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#043 - 📑 Journal Club 21


NICU journal club the incubator podcast

 

Hello friends 👋


Thank you for tuning in for journal club. This week is packed with interesting article. Daphna and I discuss Kangaroo care, first gases in preterm babies, family integrated care, PDA, feeding protocols, TORCH, Marijuana, racism and long term management of preterms with respiratory disease.

We hope you enjoy this episode. Thank you for listening and for your support.


As always, feel free to send us questions, comments or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through instagram or twitter, @nicupodcast. Or contact Ben and Daphna directly via their twitter profiles: @drnicu and @doctordaphnamd. Papers discussed in today's episode are listed and timestamped below.

enjoy!



 

The articles covered on today’s episode of the podcast can be found here 👇

Charpak N, Tessier R, Ruiz JG, Uriza F, Hernandez JT, Cortes D, Montealegre-Pomar A.Acta Paediatr. 2022 May;111(5):1004-1014. doi: 10.1111/apa.16265. Epub 2022 Feb 1.


Association of umbilical cord blood gas values with mortality and severe neurologic injury in preterm neonates <29 weeks' gestation: a national cohort study. Shah PS, Barrett J, Claveau M, Cieslak Z, Makary H, Monterrosa L, Sherlock R, Yang J, McDonald SD; Canadian Neonatal Network; Canadian Preterm Birth Network Investigators.Am J Obstet Gynecol. 2022 Jul;227(1):85.e1-85.e10. doi: 10.1016/j.ajog.2022.01.001. Epub 2022 Jan 6.


van Veenendaal NR, van der Schoor SRD, Broekman BFP, de Groof F, van Laerhoven H, van den Heuvel MEN, Rijnhart JJM, van Goudoever JHB, van Kempen AAMW. JAMA Netw Open. 2022 Jan 4;5(1):e2144720. doi: 10.1001/jamanetworkopen.2021.44720.


STORCH Infections Among Very Low Birth Weight and Preterm Infants: 2018-2020. Edwards EM, Greenberg LT, Ehret DEY, Soll RF, Lanzieri TM, Horbar JD.Pediatrics. 2022 Jan 1;149(1):e2021053655. doi: 10.1542/peds.2021-053655.


Gover A, Levy PT, Rotschild A, Golzman M, Molad M, Lavie-Nevo K, Kessel I.Pediatr Res. 2022 Oct;92(4):1146-1152. doi: 10.1038/s41390-022-01944-w. Epub 2022 Jan 27.


Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants. Morgan J, Young L, McGuire W. Cochrane Database Syst Rev. 2014;2014(12):CD001970. doi: 10.1002/14651858.CD001970.pub5. Epub 2014 Dec 1.


Birth Outcomes of Neonates Exposed to Marijuana in Utero: A Systematic Review and Meta-analysis. Marchand G, Masoud AT, Govindan M, Ware K, King A, Ruther S, Brazil G, Ulibarri H, Parise J, Arroyo A, Coriell C, Goetz S, Karrys A, Sainz K. JAMA Netw Open. 2022 Jan 4;5(1):e2145653. doi: 10.1001/jamanetworkopen.2021.45653.


Antiracism in the Field of Neonatology: A Foundation and Concrete Approaches. Montoya-Williams D, Fraiman YS, Peña MM, Burris HH, Pursley DM. Neoreviews. 2022 Jan 1;23(1):e1-e12. doi: 10.1542/neo.23-1-e1.


Goulden N, Cousins M, Hart K, Jenkins A, Willetts G, Yendle L, Doull I, Williams EM, Hoare Z, Kotecha S.JAMA Pediatr. 2022 Feb 1;176(2):133-141. doi: 10.1001/jamapediatrics.2021.5111.


 

The transcript of today's episode can be found below 👇

Daphna 0:00

Hello, everybody, welcome back to the podcast Daphna. What's going on?


I'm good. I feel like a lot has happened since our last Journal Club. We've been busy. But I'm excited. Yeah,


Ben 0:55

we recorded a bunch of episodes. And, and this, I think people are going to be excited about our series about with the giants of neonatology. Because I thought I had this idea in mind, and we have some personal connections with Dr. Wily Carlo, that allowed us to make that interview happen. But I thought if we make it a series, we're going to have to reach out to all to all these more senior and older neonatologist and it's going to be such a difficult


Daphna 1:27

yes, they can say, you know, and they were like


Ben 1:31

the most easygoing people your email here, these guys are like 75 years old, and you say, Hey, do you want to get on like a zoom call talk that I yeah, what are we doing this? And


Daphna 1:43

they're like, they're kind of cute, because they're like, did what about my friend so and so do you? Do you know my friends? Yeah. So we'd love to record with


Ben 1:55

ya when Dr. Martin tells us. Do you know about Dr. fanaroff? Like, yes, we do. We read the book. So yeah, this is fun. You're right. We have a lot of great guests this coming year. I mean, this is going to be a great season for the podcast. And and, and this is fun. But I'm super excited about today's Journal Club. The articles are magical. And, and I can't wait to go over some of the data presented because it's just awesome. So you want to get started?


Daphna 2:26

Yes. So this first article is in ACTA paediatrica. The title is kangaroo mother care how to protective effect on the volume of brain structures in young adults born preterm. The lead author, Natalie Napoli char pack. This is out of Colombia, which is actually not a surprise because Colombian teams were really the pioneers of kangaroo care. Colombia, the country, Colombia, the country, yes. Coming from, from Bogota. So the fact that they were able to do this follow up is is actually really cool. So this was part of a long term follow up study of kind of one of their first randomized control trials about kangaroo care that was conducted in Bogota, between 1993 and 1996. So that trial studied 746, preterm and full term infants born weighing less than two kilos, and participants were stratified into four categories by birth weight. And then subjects in each group were randomly allocated to either kangaroo care, or the control group, which was like standard neonatal care in the incubator. The present study is


Ben 3:47

Can I interrupt you for a second? Yeah, did you I didn't know this study. So of course, I


Daphna 3:51

know this study. So. So then,


Ben 3:54

you know, so then I went back and read the original study. Yeah. So you realize that these mothers were delivered? They were assigned the kangaroo care group. And sent home? Yeah. Yeah. I mean, the To me that was


Daphna 4:11

basically,


Ben 4:12

yeah, they were sent home with, like, small babies with their very small babies. And then I looked, and I said, Oh, you know, I thought, you know, this is going to be like a study of like, kids that were weighing 2900 grams. No, no,


Daphna 4:25

no, in fact, I mean, most of them are smaller than we discharge babies home today.


Ben 4:31

Yeah, I mean, I was looking and in the kangaroo group. So I feel like in the control group, nothing really is really surprising. But they had like 382 Kids in the kangaroo care group. And like 26, were weighing less than 1200 grams. You're looking at the number of them that were less than 32 weeks. It was like 137 kids. And to me, it's mind boggling that they this is not the place I was Looking back, and I was like, oh, maybe they went into a small village where that's what they did anyway. But no, these are delivered in the hospital. And God randomized. And they're like, they're On you go.


