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#058 - Journal Club 28

NICU journal club the incubator podcast

Hello Friends 👋

Welcome to a new episode of Journal Club.

We have some very interesting articles for you this week. We hope you enjoy this episode!


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

The ethics of family integrated care in the NICU: Improving care for families without causing harm. Janvier A, Asaad MA, Reichherzer M, Cantin C, Sureau M, Prince J, Luu TM, Barrington KJ.Semin Perinatol. 2022 Apr;46(3):151528. doi: 10.1016/j.semperi.2021.151528. Epub 2021 Nov 9.

Association of multiple tracheal intubation attempts with clinical outcomes in extremely preterm infants: a retrospective single-center cohort study. Miller KE, Singh N.J Perinatol. 2022 Sep;42(9):1216-1220. doi: 10.1038/s41372-022-01406-5. Epub 2022 Apr 26.

Effect of antibiotics in the first week of life on faecal microbiota development. Van Daele E, Kamphorst K, Vlieger AM, Hermes G, Milani C, Ventura M, Belzer C, Smidt H, van Elburg RM, Knol J.Arch Dis Child Fetal Neonatal Ed. 2022 May 9;107(6):603-10. doi: 10.1136/archdischild-2021-322861. Online ahead of print.

Recognition and Management of Cardiovascular Insufficiency in the Very Low Birth Weight Newborn. Goldsmith JP, Keels E.Pediatrics. 2022 Mar 1;149(3):e2021056051. doi: 10.1542/peds.2021-056051.

Postdischarge Iron Status in Very Preterm Infants Receiving Prophylactic Iron Supplementation after Birth.Landry C, Dorling J, Kulkarni K, Campbell-Yeo M, Morrison L, Ledwidge J, Vincer M, Ghotra S.J Pediatr. 2022 Aug;247:74-80.e2. doi: 10.1016/j.jpeds.2022.04.050. Epub 2022 May 14.

Compatibility of rapid enteral feeding advances and noninvasive ventilation in preterm infants-An observational study. Behnke J, Estreich V, Oehmke F, Zimmer KP, Windhorst A, Ehrhardt H.Pediatr Pulmonol. 2022 May;57(5):1117-1126. doi: 10.1002/ppul.25868. Epub 2022 Mar 9.

Association of early discharge with increased likelihood of hospital readmission in first four weeks for vaginally delivered neonates.Pohjanpää M, Ojala R, Luukkaala T, Gissler M, Tammela O.Acta Paediatr. 2022 Jun;111(6):1144-1156. doi: 10.1111/apa.16290. Epub 2022 Feb 27


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

Ben 0:58

Welcome Hello, everybody. Welcome back to the podcast. It's Sunday. We are in a journal club week definite. How are you?

Daphna 1:09

We'd love Journal Club week, don't we? Definitely.

Ben 1:12


Unknown Speaker 1:14

So everything's good.

Ben 1:16

Everything's good. Good.

Daphna 1:17

Yeah. Yeah, we we had a tough week in the unit. However, it was nice to get the board scores

Ben 1:25

back. Yeah. But it's the halo effect. Right, the positivity of one thing carries over to others. So

Daphna 1:32

yeah, you know, I actually posted about that on Twitter, like, the next day, there was like, you know, the world is still a little bit in chaos. So it just puts it puts a damper,

Ben 1:44

even but it also goes to show how our experiences so can I can I can I, I wouldn't expect me to rent so early now in the episodes here. But that goes to show how maybe just maybe the forces that be should be conscientious of adding more stressors on our lives as clinicians, because when you realize that you pass your boards, and you're like, Oh, my God, what a relief life is so much like the, the, that you take a breath, right? And it's like, Why was I made to feel so stressed about this? Yeah. When, when when I graduated from medical school, I completed my residency, I completed my fellowship like this, this should really be a formality. And, like, I remember for myself, I was terrorized before the end before the results. I was like, can you imagine like, I'm supposed to be this, this young neonatologist was supposed to know all these things. And I just found my boards. Can you imagine what does that mean? And I know that you're not supposed You're bigger than your board scores and divorce court.

Daphna 2:48

Finally, know that I mean, in standardized test, in general don't predict clinical success, right. But it still feels like this,

Ben 2:56

it made me feel like the bottom line is that from the end of the exam until the results, I felt like shit. And I was working for clinical schedule hanging in the balance, kind of Yeah, and we had sick patients, and we have other personal stuff that are going on. In our case, we were in the midst of the COVID pandemic. So maybe, maybe we can find ways to make this a safer place for for our trainees. All right, that was the rent of the morning. That was approved. Okay, so some announcement that we wanted to go over. So obviously, we're we got a ton of feedback on Twitter about the board review and how people were thankful for the board review podcasts, were very grateful that this was of help. We want to thank again, Dr. Martin and Dr. Brodsky for making this possible. Because obviously, without their support, and without their content, this would not have been this would not have existed. They've been super flexible in making this happen for you, the audience, because let's just say without naming names that we reached out to other other provider of educational content, and they were less receptive to the idea of helping trainees on their commute.

Daphna 4:03

less receptive is, is an understatement.

Ben 4:08

So doctor, so can be Martin dobrowski. They're legends. Let's just we're very, I'm very thankful that we were able to make this happen. And check out the new format of the podcast until the boards are coming back up again. And then we'll kick back into gears with more questions and things like that. But we still are doing questions and we're still keeping you in shape.

Daphna 4:28

So I think I think the point of this kind of new format is to kind of do the dive the deep dive before it's time to like really cram for the boards where we will amp back up with just questions led to you with questions. But I think this will help prepare people in a less intensive way. Oh, yeah.

Ben 4:51

Yeah. The other thing that we wanted to announce is that there's the incubator podcast is going to provide more content I will talk about some things that we're doing for different languages very soon, like very, very soon. But for the time being, we've recorded our first episode of what we're calling Tech Tuesday, where we don't have a frequency but on on certain Tuesdays, we'll release a short episode with the creators and founders of mobile technology or other form of technology solutions that can be used in the NICU so that we can bring people up to date as to what's available out there. I think what we've noticed with Dafna was that people tend to have a set of favorite apps and different other tools that they use and, and it's always like, you know, you're peeking, you're like, Oh, what is this person? You know, what is that person. And we don't really have a good repository of all the of all the cool things coming out. So we talked to Yaya Ren this week, and she's talking to us about her app Premium Plus you. And it's also a great thing, because sometimes you download these apps that have some form of premium NICU in it, and you're like, I'm not exactly sure what they're trying to do. It's hard. Like, they're thanks to the small episodes, like the creators will tell you like, alright, this is what this is for. And then you can decide I want to download it. I want to work with these people. It's very cool.

Daphna 6:14

Yeah. And I think people might wonder we don't have any stakes in any. Oh, no. Yeah. If I mean, you are developing an app. We'll talk about that at some point in time. And we'll let you know if we have any stakes. But we definitely

Ben 6:27

we definitely have a stake in this app, like the app I'm developing. And the stakes are a lot of stakes. But but the others No, I mean, but this is the theme of the incubator, right? Where like, we're, we're, we're not getting paid for any of the things we're doing just so that we can remind everybody. And but the goal is really to create this platform where people can actually have access, so I'm not alone. And to be honest with you, we're not getting paid for this. But the feedback we get like right after the boards, for example, is so invigorating, and it's worth more than whatever amount of money.

