Hello Friends đ
In this latest episode of The Incubator Podcast's Journal Club, hosted by Ben and Daphna, the focus is on cutting-edge research relevant to experts in newborn intensive care. The episode begins with a comprehensive discussion on the use of hydrocortisone in very preterm neonates aimed at preventing bronchopulmonary dysplasia (BPD), delving into a meta-analysis that scrutinizes efficacy and identifies potential effect size modifiers. The conversation then shifts to an insightful study from China exploring the factors influencing C-reactive protein levels in neonates, shedding light on the impact of various maternal and neonatal conditions.
The podcast also features a longitudinal study on the transition to adulthood for extremely preterm survivors, revealing encouraging outcomes in terms of education, employment, and health compared to term-born controls. A rigorous cluster randomized control trial examining CPR techniques for asphyxiated newborns is discussed, comparing sustained inflation with chest compression to the conventional 3:1 ratio, offering valuable insights for clinical practice.
Lastly, the episode explores a study on the timing of tracheostomy in infants with severe BPD, highlighting the neurodevelopmental implications of early versus late interventions and the role of postnatal steroid exposure. This diverse range of topics not only underlines the podcast's commitment to showcasing seminal work in neonatal care but also stimulates thought-provoking discussions on the evolving landscape of neonatology.
Enjoy !
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The articles covered on todayâs episode of the podcast can be found here đ
Taha A, Akangire G, Noel-Macdonnell J, Gladdis T, Manimtim W.J Perinatol. 2023 Dec 29. doi: 10.1038/s41372-023-01864-5. Online ahead of print.PMID:Â 38158399
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Schmölzer GM, Pichler G, SolevÄg AL, Law BHY, Mitra S, Wagner M, Pfurtscheller D, Yaskina M, Cheung PY; SURV1VE- Trial Investigators.Arch Dis Child Fetal Neonatal Ed. 2024 Jan 11:fetalneonatal-2023-326383. doi: 10.1136/archdischild-2023-326383. Online ahead of print.PMID: 38212104
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Pirlotte S, Beeckman K, Ooms I, Cools F.Cochrane Database Syst Rev. 2024 Jan 18;1(1):CD013353. doi: 10.1002/14651858.CD013353.pub2.PMID:Â 38235838
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Pigdon L, Mainzer RM, Burnett AC, Anderson PJ, Roberts G, Patton GC, Cheung M, Wark JD, Garland SM, Albesher RA, Doyle LW, Cheong JLY; Victorian Infant Collaborative Study Group.Pediatrics. 2024 Jan 1;153(1):e2022060119. doi: 10.1542/peds.2022-060119.PMID:Â 38124530
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Nagaraj YK, Balushi SA, Robb C, Uppal N, Dutta S, Mukerji A.J Perinatol. 2024 Feb;44(2):257-265. doi: 10.1038/s41372-024-01870-1. Epub 2024 Jan 12.PMID:Â 38216677
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Eckermann HA, Meijer J, Cooijmans K, Lahti L, de Weerth C.Gut Microbes. 2024 Jan-Dec;16(1):2295403. doi: 10.1080/19490976.2023.2295403. Epub 2024 Jan 10.PMID: 38197254 Free PMC article. Clinical Trial.
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Hydrocortisone in very preterm neonates for BPD prevention: meta-analysis and effect size modifiers.
De Luca D, Ferraioli S, Watterberg KL, Baud O, Gualano MR.Arch Dis Child Fetal Neonatal Ed. 2024 Jan 17:fetalneonatal-2023-326254. doi: 10.1136/archdischild-2023-326254. Online ahead of print.PMID:Â 38237961
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Cao C, Wang S, Liu Y, Yue S, Wang M, Yu X, Ding Y, Lv M, Fang K, Chu M, Liao Z.BMC Pediatr. 2024 Feb 1;24(1):89. doi: 10.1186/s12887-024-04583-8.PMID:Â 38302903Â Free PMC article.
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To learn more about the work done by Dr. Leah Jordan and her team check out the following links:
Learn more about the NICU & Neonatal Care Program at Children's Minnesota
Feel free to contact Dr. Jordan with questions here:Â leah.jordan@childrensmn.org
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The transcript of today's episode can be found below đ
[00:00:00] Ben: Hello, everybody. Welcome back to the incubator podcast. It is Sunday journal club is upon us. Daphna, how are you?
[00:00:05] Ben: Um, I'm doing well. I'm excited about Journal Club. You picked way too many journals, since, uh, you have been so busy this week.
[00:00:14] Ben: That's right. My wife and I welcomed a baby girl on Monday and, um, it's been, uh, it's been fun, it's been a lot of fun and, um, but, um, baby or no baby. Journal
[00:00:27] Daphna: Journal Club it is! And you couldn't help but stuff your folder full of articles.
[00:00:34] Ben: Well, there's a lot of downtime so And i'm thankfully not working this week. So, uh, I have no excuse
[00:00:41] Daphna: I guess so. Except for all the snuggling and cuddling that you're
[00:00:46] Ben: That's right Even though that's really not true. I did procrastinate for this journal club. So Um, but yeah, um, we have a very um interesting set of articles We also [00:01:00] have an interesting segment this week where we're going to welcome Dr. Jordan from Minnesota. Who's going to tell us a little bit about something that her and her team have worked on to try to improve rates of donor breast milk in her community.
[00:01:10] Ben: Fascinating stuff. Um, and as we've said before on the show, we're going to try to feature more Newsy type of content like this on, on journal club episodes. So if you're working on something cool and it's not a study and it doesn't get published, then. We feel, Daphne and I, that it still should be celebrated,
[00:01:27] Daphna: still want to hear about it.
[00:01:29] Ben: yeah.
[00:01:29] Ben: So when the next society meets with the FDA, that's, that's an important thing that they're doing. And, uh, it doesn't really come out in, uh, in JAMA or something. And yet, it's helping us moving forward. And what we're going to talk about with Dr. Jordan is another thing that helps that community specifically and could inspire others to do the same.
[00:01:46] Ben: And it's not going to be a randomized clinical trial. So we should still have a venue for, for these, um, Thanks to be celebrated. So that is the, um, that is going to be a part of the, of the journal club today. Uh, [00:02:00] did I forget anything or should we just get started? What do you think?
[00:02:05] Daphna: Well, we should remind people about the conference coming up, but then we should get started.
[00:02:09] Ben: Yeah, Delphi Conference. I was supposed to finalize the agenda. We have, um, a great lineup coming up. I'm gonna give people who are listening to the podcast a sneak preview. We're gonna have a star studded lineup. We have Dr. Pia Wintermark that we featured on the Journal Club not too long ago. We're gonna have Dr.
[00:02:26] Ben: Ryan McAdams. We're gonna have Kimberly Novod from Soul's Light. Dr. Atul Malhotra from, from Australia. We have Dr. Guillerme Santana. We have so many people coming in. Dr. Henry Lee, Dr. Uh, terry inder Believe me, this is going to be and we have obviously our tedx speakers Uh this year Uh, some physicians there, Dr.
[00:02:49] Ben: Aneesha Veer is coming, um, and many more. So I'm not going to reveal too much, but there's big names. And, uh, I have to finish putting this agenda together so that people can take a look and start signing up. But this is very [00:03:00] exciting.
[00:03:01] Daphna: And we're working on it like around the clock. So just, just to have people here, down here with us and learning and sharing. And so we're, we're pumped.
[00:03:11] Ben: Mm hmm. That's right. Okay. So should we begin?
[00:03:16] Daphna: Let us.
