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#210 - 📑 Journal Club - Sunday May 19th - The complete episode

Hello friends 👋

In this episode, we discuss several recent neonatology studies. First, we examine an algorithm developed by Shah et al. for the timely detection of hypothyroidism in preterm infants based on gestational age and TSH levels. Next, Daphna reviews a study by Halling et al. comparing initial endotracheal versus intravenous epinephrine administration during neonatal resuscitation. While endotracheal epinephrine was given faster, IV epinephrine achieved return of spontaneous circulation more quickly.

We also discuss studies on the feasibility of using intranasal human milk as stem cell therapy for intraventricular hemorrhage, the association between relaxation interventions and human milk outcomes, and the timing of red blood cell transfusions in relation to necrotizing enterocolitis risk. Finally, Daphna highlights a one-year follow-up of the WISER intervention, showing sustained reductions in burnout and depression among NICU healthcare workers.

Throughout the discussion, Ben and Daphna provide thoughtful analysis and identify areas needing further research. We conclude by reminding listeners about a survey with prize giveaways in honor of The Incubator's 3-year anniversary. This informative and engaging episode provides a helpful overview of some of the latest neonatology research.

Have a nice Sunday!


🎉🥳 We’re thrilled to announce that The Incubator Podcast is turning 3! To celebrate this milestone, we’ve organized an exciting giveaway with a range of fabulous prizes! 🎁

Want a chance to win? It’s simple! Just fill out a short survey and you’ll be automatically entered to win one of the many prizes we have lined up. 🌟

👉 Join the celebration by clicking the link: Enter the Giveaway!

Thank you for being part of our journey and helping us grow. Here’s to many more years of exploration, learning, and fun! 🚀


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

Halling C, Conroy S, Raymond T, Foglia EE, Haggerty M, Brown LL, Wyckoff MH; American Heart Association’s Get With The Guidelines–Resuscitation Investigators.J Pediatr. 2024 Apr 16;271:114058. doi: 10.1016/j.jpeds.2024.114058. Online ahead of print.PMID: 38631614


Hoban R, Gallipoli A, Signorile M, Mander P, Gauthier-Fisher A, Librach C, Wilson D, Unger S.J Perinatol. 2024 Apr 30. doi: 10.1038/s41372-024-01982-8. Online ahead of print.PMID: 38688998


Salas AA, Gunn E, Carlo WA, Bell EF, Das A, Josephson CD, Patel RM, Tan S, Kirpalani H; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network.JAMA Netw Open. 2024 May 1;7(5):e249643. doi: 10.1001/jamanetworkopen.2024.9643.PMID: 38700862 Free PMC article. Clinical Trial.


Wynter Z, Gorham JA, Thompson AB, Mundy C, Waller JL, Stansfield BK.J Perinatol. 2024 May 9. doi: 10.1038/s41372-024-01998-0. Online ahead of print.PMID: 38724605


Profit J, Cui X, Tawfik D, Adair KC, Sexton JB.J Perinatol. 2024 May 11. doi: 10.1038/s41372-024-01993-5. Online ahead of print.PMID: 38734802


Shah AN, Li W, Zheng D, Lalani S, Kaluarachchi DC, Findley TO.J Perinatol. 2024 May 11. doi: 10.1038/s41372-024-01985-5. Online ahead of print.PMID: 38734804



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

Ben Courchia MD (00:00.718)

Hello everybody, welcome back to the incubator podcast. It is Sunday, we are back with journal club. Daphna, how are you?


Daphna Barbeau (00:07.582)

I'm doing great buddy, we're recovering from all of our trips, but right back in the swing of things with Journal Club.


Ben Courchia MD (00:14.99)

That's right. There's a little bit of housekeeping that we need to do. First of all, we wanted to share our, I mean, this is kind of a somber way of starting Journal Club, but that's okay. We wanted to send our love and support to our friends in Brazil, our colleagues, Dr. Mariana Gonzalez de Oliveira, Marola Scheeren, people that work with us at the Incubator who are in,


They're located in Brazil, and they're truly suffering from the recent climate catastrophe. So anyway, if you want to stay up to date as to what happens, I suggest following Marianna on Twitter. She posts a lot of updates. And yeah, she said that hopefully they see the light at the end of the tunnel around May 30th. So hopefully they're going to be able to recover from that. So Marianna, Marola, we're thinking of you guys. And yeah.


That's number one. The other thing that we wanted to talk about is that there's a funny thing that happened on Twitter. And we blame Michael Narvey for this.


Daphna Barbeau (01:29.086)

We thank Michael and Arnie.


Ben Courchia MD (01:31.63)

Michael Narvey is a good friend. And so I feel perfectly comfortable saying, Michael, you put us in an interesting position. Because the Incubator is celebrating its three -year anniversary, which is phenomenal. And for that, we're going to post online a little survey where we want to get some feedback from our community. So.


The survey will be posted on all our social media platforms. It will be posted on our website and you should just go and fill out the survey. It will not take more than five, 10 minutes at the most, but that survey automatically enters you to win a bunch of potential giveaways, whether it is incubator swag, whether it is, I guess, AirPods, we're going to have Amazon gift cards, we're going to have books. So there's a lot of gifts that potentially could be won. All you have to do is go fill out the survey. Now.


And we're very excited to hand out all these gifts. Now, two years ago, we did a giveaway for AirPods and somehow Michael Narvey found this post and liked it and retweeted it like...


Daphna Barbeau (02:44.446)

You know what, I'm not sure if it was Dr. Narvey. It may be our friend, Dr. Tala. But regardless, in any case. That's right.


Ben Courchia MD (02:51.918)

It may be one of it's possible because they're both they both have huge followings. So it's very possible. So Michael, maybe I'll take that back. I'm sorry. But they kept they posted it and I think people think this is the giveaway. Yeah. So the survey that we will post will have an option like one of the giveaways will be AirPods this way. Nobody is left behind. But yeah. So look out for this. Well, we'll post the survey.


Daphna Barbeau (03:06.686)

that it's active.


Daphna Barbeau (03:16.094)



Ben Courchia MD (03:21.07)

on this morning, I guess, as we are releasing this episode. And we're so happy to just thank you for your support with gifts and giveaways. And the feedback you'll provide with the survey will be very valuable to us as we pay very close attention to what the community says. And we do get these feedback on and off, but this will provide a systematic way for us to get one big feedback at the three -year mark for the podcast. So that's the announcements.


Yeah, that's all the announcements for today. And I think we've spent enough time and we can definitely begin Journal Club. That sounds like a plan? Okay. I guess you want me to begin?


Daphna Barbeau (03:54.846)



Daphna Barbeau (04:02.878)

All right, let's do it. Yeah.


