Hello Friends 👋
Today we have the pleasure to chat with Dr. Ariel Salas from the University of Alabama in Birmingham. Dr. Salas is truly an inspiration for many of us. As an international medical graduate from Bolivia he has managed to reach the pinnacle of academia and has been a prolific researcher. His work on neonatal nutrition has given him a notional notoriety and he was recently presenting his work at PAS 2022. If you would like to reach out to Dr. Salas, he graciously allowed us to share his email with our audience and can be found at: firstname.lastname@example.org
Short Bio: Dr. Salas is a board-certified, attending neonatologist at the Children's Hospital of Alabama and an Associate Professor of Pediatrics at the University of Alabama at Birmingham (UAB). He has an M.D. degree from Universidad Mayor de San Andres and an M.S.P.H. degree from UAB. He currently receives grant support from NICHD to study the effects of human milk diets on body composition outcomes of extremely preterm infants. His long-term career goal is to reduce the burden of postnatal growth faltering through novel translational studies and large-scale, multi-center clinical trials of promising dietary interventions that optimize growth, reduce dysbiosis, and ultimately improve neurodevelopment.
The transcript of today's episode can be found below 👇
Hello, everybody, welcome back to the podcast. It's Sunday. Daphna. How's it going?
I thought you're gonna have a new intro.
I'm not changing the intro. It's very generic.
I think people probably find comfort in hearing you say the same thing. Every
other podcast I've listened to. They all have like their intro. I mean, ours is, like I said, very generic. But this is not what this this is not what's going to make people either listen or not listen, right. I mean, the content is what matters content is king.
And we have great content today.
Yeah, I'm very excited about about the, about the guests that we have on today. We've been receiving this week. I don't know what you thought. So we've been receiving a lot more messages of thank you and support. It's been overwhelming. I am humbled. We are both humbled by Yeah, I
wonder if you know, a lot of people went to the big meeting this this weekend. And I think you really value the neonatal community and everything you know that you can find.
I also I was we weren't, we were not a PS obviously. And then I am sure that there's this feeling that I've been wanting to have where you go to an in person meeting and you start connecting with the people you you've met on your Twitter, there's actual people on your Twitter that I have collaborated with all the way to publishing a paper, and I've never met. Yeah, that's crazy is that. So that's, that's going to be very exciting. But thank you for for sending all these messages. We're very happy with the direction the incubator is taking. We're putting out a lot of good educational material on the neonatology review side, we've started the neonatal network on the rounds.com, you can find out more information on our website about how to register, we're giving away basically, we're giving away access to software resources to conduct research, anything you need for research purposes, will be available there. And we're going to open the grant application process for this first cycle. On June 1, I think we will have we will have up to we will have around $10,000 worth of grants available. And I mean up around because it might be more. But this first round. And we're just very excited. If you have ideas. If you're a new fellow or prospective fellow, and you want to get a quick grant, we are going to cycle through grants. So fast meaning application starts June 1, grants are awarded August 30. And the money will come quickly. So no, no truncating, your fellowship by 50% to get access to funding for research, you're going to be able to get this off the ground quickly.
Do we want to remind people why and what's cool about how we will pick?
Yeah, definitely. Go ahead.
Well, we again, we want the power of the neonatal community to drive, what you guys think, is research that that should be funded. So we will have a voting process so that people have the opportunity to pick the projects that they are most interested in. So we'll let the community decide.
And that's that's a reason to join us on the rounds. Even if you're going to be a spectator, which I think it's perfectly fine. But you will get to weigh in on all these ideas that are coming out and saying, oh, I want to see this funded, oh, I want to see this project come to fruition. I want to participate and join the efforts in this project. Right. It will be such a cool, it's going to be a cool thing to see. It's going to start August 1. You submit your applique we're going to have application process open from June 1 to July 30. We're hoping to catch For a lot of new fellows, or a lot of starting second year fellows who may be like we know when you have these front loaded first years, and you got to start really your research like year two. Yeah, this is going to be very helpful. I mean, I wish I had access to, to that kind of stuff when I was a fellow. So
I know I was, I was using my book money for salivary swabs. And buy a single book. Tell you what.
Yeah. So on this note, I think it's actually fitting that we are talking about research because we have the pleasure of having with us today, Dr. Ariel Salas. Dr. Salas is a board certified attending Neonatologist at the Children's Hospital of Alabama, and an Associate Professor of Pediatrics at the University of Alabama in Birmingham. He has an MD degree from the Universidad mejor de San address, and an MSPH degree from UAB. He currently receives grant support from the NI CHD to study the effects of human milk diets on body composition outcome of extremely preterm infants. His long term career goal is to reduce the burden of postnatal growth, faltering through novel translational studies, and large scale multicenter clinical trials of promising dietary intervention that optimize growth, reduce dysbiosis and ultimately, improve neurodevelopment. Please join me in welcoming to the show, Dr. Ariel Salas.
Ariel Salas 6:36
bandanna, thank you for inviting me. It's a real pleasure to be here.
No, we're we're very excited to have you on and as we've mentioned in the intro, you you you grew up in Latin America, and in Bolivia, specifically, and then you you went through schooling there. And my understanding is that you did your pediatric residency there as well. And then, and then came to the US. My first question to you is what prompted this departure from from home? I'm always interesting, when people like myself, leave home to come to the US, what is the motivation there?
Speaker 3 7:11
Well, let me tell you that wasn't on the cards, you know, I wasn't planning to till the very last year of residency, you know, I went through med school with a plan of, you know, doing my residency in pediatrics, and eventually have a clinic, you know, started seeing patients after training. But during my last year, I got the opportunity to do an observer ship here in the US. And it was just curiosity, mostly, I wasn't really planning to do anything here, just just wanted to see the system, you know, because at that point, during residency, I was reading so much about, you know, studies and things that in how things were being done somewhere else, and I just wanted to see it, and I thought that was it, you know, it will be just just life experience, and then, and then go back to normal, basically. But then, you know, I really felt that there was, there was a chance, you know, that I should consider pursuing it, because it was very life changing experience, I got to see, the chairman had such a great experience during those it was, I think, eight weeks or so,
where did you? Where did you do that observership
Speaker 3 8:18
I ended up going to chop for for just an observer ship. So it was a very fulfilling experience, you know, I got to see a lot of things that I wasn't seeing on residency. And then I left with that idea, you know, maybe I should consider, you know, to apply for residency, even though you know, whether residency really just more training. But then, you know, had to go back to reality, right, so I just spent all my savings on this trip. Now going to have to start from scratch, you know, work really hard. So for that first year, I ended up practicing as a general pediatrician for a year before even applying for boards, fellowship. And I think that's, that's when I knew for sure that one I needed to do something else. Because it was very interesting to go from academic hospital, you know, where you have trainees, residents all around, and teaching all the time talking about new studies and things like that to the cold office with just your registered nurse. They're, you know, helping you with the patients and, you know, nobody around you to explain why you're doing things.
