#007 - The Cardiac Newborn in India (ft Dr. Kiran More)

In this episode of The Incubator India Podcast, host Akanksha Verma is joined by Dr. Kiran More, neonatologist, targeted neonatal echocardiography trainer, and founder of the Little Fun NICU chain, for a wide-ranging conversation on congenital heart disease in the NICU.

Dr. Kiran draws on 22 years of experience across Australia, Canada, New Zealand, and Qatar to discuss what the cardiac newborn looks like when cardiology isn't next door. The conversation covers how to rule out TGA, TAPVC, and TOF at the bedside with limited resources; a practical framework for prostaglandin use in suspected ductal-dependent lesions, including common pitfalls and monitoring essentials; and the case for making pulse oximetry screening universal across Indian delivery rooms.

The episode also addresses the concept of a cardiac NICU, the critical role of nursing training in cardiac care, the neonatologist's place in antenatal counseling when a fetal cardiac defect is detected, and what comprehensive echo training should actually look like versus the half-knowledge that has become common.

Throughout, Dr. Kiran is direct about what Indian neonatal care still needs to get right and why timely referral, honest family counseling, and knowing your limits are as important as any clinical skill.

Transcript

[00:00] Akanksha Verma: Hello and welcome again to yet another episode of the Incubator India podcast. Today we're talking about something every neonatologist deals with but few feel truly confident about — congenital heart disease (CHD) in the NICU. And we have the perfect guest for this today: Dr. Kiran More. He's a neonatologist whose journey has taken him across four continents — fellowship in Australia, targeted neonatal echocardiography (TNE) training at SickKids Toronto, consultant at Christchurch New Zealand, and then building an entire cardiac NICU from the ground up at Sidra Medicine in Qatar. He then finally came back to his homeland, India, where he served as Head of Department at BJ Wadia Hospital in Mumbai, and also headed the NICU at MRR Children's Hospital in Mumbai subsequently. Now Dr. Kiran runs his own chain of Little Fun NICUs as founder and director, with nearly 50 international publications. With this, I welcome Dr. Kiran to the Incubator India podcast.

[01:18] Dr. Kiran More: Thank you, Akanksha. Thank you for having me here. I think this is a great platform. I was aware of the Incubator platform when I was overseas, and now, thanks to your team, you've brought it to India. It's a great podium for conversational discussion and sharing experience.

[01:41] Akanksha Verma: Thank you, sir. It's a privilege to have you. So let's get started. As I mentioned, you've worked across so many continents and now you're back in India. We'd love to know — what brought you back, and what differences do you see in how we approach the cardiac newborn here versus abroad?

[02:03] Dr. Kiran More: Sure. I was fortunate to gain experience across continents — not always by plan, but because I was always hungry for knowledge and grabbed opportunities wherever they came. My first overseas posting was in Australia, in Perth and Melbourne. Australia is quite advanced in neonatology — very hands-on, very practical. A lot of my training refinement happened there. We had 120-bed NICUs, heavy preterm care, and echo was completely routine — beginning of shift, end of shift, four or five babies a day. Then Toronto, where I got formally trained in targeted neonatal echo (TNE) and structural heart disease through the cardiology team. Then New Zealand as a consultant, then Doha where we established the hemodynamic and ECMO programs. When I was in New Zealand, family reasons brought the idea of returning to India, but there was also a feeling that after so much experience, I owed something back. I was fortunate to get the opportunity to head Wadia Hospital — which was actually my childhood hospital, right next to where I grew up. When I came back, I found passionate people, but protocols that hadn't been updated, limited equipment, and significant gaps in hemodynamic training. The choice of inotropes, the management of pulmonary hypertension (PPH) — there was a lot of variation. Very few people were hands-on with echo when I started doing workshops. That's changed now, which is a good sign.

[06:01] Akanksha Verma: That's a remarkable journey. After Australia, New Zealand, Canada, Qatar — you chose to come back and bring all that training home. That says a lot. Now, it must be very different from a setup like Sidra or SickKids where the whole cardiac team is in-house. You set up a cardiac NICU at Sidra — can you tell our audience what a cardiac NICU actually means, and why it should exist as a distinct entity?

