articulo

1. Using telehealth to support
pediatricians in newborn care
Jennifer L. Fang, MD, MS,a
* and John Chuo, MD, MSb
This clinical scenario-based review will discuss how telehealth
programs improve access to specialty care for neonates, their
caregivers, and primary care pediatricians. Tele-resuscitation
supports pediatricians during complex, high-risk newborn
resuscitations, improves the quality of delivery room care, and
reduces odds of transfer to a higher level of care. Neonatolo-
gists and other pediatric specialists use telehealth to provide
more effective consultations that positively influence manage-
ment decisions and patient outcomes. When neonatologists
provide video visits to home and meet virtually with primary
care pediatricians, infants discharged from the NICU experi-
ence fewer emergency room visits and hospital re-admissions.
With further implementation and dissemination of neonatal tele-
medicine programs, it is important that these programs con-
tinue to be thoughtfully designed to achieve measurable value
that is relevant to patients and caregivers, providers, healthcare
systems, and payers.
Curr Probl Pediatr Adolesc Health Care 2021; 51:100952
Introduction
T
elemedicine, as defined by the Centers for Medi-
care & Medicaid Services, is the “two-way, real
time interactive communication between the
patient, and the physician or practitioner at the distant
site”.1
Telehealth expands the term to the use of telecom-
munication technology to provide access to health assess-
ment, diagnosis, intervention, consultation, supervision
and information across distance.1
Telehealth is viewed as
an efficient and cost-effective way to improve access to
and delivery of medical care.1,2
Neonatology is one of
the most common specialty services offered by pediatric
telehealth programs.2
The rise of neonatal telehealth pro-
grams may be partly due to the regional variation in neo-
natal intensive care capacity in the United States (US)
that is not optimally aligned with patient need.3
Non-met-
ropolitan communities are more likely to be underserved
by neonatologists and geographically remote from a
neonatal intensive care unit (NICU). In rural US counties,
the loss of hospital-based obstetric services has been
associated with increases in preterm births, births in hos-
pitals without obstetric units, and out-of-hospital births.4
Furthermore, hospitals that deliver less than 500 new-
borns per year experience a threefold higher early neona-
tal mortality rate compared to hospitals with more than
1500 births per year.5
In an effort to reduce outcome disparities, telehealth can
be used to achieve more equitable and timely access to
neonatology expertise. Neonatal telehealth programs can
address challenges experienced by primary care providers
(PCPs) who provide newborn care, including resuscitation
support, newborn consultation or virtual rounding, and
transition of care from the NICU to the outpatient setting.
Telehealth is also being used to allow families to view
their newborn in the NICU when they are unable to be at
the bedside.6,7
Importantly, parents view telehealth as a
means to receive medical care, improve triage processes,
and enhance communication and care coordination.8
We
will review the various applications of telehealth in neo-
natal care using a scenario-based approach that maxi-
mizes relevance for pediatricians.
Telehealth for neonatal care, a scenario-
based review
Neonatal tele-resuscitation
You are the pediatrician covering newborn deliver-
ies in a small, community hospital. The delivering
Abbreviations: NICU, neonatal intensive care unit; PCPs, Primary Care
Physicians; ROP, Retinopathy of Prematurity; KPI, Key Performance Indi-
cators; EHR, Electronic Health Record; SPROUT, Supporting Pediatric
Research in Outcomes and Utilization of Telehealth; STEM, SPROUT
Telehealth Evaluation and Measurement
From the a
Division of Neonatal Medicine, Mayo Clinic, 200 First St. SW,
Rochester MN, 55905, United States; and b
Division of Neonatology,
Department of Pediatrics, Children’s Hospital of Philadelphia and Perel-
man School of Medicine, University of Pennsylvania, Philadelphia, PA,
United States.
*Corresponding author.
E-mails: fang.jennifer@mayo.edu chuoj@chop.edu
Curr Probl Pediatr Adolesc Health Care 2021;51:100952
1538-5442/$ - see front matter
Ó 2021 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.cppeds.2021.100952
Curr Probl Pediatr Adolesc Health Care, January 2021 1

2. obstetrician notifies you that a pregnant woman has
presented in the advanced stages of preterm labor
at 29 weeks’ gestation. Vaginal delivery of this
very preterm infant is imminent.
