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#134 - Dr. Amy Hair & Dr. Misty Good

Amy Hair Misty Good Incubator podcast

Hello Friends 👋

This week's interview on The Incubator Podcast features not one but two inspiring neonatologists. We have the pleasure of bringing Dr. Amy Hair and Dr. Misty Good to the show. They are both accomplished neonatologists and have distinguished themselves for their exceptional dedication to the prevention and treatment of necrotizing enterocolitis (NEC). Dr. Hair has recently been awarded an RO1 grant from the NIH and Dr. Good's work was recently awarded a grant from the Chan Zuckerberg Initiative. We hope you enjoy this episode.

Have a nice Sunday! 😎


Dr. Amy Hair is currently an Associate Professor in the Section of Neonatology and Department of Pediatrics at Baylor College of Medicine. She is also the Program Director of the Neonatal Nutrition Program and Co-director of the NICU Intestinal Rehabilitation Program at Texas Children’s Hospital. Dr. Hair’s research focuses on neonatal nutrition, specifically growth and the use of human milk in very low birth weight infants. Dr. Hair is the principal investigator for multiple ongoing research studies and was recently awarded a R01 grant from the National Institutes of Health to study fatty acid absorption in preterm infants. Dr. Hair is recognized nationally as an expert in human milk and neonatal nutrition.


Dr. Misty Good is the Division Chief of Neonatal-Perinatal Medicine at UNC Children's since November 2021. She began her journey in biological sciences at the University of Southern California, subsequently earning a combined MD/MS from the American University of the Caribbean in St. Maarten. Her medical training continued with a residency and stint as Chief Resident at the Children’s Hospital of Illinois, followed by a fellowship in Neonatal-Perinatal Medicine at the Children’s Hospital of Pittsburgh in 2011. Dr. Good then served as an Assistant Professor at the University of Pittsburgh (2011-2016), and since 2016, she has worked at Washington University as an Assistant Professor and Co-Program Director for the Neonatal-Perinatal fellowship program. Known for her extensive research on gastrointestinal diseases in premature infants, particularly Necrotizing Enterocolitis (NEC), she established a substantial multi-center biorepository to study NEC and implement prevention strategies, with her ultimate goal being to control and prevent NEC through understanding its immune response signaling pathways.


Find a list of selected articles authored by our guests below 👇

Reniker LN, Frazer LC, Good M.Semin Pediatr Surg. 2023 Jun;32(3):151306. doi: 10.1016/j.sempedsurg.2023.151306. Epub 2023 May 30.PMID: 37276783 Review.

Mackay S, Frazer LC, Bailey GK, Miller CM, Gong Q, Dewitt ON, Singh DK, Good M.Front Pediatr. 2023 May 31;11:1184940. doi: 10.3389/fped.2023.1184940. eCollection 2023.PMID: 37325361 Free PMC article.

Singh DK, Miller CM, Orgel KA, Dave M, Mackay S, Good M.Front Pediatr. 2023 Jan 11;10:1107404. doi: 10.3389/fped.2022.1107404. eCollection 2022.PMID: 36714655 Free PMC article. Review.

Bergner EM, Taylor SN, Gollins LA, Hair AB.Clin Perinatol. 2022 Jun;49(2):447-460. doi: 10.1016/j.clp.2022.02.010. Epub 2022 Apr 21.PMID: 35659096 Review.

Hair AB, Good M.J Perinatol. 2023 Jan;43(1):114-119. doi: 10.1038/s41372-022-01504-4. Epub 2022 Sep 20.PMID: 36127395 Free PMC article. Review.

Hair AB, Scottoline B, Good M.J Perinatol. 2023 Jan;43(1):103-107. doi: 10.1038/s41372-022-01502-6. Epub 2022 Sep 12.PMID: 36097287 Free PMC article. Review.

Neves LL, Hair AB, Preidis GA.Gut Microbes. 2023 Jan-Dec;15(1):2190301. doi: 10.1080/19490976.2023.2190301.PMID: 36927287 Free PMC article.

Hair AB, Patel AL, Kiechl-Kohlendorfer U, Kim JH, Schanler RJ, Hawthorne KM, Itriago E, Abrams SA, Blanco CL.J Perinatol. 2022 Nov;42(11):1485-1488. doi: 10.1038/s41372-022-01513-3. Epub 2022 Sep 28.PMID: 36171356 Free PMC article.


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

Ben 0:56

Welcome Hello, everybody. Welcome back to the incubator podcast. It is Sunday, we have an amazing interview scheduled for you today, Daphna. How are you?

Daphna 1:09

I'm tired. But other than that, I'm very very excited that we finally have the opportunity one to have recorded this, this interview. But finally to release this interview,

Ben 1:27

extra Yeah, so for people definitely post call as we are recording the intro. And since she was not POST call on the day of the interview, and you're, you were peppy that day, so I don't want people to sound like God, she's going to be like slumbering through the internet. True. Not true. Not true. Now, it's already

Speaker 1 1:48

do not tune out. You're not gonna want to miss the rest of this episode.

Ben 1:54

I guess we said we had no updates. I just want to tell people I have not yet released the Delphi videos on the YouTube channel. They're coming. They're coming. I'm getting the final edits. It's just a bit slower than trust you. And I would like to see stuff stuff is gonna get released and then they don't get released. In any case. We have a great interview for you guys. Today. We have two guests on the show. We have Dr. Amy hare and Dr. Misty, good. Lucky and definite. Yeah, like yes, they are the at the neck team. If you are not familiar with who they are, number one, they are both very active on Twitter. You can find out to me here at Amy hair MD. And then you can find Dr. Misty good on Twitter at Mr. Good lab. Dr. Amy hare is an associate professor and dissection of neonatology in the department of pediatrics at Baylor College of Medicine. She's also the Program Director of the neonatal nutrition program and co director of the NICU intestinal rehabilitation program at Texas Children's Hospital. Dr. Misty GERD is the division chief of neonatal perinatal medicine. She's also an associate professor of that at the University of North Carolina Children's Hospital. She is the director of the good laboratory. They are both extremely accomplished in the field of nutrition research. I mean, it will take us the whole hour just to read their numerous publication, numerous grants, and we'll talk to them a bit a bit about some of these awards and some of the things that we're working on. And so, without further ado, please join us in welcoming to the show Dr. Misty, good and Dr. Amy hare, Dr. Amy hare Dr. Misty, good. Thank you so much for being on the podcast with us today.

Speaker 3 3:44

Thank you for having us. We're so excited to be here. Yes,

Unknown Speaker 3:48

thank you very much.

Ben 3:49

We're excited because it's it's nice to have an episode on neonatal nutrition. I have a lot of questions as a as a as an amateur, not as an expert. But I guess the first thing the first thing that I wanted to ask you was how did your collaboration How did the collaboration between me and Mr. Good begin? What are the inception of that? of that club?

Speaker 3 4:15

I'll go first with that one. I think I forced Misty to be my friend. Just to put no I'm not sure if that'll be cut or not. Anyways. It's too late. No, no. Honestly. Missy and I had overlap, I think in research regarding nutrition and necrotizing Eric colitis, and we have mutual friends in common like CAMI Martin and Steve McElroy, and I believe the next Society meeting a long time ago out of his 2014 We were able to kind of, you know, chat about research and I think that's where it started.

