflow goes up that through those walls. And there's a reason for that, couple reasons actually. Number one is that the air can actually be warmer because the baby can't actually feel that air. It can't put their hand over the vent, if you will, and get hurt in any way because that air can be a little hotter because the baby can't touch that air. And it comes out kind of at the top of the door. It, at the same time, is actually warming that inner wall. So when we talk about our radiant energy, that baby is looking at the next solid. Well, that next solid is the inner wall. 

So now, the room temperature, if you will, has no, has less relevance to how the baby's going to either be warm, be cool, it's really in our control. We think about portholes. Now, so when we talk about interventions, clinicians are in the portholes, as you know, a lot, and so we've designed the portholes such that they're little tunnels, if you will. So those portholes do not in any way break up that inner wall airflow.

So if there were, for instance, if there were just portholes there and all we did was open the porthole doors, a lot of that airflow coming through the inner walls would try to escape. And if it tried to escape into the room, it's not gonna draw negative pressure in the incubator, there's gonna be air that's going to displace it. Well, that air that's gonna displace it will be room air. So now I'm gonna get cold in my incubator. So we have these tunnels, they're gaskets that go around the porthole. And so what happens is you open the porthole,

Those open portholes are not in any of the forced convection that we are putting into the incubator. So the only escape of that warm air is just that natural sort of mixing that happens very slowly and it's not actually very effective. So we really don't have any significant temperature drop when you open portholes. That was done very purposefully. When it comes to the air boost you mentioned, so we have an ability to push a button and boost the air. What does that mean? It changes the fan speed such that when I, for instance, open the door of the incubator, you could feel the air coming up because that's the vent that's gonna come up. And when you boost that air, it's very similar to, I'm sure you've gone into a supermarket or some sort of store where they're trying, you feel this burst of air as you're walking through the entrance. That air can actually divide warm air and cold air and keep those divided. They, it's very difficult for that air to kind of cross the air curtain. The faster the air, the better.

Ben Courchia, MD: If the flow is fast enough, then it acts as a barrier. Got it.

Steve Falk: Correct, correct. And what we also do is there's a little feature inside of that incubator that when you do that, when the door is open, it kicks the air about four or five degrees inside the incubator, slightly off a vertical. So what we're making sure, not only do we have an air boost curtain, we have an air curtain, we have an air curtain that is leaning into the incubator because we don't wanna waste that beautiful warm air and put it into the room. And so those are the kinds of like, little features that I think clinicians may not either know about or maybe appreciate that we spent time doing to make sure that any intervention of cares or anything into the baby that the baby gets the best normal management they can get.

Ben Courchia, MD: Yeah, and these are the kinds of things where if you're a provider and we do get, there's always some form of in-service happening in the unit. And I think I'm talking to the doctors and providers here. When people from GE come to go over some updates or whatever it is about beds, even if you're a clinician and say, oh, that's for the nurse, that's not for me, go and listen, because that's how I find out. I found out about all these different features and I was like, holy smokes. I never knew about this. Nobody told me that I should have to press air boost when I'm going into the, into the incubator. 

That's super helpful. Can you tell us a little bit as we're discussing all these features at the bedside, how does feedback from your users, from the clinical team, how does that play a role in how you iterate on the different products?

Steve Falk: Huge role, huge role, Ben. So we have a clinical staff in the maternal infant care business, as well as we have tremendous key opinion leaders and clinical partners out in the world. And we're constantly going and having those conversations. Those that are listening are probably laughing that maybe we do that too much and bother them a little too much. But anyway, we see them at conferences, we call them. And that feedback is fantastic. As a matter of fact, in developing the giraffe OmniBED and that platform, we probably talked to more than a thousand clinicians all around the world as we were developing it and we continued to do that. It wasn't that we scoured the earth and got all this feedback and then just developed this product and launched it. It was continual feedback from focus groups to conferences to road shows to conversations to studies all throughout the development and even as we were launching the same thing. And to be honest with you, even post-release, now it's in the market. We continue to get that feedback so that we can iterate and innovate on what's next and what is the next incubator and what should we be paying attention to and all of that. And we love not only speaking and having these discussions with these clinicians, but they learn, we learn. 

Look, diversity in the room is huge, and it brings the best solution possible, as well as we believe wholeheartedly that the clinicians can be part of this design process.

Ben Courchia, MD: Something that's interesting sometimes in the clinical field is that we feel as providers wrongfully that we are finding best use for tools that we have at the bedside and forget that we are aligned with the team that developed the tool. And I think to that end, a topic that we've discussed a lot on this mini series has been how there are various aspects of maintaining thermal regulation that are very different from one another most notably in and around the time of birth when we're talking about the concept of golden hour. And so I am wondering if you could share with the audience a little bit, how has this entity of golden hour and the challenges that it presents influenced or sparked any design or functionality of the tools that is developing to address thermal regulation in a new one.

Steve Falk: The golden hour is an interesting one because there's sort of many different things that are happening within that golden hour evolution even currently from delayed core clamping to all sorts of other things that are going on. And so we still step it back to the science and the physics. So this baby comes out, look, this baby was what, 37 and a half, 38C inside of mom. They come out to a what, 22 degree room wet.