Daphna 7:03

Yeah, and actually it helps a lot, right, because our goal is to get more people listening because we think that the the accesses is useful and we can tell that when you guys post about it, that that it that it helps, right it gets more people engaged in the conversation and growing do Twitter and so thank you guys for for you know, you don't have to comment, but you do and it's helpful. Yeah,

Ben 7:33

I agree. Okay, so today we're doing Journal Club. should I should I start? Yes. Okay, so the first journal, the first paper I'm reviewing is published in the Journal of parasitology. It's called the association of multiple tracheal intubation attempts with clinical outcomes in extremely preterm infants, a retrospective single central cohort study. first author is Caitlin Miller from Dartmouth in New Hampshire. So the background is is interesting but but nothing really earth shattering. If you if you know that a bit about tracheal intubation, you should be familiar with a lot of the points that they're making. They're talking about ivh, for example, being a complication that's associated with tracheal intubation. And that the risk of ivh really increases with multiple attempts and that multiple attempts is frequent in neonatal resuscitation. They're also quoting this paper, which I think was nice in terms of putting numbers on these on this data that only 49% have tracheal intubation in the NICU and 46% of tracheal intubation is in the delivery room. So both of them less than 50%. were successful on the first attempt. So it's a it's a humbling reminder, right, that we're not as I think if you talk to any neonatologists we think like we're we're mastering debaters. But it's a good reminder that looking at the numbers, there's there's work, there's there's improvements, there's room for improvements, for sure. So the question was, is there any association between tracheal intubation attempts and the outcomes in extremely preterm infants, and more specifically, the objective was to identify if preterm infants exposed to either one, two, or three or more intubation attempts during the initial encounter in the first four days of life, have increased incidence of death or severe ivh. I think it was very important to underscore the word initial intubation because I'm assuming that if your baby has like six intubation during the hospital stay, it's most likely also associated with a higher degree of illness and stuff. So I think I think that that was the reason why they did that. So this was a retrospective cohort study using data that was collectively prospectively collected from a level three B NICU in an academic tertiary center and that was in Dartmouth, New Hampshire. And it was kind of nice for them to go over their their protocol but their, their practice, right, I think it's I really, I really respect the groups and institutions who through these papers have to devote a lot of their practices because because many people don't feel comfortable doing that. So it's kind of nice.

Daphna 10:01

Why is that? You know, we're all just trying to learn from each other right now.

Ben 10:07

So at their center, extremely Prim, extremely preterm infants are either intubated in the delivery room for poor respiratory effort or selectively intubated for surfactin administration in the NICU for rds, the premedicate all their intubation with atropine, phenol and succinylcholine in rapid succession, and that's only done obviously in the NICU. This is not something that they have the luxury of doing in the delivery room, which kind of makes sense, I guess. From a logistics standpoint. Interestingly enough, right. That's the big point of discussion of this paper. The provider chosen to attend the intubation is selected based on experience, staffing, availability and comfort level. So reasonable, but not very rigid in terms of of structure. On the NICU providers that perform most intubation for infants less than 28 weeks are the nurse practitioners, physician assistants and fellows. at their institution providers performing intubation need to have at least three intubations under supervision to be considered to be considered competent. And in addition to that the residents, the fellows and respiratory therapists have quarterly intubation simulations to maintain competence. So the babies that they looked at were babies who underwent a first intubation course in the first four days of life and they were had to be born at 28 or less weeks of gestation, and that was looked at from 2016 to 2020. They excluded any babies that were born at outlying hospitals, or who had significant congenital anomalies. So some more important information on the study. Only the first encounter count was counted. They took data from the NIR for Neos collaborative if you don't know who are the near for Neos, you should check them out. They have great collaborative for for trainees and for intubation in general. And they looked at the date of intubation, the reason for intubation, the location the use of premedication. They had some operational definitions as well, that were similar to the near formulas registry, but an intubation encounter was defined as an episode of airway management ending with the successful intubation. The attempt was any maneuver where you had to insert a device and ended with the device removal. So if you entered the laryngoscope, and that was considered an attempt and the attempt was considered stopped when you remove the device, a severe oxygen saturation was defined as 20% or more decrease in saturation from the highest point right prior to the intubation. Bradycardia was the lowest heart rate under 100 beats per minute if the infant had a heart rate of about 120 beats per minute prior to the first ti attempt. So they had some outcomes. Their primary outcome were death prior to NICU discharge or severe ivh defined as grade three or four. And then they have a bunch of secondary outcomes, adverse events during the intubation and complications of prematurity, the adverse intubation and the adverse intubation. events were considered oxygen saturation bradycardia as a federal intubation dysrhythmia right mainstem Bronco and bronchial intubation, which, by the way, like Yeah, I mean, I don't I don't know about that. I was wondering what you thought about that. Like if you if you're right mainstem you push the tube too far,

Daphna 13:24

right? But it's the baby's intubated Right. And, and that can happen days after a successful intubation is eventually being you know, right. So anyway instead, but

Ben 13:39

today oral oral trauma emesis pain or agitation cardiac arrest, hypotension cardiac compression, less than one minute laryngospasm and then they had some complications of prematurity pneumothoraces neck ROP sepsis BPD using the Vaughn definition, okay, so let's see what the data shows they had 99 infants the mean gestational age was 26.5 weeks mean birth weight was 900 grams. 46.5% were intubated on the first attempt to 29% required two attempts and 24% required three or more attempts for successful intubation. Yeah, humbled humbling numbers. In terms of the, the outcomes themselves, there was a statistically significant association of tracheal intubation attempt with death P value point 004, but not with severe ivh, or the composite outcome of death and severe ivh. So that was quite impressive. So when you're looking at the table, table three in the paper, in the one attempt, the number of patients who died was 4.3% and then it jumped to 27.6% to attempts and then to 29.2% in three or more attempts, so quite impressive compared to successful intubation on first attempt Increasing ti attempts were associated with higher risk of death when adjusted for gestational age mode of delivery antenatal steroid exposure, sex and location of intubation. In multivariable regression analysis, the number of attempts was also adverse was also associated with adverse events during the intubation that were associated with adverse TAs. It's interesting because during in the paper, they keep mentioning adverse T I A is right so adverse tracheal intubation adverse events, but I feel like it versus already in the in the thing so. I know, I don't know. So that's so that's that's the primary outcomes in terms of the secondary outcome. They found no association between intubation attempts and complications of prematurity including pneumothorax neck retinopathy of prematurity, ROP nosocomial infection, or BPD, which was kind of nice, because I was afraid that if they had found any association, then you would have wondered like, oh, how much can you actually connect the two or whatever? So it was it was it was good. Some other interesting results in a post hoc analysis of the intubations in the delivery room, which were 57 of them, and in the NICU, that was 42 of intubation. That was statistically associated with tracheal attempts in the delivery room, but not in the NICU. So that was very interesting to me, because obviously, I think it goes to show how a controlled intubation which based on the methods, right, I'm not saying that they don't have controlled intubation, but based on the on the methods and how they describe them, and how they had the opportunity to pre medicate the babies in the NICU. And obviously, I'm assuming the like everybody like us included in the delivery room, it's always quite chaotic, it kind of is.

