Inside the mind of a Neonatal Blogger.  Why am I doing this?

Inside the mind of a Neonatal Blogger. Why am I doing this?

I get asked from time to time why I started blogging, set up a Facebook page, Twitter account and bombard the internet with more information.  Let’s face it there are a lot of people out there writing about plenty of things including Neonatology.  So the question is, does the world need one more?  As you would surmise since I have been doing this for about four months now, I think the answer is yes!

Last night the reasons for writing crystallized in my head at a dinner.  A friend of mine who I hadn’t seen in awhile asked me the most common intro question that people start with; a simple “What’s new?”  I mentioned the usual things that people talk about, work, life and such and then mentioned the writing.  After asking me some probing questions about the topics that I cover (none of which would be of much use to him with older children) he told me that my motivation for doing all this could be summed up with one quote by Winston Churchill as shown above.  After digesting my meal and his words, I realized that the motivation is in fact my desire to stimulate myself and others to think about care of the newborn and expand our pool of knowledge.

We live in the age of the internet and with it the limit of ones reach is really limited to the content that they publish in terms of interest to the masses.  I have always enjoyed teaching others but as my career has progressed, my time has been spent far more on administrative duties than in the proverbial classroom.  I suppose part of my motivation could be described as selfish in that I am wanting to satisfy a desire to teach but if in so doing I can help others, that seems like a forgivable fault.  The internet has the potential to be one of the greatest wasters of time for some but there is no doubt that the reach of the “teacher” is multiplied a thousand fold by the vast network of interconnectivity that exists out there.  It is the potential to reach others and inspire positive change that has driven me to continue my writing.

Truthfully, I hope that I don’t make any enemies out of this creative endeavour but I do believe that the Churchill quote does apply in the sense that with each post I hope to achieve a few things.  The first is to inform you the reader about topics that you may find interesting.  The second is to get positive or negative (the enemy so to speak) feedback.  If the idea that is being proposed is something that inspires change in another centre and benefits at least one baby out there I have succeeded in the third goal which is to help children beyond the borders of Winnipeg.  On the other hand if I am mistaken in my conclusions about a direction for clinical care or a new device to try in our units then some negative feedback helps me reshape my views and perhaps save our babies from something that has been tried and found to be not worth the effort in pursuing.

In all of this I do not mean to come across as arrogant.  I have the same training as many of the people who read these posts do and in some cases even less.  I do not mean to suggest that I know more than others but I am aware that there are many centres around the world that are simply not academic.  They do not have residents or other learners with regularly scheduled rounds.  How do they get their information about new directions or products?  I suspect they turn to the internet and utilize such blogs as this.  I aim to provide as accurate commentary as possible about the things I am passionate about.  If a non academic centre can benefit that is wonderful.  Furthermore if an academic centre gains something by my contribution to the pool of knowledge all the better.  If I in turn learn that I have made an error in my thinking then for my personal development that is more than welcome.

An example of this came just this week on my Facebook page when I commented on the NICE findings from the UK comparing Midwife assisted births to Hospital births by Ob/Gyns. I incorrectly stated that home births with a midwife were found to be equally safe in terms of outcomes.  A social media friend in the UK corrected me by indicating that it was home birth OR hospital birth by a midwife.  Furthermore, about half of the births occurred in hospital so we cannot conclude that for low risk births all home births with a midwife have equivalence.  I seemed to have learned something here that I would not have taken away if I hadn’t put my thoughts out there so I thank my friend in Bristol, UK!

On the other hand, the post on the use of Dextrose Gel to Treat Hypoglycemia has probably helped hundreds of infants by now.  I received several requests for more information including our guidelines which I have posted in a page of guidelines on this site.  I can only wonder how many pokes have been spared for placing an IV in a well newborn who would have only been hypoglycemic once or twice.  How many have avoided a trip to an NICU and instead bonded with their parents in their room?  Truly as I write this, it puts a smile on my face!

I am a doctor who also happens to be human and with that has the potential to make mistakes. I put my thoughts out to you in part as a means of testing myself.  I am very fortunate to have a colleague who has no hesitancy when it comes to challenging others conclusions.  This contrarian viewpoint helps make others including me stronger.  As the audience for these posts grows and the feedback (which I have noticed is increasing) comes I seem to take a little bit of extra time formulating my ideas before they are put out there.  So in essence this post is a thank you of sorts that goes beyond explaining why I take the time to write.  I write to inform, create change beyond our borders when needed and receive feedback on my own beliefs about optimal care to make me a better Neonatologist.

Shouldn’t we all stand up for something, sometime in our lives?