Daphna 5:15

Yeah. And I mean, it's really remarkable. And actually, I mean, maybe now's a good time to talk about, like what they found in in the first study. So they weren't looking at brain volumes in that study. But they looked at Oh, hold on. I don't have the I don't have the results of the first study. I have them in front of me Do you want? All right, well, just just talk about the first study then I guess.


Ben 5:42

Oh, yeah. So then. So that was pretty much right. So that was the premise. So then half of them were randomized to I guess what we can call routine neonatal care placed in an incubator? Not not, I'm not sure if in the original study that so the babies that were in the incubator, were not being given kangaroo care, until they were ready to come out of the isolette. And the others were,


Daphna 6:06

yeah, medically stable for


Ben 6:08

Exactly, exactly. And so then the other group was sent home. And what they found was that in terms of the outcome, there were no differences in growth. Actually, the patients who went home on kangaroo care had less infections like like less nosocomial infections. And the obvious hospital stay was shorter. Kangaroo care. And I think they were trying to do more than anything, a proof of concept to show that kangaroo. I mean, at the time, they called it kangaroo mother care was like a safe approach to babies who were clinically stable. But obviously, the point was to do long term follow up. And today, we get to review the longest follow up that they were able to do when these kids are like now in their late teens, early 20s.


Daphna 7:00

Yeah, they also did this additional study, which I guess now's a good time, to mention, really about kind of how did it affect Parent Infant bonding. So they had another 20 year follow up study that reported that parents in this kangaroo care group were found to be more protective and nurturing the children had less school absenteeism, and a more stimulating home environment and they had higher IQs. Even in the most fragile groups. And interest. This is striking, but the kangaroo mother care had a greater impact on the quality of the home environment when the mother had a lower level of education. And the family had a lower socioeconomic status. So it just goes to show you that our highest or highest risk infants really need like the most kangaroo care. Young adults who were premature and receive kangaroo mother care, were less hyperactive, less aggressive, showed less internalization, externalization and less socially deviant conduct. And furthermore, parents who were involved in kangaroo, Mother care knew their children better. So that was really cool. So what they wanted to do in this additional 20 year follow up of the same cohort, they was to look really at brain volumes, and also some like psychometric testing. So they had 433 subjects, the from the initial group, they were weighing up to 1800 grams. 412 of these survived up to one year and 264 were traced and re enrolled in this study between 2012 and 2014. It's also interesting what they did for the control group. So in 1995, they traced back a cohort of full term healthy newborns born at the same hospital where the original RCT was performed. And so they found 37 of those adults who were born full term and healthy at the same time. And they also underwent the same testing as a randomized control participants so that they can have reference values for the study. Just a little more about what did the kangaroo mother care intervention again, exclusive or nearly exclusive breastfeeding, prolonged continuous skin to skin contact in the kangaroo position, and early home discharge and kangaroo mother care with daily follow up visits at an outpatient kangaroo mother care clinic so the parent the mother really basically served as the infant bear in the those kinds of leader weeks. These daily visits continued until the appropriate weight gain had been documented, and then they took place weekly until the infant had reached 40 weeks of gestational age. And then, like you said, the preterm infants who received traditional care were kept in incubators until they achieved to normal temperature regulation, and they were discharged according to hospital practice, which was about 1700 grams, which is still less than a lot of us are discharging babies today. And and then both groups, this, this group received the usual outpatient care a lot. So what they were looking for the outcomes of interested 20 years were cerebral volumes of gray and white matter, the organization of the white matter. And then they did some neurologic and neuropsychological tests. So those included cognitive performance measured using the Wechsler abbreviated Scale of Intelligence, or the wasI, to looking at fine motor skills and coordination using the nine hole peg test, and the learning and memory assessed by the California verbal learning test. So to start with their statistical analysis, more infants in the control group, then the kangaroo mother care group died during the 20 year follow up period, which is super interesting. And so they did anticipate a survival cohort effect and they fitted this Rosch model, which, admittedly, I didn't know anything about, it really had to look at, but to estimate the overall degree of kind of vulnerability, which they called the fragility index attributable to the factors that were present before allocation. So they basically found 22 additional binary items about the infants characteristics that overall taken together provided a score that represented a type of severity index for that patient. And then this provided a composite variable that kind of represented the joint potential for confounding and was used as its own covariant in the adjusted analysis. Anything else you want to add about that modeling?


Ben 11:54

No. Okay.


Daphna 11:56

So other 264 young adults re enrolled, who underwent neuro imaging, they did have to exclude some so 18 They found born at term and 68 of the images had to they weren't able to use because they had like braces or other dental implants, so that they couldn't use the MRI imaging. So they were left with 178 participants with reliable MRIs 97 of which had received kangaroo mother care and 81, or controls, which actually, I think is a pretty decent 20 year follow up. So I really, really impressed regarding the starting characteristics at higher proportion of those who receive kangaroo mother care were male, they had received invasive ventilation had been hospitalized in neonatal intensive care unit and had a higher severity index. So in general, they were kind of the worst off group. They had a shorter median hospital stay again, because that's what they were randomized into. And they had a lower gestational age and weight at discharge than the control group, which makes sense.


Ben 12:59

Do you think they're gloating about the fact that they had a lot shorter hospital stay? Like we know we get it fine. You sent them home,


Daphna 13:05

you sent them home super early. But I mean, I think it just shows, I think it's just super inch. This is a super interesting study. And it just shows that the that based on our usual characteristics of well being I mean, this this group was higher risk. Basically, what they did when they looked at the preterm STEM subjects all together, which isn't surprising, they had smaller volumes and all structures except in the amygdala. They had smaller fractional anisotropy and smaller length and total white matter fiber content. So that's really talking about kind of the organization of the white matter. But when they looked at the the two groups, the kangaroo mother care group had larger volumes of total gray matter and cortical gray matter and subcortical gray matter in the stratum hottie in the putamen, there's no difference in the volumes of the Cubans nucleus, the globe is pallidum, the amygdala, the hippocampus, the thalamus or cerebellar gray matter. With regard to white matter, the kangaroo mother care group had significantly higher volume of corticospinal tracts. No differences were found in total fractional anisotropy or the fiber length or total fiber count. And then they were looking for markers really of cognitive function. And you love it when they say this, but when they give us these kinds of parameters, so they found for each day of kangaroo mother care, the volume of total gray matter increased by point one five millimeters cubed after adjustment for the Severity Index, and their cognitive testing that we see to full scale Composite Score also increased by each day of kangaroo mother care. And they also found a similar Association for the volume of total sub court Recall gray matter which increased by point one five millimeters cubed per day of kangaroo mother care after adjustment for the Severity Index. They also showed that for each day of kangaroo mother care, the total volume of the cardiac nucleus, the putamen at humans nucleus increased by point one nine millimeters cubed. Even after the data was controlled for the severity index and the cognitive function, they also found that the total volume of the cognate nucleus increased point to four millimeters cubed after it was controlled for the Severity Index, and some of the other cognitive scores and that the cerebellar volume increased as well. So I just thought this, this was an interesting study. I mean, the volumes are bigger. What does that mean, exactly? It's hard to say. But certainly, you know, they did have these, the wasty to full scale composite scores to show that, that there were increased scores.


Ben 16:03

Yeah.


Daphna 16:06

And then again, they had that other follow up study that just talked about kind of Parent Infant socio, like emotional regulation, which is really cool.