Daphna Barbeau (04:09.502)



Ben Courchia MD (04:10.958)

Okay. I have some very high yield topics today. And there's some very interesting studies. The first one I'm looking at has to do with newborn screens, hypothyroidism, preterm babies. It's a paper published in the Journal of Perinatology by Dr. Shah and colleague out of, I think it was Texas, and the...


Daphna Barbeau (04:13.438)



Ben Courchia MD (04:38.99)

The title of the paper is a practical gestational age based algorithm for timely detection of hypothyroidism in premature infants. And so I was attracted to this paper because we all get these newborn screens that are like low T4 and every time. And then these babies are small and you're like, do I just repeat it now? What do I do? Do I call Ando? Do I not call Ando? So I thought this was an interesting paper to review.


Daphna Barbeau (04:53.022)

Every time. Every time.


Ben Courchia MD (05:05.166)

The background is very interesting because it puts a little bit in perspective this issue that we see so commonly. So talking about the occurrence of transient hypothyroidism in infants born prematurely, they're mentioning how this was first reported in about 1978 and that since then the rates of congenital hypothyroidisms have nearly doubled from one in 3000 to one in 1600, largely attributed to the lowering of screening threshold for serum TSH in newborn screening program.


as well as the improved survival rates of infants born prematurely. Now they're saying that due to thyroid hormone dysfunction and prematurely newborn screening programs have long dealt with high rates of inaccurate newborn screening results for congenital hypothyroidism and that approximately half of extremely low birth weight infants born, those born below one kilo and about one fifth of the ones born below 1 .5 kilo have falsely abnormal newborn screening results.


any abnormal newborn screening results warrants measurement of TSH and 3T4 and the initiation of medical therapy for elevated levels of serum TSH. However, there's really no consensus on the serum TSH threshold at which to initiate levothyroxine. And so this team out of Texas developed in, I forget when, actually I don't know the date, it doesn't matter, a serial screening algorithm based on gestational age for the use in their NICU.


which closely aligns with the 2023 AAP recommendation for repeat screening for delayed TSH surge. And so what they wanted to find out in this paper is what is the efficacy of this algorithm in detecting congenital hypothyroidism using this gestational age -based screening algorithm. So I thought this was very cool. I want to go over...


maybe the way the algorithm is structured, this way people can have an idea. One of the things they did in this unit, and I thought this was interesting, is that regardless of newborn screening, they always measured tariff function tests at 30 days of life. And 30 days of life was not a hard deadline. It was around 30 days of life with the nearest routine lab blood draw. And basically what they did is that...


Daphna Barbeau (07:01.598)

That sounds good.


Ben Courchia MD (07:24.142)

they looked at the TSH values and they categorized the TSH as low, normal, or elevated. Low being less than 0 .5 micro international units per ml, normal 0 .5 to 0 .6, and elevated above 6. And basically, they had an algorithm following this. So if your TSH is less than 0 .5 at 30 days, they say consult endo irrespective of your gestational age.


Then if your TSH is relatively normal, 0 .5 to 0 .5 all the way up to 6, then they look at what is your free T4. And if your free T4 is low, meaning less than 0 .7 nanograms per deciliter, they'll say, well, just repeat the TSH and the free T4 in two weeks if the babies are less than 32 weeks. And then if they're above 32 weeks, they'll say repeat it in one week. If they say that the free T4 was normal, 0 .7 to 2 nanograms per deciliter,


they'll say repeat the TSH and the 3T4 at term corrected, which is about 40 weeks or prior to discharge. If the 3T4 is elevated more than two nanograms, then they'll say just consult the endocrine team. And then the last part of the algorithm is if you had an elevated TSH, which is above six micro international unit per milliliter, then they'll look at it, whether it's mildly elevated versus very much elevated. And then if it's very, very elevated above 10, they say just consult endo. If it's mildly elevated, they'll look at


the level of free T4, whether it is low or high, and then tell you to repeat the test maybe two weeks or one week. So I saved this algorithm. It's super useful. And I'm probably going to whip it out on rounds. So they did this prospective observational study at this single academic center in Texas for infants who are born at less than 35 weeks. And they did this observation over three years between 2018 and 2021.


The inclusion was that the babies have to have a length of stay of 21 days to capture the patients who were being screened on day of life 30. Now, they collected a lot of different variables, just stationery age at birth, birth weight, the newborn screening results, the serum TSH, free T4, and so on. And just so you know, in Texas, the babies receive a newborn screen at 24 hours of life and then at 10 days to 14 days of life.


Ben Courchia MD (09:47.822)

And that's really it. I'm going to start going into the results because we spent a lot of time reviewing that algorithm. They looked at 938 preterm infants that were included. 28 % were less than 1 ,000 grams. 32 % were 1 kilo to 1 .499 kilos. 36 % were 1 .5 to 2 .5 kilos. And 3 % were above 2 ,500 grams. So.


significant portion of them, right, 262 were actually less than a thousand grams, which is really the study that the population that I was interested in hearing about. And despite having 938 infants, during that three -year study period, only 16 infants were treated with levothyroxine. And I thought that was quite low. And I think it puts in perspective that really it's not something that is as common as we may perceive it to be. The CRMTSH threshold of six


micro units per ml in the screening algorithm yielded a sensitivity of 0 .88 and a specificity of 0 .92. So yeah, so micro units per ml. So that's the one that I just reported to you. And now what's interesting is that when they looked at this different index, the Youden index,


the optimal TSH threshold of if they're using a higher threshold of eight micro units per ml, then the specificity increased from 88 to 97 and the sensitivity went up went down from 92 to 88 percent. So what were some of the outcomes in the treatment group? Out of the 16 infants who were treated for congenital hypothyroidism, four infants passed away prior to discharge and the remaining 12 were discharged from the NICU on levothyroxine. They lost two to follow up.


and two infants were successfully transitioned off their levothyroxine and thus they were confirmed diagnosis of transient congenital hypothyroidism. And at the time of the publication, eight of these children still remain on levothyroxine. When they're looking at the difference between the pre and the post algorithm era, the incidence of treated hypothyroidism in the current study population was 1 .7 % and it was higher.


Ben Courchia MD (12:08.43)

than the 1 % in the previous year. So they were able to actually properly identify more babies to address this issue of hypothyroidism. In the post -algorithm era, there was an improved detection and treatment of disease in the infants who were bigger than 2 ,500 grams. And the rate of treatment did not change in the ERBW between the pre and the post. So.


