Improving Care of Newborns, One Baby at a Time

As a new parent, you want to hold your baby close the minute you lay eyes on him. You want to cuddle, love, calm, and protect. The last thing you want is to hear that your baby needs to go to the Neonatal Intensive Care Unit (NICU) and be separated from you unless absolutely necessary. Now, moms with an intra-amniotic infection during labor called chorioamnionitis and their well-appearing baby get to stay together safely and experience important family bonding time after birth, thanks to a new clinical approach pioneered at Stanford Children’s Health.

“It’s a more baby-friendly way of doing things. It focuses on the mother and baby and allows the parents to cherish that most special time with their newborn,” says Adam Frymoyer, MD, a Stanford neonatal hospitalist.

Approximately 3 to 6 percent of babies are born to moms with chorioamnionitis each year in the United States. With chorioamnionitis, bacteria enter the membranes that surround the fetus and put the baby at risk for developing bacterial sepsis after birth. Until recently, the standard of care at Lucile Packard Children’s Hospital Stanford, and most hospitals across the nation, was to immediately take newborns exposed to chorioamnionitis to the NICU. There, the baby would receive antibiotics and remain separated from the mother for at least 36 hours until blood tests confirmed that there was no infection present.  

Now, well-appearing babies born to moms with chorioamnionitis get to stay with their parents through a new approach that received remarkable results in a recent study at Stanford Children’s Health. Instead of automatically receiving antibiotics, an exposed baby who appears well after birth is monitored closely by the neonatal care team while staying with mom. The approach reduces unnecessary antibiotic use by 88 percent in babies and, most important, preserves crucial early family bonding time. The study won an award from Hospital Pediatrics, the journal that published it, and is influencing the standard of care for babies born to moms with chorioamnionitis across the nation.

“It’s much less scary for parents to be able to see and hold their babies, rather than having them taken away to another unit. It is very rare that an infant who has an infection doesn’t exhibit warning signs, and this study showed that,” says Lindsay Stevens, MD, a pediatrician in Stanford’s newborn nursery. “That’s why we watch and wait, as we now know a well-appearing infant will do great and does not need antibiotics.”

Carefully waiting and watching, rather than quickly administering antibiotics, is the crux of the new approach. Of course, infants who need antibiotics will still get them, but those who don’t will not.

“This goes beyond Stanford Children’s. It makes our care better, but the study also opens up discussions among other hospitals that want to change their own approach,” Dr. Frymoyer says.  

Newborns are closely watched by specially trained bedside nurses for any sign of infection or fever during the first 24 hours of life. In a nutshell, the new approach avoids unnecessary separation, antibiotics, and lab tests.

“The beauty of this protocol is empowering the bedside nurses to be our safety net and catch signs of sepsis. Working together as a multidisciplinary team is key to this approach,” says Neha Joshi, MD, a Stanford neonatal hospitalist.  

The study was conducted in two phases: in the first, well-appearing babies exposed to chorioamnionitis were watched closely in the intermediate care nursery. In the second, these same babies were allowed to stay with their parents; and all babies, regardless of risk factors, received frequent assessments in the first 24 hours.

“We knew we needed to change our approach to care for well infants who are at higher risk for infection. We initially considered creating complicated algorithms to determine which babies we should watch closely. After reviewing the data and literature, it was apparent that any well-appearing infant, exposed or not, could get sick. That’s why we decided to increase our monitoring for all babies uniformly,” says Dr. Jessica Allan, pediatric hospitalist at Palo Alto Medical Foundation and one of the physicians in the initial working group questioning antibiotic use in well-appearing newborns. “It became a perfectly simple approach.”    

To make the change, Stanford Children’s did what it does best: collaborate across specialties and break down the invisible lines between doctors, nurses, and technicians—all with the best outcome for the patient and family in mind. When challenging a current standard of care, hospitals have to get several specialties to see eye-to-eye and carefully take one step at a time.

“It’s always scary to make changes, especially when working with newborns. We did it in a very methodical, slow fashion and proved we were pushing care in the right direction. Our strong data got us to a place of comfort,” Dr. Stevens says.

The seed for the new approach has long roots at Stanford. William Benitz, MD, a neonatologist in the NICU, started discussions nearly a decade ago as then chief of neonatology on lowering antibiotic use in newborns. Dr. Benitz credits getting buy-in from front-line nurses, related care teams, and even pediatricians outside of Stanford Children’s—including Dr. Allan at Palo Alto Medical Foundation—for creating what he calls a bottom-up change.

“I’m really proud of everyone for making this change happen,” says Dr. Benitz. “I think we are leading the world with this new approach. We’ve always had a well-established culture of evaluating evidence and implementing change here at Stanford.”

This new approach demands more attentive care from nurses and doctors, but it pays off big-time in health benefits for the baby.

“Giving antibiotics is not without its downsides. We know that a baby’s gut microbiome, which is impacted by antibiotics, is very important for growth and development,” says Ronald Cohen, MD, neonatologist and director of the Intermediate Intensive Care Nursery. “Plus, it’s hard to quantify the benefits of not having to endure IV sticks, lab draws, and time away from mom.”

Another reason Dr. Cohen is pleased that Stanford Children’s made the change is that it’s “the right thing to do—it lowers costs for society, insurance companies, and families, and that’s all positive.”

Moms love the change. It lets them keep their babies with them, allowing for critical skin-to-skin time and a more natural opportunity to start breastfeeding. Dr. Allan recounts one mom who gave birth before the study and then after it. She had a fever at the time of each delivery, revealing the possibility of an infection. Her observations were living proof that the new approach is better.

“She said to me, ‘Thank goodness we get to keep our baby with us this time. With our first, we couldn’t understand why you took her away from us.’ Her statement made all our efforts worth it,” Dr. Allan says. “It’s empowering for parents to have their baby with them and to know that we are watching closely.”   

A ripple effect has already begun. Other regional hospitals are following suit, including those in San Jose, San Joaquin, and Mountain View, California.

“Our study could change care for hundreds of thousands of babies born each year,” Dr. Stevens says.

Stanford Children’s doctors are getting the word out by visiting other hospitals and presenting annually at national conferences. Each year, more and more people are interested.

“Nationally, as more centers learn about our study, we hope they will embrace the importance of the clinical examination in identifying sick infants,” Dr. Joshi says. “The American Academy of Pediatrics now considers it one of three recommended approaches for babies born to moms with chorioamnionitis.”

The team hopes—and expects—to someday hear hospitals across the nation announce it as the premier standard of care. For moms who deliver at Packard Children’s, it’s already number one.

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