Ben 16:16

Yeah, I mean, this is, this is mind blowing this study, to be honest with you, I think, number one, you think about the fact that they did their original studies in the late 1990s, right? This was not a time where you were sending patients home on kangaroo care in the 1960s, where you're like, you know, what we have to offer in the ICU is pretty much not much better, like the NICU was were well developed at that time. So to send babies home at 1100 grams, 1200 grams on kangaroo mother care with, with no IVs with no meds and all that stuff. It sounds like a recipe for disaster. So the fact that they did okay, and survived and all that was already very, very impressive. The fact that it did better, is insane. I mean, it's


Daphna 17:07

it, some babies will do well, in spite of us.


Ben 17:11

And I don't know, then if, and I do think where this paper is really crucial. Where does this so what does this paper tell you really, but I think we're going to talk about this later in the episode where the fight care model is the is the alternative, in my opinion, because obviously, you cannot send babies home. In this environment, it may not be the safest. But the idea of providing kangaroo care in the family centered care model, integrated family integrated care model is is something that probably is the solution. Alright, so 17 minutes in, we have to move on to many other articles I'm going next. So this was my favorite article of the week, I guess, the month whatever, whatever interval we're looking at. This is an article that was published, I don't know where actually, this article was published in the American Journal of Obstetrics and Gynecology. And the title of the article is association of umbilical cord blood gas values with mortality and severe neurological injury in preterm neonates less than 29 weeks gestation in national cohort study, so a long winded title, and I thought this was gonna be a super boring paper. First of all, kudos. The first author is Prakash Shah, Dr. Prakash Shah, and it's on behalf of the Canadian neonatal network and the Canadian preterm birth network investigators. So first of all, to the authors who wrote this paper, kudos super clear, super well written it was. So the objective of the study was to explore the association of umbilical artery and umbilical vein blood gas values with neonatal mortality, and severe neurological injury in a cohort of babies that we're born below 29 weeks of gestation. So how did they do this? This was a retrospective cohort study of preterm neonates the collected data from 2018 to 2019. And this included 31 level three units, so pretty large multicenter the study population included neonates born between 23 and zero to 28, and six and these babies had UA or UV blood gases. And they excluded a lot of babies, which I think was interesting. You can look at the exclusion criteria, but obviously major congenital anomalies was what was one thing they looked at excluding babies who are small for gestational age babies who were large for gestational age, and those whose reason for preterm birth was either into the uterine rupture, placental abruption, or antepartum hemorrhage. I think the idea was was smart if you're trying to assess the blood cast values if the maternal history or the delivery history is so significant that you could have a massive confounder that or to maybe exclude and clean up the data this way. The sampling of the bill chord chord was done immediately after birth. And they have a bunch of explanations as to how did they deal with the data? Like, if the data didn't make sense, how do they interpret some of that? I think it all made a lot of sense, there was no issue. The kind of values that they used for pH, were either you had a pH of 7.2, or below 7.1, or below 7.0. or below, they did the same thing with P co2 55 and or above 65, or above 70, more than 75. And then when they looked at the base success, they had minus eight or or, or more minus 12 or more minus 16 or more. And they also looked at lactate, which is something that I don't know about you that when I was training, we didn't look at that tape as frequently as we do, for example, in the PICU. So it was interesting that they had an active values there as well. We used a lot of lactate. Interesting.


Daphna 20:55

Yeah. It's especially like say an Hae case, we had a lot of cardiac cases. But yeah,


Ben 21:00

so So yeah, so the lactate for the same same year, HIV cardiac cases, but not routine, like it was was not like any LBW always got lactate check, right? That's true. So lactate will either more three or more four or more, or five or more the outcomes that they were interested in were mortality. So obviously, whether they be lived or died and severe neurological injury, which they defined as a great three ivh or greater, or parenchymal injury, including PVL. And that was diagnosed either on cranial ultrasound, or MRI. So the the results included 1566, neonates with either a UA or UV blood gas. This mean gestational age was 26 weeks, the mean birth weight was 937 grams. And in the study cohort, the overall prevalence of mortality and severe neurological injury was 10% and 9%. This is very important, because we're going to talk about pretest and post test. And if you are studying for the boards, first of all, subscribe to the incubator annual review podcast. But this is something that's critical, right? So the pretest, and post test, so the pretest probability as your incident, it's like so all things consider what is your baseline risk of having these issues. So in this case, mortality rate in this unit, or in this network was 10%. Fine. Now, what we're going to try to find out is, as we get these different lab values, how does that change your likelihood of having the outcome after this test has happened, and that's your post test probability. So for the umbilical artery gas parameters, significant increases in the odds of mortality were observed with both with lower pH with higher co2 with lower base access and higher lactate values. So so far, that was not surprising. However, with the UV gas parameters, and increase, an increase in the odds of mortality was identified only with higher lactate values. So the values for pH P, co2 and base excess did not really become really significant factors. And I think that was very interesting, because many times we will just get a UV and forego the UAE, and use that association between severe neurological injury. And UAE or UV blood gas values were observed only for lactate levels in the umbilical artery. So again, and so then they looked at sensitivity and specificity of UAE and UV blood gases. Value corrupts. And so let me just go into some of the results because this is the meat of the paper. So for the outcome of mortality, the umbilical artery pH value of less than seven and less than 7.1. And the UAE base excess of less than 12, less than minus 16, were associated with an increase in by 25% in post test probability for positive tests, whereas lactate values of less than three for both UA and UV, were associated with a reduction by 7.5%. In post test probability for negative test for the outcome of severe neurological injury, you use a basic set values of less than minus 16 was associated with a an increase of 22.5% post test probability for severe neurological injury. And lactate values of less than three were associated with a decrease of 6.75% and post test probability for severe neurological injury. So this, this is a lot of numbers. And I suggest that you download the paper and that you look at specifically table two and table three. So table two basically looks at the umbilical artery and Venus values for PHP co2 basics s and lactate. And you remember that in the case of mortality, we're talking about a 10% incidence And then you'll look at the column before last, which says post test probability for a positive positive test considering your 10% prevalence, which means if let's say the first line, the first line is a UA with a pH of less than 7.0. What is the post test probability? So you know that the mortality prevalence in the unit is 10%. If you have a pH of less than 7.0, that post test now goes to 38%. So you really see that


Daphna 25:26

jump? And so if that's how it feels when you get that, yes, yes,


Ben 25:29

yes. So to be honest with you, I think that the categories that they used were both interesting and uninteresting. So for example, for the babies who have a pH of less than seven and a basic sets of minus 16, I didn't really need this paper to tell me that, yeah, their outcomes are pretty bad. Because I know that this is associated with with really negative outcomes. What was interesting to me was the 7.1, the 7.2, the success of minus eight minus 12. Because we see these kits, they come out, and they have 7.15 and minus 10. And you're like, alright, I can fix this. And but does it does it have really important significance. And what we find is that the UAE is very good in terms of providing you the data that you need. So when you look at the UA, and you have a pH of 7.2, or 7.1 or less, you see that the post test probability increases from 10% to 14%, if the pH is 7.2, and to 26%, if it's 7.1. So these are not benign. When you're looking at your B success, obviously, a basic sense of minus 16 or less is is going to be associated with a high incidence of mortality. In this case, the risk the post test probability was 58%. So we went from 10 to 15%. That's, that's nuts.