Given the infrequency of high-risk deliveries in hos-
pitals with Level I well newborn and Level II special
care nurseries,9
it can be chal-
lenging for pediatricians and
other PCPs to maintain the
knowledge and skills required
for advanced neonatal resusci-
tation. Studies have shown that
resuscitation skills rapidly
decline within months of com-
pleting neonatal resuscitation
training.10
Additionally, in rural hospitals, staff com-
fort with, and frequency of, performing advanced neo-
natal resuscitation skills is generally low.11
On
average, physicians in rural hospitals ventilate a neo-
nate with bag and mask 1 3 times per year, with intu-
bation and umbilical line placement being even less
frequent. Moreover, there is substantial variation in
overall hospital preparedness for neonatal resuscita-
tion. Preparedness is associated with delivery volume,
with low volume hospitals (<125 deliveries per year)
having lower preparedness scores than high volume
hospitals.12
Neonatal tele-resuscitation programs can provide
additional support for care teams in community hospi-
tals with lower levels of neonatal care. The remote neo-
natologist can establish a real-time audio-video
telehealth connection to provide guidance and coaching
during high acuity, high complexity resuscitations
(Fig. 1). In a simulated setting, neonatal tele-resuscita-
tion has been shown to decrease
the time to effective ventilation
and improve adherence to neo-
natal resuscitation guidelines.13
Clinical neonatal tele-resuscita-
tion programs have been shown
to improve the value of care. A
retrospective cohort study dem-
onstrated that tele-resuscitation
improves the quality of high-risk neonatal resuscita-
tions, with earlier consultation likely providing greater
positive benefit.14
Presence of a remote neonatologist during advanced
neonatal resuscitation improves adherence to impor-
tant process metrics such as measurement of the
patient’s temperature, glucose, and blood gas. In addi-
tion, use of neonatal tele-resuscitation has been asso-
ciated with a 30-50% reduction in odds of neonatal
transfer to a higher level of care.15 17
Reducing the
need for medical transport permits more neonates to
safely remain in the community hospital with their
Fig. 1. A remote neonatologist works with a community hospital care team during a tele-resuscitation consult.
Tele-resuscitation improves the
quality of high-risk neonatal
resuscitations, with earlier con-
sultation likely providing
greater positive benefit.14
2 Curr Probl Pediatr Adolesc Health Care, January 2021

3. mothers, allows for efficient bed utilization across a
health system, and generates cost-savings.15,18
Neonatal tele-consultation and virtual rounding
You are the pediatrician covering an 8-bed Level II
special care nursery. The nurse calls you about a
36-hour old infant born at 34 weeks’ gestation who
has developed tachypnea and is desaturating after
previously being stable in room air.
When a newborn’s clinical status worsens and transfer
to a higher level of care may be needed, it can be helpful
to consult with a neonatologist. Historically, this has
been done via telephone, but this method of consultation
is limited as the neonatologist cannot visualize the
patient. Tele-consultation allows the remote neonatolo-
gist to visually assess the neonate and partner with the
pediatrician to collaboratively determine next steps in
evaluation, management, and transfer, if needed. Tele-
health consultation is frequently
used for neonates who are born
prematurely or have respiratory
distress.17
When telehealth is
used prior to medical transport, it
may influence the neo-
natologist’s perceived stability of
the neonate and inform the
assessment and recommendations.19
In a prospective
pilot program of telehealth for pediatric and neonatal
transport, telehealth was found to be more useful in
patients with visual findings on examination, and in
some cases, telehealth changed patient management or
outcome.20
Scheduled virtual rounds between a neonatologist
and community hospital care team offer similar bene-
fits to episodic tele-consultation. In medically under-
served areas, pediatricians with limited training in
neonatology may need to provide continued care of
moderately ill neonates.21
In a small feasibility study
including 20 matched pairs, neonatologists were able
to successfully complete daily virtual rounds, without
significant differences in care or outcomes.22
How-
ever, the time taken to complete the patient encounter
was longer for the remote neonatologist than the on-
site neonatologist. In a prospective study of 155 neo-
nates born at 32 35 weeks’ gestation, those in a Level
II special care nursery cared for by a neonatologist via
telehealth had fewer days of respiratory support,
achieved full oral feeds sooner, and had shorter hospi-
tal length of stay than similar neonates in a Level IV
NICU.23
Virtual rounds with a neonatologist allowed
these preterm infants to remain in a community hospi-
tal closer to home. This proximity to home may have
facilitated greater family participation in newborn
care and enhanced mother-infant bonding, resulting in
the positive study outcomes. This hybrid telehealth
program was well received by parents and allowed
neonatal intensive care services to be safely and effec-
tively extended to a medically underserved area.