I thought that was kind of mitigated and the conclusion are that the detection of congenital Hypothyroidism can be challenging in the preterm infant population. And there's uncertainty in the guidelines for detection and treatment. And their study correlates with recent AP recommendations for the assessment of thyroid function in the preterm population until 36 weeks corrected age. And while the AP recommends assessment to be performed through newborn screening, TSH and T4 reference range.


for the preterm population in newborn screening programs have not been widely implemented in newborn screening programs. And so they demonstrate the feasibility of a gestational age screening algorithm to improve the detection of transient and permanent congenital hypothyroidism in preterm infants. Obviously, they recommend that further research is needed again to better quantify and define these issues and that larger studies also would be helpful. So an interesting study and again,


very valuable, I think, the publication of this little algorithm tool.


Daphna Barbeau (13:33.278)

Yeah, absolutely. Like you said, it comes up all the time. And what I was taught as a young trainee was that, well, they all get better. It's just because they're premature. And I mean, this is clearly not the case. So I think, and I always, I'm always sending thyroid studies and we never know what to do. So I appreciate that.


Ben Courchia MD (13:48.27)

That's right.


Ben Courchia MD (13:54.638)

Exactly. So that's, yeah. Of course, I'll post this on social media.


Daphna Barbeau (14:01.598)

Perfect, perfect. All right, shall I go?


Ben Courchia MD (14:05.55)

You shall.


Daphna Barbeau (14:06.59)

Push out. Okay. I wanted to start this was a paper that there was a lot of buzz on social media called Use of Initial Endotracheal Versus Intravenous Epinephrine During Neonatal Cardiopulmonary Resuscitation in the Delivery Room Review of a National Database. This came out in the Journal of Pediatrics. Lead author, C. Halling, but it was the work group for the American Heart Association's


Get with the guidelines resuscitation investigators. I know, that's a little heavy handed, but just so people who are not familiar with the registry, and I was not, it's a large multi -center national database of in -hospital cardiac arrests, but they did include neonates. So they really wanted to see whether initial epinephrine administered by endotracheal tube or by...


Ben Courchia MD (14:38.478)

with the guidelines as says it all.


Daphna Barbeau (15:03.774)

you know, IV epinephrine was more efficacious in neonates receiving chest compressions in the delivery room. Okay. So they did a retrospective review of neonates who, like I said, both received chest compressions and epinephrine in the delivery room from October 2013 to July 2020. So retrospective analysis. The cohort included newborns from 142 study centers.


And the exclusion criteria was mostly that they didn't have enough data. So no gestational age recorded, missing time or date of birth, no, sorry, a gestational age less than 22 weeks. Those babies were excluded, but they did go down to 22 weeks. If the time to first epinephrine was not within 30 minutes after birth, because they really, again, wanted to capture what was happening in the delivery room. And so they wanted to evaluate,


Really, the primary outcome was a return of spontaneous circulation defined as a heart rate greater than 60 for at least 20 minutes after the resuscitation. So that didn't mean the babies didn't need another code event down the line, but that they no longer needed chest compressions for at least 20 minutes. They had 1 ,288 infants from 142 sites that received chest compressions.


538 infants received at least one dose of epinephrine. Then they really had 408 infants that met all the inclusion criteria. And of these 281 or 69 % received initial endotracheal epinephrine and 127, 31 % received initial IV epinephrine. Overall, the mean gestational age of the 488 infants was 31 .1 weeks and the median birth weight was 1 .9 kilos.


Those infants who received initial endotracheal epinephrine, they tended to be a little bit bigger, two kilos versus 1 .6 kilos. They had slightly higher gestational ages, 32 .4 weeks versus 30 weeks. And a higher percentage of those receiving initial endotracheal tube epinephrine were born via emergent C -section delivery, 79 .8 versus 66 .7. They were more likely to have a cord pH of less than seven, as well as a lower one minute Apgar score.


Daphna Barbeau (17:28.286)

And those who received endotracheal epinephrine were more likely to be asystole compared with those who received initial IV epinephrine, 41 % versus 31%. So really the babies who received initial endotracheal epinephrine while they were bigger and a little bit older seem to be a little bit sicker. So you can take that into account. And to be clear, when we move into the data, the initial endotracheal epinephrine group,


does still include infants who also received IV epinephrine when the endotracheal epinephrine failed to achieve a return to spontaneous circulation. So it didn't mean they didn't get IV epinephrine. It's just that the first dose was endotracheal.


Ben Courchia MD (18:10.542)

Yeah, but...


Ben Courchia MD (18:14.19)

But that makes sense because, I mean, obviously if you had an IV access from birth by miracle, you would have given it through the IV right away. The point is that obtaining the IV access may be delaying that potentially initial epinephrine dose that could just go through the ET tube basically, right? I mean, yeah. And I think, yeah, I think they're not really questioning, that's not, they're not questioning whether IV versus endotracheal tube is better. They're saying.


Daphna Barbeau (18:15.646)



Daphna Barbeau (18:20.414)

You'd give it. That's right.


Daphna Barbeau (18:32.414)

That's right.


Daphna Barbeau (18:36.318)

Well, I think that's what... Go ahead.


Ben Courchia MD (18:41.678)

while you're waiting to get your IV access, aren't you better off just getting another dose in through the ET tube? And would that just improve your outcomes? So I think it's reasonable that they would include these two.


Daphna Barbeau (18:52.83)

Yes, but notably 31 % received the first dose by IV. So I think that's already interesting in and of itself. So they wanted to look at a few different things. So the first thing they wanted to look at was comparing initial endotracheal epinephrine with initial IV epinephrine. What was the rate of retraction?


Ben Courchia MD (19:02.51)



Daphna Barbeau (19:17.822)

like return of spontaneous circulation. So it was achieved in 70 .1 % in those babies with initial endotracheal epinephrine versus 58 % in those babies with IV epinephrine. But that may have meant that they got multiple doses. So what I think is really valuable is the return of spontaneous circulation was achieved in 58 .3 with IV epinephrine alone, 47 % with ET.


epinephrine alone, but 40%, so another group received subsequent IV epinephrine. So still 40 % of the babies who got ET tube epinephrine still needed IV epinephrine, but there was 47 % who just got ET tube epi that helped them have return of circulation. That ROSC, that's right.


Ben Courchia MD (20:11.918)

They had ROSC.


Daphna Barbeau (20:15.39)

So they wanted to look at after just one dose of E .t. or IV epinephrine, the rates of ROSC were actually similar between the two groups, 34 .2 in endotracheal epinephrine compared with 36 .2 for IV epinephrine. Then they wanted to look like, okay, how quickly did it happen? So the median time to first dose of epinephrine, so the time corresponding to when 50 % of infants in the given group had received the first dose was six minutes for initial endotracheal.


and eight minutes for initial IV group, and this was statistically significant. And like you said, I think this makes sense in general. We usually secure the airway first. So the median time was faster in the endotracheal tube epi group. However, the median time to ROSC, the time corresponding to when 50 % of the infants in the given group achieved ROSC, was 12 minutes in the initial endotracheal group and nine minutes in the IV group.