It's a very lonely experience. Yeah. Right. So So
Speaker 3 9:31
while I was doing all that I was studying for the boards and then eventually, I, I took them, you know, and I passed the steps. And then at that point, I said, Well, maybe there is a chance to apply for fellowship. It was a bit different for me because I had residency training already. I was I had the opportunity to apply for fellowship back then. I don't think that's an option anymore. I was able to look for residency fellowship programs now. I have to admit that I actually met my program director to PHS. Because I, I was presenting some very basic study on hyperbilirubinemia. A PDA is something that I did back home in Bolivia. So So with that, you know, that put me in PBS and PBS is sort of a melting pot. Right. So everybody's there. And, and I was able to connect with with him and think
that's great, and go from there. And so then, so then neonatology was always in the cards for you, or, or how did that come about?
Speaker 3 10:37
I was definitely interested in the field, I was I wasn't, I was more into pediatric intensive care, I think. But then when I did that, observership, I realized that I couldn't really deal much with that chronicity in the acute care setting, I think the acute care that I was used to back home, it was mostly previously healthy children. See, kids with chronic conditions that don't make it that long. So they don't really get to be seen in intensive care unit. So my experience in an intensive care was very limited. And what I saw in a very complex health system was very different, what I expected from from acute care. And that's why I thought about neonatology probably is the best path. And I did have some research on it as well, you know, and I have to admit, that's one of the things that I think was very interesting for many people that saw me from coming abroad, you know, because I did have some hours being interested in research. Somehow, you know, my last year of med school, I had to do this after an internship. And back home in Bolivia, I met this guy that became a first mentor, I guess that taught me just the basic of statistics, just just t tests and chi squares. And I just got hooked and research with that. And I would always, even though I was very busy clinically, I always have found time to do some some small studies, you know, nothing big, you know, I did. I don't even mention those publications that I have back home because they were not peer reviewed. But I was very proud of those things. But
I think that's so interesting. You know, I think you really got an introduction to test statistics early on. And I feel like we do things backwards, we say, okay, the trainees have to do research, get into research. And then once you're into your project, we'll do the statistics. And it can be so daunting. If you don't have even that, like little bit of background. That's, that's so cool that you got exposed to it so early.
Speaker 3 12:45
Yes, I think it helps. Just to knowledge about it, you know, at the beginning, but then, over time, you also start learning your limitations. And I think that's how I feel about statistics nowadays. I feel like there are things that I'm comfortable with, but I think there are things that you should just ask an excitation biostatistician to do for you. That's fair. Yeah, it was eye opening from the MSPH program. I think just just knowing your limitations.
And it's and it's not just important for you to conduct research, but it's also important to be able to appraise the data that you're reviewing, right? I mean, every project starts with the lit review. And if you don't know how to discern good data from corrupted data, and what I mean corrupted, I mean, some data's are corrupted by confounders, right? Not that anybody is messing with the data. That's not my intention to say that, but like confounders overfitting all these concepts that are so important in statistics that are that are critical. It's funny that a lot of the things you're saying are echoing what Dr. Carlo said on the podcast not too long ago. And so it's it's very interesting to see this filiation where you're hitting similar notes. I wanted to go back to Bolivia a little bit, and I've never been to Bolivia. I don't know about you, Daphna but what
I'm in a flight. That's
what I'm curious about the cultural aspect of the practice of medicine and Bolivia. What does that look like? And what of that experience? Have you taken with you to the US and you and something that you're applying every day?
Speaker 3 14:26
Well, I think there's there strengthening of bedside experience, you know, they're not subspecialty training, not at least back, you know, a couple 10 years ago when I was training, so it was mostly driven by residents, pretty busy hospitals, as you can imagine, so a lot of patients to see a lot of procedures to do. We had to take the blood samples for all our patients. So we get used to and I think that makes you more rational about what you really need because you know, if you have to collect samples and write notes and see patients you know, you might not finish on time. So a lot of better experience for sure. access to technology limited. But I don't think it was it's necessarily resource. I think some of it depends on when you practice where you practice, I think there's a little more inequity in terms of what you see in private practice versus what you see in public hospitals. That's pretty obvious. And then you have to adapt. Right? So so if you're in a setting, this you know, during that year that I was doing a lot of Gen peds. You Most pediatricians actually end up covering NICUs unit, because well, now probably their money ontology is but you know, 10 years ago, is mostly general, pediatricians covering NICU NICUs, across the city, and and then they would, you know, there was there was always that, that there's limitations, you know, of how much you can do, you know, in some places, you will have everything that you need, and others, you will just have to adapt. So, just very different, depending on where you were. But the academic Hospital where I actually did my residency, it was it was just volume, I think the most important thing that makes you, I guess, seen so many patients, it helps. Now, in my current practice, it just keeps so much perspective about about medical decisions, I guess, you know, because sometimes you have to do those without a lot of information. And now, sometimes we find those things challenging. Here's even though we do have access to more information, right, so we have more testing, we have more imaging available, and we still struggle with with making clinical decision. Yeah. So I find that interesting that sometimes it's you, you think that by having more information, you will be able to make better decisions, but I don't know, I don't think that's always the case. You know, sometimes you you still need to have that clinical experience, you know, that clinical acumen to to make a diagnosis?
Well, I think having, you know, being challenged with, you know, less technology really enhances the clinical exam. Right, you, you know, you rely so much more on your clinical exam. I think that's so valuable. That experience.
Speaker 3 17:29
Yeah, for sure. You know, but but I'm not against it. You know, I definitely think that, you know, if you have access to technology issue, you said, I don't think you can use that as an excuse to just keep relying on on things that sometimes are subjective. But if you don't, then then I think it's justifiable to make decisions without them.