[06:49] Dr. Kiran More: A cardiac NICU is really a concept more than a separate physical space. I believe the first hospital to formalize it was in Colombia, in the USA. Essentially, you dedicate a certain number of beds — 10% is often enough — with everything tailored for cardiac patients: specialized monitoring, trained nurses, trained physicians, and dedicated space for pre- and post-op care. At Sidra, which was a single-room center with 54 rooms, we dedicated four or five rooms as the cardiac NICU. Each was equipped with advanced hemodynamic monitoring — near-infrared spectroscopy (NIRS), non-invasive cardiac output monitoring, Hero monitors — all integrated into the Cerner system, with bedside echo machines on each floor. We had specially trained nurses, similar to ECMO specialists. We had five or six consultants out of fifteen or sixteen who were specifically trained in hemodynamics and echo, and we held weekly multidisciplinary meetings with cardiology to review catheterization findings, pre- and post-op plans. It was all about collaboration and focused care.

[09:38] Akanksha Verma: So it differs from a regular NICU in terms of staffing, monitoring, and equipment. Do you think this model is feasible in India — maybe not a full cardiac NICU everywhere, but some version of it in larger tertiary centers? What would the minimum requirements be?

[10:00] Dr. Kiran More: At Wadia, there was something similar — a medical ICU where cardiac patients were kept, jointly managed with cardiology. But the thing is, many of these babies have neonatal problems beyond just the cardiac lesion — cardiac is sometimes just one component of a larger syndrome. As neonatologists, I strongly believe we care for these babies better overall. Cardiologists are focused on the heart; we look at the whole baby. The ideal is a joint approach, where someone like us — trained in structural physiology and hemodynamics — bridges the two. What often happens is a cardiac baby ends up in a general NICU where the nursing team isn't briefed on the physiology. A baby with a mixing lesion saturating at 70% will cause panic if the team doesn't understand that 70% is an acceptable sat for that baby. Once you understand the physiology, there's no panic — everyone is calm, protocols are followed, tet spells are managed appropriately. That's where training makes all the difference. In larger centers, a dedicated area with isolated nursing care is worth pursuing — these babies are prone to sepsis and severe respiratory infections from shunt-related pulmonary overflow. And critically, the crux of it all is nursing training. You train doctors; nurses rotate, new ones come in, and you start from scratch. Continuity of nursing knowledge is the key to better outcomes.

[12:39] Akanksha Verma: That's such an important point. We focus on training residents and doctors, but integrating nursing care is what actually drives outcomes. And there's almost a fear factor around cardiac babies — the moment someone mentions a possible CHD, the instinct is to freeze and wait for the cardiologist. But what you're saying is that with the right training and framework, the neonatologist can and should be confident in the initial assessment and stabilization.

[13:21] Dr. Kiran More: Absolutely — it's always a joint effort. At Wadia, once we demonstrated our level of hemodynamic assessment and showed alignment in management decisions, the cardiologists were more than happy. They have their own OPDs, catheterizations, ICU responsibilities — if we can manage the neonatal side without mismanaging, everyone benefits. It's always teamwork.

[13:58] Akanksha Verma: Absolutely. Now let's get into the practical core. If you have a baby in the NICU, you suspect a cardiac lesion — maybe a murmur, differential saturations, or just a gut feeling — and the cardiology consult is hours away. What should the neonatologist be doing in that window?

[14:32] Dr. Kiran More: That's exactly what our echo training program addresses. We're not training neonatologists to become cardiologists — we're training them to rule out the major structural heart diseases at the bedside. A baby with sats of 60-70-80% could be persistent pulmonary hypertension of the newborn (PPHN), but you need to confirm you're not dealing with a cyanotic heart disease. The key lesions to rule out are transposition of the great arteries (TGA) — you need to show in the subcostal or five-chamber view that the great vessels are crossing, not parallel. Tetralogy of Fallot (TOF) physiology — if there's a perimembranous ventricular septal defect (VSD) with outflow obstruction, even if you can't fully characterize it, you know there's turbulence and right-to-left shunting potential. Total anomalous pulmonary venous connection (TAPVC) is trickier — partial anomalous connection is less immediately dangerous, but infradiaphragmatic TAPVC can be fatal if missed. I've personally diagnosed two infradiaphragmatic TAPVC cases that were initially referred as severe PPHN. In both cases, on high-frequency oscillatory ventilation (HFOV), I couldn't clearly visualize the pulmonary veins — but the absence of veins on echo was the red flag. Once I switched to conventional ventilation to optimize the echo window, the picture became clear. I called cardiology, we confirmed with CT. The lesson is: trust the gut feeling that something doesn't fit the PPHN picture. Coarctation of the aorta is another critical one — a baby whose ductus closes can crash without warning. Cardiomyopathy is also important — a severely depressed ejection fraction (EF) in a baby that looks like sepsis is a very different management scenario. If you start dopamine or norepinephrine in a baby with cardiac dysfunction, you're increasing afterload and you may lose the baby. You need an afterload-reduction agent — milrinone — not a vasopressor. And even if you see a four-chamber view that just looks "not right" — grossly asymmetric, hypoplastic — you don't need to know the exact diagnosis. You know it's not normal, and you call for help or refer urgently. Even pericardial tamponade — a colleague recently sent me a video from a remote area: the heart was clearly floating in fluid. He wasn't confident to tap. The right call was to transfer immediately, which he did.