Speaker 4 4:56

I agree I think I think I knew about Amy long ago. Like when back when I was a fellow, and we used to see each other PHS and present to get there. And I felt like she always had it together. And she gets up there and presents so beautifully. And I remember thinking to myself, Oh, I wish I could present like that. She's incredible. So now, dear friends and have, you know, an r1? Together as well. So it's really,

Ben 5:22

it's a testament to the fact that you don't really need to collaborate with the person like next door to your office, right? I mean, I think it's a nice testament to that you can actually establish meaningful and productive collaboration with people even in other areas in other parts of the country as well. Absolutely.

Daphna 5:41

We find when we interviewed people, collaborators, that they're different personality types that tend to pair up. So do you guys have pet peeves for one another or unit smooth sailing? All?

Speaker 4 5:57

I'll take that. I know, we're pretty tight Bay. Though, we, I would say we keep each other in line and make sure that we stay on each other's To Do List, which can get pretty long. But I think that I think that we keep each other accountable. And I wouldn't say pet peeves do would you say me? No, maybe I'm I'm nagging me. Maybe that's nagging her for a deadline?

Speaker 3 6:23

No, I Yeah. No, I think we're both incredibly busy. And if anything, you know, messy is a great support system. I remember when I was writing my r1. I mean, it's a lot of writing. And I'm not believe it or not, despite all my publications, I'm not inherently a good writer. Or at least that's how I feel. It's not exactly easy for me to write. And so Missy is always like, just keep writing. Guess just keep trying, it'll get there, you know, um, yeah, I think that's, that's some great advice you've given me but ya know what, missy, when she decides she wants something done, it gets kind of get done, which is great, because I am more of a procrastinator. So when she's ready, then like, I really make sure that and then I can really, you know, like rev up and finish, like some of the papers we've done, etc. So it's a good thing.

Daphna 7:11

Well, Anona, Naess Hana kind of work. serious note, it's obvious that you guys are collaborating together, but you individually are having all a number of projects. Right. And so I think, you know, we have a lot of trainees who listen or early career Neos, so for people who are starting out and you know, they've got their whiteboard or been I'm sure has some virtual form of the whiteboard with the checkboxes, you know, when you have a bunch of different projects going on, like how, how are you allotting the time to different projects? How are you managing triaging the situation? I guess? No,

Speaker 4 7:48

I think they do have a big whiteboard, I live and die by the whiteboard, which has, you know, one side is like all projects and manuscripts, the others, like invited, review articles or book chapters. And then another section is grants. Another section is like mentees deadlines, just so I can keep them all straight. And another one is invited talks. And so just so I can know, you know, logically what's upcoming without having a hit my calendar, and then having a reality check on Sunday, when I check that I have, you know, a couple of talks in a week or something. So that's what I do. I would say from a project management perspective, especially as my lab has grown, I will say it's important to have check ins with your team pretty frequently just so they stay on task and you stay engaged in their project, which I think as a mentor is really important. But as a mentee, one of the things that I learned early was how to manage up and recognizing that mentors are really busy. And so something that I have my team do, but also I did when I was a mentee was provide weekly updates to my mentor so they knew what I was working on for like the previous week, and then why I was planning to work out the upcoming week, which I think as a mentee helped me stay focused even though sometimes it was a little bit of a chore but I do think it kept my mentor engaged in my projects. And you know, then I was also held accountable for moving them forward every week, which is always important on Steam.

Daphna 9:22

And lead that I'm going to start sending Ben an update in the mail.

Speaker 3 9:27

I'm telling you, I'm a post it person, I do have a whiteboard, but I'm a yellow post it lots of post it so depending on how busy I am, but I I do stay pretty organized because otherwise it's a little crazy. I will be honest, I am really behind on email right now. So I've been telling a lot of people you just might have to text me or you know, it just kind of got behind at one point and I'm never going to catch up so that's okay, but I just want everyone listening to this like we are all behind. We mentioned this recently As in the lecture we're given, like, I think once I realized that everyone's drowning, even the most successful people, there's a lot of tasks to do. And I think it just made me feel better, like, Okay, everyone feels this way. So you know, you just try to get as much done, you know, each day or when you have time to work as

Ben 10:18

possible. Definite, there is a whiteboard that you should know of. So you know, where you have in our office. Okay.

Daphna 10:28

Yeah, that's yeah. But I know that you have digital format for

Speaker 4 10:36

short, real quick, since we're talking about whiteboards. One of the things that a few of us said was get a whiteboard, right. And I have a big project management whiteboard, but I have a whiteboard right in front of my like screen, in case you're on a zoom, and somebody says something that you really have to do, and you can just write down really easily. So it's the small whiteboard. That is like, also the crutch that helps you know, when you're zooming, so you don't forget,

Daphna 11:02

so you don't forget anything. Really. That's it, like, shall we

Ben 11:05

talk about neonatal nutrition Dafa.

Unknown Speaker 11:10

Oh, this was a very important to discuss, I want

Ben 11:13

to I want to make sure we cover to cover. I wanted to start the discussion about Neandertal attrition, with the confusion that is going to jump, you're gonna lose a lot of confusion, I think for people who have trained at different stages of the past 20 years. And it seems like, as we were saying, with definite before we come on air. When we talk to parents in the NICU, we say hey, the NICU is like two steps forward, one step back. But with neonatal nutrition, it feels like it's one step forward, one step back, and we have no clue where we're supposed to go anymore. People who train some time ago, when I was a resident, it was you advanced feeds 20 mL per kilo per day. And then now it's no longer thing. And then there's probiotics. And now the AP say maybe it's not a thing, then there is human milk versus bovine. There's fortifiers. And I think no matter how much resources are poured into neonatal nutrition, no matter how many papers are published, I have a feeling that for people like me who are not experts in this field, we are reaching a point where it's like I have no I no longer have any clue as to what I'm supposed to do and what's okay, what's not okay. Because if I advanced by 20, somebody's going to give me the the starchy local, you really don't need to do that. So I wanted to ask you, what are some of the certainty that we've achieved in neonatal nutrition that we know are beneficial that we know we can rely on? And where do some of the controversies remain?

