#002 - Redefining Neonatal Care: Insights from Surgeon Rear Admiral Professor Girish Gupta

In the second episode of The Incubator India Podcast series, Dr. Akanksha Verma engages in a profound conversation with Surgeon Rear Admiral Professor Girish Gupta, a trailblazer in neonatology and early neonatal intervention. Currently leading the Department of Neonatology at Grafikira Institute of Medical Sciences, Dehradun, Professor Gupta draws on his 37 years of distinguished service in the Indian Armed Forces to share transformative insights into neonatal care.

This episode delves into the concept of early neonatal intervention, presenting it as a comprehensive approach that starts before conception and continues through antenatal, delivery, and postnatal periods. Professor Gupta discusses impactful practices such as delayed cord clamping, Kangaroo Mother Care (KMC), and multisensory integration, explaining how these strategies foster neurodevelopment, reduce stress, and optimize brain plasticity. He also underscores the importance of developmentally supportive NICU environments designed to minimize stress and support healing.

Highlighting the role of parents and innovative technologies, including artificial intelligence, Professor Gupta offers actionable advice for both healthcare professionals and families. This second episode continues to establish the podcast as a vital resource for advancing neonatal care, combining practical insights with inspirational guidance. Tune in for an enlightening exploration of strategies to ensure the best outcomes for newborns.

Transcript

Akanksha (00:02)

Hello everyone and welcome back to the yet another episode of Incubator India podcast. I am Dr. Akanksha, your host for today and we have a very special guest with us who has been actually a guiding force in my career. He's a renowned neonatologist and a key author of a review article that we're going to discuss today. Surgeon Rear Admiral Professor Girish Gupta is currently heading the Department of Neonatology at Graphic Era Institute of Medical Sciences, Dehradun, Uttarakhand in India and he was a former head of Neonatology at SGPGI Lucknow. Sir, he has served the Indian Army and Naval Forces for 37 years and he has been awarded with distinguished Nau Sena Medal and prestigious Vishisht Seva Medal award by the President of India 

And it is not possible for me to summarize his contributions in the field of neonatology at this platform. But we are really privileged and honored to have him with us today. And the topic that we have chosen to talk about 

would be early neonatal intervention, a newer conceptual paradigm. Please join me in welcoming Professor Girish Gupta sir.

We welcome you, sir, to the Incubator India podcast, and it's an honor to have you here.

Girish Gupta (01:39)

Thank you, Dr.Akanksha 

It is really a singular privilege to talk to you and show you to the podcast group on a topic which is extremely relevant in Neonatology. Today, aim is not to save a baby, but the baby saved must be intact. It means that all 

the functions of the baby should be as normal as possible. However, given the stresses at birth, the variety of cases, the severity of problems and difficulty of transition from fetus to a newborn, newborn becomes highly vulnerable to various organ damage. And therefore, we have brought a different concept that as I stated, various organ damages, it's not just the brain. And hence, we have changed the paradigm.

that every organ of the body is to be taken care right from the word go should the situation arise and newborn when he turns into an adult he becomes comprehensively capable human.

Akanksha (03:15)

That's very aptly said, So let's now just dive into the topic of early neonatal intervention with none other than the reviewer of the author of the article himself. And this, when I say early neonatal intervention, this word, this topic is actually gaining significant attention in the current neonatology. So may I please ask you, sir?

if you can start by explaining for our listeners and for all of us the concept of early intervention and why it's becoming so crucial in neonatal care.

Girish Gupta (03:54)

Excellent question, Dr. Akanksha. 

conventionally and normally in the past when we thought of early intervention.

We thought this early start from somewhere in the early infancy.

Akanksha (04:12)

Yeah, that's what most of us would think.

Girish Gupta (04:20)

But if we have to have a newborn as intact, then the early intervention should not start only in NICU, in my opinion, which we have also addressed in the article, that it should start periconceptional, so that a fetus or an embryo is formed in the right environment with the precautions which ensures this. The entire gestation should be neonate, I would say embryo and fetus centric for the delivery. And thereafter 

comes the direct role of the neonatologist that rather than waiting for any day and letting the organ damage and then doing a tertiary prevention. 

we would like to go for early intervention. And hence the role of we in particular as pediatrician on neonatologist to start right from the time of 

birth, but it would be much wiser as I stated earlier that it should start from periconceptional period and should continue so.