Daphna 16:43

It's well, and, and those were the babies that could stay on noninvasive, right until they got to the very top that's something to

Ben 16:52

very true. There was no association between tracheal intubation attempts and ivh or the composite outcome of death or ivh in either the delivery room or the NICU. So in conclusion, the paper is showing that increasing attempts before successful intubation is associated with death and adverse trigger intubation events, but not severe ivh or other complications of prematurity. And this is the point the conclusion that, to me is what we should discuss, obviously, is they speculate that carefully selecting the first provider for intubation in extremely preterm infants could decrease attempts required before successful intubation and decrease adverse event and improve outcomes for future research with larger sample size is indicated. Obviously, that's the two biggest limitations just in case you we lost you in the shuffle here was, it's a small study, it's like less than less than whatever it's like about 5050 patients in each arm. And it's a retrospective cohort study. So all the limitations associated with that design are present. But But does that mean that we have to now return to attendings and more experienced providers doing intubations?

Daphna 18:06

Yeah, you know, there have been other studies that showed the opposite, right, especially when it comes to delivery room intubations, that increased attempts were associated with increased ivh. So I think it begs the question that we need, we need bigger studies and way more opportunities, right for people to practice. Because at some places, the most experienced provider may not have intubated in a while. So it's, it's complicated. It's complicated.

Ben 18:39

It's very complicated. I think it's it's also something where I like the way they phrase it right, that you have to pick the provider because, for example, at my training institution, the best person to intubate was probably the second and third year fellow, right? Because the fellows covered all intubations meaning even if a if a nurse practitioner or a therapist was intubating, the backup was going to be the fellow. And I think the attendings, thankfully for them very rarely had to write. If you're a first year fellow, you're you're still I guess, learning but once you were a second or third year, you were you were pretty, pretty competent. So I think it would be misleading

Daphna 19:15

and and you had been doing them, right, like you'd been having the opportunity. Right. So

Ben 19:21

I think it'd be it would be misleading if you just looked at another paper that said all fellows should not be right. I mean, careful. But also, I think this paper is a very interesting follow up to our last journal club where we talked about using high flow nasal cannula during intubation, right. Another reason why maximizing successful situations is is very important because of because of these outcomes. And like you said, it's bizarre that didn't find a nose position with AVH because that data is pretty strong and it's out there. But irrespective of that their their association with with death is pretty scary. And interesting

Daphna 19:56

isn't enough. Okay, um, I wanted to talk about this article which perfectly dovetails with our interview this week. So we had on Dr. Andy John beer and if you haven't listened to the interview, we hope you'll take a listen. But it just so happens. One of her articles was released this month the ethics of family integrated care in the NICU, improving care for families without causing harm. And Dr. Janvier is the lead author. And of note, I think this is really important that the author list includes a lot of parent groups and parents as primary authors on the study, which I think is something that we should really be doing more of the journal seminars of Perinatology This is coming to us from Canada. The CG St. giusti NICU is the largest Mother Child NICU in Canada. And so I think it's important to note when we're talking about family integrated care what what does it look like in the unit where the data is coming from? So it's a 75 bed level for unit about 35 beds dedicated to intensive care, they have about 1000 admissions a year. So what's the question? The question was really, are there some aspects of family integrated care that cause harm to families, and I guess some background information. Dr. Janvier is in neonatologist, who's also the parent of a NICU infant. And I think some of this work has come out of those experiences,

Ben 21:36

go listen to the episode, people just listened to the manual now.

Daphna 21:40

Is it a valid question? So absolutely, there's a huge push for family integrated care, which has been shown in you know, a number of studies to improve stress, anxiety bonding for most parents, however, the studies are small, the studies have a lot of heterogeneity. And, and it may lead everyone to believe that all families want to do all of the things that we propose for family integrated to care when it might not be the right thing for every family. So that's what they wanted to look at. I think the the group does a really good job talking about some of the ethical issues and family integrated care. So I'll talk about that a little bit before the survey data. So some of the limitations, let's say to the research that's been done and feel me integrated cares that many control groups were basically these quote, unquote, non participating parents. So they were just parents who were absent, which we see all the time in the NICU. And studies were rarely addressing why the parents were non participating, you know, what were the barriers to having those parents in the unit, which is a huge implication on on on those studies. There's still not enough studies or large enough studies. And then one criticism of the major family integrated care trial was that parents in the intervention group, again, in stark contrast to the quote, unquote, non participating, participating parents, or parents who are present for at least six hours during the day, caring for their infants, which is truly not feasible for most, most families. And this definitely limits generalizability. In addition, families who could spend that much time at the bedside tend to have a lot more additional resources, including things like family and social support. In addition, a lot of the family integrated care studies had large exclusion criteria, and I won't go over those, but in general, a lot of them are very vulnerable patients and families like the extremely preterm congenital anomalies, high risks for for death in the NICU. And so excluding those parents may limit some of the information we get from those studies. Do we exert too much unreasonable pressure on families such as parent presence during the rounds? So for example, what if our families work during the day? What if they have a fear of public speaking? So are our options for family integrated care, unreasonable? shared decision making? Is this the right model for all families? So some families actually prefer a more paternalistic approach, which is kind of this pendulum swing that we've had in terms of working with families. So these were some of the concerns that they were worried about and why they engaged in this study. So the study design is survey data of parents. And the inclusion criteria is all a study. They did a study survey data, both of parents and providers in the NICU. So inclusion criteria was all groups a full time clinicians who worked in the unit So they had physicians, including Neos fellows residents, they had nurses, respiratory therapists, social workers, psychologists, pharmacists, nutritionists, clerks, chaplains, basically anybody you can think of that was having face to face contact with families. And then they involve parents who were hospitalized in the NICU for more than one month and parents attending the neonatal follow up clinic after discharge, so one parent was asked to participate for each child. There's no real exclusion criteria except for not meeting the inclusion criteria. And I'm going to make a point about this because, for example, we have lots of babies admitted that don't stay in the NICU for a full month. And so we know that those families still have increased rates of stress and anxiety and trauma associated with the NICU admission. So I would have liked to have seen that group included. The intervention is really over a two month period, they asked participants their opinions regarding a list of potential items that could be included in quote unquote, family integrated care. And then some of the questions for example, we're at the present time, in this unit, can parents do this activity if they want to? Have you been engaged in this activity? And ideally, should parents be offered the opportunity to engage in this x activity? So I'm gonna go over this the data and then there are some really good quotes, I think that I'd like to share, like the talks, but I love the quotes, obviously. And I want to hear all of them, I promise. So you can, you can take a look if you'd like. So based on characteristics, they had 332 participants in 240 healthcare professionals and 92 parents, I told you about the makeup of the health care professionals. The 92 parents who participated 48 were families of the currently hospitalized children and 44 parents who participated at follow up 90% of the parental respondents were mothers, which is also not uncommon in studies of family integrated care. And that's something else that we can definitely work on is including, you know, the non birthing partners 60% were aged between 30 and 40 years, which is interesting. Also, depending on where you work, and what your makeup of parents looks like 9% were single mothers and 34% were primate. So this was their first child. The majority of infants that follow up were preterm infants who are born at less than 29 weeks, so that may skew the data a little bit and the hospitalized infants of the parent respondents were also majority preterm or congenital malformations 20%, and they had an overall mean gestational age of 29 weeks. So again, another ongoing criticism of our of our research is that we have a focus really on the on the moderate to extremely preterm. So the primary outcome was looking at really the non medical items. So these sorts of activities include changing the diapers, giving the bottle feeds, reading stories, singing, taking photographs, getting information about breastfeeding, being present, at rounds, not not providing the rounding, but being present at rounds. And for each of these items over 97%. And usually 100% of parents and all of the health care professionals agreed that parents were participating in these activities and that they should be participating. The main frustration parents expressed regarding these kinds of quote, unquote, non medical activities was variation in practice from one nurse to another, we'll talk about them a little bit. Then they wanted to look at these more medical items. And so these medical items included being present for resuscitation for intubation, being part of the vaccination, presenting their babies at rounds and doing things like tube feeding, or managing the oxygen titration while they're at bedside. So, not surprisingly, physicians were generally in favor of more parental involvement significantly more than other groups, including parents, which I think that's kind of the surprising component. Nurses were divided and other providers had even more reservations and were even more split on their responses. For example, 35% of parents reported being present during a resuscitation or thought that parents should be there when they want to. In contrast, 80% of physicians that parents should be there. 30% of nurses and 22% of other providers thought that parents should be present for recess. dictation. And in terms of parents satisfaction being present during intubation was 48%, resuscitation 35% vaccination 88% and presenting their baby at rounds was 53%. And so this is an intervention that is being rolled out at a lot of institutions. And for this cohort of families only 53% thought that parents should be presenting their babies at rounds. Parents reported that they were present, parents who reported they were present generally reported that parents should be present if they wanted to. So, if the parents had engaged in an activity, they felt, they were more likely to say that parents should be present. However, if parents were not present, like during intubation, they either did not think parents should be present, or only parents who wanted to should be present, there was consensus for some items, for example, parents did not want to be in charge of checking the site of IV infusion. And in general, me, I don't want to be in charge just checking patients. And clinicians also generally did not think that this should be delegated. And other items were more variable, such as adjusting oxygen concentrations. So 30% of parents wish to adjust the oxygen, which was less than I thought, compared to 50%, who have physicians who thought that they should be engaged in that activity and only 13% of nurses or other professionals. I know the nurses in our teas did not want anybody even they didn't want the physicians titrating oxygen.