Speaker 3 12:40

Now, there's a lot to keep up with, I think that's part of it, too. And, you know, some of the larger studies, over the past few years, they've been great studies, but not all of them have given us results that we can take back to the bedside. So like for, for instance, like with feeding advancement, you know, the SIF trial by John d'Orleans group and others, it was a long list of authors, so it will leave anyone out. But you know, it showed us that we could advance by 30 per kilo per day versus like 18 per kilo per day. And the problem that I'm having is implementing that clinically, we're so used to doing kind of Ben, what you say like 20 per kilo per day are our you know, we have our set ways. And so trying to kind of change clinical practice is is a little tough, especially I have a very large NICU at 175 beds. And so with many, many nurses, you know, other staff, you know, nurse practitioners, fellows, residents, etc. So I think one of one of my biggest struggles is how all these little changes or big changes that are occurring, how do we implement clinically and keep it going and change what we're doing? But I think the other is, I think pretty much we've settled that, obviously, we need to focus on increasing the use of mom's milk. I think out of everything that you kind of listed or anything we do in the needle nutrition, we do know that the more you know, mother's milk or baby gets better their outcomes, etc. And I think most people would agree that the LBW infants are less than 1500 grams would benefit from pasteurized donor milk if mother's milk is not available, but then where we go from there in regards to fortification and grow, growth is still a challenge despite when you calculate on paper, you think you're giving the baby enough calories? So I do think I'm hoping there'll be more research coming out. But I will say that, for the big studies that are occurring, they're not as many as there used to be and for whatever reason, some of our big funders hadn't been funding you need or nutrition or even from a physiology standpoint, all the nutrition physiology studies are from the 80s on bigger babies, or maybe the 90s. But any, any way you look at it, like tiny babies less than seven 50 or even less than 1000 Haven't been well studied. So I think I think it's coming. But I feel it even as a researcher at the bedside trying to change practice or keep up with practice and do what I think is best for babies.

Unknown Speaker 15:14

That makes sense. Does.

Daphna 15:19

Yeah, I feel like we feel that in our unit a lot. Exactly what you said is his primary clinicians are trying to take the data that's been done on older babies, potentially healthier babies, and try to translate it. And some of the babies we're working with have these other risk factors like very extreme, prematurity, this long exposure to severe preeclampsia, and these babies are surviving in numbers that we've never seen before. And so they may have risk factors still for, you know, catastrophic outcomes that are unrelated to advancing their feeds. And we, you know, we're having I think, trouble managing that now. So

Speaker 4 16:04

one of the biggest things is we don't know what is optimal. like Amy said, we know what, we know that mother's milk is optimal nutrition, but every every mom's milk is different, right? So then, what is the optimal nutrition that we can put into our babies and to only modify that through the mom's diet or other other ways, you know, especially individualized nutrition or personalized nutrition and how we can do that at the bedside? I think is it's really an area of research that really needs to investigate it further. It certainly in the basic science realm, not not saying we need to experiment on baby smell, but I do think that there is a lot left to be investigated in this area. Yeah, absolutely.

Ben 16:51

What do you think? What do you think should be our approach to to the variety of infants that we're now seeing in the NICU, as you guys have mentioned, it's no longer that the NAAQS are populated by infants that are born between 32 and 37 weeks, we see such a wide range starting at now 22 weeks all the way to late prematurity. And I think there are so many categories that are represented, each with a different set of risk factors. How do you approach this diversity, specifically from a nutrition standpoint? Yeah,

Speaker 3 17:25

I mean, I think Missy is right. I mean, ideally, we and I hope and I think we'll get there, it's going to take some time and some studies, but I do think personalized nutrition, whether it's analyzing mom's milk, or figuring out not sure biomarkers is the right answer, but some way and we My dream would be to somehow be able to tell which baby's going to have trouble feeding and which you know, which not, etcetera, and something to guide us, I do think we need to study our babies, and not listen to actual babies look at our data. So for instance, we are now taking care of those tiny, tiny babies, right now we have about three babies or 400 grams in the unit, and that baby is just so different from, you know, even a baby that 750 grams. And so I think we also need to look at our data and figure out what is reasonable, for instance, some of our babies that our 22 weeks don't get to full feeds, on average, about a month of age. So you know, it takes a month of age, then, you know, it's it's okay, that we stop, start and stop feeds, etc. I just think we need to know like, at least what are we doing now? Or at least? What are the babies doing right now? And then how do we change that? So we are collecting data from our center, but we'll need multiple centers of data to kind of fine tune that.

Speaker 4 18:44

And Dr. Cami Martin had put together the neonatal nutrition collaborative that Amy and I and several other centers are working towards that effort where we're collecting data on the babies and what they're feeding and trying to get to some of that granular data that has been missing, I think, in the literature over the past several decades.

Ben 19:07

And so then you mentioned whether a baby quote unquote, tolerates feeds or not, and I think that's a subject that also has become quite controversial. What does that mean for a baby to not tolerate feeds? I think so many people would say, Well, I check the abdominal girth. Some people would say I check residual, some people would say, I'm looking for MSS. And it's interesting to me how we have certain tolerances when it comes to full term infants that we would tolerate a few setups here and there. But then our our compass becomes so warped when it comes to more immature infants. And there's, we're so scared, right? We're so scared of, of the dreaded necrotizing enterocolitis that that we want to we it becomes very difficult to parse out the signal from the noise and I'm just curious if it what does that look like for you guys?

Speaker 4 19:56

I'm certainly not a feeding intolerance expert but I do think it That's one of the problems in our field is that we are all terribly afraid of necrotizing, enterocolitis or neck. And what do we do about it? And so a lot of us are working in this field to try to figure out, Is there a biomarker? You know, like for neck specifically, not necessarily feeding intolerance. But I think you're right then that, you know, we do tolerate a few spit ups here and there, then what happens is, you know, that nurse is very worried about the baby or very worried about the ask spreads, which should we be checking or not, I think, you know, the data shows that we shouldn't be checking. But in a lot of units, we still are right, and so including my phone, you hit. So this was one of the bane of my existence, I think, when I was a resident, and one of the reasons why I actually started studying I was because we just don't know much about this disease. And we have some success in units that are striving to get to net zero. And we haven't been able to make a lot of headway with that nationwide. So I do think it's a clinical conundrum at the bedside. And, you know, whether a baby progresses to have neck or not, can really be devastating for not only baby but their family and the whole medical team. And so I think there's a lot of research that really needs to be done on this disease. But the problem is, it's frustrating to study. And so when we think about, you know, ways to modify their nutrition or ways to advance their feeds, etc, we do need neck is an endpoint. And that means that, you know, we need a lot of babies for those studies, because when you go to power, clinical study for neck, it just takes a lot of different babies so that, like Amy mentioned, we have to study the smallest babies that are at the highest risk.

Daphna 21:50

Well, it's helpful, I think, to all of us that it's hard even for you to change the culture in your unit, right? Because it's so deeply rooted in in, in in so many units. But that was going to be my question, why do you why why is neck so hard to study as compared to some of the other pathologies?

Speaker 4 22:11

I think? I think it's just like we talked about, it's one of those diseases that's really feared. And We don't have a really good definition of neck. So when we think about what is this feeding intolerance? You know, what is this abdominal? distension? Is it CPAP? Le? Or is that bell stage? What? I think the issue is, we don't know for sure. And sometimes, you know, babies are included, and I've even included them in my studies where it's like, you know, maybe this space won't be and they had, you know, their questionable neck, but not, you know, maybe we call it Cooper ptosis, you know, on their on their abdominal X ray. And so, is it, is it a WLC issue or not? I think, I think for those of us that are studying it. From a research standpoint, it can be really frustrating that the medical team will call it neck and it's not I mean, you're looking at the X ray, and you're like it's not NEC, please don't enroll them. Because we're collecting with Amy and other collaborators reflecting all the biological fluid from these babies. So we can study to see, you know, is there a particular biomarker that we can find? And is it in the urine? Is it in the blood? Is it in the stool, etc? And so, I think until we have those answers, we don't know for sure, but I will say it's hard to study because there's a lot of different, you don't know the definition, the upgrade, and then the phenotypes are all incredibly variable. So Amy does a lot of studying on babies with cardiac neck. And cardiac is completely different than preacher neck. And so I don't know if you want to talk about that. Amy?