Akanksha (05:28)

That's really fascinating sir. And I have gone through the article and in your article you emphasise that as you just now told that it should start even before conception and continue throughout the periconceptional, antenatal and the postnatal periods. But we would just like if you can elaborate more on this holistic approach for all of us.

Girish Gupta (05:56)

Yeah, right. Now, one is that when do we start, what all we do, and what are the specific actions? I would personally feel that as it involves the general care, the obstetric care, and the neonatal care, I would focus my discussion on the neonatal care so that it should start from the area where we have some influence on the baby's management. Now, for example, in the antenatal period, and if we have a baby who is likely to be delivered early, we should go all out with the interventions, 

which ensures perfusion to the new fetus, ensures brain's intactness and other organs' intactness. To be precise, if need be, we should give neuroprotective agents to mother, for example, mag sulphate or to enhance maturation of different organs, steroid administration to the mother as required. In addition to that, must ensure the right environment, right nutrition to the mother so that the fetus continues to get best nutrition during the period whatever he stays in fact. So that's 

on the antenatal management. Does it satisfy the component which I've addressed Dr. Akanksha?

Akanksha (07:17)

Yeah.

Yes, yes sir, please like you have mentioned it very correctly and right on.Maybe we can just move on to the further periods of the approach

Girish Gupta (07:38)

Yes,

I agree with you. Now I am moving beyond the fetal period to the time of arrival, the delivery. There is a most critical period. From the wonderful environment of fetus, there is a sudden transition to the extra – uterine environment. And therefore, the pregnancy termination means the natural termination of the delivery should be most appropriate, starting from time of delivery.

Normally it is happening that for various medical reasons the baby is delivered pre -term. Fine, as far as it is medical reasons, is okay. But one must know that if the delivery is taking place prematurely, even early term, all these babies are going to have long -term consequences. Means they might have brain challenge or various diseases. The first and foremost point which I am conveying is that we must deliver only term and term deliveries not pre term or early term it should be term delivery and if it is a few

Akanksha (08:44)

Yes, that is a very strong message that has to be conveyed loud and clear and you have done it precisely.

Girish Gupta (08:55)

Yeah, so we must ensure that in our society for various non -medical reasons, social reasons, a date for importance, time is important, and the baby is delivered before the exact date of maturity or expected date. That has to be discouraged at all costs. It is doable. So we have to educate both the society, the mother, the parents.

Akanksha (09:15)

Yeah.

Girish Gupta (09:24)

and also the obstetrician. So that becomes very important, the timing of delivery to ensure that we have only term delivery.

Second thing is that this transition should be most effective, best facilitated, not taking any chance, no compromises. And especially if there is a high risk delivery, the best team, be it a neonatologist,

Akanksha (09:33)

term delivery.

Girish Gupta (09:53)

Be it observation, be it the infrastructure, be it the labor room, the labor room staff. Be it transport, it should be taken into account. So I suggest that if there is a high risk delivery, the most experienced people should come and the infrastructure should come. However, if one feels that the baby after delivery is not like to get care in the institution where he is 

delivered, then it may be much wiser to do a in utero transfer.

to other institutes so that the baby has intact survival. So these are the few salient points which I would like to cover at birth so that one becomes very clear and gives most optimal at birth. Is it all right, Dr. Akanksha? At birth?

Akanksha (10:37)

Yes sir, absolutely. I think as you said, in the recent days we seeing that there is a very common trend of taking out the babies early. It can be for various reasons, sometimes justified, sometimes not justified, but then every attempt should be made to ensure that the fetus is maintained in utero till term gestation and is not taken out unless and until it is 

absolutely necessary. And apart from that as you mentioned about the trained personnel being always present, remaining always present at the time of delivery, I think especially for the resource constraint settings as we talk of that is always not possible.