Daphna 26:44

And you said or less, but you mean, more, more negative?


Ben 26:48

Yes, thank you for clarifying that. But when you look at the basic says that is minus eight, okay. Or, or more negative than that, right? or greater? Greater is that? Yeah, great. Yeah. So the post test probability went from 10, to 8.8. So it actually went down, right. But when you look at minus 12, it goes from 10% to 27%. So there is a huge like this is this is a an area of this is a transition area that we should pay attention to. Now, when you look at the UV, it's not very impressive. The post test probability whether you have a pH of 7.0 7.1 7.28, just goes from 16 to 15.7, to 12.7. So obviously, less than 7.0 is never good, whether it's on a UA or UV. But once you get to a seven point to want to have enough gas, it's quite close to the original pretest probability. And same thing with the basics s minus eight or greater, the post test probability is 1.7. So it actually goes down in terms of mortality, but minus 12 actually gets you from 10% to 17%. So the trends make sense. I think it's, again, I'm trying to make a case for you guys to just go and look at those tables. And they did the same thing with a severe neurological injury. So I think this is very interesting. Because we tend to pay a lot of attention to the first gas of a full term baby, think about cooling, we think about neurological injury. But because cooling is not an option for babies that are born extremely preterm. I'm not sure if we pay as much attention to the initial gas, and what are the long term consequences of that gas for the course of the baby. And when I think I'm talking for myself, here, I'm focusing more on how am I going to fix this quickly and get this baby back to a normal lab values, normal pH, no more co2, and so on and so forth. So that was super interesting paper. The conclusion obviously, is that in preterm neonates, less than 29 weeks low umbilical cord, arterial pH and high umbilical cord arterial, the success values were associated with a clinically important increase in the process ability of mortality. Whereas a low umbilical cord arterial or venous lactate values were associated with a decrease in the post test probability of mortality. So


Daphna 29:04

yeah, I mean, I took a few things from it that obviously, I mean, when you're evaluating, you know, acid base status and lactate and perfusion that the I mean, the arterial blood sample is the gold standard, right? So it matters. And maybe you don't get the UI, but maybe you can get one arterial, you know, sample so that you have that information. And it's interesting because in general, you were taught and we see clinically that the preterm baby seems to tolerate hypoxia better than then the full term baby but they weren't comparing preterm babies to full term babies, they were comparing the whole cohort of preterm babies. So it stands to reason that a preterm baby who has some decreased perfusion for some reason and they look, you know, they don't list all the reasons or all the clinical scenarios, but that that something's going on right and it could be a key EWT or it could be chronic. And so it's interesting. I think it's something we have to remember when we're, you know, providing anticipatory guidance for families. And not just that those babies with the worst gas additionally are at risk for, say, the bleeding in the first week of life. But that it's even even after that. There's some some things that we we can't see going on. Very interesting.


Ben 30:28

All right. Are you taking us next step?


Daphna 30:30

Well, I guess since you alluded to it, we might as well do the family integrated care model. So this was in JAMA, but in the Open Network, journal, and in the pediatric section, so association of a family integrated care model with paternal mental health outcomes during neonatal hospitalization. Later author and Nicole van Veenendaal. We practice we should practice these before


Ben 31:04

on your own on this one, where are we from the Netherlands.


Daphna 31:07

This is from the Netherlands. Which, if anybody could pull this off, it was in another bunch. So I'm really impressed by this study. So this was a prospective multicenter cohort study conducted from May 2017, to January 2020, as part of this larger study, family integrated care in the neonatal ward study, done at level two units throughout the Netherlands. So for this study, one use this family integrated care model, and the two other control sites use it used standard neonatal care. And so let me explain to you with their family integrated care model. Yes, please. Yes. So this was single family rooms. However, the most important part was that they had complete complete care for the mother infant dyad, during maternity and through the neonatal stay. So mom's recovery was completely done in conjunction with the baby at bedside. So mommy bed and an incubator or bassinet, right nearby. Mothers never had to be separated from their infants and fathers could also remain throughout the entire stay.


Ben 32:29

Never, the answer wasn't you never, never had to be separated, they never


Daphna 32:32

had to be separated. Yeah. And I think even more, just as importantly, parents were being trained to be the primary caregivers for their babies with nurses serving only as a supporting counseling and educating role. So so and they talked about this in the paper, it wasn't just the family presents, but it was that the families really not only participated, but really took over the infant's care


Ben 32:57

took over the care. So the room was meant to be the baby in the mother's room while the mother was still hospitalized. And then the mother can room in after discharge in the same room as the baby. And she was encouraged to the parents were encouraged to take care of the baby as many hours during the day as possible. And if they elected to leave for running errands and stuff like that, that's only only then would the nurse kick in right, and then start taking over the care. Or the nurse would kick in and the nursing care would kick in. If the parents asked for help or something like that. And they would allow I think I read somewhere in the paper that they would allow siblings in the room as well. Absolutely. Yeah.


Daphna 33:35

This was notably in pre COVID time, but still. So the families enrolled had infants less than 37 weeks in any anticipated stay greater than one week. And again, you know, this was a level two, these were level two units, so not our sickest babies. However, sir, certainly the same could be said that same thing could be done for a higher acuity group. So they looked at a variety of outcomes around paternal mental health, which is also really cool because we are really just starting to study. Dads are the supporting parents mental health, you know, just in the last five to eight years, we've looked at mothers or the the laboring parents mental health, and now we're extending it to the rest of the family, which is really important. So they used a variety of scales. They looked at the parent, the parental stress scale, the NICU hospital anxiety and depression scale, the postpartum bonding questionnaire, the perceived parenting self efficacy, scale and satisfaction with care and the parent participation or the CO partner tool to look at was parent really participation in the care a mediator of the of the five care model effect? So they had three under nine families included in the initial study the family integrated care in the neonatal ward study, and 263 Fathers, so 85% Of all the families agreed to participate 126 Fathers were enrolled in five care and 137 were enrolled in kind of standard neonatal care. And like I said, the control group were infants in left open bay units that were single day.


Ben 35:26

Yeah, so that's important. The controls were not in a single room, there weren't an open day, NICU.


Daphna 35:33

Yeah, and that's interesting for firm by a variety of reasons. They didn't look at developmental outcomes here. But that's something.


Ben 35:41

But that's the thing I wanted to mention is that this study is part of this Amiga study, which is the feminine integrated care neonatal ward study, which aims to look at the development of babies. So this made me really excited for whatever's coming next from this larger study.