So other interesting results, so they really tried to quantify classified the kind of open ended benefits of family integrated care. And then general most parents liked the family integrated care model or concept which one enabled them to be a family and feel like real parents, too. They had a desire to feel like it'd be quote, unquote, good parents, and three, there was strength and empowerment associated with family integrated care, in some cases, even repairing past trauma, such as guilt, they felt about having delivered a sick baby. So I'll try to get you some quotes now. I'll go the overall message is that families do like family integrated care. So that that's the goal of this article is not to say we shouldn't be doing it, but should we be doing it a little bit differently. So at first, I felt the nurses did all the things I should have done the job my broken uterus should have done that I wasn't a mom, I was scared in the unit and even on my baby, I started feeling stronger though, because of all these things I did, I think the nurses for their help. And it was really nice to be able to suggest things to improve this for other parents in the NICU. Not surprisingly, a third of parents reported guilt associated with being asked to perform tasks that they were unable or unwilling to do, or felt pressure to do. Another quote every day, a nice nurse would ask me if I would come back in the evening, but I had two other small children at home who reacted to my absence and an exhausted husband who couldn't stop working. So I ended up every other night either crying at home missing my baby or crying in the NICU missing my other kids, your family integrated care occurs at home too. I wish they understood that sometimes just asking us hurts. Another quote, There are many questions that made me uneasy. No, I do not want to feed my baby with a tube. I never have wanted to describe her on rounds. This is my third child and I wanted to be a good dad to all my children. For me, dads don't do those things, even if you told me that they could or should. These are temporary medical things. But being a dad, for me means things. Like speaking to her singing her songs, changing the diaper, giving her baths, taking her in my arms, being interested in the next step and what is going on. I don't want to be a nurse or a doctor, it is important to me to remain a dad, if she needs to come home with tubes, then my answers would be different. Because then that would be part of their routine care. And then certainly this quote on nursing variability I think is very valuable. It's hard to know what your role is as a parent the same day I can be told she's too unstable for kangaroo. And then after the nurse changes that I it would be good for me to kangaroo her. Why hasn't it been done yet? And then you feel super down you feel anger? Like is one nurse too stressed or is another to care free? And then you just want to leave the unit. The small things really affect me right now. So I think the quotes can really help you understand that like having parents engaged in things that they feel our parents like is important, and that that's different for every family. The other thing they wanted to highlight was the importance of veteran parents. So involving resource parents was overall deemed as positive and Definitely To be continued. This father said, it took me a long time to feel like a parent. I could like I could face the music, it did not happen all of a sudden, and the nurses and doctors need to know this, do not force us to do things if we're not ready. What helped me the most was communicating with other parents online support groups helped me connect with parents who had been there to understand that some of my feelings were normal. So you don't even have to have veteran parents in the unit really just having access to them even by a number of online support groups. And then finally, guilt and decreasing guilt in the way in the language that we use. So just asking, do you want to be here during the intubation makes me think that I need to be there, even if I don't want to? This is what good parents do. And I want to be a good parent, or at least show them that I'm a good parent. And I want to feel like a good parent. What kind of parent wants to leave their child when asked if they want to stay? If there's no good answer, they should say something like, some parents want to be there during the intubation, it makes them feel in control for these parents imagining is worse than seeing. For other parents. It is different seeing an intubation on their child is too stressful, and it does not help them or their family. What kind of parent are you and I'm Dr. Gambier talked about that, in our interview with her saying some parents, other parents and just describing that there are different types of parents, and neither is good or bad. Finally, they identified a list of priorities in terms of family integrated care and some specific Qi actions that their teams were going to take. So the major priorities were assisting parents early to adapt to their new roles in the NICU as team members by providing a welcome package that was written by parents and having prenatal support groups, improving integration, appearance and discharge planning. So that was an especially valued component. And they had the development of a new discharge nurse role, decreasing family integrated care, nursing variation, by developing guidelines and protocols. I think everybody on the team feels this, and then to more particular attention to personalized care where parents described potential harm and enhancing interaction with veteran resource parents. So I've already told you what I think that's,

Ben 37:27

yeah, no, it's fantastic work. I love the idea that what we think matters tremendously does not matter as much this is sort of my moral compass. Because I think, I think many of the guests we've had on the podcast for the past year have said the same thing that it's not because sometimes an association is found, or, or a relationship is identified that if you don't do it, then everything's going to fall apart and the patient's gonna die. Right. So I think this is the type of paper that shows that you have room you have room to write, it's like, yeah, it's great if you could, if you could be at your baby's bedside. 24/7 right. But it may not be feasible. And guess what? It will be okay. Right? I just love this idea that we can be forgiving with our, with our families, and we can give them the room to just breathe a little bit. And that this is something that can be quantified. And Dr. Janvier is so good at doing that. So I love it. I just because because sometimes overall

Daphna 38:26

message is just, you know, meeting meeting parents where they are.