But then every attempt should be made at each and every level that no delivery should go unassisted. So I think that is what we must remember to take away from whatever we have heard from you in the past few seconds. Please go on,

Girish Gupta (11:52)

Yeah, I would like to add one or two more important points which are essential to be practiced and they are at the time of delivery as we know the umbilical cord has been taking care of the future. Now let's not be in a great hurry to cut the cord at the time of delivery. Let's do a delayed cord clamp. There should not be any ambiguity about it.

Akanksha (12:15)

...Delayed cord clamping

Girish Gupta (12:20)

You have to find out reasons why not to do it. Otherwise, the norm should be that we would do a delayed cost changing. And one more thing which I would like to address for our learned audiences, placenta is a hugely beneficial organism. And therefore, we must look at the placenta for whatever information, be it diagnostic and therapeutics it can provide, 

including some blood collection from placenta for diagnosis and therapy of the newborn So these were a few more points which I thought Dr. Akanksha at the time of birth one should consider. Is it fine with you?

Akanksha (12:54)

Yes, yes sir. Actually, talking of cord clamping now, we see a lot of evidences nowadays coming up like that whatever we have been doing for decades earlier, the immediate cord clamping that has to be just foregone off and the era is now of delayed or whatever we may call physiological cord clamping. People are now thinking of intact cord resuscitation, providing the baby, resuscitating them with their intact cords. How can we make it feasible?

So, a lot of work we seeing is coming up on that and placenta as you correctly emphasize sir, that is something which is often overlooked, that is one organ that has supplied and actually nourished the fetus for the last 9 months or whatever gestation baby was inside. But as soon as the baby is taken out that is just taken as a piece of tissue and not looked at, not examined and we undermine the importance of that very invaluable organ we have. So, 

very correctly you have emphasized upon the importance of the placenta and having a look at it and not to forget that this was what has nourished and maintained the foetus till now. Talking of early intervention sir,

Girish Gupta (14:14)

Dr. Akanksha, I make one more additional point here?

Akanksha (14:19)

Yeah, yes, please sir, please sir, go

Girish Gupta (14:14)

Thank you for permitting me. Friends, it is for last 200 years or so, we have started talking of delayed cord clamping. But I'm very proud person to express. We as Indians, we're doing

Girish Gupta (14:42)

before say about 500 years before Christ. It's published. It is more in the Indian literature. In the Indian literature, it is mentioned as Nal Chedan. I would request all of you have to read it. In case if you need any more information, I shall be very privileged as a Neonatologist and a proud Indian that for more than 3000 years before we were practicing.

Akanksha (14:48)

Okay,

Girish Gupta (15:13)

And therefore, I would request that have faith in your own system, read the literature and do a scientific evaluation in the contemporary environment so that you feel convinced. Thank you Dr. Aakansha, giving me this opportunity to

Akanksha (15:27)

That's so fascinating to hear that from you sir, like even I was not aware of it, I am surely going to go and take a look at it. thank you. So, now moving forward sir, like as we have been speaking for the past 10 or 15 minutes regarding the early intervention. are we just, is it just okay to focus on the brain? Is it all about neuro protection and is all the early intervention

targeted towards brain or what about the other organ systems, like what are the what have to be done in order to ensure to in order to be practicing the early intervention because it not just the brain it is organ system human body in entirety that has to be maintained intact. So, what is your take on that? So, please guide us through.

Girish Gupta (16:22)

I am very, very happy that you have posted me this question

Friends understand that whenever there is a poor blood supply or poor oxygen or glucose means some asphyxia. Now it doesn't differentiate a cell versus other cell. Though a cell which has a higher metabolic rate and hence in turn tissue and system would get more affected, but the ones which have a relatively lesser metabolic rate will get a little lesser effect

But then across the board, all systems get affected. And therefore, we have to realize, though one may prioritize, but for living intact, we need every organ of the body, including a skin, including our. And hence, when we plan our early intervention, please don't have a biased approach. If heart is working, brain would be intact.

Akanksha (17:09)

Yeah, that's true

Absolutely.

