Thermoregulation of the Neonate with Dr. John Ibrahim

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.