Hello friends 👋

Happy Sunday, we have an exciting podcast episode ready for you today. Daphna and I spoke to the talented Dr. Anup Katheria from Sharp Mary Birch Hospital for Women & Newborns in San Diego, CA. Anup has become famous for his pioneering work on umbilical management, for which he has both published and spoken about around the globe.

Cheers!

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Short bio: Dr. Anup Katheria is an Associate Professor of Pediatrics, and the Director of the Neonatal Research Institute and the NICU follow-up clinic at Sharp Mary Birch Hospital for Women & Newborns. Dr. Katheria earned his BS in Biology from the University of California, Los Angeles, his MD from Drexel University College of Medicine, completed his pediatric residency at Children’s Hospital of Orange County, and his Neonatal-Perinatal Fellowship at the University of California, San Diego.

He is the principle investigator for several trials: 1. Comparing cord milking to early cord clamping in term non-vigorous infants (MINVI trial). 2. Comparing delayed cord clamping to umbilical cord milking in preterm infants (PREMOD2 trial). 3. Comparing early CPAP to early caffeine plus LISA (CALI trial) in preterm infants. 4. Comparing hi versus low oxygen during delayed cord clamping in extremely preterm infants (DOXIE trial).

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

[00:00] Ben: Hello, everybody. Welcome back to the incubator podcast. It is Sunday. We have a great interview for you today. Daphna, how are you?

[00:01:06] Daphna: I'm doing good. I've been at the beach. How are you?

[00:01:10] Ben: Surviving. I'm surviving,

[00:01:12] Daphna: I know.

[00:01:13] Ben: but things are good. Everybody is doing well. The unit is holding up.

[00:01:18] Daphna: That's all we can ask for.

[00:01:19] Ben: That's all we can ask for. And for people who are wondering, we've recorded this interview before I was on service. We're just, we're just recording the intro, um, after hours. On this week of service, but these weeks of service, you know, they start off well, and then they take a toll.

[00:01:34] Ben: Oh my God. And

[00:01:35] Daphna: Yeah, they become, the stressors become additive, don't

[00:01:38] Ben: Ooh, yeah. And, uh, but, but you know, I can't, if the babies are doing okay, can't complain, you know, I can't ask for more than that. So that's, that's all we're going to ask for today. So we have a pretty cool interview. That's, that's actually an interview that I've been meaning to record for some time because I've, I've listened to Anup's work at multiple [00:02:00] conferences, read some of his papers, and he's a fascinating physician.

[00:02:02] Ben: Um, we're going to give you the privilege of, uh, of introducing our audience to, to Anup Katheria Dafna. Do you have his bio handy?

[00:02:11] Daphna: I've got it right here. We learned so much. I hope everybody's gonna love this one. Today we are so glad to have on Dr. Anup Katheria, an associate professor of pediatrics and the director of the Neonatal Research Institute and the NICU follow up clinic at Sharp Mary Birch Hospital for Women and Newborns.

[00:02:30] Daphna: Dr. Katheria earned his bachelor's in biology from the University of California Los Angeles and his, uh, medical degree from Drexel University College of Medicine, pediatric residency at Children's Hospital of Orange County, and a neonatal perinatal fellowship at the University of California, San Diego.

[00:02:45] Daphna: He is a principal investigator for several trials. The first comparing cord milking to early cord clamping in term non vigorous infants The MINVY trial, uh, comparing delayed cord clamping to umbilical cord milking in preterm infants, [00:03:00] uh, the PREMOD II trial, comparing early CPAP to early caffeine plus Lisa, the CALI trial in preterm infants, and comparing high versus low oxygen during delayed cord clamping in extremely preterm infants, the DOCSI trial.

[00:03:15] Daphna: Please help me welcome Dr. Anup Katheria to the podcast today.

[00:03:22] Ben: Dr. Anup Katheria. Thank you so much for being on the podcast with us this morning.

[00:03:26] Anup: Yeah. It's such a pleasure to be here with both of you. Really excited.

[00:03:28] Ben: Yeah, same here, same here. Um, you um, there's a lot of things that we want to talk to you about, especially about your research, but, but before we even begin, as we do with many of our guests, um, we wanted to know a little bit about how you, how you, you found your way towards neonatology and the care of critically ill newborn.

[00:03:47] Ben: Uh, can you tell us a little bit about that, that story?

[00:03:50] Anup: Yeah, I do. I mean, I think like most of us that go into pediatrics, we love working with children, but definitely, you know, the ability to really connect and bond with families over a longer [00:04:00] period of time really sparked my interest in med school when I was doing an acute rotation. And I love the teamwork approach.

[00:04:06] Anup: I mean, I'm actually terrified in doing outpatient pediatrics of the chance of, you know, missing something or having a short visit with a patient and God forbid something happens. And You know, working with our nurses and therapists is, it's, it's really rewarding. Um, obviously the, uh, resuscitation is something I'm really excited about and passionate for and I love going to deliveries and that's something that makes me want to be at house and on call and when I get busy doing, um, uh, going to deliveries, it's really keeps things exciting.

[00:04:35] Anup: Sorry, I'm having some feedback. Yeah. Close this.

[00:04:40] Anup: Go ahead. Are you still hearing that,

[00:04:45] Ben: Uh, we were hearing some of the, the bubbly sounds from like, either text messages or emails that you're receiving.

[00:04:50] Anup: Microsoft team? I'm sorry.

[00:04:52] Ben: Goddamn Microsoft Teams.

[00:04:54] Daphna: Our least favorite, uh, platform. Yes, sometimes

[00:04:57] Anup: No. Okay. Well, Mark. [00:05:00] that's sort of why. I mean, I think we all have journeys to getting into neonatology per se, but, um, it was really that continuity in the ICU that I really enjoyed in terms of why

[00:05:10] Ben: That's interesting. I always say that people don't realize that for us being in the NICU is kind of chickening our way out. We have continuous monitoring. We have labs anytime of the day or night. It's so it's such a, I mean. While the acuity is high, there's a sense of security that I can get or do anything at any time of day or night.

[00:05:29] Ben: And that's very reassuring as a physician, like you said, seeing a patient in the clinic for 15 minutes and then hoping you didn't miss anything during the chaos of a visit is, is, is a testament to the quality of the physicians that are practicing outpatient pediatrics. So kudos to them.

[00:05:48] Daphna: hardest thing we have to do all week is discharge a patient. You know, some of these really complicated, um, babies that you really worry about. And so, yeah, our [00:06:00] outpatient colleagues must be thinking about that all the time.

[00:06:04] Anup: it, how they do.

[00:06:05] Ben: Um, I know you've. You're now speaking around the world about your, your research and, and your interest in umbilical cord management. And it's, it's interesting to me that umbilical cord management is something that is such a discussed topic. It's something that we talk about intensively in our field, and yet it's probably one of the most primordial aspects of a newborn's baby's birth of, of the newborn's birth.

[00:06:32] Ben: Um, we've been dealing with the court since. Dawn of time and yet we're still debating. What are we supposed to do? Um, how did you, um, find this area of, of neonatology interesting and fascinating to lead you towards all the research and the, and the, and the work you've done on the topic?

[00:06:52] Daphna: Yeah.

