Maggie McKay (Host): When you're a parent of a newborn, you want the best in care. So today, we'll find out about innovation in infant care as St. Joseph Hospital partners with Dartmouth Health Neonatology. Our guests are Chief of Neonatology, Dr. Steven Ringer, and PA in the Special Care Nursery at Dartmouth Health, Dael Harrison.

 Welcome to Wellness First, a St. Joseph Hospital podcast, where we hear and learn directly from the experts on all things health and wellness. I'm your host, Maggie McKay. Thank you so much for being here today, Dr. Ringer and Dael. Would you tell us about yourselves and your experience with newborns to start off with?

We'll start with you, Doctor.

Steven Ringer, MD, PhD: Sure. So I'm Steven Ringer, and I'm the Section Chief of Neonatology at Dartmouth Hitchcock and Dartmouth Health. And, I've been a Neonatologist for about 40 years, so that means that length of time focusing on the care of newborns.

Dael Harrison, PA-C: I'm Dael Harrison. I'm a Physician Assistant. I've been working in Neonatology and in Neonatal ICU in New England for the past 20 years and more recently have become the lead Advanced Practice Provider for the group that's covering nursery coverage at St. Joseph's Hospital.

Host: And Dael, what is Dartmouth Health's role in the newborn nursery at St. Joseph Hospital?

Dael Harrison, PA-C: As of last summer, in mid July, we made a partnership with St. Joseph's and we're providing the pediatric care, 24/7 here. So we have a group of Nurse Practitioners and Physician Assistants, with the backup supervision of the Neonatologist in Lebanon at Dartmouth Hitchcock Medical Center, to provide pediatric care for the newborn nursery at St. Joseph's.

Host: And what are some of the anticipated changes to the St. Joseph Hospital Nursery now that this partnership has been formed?

Dael Harrison, PA-C: So we're looking to build the unit a little bit in Nashua and expand some of our clinical coverage, to include a little bit younger babies and just a little bit of wider variety of medical care that we can provide for this age group.

Host: Dr. Ringer, what is a late preterm infant?

Steven Ringer, MD, PhD: So we tend to classify infants or newborns by the gestational age at which they're born. And everyone I think is familiar with full term infants. And they are babies who are greater than 37 weeks of gestation, where we consider 40 weeks sort of the official full term. So babies up to three weeks early are still considered full term.

There's a special group of babies who sort of sit between, what we often think of as the more premature babies who we call late preterms, so they're 34 up to 37 weeks. And, we've chosen this nomenclature because we recognize that these babies who generally are well, but they're a bit on the early side, and so they face a number of potential issues that babies closer to term may not see. I had a long time colleague who refers to them as the Al dente babies. Not quite fully done.

Host: And so any other differences between late preterm infants and term infants?

Steven Ringer, MD, PhD: Yeah. So particularly babies who are born before 35 weeks may have problems much more closely related to those of more premature babies, not being able to adequately eat by mouth or maintain their temperature; really issues of immaturity that make it difficult or impossible for them to go home right at that time. And, of course, there's always the question of what causes a baby to come earlier than they're due, so that it puts us on alert for the potential, at least, for babies having some more difficulties. Difficulties with breathing, or other issues starting after birth.

Host: Dael, what's involved in expanding care to include 34 week preterm infants at St. Joe's?

Dael Harrison, PA-C: Yeah, so that's a project that we're working on currently, along with Amy Carter, the Nursing Director in the nursery. We're instituting a large training program basically for nursing staff and provider staff alike to try to identify the differences between a preterm baby, a late preterm baby, and a term baby, and the things that we'd have to change in the unit.

So, the way that we monitor those infants is a little bit different. We're in the process of trying to establish a more continuous, remote monitoring system so we can see the baby's breathing and their vital signs 24/7, without having to have a nurse in the room with the baby the entire time. That will really facilitate this process.

And then it's just education, and working with a little bit of different equipment, gavage tube feedings and IVs and infectious source workups and that type of thing. Institution of phototherapy at a younger age and temperature maintenance, especially a lot of these babies are small and they need to be in an incubator or an isolate to maintain their thermal regulation.

Host: Dr. Ringer, what are some public health issues pertinent to newborns that you'd like to highlight?

Steven Ringer, MD, PhD: Well, just to add on to what Dael was saying, you know, these are babies, many of whom would have had to leave St. Joseph's to go to another hospital for more specialized care. So the big goal is making it possible to keep them here, with their moms. You know, there are a number of public health issues focused around newborns.