[20:32] Akanksha Verma: So for the cyanotic newborn, the three things to quickly differentiate are TGA, TAPVC, and PPHN — because each can crash fast and the management is completely different. Prostaglandins for TGA, possible surgical emergency for TAPVC, pulmonary vasodilators for PPHN. Getting that differentiation right in the first few hours is where neonatologist skills really matter.

[21:09] Dr. Kiran More: Exactly. And many times what looks like cyanotic CHD is actually severe PPHN — which needs good ventilation, nitric oxide, sildenafil, and appropriate PPHN management. The ability to differentiate is everything.

[21:29] Akanksha Verma: Absolutely. Now let's talk about something deceptively simple but incredibly powerful — pulse oximetry screening for critical CHD. Pre- and post-ductal saturations. We all know the concept, but implementation in India is still very inconsistent. What's your take on making critical congenital heart disease (CCHD) screening standard practice, even in resource-variable settings? And what are the red flags every neonatologist — tertiary or district level — should not miss in the first 24 to 48 hours?

[22:17] Dr. Kiran More: Very important question — and it's also the simplest thing anyone can do, regardless of whether they have echo access. The UK and many other centers have already adopted this. Every baby over 35 weeks should be screened, ideally around 24 hours of age — allow transition to happen first, then screen before discharge, somewhere in that 24-48 hour window. Place the baby on a pulse oximeter for at least 15-30 minutes. If saturations are above 95%, reassuring. Below 95%, repeat in an hour, then again at six hours if still borderline. Clear criteria now exist: below 90% in the right hand is definitely abnormal. A pre-post-ductal difference of more than 3-5% is also a positive screen. From there, request an echo. Make sure the perfusion index is adequate — cold peripheries will give you a false read. Check for murmur, temperature instability, and other signs. Multiple studies confirm good sensitivity for picking up hypoplastic left heart syndrome (HLHS), atresia, TAPVC, TGA, tricuspid atresia, and other cyanotic lesions. We are missing a lot of CHD in India, and too often these babies get labeled as aspiration pneumonia. Term babies don't aspirate — that's not really what happens. When we say aspiration, we're often blaming the mother, and she carries that guilt for life when the real diagnosis was a missed cardiac lesion. We do screening echo routinely in our unit — it takes three or four minutes — and we offer it free to many patients. At minimum, everyone should do pulse oximetry.

[25:36] Akanksha Verma: We really need to push for this to be universal — not just in tertiary centers. It should be as routine as checking birth weight.

[25:48] Dr. Kiran More: Absolutely. And maybe tie it to birth vaccinations — nobody forgets vaccinations. If you're already observing the baby for the post-vaccination window, put the pulse oximeter on at the same time and give them a report. With one caveat: parents need to understand that a passed cardiac screen doesn't mean no cardiac disease ever — it's not 100% sensitive, and some conditions can still present later.

[26:46] Akanksha Verma: Absolutely. And speaking of duct-dependent lesions — this is where the stakes are highest. Can you walk us through common pitfalls in prostaglandin management, and what every neonatologist needs to know about keeping that duct open safely?