Daphna 36:00

Yeah, and for anybody who's not kind of up to date on that, so when a lot of units were moving to single room units, they found that actually, the developmental outcomes suffered a little bit, because the babies who were in these large bay units were getting stimulation, not all of it was good stimulation. But some of it was good stimulation, hearing people talking to other language talking to one another. And so we know that the preterm baby is really impacted by the literal bulk or number of words that they hear every day. And so if you have a very active family in a, in a single family room, that baby can still do very well, if not better. But especially given our, you know, standard parental presence here, let's say the United States or the ability of parents to be in the unit because of our parental leave policies. I mean, we don't typically have parents who are in the rooms around the clock. Obviously, the Netherlands have a different health care and leave policy than we do. So they're able to do a study like this. So back to the study, no differences were found in baseline characteristics between the fathers who were responders and non responders, so that 15%, who did not enroll in this study, newborns in the fikir model have lower gestational ages, so 32 weeks, one day compared to 34 weeks and zero days, and longer hospital stays 39 days versus 21 days compared with the standard neonatal care group. So that's interesting, especially when they when we see the data on the developmental outcomes. That is something of note, fathers in the fikir group experienced a higher level of stress at birth than fathers in the standard neonatal care group. So basically, that was kind of like their starting stress scores before they were enrolled in in an intervention or the control. And then they looked at discharge. So father's total stress score in the family care model was lower than those of fathers in the standard neonatal care units. Fathers in the family, the five care model participated more in the care of their newborn, compared with those in standard needle neonatal care. Specifically, in the fire care model, fathers were more often able to be present and had higher total participation scores. They searched less for information during hospital stay, and participated more in the overall medical care, including things like tube feeding, monitoring of the newborn regulation of visitation to the newborn, and participation in daily rounds than those fathers involved in. In standard neonatal care. They also indicated and being an advocate of their newborn more, which actually comes up a lot in research about father's in the NICU. And then they wanted to see was it the family integrated care model? Or was it because the dads participated? Didn't we're doing more hands on care. So they did find that increased total participation in the five care model was associated with fewer depressive symptoms, and lower impaired parent newborn bonding scores. The five care model itself was associated with less stress for fathers at discharge compared with fathers and standard neonatal care, but that parent participation was not necessarily a mediator of this association. In father's participation in the neonatal care was not a mediator necessarily the association between the model and their self efficacy at discharge or with their satisfaction for care. So this was interesting because you even though the dads were there more they may not it wasn't necessarily that they were doing the hands on care more that that mediated the the effect. They also alluded too What does this mean for babies who aren't in an enrolled in family integrated care? Model or are in a large Bae unit? You know, can we engage parents, especially dads in care and change outcomes? So, I mean, I thought this was an interesting study, I think the model itself is very interesting. And you've talked about this medicine has kind of swung from when we used to do all of our medical care like in a very home like environment to now we've really swung in the other direction, and maybe these couplet care is kind of a way to swing more back to midline.


Ben 40:48

Yeah, trying to, to re to merge again, OB and neonatal care a little bit more not make it as separated. I think the fact that a lot of NICU and OB postpartum areas are in different floors, sometimes in different buildings, like that's just the extreme opposite of where we should be. And I think, for people putting this into perspective, where it's like, this is doable, like they're doing it. Yeah. This is what's great about these papers is that this is not theory. This is not somebody that says, I believe that if we were to do XYZ, this like, they're like people, they're they're doing it, like they're having the mother and the baby in the same room. It's happening. And and they're seeing some positive outcomes, especially when we're talking about maternal mental health in this particular paper, and we'll see whether your mental outcomes will be like,


Daphna 41:35

yeah, obviously, again, they have a different structure for health care, and for parental leave, which is a whole nother, that's a whole other that coherence can be present at the bedside.


Ben 41:48

And we're gonna have on the podcast, Sarah De Gregorio who's the author of the book early in which she she goes through some of the history of neonatology. And she talks about her own experience being a NICU mother. And throughout the book, she does mention how her husband had to basically keep working so that they wouldn't lose coverage for health care insurance. And then it's very stressful, I feel like and especially not just on the family, but on the father where the father makes the sacrifice in this case, I mean, to me, it makes sense. But it makes sense that the Father would be the one making the sacrifice, especially after birth, but it's still a lot of things to ask from the spouse from the supporting partner to say, hey, like, yeah, you're not going to be in NICU as much, yes, you're, you're going to go back to work while your baby is between life and death in the NICU. Just so that we don't lose our health insurance. That's, that's wrong. It just it feels like we could do so much. We're better than that. And so anyway, I'm, I'm curious to ask her about how that went. Because, because she went through it. And


Daphna 42:44

yeah, and I mean, especially for households like mine, and for households like yours, where, you know, the the father figure shares, like, you know, a lot of the child rearing burden. And, I mean, my daughter is just as bonded to my husband as she is to me, you know, and so this would have a neonatal admission, for him, would have been really difficult, you know, having to not have and at that time, he didn't he, there was no parental leave of paternal leave, and so he wouldn't have been able to stay. The other thing I want to mention about this study that I think they did a really good job with, is that they assigned the term father really was any parent was any partner of the laboring parent who was going to assume a parental role. So they did include same sex couples. And I think that's really important because it, it may or may not matter the sex of that, that the partner or the second parent, but some of these stressors are the same no matter no matter what sex, depending on the table, again, no partners, you know, so anyway, so faxes, please, we have to study all of all of the parents involved.