[00:03:17] Ben: Let us. So the first paper, the paper that I wanted to talk about, uh, today is a paper that was published in the archive of disease in childhood. And it's called hydrocortisone in very preterm neonates for BPD prevention. Meta analysis. and effect size modifiers.
[00:03:31] Ben: I know we're talking a lot about hydrocortisone, but this is a great meta analysis. All the big names are on it. Christy Waterberg is on there. Olivier Beau is on there. And, uh, first off there is Danielle DeLuca, which, um, if I remember correctly, um, we have, um, mentioned on the show several times. So, um, I'm going to skip the background, but really the study looks at whether systemic hydrocortisone started in the first two weeks of life, in the first [00:04:00] 15 days of life, uh, aimed at preventing BPD and other adverse, uh, outcomes.
[00:04:06] Ben: Um, Does, is, is that, is there a signal there basically, right? Uh, does systemic hydrocortisone in the first 15 days of life prevent BPD or other adverse outcome? And then looking at potential effect size modifiers. Now, this was a systematic review meta analysis approach. It followed the PRISMA guidelines and it included RCTs following the full, fulfilling the following criteria, which are Published papers peer reviewed, uh, the neonates in question had to be 30 weeks of gestation or less, or, um, 1000 grams or less.
[00:04:41] Ben: They looked at the administration of systemic hydrocortisone, uh, at any dose. And it had to be done. Like, like we said, before the 15th day postnatally aimed towards prevention of BPD, right? Um, And obviously there are studies that look at adrenal insufficiency and they mentioned that in the background, but that was the criteria [00:05:00] now They were ineligible studies if they used hydrocortisone for bpd prevention in combination with other drugs um, or if they investigated hydrocortisone for reasons other than bpd like hemodynamics, for example, as we mentioned, so The results are very interesting.
[00:05:16] Ben: Uh, it involves 2193 infants and that is spanning seven trials generally, as they mentioned, of good quality. And I'm going to go through some of the results because that's quite interesting. So hydrocortisone itself did not reduce BPD. The risk ratio was 0. 84 and the trials showed significant heterogeneity.
[00:05:40] Ben: But it's the following results that to me were quite interesting. So mitral regression showed that the effect size was inversely associated With the duration of treatment. And so a reduction in BPD was obtained with 10 to 12 days duration of treatment. And that was statistically significant. [00:06:00] So. Should like, is there a certain time that we should leave?
[00:06:05] Ben: Right. We try to wean as, as much as quick as possible sometimes, but maybe not, maybe we should leave it for a certain period of time. Another interesting factor was that the greater, um, the percentage of neonates with chorea immunitis enrolled in the trial, the greater the effects on BPD reduction. So.
[00:06:24] Ben: These babies that are born with choreo do benefits seemingly more from, from the medication hydrocortisone did reduce mortality significantly. And, um, this finding, we did not show any significant heterogeneity between the trial, the reduction in mortality. tended to be greater with increasing percentages of males enrolled in the trial.
[00:06:48] Ben: And in terms of other effect size modifiers, they could not find one. They have a long list. I'll let you go and review it. Looking at other factors that are interesting, maybe NEC. And figure [00:07:00] three of the paper shows that NEC was significantly reduced by the use of hydrocortisone. And there were neither significant heterogeneity nor effect size modifiers, uh, for, um, for that finding.
[00:07:13] Ben: Another important comorbidity is IVH. And so IVH was kind of interesting because they looked at The effect size of the use of hydrocortisone for IVH and PVL, and it was not significant, but it was close to being significant. Like the, the, the forest, um, the, the, the bar like hugs the, the non significance line, but doesn't, uh, but, but just touches it.
[00:07:37] Ben: And what's interesting is that, um, it, um, for IVH controls are favored. But for PVL, the hydrocortisone group was favored. None of them were significant by the way. I want to remind people of that, but interestingly enough that it had an opposite type of response. It was, it was going in opposite direction, meaning IVH favor the controls and PVL favored the [00:08:00] hydrocortisone in terms of some respiratory stuff that they do mention reintubation duration of oxygen support or ventilation were not analyzed despite that being one of the original plans because didn't have enough data.
[00:08:11] Ben: And so in conclusion, this mid analysis of seven trials. more than 2000 neonates shows that hydrocortisone did not reduce BPD. And I think what they're saying in the conclusion is exactly where I land. Hydrocortisone should benefits on some secondary outcome that is mortality and neck. Thus, it can be considered on a case by case evaluation for these purposes.
[00:08:30] Ben: And there are some potential effect size modifier for mortality and BPD, which should be addressed in future explanatory, exploratory, uh, and explanatory trials. So, very interesting paper. Uh, a little baby boy with choreo. You might want to look at this kid
[00:08:45] Daphna: I mean, I, I, I, we just keep getting that more and more. We can't not, there are no two babies that are the same and we're just looking, hoping, praying for something to be protocolized that we can just give to all the babies and they'll [00:09:00] all be better. But um, I think looking at these groups and breaking them down and finding out, I mean, there are just groups that seems to help and maybe because we just hit.
[00:09:10] Daphna: You said, like you said, a little boy with choreo, and it had happened to really, really help, you know. Um, but I think we will learn over time that our
[00:09:21] Ben: Yeah,
[00:09:22] Daphna: protocols will be multi linear, you
[00:09:25] Ben: we're still thinking like we're looking for a vaccine, right? We're looking for a vaccine for these diseases that's like, hey, I just give it to everybody and it just takes care of it. But it's not how it works. So, fascinating paper. Fascinating
[00:09:37] Daphna: And I just, it's such a reminder about the mother infant dyad, and not just that, but also This is just, it keeps coming up how inflammation in the body, it's just inflammation everywhere, right? So those are the kids that are really at risk and, um, those are the kids we have to be, I think, the [00:10:00] most cautious with.
[00:10:03] Daphna: Very interesting.
[00:10:04] Ben: Yeah. are you taking us next?
[00:10:07] Daphna: well, I had an interesting paper that I wanted to look at. It did not answer all of my questions, but I thought it was an interesting paper nonetheless. This actually came, um, uh, from BMC Pediatrics, um, out of China, um, and it was Factors Influencing C Reactor Protein Status on Admission in Neonates After Birth.
[00:10:26] Daphna: And I will preface this by saying, obviously, CRPs, depending on where you work, are either in favor or out of favor, um, but I just thought it was an interesting,
[00:10:38] Ben: And since, and since the paper is coming out of China, I'm going to mention something there. We are looking to expand the podcast in Mandarin. So if, if you know somebody who is of Chinese descent or who is Chinese or who speaks Mandarin, um, please let us know.
[00:10:53] Daphna: yeah, that's right, thank you for that. And so, what they did basically, this was a retrospective cross [00:11:00] sectional, uh, analysis of 872 neonates born at Xi'an, yeah, I think, that's how you say it, hospital in central So. South University between January 2020 and December 2020 that were admitted to the neonatal ICU within two hours of birth.
[00:11:15] Daphna: So basically all these infants had CRPs measured on admission and then they basically looked back at what were their. Other characteristics, so they had a total of 820 neonates enrolled and the neonates were categorized into two groups based on whether they not they had a high CRP, which is greater than or equal to eight milligrams per liter, um, or a low CRP, which was less than the eight milligrams per liter group.