It feels good.

Bressure, Lactavists and Brelfies

Bressure, Lactavists and Brelfies

Nineteen seventy two was notable for many things aside from the year of my birth.  Canada defeated the Soviets in the summer series, the Watergate scandal took down a Presidency, The GodFather was released and for the purposes of this post breastfeeding rates in the US reached an all time low of 22%.  For an excellent review of the history of breastfeeding the article by AL Wright is excellent.BF rates

Rates of breastfeeding began a steady decline in the 1960s as more and more women entered the workforce and seemingly had to choose between employment and breastfeeding.  This was a time when it was not seen as being acceptable to breastfeed in public (although that is not the case in many places still to this day) and the workplace was not as conducive to supporting women as in current times (think onsite daycares).  Add to this that the 1970s also saw a backlash of sorts in the appeal of breastfeeding due to science “perfecting” a better source of nutrition in formula and we had the low rates that we did.  In fact through discussions with parents from that generation, mother’s who chose to breastfeed may have been viewed by some as being silly for not using something like formula that could let the whole family in on the experience.  Mom, Dad, kids and grandparents could all take part in the wonderful act of feeding.  Why be so selfish?

Following this period as research began to demonstrate improved outcomes with breastfeeding including reductions in atopic disease, less hospital admissions and more recently positive impacts on intelligence and your microbiome the trend reversed. In fact, as the above graph demonstrates, rates approximating 70% were reached by the late 1990s.  Since that time the CDC has shown that initiation rates have continued to rise and currently are at the highest documented levels in history.

Screenshot 2015-06-01 00.38.37

Looking at the CDC data though reveals some very important information.  While the rates of any breastfeeding reach 80%, the rates at 6 months hover around 50%.   This means that a significant portion of US women are using some formula when they come home and from the graph on the right about 35% by three months are exclusively breastfeeding. This number is far short of the goal the WHO has set to encourage exclusive breastfeeding for the first 6 months however it is a remarkable achievement for infant health.

http://www.who.int/topics/breastfeeding/en/

A recent trend on social media and print media has been the Brelfie.  As you may know, this involves taking a picture of yourself breastfeeding your baby and posting it in one forum or another.  This has been popularized by many celebrities and made it’s way onto the cover of Elle magazine this month.

CF8PngLVAAMCIoSSo called Lactavists have been overjoyed to see such public acceptance and promotion of breastfeeding.  As a Neonatologist I am delighted to see such high rates of breastfeeding and with it the beneficial effects that it brings.

Curiously, though all of this attention and promotion of breastfeeding has created a culture that is now being called bressure.  This is defined as pressure to breastfeed and was the subject of a recent survey by Channel Mum in the UK.  The highlights of the survey that went out to  2,075 mums showed:

–  16 per cent of bottle-feeding mums have been on the receiving end of cruel comments from other mothers they know

 – one in 20 being attacked on social media

 – 69 per cent of bottle-feeding mums said they had been judged negatively

–  41 per cent made to feel they have ‘failed as a mum and failed their child’ by not breastfeeding

–  15 per cent of mums have even lied to cover up their bottle-feeding and appear to be ‘better’ mums.

This so called bressure has led to a public campaign to increase awareness of the harassment that some mothers feel which involves taking selfies with cards having one word describing what breastfeeding meant for them.  A video from Channel Mum can be seen here

Channel Mum Video Response to Brelfies

While I am all for breastfeeding, I find it peculiar that the experience that breastfeeding mothers (all 22% of them) had in 1972 is now being felt by a larger percentage in 2015 who are bottle feeding.  It is unfortunate that assumptions are being made of many of these women who put a bottle in the mouths of their infants.  How many times does one conclude that the mother simply chose not to breastfeed because they were worried about the way their breasts would be affected cosmetically or that they simply chose to go back to work and breastfeeding would just get in the way.  I suspect in most cases the truth is much different.  Many of these mothers have tried to breastfeed but couldn’t produce enough.  Others may have suffered from cracked nipples, mastitis, abscesses or due to prior surgery were unable to produce milk.  Many such mothers have agonized over their “failure” to do something that they hear “everyone can do”.  While they are told it takes some work for many that is a huge understatement.  Is it not bad enough that these women have suffered the feeling of failure?  To be looked at or spoken to in a disapproving way does nothing to support them.  Add to this that by 3 months of age at least in the US 65% of mothers are providing some formula and it seems silly to take the “high and mighty” approach in the first couple of months and assume the worst of these women. Many of the “breastfeeders” will soon enough join the ranks of those using some formula.