Ben 44:01

Yeah, I think that was really good. The way they did it, they very, very quickly in the methods and in the introduction, laid it out. Like there's no bias here. And we're like 45 minutes, and we're really behind. So there's a bunch of papers I want to go through relatively quickly. So forgive me, I want to go over two papers quickly. The first one was published in pediatrics, and is basically a report from the Vermont Oxford Network and it's called storage infections among very low birth weight and preterm infants. 2,018/2021 author is Erica Edwards who's Yeah, and Roger soul is on it who's published a ton of stuff with with Vaughn. And this is a very, very short paper. It's a it's a brief report, as they call it, and the goal was really to try to provide population based prevalence rate for storage infection. Listen, I knew these as taught before now the then i i was I feel so old now. But I'm like I knew when they went from torch to torches, now they went to storage. So you know, you know what we're talking about. And basically just trying to provide incidence for very low birth weight infant and preterm infants in the United States. They looked at data from 2018 to 2020. And they looked at toxo, rubella, syphilis, CMV, herpes, Parvo, B 19, Zika, and very sad, and varicella. And they basically reported their outcomes. And it was interesting that obviously, the more the, the prevalence of storage infection was 7.4 for 1000 births, the most common was CMV, with a rate of 3.37 per 1000 births, followed by syphilis with an with a rate of two per 1000, followed by herpes. And then after that, it drops off. So herpes was 1.8, per 1000. And it really drops off then for Parvo, toxo, rubella, varicella, and Zika. I think, a few things that were interesting is that infants with CMV, had the lowest birth weight, and were nearly twice as likely to be SGAE, or microcephalic. as infants without infections. However, the babies with CMV were the least likely to just have isolated microcephaly. So it was interesting to hear that that it was always in combination with something else. Survivors with CMV had the longest length of stay. Only 70% of mothers of infants diagnosed with syphilis, with syphilis received any prenatal care compared with 96% of mothers without infections. And the babies with and without infections with Tosh infections had similar survival rate of about 86 to 87%. The big the big caveat with this paper, obviously, is the fact that there is no standardized guideline for universal screening of this disease. So the baby's not every baby is screened for CMV to give you the true rate of C CMV in the population. And I'm not being critical that you mentioned that in their discussion, they do say, quote, We do not know whether NICU is performed universal screening for such infections. And so obviously, they may be under estimating the prevalence of this disease. But obviously, like we said, yet, last last time, when when one of these big networks come out with data, you should be aware of it and so we brought it up to your attention, and you can go check it out. The next paper I want to go into because I had some issues with it. And I just want to briefly mention it so that we can talk about it because it came up on Twitter. This is a paper that was published in pediatric research. And it's called oral versus IV paracetamol for PDA closure and preterm infants. first author is alr. Grover, and this is a paper out of Haifa, Israel. And it was a very interesting idea right about like in terms of closure of the PDA, if you're using Tylenol do you do IV versus po and they were looking at the rates of closure between the two treatment. And I'm going to spare you a little bit of the details because the conclusion of the paper was that oral administration of Tylenol as a first line agent is more efficacious to constrict the PDA than the IV route, irrespective of gestational age or course duration. It looked at a lot of different factors, using it but one course follow up another course et cetera, et cetera, the only you looked at babies that were born preterm that had hemodynamically significant PDA and and that were only treated with Tylenol. Now the big issue with this paper that I have is that it was not prospective, it was retrospective. And at the end of the day, when they talk about the administration of Tylenol, and I quote, they said the attending neonatologist determined the initial route of administration. Now, I don't believe that these neonatologist, who have published in the past who are very well qualified, do this at random, I think there's a lot of factors that influence whether you give Tylenol po or IV for PDA closure, because you can say this baby is really sick with some gut thing. And so I can give it to. And then if all these factors start entering into discussion, then maybe the baby who got it IV because they couldn't get it to because they have some inflammatory process going on is also the reason why their pa may not have posed as readily as the kit was receiving pill. And the bottom line is, is that it's not the author's fault. It's the it's the fault of the of the retrospective study design, that you can't really do anything about those things. And I think that this is in my you can read it. And I think it's interesting data. But I do think that, again, this is where the retrospective model can sometimes be an issue. So I just wanted to mention that paper. And that it would be interesting to see if when they do when they do randomize these babies we can see a different outcome. Before Is there any? We have we have we have a few more articles to go to. So let me talk about one more article which is a Cochrane review. So the Cochrane Library published a paper called delayed introduction of progressive enteral feeds to prevent necrotizing enterocolitis in very low birth weight infants. first author is Jesse Morgan. This is from a group out of the University of York in the UK. What they wanted to know, was basically, what is the effect of delaying the introduction of progressive enteral feeds I was very puzzled by what do they mean by progressive atrophied meaning feeds are meant to be increased, not just like a trophic type of feed that stays on for four or five days meaning the field that when you began, you're expecting to go up by 20 to 25 ml per day. And they wanted to know if the effect of delaying the introduction of enteral feed had any incidence on either necrotizing enterocolitis, mortality and other morbidities in preterm or very low birth weight infants. And so let me they looked at babies that were born less than three, two weeks, or less than 1500 grams, and the primary outcome was any see. And all cause mortality, they had a bunch of secondary outcome that included growth, the time to regain birth weight, long term growth, neurodevelopment time to establish for enteral feed time to establish oral feeds, feeding intolerance, incidents of invasive infection, and duration of hospital stay. A very importantly, what did they define by delayed introduction of feeds if you waited four days or more, to actually start? So I am wondering what your thoughts are. So they were able to identify 14 trials that met the requirements for the quality of the evidence and for other obvious requirements from the Cochrane Library. And then you look and three of these seven trials were published in 1986 1987 1994. And I'm not disparaging


Daphna 52:08

here because now I mean, now it will be hard to find it's, it's nearly impossible to find a trial where they're delaying feeds


Ben 52:15

true, but then the question that I have is that I'm not questioning the quality of the evidence that's being pulled. But the state of neonatology and neonatal care at those times was so radically different. I'm wondering if this is something that's still usable today, considering how donor milk all these other options that we have today, surfactant, I mean, all these things that 1986 is like, I was two years old. It's a long time ago, a long time ago,


Daphna 52:44

it's a long time ago, especially for a field like neonatology. Right.


Ben 52:49

So they were able to identify 14 trials. Some of them, like we said, were quite old. And, but a lot of the more recent ones were included, including including one from our friend, Dr. Ariel Salas, who's going to be on the show in the coming weeks. The total number of patients included was 1551. And looking at the outcomes, the first primary outcomes was necrotizing enterocolitis. And data from the 13 trials showed no difference in the rates of any see between the when the introduction of Progressive Field was delayed, they did some subgroup analysis, but that really did not change this outcome for mortality data from 12 trials did not also show that delaying progressive enteral feeds was affecting death before hospital discharge. Looking at some of the secondary outcomes. When it looked at growth, some trials reported time to regain birth weight. Other trials reported weight gain during the trial period. And I think one other trial reported the rate of weight gain but none of these, these data points helped differentiate whether delaying introduction of progressive feeds had any effect on growth. neurodevelopmental outcomes were not measured by any of the trials, the time to establish for enteral feeds was longer in the delayed introduction group. In a selected group of trials, the time to establish for oral feeds none of them. None of the trials assessed reported that that variable feeding intolerance the main analysis from six of the trials shows that delaying the introduction of progressive material fields slightly reduced the risk of feeding intolerance. And, and one trial actually showed from 1994 showed no difference between the two groups, invasive infection, seven trials were assessed and the delaying introduction of progressive enteral feeds increased the risk of invasive infection. Looking at the duration of hospital stay The longer hospitalization or longer stay in the hospital was found in the group that was delayed in terms of the introduction of feeds. So, at the end of the day, this makes a case for not delaying the introduction of feeds. And the sooner the better. And you were the one who sent me that tweet about this protocol, the feeds one trial, where Yeah, so this is the trend people are looking at feeding earlier earlier earlier, faster, really trying to see if TPN altogether can be bypassed and just go straight to four feeds. So that that's going to be cool.


Daphna 55:32

Yeah, we'll have to keep an eye out for that study.


Ben 55:34

Okay. So Sorry for going through so many articles, but we have two or three more articles that we want to go to that we don't want to cut short. So all right, definitely. Where are we going? Next? We have


Daphna 55:46

my turn. Is that a restful year turn?


Ben 55:51

I was gonna say this is rhetorical question. Bye. Bye. We have we can talk about marijuana, we can talk about this racism.