[00:11:44] Daphna: Okay, in the more than eight milligrams More than or equal to 8 group, there were 163, there were 98 males, 65 females, the mean gestational age was 37. 7 plus or minus 3 weeks. And in the low CRP group, there were 657 [00:12:00] cases, most of the cohort, 365 males, 292 females with a mean gestational age of 35. So, they found statistical differences in gestational age, birth weight, premature rupture of membranes, uh, greater than, uh, sorry, not premature, prolonged rupture of membranes, greater than or equal to 18 hours, um, antenatal steroids, placenta previa, maternal autoimmune diseases, intrahepatic cholestasis of pregnancy, mode of delivery, they were specifically looking at cesarean, uh, delivery, and, um, MAS between the two groups. So, gestational age and birth weight in CRP, uh, greater than, greater than or equal to age group was significantly higher than, uh, sorry, the gestational age and birth weights were larger in. the, um, greater than eight. So gestational ages and birth weights were lower in the less than eight group, which was interesting.
[00:12:59] Daphna: Um, [00:13:00] and the infinite incidence rate of CRP greater than or equal to eight was significantly higher when neonates were exposed to prolonged rupture of membranes greater than 18 hours when they were exposed to maternal autoimmune diseases and meconium aspiration. Other things about inflammation there.
[00:13:15] Daphna: And they were significantly lower when newborns were exposed to antenatal steroids, placenta previa, um, and cesarean delivery, as well as intrahepatic cholestasis. Then they looked at a univariate logistic regression, and they again found that gestational age and birth weight were positively associated with a CRP greater than or equal to 8.
[00:13:35] Daphna: And the risk of the CRP greater than or equal to 8 increased by 26 percent for each week increase in gestational age. And this was Statistically significant antenatal steroids, placenta previa, and cesarean delivery were negatively associated still with CRP greater than equal to eight. Um, with a 53%, uh, reduction, uh, for antenatal steroids, and 82%, [00:14:00] uh, reduction for placenta previa, and a 69% reduction, um, in mode of delivery or c-section.
[00:14:08] Daphna: Um, and then, uh, prolonged rep for membrane is greater than the 18 hours. was positively associated with an increased risk of CRP by 77%, or an increased risk of elevated CRP, I should say. Maternal autoimmune disease also positively associated with, uh, uh, 367%, and, um, meconium aceration also positively associated with CRP greater than or equal to 8. They went ahead and did a multivariate analysis, and again, the results showed that larger gestational age and maternal autoimmune disease had a significant association with a CRP greater than or equal to 8, and these were stable even when adjusting for the other confounding factors. Cesarean delivery, at the same time, had a Again, a negative correlation with a CRP greater than or equal to eight.[00:15:00]
[00:15:00] Daphna: And then, um, they actually took a little closer look at gestational age and CRP and they have a really nice graph there that I put in my folder for you. Um, but they did a kind of a logistic regression and, um, they found what they, It's called an inflection point, so it's really kind of the nadir at 33. 9 weeks.
[00:15:20] Daphna: So on the left side of the inflection point, so basically 25 weeks to 33. 9 weeks, um,
[00:15:29] Ben: The, the, yeah, the relationship is linear
[00:15:32] Daphna: That's right, and the younger babies had higher CRPs, and they kind of downtrend to 33, uh, weeks. Um, and so they said it was reduced by 28 percent with each week of gestational age. And then, so it was lowest at 33.
[00:15:50] Daphna: 9 weeks. And then from 33. 9 weeks to 42 weeks, you saw the inverse, uh, is true. So the CRPs were more likely to be elevated the older [00:16:00] the baby was, with an increase by 61 percent with each week of gestational age. So what I really wanted at the end of the paper was them to tell me which kids actually had sepsis and infection, but they didn't tell us that, uh, unfortunately.
[00:16:17] Daphna: Well,
[00:16:20] Ben: in their headphones since you began, like, why would you get a CRP on a newborn?
[00:16:26] Daphna: they wanted to study the CRP, that's why they did it, um, and there are still units across the world that are using CRPs on a regular basis, so,
[00:16:35] Ben: listen, it's, it's, it's the CRPs live with the residuals. We all agree that maybe we shouldn't do it. And yet we all still have them once in a while. So yeah.
[00:16:45] Daphna: but I thought this was interesting and it's just a reminder of what the CRP even is, and it's a marker of inflammation, not necessarily infection, um, but it was interesting to see which of, what things. [00:17:00] You know, uh, bumped up the CRP. We were just talking about this in the unit, about C crps and vaccination.
[00:17:07] Daphna: Um, it was interesting,
[00:17:11] Ben: Yeah. Um,
[00:17:12] Daphna: and we were able to put in a plug about our Mandarin podcast,
[00:17:16] Ben: That's right, that was not intentional, by the way, but yeah, um, you know, um, I think, um, we will have, um, our friends from Minnesota joining us soon. So I'll just try to squeeze in one more paper before then it's a paper I found in pediatrics and it's called transition to adulthood for extremely preterm survivors.
[00:17:35] Ben: Uh, first author is lauren pigden and it's a very interesting study because you know, um, I tell this parent sometimes that How our baby is going to grow up as adults. We almost don't know because Our field has changed so much in the past years that um, we're getting information really continuously um, we are um getting information on the babies that were born maybe in the 80s who [00:18:00] are now like In their mid thirties and closer maybe to 40 years old, but this paper is saying, well, what about the babies who were born in the post surfactant era, which really is the time point in where, um, we feel like there was a revolution in the field of neonatology with improved survival and so on.
[00:18:17] Ben: And they're wondering how, um, extremely preterm slash extremely low birth weight, uh, survivors transition into adulthood compared to term born controls in areas such as education. Employment, financial independence, and health. I thought that was a very, uh, I was very curious to read this paper because it's something that, uh, I ask myself, uh, very frequently.
[00:18:41] Ben: This was a prospective longitudinal cohort study that was done in Australia, specifically in the region of Victoria between, uh, 1991 and 90 92. Uh, they had matched term born controls to the. Preterm slash low birth weight infants [00:19:00] and they assessed them at 25 years and they looked at educational attainment, employment, financial status, a romantic partnership, living arrangements, health, and risk taking behaviors.
[00:19:12] Ben: Uh, the results are quite interesting. There's data from 165, uh, preemies and 127 control participant. Um, And I'm going to go through the, the, the principal, um, themes. Uh, the first one they mentioned is educational achievement, and they're showing that, um, there's very little difference between the groups in the proportion of children who actually, uh, completed high school.
[00:19:36] Ben: Um, and there was evidence predominantly in the unadjusted analysis for, uh, more Preterm survivors compared with control attending, um, technical college and fewer attending university or obtaining a bachelor's degree, but the confidence interval, even for that were quite wide. So I think overall, this, this [00:20:00] was, this was fairly positive, uh, in terms of employment, uh, financial status, there's really, they didn't see any difference in the, in, in what was the main source of income between preterms and full term.
[00:20:10] Ben: Um, there was. An indication that maybe preemies are still reliant a little bit more on government support pension or allowance compared to controls but That first of all weakened significantly when they started excluding babies with major neurodevelopmental disabilities. So I think that was that was quite interesting as well.
[00:20:30] Ben: And very little difference between Terms and preterms, uh, on the proportion who were, um, in paid employments. Um, so, so that was quite nice. I forgot to mention that the preemies that we're talking about on average, we're about like 26, 27 weeks. That was the median gestational age. So not, not big preemies, you know, um, in terms of romantic relationship, pregnancy, parenthood, living situation, um, no difference in the proportion of children living independently, but there was evidence that more preemies.[00:21:00]
[00:21:00] Ben: Um. More former preemie young adults had actually never moved out of the parental home going back to this sort of Fragile maybe uh infant syndrome. I don't know if that's related. I have no idea but I think that's interesting um, and there was a weak evidence that Preterms and low birth weight and adults former low birth weight babies and adults were less likely to have been married or cohabitating Maybe having to do with if you're not really moving out of your parents home.