Speaker 3 23:43

Yeah, no. Well, so So my my interest, so I don't I love neonatal nutrition. But I also have started working we have a large cardiac ICU that houses infants, and I have a great collaborator, Jeremy Roddy there but it's been very interesting to work with the cardiac ICU doctors, many of them are critical care trained, and so they're not neonatologist. But the collaboration is good. We see things a little differently when it comes to nutrition. But I mean, they they actually have a lot of real neck and I see this because there's a neonatologist. I'm like, Oh, we're just calling it stage one. Nope. They actually bloody souls, you know, things concerning for neck and so. Yeah, no, I agree with Misty. I think there's just different phenotypes but for the cardiac ICU here, one of the things I'm most proud of that one of my fellows just meet Kataria Hale did she basically implemented a study using emphasizing mom's milk and raw pure colostrum. And we basically were able to get rid of formula and the cardiac ICU in the sense of if we didn't have mom's milk. We started using pasteurized donor milk there and to us that was, you know, kind of changing the focus on human milk. So I know I keep going back to human milk is the answer. But really, I mean, mother's milk right now is the one of the only treatments or strategies, you know, there's bundles, right to prevent neck, but mother's milk is really, obviously best. And just even in our large institution where we have a huge lactation service, we still have our challenges and are still troubleshooting. How are we not supporting moms? Or what what could we do differently to to help our families?

Daphna 25:30

I want to come back to mother's milk. And but I have a different kind of question. Certainly, I feel as a clinician, you know that that threat, when you haven't figured out which way this baby is going to go yet. And I think one of the things we do know, in terms of long term risk factor for neck is that antibiotics are certainly a problem. But the way we cover ourselves for for neck is antibiotics. So do you think that we will get to a place where, you know, maybe we're still figuring out how to diagnose it, but that we'll have a better way of ruling out babies with necks so we can stop antibiotics even though we've started? That's a great question.

Speaker 4 26:15

I think that's certainly what we all want to strive for is does this baby have neck or not? So we can continue feeds or we can continue on? That's, that's really the only way that we're going to be able to personalize these into Mealer. Really our management but like, like you mentioned Daphna, I will say that every day that a baby's on antibiotics wipes up their microbiome and increases the risk for neck. And so how can we then modify that in this era of fear in the NICU for this devastating disease? I don't know, there has to be another way like either with, you know, targeted intestinal epithelial therapies or things like that, that we're working on in the lab. But I do think that you need to get to a place that we're able to know, does this baby have neck or not roll it in or out and then be able to move forward? Yeah,

Speaker 3 27:04

and just to add with the microbiome, I completely agree Misty, but you know, I, I'm starting to study postnatal growth failure in the microbiome, and it actually matters what microbes are there, because the metabolites that they they make, you know, can contribute to digestion and absorption. And so, obviously, NAC is like, we want to treat Mac. But secondarily, you know, there are other impacts that we all know of using long term antibiotics. So yeah, we could find somewhere in the middle, or at least a subset of babies, that we could maybe lessen their antibiotic course, I think that would be really great.

Daphna 27:42

So if that if the answer is mother's own milk, then what are our obligations to support people who are pumping and you know, the procurement of human,

Speaker 3 27:58

I would just say that, what I've learned, you know, I've been here at Texas Children's for about 14 years now. And for us, or at least my what I've learned along the way, it's, it's kind of it's a team effort. And it's a cultural change in the sense, and we still struggle with this. So by no means are we perfect Daphna, if at all, but you know, we're always trying to be better. But what I really noticed is when you have the if it's discussed in rounds, you know, How's mom doing, how's the pumping going? You know, if the nurse mentions it, we actually have milk being technicians, we have a centralized milk bank, and they will go and deliver milk, we have individual frigerators in the rooms for moms to put their milk in. We have lactation consultants. We're currently doing a free pump rental system. So trying to just from all avenues, try to encourage the discussion and culture of how can we help mom. But you know, for us, for example, we have major barriers, a lot of our families live two hours away, so they can't come every day. And so we haven't done this yet, but try to get creative about can we ship mom's milk to us like FedEx wise or, you know, I just think more more needs to be studied. But from my standpoint, it's everyone pitching in trying to talk to mom about how pumping going, how's your milk supply, and then trying to troubleshoot from there?

Speaker 4 29:25

I agree with Amy, I think, I think it also just takes a holistic approach. So not just us in the NICU with all of the resources that we all have in terms of, you know, pumps and lactation consultants and private rooms and, you know, just real support for them and encouragement, I think, I think it also happens on the MFM side, you know, and so, prenatally if a baby's, you know, threatened preterm birth really talking about what that milk means that baby and it's really like medicine to them. And I think the more that we do have that And we can encourage it. You know prenatally and then certainly immediately after delivery as soon as they're able, I think that's another good approach as well.

Daphna 30:11

I will say one thing, just as a thought since you mentioned our collaboration with our obstetric colleagues. One thing we recently changed in our unit is the the minute you know a delivery happens is that we're having our obstetric colleagues go ahead and, and write those orders and requests for pumps before moms ever leave the unit. Because we found once they were gone, that I mean it was taking us weeks and weeks and weeks, and by that time, the milk supply had diminished, even in moms were really dedicated to pumping. So that was a small change that we've made in our in our youth has made it a big difference. That's great. This episode

Ben 30:51

is proudly sponsored by Reckitt mi Johnson recommened Johnson is dedicated to the research and development of nutrition products that help support baby development at every stage, including an extensive Enfamil portfolio for premature and low birth weight infants learn more at HCP dot meet I wanted to talk about since we're talking about human milk, I wanted to bring up the subject of fortification. I think this is something that has been the standard of care but I mean from from speaking to people at PHS. And and I think outside of of yet formal PubMed publications and peer reviewed publication, there is a discussion I think that is ongoing about should we be fortifying breast milk for preterm infants, would they be doing maybe better with just straight up breast milk? And I am wondering, what are your thoughts on that? And, and and what are your thoughts in general about fortification? Because I do know that there's multiple avenues to explore when it comes to fortifying preterm breast milk.