[00:06:52] Anup: no, it's actually, that's a great, um, actually interesting story. I, so I, I didn't, it sort of ties into my interest in research, which I know [00:07:00] wasn't your question, but you know, I, I wanted to go in and take care of babies. be a clinical neonatologist and at UC San Diego, where I did my fellowship, you know, Tina Leoni, who is now at Columbia, but she was our fellowship director, had just come back from Australia and learned how to do echoes.

[00:07:16] Anup: And, um, it was really neat. This was over 15, 17 years ago. And the idea of looking at a baby's heart and understanding physiology, I done, I was a physiology major in undergrad. It really piqued my interest. And so one of the studies I did was looking at physiology of bits of diabetic mothers and sort of looking at the changes in pulmonary artery pressure, etc.

[00:07:39] Anup: And as a, uh, fellow, I presented at PAS and these two ladies came up to me and said, you know, that's not really, Um, normal physiology in babies with diabetes. I said, well, what do you mean? She's like, well, when were their cords clamped? And I said,

[00:07:52] Daphna: Yeah. Mm.

[00:07:53] Anup: don't know. I assume right at birth. Isn't that what we do?

[00:07:55] Anup: Right. This is. And, um, those two ladies [00:08:00] happen to be Heike Reh and Judith Mercer. And if you never know what early pioneers of cord management, I really piqued my interest in thinking about how I wonder if blows are different if we give these babies more blood. And so, you know, we started looking at what can we do delayed cord clamping again in early 2000.

[00:08:18] Anup: And my OBs were like, There's no way this wasn't even recommended. So we looked at, you know, milking and other things, and I always had outcomes that were looking at improving flow in babies. And over time, it became clear that you can't just do little studies looking at flow. You've got to look at clinical outcomes to really impact change.

[00:08:36] Anup: And so that turned into doing bigger studies and larger trials that sort of moved past the echo piece and looked at more of whether or not we're improving certain things. No, you're right. Then delayed cord clamping seems like a no brainer. Why aren't we just doing it in every baby? It just gets then into the, the opportunities for research on the nuances, the non vigorous baby, extremely preterm.

[00:08:58] Anup: Is that okay to do it in [00:09:00] these populations or subgroups? That's what gets

[00:09:03] Ben: We will get you to speak about that in a few moments, but isn't that the most terrifying thing when you are at PAS as a junior physician and the expert of some field raises their hands or comes to the mic and you're like, Oh my God.

[00:09:17] Daphna: What am I gonna do?

[00:09:18] Anup: I remember that when you did your first topic, anybody comes to you, you're like trembling. You have no idea. These people all, and they've always big names,

[00:09:27] Ben: I barely know what I spoke about. Do not.

[00:09:31] Daphna: That's the worst. When you didn't even know that they, you know, that you, you may, you may have known, but people came to talk to me. I didn't even know they were the experts, right? That's how little I knew. terrifying.

[00:09:45] Ben: When you did your work on, on, and research on, on the biblical corn management, I'm wondering if. You can give us a glimpse as to how the cord was managed at the, before neonatology was even a thing. So, so when mothers gave birth, um, I don't know, in the [00:10:00] 17th, 16th century, did, did, what was the routine practice before the medicalization of childbirth to, to let the cord sort of dry off?

[00:10:11] Ben: Or was it something that cutting the cord was a cultural thing that happened even way back when?

[00:10:17] Anup: Yeah, I know. So a lot of, if you read these historical papers, and sometimes I have slides, the two famous people are, are Darwin and Aristotle. So they both have references to, to court management, which is sort of striking. And so, um, they talk about the baby who's born that may not look as, uh, vigorous or, or pale can benefit from just keeping the cord attached and tying it with a string, um, and, you know, allowing that cord to sort of, um, uh, turn white and, and have less blood flow in it.

[00:10:46] Anup: Um, you know, obviously people didn't even deliver, um, sitting down. They used to just stand and squat and the baby would come and there were the benefits of gravity and, and delayed cord clamping as well. But it was always about sort of that natural detachment process. [00:11:00] Usually tying it off and, um, and sort of midwives, right, were the ones that delivered babies and, and still do and, and, and kudos because they're really the, in my mind, the champions of delayed cord clamping, as you know, the stories, uh, there's, there's sort of three ideas.

[00:11:14] Anup: One is as a field of obstetrics, obstetrics, which came a little bit before neophysiology came up, the idea of, uh, urgently trying to, um, deliver the third stage of, of management of labor. And part of that was traction on the placenta as well as clamping of the cord to reduce postpartum hemorrhage. That's been one big theory as to why, um, immediate cord clamping came into vogue.

[00:11:35] Anup: The other one is Virginia Apgar and the need to assess at Apgar right away at one minute. And as an anesthesiologist, she was worried about anesthetics getting into the babies as well. So part of that involved early cord clamping. And so around the 60s, these two sort of, I, concepts kind of made it, made, you know, mainstream into medicine.

[00:11:54] Anup: And we always say as researchers, um, immediate cord clamping was the [00:12:00] intervention adopted without evidence. Yeah, now we're trying to have evidence for delayed cord clamping or other methods of providing placental blood. So it's always interesting when you look at that.

[00:12:09] Ben: Yeah, I was going to ask you about like how Virginia Abgar is revered in Neonatology for, for, for very good reasons, for very good reasons, but she may be to blame for us cutting that cord a bit quickly. And, uh, and I was going to ask you, but I'm happy that, that, that you mentioned that.

[00:12:25] Anup: Yeah.

[00:12:28] Daphna: Um, I, as we're talking about all of the methods of umbilical cord management, and we're going to, we're going to get your first hand expertise on that. Why do you think it's been so difficult to study?

[00:12:41] Anup: Um, I mean, it depends on this, uh, obviously the types of groups. I would say it's, it's like most of our field in neovictology changes really part, right? We've been doing something. We all believe when we take care of a patient, we're doing the best, um, that we can for those individual and the idea of [00:13:00] not doing something right away for a 23, 24 weeker and letting them sort of sit and wait, that's really hard.

[00:13:07] Anup: And, and so you really need to convince me that that's what's best for that baby, um, rather than letting that baby come into my hands where I can aerate the lalos and do all kinds of other things to that infant. Um, I think that's been the biggest struggle. I myself was guilty. I will tell you as a fellow.

[00:13:23] Anup: But when babies would, you know, be, um, sort of born by midwives, because we had a midwifery service in our hospital, and I know that some universities do this, and they would put the baby on the mom's belly, the baby wouldn't look good, and I would sort of, you know, raise my voice and tell midwife, I need to look at that baby, bring that baby over here, cut the...

[00:13:40] Anup: I wasn't even thinking that that actually is a good first step for that baby to provide some additional blood volume to make it easier for me to resuscitate the baby. You know, I think we're all guilty. My, my, I have confession, my first two, I have three children, my first two had immediate cord clamp. I still wonder about them, if they would have been better than my daughter.

[00:13:59] Anup: I've got [00:14:00] like three minutes of delay in, in the, you know, I think we realize in hindsight, you know, we, we were making a mistake, but you're right, Daphna, I think early on, change is hard, especially if you don't have this traction of evidence coming in that, hey, this seems to be working. And obviously now we're all like, duh, why aren't you doing delayed cord clamping in these babies?