Ben 38:30

Absolutely. And you see parents were so dedicated, for example, to breastfeeding, and some parents were just being wrecked by the pressure or by the commitment. And it's these types of paper that allow you as a provider and for nurses and for anybody to say hey, like just just no prep rate to be able to tell the parents no pressure, do the best you can, it will be fine. Is something that we don't say ENOUGH OF so yeah, and tell them tell you what they enjoy. Yeah, we tend to do a lot of transfer of what we think is something that they would enjoy one inch with them. Anyway, go listen to the episode with Dr. Champion. It's it's really, really great. And this is a very good follow up to that paper or vice versa. Your ticker, Daphna. Yeah, since since since you went down, took so

Daphna 39:18

long, that's what you have to rush now.

Ben 39:21

Now. Yes. Okay. So this article that I wanted to review next is called effects of effective antibiotics in the first week of life on fecal microbiota development. first author, Amy van Daly, from Utrecht, Utrecht in the Netherlands. It's published in the Archives, and it's a very interesting paper. So I'm going to skip the background. We know that we have a microbiome that can be perturbed by antibiotics and all these things. So the question was, what are the long term effects of early antibiotic exposure on the developing microbiota during the first two and a half years of life? Very interesting stuff. So like They were looking as a prospective observational study of term infants from for teaching hospitals in Holland. The included term infants who received antibiotics like in the first few days of life or without sepsis, and they categorize them whether they got like a few days versus they got seven days. And they excluded babies who had congenital illnesses, severe perinatal infections transfer for which they need to transfer to the NICU mothers who were on probiotics within six weeks of delivery or an interesting exclusion criteria, insufficient knowledge of the Dutch language. Take that. I mean, I have had many more issues with the paper, but I thought that we've mentioned that important design information. All babies were antibiotics received gentamicin with the combination of some other form of penicillin, whether it is penicillin, amoxicillin, or augmentin. They collected nine fecal samples from these infants until discharged from the hospital. And then they were they were simply they were frozen, and they were tested. And then the sampling continued at home by the parents were during the first year of life, they collected eight samples, and then they brought it to the clinic on ice. Good for them. Good firm,

Daphna 41:21

that's no small task.

Ben 41:22

And then there was a final sample that was collected to two years of age. And then they did all the sequencing and analysis, the alpha diversity on the sample. So the primary outcome of this particular study was looking at the impact of antibiotic exposure in the first few days of life on the microbiota development in the first two and a half years. secondary outcomes were to examine the short versus long antibiotic duration, the different antibiotic types, and the feeding the feeding methods, formula versus breast milk, and the delivery method. Vaginal versus C section. Okay, so let's talk about baseline characteristics. So they had two groups, right. They had a group of babies that didn't receive antibiotics, that was 126 patients. And then they had a group of babies, I received antibiotics that was 56 patients. The gestational age in weeks, was 39.4 weeks in the babies that did not receive antibiotics versus 40.4 weeks, in babies that did receive antibiotics, I mean, birth weight, compared three kilos, 470 grams versus three kilos, 711 grams. There were some significant differences in baseline characteristics. And those were based on gestational age, birth weight, and the additional antibiotic exposure between one to six months. So let me talk to you about that. So what they did is within the antibiotic group, they had two subgroups. They enter antibiotic to antibiotic seven, which represented the babies who received a shorter course of antibiotics like two, three days, versus eight antibiotic seven, which were the babies who received a Four Seven Day Course. So the babies are received the short course was 20 patients, seven days was 36 patients. And then they collected additional information, obviously, because, okay, so like the baby goes home, and you want to find out the impact of the antibiotics on the microbiome. So babies get more antibiotics, they get sick, and they more get more antibiotics. So they did try to collect this information. And this was a sort of, yes, no type of questionnaire. And there were significant differences. So between additional antibiotics between month one and six, only 5% of the patients received antibiotics in the group of the in the group of babies who received a short initial antibiotic course, versus 34%. In babies who had a more prolonged course. And when they looked at even more additional antibiotics from seven months and 12 months, then this, this difference was still pretty pronounced between 10% for the babies who received only two days of antibiotics versus 24% for the babies who received the Seven Day Course. So the results were quite interesting. So exposure to antibiotics was associated with significant increase in the relative abundance of enterobacteria at three weeks in one year, and a decrease in by federal bacteria from one week until three months of age, only in vaginally delivered, but not in C section born infants. Similar deviations were noted in babies received the full seven day course of antibiotics, but not in babies who received a short course of antibiotics of like one to two days after antibiotics breastfed infants have had lower relative abundance of potentially pathogenic enterobacteria compared with formula fed infants and recovered two weeks faster towards control. And you should look at these graphs because it's quite impressive to see the changes in the microbiome over time based on these initial exposure. Drew to antibiotic. So in conclusion, antibiotic exposure in the first week of life in term newborn disturbed the microbiota up to a year with more significant deviation after longer antibiotic exposure, ie five to seven days, both C section delivery and antibiotic administration in the first week of life are associated with deviant intestinal microbiota. But the two combined are not associated with further deviation compared to babies who just went through a C section with no antibiotic. Breastfeeding was associated with reduced severity and duration of perturbation, compared with formula feeding. But the graphs are very interesting. And you see the different variation in in the microbiome on these graphs. It's very elegant. And it's and it's puzzling to see right how these interventions early on at birth can have such a dramatic impact down the road. And that should that should make us even more conscientious of our antibiotic stewardship. So I don't think there's much there's much to discuss. It's a very interesting study. Check it out.

Daphna 46:01

Yeah. Yeah, totally agree. It's nice. Just it's it's a good reminder, right? We know about antibiotic stewardship, but when you see it laid out like that, it's hard to ignore. Okay. My next article is called association of early discharge with increased likelihood of hospital readmission. In the first four weeks for vaginally delivered neonates, lead author Maria, Pope John Paul, from the the journals, Acta paediatrica, and this is coming to us from units in Finland. So, the main aim was to determine whether hospital readmission rates by 28 days from this kind of neonatal period are elevated in babies with early discharge, again, in this cohort and Finland. We sought to identify the causes and predictors of early discharge and the causes and predictors of readmission rates and specifically admissions to the intensive care unit, and also for death in the neonatal period. So it's basically a balancing measure for this decreasing length of stay and uncomplicated vaginal deliveries, which is really gotten shorter and shorter. Over the course of the last,

Ben 47:21

and we talked a little bit about that on the new review podcast about like Billy an early discharge from the nursery. Right, this is a this is a an ongoing topic now about how early Can you send these babies home?