Yeah, well, tell us more than about your, your fellowship path we, we took around about a trip ticket.
Speaker 3 17:58
Yes. So there was a detour actually added that I think most people up but I had to consider because, you know, the US in reality was like a big shot, you know, and I wanted to be realistic, and I didn't want to take another year off, you know, without any training. So I did actually have a backup plan, just in case, you know, I couldn't make it here. And most people in Latin America, you know, they will go to places like Argentina, Chile, Mexico, they have good programs. So I had, I had that as a backup plan, you know, I did apply for for subspecialty training outside Bolivia. But then they I got my, my, my scores, and I got, you know, an interview and then after that, you know, I felt like there was, it's like everything else. Right. So there's, there's a leap of faith at some point where you say, Well, I think it's a good chance, and I'll have to, you know, I should just go ahead and try. But fellowship, you know, you know, from from the foreign medical graduate perspective, I think it's challenging. But it might be easier than studying with residency because there was, at least I didn't have a lot of clinical duty as a fellow you and I could make decisions as a follow up and but and then have the residents you know, doing the day to day kind of things, you know, notes and seeing patients and then they use ask you for advice. I think it was easier for me to adapt through that path. I think it would have been much more challenging as a resident coming from from a foreign country, just because the systems are so different, you know, in and I didn't have to deal with with a lot of that at least as a fellow. Now. I think there was some some things that I should have done more often as a fellow because I will be the kind of fellow that just stands in front of the Bentley. You're gonna start tweaking the settings and, and stay at the bedside quite a lot. But I think it's also important to us training was an opportunity to communicate with families with the team, you know, all the sorts of things that I think I didn't do much during fellowship, I did have the opportunity to do all of that through a second residency. So I felt like at least I was able to, to catch up a little bit more with, with being, yes, being at the bedside, and making make decisions there, but also just communicating with families, and being a good team player.
Yeah, that's something that's often goes unnoticed, especially to our American colleagues that a lot of IMGs have to repeat residency and, and for 90% of us, this is not a fun idea. Prospect of saying yeah, residency is over. Let's do that one more time.
My why I had in my residency class, my colleagues who were doing their second residency were Gosh, such a such a wealth of information. Right? Well, we didn't know we went to them first before the attending before the fellow because, you know, they knew exactly what to do. So gosh, I, my whole experience in residency was was really made better by by my colleagues who were who were because of the system doing their second residency. So
I had a friend in the residency was from Japan, his name was Shikara. He was a peds ID attending in Japan. But apparently, somehow, I don't want to say that there's no peds ID fellowship in Japan. But there was he wanted to get a certification in peds. It, he wanted to pursue a fellowship. So he was my co resident. And it was amazing. You could get an ID consult in an instant. And he did eventually go into peds ID and he did eventually, I think he's, I think he's the director of a peace IT department somewhere. I want to say in Seattle, but I'm not sure. I have to check in with him. area I want to I wanted to ask you about you're known for your interest in nutrition, you're you're you publish a lot on this topic. I'm curious as to you describe yourself as the fellow who stands by the ventilator? When did this interest slash passion for neonatal nutrition began?
Speaker 3 22:28
Well, actually, actually was during my second year of fellowship, you know, first year, I was trying to get to the system I was trying to get comfortable with, with all the management. So I kind of put a halt on my research interest. At first, because I was doing some work in hyperbilirubinemia, back home, I thought that that was the path I wanted to take. But then I felt like there's really not a whole lot to do since there's such an effective therapy for it. You know, I really felt like there's just not a whole lot of research that could be expanded on on hyperbilirubinemia. That's why, you know, after discussing with my mentors, I, I just started thinking about what things have not been studied much. And, you know, as you know, the respiratory research area in psychology is saturated, wide saturated. Right. So there's there plenty of researches on that area, and I feel like, you know, I think will be very hard to, to come up with something new, since so many people are working on this field. So that's when I thought about, you know, started looking at practices, daily practices in the NICU and in the nutrition was the one with a lot of viability. So then that's when I say, Well, if we, we start working on this practices, so variable cross, so then maybe we should, you know, this is a career path that can actually expand. So there was a bit of like some those, those are, to some extent, strategic decisions, right to see that there's a field that has a lot of potential to grow versus us with the research that has grown a lot already, and actually has been very successful at achieving, you know, decrease mortality decrease BPD. Not in its totality, but definitely, in a lot of progress. Nutrition wise, though, we've been behind for quite a while if you think about it. So that's how it started. And we started with a very basic project as a fellow just just refeeding gastric residual volumes versus fresh feeding at that point, you know, not checking residuals was an even under consideration that you have
to quantify that. So we said this, this is the hot topic of residuals that's
Yeah, but yes, still a topic in that a lot of units, you know, so this is really important work, you know.
Speaker 3 24:46
So that's why we try we said we know let's provide some evidence about it. And I think that's that's how I selected nutrition. I think there are things that need to be studied. But I don't know if you know And then but we're going to need more large multicenter trials to to have a final answer on them, but at least you know, provide some, some direction of effects, some some, some, at least preliminary findings that can provide some ideas of where things are going, or at least, at least the proof safety of some of the interventions still relevant. So Nutrition has been, I think, probably gaining an area of opportunity, then also did something with vitamin D as a fellow, that was the last thing that I did. And then, and then for residency happened for ice, which was a pass of research for two years.
Let me ask you about nutrition research, right? I mean, so many things are being studied these days on nutrition. I'm wondering, in your opinion, what is for you the most pressing issue that needs to be worked out? Right? I mean, we talk about and we talk about many, many different things, we talk about the way we feed babies, whether drops by mouth versus OG feeds continuous versus bolus, we're talking about feed advancement versus slow feeding, rapid feed advancement versus low feed advancement, feeding on CPAP. There's a million controversies. And it's to be honest with you, I am interested in nutrition, but not to the extent that you are or some of my colleagues are, so I look at it from the periphery. But it can make your head spin a little bit as to like, what am I supposed to focus on? In your opinion, what is the most pressing issue to study and investigate?