Girish Gupta (17:23)

If respiration is brain would be intact. If the kidneys are working, brain would be intact. But if we only focus on the brain, then we are away from the target. And that is my primary aim of writing this article. Let's change the paradigm that though we must be brain -centric, but each and every cell, tissue, system of the body must get early intervention. So 

this is my first concept, but I'd like to make another point right here. 

that in my opinion the maximum damage to the baby occurs in the first 24 to 48 hours maximum, because that is the time when we give maximum intensive care give the baby pain, prick, environmental distresses and that compromises our micro circulation which is not adequately auto controlled in these sick babies so in case if one has to save baby and save intact it is right at birth, first few hours and first few days. whatever we do, they should be all newborn centric, should not harm, should not disturb the environment and hence minimize the damage, starting with the pain relief or putting central lines. Please keep that in mind. No pricks, no pain. And then we move.

Akanksha (18:46)

Yeah, that's, think when you say that, I can imagine my like residency days as soon as a baby is born and like, if the baby does not cry, my God, everyone, like the staff nurse, the doctors, the faculty, the resident, everyone is on the baby. And there are so many things going on, putting the monitors, intubating the baby, putting them an IV cannula and umbilical catheterization, this and whatnot. 

And in all of that what we forget is it is just a fetus, it is just a baby who has got out of a protected in utero environment and maybe the damage is

made then and there only. So, I think that is a very important message that you have conveyed here that we should not forget that the early intervention should start right at from that point and just not includes the neuroprotective interventions, it has to be a holistic approach wherein all the organ systems are taken care of. I hope this is what you have been trying to tell us.

Girish Gupta (19:56)

Yeah. Yeah, what I would also like to state here is that as I normally talk in when I talk about principles of becoming a good doctor, human being, or when we conduct Ek Pehl, initiative in building up human resources, medical resources, we take vows. And the first vow is not to harm. And the second one is to do good. So apply here at the newborn care.

Not to harm, that we must critically analyze at birth in our NICU practice. And you would realize there'll be N number of procedure we were doing or we are doing which are harming the baby. So question each procedure, each intervention. Does it disturb the baby? They are to be prevented. And there comes a role of developmentally supportive environment. 

So please bring in your developmentally supportive environment, the sound, temperature, light.

handling, touching, talking, so on and so forth. So that's something whichcan be dwelled upon differently at length, but what I'm trying to convey is environment should be non harmful. That's number one. Secondly, what we should do, which is good for the wages, that we can call is early intervention or whatever way. So we should come out with various interventions with procedural, pharmaceutical, caring, and others which gives a baby the chance to optimally develop. So this is a general concept. Maybe I will dwell on that. Dr. Akansha.

Akanksha (21:35)

Yes, so that's incredibly insightful sir. It sounds like early intervention is about creating the right environment for these babies from day one or even before actually. You also mention about KMC or Kangaroo Mother Care or skin to skin contact as we all know of as a cornerstone of early intervention in the article. Can you tell us a little bit about why is it so important?

Girish Gupta (22:07)

It is a wonderful question. 

Now it is always good when suppose we have to do 10 things and do differently put 10 efforts versus there is one complex compound package giving all 10 things together. it is precisely kangaroo mother care does everything which an early intervention requires. Be it a neuro protection, neuro intervention and then we also talk about multi -sensory integrations and how the brain growth can be facilitated in the early period.

Akanksha (22:27)

Mm -hmm. Yes.

Girish Gupta (22:44)

Now kangaroo mother care is one very special intervention which stimulates all sensations. Be it somatic sensations, be it special sensations. So they are coming as a package. And over and above, the affection of mother, which we don't understand as a soft variable today, the baby undergoes tremendous degree of stress.

more sick, more stress.

Akanksha (23:08)

stress.

Girish Gupta (22:44)

And one of the comprehensive intervention is taking mother to the baby and giving kangaroo mother care. Stress reduction. And therefore, it is essential that if best is to be offered to the mother, it is not the open care system, it is not the incubator, it is the nature's incubator, which is mother.