Daphna 47:32

Exactly, exactly. And so their inclusion criteria, they have this large registry so they have the medical birth register of Finland, and included 333,321 vaginally delivered live burn, live born singletons added adjusted live burn. That they were not live burn. They were live born singletons, a gestational age of greater than or equal to 37 weeks. exclusion criteria. Obviously, were delivered via C section if you're born out of hospital. If you were admitted after birth directly to the neonatal ICU or admitted after birth to a different pediatric ward. They were excluded also excluded chromosomal babies with chromosomal anomalies. If they they did include some babies with chromosomal anomalies, but only if those anomalies were detected like after the perinatal period. So if you knew prenatally or were diagnosed in the neonatal period, you were excluded. So what is their routine care look like? So in Finland, pediatricians examine all newborns before discharge. And if the checkup occurs when the infant is less than 24 hours old newborns are invited to a pre scheduled reexamination by a pediatrician by three to five days of age, which is a little different than what we do here. And in addition, infants discharge at the age of less than 48 hours. So not less than 24. But yes, still less than 48 hours. And infants with risk factors were referred to checkup via an outpatient clinic run by a midwife at the hospital in the remaining cases. So if you stayed more than 48 hours, a public health care nurse checks the newborn at three to seven days of each. So that's the system there. And they split the babies into three different groups, babies who were discharged on the day of birth first day, discharge one day after birth, second day and discharge beyond the day after birth. So after the second day, and then two, they looked at the data first in these three cohorts, and then they looked at it and in terms of early discharge, which meant babies discharged on the first or second day, as combined as compared to babies who were discharged after that point. So As I told you, they have this really large cohort and total 8% of newborns were discharged, quote unquote, early, that is on the first or second day. And this percentage increased over time. So over the years that they looked at more and more babies were being discharged in the first your second day. The yearly change was statistically significant between the force or second day and after the second day, but not between the first and second day. So they had more babies leaving before 48 hours, but not necessarily more babies leaving before 24 hours. And in this early delivery, Airlie discharge group, most of the mothers were more than more than or equal to 30 years old. They were quote unquote, upper level employees. So I had to look this up, but in Finland, that meant administrative managerial or professional

Ben 50:52

work that we have that

Daphna 50:53

occupations. Yeah, and most of the newborns were born at the Central Hospital. So they also looked at the data by delivery hospital, and the babies were less likely to be SGA. They were less likely to be LGA and they were less likely to have needed phototherapy. So those were the predictors of early discharge of all comers have all neonates 3% were readmitted to the hospital by the time they reach 28 days of age. So for this cohort that was of just over 10,000 babies, the infants discharged after the second day were readmitted less often than those discharged early readmission rates increased over time, especially among infants discharged early, and the time between hospital discharge and readmission was shortest among infants discharge on the first day. So the median readmission time was five days. And of of all of the infants readmitted most initial readmissions occurred at less than seven days. So 32% 29% were admitted between seven and 13 days 20% between 14 and 20 days and 18% between 21 and 27 days. The most common reasons for readmission were miscellaneous minor causes, especially among infants discharge on the first day. The most common single cause for readmission was jaundice, which is not surprising, so 30% of infants followed by infection 20% of infants readmission because of hypoglycemia, and inadequate nutrition affected point 3% of newborns on the first day, point 1% of newborns on the second day, who were discharged and after the second day discharge, even less than other categories had no statistical differences. So early discharge was a significant risk factor for readmission when the groups were divided into two discharge groups, so an after second day discharge was associated with decreased risk of admission. However, a first day discharge was not statistically significant risk factor for readmission. Events and mothers with BMI is greater than 30 or less or age less than 25 years as well as infants born. Interestingly, between 38 and 38 and six weeks, who were male LGA with a history of phototherapy are born after the year 2009 were more likely to be readmitted infants of prime EPS, infants with gestational age greater than 41 weeks are born in the Northern University Hospital had a decreased risk of readmission. They lifted ICU admissions in total in the group 75 newborns were admitted to the NICU. 12% of those infants were discharged on the second day 88 were discharged after the second day, and none of the babies admitted to the ICU were discharged on the first day and pence admitted ICU increased over time and differed significantly by hospital. The causes of these admissions included infections gi problems, neurologic problems, respiratory problems and cardiac problems. And, and still jaundice was the most common single cause followed by respiratory tract infections. It nine of the later cases RSV was diagnosed, nine additional neonates were readmitted because of sepsis to early onset and the remaining late onset. All 12 newborns who died had been discharged at greater than or equal to two days old. So they were not in the early discharge group. The causes of death are sudden infant death syndrome and five cardiac problems in for including a baby with hypoplastic left heart and infections in two cases. So this was obviously a huge cohort. Pretty good data because of the National Registry. The limitations are really generalizability I guess, to the rest of us who have Have a very different, you know, parental leave policy and the different outpatient pediatric structure. And maybe we do in Finland. I was reassured that the babies in the early discharge did not necessarily have more ICU admissions are death. But certainly readmissions, especially for Billy Rubin.

Ben 55:25

Yeah. Fascinating paper. Fascinating paper. The few takeaways I have is take a look at table three. Look at the gestational age breakdown, it seems pretty clear that obviously, the more immature the baby, the more likely you are to get readmitted. I really, I really got

Daphna 55:41

Yeah, and this was a cohort just a greater than 37 weeks, right? So even that those just looked at

Ben 55:47

3738 441. And then more than 42, and the rates of readmissions were 7.4% at 37 weeks, 5.3 38 2.2 at 41 and 2.1 at more than 42. So obviously, the even if still term, quote unquote, term, you still had a difference there. I think it to me, it highlights the huge dilemma. Because if you like there's also this this graph in this table, which one is it figure two, I think it is where you see a nice difference over time in the rates of readmission, where the babies will get discharged early get readmitted more. But when you look on the y axis, like you're oscillating between 10 and 15%. And we're talking about rates of readmissions that are like three 5% chance, which means that there's 95% Chance these kids don't get readmitted. And so I'm putting myself in the perspective of the clinician or the parents. And as a clinician, these are pretty good odds. I mean, if the chances are 3%, it's really not that bad. But I'm thinking as a parent, it's like, I don't want to 3% chance of sepsis and, and all these things it's concerning. So I don't know, where people will end on a cognitive bias standpoint. And also the hospitals. Yeah, I

Daphna 57:00

think this could confirm either bias if you had

Ben 57:04

absolutely. And I think for us in the US, maybe this is a sign that we should stop measuring, because you know how adult I mean, I work with an adult physician at home. So rates of readmission in the adult world are a thing like if you discharge a patient from the internal medicine floor or from the cardiology unit, and they come back within seven days, it's a it's a quote unquote ding on the hospital run the department. But maybe that we shouldn't be subjected to that as neonatologist because it's like, let them go home. What am I supposed to do? Yeah,

Daphna 57:33

and and there's so many things we don't know about the baby yet. And you can only learn so much in the first.

Ben 57:38

Absolutely, absolutely. So that's why I think this bias is going to be an issue because if you tell me 5% chances kids get readmitted. And I know that if the baby gets readmitted within seven days, I'm going to have the hospital saying hey, your babies are coming back after you discharge. It's an issue. So very interesting paper. Take a look. I love the figures. Very elegant stuff.