So even though the dose got in faster for most of the ET tube kits, they had slower time to achieve ROSC. And then I thought this was interesting just from information standpoint. They started to look at the ROSC curves. So had a much steeper slope in the first 15 minutes and then it starts to flatten out. So few infants achieving ROSC after the initial 15 minutes after the event, but the curve,


for infants not achieving ROSC is much flatter in the beginning, which again, they said is expected given the fact that resuscitation efforts don't typically stop after a few minutes. So people continued. And this plot didn't account for repeated doses of epinephrine when they got them and what route they were given. So they wanted to look a little bit more at that initial endotracheal tube epi group. So of the 281 infants who received initial endotracheal tube epi,


80 % who were born 34 weeks gestational age or more received ROSC compared with 62 % with those babies who were born less than 34 weeks. So the older you were, the more likely you were to achieve ROSC. And of the 127 infants receiving initial IV epi, 58 .3 achieved ROSC. Of the 281 infants receiving E2 tube epi first,


Daphna Barbeau (22:38.014)

47 % achieved ROSC with only endotracheal tube epi. That may have been multiple doses, but they only got it through the endotracheal tube. 13 .2 % did not achieve ROSC, but they did not receive IV epi. And then 39 % or 112 infants subsequently received IV epi. And 58 % of those infants achieved ROSC. However, 42 % did not. So,


All of that is to say the group felt that it is still reasonable to use endotracheal tube epinephrine, especially as if you get the UV line and you have it, then it was totally reasonable to give it as there were higher rates of ROS compared with the initial IV epinephrine administration. However, because ROS -


seem to happen faster with IV epinephrine that we shouldn't delay giving IV epinephrine to those babies who didn't get ET tube or got ET tube and didn't respond. We shouldn't delay IV epinephrine.


Ben Courchia MD (23:52.622)

Yeah, so basically, it's not a bad idea to give ET tube epinephrine while you're getting access, but you should definitely not delay getting access to see if your ET epinephrine is going to kick in or not, basically.


Daphna Barbeau (24:04.99)

Yeah, and it's not surprising still that if you give ET tube epi that you will still need to give IV epi. So you just have to be doing them both in parallel. So I thought that was a good study.


Ben Courchia MD (24:14.19)

Makes sense.


I agree. I like it.


Daphna Barbeau (24:18.622)

Okay. I have another quick one if you want me to. You want to go? Okay fine. Fine.


Ben Courchia MD (24:23.47)

No, we alternate.


Ben Courchia MD (24:29.006)

I don't care. Is it on the same topic? Go ahead. I'm kidding. I was messing with it. Okay. So I'll do it. Fine. I'll do a quick one then. I found this paper again in the Journal of Perinatology called immediate fortification of human milk with bovine milk derived human milk fortifier and very low birth weight infant and randomized clinical trial. First author is Zanna Winter. This comes out of the paper coming out of the U .S.


Daphna Barbeau (24:31.422)

No, you go. No, you go.


Now it's your turn.


Ben Courchia MD (24:59.214)

So we know basically, right, that preemies get fortified feeds. And they're quoting the paper that we reviewed by Ariel Salas saying how Ariel's group reported that the addition of human milk derived fortifier on feeding day two in preterm infants that were less than 28 weeks at birth resulted in greater length and weight gains without really altering the fat free mass of 36 weeks. However,


They're saying that we don't really have a lot of information when it comes to the rate of necrotizing enterocolitis, SIP or DEF. I always find it interesting when people quote other papers in the introduction because it sets really the stage for your paper. And so when you cite like a paper like Ariel's, which was a pretty big study, like you expect the paper to really take on the question. And so the question in this case was, what are the growth and feeding related outcomes if...


bovine and milk derived HMF were added to the first feeds compared to delaying fortifications until the baby reaches about 80 ml per kilo per day. So they did a double blind randomized control trial where they included babies who were born between one and 1 .5 kilos. They had to be admitted to the NICU within 24 hours after birth and there had to be a maternal intent to supply breast milk and the ability to get consent. They excluded infants that were born SGA, so below the third percentile on the


Fenton chart or whose enteral feeding were not initiated in the first 72 hours after birth or those who had major congenital anomalies that might impact feeding growth or survival. The intervention itself was giving basically HMF, human milk fortifier, on the first enteral feed. And they used the Enfamil HMF. And I know that, yeah, so.


I know that Enfamil supports the podcast, so there's no conflict of interest on our end in terms of presenting this data. And you'll see. The control received the bovine HMF, however, only when the baby reached 80 ml per kilo per day. The feeding protocol was fairly standard, like didn't have a weird sort of protocol. All study infants were provided 20 ml per kilo per day of the mother's own milk or donor human milk. They were advanced by 20 until they reached about 150 ml per kilo per day.


Ben Courchia MD (27:22.254)

They collected a bunch of anthropometric measurements and other clinical outcome variables. And so the babies in the end, this randomized trial ended up including only 52 infants. So that was kind of disappointing that there wasn't more babies with 26 participants included in the early and 26 participants included in the late fortification arm. The mean birth weight and gestational age at birth was 1 ,285 grams, so not really small.


And they gave the, interestingly enough, I had not seen this, I don't see this too often, but they had given the gestational age in days, but it ends up being about 30 weeks. So it was like 200 days and change, but it's about 30 weeks of gestational age. So not a very, very, very preterm population. When it comes to the primary outcome, the weight velocity at day of life 28 was not really statistically significant between the two groups.


When they looked at length and head circumference, similarly, they did not find any difference between the groups at day of life 28. They had several secondary outcomes that were analyzed, including weight, length, and head circumference velocity at 36 weeks post menstrual age. And again, no statistically significant differences. The weight at 36 weeks did not differ between the two groups either. 2 ,237 grams versus 2 ,176 grams. Again, p -value was not even close.


They also found no statistical significance in the stool output, emesis, the volume, or the emesis volume, sorry, or the number of events, feeding -related NPO occurrence, or metabolic acidosis between the groups. And when looking at the number of infants diagnosed with any, like, neck, oxygen at 36 weeks, retinopathy, or culture -positive late onset sepsis, again, no difference between the groups. And so I'm interested to hear your thoughts on this.


because obviously they're comparing very early fortification versus a little bit later. And they're saying, we provide valuable clinical data that addition of a bovine HMF is safe and well tolerated in very low birth weight infants despite no clear growth benefits noted. So first of all, it would have been nice to have a little bit more patients and a little bit smaller population. So very low birth weight infant is accurate. And they're saying, since bovine milk derived HMF are used by nearly three and four NICUs in the US,


Daphna Barbeau (29:33.406)

Mm -hmm.