Speaker 3 31:54

I think it's always important for us to question what we're doing meaning we've been fortifying for years in the NICU. And I think then it is important, you know, do we need to fortify. And so I think it depends which preterm babies you're talking about. So I know. So a couple of things, the population, the volume of feeds that you can give the baby, and kind of what they're calculated needs are. So I know some of our European colleagues do not fortify or they rarely fortify. And but they also report that they're giving 220 mils per kilo per day fluid. And i No matter what I did in my unit, we would never be able to do that. And in fact, it's hard for me to get our physician to our team to go above 140 mL per kilo per day. And so even if they're giving 220 of fluids, you're so not giving enough protein, calcium and Foss, but I do understand the concept of well, but you're giving all mom's milk and that's protective. So I do think the dose of mom's milk and how much you're getting is important. But when you're calculating the numbers and some of our review articles, we've put this in there because it if you don't think about it, you don't realize that oh, you know, so if you're, for instance, a baby's blood restricted, or even if they're on 160 mL per kilo per day, they do have additional needs, so like definitely less than 1000 grams, they would need extra protein, calcium and FOSS. If you have a 1250 a 1500 gram, and you can give high volume fluids, you might be able to convince me not to fortify but probably not. Because I just feel like we're already not giving enough acid is even with current fortifiers. So I think, you know, especially for the tiny babies, and then if they do fortify a lot of units that, you know, kind of give this higher volume of feats, and then attempt to not fortify before to fight late. And I'm not sure you know, the critical needs are in the first you know, month of life. I mean, they continue right. But the minute babies born, they have significant protein loss, as long as you know, as well as losses of everything else. So I think that we should be thoughtful and you know, emphasize the mother's milk dose, but I personally don't think that in small babies you can get away without fortified.

Speaker 4 34:10

I do think we have to also think about the postnatal growth failure that occurs in these babies. So not only just the micro macro nutrients that they're not necessarily receiving from an exclusive human milk diet, but I think, as Amy mentioned, I think we have to be thoughtful in our approach and careful in what we're giving the baby. So, you know, a lot of people talk about certifications, but you know, if a baby's not growing, for example, instead of you know, adding more calories, maybe they'll add sodium fluoride because maybe they're chlorides a little bit lower. So I think taking a holistic approach to everything that we do in the NICU. I think it's really important because you know that sodium chloride or you know, just their electrolytes are a little bit off and giving them an oral medication does modify their intestinal microbiome by environment. And so we talked about that when I'm rounding a lot. And my team knows that I obsess about those things. But there is a critical developmental window that occurs in, in these babies. And so from 28 to like 33 ish weeks, you know, those babies aren't really high risk for neck in that time point. And so being really thoughtful in their approach, I think is important in just how we move forward from there, I think is yet to be determined. But I think there's a lot of focus on how do we grow our babies safely? And how can we really optimize their outcomes?

Daphna 35:37

That's something we've been talking a lot about in our unit, when we looked at, like, the amount of medications that our tiny babies were getting, in addition to the board of fire, which you know, was standard in our, you know, in our protocols. But we had a, you know, the multivitamin, we have iron, we have an estrogen protocol that's accompanied with the other additional folic acid, vitamin E, if the baby was on diuretics, and the baby then needed the sodium chloride to cut and because they were on the diuretic, you know, what role? Do those I mean, you started to mention it, but play on, you know, just what the intestines can tolerate.

Speaker 4 36:23

I think the intestines can tolerate a lot. I think one of the, one of the issues is this really hasn't been that well studied. It's been studied in, you know, like, just in terms of osmolality of different medications, etc. But how does that really affect a 22? Week infant intestine, you don't have good studies for that clinically, one of the things that we're doing in the lab that we're funded to do is taking pieces of intestine once they're resected for neck or other indications, and then having what is considered a personalized medicine approach to testing different different drugs that we use in the NICU all the time, on what we call gut on the chip approach. So a microfluidic chip, where we can grow up in infants intestines from their stem cells, make this intestinal monolayer, for example, and then attack it different with different drugs and see how the what is the direct effect of that particular medication on a preterm infant intestine, for example. And so that's one of the ways it's not obviously the best way, because you don't have, you know, the intestine is not in vivo. But I will say it's an ex vivo approach that we're trying to use to get at these questions. And so more to come on.

Speaker 3 37:40

Yeah, I was gonna say missing it. You know, your research is fascinating. That's why we're friends. You teach me so much. But honestly, missing it talked about this. I'm like, I don't even understand how we're able to feed preemies, especially between 22 and 23, weekers. Because if you look at the physiology of the gut, if you listen to Misty, give a talk about the immaturity of the gut, the microbiome is not there initially. Yeah, I'm like, I don't even know how we feed these babies. It but yet we do. So like Missy said, the intestine cannot adapt and take a lot. But yeah, when when you really think about it kind of freaks me out. Like, I'm not sure how we're feeding them, but they're feeding. Okay, great.

Speaker 4 38:25

I think it shows how resilient babies are and how, you know, the various things that we teach them, somehow they end up, you know, doing well, for the most part, so I think just, you know, remembering that some of what we do is, you know, stand back and let them and let them, you know, lead the way,

Ben 38:47

when we when we study for board review and you review the development of the gut and neonatal, neonatal digestion, your like how they digesting all the stuff we get

Unknown Speaker 38:58

great earlier.

Unknown Speaker 39:00

Yeah, they're just not supposed to be doing.

Ben 39:01

I wanted to ask you a little bit about parental counseling. I think I think there's there's a lot of exotic practices that sometimes parents bring to the forefront about how they want their babies to be fed. And, and it could get quite challenging to provide counseling and perform some some adequate shared decision making with families. When as a field, we are so clueless about about your trician and about neck and about all these diseases because parents was well, I've had parents tell me Well, you guys don't know very much about this. Anyway. So what how come What I'm suggesting is not a valid option. And so I think, I think in in I think in nutrition is such a primal thing that parents like it's it's one of the core tenants of being a parent, we feed our children and so I think it's such a touchy subject, and I'm wondering what are your experiences and maybe some tips and tricks on on how to navigate the counselor, those counseling sessions?

Speaker 3 40:05

Ben, that's an excellent question. And it can be a challenge. And honestly, I occasionally I'm the medical director of our milk banks, I occasionally get called when families are, you know, just very, they have their own ideas about nutrition, and they would not like to use pasteurized stoner milk. So I'm called in sometimes for those cases as well. You know, honestly, from, I guess, out to bring up donor milk as an example. So we generally mentioned it in the prenatal console, we mentioned it at delivery. And we want parents understand why we're doing it. But at least for our less than 1500, grand babies, you know, we say that this is our this is our approach. This is our protocol, we think this is best practice. And I will tell you, that I think that this is interesting, because I've seen a huge change. But back in 2009, when we introduced donor milk, we had a written consent form. And that's just how it was. And across the board, I'd say majority of parents are like donor milk, you gross, those exact words, I'm not making it up in no matter what their background was, and their beliefs or their education. And you know, these days, parents are asking it, I don't even have to mention it. They're like, Can my baby have donor milk? And so and now we've moved to like a verbal assent. So I mean, we have made some progress. I think some of its education as well, for instance, you know, donor milk is more mainstream now. But I really, I think, Misty said this about a holistic approach. But I really think, you know, we need to validate our families and acknowledge, yeah, you know, I understand where you're coming from, but this is what we think is best, I will say, I've had some families that when it comes time to switch off both, either off bovine or human milk fortifier. To formula or because they don't, you know, mom doesn't have a lot of milk. Unfortunately, that's a struggle too, because there's lots of opinions about formula, or some families want goat's milk, or they want, you know, I don't want to give my baby all those ingredients that are in formula that might, you know, maltodextrin that's fair, you know that. This is where we're at. So I think, educating them supporting them, and then try it, or sometimes I'll negotiate if it's a negotiate, you know, we can negotiate like, Okay, this might be okay, for this baby. And this is going to make this family feel like they're part of the care team. I'll do that. But you know, when it comes to little babies, if we can't do that, that's my point of view.