[00:21:27] Ben: That might be an impediment for uh for many god knows um Interestingly enough when they looked at mental health They didn't find differences in the proportion who had experienced psychiatric or mental health problems alone or over the previous 10 years And I think that's that's tremendous because you might think that Could there be a stigma of prematurity, something like that, but to read this was quite good.
[00:21:49] Ben: Good for our preemies, no difference in smoking rates, but preemies were less likely as adults to have ever smoked compared with controls, and they were also less likely to binge, [00:22:00] to binge drink alcohol and try street drugs. So. You see, you see, there's
[00:22:05] Daphna: you go. That's
[00:22:06] Ben: good, um, they looked at interpersonal relationships and they showed that they really did not see differences between reported problems, uh, getting along with colleagues, fellow students, adults with whom they leaves or they live or neighbors.
[00:22:19] Ben: So, so they didn't have issues making, uh, relationships and in terms of life satisfaction, um, they are former preemies did not feel more lonely. Uh, or had difference in their current satisfaction with education, work, financial situation, housing, social life or relationship. Something that we talk about all the time, where what is the quality of life for our preemies and, and to hear these numbers are, are quite good.
[00:22:44] Ben: Um, I think, um, in summary, um, this, this study indicates that survivors born preterm or extremely low birth weight, uh, in the post surfactant era, and remember it's only like from 91, babies born 92, it's a very narrow cohort, but still [00:23:00] go to a study with 25 year follow up, um, are mostly transitioning satisfactorily into early adulthood.
[00:23:06] Ben: It will be important to continue to reassess this cohort as they move through their adult years to monitor changes over time. The, um, EPELBW cohort, the extremely preterm, uh, extremely low birth weight cohort, uh, may be at higher risk of adverse health outcome with age, particularly cardiovascular and respiratory health based on prior studies.
[00:23:23] Ben: Um, so that's something that will require further investigation. But I think that as parents are asking us, What's in state for my baby. This is a great study to look at. And it's actually quite positive. I take this quite, uh, with a, with an optimistic, um, turn, because I think there's a lot to be scared about, especially, especially when you are looking at these babies, like I said earlier, um, The baseline characteristics are interesting.
[00:23:48] Ben: The median gestational age was 26. 6 million birth weight, 880 grams. That was in 1991, by the way, uh, 32 percent from multiple births. And, um, yeah, so, [00:24:00] um, yeah, only 38 percent received surfactant. So. Even though they're in the post surfactant era, they still probably wouldn't match what we are doing today.
[00:24:08] Ben: So very interesting. I thought
[00:24:10] Daphna: Yeah. And I mean, it's totally in line with previous research about, especially quality of life for, for our patients. So I think it's. It's, it's nice to see that. And hopefully we'll just keep getting better and better, so there's no difference between
[00:24:24] Ben: That's right.
[00:24:25] Daphna: former preemies and their full term cohort.
[00:24:28] Ben: All right, we're going to take a quick break and then we'll be back with uh, dr. Leah jordan, uh for um, Our next segment
[00:24:34] Mhm.
[00:24:37]
[00:24:59] [00:25:00] Mhm.
[00:25:02] Ben: So this week we are joined by Dr. Leah Jordan, who is a neonatologist at Children's Minnesota. Uh, Leah is here with us today to tell us about a community initiative that, uh, is quite cool. Uh, Leah, thank you for making time to be on the show with us today.
[00:25:17] Leah Jordan: Yeah, thanks so much for having me. I'm really excited to share with you today about a really wonderful collaborative project that we've been doing in the Twin Cities in Minnesota about donor milk use for infants of the Islamic faith. We recently had the blessing or approval from Islamic leaders by way of a religious ruling called a fatwa.
[00:25:39] Leah Jordan: This is a religious clarification and their clarification for the Muslim faithful has encouraged the use of donor milk for infants. Um, which is the first time in the nation that this topic has really been addressed.
[00:25:52] Ben: Yeah, that's, that was very interesting. And I, and I believe that, um, what, uh, reading some of the articles that were published on the, on the subject that you [00:26:00] guys identified, um, something within your community that, um, really made, um, Patients, families of Islamic faith, reluctant to using donor milk. Can you tell us a little bit about, um, what did you guys notice and, and, and how that sort of, uh, led to, um, you reaching out to community leaders?
[00:26:19] Leah Jordan: Yeah, the challenge we primarily identified was really a difficulty partnering with and communicating with Muslim families around donor milk. In the Islamic faith, there's a belief that breastfeeding a non biological child establishes a familial relationship between the mother and the infant that she's breastfeeding.
[00:26:39] Leah Jordan: And this is really an intimate relationship that, um, Prohibits future marriage between her children and her milk children later in their life. With donor milk, obviously in the United States, our donor milk is pooled, it's anonymous, and so the families expressed a real worry that their child would receive this [00:27:00] milk, have these familial relationships established and not know, and that they could unintentionally marry their milk sibling later in life.
[00:27:07] Leah Jordan: And that was a really heavy burden and a heavy worry for these families. When I was early in my residency training and fellowship, there was certainly this recognition in the local medical community that our Muslim families tended to use donor milk differently than other families, they tended to be more reluctant and hesitant.
[00:27:27] Leah Jordan: But, um, I think, you There was very little discussion initially about what these concerns were and how we as the medical team could address them, which really compounded our communication challenges, right? You can't answer a family's question if you don't know what that question or that worry is.
[00:27:43] Ben: Yeah. And I'm, I'm fascinated by the fact that. These are the type of issues that as a neonatologist, I would have been like, Oh my God, how, how am I going to fix, how would I even fix this? And I'm amazed that you guys were able to find a path where you were able to get, uh, the right people involved. And so can you tell [00:28:00] us a little bit, how does that process look like for you to get out of your comfort zone, meaning out of the NICU and really finding the people, the right stakeholders.
[00:28:08] Ben: I hate that word, but the right stakeholders to actually come to the table and have a constructive conversation, really centering everything around the babies.
[00:28:16] Leah Jordan: Yeah, some of this ended up being very serendipitous and fortuitous. So, um, as a neonatology community, we started talking about this, um, myself, uh, my partners from Children's Minnesota, Tom, Drs. Tom George and Dr. Anne Downey. Um, and Dr. Nancy Fahim, one of our collaborators at the University of Minnesota, M Health Fairview, just kind of talking amongst ourselves.
[00:28:38] Leah Jordan: Those conversations ended up kind of spilling out. side of the neonatal community. So Dr. Nancy Fahim, um, is also the leader or is involved in leadership of the Minnesota Milk Bank for Babies. And through that, um, conversations also reached the Minnesota Breastfeeding Coalition. One of our key stakeholders at the Minnesota Breastfeeding Coalition is Shukri Jumale, [00:29:00] who is my colleague at Children's Minnesota.
[00:29:01] Leah Jordan: She directs our Midwest Fetal Care Center. Um, and she's the treasurer for the Minnesota Breastfeeding Coalition. And in her role at the Fetal Care Center, she had previously done work, um, with the Minnesota Islamic Council around fetal surgery and actually discussing what the implications of fetal surgery are for Muslim families.
[00:29:21] Leah Jordan: And that work had been coordinated by a community health advocacy group called Brighter Health, Brighter Health Minnesota. Um, and so she roped them into this conversation and really, um, just, it was a gathering of people slowly, but surely.
