All About the NICU with Dr. Abeer Azzuqa

About Neonatal Intensive Care Units | CHP.edu

About Extracorporeal Membrane Oxygenation (ECMO) | CHP.edu

About Neonatal Neurocritical Care Unit | CHP.edu

About Fetal Diagnosis and Treatment Center (FDTC) | CHP.edu

Understanding NICU Levels: Specialty Care for Your Newborn | UPMC Healthbeat Blog

Levels of Neonatal Care | American Academy of Pediatrics

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Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.

Dr. Amanda Poholek: Welcome to That's Pediatrics, I'm Amanda Poholek.

Dr. Arvind Srinath: And I'm Arvind Srinath.

Dr. Poholek: Our topic today is all about the NICU at UPMC Children's Hospital of Pittsburgh. And our guest today is Dr. Abeer Azzuqa. Dr. Abeer Azzuqa is an associate professor in the department of pediatrics and also the clinical director of the NICU. She received her medical degree from Jordan University of Science and Technology and completed her neonatal perinatal fellowship at UPMC medical center. She provides oversight of the entire breadth of clinical activities. She's been instrumental in establishing the neonatal telemedicine program and serves as the associate vice chair of clinical affairs for telehealth. Her research interests include digital health innovations, neonatal nutrition, and neonatal hyperbilirubinemia. I hope I said that, right. I probably didn't. Welcome.

Dr. Abeer Azzuqa: Thank you so much for having me here. It's an honor to be with you here today and I'm looking forward for our discussion today.

Dr. Poholek: Fantastic, so can you tell us a little bit about your path to neonatology, especially here in Pittsburgh?

Dr. Azzuqa: So that's a really nice question about the path to neonatology. I was inspired by my dad as a child. My dad is a surgeon and watching him every day his commitment to the profession, his commitment to his patients inspired me to become a physician.

And in med school when I joined during my clinical rotations, amazing reason I was drawn to pediatrics and neonatology. I still remember the first day when I actually had my NICU rotation. I was a med student at that point and that day was an amazing day. It was a remarkable day by all means. This is the day when I knew that, okay, this is the place I want to be in and spend my career in and this is me.

It's a fascinating subspecialty, very, very rewarding one. You get to see a lot of pathophysiology to talk to parents every day. It's an amazing teamwork and you watch the baby grow and heal over time in front of your eyes. And you partner with the parents, become part of their support system also. So it's an amazing subspecialty.

Then my husband actually got matched in pediatric gastroenterology and I was lucky enough to join the program, the fellowship program here at children's and to witness all the innovations and how we become world leaders. In addition to being trained by world renowned physicians here that was a big influence in my career. And I'm so fortunate to be trained by the best neonatologist and pediatricians here at UPMC Children's Hospital of Pittsburgh.

Then all of this and the people here made it a very easy decision for me to join the program as a faculty. I'm so honored to be part of this wonderful team.

Dr. Poholek: Sounds like we're lucky to have you. Can you share with us a little bit about some of the most, you know critical neonatal services that you feel the NICU provides and then as well, I'm really interested to hear about some of the innovations that has been recently incorporated.

Dr. Azzuqa: So our NICU here at UPMC Children's Hospital is a level four NICU and this is a designation actually that the APP have. It depends on the level of services that each NICU provide. So the level four is the highest level of NICU services.

So basically what it means, we provide as a level four NICU, care for all infants who require admission to the NICU, whether it's simple illnesses that babies might have or a complex medical condition, complex surgeries. In addition to ECMO.

What's ECMO? It's extra corporeal membrane oxygenation and we call it ECMO all the time. So this is another big services that we provide here at UPMC Children's Hospital. And actually it's the only hospital in the Pittsburgh and surrounding areas that provide ECMO here.

One of the things that we have a 55 bed unit, each bed is designed in a way that it supports the development of the baby. In addition, it's also supports the family centered care that we embrace in our NICU here and the family integrated care. Each bed is equipped with little webcams, NICVIEW camera which is really important because mom and dad and the caregivers they can watch the baby at any time, every day. And actually they can share the password only mom and dad or the caregivers can share that password. And the extended family can watch the baby at any time they wish. So this is another thing that we ensure that we reduce the anxiety amongst the caregivers and the parents because being in the NICU is not an easy place. Sometimes it can be very stressful.

Being also part of the children's hospital, we have a lot of collaboration with a lot of subspecialists and a lot of great projects going on. So when we provide our care we look at the entire baby journey before the baby is born, during their stay in the hospital, and afterwards. So before the baby is born there's a lot of great collaboration between us and the Center for Advanced Fetal Diagnostics. And this is a center that have a lot of collaboration amongst the maternal fetal medicine. A lot of subspecialist neonatology provides care for high-risk moms and also babies who are anticipated to require admission to the NICU before they are born.