That's incredibly impactful, as you can imagine. Thank goodness we don't remember that experience. And so we think about the four heat partitions. So first of all, the delivery room temperature. Maybe that should be higher, and I know that there's a strong indication that that's the case. Obviously the radiant warmer brings a tremendous amount to that table, so it's infrared energy radiantly coupling to the baby that's trying to balance all the ways the baby's losing heat, you know, you hear about sort of very premature babies, some of these extremely low birth weight babies being put in plastic bags. What does a plastic bag do? It, first of all, reduces the evaporative heat loss tremendously. It actually reduces a lot of the heat losses, radiantly, convectively. There's no air flow really in the bag. So the bag, as much as it may seem a little primitive to hear about that, is actually amazing to benefits.

And so we think about that as we start innovating kind of where we want these microenvironments to go within the golden hour. And thinking about delayed cord clamping, you know, it's funny. We had, I've had conversations with some of the clinicians about just the delayed cord clamping. So when the cord is intact, for instance, for the first, let's say, couple minutes, is the baby gaining heat or losing heat because the cord, you know, the placental blood is still transfusing into the baby.

And the answer is we don't know. And the answer is it's controversial and the literature would suggest both ways. And what it does, it depends on a tremendous amount of things from gestational age to perfusion in the core, to even the heart rate and sort of the blood flow, if you will. And so we're looking at those kinds of things and how do we get the golden hour to be a smooth thermal sort of transition, if you will, because at the end of the day, the thermals are tremendously important, but airway breathing and circulation is obviously more important, and we don't wanna sacrifice one for the other.

Ben Courchia, MD: That's great. I mean, as we are getting close to the end of this chat, I'm hearing you speak about all these things and you can definitely hear a passion behind all these tools and all the development that goes behind it. And you have an impressive resume. I am wondering, you could work in a variety of industries and yet you are here working at GE for maternal and newborn health.

What kind of satisfaction does that bring you and what keeps bringing you back to this field day in and day out?

Steve Falk: You know, I get asked that a lot, especially when you're at any place 30 plus years, you get asked a lot. Honestly, it's the babies. It's, you know, you save one life, you save the world, right, so it's the babies. It's the clinicians out there, they're saints, and I just love working with them. It's obviously the team that I work with and in our products, but honestly, it's waking up and saying, you know, how am I putting something, how personally, and our team, how are we making the world better in some way?

And the baby business is such a fantastic business. There's been plenty of opportunities to go elsewhere and I just love it. It's just, it's very personal and it's very, it bleeds into your sort of your personal life. And I couldn't think of working anywhere else.

Ben Courchia, MD: Yeah, I think it's important for me to ask that question because as clinicians, as frontline healthcare worker, we can sometimes see a company, we can see a logo and think really like a faceless corporation. But I think we should be reminded that behind these tools that we use, there are people that are people that have and that share the same dedication and passion for newborn health. And I think in this day and age to see someone working at a company for over 30 years, it's an outlier. It's people tend to move and seek whatever compensation package is more enticing somewhere else, you know? So, uh, I think, I think it's, it's so refreshing to hear your perspective and, and to hear this dedication, uh, to, to newborn health.

Ben Courchia, MD: There's a lot of, you're an engineer, there's a lot of tech and technology is now making the rounds in the news, and it's something that we tend to read about every single day. I am wondering if there are any things coming up on the horizon that you are looking at, and you are just getting super excited about when it comes to the tools that we talked about, when it comes to the care of critically ill newborns.

Steve Falk: Yeah, there's actually a bunch of technologies out there. I know there are everything, and it sort of goes throughout the whole spectrum. I know you guys are probably, anybody listening has probably seen some of the literature on that's happening at the University of Pennsylvania with the artificial womb, with the lambs, and yes.

Ben Courchia, MD: Yeah. With the bio bag, I think that is something that had made the rounds in USA Today where they basically put fetal lambs in this, literally looks like a plastic bag full of fluid but basically creating an artificial womb where they could potentially maintain a fetus for X amount of weeks. And that, I think that was about like a year or two ago, I think, right? Yeah.

Steve Falk: It was, they're still working on it. And I'll tell you, I don't know that I yet have, what my opinion of, is that really the ultimate future? But what I love about the fact that they're doing that is that there'll be some amazing technologies we're gonna find along the way. And that's what excites me about going, kinda going for the true blue sky, whether we ever get there or not, whether that's technically gonna, acceptable or technically gonna happen, going to, you know, acceptable. But at the end of the day, some of these technologies along the way, how what we're going to learn about the survival and actually it's not even so much survival, it's kind of the morbidity and the ability to have a fantastic trajectory of health for these 22, 23, 24 week kids. What we're going to learn from this journey is going to be fantastic and I can't wait.

Ben Courchia, MD: That's fun. That's exciting. Steve, thank you. Thank you so much for making the time to be on with us today. I think it was a very enlightening conversation. I think everybody is going to leave this podcast thinking, I never knew that my incubator did all these things. So I'm sure there's going to be a lot of calls to GE to have some rep come and show us around the incubator once again.

And we're very excited about what you guys are gonna come up with in the future. I think the dedication you guys have for newborn care and for maternal health is impressive, and I think that's gonna translate into more innovative tools. So thank you for all the work that you do. Thank you.

Steve Falk: Thank you, thanks for having me.