[00:29:38] Daphna: Um, I love, um, what you said about we can't answer parents questions if we don't know what that question is. And there are so many things that we ask families to do, which, for a variety of reasons, cultural, uh, ethnic, religious, um. um, educationally that, that, um, is maybe in conflict with, [00:30:00] with what, um, they accept for their babies.
[00:30:05] Daphna: Um, so I wonder kind of what advice do you have for other people who are trying to tackle the same sorts of issues in their community?
[00:30:16] Leah Jordan: Yeah, I think sometimes it's easier for us, we've spent so much of our lives in book knowledge, um, that sometimes this cultural competency or that topic can become a list of rules or a list of almost just biases that we have about certain populations. And moving to a more anti racist approach to these questions, I think really involves humility, it involves being willing to ask questions, even if you don't always understand where families are coming from, and being willing to, to listen to what those answers are, and, and take them seriously.
[00:30:51] Leah Jordan: You can imagine a family in this position, they're new to the NICU, right, this conversation comes up right away, they're dealing [00:31:00] with all of the trauma that comes along with a NICU admission, expected or unexpected. For some of the families in the Twin Cities, we have a really large Somali American population, and so they were navigating these conversations with an interpreter or with Sometimes without an interpreter and some limited English proficiency.
[00:31:17] Leah Jordan: So that was really challenging for them, and they're hearing that the answer for their baby is either, um, you know, something that could cause their child to die. Getting formula when they're at really high risk for necrotizing enterocolitis, or something that carries these lifelong religious implications for them.
[00:31:31] Leah Jordan: And so just taking a moment to put ourselves in their shoes and, and understand where they're coming from was really crucial.
[00:31:37] Ben: Yeah, talk about being between a rock and a hard place
[00:31:39] Daphna: Mm hmm.
[00:31:40] Ben: scenario. And so can you tell us a little bit about, um, what was the response that you encounter from the community leaders? Because it does feel sometimes that if it's a religious issue, it's very inflexible. But you're, you're the demonstration that it is not like that.
[00:31:54] Leah Jordan: yeah, I want to thank the Minnesota Islamic Council for their willingness to come and sit down [00:32:00] at a conversation that at face value felt really, you know, in conflict with their beliefs and kind of out there for them. This is a big change. Um, It was amazing to have the help of Brighter Health Minnesota and some of the other, um, Somali Muslim healthcare workers who were kind of bridging the gap and, um, forging those relationships with us.
[00:32:23] Leah Jordan: So we sat down at a luncheon and we talked with the Minnesota Islamic Council, the scholars that were there. We went through all of the medical benefits of donor breast milk. What is necrotizing enterocolitis? What does it look like when a baby gets necrotizing enterocolitis? We also had leaders from the Minnesota Milk Bank who talked through from, you know, A to Z, how we screen, collect, pool, process, and test all of the milk that we get. And then we just sat around a table and talked really openly and, and honestly and respectfully about what a solution would look like. And for the Muslim scholars, obviously the medical information that we [00:33:00] provided was new. And for the medical workers, some of the intricacies about the Islamic faith were new to us too.
[00:33:08] Leah Jordan: Um, and so it just took a lot of vulnerability on everyone's parts. And that was, uh, really incredible moment to be a part of at a time when our world feels so separate and, um, divided to be able to sit with people and find a solution based in our common desire for Muslim infants to go home and survive and thrive in their lives long term.
[00:33:29] Leah Jordan: So it was a really beautiful moment.
[00:33:30] Ben: As I like to say you created a bubble of hope,
[00:33:32] Daphna: Mm
[00:33:32] Ben: uh, yeah, so that that's kind of cool Can you tell us a little bit since that, uh fatwa was issued? Uh, how has been how has that changed your uh day to day, uh work in the nikku, uh, especially with families of islamic faith
[00:33:46] Leah Jordan: Yeah, I will say I think many of us were hopeful that this would be the, you know, complete solution that we would have these perfect and easy conversations going forward with this FATWA text in hand. And it certainly has [00:34:00] been beneficial. We have now had families come in very eager and excited to use donor milk, which feels like a very subjective change to me, but a change nonetheless.
[00:34:10] Leah Jordan: There are some families who really want still time to think about what this. and process it with their imam and have further conversations. How did this come about? What does this mean about previous teachings? And there have been families who disagree with the ruling from the fatwa, and that's okay. I think that's normal for any religious ruling on any subject.
[00:34:33] Leah Jordan: And so we're just trying to continue to collaborate with our partners. How can we continue to Um, create culturally sensitive, um, resources so that families in this acute situation in the NICU have the answers from their community that they want.
[00:34:50] Ben: And what's interesting about this is that it looks like from what you're describing is that this this ruling has pretty much given uh Uh, your your family's agency to make a decision [00:35:00] without without the concern too much of saying maybe I will be Uh infringing on on rules and so on So I think that's kind of it's kind of I was not expecting this answer But it's kind of interesting to see that then your fall back into I guess normalcy where some parents will still say no to donor Milk, even if they're not of the most of the islamic faith And so I think it's kind of nice to see that.
[00:35:19] Ben: Yes, then People have their opinion and there's that gaussian curve of distribution and that's just the way it is It's uh, it's amazing. So i'm very happy. I'm very happy to hear that.
[00:35:27] Leah Jordan: Yeah, and now that you know the question of milk kinship at least has been addressed in the text of the fatwa I think we're seeing new questions and concerns come to the surface and so we'll continue to answer those and and provide clarity where we can.
[00:35:40] Ben: That's
[00:35:40] Daphna: Yeah, I think you've done such a neat thing. I think when we think about this topic, this umbrella term of advocacy, we think legislation and lobbying, but basically you've said this is something that is really prevalent in our community and, um, it's, um, impacting the care of our babies. How, how can we [00:36:00] tackle it even locally.
[00:36:01] Daphna: And I think that you will see a trickle effect, um, past the walls of your NICU. What has that looked like?
[00:36:10] Leah Jordan: Yeah, the Brighter Health Minnesota organization that we worked with on this project has had an email line that people can find in all of the press releases and within a matter of hours of the press release going live about the Fatwa text, they had hundreds of emails and some of those were local. Many of those were national as far away as Washington and other parts of the country.
[00:36:35] Leah Jordan: And then the news story also got picked up by an Australian news channel and a newspaper and has made its way to an Islamic council in Australia that's now adapting our text of the Fatwa and promoting it in their community. So we certainly have already seen this beyond the walls of our, um, our hospital, our state, and our community, which has been wonderful.
[00:36:59] Ben: That's [00:37:00] amazing. Dr Leah, jordan. Thank you for making the time. We will link uh, the article describing this This initiative on our website and we'll leave contact information for you as well So that if people want to find out more and maybe uh are inspired by the work that you did Uh can actually get in touch with you.
[00:37:15] Ben: Thank you so much for being on with us today
[00:37:17] Leah Jordan: Yeah, thank you for having me.
[00:37:18]
[00:37:20] Daphna: well, we're so, uh, glad to have on Dr. Jordan. Um, we love this new, uh, news, news channel, uh, that we will have on, on Journal Club. So we've been excited to roll that out. Now you have some more papers for us.
[00:37:34] Ben: Yeah, very quickly. I found this paper in the archives of these in childhood called sustain inflation and chest compression versus three to one chest compression to ventilation ratio during cardiopulmonary resuscitation of asphyxiated newborn to survive trial a cluster randomized control trial.