Ben 42:32

Well put your email in the episode show notes. Yeah. For the consults

Speaker 4 42:37

for the console. Yeah, right. I will just echo Amy's approach, I do think, you know, hearing the families out and hearing what are their concerns and where they're coming from, I think it's really important in getting, you know, moving through all the emotions surrounding feeding, and what it is that they're worried about. So there's a lot going on right now in the mainstream media about how we're feeding premature babies. And I think that it's important for them to be well informed, but obviously also, you know, letting them know, like, this is a lot of the literature that surrounding, you know, your particular age, baby. And because I think a lot of what people are hearing may be really scary to them. And so just figuring out, they're coming from a place of fear or coming from a place of family tradition, for example, of what what is it that is driving the conversation, and then I think, you know, just hearing them out, as Amy said, and, and coming to a consensus about how to feed that baby, I think is important. Because if you're just pushing the practice on them, whatever it may be, that they don't agree with, then they may not be comfortable in other aspects of the NICU. And it is a long road, as we know. And so I think, I think, you know, making them a partner in those decisions is going to be really important for the whole medical team.

Ben 44:03

So continuing on that note, I think there's something interesting for us as providers where we do have some experience bias where we do have a baby that develops next we're a bit a little bit squeamish with feeds for a few days after that, but some, but there's other babies that do very well. And we get back into the rhythm of things. But when it comes to families, how do we in the cases of babies who do go through episodes of neck and and thankfully come out on the other end? And how do we counsel these families? And how do we prevent a situation in which a family will be terrified of anything gi happening to their babies because they had this traumatic experience of whether it is the next stage two or even a surgical case of neck, where every feed is is is analyzed where every stool is dissected, and so how do we how do we prevent that from happening and try to allow families to go back to norm We'll see if they if they ever attempt.

Unknown Speaker 45:03

Like, missy,

Speaker 4 45:04

I was just gonna say, I don't know, I mean, from, I don't know, if a family will ever get back to normalcy after, after neck, I mean, we do a lot of work Amy and I and others with the next society. And so, you know, it's really a wonderful resource for families, if you haven't, if you haven't recommended that to your families with neck, I highly recommend it, because they do have parental support and a lot of a lot of like flyers and different information that is really family friendly, and, um, can really help them through a lot of those feelings and, you know, worries that they may have, I do think it's scary for all of us, right? It's scary for them, it's scary for the providers, and we just want what's best for the baby, we want them to have a good outcome. So until the science catches up with all of those, you know, feelings and how we can advocate for these babies at the bedside, whatever it whatever that may be. I do think that we all need to work together on it, I would say that, you know, for babies that have had neck, you know, really pushing mom's milk as much as possible, you know, if they've been saving it, or if they're stressed, just really supporting them to continue pumping. And if not, then donor milk when mom's mouth is unavailable. Post snack, I think it's incredibly important. The issue really, is that, like we mentioned before, we don't know the best way to feed babies. And we certainly don't know the best way to feed babies post snack. But, you know, slow and steady post snack usually, is all that we can do.

Daphna 46:48

I wanted to shift gears a little bit in in more into kind of this global nutrition. So what do you think like we know a lot about how not in the NICU so much, but how important early nutrition is for the development of chronic disease, adult disease? Normal neurodevelopment or quote unquote, typical neurodevelopment. So, you know, we're still collecting that data. But what do you think we will find, you know, in 234 decades about kind of these, the the long term nutritional outcomes from these these babies who have spent such you know, these medically complex babies who spent so much time in the NICU?

Speaker 3 47:36

Yeah, no, I was thinking two things. Because when when you talked about global, it, may I have two answers. So thinking globally, what popped into my head was that, you know, malnutrition, granted, we are feeding our babies and giving nutrition the NICU, but to some degree, they are malnourished and as a nutrition person to see that. It's a little crazy. But you know, if they're, if they're not fully growing, we're not giving them something. But I don't mean to keep going back to the microbiome. But with my collaborators, and working with misty and my recent grant I received there, it's pretty profound. It really depends on what gut microbes you have in relationship to malnutrition and protein absorption, etc. So I feel like one we're going to make, I really do feel like we're going to learn more in the next couple, well, 20 years, hopefully, before I retire, we will, that will, which is a long way away. But still, that one thing that that made me think of but ya know, we we don't know. And I will be honest, you know, our early the early days in the NICU, meaning like 15 years ago, 20 years ago, when our BPD, you know, chronic lung disease babies, they they weren't, there wasn't an emphasis in growing them in lead there is, you know, just let them gain weight. And we found that there were a lot of health problems later on related to you know, they had too much catch up growth, early childhood, you know, adult diseases like obesity, etc. And so then we put this emphasis on making sure they grow in length. And so, you know, I agree, I agree, we need long term studies. The problem is I've done some folks studies, I love seeing these babies back, but trying to get funding, or it is is very difficult. And so it's like something that's really needed, and we need to study it, but but we need to be creative about how to go about that.

Speaker 4 49:37

I agree. And I would just add, it's not only just the microbiome, right? It's what we're feeding. So we're talking about feeding our babies, but we're also feeding the microbiome that is there. And so what are how are we doing that? And is that, you know, is that probiotics is that prebiotics, or a combination of both? I think all of that needs to be um, While there's been a lot of studies about probiotics, but but certainly there's other ways, right, so a lot of units are not adopting the probiotic bandwagon. And so then how do you move forward from that? And, you know, what is the best way to build that, like what we call healthy microbiome for these babies. And so in order for them to grow, as, as Amy mentioned, I think a lot of that there's so much that we could all be doing, and if only there was unlimited funding for us all to fall to do it. But I think I do think we need to think about that, because those microbes, you know, produce metabolites and those metabolites and how they interact with, you know, that like the host immune response to inflammation, etc. I think a lot of that plays a huge role.

Ben 50:50

You're both very humble. I mean, we, but we would be silly for us not to mention that you're both been awarded grants to study these exact issues whether it is postnatal growth, as as in you mentioned, and Misty, really talking about this sort of intestinal athletes, do you want you want to tell us a little bit about about your your recent awards and what you're hoping to achieve specifically you with with these grants?

Unknown Speaker 51:16

Go ahead, Amy. She just got an amazing new award.

Speaker 3 51:19

Oh, no. Well, I had a lot of support. It's a it's a team effort, I think, encouragement end of the day. No, I will say Kami, Martin helped my hand as well as Misty, good. So, you know, anyway, so you got me through it. But yeah, I was just, I'm very thankful to be awarded an r1 Clinical grant for five years, basically, as you mentioned, to look at postnatal growth failures, specifically looking at the interaction between the liver gut microbiome, and specifically, we're looking at fat absorption and bile acids. So you know, we think about bile acid, maybe when we give versatile to some of our CO sciatic babies, but they actually have signaling pathways in the intestine and in the body related to fat absorption. And so what I'm hoping to find is, you know, what's different about babies that don't grow? And is their, you know, my dream would be? Is there a certain mix of bile acids that we need to give or as Missy mentioned, a certain microbe that makes this certain metabolite? You know, maybe it's just one and we're not doing it to prevent neck, we're giving it to promote growth. So I really think it'll give us some physiology as well. The last time bile acids haven't been studied in preemies, there was like one study maybe. And so it's a really under studied area. So I'm excited.