Speaker 3 26:36
That's a very good point. And I think when we talk about nutrition, I think just just as you mentioned, it's very important to optimize all the other practices as well. Okay, so I think you need really good clinical practice first, and then you can study nutrition as something that can make things better, but just providing good nutrition is not gonna fix a lot of health problems, if the practice is not evidence based. So it's at least good enough. You know, and that's why for us, you know, in our unit is so important to standardize respiratory management. So I think that's why for us, you know, it's easier to detect those effects that nutrition have on outcomes, just because although the practices, you know, have been really, really validated, you know, through through research and, and protocols. So, I think nutrition needs good clinical practice to show effectiveness. But within the field within nutrition, of course, there I think the main is the elephant in the room, right? So, neck neck is what has been always challenged when when we think about nutrition. And naturally we connect it to right, so if you think about nutrition, somehow automatically, net comes in mind in there. But I mean, nutrition, yes, is one risk factor of neck, but it's not the only one. And I think it's important to remind everyone thinking about nutrition, that? Yes, that's one of the risk factors, but not the only one. And nutrition needs a lot of nutritionist to optimize growth. It's not I don't know if we're going to be not yet though I don't see this any time soon. We're not going to find a nutrition practice that will decrease the risk of neck, we might actually be able to maintain the risk, I need not to increase it. But I don't I don't think we can offer yet what everybody wants a nutrition practice that can improve growth, and decrease neck at the same time. I think those those are very ideal goals, but I don't think they're possible to achieve. Not at this time, at least. Because you know, as we optimize attrition, that means that we have to provide more nutrients, more enteral nutrition, and that could potentially come at risk for neck. We don't know yet for sure. But that, yes, might actually not decrease the risk of mechanist. But if it stayed the same, so I think we can claim that that nutrition practice, yes, it improves growth, but it doesn't decrease neck. And I think that's the challenge because everybody wants a trial power for the outcome of NEC. And and then and then we just don't find anything you know, anytime that we are always it's just make it impossible. Through a truly powerful NEC study power from NEC we'll need close to realistically 1000 patients to show what we want to show in terms of the negative effect on NEC. So that's a lot. That's that's a big challenge. Yes.
I was gonna say it's not what I would have expected you to say, right? I mean, it's very interesting. It's super interesting that as an expert on nutrition, your recommendation is maybe focus on In better clinical practices, more consistent care and don't always seek to reduce the effects of neck because it might be an extremely, extremely high goal that as a as a first time researcher, you may not be able to, to hit right off the bat, I think this is an interesting, it's a very, it's a very practical approach. Sorry, definitely, you're gonna say something?
No, I was gonna say it's, it's there. They're all interconnected, right? Like, Ben, nutrition is not my primary area of interest. It's really neuro development. And so what I like about what your research is really looking about, how does nutrition How can nutrition optimize neurodevelopmental outcomes? Because I think they're very related. And so I'm desperate to learn more about nutrition and optimize nutrition because I know it's going to change my outcome of interest, which is really neuro development. And I, obviously reducing neck is something we should do, but there are so many, like you said, components to nutrition that change long term outcomes for babies, obesity, and metabolic syndrome, allergies, school age learning, and, you know, I, I am glad that, you know, there are people who are not just looking at neck right, as important as it is, but there's so many variables to nutrition.
Speaker 3 31:22
And I've had so that's a very good point, you know, sometimes we created all this short term outcomes, you know, BPD is has an operational definition, you know, it's not something like diabetes that is permanent, you know, we, we, we are we came up with that definition. Same thing with an NEC, right. So we, it's an operational definition, but the long term impact of those outcomes are, are still, you know, not well defined. And what matters the most is probably those, those sort of our contracts, what happens at two years of age, what happens if you have neck at 28 days, but then your outcome at two years is, is just as normal? This snack really mattered than, you know? What, what's the goal of decreasing that one outcome if the outcome at two years of age was exactly the same? So I think just like BPD neck needs a new definition. I'm sure there are a lot of experts in the field working on it, but it's just, it's just being a very limiting factor to advanced nutrition research. Because, you know, we all get so worried about it. And then and then that's, that's just, it's, I mean, don't get me wrong, it is an unfortunate event. But um, but But anyway, so it is when when babies end up with with malnutrition, we don't even want to call it that way. Right? So we call it postnatal growth failure, just because malnutrition sounds
sounds like we
Unknown Speaker 33:05
especially in especially in a place like here in the states to feel like babies are having malnutrition in our hospitals. Seems like, we can't say that right, you know,
Speaker 3 33:16
right. Yes. So, so I think we need to focus on on that outcome in as well. You know, just I think this is probably equally important. So when we asked for effects on neck, I think we should also ask for effects on on growth, and prevention of postnatal growth. faltering.
I wanted to ask you something that I've heard many times over, which is that sometimes you should disregard the current evidence at the expense of consistency of care, meaning that regardless of what the quote unquote best practice would be, sometimes having a consistent practice is more beneficial to to just practicing sometimes to practicing, more, more advanced, more advanced, especially in nutritional care. Because the variability that you might encounter does impact the outcomes more than if you had a different practice, but more consistent. I'm really trying to talk.
We were gonna give easy questions. This is a this is a minefield,
I know. But I'm trying to really toe the line not to say that it's good to not I'm not trying to say that it's good to practice not evidence based medicine, but what I'm saying is that, instead of adopting the latest and latest practices, sometimes consistency is maybe as important if not more important, and I feel like this is something I've heard, especially in the context of nutritional nutrition care and stuff like that. Can you can you talk a little bit about that. Do you agree with that with that idea?
Speaker 3 34:56
Yes, man, I definitely see value of standardization prac This right and I think it's the first step forward. But I think we should add flexibility to those those per class management because they need to evolve my concern with them. I think I think that that's been proven right. So that when you standardize something, outcomes improve. The question is, and then you're right, you might be standardizing practice that have not been validated through evidence based medicine. But you know, the moment that you find out that 25 CC's particulars just as good as 20, I think we should have some flexibility in the system to evolve. Because what I've seen is that sometimes when we standardize some practices, no one wants to change those a year later. And the reality is, is that how fast things happened in neonatology and I think we should be able to adapt to those new changes. I know nobody, no one likes to be taught, again, the new practice the new protocol, and everything else. But But if we want to provide the best care, so we need to evolve with the field in and yes, you know, I think the first protocol that did not have all the evidence available, when when it was developed, and so now it should, should evolve and should, should be changed to incorporate all this new new things. So that's why anytime that we are very careful, in our unit, call it protocol, you know, we don't have a freedom protocol. Technically, we do have a guideline, but they always do. So a warning there that this might change. You know, this is what we do currently, to standardize just to get the benefit of just decreasing variability. But you know, just just a warning that this will evolve, most likely, I think it's important, so people are prepared for what additional changes, we should be willing to adapt. I think sometimes that's the fight with feeding, you know, because they will say those things, right. So that, now that we have the protocol final, it's been, it's been a year now it's the protocol is, you know, it's printed, and it's ready. Now abide by this laminated.