[00:37:48] Ben: The research question of the paper is well, instead of doing the,
[00:37:51] Daphna: Hold on. I'm writing that one down. That's gonna be a, a front runner for our favorite, uh, trial
[00:37:57] Ben: all right, I'm gonna, I'm gonna, I'm gonna dampen a little[00:38:00]
[00:38:00] Daphna: You don't.
[00:38:01] Ben: while the authors, Dr. Schmalzer and colleagues did a very nice job at finding survive. It's a little bit capital attracted, as we say in French, it's a little bit stretched, but, uh, yeah, the name sounds good
[00:38:14] Daphna: All right.
[00:38:15] Ben: the, I yeah, the I and survive as a one, first of all.
[00:38:19] Ben: So, I don't know. I don't know. Well, put it in a notable mentions, but the question they're asking is saying instead of doing three to one, uh, compression to ventilation ratio, what if we did, uh, sustain inflation while you're doing chest compression, right? And would that help in, uh, reaching the time to reach Rosk?
[00:38:37] Ben: Which is the return of spontaneous circulation. If you've done NRP, ACLS, whatever, you know what ROSC is. So this was a cluster, a cluster, a prospective cluster crossover, randomized controlled trial conducted in four hospitals across Canada and Austria. They looked at babies that were born above 28 weeks of gestation, uh, [00:39:00] requiring a chest compression.
[00:39:01] Ben: The exclusion were congenital anomalies, um, and congenital heart disease required. immediate intervention or if the parents did not consent. Uh, basically they randomized the hospitals to either doing chest compression with sustained inflation or the three to one, uh, chest compression, uh, to ventilation.
[00:39:19] Ben: And then they crossed them back to the other intervention with a two month washout period to allow for retraining. And the primary intervention was. The time to reach Rosk, there were some secondary outcomes. And what do we mean exactly? So the three to one, I think everybody gets it. It's like one, two, three, breathe, right?
[00:39:34] Ben: I mean, that's the, that's what we currently do, but the chest compression with sustained inflation is what we're interested in. So basically what does that look like? You put the peak inflit inflation pressure, the peak inspiratory pressure at 25 to 30 centimeters of water. So pretty high. And, um, you deliver this breath for 20 seconds.
[00:39:54] Ben: Then you revert to just positive end expiratory pressure, a peep of [00:40:00] either five to eight for one second. And then you go back for another 20 seconds of sustained inflation. And you do this, uh, for, um, uh, three times, and then you reassess their heart rate. Now, if after five minutes, they still needed to resuscitate the baby, they would revert back to the three to one, uh, chest compression to ventilation ratio.
[00:40:23] Ben: Now, Interestingly enough, if you are familiar, this original power calculation looked for 200 patients to be enrolled, but then when the actual results of the SAIL trial, which looked at sustained inflation actually came out, they temporarily stopped this current trial, the SURVIVE trial. They adjusted the inclusion criterias in order to account for the results of the SAIL trial and If you need a reminder, the sale trial looked at sustained inflation in 23 to 26 weekers.
[00:40:52] Ben: And basically what they found was that the primary outcome death or BPD was actually higher in the sustained inflation group. And when they looked at death before 48 hours, it was also [00:41:00] higher in the sustained inflation group. So that's what really led to a reframing of the, of the inclusion criteria to actually include more.
[00:41:09] Ben: No more mature babies, like 28 weeks or more. And eventually they had to stop the trial early because of funding constraints. So the poor investigators really, um, did not have an easy time, uh, for something that's related to sale. It was a really stormy, uh, um, research endeavor. There you go. Thank you very much.
[00:41:29] Ben: Um, only 25 infants were ended up, ended up being randomized 11 in the sustained inflation and chest compression group 14 in the three to one, and basically not very much to report except that, uh, the time to reach ROSC was not really different between the two. Uh, no significant difference, however, observed in neonatal mortality, brain injury, or other secondary outcomes.
[00:41:52] Ben: Um, and then in terms of the main safety outcome, which was mortality, they had 18 percent mortality in the sustained [00:42:00] inflation compared to 57 percent in the conventional three to one. Um, but I think this is something that again, crossed my Window and I was like, I'm going to read this, but yeah, so no real difference in that trial since we're talking about ventilation.
[00:42:15] Ben: Um, I just wanted to mention a journal An article in the journal of perinatology called peri extubation settings in preterm neonates a systematic review and mid analysis Everybody always asks what are extubation? What are what are extubatable settings, right? I mean, we've all had trainees as a trainee.
[00:42:32] Ben: I asked that question many trainees wonder this
[00:42:35] Daphna: Don't we still ask that question between ourselves as attendings?
[00:42:40] Ben: And I think it's institution dependent, it's protocolized, but this group decided to do a meta analysis to look at what do the papers say when it comes to peri extubation settings. And they looked for peer review articles published in English, including observational and experimental designs. Um, and they [00:43:00] followed the Prisma guidelines and, and, and tried to look, they were able to find about a hundred studies that met their criteria.
[00:43:06] Ben: And, um, what's interesting is that, um, They, uh, they publish in their different tables. They, uh, the settings on conventional on high frequency. And I think they're interesting. They're quite in general, lower than I thought they would be there. The rate, for example, at extubation for conventional ventilation is 11.
[00:43:28] Ben: 3. Which I would extubate at higher rates. Um, the peep is five. The pip is 15 um, and that's um, And that's 48 studies. Um, and they have the number of studies number of participants So I think that's interesting. They also have high frequency oscillation extubation setting They also have the settings that people put babies on after extubation.
[00:43:50] Ben: So the mean, um Peep level for c pap is usually about seven. Uh, if they put on an imv Then they're usually looking at a rate [00:44:00] of 35 with a PIP of about 16 over 6. Um, so I think this was all very interesting. There's not much more to say. I don't know what you do with this data. I think every institution has usually thought carefully about what they like to do.
[00:44:13] Ben: But interesting that someone took on this challenge and, uh, and looked at that. So, um, I thought this was interesting. Um,
[00:44:21] Daphna: I mean, same thing we were saying before that different groups of babies are different and I, it would be interesting to see it's, you know, really stratified by gestational age, because if you wanted a hot, hop into a hot topic on Twitter or X, uh, Extubation in the first week of life. Yeah, especially in the micro preemie
[00:44:43] Ben: You know, there's, there's, so why, why am I interested in this? You could say, well, I have very strict extubation settings that I follow. But the question is, I think as you get comfortable with anything, there's a creep. You're like, well, maybe, maybe I can extubate at a rate of 25, but it's kind of nice to have these kinds of tables published so [00:45:00] that you can say, well, here's where the field really anchors itself based on published evidence.
[00:45:04] Ben: And then.
[00:45:04] Daphna: where do I sit?
[00:45:05] Ben: Exactly. And I think it's okay to sit either, uh, on more extreme ends of the spectrum, but then you know how far you're deviating if you decide to
[00:45:13] Daphna: closely closely
[00:45:15] Ben: Exactly. Exactly.
[00:45:18] Daphna: Okay,
[00:45:19] Ben: um, do you want, do you want me to squeeze in one more? It was an interesting one that I, yeah. Or do you want to do,
[00:45:25] Daphna: fine buddy
[00:45:26] Ben: um, in the journal of perinatology, there's a, there's a paper called the impact of early tracheostomy.
[00:45:32] Ben: On neurodevelopmental outcomes, uh, in infants with severe BPD, uh, and exposed to postnatal steroids. So It's a very, it's always a hot topic when you talk about tracheostomy and, and, um, tracheostomy and, uh, BPD, because no one knows when we should be doing it and so on and so forth. Um, now the management of severe BPD is, uh, something that people have a lot of questions.