Speaker 4 52:40

To see, that's great. We are just doing a whole bunch of things. So just briefly, I will say that we, one of the grants that we have is to study how we can modify the decimal immune response in neck and how we can obviously, the goal would be to prevent neck completely. And so we're looking at some immunotherapies, specifically interleukin 22, which has both anti and pro inflammatory properties. And so we're working with the FDA on trying to get that into a clinical trial for treatment for neck first and then hopefully prevention after that. We have another grant that is looking at biomarkers for necrotizing enterocolitis. At both the stool level but also using blood as a biomarker. Looking specifically at DNA methylation, as a potential biomarker for that, or what we talked about, you know, rolling in or out neck, I think would be, you know, really important. And I mentioned briefly we have, we have funding to take human infant intestine once it's resected and then do like a neonatal gut on a chip approach, and test, test different therapies and see how the premature gut handles different therapeutics. Both the you know, in the healthy and the disease state as well. And then we're really fortunate to get a chance Zuckerberg grant in collaboration with me, and then kami Martin, and Troy, Markel, Indiana and Scott Magnus at UNC here, I'm one of my collaborators. And were building neonatal intestine with and you know, in the context of several diseases by including NAC and so seeing at these just different gestational ages, you know, what is happening at the cellular level and the molecular level and all the different signaling pathways, again, during all different diseases, and so, I think together, you know, we have, we have this neck bio repository that we're really grateful for, and we have up to 10 centers now that are are collecting and tested, and, you know, all different, all different samples as well. So certainly one of the largest, I think neonatal biobanks in the country. And so hopefully with all of us dedicated to that, we will get some answers for all of us feature.

Ben 55:17

It's in your voice, you can hear all the work that went into getting those awards, but also at the, the realization that the work only begins.

Unknown Speaker 55:29

Yeah, that's right.

Speaker 3 55:31

Yeah. Yeah, I'm thinking, you know, for our, you know, colleagues that are really focusing on clinical care, you know, I am working on some other things, don't miss these two that are, my goal is to try to get as much bench to the bedside quickly as possible, so that we can, you know, take it. Yeah. So I'm also working on a few things to try to answer some of these questions for neonates, especially some of our 20 to 23 weekers. Or at least where are we are the babies we have, you know, just so we can start somewhere and then study and I think the new needle nutrition collaborative will be great for that as well answering some of those questions, what we're

Daphna 56:12

looking forward to all of that work through and looking forward to reviewing those papers that come from all of that hard work. And my last question is, is related, though? You know, for people who are interested in neonatal nutrition or enact research, what are some tips and tricks to you know, get get close to you experts. But also, I mean, obviously, you guys are layering, you know, the work that you're doing along your careers, but are there things that and in regards to need animal nutrition are still like, totally like unstudied potential goldmine? Oh, wow.

Speaker 3 56:55

I mean, that's that. Yeah, great question. You have no, I mean, I think any honestly, any topic related to neonatal nutrition that someone can publish their data from their center, even though it's single center will just get us closer, you know, to answering some of these questions. I, you know, I'm trying to think what hasn't been studied. Now, now that I'm on the spot, I can't, you know, I have a whole list. I think we all have a running list of like, next ideas or projects, but I mean, even TPN, TPN hasn't been well studied. I mean, there was a recent study looking at protein. And that was very nice. But even follow up, there's very limited follow up of our BBs. And I know, you know, there are some groups looking at that. But even just looking at your cohort, and looking at nutrition from that follow up is a huge one late preterm infants, no one pays attention to them. I mean, you know, because we have these tiny babies, and so they are a separate population, and they are still immature. And I don't wanna say, No one pays attention. And just in general, the literature is not focused on that subset. But that is a huge, you know, what do you do with that 3436 week or even 30 to 34 weeks? So that's a huge population is well, as well.

Speaker 4 58:18

I would say, the most important thing that people can do that, you know, that are thinking about entering either nutrition or standing neck in those fields, is be curious, right? And what bothers you at the bedside? Think about studying it, I think that's one of the most important things that we can do is be curious, ask questions. There's so many questions in neonatology in general, been answered. But specifically, as we mentioned, related to nutrition and neck throughout this podcast, I would say be curious and lean into that and know that you can answer that question. You know, I think one of the things to remember is that, like those of us that do research, you know, people from the outside are like, Oh, it seems like hard. It seems like you have two jobs. But really, we're trying to like save all the babies in any way that we can with our work. And so you could also do that, and so lean into that. We're happy to help, I think, yeah, one of the things is, when people are at their centers, they don't know who to reach out to, or maybe there's no researchers that are in that field, but we're always happy to help. The next society actually just started this mentor mentee program for early career investigators at any stage whether it's trainee or faculty level, that are interested in study neck, but maybe don't know how to do it and so matching them with a knack investigator with their interests, whether it's clinical or basic science or translational, and how to get that started at their center. I think that's, that's really one of those fantastic opportunities, but also just going to PA So are other, you know, AP or other meetings, I think, and meeting us and talking, talking about, you know, what it is that you want to do and how we can help inspire the next generation. So

Speaker 3 1:00:15

innovation? Yes, we were not very nice, right? We could tell them,

Ben 1:00:21

I can convince a friendly

Unknown Speaker 1:00:22

bunch. The nutrition bench is a friendly bunch.

Speaker 3 1:00:25

We want to help. Yeah, cuz that's how we got to where we're at people helped us, you know,

Ben 1:00:30

ask you that question. And since you're bringing it up, I'm wondering what led you and I have one more question after that. But what led you to your interest in neonatal nutrition? Was there was this a patient? Was this just curiosity about the physiology, but I'm just, and at what point in your career because I think we tend to dismiss our training years, but I think our career begins much earlier than we tend to think. At what point in your career did you say that's something that I want to I want to focus my my career on?

Speaker 3 1:00:57

You don't make me go first. My my, I feel like my story is is a little interesting. I don't think many people would believe that I wanted to be a general pediatrician, and I fell in love with the NICU. So I was like, Okay, we're gonna do three exteriors fellowship training, I did a project related to math in residency, a clinical project, because I had a patient that really impacted me. And she got very ill from neck and I was like, we've got to study this. So I came here to Baylor. And um, Steve Abrams was running the nutrition program at a time I was actually I teased Misty, because I was going to do a basic science project, going to look at DAX, and liver receptors. Well, my mentor for that left. So then Steve Abrams said, you're going to come work with me, and I was like, you Oh, okay. And you know, I've always had a little I actually, you know, what I wanted to learn how to write TPN as a resident, so I guess I did have some nutrition tendencies, right. But then it just kind of evolved from there. I mean, I know that sounds crazy, but it just kind of, and then, you know, my mentor left early, early in my career, so I didn't have a key award. And I just got this r1. And so there's all different pathways. I would say anyone listening, you can do research. Well, we'll help you any any question you have the answer, but you don't have to follow the path. I mean, if you have the passion and the drive, I would just say, you don't have to, I mean, yes, the path might have been a little easier. Had I followed it the way it's supposed to go. But But ya know, so here I am. And I did a little differently. And I'm loving what I do.