So there is a care plan formulated there and it's very helpful, not only for the parents as they prepare for this and get their support system in place. It's also helpful for the NICU team to prepare for the arrival of this baby, when the baby is born.

Another great services that we have the ECMO service as I mentioned earlier, it's basically heart lung bypass for babies who are so sick and they are not getting better on the ventilators and other therapies. And this is one of the things that we provide to our patients and one of the things that I'm so proud of, we are excellent center and we got the gold status, also, so it's very rewarding. And this is as a result of the outcomes of our babies who go on heart, lung bypass.

Another great service is our neonatal neurology ICU which is a collaboration between us and the neurologist providing critical care for babies who have hypoxic injuries. At that point we do something called therapeutic whole-body hypothermia. It's another word for it, it's cooling. So this is another service that can make a big difference in baby's outcomes and we have state of the art imaging in our NICU.

One of the other things that we are so fortunate to have our neonatal transport team it's staffed by amazing team members. It's basically almost an ICU on wheels or sometimes we have an ICU in the air. We literally bring all the expertise to the baby from the get go before even they come to the NICU. So the transport team will provide a stabilization of the baby at their regional hospitals before they come there, we can do ventilators during the transport. Even ECMO can be provided on transport and cooling.

So it's amazing how our transport team functions. It's literally an ICU that's going everywhere starting the care from the get go. We just wanna make sure to reach the babies where they are and provide the ICU care to them.

There is also an exciting collaboration with multiple subspecialties. So we have a collaboration for multiple things, for instance, Spina Bifida program. The other thing that care of babies who have chronic lung disease, we have collaboration with our cardiologists, pediatric surgeons. The other exciting thing that we started recently, great collaboration with our intestinal care and rehab center to provide consistent approach to babies who have intestinal dysfunction that we are thrilled about.

And all of this it's because of the awesome subspecialists and amazing NICU team that we have. We have amazing specialized neonatologists. In addition to this, our amazing, amazing bedside nurses I cannot say enough. Respiratory therapists, advanced practice providers, whether our neonatal nurse practitioners also neonatal physician assistants. In addition to OT, occupational therapy, physical therapy, developmental specialists, speech language pathologists, our neonatal dieticians, neonatal pharmacist, child life specialist. I bet I forgot someone but everyone who works in the NICU is amazing.

And without this team approach, the most important thing our families and babies, because they are really big part of our team and they are the ones who inspire us every day to provide this care and continue to work on our NICU or our innovations to make sure that we are providing to our babies the best care at every time, all the time.

Dr. Srinath: That is an amazingly comprehensive overview of the services you provide and the infrastructure that we have here at Children's, that it's amazing. And some of it's unfathomable in terms of what technology has enabled you to do. Along those lines of technology, can you talk about how you incorporate telehealth into NICU care and what type of referrals or how you approach care through telehealth, as well as the common referrals you get within and outside the hospital for children for the NICU?

Dr. Azzuqa: Absolutely, Arvind. That's a great question. Telehealth actually has been here and in the NICU has started over the past probably 10 years. And with the pandemic, there has been a tsunami growth in all the activities that we have in telehealth. In the clinical area, and one of the major things for us to make sure all our babies in the region have access to the right care. So our telehealth or telemedicine or tele-NICU services basically it's staff 24/7, we have 24/7 coverage. And what we do, we have state-of-the-art video, audio connection, with our partners in the community hospitals.

So if any of our partners have a baby, they need a question about or a consultation or pre-transport care, they can call us and we can have a connection and bring the ICU expertise to the bedside for our partners. We also do tele-rounds for babies who are located in some of our level two NICUs. So this helps to provide the care at their home hospital as well as to avoid some of the transfer when the babies can receive their care in their local hospitals and it's amazing advanced practice providers.

So, and it's a hybrid some times there is an neonatology site and sometimes we do the tele-rounds to make sure that we are present there virtually when the baby is needing to be in a level two NICU or a special care nursery.

The other thing that there are many applications for digital health throughout the baby journey. Even before the baby's born and with the pandemic we pivoted to telehealth services. So we are able to meet with the mom through telemedicine and do all the counseling and the consultation and prepare for the delivery through our connection with video visits for moms who are anticipated to have a baby with birth defects or any reason for the baby to come to the neonatal intensive care unit here at Children's.

Other things that we are excited about and we are working on even to leverage all this technology to our transfer team and have presence virtually to complete the picture and bring all the expertise at any time as well.