Ben Courchia MD (29:43.662)

and are commonly employed throughout the world are finding should encourage clinicians to initiate fortification earlier in their feeding protocols and provide good rationale for future clinical trials. However, we also acknowledge that the gestational age and birth weight of the population of the study was conservative and that the safety or tolerability of immediate fortification with bovine HMF of more immature infant must be examined in future prospective clinical trials. So basically they have no difference whatsoever in that VLBW population.


I mean, I'm curious what your thoughts are because to me it's like, well, then just give them straight breast milk. Just wait. If everything is the same, why fortify so early then? I don't know what your thoughts are.


Daphna Barbeau (30:27.038)

No, I agree. I think based on this study that I don't think you can make that claim. I anticipate the more we do this work that we will see a difference because we have with other parameters and hopefully we'll show that these little babies are more resilient than we think. And like they said with the...


Ariel's paper, you know, that there were differences, right? So I think that's what the research will show, but right now I don't think we're there yet. And I think until we're there yet, it's going to be hard to convince people to do otherwise until we have more data.


Ben Courchia MD (31:07.886)



Daphna Barbeau (31:16.222)

We'll see.


Ben Courchia MD (31:17.966)

tell us about intranasal human milk. Was that what you wanted to talk about? -huh.


Daphna Barbeau (31:20.446)

for sure. But that was not my short paper. This is not a short paper, but I have been very much looking forward to this paper. As you know, that's okay. I will do that one next.


Ben Courchia MD (31:27.566)

I'm sorry. no, no, no. Tell us about the one you wanted to tell us about. Now, people, we've teased it.


Daphna Barbeau (31:33.31)

No, well, I want to tell you about all of them. I want to tell you about all of them. And I was very looking, I was very much looking forward to the intranasal human milk paper. So I will do that one. It's called feasibility of intranasal human milk as stem cell therapy in preterm infants with intraventricular hemorrhage. I'll tell you the, this is really a safety paper.


Ben Courchia MD (31:37.166)

I won't interrupt you this time.


Daphna Barbeau (31:58.878)

We're very much looking forward to more from this group about their experience with this intranasal human milk. So for people who aren't familiar with it, there have been a few studies on intranasal human milk, and there's a lot of good animal data to support the practice.


So what they, this is, sorry, lead author Rebecca Hoban, the Journal of Perinatology, and this is coming to us from Canada. So basically what they are doing is giving intranasal human milk, just like it says, to babies with IVH, and I'll tell you a little bit more about that in just a moment, hoping that the stem cells, if we could give a high enough stem cell load through the human milk, it'll cross the blood -brain barrier.


and cause better brain growth in babies who are already at risk. So they enrolled infants less than 33 weeks at birth with IVH diagnosed in the first 10 days. And one of the inclusion criteria was that they had a lactating parent because they only used fresh human milk. So of note, they initially only enrolled infants with grade three to four IVH. They used the Papille criteria.


I'm eligible for the study, but fortunately they had not enough babies with grade three, four IVH. So they modify the study protocol to include all grades of IVH. And they do say this in the paper. And of course it's true that even babies with grade one and two IVH do have some differences, you know, increased odds of neurodevelopmental impairment. So I agree that we can, you know, it was smart of them to enroll.


all the babies with IVH. Exclusion criteria, unknown lethal diagnosis, a disorder associated with neurodevelopmental delays, critical illness with plans to redirect care, any problem that would prevent intranasal treatment like choanal atresia, a surgical condition for which the medical team felt the study was contraindicated, if they were already enrolled in a different trial.


Daphna Barbeau (34:18.046)

a parent who was unable to lactate or a parent who was unable or unwilling to provide fresh pumped milk because it was very important that the milk was fresh. So it was a non -blinded prospective intervention study because obviously everybody can see what was happening to the babies. And for the enrolled patients, basically what they did was they did one dose of intranasal pumped milk.


to be given on or before day 10 after birth. After ensuring clinical stability and monitoring the vital signs, the type of respiratory support, they were able to increase the dose. So they started with an initial dose of 0 .2 mLs of, like I said, fresh, never refrigerated, pump within three hours, milk administered into one nostril by a study physician or trained RT using an oral syringe.


If this was tolerated, the dose was then increased to 0 .4 mLs given before and after nursing care, ideally twice daily for a goal of 1 .6 mLs per day. This was just so you know, they give us some background about that, what they hope to actually give more than necessary stem cell dose.


Administration was planned to continue until 28 days of age and was done by the bedside nurse, the RT, or a physician after training. And then some parents were also trained because they requested to be trained. So I thought that was really neat. I also thought, I hope they will give us some information about the parents who wanted to be trained and parents who are involved in the administration because I think it will be positive.


I also wanted to holly that part of their study included having a courier available to get milk to the hospital so that fresh milk could be delivered within three hours of pumping. This is a reminder that if we work hard enough, we could get fresh milk at the bedside without having to refrigerate it, which is really cool. They screened 234 infants, they approached 104, and they enrolled 37. So it's a small study. Again, it's a pilot really looking kind of at safety.


Daphna Barbeau (36:29.982)

Three infants died during the study period from unrelated causes common in the very preterm populations. That's how they stated it. These babies either had neck or sepsis. 14 infants had administration stop prior to 28 days of age. This included the three infants who passed away, three infants who were felt by the medical or study team or the parents to be too unstable due to surgical or other clinical conditions, and eight infants who were transferred to another facility before day 28.


Steady infants received a median of 17 days. Remember the goal was 28 days. 36 or 97 % received at least three days, which was the minimum target. 84 % received at least seven days and 62 % received at least 14 days of intranasal milk. Now in some of the smallest patients, so they say IE 500 grams, the 0 .4 ml volume seemed to be too much for their actual nasal passages.


Ben Courchia MD (37:09.55)

Mm -hmm.


Daphna Barbeau (37:27.582)

So milk was noted in the mouth immediately after the administration. They appear to be swallowing down milk or milk flowed back out in the air. And so if this was the case, the dose was reduced to 0 .2 mLs on an individual basis. So then they really wanted to look at the major safety reactions related to the study intervention. They had 32 total reactions, not subjects that had a reaction, but 32 total reactions were reported. And...


These were recorded as possibly or probably related to the intervention of itself. 30 of the 32 were deemed quote unquote minor. These were defined a priori as required minimal to no treatment. The vast majority of them were bradycardia and oxygen desaturation associated with the interventions. There were two babies out of the 32 who were noted to have an increased requirement in their respiratory settings.