[00:14:20] Anup: It's. But, but that was a hard measure. I think for us as intensivists, we like to loop. We like to get that it to bid right away. If that baby's hypoxic or. Um, you know, be able to, you know, improve that baby's, uh, lung aeration quickly on the ventilator. We do all kinds of things fast. And I think delayed cord clamping, and when we talk about the nomenclature, I get a lot of, we should change the name, but I think that's a hard thing for us to, to deal with in this field.

[00:14:46] Ben: Do you think it has to do with the segmentation of care? Do you think that because I mean, at the end of the day, what we tend to forget is that pediatricians did not exist for some time, and the obese were the one who cared for both mother and baby. And [00:15:00] then we we proceed through the ages, and we have this segmentation that happens where now the pediatrician is is here.

[00:15:06] Ben: And then we have a mother that's being cared for by an obstetrician and a baby that's there to be seen by a pediatrician. So is. And it seems very confusing as to who's responsible for what, right? Is the late court clamping the duty of the OB? Is it the ACOG's responsibility? And then the AAP will say, we support that.

[00:15:26] Ben: Or is it our responsibility? I'm just wondering, what is your thought? What are your thoughts on that?

[00:15:32] Anup: Yeah, I know. It's, it's really, that's a great point. Uh, cause you think of our obstetricians, they're, they're not NRP trained, right? So first steps of, you know, even warm, dry stimulation, that's something I really advocate as a success for delayed cord clamping in preterms. Um, has to sort of been, you know, be pushed with their obstetrical callings.

[00:15:51] Anup: And I think that, um, that change, you know, I have obstetricians tell me, wow, I've never actually held a 24 weeker in my hands and looked [00:16:00] at them because there's just all they can do for a minute is stare at this baby. And it's, it's, it's amazing to see their whole change in, in, in sort of persona and, and reaction in terms of helping us, uh, implement delayed cord clabbing in these infants.

[00:16:12] Anup: So you're right. I think that. That's probably one important issue is to try to figure out a way to get our obstetrical colleagues to be more part of that initial first step. Um, it gets even trickier, which is a new field, um, if we get time to talk about with the idea of actually doing resuscitation on the cord.

[00:16:29] Anup: Now, you're Melding in both parts where we're now providing assistance while the obstetrician is still helping us maintain the cord and keeping it intact. So, um, I do think it's an issue, uh, but it's not one we can't overcome. We, we love interacting, right, with our obstetrical colleagues. We're, we're joined at the hip.

[00:16:45] Anup: Our, our busyness and ridicule depends on how busy they are. And, and I think we work together a lot already. It's just more now in terms of managing this baby, uh, together. That's, that's sort of the new era for us.

[00:16:58] Daphna: I have kind of a related [00:17:00] question about, you know, the umbilical cord is this last, uh, remaining conduit, right, between. between mother and baby. And so we're going to talk a lot about the management of the cord, but do you think there's still answers in the umbilical cord that will help us, you know, just individualized care for patients?

[00:17:23] Daphna: Tell us more about the baby. You know, I feel like the cord, we make a decision about management. We cut it. Sometimes we draw labs from it, then we just dispose of it. But do you think there's more we can learn from the cord itself?

[00:17:36] Anup: Well, absolutely. I mean, there's, you know, people think of the cord is just blood, right? But we, we all know it's way more than stem cells, metaglobulins, white blood cells, lots of things that we can look at. Even all these stem cell, right, therapies that we all think about, those of us in the cord clamping world, we're like, look, you're looking at stem cells for BPD.

[00:17:55] Anup: We're giving stem cells through the cord. And so I do agree. There are [00:18:00] definitely, um, benefits of, of looking at cord blood. Obviously, people are looking at even analysis with totally different topic, but you know, there's lots of things we can draw from cord blood. Already I was on an OB call this morning, and now it's very common, baby with anomalies, we draw the whole genome or some form of testing off the cord.

[00:18:16] Anup: We do more and more things on the cord, and you're right, I think eventually we'll be looking at different markers, things for infection, other things that might help us personalize how we treat that baby postnatally. I do think as far as personalized medicine or cord management. There is this sort of debate in our community, well, what, what's really physiological based court clamby?

[00:18:37] Anup: Can you individualize how long to keep the baby on the court? I will say it's great for animal physiology and studying it in practice, I think we as neonatologists still need a duration of time. The one caveat I'll say is a sicker baby probably needs more time on the court to be able to breathe and sort of transition.

[00:18:56] Anup: And we seek this all the time with a baby or a fetus that has bradycardia [00:19:00] and they go to do the suction. You're almost like hoping that heart rate will recover before you go in, right? And then they bring you a baby that has a low heart rate. So we're already kind of thinking that way anyway, it's just a matter of how to extrapolate that when the baby's already out on the court.

[00:19:14] Anup: Can you provide support in a baby who's lip blue, non vigorous and still allow that baby to recover and then resuscitate the baby after? So I think some of that gets into personalized medicine, but I don't know for. Um, there yet where we can sort of prescribe that for, for everybody.

[00:19:32] Ben: I'm curious as you, as you are, uh, going through the early stages of your career and you stumble upon this, this area of umbilical cord management. At what point do you realize like, Holy smokes? Like I could, I could dedicate my career to this. And there's so many questions that need to be answered. Um, I think it's, it's a feeling that not many of us get when we stumble upon something that's.

[00:19:57] Ben: That's a gold mine. And you say, Oh my God, I could, [00:20:00] I could study this from so many angles. Um, what does that excitement look like? And, and how did that happen for you? I mean, what was there like a, uh, an initial project where you saw a lot of data coming at you that you say, Oh my God, this could be looked at from a multiple, uh, from a number of angles or, or how did that, how did that, how did that occur?

[00:20:18] Anup: I know, I wish, I wish I had something more, you know, sort of like a great story to say like, this is why I have a passion for cord management. I really, the dirty secret is, um, it came down to what work. Like I, I looked at lots of things as a fellow with, with hemodynamics, caffeine. I looked at surfactant.

[00:20:38] Anup: Um, the only thing that the, the, my story of getting into cord management, even this whole, all this cord milking stuff was, Um, I had put in a few, there was this awkward, um, NIH grants and resuscitation. And so I put in, um, something with caffeine and something with cord milky, and the caffeine thing totally bombed.

[00:20:56] Anup: Nobody liked the idea of looking at late versus early caffeine, [00:21:00] you know, that's a whole topic. But, um, they liked the idea of cord milky, like I got a close to fundable score. So I resubmitted, it got funded. Um, and then I tried some other things and still those things didn't get funded, but anything related to cord milking, and the funny thing with cord milking is nobody wants to study it, you know, they're always like, oh, that's, that's not physiological, it's not growth, but from a funding aspect, you're like, look, this is an untapped question, and honestly, the only reason I keep going back to the cord stuff is, You can get those big grants.

[00:21:27] Anup: I mean, so we've been able to do that with NIH several times. At the end of the day, in research, it's sort of like, well, if you don't get funded for something, you're not really going to be able to, but I like lots of things. I think I get this bias that all I care about is, is cord management. You know, there's so many areas I'd love to study, but you really do, I think, in a, in a research track.

[00:21:49] Anup: It's like you have to build on that last proposal, uh, because that's what funders look at. They want to know who's been able to do this successfully, so. Um, so that's why I'm still in the court. I thought they would move up.[00:22:00]

[00:22:00] Ben: But what's interesting about the work that you've done on, on the biblical court management is that you, um, you started. Showing a way of thinking about the neonate at birth that is a bit different from what we've all been taught. So I think for most of us, there was, uh, term preterm, but you started thinking about how do we manage the cord in term preterm, vigorous, non vigorous.