That's it, you cannot edit it.
Speaker 3 37:12
Exactly. And I think we should, and I think we just need to go back to what has happened with with really literature now. Right. So and I like to use this analogy with between encyclopedias and Wikipedia, right, so So 20 years ago, you know, for something to make it to an encyclopedia had to be curated, you know, for who knows, five years or so that would delay the introduction of that concept into the encyclopedia, but was was considered to be like the one thing that is already validated and studied and good enough to be in the superior. But then there was, in that process, there was a five, five to 10 year delay, just to have that information, actually is available for everyone. And now Wikipedia, you know, it's something that is being edited, you know, weekly, monthly basis. And in, there's one that has survived, right? So we compete is the one the source now of information for many, and encyclopedias are now so obsolete. So sometimes we have to acknowledge that knowledge evolves at a much faster paced. And then before that
my dad used to have we had this beautiful encyclopedia at home. Back in France, like I forgot how many like maybe, like 60 volumes. It was a great enciclopedia. And when we moved in my parents and we left the country, my dad was trying to either sell it or give it to a library. No one wanted it. Like the library said, No, don't don't bring it to the library. Like we don't want it. We don't want I know, but it's like, it's what you're describing the survival of of the more nimble, right, the agility and how that allows you to survive better. I wanted to ask you one more. I guess that's a tougher question. But I wanted to ask this because you're Dr. Salas, you work at UAB, you do work on nutrition. And then there's the other neonatologist who work in a smaller institution that does not have a large academic center maybe doesn't have a nutritionist doesn't maybe even have a neonatal pharmacist. And all these data's coming down the pipeline's when it comes to neonatal nutrition. And I'm putting myself in their shoes saying, Well, I don't have all the tools to really optimize the nutrition to the extent that some of these papers are recommending because I don't have a nutritionist and I'm by myself rounding on 25 patients. It could feel very overwhelming when you see those discussions, especially considering what you were talking about before, which is that it's not categorical evidence that's really coming down, right? If it were something categorical where we say yeah, you advance feed by 15 mils per kilo every day. That's the evidence. Then you could say fine now I'll follow The evidence, but it's still so murky. What is your advice to people practicing in smaller units where the resources are a bit more limited? In order to optimize, as you said, growth reducing any see like, what is? What are some of the basic principles in your opinion that should be applied everywhere?
Speaker 3 40:20
Well, I actually had the opportunity to have these conversations, you know, with some neonatologists in Latin America, because I had the opportunity to visit some cities, you know, virtually, you know, just symposiums and there's always that question, right. So yeah, you talk about all these things that can be done. But you know, we don't have this, we don't have all this other things. And, you know, I think, for me, I said, I definitely one of the big limitations in most places is just parenteral nutrition, right? Whether that's customized, and, you know, to the points that you mentioned, and you know, now there's so much about, you know, customized TPN, customized fortification, I think those things are so far away from the bedside in places like the ones you're describing, so so I'm worried when, when, when, when that's kind of the direction they want to take, because it may not be generalizable. So but I always try to rescue the things that can actually be being done, regardless of resources. And I think that's human milk feeding. You know, if you can facilitate pumping milk extractions, then then you become less dependent on TPN. So you might be able to, we've, you know, we've shown that, you know, the faster you advance feeds that the sooner you come off TPN. So, so So you might be saving very important resources by just being a bit more aggressive with it. Now, of course, you will need more human milk. Right. But But then, and that's something that it is available. So it's at, to me, that's more like a supply supply chain issue, right? I mean, there is the producer,
and God knows we know about that.
Speaker 3 42:07
Alright, and then it's just just how we facilitate that. And, you know, the problem is that some basic clinicians are not, you know, don't have the time to, to get involved in that process. But it's so important, especially if you want to provide good nutrition, I think, you know, we rely a lot on donor milk nowadays, but you know, in some places they don't have access to milk bags in for them, it's even more important to facilitate lactation and facilitate a pumping pumps, you know, so important, even even in very resourceful settings, you know, just just the practice and teaching of it. So I see value in that. The other common concern I hear is just for dedication, you know, how that's going to be done, whether you have access to them or not, I think, yes, yes, it's a resource dependent thing, but, but it can be done, you know, just just, first you have to optimize your entire nutrition practices, then we'll talk about fortification, but but most interestingly enough, and triangulation seems to be more efficient, and parental, even the parental makes you feel comfortable with the numbers, right? So you give him four grams, you're given two grams, but somehow those did not translate into better growth. But when you look at the low numbers of enteral, nutrition, they still seem to be very effective to improve growth. So I don't think it's just an issue of numbers, but also an issue or not quantity, but also quality. And I think the enteral nutrition, they provide better quality, better via availability, probably in the fall, you know, much more effective in achieving the goal that we want. Plus, you know, is what nature does, right. So I always wonder, you know, if you think what happens in mammals is always the same story, right? So the first thing that the offspring of mammals can do is just to feed in somehow we felt we thought that not feeding was the right thing to do for a while, you know, and then we'll get we're going against nature. And I think that was probably something that we need to be mindful anytime that you tried to mess around with no nature you might be proven wrong. Have I regretted Yeah, yes. Is
that I love No, I love that focus on on. You know, we have something that is it is available to us, but it's like a lot of work right for these just postpartum people to be pumping around the clock. And I find that you know, no matter where I practiced at There were still plenty of people who weren't asking moms about how was pumping going, you know, what can we do to optimize? How can we support you? When it when we know that despite all of our technology, and despite all of these things that we are putting into babies, the one thing that has like always rang true is that breast milk is is something we should treat as, you know, medication for these these neonates. So how can we get people, you know, engaged in having that discussion? Maybe they're uncomfortable having the discussion? I don't know, you know, how can we get all neonatologist to just be asking parents about, you know, pumping practices? And how should we better support them in the unit and at home?