[00:45:55] Ben: The incidence of tracheostomy ranges between two to 37%, uh, in [00:46:00] babies who are, uh, suffering from severe BPD and what's, um, So what's even more interesting is when do we do the tracheostomy early versus late? So this is, um, a study that aimed to compare another mental outcomes of preterm infants with severe BPD who received early or late tracheostomy, as well as those who did not receive a tracheostomy at all, focusing on the role of postnatal corticosteroid exposure.
[00:46:26] Ben: So this is a retrospective cohort study that analyzed data from infants with severe BPD who underwent tracheostomy at level four, at level four NICU. Uh, the study, uh, was divided. Actually, I don't know if I mentioned the authors because I think that's important too. Uh, Ahmed. I'm, I'm Jad Taha. Um, and this is coming from, uh, Kansas City in the us but what's interesting is that they divided them into three groups.
[00:46:54] Ben: Either you had no tracheostomy or they looked at early versus late, and they defined early versus late [00:47:00] based on the number of 122 days. And that was what was referenced as early versus late in prior studies, which there are very few of, um. Their decision to place a tracheostomy is not evidence based or anything.
[00:47:15] Ben: It's a consensus recommendation by the multidisciplinary team. So they're not following anything specific. And then they looked at barely three at two to three years of age. So 137 infants were eligible and they, uh, 44 in the no tracheostomy group, 93 in the trach group. And then, um, What they ended up doing is that after they applied exclusion criteria, they matched the babies and they had 28 in the no tracheostomy group, 21 in the early trach, 22 in the late trach.
[00:47:45] Ben: Um, So at 36 weeks postmenstrual age, most infants with early trach, most infants with early tracheostomy, 85%, half of the ones with late tracheostomy and a quarter of the ones who never really had a [00:48:00] tracheostomy were actually on invasive mechanical ventilation, which I think is very interesting because if at 36 weeks you're still intubated, I'm kind of a pessimist about what the outcomes are for these babies.
[00:48:10] Ben: But you find out that, um, 25 percent actually never ended up needing a trach. Now, in terms of neurodevelopmental outcome, I thought this was a retrospective study and that the kids who got the early trach were going to be biased towards poor outcomes. Cause I'm like, if you trach them early, then they must be quite sick.
[00:48:30] Ben: And I was very surprised to see that the late tracheostomy group had lower total language median scores compared to the no trach or the early trach group. Similarly, the late trach group had significantly lower total cognitive median scores compared to no trach. and early trach. And the late trach group had worse motor scores as well.
[00:48:51] Ben: And I'm like, this is fascinating because I thought that the retrospective nature of the study was, I read and I was like, this is going to be a doozy. It's going to tell me that those kids who had like the early trach were [00:49:00] sicker and they had horrible Bailey's. And that was not the case. And then when they looked at the exposure to steroids, what was interesting and maybe is shining a bit of a light.
[00:49:08] Ben: I think that's what maybe the authors wanted to do on. Why this is happening, they found that the kids who received the late tracheostomy had the highest postnatal dexamethasone and cumulative hydrocortisone dose equivalent exposure, followed by the early trach group and then the no trach group. The late tracheostomy group had the highest, um, and the anti group and the no trach group, the lowest median cumulative postnatal corticosteroid dose in milligram of hydrocortisone equivalent.
[00:49:36] Ben: Um, and so maybe, maybe they get exposed to so much steroids and we still, I have a feel, I could see myself sometimes being hopeful that the kid who's going to get away with no trach still doesn't get away with it. And maybe all the things that we do in between the time we could have potentially tricked them and the end up the actual trick itself.
[00:49:53] Ben: Could be harmful. Um, so I think this was a very, um, a very interesting, uh, very interesting study. The [00:50:00] conclusion are that in infants with severe BPD exposed to postnatal steroids, um, the ones who receive an early tracheostomy are associated with better cognitive outcome and a trend towards improved language and motor outcomes compared to late tracheostomy and that the timing of trach in conjunction with corticosteroid exposure may have significant implication on neurodevelopmental outcomes.
[00:50:21] Ben: Obviously. It is still a retrospective study. The numbers are low. Um, but anytime I see something related to trach and timing, I read, cause there's just not enough evidence.
[00:50:31] Daphna: I think this is terrifying is all I have to say about that because, you know, we've all had that case where you're like, I think the kid can do it. I really think
[00:50:40] Ben: I know, right? This is always the
[00:50:41] Daphna: oh, we just had to wait a little bit longer. And you know, there's somebody in the group who's like, they probably just need one more round of steroids.
[00:50:47] Daphna: And you're like, they probably don't need one more round of steroids if the other rounds of steroids didn't do the trick. You know, if you tell me, okay, weight gain, okay, fine, maturity, okay, but they probably don't need another round of steroids. That's one thing I think I'll [00:51:00] take away. But, um, you know, we got to be pretty sure the kid's going to be able to do it or that you have something new to offer.
[00:51:07] Ben: I think sometimes we get so bogged down that we also interpret like an insignificant change as a major, like he was on 55 percent and he's now on 49 percent FIO2 and it's like, yeah, this is, you're far away from getting off
[00:51:21] Daphna: I, that's exactly right. And
[00:51:25] Ben: but we invest, but, but we invest so much in these babies that the slightest improvement is something we want to hold on with, with
[00:51:32] Daphna: but I think too in the community. I'm just gonna I'm gonna go ahead and say it I think people sometimes see trach as a failure and it's not a failure it is the necessary mode to get some children home safely and get them where they can get optimal development and Nurturing by their families at home and not with us in the NICU.
[00:51:56] Daphna: So Okay, I just had two, [00:52:00] uh, quick ones, uh, this one caught my eye, Daily Skin to Skin Contact Alters Microbiota Development in Healthy Full Term Infants. It's in the
[00:52:08] Ben: like, just like me, when I see trach and timing, I read, if there's skin to skin somewhere, Daphne is going to be like, I'm reading this one.
[00:52:15] Daphna: yeah, so this is in the Journal of Gut Microbes, I've never read an article in gut microbes before, um, and, uh, I thought this was interesting because in Uh, what's it called? Their, um, background. They said this is the first report of a microbiome related to skin to skin. And I just wanted the community to know that I have a boatload of premature samples, stool samples, related to skin to skin exposure in a freezer somewhere at the University of Florida.
[00:52:48] Daphna: So if anybody wants to do this in the preemies, then But, um, basically what they wanted to look at was they, uh, [00:53:00] randomized dyads to, um, one hour of skin to skin care for five weeks versus routine care, whatever the family wanted to do. And as a reminder, these were full term infants. These are not NICU patients.
[00:53:16] Daphna: Um, in total, they had 315 samples. They took, uh, 105 samples at week 2 of the intervention, 107, uh, samples at week 5, and 103 at week 52. So, again, the one year follow up I thought was pretty impressive, actually. Um, the baseline results, the skin to skin care group did more skin to skin care. That's not surprising.
[00:53:39] Daphna: Um, they had an average of 2, 067 minutes, plus or minus 850 minutes. The, um, routine care, care as usual group had 308, um, plus or minus 442. This was statistically significant. And then they looked at some of these [00:54:00] markers of, uh, bacterial or microbiome diversity. So they looked at the alpha diversity, which, for people who need a reminder, this is kind of the richness, um, or number of taxa that is seen in, in, in a, an average sample.