 Always, of course, the challenge of are there enough places for babies to get born and, you know, provide service to the community as a whole. But we also look at general issues in the care of newborns. Screening tests and the administration of some standard medications. The two big ones that come to mind that are generally done for every newborn are erythromycin eye drops, which can prevent the transmission of eye infections to the newborn.

And, vitamin K administration. And vitamin K is an important vitamin that's primarily involved in helping our blood clot. And it's made in all of us by the bacteria in our bodies. And, newborns, of course, are born without bacteria. So they're more at risk for the possibility of serious bleeding disorders.

So, we have moved as a nation to recommend strongly that all babies get treated with vitamin K right after birth.

Host: And Dael, why can't vitamin K be given orally? Why do you have to do eye drops?

Dael Harrison, PA-C: Yeah, this is a question that we get often, from families and it's understandable because the FDA approved method of giving vitamin K is through an IM injection. And so I think parents are looking to spare their infants from getting an additional injection, which is understandable.

 But that's what we have, as far as the most efficacious way to administer the medicine. It does not absorb well through the intestines, for multiple reasons. One is it takes a very large dose, to be able to be absorbed through the intestines. The other problem is like Dr. Ringer was alluding to, babies don't really have a well established microbiome like adults do. So they don't have their whole host of bacteria and you really need that bacteria in your gut to absorb vitamin K efficiently. So, for all of those reasons, the babies can't really absorb it. And in addition to that, we do not have a safe, well tested FDA approved oral form of vitamin K.

In addition to the fact that it's not particularly, efficient, doesn't work very well.

Host: Dael, I hear that one of the Dartmouth Health pediatric providers recently was awarded the Daisy Award at St. Joseph Hospital. Tell us about this.

Dael Harrison, PA-C: Yeah, I was very excited. One of our Nurse Practitioners was recognized for this award a few weeks ago, for the Daisy Award. If you don't know, it's a nursing award that's given for outstanding excellence in nursing care. Typically it's a patient that will nominate a nurse or a provider.

 So this was a family of, an extremely preterm infant born under 28 weeks gestation, which is not what we care for here in a level one nursery. And, the care that the family and the whole staff felt was given by this provider was phenomenal. So I was very proud and happy to see that and I thought it was a testament to that provider, of course, this nurse, a nurse practitioner, but also to the fact that our group has only been working together as nursing and providers for the past six or seven months.

And it's a testament to the fact that we've really built a team in a very short time. And I think that's wonderful.

Host: That's amazing. Well, congratulations to that nurse. Dr. Ringer, what does the future of this partnership look like?

Steven Ringer, MD, PhD: Well, I think we're always looking at ways to enhance the care and consider ways of keeping more babies here at St. Joseph's and facilitating the care of those babies and babies who may require specialized care at a higher level. So expanded use of telemedicine and involvement of the neonatologists as needed to actually look at the patients and be able to see them from far away. And slowly but surely look at how we can potentially move a little bit further down the age range, depending on staff education, staff comfort, et cetera, because we've been incredibly pleased with the progress we've made so far and Dael and the group have just done a fabulous job of forming this wonderful partnership and relationship so we can see great things in the future.

Host: Dael, what would you like to add?

Dael Harrison, PA-C: I just wanted to say that I think our primary goal is to try to the best of our ability to keep as many families together as we can. And so, we're always looking at ways to try to facilitate that and have the baby cared for in the right place at the right time. And we want to try to make St. Joseph's the best place for as many babies as we can in a safe way and a careful way, but kind of a deliberate way. And, to support the families.

Host: Is there anything else in closing that either of you would like to add?

Steven Ringer, MD, PhD: I think we're happy to be the representatives from our side of the partnership, but I think as Dael has mentioned several times, the fabulous nursing staff and nursing staff leadership have really been the keys to making this an enormous success.

Dael Harrison, PA-C: I agree. And to work as a team. It's been very pleasant and it's going really well. We're all quite happy.

Host: I think it's amazing that you've accomplished so much in like you said, a half a year? I mean, that's amazing. So, keep up the good work. Thank you so much, both of you, for making the time to share this information with us. It's been fascinating.

Steven Ringer, MD, PhD: Thanks for having us.

Dael Harrison, PA-C: Thank you. Thank you. for having us.

Host: Again, that's Dr. Steven Ringer and Dael Harrison. To find out more, please visit stjosephhospital.com. If you found this podcast helpful, please share it on your social channels. And check out our entire podcast library for topics of interest to you. Thanks for listening. I'm Maggie McKay, and this is Wellness First, a podcast from St. Joseph Hospital.