Daphna 56:00

That I have two more I really wanted to highlight. Go ahead. So fine, we can start with this marijuana study. Again, the JAMA Network open in the section obstetrics and gynecology. So they the title is birth outcomes of neonates exposed to marijuana in utero. Lead author Greg, Mark Marsha, and, and so I thought this was an interesting study. I won't belabor the methods, but they looked at it at neonatal characteristics of babies whose moms were exposed to marijuana during pregnancy. And so this was a meta analysis. So it's hard, you know, you'd have to look at all the individual studies to look at what the degree of exposure was, what they wanted to see overall. What are does it affect some of these neonatal outcomes. So the things they looked at were incidents of a birth weightless and 2500 grams. A baby who was small for gestational age defined as less than the fifth percentile fetal weight for gestational age, the rate of preterm delivery defined as before less than 37 weeks gestation, gestational age at time of delivery, birth weight and incidence of neonatal care unit admission, the Apgar scores at one minute and five minutes, the incidence of an Apgar score less than 75 minutes, the fetal head circumference and fetal length. So after a lot of work, they had 16 studies which included 59,138 patients, and then they found significant increases in some of those neonatal outcomes and no difference in others. So, infant length, no significant differences, and Apgar is at five minutes. No significant difference, but they found that for when they were looking for low birth weight less than 2500. That was eight studies, so included about 47,000 patients and the risk ratio was to among pregnant women exposed to marijuana did have significant heterogeneity for the small for gestational age less than the fifth percentile, six studies, which included 22,000 patients risk ratio of 1.61 for preterm delivery less than 37 weeks 12 studies, and they had a significant increase in preterm delivery with a risk ratio of 1.24. For those mothers exposed to marijuana, again, significant heterogeneity, but they were able to control for that. For admission to the NICU. They had six studies about 18,000 babies, which showed a significant increase among babies exposed with a risk ratio of 1.38. And then they did look at again the Apgar scores and they had two studies looking at the one minute Apgar with about 1200 patients with a decreased Apgar score, Apgar score. And those babies who whose mothers were exposed. So I mean, I think this is an interesting study marijuana use is becoming more prevalent. Again, it's being marijuana is being legalized in a number of states. And so we're gonna see more pregnant people taking and using marijuana. So all of this is to say it looks like there are some effects, particularly in terms of growth. So


Ben 59:27

yeah, I think I think this this was a well, an overdue mid analysis and systemic review. I think you have that kind of data now is very important as we counsel more parents about the negative effects of marijuana. And, and I liked the way they phrased it in their, in their conclusion that it's associated with significantly increased risk of some adverse neonatal outcomes like this is significant stuff, and parents should be aware of it. I think that what I've heard a lot of times from parents who were are a bit I guess I don't want to use the word disparagingly, but ignorant about what the potential ramifications would be. There's a lot of there's a lot of hearsay that like, oh, it's safe, it's healthy, it's natural. It's like that that's not that's not true. And then if you're pregnant, you have to be really careful. So super reliable.


Daphna 1:00:19

Well, there are lots of things that we get we have in life, that we don't use it during pregnancy. So this, okay, we are running out of time, but I really wanted to highlight this piece. I


Ben 1:00:31

have one more after that.


Daphna 1:00:34

So you want me to hurry up? That's it? No, I want to say


Ben 1:00:36

we're running out of time, but we're gonna we're gonna do the due diligence of doing these papers because they're too good, we can skip on them.


Daphna 1:00:43

So this is in the air reviews article and the perspective section antiracism in the field of neonatology, a foundation and concrete approaches. I my disclosures are that the lead author is Diana Montoya Williams, who is a close friend of myself and the end of the podcast. So we're happy to present this article. There's a lot of information here, though, I'd love to read it to you verbatim, I can't do that all the time, we have a lot. It's a really, I think people should just take a look at it. If you're having difficulty with talking about racism, or this term anti racism, I think it helps a lot with just some basic terminology, and just really implores you about why this discussion is important. And so I'll leave you with some of the main points but and we know that there are things like social determinants of health like economic stability, community, neighborhood and education that affect both health outcomes and quality of life. But, again, a main highlight of the articles that have focused solely on determinants, quote, unquote, fails to recognize that the distribution of social determinants of health among the population is not random. And so I will read this part verbatim that social economic and political systems distribute these determinants inequitably. Across the population, black indigenous and people of color are more likely to experience reduced access to health care, receive care and lower quality hospitals live in neighborhoods with more risks and fewer resources, have increased exposure to environmental pollution be over criminalized and have diminished access to employment and wealth opportunities. The inequitable racialized distribution of social social determinants of health in the United States highlights the prominent role of racism as a key factor in social determinants of health. And so you may say, Okay, well, I'm a neonatologist. How does this work? What Why should it why should I care? Why does it matter? Aside from the obvious that that is should matter is a is a discussion point that is very much in our social political arena right now. But specifically for neonatology, we know that black infants are more than twice as likely to die in the first year of age compared to white counterparts. And that is getting worse, not better. pregnant patients who identify as black or Hispanic or Latin X receive care and lower quality hospitals and have higher rates of preterm birth and higher rates of low birth weight infants, black Hispanic, or Latinx infants admitted to NIC use have been shown to receive lower quality of care, have lower patient satisfaction score and decreased rates of post discharge infant follow up. And so talking about race is important should be important in all of our NIC use, because it does affect both short and long term outcomes. And so I think the article describes a lot of key definitions regarding racism that can help all of us kind of communicate about these inequities. Specifically, what does it mean to be anti racist, which is different than not being racist. And I think that's very much becoming a part of our vernacular, but not everybody understands that. And what that means is that you're taking concrete actions towards the creation of policies aimed at dismantling ideas and structures that produce and normalize racial inequalities. And they really describe how the NICU is an optimal setting for anti racist work. First, because racial and ethnic disparities and fetal and infant health outcomes have been well described for decades, and they have a major impact across the lifespan and contribute to life on health inequities. Second, racially minoritized families face disproportionate exposure to the NICU setting given the high rates of preterm birth and low birth weight in these communities. And third, that the NICU experience occurs during a critical phase of infant development, which we all know very well, as well as the development of the Parent Infant diet, and antiracist interventions in the NICU had the potential to improve long term health trajectories for parents for patients and their families, so then I think they did a really nice job of just giving us concrete ways that we can use anti racist concepts in our in our day to day work. The first is through education, with self education, creation of new curricula for trainees, and reform of existing structures and processes. And I like how they labeled this starts with teaching the teachers. So we need to make sure that our medical educators are aware of some of this data and then they include it in education. How can we be anti racist in quality improvements, we need to look at all at Quality Improvement interventions with an equity focus. So if we find a disparity, we really have to be intentional in mapping key stakeholders to include patients, families, and relevant community partners, particularly inviting groups experienced the disparity to the table in research, so anti racism and research requires an understanding that conducting studies focused on exploring health disparities is not synonymous with being anti racist. But that really, we have to use race very thoughtfully, as a variable in our human studies. And actually, I think Dr. Montoya, Williams did a good discussion about that when she came to visit us on on the Podcast, episode 18.


Ben 1:06:29

People check it out, thank you.


Daphna 1:06:33

But remembering that some of those other underlying variables that are kind of proxies for our socio environmental systems are really challenging, and they're very difficult to measure. And that potentially, instead of using race, we might be better off using the concept of ethnicity, which is still very difficult to measure. And so it necessitates that, whatever our findings are, that we can connect that information back to the communities and the people whose lives the study aims to describe, or to improve the talk about what we can do in healthcare administration. And the underlying point there is about diversifying the medical workforce and those benefits are well documented. It increases group performance promotes cultural awareness and humility, it increases access to racially and culturally concordance care, increases overall health care coverage, mitigates provider bias, and improves patient experience and satisfaction in health care. And then finally, what what can we do via community engagement. And so central to anti racist work, they say, is the lived experience of the groups experiencing racism. And so really, again, they underscore that any project that we undertake, we must include the voices of racialized families, and there's perspectives. And it's important that they're incorporated from the very conception of a project. And so they use like breastfeeding medicine as the example here. So these are just some some of the the top kind of concrete examples, but I hope everybody will take a look at that paper and see what we can do in our day to day practice to start making changes.