Speaker 3 45:47
Yes, I mean, there are some programs that have been very successful, you know, I think, have made programs and supportive groups. But implementation is complicated, again, you know, comes down to logistics, that's why I think it's just just as supply chain issue really, and then we need someone very involved in in logistics to make it work. Because I get it, you know, sometimes it's an anthology, you have to, you know, be at their side or call you for deliveries, though, you're busy in the unit, you might not have enough time to have this one to one conversation with the mom. But I think, you know, someone should have that as a responsibility. And sometimes we let that to our lactation consultants that might be seeing a lot of other babies, you know, even in newborn nurseries plus the NICU and and they do their best, but it's just not. And there's no good communication either, right? So we don't know what they have told them already what things they happen, but apparently, for what I've read is very important when it comes from from the primary doctors. So I think it's important to say a few words, at least of what you think. Now, I always worry about people thinking that that's just been too paternalistic. Because that's always is feels like a bad word sometimes. But I think sometimes parents need that, that guidance needs that need that your youth they want to hear what you think in we should take the time to at least express how we feel about some some practices. And that's, I think it's fair to call it libertarian paternalism. I like that term, because you know, they still have the choice, but you're providing some guidance or what you think is probably best in in that case, the priority with breast milk feeding, I don't think you you will be wrong.
I'm so happy. You mentioned that because it touches on the history of our field, where, number one, David Barker, through the Barker hypothesis has shown clearly that there's a there's a there's a fetal origin to adult disease, meaning how how a mother feeds during the pregnancy, how she feeds after the pregnancy affects the nutritional and growth development of the child. Right. The studies from the Dutch famine have shown that were mothers really were were starving because there was a famine, how that affected the infants and their postnatal growth. The other aspect of our field that was interesting was that it didn't use to be separated in we didn't use to separate the care of the mother and the care of the baby, right OBGYN used to be taking care of the mother delivering the mother and then have to take care of the babies and only more recently, I guess, quote unquote, have have we have we divided that care. And now the neonatologist takes care of the baby and the mother is being taken care of by the OBGYN. But I'm wondering if what is your opinion on the idea that we should be talking to mothers about their diet during the pregnancy about their diets during in the postpartum phase, like, I've never asked the mother what she's feeling. And it also not just relates to nutrition, but also to mental health and rest and all these things that could potentially optimize the delivery of breast milk to the baby and in turn, help the baby's growth. And it's, it's such an intricate network of variables. And like you said, we tend to delegate a lot of that stuff to others. The OB is going to talk to the mothers about vitamins about supplementing with vitamins about supplementing their diet, about talking about their diet, the lactation consultant is going to talk about pumping, and we're completely looping ourselves out. And so I'm wondering if you agree that we do need to get our hands in the dirt and ask those questions and if you have an approach that you would recommend for people who may not be super comfortable talking about these things to parents.
Speaker 3 49:54
Yeah, I definitely see great benefits, you know, of combining efforts and come up with a plan together, but also think about the challenges, you know, we came up with our breastfeeding initiative as recently as we were implementing our new feeding practices and and it's definitely challenging, you know, to agree on things, you know, like, we want it to get a little bit of a maternal diet, postpartum to see if we could provide some recommendations. But but then the evidence is so weak. And then and then you are in that dilemma arises, should we provide recommendations based on limited evidence? Or should we just try not to make any inference yet because this is going to be, you know, printed information? And we don't want to get into yes into into something that might actually be wrong, you know, that. And I think that's a problem that, that goes back to the importance of research of any extent, you know, sometimes, sometimes you feel like a project is too small. But those are small contributions in still, you know, is the aggregate that is going to move the field? Of course, you know, we would like to say there's going to be one study that, and there have been a few studies out there that we're able to move the field vertically, just with just one study. But in many other areas, in most cases, it has been just the aggregate of multiple in small studies. So I think that's why we shouldn't let this get discouraged by the size of the problem, just with this deal. Make small contributions.
Yeah, I love that. And what's so interesting about your research, is you do nutrition research, but that's such a big umbrella. But what you have done is very, is varied, right, including not just nutritional components, but even working on infant feeding. Right. So actual oral feeding, maybe you can tell us a little bit about some of those projects. I know you're working on a bottle nipple design, which is really cool.
Speaker 3 52:02
Right? Yes, I put that on hold, you know, haven't been doing anything on oral feeding in the past year. But um, yes, we're very interested in another field with a lot of variability. And with a lot of subjectivity, you know, on our feeding is so subjective. You know, some nurses would say the baby's not sucking Well, it's not good strength not swallowing all this is so subjective, you know, next person tells you gives you a total different report. So I think that's something that needs more objectivity, especially for us to neonatologist, you know, we're so on number driven. We like to see monitors, we like to see how things change day by day. With with auto feeding, I feel like the report is oh, well, maybe it was an interesting today, you know, the Cubase feeding too, sometimes it's still subjective, even though we have like parameters. So that's why we thought about it. And we came up with this idea of of having this bottle to assess nutritive sucking, which was, again, you know, it's at a very early stages, but we feel like we can at least define a couple of patterns that could guide us to define who are going to successfully get to full on our feelings sooner, at least detect those and then later we'll be able to tell which ones might benefit from specific therapies and things like that. But yeah, I think that's another field for for research. That is, has a lot of potential.
Since we're talking about research, and you are funded by the NI CHD, I wanted to talk to you a little bit about the the journey to actually achieve grant funding in the US. Number one, I mean, we've talked to Eric Jensen, who is a is a mega accomplished clinician and scientist, and even him had to say that his grant proposal got rejected without even an opportunity for review. And it was very eye opening. It was an eye opening experience for us to hear somebody of this caliber describing the struggles of going through the grant application process. And so I was wondering, as a as a foreign medical graduates, I think there's a lot of stigma around applying for grants, many people think that it's even not available. Can you tell us what was your experience getting through to obtaining grant funded research projects?