Tele-consultation with pediatric subspecialists
You are covering the Level I well newborn nursery
in a rural hospital. A two-day old, full term infant
has failed the screening for critical congenital
heart disease. The patient requires an echocardio-
gram and may need consultation from a Pediatric
Cardiologist.
Hospitalized neonates cared
for by pediatricians or other
PCPs may require evaluation
and consultation from neonatol-
ogy or other pediatric special-
ists. Telehealth improves
access to specialty care and can prevent unnecessary
transfer to tertiary care centers.
For neonates with suspected congenital heart dis-
ease, like the patient described in the clinical vignette,
telehealth can facilitate interpretation of echocardiog-
raphy and consultation with pediatric cardiolo-
gists.24,25
In a multicenter trial of infants <6 weeks,
telehealth lessened the time to diagnosis and reduced
the need for transport of patients with mild or no heart
disease.24
Telehealth is also being used for other neonatal
specialty consultations most commonly for reti-
nopathy of prematurity (ROP) screening. For com-
munity hospitals that offer special care or intensive
care services but do not have a qualified ophthalmol-
ogist, telehealth provides access to ROP screening
without needing to transfer preterm neonates to a
hospital with a pediatric ophthalmologist. Studies
have demonstrated that digital images of the fundus
obtained by an on-site trained imager can be
Telehealth improves access to
specialty care and can prevent
unnecessary transfer to tertiary
care centers.
Curr Probl Pediatr Adolesc Health Care, January 2021 3

4. interpreted by a remote ophthalmologist with a high
degree of sensitivity and specificity.26,27
In addition to cardiology and ophthalmology, tele-
health can be used for neonates who require evalua-
tion by pediatric specialists in surgery, neurology, and
genetics. In a small study of 19 infants, pediatric sur-
geons were able to successfully
and accurately diagnosis com-
mon neonatal surgical issues
via telehealth, including
abdominal wall defects, imper-
forate anus, and need for gastric
tube placement.28
Pediatric
neurologists have successfully
used telehealth to evaluate neo-
nates for encephalopathy.29,30
Telehealth allows for
the timely evaluation of neonates with moderate or
severe encephalopathy, which facilitates faster times
to transfer initiation and therapeutic hypothermia.31
Geneticists have utilized telehealth to effectively per-
form dysmorphology exams in NICU patients. In a
small prospective evaluation, telehealth examination
of 10 neonates identified 93% (81/87) of dysmorphol-
ogy abnormalities.30
Remote viewing by parents and caregivers
My baby twins, Hope and William, were born too
early at 27 weeks and admitted to the NICU two weeks
ago. The doctors and nurses are great and take good
care of them, but I know my babies are in a strange
place with scary lights and sounds. I wish I could see
them and make them feel better. In this pandemic, it’s
been 10 days since I last saw them I am afraid to
take the train or bus to see them in the hospital.
Approximately 10 12% of neonates born in the U.
S. will be admitted to a NICU.32
Parents whose new-
born requires care in the NICU are often separated
from their baby who many face an uncertain progno-
sis. Having a baby hospitalized in a NICU is a stress-
ful and potentially traumatic event for parents. As
such, NICU parents may experience emotional dis-
tress, including symptoms of depression, acute stress
disorder, and post-traumatic stress.33 40
Family-cen-
tered care, including kangaroo care and educational-
behavioral intervention programs for parents, can
provide valuable emotional support.32,41,42
Telehealth may be a means to further support parents’
psychosocial needs during the hospitalization of their
newborn.