Girish Gupta (23:31)

and kangaroo mother care. Maybe one can bring in also kangaroo father care if it is required. My bottom line is that we are custodians only. The baby belongs to mother, belongs to father. Have them in the unit at the earliest. You would not know how in the best possible manner this baby and the mother dyad will get the most optimum outcome in times to come.

Akanksha (23:58)

Surely, absolutely sir. When we talk of KMC, actually it reminds me of the residency days when we used to bring the babies to their mothers and like earlier it used to be once the baby is stabilized, then the mother gets to take them in their lap and it was such a positive feeling. It was such a great moment for both the babies and for their mother. was like it's a big, big moment.

And it really brings home the importance of involving the parents as well in the caregiving process. Like it's not just about the healthcare workers, it's about how we can involve the family, the family -centered care that we talk of. So I think KMC is something which can take care of it in all the aspects..

Girish Gupta (24:49)

Yeah, yeah, if I can add a little more on KMC.

Akanksha

So here only, sir? Yes, sir. Yes, sir, please

Girish Gupta

See for example in early intervention we say that there should be visual facilitation, there should be hearing facilitation, there should be olfactory facilitation, there should be gustatory facilitation, there should be occupational facilitation. KMC is one singular intervention. So let mother sing a lori.

Akanksha (25:11)

Yeah, yeah. That's what I wanted to come next on the multi -system sensory integration.

Girish Gupta (25:26)

song to the baby. Let mother hold the baby in front of her and allow baby to fixate eyes and move the eyes, following the... So, in nutshell, it is involvement holistically of the mother with adequate respect or more respect from the care provider, taking them almost as equal as the nursing personnel or maybe beyond will do tremendous good and it's nearly assured that the baby will have wonderful outcome

Something else I would like to mention here is that it is a mother's milk and colostrum that is very, crucial for the immediate and long -term salvage of the baby. So if we bring in KMC early, right from the time birth, as we say, skin -to -skin contact, these wonderful, in my own language, I call them as amrit or nectars of the life, they will be plenty without any delay. And we would provide them that will further guarantee that there will be If at all there are organ damages, will be minimum including infection would be much higher. It will guarantee human milk including colostrum

 Akanksha (26:34)

Yes sir, that's wonderful and actually the concept of the mother singing lori for their baby, I think no voice, no sound can be a better stimulus for a baby who is in the stressful environment of an ICU than a mother who singing for him or her right then and there. In continuation with this, can you elaborate a little more like we… talk of multi -system sensory integration in this article. So, would you like to elaborate, I think we have touched upon it in through KMC, but maybe if you would like to elaborate it a little

Girish Gupta (27:17)

Yeah, it's a very good question in the sense that it will bring you logic and reasoning that what do I mean by multi -sensory integration, the plasticity of the brain. Now, firstly, we must remember that the brain is, or the neuron or the encephalon or the brain tissue is ready to adjust in the earlier days of life. After that, it doesn't adjust, number one. So that’s the neuroplasticity.

As the days pass by, it becomes more of a stress. Now coming to the integration, there are enough work. In fact, in this article we have published, even shown a cross section or a cut section of the brain, where we have shown that how the fibers, say at the level of the brain stem or maybe the upper part, how they are getting combined. The olfactory fibers are coming, the visual fibers are coming, the auditory fibers are coming.

they are decussating and then becoming mixed finally making common pathways. Therefore, the practical implication is this that suppose one of these sensations are compromised, the other sensations compensate for it. Suppose a person has less vision. Now if we do a hearing over stimulation, it will take care of his visual deficit and vice versa. So this is what is a multi -sensory integration and plasticity means in the earlier days. So the bottom line is this that we do all these stimulations at the earliest because if we will start later these multisensory integration would become less and less. Hence in an ICU a comprehensive package must be practiced right from the word go provided the baby's cardio respiratory system is stable. It should not happen once we are doing these practices we are bringing to fore. Baby should not settle the

Akanksha (28:49)

less effective.