[00:22:23] Ben: Can you tell us a little bit about what these different categories have, uh, what, what these different categories have that are notable for each one, and, and how does that impact how we care for them?

[00:22:35] Anup: Yeah, I mean, a lot of, you know, there's a lot of old data that I think, um, doesn't get tapped into too much. It's hard to get these old papers on PubMed. But, um, Alice Yao, if you follow her work, she wrote a lot of great initial studies in the 60s. And so, like, the only way to sort of get these papers is, like, to go to the library and get a book.

[00:22:53] Anup: And she wrote a whole book on placental transfusion. And it really breaks down, sort of, what are the differences [00:23:00] between term and preterm babies. And we try to be able to look at, in fact, the preterm babies, which are less likely to get delayed cord clapping, actually have less total blood lung. There's actually more blood in the placenta in a preterm birth.

[00:23:11] Anup: Under 30 weeks, it's about two thirds in the placenta and only a third in the baby. And so you sort of look at, well, a preterm birth actually might need to stay on the cord longer. And these big healthy turn babies that are very easy to do delayed cord clamping on. And so, part of our research was looking how to get more blood, and that was sort of how milking came out.

[00:23:29] Anup: Some of the early studies showed you can clearly transfer more blood with milking the cord versus not. Well, that didn't go so well with an extremely pre turn baby, but it could be an option in other, um, sort of gestational ages. The non vigorous one goes back to, I think, Dapta's question about personalized medicine, is that, are there some babies that you should do something different on and help them?

[00:23:48] Anup: And I think the non vigorous baby is one that needs more time on the court. Um, and I think, uh, that's where we've started looking at other methods, like, can you milk the court? Are those babies you could resuscitate on the court? [00:24:00] Um, and, and looking at, and nuances. I think if we just say, well, we're going to do research on delayed cord clamping alone, most babies are able to get that.

[00:24:09] Anup: It's the subgroups that we're trying to study and research, and that's where the breakout comes in. Right? Preterm births, babies that are 28 weeks, that's less than 1% of all deliveries. But those are the kids that have bad outcomes that we're trying to prevent. Um, so I, you know, for researchers, I think that's, it's those little ends of the tale that we're trying to.

[00:24:27] Anup: Improved things on not the big group of healthy churn babies.

[00:24:33] Ben: Sorry, I was muted. Um, absolutely. And so we've been using the word delayed cord clamping for some time now. And when I do 30 seconds of delayed cord clamping, is that even delayed cord clamping?

[00:24:45] Anup: I got caught when someone quoted me on that. Say, okay, that's not 30 is not delayed. You know, the truth is, you know, when you compare 60 versus 30, right? That's a double dose, right? That's like saying, hey, I give 10 of caffeine and you get five, right? There's differences there. [00:25:00] And so, you know, when you look at the onset of babies who actually breathe in the first 30 versus 60.

[00:25:06] Anup: You look at how much blood flow based on what's left in the placenta in these old trials. Um, I don't think 30 really is delayed cord clamping. Ben, the reason, and I'll give you the story, the reason the guidelines from ACOG you can ask, you know, people that have studied this, is they look, they had to lump in all the studies with delayed cord clamping to come up with the guidelines.

[00:25:26] Anup: So the early studies in the 80s only used 30. But if you look at every trial today, Ben, is that the standard is 60 at least. Since the control arm is 60. So when we're telling people, we'll do 30, you're already like substandard than what we're trying to improve on. So, um, we're trying to even move the term instead of saying, um, for, for the, the intervention.

[00:25:48] Anup: It's not immediate clamping anymore. It's early court. Early court clamping is defined as less than 60. So what I'd say to you is you're doing early court clamping. Now if you want to get to you want to call it. [00:26:00] You got to get to the 60s.

[00:26:02] Ben: And so, and then, and then, so what is the range then? Because, I mean, I've seen studies where Um, delayed court clamping can be extended to like five minutes and some people may say, well, that's that I can't, I mean, that seems something very difficult for me to implement, but what is, um, well, well, delayed court clamping usually could be considered after a minute.

[00:26:21] Ben: Then, then what is the, the, the, the most common range I would say that you would, you would say you, you would see, uh, for, for what's considered delayed court

[00:26:29] Anup: Right. And

[00:26:29] Daphna: how long, how long is too long? Mm hmm.

[00:26:32] Anup: it works. So we won't do like Lotus Birds on this podcast. I promise that that's not something, but I think, you know, so again, gestational plays a big role. Then you look at WHO, they have recommendations of two minutes longer, um, people that are doing longer delays in terms of, uh, in PREMS, they're only doing that on the core.

[00:26:53] Anup: So the, the big, there's a big study in Europe that the average time is five to seven minutes, but they do the old transitional, the core, like [00:27:00] everything monetary. Baby, by the time the courts come, the baby's ready to go to the NICU. That's a whole different concept, and I'm not advocating that we know that that's the right approach.

[00:27:09] Anup: Um, I think it's a balance, right? For us as neonatologists, right, I think in our, our head, we're like, okay, I will do the delay, but how long will I do the delay where I don't have the ability to monitor the baby, right? I'm not going to be able to provide any FRC eventually. That baby is going to die. Going to not have an expanded lungs at some point.

[00:27:26] Anup: So that 60 cutoff without any support seems to be reasonable enough of this risk benefit because I don't think delayed cord clamping, just generically saying, just keep the baby on as long as possible is the right answer for every baby either, right? There are things we do really well in neonatology. We titrate oxygen.

[00:27:43] Anup: We give pressures that at the right amount, not too much, not too little. We don't want to abandon all that just because. We want to just do delay as long as possible. So I think I like the idea of where we're at with that one minute cut off. And, um, again, having sort of both hats as a clinician, that's what I pushed for [00:28:00] as a researcher.

[00:28:00] Anup: I've been finding out other ways to optimize it. Um, it seems to be a right cutoff for most of our prems, our babies that, um, need a little more help on the court. If you can stimulate, get them to a minute, that seems to be a good, good starting for most people.

[00:28:17] Daphna: Um, I'm hoping, I mean, you've alluded to it, but obviously the research is moving to this resuscitation while still, you know, connected to the cord. So tell us a little bit about that and the future of that work.

[00:28:31] Ben: Yeah. Cause I mean, I think to, to add to your question, Daphna as well, is that many papers say, oh, it's feasible. But you read them and you're like, I don't know if I could do it. How am I, how am I going to, how am I going to get this done in my institution? But so, so, um, yeah, I think that's beyond, don't just tell us it's feasible.

[00:28:49] Ben: Please give us more.

[00:28:50] Anup: the great, look, look, it's a, it's a very parted question because even right now we're trying to see if we can do a larger trial here in the States and one's been, one has been attempted as [00:29:00] well. Um, I think the challenge, the challenge that the intact corpus acetation. It's again, marrying of obstetricians and neonatologists throughout now on that same space with the mother tried to balance, um, uh, space, sterility, logistical issues, equipment, and monitoring.