The use of bedside camera systems in the NICU has
allowed parents and caregivers to see their babies
from afar at any time of day from almost anywhere
with internet access. During the Coronavirus disease
2019 (COVID-19) pandemic
with social distancing and strin-
gent visitor restrictions, such
camera systems have been
widely used to allow siblings,
other family members, and
friends to “meet” the baby via a
video visit. Use of infant view-
ing technology has been associ-
ated with an increase in parent-infant attachment and
reduction of parental stress and anxiety.6
Guttman et al. administered the PSS-NICU (Parental
Stress Scale NICU version) to parents of babies
admitted to a NICU to measure their stress related to 52
items in 4 domains (Sight and Sounds in the Unit,
Appearance of the Baby, Relationship with Infant and
Parental Role, Staff Behaviors and Communication).7
The authors found an association between the use of
bedside cameras and reduced parental stress. However,
when implementing remote viewing for parents, organi-
zations should consider the potential of increased nurs-
ing workload and disruption; therefore, endorsement
from nursing leadership and staff is paramount for suc-
cess.43
To protect privacy, cameras are generally posi-
tioned directly above the baby so that only the baby is
visible and NICU microphone is disabled. Parents pro-
vide consent to use the system when the baby is admitted
to the NICU. Another consideration is that some families
may not have internet access or needed devices, and
therefore, would be unable to use the system to see their
baby remotely. With the COVID-19 pandemic drawing
increased attention to this technology gap, health sys-
tems, state establishments, and federal agencies (e.g.,
Federal Communication Commission) have begun to
collaborate to establish wider broadband access54
.
Video visits with caregivers following NICU
discharge
After being in the NICU for more than 150 days, we
are finally home with Annie. She is so fragile, with a
G-tube, on nasal cannula, and on more medications
than my father. I am nervous about being a good
Infant viewing technology has
been associated with an
increase in parent-infant attach-
ment and reduction of parental
stress and anxiety.6
4 Curr Probl Pediatr Adolesc Health Care, January 2021

5. mother and making sure I know how to take care of
her. The nurses were great in teaching us what to
do. . .but it was so much all at once. I am not sure I
remember everything. Who can help me?
Nearly 50% of preterm NICU graduates are seen in
the emergency department within three months of dis-
charge and 30% are readmitted to the hospital.44,45
When medically complex, technology-dependent
infants transition from the NICU to home, PCPs must
often provide and coordinate complex outpatient med-
ical care, that may include pediatric specialists, thera-
pists, nutritionists, and others. Accessing multiple
care providers and coordinating efficient care delivery
across many specialties can be a challenge for the
PCP and family. Effective interventions for decreas-
ing caregiver stress and ensuring infants continue to
thrive when transitioning home
include home nurse visits, care-
giver education, and effective
communication between
healthcare provider and fami-
lies.46
Telehealth can help facil-
itate a safe and efficient
transition from the NICU to the
medical home. Several NICUs
have reported using video visits
to communicate with caregivers in the immediate
post-discharge period.
In an observational cohort study of post-discharge
telehealth visits with parents of medically complex
infants, Willard et al found caregivers had knowledge
gaps related to surgical site assessment, feeding, respi-
ratory assessment, and medication administration.47
Although technology failures prevented 5% of tele-
health visits from being com-
pleted, 75% of families
preferred a telehealth visit to an
in-person visit, with caregivers
rating the effort highly for
video quality, internet reliabil-
ity, and ease of use. In a ran-
domized control study of 89
families receiving home health care for their infants,
the addition of post-discharge telehealth was associ-
ated with a reduction in emergency hospital visits.48
When evaluating at-home care of infants with single
ventricle heart disease, use of a digital home monitor-
ing program platform has shown promising results in
shortening the post-operative length of stay, transi-
tioning off nasogastric tube feeds, and achieving oral
feeds.49
Tele-sign-out from the NICU team to
pediatrician
As a community pediatrician, I have cared for many
newborns and watched them grow into thriving
adults. Some of these newborns have complex medi-
cal issues and come to me after spending months in
the NICU. The discharge summary is often “hit or
miss” in terms of giving me a concise, informative
summary of what happened. It would be very help-
ful to get a warm handoff from the neonatologist
for these more complex patients.
An anonymous survey
administered to pediatricians
showed 64% of PCPs were sat-
isfied with the transfer of
NICU discharge information
for premature infants.50
A
recent multi-center pilot study
found neonatal tele-sign-out
to PCPs offers opportunity to
clarify plans, provides a venue to answer questions,
and expands on traditional methods of sign-out that
may not be very effective.51
When asked how much
they agree that the benefits from the telehealth hand-
off outweighed the time, effort, and cost of perform-
ing the session (0=strongly disagree to 100=strongly
agree), PCPs scored a mean of 83 (IQR 74-100).