However, one of these babies had recently been extubated to a non -invasive modality. So was it just nature of the clinical course or was it an intervention? Nobody knows. And the second was later found to have pneumoperitoneum that same day. So I think it's unrelated to the intervention. So that was the safety profile. They also talked to the staff. Results suggested that providers felt the administration was feasible in the planned protocol.


They did a bunch of free text responses and people felt that intervention was overall easily able to be part of the clinical care routine without major disruption to the infant, the family, or nursing routines. There was some suggestion of perceived stress to the provider infant in some responses, about 25%. Now they also did a stem cell analysis of the milk. So they utilize samples from six test subjects who were not in the study.


and 15 study subjects to look at the stem cell analysis. So they were hoping, again, these babies all received milk before 28 days of life. So that's the type of milk they were looking at. Unfortunately, that's not all the milk they got. The analysis occurred between six and 77 days of age. Cell counts and viability testing was performed on 19 processed samples.


Daphna Barbeau (39:53.534)

The median cell viability was 68%. There was a significant negative correlation between viability of stem cells and day of age. And in these 19 samples, the median live cell concentration was, I don't even know how to say this, but 0 .23 with 10 to the sixth with a large range in different samples.


But the samples with the highest concentration of live cells were all collected in the first 28 days postpartum. So I think the overall take -home point is the older the milk, the less viable the stem cells. But again, they wanted to look at the stem cells themselves and they wanted to see about the safety profile. And I hope soon they will release the rest of the data.


Ben Courchia MD (40:47.072)

Yeah, that was kind of cool that they had this stem cell analysis on the breast milk. It's rare. We talk about stem cells in breast milk all the time, but we rarely see the different cell populations, the markers, and the percent of live cells, and the range. So that was kind of neat.


Daphna Barbeau (40:50.366)



Daphna Barbeau (41:02.398)

Yeah, absolutely, absolutely.


Ben Courchia MD (41:05.262)

And we strongly believe in our unit that this is a valuable intervention for our preemies.


Daphna Barbeau (41:11.998)

that I think we're going to get more and more data, more and more studies about how are the many ways we can use breast milk. I think one day we're going to be using breast milk to treat adult pathologies, but we're not there yet.


Ben Courchia MD (41:18.51)

That's right.


Ben Courchia MD (41:24.974)

Yeah, let's see. Let's see. I don't want to give too much momentum to that because I think some people are trying it already, even though there's not a lot of studies. So I think people have to still be careful. But you might be right. I mean, there's so many benefits. And it's always the same. We find the benefits for very fragile preemies. And then adults come around and be like, we could use that as well, whether it was surfactant or proning or whatever that was.


Daphna Barbeau (41:49.338)

That's right. That's right.


Ben Courchia MD (41:53.486)

Alright, you want to tell us about another one? I feel really bad about cutting you off earlier.


Daphna Barbeau (41:57.31)

No. There's a related, potentially, paper, Relaxation Therapy and Human Milk Feeding Outcomes, a Systematic Review and Metanalysis, lead author Alana Levine. So basically, they wanted to look at what was the association between the provision of this, quote unquote, relaxation intervention, and they studied multiple and lactation outcomes. So it was overall...


The meta -analysis includes 16 studies of 1 ,871 participants. Like I said, heterogeneous relaxation interventions, but they included music, meditation, mindfulness, guided relaxation, all compared with standard of care. So the primary outcomes were length and exclusivity of human milk feeding. They wanted to look at milk quantity. They wanted to look at macronutrients, which I thought was brave of them.


Cortisol levels and infant growth and behavior. Secondary outcomes were mental health and other lactation and stress parameters. Okay, six studies with 469 participants used similar lactation -specific guided relaxation recordings. So they used relaxation media, but it was specifically aimed towards the time while they were lactating. Seven studies with 1 ,249 participants.


used instrumental music or singing. The remaining studies used yoga breathing exercises and muscle relaxation, a mindfulness app and mindfulness training. Okay, and then we'll get into kind of the data. There was low certainty evidence of no difference in any human milk at one month of age. There was low certainty evidence of no difference in exclusive human milk at two months of age. Two studies contributed to these outcomes providing music.


for up to 48 hours after birth or lactation specific guided relaxation for several weeks. There was moderate certainty evidence that relaxation was associated with an increase in milk quantity, a medium effect size. 10 randomized clinical trials contributed to this outcome measuring milk quantity expressed in NICU settings or in healthy infants at the breast. They used baby weights.


Daphna Barbeau (44:16.094)

The studies used lactation -specific guided relaxation, music, breathing exercises, and a mindfulness app. There was high certainty evidence of no difference in milk protein. There was moderate certainty evidence of a small increase in milk carbohydrate and milk energy. There was a moderate certainty evidence of an increase in infant weight measured in the change in SD score. And there was a moderate certainty evidence of no change in infant


length. Then I told you they were looking at maternal health. So there was moderate certainty evidence of a reduction in maternal anxiety. Six studies, so they use specific guided relaxation, a mindfulness app, instrumental music, breathing exercises, and mindfulness training. There was moderate evidence of a reduction in maternal stress using six studies. There was a moderate certainty evidence for reduction in maternal blood pressure and heart rate and an increase in fingertip temperature.


in one crossover randomized control trial. This is interesting because actually the obstetric colleagues are really looking at mindfulness in its utility in pregnancy -induced hypertension and preeclampsia. There was low and very low certainty evidence related to maternal salivary cortisol, perception of relaxation, depression, breastfeeding self -efficacy, breastfeeding frequency, expressing frequency, breastfeeding duration.


time to lactogenesis II or colostrum quantity. They also wanted to look at subgroup analysis, but human milk yield was the only outcome with sufficient number of studies to explore subgroup outcomes. There were no significant differences in the pool estimate according to the nature of the relaxation intervention or a binary consideration of gestational age at birth. So overall, I think...


I think we can see there are trends to reduction in maternal anxiety, reduction in maternal stress, and the primary outcome of an increase in milk quantity, which I think is valuable. Obviously, we didn't know which intervention is the most effective, but I think it's good that we're looking into it.


Ben Courchia MD (46:33.91)

Thank you.


Daphna Barbeau (46:37.438)

Thank you. It is.


Ben Courchia MD (46:38.51)

Is it my turn? All right, I don't know where I'm going to go next, but maybe this is an interesting paper. I have a paper from Ariel Salas's team published in the JAMA Network Open called Timing of Red Blood Cell Transfusion and the Occurrence of Necrotizing Enterocolitis, a Secondary Analysis of a Randomized Clinical.


Daphna Barbeau (46:57.662)

Well, please tell me.