Speaker 4 1:02:40

So hard act to follow. So say, I mentioned earlier, that I became interested in NEC as a resident only because of these aspirants. And really, you know, as an intern, it was like the nurses would come bring you to ask spreads? And do you want to feed or not feed? And it was really puzzling to me that I felt like in that moment, I had such power to decide. And there was no good literature to support it. So it's like, are you going to feed that partially digested? Baby? Is there a green tinge? I'm not sure. Ask for it back, are you going to pitch it and restart. And I remember thinking, gosh, we could really do a lot more for this disease. But I didn't know any thing. I wasn't at a research center. I didn't know anything, really about neck other than we were all afraid of it. And so when I became the fellow at Children's Hospital of Pittsburgh, I decided that I was going to, you know, from my fellow only project, I was going to study neck. And I went into David Hawkins lab, who's you know, neck expert, surgeon scientist, and just really fell in love with discovery and like, how can we change this field for babies? And so how can we feed them better? How can we nutritionally modify that gut environment, Alchemy model neck in the lab, which is such a crazy thing that we did today, but but, you know, ways in which we can do that in different animal models, including mice and piglets, like, I never thought that I would ever take care of, you know, Piglet and my wife. But, but you know, the things that we do along the way, and I will say, as Amy mentioned, there are struggles that happen, like mentors do leave. And so I was fortunate enough to get my key award. And then my mentor, and my lab did leave, and for a better opportunity, and I couldn't leave at that time. But I will say that you do, though, in those times of, you know, crisis or a career change, you do need to sit back and think, you know, what are you going to do and are you going to pivot? And, you know, surrounding yourself with an amazing mentorship team I think is really important. And my mentorship team did pick me up, you know, at that time in my career when my center left and it was Dr. J. Cole's and he's just fantastic. So I basically did a second postdoc and mucosal immunology of the gut And then really became fascinated with how we can modulate that, you know, either nutritionally or chemically. And so I think when you're thinking about what to study, just go with, as Amy mentioned, what you're passionate about. And one of my mentors once told me, you know, it just keep doing research till you don't get funded or more, or all the questions have been answered. And so, so that's been, honestly how I've come across my whole career. And I've been really fortunate to have amazing institutional support, mentorship and funding throughout the way so grateful for that.

Ben 1:05:37

My last question for you both is related to nutrition culture inside the NICU. And I feel like there's sometimes feel like there are chips, you know, that we can, there's only so many that we can redeem. And, and the paradigm has changed so often, both because we're taking care of different babies in the NICU than we were 20 years ago. And because we're learning more, and so we're changing our practices. But I feel like nutrition is something that is not the propriety of physicians alone. It is something that we deeply share with our nurses. And I mean, I've had nurses tell me, Honey, I've been here for 20 years, and I've seen you guys switch it back and forth. And I know when to feed a kid and I know when not to feed a kid. So I Well, what's interesting is that when I get these comments, I don't feel offended. I just I love that, right? I mean, this is this is NICU, this is prime NICU, and I think they have a place in the culture of a unit. Now I'm wondering, how do we take it all in, and we keep our unit marching forward in the right direction, without also maybe letting this attitude be too contagious, so that there's inertia.

Speaker 3 1:06:50

I was just gonna say that I feel like I need a degree or specialty in Implementation Science, or sustained cultural change. And and I say that because I, we have such a large staff, and we do have turnover, we're big Children's Hospital. And so I do feel like, we kind of get everyone on the same page through education and working together. And then we have a new set, we have new faculty, we're actually expanding. So we have a lot of new faculty as well. And so that's great because they bring other ideas and experience that we can, you know, include in our nutrition practices. But I do feel like and that's why I say like, how do you sustain change or sustain this culture? And I don't have the exact answer, I'm sorry, I wish I did. But other than just to keep trying, oh, and I have left out there on this podcast, our amazing neonatal dieticians. I mean, they're the ones at the bedside really helping the teams. And so I think for us, it's just every member of the team, including our dieticians, bringing in our nurses, just trying to do the best we can for nutrition, but as per sustaining it, and then not letting practice creep go back to where we were, I have not found a great way other than just to keep trying. And then when we noticed that, oh, you know, we did this oral care with colostrum, you know, project and we were doing great. And then we weren't and so you know, having to go back and figure out okay, what do we need to do differently? Or do we just need more education? So it's, it's a big challenge, Ben,

Speaker 4 1:08:28

I would say something that's, I think worked over the years is making sure that when you have like protocol or guideline development, that you have all the stakeholders there. So if you have somebody that is passionate, one way or another, I do think inviting them to be a part of the the process is going to be fruitful in that regard. And then making sure that the people that you have on those, you know, guideline committees or protocol development team, that, you know, they can then bring that back. So whether it's you know, whether it's, you know, your you go and present to like an A nursing meeting or charters meeting or, you know, a dietitian meeting, I think, I think you making sure that everyone, like the whole team that's involved feels invested. And especially if they care deeply, and they're challenging, you're at the bedside, I think that may just be a signal that maybe they need to be involved and like to help the process where if there's new data, making sure that it's shared widely with the team, and when we do have a lot of turnover in every NICU nationwide, I think, you know, ongoing education is very important. Not all of them.

Daphna 1:09:47

I just want to highlight what you just said about how challenge at the at the bedside is really just evidence that they you know, people care deeply about their patients. You've given us lots of tidbits, This this, this last hour and change but then I

Ben 1:10:04

also think it's not really it's not really being challenged at the bedside. I think I always welcome this idea that this is an ongoing discussion. And, and it would be, but not everybody know, but I think it's important to remind ourselves and I think this discussion was so great because we we have very few certainties in life and especially in neonatology. And so I think having these questions being asked until we have we reach a level of certainty is is the healthy is a healthy process. Yeah.

Daphna 1:10:31

And being humble about them. Yeah.

Ben 1:10:35

We are overtime and at the end of our of our but it was it was a great conversation. Dr. Amy here, Dr. Misty, good. Thank you so much for making the time to speak with us today. We will have links to all the resources you've mentioned. And we'll we'll put ways to get in touch with you for people who are interested in unit on nutrition and who would like to explore potential ways to to help you on your journey to eradicate neck and improve the nutritional outcomes of our preterm babies. Definitely. Thank you. Thank you, everybody.

Unknown Speaker 1:11:07

Thank you. So

Ben 1:11:12

thank you for listening to the incubator podcast. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcasts, Spotify, Google podcasts, or the podcast app of your choice. We would love to hear from you so feel free to send us questions, comments or suggestions to our email address NICU You can also message the show on Instagram or Twitter, at NICU podcast or through our website at WWW dot the dash This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns. Please see your primary care professional. Thank you

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