Daphna 57:56

Great figures. So

Ben 57:57

we'll post some of them on Twitter. But yeah, excellent stuff. All right, we're running short on time. I gotta go. I have two more papers and you have one right. Two more two. Okay, I have to go check them. First one is in Journal of Pediatrics. It's a subject I'm very attached to. It's called post discharge iron status and very preterm infants receiving prophylactic iron supplementation after birth. first author Carmen Landry. This is a group out of Nova Scotia in Canada. The background is we know preterm babies are at risk of iron deficiency iron deficiency anemia. This has long term nodal mental consequences. So the purpose of this study was to assess the current status, prevalence of iron deficiency and associated factors at four to six months corrected age in very preterm infants to determine if routine testing for an iron deficiency should be considered at this age. They use the database from the the ACL and Nova Scotia provincial perinatal Follow Up program. It was a retrospective cohort study, they looked at all babies born less than 31 weeks of gestation. Between 2005 and 2018. They included babies who were 23 and zero to 30, and six. Any babies with congenital chromosomal anomalies hematological problems infants who are seen outside the clinic system, and those who died before 46 months of corrected gestational age were excluded. So some of the design important design information. All eligible preterm infants, are supplemented with prophylactic iron at a dose ranging from two to four milligram per kilo per day starting at two to four weeks of chronological age. Per the Canadian Pediatric Society guideline. The amount of iron received through formula slash qualifiers is accounted for while calculating this iron dose. Again, we'll talk about this when we talk about the app we're building. Iron was not routinely held for patients in sepsis unless a blood transfusion was given at discharge iron prophylaxis is recommended to continue until nine to 12 months corrected with those those adjustments for weight obviously, the infants are seen at four to six months correct today. through the clinic, they're being monitored for neurodevelopment. And they define iron deficiency as a serum ferritin of less than 20 grams per liter, or less than 12 grams per liter at 46 months respectively. The iron deficiency anemia was defined as a hemoglobin of less than 105 grams per liter, along with meeting criteria for iron deficiency, and iron overload is 300 grams per liter. So 411 infants were included in the study 32% had iron deficiency at follow up 32% 2.7 had iron deficiency anemia, zero had iron overload. The infants with iron deficiency were more likely to be born with born to women with gestational hypertension, lower gestational age, lower birth weight, and they were more likely to have received the blood transfusions during the NICU stay. And they were more likely to have a higher rate of culture positive sepsis. So in the cohort 38% of infants stopped receiving iron supplementation before follow up 38%. So they showed up to follow up and they were not being given the iron supplementation, supplemental iron intake at follow up was significantly lower in the group receiving exclusive formula feeding compared with groups receiving mixed and exclusive breastfeeding, which I think stems from the fact interested people must be under the impression that because formulas are supplemented in Ireland is sufficient for a premium, but for premium

Daphna 1:01:29

so it may less babies were discharged on iron,

Ben 1:01:32

I think no, I think they were discharged on their own. But I'm sure that between discharge and the and the follow up, maybe there's a misconception that can build up as like oh formula has iron in it, my baby doesn't need it when in truth is like a regular baby, maybe okay, but to preemie needs much more. The odds of iron deficiency were lower in the group receiving mixed feeding at four to six months compared with exclusive formula feeding group. I think this is where my theory, maybe maybe true. Iron indices at four to six months in the iron deficiency and the non iron deficiency groups showed different mean corpuscular hemoglobin count and mean reticulated hemoglobin, however, there were no differences in mean corpuscular volume mean corpuscular hemoglobin red blood cell distribution with reticulocyte Count and hemoglobin between the two groups. So it was very interesting is that they were measuring ferritin. So when you're looking at it from the standpoint of hemoglobin, there was not much difference between the groups. But when you looked at the ferritin, the iron deficiency group, which was 132 babies had a fair return on average of 14.9 versus 38.7. So they're identified some risk factors, lower gestational age, as we've mentioned, maternal gestational hypertension, mixed feeding, breast milk and formula was protective for iron deficiency compared with exclusive formula feeding. And so the conclusions are that the study demonstrates that iron deficiency is a common and significant issue in preterm infants and requires early prophylactic supplementation. Because significant iron deficiency occurs in preterm infants prior to the development of anemia. Follow up with the CDC, at one year alone may not be adequate. And I think that's the key there. Monitoring of vitamin stores during the first year of life for early identification of iron deficiency is important to obviously make the point that iron deficiency is a preventable cause for neurodevelopmental impairment. I wish they had shared some of their neurodevelopmental data with us that would have been that would have been cool. And they talk about these different risk factors. So I think that's a huge issue when we're when we're looking at all the different things we could do to improve neurodevelopmental outcome by like one point 40% of kids showing up at four to six months with no iron supplementation, when you know how IQ and iron stores are related is like, come on, so it's low hanging fruit.

Daphna 1:03:51

Yeah, we forget, as neonatologist, we forget how much through development is impacted after they leave the unit. Right. So we have to focus on that. And none of the babies had iron overload, which is major is a major argument for supplemental iron administration. So okay, I guess we'll leave it at that. I'll be quick. I just wanted to point out that in pediatrics, there was a new clinical report from the AAP entitled recognition and management of cardiovascular insufficiency and the very low birth weight newborn. This was a collaboration between the Committee on fetus and newborn and then the National Association of neonatal nurses. So what's the question to provide an evidence based clinical guideline for the management of systemic hypotension in very low birth weight infants during the first three days of postnatal life? So since we're low on time, I mean, really the I think this gives us more questions than answers but is there really good review for everybody trainees and experienced clinicians alike. They talk about really the difficulty in managing hypotension in the very low birth weight infant, that they have numerous reasons for hypotension, and in addition, much more difficulty than the term neonate. And adapting to the transitional changes that occur. This puts them at risk for ivh, especially given abnormal cerebral autoregulation. However, both hypertension and the treatment of hypertension are associated with increased morbidity and mortality. Obviously, we have difficulty monitoring blood pressure, and even more difficulty assessing organ perfusion. They did highlight some opportunities for better looking at those things like point of care ultrasound through functional echo nears amplitude, EEG, and impedance, electrical cardio, cardio symmetry, they also do a brief review on the data for the different pressors in the eel BW. I think in general, it underscores the need to evaluate and really identify the cause of hypotension in your specific patient before deciding how to treat. And if you're on to Twitter, this is like literally a conversation every single day,

Ben 1:06:22

barely comfy. But that's the point. Right? People are saying people are all in agreement that saying, Hey, you the mean arterial pressure, if it's the gestational age or above, then the baby is well, perfused everybody is now in agreement that this is kind of it's not kind of obsolete. But then people are saying, well, how do you assess cardio hemodynamics and there's all these different arguments being made. And that that paper is really good and reminding you what to look for on physical exam, what to look for, in and organ perfusion, like urine output and stuff like that. So I think if you are, I mean,

Daphna 1:06:50

yeah, the basics that you actually don't even need additional technology for right that can help you determine the cause of your Absolutely.

Ben 1:06:58

And it's kind of nice when when the coffin, as we've talked with head, Christi, whatever comes up with these summaries where it's like, alright, like, it's the evidence is weighted. So you know what, like, the things are really important, the things that are less evidence based. It's really great. You should all you should all take a look at it. All right. Can I do one more? One more?

