Leading the Vanguard in Neonatal Care
Over the last 20 years, Canada has slipped from the top 5 in lowest infant mortality rate to rank 40th in the world.
“That’s unacceptable to me,” says Dr. Shoo Lee, a neonatologist and health economist, recently appointed as Scientific Director of the Canadian Institutes for Health Research (CIHR)’s Institute of Human Development, Child and Youth Health. “Canada is a rich country. Why are so many other poorer countries ahead of us? Not only that, in native communities, the infant mortality rate is 3 times higher than in the general population.”
Infant mortality isn’t the only problem that Dr. Lee wants to tackle in his new job. “We’ve had a 30% rise in prematurity rates in this country over the last 20 years. We need to pay attention and develop ways to deal with this problem.”
“In many areas of maternal and child health, we can do a far better job.” In the next few months, he plans to consult with all stakeholders in the maternal, neonatal, child and youth communities to develop a strategic plan in order to mobilize CIHR resources to meet those objectives.
Dr. Lee is the just the person for the job. In addition to his new position at CIHR, he is a professor of Pediatrics, Obstetrics and Gynecology, and Public Heath at the University of Toronto; Pediatrician-in-Chief and Director of the Maternal Infant Care (MICare) Research Centre at Mount Sinai Hospital, Toronto; Chief of the Department of Newborn and Development Pediatrics at Sunnybrook Health Sciences Centre, Toronto; and Head of Neonatology and The Women’s Auxiliary Chair in Neonatology at The Hospital for Sick Children (Sickkids), Toronto.
Founder of The Canadian Neonatal Network™
When it comes to improving neonatal care, Dr. Lee’s track record is Olympian. In 1995, he founded The Canadian Neonatal Network™ (CNN) by uniting neonatal researchers from 30 hospitals and 17 universities across Canada.
The network developed and maintains a standardized neonatal intensive care unit (NICU) database that provides Canadianneonatal researchers with unique opportunitiesto study neonatal care on a national scale.
Dr. Lee came up with the idea while contemplating a move back to Canada after his fellowship at Boston’s Children’s Hospital. One of his American colleagues challenged his plans, countering that Boston could provide everything he needed for his career – money, prestige, world-class institutions, and infrastructure.
“He was right,” conceded Dr. Lee. At the time, nowhere in Canada had the mass of resources that existed at Harvard University and “if you tried to bring all of those resources in Canada to one place, you would decimate the rest of the country.”
Determined to find a different way of doing business, he realized that, if united, Canadian researchers would be able to study neonatal issues in the entire population – something difficult to do in the United States. He contacted the chiefs of every neonatal intensive care unit (NICU) in the country and proposed the idea of working together in The CNN. “Since then, it’s been a good journey.”
The CNN provides the infrastructure for collaborative research between multidisciplinary Canadian researchers in perinatal and neonatal health. The standardized NICU database has enabled them to study neonatal outcomes and variations in medical care to find better and more efficient ways to improve neonatal health across Canada.
An EPIQ outlook
Dr. Lee was also instrumental in developing Evidence-based Practice for Improving Quality (EPIQ), a science-based, knowledge-translation process that uses a “plan-do-study-act” approach to improving neonatal care. Clinicians, front-line workers, and researchers from 27 sites across Canada collaborate in EPIQ, which encourages these professionals to adopt evidence-based practices in neonatal care by approaching key issues from the ground up.
Revolutionizing neonatal care
As Director of the MiCare (pronounced “My Care”) Research Center at Mount Sinai Hospital, Dr. Lee oversees $55 million in research projects.
As part of an Evidence-based Practice and Identification (EPIC) study, his team has examined NICU practices around the world. They found that, in Estonia, the philosophy of neonatal care, out of necessity, is very different than in Canada. Due to limited healthcare resources, parents stay in the NICU 24/7 and they are responsible for all neonatal care, except for intravenous fluid and medication administration. The nurses’ role is to train parents.
This practice, which is common in many developing countries, led to a 30% improvement in infant weight gain, a 20% reduction in length of stay, 50% less nurse utilization, a 30% lower infection rate, and greater parental and staff satisfaction in Estonia. And, when newborns went home, parents knew what to do.
Armed with this information, Dr. Lee’s team obtained a research grant for a pilot project in Family Integrated Care that began at Mount Sinai Hospital in March 2010. Parents, physicians, nurses, and other stakeholders had a hand in designing and implementing the project.
“Our babies are looked after by parents instead of nurses,” explains Dr. Lee. “Parents love it. We thought that maybe 30% would be interested in doing this, but we’re seeing an 80% uptake. Parents are lining up to get into the program, and they do a fantastic job.”
Preliminary results show a 38% increase in weight gain among premature newborns in the pilot study. Infection rates have fallen from 11% to 0.
Dr. Lee describes this model of neonatal care as “quite a revolution. It will change the way that we provide care for babies in the future. In addition, the model may be applicable in other areas of health care, such as paediatrics, geriatrics, chronic care and palliative care.” He hopes to obtain funding to expand the project to 16 hospitals nation-wide.
Breast vs cow’s milk in the NICU
About 7% of very-low-birth-weight infants weighing less than 1500 grams at birth worldwide suffer from necrotizing enterocolitis (NEC). This intestinal infection is one of the single biggest killers of premature babies. In Canada, neonatal death rates from NEC have risen as high as 33%. The only country that has succeeded in reducing NEC is Japan, which currently has an incidence of 0.5%.
“Japan does not do evidence-based research, so we sent a delegation there to watch,” explains Dr Lee. “One of the things that impressed us was that they do not allow cow’s milk in the neonatal nursery. Only human milk is allowed. If the baby’s mother cannot produce milk, they use donor milk from another mother.”
By 7 to 10 days, every infant has been converted from intravenous fluid or parenteral feedings to full feedings of human milk. Conversion rates are typically slower in Canada.
Projects were started in Vancouver and at Sunnybrook Health Sciences Centre in Toronto to feed only human milk to premature babies, unless mothers objected. Within 2 years, the incidence of NEC had dropped from 10% to 2% in Vancouver and from 8% to 1% at Sunnybrook.
“To me, this is good enough proof,” says Dr. Lee. “We are working to build human milk banks in the rest of the country and to supply all the babies who need it.”
Working together for a better future
Dr. Lee excels at inspiring people to work together to make a difference. “The people at the hospitals do all the hard work,” he says, “I try to help them by organizing things to enable them to do it better.”
“When we first started, people were unsure how it would work out,” he recalls. “It was fascinating to see that, as time went by and people worked with each other, they developed a trust.”
“The whole country has come together and works well together. That’s something very few other countries can beat us at. Canadians are very good at that.”