Ben Courchia MD (46:59.086)

So we're running low on time. So I'm going to skip a little bit some of the background. But basically, what they're asking is that we know there's a lot of data being published on association between neck and transfusion. What they're saying is lacking is data on the temporality of neck and RBC transfusions. So the goal of this study is to compare the risk of neck during what these are hazard periods of exposure to RBC transfusion by.


focusing only on the neck cases that developed shortly after exposure to RBC, they differentiated neck associated with transfusion from neck explained by other causes. And so that's really the gist of the paper. They did a secondary analysis of the top trial. If you don't remember, this was the transfusion trial where they looked at transfusion depending on two different thresholds. So that's a secondary analysis of that trial.


The infants in this study obviously were born between 2012 and 2017. They had a birth weight of 1 ,000 grams or less, a gestational age between 22 and 28 weeks and six days, a postnatal age of 48 hours. And infants were randomized to either a transfusion threshold that was either high or low. And they had this data stratified by birth weight. Now, what they did is that they created a model establishing hazard period around the time of


red blood cell transfusion. So for instance, an infant undergoing a mean of five transfusion within a 50 -day window from postnatal day 10 to 60 would contribute to this data set with five post -transfusion hazard period and five pre -transfusion hazard period. And so if you look in the paper, they have this graph, which is actually quite eloquent, where you see basically a control period. Nothing is really happening.


And then they give a blood transfusion, which again, could potentially be an association with transfusion -related injury. And so they created this area as the hazard period. And once that period was over, then you went back into a control period. So the observation period in the cohort began on postnatal day 10 and continued until postnatal day 60 or until the occurrence of neck death if.


Ben Courchia MD (49:16.942)

earlier. Now by limiting the observation period to postnatal A60, they excluded these late cases of neck which are often reported not to be associated with any red blood cell transfusion. Now the hazard period that we're talking about or the time after exposure to an RBC transfusion with the highest risk of neck began on the hour of the transfusion and ended


after 72 hours or if there was a diagnosis of neck. The time of diagnosis was confirmed for all neck cases. So that's kind of impressive. And I'm amazed that they had this data. A control period was basically a non -hazard period between postnatal day 10 and postnatal day 60. The primary outcome was neck stage two or three.


So looking at some of the results, they had about 1700 ELBW infants considered at risk for neck after post -needle day 10.


They identified 4 ,947 hazard periods and 5 ,813 control period. The mean gestational age was 26 weeks. The mean birth weight 765 gram. A total of 133 ELBWs developed next stage two or three between day 10 and 60. So of these events, 44%, 59 of these events of next two or three occurred during the hazard period.


55 .6 % of them occurred during the control period. The risk of NEC was 11 .9 per 1 ,000 post -transfusion hazard period and 12 .7 per 1 ,000 control period. Obviously, these numbers are all very similar and so not statistically significant. The stratified analysis according to the top trial randomization groups showed that the unadjusted risk ratio for developing NEC


Ben Courchia MD (51:14.83)

among the hazard periods as compared with the control period was 0 .91 for the higher threshold and 0 .99 for the lower threshold. These risk ratios were not different from one another with a p -value of 0 .81, indicating that there's no apparent moderation of the risk of neck by transfusion threshold. Now, what's interesting is when they divided the follow -up period into 10 -day intervals, they showed that the risk of neck was really at its highest between postnatal days,


20 to 39. And I think that's very interesting. During postnatal day 20 to 29, the risk of developing neck was significantly higher during these hazard period around the time of blood transfusion compared with control period. We have an adjusted risk ratio of 2 .17 and a confidence interval of 1 .17 to 4 .04 and a p -value of 0 .01. However,


They said there was no significant difference during post -natal days 30 to 39. So when they did one more analysis, a secondary analysis looking at the number of days at risk, they have this very nice figure where they have a graph where basically you can see the risk of the neck rate per 1 ,000 days comparing the higher versus the lower threshold group. But on the...


On the B side of the graph, you have the duration of the exposure to our BC transfusion. What you see there is that during the specific 20 to 29 day time frame, the incidence rates of neck per 1 ,000 days were higher with the lower threshold group exhibiting the highest incidence rate, which was about, I want to say 3 .2 based on the graph.


Despite this, the 6 % difference observed between the two threshold groups in the time exposed to hazard period during this specific 10 -day interval did not surpass the mean 7 % difference seen in other 10 -day intervals. So what was interesting was that they found that, again, this time period of day 20 to 29 in this population that was born at about 26 weeks really represented the highest risk for neck. And at that point, the kids with the lower threshold


Ben Courchia MD (53:35.758)

did worse. But when we're really looking at the number of time they spent in these hazard period days, this was not significantly different from other times. And so I think this is a piece of information that will be very interesting to study further. The conclusion are that the post -hoc analysis shows that ELBW infants with hemoglobin ranges defined by the top trial.


RBC transfusions are not temporarily associated with a higher risk of neck during 72 hours post transfusions. A more in -depth examination of the peak incidence rate of neck between postnatal day 20 and 29 among infants with lower hemoglobin values is warranted in future study with larger samples, as we just mentioned. So I thought that was very interesting.


Daphna Barbeau (54:22.27)

Yeah, I think so too. A little complicated statistical gymnastics there, but I guess it's reassuring.


Ben Courchia MD (54:23.374)



Ben Courchia MD (54:32.686)

What's interesting is that when I was a resident, you hear these heuristics. It's like, 29 weeks to 30 weeks is really the time. In that case, that matches that data. And maybe, I don't know. And now I'm going out on a limb, but maybe this data means that there's going to be a window where we shouldn't use too low of a transfusion threshold because that's their high risk period. And maybe the transfusion threshold is going to be variable depending on.


Daphna Barbeau (54:40.67)

Exactly. It makes sense, right? That's what I was going to say. Yeah.


Daphna Barbeau (54:53.854)

Mm -hmm.


Ben Courchia MD (55:02.254)

the days of life, the gestational age, and maybe instead of having a one word answer, which is associated versus not associated, the answer might be closer to its variable depending on the time and depending on the hemoglobin. And so I think that's, I'm sure this is getting us closer to the answer. So yeah.


Daphna Barbeau (55:22.526)

Yeah, I think like you said, we're kind of narrowing it down, refining it, but we know that there's a time period where babies are most vulnerable. So it makes sense that potentially we should be the most cautious with them during that time period. And for some, this is not uncommon, right? Some babies are many weeks old at that time, you know? And that's why it's so devastating, I think. But yeah, I think it's useful to add to the knowledge base for sure.


Ben Courchia MD (55:49.71)

Mm -hmm. Mm -hmm. Do you have one more? Yeah, always.


Daphna Barbeau (55:51.87)

All right, do you have time for one more? You have one more?


Ben Courchia MD (55:56.686)

I have one more but I can do it next time.