[00:29:16] Anup: I think there's a lot of things. It can be done. In fact, Europe is way ahead. There's, there's even a statement. I think that might've been what you're referring to, Ben. Uh, the European Consensus Statement says, when it can be done, you should do it. And babies who, in fact, are non vigorous might benefit from longer duration on the core.

[00:29:32] Anup: They actually come out and say that. But that's not what ILCOR or NRP, um, are actually explicitly saying either. They just give you a duration guideline. So, um, the Europeans are further along than we are. Um, they're using it more routinely. In fact, I think it, In the UK, there's hundreds of units that are actually using it, just in terms of personal communication with several of these practitioners, and it's even obstetric, uh, driven by obstetricians in the UK.

[00:29:58] Anup: They like this concept of doing it, [00:30:00] um, but for us, I think it's getting down to those other things. If you're going to set this all up, how long do you go? What's the balance of not putting monitors, et cetera, and even in my hospital, sterility is a big issue. We have to try to balance how much we can. And, you know, the masks, uh, the T pieces, they're, they're not sterile, they're clean.

[00:30:19] Anup: So you, you, you sort of put the baby on these little, uh, platforms that you try to provide some CPAP, but you have to balance how long you can sort of do that with, um, the baby still connected. So we're, we're studying that now. There's an ongoing plant study that we're, we're looking at. There's a trial that's going to present the results.

[00:30:35] Anup: Uh, at Hot Topics, um, in D. C., this event, first trial led by Karen Birchall, that will be really exciting, um, to find out if there are truly benefits compared to, again, delayed cord clamping alone, not to immediate. We're trying to compare enhancing delayed cord clamping by providing some extra support.

[00:30:55] Daphna: [00:31:00] Um, we've talked a lot, uh, kind of peripherally about our, um, our collaboration with our obstetrics colleagues. So what are your best recommendations for kind of communication with OB when making a decision about cord management in real time? I think their preference would be that like, we've made a decision before we even enter, say the OR or the delivery room, but that's not always the case.

[00:31:39] Daphna: Um, and so thoughts

[00:31:41] Anup: Yeah. I mean, I mean, for us, it's, it's usually just like, Hey, are you good doing the 60 second delay? Are there any concerns? You know, and usually if. They say, no, it's like, well, the placenta is really anterior, or, you know, I'm not sure she's, mom's bleeding a lot, which, you know, there's another common myth, even with trial design, but [00:32:00] talking to people is that, well, the mom has vaginal bleeding.

[00:32:02] Anup: Well, interestingly, obstetricians can do delayed cord clapping in situations of some mild abruptions, like where you're having a little bit of bleeding. It's when the mom's clearly, um, abrupting, like an acute bleed where they're, obviously, we don't want them to, to risk the mom or the baby's safety. But the majority of, uh, babies can be pretty safely, uh, managed with delayed cord clapping alone.

[00:32:25] Anup: But it is right, it is that, um, you don't want to ask when the baby's already out, or Hey, hey, can you wait? You know, they're, they're in this mode, especially, um, when I first, uh, came to my hospital in 2013, every baby got clamped right away. It was a whole, I've said to the obstetricians, we had to have discussions, and Once they sort of came along with these other guidelines coming through, it became much more easy because it was in their literature as well.

[00:32:50] Anup: So I think it's easier, but I do hear from people like, you know, this OOB will not, you know, do delay. So we have to have those conversations.

[00:32:59] Daphna: Um, it's interesting that [00:33:00] you brought up, um, abruption, um, because actually in my review of the literature, I mean, there's some potential real benefits to managing babies, particularly with abruption, um, on, with an intact, uh, cord or a, a truly delayed cord clamping. And I think for the community, like you said, we want to act, we are, uh, it's maybe counter intuitive.

[00:33:23] Daphna: Um, so maybe you can, um, speak to that. And, um, is there any research ongoing for other babies where we're concerned for like, uh, a hypoxic ischemic injury?

[00:33:38] Anup: Yeah, you know, so a couple things. One is, yeah, abruption, obviously, you want to be able to get as much olsenol blood in those babies, so you can delay up to a point. Um, there's some rare cases where those babies, if it's a severe abruption, we still may offer them to get some milky, provided they're above at least 20 weeks gestation.

[00:33:58] Anup: Um, but there are lots of other [00:34:00] groups too that we think, man, these babies also benefit the baby by a different mechanism. One common question I get a lot is, What about IUGRB? It's like those babies, the placenta's not even working. And there it may be more of a hemodynamic benefit of allowing that baby to start to breathe, drop their pulmonary vascular resistance, and now you're allowing, then you're clamping the cord after that baby's had a chance to adapt because they already have this high afterload with the placenta not working.

[00:34:24] Anup: You want to be able to allow that baby to transition. And there's been a few papers. Suggesting better blood flow, um, one, I'm sorry, sub study saying that, well, they might have less medical neck. So things that we as neonatologists kind of can understand that this script still could benefit. There's no reason just because.

[00:34:41] Anup: There's absent flow or retrograde flow that you can't still delay that baby. Twins is another big one that comes up. Well, if they have their own placentas, okay, that I might be okay with. What if they share a placenta? Is there some reverse flow? So, there's been new cohort studies suggesting that they still benefit because we know that di-mo twins or any twins actually [00:35:00] have more risk of IBH.

[00:35:01] Anup: So, why not allow an intervention that could help those babies? So, you know, there's a lot of room for research in these nuanced areas. The HIV one is really fascinating because Um, you know, when we did our term trial looking at non vigorous babies, we knew we weren't going to show a reduction in HIE, but we still had a difference, uh, between the babies who had milking and cord clamping.

[00:35:21] Anup: So I do think. Particularly, H. I. E. patients are, are great patients that could benefit from not just the blood, but the stem cells and all the other things that are in that cord blood that are beneficial to them.

[00:35:35] Daphna: In, in, um, managing this, uh, logistically, I think a lot of people say, I read the research, I get it, I buy in, how, how can I make this change, um, in my hospital? And you alluded to the fact that, you know, the, it was, uh, There was some difficulty, even at your institution, in making the change. And I wonder, what is the role for, um, like, simulation with our [00:36:00] obstetrics colleagues?

[00:36:00] Daphna: Teaching them, like you mentioned, the basic steps of NRP. Um, where they could still be doing some of those steps while doing the delayed clamping. Mm hmm.

[00:36:10] Anup: Yeah, I know. I think SIM is always great to do. Um, we, we do a lot of SIM with even the, the intact cord resuscitation because there's a lot of logistics there. But absolutely, I think, you know, for, if I was in a hospital, like, let's say I came in on 2023 and my hospital is only doing immediate cord clapping, I would start with getting them comfortable to just going to a C section and making sure they can push the delay out in those healthier kits and moving your gestation down.

[00:36:36] Anup: In fact, you see this in so many QI, in fact, DCC is really big with QI projects. Lots of hospitals are like implementing and showing reduction in morbidities because of increasing the delay. But. They usually start with a higher, more mature population, and they just keep moving. So that's probably the best way to start.

[00:36:54] Anup: You don't want that first 23, 24 weeker who may do poorly for other reasons and then sort of get [00:37:00] blamed for the delayed cord clamping, you know, that sort of thing. So, um, starting with mature kids is probably a good start. And yeah, discussions. I think our obstetricians are open to, uh, a neonatologist coming to them saying, Hey, you might give me a better baby.

[00:37:13] Anup: You wait. And I think they get that.