Girish Gupta (29:11)

So maybe we just see first few days depending upon the baby's fragility. But if they are not there, they should be started at the earliest, maybe right from the word go

Akanksha (29:23)

Surely, And that's like, it's fascinating to know like how interconnected everything is when we talk of the early intervention starting right from the antenatal periconceptional and the postnatal period. So, I think most of the major aspects of it, we have tried to cover. But before we wrap up, sir, is there like any advice, something you'd like to add on or for our listeners?

Girish Gupta (29:51)

Yeah.

Akanksha (29:53)

especially those who are working in the NICUs or even the parents of the preterm babies or who have to like daily struggle in with the daily challenges that come up with such. 

So, please we would like to hear that

Girish Gupta (30:06)

Dr. Akanksha, it is something which is extremely critical and crucial, both for care seeker, care provider, and the attendants. The catch -mantra is counseling and communication. It should start at earliest whenever you can dream, and should come keep on going on regularly at a regular frequency, plus SOS as and when required.And if we give this comfort, then the compliance of parents would be very good for developmentally supportive care and early intervention. They will do everything possible, including KMC and other things as required. 

And they will be comfortable. That's the one. Number of in the counseling also, there are difficult situations where we reassure parents of our capabilities as a doctor, which means we tell them that we as doctors will do our 100 % best with respect to technology, drugs, prescription. But we cannot guarantee outcome. 

And hence, it is important to convey to the parents that everything possible under the sky, depending upon the capability of the institution, but surely our efforts are guaranteed. But for the outcome, we need something more than that, which means Almighty's blessing. And therefore, we request our parents. that they should do bring us that blessing. So in Hindi I say, we will give dava, dua you bring from your Almighty. So there is a concept of partnership between parents and doctors. And therefore they accept things much better. Lastly, I'd like to make a statement that since, you know, it's a time of technology, the time of artificial intelligence, and therefore one could utilize artificial intelligence

Akanksha (31:41)

Thanks.

Girish Gupta (32:01)

in this entire process, be it developmentally supportive care, early intervention, counseling, because I personally, am doing in all the domains, getting AI involved. Of course, a world of caution is that don't take the AI statement as sacrosanct. So a general concept, will provide you, and then you rationalize it in your context. 

and maybe use, make use of some medical expert in the field if there something which is doubting. So therefore, I would suggest that all of us should master counseling and use technology to make it most apt and up to date.

Akanksha (32:43)

Surely, wise words indeed. And actually, I think it's very important, especially whenever we are counselling, the frame of the counselling that is being conveyed to the parents is very, important. Whether it is being done in an optimistic or a pessimistic frame, it really makes, I think, a lot of difference for the one. 

We may be on another side of the table but for the parents through the table I think it's very very important that we frame our, the counselling is to be framed in such a way that we can weigh to them the important points they obviously must know what the chances are of their baby making it through but then as far as possible it has to be done in a in the most optimistic

which could be possible to make it the best, at least pleasant, if not pleasant at least not a bad experience I may say for the parents to listen and sit through it. 

So thank you very much sir for joining us today and sharing your valuable insights on early  neonatal intervention. I hope that I found it a really enlightening conversation and I'm sure our listeners must have gained from it as well. For our listeners, you can find the link to the article in the transcript below. And thank you very much for tuningin to the Incubator India podcast. If you found this episode helpful, don't forget to subscribe and share it with your colleagues. Until next time, 

take care and keep making a difference in the lives of our tiniest patients.

Thank you for joining us today.

Girish Gupta (34:42)

Thank you

Akanksha (00:04)

So, to wrap up our conversation with Surgeon Rear Admiral Professor Girish Gupta, really brings home the importance of early neonatal intervention starting right from the periconceptional stage and continuing through the antenatal and postnatal phases. It is not just about neuroprotection, it is about taking care of baby's overall health focusing on all organ systems.

We also touched on the incredible impact of Kangaroo Mother Care and multisensory integration for supporting brain development and growth. 

Lastly, involving parents through effective counseling and using technology like AI can truly enhance how we approach early intervention.

So these takeaways are a great reminder of how holistic and thoughtful care can make all the difference in a baby's development