Speaker 3 54:41
Yes, absolutely. So so when I started as I said, I did some research back home, you know, no funding not given support at all from from the programs, I would just do it on my own. So I was fine with the idea of doing my research without any funding. So the enduring fellowship I think for most Fellows is probably this then you don't really feel that much pressure, you know, you can really pursue any interest that you have and your programs going to support that research. But then, you know, once you start your, your faculty position, that's when the funding becomes a question. Right? So so how is, how's this gonna get funded? How are we gonna support this idea that you have? And, you know, so foreign medical graduate, you're right, if you don't have access to federal funding, unless you change your visa status, and you eventually become either a permanent resident or a citizen. So in the meantime, there's, there's a lot of challenges ahead, right, because the only options for for instance, is mostly foundations that do not have any specific requirements in terms of citizenship or permanent residency. So, so that's usually the initial path. But as you can imagine, those are just as competitive as as, as NIH grants sometimes so. So there's a lot of disappointment, for sure, you know, as you advance in the career. And it's, it's, I think, something that we need to be prepared, I guess I wasn't, you know, because sometimes you have this success story, right. So you came from a foreign country, then you do fellowship you the residency, you get productive, you do your research, then you feel like you're in an exponential trajectory of growth, and then suddenly, reality hits. And then there's, there's no funding rights. And then there's all these other things. And, and I think, I wasn't prepared for that, right. So I felt like, you know, because I did all these great things, before you at least had something to show that would give me better put me in a better place. And that's not always the case. Sometimes. It just those things don't don't count, you know, that you still have to go through through this, this waiting process. So. So there are definitely ups and downs on that. And I think we should all be prepared for that. And research in general, right. So there's so much uncertainty with it, you know, sometimes your project doesn't show what you want, and you have to start over again, you know, you you see the final results, you get disappointed for a day, and then the next day, you come up with the next study. And then you move on. And, and I think it's important to live with that. Now. The good thing is, though, that you find very supportive people along the way. And I have to say that Eric, actually, Eric Jensen was one of those people at some point, you know, we had remember talking with him at one of our national meetings, and I told him, You know, I just, I don't know about this guy, you know, it's this grant is just I don't know, if I'm ready or not. And then and then just just knowing those experiences, just help, you know, just and I think that's how I am now, too, you know, I'm really very open to share, you know, my successes, but also my, my failures and the things that helped me to get better at what I do. I think that's so important. And because you know, sometimes you go to these conferences, and you hear all the good things that people have done, and you hear about all the success that they've had. But, you know, there's always a story of failure behind that that might actually be be very instructive for you as a trainee. So it's good to hear that not not to discredit the success that the person has had. But actually to learn from from those those failures that are so important. I feel like as you're building your own career, so it's very helpful to hear from others. Yeah,
I think I think this is this is very important what you're describing, we tend to have a culture in medicine and science that does that that is almost allergic to failure, we do not want to talk about our cases, we don't want to talk about our bad outcomes. We don't want to talk about our rejections when in truth, everybody is going through it, everybody is actually having to deal with it. And the fact that we're not sharing more of our experiences means that we don't get to utilize the network of support that we have available from our immediate colleagues and from the community at large. So I think it's very important, like you said, not to discredit anything, but you realize that somebody like you, somebody like Eric Jensen, have been rejected through the grant application process, and that's normal. And that if you're young investigator, and your grant proposal does not get funded that it doesn't mean that you're, you're not worthy. It just
is not good, right. That's right. Yeah.
Right. And so I think this is this is critical, in my opinion, that people understand that everybody is going through the same struggle, but I do think where your advice is Medical is because many young neonatologist providers investigators will make career decisions based on on the stigma or based on the hearsay that like, Oh, like this is not an avenue that's available to me. So I'm going to reroute myself to a more clinical job, because I know like funding is going to be super difficult. So I think it's important for people to know that there are many paths to getting funded and to getting your research off the ground. And I think it's important for people to know that
Speaker 3 1:00:33
grant is going to come if you you know, if you try harder, as much as you can. And if you put your effort, and I think that's something that's so hard to measure, but if you see that people put effort on things, you know, there's a good chance that you might actually be able to succeed. And I think that is what's needed.
And so, go ahead, and I'm sorry,
no, I know you have one more question about this.
I wanted to ask you then. So it's okay. If we share your email address in our in our show notes, correct?
Speaker 3 1:01:22
Absolutely. Yes. Yes. Very. Okay. So,
so then my question, I know, I know, you enjoy mentoring. I mean, you're, you're a student of Dr. Carlos. So So mentoring is like in your DNA almost. But what I wanted to ask you was for somebody seeking mentorship, in your opinion, what is your advice to young investigators in seeking advice and help from more accomplished researchers?
Speaker 3 1:01:46
Well, I think that it's important to have a good sense of their research profile. And if you're looking for a research mentor, I really like to see if they sort of have this growth mindset. In general, you know, they expect for it expect trainees to grow over time, you know, some people really think that there's, there's, this is the thing about nature and nurture, okay, so some people sometimes classify us whether you have it or not, and you can still be successful with that approach. But you know, when you're in training, you don't really benefit much from people that think that it's all, all nature, you know, so So I think, knowing if they feel that way, is it's important. Also, just how they collaborate with with others, you know, just just gives you a sense of how approachable they are, you know, how they're willing to share information, is if it's if it's, I would say, even an isolated researcher that has done a lot of work with other people, you know, I think that could be, you know, a red flag. Yes, person very successful, but it's having problems getting along with others might have the same problem with you.
If they're the only authors on every one of their papers, it's probably not Yes,
Speaker 3 1:03:05
right. So I think those the seven main ones, it's not much about success, and then the resources, right, so see, if they have access to a lot of team having, it's not like they need to have them all, manage all of the resources, but at least have access to, to support to people that can provide support, you know, with with analysis, you know, have you contact with a good statistician, with with a good with good research, nurses, coordinators, those sort of things?
And do you think it's important for people to to seek mentors at the very early stages of their idea saying, like, I have an idea, I need to check in with a mentor or saying, do a bit of the work and then seek help?
Speaker 3 1:03:52
That's, that's a good one. I think I've seen I think both, you know, I've heard I've heard residents come in to me, you know, with very well developed projects, and some others just just very early stages, you know, what, what do you think should be doing and those sort of things? I think it's, that's, that's probably an issue and a matter of preference. I would think that the sooner you approach them, the better just because then they you start getting more input as you build your, your, your, your protocol, or, or your study ideas, I think, I would say maybe sooner, the better. Because you don't need to have the final product back to that right. So I don't think even if you've when you think is final, I think that happens with manuscripts as well. Sometimes you feel like manuscript is ready, and then it goes out for internal review. And then suddenly, it's you have to start all over again.