Daphna 1:07:18

That's it. That's all we have time for. You gotta go. Quickly. No, yeah,

Ben 1:07:23

I go quickly. Okay, so the last paper I wanted to talk about today is called compatibility of rapid enteral, feeding advances and non invasive ventilation in preterm infants and observational study. It's published in pediatric pulmonology. And its first author is Judith banky, from Germany. So the background is actually quite interesting. It mentions how within recent years, we've we've gathered more and more data to show that nutritional supply reduces BPD. And it's and it has become a major focus of BPD prevention and also BP management. Now, they're quoting, they're saying that the one of the major concerns responsible for slow enteral feeding advances is the potential interference with successful stabilization of the preterm infant or non invasive respiratory support. And that's something that I've heard myself as well, where people say, you know, we're trying to activate these babies too early, which we should just leave them on the vent group, quote, unquote, grow them and then next debate them with no problems. And so that's that's true that this has been something that's that's simmering still in our in our units. Further concerns obviously, is that if you go too fast, then you are putting these babies at higher risk of sips or neck. And we have ourselves a very aggressive feeding protocol. And when we have people providing our units, it's sometimes the big concerns like, why are you guys having excessive rates of neck, which is not the case. So the question of this paper was to evaluate the safety and some clinical outcomes related to rapid enteral feeding and preterm infants weighing less than 1500 grams. So this was a single center retrospective cohort study, they looked at the regular feeding regimen that they used to use 2015 to 2016. And then the new faster feeding regimen from 2017 to 2018. And included any preterm infants weighing less than 1500 grams that were admitted that was admitted to the NICU and they excluded babies with major congenital malformation severe syndrome or disease or who died before 36 weeks of gestation. So their old feeding regimen was quite was quite classic. Start at 10 mL per kilo advanced by 10 to 15 mL per kilo per day and until you reach 140 150 mL per kilo per day. All the feeds were given as a bolus or intermittent gravity feed by an NG tube over 10 to 30 minutes at the discretion of the attending nurse. There were options also to put this over the pump as there is in Every unit and this new Rapid standardized syndrome nutrition advanced the standard protocol as they call it involved going instead, instead of 10 into 10 to 15, you're going up by 20 to 30 mL per kilo per day to a target feeding volume of 160. Feeding was initiated within three hours of life for with standard either preterm formula or the mother's milk or the colostrum, whatever, whatever was available. I don't think they didn't mention donor. So that was that was interesting. And then they had specific deviations from the protocol. If there was any issues with how the feedings were going to collected lots of data, perinatal clinical characteristics, gestational age, sex, somatic parameters at birth and 36 weeks data returned 04 and zero feast days to regain birth weight. And to know steroids, surfactant apnea, diuretics, hypertension, surgeries, all sorts of things. Regarding respiratory stabilization, the mode of ventilators support whether it was invasive versus non invasive, including areas including nasal CPAP, and nasal IMV. So that was differentiated and the end of oxygen therapy was recorded. In terms of their respiratory management, I think that was very interesting because obviously, if they have non classical respiratory management, you can say, well, that doesn't apply. But standard settings for non invasive ventilation were equal in both periods before and after the implementation of the new protocol and involved using a peep of five to eight, the peak inspiratory pressure of 12 to 18 and the respiratory rate of 40 to 60 with an item of point three seconds. The clinical criteria for intubation or failure of non invasive ventilation was primary respiratory failure in the delivery room or after delivery and FIU two or 40% or more, after a maximum of three less Lisa maneuvers pneumothorax any spontaneous intestinal perforation, NEC severe prolonged apnea with bradycardia under an appropriate level of caffeine treatment, and the development of and then there and then the last thing I wanted to mention, I'm sorry, was that BPD as a clinical outcome was was followed and using the 2001 nih definition. Okay, so in total, they had about 300 Something patients in the standard group, which was the old protocol, they had 145 infants. And in the new faster feeding group, they had 148 infants. The median gestational age and birth weight was similar between the two groups in the old cohort it was 29 weeks and 1100 grams in the faster and newer group it was 29 weeks and 1065 grams. So they weren't they were quite mature infants, you know, they were not 23 weekers. But obviously it is though the mean and there's some variation and some deviations around those means. The postnatal treatment strategies, including quarters corticosteroid surfactant, treatment for apnea did not differ between the two groups. Obviously, the babies who were being fed on the faster feeding regiment reached for for years sooner than the standard cohort. That's not really surprising. Okay, so some of the outcomes when it came to days to full enteral feeding that was significantly different and then went down from 11 days to seven days, days to regain birth weight went down from eight days to seven days, when it came to this course, at 36 weeks gestation, for weight, length and circumference. These scores were all improved after the introduction of the fast feeding regimen. When it came to ivh. There was no difference necrotizing enterocolitis no significant difference. Sip no significant difference retinopathy of prematurity, no significant difference. PDAs, no significant difference, there was a trend toward less nosocomial infection, a reduction of 11% to 5%. But the p value really didn't make it to statistical significance. And it kind of would make sense if you're feeling these babies faster and you get off TPN sooner than central lines come off the decreased risk versus damage infection. So it could very well be when it came to needing surgeries. That was there was no statistical difference. And the no total number of surgeries also was not significantly different. So in terms of the respiratory outcomes, there were some very interesting results. So when it came to bronchopulmonary dysplasia, there was no significant difference 42% versus 36%. When it comes to mechanical ventilation, the number of babies needing mechanical ventilation that was reduced from 46% to 25%. When it came to needing non invasive ventilation, this was 54% versus 75%. So it was much much easier to manage babies on non invasive ventilation in the new faster feeding regimen. The rest of the outcomes were Were not significant whether it was need for surfactant need for inhaled medication, caffeine, postnatal cortical steroids as well. The last thing I would like to mention is that when it came to radiologic, imaging, and septic workups, within the 21 days that they looked at, it was actually performed less frequently in the rapid advancement group than in the regular control group. And so that's very interesting for the concern of whether these babies need more sepsis workup, they have more risk of neck Well, it turns out that they got less imaging and they got less, people were less suspicious of it on this baby. So that's, that's really, really neat.

And then they stratified the data based on birth weight. And that was something that was there was something that was very interesting, they said, and I quote, as birth weight plays a substantial role in volume targeted enteral feeding. We also analyzed the total cohort in an ROC analysis concerning the cutoff for the strongest effect to reach full enteral feeding within one week, meaning they were looking at what will used to be the weight before which reading for feeds within a week was really the breaking point. And they found that before implementation, it was 910 grams, meaning that if you were smaller than 910 grams, you had trouble reaching for feeds within a week. And after the implementation, it dropped down to 530 grams. That's huge. In terms of birth weight strata, the days to reach full enteral feeds. They had very low numbers in the less than 500 gram groups. So that was not really significant. But to reach full enteral feeds babies between 500 and acute 500 grams and a kilo, that was significantly faster in terms of days, 13 days versus nine days 1000 to 1500. That was also significantly lower eight days versus six days, time to regain birth weight was not really significant except in the 1000 to 1500 gram group. And then in terms of growth in the z scores, there were significant improvement in terms of growth in the babies that were on the faster feeding regimen. And then finally, and I'm sorry, we're going over time, but the last point I wanted to make was the need for mechanical ventilation. By birth weight, babies were 500 grams to 1000 grams, the need for mechanical ventilation was reduced from 68% to 40%. And from 1000 grams to 1500 grams. It was reduced from 26% to 8%. So very impressive. The contact the conclusion of the paper are that rapid enteral feeding advancements in preterm infants are safe. And concerning major clinical short term outcome parameters, improve somatic growth and do not impede non invasive respiratory support. And so that's, I think, a great paper to justify, we implemented a rapid advancement feeding in our unit. And this is this is really great. That was quick. I'm sorry, I went really fast. That was a whirlwind. But it's good. Just go fast. It was it was a rapid review of a paper about rapid feeding advancement done very rapidly. Yeah, makes sense for rapid, rapid, hashtag rapid. And that's all we have time for today. All right, definitely. So much. Thanks, everybody.

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