[00:37:18] Ben: A few more questions about the court. And then I want to talk to you about some other stuff, but, um, interestingly enough, right? I, I was interested in the, in the roller coaster that was umbilical cord, umbilical cord milking, where initially we thought this might be the savior, then it fell out of favor, and then it's coming back now.

[00:37:38] Ben: And we're realizing that which patient do we apply this to really makes a big difference. Can you tell us a little bit about where we are right now, when it comes to umbilical cord milking and, and which patient should we consider this for?

[00:37:49] Anup: Yeah, I know. Yeah. I mean. You know, umbilical cord vulcan I think is one of the most controversial topics. And you sort of have to be at one end like an [00:38:00] evangelical and pushing people to consider it. And on another end, you're like constantly trying to defend yourself from these people like so I'll be honest, like I'll give a talk and there'll be somebody saying, well, I really think, you know, these small babies could have been okay with milking if you had done it this way.

[00:38:15] Anup: You wouldn't have seen this. And I've other people be like. Thank God that's published. Like we never want to touch that again. I'm glad it's done and you have this polarizing area. And again, I'm not saying cord milking is best for any kid. I think we often understand that we're looking for alternatives when we can't do a delay.

[00:38:31] Anup: And I think people forget, um, we're so much better at delayed cord clamping now. The need for milking is becoming less and less important. Um, but yeah, the journey was, uh, looking at milking as an alternative for delayed cord clamping. Our large trial. Which was stopped because we saw harm.

[00:38:49] Anup: It was originally designed as a non-inferiority study. We just wanted to say, Hey, the end of the day of milking has the same rates of I V H as delay. People could use it when you can't do a delay. But [00:39:00] lo and behold, in these babies at 27 weeks and under, 'cause we had these two stratas, we found, hey, um, we're actually seeing more severe IVH and NEC and then we're continue, we, you know, we're gonna, um, publish our results in the next, uh, few months.

[00:39:13] Anup: But looking at babies above 28 weeks, is it in fact, Um, say, are you not seeing any increased IVH in, in those babies? And then at the same time, we studied, uh, non vigorous term babies, because there's no point in milking a healthy term kit. Why would you do that? You can do a delay. But in a non vigorous baby who's limp, not breathing, not responsive, like, oh crap, I have to do something.

[00:39:36] Anup: Does milking do anything? Does it make it worse? Does it make that baby better? And that was our, um, 35 weeks in a non vigorous study, the MINVI trial that, that we published. So. It's, it's the idea of picking and choosing where milky could be beneficial, but remember a pretense that the lake or climbing is your goal state.

[00:39:53] Anup: And then where, where does milky fit in? Where does recess with an intact courts that in. Um, and that's where we're sort [00:40:00] of at. And as you guys are both acknowledging, like, this is moving. As we're doing more and more delay, getting more comfortable. It's changing the landscape of what a trial looked like in early 2000 persons. I don't think anybody should be doing a milking delay study in extremely preterm babies. It's delayed. So, I think that's where things have changed quite a bit.

[00:40:23] Ben: The, the last question I had about the cord is how, when, when I was reading, I've not done research on umbilical cord management, but the papers I was reading initially really, really focused on this sort of bolus of blood that we could give babies and like the extra hemoglobin, hemoglobin F and so on and so forth.

[00:40:40] Ben: But what was interesting about some of the papers you published is this, all these other additional. benefits from umbilical cord, uh, delay cord clamping and umbilical when it comes to hemodynamics. And I think that's very interesting, especially as this is gaining in popularity. So can you tell us a little bit about not just the, [00:41:00] not just the hematological effect on the baby's blood, but also like the hemodynamics benefits that you've identified when managing the umbilical cord appropriately.

[00:41:10] Anup: no, I, uh, you know, it's the hemodynamic pieces, um, I would have given you one response a few years ago, and then I, I, I think, I think my, you mentioned my PAS session where we talked about hemodynamics of the cord, and now it's sort of changed a little bit. Whereas we always thought delayed cord clapping was all about avoiding bradycardia because of the lamb studies, and then there was this other animal study that showed, in fact, you don't get bradycardia.

[00:41:33] Anup: Yeah. In fact, what we're probably seeing, the hemodynamic benefit is the heart is getting additional preload. It's getting more blood. Um, when you look at the baby who's asphyxiated or hypovolemic, you're getting a tachycardic baby sometimes where now you're giving that extra blood and the heart rate comes down nicely.

[00:41:50] Anup: So we're, we're sort of rethinking what we thought about what the hemodynamic benefit was, which isn't just really the, the heart rate. That's just, that's just our old basic surrogate [00:42:00] marker. What it's really doing is improving how well the heart is functioning, because we're giving Uh, better preload to get better cardiac output, um, but most importantly, the avoidance of early cord clamping is probably where the hemodynamic harm is occurring.

[00:42:15] Anup: So whether you delay in the baby transitions in the first 30 seconds or a minute, that baby might be fine from a hemodynamic standpoint if that point works. If I clamp at that, at 60 seconds or 40 seconds or something, as long as that baby's transitioned, it's fine. That's where I think the blood benefit comes in more by leaving the cord intact longer.

[00:42:33] Anup: Hemodynamic benefit for me is, yeah, the baby who is severely hypovolemic or asphyxiated, maybe then you can get that baby to transition a little bit more before clamping. So, It's, it's a really debated topic, which is, is it the hemodynamics or the blood that we're doing this for? It's both. And it depends on that case in terms of what you're really going for.

[00:42:54] Ben: Another thing, another thing you're mentioning, you're talking about these animal studies. I just wanted to ask you this question because I know the [00:43:00] answer. I've heard you answer this question before, but, uh, why should we be reluctant about how we look at this data, especially considering the anatomy and physiology of some of these animals?

[00:43:09] Anup: Yeah, no, it, I mean, and, and I, I know the guys really well that have done such phenomenal work in Australia, um, using the LAM model. It's just, it's the only model that we have that's being, you know, it's easily obtained and they're able to do such great detailed physiology in it. But the challenges. The lambs are intubated, right, they're anesthetized, and, you know, they have the lung fluid drained, and now you're trying to do delayed cord clamping and look at different parameters, such as, you know, I'm milking the cord in that lamb, or I'm, you know, giving a breath in that lamb and looking at whether ventilation has an impact.

[00:43:42] Anup: What we need is a model where, um, the animal is breathing or has the ability to spontaneously breathe and look at the hemodynamics, um, in that setup. And then there's the differences in the cord. Lambs have two veins, two arteries. There's no Wharton's jelly. It's a very different, and it's, it's only a few centimeters [00:44:00] long.

[00:44:00] Anup: It's not what we normally see in these big babies where whether you melt or you hold them up, down, I mean, so I think it's hard to make a lot of extrapolations, the animal data. What needs to happen, the animal data should guide what we, as trialists, are trying to do. Asking the question based on it. But for us to just say, well, because I see this in animals, it must be happening in humans, I think is a little backwards.

[00:44:22] Daphna: And, you know, we're talking a lot about the big picture of hemodynamics, but given the, you know, gaining popularity of point of care ultrasound, do you think there's a role for melding these two areas of interest, umbilical cord management and point of care ultrasound?