[27:12] Dr. Kiran More: When I go to medical colleges as a visiting professor — often the only person in the room who does echo, sometimes without a pediatric cardiologist on staff — I always tell residents: if you suspect cyanotic heart disease and you're not sure what you're dealing with, it is always safe to start prostaglandin E1 (PGE1). You can always stop it later. The only real contraindication is infradiaphragmatic or obstructed TAPVC, where PGE1 can worsen things. But for virtually any cyanotic lesion, starting prostaglandin will not kill the baby — it will buy time. Keep one vial in the fridge. Once you start it, you're committed — call cardiology and start planning the next step: referral to a tertiary cardiac center. Two major caveats: first, babies develop apnea after starting PGE1, often quickly. You cannot start it and walk away. The baby must be in a center where you can monitor closely and be prepared to intubate — you don't always need to intubate electively, but backup must be there. Second, if the ductus was not actually needed and you open a large duct — say four or five millimeters — in a non-ductal-dependent lesion, you can cause pulmonary flooding and bleeding. That's happened in our unit. Echo monitoring is essential: if the ductus is large and the baby doesn't need it, taper and stop PGE1. For PPHN, the duct naturally tends to stay open — PGE1 isn't routinely started, but if the duct is closing and the right ventricle (RV) is dilated, especially in diaphragmatic hernia, having PGE1 on board as an RV pop-off valve is reasonable. Whatever you do, monitor with echo. The baby will tell you if your decision was right. If the baby is deteriorating, your drug choice was wrong. If improving, you're on the right track.

[31:01] Akanksha Verma: So you're weighing the need for an open duct against the risk of apnea — and losing the duct is far more dangerous than managing an apnea. The practical approach for a smaller center should probably be: start PGE1, secure the airway electively, and refer. Don't wait.

[31:29] Dr. Kiran More: Don't wait — refer. And I want to say something to the youngsters: I'm also relatively new to private practice in India — only two and a half years. I understand the pressure to hold on to babies, to prove yourself, to worry about referrals reflecting on your ability. But the right practice — the one that actually builds your reputation — is doing what is right for the baby. If the baby needs a tertiary cardiac center, refer boldly. Parents will always value a timely referral. If the baby survives, they'll thank you: "You diagnosed it, you started prostaglandin, you intubated, you referred in time — that's why my baby is alive." The cardiac surgeon didn't save the baby alone — you did, by making the right call at the right moment. All the doctors who become truly respected do so because they consistently prioritize the baby's interest. Timely referral, honest communication with families — that's what builds a practice.

[33:33] Akanksha Verma: Absolutely. The ethical responsibility is clear — recognize, stabilize, refer. That baby is not one to hold on to. On another topic: fetal echo is changing the game globally, but in India access is still very patchy. Any thoughts on bridging that gap, and what role can the neonatologist play in prenatal counseling when a cardiac defect is detected?

[34:15] Dr. Kiran More: This is a topic I feel strongly about — I've been trying to organize a perinatology conference on exactly this. In Australia, New Zealand, and Qatar, we had dedicated days on call for antenatal consults — surgical, cardiac, genetic conditions, anything. The neonatologist is the point of contact, because we are the ones who will manage these babies. The surgeon operates; the cardiologist does the catheterization; but we are always there. In India, that culture doesn't exist. Obstetricians do the scan, call the surgeon or cardiologist directly, or sometimes counsel the family themselves. I've seen CDH counseling quoting 50% survival — that's a 20-year-old figure. We're achieving 90% now. Counseling has to change. For cardiac lesions, the neonatologist should be called. When you receive a fetal anomaly report, meet the family first, understand their expectations, then refer for fetal echo at a center with fetal cardiology capability — either an obstetrician or cardiologist trained in fetal echo. Once the fetal echo is done and prognosticated, come back to the family with a clear plan. For a favorable lesion like TGA without soft markers, the prognosis is good — you have six months to plan delivery and surgery. You can document: this baby has intact atrial septum, TGA with restrictive patent foramen ovale (PFO), needs PGE1 at delivery, echo at one hour, further plan. For a poor prognosis, termination may need to be discussed — and that conversation must be well-documented. Getting fetal echo done is essential.

[37:03] Akanksha Verma: As you said — family expectations, financial realities, access to surgery. Sometimes there's pressure to terminate even for correctable defects. That counseling becomes incredibly complex in the Indian context, especially when families ask: will my baby be normal?

[37:37] Dr. Kiran More: Everyone wants their child to be a doctor or engineer — the most competitive child in the world. And that competitiveness means they don't want to take any risk. But a baby is a baby. You have to give that child a chance at their potential. Finance is increasingly not the barrier it used to be — crowdfunding, donations, charitable surgical programs, government schemes. The willingness to fight for the baby is what matters. The real problem I see is families who simply don't want a baby that isn't perfect. Even when you tell them the prognosis is excellent — the hole will be fixed, the child will live a normal life — they've already decided. That mentality needs to change. Society needs to change. And that will take time.

