Telemedicine Consults to Assess Neonatal Encephalopathy are Feasible in the Neonatal Intensive Care Unit

Neonatal Encephalopathy (NE) is a clinically defined syndrome describing abnormal neurological function in a newborn >35 weeks gestation(1). NE can be challenging to diagnose(2) as symptoms can range from mild to severe with fluctuations in the first several hours of life(3). Given the high reproducibility of neonatal neurological exams performed by telemedicine(4), we implemented synchronous, unscheduled teleconsultations for neonates for whom there were clinical concerns for NE following a difficult transition after delivery, a significant resuscitation or acidotic cord gases. Our goal was to demonstrate that use of telemedicine was feasible within the tertiary care center to allow pediatric neurology and neonatology to jointly examine neonates.

A convenience sample of 26 neonates with gestational age >35 weeks received teleconsultations between October 2017 and October 2018. A high resolution, 5X zoom, camera was used with Cisco Jabber video conferencing software, to connect the neonatologist at the bedside to the pediatric neurologist at a remote location. A modified Sarnat exam(2, 5) was performed by the neonatologist and observed by the neurologist. The following elements were jointly assessed; level of consciousness, spontaneous movement, muscle tone, posture, primitive reflexes (e.g suck and Moro) and autonomic function (e.g. breathing, heart rate and pupillary function). Neonates with symptoms of moderate or severe NE and who met other criteria for therapeutic hypothermia were treated. Neonatologists were asked to respond to a short, questionnaire following the teleconsultation (Supplement 1). The IRB exempted the retrospective abstraction of clinical data from the electronic medical record.

There were 14 (54%) questionnaires completed and included responses from neonatologists (9), neonatal nurse practitioners (3), and resident physicians (2). The average time to start the teleconsult was 9 minutes and the mean duration of the teleconsult was 30 minutes. All respondents strongly agreed that the teleconsult system was easily implemented. The majority of respondents (93%) strongly agreed that the teleconsult assisted in decision making.

Fifteen (58%) neonates were born in the tertiary care center and evaluated by telemedicine; 11 (42%) others were born in a community hospital and transferred to the tertiary care center for teleconsultation (Table 1). There were no major differences between these groups. The first teleconsultation occurred significantly later for community hospital born neonates (4.7 versus 2.1 hours, p=0.001). Nine (60%) neonates from the tertiary care center had a second teleconsultation compared to 4 (36%) from community hospitals and community hospital born neonates’ second consultations were also significantly later (5.1 versus 3.1 hours, p=0.007). Four neonates in each group were treated with TH.

Table 1:

Characteristics of newborns according to location of birth

	Tertiary Care Center (n=15)	Community Hospital (n=11)	p-value
Gestational Age (weeks)	38.5 (1.5)	39.6 (1.4)	0.054
Birth via C-section (n, %)	7 (47%)	5 (46%)	1.0
Delivery Complications:
Nuchal or body cord	6	6
Fetal bradycardia or decelerations	4	6
Meconium stained amniotic fluid	1	5
Shoulder dystocia	2	3
Placental abruption	2	1
Intrauterine growth restriction	0	1
Home birth	0	1
Footling breech delivery	1	1
Maternal general anesthetic	1	1
Twin gestation	1	0
Hypermagnesemia	1	1
Birthweight (kg)	3.3 (0.7)	3.1 (0.7)	0.61
Apgar 1 minute (median, IQR)	2.0 (2.0, 3.5)	2 (1.5, 2.0)	0.28
Apgar 5 minutes (median, IQR)	7.0 (5.0, 7.5)	5.0 (4.0, 6.5)	0.24
Apgar 10 minutes (median, IQR)	8.0 (8.0, 9.0)	6.0# (6.0, 8.0)	0.004
Arterial Cord pH	7.12* (0.13)	7.08$ (0.10)	0.56
Arterial Cord base deficit	10.4* (5.6)	11.1& (5.0)	0.77
Venous Cord pH	7.18 (0.10)	7.13& (0.16)	0.36
Venous Cord base deficit	9.7 (4.4)	9.8% (5.0)	0.96
Required positive pressure ventilation in the delivery room	9 (60%)	6 (55%)	1.0
Intubated in the delivery room	3 (20%)	0 (0%)	0.34
Duration of first NE consult, minutes	29.3 (17.3)	30 (7.7)	0.90
Treated with Therapeutic Hypothermia	4 (27%)	4 (36%)	0.92
Hour of Life of First Teleconsult	2.1 (1.4)	4.7 (2.2)	0.001
Hour of Life of Second Teleconsult	3.1 (1.1)	5.1 (0.63)	0.007

Abbreviations; kg, kilograms; NE, Neonatal encephalopathy

^*n=13

^#n=10

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We demonstrate that telemedicine can be used in the NICU to assess NE in a timely fashion that is perceived to be beneficial by neonatologists. Community hospital born neonates, who were examined in the tertiary care center by telemedicine, had significantly delayed assessment of NE due to the need for transfer. We propose that future research could investigate use of telemedicine within the community hospital to potentially avoid unnecessary and costly transfers(6), decrease family separation(7) and improve the exam skills of the community hospital team through regular interactions with neonatal experts. A weakness of this unfunded study was lack of brain imaging, electroencephalogram or developmental outcome data on the neonates excluded from TH to be certain the correct clinical decision was made.

Abbreviations:

NE

Neonatal Encephalopathy

NICU

Neonatal Intensive Care Unit

TH

Therapeutic Hypothermia