[00:44:40] Anup: Oh, absolutely. In fact, you know, the same group actually did some work, um, on antipostos group in Leiden. Did, they actually ultrasounded the babies while they were on the cord and showed that when you breathe, You actually get more blood through the ductus venosus into the right atrium. So, inhalation is like sucking blood from the placenta into the [00:45:00] baby.

[00:45:00] Anup: And the importance of breathing and placental transfusion seems to be a really neat way to integrate how we can learn physiology in humans rather than having to resort to just studying inhaling. So, you're right. Can we, and the group, there's a great poster that I think we'll have a paper published too.

[00:45:17] Anup: Um, they were, they were echoing babies while they were getting delayed cord clamping at cesarean section right before the cord is clamped after ensuring improvements in cardiac output. So, absolutely. Now, I guess the bigger question, Daphne, is are you ever going to use point of care that to determine when to clamp and cut the cord?

[00:45:33] Anup: That might be a stretch. Someone might prove me wrong, but I can't imagine all these people echoing and saying, okay, clamp now.

[00:45:39] Ben: Then the OBs will definitely hate us at that point. Um, Anup, what's interesting is that when we hear you speak, you, we may be tempted to think that you are at this large university center. Um, when in truth you are, you are in a, uh, you are in a children's hospital, but you are in private practice officially, right?

[00:45:59] Ben: You are [00:46:00] not in, uh, in a university. And I think that for many of our listeners who are young, young physicians who are trainees, who are considering career choices, I think it's fascinating the amount of work, the grants you've been able to obtain, um, while being a physician at a sharp medical center. And so I'm just curious about.

[00:46:19] Ben: What you could tell us a little bit about, uh, the opportunities that you've been able to, uh, exploit in your role and the, uh, and any obstacles maybe you faced, uh, because I think it's becoming more and more point of discussion as people. Are no longer satisfied with the dual option of saying, well, it's either this or that people want hybrid models.

[00:46:41] Ben: People want to be able to do a bit of everything. Um, I'm very curious about, about your path and, and how you've been able to be so successful outside the university slash academic, uh, traditional model.

[00:46:54] Anup: Yeah, no, thanks for that. I mean, I, you know, I, I, I have a long way to go in terms of [00:47:00] doing, you know, more research and being able to, to, to make this model work, but, you know, my, so my mentor, um, was my division chief, Neil Fider, um, and he basically 10 years ago said, you, you need to leave your hospital and go to this big community hospital that has lots of dilemmas.

[00:47:19] Anup: So. Our hospital, Chaudhry Burton, at that time was the biggest delivery hospital in California. It's like the sixth largest. We had like 10, 000 deliveries at that point. And so it made sense, um, to, if you like resuscitation, to go to a place that had lots of volume. The challenge then was, well, at a community hospital, you don't have...

[00:47:35] Anup: Uh, fellows, med students, residents, you don't have all these coordinators to be able to do research for you. So you're competing with big universities. But the beauty of, I think, private hospitals, it's, it's very level. You know, when I was at the university, I, I never met the CEO or nobody. And I was, I was nobody then anyway, but you couldn't get to that person to like have those conversations.

[00:47:58] Anup: When it came to sharp, the [00:48:00] CEO was like, Hey, let's talk. What do you need to get started here? How do we build a program for you? And, and we just built it and we hired people and the hospital said, okay. Um, you know, when you get grants and you get this overhead, you know, when you get an NIH grad, you get like 55% indirect, well, there's no dean or med school to give it to.

[00:48:17] Anup: So it just comes right back to us. So they're able to build on that. And I think what's been really great is the organization and my group too, you have to have private NEOs that support what you do. And we've had a fantastic collegial effort, um, where my hospital used to be part as a satellite hospital in the neonatal research network.

[00:48:35] Anup: So they enjoy the idea of being part of health research. But now we were like, well, we want to lead, we want to run our own trial. So if you're at a private hospital, you have a great idea. So why can't you go out and write a grant and get funding for it rather than. And I think the model today is always like, well, we could do research if we partner with this university or as a satellite, which I know nothing against, but if you have your own ideas, well, then you should be able [00:49:00] to run with it and do it.

[00:49:01] Anup: And I think, um, our hope is to continue to sort of paint that picture for other places. Um, and you know, we're, we're, we're really excited what we found on it, April, that we got into the neonatal research now. We knew we were, we don't have, I don't have a big lab. I don't have a bio repository where I can look at all these samples.

[00:49:19] Anup: We had to go on the ability to recruit patients and to do trials. And our argument in our proposal was that we need to get trials done faster. The NRI takes way too long to get these studies done. They do a great job, but we don't need to wait 10 years for the next big therapy. Right? We want to know now, right?

[00:49:36] Anup: We want to know about surfactant and budesonide. We want to know about. Which kits should we start looking at to cool that we weren't doing before? We, we can't wait. And so you need big community hospitals to get research done. So we leverage that, but we're also not okay just participating. We wanna run trials, so we're gonna push the other end and other networks to be able to conduct research together.[00:50:00]

[00:50:00] Anup: I hope other people that are listening to this too could say, you know, I think I could do this too. I could apply for grants and, and do the same thing. 'cause there's nothing special. We were, we weren't some program that everyone had heard of that said, okay, well, we'll give it to Sharp. I think most people probably listening to this don't even know where Sharp is.

[00:50:17] Anup: And I think that's what we're trying to sort of advocate is anybody can do this. It's not, I graduated from that prestigious fellowship and I'm under Dr. So and so, so now I can get this grant. I think, you know, you have a great idea. You should be able to apply for a grant. And people will see that if you put it together in a way that makes sense,

[00:50:38] Daphna: I also think there's this mistaken misperception that people in private practice, quote unquote, don't want to do research or don't want to be engaged in research. How have you kind of tackled that when, when meeting with our academic colleagues?

[00:50:55] Anup: Yeah. Well, I mean, I, I, and obviously hearing you say that, you know, that's, that's not the case. You talk to [00:51:00] people in private medicine, they like to take care of babies. I like to take care of babies. I think it's a matter of, well, we're the ones in the unit asking questions and seeing patients. You know, what, what the best advice Neil gave, you know, he's, he's no longer the chief at UCSD.

[00:51:15] Anup: He said, never. Give up being a clinician. He's like, it drives him crazy when he has these researchers that haven't even been to the delivery room that are telling us the next intervention. We have to stay in the unit. And I think it's an important thing that you're on the academic side. You have to still do clinical service to be able to be a good clinical researcher.

[00:51:32] Anup: And um, I think people at private practice have lots of great ideas of, well, I'm seeing this. You know, what if we did this differently? I'm seeing that go up. Maybe we should look at this therapy. And they're the ones that are ideally suited to be able to ask these questions. So, um, I think it's, it's just that inhibition saying, well the NIH will never give me a grant because I'm not at a university.

[00:51:54] Anup: And that is absolutely not true. Absolutely not true. And I think that's the big thing that we need to get rid [00:52:00] of here is like, you don't have to ask the hospital for some money to do research. You can go out and get these grants and they will, they will respect you. And it's not NIH, it's Thrasher. All these big organizations are really keen on funding people that are doing great work.

[00:52:14] Daphna: I think you touched on some major barriers or obstacles, right? And that's getting the grant funding. But tell us a little bit more about like the nitty gritty meeting with the C suite, um, designating FTE for research versus clinical time. You know, how did the logistics really play out?

[00:52:35] Daphna: Um, at least for you.