Daphna Barbeau (55:58.878)

I have a really quick one. Actually, you added it to the folder and I love it. It is a follow -up on the Wiser, W -I -S -E -R, Intervention to Reduce Healthcare Worker Burnout, a one -year follow -up. I know. You knew I would pick this one. This is Dr. Johan Profit. It's in the Journal of Perinatology. And if you're not familiar with the Wiser intervention, this is great because it's not


Ben Courchia MD (56:11.758)

I know my audience, you know?


Daphna Barbeau (56:26.366)

that you're not familiar with it, but it's a great intervention because it is specifically targeting being validated for NICU professionals. So it is the web -based implementation for the science of enhancing resilience intervention, and it can reduce emotional exhaustion or EE, a key component of burnout among healthcare workers in NICUs. So this is a follow -up study, but in the first study, the Wiser intervention just...


To learn more about it was a mobile phone -based program. It's comprised of six guided well -being modules. The first, gratitude. The second, three good things. The third, awe. Four, random acts of kindness. Five, identifying using signature strengths. And six, relationship resilience. So those are the modules. And I know people say, a module, another module. But the wiser intervention was, I know you.


Ben Courchia MD (57:16.438)

That's true. I'm that person.


Daphna Barbeau (57:21.758)

but it was effective in reducing EE, that's the emotional exhaustion. It was effective in reducing levels of depression, and it was effective at reducing work -life integration problems among healthcare workers in the NICU at a six month follow -up. So it did what it was supposed to do, and we all need this improvement. The one thing it didn't change was this marker of...


quote unquote happiness. So subjective happiness was evaluated with this subjective happiness scale. It couldn't do all the things, I guess. But the other interesting thing, they had two cohorts. Cohort one participants were invited to view modules by mobile or email. These were each introduced monthly and lasting 10 days. So it was like six months. And then cohort two,


Ben Courchia MD (57:55.054)

Mm -hmm.


Daphna Barbeau (58:11.102)

These were people who were on a waiting list for the trial, received the intervention in a condensed form or the course of 28 consecutive days because of feedback from cohort one that felt like the six month intervention period was too prolonged for sustained engagement. I could see that. They basically used the outcome of burnout, a widely used five item derivative of the emotional exhaustion scale off of the Maslach Burnout Inventory.


They used work -life integration, using the work -life climate scale, subjective happiness was evaluated, like I said, the subjective happiness scale. And then they looked at a bunch of characteristics. So the punch line is that the outcomes at one year showed a very similar pattern to six -month results. And they had some really nice graphs, I thought, that showed this. So you could see actually...


that the work -life integration, so it decreased significantly from baseline to six months, and then it stayed pretty consistent for six months to one year, but still decreased significantly from baseline. The same thing for depression. It decreased significantly from baseline to six months, stayed low or percent concerning from six months to one year post, but still a significant difference from depression.


happiness scores stayed about similar. I told you there was no significant difference from baseline to six months and that didn't change at one year. Now the emotional exhaustion scale, it was a significant difference from baseline to six months, but it continued, the percent concerning continued to decrease. So people's emotional exhaustion improved even at one year follow -up. So I think this is


Great news. I think it seems like a simple thing. We're all looking for ways to support our healthcare teams. This intervention is available for free. The link is https colon, not colon, semicolon, backslash, backslash, C -A -W -S dot dukehealth .org, backslash toolkit dash on.


Ben Courchia MD (01:00:15.598)



Daphna Barbeau (01:00:27.486)

Dash Demand. And there's actually a whole lot of interventions on that site, but Wiser is one near the bottom of the list for people who want to check it out. That was my quickie.


Ben Courchia MD (01:00:45.454)

Yeah, I mean, this is not a quick paper. I'm curious. What do you think is the reason for the fact that this might actually work? I mean, I'm curious. This seems a little bit too good to be true. And I know that the work that Dr. Profit is doing is quite excellent. But it's interesting, right? I mean, I'm just curious what you think. Yeah.


Daphna Barbeau (01:01:09.758)

Okay, I'm going to say something silly, okay? And I think what it is, is that NICU healthcare professionals are still also just humans, okay? And so these components of the modules have all been shown to be effective at reducing anxiety -type symptoms, emotional exhaustion -type symptoms, so it makes sense that they would work in burnout. And I mean,


Ben Courchia MD (01:01:20.174)

Mm -hmm.


Daphna Barbeau (01:01:39.198)

Admittedly, I haven't done all the modules, but focusing on gratitude, focusing on awe, those are all things that have been heavily described in mental health literature as being effective. So it stands to reason that they would still be effective for people like us in the medical profession, even as stressful as the NICU is. We just don't all take advantage of them or learn about them or do them on a regular basis.


Ben Courchia MD (01:02:04.686)

Yeah, I think sometimes we also create maybe I'm thinking about this very, I'm thinking this about this out loud, but I'm wondering if maybe the reason the reason a module could be so effective is because we create a narrative around our situation that could be completely biased based on our degree of fatigue and based on our experiences. And maybe that's maybe just having something like that is helpful.


Daphna Barbeau (01:02:22.846)



Daphna Barbeau (01:02:32.798)

And listen, you know, that doesn't mean I don't think we shouldn't disrupt the system, right? And we shouldn't have a good duty hour restrictions or, you know, safeties and prolonged shifts and having good backup coverage and not running too lean on our healthcare teams, right? I mean, that is still a problem and this doesn't solve any of those things. But I think there are parts of our job that are unrelated to the healthcare system, right? Just the...


the knowledge base, dealing with really sick patients, dealing with unhappy families, being connected to your patients. I think that takes a toll on us. And I think these modules can certainly target some of those emotional needs.


Ben Courchia MD (01:03:17.366)

I agree. I agree. I think these are helpful and there's still hope for modules to help us.


Daphna Barbeau (01:03:24.51)

Absolutely. They have to be the right kind and you have to be motivated to do them.


Ben Courchia MD (01:03:29.198)

That's right, that's right. Okay, I had one more, but I'll save it for next time. It has to do with kangaroo mother care, and I don't want to have to go through that one quickly. So if it's okay with you, I'll call it a day for today.


Daphna Barbeau (01:03:41.438)

That sounds good, buddy.


Ben Courchia MD (01:03:42.958)

All right, so for everybody who, I'm going to pretend like it's a radio show, so if you're just joining us, remember there is a survey where there's going to be many giveaways for you to win if you just fill the survey out. Otherwise, you can always find more information about everything that we do on our website at www .the-incubator .org. Thank you everybody for following us and for supporting us. Thank you and have a good rest of your day.


they can't see you waving.


Daphna Barbeau (01:04:16.35)

Signing off.



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