Qualitative data from the three participating institu-
tions found tele-sign-out had the ability to facilitate
outpatient management of con-
ditions that were at high risk
for emergency room visits and
hospital re-admission. In one
example, the neonatal team
was able offer advice to the
PCP on managing the dressing
of a giant omphalocele that was epithelializing. In
another, an infant with a ventricular septal defect
was seen at the PCP office and noted to be more
tachypneic by the neonatologist. A cardiologist was
called immediately to see the patient and
The addition of post-discharge
telehealth was associated with a
reduction in emergency hospital
visits.48
Tele-sign-out to PCPs offers
opportunity to clarify plans, pro-
vides a venue to answer ques-
tions, and expands on
traditional methods of sign-out
Curr Probl Pediatr Adolesc Health Care, January 2021 5

6. subsequently started diuretics avoiding a hospital
readmission.
Practical considerations for
implementing a neonatal telehealth
program
W
hile there are many frameworks for program
design and implementation, one straightfor-
ward, effective approach for implementing
a neonatal telehealth program is to: 1) understand and
articulate the value proposition, 2) identify the system
components needed (people, process, tools), and 3)
identify actionable measurements for success and
improvement.
Value proposition
Answering the question “So what, who cares?” from
the perspective of four stakeholder groups (patient and
caregiver, providers, health system, and payers) is criti-
cal. Because the role of each stakeholder differs in the
health system, the value proposition may or may not
align amongst the groups. Therefore, a shared mental
model for determining value is critical in order to iden-
tify telehealth programs that produce win-win situa-
tions for most if not all stakeholder groups. For
example, tele-sign-out benefits: the patient and care-
giver by ensuring optimal delivery of care; providers
by establishing effective transfer of critical clinical
information and insights; health systems by avoiding
unnecessary hospital admissions that payers may not
reimburse; and payers by reducing costs associated
with ED visits and hospital utilization. Tele-resuscita-
tion benefits patients by enabling better adherence to
neonatal resuscitation guidelines; providers through the
presence of a remote neonatologist who offers guidance
and support for complex resuscitations; and payers by
avoiding short- and long-term morbidities that incur
substantial healthcare costs over a life course.
Systems approach
People
The individual staff and their roles in the telehealth
program should be clearly delineated, ranging from
medical leadership, physicians, advance practitioners
and nurses to support staff such as coordinators and
technicians. These individuals utilize tools and follow
processes defined by the program to execute the tele-
health sessions successfully. In addition, administra-
tive stakeholder input and buy-in are critical to
programmatic decisions and success. Collaborating
with legislators and payers to enact effective policies
and reimbursement models is critical for facilitating a
more equitable and friendly environment for tele-
health use.
Process
A telehealth program operates by many predefined
processes that ideally have been optimized to yield
the desired results such as identifying, registering, and
scheduling patients into the telehealth system, rapidly
alerting the on-call remote neonatologist about a tele-
resuscitation, launching a video visit session, ensuring
all participants are able to enter a multidisciplinary
video session, documenting the telehealth consult in
the electronic health record, and redesigning the clini-
cal workflow. For most processes, a “swim lane dia-
gram” or process flowchart55
is helpful to delineate
the individual workflow steps, their temporal relation-
ships to each other, and the stakeholder responsible
for each step. In addition, information technology
resources and processes are needed to ensure that
technological issues can be addressed. Processes for
making programmatic decisions are also important to
consider. For example, alignment with the organ-
ization’s strategic goals may affect a telehealth pro-
gram’s funding and prioritization. Additionally,
participating in the legislative process as consultants,
experts, and advocates can help create policies and
laws favorable to telehealth practice, medical licens-
ing, payment parity, and reimbursement.