There's no such thing as a final draft, right.
I'm so struck by your story about how like your experiences have shaped you and your interactions, you know, with mentors have shaped you. And I wonder how Do you feel like this COVID These COVID Times have impacted, you know, research? And how are we more stagnant? Or have we had time at home to be writing more or, you know, not being able to go to meetings and not being able to maybe have more experiences? Like, how do you think that's impacting trainees and research as a whole?
Speaker 3 1:05:23
Well, I think, I think we've probably all of us have been through different cycles to this pandemic, right. So so the first half, I would say, you know, a lot of fear, you know, just just of losing someone or, you know, not being there for the family, those sort of things, I think we're pressing towards, you know, to throughout, you know, what you're doing and, you know, seeing patients and, and having to do to create your reports being productive. Actually, the pandemic, my first year of the grant happened throughout the first year of the pandemic. So, I was trying to show productivity, but at the same time, you know, there's so many patients plus, you know, everybody else was living in such a survival mode. Right, trying to do the best you can, but definitely not being able to, to maximize your opportunities, I think, that has been expected we struggle a lot with our, some of our research, support people, you know, some some people had existential crisis, you know, like, expected, you know, is this what I want to do, you know, for the rest of my life. So, I think that has helped us have, you know, made us reorganize, sometimes our team sometimes, you know, had to be respectful, because I think it was, it was a time to question things again, I think we, and probably, you know, same thing for for many researchers, from clinicians as well, right. So it's this what I want to do the rest of my life, you know, this is what I want. So I think I had this moments, like, probably everybody else, then there's this face of, you know, overwhelming, you know, when things were starting getting better, sadly, you know, the list of things that you been waiting for, finally, are about to happen, and I just felt so overwhelming. I just couldn't catch up with my emails for almost a month, you know, because I had so many things that I was postponing. And, yeah, I think it's gonna take time, you know, to to get back to, to a traditional routine. But, you know, I think it's been eye opening for for many of us, in some ways, you know, to try to find that balance that probably doesn't exist, really, but you know, just seeking for it, maybe it's difficult. It's first step.
Yeah, I glad you use the word balance, actually. And I think the pandemic has pushed all of us right to our, to our limits, but being a researcher still working, you know, doing clinical time having family obligations, you know, we like to ask all of our guests like, how do you how do you navigate it all? How do you balance it all? And how do you, you know, manage productivity, but keeping your, your mental health? On Track? Also?
Speaker 3 1:08:18
Yeah, I didn't realize how much how you isolated, you know, I haven't seen my colleagues in a long time, you know, we haven't gathered, you know, we see each other, you know, during checkouts and, and that's it. Sometimes, we have our division meetings in over zoom, but it's not the same, right? Yeah. So I'm really looking look forward to seeing no in colleagues from other institutions. As you know, it's been so long human
contact is what is what keeps the balance going out?
Speaker 3 1:08:52
I think so yes. I don't think much about it. But you know, when you miss it, it's just it becomes like an email or in some way we are social
beings, after all. So yeah, I mean, there was a lot of discussions early on in the pandemic about not saying social distancing, with more physical distancing. And I know Daphna is very keen on nomenclature. So that I think I think, at the end semantics, I think this is very important. We should try to remain social. And that's one of the things we're trying to do, I guess, on the podcast. Before we let you go, Ariel, I mean, you do have a website called neonatal nutrition research.com, which we'll we'll link in the show description for people. But can you tell the audience where they can find on that website and to where they can find if they're interested in your research or participating and stuff like that?
Speaker 3 1:09:43
Yes, absolutely. Thanks. So we created this website just to Well, initially, we wanted to have some sort of parental resources about our studies. We want them to have access to additional information because sometimes, you know what we can explain In it, you know, throughout the consent process might be limited, you know, sometimes it might be helpful to have figures to have some, some additional resources developed in one place. So that was one of the purposes of this site. But also just to show the studies that we've done, also to provide some information about the evidence available some of the things that we're studying, because sometimes it's hard to cover those when we explain things to parents, and even even our own staff. So it's a great resource for us to have, in terms of things that we can explain right away. And so you know, we have this information on the website, if you need more about the study, and why we're doing it, so can use this resource. And also, you know, eventually would like to have that center as, as a site to collaborate with other institutions. You know, we're very happy, very happy to share protocols, though, that's the one thing I learned as a researcher that first you know, you want to keep your ideas for yourself, you know, you want to be the one that come up with the good studies. Now, there's no much time left, we have to do as much as we can, the sooner you share the ideas, the better, someone might actually find a way to do them. And I'm more than willing to share my thoughts and some of the research briefs that with Don limitations, the opportunities, and and I think, you know, a website like that will help us to, to share study protocols, you know, without a big commitment, you know, if someone can do it easily in their center, they could easily have access to our actual study protocol and use it as they want. I think
the website is very well designed, it has like a page about each one of you guys. And it's and I think it's to me, that's what it felt like most it's, it lends itself to like, this is a group that wants to collaborate that wants to engage with other groups. So again, well, Lincoln to destroy descriptions. It was it was, it's, I think it's a very valuable resource. Definitely thing to close the show.
Yeah, he's gonna say, No, I it's, it's the the website is extraordinary. It's very easy to use, it's so inviting, comforting, you know, even as a as another physician to see what you're doing. And it's so important to know what people are working on, right. So we know what to be looking out for, even if it's not our area of interest. And I hope all of our listeners take note about your guidance on collaboration, because I think that's the future. That's how we move the needle faster. I think. So thank you for sharing. We'd love to have Yeah,
it was a lot of fun. Ariel, thank you for taking the time. And, again, we look forward to yours, research being published and all the work you're doing on neonatal nutrition. Thank you for being on the show with us today.
Speaker 3 1:12:50
Thank you, man. Thank you, man. Please keep bringing more episodes. You know, I always like to hear your nipples. I like your perspective. I'm also I didn't tell you this, but I like the pace and analysis to future that you in neonatology, we just need. Yes, we need to just keep growing, you know, just one by one. We're going to start convincing more people on Bayesian approach