[00:52:37] Anup: For, for me, yeah, um, and I, I'm not saying this is how it should be. I, I, I didn't come in with a ton of protected time. Um, they were able to slowly cut down my weeks of time as I got some more grants. But they did come in with say, you know, we'll give you some time. That was new to the group to have anybody with any protection.

[00:52:54] Anup: So they said, okay, we'll give you some, some time every month to, to be able to write some grants and, and protocols. [00:53:00] And then when we got to a point where we had multiple, you know, different hours, we could say, okay, look, we're, I'm already overfunded on this, bring me down to something, you know, like eight weeks or whatever it may look like, so I can have some time to do this or that.

[00:53:13] Anup: Um, but I think it's just having that honest conversation saying, look, I need time to be able to do this. The way I started though, was with a conversation with my CEO saying, what can you kick in? Cause here's the, the hardest thing is most neonatology groups are not going to say. Well, Daphna, you seem really nice. I'm going to give you, you know, 200, 000 of our group's money to, to protect your time, right?

[00:53:36] Daphna: definitely not

[00:53:37] Anup: Right. And so I think, I think, um, hospitals that see the value of, of doing clinical research and getting their name out there, um, I think is, is the way to do it. So if you're a hospital's like, well, we want to get on the map to, um, you know, build our prestige off by being involved in NIH funded studies or collaborations.

[00:53:57] Anup: And, and that's how I sold it to our CEO that this is something [00:54:00] that will boost our reputation over time. Um, you know, improve our recognition in San Diego as being this big research center that, that, you know, pregnant women want to be able to get the latest care for their babies, they can come here. And she, she bought that and she's still here supporting it, which has been great.

[00:54:19] Anup: We're not making the hostile money and I'm really have to be clear. NIH. You actually lose money doing NIH studies because you're always expected to sort of do a lot more work than you're able to be compensated for. But the recognition you get with that is huge, and it really helps you kind of leverage the next study.

[00:54:37] Ben: Yeah, it's not about a financial, it's not about a financial gain, but it's a decision to say, do we want to be at the tip of the spear or just, you know, in the back in the,

[00:54:47] Ben: um,

[00:54:47] Daphna: I have, I have one more logistical question.

[00:54:49] Ben: please, I'm so sorry.

[00:54:51] Daphna: Uh, tell us about your engagement with IRB, we know that a lot of, um, community hospitals don't have an [00:55:00] associated IRB. And so we've heard in the community that some people struggle to get research off the ground because they can't, um, find an IRB to associate with.

[00:55:10] Anup: What was helpful for me at a community hospital, though, was that. We actually get five minutes to sit in front of a room of people on the IRB. So we do have a local IRB. Um, and so they, they basically, instead of getting like that 10 page report of edits that you have to go back and fix, you get a chance to engage with the IRB, which is really helpful.

[00:55:28] Anup: And they didn't have that at the university. And so having that discussion with the chairs as I'm pitching the study and they've already read the protocol and they can said they can ask me some questions that need clarification. And then I get the feedback afterwards. Um, I think the challenge with community hospitals, though, uh, in general, unless you do go to these big, um, private IRBs, right, Advera, Western, there's all these big companies, um, is you can't do, a lot of them don't want to be a central IRB.

[00:55:56] Anup: So the new mandate now is if you do a large multi center trial, [00:56:00] it's got to go through a central IRB. And so, um, I think for most people that are starting off to do research at a community or private hospital, they're not looking to do a large multi center trial as their first go run. Um, I think local IRBs are still available and, and helpful at most centers, but if not, you do have to engage these private groups, um, which are more expensive, but then they get things done a little bit faster.

[00:56:23] Anup: So that probably would be my advice for people looking to, to jump into their first study.

[00:56:28] Ben: We're really doing a Dr. Katheria consult for us on Daphna.

[00:56:33] Daphna: Mean, we, we had, we had a vested interest in some of this line of questioning.

[00:56:37] Daphna: Yeah, we

[00:56:37] Daphna: do.

[00:56:38] Anup: absolutely.

[00:56:40] Ben: Uh, my last question for you Anup, uh, really has to do with, um, you, you picked, you picked, you didn't want to give up clinical practice. You didn't want to give up research. What do you do to unwind? What's your, what's your trick to keep everything in balance?

[00:56:53] Anup: Ah, well, I have, as I kind of alluded to, I have three young kids. That keeps my time very

[00:56:58] Ben: better. Yeah. Even [00:57:00] attack, tack it on.

[00:57:02] Anup: No, no. So, so, I mean, what I do like, I'll say about private, um, practice is that it is very fluid. I mean, people are really great about balancing work life and you probably hear that a lot too. Um, you know, as much as I love my mentor, you know, Neil, when we were at, when I was in his division, you were expected to just staying in the hospital or at least doing research or on your computer to run five or six every night.

[00:57:27] Anup: You come in around seven or eight and that was, that was your nonclinical. And so I think, you know, the idea of, of being able to get out of all of this and, and unwind is really important. So that's always worked well for me. It's just that balance with getting out to my kids, getting to make sure as a neonatologist, we're always guilty, right?

[00:57:45] Anup: If we don't balance things, we miss our kids, like big events, you know, up to those things. And I think it's important

[00:57:53] Ben: Yeah. And as my wife says that time, you don't get back.

[00:57:56] Anup: you don't, yeah. You need to understand your spouse for that too. That's really important as [00:58:00] well.

[00:58:00] Ben: Yes, that's

[00:58:01] Daphna: That's right.

[00:58:02] Daphna: That was very good advice. I have, I have one last question also. Um, so, uh, we read a lot of article titles, and I love the titles of your articles. One, they're usually super descriptive, but they often, Like invoke a lot of emotion. Uh, you had, you know, the applying the principle first, do no harm, uh, during the pandemic, a newborn's lifeline, uh, sustain inflations as the initiating positive pressure, not yet ready for prime time.

[00:58:33] Daphna: So what advice do you have about naming your, your articles?

[00:58:37] Anup: You know, it's interesting. Nowadays, um, even journals are pushing for you to come up with better names because that's how people search search for dates. And so, yeah, I think putting there's a balance. Um, now if you do a randomized control trial, you actually have to have that word in there, otherwise it's accepted.

[00:58:55] Anup: But for, for things like reviews, which I think is what you were talking about, um. [00:59:00] Yeah. I think asking the question, prompting the reader to say, well, if I want to know this, I have to read it based on this, this title that I'm, is there some uncertainty in that is always, is always a great, I mean, reviews are fun to write, but I think, you know, you always are trying to balance like, you know, I got to get some data out versus yeah.

[00:59:20] Anup: Make your title catchy. Don't just say umbilical cord milking. This is a review, right? You need to be able to get into. It's kind of hard to read that, right? So,

[00:59:31] Ben: Dr. Anup Katheria, thank you so much for making the time to chat with us today. It was a fun and enlightening conversation. We will link a lot of the papers that you've referenced in this episode on the episode page. Um, and you are also very active on Twitter so people can find you there. Um, but thank you again for, for a great time and a great conversation today.

[00:59:53] Anup: yeah, thank you both. You make it so welcoming and easy. You know, I wasn't sure what to expect up this thing, [01:00:00] so thank you both. It was, it was a

[01:00:01] Ben: Our pleasure. Our pleasure. Thank you so much.

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