Tools
The telehealth devices and platforms should be intu-
itively easy to operate and feasible with high connec-
tion reliability. Difficult and unreliable access to
telehealth sessions can cause an expensive, high value
program to fail. Seeking stakeholder input, properly
vetting the technology, and obtaining feedback from
other institutional peers will minimize the risk of
selecting an ineffective telehealth platform. An imple-
mentation team can better adjudicate which technol-
ogy to purchase if they are given a detailed
explanation of when and how the technology will be
used, for whom, and in which scenarios. In addition,
federally supported Telehealth Resource Centers52
6 Curr Probl Pediatr Adolesc Health Care, January 2021

7. can be great resources for facilitating and/or removing
barriers to effective telehealth use.
Actionable measurements for success and
improvement
The American Academy of Pediatrics Section on
Telehealth Care’s SPROUT (Supporting Pediatric
Research in Outcomes and Utilization of Telehealth)
has combined the invaluable work of the National
Quality Forum and the World Health Organization
with its own member expertise into a toolkit called
SPROUT Telehealth Evaluation and Measurement
(STEM).53
STEM’s four measurement domains: (1)
Health Outcomes, (2) Health Delivery Quality and
Cost, (3) Experience, and (4) Program Implementation
and Key Performance Indicators (KPIs) cover themes
that are relevant to the stakeholder groups in varying
degrees (Fig. 2).
To use the STEM toolkit, telehealth evaluators are
encouraged to identify measures assignable to each
STEM domain (Table 1). Evaluators can collect
objective or opinion data from various sources such as
electronic health records, state- and nationally-
Fig. 2. SPROUT Telehealth Evaluation and Measurement (STEM), a health outcomes centric telehealth evaluation framework. b
TABLE 1. Example of using the STEM toolkit to evaluate subspecialty tele-consultation.
Telemedicine
intervention
Domain 1:Physical or
mental health outcomes
Domain 2:Health
delivery quality and cost
Domain 3:Patient/
provider experience
Domain 4:Program KPIs
Subspecialty tele-con-
sultation for neonates
born in a community
hospital with sus-
pected hypoxic ische-
mic encephalopathy
1. Percentage of
neonates with HIE
who are discharged
home on gastric tube
feeds
2. Rates of epilepsy and
cerebral palsy in
neonates with HIE
1. Compliance with ther-
apeutic hypothermia
protocols in the com-
munity hospitals
2. Timely transport of
neonates to higher
levels of care
1. Community hospital
care team satisfac-
tion with tele-
consultation
1. Number of
subspecialty
tele-consultations
2. Average number of
technical issues per
month
3. Cost of program
implementation
Data source for
measure
EHR EHR Telehealth Usability
Questionnaire
EHR, issues tracking
STEM=SPROUT Telehealth Evaluation and Management; KPIs=key performance indicators; HIE=hypoxic ischemic encephalopathy; EMR=elec-
tronic health record.
Curr Probl Pediatr Adolesc Health Care, January 2021 7

8. reported data, and surveys. Many clinical health out-
comes and measurements of health delivery quality
and cost are defined already by expert consensus (i.e.,
National Quality Forum); however, collecting such
information should undergo statistical vigor and sam-
pling. Surveys seeking individual opinions, experien-
ces, and preferences can yield rich subjective data but
must be carefully distributed and worded to mitigate
sampling and responder bias.
Conclusion
Telehealth programs improve access to specialty
care for neonates, their caregivers, and primary care
pediatricians. Tele-resuscitation successfully supports
pediatricians and PCPs during high-risk newborn
resuscitations, improves the quality of delivery room
care, and reduces transfer rates to a higher level of
care. By using telehealth, neonatologists and other
pediatric specialists can provide more effective con-
sultations that positively influence management deci-
sions and patient outcomes. When neonatologists
provide video visits to home following NICU dis-
charge and meet virtually with the primary care pedia-
trician, neonates experience a safe transition of care
and avoid emergency room visits and hospital re-
admissions. With further implementation and dissemi-
nation of neonatal telehealth programs, it is important
that these programs are thoughtfully designed to
achieve measurable value that is relevant to patients
and caregivers, providers, healthcare systems, and
payers.
Financial disclosure statement
Dr. Fang has licensed intellectual property with and
can earn royalties from Teladoc Health. Dr. Chuo
serves on the clinical advisory board for AngelEye
Health.
Acknowledgments
This work is supported through the SPROUT-CTSA
Collaborative Telehealth Research Network and
funded in part by National Institutes of Health (NIH)
National Center for Advancing Translational Science
(NCATS) Grant #U01TR002626.
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