Ben 1:08:27

Thoughts? No, I think I think Diana is Dr. Montoya Williams, but Diana is our friend. She's great at at breaking these concepts down and explaining them in a manner that is understandable. And also, she does something really well, where is she knows what the questions are. And so she she preempts everything by almost answering it before because you walk into you don't have to ask the question. Exactly, exactly. And I do think that what I take from this paper, specifically, is the idea of social determinants of health, which is a concept we've heard over and over again. And we're like you said, like, you can say, well, what am I going to do about like the way neighborhoods in my city are arranged like I don't have this type of power, but then it's true, you may not be able to rearrange the map, in a in a state or in a country, however, at least understand that when the patients are walking into the unit, they carry this baggage is with them, and try to create an environment right off the bat that is there to show that this is not a place that's going to perpetuate the the symmetries that you may see elsewhere is where in my opinion, neonatologists staff whoever works in the NICU can have the ability to make a change. And I think that's what I got from the paper when I read it. So I think this is very, very valuable. And then obviously, she gives all these examples that you've mentioned, which I had read about also about making sure education is done in You know, in a great job.


Daphna 1:10:04

Yeah, I like to think in some of these are still very big ideas, right. And so maybe somebody who's, you know, clinician, you know, you weren't 100% in the NICU, you know what, maybe you didn't find yourself in this in this in this paper in particular. But I think, like, for me, my interest is in neurodevelopment. And we know that all of these factors impact long term development. So, for our unit, I like to really make it a priority that any developmental intervention, you know, I can't, I can't control how much parents can be at the bedside or if they have to work or what their educational status or what the financial status is. And so you know, we really make it a priority in our unit that if there's a developmental enrich, and that we think is important that we find a way to provide it for all the babies. So if that is a cheer, if that is a playtime, that if that is books, if that's music, we can't just rely on the parents that can bring that into the unit. And so I think our unit has done a really good job of trying to go above and beyond and try to get those at least those basic resources in terms of neurodevelopmental care to every every baby. So I think that's something every unit could do. It just takes some some time. So I hope everybody will take a look at the paper and just try to see you know, that some concrete ways at least one of the terminology, try to engage in the discussion and see what we could do every day to try to decrease the inequities in our unit.


Ben 1:11:43

Yeah, I also think that this is a topic where you can actually branch out of neonatology and every specialty has been addressing this and it's always also interesting, I find that the same thing for research sometimes if you're listen to people, if you're if you're looking for an idea for research, sometimes you just go in the other specialty, you see what they do, and you're like, can I feel this? This works too. You could you could listen to how do they have they deal with racism in internal medicine and surgery and and there's always things that you can learn. So this is okay. All right. So I'm going to go over one more paper that I wanted to go discuss that I posted about on Twitter, it's in JAM peds. It's called inhaled corticosteroids alone or, and in combination with long acting beta two receptor agonist to treat reduced lung function in preterm born children a randomized clinical trial, the first author is nya golden. The reason I was telling I was I wanted to talk about this paper is, this is a paper that looks at babies who were born preterm, and who are now like 710 12 years old, and they were looking at these babies with FEV, one that is less than or equal to 85%. So they have signs of obstructive disease. And what they wanted to know is that a treatment of about 12 weeks with either inhaled corticosteroids in this case, they use particular zone, which is Flo vent, plus minus a bronchodilator, or all placebo made any effect on their lung functions. And what the what the study showed was that they were 53 infants were randomized to these different groups. 20 children's received inhaled corticosteroids 19 had steroids plus long acting beta two agonist and 14 children's were all placebo. The mean age of these children was about 10 years old, and the post treatment FEV one, so FEV one for those who don't remember, it's like how much air can you get out in one second, and I have asthma. So this is, this is not This is like your PFT is when you go for PFC, it's just not the fun part anyway. The posttreatment percent Fe one was adjusted for a bunch of variable and the mean percent FEV. One worked 7.7% higher in the inhaled corticosteroids group, and 14.1%, higher in the inhaled corticosteroids and long acting beta two agonist group compared to the placebo. So they show a clear increase almost a an increase of 7% with the steroids and 14% with the beta two agonist in the group that were being treated. And the conclusions of the talked about also, the response to improving exercise capacity. I'm going to leave that aside, but the results of the trial that suggest that inhaled corticosteroids and beta two agonist treatment is beneficial for preterm prematurity associated lung disease in children. Why do we care about this? It's because the parents were counseling about chronic lung disease or respiratory disease in the in the NICU often want to know what does the future look like for my child? And specifically, always ask Yeah, from a respiratory standpoint, and we know that these babies are often treated a bit like asthmatics and stuff so I feel like if the field is changing downstream from us, independent Patrick world, and we have papers published in JAMA peas which are extremely reliable and strictly peer reviewed, then we should know about it, we should know about it. And we can talk to parents about the possibility that your child may need to be treated with steroids and inhalers and bronchodilators. And that can help parents foresee a little bit of the future these babies were. They were not like the most, the most the sickest of all like, I think their gestation age was like 2930 weeks, but didn't have some some pretty significant percentage like 3015 to 30% of them with severe BPD. So they were they were, they were an interesting population. Many of us may not care about these things. But if you are counseling families about long term respiratory outcomes of preterm babies, this is a paper you might want to review. It's well written. So I suggest you read it and we're way way over time. So


Daphna 1:15:54

well, no, but to that point, I mean, they ask all the time, so whether you care about it or not. You should know what he's going to ask you. Yeah,


Ben 1:16:01

you should know. And I know. Yeah. And I've used data from Italy about like how their their future looks a bit like the course of of patients with asthma. But they'll ask you practically like, can they run? Can they exercise? Some families have very high aspirations when it comes to their kids becoming professional athletes? Like you're asking very pointed questions. And so yeah, I when I was a fellow, I bought this book called Beyond the NICU, and it goes over all the long term care of the preterm baby. And that was super helpful when parents were asked you like, how long is my kid going to have nasal cannula on? When does it usually come off? And as a resident had no clue? No clue. Yeah. So it was good to be able to see to have


Daphna 1:16:40

a frame of reference.


Ben 1:16:42

All right, Daphna. This was a long journal club, but this was a ton of fun.


Daphna 1:16:47

Yeah, a lot of ground to cover.


Ben 1:16:49

Guys, just check out our other podcasts, the incubator and neonatology review that we're doing in partnership with Dr. Dara Brodsky and Dr. Camilla Martin. It's going very well, we're powering through a lot of different subjects, we're going over going over a lot of high yield content, whether you are taking the boards or not, I'm getting the prime example of I'm not taking the boards this year. And I'm taking tremendous enjoyment in reviewing that data. And no matter what you say every unit has is always skewed towards one specialty, like some units do a lot of genetics and some more pulmonary. So it's always good to refresh your memory about the subjects that you do not commonly encounter in the NICU to keep your mind sharp. So yeah, thank you Daphna, for getting this started. And yes,


Daphna 1:17:34

it's been a wild ride.


Ben 1:17:36

Yeah, it's wild. But I was saying we may need to take a break after the board, maybe like a week, what breaks that we can just like, Yeah, but yeah, we'll see you guys tomorrow for board reader prep.


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