Maybe the better option is to try and help.  Many of the above problems whether it be producing enough quantity or pain related to breastfeeding can be addressed through tips on technique.  While I am not an expert in this, hospitals would do well to increase staffing of on site lactation consultants to help mothers who wish to breastfeed get off on the right foot so to speak.  A larger working force of midwives in North America in particular could certainly provide help in this regard.  What I can say is that if a woman suffers a bad experience with breastfeeding in their first pregnancy the likelihood they will try again the next time is lower especially if we as a society make them feel like a failure.

Yes we need to promote breastfeeding and we should do what we can to follow the WHO recommendations and minimize the use of formula when possible.  While bressure may have been intended to yield something good we need to be sensitive.  Perhaps a better strategy next time a friend says they are going to use formula is to ask if they are having trouble with breastfeeding and if they need some help. Not having the discussion will ensure that nothing changes and a chance to do something will be lost due to misdirected bressure.

The Healthy Vaccinee Effect. Waiting till ELBW infants are “better” to vaccinate puts them at risk!

The Healthy Vaccinee Effect. Waiting till ELBW infants are “better” to vaccinate puts them at risk!

Ask any health care professional how our tinyest babies fare after an immunization and they will tell you “not well”.  In fact the belief is so pervasive that we go out of our way to find excuses to delay immunizations.  I have heard myself uttering such comments as “today is not a good day” or “let’s wait until there is greater respiratory stability” or simply “they are too sick”.  Perhaps this tendency develops because we are shaped by our past experiences and if we have had a baby get intubated who was on CPAP after an immunization, we subconsciously say to ourselves “that won’t happen again”.

By no means am I writing an anti-vaccination piece but rather exploring our behaviours and trying to come up with a means of changing them.  Adverse Events After Routine Immunization of ELBW Infants was published on this very topic this week and with nearly 14000 infants from 23 – 28 weeks included who received their first 2 month immunization, it certainly caught my attention!

The table indicates the risks of certain adverse events in the 3 days preceding the immunization to the 3 days afterwards. Table 2 What you will note is that the evaluations for sepsis increased 4X, Respiratory support and intubation almost 2X, with no difference in seizures.  It is important to note that the definitions for sepsis were based on two blood cultures being drawn rather than fever alone. Curiously with respect to sepsis there was an increase in the number of positive cultures as well from 2.1 to 3.8% in the evaluations that were done before and after.  It is worth pointing out though that I can find no analysis of those results to determine if they were statistically different so at most it is an “interesting” finding.

The figures below demonstrate the rate of the same adverse events before time zero and then afterwards for the same duration as in the table.
What you notice aside from the rise in adverse events is a sharp decline in the rate of adverse events just prior to the immunization and then a sharp rise after it is given. figure The steep decline just prior to immunization is known as the Healthy Vaccinee Effect. That is to say that we may see a higher rate of complications simply due to the fact that we wait for kids to be at their healthiest and when they have only had one or two days without apnea or are off their antibiotics that is when we choose to give the vaccine as we believe they can now “handle it”.  What we have created is a special sample of patients that actually does not reflect the whole population.  What I mean by this is that the response of all patients to their vaccines in this age group might be quite different with no increases in any adverse events if we paid no attention to our preconceived notions that the infant in our care is “too sick” to get their immunization.  When we only immunize those kids that are at their best, the likelihood of them deteriorating is higher than when they were “worse”.

We know from previous literature that ELBW infants have higher rates of apnea and need for respiratory support after their vaccines. If we gave them an immunization when they were on CPAP or a higher dose of caffeine would we notice the impact as much?  By waiting till they have weaned off CPAP or outgrown their dose of caffeine we are setting ourselves up for a setback.

Similarly perhaps the optimal time to give the vaccine is when they are actually on an antibiotic for a sepsis evaluation or have had a CRP for one reason or another in the preceding 24 hours.  Would a mild fever after the vaccine trigger the same response to do a septic workup or would you take comfort in knowing your patient was already on antibiotics or had no signs of inflammation prior to the vaccine?

In summary I question if I have had it all wrong.  I am not saying to give a vaccine to a patient who is on high frequency ventilation and inotropes due to septic shock but rather when they are recovering and off the inotropes but still ventilated what is the harm?  They are already intubated, and covered with antibiotics.  Seems to me to be the perfect conditions to prevent me from either escalating their respiratory support or doing a septic workup. They are already covered!

Practice Makes Perfect? Building Better Neonatal Teams.

Practice Makes Perfect? Building Better Neonatal Teams.