[00:54:17] Daphna: And interestingly, um, they did not find that skin to skin care had any effect on alpha diversity. They did see differences in the tire cohort between kind of the early infancy period and the one year period. That's an interesting, um, scatter plot of, of the samples. Um, and then they used, uh, a permanova to look at the microbiota composition of the CARES usual group and the skin to skin, uh, group.
[00:54:47] Daphna: And this was showed that there was significant difference in the early infancy samples. Um, so that was statistically significant, but it was not statistically significant in the late [00:55:00] infancy samples. They also looked at, um, breastfeeding as a covariate. They thought that might Certainly changed the, um, the, the microbiota, but the effects, uh, remained, uh, significant and the effect size was unchanged.
[00:55:14] Daphna: So this suggests that the skin to skin care had an effect on microbiota composition independent of its effects on breastfeeding duration. And then they looked at what, uh, types of bacteria were there. And I think for the people who do a lot of microbiome research, they'll think this is interesting. So, um, they detected a lower relative abundance of, uh, Fascila bacterium, Eubacterium, Hali, and Rothia, and a higher abundance of Flavonifractor, Lactobacillus, Bacillus, I got it, Bacterioides and Megasphaera in the skin to skin group compared to the care as usual group.
[00:55:54] Daphna: And there were differences in the genera between early and late infancy. They also looked at this measure of microbiota [00:56:00] volatility, and this is defined as kind of the intra individual change in microbiota composition over time. And in general, microbiota volatility is Seem to be like elevated in certain disease processes elevated in stressful situations And what they found was the volatility was lower in the skin to skin care group in early infancy As compared to the care as usual group and the effect remained unchanged after including breastfeeding Again suggesting that skin to skin care um independently affects the early microbiota. Breastfeeding and gestational age were negative, negatively related to volatility. And then they looked at microbiota age. So this is kind of a measure of the maturation of the microbiota. I don't know what to make of this. I think it's kind of interesting. Um, but really it showed that the treatment group or the skin to skin care group was actually associated with a lower microbiota age, [00:57:00] um, with an average decrease of of 25.
[00:57:03] Daphna: days at one year of age. After adding breastfeeding, the effect size decreased. So while breastfeeding was associated with lower microbiota age, which has been shown previously, um, it did change the effect for the skin to skin care. So anyways, I thought it was
[00:57:23] Ben: you mean? What do you make of this? Because this is, I'm going to say something. All these microbiome papers are flying way above my head. There's, there, this is, this is very detailed.
[00:57:34] Daphna: I would say In general, there are happier bacteria, some bacteria happier, better for you than other bacteria, so you want more of the happy bacteria. And having, uh, this richness or the, um, diversity is, is a good thing. And I think the hope is that, like, say for our preterm population who's at risk for, say, something like [00:58:00] neck, um, that if we can increase, if we can stabilize the microbiome, they're less likely to have something like neck.
[00:58:09] Daphna: And could skin to skin be a vehicle for doing that? Maybe. I don't know. Nobody's shown it yet.
[00:58:14] Ben: and, and do you think that this paper moves the needle forward in terms of getting us to an answer? What do you, I mean, because there are some interesting findings that you presented.
[00:58:22] Daphna: I think it moves the needle forward in that I hope people will be looking at skin to skin care in a different way. Um, I think that My personal belief is that skin to skin care is dose dependent, and we haven't proven that
[00:58:36] Ben: you presented something like that as well on, on those, almost those dependent for skin to skin, not too long ago. But because this paper is showing some interesting Signals maybe, maybe it's noise and we'll find out. But there's definitely some things that are happening. So I think, I think that's interesting.
[00:58:50] Ben: Um, what will that materialize to end up? Uh, yeah. Um, we're
[00:58:55] Daphna: Oh, I had one more.
[00:58:57] Ben: I was gonna say. Yeah, I was gonna say, you, you said you had to
[00:58:59] Daphna: [00:59:00] Uh, yeah. Well, this one is really quick. It's another Cochrane review. Um, it is called Non Pharmacologic Interventions for the Prevention of Pain During Endotracheal Suctioning and Ventilated Neonates. Um, this is coming to us out of Belgium. You know, it's a small, it's a small review, right?
[00:59:18] Daphna: They included eight randomized controlled trials, which enrolled 386 infants, and they really used five of the eight studies included in this, um, meta analysis. So they were looking at three, um, interventions. Again, during endotracheal suctioning, um, and wanted to see those effects on the infant. They looked at facilitated tucking versus standard care, and I'll tell you what facilitated tucking is.
[00:59:42] Daphna: So it's basically where you kind of hold the infant in this flexed posture. I like to think of it as like they're intrauterine. posture. You know, they're all kind of tucked, tucked up. Um, so bent midline position of the [01:00:00] legs. Um, you can do this on the back or lying on the side, um, or even lying on their tummies, but they're just kind of in this contained, um, I'm showing you with my hands, but the people can't see.
[01:00:14] Daphna: It basically means that you've held the baby from the top and the bottom and that you have them in this tux flexed, um, position. And so I think it goes back to the importance or the discussion in the community about two person care or four handed care. So somebody, two of the hands, are doing the work of the touch time, and two other hands are there just to be the advocate for the baby, basically.
[01:00:40] Daphna: So they wanted to look at, um, tucked, uh, facilitated tucking. They used something like familiar odor, um, so like, um, a scent cloth. for example. Um, and then they wanted to use, uh, look at white noise, um, you know, from a noise machine. [01:01:00] So unfortunately, familiar odor basically only was done in one study, but, um, during endotracheal suctioning had little or no effect on the, the PIP score, which is a pain scale, the premature infant pain profile score.
[01:01:13] Daphna: It had no difference on the heart rate. Or, or oxygen saturation during endotracheal suction. Okay. White noise during endotracheal suctioning had little to no effect on the PIP score, the pain score, uh, heart rate, or oxygen saturation. And then they looked at facilitated tucking. So facilitated tucking probably has little to no effect during endotracheal suctioning on the heart rate, on the oxygen saturation, um, and on defensive.
[01:01:42] Daphna: behaviors, but it did result in an increase in self regulatory behaviors during endotracheal suctioning and it reduced, um, the PIP scores, the premature infant pain profile scores during endotracheal suctioning. So I thought this was just a [01:02:00] good reminder to the community. Including our community in our NICU about why we are harping on about two person cares.
[01:02:11] Ben: Yeah. And, and, and it's something that, uh, I initially looked at it, I glanced at the title when you put it in the folder, and I was thinking of endotracheal intubation, and. And then I read the title again and I'm like, no suctioning, which in my opinion shows my personal bias, which is that I, I don't even, we don't even think about endotrachea.
[01:02:32] Ben: That's right. Yeah. I mean, to me, it's a, the, the respiratory therapist does it. If we have issues, we'll say, Hey, how did you suction the baby? Not too long recently, but yeah, it's a, it's an intense procedure. Yeah.
[01:02:44] Daphna: think, oh, I mean, the babies must have secretions. I'm helping the baby. They'll feel better, but it's It's, it's still an, it's still a procedure, like you said, and some food for thought.
[01:02:57] Ben: All right, buddy. This was fun. We covered a lot of [01:03:00] articles today.
[01:03:00] Daphna: We did. We did. Well, go snuggle that little bug. We'll see you soon.
[01:03:05] Ben: We'll see you guys soon. Um, uh, stay tuned this week for episode two of at the bench where misty good is being interviewed. Um, so stay tuned for that and, um, more interviews coming to you next week. Definitely. Thank you very much.
[01:03:22] Daphna: Bye everybody.
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