So there are really exciting things happening and there is a lot of collaboration with the subspecialist to provide consults to babies in other NICUs. So this is another exciting thing. And we also recently with the whole pandemic, it's apparent to us that moms and other caregivers are not able to be here at the bedside 24/7. Sometimes mom is hospitalized. Sometimes they have other babies or other children at home. And at that point it will be easier. It's not easy for them to join round, so what we are doing now to have them join us virtually, whether it's via the phone, or if we have a care conference, we can do video connections. So we can leverage technology at every stage of baby stay in the NICU.

The other part of your question about what's babies we see here. We see everything. The common things that we see usually premature babies who have trouble breathing and they have feeding problems. Also, they might have temperature and stability and we have another big reasons for the babies to be here in the NICU term babies, they might have birth defects they might have infections, also other common things.

They can have seizures, there's a hypervolemia. They also can have cardiac defects. There are various reasons for babies to be here in the NICU.

Dr. Poholek: So there's been a lot of news lately about a shortage in formula which I think really highlights the importance of feeding and nutrition for infants. I'm curious a little bit about how nutrition plays a role in the care of newborns.

Dr. Azzuqa: That's a great question. Nutrition actually is a key in the care of babies in the NICU, and it's really studied well. A good nutrition makes a big difference in terms of neurodevelopmental outcomes in terms of helping the baby to heal and also to fight infections. So when we look at the nutrition in the NICU there are a couple of things.

We look at the way, the babies feed and the other thing that what to feed the baby, what kind of nutrition. When we look at how to feed the baby, not all the babies are able to if mom is breastfeeding to nurse from the get go or take a ball, some of the babies are too sick, they're on the ventilators and we have premature babies, their feeding skills are not well developed. So there's coordination between sucking and swallowing and breathing is still immature. And there are different stages till the baby reached the mature feeding stage.

In that situation, there are some options like IV nutrition. There is options of feeding tube and as the baby grow they get better, we introduce the feeding by mouth at that point. So we actually, this is one of the things that we are excited about. Our feeding program evolved. It's a very specialized program. We have neonatologists in this program, feeding champions there are nurses in the NICU, occupational therapy, feeding therapists, speech language pathologists. Gastroenterologist also are part of this team. And we looked at how we feed the babies and at that point we do cube-based feeds and this has been evolving and it's really great for our baby's outcome.

The other big part of our, when you look at nutrition, is what type of nutrition to ... In addition to what we talked about, the IV feeds the one that everyone highlights is mom's own milk, human milk, breast feeding. This is the one that is the most nutritious feeding ever that babies can have. It helps the baby development. It helps the baby to fight infection, with our preemies, it's also one of the things that help them to prevent a condition called necrotizing entercolitis or NEC.

So there is something that the moms can help their babies because it's like liquid gold. We call it medicine in the NICU and it's a huge thing and very nutritious and we look at it really as a medicine. So our lactation consultants, they do phenomenal job helping the mom till they can establish the pumping for babies who are not able to nurse from the get go. Every baby will need to have a specialized feeding plan because their needs are different giving how early they are. So sometimes babies might need extra fortifiers in order to optimize their nutrition. I mean, by this giving them extra fat, extra protein, extra minerals, extra vitamins in order to optimize their nutrition. So each our dieticians and pharmacists are really helpful to give us an individualized, specialized nutrition plan for the babies. And in some instances if mom is not able to provide breast milk, for any reason we can give a donor human milk and this is something that help the baby. Still they are at certain weight that we can wean them off. And sometimes we need to give them some specialized formula. So we look at every baby individually and give them this specialized feeding plan.

Dr. Srinath: That's amazing. In the last few minutes, are you able to talk about the challenges in general facing care in the field of the neonatology?

Dr. Azzuqa: When I think about the challenges, I think about despite of all that growth that we've seen in the field of neonatology in the past 50, 60 years, one of the things that we see here in the United States is the infant mortality, we still, despite all the advances and all the state of the art that we have, we have huge issues with infant mortality here. And unfortunately, even the Allegheny County, our infant mortality rate can use some help. So one of the major challenges that we continue to see the disparities that we see to healthcare services amongst some of our moms and even babies it also depends on race disparities and their access to even food and also medical care when it's needed.

So this is an area that needs a lot of work and this is something that make me stop and think every day how we can help everyone, wherever they are located at and make sure that they have access to state of the art healthcare, regardless where they are.

Yeah, thank you for highlighting that. I think that's definitely something that we've heard as a team across multiple divisions of this notion of access to care, not being equivalent and making sure that that's something that we address in the future. It's been wonderful to have you, thank you so much for joining us and sharing with us all about the NICU and all of the wonderful things that are going on here at UPMC Children's Hospital.

Dr. Srinath: Thank you, Dr. Azzuqa. It's absolutely unbelievable.

Dr. Azzuqa: Thank you so much for having me and opportunity to speak with both of you today.

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