[38:59] Akanksha Verma: Absolutely. Before we close — since we likely have fellows listening, and you've trained in targeted neonatal echo abroad and taught echo across India — what is the minimum echo skill set a neonatologist without formal cardiac training should have?

[39:26] Dr. Kiran More: Echo training has become fashionable — and I have no objection to spreading knowledge, but half-knowledge is dangerous. What I'm seeing in medical colleges is residents doing echo on rounds, presenting findings, starting dobutamine because contractility "looked off," giving boluses because the inferior vena cava (IVC) looked collapsed — and "selling" the echo findings without real understanding. That's detrimental. Any online-only course of six months is not sufficient. I've seen people after six months who can't even get a proper four-chamber view. In our courses, we offer two weeks of intensive hands-on training — twelve days, eight hours a day, 30-50 echo scans per trainee. I've seen someone who had never held a probe doing competent echos by the end of week one. The training must be comprehensive: proper views, functional assessment parameters, and the ability to rule out structural heart disease. Half-knowledge is dangerous because you might look at IVC and give a bolus when the baby actually has a structural lesion where volume loading is harmful. You might eyeball a tachycardic heart at 190 bpm and think contractility is fine — but if you haven't measured left ventricular output (LVO), you might be missing a critically low output state with a lactate of 10-15. The baby is hyperdynamically contracting but not functioning. So either commit to comprehensive training, or learn the absolute basics — rapid crash protocol assessment: IVC, eyeballing — which at least won't get you into serious trouble. What you must avoid is learning just enough to confidently present findings on rounds without the knowledge to back it up. I've been scanning for 15-16 years and I still call my cardiology colleagues at night when I'm unsure. Echo is a deep field — the more you do, the more interesting it becomes.

[43:13] Akanksha Verma: That's really powerful. And what you're doing with the echo workshops, the courses, building Little Fun NICUs — it's not just talking about change, it's making it happen.

[43:33] Dr. Kiran More: I've since left MRR and now run a chain of three NICUs under the Little Fun brand — with a fourth opening this Sunday. The philosophy is evidence-based, integrated, affordable, and accessible care, in a loving environment for families and staff. Families attend rounds, ask questions, learn about apnea, patent ductus arteriosus (PDA), necrotizing enterocolitis (NEC). We've diagnosed quite a few cardiac conditions in the last six months — a baby with a heart rate of 30 with SLE-related complete heart block requiring a pacemaker, TGAs, perimembranous VSDs, arteriovenous (AV) hemangiomas managed with glue. Once you do echo routinely, you attract complex cases. We're targeting 100 beds by end of year.

[45:15] Akanksha Verma: That's game-changing work. Thank you so much, Dr. Kiran, for your time and for such a rich conversation. Any final words?

[45:36] Dr. Kiran More: India has a lot more to do in improving neonatal mortality and outcomes. Neonatal care must be comprehensive — no half-hearted approach, just as I said about echo. If you can't manage, refer early and save that baby. More people need to reach the peripheries — that's how neonatal care across India will improve. For echo: learn it, but know your limits. Keep a learning mindset. In a crisis, echo is your stethoscope. In my unit, my fellows tease me for picking up the actual stethoscope — I almost always go straight to the probe. Lung scan, head scan, echo. It's an essential tool. Our next training batch launches in July — we're open to teaching anyone who wants to learn.

[47:13] Akanksha Verma: Absolutely. We've come a long way, but there's still so much to do. Conversations like this are part of that change.

[47:31] Dr. Kiran More: Young India is dynamic and smart — you'll pick this up faster than any previous generation. I've trained fellows who are now running echo programs in Guwahati, in Assam, in places that had nothing before. The passion and the dedication to keep learning — that's what makes the difference.

[48:39] Akanksha Verma: Thank you so much, Dr. Kiran, for being so generous with your time and experience today. This has been incredibly valuable. That was episode seven of the Incubator India. If this episode helped you, please share it with a colleague or fellow who needs to hear it. Until next time — keep learning, and we'll see you in the next episode.

[49:02] Dr. Kiran More: Thank you.