The following piece is by guest writer Nicole Sneath NNP at the University of Manitoba. I am delighted to have her write on the use of simulation in the NICU and encourage you to watch the video she made for a recent charitable luncheon for the Children’s Hospital Foundation of Manitoba.

Practice makes perfect. This is something we’ve all heard at one point or another. Whether it was when we were learning how to ride a bike without training wheels, or print our name, or pitch that perfect strike. It seems a basic lesson, common sense, but do we practice what we preach?

In health care we deal with stressful situations, complex syntheses of information and multiple unique interactions. For the most part, we work in interprofessional teams, each one responsible for some part of care to our patients and each one dependant on the other whether we like to admit it or not. Our groups are varied, ranging from hands on direct care providers, to consultants, support staff, administrators and maintenance workers. Each one plays a unique role complementing the other. Sounds like the perfect set up. In practice however, do we really complement each other? Do we communicate effectively? How often do things fall through the cracks? Do we use our skills and strengths to everyone’s advantage? Is this diverse system a well-oiled machine working together and collaborating to provide optimal patient care? I would guess if you looked at your organization critically you may not be happy with all the answers.

Most of us trained and practiced with members of our own profession, doctors with doctors, nurses with nurses and so on. We were hired into our jobs and again did our orientation and continuing education within our own groups. In the everyday workplace however we are all blended together, modeling those that have practiced before us. Sometimes we work together well, seamlessly collaborating for a common goal. When we don’t, who pays the price? Perhaps it’s the patient with an untoward outcome, perhaps its the administrator with a complaint on their desk, perhaps its the consultant frustrated by the miscommunications or perhaps it’s the staff member not satisfied or content with their work.

Training programs have started to recognize that collaboration needs to start at the beginning. Waiting to introduce these concepts until arrival into the workplace is too late. Interprofessional learning is defined as learning with, from and about each other and this should happen at all levels of education and training. Teams function well not only by practicing together, but by creating environments where teams can get to know each other. Creating a relationship, no matter how small, can go a long way when stress increases and trust is needed.

It’s been shown that errors are often caused by breakdowns in communication. Maybe the nurse that administered the wrong dose of medication just didn’t know the dosing for that particular medication? Solving the problem could be teaching the proper dose and voila, problem solved. Or was the problem that they didn’t know where to find the information, weren’t comfortable asking for help, or didn’t want to question the doctor that ordered it? When the surgeon amputates the wrong leg is it because that one surgeon just isn’t that bright? Or could it be that no one else in the operating room double-checked, no one spoke up when they thought-wait, was it the left or the right, each one assumed that someone else must know best? Speculations abound for what goes on in critical incidents such as these. A common thread in preventing many critical incidents is the need for improved communication. Closed-loop communication, a shared mental model, role identification and clear leadership are integral to good communication in stressful situations. These concepts are best taught through experience rather than didactic lectures alone. So how do we go about teaching these skills?

Practice. Practice in an environment that is like the real thing, but lacks the risk to patients. Gone is the see one, do one, teach one mantra but it is replaced by see many, simulate even more, then do. Simulation allows us to breakdown specific skills and practice them over and over until we master them. We can practice individually or to harvest the greater benefit we can bring our interprofessional groups together and practice the skills that can’t be taught by reading a book. We can video record the sessions and debrief them afterwards. Instead of debriefing by giving a reassuring pat on the back or a not helpful shaming, perhaps we should try the “debriefing with good judgement” method and gain insight into the frames that guide individuals behaviour and actions. We can stop asking “dirty questions”-you know, the questions that we ask when we already know the answer, the “guess what I’m thinking” questions. Instead we can develop true curiosity into what individuals are thinking and then be able to change behaviour and facilitate critical thinking and problem solving.

We all come to work and want to do a good job. We want to be told that we made a difference, that something we did during the day has made a positive contribution to someone’s life. If this doesn’t resonate then perhaps a change in occupation is in order. If we critically examine our own practice, we would find areas that we could improve, skills we wish were a little more precise, or areas of specialty that we wish we knew a little more about. Traditional responses would be to dust off an old textbook or perform a literature search and get the information we need. Is this manner of learning effective? Does this address all the skills and knowledge we are seeking? Do we really know our areas of weakness? Do we want to?

References

1.  There’s no such thing as “nonjudgemental” debriefing: a theory and method for debriefing with good judgement. http://www.ncbi.nlm.nih.gov/pubmed/19088574

2. Debriefing with good judgement: combining rigorous feedback with genuine inquiry.

http://www.ncbi.nlm.nih.gov/pubmed/17574196